Carbon Neutral Hand Surgery: Simple Changes to Reduce Carbon Footprint

Abstract

Introduction: Rapid climate change poses a major challenge to healthcare. The operating room is especially responsible for carbon emission, with 20% to 70% of hospital waste traced back to the operating room. This literature review aims to suggest changes that can be made in hand surgery for a more sustainable practice. Methods: A literature search was conducted from PubMed, Medline, and other online search engines with the keywords “carbon footprint, environmental health, carbon neutral, plastic surgery, hand surgery, surgery.” Results: “Reduce, Reuse, Recycle, Research, Rethink and Culture” was the framework used to recommend a more carbon neutral practice. In reduction, techniques such as cutting down oversupply of materials, adopting protocols to perform cases in ambulatory settings, and simple measures to reduce energy were identified as valuable methods. Modified sterilization techniques and reprocessing single-use devices were techniques identified for reuse and recycling involved single-stream recycling, staff training, and donation of basic surgical supplies. Research involved adopting data-driven programs for life cycle assessment of all equipment in the operating room, while the use of telemedicine and “green meetings’ were suggested for rethinking. Finally, strategies to encourage a team approach to environmental responsibility were discussed. Conclusion: Carbon neutral practice must be implemented to safeguard sustainable and cost-effective operating rooms and healthcare systems. Hand surgery can pave the way for other specialties through the use of available resources to develop guidelines for carbon neutral practice. This requires active effort from hand surgeons to act as role models for other healthcare professionals.

Introduction

Although a very broad term, being “carbon neutral” simply suggests reducing the carbon footprint (total greenhouse gas emission expressed as carbon dioxide equivalent) so that the total emissions are equal to the total amount avoided or removed. Ever-rising awareness of alarming environmental ramifications due to emissions alongside its impact on healthcare expenditures have contributed to the growing attention of cost-effective and carbon neutral hand surgery.

From a hand surgeon's perspective, patient health is more of a priority, not environmental health. The latter however becomes relevant as climate change has challenging implications toward public health, especially as healthcare systems continue to contribute more to total greenhouse gas emissions. In 2007, for example, the United States healthcare facilities contributed to 10% of greenhouse gas emissions and were second only to the food industry with regard to landfills.^1,2 In 2009, the World Health Organization (WHO) also emphasized the hospitals’ responsibilities in making healthcare more sustainable, ³ further suggesting the importance of reducing carbon footprint.

Studies have shown that 20% to 70% of hospital waste can be traced back to the operating room.^1,3 This presents as an opportunity for hand surgeons to take responsibility in the form of acknowledging, understanding, and addressing environmental concerns which may further raise awareness, reduce carbon footprint, and increase the value of service by lowering the cost to ultimately improve patient health. Hand surgery procedures are commonly performed, typically short, with high operating room volume and more often under local anesthesia. ⁴ Environmental impact mainly arises from waste production before, during, and after surgery along with other aspects including energy consumption, sterilization, and anesthesia. As such, addressing both waste and non-waste elements is likely to be environmental hotspots ripe for intervention. Fortunately, hand surgery is well-positioned for change, as several procedures can be performed in ambulatory or office-based settings where environmentally friendly practices can simultaneously enhance value-based care. ⁴ The five Rs (Reduce, Reuse, Recycle, Research, and Rethink) ³ offer a comprehensive framework for tackling carbon footprint.

Methods

A literature search was conducted with the use of keywords “carbon footprint, environmental health, carbon neutral, Plastic surgery, Hand surgery, surgery” from PubMed, Medline, and online search engines to generate relevant papers based on the title and abstract. After all the relevant papers on the topic were selected, each paper was reviewed to select relevant information to the topic.

Results

Reduce

Reduction involves methods that decrease the waste of environmental resources and the amount of disposable waste produced. With medical equipment being one of the largest contributors to carbon footprint, minimizing this impact therefore can yield significant changes toward carbon neutrality. One measure is the reduction in the oversupply of materials, a common source of waste, as opened but unused materials are discarded. ⁵ A strategy for waste reduction is to adopt a “just-in-time” model where only essential materials are supplied ready and open, with additional equipment remaining available but unopened. ⁶ A study in 2017 at the Department of Plastic Surgery at Portsmouth's Queen Alexandra Hospital found that the extrapolated cost of wasted items which included surgical instruments, dressings, and sutures equated to £19,015,900 a year across the region's 3017 theatres, excluding weekends. ⁷ As some operations are predictable in terms of equipment usage, a “just-in-time” model may reduce both environmental and financial implications. Careful recording of the quantity and type of unused materials at the end of each procedure over time may also help staff use this information to gear toward more environmentally friendly practices in perhaps less predictable operations.

To prevent further surplus, surgeons can work directly with suppliers to reformulate prepackaged kits to include essential materials for specific procedures. A study by Albert and Rothkopf stressed the importance of judicious selection of instruments and supplies. ⁸ The authors examined current plastic and hand surgery sets, interviewed surgeons, and identified the excess instruments to form new packs which were estimated to have saved $17,381.05 per year. The redesigned packs also reduced autoclaving, labor, and turnover time which are indirect effects on carbon footprint. However, even in a particular plastic surgery department, there may be varied preferences of equipment between surgeons. Communication between surgeons is therefore vital to form a standardized prepackaged surgical pack that lowers the carbon footprint.

Simple measures in reducing energy use can have big impacts on carbon footprint. Such interventions include appropriate temperature regulation, turning off electrosurgical equipment when not in use and turning off ventilators at night. ⁹ For example, an initiative implemented by Barts Health NHS Trust, “Operation TLC” (Turn off equipment, Lights out, Control temperatures), reduced annual carbon emissions by 2200 tonnes and energy costs by £500,000. ¹⁰ Further methods include replacing older lighting, air conditioning, water chilling, and pumping systems with more efficient models. ³ Energy consumption can also be reduced by having a shorter case duration, decreased turnover time, and through running two operating rooms. ¹¹ Simple measures are unfortunately more often than not forgotten. Implementing visual reminders or through formulation and use of a “carbon neutral checklist” at the end of each surgery may be efficient tools for efficient energy management practices.

Reduction opportunities can also be found in surgical practice. One such example is using wide-awake local anesthesia with no tourniquet (WALANT) which allows many cases to be performed in an outpatient setting or an in-office procedure room. ¹² In a pioneering study involving 1099 hand cases, Van Demark et al saved $13,250.42 and 2.8 tons of waste over two years. ¹³ Aside from financial and environmental advantages, WALANT has also been shown to be safe and well received by patients. ¹⁴ Adopting WALANT protocols eliminates the need for preoperative tests and the need for an anesthetist which reduces operating time, patient recovery time, and need for transport home, especially when performed outside a traditional operating room. ¹⁵ Concomitantly, minor field sterility can be used in ambulatory settings as described by LeBlanc et al. ¹⁶ In doing 1504 carpal tunnel releases with this technique, results showed a lower infection rate and a significant reduction of cost and waste in ambulatory settings compared to the operating room. These studies highlight the opportunity for hand surgeons to be more productive in ambulatory settings where they can concurrently employ carbon neutral initiatives.

Reuse

Reuse concerns the substitution of disposable material for reusable ones, which leads to less waste production and less use of natural resources. For example, the proliferation of single-use devices (SUDs) has promoted a throw-away culture in healthcare that has adverse effects on carbon footprint and healthcare spending which can be avoided through reprocessing such devices. ¹⁷ Reprocessing has been shown to divert 2150 tons of medical waste from landfills, making this practice safe and environmentally friendly. ⁴ The SUDs eligible for reuse in hand surgery range from drapes and gowns to endoscopic carpal tunnel blades and biopsy forceps, but more creative measures can also be valuable. This ranges from using surgical packs as keyboard covers to using suture packaging as a digital splint or sterile ruler in planning skin repairs.^18,19 Although such propositions seem small, continual sharing of such practices may facilitate widespread change. Acknowledgments however must be made in the quality and sterility of reprocessed instruments and its effects on patient care.

In Aravind, South India, reuse and modified sterilization techniques are commonplace in ophthalmic procedures. Aravind's practice of reuse consists of completing multiple surgeries in one room at a time, nurses, and scrub technicians not changing gowns or gloves, sterilizing gloves only between patients, and flash sterilizing instruments. ²⁰ This has allowed them to perform more surgeries with quicker turnaround time as well as producing fewer carbon emissions, 3.76 times less waste and fewer postoperative infection rates compared to the United States. ¹⁹ Although not directly applicable to hand surgery, this is an example of integrating environmental sustainability into daily operating room practice that the specialty can learn from.

Recycle

Recycling is the process of converting waste materials into new materials to redistribute carbon emissions produced by incinerating the waste. With an estimated 90% of domestic waste found misclassified as clinical or hazardous in Australian theatres, effective recycling depends upon proper segregation. ²¹ Solutions include single-stream recycling, ⁸ in which all recyclable materials are collected in one collection bin and separated at a material recovery facility. The materials, especially blue wrap, could then be broken down into plastic pellets and reused to form other items. ⁸

Studies have also shown that barriers to waste recycling included inadequate recycling facilities (49%), negative staff attitudes (17%), and inadequate information on how to recycle waste (16%). ²² With this in mind, potential solutions may range from educational posters to formal staff training. Domestic waste bins can also be made more readily available during surgical set-up and segregation of waste prior to patients’ arrival can dramatically reduce the volume of waste produced. ¹

Basic surgical procedures are among the most cost-effective interventions in developing countries, preventing around 1.5 million deaths a year. ²³ There is therefore a need for basic surgical supplies in these countries on routine bases especially when exacerbated during emergencies or medical disasters relief. ²⁴ Given that much surgical waste comes from partially used prepackaged sets, this is an area where a greener operating room and global surgical work intersect. ²⁵ Organizations such as the British Foundation for International Reconstructive Surgery and Training already exist to share surgical skills and deliver surgical supplies. Hand surgery can work closely with such organizations to collect and donate unused medical supplies to countries in need. However, recommendations such as the WHO's principles of good medical equipment donations must be followed to ensure avoidance of unforeseen consequences for the intended beneficiaries. ²⁶

Research

The impact of implementing any environmental interventions will be difficult to measure without further research that quantifies the carbon footprint of hand surgery procedures. This evidence gap is problematic as it prevents selecting interventions that are the most cost-saving use of resources. Data-driven healthcare sustainability can be achieved through quality improvement projects that monitor compliance with interventions but also through using tools to calculate carbon emissions in practice. The US Environmental Protection Agency for example has an online calculator that converts energy used to carbon emissions. More advanced software is also available to calculate life cycle assessments which connect ecologic burden and impact to every product and system used. ²⁷ Life cycle assessments consider every step needed to bring a product into the environment from production to disposal and if hospitals or practices optimize this process, this may be a useful tool to identify the evidence gap.

Hand surgeons also have the opportunity to work closely with the industry to find vendors that focus on producing sustainable materials that drive down emissions associated with manufacturing. Collaborating with such companies allows research into greener devices and renewable energy that would directly affect future practices to be environmentally conscious.

Rethink

Rethinking is the consideration of how current patient care is delivered and how this can be reformed to provide more sustainable services. For example, with patient and visitor travel accounting for more than 50% of air pollution produced by the health and social sector in the United Kingdom, ²⁸ telemedicine has already paved a way for reducing this carbon emission burden, especially during the COVID-19 pandemic. One study, based on 111 hand surgery online consultations during the pandemic, showed that an estimated 5939 km of patient travel were saved. This equated to 1.25 tonnes of carbon dioxide emissions avoided over the six-week period or 10.8 tonnes over a one-year period, assuming all patients had traveled in a medium-sized petrol car. Despite many challenges faced during the pandemic, improvement in telemedicine has become an unexpected silver lining for carbon neutrality. With some more trial and error, telemedicine might remain as common practice after the pandemic and expand into territories such as post-procedural follow-ups, education on surgical after-care, and simple urgent consultations. ²⁹

With the abundance of scientific meetings, environmental impacts of attending events may need to be reconsidered. Hosting “green meetings” that consider impacts such as travel, waste disposal, food service ware, and accommodation may be beneficial as such meetings influence independent industry sectors. ³⁰ More “green meetings,” especially if held at the same location, may in turn create local market demand for products and services that encourage sustainability in communities.

Although the last of the R's, rethinking is by no means the least important. It is in fact the reverse, in that rethinking should be initiated first and foremost for positive changes to be achieved. ¹⁷ Rethinking should govern the other R's by taking a step back to systematically assess how we reduce, reuse, recycle, and research before implementing measures that are more carbon neutral. Blindly diving into making changes may lead to the proliferation of environmentally friendly practices that are misplaced, wrongly sized, or inappropriately laid out that jeopardize the long-term sustainability.

Culture

With the growing urgency toward controlling carbon footprint, hand surgery's attitude towards the environment should no longer be dyed-in-the-wool. Surgeons must prepare to educate themselves before effectively communicating the carbon neutral message to others as the interventions with the largest impact on sustainability need the engagement of many individuals. A team approach is critical for the success of cost-saving environmental endeavors which in turn allows the launching of campaigns to promote such practices to the wider collective.

New programs may be difficult to follow and are more likely to succeed when instructions are simple and easy to follow. A “Red-Yellow-Green” system, in the form of charts posted on the wall of each operating room, has been used to alert orthopedic surgeons of the cost of implants before they were bought. ³¹ Similar systems might be used to inform the hand surgery team of the cost and carbon footprint of using and disposing each material to encourage environmental responsibility. Department chiefs may allow surgeons to compare their operating costs and footprint with those of their peers which may further enhance a sense of a community focused on carbon neutrality.

Conclusion

Hand surgery must equip itself with all available resources to battle against the predicted health consequences caused by carbon emissions by drawing possible solutions from various specialties and countries to develop guidelines for carbon neutral practice. Although wider work involving many disciplines is essential, it is worth noting that small changes in practice applied at a larger scale are oftentimes the key to facilitating significant reductions in environmental impact. Hand surgeons should therefore endeavor to act as role models to other healthcare professionals in applying these small changes for an even bigger change in clinical practice. It should be anticipated that a move away from the traditional operating room may be met by obstacles. Although this may be challenging, hand surgeons must not think of them as insurmountable and seek to find resolution in knowing that their actions serve the greater good. Acknowledging, understanding, and addressing environmental concerns evolve slowly but will eventually result in an ever-growing healthcare community geared toward environmental safety.