“Bring your own” reusables to surgery: an environmental sustainability quality-improvement initiative

Abstract

Background:

Operating rooms (ORs) produce more than 30% of a hospital’s total waste, with plastic accounting for 20% of that waste. Our project aimed to reduce OR plastic waste by encouraging patients at London Health Sciences Centre sites to bring reusable bags for their belongings and reusable water bottles.

Methods:

We used the Plan-Do-Study-Act (PDSA) quality-improvement method, conducting 3 PDSA cycles, first at Nazem Kadri Surgical Centre, and then at Victoria Hospital and University Hospital. Educational interventions informed staff and encouraged patients to bring their own reusable items. Outcome measures included environmental carbon footprint savings, waste savings, and cost savings over a 1-year period. Process measures included the percentage of patients who brought their own reusable bags and water bottle, the percentage of plastic belongings bags purchased, and the percentage of patients informed to bring their own reusables. Balancing measures assessed patient satisfaction and administrative workflow changes.

Results:

In PDSA cycle 3 at University Hospital and Victoria Hospital, 60.0% and 78.0% of patients brought their own reusable bags for belongings, and 15.7% and 57.8% brought a reusable water bottle. There was a 45.7% reduction of plastic bags for patient belongings purchased annually, which equated to a reduction of 2141 kg of carbon dioxide equivalents, 10 393 km driven equivalent emissions, $1259.55 saved, and 252 kg of waste saved. Most patients and staff agreed that bringing reusable bags for surgery is easy.

Conclusion:

This quality-improvement initiative achieved high patient uptake of reusable items and resulted in substantial reductions in plastic use, waste, and associated carbon emissions. Transitioning to reusable bags for patient belongings and reusable water bottles is an environmentally friendly initiative to reduce the carbon footprint of an OR.

Operating rooms (ORs) produce more than 30% of a hospital’s total waste, equating to 2300 kg of waste per OR per year.^1,2 The waste generated by a single surgery may be more than the waste produced by a family of 4 in a week.³ Around 80% of OR waste is produced perioperatively, with plastic waste contributing to 20% to 25% of total OR waste.² Some sources of perioperative plastic waste include instrument packaging, disposable supplies, and personal protective equipment. Single-use items are particularly concerning for the environment, as they have a larger global warming potential than reusable equivalents.⁴

Methods to reduce waste from single-use items include reprocessing, recycling, and minimizing the use of disposable items.^1,5 To minimize the use of disposable perioperative items, St. Joseph’s Health Centre in Toronto introduced a “bring your own bag” program, encouraging patients to bring reusable bags for their personal belongings on the day of surgery instead of using plastic hospital-provided bags. This initiative was later adopted by North York General Hospital in Toronto using a quality-improvement approach. During a trial launched in July 2022, 52% of patients participated by bringing reusable bags, diverting 1500 plastic bags from the landfill each month.⁶

Similarly, at London Health Sciences Centre (LHSC) in London, Ontario, surgical patients typically receive 2 plastic bags for belongings along with a plastic water cup, which contributes substantially to OR waste. From June 2022 to May 2023, LHSC distributed 30 600 plastic garment bags to surgical patients, equivalent to the carbon emissions of driving halfway around the earth (22 727 km) or 4681.8 kg of carbon dioxide equivalents (CO₂e). This also incurred a financial cost of approximately $3000.

The Ontario Surgical Quality Improvement Network, a Canadian provincial surgical quality network, is promoting surgical waste reduction through their Cut the Carbon campaign for 2022 to 2024. As part of this campaign, the OR Planetary Health Intervention Team (OR-PHIT) at LHSC sought to reduce surgical waste by minimizing the number of plastic belongings bags and plastic water cups used in the OR. Considering this, the aim of this quality-improvement project was to increase the percentage of patients scheduled for day surgery who bring reusable bags for their belongings and reusable water bottles by 50% over 1 year at LHSC, and to reduce our environmental carbon footprint.

Methods

In this quality-improvement project, we used the Plan-Do-Study-Act (PDSA) method, guided by CASCADES Canada’s “Bring your own reusable bag (BYORB)” perioperative charter.⁷ We followed the Standards for Quality Improvement Reporting Excellence 2.0 to report our approach.⁸

Local setting

We conducted this project at LHSC surgical sites, which include the Nazem Kadri Surgical Centre (NKSC), University Hospital, and Victoria Hospital in London, Ontario. The NKSC is a smaller surgical site consisting of 2 ORs and conducts procedures for low-risk patients, including ligament repairs and arthroscopies. University Hospital and Victoria Hospital are LHSC’s 2 larger hospitals, with Victoria Hospital including the Children’s Hospital. There are 16 ORs at University Hospital and 17 ORs at Victoria Hospital. In the day-surgery unit, the number of nurses working daily is 15 at University Hospital and 26 at Victoria Hospital. In 2023, the numbers of surgeries performed at the NKSC, University Hospital, and Victoria Hospital were 2046, 10 982, and 16 804, respectively.

Forming the team

The team consisted of surgeons, OR managers, nursing staff, infection prevention and control (IPAC) specialists, facilities management, surgical administrative partners, research staff, a quality-improvement facilitator, corporate communications, and a medical student.

At Victoria Hospital, the OR-PHIT has championed various projects in environmental sustainability, including desflurane reduction, instrument-tray optimization, waste-stream optimization, and promotion of reusable gowns.

Implementation of interventions

We conducted 3 PDSA cycles to implement and evaluate the change idea. We conducted PDSA cycle 1 at NKSC in May 2023, and PDSA cycles 2 and 3 at Victoria Hospital and University Hospital in November 2023 and April 2024, respectively.

Interventions

We implemented educational interventions to address the aim of this quality-improvement project. We targeted educational interventions at OR staff, administration, and day-surgery patients.

Emails were sent from the OR-PHIT to clinical managers and clinical educators of perioperative care and inpatient surgical services, with educational infographics to inform staff of this initiative and the associated environmental impact of plastic belongings bags. The email was forwarded to nursing staff in perioperative and inpatient surgical units. The infographic was designed in collaboration with CASCADES Canada (Figure 1). Information in the email included what we were doing, why we were doing it, how they could help, when we were starting, and IPAC recommendations for best practices.

Fig. 1.

CASCADES Canada infographic. Reproduced with permission from CASCADES. LHSC = London Health Sciences Centre.

We consulted IPAC to provide best-practice recommendations for staff to mitigate the risk of transmission from using reusables. We summarized these recommendations into a poster (Appendix 1, Supplementary Figure 1, available at www.canjsurg.ca/lookup/doi/10.1503/cjs.001325/tab-related-content), which was hung in surgical areas.

We provided a script to surgical offices to include in preadmission instructions to patients to inform them to bring their own reusable bags for belongings and water bottle.

After PDSA cycle 2, we received feedback from day surgery regarding the poor suitability of paper bags in the perioperative areas at University Hospital and Victoria Hospital, which had been suggested as options for patients in the preadmission instructions. In response to this feedback, we developed a new script accompanied by visual aids to provide more suitable alternatives (Appendix 1, Supplementary Figure 2). The updated script was included in patient preadmission instructions before PDSA cycle 3.

Corporate communications assisted by creating social media features on Instagram, Facebook, LinkedIn, and the corporate website to share the implementation of this initiative.

Family of measures

We established a family of measures to assess the success of the educational interventions. Outcome measures quantify the impact of a change idea on achieving intended goals for improvement. The outcome measures consisted of carbon footprint savings, waste savings, and cost savings over a 1-year period. Process measures assess whether the change idea is having the intended impact on the system. The process measures included the percentage of patients who brought their own reusable bags and water bottle, the percentage of plastic belongings bags purchased by the hospital, and the percentage of patients informed to bring their own reusable bags and water bottle. Balancing measures assess potential unintended negative effects of the change idea on other aspects of the system. Balancing measures were patient satisfaction and changes to administrative workflow.

Assessment of outcome measures

We assessed the outcome measures after each PDSA cycle. To assess carbon footprint, we used the following emission factors: 0.153 kg of CO₂e/bag⁹ and 0.206 kg of CO₂e/km.¹⁰ To assess cost savings, we used a cost per plastic bag of $0.09, and to assess waste savings, we used a weight per plastic bag of 0.018 kg/bag. We performed the following calculations:

• bag production emissions = total quantity of bags used × bag emission factor

• kilometres driven equivalent emissions = bag production emissions ÷ driving emissions factor

• cost = total quantity of bags used × cost per bag

• waste = total quantity of bags used × bag weight

Assessment of process measures

To assess the percentage of patients who brought their own reusable bags and water bottle, audits were conducted by day-surgery nurses. Nurses tallied the number of patients who brought their own reusable bags and water bottle. For PDSA cycle 1, we performed audits for 6 weeks following 1 month of educational interventions. For PDSA cycles 2 and 3, we performed audits for 1 week following 1 month of educational interventions. To assess the percentage of plastic belongings bags purchased, we retrieved purchasing data from the health care materials–management service to compare monthly purchasing. To assess the percentage of patients informed to bring their own reusable bags and water bottle, audits were conducted by day-surgery nurses. For patients who did not bring reusable bags or a water bottle, nurses tailed the number who were informed or not informed. This was assessed only in PDSA cycle 1 because of limitations in data collection at the larger sites.

Assessment of balancing measures

We assessed patient satisfaction and administrative workflow using surveys through Microsoft Forms. The patient satisfaction survey was conducted in day-surgery waiting areas of all 3 sites using a smart device. We conducted the administrative workflow survey by emailing administrative staff, preadmission staff, and day-surgery nurses the survey link. We performed surveys to assess balancing measures after the completion of PDSA cycle 3. The staff survey was available to complete for 2 weeks, and the patient surveys were conducted for 1 day at each site.

Analysis

We reported quantitative data from the audits and surveys descriptively. We thematically analyzed free-text responses from the surveys.

Ethics approval

Our local research ethics board provided ethics exemption for this study as a quality-improvement initiative.

Results

Outcome measures

The yearly estimated carbon footprint savings, waste savings, and cost savings are shown in Table 1.

Table 1.

Yearly estimated carbon footprint savings, waste savings, and cost savings

PDSA cycle	Reduction in kgCO2e	Kilometres driven reduction	Waste savings, kg	Cost savings, $
1	206	898	24	121
2	1954	8630	230	1149
3	3202	16 829	377	1883

kgCO₂e = kilograms of carbon dioxide equivalents; PDSA = Plan-Do-Study-Act.

Process measures

For PDSA cycle 1 at NKSC, 302 patients were audited over a 6-week period. Of patients, 87.4% (n = 264) brought their own bags for belongings, and 80.5% (n = 243) brought their own water bottle. For PDSA cycle 2 at University Hospital and Victoria Hospital, 171 and 208 patients were audited, respectively, over a 1-week period. At University Hospital and Victoria Hospital, 52.0% (n = 89) and 39.9% (n = 83) of patients brought their own reusable bags for belongings, and 1.2% (n = 2) and 4.3% (n = 9) brought their own reusable water bottle, respectively. For PDSA cycle 3 at University Hospital and Victoria Hospital, 70 and 109 patients were audited, respectively, over a 1-week period. At University Hospital and Victoria Hospital, 60.0% (n = 42) and 78.0% (n = 85) of patients brought their own reusable bags for belongings, and 15.7% (n = 11) and 57.8% (n = 63) of patients brought their own reusable water bottle, respectively.

Monthly purchasing data for plastic bags for patient belongings from June 2022 to June 2024 are shown in Figure 2. Purchasing data from June 2022 to May 2023 showed 30 600 plastic bags for patient belongings purchased at all 3 sites. Purchasing data from June 2023 to May 2024 reported 16 605 plastic belongings bags purchased at all 3 sites. Therefore, there was a 45.7% (n = 13 995) reduction in plastic belongings bags purchased per year after the implementation of PDSA cycle 1 compared with the year prior. This equated to a reduction of 2141 kg of CO₂e, 10 393 km driven equivalent emissions, $1259.55 saved, and 252 kg of waste saved.

Fig. 2.

London Health Sciences Centre purchasing data of plastic bags for patient belongings from June 2022 to June 2024. PDSA = Plan-Do-Study-Act.

For PDSA cycle 1, patients who did not bring their own reusable water bottle or bags were asked if they were informed to do so. Of these patients, 34.2% (n = 13) were informed to bring their own reusable bags and 49.2% (n = 29) were informed to bring their own reusable water bottle.

Balancing measures

Thirty patients were surveyed to assess patient satisfaction (Table 2). Of patients, 93.3% strongly agreed or agreed that bringing a reusable bag on the day of surgery was easy. A total of 90.0% of patients strongly agreed or agreed that bringing a reusable water bottle on the day of surgery was easy. Two-thirds (66.7%) of patients felt encouraged to be sustainable or to look for more opportunities to be sustainable because of this initiative.

Table 2.

Patient satisfaction survey results

Variable	No. (%) of patients n = 30
At which site are you a patient?
Victoria Hospital	13 (43.3)
University Hospital	8 (26.7)
Nazem Kadri Surgical Centre	9 (30.0)
Did you bring a reusable bag today?
Yes	24 (80.0)
No	6 (20.0)
If yes, how did you know to bring your own bag?
Secretary phone call	6 (25.0)
Email/preadmission handout from office	15 (62.5)
I usually carry reusable items and just happened to have them with me	3 (12.5)
Other	0 (0.0)
If no, why not?
No one told me to bring the item	1 (16.7)
It was not clear in the preoperative instructions	0 (0.0)
I forgot	2 (33.3)
I chose not to	1 (16.7)
Other	2 (33.3)
Did you bring a reusable water bottle today?
Yes	21 (70.0)
No	9 (30.0)
If yes, how did you know to bring your own bottle?
Secretary phone call	5 (23.8)
Email/preadmission handout from office	14 (66.7)
I usually carry reusable items and just happened to have them with me	2 (9.5)
Other	0 (0.0)
If no, why not?
No one told me to bring the item	0 (0.0)
It was not clear in the preoperative instructions	1 (11.1)
I forgot	2 (22.2)
I chose not to	3 (33.3)
I don’t need one	3 (33.3)
Other	1 (11.1)
To what extent do you agree with the following statement: Bringing a reusable bag on the day of surgery is easy
Strongly agree	22 (73.3)
Agree	6 (20.0)
Neither agree or disagree	2 (6.7)
Disagree	0 (0.0)
Strongly disagree	0 (0.0)
To what extent do you agree with the following statement: Bringing a reusable water bottle on the day of surgery is easy
Strongly agree	21 (70.0)
Agree	6 (20.0)
Neither agree or disagree	2 (6.7)
Disagree	1 (3.3)
Strongly disagree	0 (0.0)
Did this initiative motivate you to engage in more environmentally sustainable behaviours in your life?
Yes. I wasn’t previously thinking about sustainability efforts in my own life, but this initiative has encouraged me to be sustainable.	5 (16.7)
Yes. I already try to be more sustainable, but this initiative has motivated me to look for more opportunities.	15 (50.0)
No. I was already engaging in sustainable behaviour wherever possible.	9 (30.0)
No. I am not interested in sustainability efforts.	1 (3.3)

We surveyed 62 staff to assess administrative workflow (Table 3). For staff who reported a disruption to workflow, in the open-text section the most frequently mentioned disruptions were patients bringing inadequate bags (e.g., bags were dirty or did not close) or water bottles (e.g., their own disposable or glass cups without lids). Eighteen staff responded to the open-text question for additional comments. Most reported they were pleased with this initiative and happy to support and continue, and some provided feedback regarding more consistent messaging to patients on the appropriate type of bag to bring on the day of surgery (e.g., can be zipped or closed and a sufficient size).

Table 3.

Administrative workflow survey results

Variable	No. (%) of staff members n = 62
What is your role?
Administrative partner/secretary	13 (21.0)
Nurse	49 (79.0)
Preadmission staff	0 (0)
Which site do you work at?
Victoria Hospital	49 (79.0)
University Hospital	9 (14.5)
Nazem Kadri Surgical Centre	4 (6.5)
Did the use or implementation of patient’s reusable bags disrupt your workflow?
Yes	7 (11.3)
No	55 (88.7)
If yes, how did the use of patient’s reusable bags disrupt your workflow?
Increased time spent per patient	2 (28.6)
Patient safety concerns	0 (0.0)
Other	5 (71.4)
Did the use or implementation of patient’s reusable water bottles disrupt your workflow?
Yes	4 (6.5)
No	58 (93.5)
If yes, how did the use of patient’s water bottles disrupt your workflow?
Increased time spent per patient	1 (25.0)
Patient safety concerns	0 (0.0)
Other	3 (75.0)
Did implementing this sustainability initiative add time to your workflow per patient?
Yes	7 (11.3)
No	55 (88.7)
If yes, how much time per patient was added to your workflow?
1 to 2 min	5 (71.4)
2 to 5 min	1 (14.3)
5 to 7 min	1 (14.3)
7 to 10 min	0 (0.0)
More than 10 min	0 (0.0)
To what extent do you agree with the following statement: This sustainability initiative was easy to implement.
Strongly agree	26 (41.9)
Agree	24 (38.7)
Neither agree or disagree	9 (14.5)
Disagree	3 (4.8)
Strongly disagree	0 (0.0)
Do you support the continuation of this initiative?
Yes	61 (98.4)
No	1 (1.6)

Discussion

This quality-improvement initiative explored an environmentally sustainable change that can be implemented to reduce surgical carbon footprint, waste, and cost. Our aim of 50% of day surgery patients bringing their own reusable bag was surpassed at NKSC (PDSA cycle 1) and University Hospital and Victoria Hospital (PDSA cycle 3). The results from PDSA cycles were reflected in the data on monthly purchasing of plastic bags; as the number of patients bringing reusable bags increased, the monthly purchasing data showed a downward trend. There was a substantial environmental impact associated with this initiative. Based on monthly purchasing data, a year after PDSA cycle 1, a reduction of emissions equivalent to 10 393 km driven was achieved compared with the previous year. Considering audit data from PDSA cycles 1 (NKSC) and 3 (University Hospital and Victoria Hospital), there is potential for even greater environmental benefits of an estimated yearly reduction of emissions equivalent to 17 727 km driven.

Regarding reusable water bottles, at NKSC our goal of 50% of patients bringing their own reusable water bottle was surpassed; however, we did not reach this goal at the 2 larger sites. We did see improvement in the number of patients bringing their own reusable water bottle over the 2 PDSA cycles conducted at Victoria Hospital and University Hospital. A possible reason for the lower uptake in reusable water bottles compared with reusable bags is the national single-use plastic ban in Canada that has encouraged the use of reusable bags. Ninety-seven percent of Canadians used their own bags or containers when grocery shopping based on a 2021 Statistics Canada survey.¹¹

This environmental sustainability quality-improvement initiative was positively received by patients and was associated with minimal administrative workflow burden. Most patients and staff reported that this initiative was easy to follow or implement.

Additionally, from April 2023 to March 2024, hospitals across Canada implemented the “bring your own” initiative as part of the Ontario Surgical Quality Improvement Network’s Cut the Carbon campaign. Data from participating hospitals (including LHSC) reported 64% of patients brought their own reusable bag, 34% of patients brought their own reusable water container, and there was a 63% reduction in plastic bags purchased in surgical departments (Ontario Surgical Quality Improvement Network, Ontario Health, Toronto, Ontario: unpublished data, 2024). In comparison to these provincial data, 73% of LHSC patients (from PDSA cycles 1 and 3) brought their own reusable bag.

Several key facilitators contributed to the successful implementation of this initiative. First, this was initiated by an established OR green team. The OR-PHIT has previously championed successful environmental sustainability initiatives using quality-improvement methodology, while engaging with diverse partners within LHSC. A lack of strong leadership is a commonly cited barrier in the implementation of environmental sustainability initiatives;² hence, having strong leadership through the OR green team was vital to our success. Second, conducting PDSA cycle 1 at NKSC, the smaller surgical site, permitted greater flexibility and ability to troubleshoot without the complexity of coordination typically associated with a larger site. Also, collaborating with a diverse group of partners was imperative in ensuring long-term sustainable change within LHSC. Various hospital departments were involved in this initiative, including surgical departments, IPAC, and administrative partners. Additionally, the interest of patients and staff at LHSC to switch to reusables supported the implementation of this initiative. As part of OR-PHIT’s greater efforts, hospital staff and patients and caregivers were surveyed to assess their perceptions on environmental sustainability in the OR. The survey showed that 51.4% of patients and 74.7% of staff rated switching single-use items (e.g., plastic garment bags) to reusables as a sustainability initiative they would like to see implemented or prioritized.¹² Lastly, working with corporate communications to celebrate the success of this initiative and staff leading this change assisted in raising awareness and amplifying the positive outcomes of everyone’s efforts.

Common strategies for OR waste management identified in the literature are centred around the “5 Rs” of sustainability: reduce, reuse, recycle, rethink, and research.^2,3,13,14 The “bring your own” initiative falls under reducing plastic waste, which has been cited as the most effective method to reduce an OR’s environmental footprint.^2,14 Along with this study, other quality-improvement initiatives focused on the 5 Rs principles have shown environmental and cost savings in the OR.¹⁵ This highlights the benefit of quality-improvement methodology to introduce institutional change regarding environmental sustainability.

Next steps are needed to continue the success of this project. First, expanding the scope of the project to include more hospital departments — such as medical imaging, minor procedures, and endoscopy — can promote sustainability beyond the OR. Second, continuing to work with corporate communications to highlight the success of our initiative and promote it to the London community can encourage more patients to participate. Finally, we will continue to audit patient reusable bag and water bottle use to monitor the ongoing success of this initiative. Our most recent audit in October 2024 highlighted sustained success, with 72% of patients at University Hospital and 79% of patients at Victoria Hospital bringing reusable bags, and a large improvement in reusable water bottle use, with 51% of patients at University Hospital and 67% of patients at Victoria Hospital bringing reusable water bottles (Figure 3).

Fig. 3.

Percentage of patients who brought reusable bags and water bottles at University Hospital (UH) and Victoria Hospital (VH) from November 2023 to October 2024.

Limitations

One barrier to this initiative was the data-collection method used. Unique to our quality-improvement study was the use of weekly audits to assess our process measures. The BYORB project conducted at North York General Hospital used the electronic medical record (EMR) system for auditing patient reusable bag usage. Given limitations in the capacity of the EMR system at LHSC and concerns with increased workload to input data, we were unable to implement this auditing method into the EMR. The use of auditing via tallying was an effective and simple method that other facilities with limitations to their EMR system can use to implement this environmental sustainability quality-improvement initiative.

Conclusion

Health professionals have a critical responsibility to advocate for sustainable and resilient health care systems. Our study demonstrated that switching to reusable patient-belonging bags and water bottles is an environmentally friendly initiative that can help reduce an OR’s carbon footprint and costs, and is associated with positive patient satisfaction and minimal administrative workflow burden. This quality-improvement initiative emphasizes that small changes toward sustainability can have meaningful systemic impacts not only by reducing the OR’s environmental footprint but by promoting healthier futures for all.