The ACS is committed to providing high-value surgical care to patients. Identifying opportunities for optimal, efficient, and cost-effective medical care is aligned with efforts to embed sustainable practices in the operating room (OR) that meet present patient needs while minimizing environmental harm and preserving resources for future generations. This statement serves to outline the importance of sustainable surgical practices to improve cost efficiency and reduce the environmental impact of surgery while maintaining clinical excellence.
ORs use more energy and supplies than other areas of the hospital.1 More than 3 million tons of waste are produced in America’s ORs each year,2 and surgery is a major driver of the estimated $5 billion US hospitals spend annually on energy.3 While many of these resources are necessary for providing safe and effective surgical care, practicing sustainable surgery can help reduce delivery costs and decrease the impact on the environment.
Sustainable surgical practices seek to limit the environmental impact by decreasing energy use, waste generated, and greenhouse gas emissions. These efforts further reduce healthcare delivery costs.4 Programs to reduce healthcare waste are estimated to save $5.4 billion over 5 years and $15 billion over 10 years.5 Practicing sustainable surgery also increases supply chain resilience, limiting disruptions to care during emergencies.6
Surgeons have an unparalleled understanding of ORs and are uniquely positioned to collaborate with OR team members, hospital administrators, and others to lead and advocate for optimizing sustainability within their institutions.
Opportunities for Enhancing Sustainable Surgical Practice
The ACS has identified four areas for optimizing sustainable surgical practices in institutions. A consideration of implementation feasibility is supported for these efforts, such as in the example of safety net hospitals with limited resources.
Streamlining OR Materials and Reducing Waste
Eliminating unnecessary OR waste can generate cost savings without sacrificing clinical care. Studies have demonstrated that many surgical supplies, such as gloves, sponges, and towels, are disposed of without ever being used.7,8 Customized disposable supply packs are often used to increase efficiency, but they can inadvertently increase waste and cost.9
The use and disposal of single-use supplies also can have a major environmental impact.10 Systematic reviews show there is no benefit to single-use instruments over reusable or reprocessed items when it comes to instrument function, ease of use, patient safety, or long-term patient outcomes.11,12 Reusable instruments and linens are more cost-effective, have lower environmental impact,13 and support supply chain resilience when compared to single-use instruments and textiles.14 Additionally, optimizing surgical trays reduces the cleaning and sterilization of unused instruments, resulting in opportunities to decrease waste, extend the life expectancy of instruments, and decrease labor costs.15
By working with all team members in the OR, such as trainees, scrub technicians, circulating nurses, vendors, and environmental services, surgeons can lead the way in making sustainable choices.16
Improving Supply Chain Sourcing
The reliance on single-use items can make hospital systems vulnerable to events that cause supply chain disruptions. These events, such as natural disasters, can increase healthcare costs and place healthcare systems and patients at risk during emergencies when supplies are needed most.
Surgeons can partner with supply chain leaders to advocate for sustainable procurement practices. In evaluating products, a sustainability review should be conducted that includes a report on emissions, potential for reuse or reprocessing, extent of packaging, and electronic Instructions for Use documents.
Advocating for Energy Efficiency Practices
ORs are responsible for significant energy use. Lights, equipment, and monitors in the OR can be powered down at the end of the day. Increasing energy efficiency by transitioning to LED lights is another opportunity to reduce energy use. Setting back air change rates for unoccupied OR rooms also can reduce energy use.10
Comparable efforts can be made in perioperative spaces, exam rooms, and administrative offices.17,18 Inefficient systems and the accompanying costs divert funds that could otherwise be allocated toward patient care.
Environmentally Conscious Anesthetic Selection
Volatile anesthetic gases, such as desflurane, isoflurane, and nitrous oxide are potent greenhouse gases.19 The American Society of Anesthesiology recommends eliminating desflurane and decommissioning central piping of nitrous oxide in favor of cylinders at the point of care.20 The use of total intravenous anesthesia or use of local, regional, or spinal anesthesia, when appropriate, can help reduce the use of anesthetic gases. Surgeons can partner with anesthesia colleagues to limit greenhouse gas emissions and capture significant cost savings.
Sustainability in Action: Improvement, Innovation, Collaboration, and Advocacy
The ACS will continue to promote the use of sustainable surgical practices through continuous improvement, research and innovation, collaboration, and advocacy:
Continuous Improvement
Educating surgeons on sustainable practices is a cornerstone of this statement. Promoting awareness of best practices and practical information on sustainability is paramount. Developing and embedding sustainability metrics into quality improvement should be prioritized to evaluate clinical outcomes associated with implementing sustainable surgical practices, and may be an opportunity for a quality collaborative. Incorporating sustainability into surgical education and promoting a culture of environmental responsibility will also support lasting adoption of these practices.
Research and Innovation
Supporting research in sustainable processes and surgical devices is critical to better understanding their impact on the delivery of surgical care. Pragmatic toolkits can foster the evaluation of surgical equipment to compare sustainability and improve patient care. Dissemination and implementation of sustainability practices offer opportunities within the OR and within the organization.21
Collaboration and Regulatory Compliance
Implementation of sustainability practices must adhere to state and federal healthcare regulations and comply with oversight organizations. Continued collaboration among OR team members and industry, and with organizations who have published guidelines supporting sustainability practices—such as American Hospital Association, American Society of Anesthesiologists, Association of periOperative Registered Nurses, and the Occupational Safety and Health Administration—is necessary to align sustainability efforts. The opportunities for sustainability accreditation through the Joint Commission and the International Hospital Federation may provide frameworks to support institutional efforts. The ACS will continue to build upon these established standards and accreditation efforts.
Advocacy
Supporting the development of more sustainable surgical devices and advocating for changes, when appropriate, to ensure that state and federal healthcare regulations are responsive to evidence-based sustainability efforts.
Through these efforts, the ACS will contribute to sustainable, high-quality surgical practices that benefit patients, reduce delivery costs, and decrease the impact on the environment through the elimination of unnecessary waste and use of energy.
Sustainability Resources
