March 8, 2023
Dr. Gwyneth Sullivan (right) and surgical research fellow Andrew Hu, MBChB, examine refuse during a postsurgery OR waste audit at Ann & Robert H. Lurie Children’s Hospital.
For many healthcare professionals, the last several years have led to a diminished separation between patient care and public life, as well as between medical specialties.
From the COVID-19 pandemic’s quarantines, dangers of overloaded health systems, and personal health risks to public revelations regarding health and social discrimination, it has become even more clear that environment plays a significant role in determining an individual’s health; these environmental factors include the planet’s changing climate.
Climate change, caused in large part by human carbon-producing activities, has been identified as a major driver in human health,1 with the US healthcare system releasing more than 8% of the nation’s carbon.2
As an energy- and resource-intensive field, surgery plays an outsized role in these emissions, and surgeons are beginning to take action and address the unintended environmental impact of their practice.
A recent scoping review in the Journal of the American College of Surgeons (JACS)3 provided a look at studies that have examined the environmental sustainability interventions that hospitals around the US have implemented to reduce their carbon footprint. In this article, study authors and experts on the intersection of healthcare and climate change discuss how to move forward in creating a more sustainable health system.
Pediatric surgery supply packs from an initial waste audit contain extra packaging and cardboard that could be reduced.
The inspiration for the JACS review started with lead author Gwyneth A. Sullivan, MD, MS, a research fellow at the Northwestern Quality Improvement, Research & Education in Surgery Center at the Northwestern University Feinberg School of Medicine in Chicago, IL, and coauthors considering efforts they could make at their institutions to reduce costs and environmental impact of the operating room (OR0.
“When I started looking into the literature, I realized there was a gap in identifying studies that meet both of those purposes,” Dr. Sullivan said.
And there was no denying that performing surgery leaves a visible aftermath.
Disposal of typical waste products from surgery and acquiring replacement supplies contribute to an OR’s significant carbon footprint.
“I think every surgeon can attest to the fact that, at the end of a case, there’s a tremendous pile of garbage that is generated from what we’ve done in the OR,” said Mehul V. Raval, MD, MS, FACS, a pediatric surgeon at Ann & Robert H. Lurie Children’s Hospital of Chicago, professor of surgery at Northwestern, and senior author of the JACS review. “Coming to the forefront was this idea that hospitals and health systems in general are huge waste producers in the modernized world, and when you really look at it, ORs disproportionately create a large amount of that waste.”
As such, one of the requirements for the selected studies in the review was that they needed to identify and attempt to address both cost and environmental impact.
In addition, there was a third pillar of interest that ultimately did not make it into the scoping review, but remains a critical part of the “triple bottom-line”—a sustainability framework that is increasingly used in the healthcare, business, and other sectors.
“The other aspect that we considered was the potential social impact,” Dr. Sullivan said.
The social aspect of the triple bottom-line approach to operating a healthcare facility, for instance, refers to stakeholders affected by the facilities’ decisions—the patients and communities in which they live.4 They are a critical part of this triad, even if the impact of a hospital’s environmental sustainability is not simple to measure.
“Once that connection between healthcare’s carbon footprint and the climate is made, it’s very difficult to move away from it because of all the climate events that are happening on a regular basis around the world,” said Husein Moloo, MD, FACS, a colorectal surgeon, associate professor of surgery, and director of planetary health for the Faculty of Medicine at the University of Ottawa in Ontario, Canada.
“If you care about social justice, climate change affects racialized communities more, and it affects those communities that are socioeconomically depressed. That’s just within North America—but it’s also seen when you expand that notion around the world, where lower- and middle-income countries are disproportionately affected,” Dr. Moloo continued.
The growing corpus of scientific literature suggests that healthcare institutions are taking action to address sustainability and that these actions can have a positive impact on cost and the carbon footprint.
However, these are still the early days of connecting climate action to a hospital’s value proposition, and there may be hesitance to get involved as a team, department, or hospital.
Surgeons often work in constrained environments with an institutional aversion to making significant capital investments in sustainability, Dr. Raval explained. But the hope is that studies like the recent scoping review in JACS will allow surgeons to have necessary conversations in a more meaningful way with leadership and be able to support the statement that not all interventions require large financial commitments.
Part of the solution comes in realizing that some of the infrastructure for sustainability is already in place due to the nature of surgical quality improvement (QI). “What we need to do is be more thoughtful about using the resources we’re already expending funds on and the downstream effects of our choices,” Dr. Raval said.
Being thoughtful about resource use and downstream effects, in the case of environmental impact, can be achieved by reframing the work already being done on QI projects.
For example, the efficacy of the ACS National Surgical Quality Improvement Program® (NSQIP®)—a bedrock of the College’s suite of Quality Programs—is based on identifying and addressing patient risk of complications or morbidity through 30-day patient outcomes.5
NSQIP-participating hospitals gather, review, and use data to create QI initiatives that keep surgical patients healthier and reduce or eliminate additional episodes of care. In each of these prevented episodes of care—in each test avoided, in each recovery room where lights are kept off, in each operation averted—thousands of dollars are saved and many resources and carbon-producing activities unused.
Awareness of this effect can help drive understanding that improving patient outcomes also can heal the climate downstream.
“We’re not forgetting about surgical site infection (SSI) and readmission and all these things that are really important, but surgical quality programs and improving the environment can really align and move together,” Dr. Moloo said. “When you decrease SSI, that’s decreasing your carbon footprint, as well. So, let’s encourage a reframing of the way we look at problems, which I think enables people to think more creatively around the actions they take each day.”
Addressing climate change or environmental sustainability on a political or societal level demands pointed action, such as legislation to improve public transit infrastructure, reducing personal automobile use, or demanding that private corporations lower their emissions. But there is a surprising benefit when a healthcare institution proactively shapes its carbon footprint by refusing to act—that is, deciding not to use certain products with significant environmental impact or using viable alternatives.
The JACS scoping review examined the five “Rs” of sustainability—refuse, reduce, reuse, repurpose, and recycle—and found a plurality of the initiatives included in the study fell into the refuse category, which Dr. Sullivan said was not a surprise. (See Figure 1 for a breakdown of the initiatives and their categories.)
Figure 1. Quality Improvement Initiatives Grouped within the Rs of Sustainability
“Many of the interventions in the refuse category are things like operating room (OR) tray reformulation or reducing the number of supplies used in surgical packs, which are things that a team of people who are invested in seeing a change happen can critically evaluate and then find ways to improve upon,” Dr. Sullivan said.
The small successes are easier to achieve; for example, smarter, more “lean” surgical packs can help pave the way for conversations about larger-scale initiatives that will require more capital investment.
At the University of Ottawa, Dr. Moloo noted that the hospital currently is focused on using reusable gowns for medical staff, instead of disposable gowns, which data have suggested creates significant cost savings and less waste.6
“We’ve got our whole perioperative group behind it in terms of nursing, anesthesia, surgery, and administration, and we’re going to be moving from disposable isolation gowns as well as disposable gowns in the OR to reusable,” Dr. Moloo said, adding that moving away from paper faxing, changing anesthesia agents to less greenhouse gas emitting agents, and small-scale changes like getting patients to bring their own reusable bags for personal effects also are making an impact.
Interventions that start at an individual level have the potential to grow into hospital and health system-wide actions that have a significant effect on a large scale, especially once leadership is ready to invest.
Handwashing before an operation is one such example, Dr. Raval suggests. If surgeons committed to using a waterless scrub before operating instead of relying on a constantly running sink, how many gallons of water and associated energy and costs could be saved?
“It’s actually a tremendous number of gallons of water saved each day for an individual surgeon,” Dr. Raval said. Over the course of a week, month, year, this type of decision, made within the scope of a surgical department, is profound. Further, this type of behavioral change or choice is well within a surgeon’s purview.
Ultimately, the goal is for a surgeon to start taking environmental action where they can and to see what ends up being possible in their context.
“What we’re asking is for people to be thoughtful about things that they can do day in and day out, things that they have control over, and then work with their leadership, their institutions, and other interested parties to tackle some of those other bigger projects over time,” Dr. Raval said.
A cornerstone of effective surgical QI is the surgeon champion, an individual who oversees the development, implementation, and maintenance of an intervention or program to help ensure its success.
In much the same way—and sometimes embodied in the same individual—green champions can help lead the way to a more sustainable OR.
“As someone who does a lot of work in patient safety quality improvement, I have found that surgical QI and environmental efforts actually fit hand in hand,” Dr. Raval said. “Many of the principles that we apply to continuous quality improvement can be applied to many processes, including those that make our institution more environmentally sustainable.”
Equally important to a green champion in environmental sustainability initiatives is a team. As with other surgical QI, it takes buy-in and commitment from nurses, technicians, and administration, as well as dedicated sustainability staff to achieve the desired outcomes.
“While the role of a surgeon champion can’t be understated in sustainability efforts, it certainly can’t be an effort in isolation,” Dr. Sullivan said. “The people who I’ve seen be instrumental in moving some of these initiatives forward are often sustainability managers. They’re the ones who really know the current landscape and know who to speak to about these efforts.”
Not to be forgotten in these projects is the input of environmental services and waste management staff. These team members know better than any hospital staff the logistical realities of addressing disposal efforts.
“We’ve had conversations with their teams and we’ve engaged them early on, which is important to make sure that you’re not trying to influence something where they don’t have the capacity, staff, or infrastructure to really make those differences,” Dr. Sullivan said.
Maybe the most important role of a surgeon champion in environmental sustainability, Dr. Moloo suggests, is to engage staff and start necessary conversations within teams and healthcare institutions.
“Being able to have those conversations about the intersections of carbon footprint and the extent of that carbon footprint with healthcare professionals and surgeons is a big deal,” Dr. Moloo said. “Once you start having those conversations and have surgeon champions involved, it helps to start driving that change from within teams.”
Though a reduction in costs and environmental impact currently lead the way in incentivizing climate action for physicians and hospitals, as the JACS scoping review suggests, these two pillars ultimately exist to support the third in the triple bottom line—people and communities. Healthcare can no longer ignore the deleterious health impact that their outsized carbon footprint may be having on the patients they are meant to heal.
A hospital and healthcare system infrastructure facilities are part of the community, and part of their responsibility is to improve the community’s overall health and well-being, according to Dr. Sullivan.
“A big part of that is being better environmental stewards. The health implications of climate change and global warming are astronomical, and I think part of that ties into a lot of initiatives that we’re seeing at the hospital level to integrate into other actions aimed at improving the well-being of local communities,” she said.
The power of surgeons’ voices and their actions extends beyond themselves, their teams, or even their hospitals. Healthcare workers are among the most trusted professionals in the US, and because health now represents 20% of the US gross domestic product, “We’re a major player in any social or environmental policy going forward,” Dr. Raval said.
However, there are perceived constraints within healthcare, and especially within surgery, that might seem to make the sector less affected by the growing demands of broader society to decarbonize or at least reduce its carbon footprint.
The existing policies and bureaucracies that exist within healthcare systems, such as safe disposal of hazardous materials, proper sterilization of equipment, or meeting patient treatment expectations, can make it challenging to apply into the setting of a hospital some of the social desire to be more environmentally friendly.
“Sometimes, the rules of engagement that we would expect for people to be environmentally friendly somehow don’t permeate into hospitals and healthcare systems,” Dr. Raval said. “But as we are being safe and responsible with our approach, we can do a lot of the things that I think society would want us to do within healthcare.”
See the related Viewpoint article.
Matthew Fox is the Digital Managing Editor in the ACS Division of Integrated Communications in Chicago, IL.