Sustainability Practices Implementation Made Easy
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To ensure greater sustainability in operating theatres, some easy practices can have a positive impact without compromising patient safety. You can focus on them and encourage your fellow surgeons to do the same for the best effect.[1] Incorporating new sustainability practices can face challenges, including the initiation process; for this reason, focusing on some small changes may be interesting. There is the risk of burnout for effort, time, and negotiation with staff (nurses), conflicts with infection control, regulatory and legal requirements, and cost containment.[2]
Enable ventilation 30 minutes before surgery
Instead of running OR ventilation continuously (during the night and on weekends), which wastes electricity and increases carbon emissions that intensify climate change, switch the ventilation off outside of office hours. Studies show that this offers equal infection control to continuous use. Discuss this with the infection control team of your hospital or surgical center.[3][4][5] Reducing continuous ventilation in the OR lowers maintenance costs and expenses that will be valued with easy implementation in eye facilities. In OR, running 24 hours for other specialties can be more difficult.
Use Disposable Medical Sponges Sparingly
Alcohol-based hand rub disinfectants or liquid preparations provide superior disinfection, acting against a broader spectrum of microorganisms and offering a longer duration of action, with less skin dryness, irritation, and allergies, increasing compliance among healthcare workers and saving water consumption.[6]
The routine use of waterless scrub solutions for surgical hand antisepsis has been endorsed in a joint compendium by prominent healthcare organizations, including the Society for Health and Epidemiology of America, the American Hospital Association, the Infectious Diseases Society of America, and the Joint Commission.[7] The WHO has also declared waterless chlorhexidine gluconate-based hand rubs more effective than water-based scrubs and recommended their incorporation into daily practice.[7] Moreover, the current draft of the NICE guidelines on preventing surgical site infections similarly suggests a scrub technique at the beginning of the surgical list, with alcoholic rubs used between cases, provided hands are not visibly soiled.[6]
If your hands are visibly dirty, a surgical scrub brush is the answer (needed before the first surgery of the day only). If they are not visibly dirty, studies show you don't need a brush to protect your patient from infection. An alcohol-based wash alone is sufficient. [8]
The estimated water usage during a surgical 3-minute period scrubbing is around 18.5 litres, requiring 47.7[7] to 60.2 litres per surgery.[6]
Replace the Full Body Drape with a Face Drape
Studies show that face drapes are as effective as the much more wasteful full-body drapes.
20% of the waste during eye surgery is due to the plastic face drape worn by patients.[9] Smaller face drapes are sufficient[10] with the advantage of reducing waste, gas consumption, claustrophobia, anxiety, and temperature-related discomfort and increasing economic and ecologic savings.[11]
During surgery, CO2 exhaled by the patient escapes incompletely through paper or plastic drapes,[12] leading to an immediate increase in blood CO2 concentration.[12][13] To reduce this rising CO2 concentration in the bloodstream, patients increase their respiratory rate with progressive hyperventilation.[12][13]
The larger the drape, the higher the amount of CO2 pressure, hyperventilation and increased temperatures beneath the drape, even when using oxygen or paper drapes.[11] [14] [15] [16] [17]
Cover Armrests with Your Gown
Separate armrest covers create extra waste - instead you may use your gown. In cataract surgery, your back does not need to be sterile as it does not come into contact with surfaces, medical staff, or the patient. Try to leave the gown open at the back while still standing and cover the armrests with it when you sit. The gown is wide enough to include the armrests, without risk of contamination to others.
Dispense with Eye Shields for Post-op Patients
Eye shields have no beneficial effect on post-operative recovery after uncomplicated cataract surgery. Not using a shield has become common practice in many facilities throughout Scandinavia and the Netherlands. [18]
Reducing topical drug waste by reusing medications.
Topical drugs in multidose containers can be used on multiple patients in surgical facilities if proper guidelines are followed.[19]
Topical drugs in multidose containers can be used until the manufacturer’s labeled date of expiration if proper guidelines are followed.[19]
When applicable, patients should be able to bring their partially used medication home for postoperative use.[19]
Surgical textiles
Disposable textiles, such as surgical gowns, towels and drapes, contribute significantly to the waste generated in operating rooms and are considered inherently unsustainable.[20] Single-use textiles use 200-300% more energy, 250-330% more water and generate 750% more waste than reusable ones.[21]
In 2019, the Association of perioperative Registered Nurses made a clear declaration, promoting using reusable equipment and supplies for perioperative practices as the preferred choice to reduce waste and adopt more sustainable practices.[20] Despite this recommendation, a significant number of healthcare institutions in the USA remained reluctant, with disposable materials accounting for a staggering 80% of the healthcare textile market.[20] A survey conducted in the USA highlighted the concerns and uncertainties about safety, environmental impact, and cost of reusable surgical textiles despite scientific evidence.[20]
An easy approach is to customize surgical packs to usual needs because, commonly, plenty of material is not used. ESCRS SIDCS application allows calculating specific savings of waste and money by reducing the surgical material. [22]
Additional Resources
- EyeSustain: Sustainability Resources for Ophthalmology
- Ophthalmology and Climate Change
- The Environmental Sustainability of:
References
- ↑ ESCRS’ Young Ophthalmologists For Sustainability (YOFS)
- ↑ Sherry B, Lee S, Ramos Cadena MLA, Laynor G, Patel SR, Simon MD, Romanowski EG, Hochman SE, Schuman JS, Prescott C, Thiel CL. How Ophthalmologists Can Decarbonize Eye Care: A Review of Existing Sustainability Strategies and Steps Ophthalmologists Can Take. Ophthalmology. 2023 Jul;130(7):702-714. doi: 10.1016/j.ophtha.2023.02.028. Epub 2023 Mar 6. PMID: 36889466; PMCID: PMC10293062.
- ↑ Dettenkofer M, Scherrer M, Hoch V, Glaser H, Schwarzer G, Zentner J, Daschner ED. Shutting down operating theater ventilation when the theater is not in use: infection control and environmental aspects. Infect Control Hosp Epidemiol. 2003 Aug;24(8):596-600. doi: 10.1086/502260. PMID: 12940581.
- ↑ Zarzycka A, Maassen WH, Zeiler W. Energy saving opportunities in operating theaters: a literature study. REHVA Journal. 2019 Apr 1;2019(2):25 -31.
- ↑ J.L.A. Lans, N.M.C. Mathijssen, A.A.L. Traversari, I.M. Jacobs, J.J. van den Dobbelsteen, M. van der Elst, P.G. Luscuere, Capital and operational expenditures of different operating room air-handling installations with conventional or ultra-clean air supply systems, Journal of Building Engineering, Volume 78, 2023, 107714, ISSN 2352-7102, https://doi.org/10.1016/j.jobe.2023.107714. (https://www.sciencedirect.com/science/article/pii/S2352710223018946)
- ↑ 6.0 6.1 6.2 Jehle K, Jarrett N, Matthews S. Clean and green: saving water in the operating theatre. Ann R Coll Surg Engl. 2008 Jan;90(1):22-4. doi: 10.1308/003588408X242277. PMID: 18201493; PMCID: PMC2216709.
- ↑ 7.0 7.1 7.2 Javitt MJ, Grossman A, Grajewski A, Javitt JC. Association Between Eliminating Water From Surgical Hand Antisepsis at a Large Ophthalmic Surgical Hospital and Cost. JAMA Ophthalmol. 2020 Apr 1;138(4):382-386. doi: 10.1001/jamaophthalmol.2020.0048. PMID: 32105297; PMCID: PMC7047872.
- ↑ Javitt MJ, Grossman A, Grajewski A, Javitt JC. Association Between Eliminating Water From Surgical Hand Antisepsis at a Large Ophthalmic Surgical Hospital and Cost. JAMA Ophthalmol. 2020 Apr 1;138(4):382-386. doi: 10.1001/jamaophthalmol.2020.0048. PMID: 32105297; PMCID: PMC7047872.
- ↑ Thiel CL, Schehlein E, Ravilla T, Ravindran RD, Robin AL, Saeedi OJ, Schuman JS, Venkatesh R. Cataract surgery and environmental sustainability: Waste and lifecycle assessment of phacoemulsification at a private healthcare facility. J Cataract Refract Surg. 2017 Nov;43(11):1391-1398. doi: 10.1016/j.jcrs.2017.08.017. PMID: 29223227; PMCID: PMC5728421.
- ↑ Sherry B, Lee S, Ramos Cadena MLA, Laynor G, Patel SR, Simon MD, Romanowski EG, Hochman SE, Schuman JS, Prescott C, Thiel CL. How Ophthalmologists Can Decarbonize Eye Care: A Review of Existing Sustainability Strategies and Steps Ophthalmologists Can Take. Ophthalmology. 2023 Jul;130(7):702-714. doi: 10.1016/j.ophtha.2023.02.028. Epub 2023 Mar 6. PMID: 36889466; PMCID: PMC10293062.
- ↑ 11.0 11.1 Preferred Practice Guidelines for Reducing Waste in Cataract Surgery. https://ranzco.edu/wp-content/uploads/2021/12/RANZCO-Guidelines-Preferred-Practice-Guidelines-for-Reducing-Waste-in-Cataract-Surgery.pdf
- ↑ 12.0 12.1 12.2 Schlager A. Accumulation of carbon dioxide under ophthalmic drapes during eye surgery: a comparison of three different drapes. Anaesthesia. 1999 Jul;54(7):690-4. doi: 10.1046/j.1365-2044.1999.00889.x. PMID: 10417465.
- ↑ 13.0 13.1 Schlager A, Luger TJ. Oxygen application by a nasal probe prevents hypoxia but not rebreathing of carbon dioxide in patients undergoing eye surgery under local anaesthesia. Br J Ophthalmol. 2000 Apr;84(4):399-402. doi: 10.1136/bjo.84.4.399. PMID: 10729298; PMCID: PMC1723433.
- ↑ Haripriya A, Ravindran RD, Robin AL, Shukla AG, Chang DF. Changing operating room practices: the effect on postoperative endophthalmitis rates following cataract surgery. Br J Ophthalmol. 2023 Jun;107(6):780-785. doi: 10.1136/bjophthalmol-2021-320506. Epub 2022 Jan 11. PMID: 35017161.
- ↑ Winklmair N, Kieselbach G, Bopp J, Amon M, Findl O. Potential environmental effect of reducing the variation of disposable materials used for cataract surgery. J Cataract Refract Surg. 2023 Jun 1;49(6):628-634. doi: 10.1097/j.jcrs.0000000000001170. PMID: 36806589.
- ↑ Chang DF, Thiel CL; Ophthalmic Instrument Cleaning and Sterilization Task Force. Survey of cataract surgeons' and nurses' attitudes toward operating room waste. J Cataract Refract Surg. 2020 Jul;46(7):933-940. doi: 10.1097/j.jcrs.0000000000000267. PMID: 32773547.
- ↑ Chang DF, Elferink S, Nuijts RMMA. Survey of ESCRS members' attitudes toward operating room waste. J Cataract Refract Surg. 2023 Apr 1;49(4):341-347. doi: 10.1097/j.jcrs.0000000000001096. PMID: 36975010.
- ↑ Lindfield D, Pasu S, Ursell P. Shield or not to shield? Postoperative protection after modern cataract surgery. Eye (Lond). 2011 Dec;25(12):1659-60. doi: 10.1038/eye.2011.234. Epub 2011 Sep 16. PMID: 21921954; PMCID: PMC3234476.
- ↑ 19.0 19.1 19.2 Palmer DJ, Robin AL, McCabe CM, Chang DF; Ophthalmic Instrument Cleaning and Sterilization Task Force. Reducing topical drug waste in ophthalmic surgery: multisociety position paper. J Cataract Refract Surg. 2022 Sep 1;48(9):1073-1077. doi: 10.1097/j.jcrs.0000000000000975. PMID: 35608314.
- ↑ 20.0 20.1 20.2 20.3 Yap A, Wang K, Chen E, Melhado C, Ahmad T, O'Sullivan P, Gandhi S. A mixed-methods study on end-user perceptions of transitioning to reusable surgical gowns. Surg Open Sci. 2022 Nov 8;11:33-39. doi: 10.1016/j.sopen.2022.10.003. PMID: 36444285; PMCID: PMC9700296.
- ↑ Birtel J, Heimann H, Hoerauf H, Helbig H, Schulz C, Holz FG, Geerling G. Nachhaltigkeit in der Augenheilkunde : Adaptation an die Klimakrise und Mitigation [Sustainability in ophthalmology : Adaptation to the climate crisis and mitigation]. Ophthalmologie. 2022 Jun;119(6):567-576. German. doi: 10.1007/s00347-022-01608-4. Epub 2022 Apr 22. PMID: 35451609; PMCID: PMC9024069.
- ↑ SIDICS: Sustainability Index for Disposables in Cataract Surgery
