Hospital operating rooms are going 'green'

If you’re one of the people who, while being prepped for surgery, wants to know what your operation’s carbon footprint will be, then this article is not for you.

I think there’s this dichotomy when we enter the hospital and we turn into clinicians and oh, we’re doing everything for the patient and then we come back out of the OR and I have to think about where I’m throwing my cup noodle cup… It’s like, why am I being so picky about that, but not picky about the 70 pounds of garbage that I’m creating from this one case?

These words were spoken by Dr. Ava Yap of the University of California, San Francisco. Dr. Yap is a general surgery trainee. She’s also a climate warrior who is deeply concerned about the amount of garbage generated from hospital ORs. Dr. Yap is featured in a JAMA (Journal of the American Medical Association) video titled, “How Can Operating Rooms Be Greener?”

Have you ever considered the environmental impact of the OR? We thought not

JAMA, one of the premier medical journals in the world, waxes enthusiastic about the “experts working to make ORs more sustainable in the hopes of inspiring others to make similar changes.”

Operating rooms have not focused on environmental impacts. But a growing movement among surgical teams is trying to change that. The modern OR is energy-intensive, produces bags of plastic waste, and outputs substantial amounts of greenhouse gases. Simple changes — from swapping anesthesia medications to reusable materials — could make a big difference.

It may be purely coincidental, but the words “hygiene,” “germ,” “clean,” and “sterile” don’t appear in the video even once.

Then again, it may be by design, because the video opens with the suggestion that the viewer should,

Think about an operating room from the perspective of its carbon footprint...

Don’t like reusable gowns? We’ll re-educate you

70 pounds of garbage is a lot of garbage from one operation. According to Dr. Yap, around a third of that is made up of disposable gowns, towels, and drapes.

“We knew that in the past, these used to be reusable,” she adds. Last year, Dr. Yap led a study at a California hospital to investigate switching to reusable gowns. Her team found that making the switch saved 371 pounds of waste over the 618 operations involved in the study, and saved 2 cents per gown.

The study doesn’t mention whether the researchers investigated whether sterility in the OR was impacted (either positively or negatively) by the switch. They did note, however, that,

Enthusiasm for broad adoption was especially strong among surgeons, although some declined to participate due to wary perceptions of sterility for cases involving implants, transplants, or chemotherapy infusion.

The study concluded with a number of observations, among which was that “staff education” would be needed in order to implement use of reusable gowns because of staff who were “ambivalent” toward using them.

JAMA’s video also notes that some surgical staff are concerned about infection risk associated with reusable gowns, but reassures that “the technology has evolved significantly [over the past decades], making many of these concerns obsolete.”

And so, we’re reducing our water at the scrub sink...

That takes care of a third of the pounds of “waste” from hospital ORs. What about the other two-thirds? After all, JAMA tells us, this issue urgently needs to be addressed, because, “if the entire global healthcare system was a country, it would be the fifth largest emitter of greenhouse gases,” and the OR “accounts for around 20 to 40 percent, and some say up to 60 percent of all hospital waste.”

The video then introduces Dr. Sofya Asfaw, a surgeon at the Cleveland Clinic, who shows off all the energy-saving innovations she has introduced in her hospital’s OR.

There’s setting back our operating rooms and our HVAC systems, changing the type of anesthetic gas that we use, reducing our water at the scrub sink, reprocessing and recycling devices that we use, we turn off the computers when not in use, we’ve installed occupancy sensors in the OR when not in use so we reduce energy…

Recycling pre-incision plastic waste might be a good idea if the recycling process didn’t use more energy than producing new plastic items from scratch. But what about “reducing our water at the scrub sink”? Dr. Asfaw doesn’t mention how the hospital’s OR teams ensure that they are clean enough despite using less water. And who decides how much is enough?

... and we’re cutting down on the number of items a surgeon has readily available

Surgical towels are next to be scrutinized. As Dr. Asfaw says, surgeons should be asking themselves, “Hey, do we really need to use that? Hey, do we really need to open that?”

The problem, if defined as such, begins with what are called the surgeons’ preference cards. These are cards listing all the items the surgeon wants to be open and ready on the operating table before surgery begins, obviously in order that they should be immediately available when needed, as lost time can be critical.

Dr. Yap has other concerns. One might be forgiven for assuming that her concerns for the environment are her only concerns, because not once does she mention how an OR team can continue to ensure the safety of the person being operated on, while cutting down on the amount of equipment being made available on-demand to the surgeon.

Instead, she complains about how disposable towels are “really bad for the environment. They’re thrown away after one use or half a use or even no use at all because they just land on the table. Sometimes in the OR we use them to adjust our headlights and then five seconds afterwards they’re in the bin.”

Why are they put in the bin after being used to adjust headlights? Presumably because the headlights are not sterile. But Dr. Yap doesn’t mention that. The closest she gets is exhorting OR teams to ask themselves,

... if the item is getting used in a way that justifies immediate throwing away.

We also found a much better (for the environment) gas to put you to sleep...

Another key factor in the OR’s environmental impact is anesthesia, JAMA notes.

The patient is breathing in greenhouse gases in the form of inhaled anesthetics. And when they’re exhaled, the gases eventually make their way into the atmosphere.

Some commonly used inhaled gases are potent greenhouse gases, and the anesthesiologist’s choice of gas can significantly change the environmental impact of the case.

JAMA invited two anesthesiologists to discuss this problem, Dr. Praveen Kalra from Stanford Health Care, and Dr. George Mashour from Michigan Medicine.

According to Dr. Mashour, the choice of gas for an operation can have a huge climate impact. His suggestion is that sevoflurane should be used instead of desflurane, because while “clinically they’re relatively interchangeable, from the environmental perspective they have really divergent effects.”

JAMA’s narrator then states that desflurane’s impact on global warming is 2,500 times greater than that of carbon dioxide, and that using it for an hour “is like driving a car for almost 200 miles, while using sevoflurane for an hour is like driving a car for 4 miles.”

Dr. Kalra mentions that desflurane is actually more expensive than sevoflurane, leading to savings for hospitals who make the switch (or may have done so already). For those who haven’t, it seems like a no-brainer — why would they want to continue using a gas that is all drawbacks and no benefits?

... and if it takes you longer to wake up from this one, too bad

The answer is hinted at in Dr. Mashour’s words when he describes desflurane and sevoflurane as “relatively” interchangeable. The fact is that desflurane has some important advantages in surgery, which is why many ORs do still use it.

According to one study, “desflurane produces stronger effective analgesia than sevoflurane anesthesia ... In addition, patients receiving desflurane had significantly lower HRs [heart rates] compared with those receiving sevoflurane...”

This matters because the “reduced analgesia and gamma oscillations” associated with sevoflurane can “be used as a surrogate marker for pain perception during volatile anesthesia.”

Another study echoed these findings and added that using desflurane has the added advantage of a faster recovery time for patients:

... we discovered that desflurane considerably sped up the retrieval of airway reflex and cognitive ability compared to sevoflurane, in addition to responding to vocal orders...

Desflurane is the favored option over sevoflurane whenever one needs a fast revival such as in elective procedures or among subjects who have medical conditions...

There are of course pluses and minuses associated with all the gases used in ORs. However, none of them are mentioned by JAMA. Instead,the “greenhouse” effect is presented as the overriding factor to be taken into consideration.

Therefore, nitrous oxide is also in their sights; Dr. Kalra calls it the “biggest culprit from an ozone depletion point of view.” At Stanford, they have replaced piped-in nitrous oxide with gas cylinders. Whether or not this has implications for safety and efficacy is left unstated.

It’s the culture, stupid

Around 90 percent of surgeries are elective, meaning that there’s plenty of time pre-surgery to plan how many towels are really needed, which items really need to be opened and placed on the table, and whether the patient has any pre-existing health conditions that may make sevoflurane not the best option for him.

For the 10 percent of surgeries that are emergencies, however, plus the unknown percentage of surgeries that become emergencies during an elective procedure due to unforeseen occurrences, it may make all the difference whether the surgeon has what he needs immediately at hand, or not.

From the perspective of the climate-conscious doctor, it may “feel better” to know that they threw away fewer disposable gowns and towels and bottles and phials, but it seems not to have occurred to JAMA’s guest surgeons and anesthesiologists that their patients may also have views on the subject.

Dr. Yap sees it as “our responsibility as clinicians, if we care about health, then we should care about the environment.” Does she ask her patients whether they want the surgeon to wear a reusable gown? Does she offer them a fact-sheet, telling them, “Don’t worry, all the gowns were sterilized prior to surgery and kept in sterile packaging”? Does she give them the choice between having all the towels and instruments open and ready on the operating table, or having them in a cupboard, or shelf, or perhaps not readily at hand at all?

In short, are patients at all these “green” ORs being given informed consent?

Or is informed consent deemed irrelevant, because the information doctors are giving comes in the form of “re-education,” or, as Dr. Kalra puts it,

In every profession, changing the culture is always the hardest thing and I think the only way to change the culture is to provide education to increase awareness.

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