Green surgery: reducing the OR carbon footprint

• Feb 03, 2022

The event provided an insight into some of the pioneering projects underway which are expected to deliver a CO2 reduction of 133 tonnes per year.

Climate change has far-reaching implications for global health and, although healthcare organisations work to improve population health, their daily operations contribute to climate change. Sustainability is increasingly becoming an important focus for the healthcare sector, but how can surgical teams play their part in reducing their carbon footprint?

This question was recently addressed by the Green Surgery Conference which provided an insight into how surgical care could be transformed to become more environmentally (as well as socially and financially) more sustainable. The conference showcased five surgical teams from the UK who have risen to the challenge using a sustainable quality improvement approach through the ‘Green Surgery Challenge’ initiative. 

Dr. Olivia Bush, programme lead for sustainable clinical practice at the Centre for Sustainable Healthcare set the scene for the discussion with some alarming figures on the environmental impact of healthcare – in fact, the NHS accounts for 4% of the total carbon footprint of the UK.  

“The figure is enormous for a single organisation. It is equivalent to the total emissions of Croatia. The target for reducing the carbon footprint for the NHS is net zero by 2040,” she pointed out, adding that the operating theatre is the most resource intensive area of the hospital.

“Operating theatres contribute up to 30% of total waste output for the hospital and theatres have 3-6 times higher energy consumption compared to other areas of the hospital. A typical operation produces 150-170 kg CO2e (equal to driving from London to Edinburgh in a petrol car),” she continued. 

Dr. Bush went on to highlight some of the key areas that need to be tackled – including energy use, anaesthetic gases, and consumable equipment.  

The ambition to reduce the carbon footprint of the NHS was previously outlined by the Government in the report: Delivering a ‘Net Zero’ National Health Service (October 2020). It states: “Our intention… is to construct the most ambitious, credible declaration to reach net zero of any national health system in the world. However, … [this] can only be delivered if…supported by collective action from all NHS staff and collaborative partnerships within and beyond the NHS, as well as appropriate investment.”

The Green Surgery Challenge

“This is why the Green Surgery Challenge was launched,” explained Dr. Bush, adding that there is a need to ‘upskill’ members of the surgical community to become leaders and to ensure they have the right skills to make these changes happen. “Green surgery is the future of surgical practice,” she asserted.

Neil Mortensen, president of the Royal College of Surgeons of England, added that he believed that the core responsibility of the RCS and other Colleges is to help make surgery greener: “We must look at how we can help drive wider adoption of environmentally sustainable surgical techniques across the NHS,” he commented

The principles of sustainable surgical practice were presented to delegates in the form of a pyramid (see fig 1). These included:

1  Surgical disease prevention
2 Patient education and empowerment
3 Lean service delivery (reduce)
4 Low carbon alternatives a) low carbon treatment options b) reusables c) maintenance, repair and recycling

The Green Surgery Challenge was launched on 3 February 2021, with five surgical teams competing from around the UK. The teams received mentoring from sustainable healthcare specialists at the Centre for Sustainable Healthcare over a ten-week period to hone a specific question, design a project, implement the project, and measure the outcomes. Each of the teams used the Sustainable Quality Improvement (SusQI) framework (https:// sustainablehealthcare.org.uk/susqi) to help carry out their projects

Through the challenge, they effectively reduced the carbon footprint of surgery by creating new devices, streamlining procedures, switching to reusable equipment, and altering the type of anaesthetic used for certain operations.

During the conference, the five teams showcased their projects, including the forecast savings and opportunities to spread and scale up the changes they had made. A judging panel listened to each of the presentations and then announced the winning team.  

University Hospitals Plymouth NHS Trust

The University Hospitals Plymouth NHS Trust team highlighted a project which involved replacing single-use instruments in laparoscopic appendicectomy sets with reusable ports and other instruments. 

Consumables account for one-third of surgical procedure-related emissions, so a reduction has the potential to make a significant impact on carbon emissions in their department and Trust. There is also significant potential to scale up their work across the NHS with 42,000 appendectomies performed in the UK each year

The team was led by Mr Peter Labib, ST6 general surgery registrar and Dr. Bryony Ford, Foundation Year 2 doctor; Ms Michelle Winfield, senior sister and clinical procurement specialist who was pivotal to the success of the project, liaising with company representatives and the sterilisation and decontamination unit. The project leads were supported by Mr Aditya Kanwar, consultant hepatobiliary surgeon, Mr Grant Sanders, consultant oesophagogastric surgeon, and Mr Walter Douie, consultant colorectal surgeon. Dr. Ford and Mr Labib presented each of the key facets of the project:

Involving colleagues: Dr. Ford highlighted the importance of “getting colleagues involved early on” and defining the project. To initiate the quality improvement project, the team first introduced their colleagues to the concepts of sustainable healthcare, how the climate crisis has health impacts, and how surgery is contributing to the climate crisis.

Survey: Following this well-received presentation, the team surveyed their colleagues to find out about surgical practice in their department so that they could identify the hotspots of consumption of single-use surgical instruments. In the survey, many colleagues reported frequently opening disposable instruments during laparoscopic appendicectomies, which is one of the most frequently performed procedures in their department (each year, around 500 appendicectomies are performed at the Trust) and nationwide. Only 50% were satisfied with the current appendectomy set. Surgeons’ reasons for not using the existing ports were also surveyed 

Audit: The team then carried out an audit of 25 appendectomies which revealed that 109 single-use items were opened. The data showed that singleuse ports and Johann graspers were opened in every case; single-use scissors and Marylands were opened occasionally. All of the items opened have a reusable alternative that could be included in the set.

Costing and procurement: Ms Winfield and Mr Labib researched, costed, and procured reusable instruments (including ports with specifications that would address the surgeons’ concerns). Mr Labib and Dr. Ford then meticulously modelled the environmental and financial impacts of the change, using carbon footprinting methodology and procurement prices.

The team was then able to propose a revised laparoscopic appendicectomy procedure set that included reusable replacements for the single-use items that are commonly used. 

They found that the updated appendicectomy set could significantly reduce both the carbon footprint and the financial cost of laparoscopic appendicectomies. The total estimated cost of single-use instruments used in appendicectomies was £49,656 per annum. The instruments used were not manufactured locally and when the team calculated the carbon cost of single-use items per annum, they found that it totalled 692.2 kg CO2e

Solution: The team found a new type of reusable port. These were trialled and additional reusable instruments were also costed. The cost of additional items (ports and instruments) was just £19,730. The ports are expected to last seven years based on current usage. Presuming that the revised set will reduce single-use instrument usage by 75%, the team forecasts a saving of £240,963 over seven years and an environmental saving of 3.59 tonnes CO2e. 

Benefits: The benefits include safer design of reusable ports and trocars, reducing patient risk; annual savings of £34,423 (the new instruments will pay for themselves within six months); savings of over a half tonne of CO2e per year; and higher surgeon satisfaction with the appendicectomy set.

Outcome: In addition to the changes they have made, the team have become influencers and catalysed significant cultural change in their department, division, and in the Trust. Their colleagues have been inspired by the team’s Green Surgery Challenge project to work on changing other surgical sets and there is discussion in the surgical department about switching off air conditioning in elective theatres overnight (this would have the forecast impact of reducing energy usage by up to one third, which alone could allow the department to meet their target of a 20% reduction by 2025 target given the contribution of energy to the overall emissions from theatres). 

Dr. Bush commented: “This team were especially successful in engaging large numbers of their colleagues to contribute to identifying the hotspots of single-use surgical instruments in their department and to implement this project. This broad engagement has paid off as we’ve seen by the significant and impressive ripple effects of the project on changing the culture within their department and University Hospitals Plymouth NHS Trust as a whole.”

Leeds Teaching Hospitals NHS Trust

The conference went on to provide an insight into ‘green appendicectomy’ at the Leeds Teaching Hospitals NHS Trust. The team’s Green Surgery Challenge project included four components:

1.Replacing CO2 insufflation with the RAIS (Retractor for Abdominal Insufflation-less Surgery) device
2.Changing from disposable to reusable gowns and drapes
3.Replacing urinary catheterisation with pre-induction toileting
4.Replacing single-use instruments with reusable instruments in the instrument tray for appendicectomy

Cooper, consultant emergency general surgeon and honorary senior lecturer, Mr Aaron Quyn, consultant general surgeon, associate clinical professor of surgery, deputy director NIHR Surgical MedTech Co-operative.

The project team included Mr Noel Aruparayil, general surgery specialist registrar, honorary research fellow, Global Health Research Group-Surgical Technologies, Mr Thomas Pike, general surgery specialist registrar, NIHR clinical lecturer, Dr. Katie Boag, emergency general surgery clinical fellow, Dr. Peter Culmer, associate professor in healthcare technologies, engineering lead NIHR Global Health Research Group-Surgical Technologies and Mr Tim Ho, medical student 

Mr Peckham-Cooper explained that a holistic review of the laparoscopic appendicectomy process, using a process map, revealed numerous opportunities to reduce the environmental impact. The team listed all the instruments in the current procedure packs and were able to reduce these from 119 to 49, both reducing the number of trays of surgical instruments requiring sterilisation and the number of single-use items opened but not used. These ‘Green Trays’ are now being used routinely. Patients are now asked to pass urine before entering the anaesthetic room to eliminate the need for urinary catheterisation, reducing the use of consumables and potentially improving the patient experience.

The team also modelled a change in resource use by using a gasless procedure for laparoscopic appendicectomy by carrying out a real-time cadaveric study, simulating the innovative surgical procedure. The Leeds Global Health Research Group has developed a new device, RAIS (which mechanically creates a space within the abdomen to allow surgery to be carried out), rather than using insufflated gas.

The procedure was modelled using the standard procedure packs and the green tray, as well as further changes such as re-usable drapes and gowns.

All these interventions were shown to both reduce the environmental impact of the procedure and reduce cost. Medical gas use was a surprisingly large contributor to the overall carbon footprint of the procedure. 

From a global perspective the team think that the RAIS device would expand global surgical access (where access to medical gases is scarce and funds for consumables severely constrained) and contribute significantly towards UN Sustainable Development Goals.

Mr Quyn explained how the development of the RAIS solution was initially motivated by the desire to improve surgical care in rural India. The uptake of laparoscopic surgery in this area was limited by access to general anaesthesia, access to CO2 and the cost of laparoscopic instruments. RAIS has been rolled across the region to tackle some of these resource issues. 

However, working with surgeons in low - and middle-income countries also provides an opportunity for reverse innovation – improving sustainable surgical practice in the UK. To date, it has been used safely in over 200 procedures.

Impact

Replacing CO2 insufflation with the RAIS device has forecast savings of 107.3 tonnes CO2e/year, and £78,000 in procurement costs alone (based on 50% applicability of the RAIS). Changing from disposable to reusable gowns and drapes also has forecast savings of 1.9 tonnes CO2e/year (based on 95% applicability).

Replacing urinary catheterisation with pre-induction toileting has forecast savings of 0.36 tonnes CO2e/year, and £1128 in costs (based on 80% applicability).  

Finally, replacing single-use instruments with reusable instruments in the instrument tray for appendicectomy has forecast savings of 0.74 tonnes CO2e/year, and £9,567 in costs (based on 80% applicability). In total, these projects have a forecast saving of 110.3 tonnes CO2e and £88,695 per year.

The University Hospitals Sussex NHS Foundation Trust

The team at University Hospitals Sussex NHS Foundation Trust focused on streamlining the pre-operative pathway for elective surgery and turned their attention to pathology testing as this is the single highest volume clinical activity in the NHS. Reducing this activity had the potential to make a significant impact for sustainable healthcare. 

The team was led by Dr. Alyss Robinson, Mr Shameen Jaunoo and Professor Mansoor Khan. The team chose to assess laparoscopic cholecystectomies as it is a common procedure carried out frequently by members of the team; on average 250- 300 laparoscopic cholecystectomies are performed in the Trust per year. 

Patients who have day case laparoscopic cholecystectomies (LC) are required by University Hospitals Sussex (UHS) Trust guidelines to attend on two separate occasions for group and save (G&S) blood tests to be taken. The rationale was to facilitate urgent perioperative transfusions, if needed, despite clinical experience suggesting that the procedure has a low bleeding risk. The team decided to investigate the impact on sustainable value of eliminating one G&S test prior to laparoscopic cholecystectomy.

To present their ideas and address any concerns, the team approached colleagues by email, in person and at departmental meetings. They successfully gathered support for their project with a number of the team helping with data collection and engaging other staff. 

The team systematically assessed all the elements of sustainable value of the Sustainable Quality Improvement framework:

• Clinical implications and patient safety: Dr. Robinson conducted a literature search and audit of all patients who had a laparoscopic cholecystectomy at the Trust since January 2020 to assess the risk of significant perioperative bleeding requiring urgent transfusion. 
• Environmental impact: The team calculated the carbon footprint of outpatient G&S tests, including the processing and patient travel, that was surprisingly high as the team found that preoperative tests are carried out at a site located at the greatest distance from main residential areas.
• Social impacts: To understand the social implications of the existing preoperative pathway, the team performed a patient survey.
• Financial impacts: A cost analysis for the G&S tests was performed (finding that costs ranging from £10-24 depending on the Trust) and travel costs for patients was also estimated 

The team concluded that eliminating the second G&S tests from the preoperative workup for laparoscopic cholecystectomies is a safe intervention that will have carbon and financial savings for the Trust, when implemented, and is more convenient for patients without compromising their safety or clinical outcomes. This simple intervention could be applicable to a variety of surgical procedures.

The project was presented at an Anaesthetics Governance Meeting in August 2021 with the aim of gaining agreement of anaesthetist colleagues to apply this intervention to several operations.

The team also aim to raise awareness about the carbon footprint of the preoperative process in general as they see further opportunities for streamlining the pre-operative process, especially with the advent of digital pre-operative assessment, including the opportunity for patients to complete their own assessments and even upload some of their own clinical data such as blood pressure, height and weight

The project was also presented to the Trust’s group of ‘Green Ambassadors’ to inspire and encourage them to take action in their own clinical areas and provide an example of sustainable quality improvement in action in their local Trust. 

Carbon and cost savings: Eliminating the second G&S tests from the preoperative workup for laparoscopic cholecystectomies has forecast annual savings of 2.5 tonnes CO2e/year, and £3,000 for sample processing.

With approximately 61,220 laparoscopic cholecystectomies performed in the UK per year, there could be potential savings of over 600 tonnes CO2e per year, and this approach could be used to address blood bottle shortages in the NHS. 

Wrexham Maelor and Ysbyty Gwynedd Hospitals

The Wrexham Maelor and Ysbyty Gwynedd Hospitals team focused on the carpal tunnel release (CTR) pathway as this is the most commonly performed procedure in the field of hand surgery 

They considered the whole pathway and chose interventions that would reduce the consumption of single-use surgical equipment and reduce energy use by moving out of the operating theatre, reducing size of autoclave trays by streamlining the reusable surgical sets and eliminating the need for ward admission

The multi-disciplinary team was led by Mr Prash Jesudason and Mr Preetham Kodumuri, consultant hand and orthopaedic surgeons. Team members included Iona Williamson, sterile services manager, Teresa Revell, deputy team leader day case unit, Shan Roberts, theatre practitioner, and Jack Houghton, specialty doctor in orthopaedics.

The team listed all the consumables used and the volume of clinical waste generated, while performing a CTR. They used this to identify what changes could be made:

•  Single-use plastic pots and bowls were abandoned and replaced with reusable plastic receiver.
•  Large limb drapes (required for hip or knee replacement but not hand surgery) were replaced with 2 x small 90cm square drapes.
• A large number of reusable surgical instruments in the procedure set were reduced, meaning that the containing tray size could be reduced (meaning that more trays can be accommodated in the autoclave per cycle)

The team made these changes, creating a new procedure pack. The team also gained approval from the theatres manager to carry out CTR in a procedure room rather than theatres (theatres have a high energy requirement, mostly due to the ventilation systems) and for patients to bypass ward admission and come straight to the procedure room.

Results and projections: This project demonstrated that this ‘green carpal tunnel pathway’ was not only safe but also increased productivity, had a lower environmental impact, a lower economic cost and also reduced time in the hospital for patients. The project has forecast annual savings of 11.6 tonnes CO2e/ year and £12,641 (based on 75% applicability). 

Imperial College

The Imperial College Healthcare NHS Trust team selected two areas to work on as part of the Green Surgery Challenge: tackling the use of anaesthetic gases by encouraging the use of local anaesthesia (LA) with/without sedation for inguinal hernia repair (IHR) instead of general anaesthesia (GA) and reducing the use of single-use consumables by switching from disposable sterile surgical gowns to reusable surgical gowns.

The project was co-led by surgical registrars and clinical research fellows, Jasmine Winter Beatty and Jonathan Gan. Members of the team were Henry Robb, surgical core trainee, Simon Dryden, clinical research fellow, Institute of Global Health Innovation, Patricia Ortega, bariatric surgery fellow, Tabitha Grainger, surgical core trainee, Ben Russell, Foundation Year 1 doctor, Sanjay Purkayastha, consultant bariatric surgeon and senior clinical lecturer. Mike Kynoch, anaesthetic consultant, gave specialist advice to the team on anaesthetic practice.

1) Increasing use of LA (+/- Sedation) instead of GA for open IHR where patients were eligible:

The team found anaesthetic gases to be an important carbon hotspot in surgery with anaesthetic gases being responsible for up to 42% of the carbon emissions related to a surgical procedure. Anaesthetic gases account for almost 5% of the whole of the NHS’ carbon footprint and they are potent fluorinated greenhouse gases. IHR surgery was identified as an operation which can be commonly performed under LA and a large body of evidence shows this offers significant clinical benefits for patients, financial savings, and a quicker return to daily life and work due to a reduced length of stay (LOS) in hospital.

The team checked national guidelines for assessing patients’ eligibility to undergo IHR under LA. The team then discussed the guidance and the benefits of carrying out surgery for IHR under LA with surgical and anaesthetic colleagues.

Eligible patients were identified by prospectively screening surgical lists, speaking to the consultant responsible for their care to agree eligibility, and then discussing different anaesthetic options with patients.

• Clinical outcomes were compared for the groups of patients undergoing inguinal hernia repair under general and local anaesthetic. Although this was a small QI project, length of stay in the LA group was on average 4 hours shorter, with 40% of patients in the GA group having an unplanned overnight stay or a subsequent re-admission compared to only 10% of the LA group.
• Environmental impacts of the change were calculated by auditing how many IHR were carried out under GA vs LA. The team then audited the usage of drugs, equipment, anaesthetic agents, and energy use in the patient pathway from anaesthetic induction through to discharge for carrying out IHR under GA and LA; this allowed them to calculate and compare the carbon footprint for the two anaesthetic approaches, which they estimated to be equal to at least 10.2 kgCO2e/case.
• Financial savings were determined by calculating the differing cost of the two anaesthetic options, including pharmaceuticals, equipment, anaesthetic agents, and energy use, so that a comparison could be made. Additionally, the team compared the average length of hospital stay for IHR under LA and GA, as well as the associated costs to the Trust using prepandemic 2019 data. According to their analysis, each case performed under LA in our intervention period saved the Trust almost £70. When considering the LOS from 2019, this would increase to £115.83 per case.
•  Simon Dryden led on evaluating social impact by devising and conducting patient surveys on the amount of time patients and their caregivers took off from work, any additional income lost due to the hospital stay, and impacts on activities of daily living.

2) Replacing disposable surgical gowns with reusable gowns

Switching from disposable surgical gowns to reusable gowns has the potential to decrease pollution and the production of carbon emissions, and is a way to allow staff to carry out their work in line with  sustainability values that are important to most healthcare professionals (this can contribute to improved staff morale) and generate financial savings associated with reduced resource use, waste disposal and transport. Samples of reusable surgical gowns were procured and made available for theatre staff to use.

• Clinical outcomes: gowns met safety standards for medical use.
• Environmental impact: the team used 2019 procurement data from the Trust and calculated the projected environmental impacts of switching to reusable gowns based on data from peer-reviewed studies.
• Financial impact was determined with assistance from the procurement department who provided the team with key metrics regarding the financial cost of the Trust’s current reusable gowns. The suppliers of the team’s current reusable gowns provided a cost per use estimate for the reusable gowns, which included waste disposal and transportation. 
• Social impact was determined by distributing surveys to staff to assess their use of reusable gowns. The team supplemented the survey with face-to-face interviews with surgeons, anaesthetists and nurses who had tried out the reusable gown samples.

Results: Both interventions resulted in significant gains in sustainable value, with environmental and financial benefits. During the project period, the projects saved 1.175 tonnes CO2e and £1,276.82, which leads to a forecast annual saving of approximately 8.5 tonnes CO2e/year and £16,740. If the reusable gowns were spread to the whole Trust, it could save 234.7 tonnes CO2e over a year. 

Conclusion

The teams from Imperial and Wales were awarded £400 each as runners up in the Challenge, with the team from Leeds awarded the winning prize of £1,000 to reinvest in advancing their projects. The combined projects of the five Green Surgery Challenge teams have projected annual savings of 133.4 tonnes CO2e, which is the equivalent of 38 round-trip flights from London to Hong Kong.  

With potential to be scaled and spread further within their Trusts and across the UK, the teams participating in the Green Surgery Challenge have transformed surgery to be more environmentally sustainable and have actively contributed to the NHS’s commitment to achieve net zero by 2040.

Commenting on receiving the award, Mr Peckham-Cooper, from the Leeds Teaching Hospitals NHS Trust team, said: “We couldn’t have done it without our team…We have been on a massive journey and are very much converts in driving these projects forward in the future. I hope that we can inspire others.”

Dr. Bush concluded: “There has been an enormous saving achieved by these teams in just ten weeks. This really underlines what a difference we can make; if just a small number of us take action, following this conference, it could make a big impact.”

For further information visit: https:// sustainablehealthcare.org.uk .

Resources:

• Sustainable Operating Theatres Network: https://networks.sustainablehealthcare.org. uk/network/sustainable-operating-theatres
• SusQI open access resources: https://www. susqi.org/
• Sustainable Healthcare Courses: https://sustainablehealthcare.org.uk/ courses l Sustainable Surgery Groups: https://www. rcseng.ac.uk/about-the-rcs/about-ourmission/sustainability-in-surgery/ & https:// www.rcsed.ac.uk/professional-supportdevelopment-resources/the-environmentalimpact-of-surgery
• Research & evidence: https://www.bsms. ac.uk/about/sustainability.aspx

The Green Surgery Challenge

The Green Surgery Challenge is a special adaptation for clinical specialties of the Centre for Sustainable Healthcare’s flagship programme, the Green Ward Competition (an awardwinning clinical leadership and engagement programme to improve the environmental sustainability of healthcare). The challenge has been created and delivered through collaboration with a group of supportive partners including NIHR MedTech Cooperative in Surgical Technologies, Royal College of Surgeons England, Royal College of Surgeons Edinburgh, The Sustainable Healthcare Coalition, Brighton and Sussex Medical School and the Association for Perioperative Practice

The Challenge has been made possible through the generosity of Gold Funders and Sponsors NIHR MedTech Co-operative in Surgical Technologies and Elemental Healthcare, Silver Sponsors Royal College of Surgeons England and Royal College of Surgeons Edinburgh, Bronze Sponsors the AHSN Network, Vanguard Medical Remanufacturing, and Bowa Medical UK.