Going green, particularly in the operating room (OR), is a meaningful goal for many environmentally conscious surgeons, but for budget-wary hospital administrators, the decision to adopt more sustainable practices is often about the other green—money. Current research suggests sustainable OR initiatives do, in fact, reduce operating cost while eliminating waste and improving environmental sustainability.
According to Greening Health Care: How Hospitals Can Heal the Planet, U.S. hospitals produce more than 2.3 million tons of waste each year, with an average of 26 pounds of waste per staffed bed in the course of a single day.1 When the environmental ramifications of these numbers are considered along with the impact on health care expenditures, the validity of cost-cutting environmental stewardship programs becomes increasingly apparent. Whether it’s the red bag waste reduction initiative of the Carolinas Medical Center (CMC), Charlotte, NC, which resulted in a $50,000 per year savings, or the streamlining of surgical kits at the University of Minnesota Medical Center, Fairview, which has yielded $104,000 in savings annually—these programs have demonstrated that they protect both the environment and the institutions’ bottom line.2,3
In this article, surgeon leaders discuss effective green OR strategies, offer guidelines for reporting program outcomes, and highlight practical solutions for promoting the kind of culture change necessary to achieve long-lasting results.
Single-use devices and surgical kits
“The first step toward [creating] a green OR is to observe what is going on around you and to find out how you are contributing to your environmental footprint,” said Tom Paluch, MD, a general surgeon with the Kaiser Foundation Medical Center, San Diego, CA, and co-presenter of The Environmentally Responsible Surgical Practice Panel Session at the 2014 Clinical Congress. “Reducing disposable instrumentation is the single biggest way a surgeon can have a positive impact on the environment. We eliminated single-use devices (SUDs) for laparoscopy, and we went from consuming $300,000 worth of equipment a year to virtually nothing—and that’s just in one hospital here in San Diego,” said Dr. Paluch.
Each year, Kaiser Permanente reduces medical waste by recycling and safely reusing SUDs, according to Dr. Paluch. Recycling SUDs—which is conducted in strict accordance with U.S. Food and Drug Administration (FDA) regulations—reduces purchasing and overall waste disposal costs.4
In addition to recycling SUDs, Kaiser Permanente has partnered with MedShare, a not-for-profit organization dedicated to repurposing unused, unexpired medical equipment that previously ended up in landfills. MedShare is one organization that redistributes these supplies to clinics and hospitals in the developing world.4 Approximately 2 million pounds of recoverable medical supplies can be found each year in large, metropolitan U.S. academic medical centers. Collectively, these materials hold a potential value of at least $15 million per year.5
Another way surgeons can contribute to the sustainability of their health care institutions is by working with colleagues to standardize operative packs and trays, according to Daniel Klaristenfeld, MD, FACS, FASCRS, a colorectal surgeon, Kaiser Permanente, San Diego, and moderator of the 2014 Clinical Congress Panel Session. “For common procedures like gallbladder surgery or hernia repair, we walk into a case and instead of having every available instrument open and on the table, they are available but not opened, which saves time and money,” he said. All opened instruments, regardless of whether they are used in a procedure, must be sterilized again and repackaged.
Streamlining surgical kits or packs has been a priority for Rafael Andrade, MD, FACS, a general thoracic surgeon at the University of Minnesota Medical Center, since 2009. Dr. Andrade, along with Lynn Thelen, RN, launched a grassroots OR Green Team to explore the feasibility of reducing waste at their hospital. After soliciting input from colleagues, they examined 38 different types of OR packs to determine which devices, such as plastic basins, catheters, and syringes, were unused and then instructed their product vendor to remove the items from the packs.3 For example, a pack designed for inserting an intravenous port in chemotherapy patients was whittled down from 44 devices to 27, and disposable gowns and linens were replaced with reusable items. Overall, this initiative resulted in a reduction of one pound of trash and $50 in supply cost savings per procedure.3
“Most surgeons don’t know what exactly is in the kit when they enter the OR. They simply want to come in and start operating and not waste time trying to get [supplies that are] not available,” said Dr. Andrade. “We explained to the surgeons that items that are never used are going to be removed [from the kits] and that items that are sometimes used can be on hold in the room, but not included in the kit so they don’t get wasted every single time.” Dr. Andrade said in-person meetings with hospital and surgeon leaders were key in dealing with resistance and quickly led to acceptance and support of the initiative. “All upfront work—getting buy-in from the surgeons—is done in person,” he said.
Red bag initiative
At CMC, red bags in the OR and intensive care units (ICUs) are designated for biohazardous waste. According to B. Todd Heniford, MD, FACS, chief, division of gastrointestinal and minimally invasive surgery, CMC, it costs 10 times as much per pound to dispose of these materials than other waste, primarily due to the cost of transporting and incinerating red bag waste, not to mention the effect of the toxic release of dioxin on the environment as a result of this processing.
“What we found was that staff was throwing essentially everything that touched a patient into a red bag, so it was simply a matter of educating our teammates about the difference between biohazardous materials and general waste, which typically goes to a landfill. While a landfill is not a great option, it is certainly better than incineration,” explained Dr. Heniford, co-author of “The green operating room: Simple changes to reduce cost and our carbon footprint,” published in a 2013 issue of The American Surgeon.2
“We also found that in the ICUs the biggest trash cans held red bags, so people threw everything in there,” Dr. Heniford said. “We changed the trash cans—I say ‘we,’ but it was the institution’s custodial staff who suggested changing the size of the trash cans. They made the red bag trash can the smallest one in the room, and they also purposely placed these cans in the corner of the room so that you had to walk a few feet to dispose of an item there,” he added. Staff members now have to make more of an effort to dispose of an item in a red bag, which serves as a reminder to only place heavily soiled materials in these receptacles.
Dr. Heniford said his institution observed a 75 percent reduction in red bag waste, with an estimated savings of more than $50,000 a year. The red bag initiative is a product of the CMC’s Green Operating Room Committee (GORC), formed in 2008 with members from surgical, nursing, anesthesia, and OR staff, and environmental services.2
Educating staff members on proper disposal of biohazardous waste versus general waste, rather than underscoring policy mandates and regulations, is the best way to ensure team member buy-in, according to Dr. Andrade. At the University of Minnesota Medical Center, staff members are now required to take an online course on proper waste disposal as part of their annual education requirements.6
Environmentally preferred purchasing
Surgical kit reduction, waste elimination, water conservation, and other green OR initiatives essentially start, in some form or another, with purchasing. Environmentally preferred purchasing (EPP), according to Dr. Paluch, can be defined as the “purchase of products and services whose environmental impact have been considered and found to be less damaging to the environment and human health when compared [with] competing products and services.”7 These items could include reusable surgical instruments, environmentally safe/reduced product packaging, and even general cleansers and solvents formulated specifically for a reduced impact on the environment.8 In a sense, EPP can be considered “preventive medicine” that promotes a healthy environment through products that are green friendly.8
According to Vanessa Lochner, director of EPP for Kaiser Permanente, buying green occurs in three distinct phases:9
- Pre-sourcing: This step involves the work prior to a sourcing event—researching what various vendors have to offer. For example, it might entail sending a chemical disclosure questionnaire to suppliers or reviewing a product category for reduced packaging opportunities.
- Sourcing: In this phase, also known as procurement, hospital administrators and green OR teams define their requirements so that suppliers in the marketplace may bid on goods and services.
- Implementation: This step is the execution phase of a project or initiative that produces a positive environmental outcome—one that is trackable with metrics.
Surgeon leaders can have an impact on a facility’s purchasing decisions, Dr. Paluch suggests, particularly at the sourcing phase when product requirements are addressed with vendors. Surgeons and OR green teams can also contribute to EPP initiatives by assisting in product assessments, tracking purchasing decisions, and monitoring cost-benefit analysis of these products and services. Perhaps most importantly, surgeons who are champions of EPP can help develop stakeholder and colleague engagement in these purchasing decisions by promoting the positive effects on the environment.
In 2014, Johnson & Johnson, the pharmaceutical and manufacturing company, partnered with Harris Poll to measure the importance of sustainability issues among global health care professionals, including surgeons, OR nurses, and hospital executives in the U.S. and five other countries.10 More than half (54 percent) of respondents to the study report that their hospitals currently incorporate sustainability into purchasing decisions, and 80 percent anticipate that will be the case within two years. More than 300 health care professionals participated in the 2014 survey, either online (289) or by phone (40).10
According to the study, health care professionals also agree it makes good financial sense for hospitals to go green, both in the U.S. (79 percent) and globally (69 percent). In fact, 67 percent of domestic and 60 percent of international respondents report a growing commitment to sustainability from top hospital management.10
“The biggest reason for hospitals to be involved in green initiatives is cost savings—but it is a nice benefit to be able to say to the public that you are environmental [stewards],” said Dr. Paluch. “When we say we are here for your health—we mean it on every level. Green OR programs are a great way to show commitment to the overall well-being of a patient—not just giving them medicine, but providing an environment in which they will be safer, cleaner, and healthier.”
“By being green, we sacrifice nothing,” added Dr. Heniford. “Being green demonstrates our responsibility to not only to our patients but to our communities.”
Surgeon leaders can accelerate the culture change needed to encourage and sustain green practices at their institutions. To ensure the longevity and success of these programs, surgeon leaders should develop a collaborative support network throughout the organization and provide hospital executives and staff members with measurable results.
“The raison d’etre for a hospital is not to be an environmentally savvy organization; it is to take care of the patient,” said Dr. Paluch. “How do we best do that? By providing quality care, but also by being environmental stewards. To make these kinds of changes, it is as simple as going to the administration; and, yes, it is as difficult as going to administration. It’s like turning a battleship with a canoe paddle—it’s not an easy thing to do. However, these initiatives tend to catch on—one, because it’s smart, and two, because they save money. That is what gets people interested because it’s measurable. If you can’t measure it, you can’t manage it.”
Providing hospital administrators with tangible results was the justification behind the first green initiative—water conservation—led by the GORC team at CMC. According to Dr. Heniford, the scrub cycles of 100 consecutive physicians, nurses, residents, and technicians were observed to determine how much time they spent scrubbing before an operation. In all but two cases, water ran nonstop while staff members scrubbed, whether their hands were under the water or not. And frequently, the water was left running even when no one was at the sink. To minimize this problem, OR sinks were outfitted with flow meters, and the GORC estimated daily, weekly, and yearly use.
“We demonstrated to OR staff that we could save real [amounts of] water by making a conscious effort to conserve it,” said Dr. Heniford. “At that point, only 20 percent of the surgeons, nurses, and scrub techs used waterless scrub prior to surgery, and when we surveyed staff, the reason was purely based on tradition. There must be something soothing about hearing the water run prior to an operation. Once we convinced staff to use an alcohol-based waterless scrub—which is as safe or safer than water scrub—we have [had]an estimated savings of 2.7 million liters of water per year in the ORs alone, in just our hospital.” Tethered to this water-saving initiative were additional green-friendly cost savings from a decrease in washing and processing towels and lower sewer-use fees.2
“When we began our program, we decided it had to be cost-neutral,” said Dr. Heniford. “And very quickly we were able to demonstrate with a few small, grassroots initiatives that not only were we able to remain cost-neutral, but we actually saved money. Saving money and reducing our carbon footprint energized the committee and captured the administrators’ attention.”
In addition to offering hospital administrators tangible, measurable results, such as cost savings and waste-reduction outcomes, Dr. Andrade and his colleagues were able to help achieve a culture change throughout his organization through peer-to-peer communication. “Ours has been a grassroots movement; it was not led by [the] administration,” revealed Dr. Andrade. “Peer-to-peer communication means there is a representative from each group on the green team—surgeons, nurses, surgical technicians, physician assistants, custodians, and so on. If I need to get a message out to the surgeons, I talk to them as the surgeon representative on the green OR team. If someone needs to communicate something to the nurses, then the nurse on the team conveys that information. We’ve emphasized this model from the very beginning because it’s where you get more bang for your buck. It’s not a surgeon imposing a message or request on nurses, or a surgical tech trying to sell something to the surgeons. Peer-to-peer communication is the best way to engage staff members in green initiatives,” said Dr. Andrade.
“It’s interesting because people tend to come out of the woodwork as soon as you start to talk about green OR initiatives openly,” said Dr. Klaristenfeld. “Other hospital systems and organizations may have this kind of program already in place, with people in place whose jobs are focused on these issues, and you might not even be aware of it. Go and see if something like this already exists.”
Transparency regarding the sustainability efforts of a green OR team is also key to maintaining staff engagement. Reporting green team outcomes and comparing results from previous years or even results from different departments within the same facility can help generate renewed interest in a water use reduction program or a red bag initiative.
“As a surgeon, being green is not going to be at the forefront of my daily existence, so the only way to keep it a priority is to keep putting it in front of me and my peers,” Dr. Paluch noted. His institution has a regular reporting cycle that details the team’s accomplishments on a monthly or bimonthly basis. “When we remind surgeons that the same patient care can be administered with environmental savvy or stewardship, we’re going to sign on to this—but we need reminders because this is not our primary focus.”
“One of the most important things we were able to do is keep score,” added Dr. Heniford. “Keeping score energizes people because they see that they can make a difference.”
Demonstrating a return on the investment of time and resources is essential when launching a sustainability program and is likely the most convincing way to foster a culture change throughout an organization. Surgeons are natural leaders who foster collaboration both inside and outside the OR and are essential to the long-term success of a green OR initiative. Leading by example, surgeons can play a significant role in developing an interdisciplinary green team, encouraging reprocessing of single-use surgical devices, establishing a sustainable waste management program, and advocating for green-friendly purchasing practices.
- Kaiser Permanente. Excerpts from Greening Healthcare: How Hospitals Can Heal the Planet. August 12, 2014. Available at: http://share.kaiserpermanente.org/article/excerpts-from-greening-health-care-how-hospitals-can-heal-the-planet/. Accessed February 18, 2015.
- Wormer BA, Augenstein VA, Carpenter CL, et al. The green operating room: Simple changes to reduce cost and our carbon footprint. Am Surg. 2013;79(7):666-671.
- Chen I. In a world of throwaways, making a dent in medical waste. The New York Times. July 5, 2010. Available at: www.nytimes.com/2010/07/06/health/06waste.html?pagewanted=all. Accessed February 18, 2015.
- Kaiser Permanente. Reducing, re-using, and recycling to eliminate waste. May 30, 2014. Available at: http://share.kaiserpermanente.org/wp-content/uploads/2014/06/WasteReduction-factsheet_20141.pdf. Accessed February 18, 2015.
- American College of Surgeons. An estimated two million pounds of unused medical supplies may be recoverable in U.S. operating rooms each year [press release]. October 2014. Available at: www.facs.org/media/press-releases/2014/wan1027. Accessed February 23, 2015.
- Hankel A. Greening the OR. Surgical Products. July 5, 2011. Available at: www.surgicalproductsmag.com/articles/2011/07/%E2%80%98greening%E2%80%99-or. Accessed February 18, 2015.
- Paluch T. A Skeptic’s Epiphany: Environmentalism in Surgical Product Procurement. Presented at 2014 American College of Surgeons Clinical Congress; October 28, 2014; San Francisco, CA.
- Practice Greenhealth. Environmentally preferable purchasing. Available at: https://practicegreenhealth.org/topics/epp. Accessed February 18, 2015.
- Lochner V, Hayter S, Johnson R. Developing and Managing a Sustainable Portfolio Mix of EPP Projects. Presented at CleanMed2014; June 2-4, 2014; Cleveland, OH.
- Advancing sustainability in health care [news release]. Johnson & Johnson. October 1, 2014. Available at: www.csrwire.com/press_releases/37402-Globally-Hospitals-are-Driving-Toward-Greener-Purchasing-Decisions-Greater-than-50-Increase-Expected-in-Next-Two-Years. Accessed February 18, 2015.