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The global FESSH green survey: sustainability in hand surgery

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Perspectives from around the World
The global FESSH green survey:
sustainability in hand surgery
Introduction
The health care sector accounts for up to 4–5% of net
global greenhouse gas emissions, which if ranked as
a country, would make this the fifth largest emitter
on the planet (Health Care Without Harm, 2019;
Lenzen et al., 2020). However, its contribution to cli-
mate change is rarely discussed. This international
survey under the patronage of the Federation of
European Societies for Surgery of the Hand
(FESSH) aims to evaluate the current opinion on cli-
mate change and sustainable healthcare within the
hand surgery community. The survey covered a
range of questions about the general attitudes and
perspectives towards climate change, their practice
in a number of common clinical scenarios and finally,
awareness of climate change initiatives within their
community. Quantitative analysis was obtained from
graded responses, while free text boxes allowed the-
matic analyses for qualitative data.
The survey was globally distributed in December
2021 via the FESSH email data base and the FESSH
social media channels (Twitter, LinkedIn, Instagram
and Facebook), with the contributions of various
European, Australian and Canadian hand surgery soci-
eties, the American Association for Hand Surgery and
the Federation Latinoamericana de Cirugia. The survey
was anonymous and accessed for data and content
analysis (SurveyMonkeyV
Rword-cloud) by the research-
ers only.
Survey results
Reflecting the worldwide distribution of the survey,
a total of 876 respondents from 62 different coun-
tries spanning six continents took part in this survey
(Figure 1; Online supplementary Table S1). The
majority of responses were received from Europe,
North and South America, with most of the
respondents practicing in the United States of
America (USA, 16.3%, n¼143), the United
Kingdom (UK, 11.6%, n¼102) and Germany (8.3%,
n¼73). The cohort of respondents, male to female
ratio of 3:1, were predominantly hand surgeons of a
senior grade (89% consultant level). Of the respond-
ents 52% practice in a teaching or university hospi-
tal setting (Online Supplementary Table S2).
Overall, there was a strong concern about climate
change, with 89% of respondents strongly agreeing or
agreeing that this is an important issue; 92%
expressed a strong desire to strive for a more sustain-
able lifestyle. Over two-thirds of respondents (73%)
have considered the environmental impact of their
practice, but only 50% have taken steps to implement
changes. The majority of the respondents (84%) feel
that health care professionals have an obligation to
raise awareness of the carbon footprint of health
care systems. There was no significant correlation
with the respondents age or seniority, when asked
about their concerns regarding climate change,
aiming for a more sustainable lifestyle or the obligation
to raise awareness of the health care sectors carbon
footprint.
For the second part of the survey, respondents
were asked to rate the likelihood of modifying their
current practice due to concerns about climate
change. A number of clinical scenarios were given,
drawn from the topical literature. Importantly, the
scenarios operate from the premises that any mod-
ification of practice (as a result of climate change
consideration) would not adversely affect patients’
outcome. The questions and the respondents’ ratings
are as shown in Table 1. Overall, these demonstrate
high levels of support for measures to integrate
waste management, recycling and reduction of the
number of consumables used in the clinical setting,
but varying and lesser acceptance of scenarios
involving direct clinical care.
In the final section of the survey, we explored the
awareness within the hand surgery community of
local or national networks committed to addressing
health care’s carbon footprint. Approximately 62% of
respondents were unaware of initiatives within their
hospitals and where the hospitals had introduced
changes, the content analysis of the respondents’
comments showed that these mainly involve the
introduction of recycling (20%), waste segregation
(19%) and energy savings or sourcing of alternative
energy (up to 8%).
The majority of respondents was also unaware of
initiatives within their national hand surgery society
or their country (90% and 72%, respectively).
Journal of Hand Surgery
(European Volume)
47(9) 1–4
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Further exemplary subgroup analysis showed
that this even applied where such initiatives are
well established: The American initiative ’lean
and green hand surgery’ for example was only
beknown to 27% of respondents from the USA.
Similarly, only 26% of the UK respondents were
aware that the National Health Service (NHS) has
committed to achieving a net zero carbon footprint
by 2040.
Further analysis of the survey’s responses accord-
ing to geo-political grouping was not possible due to
the somewhat disproportionate numbers of replies
from the individual continents and countries.
Analysis of results
Encouragingly, the survey was met with a high level
of engagement, which revealed the level of interest
Figure 1. Distribution of respondents by continent.
Table 1. Percentage of affirmative responses to clinical scenario question.
Clinical scenario questions
Affirmative responses
(number) (%)
Encouraging staff to integrate waste management & recycling in the theatre setting n¼730 (85%)
Reducing/limiting the use of drapes and gowning for simple soft tissue procedures, e.g.
carpal tunnel decompression
n¼629 (74%)
Discussing the different environmental impact of general anaesthesia versus WALANT
with patients
n¼439 (51%)
Consider the environmental impact when deciding whether to prescribe prophylactic
antibiotics
n¼418 (49%)
Use virtual clinic appointments instead of face-to-face appointments to reduce the carbon
footprint of my clinics
n¼335 (39%)
Limiting use of NSAIDs to reduce the impact of water pollution n¼263 (31%)
Choosing a surgical technique with lower environmental impact such as the use of
Kirschner wires over ORIF
n¼249 (29%)
Each question was prefixed with the statement: Assuming that there was no current evidence to suggest that the outcome for your
patients would be affected, which of the following measures would you consider taking?’
WALANT: wide awake local anaesthesia no tourniquet; NSAIDs: non-steroid anti-inflammatory drugs; ORIF: open reduction internal
fixation.
2Journal of Hand Surgery (European Volume) 47(9)
in the community of hand surgeons at large to work
towards a more sustainable and environmentally
considerate practice. The majority of respondents
expressed concerns about climate change, strive
for a more sustainable lifestyle and consider the
carbon footprint of their own practice. A full thematic
analysis was not performed but some qualitative data
was obtained from the comments. Interestingly,
comments such as climate change is not a hand
surgery problem or that health care comes further
down the line in prioritizing planetary health, were
largely balanced by others expressing frustration
how addressing the challenges of climate change
have been relegated to an afterthought or how
health care professionals are forced by law and leg-
islation to use environmentally damaging practices’.
These contrasting views showed how climate change
remains a subject that requires more discussion and
prioritization.
The World Health Organization’s (WHO) ’opera-
tional framework for building climate resilient
health systems’ sees a clear role for professional
societies in creating an environment where safe
and climate-friendly surgical ...techniques can be
used’. The survey data suggests that either only a
few organizations have engaged with this, or that
awareness of existing initiatives is limited. Further
contents analysis however showed that two areas
of change waste management and recycling as
well as the reduction of consumables are common-
ly adopted on an individual as well as an organiza-
tional level. This might not be surprising as these
concepts have permeated through everyday life and
are easily transferrable into health care. Recent
work by Lalonde et al. (Yu et al., 2019) on field ste-
rility and Van Denmark’s concept of ’lean and green
hand surgery’ (Van Demark et al., 2018) have also
helped by demonstrating that sustainable hand surgery
can be practiced economically while maintaining safe
surgical standards. Accordingly, the clinical scenario
questions addressing waste management & recycling
in the theatre setting’and’reduction/limiting the use of
drapes and gowns for simple soft tissue procedures
have achieved the highest support.
In contrast, responses for clinical scenarios
involving areas of direct patient care had less sup-
port. Approximately 50% of respondents opted to
discuss the different environmental impact of gen-
eral anaesthesia versus WALANT (wide awake local
anaesthesia no tourniquet) with patients and to con-
sider the environmental impact when deciding
whether to prescribe prophylactic antibiotics’.
These ratings could be explained by the widely
shared concept of antibiotic stewardship, if taking
into account the impact of antibiotics on the
environment (Richards et al., 2004), and the evolving
evidence showing that avoidance of inhalation anaes-
thetics significantly reduce the carbon footprint of
theatres. The effect of a single inhalation general
anaesthesia is estimated to be equivalent to releas-
ing approximately 22 kg of CO
2
into the environment
(MacNeill et al., 2017; Ryan and Nielsen, 2010) and
using alternative techniques such as WALANT, or
similarly blocks, regional or intravenous anaesthesia
would have a significantly lesser impact on the envi-
ronment. Similarly, although virtual clinics would
reduce the carbon footprint by cutting down the
need for patients to travel to hospital, the survey
showed that these would only be considered by
40% of respondents. Virtual clinics have seen a
surge during the COVID-19 pandemic and related lit-
erature showed that they overall have been met with
high patient satisfaction and acceptance by the clini-
cians (Hendrickson et al., 2021; Vusirikala et al.,
2021), but perhaps by the time of the survey was
conducted, a certain fatigue with this technology
had developed and further research will be required
to establish the future role of these clinics.
The two changes to clinical practice with the lowest
ranking in the clinical scenario category were limiting
the use of non-steroidal anti-inflammatory drugs
(NSAIDs) to reduce the impact of water pollution
(31%) and choosing a surgical technique with
lower environmental impact such as Kirschner wires
(K-wires) over open reduction and internal
fixation (ORIF) (29%). Despite being one of the most
prescribed drugs globally, surgeons might have lim-
ited awareness of the impact of NSAIDs on water pol-
lution and toxicity to non-target organisms (He et al.,
2017) which might have influenced the survey results.
The decision to use K-wires versus ORIF is at
times a complex one; the question was designed to
consider the surplus of waste generated when
performing an ORIF. This additional waste stems
from the requirements, according to recent legisla-
tions and standards (such as the International
Organisation for Standardization EN ISO 13485) that
each medical implant, that is each osteosynthesis
screw should be traceable through the processing
system and hence needs to be individually packaged.
The multiple layers of packaging are often unsuitable
for recycling and were widely criticized in the sur-
vey’s comments. This question of K-wires versus
ORIF received the least consent and also generated
the most vigorous responses from some of the
survey participants, expressing concerns regarding
possible litigation and the ethics of such considera-
tions. But even if current evidence determines a
single best method, a surgeon’s choice of technique
often simply comes down to experience and
Witt et al. 3
preference (Ferlie et al., 1999) or is influenced by
local and geographical variations and constraints
(Grove et al., 2016).
Conclusion
This global survey allowed a useful glimpse into the
perspective of hand surgeons and highlighted the
overall strong concern about climate change within
the hand surgery community. The majority of
respondents agreed that health care professionals
have the obligation to raise awareness of the contri-
bution of the health care sector to climate change.
Finding sustainable solutions to ensure that we can
maintain surgical quality care with lower carbon
footprint should be addressed in future research.
Declaration of conflicting interests The authors
declare no potential conflicts of interest with respect to the
research, authorship, and/or publication of this article.
Funding The authors disclosed receipt of the following
financial support for the research, authorship, and/or pub-
lication of this article: the authors received support in the
distribution of the survey from the office of the Federation
of European Societies for Surgery of the Hand (FESSH).
Supplemental material Supplemental material for this
article is available online.
ORCID iD Elisabet Hagert https://orcid.org/0000-0002-
6667-2593
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Paulina Witt
1,
, Egemen Ayhan
2
Elisabet Hagert
3,4
and Zafar Naqui
5
1
Department of Plastic Surgery, Royal & Devon Exeter
Hospital, Exeter, UK
2
Department of Orthopaedics and Traumatology, University
of Health Sciences Turkey, Diskapi YB Training and
Research Hospital, Ankara, Turkey
3
Karolinska Institutet, Department of Clinical Science and
Education, Stockholm, Sweden
4
Aspetar Orthopaedic and Sports Medicine Hospital, Doha,
Qatar
5
Hand Surgery Unit, Department of Trauma,
Orthopaedic and Plastic Surgery, Salford Royal Hospital,
Manchester, UK
Corresponding author: misspwitt@gmail.com
4Journal of Hand Surgery (European Volume) 47(9)
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