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How Can the Environmental Impact of Orthopaedic Surgery Be Measured and Reduced? Using Anterior Cruciate Ligament Reconstruction as a Test Case
Abstract
Background
The healthcare sector in the United States has increased its greenhouse gas emissions by 6% since 2010 and today has the highest per capita greenhouse gas emissions globally. Assessing the environmental impact and material use through the methods of life cycle assessment (LCA) and material flow analysis of healthcare procedures, products, and processes can aid in developing impactful strategies for reductions, yet such assessments have not been performed in orthopaedic surgery. We conducted an LCA and a material flow analysis on an ACL reconstruction (ACLR). The ACLR served as a test case on the assumption that, lessons learned, would likely prove relevant to other orthopaedic procedures.
Questions/purposes
(1) What are the life cycle environmental impacts of ACLR? (2) What is the material flow and material circularity of ACLR? (3) What potential interventions would best address the life cycle environmental impacts and material circularity of ACLR?
Methods
First, we conducted an LCA according to International Organization for Standardization standards for quantifying a product’s environmental impact across its entire life cycle. One result of an LCA is global warming potential measured in carbon dioxide equivalent (CO2eq), or the carbon footprint. Second, we conducted a material flow analysis of ACLR. Material flow analyses are used to quantify the amount of material in a determined system by tracking the input, usage, and output of materials, allowing for the identification of where materials are consumed inefficiently or lost to the environment. To contextualize the material flow analysis, we calculated the material circularity indicator (MCI) index. This is used to measure how materials are circulating in a system and to evaluate the extent to which materials are recovered, reused, and kept within the economic loop rather than disposed of as waste. These three methods are widely used in other fields, especially engineering, but are more limited in healthcare research. Three observations and data collection occurred during ACLRs at the University of Pittsburgh Medical Center Bethel Park Surgical Center in Pittsburgh, PA, USA, between 2022 and 2023. Data encompassing electricity usage, surgical equipment type, the use of heating, ventilation, and air conditioning (HVAC) systems, the production and reuse of reusable instruments and gowns, and the production and disposal of single-use surgical products were collected. Following data collection, we conducted the LCA and the material flow analysis and then calculated the MCI for a representation of a single ACLR. To identify strategies to reduce the environmental impact of ACLR, we modeled 11 possible sustainability interventions developed from our prior work and the work of others and compared those strategies against the impact of the baseline ACLR.
Results
Our results show that the ACLR generated an estimated life cycle greenhouse gas emissions of 47 kg of CO2eq, which is analogous to driving a typical gasoline-fueled passenger vehicle for 120 miles. The total mass of all products for one ACLR was 12.73 kg, including 7.55 kg for disposable materials and 5.19 kg for reusable materials. Concerning material circularity, ACLR had a baseline MCI index of 0.3. Employing LCA for the carbon footprint and the MCI for 11 sustainability interventions has indicated the potential to reduce greenhouse gas emissions by up to 42%, along with an increase in circularity (circularity describes how materials are circulating in a system and evaluates the extent to which materials are recovered, reused, and kept within the economic loop rather than disposed of as waste) of up to 79% per ACLR. Among the most impactful interventions are the reduction in the utilization of surgical pack products, reutilization of cotton towels and surgical gowns, maximization of energy efficiency, and increasing aluminum and paper recycling.
Conclusion
ACLR has a substantial carbon footprint, which can meaningfully be reduced by creating a custom pack without material wastage, reusing cotton towels, and maximizing recycling. Combining LCA, material flow analysis, and MCI can provide a thorough assessment of sustainability in orthopaedic surgery.
Clinical Relevance
Orthopaedic surgeons and staff can immediately reduce the environmental impact of orthopaedic procedures such as ACLR by opening fewer materials—via making custom packs and only opening what is needed in the operating room—and by incorporating more reusable materials such as towels. Larger scale medical center changes, such as implementing recycling programs and installing energy-efficient systems, also can make a meaningful difference in reducing environmental impact.
Purpose
Environmental sustainability in medicine is a growing concern. Determining the carbon footprint of medical procedures may aid in selecting a less impactful technique moving forward. The purpose of this study was to understand the environmental impact of different anterior cruciate ligament reconstruction techniques, for which there is no consensus in terms of optimal graft.
Methods
A life cycle analysis of different anterior cruciate ligament reconstruction techniques was performed. These included quadrupled semitendinosus graft, bone-patellar tendon-bone graft, iliotibial band augmented with gracilis graft, doubled semitendinosus and doubled gracilis graft, and quadriceps tendon graft. All procedures were systematically paired with a lateral extra-articular procedure. The study was conducted in a specialised centre using surgeon preference cards, with the help of a dedicated organisation for calculation according to the ISO 14044 standard. The primary outcome measure was the carbon footprint of each of the five techniques. Secondary outcomes included other environmental impact indicators, including human carcinogenic toxicity and mineral resource scarcity, among others, based on the ReCiPe 2016 midpoint guideline. The analysis had three scopes, each encompassing varying numbers of processes: graft implantation, full procedure, and entire environmental impact, from medical prescription to patient discharge. Results were reported as percentage increases compared to the graft technique with the lowest environmental impact.
Results
It was demonstrated that the surgical procedure itself accounted for <40% of the life cycle, with arthroscopy being 88% of surgery's GHG emissions, and scrubbing and draping contributing 39% to the carbon footprint. The iliotibial band augmented with gracilis tendon technique had the lowest carbon footprint (0.199 Kg Co2 eq), and the least impact in most categories at all scopes of the life cycle analysis. Using this technique as a reference, in terms of graft implantation, it was determined that extensor mechanism grafts had the highest carbon footprint (300% higher than the reference). Greater scopes showed a similar trend, with percentage differences decreasing significantly, reaching 1–3% when considering the entire environmental impact for most categories. Nevertheless, among the aforementioned factors of the ReCiPe 2016 guidelines, the semitendinosus graft paried with a lateral extra-articular procedure displayed greater difference in human carcinogenic toxicity and mineral resource scarcity (6% and 10% respectively) compared to the reference. The individual processes with the highest impact were also highlighted.
Conclusions
In the institution where the study was conducted, the studied iliotibial band graft option was found to have the lowest environmental impact. Such analyses of standardised procedures can be replicated in individual institutions in order to determine their environmental impact. Identification of procedures with comparable results and differing environmental consequences may influence the future decision-making process.
This Viewpoint describes a circular economy for operating room supply chain networks as a climate-oriented approach that maintains organizational viability and patient health and welfare.
Purpose:
The healthcare sector is responsible for 6-7% of CO2 emissions. The intensive care unit (ICU) contributes to these CO2 emissions and a shift from a linear system to a circular system is needed. The aim of our research was to perform a material flow analysis (MFA) in an academic ICU. Secondary aims were to obtain information and numbers on mass, carbon footprint, agricultural land occupation and water usage and to determine so-called "environmental hotspots" in the ICU.
Methods:
A material flow analysis was performed over the year 2019, followed by an environmental footprint analysis of materials and environmental hotspot identification.
Results:
2839 patients were admitted to our ICU in 2019. The average length of stay was 4.6 days. Our MFA showed a material mass inflow of 247,000 kg in 2019 for intensive care, of which 50,000 kg is incinerated as (hazardous) hospital waste. The environmental impact per patient resulted in 17 kg of mass, 12 kg CO2 eq, 300 L of water usage and 4 m2 of agricultural land occupation per day. Five hotspots were identified: non-sterile gloves, isolation gowns, bed liners, surgical masks and syringes (including packaging).
Conclusion:
This is the first material flow analysis that identified environmental risks and its magnitude in the intensive care unit.
Aims
In the UK, the NHS generates an estimated 25 megatonnes of carbon dioxide equivalents (4% to 5% of the nation’s total carbon emissions) and produces over 500,000 tonnes of waste annually. There is limited evidence demonstrating the principles of sustainability and its benefits within orthopaedic surgery. The primary aim of this study was to analyze the environmental impact of orthopaedic surgery and the environmentally sustainable initiatives undertaken to address this. The secondary aim of this study was to describe the barriers to making sustainable changes within orthopaedic surgery.
Methods
A literature search was performed according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines through EMBASE, Medline, and PubMed libraries using two domains of terms: “orthopaedic surgery” and “environmental sustainability”.
Results
A total of 13 studies were included in the final analysis. All papers studied the environmental impact of orthopaedic surgery in one of three areas: waste management, resource consumption, and carbon emissions. Waste segregation was a prevalent issue and described by nine studies, with up to 74.4% of hazardous waste being generated. Of this, six studies reported recycling waste and up to 43.9% of waste per procedure was recyclable. Large joint arthroplasties generated the highest amount of recyclable waste per procedure. Three studies investigated carbon emissions from intraoperative consumables, sterilization methods, and through the use of telemedicine. One study investigated water wastage and demonstrated that simple changes to practice can reduce water consumption by up to 63%. The two most common barriers to implementing environmentally sustainable changes identified across the studies was a lack of appropriate infrastructure and lack of education and training.
Conclusion
Environmental sustainability in orthopaedic surgery is a growing area with a wide potential for meaningful change. Further research to cumulatively study the carbon footprint of orthopaedic surgery and the wider impact of environmentally sustainable changes is necessary. Cite this article: Bone Jt Open 2022;3(8):628–640.
An up-to-date assessment of environmental emissions in the US health care sector is essential to help policy makers hold the health care industry accountable to protect public health. We update national-level US health-sector emissions. We also estimate state-level emissions for the first time and examine associations with state-level energy systems and health care quality and access metrics. Economywide modeling showed that US health care greenhouse gas emissions rose 6 percent from 2010 to 2018, reaching 1,692 kg per capita in 2018-the highest rate among industrialized nations. In 2018 greenhouse gas and toxic air pollutant emissions resulted in the loss of 388,000 disability-adjusted life-years. There was considerable variation in state-level greenhouse gas emissions per capita, which were not highly correlated with health system quality. These results suggest that the health care sector's outsize environmental footprint can be reduced without compromising quality. To reduce harmful emissions, the health care sector should decrease unnecessary consumption of resources, decarbonize power generation, and invest in preventive care. This will likely require mandatory reporting, benchmarking, and regulated accountability of health care organizations.
A circular economy involves maintaining manufactured products in circulation, distributing resource and environmental costs over time and with repeated use. In a linear supply chain, manufactured products are used once and discarded. In high-income nations, health care systems increasingly rely on linear supply chains composed of single-use disposable medical devices. This has resulted in increased health care expenditures and health care-generated waste and pollution, with associated public health damage. It has also caused the supply chain to be vulnerable to disruption and demand fluctuations. Transformation of the medical device industry to a more circular economy would advance the goal of providing increasingly complex care in a low-emissions future. Barriers to circularity include perceptions regarding infection prevention, behaviors of device consumers and manufacturers, and regulatory structures that encourage the proliferation of disposable medical devices. Complementary policy- and market-driven solutions are needed to encourage systemic transformation.
This paper explores whether additive manufacturing (AM) is more environmentally friendly than conventional manufacturing (CM) for the production of medical implants. The environmental impact of manufacturing the femoral component of a knee implant made from Ti-6Al-4V material was investigated. One AM method (electron beam melting (EBM)) and one CM method (milling) were analysed for the production of this part. A cradle to grave life cycle approach was utilised for each manufacturing method focusing on the primary energy consumption (PEC) and CO2 emissions. It was found that when the entire life cycle of the implant is considered, EBM is a more environmentally friendly method of producing the implant. This is mainly due to the complex geometry of the implant. For complex geometries, lots of waste material are generated using CM processes, whereas much less material is wasted using the AM process. The production of the raw material, Ti-6Al-4V, has a high PEC and associated CO2 emissions, so the amount of required raw material for either manufacturing method is the most important factor from an environmental perspective. Finally, the article presents the plans for future work and some remarks are concluded.
Background:
It is estimated that one-quarter to half of all hospital waste is produced in the operating room. Recycling of surgical waste in the perioperative setting is uncommon, even though there are many recyclable materials. The objective of this study was to determine the amount of waste produced in the preoperative and operative periods for several orthopedic subspecialties and to assess how much of this waste was recycled.
Methods:
Surgical cases at 1 adult and 1 pediatric tertiary care hospital in Calgary, Alberta, were prospectively chosen from 6 orthopedic subspecialties over a 1-month period. Waste was collected, weighed and divided into recyclable and nonrecyclable categories in the preoperative period and into recyclable, nonrecyclable, linen and biological categories in the intraoperative period. Waste bags were weighed using a portable hand-held scale. The primary outcome was the amount of recyclable waste produced per case. Secondary outcomes included the amount of nonrecyclable, biological and total waste produced. An analysis of variance was performed to test for statistically significant differences among subspecialties.
Results:
This study included 55 procedures. A total of 341.0 kg of waste was collected, with a mean mass of 6.2 kg per case. Arthroplasty produced a greater amount of recyclable waste per case in the preoperative (2017.1 g) and intraoperative (938.6 g) periods as well as total recyclable waste per case, resulting in a greater ratio of waste recycling per case then nearly all other subspecialties in the preoperative (86%) and intraoperative (14%) periods. Arthroplasty similarly produced a greater amount of nonrecyclable waste per case (5823.6 g) than the other subspecialties, most of which was produced during the intraoperative period (5512.9 g). Overall an average of 27% of waste was recycled per case.
Conclusion:
Among orthopedic subspecialties, arthroplasty is one of the largest waste producers and it has the highest potential for recycling of materials. Effective recycling programs in the operating room can reduce our ecological footprint by diverting waste from landfills, as our study revealed that nearly three-quarters of this waste is recyclable.
The worldwide increasing wealth and increased life expectancy of humans has led to an increase in the numberof medical procedures and surgeries. Surgeries are complex medical procedures which contribute to a significantshare of the total environmental impact of the healthcare system. Among other important sources of environ-mental impacts from surgeries, material consumption due to required instrumentation accounts for up to 65 % ofgreenhouse gas emissions from surgeries. This study investigates how a disposable and a reusable surgery in-strument sets for lumbar fusion surgeries contribute to the environmental impact and which system is moreadvantageous for the environment. For lumbar fusion surgeries, reusable and disposable instrumentation andimplant sets are commercially available. Both sets are capable to support a one level lumbar fusion surgery. Thereusable set is comprehensive and fully opened before the surgery, while the disposable system comes in amodular box system, and the boxes are opened on demand during the surgery. To compare the environmentalimpact of these different configurations, a comparative Life Cycle Assessment (LCA) was performed to assess theoverall environmental impacts of both alternatives. One of the keyfindings is that the selected cleaning andsterilization process for reusable instruments is responsible for up to 90 % of the greenhouse gas emissions anddecides which system is advantageous from an environmental perspective. Reducing the number of instrumentsto be cleaned and sterilized for a surgery should be the focus for future surgery instruments development from anenvironmental perspective
Background
Climate change is a major global public health priority. The delivery of health-care services generates considerable greenhouse gas emissions. Operating theatres are a resource-intensive subsector of health care, with high energy demands, consumable throughput, and waste volumes. The environmental impacts of these activities are generally accepted as necessary for the provision of quality care, but have not been examined in detail. In this study, we estimate the carbon footprint of operating theatres in hospitals in three health systems.
Methods
Surgical suites at three academic quaternary-care hospitals were studied over a 1-year period in Canada (Vancouver General Hospital, VGH), the USA (University of Minnesota Medical Center, UMMC), and the UK (John Radcliffe Hospital, JRH). Greenhouse gas emissions were estimated using primary activity data and applicable emissions factors, and reported according to the Greenhouse Gas Protocol.
Findings
Site greenhouse gas evaluations were done between Jan 1 and Dec 31, 2011. The surgical suites studied were found to have annual carbon footprints of 5 187 936 kg of CO2 equivalents (CO2e) at JRH, 4 181 864 kg of CO2e at UMMC, and 3 218 907 kg of CO2e at VGH. On a per unit area basis, JRH had the lowest carbon intensity at 1702 kg CO2e/m², compared with 1951 kg CO2e/m² at VGH and 2284 kg CO2e/m² at UMMC. Based on case volumes at all three sites, VGH had the lowest carbon intensity per operation at 146 kg CO2e per case compared with 173 kg CO2e per case at JRH and 232 kg CO2e per case at UMMC. Anaesthetic gases and energy consumption were the largest sources of greenhouse gas emissions. Preferential use of desflurane resulted in a ten-fold difference in anaesthetic gas emissions between hospitals. Theatres were found to be three to six times more energy-intense than the hospital as a whole, primarily due to heating, ventilation, and air conditioning requirements. Overall, the carbon footprint of surgery in the three countries studied is estimated to be 9·7 million tonnes of CO2e per year.
Interpretation
Operating theatres are an appreciable source of greenhouse gas emissions. Emissions reduction strategies including avoidance of desflurane and occupancy-based ventilation have the potential to lessen the climate impact of surgical services without compromising patient safety.
Funding
None.
PurposeLife cycle impact assessment (LCIA) translates emissions and resource extractions into a limited number of environmental impact scores by means of so-called characterisation factors. There are two mainstream ways to derive characterisation factors, i.e. at midpoint level and at endpoint level. To further progress LCIA method development, we updated the ReCiPe2008 method to its version of 2016. This paper provides an overview of the key elements of the ReCiPe2016 method. Methods
We implemented human health, ecosystem quality and resource scarcity as three areas of protection. Endpoint characterisation factors, directly related to the areas of protection, were derived from midpoint characterisation factors with a constant mid-to-endpoint factor per impact category. We included 17 midpoint impact categories. Results and discussionThe update of ReCiPe provides characterisation factors that are representative for the global scale instead of the European scale, while maintaining the possibility for a number of impact categories to implement characterisation factors at a country and continental scale. We also expanded the number of environmental interventions and added impacts of water use on human health, impacts of water use and climate change on freshwater ecosystems and impacts of water use and tropospheric ozone formation on terrestrial ecosystems as novel damage pathways. Although significant effort has been put into the update of ReCiPe, there is still major improvement potential in the way impact pathways are modelled. Further improvements relate to a regionalisation of more impact categories, moving from local to global species extinction and adding more impact pathways. Conclusions
Life cycle impact assessment is a fast evolving field of research. ReCiPe2016 provides a state-of-the-art method to convert life cycle inventories to a limited number of life cycle impact scores on midpoint and endpoint level.
Health care facilities produce significant waste (2200 kg/bed/year) creating 2% of greenhouse gas emissions and 1% total solid
waste nationwide, with 20–70% of waste coming from operating rooms. We performed a waste audit of hip arthroscopy for femoroacetabular
impingement (FAI) to understand its environmental impact and identify areas for greening practices. A waste audit of five
hip arthroscopy procedures for FAI was performed. All waste was collected and separated into six waste streams in real time:
(i) normal/landfill waste; (ii) recyclable cardboards and plastics; (iii) biohazard waste; (iv) sharp items; (v) linens and
(vi) sterile wrapping. The surgical waste (except laundered linens) from five FAI surgeries totaled 47.4 kg, including 21.7 kg
(45.7%) of biohazard waste, 11.7 kg (24.6%) of sterile wrap, 6.4 kg (13.5%) of normal/landfill waste, 6.4 kg (13.5%) of recyclable
plastics and 1.2 kg (2.6%) of sharp items. An average of 9.4 kg (excluding laundered linens) of waste was produced per procedure.
Given the considerable biohazard waste produced by FAI procedures, additional recycling programs, continued adherence to proper
waste segregation and an emphasis on ‘green outcomes’ is encouraged to demonstrate environmental responsibility and effectively
manage and allocate finite resources.
The healthcare sector is a driver of economic growth in the US, with spending on healthcare in 2012 reaching $2.8 trillion or 17% of the US gross domestic product, but it is also a significant source of emissions that adversely impact environmental and public health. The current state of the healthcare industry offers significant opportunity for environmental efficiency improvements, potentially leading to reductions in costs, resource use, and waste without compromising patient care. However, limited research exists that can provide quantitative, sustainable solutions. The operating room is the most resource-intensive area of a hospital, and surgery is therefore an important focal point to understand healthcare-related emissions. Hybrid life cycle assessment (LCA) was used to quantify environmental emissions from four different surgical approaches (abdominal, vaginal, laparoscopic, and robotic) used in the second most common major procedure for women in the US, the hysterectomy. Data were collected from 62 cases of hysterectomy. Life cycle assessment results show that major sources of environmental emissions include the production of disposable materials and single-use surgical devices; energy used for heating, ventilation, and air conditioning; and anesthetic gases. By scientifically evaluating emissions, the healthcare industry can strategically optimize its transition to a more sustainable system.
Background:
Anterior cruciate ligament (ACL) injury is among the most commonly studied injuries in orthopaedics. The previously reported incidence of ACL injury in the United States has varied considerably and is often based on expert opinion or single insurance databases.
Purpose:
To determine the incidence of ACL reconstruction (ACLR) in the United States; to identify changes in this incidence between 1994 and 2006; to identify changes in the demographics of ACLR over the same time period with respect to location (inpatient vs outpatient), sex, and age; and to determine the most frequent concomitant procedures performed at the time of ACLR.
Study design:
Descriptive epidemiological study.
Methods:
International Classification of Diseases, 9th Revision (ICD-9) codes 844.2 and 717.83 were used to search the National Hospital Discharge Survey (NHDS) and the National Survey of Ambulatory Surgery (NSAS) for the diagnosis of ACL tear, and the procedure code 81.45 was used to search for ACLR. The incidence of ACLR in 1994 and 2006 was determined by use of US Census Data, and the results were then stratified based on patient age, sex, facility, concomitant diagnoses, and concomitant procedures.
Results:
The incidence of ACLR in the United States rose from 86,687 (95% CI, 51,844-121,530; 32.9 per 100,000 person-years) in 1994 to 129,836 (95% CI, 94,993-164,679; 43.5 per 100,000 person-years) in 2006 (P = .015). The number of ACLRs increased in patients younger than 20 years and those who were 40 years or older over this 12-year period. The incidence of ACLR in females significantly increased from 10.36 to 18.06 per 100,000 person-years between 1994 and 2006 (P = .0003), while that in males rose at a slower rate, with an incidence of 22.58 per 100,000 person-years in 1994 and 25.42 per 100,000 person-years in 2006. In 2006, 95% of ACLRs were performed in an outpatient setting, while in 1994 only 43% of ACLRs were performed in an outpatient setting. The most common concomitant procedures were partial meniscectomy and chondroplasty.
Conclusion:
The incidence of ACLR increased between 1994 and 2006, particularly in females as well as those younger than 20 years and those 40 years or older. Research efforts as well as cost-saving measures may be best served by targeting prevention and outcomes measures in these groups. Surgeons should be aware that concomitant injury is common.
Background
Climate change is predicted to be one of the largest global health threats of the 21st century. Health care itself is a large contributor to carbon emissions. Determining the carbon footprint of specific health care activities such as cataract surgery allows the assessment of associated emissions and identifies opportunities for reduction.AimTo assess the carbon footprint of a cataract pathway in a British teaching hospital.Methods
This was a component analysis study for one patient having first eye cataract surgery in the University Hospital of Wales, Cardiff. Activity data was collected from three sectors, building and energy use, travel and procurement. Published emissions factors were applied to this data to provide figures in carbon dioxide equivalents (CO(2)eq).ResultsThe carbon footprint for one cataract operation was 181.8 kg CO(2)eq. On the basis that 2230 patients were treated for cataracts during 2011 in Cardiff, this has an associated carbon footprint of 405.4 tonnes CO(2)eq. Building and energy use was estimated to account for 36.1% of overall emissions, travel 10.1% and procurement 53.8%, with medical equipment accounting for the most emissions at 32.6%.Conclusions
This is the first published carbon footprint of cataract surgery and acts as a benchmark for other studies as well as identifying areas for emissions reduction. Within the procurement sector, dialogue with industry is important to reduce the overall carbon footprint. Sustainability should be considered when cataract pathways are designed as there is potential for reduction in all sectors with the possible side effects of saving costs and improving patient care.Eye advance online publication, 22 February 2013; doi:10.1038/eye.2013.9.
In response to appeals from the WHO and The Lancet, a collaborative statement from over 200 medical journals was published in September 2021, advising international governments to combat the "catastrophic harm to health" from climate change. Healthcare, specifically surgery, constitutes a major contributor to environmental harm that remains unaddressed. This article provides practical guidance that can be instituted at a departmental, hospital and national level to institute transformative, sustainable efforts into practice. We also aim to provoke healthcare leaders to discuss policy-making with respect to this issue and highlight the necessity for sustainability to become a core domain of quality improvement.
The average orthopaedic service produces 60% more waste than any other surgical specialty. Fortunately, simple measures such as a comprehensive education programme can decrease waste disposal costs by 20-fold. Other simple and effective "green" measures include integrating carbon literacy into surgical training, prioritising regional anaesthesia and conducting recycling audits. Furthermore, industry must take accountability and be incentivised to limit the use of single-item packaging and single-use items. National policymakers should consider the benefits of reusable implants, reusable surgical drapes and refurbishing crutches as these are proven cost and climate-effective interventions. It is crucial to establish a local sustainability committee to maintain these interventions and to bridge the gap between clinicians, industry and policymakers.
“The triple bottom line” is an approach to mitigate the environmental consequences of any business endevor by reporting on that activity affects: Profit, People and Planet. Medical organizations have begun and need to expand the this and like-minded approaches. Research, including Quality Assessment projects are the avenue to understanding how we work and how to expand environmentally sustainable healthcare. Research that identifies effective strategies for change can't be effective without buy-in from medical staff, administrators, insurers and governing bodies.
This Viewpoint discusses the opportunities afforded by modern technological advances and infrastructure that enable health care facilities to develop and rethink approaches to recycling, reducing, and reusing personal protective equipment.
Climate change has been increasingly recognized in the healthcare sector over recent years, with global implications in infrastructure, economics, and public health. As a result, a growing field of study examines the role of healthcare in contributing to environmental sustainability. These analyses commonly focus on the environmental impact of the operating room, due to extensive energy and resource utilization in surgery. While much of this literature has arisen from other surgical specialties, several environmental sustainability studies have begun appearing in the field of orthopaedic surgery, consisting mostly of waste audits and, less frequently, more comprehensive environmental life cycle assessments. The present study aims to review this limited evidence. The results suggest that methods to reduce the environmental impact of the operating room include proper selection of anesthetic techniques that have a smaller carbon footprint, minimization of single use instruments, use of minimalist custom-design surgical packs, proper separation of waste, and continuation or implementation of recycling protocols. Future directions of research include higher-level studies, such as comprehensive life cycle assessments, to identify more opportunities to decrease the environmental impact of orthopaedic surgery.
Background:
Both human health and the health systems we depend on are increasingly threatened by a range of environmental crises, including climate change. Paradoxically, health care provision is a significant driver of environmental pollution, with surgical and anesthetic services among the most resource-intensive components of the health system.
Objectives:
This analysis aimed to summarize the state of life cycle assessment (LCA) practice as applied to surgical and anesthetic care via review of extant literature assessing environmental impacts of related services, procedures, equipment, and pharmaceuticals.
Methods:
A state-of-the-science review was undertaken following a registered protocol and a standardized, LCA-specific reporting framework. Three bibliographic databases (Scopus®, PubMed, and Embase®) and the gray literature were searched. Inclusion criteria were applied, eligible entries critically appraised, and key methodological data and results extracted.
Results:
From 1,316 identified records, 44 studies were eligible for inclusion. The annual climate impact of operating surgical suites ranged between 3,200,000 and 5,200,000 kg CO2e. The climate impact of individual surgical procedures varied considerably, with estimates ranging from 6 to 1,007 kg CO2e. Anesthetic gases; single-use equipment; and heating, ventilation, and air conditioning system operation were the main emissions hot spots identified among operating room- and procedure-specific analyses. Single-use equipment used in surgical settings was generally more harmful than equivalent reusable items across a range of environmental parameters. Life cycle inventories have been assembled and associated climate impacts calculated for three anesthetic gases (2-85 kg CO2e/MAC-h) and 20 injectable anesthetic drugs (0.01-3.0 kg CO2e/gAPI).
Discussion:
Despite the recent proliferation of surgical and anesthesiology-related LCAs, extant studies address a miniscule fraction of the numerous services, procedures, and products available today. Methodological heterogeneity, external validity, and a lack of background life cycle inventory data related to many essential surgical and anesthetic inputs are key limitations of the current evidence base. This review provides an indication of the spectrum of environmental impacts associated with surgical and anesthetic care at various scales. https://doi.org/10.1289/EHP8666.
Healthcare is a potent emitter of greenhouse gases amounting up to 7% of total estimated greenhouse gas emissions (CO2e) for Australia. Australia has one of the highest incidences of skin cancer in the world but there is a paucity of data on the ecological impact of skin cancer excision/dermatologic surgery. The authors reviewed the various impact inventories in order to perform a life cycle assessment of skin cancer excision. A total of 8641 tonnes of estimated CO2e are produced from dermatologic surgery annually in Australia (6751 tonnes from private clinical rooms and 1890 tonnes from hospitals) and the waste generated contributes significantly to terrestrial ecotoxicity and acidification of land and water. Various means can be carried out to reduce this impact, ranging from simple behavioural changes to larger, policy changes.
Material flow analysis (MFA), a central methodology of industrial ecology, quantifies the ways in which the materials that enable modern society are used, reused, and lost. Sankey diagrams, termed the "visible language of industrial ecology", are often employed to present MFA results. This Perspective assesses the history and current status of MFA, reviews the development of the methodology, presents current examples of metal, polymer, and fiber MFAs, and demonstrates that MFAs have been responsible for creating related industrial ecology specialties and stimulating connections between industrial ecology and a variety of engineering and social science fields. MFA approaches are now being linked with environmental input-output assessment, scenario development, and life cycle assessment, and these increasingly comprehensive assessments promise to be central tools for sustainable development and circular economy studies in the future. Current shortcomings and promising innovations are also presented, as are the implications of MFA results for corporate and national policy.
Background::
Few population-based descriptive studies on the incidence of anterior cruciate ligament (ACL) reconstruction and concomitant pathology exist.
Hypothesis::
Incidence of ACL reconstruction has increased from 2002 to 2014.
Study design::
Descriptive clinical epidemiology study.
Level of evidence::
Level 3.
Methods::
The Truven Health Analytics MarketScan Commercial Claims and Encounters database, which contains insurance enrollment and health care utilization data for approximately 158 million privately insured individuals younger than 65 years, was used to obtain records of ACL reconstructions performed between 2002 and 2014 and any concomitant pathology using Current Procedures Terminology (CPT) and International Classification of Diseases, Ninth Revision (ICD-9) codes. The denominator population was defined as the total number of person-years (PYs) for all individuals in the database. Annual rates were computed overall and stratified by age, sex, and concomitant procedure.
Results::
There were 283,810 ACL reconstructions and 385,384,623 PYs from 2002 to 2014. The overall rate of ACL reconstruction increased 22%, from 61.4 per 100,000 PYs in 2002 to 74.6 per 100,000 PYs in 2014. Rates of isolated ACL reconstruction were relatively stable over the study period. However, among children and adolescents, rates of both isolated ACL reconstruction and ACL reconstruction with concomitant meniscal surgery increased substantially. Adolescents aged 13 to 17 years had the highest absolute rates of ACL reconstruction, and their rates increased dramatically over the 13-year study period (isolated, +37%; ACL + meniscal repair, +107%; ACL + meniscectomy, +63%). Rates of isolated ACL reconstruction were similar for males and females (26.1 vs 25.6 per 100,000 PYs, respectively, in 2014), but males had higher rates of ACL reconstruction with concomitant meniscal surgery than females.
Conclusion::
Incidence rates of isolated ACL reconstruction and rates of concomitant meniscal surgery have increased, particularly among children and adolescents.
Clinical relevance::
A renewed focus on adoption of injury prevention programs is needed to mitigate these trends. In addition, more research is needed on long-term patient outcomes and postoperative health care utilization after ACL reconstruction, with a focus on understanding the sex-based disparity in concomitant meniscal surgery.
Objectives:
To determine the carbon footprint of various sustainability interventions used for laparoscopic hysterectomy.
Methods:
We designed interventions for laparoscopic hysterectomy from approaches that sustainable health care organizations advocate. We used a hybrid environmental life cycle assessment framework to estimate greenhouse gas emissions from the proposed interventions. We conducted the study from September 2015 to December 2016 at the University of Pittsburgh (Pittsburgh, Pennsylvania).
Results:
The largest carbon footprint savings came from selecting specific anesthetic gases and minimizing the materials used in surgery. Energy-related interventions resulted in a 10% reduction in carbon footprint per case but would result in larger savings for the whole facility. Commonly implemented approaches, such as recycling surgical waste, resulted in less than a 5% reduction in greenhouse gases.
Conclusions:
To reduce the environmental emissions of surgeries, health care providers need to implement a combination of approaches, including minimizing materials, moving away from certain heat-trapping anesthetic gases, maximizing instrument reuse or single-use device reprocessing, and reducing off-hour energy use in the operating room. These strategies can reduce the carbon footprint of an average laparoscopic hysterectomy by up to 80%. Recycling alone does very little to reduce environmental footprint. Public Health Implications. Health care services are a major source of environmental emissions and reducing their carbon footprint would improve environmental and human health. Facilities seeking to reduce environmental footprint should take a comprehensive systems approach to find safe and effective interventions and should identify and address policy barriers to implementing more sustainable practices.
Purpose:
To measure the waste generation and lifecycle environmental emissions from cataract surgery via phacoemulsification in a recognized resource-efficient setting.
Setting:
Two tertiary care centers of the Aravind Eye Care System in southern India.
Design:
Observational case series.
Methods:
Manual waste audits, purchasing data, and interviews with Aravind staff were used in a hybrid environmental lifecycle assessment framework to quantify the environmental emissions associated with cataract surgery. Kilograms of solid waste generated and midpoint emissions in a variety of impact categories (eg, kilograms of carbon dioxide equivalents).
Results:
Aravind generates 250 grams of waste per phacoemulsification and nearly 6 kilograms of carbon dioxide-equivalents in greenhouse gases. This is approximately 5% of the United Kingdom's phaco carbon footprint with comparable outcomes. A majority of Aravind's lifecycle environmental emissions occur in the sterilization process of reusable instruments because their surgical system uses largely reusable instruments and materials. Electricity use in the operating room and the Central Sterile Services Department (CSSD) accounts for 10% to 25% of most environmental emissions.
Conclusions:
Surgical systems in most developed countries and, in particular their use of materials, are unsustainable. Results show that ophthalmologists and other medical specialists can reduce material use and emissions in medical procedures using the system described here.
Background:
The US health care sector has substantial financial and environmental footprints. As literature continues to study the differences between wide-awake hand surgery (WAHS) and the more traditional hand surgery with sedation & local anesthesia, we sought to explore the opportunities to enhance the sustainability of WAHS through analysis of the respective costs and waste generation of the 2 techniques.
Methods:
We created a "minimal" custom pack of disposable surgical supplies expressly for small hand surgery procedures and then measured the waste from 178 small hand surgeries performed using either the "minimal pack" or the "standard pack," depending on physician pack choice. Patients were also asked to complete a postoperative survey on their experience. Data were analyzed using 1- and 2-way ANOVAs, 2-sample t tests, and Fisher exact tests.
Results:
As expected, WAHS with the minimal pack produced 0.3 kg (13%) less waste and cost $125 (55%) less in supplies per case than sedation & local with the standard pack. Pack size was found to be the driving factor in waste generation. Patients who underwent WAHS reported slightly greater pain and anxiety levels during their surgery, but also reported greater satisfaction with their anesthetic choice, which could be tied to the enthusiasm of the physician performing WAHS.
Conclusions:
Surgical waste and spending can be reduced by minimizing the materials brought into the operating room in disposable packs. WAHS, as a nascent technique, may provide an opportunity to drive sustainability by paring back what is considered necessary in these packs. Moreover, despite some initial anxiety, many patients report greater satisfaction with WAHS. All told, our study suggests a potentially broader role for WAHS, with its concomitant emphases on patient satisfaction and the efficient use of time and resources.
This paper presents an attributional life cycle assessment of biopolymers and traditional plastics using real world disposal methods based on collected data and existing inventories. The focus of this LCA is to investigate actual disposal methods for the end of life phase of biopolymers and traditional fossil-based plastics relative to their corresponding production impacts. This paper connects commonly available methods of disposal for traditional fossil-based plastics and the compostability of polylactic acid and thermoplastic starch to compare these materials not just based on production impacts but also on various scenarios for recycling, composting, and landfilling. Additionally, three traditional resins were evaluated (PET, HDPE, and LDPE) using fossil and bio-based production pathways to assess the performance of bio-based products in the recycling stream. The results demonstrate real environmental tradeoffs associated with agricultural production of plastics and the consequential changes resulting from shifting from recyclable to compostable products. The potential for methane production in landfills is a significant factor for global warming impacts associated with biopolymers while recycling provides major benefits in the global warming and fossil fuel depletion categories. A sensitivity analysis was conducted to investigate the relative importance of locale-specific factors such as travel distances and sorting technologies to the end of life treatment methods of recycling, composting, and landfilling. The results show that composting has some advantages, especially when compared to impacts associated with landfilling, but that recycling provides the greatest benefits at end of life.
Injury to the anterior cruciate ligament (ACL) is the most common ligamentous injury, ranging from up to 200,000 injuries per year in the United States. Sports such as soccer, football, and skiing have been reported to be high-risk sports that can cause injury to the ACL when compared to other sport activities. Due to the high incidence of ACL injuries, approximately 100,000 ACL reconstructions are performed each year. Although conservative treatment can potentially be successful in the appropriate population, patients with goals of returning to high levels of sport activity may not be successful with conservative treatment. Even though reconstruction is the most common treatment for ACL rupture, there remains debate in the literature regarding the optimal timing of surgery. Therefore, the purpose of this clinical commentary is to review the available evidence to provide insight into the optimal timing of ACL reconstruction.
Background:
Operating rooms (ORs) are estimated to generate up to one-third of hospital waste. At the London Health Sciences Centre, prosthetics and implants represent 17% of the institution's ecological footprint. To investigate waste production associated with total knee arthroplasties (TKAs), we performed a surgical waste audit to gauge the environmental impact of this procedure and generate strategies to improve waste management.
Methods:
We conducted a waste audit of 5 primary TKAs performed by a single surgeon in February 2010. Waste was categorized into 6 streams: regular solid waste, recyclable plastics, biohazard waste, laundered linens, sharps and blue sterile wrap. Volume and weight of each stream was quantified. We used Canadian Joint Replacement Registry data (2008-2009) to estimate annual weight and volume totals of waste from all TKAs performed in Canada.
Results:
The average surgical waste (excluding laundered linens) per TKA was 13.3 kg, of which 8.6 kg (64.5%) was normal solid waste, 2.5 kg (19.2%) was biohazard waste, 1.6 kg (12.1%) was blue sterile wrap, 0.3 kg (2.2%) was recyclables and 0.3 kg (2.2%) was sharps. Plastic wrappers, disposable surgical linens and personal protective equipment contributed considerably to total waste. We estimated that landfill waste from all 47 429 TKAs performed in Canada in 2008-2009 was 407 889 kg by weight and 15 272 m3 by volume.
Conclusion:
Total knee arthroplasties produce substantial amounts of surgical waste. Environmentally friendly surgical products and waste management strategies may allow ORs to reduce the negative impacts of waste production without compromising patient care.
Level of evidence:
Level IV, case series.
TRACI 2.0, the Tool for the Reduction and Assessment of Chemical and other environmental Impacts 2.0, has been expanded and
developed for sustainability metrics, life cycle impact assessment, industrial ecology, and process design impact assessment
for developing increasingly sustainable products, processes, facilities, companies, and communities. TRACI 2.0 allows the
quantification of stressors that have potential effects, including ozone depletion, global warming, acidification, eutrophication,
tropospheric ozone (smog) formation, human health criteria-related effects, human health cancer, human health noncancer, ecotoxicity,
and fossil fuel depletion effects. Research is going on to quantify the use of land and water in a future version of TRACI.
The original version of TRACI released in August 2002 (Bare et al. J Ind Ecol 6:49–78, 2003) has been used in many prestigious applications including: the US Green Building Council’s LEED Certification (US Green Building
Council, Welcome to US Green Building Council, 2008), the National Institute of Standards and Technology’s BEES (Building for Environment and Economic Sustainability) (Lippiatt,
BEES 4.0: building for environmental and economic sustainability technical manual and user guide, 2007) which is used by US EPA for Environmentally Preferable Purchasing (US Environmental Protection Agency, Environmentally Preferable
Purchasing (EPP), 2008d), the US Marine Corps’ EKAT (Environmental Knowledge and Assessment Tool) for military and nonmilitary uses (US Marine Corps,
Environmental knowledge and assessment tool (EKAT): first time user’s guide, 2007), and within numerous college curriculums in engineering and design departments.
KeywordsLife cycle impact assessment–Life cycle assessment–Methodology development
This study introduces life cycle assessment as a tool to analyze one aspect of sustainability in healthcare: the birth of a baby. The process life cycle assessment case study presented evaluates two common procedures in a hospital, a cesarean section and a vaginal birth. This case study was conducted at Magee-Womens Hospital of the University of Pittsburgh Medical Center, which delivers over 10,000 infants per year. The results show that heating, ventilation, and air conditioning (HVAC), waste disposal, and the production of the disposable custom packs comprise a large percentage of the environmental impacts. Applying the life cycle assessment tool to medical procedures allows hospital decision makers to target and guide efforts to reduce the environmental impacts of healthcare procedures.
I have used data from input-output studies to determine the quantities of primary and electric energy consumed in the agricultural, processing, transportation, wholesale and retail trade, and household sectors for personal consumption of food.
Before one draws conclusions from these results, it is important to note the assumptions and approximations used in this analysis. First, the economic input-output data published by the Department of Commerce are subject to a number of inaccuracies, including lack of complete coverage for an industry, restriction of data for proprietary reasons, and use of different time periods for different data.
Second, aggregation can combine within the same sector industries whose energy intensities differ widely. For example, eating and drinking establishments probably consume more energy per dollar of sales (because of refrigerators, stoves, and freezers) than do department stores. However, both types of establishment are included in retail trade. Thus energy use for food-related retail trade may be underestimated because of aggregation.
Third, the energy coefficients are subject to error. In particular, the coefficients for the agricultural and trade sectors are vulnerable because energy use within these sectors is not well documented.
Finally, the scaling factor used to estimate food-related energy use for the 1960's is approximate, in that it neglects the possibility that these energy coefficients changed differently with time. Because of these limitations, which are described more fully by Herendeen ( 6 ), a number of important issues were not addressed here. such as relative energy requirements for fresh, frozen, and canned vegetables; and for soybeans as compared to beef.
This analysis shows that the U.S. food cycle consumes a considerable amount of energy, about 12 percent of the total national energy budget. The residential sector, which accounts for 30 percent of the total, is the most energy-intensive sector in terms of energy consumed per dollar of food-related expenditure. This is because food-related expenditures in homes are primarily for fuel to operate kitchen appliances and automobiles.
The electricity consumed in these activities constitutes 22 percent of the total amount used in the United States. More than half of the electricity is used in homes, and more than two-thirds in the trade and household sectors. Thus agriculture and processing consume little electricity relative to the total amount used.
From past trends, it appears that the amount of energy used in food-related activities will continue to increase at a rate faster than the population, principally because of growing affluence, that is, the use of processed foods, purchase of meals away from home, and the use of kitchen appliances equipped with energy-intensive devices, such as refrigerators with automatic icemakers. However, fuel shortages, rapidly increasing fuel prices, the growing need to import oil, and a host of other problems related to our use of energy suggest that these past trends will not continue. Fortunately, there are many ways to reduce the amounts of energy used for food-related activities.
In the home, for example, smaller refrigerators with thicker insulation would use less electricity than do present units. If closer attention were given to the use of ranges and ovens (for example, if oven doors were not opened so often) energy would be saved. Changes in eating habits could also result in energy savings. Greater reliance on vegetable and grain products, rather than meats, for protein would reduce fuel use. Similarly, a reduction in the amounts of heavily processed foods consumed—TV dinners and frozen desserts—would save energy.
Retailers could save energy by using closed freezers to store food and by reducing the amount of lighting they use. Processors could use heat recovery methods, more efficient processes, and less packaging. Shipping more food by train rather than by truck would also cut energy use.
Farmers could reduce their fuel use by combining operations (for example, by harrowing, planting, and fertilizing in the same operation), by reducing tillage practices, by increasing the use of diesel rather than gasoline engines, and by increasing labor inputs. A partial return to organic farming (that is, greater use of animal manure and crop rotation) would save energy because chemical fertilizers require large energy inputs for their production.
Available at: https://ellenmacarthurfoundation.org/materialcircularity-indicator
- Ellen Macarthur Foundation
Ellen MacArthur Foundation. Material Circularity Indicator (MCI).
Available
at:
https://ellenmacarthurfoundation.org/materialcircularity-indicator. Published 2015. Accessed May 10, 2023.
- Hoskins
Hoskins. Materials Circularity Indicator. Available at: https://
www.hoskinscircular.com/blog/calculator-material-circularitysimple. Published 2020. Accessed May 10, 2023.
Greening the OR checklist
- Practice Greenhealth
Practice Greenhealth. Greening the OR checklist. Available at:
https://practicegreenhealth.org/tools-and-resources/greening-orchecklist. Accessed June 15, 2022.