Greener theatre, greener surgery – environmental sustainability in a rural surgical setup

In 2009, the Lancet Global Health Commission called climate change the biggest global health threat of the 21st century.1 Surgery is a resource-intensive activity due to the emission of greenhouse gases (GHG) in the form of anaesthetic gas and single-use medical consumables resulting in large amounts of waste.2, 3 MacNeill et al. studied operating theatres in the UK, Canada and USA and found that the carbon burden of an operating theatre is about 188 tonnes CO2e per theatre per year.3 It is estimated that a typical operation has comparable emissions to driving 600 to 1100 km in an average car.2 In 2018, healthcare contributed to 4.9% of global greenhouse gas emissions.4 In the last decade, there has been a push towards environmentally sustainable surgical practices. RACS has published a position paper on the environmental impact of surgical practice that calls for action to reduce the environmental impact of surgery. Suggested approach to this issue would be the five Rs – reduce, reuse, recycle, rethink and research.5 To lead this change, in 2022 RACS moved to make the ANZ journal a digital-only publication to reduce the waste burden.6 The first step in implementing change is to acknowledge the problem. There have been few survey-based studies that indicated barriers and attitudes towards sustainable surgical and anaesthetic practices. These studies highlighted the need to understand the local institution-based knowledge among medical and nursing personnel.7-11 This study seeks to assess the understanding, behaviours and attitudes of staff of the operating theatre. It also seeks to identify barriers to sustainable surgical practice and to formulate strategies to reduce waste in the day-to-day operating theatre management. In addition to collecting opinions, this survey serves as a means of educating staff regarding the importance of working towards environmentally sustainable healthcare. This study would form part of the first phase of our plan to initiate sustainable surgical practices in our local operating theatres. This study was a cross-sectional survey including participants involved in theatre-related activity in our local hospital which included the surgical team, anaesthetic team, theatre nurses, CSSD (central sterilizing supply department) staff, clinical administration staff, operating theatre assistants and medical students rotating to the surgical department. The survey was created on Qualtrics and distributed by email and flyers with a QR code in the operating theatres. Participation in the survey was voluntary and without incentive with an estimated time to complete the survey of about 5 minutes. The survey consisted of closed-ended questions with categorical yes or no responses or using a 5-point Likert scale which ranged from strongly agree to strongly disagree. There were 7 of these compulsory questions. There were also 2 open-ended questions which were optional to allow participants to express opinions and suggest strategies that can be carried out to improve sustainability. The key sections in this survey were: (i) demographics, (ii) current attitudes and personal behaviours, (iii) engagement in sustainability and perceived barriers to change (iv) sustainability in the surgical workplace. See Appendix I for survey questions. Ethical approval was given by the Greater Western Human Research Ethics Committee (HREC 2022/ETH00898; 2022/STE02592). The survey was conducted in Griffith Base Hospital between July 2022 until September 2022. Thirty-six participants returned a response of whom 67% are female and 33% are male. The roles of the respondents included nurses (42%), doctors (39%), medical students (14%) and theatre assistants or administration staff (5%). See Appendix II for table of responses. Figure 1 shows respondents’ attitudes and behaviours towards climate change. In our regional hospital we have found staff agree that climate change is concerning (89%) and that healthcare poses significant impacts on the environment (75%). Climate change has caused most respondents (86%) to change their behaviour in their personal life but only a smaller proportion have changed their behaviour at work (61%). Figure 2 shows respondents’ willingness to engage in measures to improve environmental sustainability in surgical practice. Majority are willing to engage in environmentally sustainable activities (97%) but most felt that they did not have the support of the hospital (22%) or colleagues (44%) in achieving this. About half of respondents (53%) agreed that they had the knowledge to improve sustainability at work but of these only a small group strongly agreed (11%). The other half (47%) disagreed or were neutral regarding this. When asked about barriers to change, lack of recycling facilities was perceived as the greatest barrier (92%) followed by inadequate training and information (81%). Other barriers to change in order were staff attitude (78%), time (72%), lack of leadership (69%), lack of support from colleagues (58%) and cost (58%). Only a small proportion of respondents considered safety (39%) to be a barrier. Respondents were also asked to respond in free text if they thought of any other barriers and few respondents mentioned a lack of government and hospital policy surrounding this. Another barrier suggested were poor staffing levels and needing to determine whose role it is carry out these strategies such as disposing of the recycling waste. Respondents were asked about strategies that they believed would be helpful in improving environmental sustainability. The most useful strategies were standardizing operating trays (97%) and using energy-efficient appliances (97%). Other strategies following these include switching off lights (94%), reusing unopened surgical equipment where appropriate (92%), placing recycling bins in operating theatres (92%), using a real-time power monitoring tool (86%) and conducting an audit on energy use (86%). Other strategies which were deemed helpful but less so included eliminating or reducing single-use items (83%), using low-energy lighting (81%), conducting an audit on waste production (81%) and unplugging equipment (58%). They were also asked to respond in the free text to any proposed suggestions that were not listed. Some of these suggestions include creating a steering committee to oversee education and efforts to ensure sustainable practice in the operating theatres. There were suggestions to reduce the amount of single-use equipment and reuse or recycle unused sterile drapes that have not been contaminated. Dedicated recycle bins should be made available for staff and patients. There are many suggestions on things that can be recycled in the operating theatres such as the cardboard from equipment, oxygen tubing/masks, IV bags, copper wire stripping of diathermy plates and electrical leads. When asked about their perceptions on the economic impact of environmentally friendly changes, respondents were divided in their responses. Majority have responded with unsure (47%) while some believe it will save money and increase revenue (31%) and others believe it will incur more costs and resources (22%). Published surveys have all found medical practitioners to be concerned regarding climate change and willing to engage in environmentally sustainable strategies.7-11 This local survey which included not only doctors but also other stakeholders of the operating theatre has shown the same results regarding perception and willingness to engage. Recycling is a strategy that was suggested by respondents as currently recycle bins are not available in our theatres. The lack of recycling facilities (92%) has been perceived as the greatest barrier to change in our operating theatres. There are many items throughout the patient's surgical journey that can be recycled such as paper, bottles and blue sterile wrapping. In some studies, it was found that up to 90% of waste generated from surgery was recyclable.12 In addition to that, waste destruction processes produce high GHG emissions and hence waste segregation between regulated medical waste and domestic waste is important in reducing emissions. Literature has shown that stakeholders often incorrectly segregated waste and this is a result of insufficient education.12 The Royal Australasian College of Surgeons (RACS) position paper in 2018 outlined the environmental impact of surgical practice and recommended surgeons to take leadership roles in efforts to reduce the impact of surgery on the environment.5 More than half of respondents believed there was a lack of leadership (69%) and a lack of support from colleagues (58%) in environmentally sustainable efforts in our local operating theatre. Many studies have suggested the importance of leadership and early engagement of stakeholders.2, 13 NSW government published a policy document which encompassed a vision and strategy for 7 years (2016–2023) to mitigate the negative impact of health activities on the environment. The vision is to create a resource efficient health system that reduces cost and reduces impact on the environment. The strategy encompasses some targets and key performance indicators regarding energy use, water use and waste management.14 In keeping with this vision, a potential strategy that can be implemented in our local hospital is to set up a local steering committee regarding environmental sustainability in the operating theatres. This committee should not be limited to one profession and should be ideally made up of surgeons, anaesthetists, nurses and administration staff. This will allow collaborative oversight of all efforts to be carried out by all stakeholders. Most respondents agreed that inadequate training and information (81%) was a barrier to change in this survey. Only half the respondents (53%) believed they had the knowledge to improve sustainability at work. Studies attempting to implement changes in practice to improve waste management have found that barriers can be counteracted with staff education and continual engagement.13 There is a potential to improve staff education regarding sustainable practices through information sessions, visual signage or verbal reminders during meetings to emphasize the importance of working together to improve environmental sustainability. In a systematic review of the carbon footprints from operating theatres, major contributors were energy use and consumables. Some studies suggested that electricity accounted for majority of carbon footprint with the highest consumption of electricity coming from maintaining the theatre environment with heating, ventilation and air-conditioning.15 In this survey, respondents ranked the use of energy efficient appliances as the most useful strategy (97%) and second to that were remembering to switch off lights (94%). Strategies to improve energy efficiency such as installing low energy lighting, more efficient air-conditioning and renewable energy sources require changes to infrastructure which can only be achieved with long term planning and adequate funding. Simpler strategies such as switching off lights or equipment when not in use can be implemented immediately and enforced with visual reminders such as signs. Single-use items are considered a large contributor to carbon footprint.15 The literature suggests that reusable instruments reduce cost and environmental impact compared with disposable instruments.16 Therefore, encouraging the use of reusable instruments should be preferred. The standardization of operating trays was also considered the most useful strategy (97%). This strategy is feasible to implement in the short term but would require cooperation from surgeons in having judicious selection of instruments for their trays and nursing staff to be well learned in the contents of trays. This can minimize wastage of single use item and reduce need for sterilization, reprocessing and repackaging reusable instruments. There are several limitations to this study. Firstly, the small sample size which reflects the small number of staff in our regional hospital impacts the generalizability of our results. Another limitation is that the survey was collected anonymously to increase participation and honesty of responses but this meant it was not possible to calculate response rates. Furthermore, when respondents were asked regarding barriers to change and strategies that they believe would be helpful, the original pilot study required respondents to rank their answers. However, this was too complicated and resulted in some respondents delaying the completion of the survey altogether. Therefore, these questions were changed to yes/no responses in the final questionnaire. It has been suggested that practices that are beneficial for the environment can also be cost-saving.2 In this survey, respondents were asked about their perceptions on the economic impact of environmentally friendly changes and respondents were divided in their responses. Future projects can look into the economic costs of implementing environmentally sustainable changes and whether or not it increases or reduces cost. Further studies that seek to quantify the cost and effect of any strategies implemented would be beneficial in supporting environmentally sustainable practices in the operating theatre. Operating theatres have a significant carbon footprint. This survey has shown that stakeholders in our regional hospital are concerned regarding the impact of climate change and are willing to engage in more environmentally sustainable activities. We have proposed some strategies that can be implemented in our practice and will aim to create a steering committee to lead efforts in implementing environmentally sustainable changes in our operating theatres. Open access publishing facilitated by University of New South Wales, as part of the Wiley – University of New South Wales agreement via the Council of Australian University Librarians. Kah Ann Ho: Conceptualization; data curation; project administration; writing – original draft. Zainab Naseem: Conceptualization; supervision; writing – review and editing. Title: Greener Theatre, Greener Surgery – Environmental Sustainability in Surgery We are seeking your opinions and understanding regarding sustainability in the operating theatres of Griffith Base Hospital and its impact on climate change. There will be four pages with multiple-choice questions and a section at the end for free word responses. This survey should take no more than 5 min to complete. We will be commencing a local project in Griffith Hospital on improving sustainability in our operating theatres. Your views will inform the next part of our study which will be to implement some practical changes to the way we run our operating theatres. Your data will remain anonymous and findings will be published in a non-identifiable form. You may choose to sign in but you do not need to sign in to complete this survey. If you are doing this survey on your mobile phone, it is best done with landscape orientation so you can see all the answers in full. If you have any questions or difficulties, please do not hesitate to contact us. We look forward to receiving your feedback Kind Regards, Dr Kah Ann Ho (Email: [email protected]) Dr Zainab Naseem Department of General Surgery Griffith Base Hospital (Open question) Please list any other barriers you can think of? (Open question) Please list any opinions or suggestions regarding sustainability of surgical practice or ideas to improve sustainability in Griffith Hospital? What is your role Gender Thank you for your time If you have any further suggestions or you are interested in getting more involved with our study, please do not hesitate to contact us.

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