The business case for sustainability in surgery
Moyle, Julie K. MSN, RN; Lynn, Cecilia DeLoach MBA, LEED AP
Julie K. Moyle is the Founder of 1x1 Consulting and a Staff Nurse at Avista Surgery Center, Boulder, Colo. Cecilia DeLoach Lynn is the Director of Facility Engagement & Metrics at Practice Greenhealth, Reston, Va.
This article is based in part on a presentation given at the Association of periOperative Registered Nurses (AORN) 2013 Congress, March 4, 2013 in San Diego, Calif. The authors wish to recognize contributing partners Debra J. Savage, MSN, RN, CNOR, Beth Israel Deaconess Medical Center East, Liisa J. Nenonen, BSN, RN, CNOR, Alta Bates Summit Medical, Bonnie G. Denholm, MS, BSN, RN, CNOR, Perioperative Nursing Specialist, AORN, and Kaeleigh Sheehan, Project Manager at Practice Greenhealth.
The authors have disclosed that they have the following financial relationships related to this article: Practice Greenhealth, Centura Health, and Pfiedler Enterprises.
Because of the complexity of surgical services and their impact on hospitals' bottom line, perioperative administrators have arguably one of the most challenging and influential positions within a healthcare facility. The OR is the largest generator of revenue for hospitals and accounts for approximately 40% of total revenue.1 The OR also comprises up to 56% of overall hospital supply expense.2 Surgical services also have a significant environmental footprint.3–7 Environmental exposures associated with energy generation, climate change, waste disposal, and chemical exposures have a detrimental impact on human health.8–14 Measures that “reduce the need for medical services to treat conditions that can be prevented, thereby, helping to control costs” are included in the Affordable Care Act.15
As a management strategy, sustainability reduces costs, creates new revenue streams, and develops more innovative business models.16 A 2012 study demonstrated that if all of the nation's hospitals adopted a set of environmental best practices (a number of which were OR-specific), the healthcare system could save $5.4 billion over 5 years, with ongoing and increasing savings of $15 billion over 10 years.17
An insufficient business case is often cited as a barrier to implementation of environmental measures.16 Ironically, a business analysis of environmental best practices not only debunks the perception that “green” costs more, it actually creates a more compelling rationale for adopting such initiatives.17 An emerging set of environmental best practices is being defined for the OR that protects patient and caregiver safety, creates financial savings, and reduces environmental impact.18–21
Regulated medical waste
Perioperative services generate between 20% and 30% of total facility waste and nearly 60% of the hospital's regulated medical waste (RMW).4,5,22 RMW not only incurs considerable disposal fees, it can also present a public health threat if disposed of via incineration due to the potential release of dioxin into the environment.11,23,24 Hospitals are responding by implementing comprehensive RMW segregation practices that ensure only infectious material (as defined by each state) is placed in the RMW container with a goal of reducing RMW to less than 10% of total waste.25 A key strategy for reducing RMW is to ensure clean and/or recyclable packaging materials are not placed in an RMW container during precase setup and throughout the procedure. Inova Fairfax, an 833-bed tertiary care and children's hospital in Northern Virginia, generated more than $15,000 in cost-savings over a 6-month period and demonstrated an 18.6% reduction in RMW generated in their ORs.26 The hospital utilized an initial waste audit in surgical areas to identify inappropriate waste going into the RMW container, followed by strategic resizing and location of RMW receptacles, staff education (in-services and annual education, posters), and ongoing spot audits.
Single-use device reprocessing
The collection of FDA-approved, single-use devices (SUDs) for reprocessing is another strategy to reduce waste. Most major reprocessing vendors provide free collection services. The Government Accountability Office has validated that reprocessed SUDs pose no greater risk to patient safety than devices from original equipment manufacturers.27 Discounts of more than 50% provide financial savings while still ensuring quality and protecting patient safety.28 SUD collection and reprocessing could save hospitals more than $540 million each year or nearly $2.7 billion over 5 years.17
Reusable surgical linens
Disposable surgical linens significantly contribute to OR waste.29 A 2010 study at two major Washington, DC area hospitals piloted high-performance, reusable surgical linens against disposable linens, and clinicians overwhelmingly preferred reusable to disposable gowns for comfort, ease of use, and protective properties.29 Many hospitals employ an FDA-approved third-party reprocessing company to collect, clean, repair, repackage, and sterilize reusable surgical linens, ensuring that they meet all infection control and performance standards before reuse. In 2010, the University of Maryland Medical Center found that using outsourced, reusable surgical gowns and basins helped them avoid 138,748 lbs (62,935 kgs) of waste annually for an estimated savings of $38,849. The program also saved an estimated $39,000 by reclaiming surgical instrumentation that was inadvertently sent to the reprocessor along with gowns and table covers—instruments that would have otherwise ended up in the waste stream with the single-use disposable linens.30
Fluid management systems
A study at a Minnesota hospital found that 40% of the biohazardous waste generated in the OR was comprised of fluid waste in suction canisters.31 Used as a method of managing fluid wastes, disposable suction canisters and liners expose OR personnel to blood and body fluids when they manually cap and recap canister ports.32 Enclosed fluid waste management systems are designed to empty fluid wastes automatically into the sanitary sewer, vastly reducing the risk of exposure to staff and significantly decreasing the volume of fluid waste and weight that would otherwise be placed into the expensive RMW stream.
In 2010, Bon Secours Good Samaritan Hospital, Suffern, NY, avoided 261,999 lbs (118,840.7 kgs) of waste and saved $86,240 by using a closed-fluid waste management system.18 Fluid management systems with an integrated, reusable canister also avoid the need for single-use, plastic suction canisters and liners. Other reported benefits of these systems include reduced slips from fluid spills, reduced electrical hazards from fluid spills, and more accurate measurement of patient fluid loss during the procedure.33
OR kit reformulation
The University of Minnesota Medical Center, Fairview, implemented a comprehensive kit reformulation program in 2010 that measured avoided supply costs and avoided waste disposal fees. The hospital reviewed 39 kits and reduced waste by 10,553 lbs (4,786.8 kgs), a total savings of $116,215.34 The Mayo Clinic in Rochester, Minn., saved nearly $125,000 in supply costs in 1 year by reformulating its custom packs in collaboration with its vendor.18 New scrutiny around what hospitals are charging per procedure will also likely increase the value of waste and cost reduction programs as hospitals focus on internal drivers of procedure costs.35–38
Reusable sterilization containers
Single-use, disposable sterile wrap, a polypropylene plastic, comprises approximately 19% of the OR waste stream.39 While many institutions are investigating mechanisms to recycle the prolific material, a number of leading hospitals reduce this expense by utilizing reusable sterilization containers. MetroWest Medical Center, Framingham, Mass., purchased 211 containers and achieved a 40% return on its $75,000 capital investment within 1 year by avoiding $29,843 in purchase and waste disposal costs for disposable sterile wrap.40 Boulder Community Hospital, Colo., invested $150,000 in reusable sterilization containers in 2003, reducing supply costs for sterile wrap by $190,000 annually with a 1.5-year payback on the containers.18
Mills-Peninsula Medical Center in Burlingame, Calif. also estimated an additional annual savings of $26,000 in rewrapping costs for torn blue wrap sets.18 Other benefits include better instrument retention, improved workflow, and decreased turnover time in the Sterile Processing Department.40
Surgical settings have the highest requirements for air exchanges per hour of any area within the hospital, along with precise requirements for maintaining pressure, temperature, and humidity. They also use complex diagnostic and monitoring equipment, medical vacuum gas pumps and sophisticated surgical lighting, making ORs one of the most energy-intensive areas in the hospital. The average energy cost per OR is approximately $30,000 per year, yet many ORs are unoccupied 40% or more of the time.41,42 The American Society for Healthcare Engineering outlines strategies to temporarily reduce the number of air changes while the ORs are unoccupied based on scheduling software, occupancy sensors, or manual set back controls.42 Providence St. Peter Hospital in Olympia, Wash., utilized occupancy sensors to lower air changes in two new digital ORs during unoccupied periods, reducing the air flow by 60% and saving 25,000 kilowat hours (kWh) and 2,460 therms for a combined $4,000 in annual energy savings.43
LED surgical lighting
Halogen surgical lighting meets rigorous clinical performance criteria; however, challenges include the generation of considerable heat within the surgical field, often resulting in lower temperature set points in the OR to keep clinicians comfortable during the procedure. This creates the need for patient warming devices to prevent hypothermia. Light-emitting diode (LED) technology meets all clinical performance standards while also reducing energy use by 50% over halogen lighting and generates significantly less heat within the surgical field.44 LEDs last considerably longer than halogen bulbs (25,000 to 40,000 hours as compared to 1,000 to 3,000), require less maintenance, and fade slowly over time rather than burning out suddenly.44
Connecting to resources
With the growing momentum around sustainability in healthcare, there are a host of resources and networks to support perioperative leaders in their efforts to learn more about environmental best practices in surgical settings. (See Resources.) Perioperative leaders have an opportunity to demonstrate their leadership and influence by integrating a set of environmental best practices that align with the healthcare imperative to do no harm and better protect health while also ensuring fiscal responsibility and safety.
Greening the OR Initiative: Practice Greenhealth has developed the Greening the OR Initiative (GOR). The GOR offers tools and resources for targeted sustainability efforts within the OR. Learn more at www.greeningtheor.org.
Healthier Hospitals Initiative: A 3-year challenge to engage the nation's hospitals in adopting a basic set of environmental best practices, Healthier Hospitals Initiative (HHI) offers a series of free webinars, implementation guides. Learn more at www.healthierhospitals.org.
Association of periOperative Registered Nurses: Association of periOperative Registered Nurses (AORN) has an updated position statement on environmental responsibility and has launched a “Going Green” discussion forum. Visit www.aorn.org.
Memorial Sloan-Kettering Cancer Center Library: The hospital has collected a web-based set of resources on managing the environmental impact of the OR. Learn more at http://libguides.mskcc.org/content.php?pid=176027&sid=1482252.
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