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The business case for sustainability in surgery

Moyle, Julie K. MSN, RN; Lynn, Cecilia DeLoach MBA, LEED AP

Author Information

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

HVAC setback

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.

Resources

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.

REFERENCES

1. Shamayleh A, Fowler J, Zhang M. Operating room capacity planning decisions. World Academy of Science, Engineering and Technology. 2012;64(128):665–669. http://www.waset.org/journals/waset/v64/v64-128.pdf.

Cited Here...

2. Park KW, Dickerson C. Can efficient supply management in the operating room save millions. Curr Opin Anaesthesiol. 2009;22(2):242–248.

Cited Here... | View Full Text | PubMed | CrossRef

3. MacNeill A, Lillywhite R, Brown C. D5: reducing greenhouse gases from the operating room: a carbon footprinting study. Presented at CleanMed. Denver, CO. 2012. http://www.prolibraries.com/pgh/?select=session&sessionID=82.

Cited Here...

4. Goldberg ME, Vekeman D, Torjman MC, Seltzer JL, Kynes T. Medical waste in the environment: do anesthesia personnel have a role to play. J Clin Anesth. 1996;8(6):475–479.

Cited Here... | PubMed | CrossRef

5. Tieszen ME, Gruenberg JC. A quantitative, qualitative, and critical assessment of surgical waste. Surgeons venture through the trash can. JAMA. 1992;267(20):2765–2768.

Cited Here... | PubMed | CrossRef

6. Esaki RK, Macario A. Wastage of supplies and drugs in the operating room. Medscape Anesthesiology. 2009. www.medscape.com/viewarticle/710513.

7. Stall NM, Kagoma YM, Bondy JN, Naudie D. Surgical waste audit of 5 total knee arthroplasties. Can J Surg. 2013;56(2):97–102.

Cited Here... | View Full Text | PubMed | CrossRef

8. Smith KR, Frumkin H, Balakrishnan K, et al. Energy and human health. Annu Rev Public Health. 2013;34:159–188.

Cited Here... | PubMed | CrossRef

9. Costello A, Abbas M, Allen A, et al. Managing the health effects of climate change: Lancet and University College London Institute for Global Health Commission. Lancet. 2009;373(9676):1693–1733.

PubMed | CrossRef

10. Anstey MH. Climate change and health—what's the problem. Global Health. 2013;9:4.

11. World Health Organization. Fact Sheet No. 225: dioxins and their effects on human health. 2010. http://www.who.int/mediacentre/factsheets/fs225/en/.

Cited Here...

12. Prüss-Ustün A, Vickers C, Haefliger P, Bertollini R. Knowns and unknowns on burden of disease due to chemicals: a systematic review. Environ Health. 2011;10:9.

PubMed | CrossRef

13. Landrigan PJ, Schechter CB, Lipton JM, Fahs MC, Schwartz J. Environmental pollutants and disease in American children: estimates of morbidity, mortality, and costs for lead poisoning, asthma, cancer, and developmental disabilities. Environ Health Perspect. 2002;110(7):721–728.

PubMed | CrossRef

14. Trasande L, Liu Y. Reducing the staggering costs of environmental disease in children, estimated at $76.6 billion in 2008. Health Aff (Millwood). 2011;30(5):863–870.

Cited Here...

15. Hardcastle LE, Record KL, Jacobson PD, Gostin LO. Improving the population's health: the Affordable Care Act and the importance of integration. J Law Med Ethics. 2011;39(3):317–327.

Cited Here... | PubMed

16. Berns M, Townend A, Khayat Z, et al. The business of sustainability: Findings and insights from the first annual business of sustainability survey and the global thought leaders research project. MIT Sloan Management Review. 2009. http://www.mitsmr-ezine.com./busofsustainability/2009#pg1.

Cited Here...

17. Kaplan S, Sadler B, Little K, Franz C, Orris P. Can sustainable hospitals help bend the health care cost curve. Issue Brief (Commonw Fund). 2012;29:1–14. http://www.commonwealthfund.org/Publications/Issue-Briefs/2012/Nov/Sustainable-Hospitals.aspx.

Cited Here...

18. Practice Greenhealth. The Business Case for Greening the OR. Greening the OR ® Initiative. 2012. http://practicegreenhealth.org/initiatives/greening-operating-room.

Cited Here...

19. Kagoma Y, Stall N, Rubinstein E, Naudie D. People, planet and profits: the case for greening operating rooms. CMAJ. 2012;184(17):1905–1911.

View Full Text | PubMed | CrossRef

20. Kwakye G, Brat GA, Makary MA. Green surgical practices for health care. Arch Surg. 2011;146(2):131–136.

View Full Text | PubMed | CrossRef

21. AORN. AORN Position Statement: Environmental Responsibility. 2006. http://www.aorn.org/Clinical_Practice/Position_Statements/Position_Statements.aspx.

Cited Here...

22. United States Air Force IERA. Medical Waste Incinerator Waste Management Plan-Malcolm Grow Medical Center, Building 1056, Andrews Air Force Base, MD. 2001. http://www.dtic.mil/cgi-bin/GetTRDoc?Location=U2&doc=GetTRDoc.pdf&AD=ADA393684.

Cited Here...

23. Practice Greenhealth. 2012 Sustainability Benchmark Report: A Practice Greenhealth Member Benefit. 2012. https://practicegreenhealth.org/tools-resources/sustainability-benchmark-report-0.

Cited Here...

24. What's Wrong with Incineration? Pub 3-02 in Going Green: A Resource Kit for Pollution Prevention in Health Care. Health Care Without Harm. 2002. http://www.noharm.org/lib/downloads/waste/Whats_Wrong_w_Incineration.pdf.

Cited Here...

25. Healthier Hospitals Initiative. Less Waste Challenge. Healthier Hospitals Initiative Website. http://healthierhospitals.org/hhi-challenges/less-waste.

Cited Here...

26. Practice Greenhealth. Greening the OR® Case Study: Inova Fairfax Hospital: regulated medical waste reduction and minimization. 2011. https://practicegreenhealth.org/sites/default/files/upload-files/casestudy_inova_r6_web.pdf.

Cited Here...

27. GAO Report to the Committee on Oversight and Government Reform, House of Representatives. Reprocessed Single Use Medical Devices: FDA Oversight Has Increased, and Available Information Does Not Indicate That Use Presents an Elevated Health Risk. http://www.gao.gov/new.items/d08147.pdf.

Cited Here...

28. Kwakye G, Pronovost PJ, Makary MA. Commentary: a call to go green in health care by reprocessing medical equipment. Acad Med. 2010;85(3):398–400.

Cited Here... | View Full Text | PubMed | CrossRef

29. Conrardy J, Hillanbrand M, Myers S, Nussbaum GF. Reducing medical waste. AORN J. 2010;91(6):711–721.

Cited Here... | View Full Text | PubMed | CrossRef

30. Practice Greenhealth. Greening the OR® Case Study: University of Maryland Medical Center: Reusable Textiles in the OR. 2011. https://practicegreenhealth.org/sites/default/files/upload-files/casestudy_uofmd_r7_web.pdf.

Cited Here...

31. Minnesota Technical Assistance Program. Suction Canister Waste Reduction. 2007. http://www.mntap.umn.edu/health/resources/91-Canister.pdf.

Cited Here...

32. Barlow RD. Proper liquid waste disposal mines solid gold bottom line. Healthcare Purchasing News. 2004. http://www.hpnonline.com/inside/2004-06/liquid_waste_disposal.htm.

Cited Here...

33. Practice Greenhealth. Greening the OR® Case Study: North Suburban Medical Center: Fluid Management in the OR. 2011. https://practicegreenhealth.org/sites/default/files/upload-files/casestudy_nsuburban_r5_web.pdf.

Cited Here...

34. Practice Greenhealth. Greening the OR® Case Study: University of Minnesota Medical Center, Fairview: OR Kit Reformulation. 2011. https://practicegreenhealth.org/sites/default/files/upload-files/casestudy_uofmn_r5_web.pdf.

Cited Here...

35. Brill S. Bitter Pill: why medical bills are killing us. Time Magazine, Special Report. 2013. http://www.time.com/time/magazine/article/0,9171,2136864,00.html.

Cited Here...

36. Rosenthal E. The $2.7 trillion medical bill: colonoscopies explain why the U.S. leads the world in health expenditures. The New York Times. 2013. http://www.nytimes.com/2013/06/02/health/colonoscopies-explain-why-us-leads-the-world-in-health-expenditures.html?pagewanted=all&_r=0.

37. US Department of Health and Human Services. News Release: administration offers consumers an unprecedented look at hospital charges. 2013. http://www.hhs.gov/news/press/2013pres/05/20130508a.html.

38. US Government Accountability Office: Report to Congressional Requesters. Health care price transparency: meaningful price information is difficult for consumers to obtain prior to receiving care. GAO—11-791. 2011. http://www.gao.gov/new.items/d11791.pdf.

Cited Here...

39. Laustsen G. Greening in healthcare. Nurs Manage. 2010;41(11):26–31.

Cited Here... | View Full Text | PubMed | CrossRef

40. Practice Greenhealth. Greening the OR® Case Study: MetroWest Medical Center, Natick & Framingham: Rigid Sterilization Containers for Surgical Instrumentation. 2011. https://practicegreenhealth.org/sites/default/files/upload-files/casestudy_metrowest_r6_web_1.pdf.

Cited Here...

41. Greeley D, Griffiths J. Energy-Efficient Operating Rooms. Greening the OR Webinar Series. Practice Greenhealth. 2012. http://www.prolibraries.com/pgh/?select=session&sessionID=112#.

Cited Here...

42. ASHE Monograph: operating room HVAC setback strategies. 2011. http://www.mazzetti.com/images/uploads/ASHE_Monograph-OR_Setback_Strategies.pdf.

Cited Here...

43. Practice Greenhealth. Greening the OR® Case Study: Providence St Peter Hospital: Energy Efficiency in the OR—HVAC Setback Program. 2011. https://practicegreenhealth.org/sites/default/files/upload-files/casestudy_providence_r5_web.pdf.

Cited Here...

44. Tuenge JR. Technical Guidance Document: LED Surgical Task Lighting. United Stated Department of Energy Building Technologies Program. 2011. http://apps1.eere.energy.gov/buildings/publications/pdfs/alliances/hea_surgical_task_fs.pdf.

Cited Here...

 

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