Greening the OR through Waste Reduction

Knowledge of the environmental and public health impacts associated with current waste-disposal practices is growing. Globally, healthcare consumes about 9.6 gigatons of materials, or 10 percent of all materials used by humans. The burden of landfill disposal is growing, and an estimated 11 million tons of plastic are dumped into oceans every year. The extraction, manufacture, transportation, use, and disposal of healthcare materials generates environmental pollutants and nearly 5 percent of global greenhouse gas (GHG) emissions, of which disposable products have been found to comprise up to 20 percent.

Orthopaedic surgery is known to be both resource- and waste-intensive. Pathways to reduce waste and emissions include accurate waste segregation, recycling programs, streamlining of surgical trays and sets, and utilization of regional anesthesia and procedure rooms, among others. Orthopaedic surgeons and their teams can significantly further the goals of sustainability by incorporating such principles into their daily habits. Doing so also offers opportunities to provide high-quality care at a lower cost, which promotes health access and equity.

More than one-third of health systems’ solid waste and emissions originate in the OR. Commonly wasted materials in ORs include packaging, cardboard, blue wrap, plastic, and others. The vast majority (>80 percent) of OR waste is nonhazardous (“white bag”) and can be disposed of or recycled in a manner similar to household waste. The management of hazardous (also referred to as “regulated” or “red bag”) waste, on the other hand, requires adherence to more rigorous processing standards (Fig. 1). This makes hazardous waste more expensive and emissions-intensive to treat than “white bag” waste. Improper sorting of nonhazardous items into hazardous waste unnecessarily increases health system costs and GHG emissions. The definitions of what constitutes hazardous waste and the processing standards required for its varied subtypes vary by state and by institution.

OR recycling
In addition to improved sorting, ORs can engage in recycling initiatives. Clean paper, cardboard, and plastic are the most commonly recycled materials in ORs, comprising 2.9 of 8.8 kilograms of waste in a recent study of arthroplasty cases. Well-established recycling infrastructure exists in most municipalities for such materials, making it relatively easy to enact. By updating OR waste stream sorting, Martin et al found that recycled material weight and number of bags increased by 19 percent and 45 percent, respectively. Implementing an OR recycling education program can also generate significant cost savings.

Only 5 percent of U.S. plastic gets recycled due to several unique challenges. Most consumer plastics are labeled with a triangular symbol with a number representing resin type (Fig. 2); however, medical products and packaging are rarely labeled. Type 5 plastic is the most ubiquitous plastic in the OR, but differences in the types and grades of materials included make it a mediocre recycling candidate. Many plastics marketed as recyclable are only theoretically so—technology and facilities are either scarce or economically unviable. Composite materials (including multi-material laminations used ubiquitously in pouches, blister packs, and film bags) cannot be recycled.

Blue wrap: challenges and opportunities
Blue wrap is a polypropylene sheet commonly used to demarcate sterilized instrument trays, accounting for as much as 19 percent of OR waste, and it typically ends up in landfills. It can be recycled by specialty haulers and used to create other plastic items. An initiative at a single institution found that offering and training staff on blue wrap recycling resulted in $5,000 in annual revenue and nearly $175,000 savings per year in cost avoidance associated with disposal. Blue wrap recycling is a potential solution, but avoiding its use altogether should be prioritized. Substituting reusable aluminum sterile cases for blue wrap nearly eliminates waste between sterilizations. Life-cycle assessment studies have found that such hard cases create half the GHG emissions compared to blue wrap and avoid the high failure and re-sterilization rates related to blue wrap holes and contamination.

Fewer instruments, smaller trays
Instrument processing and sterilization generate GHG emissions through energy, water, and chemical use. Sterilization machines have limited capacity, so maximizing the number of instruments sterilized per cycle can promote efficient energy and water use while also saving labor costs and time. Reducing the size of trays and packing instruments more efficiently reduces the carbon footprint per instrument (Fig. 3). Separately packing (also known as “peel-packing”) instruments conveys a three-fold increase in GHGs per instrument. Such factors must be balanced with desires to remove redundant instruments from trays; if doing so necessarily increases the need for opening additional trays or opening multiple peel-packed instruments during most cases, the benefit of tray reduction may be lost.

WALANT surgery
Hand surgery has made remarkable strides in reducing OR waste, particularly with the advent of wide-awake local anesthetic no tourniquet (WALANT) surgery. These surgeries have been demonstrated to be safe with low infection and complication rates, and they are performed in a procedure room or office setting with field sterility, minimizing equipment and ancillary staff needs. WALANT surgery reduces emissions by avoiding inhaled anesthetics, utilizing small instrument trays, minimizing disposable items (e.g., basins, drapes, gowns), and reducing building energy consumption. In the sample procedure room shown in Fig. 4, two windows provide ambient light, and a waterless scrub dispenser saves water. In addition, patients undergoing WALANT tend to require no preoperative visits or tests, reducing GHG emissions from travel, building energy, and supplies.

Sustainability, waste, and costs 
Promoting sustainable practices and waste reduction has yielded unforeseen cost savings for many health systems. Siebr et al found that switching from large to minimal drapes reduced cost by around $4,000 per year. By eliminating disposable items from surgical packs, Albert et al generated cost savings of $17,000 annually. Tighe et al found that lean WALANT setups cost $105 versus $230 for a standard OR setup. Bravo et al evaluated opened but unused disposable items in 85 consecutive hand surgical cases and found that unused disposables amounted to approximately $2,000 and 441 kilograms of carbon dioxide equivalent wasted. Such examples are clear reminders that waste and cost are intimately connected, and sustainability offers opportunities to simultaneously reduce the burden of musculoskeletal care on patients, the planet, and budgets.

Laura L. Bellaire, MD, FAAOS, is a pediatric orthopaedic and spine surgeon at the University of Utah in Salt Lake City.

Allison Mitchell, MD, is an orthopaedic hand surgeon at Salem Hospital in Salem, Oregon.

Brittany N. Garcia, MD, is an adult and pediatric hand surgeon at the University of Utah in Salt Lake City.

Eitan Melamed, MD, is the chief of hand surgery at NYC Health + Hospitals/Elmhurst and associate professor of orthopaedic and plastic surgery at the Icahn School of Medicine at Mount Sinai in New York, NY.

Cassandra L. Thiel, PhD, is an assistant professor in the Department of Population Health at NYU Langone Health and the president and chief executive officer of Clinically Sustainable Consulting LLC in Middleton, Wisconsin.

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