Sustainability
developed – which patients like, and it has the collateral benefit of reducing unnecessary transport emissions. These are all helpful when the backlog of necessary surgery still continues to stress surgical teams with sicker patients and greater workload.
Lean surgery delivery Lean surgery involves streamlining surgical pathways to assist with the development of optimising resource utilisation – which involves equipment, time, space, financial and workforce capacity. The streamlining largely focuses on reducing consumables and avoiding opening items, which may only be needed occasionally. This author realises that times must have changed in clinical practice – we only ever opened things when they were deemed necessary, not due to planetary health, but due to operating theatre costs, which were always under pressure. There are many activities that could be listed,
which help the streamlining process, but are not often undertaken by surgical teams – due to lack of time, leadership and motivation. Choosing which interventions to implement is
Scope Definition Example
The surgical workforce needs to be supported in its educational needs by the addition of theoretical knowledge on the environmental impacts of surgery and the principles of sustainable practice to support their ability to drive change.
possibly the greatest current challenge, given the paucity of time and energy available. These will be discussed in the next article, when we will focus on clinical actions and partnerships.
Theatre design Operating theatres are three to six times more energy intensive than clinical wards in the hospital. Most of this is down to heating, ventilation and air conditioning. Gas scavenging systems (AGSS) also get a frequent mention in the literature as being very heavy on energy use with the remainder on lighting, IT and medical equipment, which is probably the many different monitoring machines and others – such as
Responsible for % of NHS England GHG emissions
Scope 1 GHGs directly
emitted from and controlled by an organisation
Anaesthetic gases Hydrofluorcarbons or chlorofluorocarbon
propellants from metered dose inhalers
Direct emissions
from combustion of petrol or diesel from NHS owned or leased vehicles
Combustion of fossil fuels onsite such as within gas boilers
Scope 2 Scope 3
GHGs indirectly emitted due to
energy purchased All other GHGs
Purchased as
electricity, steam, heating or cooling.
Supply chain including
Pharma and chemicals Medical equipment Non-medical equipment
Patient, visitor and staff travel Water and waste disposal Commissioned services
Table 1 16
www.clinicalservicesjournal.com I June 2024
10% 5% 4%
62% 10% 4% 5%
electrosurgical devices, harmonic scalpels and increasingly robotic devices. AGSS can be switched off if total intravenous anaesthesia (TIVA) is in use, which many theatre teams would not consider. It is helpful to have excellent relationships
with EBME (Electro-Bio Medical Engineering) in hospitals, so that when complex equipment develops a fault, it can be effectively remedied on site. However, there are also many major infrastructure items which can be retrofitted, that can reduce the energy use of operating theatres such as the lighting – which is far more efficient if motion sensors are installed. There should be protocols devised to ensure that heating, lighting and ventilation is switched off at the end of each day to reduce energy consumption. This too goes back to the old days where this was part of ‘closing theatres’ at the end of surgery; we used to ‘set back’ the power usage. Advanced ventilation systems can be installed but, due to their cost, are unlikely to be changed once installed. For instance, there is an energy mitigated type of ventilation called a Temperature Controlled Airflow which uses cool HEPA filtered air above the operating table, which can achieve ultraclean air conditions. It is not known if this newest type of ventilation has yet made its way into the Operating Theatre Building Note for new theatre builds. All teams involved in the design and build of new
theatres now need to refer to the NHS England Net Zero Building Standard, which provides technical guidance on development of sustainable, resilient and energy efficient buildings.6
Barriers and facilitators While evidence of implementation of successful sustainable interventions has been available for some time, generally, there is a lack of quality evidence and even less information on cost-effectiveness. Implementation of single elements of sustainable surgery will not gather the support required by hospital leadership, other surgical team members and patient groups, if there is only poor-quality research. Results will need to be ingrained into the surgical pathway and behaviours of all staff
Page 1 |
Page 2 |
Page 3 |
Page 4 |
Page 5 |
Page 6 |
Page 7 |
Page 8 |
Page 9 |
Page 10 |
Page 11 |
Page 12 |
Page 13 |
Page 14 |
Page 15 |
Page 16 |
Page 17 |
Page 18 |
Page 19 |
Page 20 |
Page 21 |
Page 22 |
Page 23 |
Page 24 |
Page 25 |
Page 26 |
Page 27 |
Page 28 |
Page 29 |
Page 30 |
Page 31 |
Page 32 |
Page 33 |
Page 34 |
Page 35 |
Page 36 |
Page 37 |
Page 38 |
Page 39 |
Page 40 |
Page 41 |
Page 42 |
Page 43 |
Page 44 |
Page 45 |
Page 46 |
Page 47 |
Page 48 |
Page 49 |
Page 50 |
Page 51 |
Page 52 |
Page 53 |
Page 54 |
Page 55 |
Page 56 |
Page 57 |
Page 58 |
Page 59 |
Page 60 |
Page 61 |
Page 62 |
Page 63 |
Page 64 |
Page 65 |
Page 66 |
Page 67 |
Page 68 |
Page 69 |
Page 70 |
Page 71 |
Page 72 |
Page 73 |
Page 74 |
Page 75 |
Page 76 |
Page 77 |
Page 78 |
Page 79 |
Page 80 |
Page 81 |
Page 82 |
Page 83 |
Page 84 |
Page 85 |
Page 86 |
Page 87 |
Page 88
