Sustainable theatres
identify new revenue products for use. However, few of them consider the whole life cycle of the item and instead are more likely to focus on price and product. Sustainability is an important feature – as well as re-usability – and, hence, decontamination and sterilisation capability of each item should be included in the consideration of each alternative product and final disposal.
Anaesthetics The Intercollegiate Green Theatre Checklist3 provides the inspiration for much of the following with the authors thoughts and additions for further action. The evidence-based compendium created by all the Royal Colleges of Surgeons seeks to provide help for local surgical teams to devise their own strategies for carbon footprint reduction. The recommendations apply the principles of sustainable quality improvement in healthcare, which aim to achieve the “triple bottom line” of environmental, social and economic impacts. Modern anaesthetic gases are expelled into the atmosphere and contribute to climate change. They also represent 5% of the carbon footprint for all acute NHS organisations, so action needed to be taken to reduce the use of sevofluorane, isoflurane and desflurane and nitrous oxide. The most damaging of the hydrofluorocarbons, desflurane has been removed from clinical practice by a number of Trusts altogether and its use reduced significantly by others. Nitrous oxide, used to support fresh gas flow delivery and in Entonox, in trauma and obstetric services, is more difficult to avoid, as there is a lack of suitable alternatives. However, technology – mobile destruction units – have been developed to “crack” the exhaled nitrous oxide into harmless nitrogen and oxygen, and some Trusts have begun to use this approach.4,5 The compendium suggests that the use of
NHS Carbon Footprint Plus Indirect emissions
Medical devices Freight transport Business services Medicines Food and catering Construction Commissioned services outside NHS Digital services Manufacturing Patient/ Visitor travel Staff commuting
Table 1
local and regional anaesthesia could be more commonly used than the default general anaesthetic with benefits for patients, as well as the environment. TIVA or Total Intra- Venous Anaesthesia is suggested to reduce the potential of volatile anaesthetic gases being used. It also suggests that some of the equipment used within routine anaesthetic care could be switched to more sustainable items – i.e. reusable laryngoscopes, direct- contact heaters, and there will be many more in individual practice.
Pre-operative Theatre drapes, gowns and sterile covers for trolleys and packs could all be returned to reusable textiles as there is considerable emerging evidence that the carbon footprint of single use items is more than first thought. However, this is not without its consequences particularly on the provision of laundry facilities locally.
It should be mentioned here that this is not a
return to the green cotton in use for much of my career, but the modern textiles which undergo thorough quality tests in line with EN 13795, together with ongoing audit of material integrity and number of uses.6
The Green Surgery
Challenge has an assessment of this practice being undertaken, among other elements, at Leeds Teaching Hospital Trust. We await the outcome with interest. There has been a mountain of literature on hand hygiene in the last fifteen years and the arguments between the effectiveness of hand rubbing with alcohol and soap and water scrubs. The energy saving way which meets the recommendations by NICE7
for reducing
the incidence of surgical site infections is to undertake a soap and water scrub at the beginning of the day, followed by alcohol-based hand rub which can be used on clean hands for subsequent scrubs. This saves time and water. It is also suggested that a further water saving technique is to install, at scrub sinks, knee or foot operated tap mechanisms, so that less water runs down the drain. Clinically unnecessary interventions are
included in this section mentioning reducing the avoidable use of antibiotics and, to follow NICE guidance, antibiotics should only be used in the presence of an implant or where surgery is occurring in a contaminated site. In addition, it suggests that single use urinary catheters have a large environmental impact. Leeds Teaching Hospital Trust Green Surgery Challenge 2021 seeks to replace catheterisation with pre- induction toileting.8
Intra-operative The compendium suggests (and this is not new but has been discussed for twenty years) that review and rationalisation of instrument sets can save set-up time and wasted energy for sterile services. The cost of decontamination and sterilisation are charged to the hospital, each time the instrument set circulates. One department found they could reduce tray contents by 70%; each of those instruments must be washed, not just the dirty ones, and inspected, packed and returned. Preference cards are full of unnecessary items and, in many instances, are out of
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www.clinicalservicesjournal.com I July 2023
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