Sustainability


and numerous studies and guidelines recommend against routine pre-operative tests for healthy patients undergoing low-risk surgery. They suggest, instead, that investigations are targeted to patient comorbidities and the risks of the specific surgical procedure. Where the procedure takes place is


also potentially open to consideration. As a perioperative nurse, this author finds this a difficult topic for consideration. The optimum degree of safety is in the operating theatre rather than an outpatient cubicle or a ward procedure room, supported by staff with knowledge of the procedure. However, the operating room is the most expensive option and may not be necessary for specific procedures. The Green Surgery Report suggests that carpel tunnel decompression, grommet insertion and transperineal prostate biopsy could all be undertaken elsewhere. Local decisions by a multidisciplinary team could list those procedures which could be done in other spaces, but this will rely on the local conditions being appropriate. (See Table 1) This argument to move procedures away from theatres, used by The Green Surgery Report, seems a little hollow. However, as this author knows, there have been reviews over the last twenty years for cost- based reasons and changes have been made. Many patients preferred the changes which suited them, including their return to ‘normal’ life sooner. The hospital ‘won’ because it freed the potential of additional surgery in theatres and team availability for more complex surgery. The


A typical operation is estimated to create 150-170 kg of CO2


budget was also better served. Post-operatively, there has been a movement,


over the past years, to the development of ERAS (enhanced recovery after surgery). This is a multidisciplinary treatment regime which has shortened the stay in hospital for the patient and the recovery period. It largely comprises of involving the patient in their own progress and recovery, as well as early mobilisation, and reducing dependence on hospital services.6


This


obviously has benefits all round, and is becoming common practice in the UK. Day case surgery is expanding too and the basket of procedures which are suitable for day surgery is increasing all the time, leading to a more efficient use of NHS resources. Further to the aim to streamline surgical


pathways is a reduction in post-operative visits to outpatients, or possibly let the patient decide. If they feel their recovery is good, and there is no need to attend outpatients (OPD), then it could be their choice. This would significantly increase the capacity of OPD appointments to plan new surgeries.


Anaesthetics


It is said that anaesthetic gases account for 2% of all NHS emissions.7


Operating Theatre Energy


High energy consumption (3-6 x the rest of the hospital).


Anaesthesia


Any modality. May be a tendency to opt for


general anaesthesia even when unnecessary.


Products


Reusable products more likely available.


Tendency to use sterile products even if not necessary.


Healthcare staff Likely to be more staff


involved, increasing use of PPE, staff travel etc.


Time


Longer wait for theatre availability, increased time in theatre and LoS.


Table 1: Options for the surgical environment 14 www.clinicalservicesjournal.com I July 2024


Faster process due to immediate availability,


fewer resources and short LoS.


Fewer staff involved often.


Option of reusables not always available.


Non- theatre setting


Lower energy consumption.


Procedures under local or none.


Desflurane is one of equivalent, the same as driving 450 miles in an average petrol car.


the most common, but also one of the most harmful. It has 20 times the environmental impact of less harmful greenhouse gases and using a bottle has the same global warming effect as burning 440kg of coal. That is equivalent of driving between 200 and 400 kilometres, compared to driving between 5-10 kms for sevofluorane, a lower carbon alternative. Scotland’s NHS became the first national health service in the UK to stop using desflurane which has a global warming potential 2,500 times greater than carbon dioxide. Removing it from use in hospital theatres across NHS Scotland saved emissions equivalent to powering 1,700 homes every year.8 Other actions which may be taken by anaesthetists have been devised by the Association of Anaesthetists9


:


1. Avoid nitrous oxide whenever possible, and use oxygen/air as the carrier gas; the effect of the increased use of volatile agent to achieve an adequate depth of anaesthesia is more than offset by the benefit of eliminating nitrous oxide.


2. Avoid use of desflurane, except for rare occasions when its use is really necessary.


3. Use low flow anaesthesia (max 1.5 l/min) during maintenance in all cases.


4. Consider swapping volatile agent-based anaesthesia for a TIVA technique.


5. Consider use of central neuraxial block or regional anaesthesia.


There is also considerable emphasis in The Green Surgery Report that using local, regional and intravenous anaesthesia may be associated with lower carbon footprint compared to inhalational anaesthetics. Capture of waste gases is also a strongly emphasised activity as, currently, waste gases are vented to the air somewhere above the hospital, but there is insufficient research or technology at present to enable any change in practice. It is being actively worked on. The report also suggests that care should


be taken not to open any supplies or drugs unnecessarily, which remains an aim of every surgery that takes place, as consideration of costs is essential at all times.10 A further controversial issue is that of omitting to build anaesthetic rooms in new hospitals, which has become more common practice in Europe and north America. This practice, suggested by The Green Surgery


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