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17th January 2023

Green Theatre Checklist: evidence based resources for greener surgery

A new Green Theatre Checklist to reduce the environmental impact of surgical care pathways.

by Fellow in Sustainable Surgery, Melissa Pegg

The UK and Ireland surgical colleges have recognised that it is imperative to collaboratively act to urgently address the environmental impact of surgery. Together, they have produced an Intercollegiate Green Theatre Checklist compendium of evidence: a comprehensive and practical checklist and guidance that focuses on the greening the surgical procedure itself. The greener surgical intervention guidance, enables climate smart solutions, and although focuses on the surgical procedure itself, the compendium provides guidance spanning the entire surgical care pathway. All information and resources can be accessed here for the checklist and compendium.

The Green Theatre Checklist is divided into four sections, the first dedicated to anaesthetic care, and the subsequent three looking at preparation for surgery, intra-operative practice and post-operative measures. The aim of the work supported by the surgical colleges is to position the checklist within each surgical procedures’ planning and standard practices. In particular, the resources serve as valuable tools for staff to broaden their knowledge of sustainable healthcare, identify opportunities to reduce the environmental impact of technologies, and, importantly, guidance on how to start to implement changes. The authors suggest the checklist is initially utilised at the daily brief: at the start of an operating list and utilised as an aide-mémoire for the surgical team. This framework will facilitate an immediate environmentally positive effect.  Importantly, the guidance can serve as a roadmap for discussion with management, or at departmental meetings, to guide required changes.

The checklist and compendium are based on the sustainable surgery principles of descending order of environmental (sustainable development) impact: surgical disease prevention, patient education empowerment, lean service delivery (reduce), low carbon treatment options (e.g., digitalisation of a pathway), reusables (e.g., reusable surgical devices), and maintenance, repair and recycling (e.g., reusable surgical devices). Major carbon hotspots of surgery highlighted include electricity use, procurement of consumables, anaesthetic gases, and waste disposal. 

The resources are focused on whole surgical pathway streamlining and rationalisation, including utilising virtual consultations, one-stop clinics, diagnostic hubs, day case surgery, whenever possible and clinically appropriate. Lean service delivery recommendations in the checklist highlight more sustainable approaches and the consideration of avoidance of clinically unnecessary interventions altogether including the use of antibiotics, catheterisation and histological examinations. 

Further many gains can be made from targeting unnecessary use of single use resources. Historically, the single-use equipment culture was driven by uncertainty in the ability of surgical instruments to transmit incurable variant CJD, at a time when surgical instrument sterilisation was of a generally substandard to today’s cleaning and decontamination protocols. Consider this with the current consensus there is no evidence to support superior quality or safety with single-use equipment. By optimising the use of reusable equivalent equipment, significant environmental and financial savings as well as improved quality and value-based healthcare provision are enabled. In support of this, the guidance provides a plethora of research publications to evidence the reduced financial, environmental and often social harms of reusable items in the operating theatre compared to single-use equivalents. For example, scissors, gowns and drapes, laparotomy pads, sharps containers, and anaesthetic items (anaesthetic drug trays, laryngeal mask airways, and laryngoscope handles and blades. In addition,  the checklist and guidance supports replacing single use textiles, for example surgical gowns, hats, patient drapes and trolley covers with reusable equivalents. Similarly, single use surgical equipment can be replaced with reusable diathermy, gallipots, kidney-dishes, light handles, quivers, staplers and energy devices. There are many other single use devices and textiles to consider switching to reusable equivalents. 

The NHS Long Term Plan sets out an aim to reduce the carbon emissions of anaesthesia by 210,000 tonnes CO2e (NHS England 2019) by 2030. Sustainable anaesthesia initiatives are an excellent example of how sustainable practices can be successfully implemented in the NHS. The use of Desflurane across the NHS is at its lowest levels, and is being decommissioned from the NHS in 2024. The checklist and compendium aligns with the NHS ambition of sustainable anaesthesia by providing a comprehensive list of recommendations to both reduce or replace anaesthesia with less environmentally harmful alternatives. The co-benefits of sustainable anaesthesia are also considerable. For example, there are significant patient benefits to using local and regional anaesthesia resulting in reduced complication risk and improved perioperative outcomes. This has been shown in total joint arthroplasty and inguinal hernia repair

Research reports a staggering 20% of carbon emissions in the NHS is attributable to the life cycle of pharmaceuticals. To address the issue of wasted pharmaceuticals in surgery, with prevention key to sustainable provision of surgical intervention, the guidance suggests “don’t open unless you need it”. It is also noteworthy to highlight the checklist and compendium spotlights the issue of water usage in surgery and the opportunity to reduce consumption. NICE guidance states: “after the first water scrub of the day, you can use alcohol rub for subsequent cases”.A single hospital site estimated saving 2.7 million litres of water annually by switching to waterless scrub.

Please see the Intercollegiate Green Theatre Checklist and compendium of evidence for further support and resources [HERE]

Find out more about the Green Surgery Project [HERE]