ASCRS News: EyeSustain update
July 2023

by Cathleen McCabe, MD

Implementing sustainable routines in the operating room requires practical knowledge and collaborative commitment from the operating room team. This issue’s EyeSustain Update highlights a team approach recommended by Cathleen McCabe, MD, the immediate past president of the Outpatient Ophthalmic Surgery Society (OOSS). Her suggestions weave OOSS’ principles of top quality patient care and safety in the efficient environment of ophthalmic ambulatory surgery centers with partnership among the OR staff and the EyeSustain Surgical Pledge. The pledge (eyesustain.org/facility-pledge) can be taken by ambulatory surgery centers, hospital outpatient departments, or any facility that performs ophthalmic surgery. Its seven principles range from educating staff, reassessing the need for disposable equipment, and optimizing surgical packs to using multidose bottles of topical medications. We encourage you to catalyze your own sustainability efforts with Dr. McCabe’s practical insights.

–Aakriti Garg Shukla, MD, EyeSustain Editor

Eckelman and Sherman found that the healthcare sector was responsible for 10% of the total U.S. greenhouse gas emissions, with a substantial proportion attributed to supply chain emissions, which are integral to cataract surgery.

Although the healthcare sector is a major contributor to total greenhouse gas emissions in the U.S., accounting for nearly 10% of all emissions,¹ a large percentage of surveyed North American (43%) and European (32%) cataract surgeons stated they were unaware of the impact of OR waste and the healthcare system on the environment.^2,3 Despite a lack of knowledge of the precise environmental impact of OR waste, nearly all respondents felt that OR waste was excessive (93%).² What can we do in our own practices to reduce waste?

A team approach can be the most effective and the most rewarding when tackling big issues with many involved stakeholders. A good way to start is to identify a sustainability champion in the practice and to take the EyeSustain Facility Pledge. The champion can be any member of the team (physician, nurse, or administrator). Ideally, this person will have a passion for reducing waste and will be able to recruit other members of the team from different roles within the OR, such as a surgeon, nurse, administrator, and supply chain manager. The team will identify areas for waste reduction and suggest solutions that can be tested with a pilot study prior to wider implementation. In a practice with multiple specialties and a wide variety of surgeries, this coordinated effort can identify areas where less sustainable choices could be replaced with more sustainable ones already being implemented in the practice. For example, some eye surgeries may be using full body drapes where other specialties or surgeries have transitioned to smaller drapes effectively. A sustainability team can look for ways to spread waste-reducing practices more broadly. The same is true when replacing single-use with reusable items. A pilot study followed by broad implementation can happen more effectively when a smooth process has been put in place for evaluation of waste reducing changes. The Outpatient Ophthalmic Surgery Society (OOSS) website is an important resource, along with EyeSustain.org, for information and collaboration on sustainability ideas. The OOSS Talks feature allows for real-time feedback from other ASC team members on questions, including those addressing sustainability. In addition, OOSS is investigating recycling opportunities to impact waste reduction in the OR and will have resources available on both the EyeSustain website and the OOSS website.

OR waste reduction strategies are often win/win/win efforts, reducing cost, reducing waste, and decreasing the impact of interruptions in supply chain for disposable items. Surgeons, administrators, nurses, and staff responsible for ordering supplies and for managing waste disposal may have individual appreciation of the impact of a coordinated effort to improve sustainability and reduce waste. One example of this effect was seen when Kaiser Permanente changed from single-use to reusable sharps containers, avoiding 300 tons of plastic waste and saving more than $2.3 million annually.⁴ A simple place to start is to evaluate surgical packs by monitoring what is not used and subsequently thrown out over a 2-week timeframe. Rarely used items such as extra syringes, marking pens, or gauze pads can then be removed from the pack and made available as single-use peel packs for times they are needed. A study of surgical pack supplies was conducted over a 3-week period in a children’s hospital. Items used less than 85% of the time were excluded from custom packs, eliminating 2 tons of plastic waste and saving more than $27,000 in pack costs annually. These efforts along with supply chain streamlining were projected to eliminate more than 6,000 tons of waste in the U.S. annually.⁵ Similarly, a survey of 58 neurosurgical cases at the University of California San Francisco showed an average of $968 per case or $2.9 million per year in surgical waste in the neurosurgery department.⁶ A task force made up of surgeons, nurses, scrub techs, and key staff that manage ordering of supplies can survey use and waste of items and make recommendations for change.

Other ideas for waste reduction include eliminating full body drapes in favor of smaller drapes, eliminating gowns for patients, proper use of multidose perioperative drops until the expiration date, and recycling plastic and paper when possible. Guidelines for use of multidose drops on multiple patients can be found in the recently published multisociety position paper on reducing unnecessary topical drug waste in ASCs.⁷ One simple step is to replace individual plastic bottles of water with a water cooler and paper cups in the postoperative setting. 

For more ideas and tools to calculate the impact of small changes on the waste produced and carbon footprint of your own OR, go to EyeSustain.org. You will find tools for making changes that can have a lasting impact on the environment, sustainability, and the financial health of your practice and the larger community as well. 

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About the author

Cathleen McCabe, MD
Medical Director
The Eye Associates
Bradenton, Florida

References

1. Eckelman MJ, et al. Health care pollution and public health damage in the United States: an update. Health Aff (Millwood). 2020;39:2071–2079. 
2. Chang DF, et al. Survey of cataract surgeons’ and nurses’ attitudes toward operating room waste. J Cataract Refract Surg. 2020;46:933–940. 
3. Chang DF, et al. Survey of ESCRS members’ attitudes toward operating room waste. J Cataract Refract Surg. 2023;49:341–347.
4. practicegreenhealth.org/sites/default/files/upload-files/reusable_sharps_containers_ success_story_3.10.pdf
5. Cunningham AJ, et al. Reducing disposable surgical items: decreasing environmental impact and costs at a children’s hospital, a pilot study. J Surg Res. 2023;288:309–314.
6. Zygourakis CC, et al. Operating room waste: disposable supply utilization in neurosurgical procedures. J Neurosurg. 2017;126:620–625.
7. Palmer DJ, et al. Reducing topical drug waste in ophthalmic surgery: multisociety position paper. J Cataract Refract Surg. 2022;48:1073–1077.

Contact 

McCabe: cmccabe13@hotmail.com