The Green OR: Environmental Best Practices ASCs Can Employ

Looking to make your center more sustainable? There are lots of little things you can do that add up.

Why should a surgery center become more sustainable? The energy intensity, expensive supplies and significant waste generated in surgery offer plenty of opportunities to realize cost savings, improve operational efficiencies and strengthen resilience against extreme weather events and disruptions in the supply chain. With the majority of surgery in this country now performed in outpatient settings, it can pay off to focus on practices that provide a return on investment, as well as attract and retain top talent.

When an ASC is nonoperational from an outside event, the financial impact is like compounding interest in reverse: Downward pressure is exerted on the margin from the loss of revenue, capital repairs, overtime and variable supply chain costs. By adopting practices that conserve your energy and water usage, and that can make essential supplies available, your ASC can reduce the risk of going offline.

To achieve buy-in, leaders and staff must understand that sustainability is not only the right thing to do for the environment, it also is the right thing to do for your bottom line.

Start with these pilot program ideas

As a sustainability strategy manager at Practice Greenhealth who is also a practicing staff nurse at an ASC, I’ve been asked this question a lot: “Where do surgery centers start in terms of ‘greening’ their perioperative environments?”

Start by asking, “What’s important to our surgery center?”

Is it reducing supply costs? Addressing staff concerns about waste? Lowering energy usage? Strengthening occupational health and safety? Reducing your carbon footprint? Or perhaps you’re simply seeking low-cost, easy-to-implement solutions?

Regardless of the priorities, starting small — with pilot projects and engaged staff to design and test workflow processes, gather feedback and troubleshoot barriers — lays the foundation for success and enables scalable practices across surgery centers. Demonstrated success in financial savings, avoided waste volumes and costs, improved operational efficiencies and staff satisfaction are the outcomes that will help you build on an early win. The authors of “Walk Out, Walk On” capture this idea well: “Start anywhere and follow it everywhere!”

With that in mind, here are 10 simple, straightforward things you can do to start greening your surgery center. Most can be a win-win in that you’ll reduce your environmental impact while cutting costs.

1. Purchase more reusables.
At Practice Greenhealth, we collect data from hospitals that participate in our Environmental Excellence Award program, including data about the common reusable supplies and equipment present in their ORs. For example, many facilities have shifted away from single-use polyurethane egg crate foam positioning devices to reusable gel-filled devices. At the ASC where I work, we use the same disinfectant wipe on our reusable positioning devices, pulse oximetry probes and EKG cables that we use on the OR table and furniture. These items also stay in the OR, which is an added bonus. Other reusable items to consider include textiles such as towels, surgical gowns, back table covers and Mayo stand covers. Keep in mind that these must be laundered and sterilized.

Potential benefits: financial savings and reduced waste

2. Follow the American Society of Anesthesiologists’ (ASA) recommendations for anesthesia gas management.
Your anesthesia providers may be using — and wasting — anesthetic gases. The ASA offers guidance for more responsible use, including avoiding desflurane and nitrous oxide, opting for alternatives like Total IV Anesthesia (TIVA) and implementing low fresh gas flow techniques with alerts. ASA provides extensive resources for greening your ORs and perioperative areas.

Potential benefits: reduced emissions of environmentally harmful gases, reduced waste of gas supplies, financial savings

OUT OF THE BLUE Reusable sterilization containers simplify instrument reprocessing, transport and storage while greatly reducing the use of blue wrap.

3. Explore energy-saving initiatives.
An energy power-down checklist doesn’t cost a lot and is easy to implement. Are the lights staying off and is the door staying closed? Are air exchanges occurring too frequently in empty or after-hours ORs? You can reduce the number of air exchanges of your HVAC system when ORs are unoccupied while maintaining positive pressure. Consider energy-saving LED lights, and time the lights to turn off during off-hours or use motion sensors to ensure lights are off when no one is in the OR.

Potential benefits: reduced energy usage, financial savings

4. Upgrade your fluid management system.
Are you solidifying and red-bagging fluids as regulated medical waste, which costs five to 10 times more to remove than municipal solid waste? Is your staff carrying and emptying heavy fluid canisters and living with the risk of dangerous fluids accidentally splashing on them? To ensure occupational health and safety is a priority at your center, direct-to-drain hands-off fluid management systems can reduce unsafe exposure and messes while saving money and accelerating turnover times.

Potential benefits: staff safety, infection prevention, increased operational efficiency, financial savings from avoided waste and supply costs

5. Evacuate surgical smoke.
Think of this in terms of greening the air in your ORs for the safety of your surgeons, staff and patients. Surgical smoke occurs during cauterization through the thermal destruction of tissue. The resulting plume inhaled by everyone in the room can contain toxic gases and vapors such as benzene, hydrogen cyanide, formaldehyde, bioaerosols, cellular material, viruses, particulates and metal fumes. A smoke evacuation system can help reduce exposure to these hazards, and is now required in 18 states. Bonus: Many fluid management systems offer built-in smoke evacuation capabilities, so a smoke evacuation system may already be in-house, just not activated.

Potential benefits: staff safety, patient safety

6. Invest in reusable sterilization containers.
Single-use sterilization blue wrap isn’t ideal. It’s prone to punctures and tears, adding extra work for sterile processing staff. Although they require an upfront investment with a roughly two-year ROI, reusable sterilization containers cut long-term costs by reducing reliance on disposable blue wrap. They also save time, as sterile processing staff simply place instruments in the containers rather than handling large wrap sheets and heavy instrument sets. Plus, OR staff can lift instrument trays directly onto the sterile field, eliminating the need to unwrap and discard blue wrap.

Potential benefits: cost savings on purchase and storage of blue wrap, reduced waste, increased efficiency and safety in the OR and SPD

ZERO EXPOSURE Fluid waste management systems remove the danger of employees being splashed with hazardous materials while diverting the waste from landfills.

7. Invest in reusable sharps containers.
A reusable sharps container doesn’t involve any change in practice from a clinical point of view, but it eliminates the continuous purchase of single-use disposable plastic sharps bins and their disposal into the regulated medical waste stream. Vendors can offer this point-of-service exchange by removing the reusable sharps container, taking it off-site for emptying and processing, cleaning and disinfecting the container, and returning it to the facility to put back into service.

Potential benefits: waste reduction, staff safety

8. Develop a waste segregation program.
An appropriate waste segregation educational program and in-service, ideally reinforced annually, will remind staff what they should do with waste. Clearly delineate and label what waste goes in which bin, and locate the bins strategically in the OR.

An additional benefit of a robust waste segregation program includes recycling: Many staff will appreciate the gesture because they recycle at home.

Potential benefits: increased recycling, less regulated medical waste, increased staff satisfaction

9. Right-size custom packs and review surgeons’ preference cards.
This low-cost, easily implemented sustainability strategy entails looking at your custom procedure packs filled with single-use disposables and working with your vendors to remove anything that’s not used in most cases. Not only will this reduce costs, but you’ll also prevent these unused items from going right into the waste stream after every case.

Additionally, look at your surgeons’ preference cards and be vigilant about not opening infrequently used reusable items for their procedures. Place these sterilized reusable items in a “hold” bag and keep it handy in the OR. That way, if a surgeon needs one of those devices, your OR staff will have it ready for them quickly, and they won’t waste supplies that are opened unnecessarily.

Potential benefits: reduced waste, increased efficiency, financial savings, reduced burden on sterile processing department

10. Reprocess single-use devices.
Reusable supplies and instruments are the better option for sustainability, but if your center uses single-use disposables, find an FDA-approved third party that can safely reprocess them for additional uses. These items will still enter the waste/recycling stream eventually, but at least you’ll derive more value from them by using “single-use” supplies and devices more than once, and you won’t be purchasing as many single-use devices in the process.

Potential benefits: reduced waste and financial savings OSM