Delivering sustainable surgical care to our patients

A new report from the RCSI sets out a roadmap for reducing the carbon footprint of surgery in Ireland

The future delivery of healthcare in Ireland will be significantly impacted by the needs of an increasing and aging population. As we live longer with additional co-morbidities there is a growing demand to expand the medical workforce to deliver safe, effective and timely healthcare to those who need it.

Delivering surgical care as an essential component of universal healthcare is challenging. As many as five billion people do not have access to safe, timely and affordable surgical care. (The Lancet, Vol 386, No 9993, p569-624 www.thelancet.com/commissions/global-surgery).

Most of these children and adults live in low- to middle-income countries. The surgeon’s role within the fast-passed expansion of the healthcare sector in high-income countries is changing. Increasingly, technological innovation, such as robotic-assisted surgery, will influence delivery of care. The surgeon will need to upskill in the use of artificial intelligence and be digitally literate, as treatment becomes personalised through the introduction of genomics.

Climate change

However, the biggest global health threat of the 21st Century, according to the 2023 report of The Lancet Countdown on health and climate change, is global warming (The Lancet, Vol 386, No 9993, p569-624 www.thelancet.com/commissions/global-surgery).

Global warming is having a serious harmful effect on human health. As planetary health continues to deteriorate so too does human health. If the global temperature increases by 3ºC this century it will be catastrophic, particularly for people in low- to middle-income countries. Unfortunately, we are well on our way to this situation unless we significantly reduce our CO2 emissions. (Figure 1).

2023 has been recognised as the hottest year to date in human history and we are witnessing the mass migration of climate refugees fleeing from an increase in vector-borne disease, drought, and flooding (Figure 2).

We are now in the Anthropocene era, where the health of our planet has been distinctly changed as a result of our human activity. The warming of our atmosphere, air, and oceans, which has been largely driven by the burning of fossil fuels and industrial processes, will continue to have a deleterious impact on the health of our planet. In 2021, it is estimated that 36 billion tonnes of CO2 gases were emitted globally. The burning of fossil fuels is responsible for the production of 80 per cent of global CO2 emissions.

The UN Secretary-General Mr Antonio Guterres , speaking prior to COP28 in the United Arab Emirates, called for “dramatic climate action, as we are out of road and can’t kick the can any further”.

“This is a failure of leadership, a betrayal of the vulnerable, and a massive missed opportunity,” he said.

Healthcare

Increasingly, we are becoming aware of the global climate impact associated with the delivery of 21st Century healthcare. If the health sector were a country, it would be the fifth largest greenhouse gas (GHG) emitter on the planet. Health Care Without Harm is an international non-governmental organisation that works to transform healthcare worldwide so that it reduces its harmful environmental impact. In 2021, it produced a green paper which identified that the healthcare “climate footprint generally reflects the overall national emissions patterns” (https://noharm-global.org/documents/health-care-climate-footprint-report). The world’s biggest climate polluters are also associated with the biggest health sector climate footprint (Figure 3).

The US, China, and the European Union (EU) account for the top three contributors to healthcare’s global climate impact. The EU accounts for 12 per cent of this impact. The Organisation for Economic Cooperation and Development states that the delivery of healthcare in Europe accounts for 5 per cent of the overall European carbon emissions. The European Commission has set an ambitious climate target plan with the aim of achieving climate neutrality by 2050.

Raising awareness among healthcare providers about the carbon footprint currently associated with its delivery has empowered them to question the status quo and seek to deliver greener models of healthcare, which are environmentally and socially sustainable. Delivering value-based sustainable healthcare must take into account the whole patient journey. The UK Centre for Sustainable Healthcare suggests that this is best achieved by utilising the four principles of sustainable clinical practice. These principles are: Prevention; patient-empowerment; lean service delivery; and low-carbon alternatives (https://sustainablehealthcare.org.uk/) (Figure 4). The HSE Climate Action Strategy 2023-2050 also seeks to deliver healthcare which is environmentally and socially sustainable utilising these principles.

“Health sector facilities are the operational heart of service delivery, protecting health, treating patients, and saving lives,” according to Dr Tedros Adhanom Ghebreyesus, Director-General, World Health Organisation.

“Yet health sector facilities are also a source of carbon emissions, contributing to climate change. The world’s health sector facilities churn out CO² through the use of significant resources and energy-hungry equipment. This is perhaps ironic – as medical professionals our commitment is to ‘first, do no harm’. Places of healing should be leading the way, not contributing to the burden of disease.”

Surgery

The surgical suite is a discrete functional unit within the hospital system and the operating theatre is used by multi-professional teams. Each surgical sub-specialty requires unique equipment and consumables. The surgical ecosystem has been identified as a “carbon hotspot” within the hospital setting, producing significant amounts of GHGs. This arises from three main sources, namely the use of volatile anaesthetic gases, high energy consumption, and the use of consumables, especially single-use plastics (Figure 5).

It is a matter of significant importance that the surgical community takes immediate steps to mitigate the carbon footprint associated with the delivery of surgical care and moves towards the introduction of low carbon alternatives. Barriers to implementing sustainable principles and practice in the delivery of surgical care have been a lack of top-down and bottom-up leadership due to inadequate education and training in this evolving area.

The Royal Colleges of Surgeons in the UK and the RCSI have endeavoured to meet these challenges. The Colleges acknowledge that it is time to review current surgical practice considering the climate crisis and the recognised negative impact it is having on human health. Currently, the delivery of surgical care relies heavily on the use of single-use, non-biodegradable products. Moving towards net-zero operating practices could reduce health sector carbon emissions and allow surgeons and policy-makers to reassess how surgery fits into the wider health eco-system. As we move towards the delivery of personalised surgical care, it is imperative that the effect on population health in general is also considered and the associated environmental consequences.

The Royal Colleges of Surgeons in the UK understands that sustainability is now an “important and legitimate” domain of quality in the delivery of surgical care. Supporting the surgical team in moving towards delivery of low-carbon surgical care resulted in the publication of the ‘Intercollegiate Green Theatre Checklist and Compendium of Evidence’ in November 2022 (nt-resources/environmental-sustainability-and-surgery/green-theatre-checklist).

This evidence-based document is for all members of the multidisciplinary surgical team and guides them in choosing sustainable options “before, during, and after” surgery (Figure 6).

RCSI report

The RCSI has taken a leadership role in embracing the United Nations’ Sustainable Delivery Goal 13 on “taking urgent action to combatting climate change”. The RCSI President Prof Laura Viani established a sub-committee on sustainable surgery in June 2022. The work of the committee, chaired by Prof Camilla Carroll (RCSI Council member), was to gather contemporary data from relevant stakeholders working in the area of sustainable healthcare, with a specific emphasis on surgery.

A document was published based on the committee’s findings – Sustainability Principles and Practice in Surgery – and was launched during RCSI’s Charter Week 2024. The purpose of the document is to provide surgeons with meaningful information that will enable them to deliver sustainable surgical care to patients, without impacting on the delivery of safe surgical care.

Among the report’s key recommendations are the adoption of the ‘Green Theatre Checklist and Compendium of Evidence’ as a tool to enable the whole surgical team to engage in delivering sustainable surgical practice at a local hospital level. Raising awareness of sustainability in surgical practice would be facilitated by the establishment of ‘green teams’ and a ‘green theatre champion’ at local hospital sites. The green team will engage with the wider hospital community and senior management to develop and implement sustainable principles and practice in the day-to-day delivery of clinical and surgical care. This enables easy wins to be implemented in reducing the local carbon footprint by focusing on the circular economy.

It is recommended to reduce the reliance on single-use items in favour of reusable items given 32 per cent of the carbon footprint of a surgical operation comes from the use of consumables.

This can be further facilitated by local engagement with the procurement team to rationalise the use of single-use items and encourage multiuse alternatives, utilising circular economy principles. Surgical sets should be evaluated and rationalised to include only those items that are necessary for the task at hand.

Appropriate attention should be paid to waste segregation. Some 90 per cent of medical waste generated in the surgical suite is non-risk waste. Local education and training on medical waste management will increase compliance with waste segregation.

Embedding sustainability

Sustainable practices must become a “core competency” for all members of the surgical team. This will require education and skills training programmes to be embedded as a component of continuing professional development. As part of the sub-committee on sustainable surgery, Ms Barbara Julius, Specialist Surgical Registrar in General Surgery, has been developing a unique e-learning programme for surgical NCHDs focusing on the theory and practice of delivering sustainable surgery. In the RCSI postgraduate surgery division, along with HSE National Doctors Training and Planning, we believe that NCHDs are well placed to undertake a leadership role in promoting green theatre principles and being ‘climate-smart’ healthcare advocates now and into the future (Figure 7).

An upskilled NCHD will be in a position to act as a green theatre champion at their hospital site. The role of the champion will be to promote and sustain green theatre principles in the perioperative workplace in collaboration with the multidisciplinary surgical team.

Each hospital site has an NCHD committee. Going forward, we recommend that each committee would have a green theatre champion representative. In so doing the green theatre checklist would be a standing item for discussion at committee level.

The environmental impact of surgical care can be reduced by interventions throughout the surgical care pathway. This can best be addressed by evaluating the four principles of sustainable healthcare referred to above.

The RCSI document is an evidence-based resource for the surgical team to guide them in the delivery of low-carbon alternatives in the surgical suite.

Author: Prof Camilla Carroll, Consultant Otolaryngologist Head and Neck Surgeon, Royal Victoria Eye and Ear Hospital, Dublin