‘Greening’ The OR
As the largest cost center and revenue driver in a hospital, the operating room has one of the largest environmental footprints. According to Cecilia DeLoach Lynn, Director of Sustainability Programs & Metrics at Practice Greenhealth, it’s estimated that an average OR generates 20 to 30 percent of total hospital waste. Combine this with the large amount of supplies and energy used in the department, and it is clear the OR is one of the most critical areas in which a hospital can make a difference in reducing their environmental impact.
In recent years, the idea of ‘greening’ OR practices to reduce environmental impact has become an important topic for hospitals and industry organizations. In April 2010, Practice Greenhealth kicked off its ‘Greening the OR’ initiative. According to DeLoach Lynn, Practice Greenhealth is an organization that works on a variety of environmental sustainability topics, including waste reduction, environmentally preferable purchasing, chemical minimization, energy use reduction and water use reduction. The organization has been membership-based since 2008, and currently includes 1,100 hospitals nationwide – close to 20 percent of the current healthcare market.
Specifically, the Greening the OR initiative looks at different sustainability categories as it relates to the OR realm, and works to demonstrate that greening practices can also benefit the department’s bottom line. While Practice Greenhealth is a membership-based organization, the Greening the OR project is free to the public. Hospitals formally join the project by downloading and signing a commitment form, but tools and resources are available to anyone on the initiative’s website.
“There are lots of little projects being done in different ORs across the country,” DeLoach Lynn says. “This initiative is meant to coalesce information, resources, tools, case studies and success stories into one place and really shine a spotlight onto the OR.”
Back to our (grass) roots
As DeLoach Lynn says, many ‘grass roots’ efforts have been in place in ORs across the country. At University of Minnesota Medical Center, Fairview, for example, surgeon Rafael Andrade, MD, founded the facility’s own OR Green Team. In 2008, he began a waste reduction pilot project for a particular OR kit. By removing disposable items that were normally included in the kit, but never used, Dr. Andrade saved two pounds of waste and $50 per procedure. From there, a group of staff members formed the OR Green Team.
“We have anesthesiologists, surgical techs, nurses, environmental services and surgeons,” he says. “Everybody is into it. It’s quite rewarding and surprising how everybody got involved.”
After seeing the impact of Dr. Andrade’s pilot project, the OR Green Team systematically sorted through custom OR kits for each surgical specialty and removed items that went unused.
“The OR Green Team’s nurses and surgical techs that represent the different units – orthopedics and ENT, for example – identified items in every pack that never get used,” Dr. Andrade explains. “For instance, in many cases, the kits included three light handles, which is a complete waste. Now, we try to remove them so the standard pack will have one light handle.”
By removing unused items from the surgical kits, the system has calculated more than $100,000 in savings and has reduced waste by more than 8,000 pounds per year.
Based on their success with reducing supplies in surgical kits, the OR Green Team set its sights on other efforts. Beginning this year, OR staff members now must take an online module on proper waste disposal as part of their annual education requirements.
Rather than focusing on regulations, the module focuses on why it is important to think twice before throwing an item into a hazardous waste bin. In addition to being costly, there is a lot of embedded energy in specialty medical wastes. Staff education can help reduce that environmental footprint.
“Sometimes staff members are unsure which items can go in the normal waste stream and which can’t,” Dr. Andrade says. “So just to be safe, they put it in the biohazardious waste. That is a huge amount of waste and cost.”
The OR also began recycling blue wrap. Their collaboration with a local nonprofit on this effort makes it a “win-win,” Dr. Andrade says. The nonprofit provides employment opportunities to adults with disabilities, who may not otherwise be able to find work. The company picks up the recycled blue wrap – which amounts to about 70 pounds/day – and the entire program is completely cost neutral for Fairview.
Along with blue wrap, the facility recycles several pounds of cardboard per day. Furthermore, at the end of every day, as the OR winds down, a surgical support staff member goes from room to room shutting down electronics such as lights and computers in order to reduce energy use.
Around the same time the employee-driven OR Green Team was formed at the medical center, which is a part of Fairview Health Services, Fairview’s system green team was also developed, and had just hired a waste reduction coordinator. When the two teams learned about each other, they joined forces.
Today, Fairview is a member of Practice Greenhealth. The efforts of the OR Green Team align with those of the Greening the OR initiative, and other Fairview hospitals have since begun green efforts in their ORs. Dr. Andrade says over approximately a two-year period, the system has saved around $900,000, and the regular waste stream has been reduced by about 1,000 pounds per day at just University of Minnesota Medical Center alone.
Despite successes such as the OR Green Team at University of Minnesota Medical Center, many hospitals still face challenges in accomplishing green goals. DeLoach Lynn says sometimes, this is more perception than actual barriers.
“I think there is always an initial impression that ‘green costs green,’” DeLoach Lynn says. “That doing the more environmentally responsible thing is going to cost their facility additional money. There are instances where you do need to make an investment to see the most substantial savings, but there are areas where there is little-to-no up-front investment in order to see substantial environmental and cost savings.”
DeLoach Lynn outlines waste reduction efforts as a starting point for most facilities, such as:
- Making sure waste is segregated to reduce red bag waste.
- Recycling medical plastics, packaging, blue wrap and overwrap.
- Utilizing mechanisms such as fluid waste management systems to reduce the waste generated in the OR.
- OR kit reformulation.
The other factor that can be problematic, DeLoach Lynn says, is time.
“The OR is a very stressful environment,” she says. “We’re constantly worried about room turnover, and patient safety is paramount. Sometimes, it’s difficult for clinical staff to find the bandwidth to have conversations to figure out how to put the new practices in place.”
However, DeLoach Lynn says, Practice Greenhealth sees hospitals overcoming these barriers all the time. At University of Minnesota Medical Center, one OR nurse who has been key to the OR Green Team’s efforts now has one day every other week freed up in her schedule to do ‘green’ work. Furthermore, all of the environmental savings have been accomplished without the facility making any investments.
Still, Dr. Andrade says the team has run into some obstacles along the way.
“Some surgeons struggle,” Andrade says. “They don’t like change, but I think it helps to hear from one of their peers. They’re less likely to complain or not cooperate. I made sure everything was done in cooperation with surgeons as much as possible so they weren’t surprised when they didn’t have something in their custom kit. It hasn’t really been an issue.”
Now, the team is trying to switch from disposable gowns to reusable gowns and it’s proving to be the biggest challenge the team has faced.
“That’s not pushback per se, it’s a lot of things,” he says. “It’s difficult to have the system make an investment. The whole infrastructure is difficult to guarantee in making sure sterilization goes well. There is the problem of the existing contracts with corporations that make the disposables, and then also storage issues.”
Dr. Andrade and his OR Green Team have made great strides on the green front, and the benefits have not been limited to environmental or cost. He offers this advice in starting green initiatives at other facilities:
Tackle something simple first. Start with a small, finite project. “You need to get some successes before you tackle bigger things,” Dr. Andrade says.
Get staff involved at all levels. “It’s very rewarding,” Dr. Andrade says. “Put yourself in the feet of the environmental services people. Nobody talks to them. Nurses and doctors walk past them and act like they don’t even exist. So, to them, to have a surgeon or nurse know them by name and talk to them and ask their opinion or if they can help – that alone will get them completely involved in the cause and gives them something to look forward to when they go to work.” Making the project a grassroots effort, driven by staff in all roles and disciplines, gives the project greater buy-in than would a top-down edict.
Surgeon leadership. “The surgeon is the highest authority figure in the OR,” Dr. Andrade says. “If the surgeon leads something, more can be accomplished than if not.”
Peer-to-peer communication. Dr. Andrade says the team has learned that peer-to-peer communication is a key to getting things done. “Nurses tend to listen more to nurses, surgeons to surgeons and so on,” he says.
Overall, Dr. Andrade says because the OR generates such a large portion of a hospital’s waste, the opportunity to make a difference is great.
“In a relatively small place, you can have a huge impact on reducing waste,” he says. “The important thing for everybody to understand is you’re saving money when you do this. It really is a win-win for everyone.”