Addressing healthcare’s climate footprint should begin in the operating theater, a study published online November 7 in Lancet Planetary Health shows.
This study was the first to evaluate the carbon footprint associated with the surgical suite, a multidisciplinary space that the authors say makes it an ideal functional unit in which to begin effecting change in healthcare.
“Emissions reduction strategies including avoidance of desflurane and occupancy-based ventilation have the potential to lessen the climate impact of surgical services without compromising patient safety,” write Andrea J. MacNeill, MD, from the University of British Columbia, Vancouver, Canada, and colleagues.
Being one of the largest service industries, the healthcare sector has a substantial carbon footprint, and the US healthcare system generates nearly one tenth of the country’s greenhouse gas emissions.
However, so far, studies examining how surgical activities affect the environment have focused on individual products and procedures, or on comparisons of alternate surgical approaches.
The researchers therefore aimed to identify components of the operating theater’s carbon footprint in different health systems, and to suggest strategies to reduce the effect of surgery on the environment.
They conducted a study to measure the carbon footprint of operating theaters in hospitals at three academic, quaternary-care hospitals in Canada, the United Kingdom, and the United States, performing greenhouse gas evaluations over a period of 1 year.
The researchers found annual carbon footprints of 5,187,936 kg CO2 equivalents (CO2e) at the UK hospital, 4,181,864 kg CO2e at the US hospital, and 3,218,907 kg CO2e at the Canadian hospital.
Considering surgical caseloads at the different sites, the Canadian hospital had the lowest carbon intensity per case, at 146 kg CO2e per operation compared with 173 kg CO2e per operation at the UK hospital, and 232 kg CO2e per operation at the US hospital.
Anesthetic gases and energy consumption were the largest sources of greenhouse gas emissions in operating rooms.
Emissions caused by anesthetic gases accounted for 2000 tonnes CO2e at each of the North American hospitals, which is 10 times the amount of anesthetic gas emissions from the UK hospital.
This difference was a result of preferred use of desflurane as a volatile anesthetic at the North American hospitals. In contrast, the UK hospital does not use desflurane because of its high cost.
The researchers also found that operating theaters were three to six times more energy-intensive than the hospital buildings as a whole were, predominantly as a result of heating, ventilation, and air conditioning (HVAC) requirements.
HVAC energy demands accounted for 90% to 99% of overall energy use in the operating theater, which is nearly double the previously reported energy demands of inpatient healthcare facilities (52%), the authors note.
On the basis of these findings, the researchers suggest strategies to help hospitals improve environmental performance associated with surgical services.
Although desflurane induces anesthesia faster than other volatile agents and facilitates a quicker emergence from anesthesia, it is the main contributor to worldwide anesthetic gas emissions, they say. Preferential use of other anesthetic agents or strategies (such as regional techniques or total intravenous anesthesia) therefore could potentially markedly reduce greenhouse gas emissions in the operating theater.
“A lack of awareness regarding the environmental impacts of anaesthetic choices is believed to be the greatest barrier to widespread implementation of low-carbon practices,” the authors stress.
They also suggest that energy conservation efforts in the operating theater should focus on HVAC system management because occupancy-based ventilation strategies reduce unnecessary airflow to unused spaces and could potentially save considerable amounts of energy.
Dr MacNeill and colleagues explain that they halved HVAC energy consumption at the Canadian hospital by implementing HVAC setbacks in the maximum number of operating theaters, reducing air flow rates to 19 of 22 theaters overnight and on weekends, and leaving three theaters online for emergencies.
“Although further work is needed to refine the benefits that might be inimize, it is clear that both carbon and cost savings are possible and that multidisciplinary action should be undertaken to inimize the adverse effects of surgery on the environment,” they conclude.
Carbon mitigation strategies in healthcare settings do not provide only environmental benefits, write Tim Taylor, PhD, from the University of Exeter Medical School, Truro, United Kingdom, and Phil Mackie, BA, FRSPH, FFPH Hon, MAPHA Scottish Public Health Network/Scottish Managed Sustainable Health Network, Edinburgh, United Kingdom, in an accompanying comment.
Indeed, studies have shown the potential for such strategies to also improve economic performance, patient choice, and patient health.
Members of the healthcare sector therefore need to better understand climate change and how to reduce it, they say.
Dr Taylor and Dr Mackie stress the need for the healthcare sector to be proactive in recognizing how their services affect the environment. This should improve decision making around carbon emissions at all levels of healthcare, they add, ranging from major decisions about the location of health services to decisions about what foods to include on the menu in the hospital cafeteria.
“Understanding the carbon footprint of health care involves everyone in that system; from the patients to the managers, from the porters to the surgeons.”
Although describing the carbon footprint of different components of healthcare is a small step in this direction, Dr Taylor and Dr Mackie emphasize that it is no longer enough to simply quantify these problems.
“[H]ealth-care systems need to be much more effective stewards of the resources placed at their disposal,” they conclude.
The authors have disclosed no relevant financial relationships. Dr Taylor reports receiving funding from the European Union’s Horizon 2020 Programme. Dr Mackie reports serving as Co-Editor in Chief of the journal Public Health.
Lancet Planet Health. 2017;1:e381-e388. Article full text, Comment full text
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