Incisive action: Cutting the carbon footprint in surgery

Hear us out: the pandemic has stretched world health services to their limits, but it may also be paving the way toward a greener future for healthcare.

When thinking of healthcare today, you probably picture the huge pressures on overworked healthcare staff and the scramble for hospital beds. What you may not have thought about is that hospitals in many countries have adopted innovation that inadvertently introduced ‘greener’ treatment. For example, the need to perform ‘virtual’ consultations has reduced patient travel to and from practices. In April 2020; within weeks of COVID-19 hitting the UK, 71% of all GP visits were remote, compared to 25% in April 2019.

A single operation can have the same carbon footprint as driving 2,273 miles in an average sized gas-powered car.

Before COVID-19, the UK’s National Health Service (NHS) produced 27 million tons of CO2 equivalent annually, which accounted for 5% of all UK carbon emissions. To combat this, in October 2020 the UK government announced plans for a greener NHS: net zero carbon emissions directly from the NHS by 2040, and its supply chain by 2045.

In the context of COVID-19, this is an ambitious goal even if we were able to sustain the kind of CO2 emission drops witnessed during lockdowns. The forced shutdown of elective surgery may have reduced hospital carbon footprints, but this has been at the expense of patient care and can’t continue. Further ahead, the NHS will be caring for an increasingly ageing population, putting demands on provisions which will lead to increasing energy and resource consumption.

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The operating theater has extensive electricity needs, powering equipment, heating, ventilation, and air conditioning, and is three to six times more energy-intensive than the rest of the hospital. This electricity reliance coupled with anesthetic gas and the need for single-use equipment has a significant carbon footprint. Chantelle Rizan, a Fellow of the Centre for Sustainable Healthcare and currently undertaking a PhD to identify carbon hotspots in surgery, found that a single operation can have the same carbon footprint as driving 2,273 miles in an average sized gas-powered car.

So, aside from upgrading hospital buildings and moving to renewable energy supplies, the UK government must explore ways to make surgical practice more sustainable in order to hit the NHS net zero targets. This won’t be easy.

Virtual clinics have helped with triage (deciding severity and service allocation) and surgical follow-ups, but it’s difficult to plan surgery without examining the patients face-to-face. Any changes must avoid extra red tape and be economically viable for healthcare services. Advances may have trade-offs between short-term losses (retraining) and long-term gains (reducing hospital stays or complications). Most importantly of all, sterility must be maintained at all costs. Here’s a new mantra to repeat: green only if clean.

We’ve recently been exploring the challenges facing surgical providers in embracing sustainable change. In our ‘Circularity in Context’ article we considered circularity filters to ensure future products and services become carbon neutral. This philosophy of circularity, maintaining the value invested in materials and products, has applications in healthcare but may also come into conflict with other imperatives, such as sterility.

Before joining CDP I spent time working closely with orthopedic surgeons, observing procedures in the operating theater first hand, showing me where improvements could be found. Innovating in the surgical space is a complex and nuanced area, where first-hand knowledge of the sector is key. Surrounded by a team of engineers, designers, researchers, and healthcare-savvy innovators at CDP, we’ve applied the filters for circularity to identify areas in which circular approaches could provide significant advantages.  

Short-term wins

There are many ways to reduce the cradle-to-grave carbon impact of surgical equipment, while engaging clinicians and being financially attractive to health service procurement. Layer upon layer of plastics and non-renewables are used in sterile packaging for implantable devices. If we can’t fully move away from these packaging conventions because of safety and transportation requirements, can we source materials from low-emission supply chains and use local production and assembly for more efficient, less carbon intensive shipping and distribution?

Delivering care with convenience and guaranteed sterility has tended to result in single-use equipment, but we are seeing signs of returning to reusable equipment which is reprocessed between uses. Reprocessing patient drapes, laparotomy pads and intravascular catheters are being used to reduce waste so long as sterility and accuracy can be maintained and improved cleaning cycles reduce energy and water usage. Reprocessing of instruments has been driven more by cost concerns rather than sustainability, but this hints at the potential economic benefits of reprocessing beyond complex instruments. This could be further bolstered if the hospital can receive reimbursement for reprocessing an instrument instead of purchasing a new one.

There will always be cases where single-use equipment is a necessity for sterility or convenience, or where a Life Cycle Analysis shows this to be the most environmentally friendly approach. We can still streamline these sets so that rarely used kit is not disposed of even when it hasn’t been used, as is often the case once a set is opened in theater.

Long-term innovation

Given the need to develop better treatments and the burden of evidence needed to establish safety and efficacy for devices and systems, the healthcare industry can perhaps be forgiven for not having led in the sustainability space. Healthcare requirements are a barrier, as materials must be well understood and de-risked for a specific healthcare scenario before they can be used, but this should not stunt long-term innovation.

One way that future technology could reduce surgical waste is by harnessing fluid-resistant materials, improving the efficacy and safety of personal protective equipment. Going further, incineration techniques could be completely transformed by advances in energy recovery processes: being able to create large amounts of heat or electricity to feed back to the hospitals efficiently and at a larger scale than currently performed.

An emerging technology that promises radical change in surgical training is extended reality – simulating virtual environments or even overlaying them with real environments to enhance the experience. Extended reality expands access to expert training while streamlining the associated hospital footfall and travel. Virtual reality headsets are allowing trainees to view, practice, and learn surgical procedures, reducing the hours needed to be spent in surgical theaters.

The advent of very low latency wireless technologies, including 5G, could allow us to push virtual care even further. Even when surgeons are in a different country and time zone to the patient altogether, mixed reality could allow expert surgeons to offer real-time assistance and robotically assisted surgery systems could enable entirely remote surgery. This reduces travel but more excitingly it widens the opportunity for patients to receive specialist care wherever they live.

Societal filters: rapid recovery and reduced complications

There’s a risk we limit our understanding of surgical carbon footprint to manufacturing, electricity usage, and disposal. But we must consider the trickier question: how can we reduce the burden of the patient on the healthcare system through improved outcomes and reduced complications? One study found that anti-reflux surgery on the NHS could, despite having a high initial financial and carbon cost, be more carbon-efficient than ongoing medical treatment by the 9th post-operative year (and cost-efficient by the 14th year).

One tool in the arsenal is less invasive procedures. These require more specialized training and increase procedure complexity, particularly during early adoption, but they can drastically reduce patient recovery times and pressure on hospital beds. Less invasive procedures can also reduce the number of rehabilitation trips required for physiotherapy and occupational therapy. One example of this is Transcatheter Aortic Valve Replacement, where the faster recovery times and associated reduction in perioperative costs are key to driving growth in the currently more-expensive technology, displacing open-heart procedures.

Innovations that reduce follow-ups should be pursued and anything that reduces post-surgical complications or provides more durable treatment is likely to drive better overall sustainability. For example, improving surgical wound closure systems could help reduce infection rates, one of the leading causes of hospital readmission following surgery (3% of patients die as a consequence). The medical device industry can also deploy digital health tools to improve medication compliance, to introduce disease prevention strategies and to stimulate rehabilitation, all of which will lead to better outcomes from surgery and minimize unnecessary procedures, in turn reducing the carbon footprint.

At the heart of innovation is the need to understand the user. Following my experiences with surgical professionals in the operating theater, it’s great to be part of an innovation team at CDP that actively pursues “green” solutions while being respectful of the vital work that surgeons do.

Find the authors on LinkedIn:

Kiron Athwal

Associate Healthcare Innovation Researcher