Green checks

Climate and ecological crises represent the biggest threat to health that humanity has ever faced, the World Health Organization has warned. As healthcare professionals, it is important for us to play our part in looking after our planet and its ecosystems, which support all life on Earth.

Surgery is a significant contributor to the environmental impact of healthcare globally, so it is absolutely vital for us to identify and tackle areas to focus on as we try to limit the environmental and ecological damage caused by our profession.

Over the last year the RCSEd’s Sustainability Champions have worked to unite surgical colleges in the UK and Ireland in an attempt to combine efforts and improve outcomes in sustainable surgery.

As part of our intercollegiate approach, we have created a new checklist, which includes a range of changes – both small and hospitalwide – that will help us make a significant difference across the field. For example, using local anaesthetic where possible, or switching to reusable equipment when it is safe to do so.

The checklist is divided into four sections: the first is dedicated to anaesthetic care, whereas the other three focus on preparation for surgery, intraoperative practice and postoperative measures. Initially the checklist can be used at the daily brief, at the start of an operating list, to remind the team of more sustainable practices that could be adopted.

Once these interventions have been embedded into practice, then the checklist may be used less frequently – for example, to monitor adherence and long-term improvement. It can also act as a scorecard to record progress.

At present, some theatres will lack the infrastructure required to enact all the suggested interventions, and so the different sections can serve as a roadmap for discussion with management, or at departmental meetings, to guide the required changes.

However you choose to use the checklist, we hope that it will be a valuable tool for you to identify and understand interventions and considerations to decrease the environmental impact of your work.

Alongside the checklist, we have compiled a compendium of peerreviewed evidence, guidelines and policies that inform the interventions suggested. The compendium should support our Members and Fellows to introduce change in their own operating departments.

Green Theatre Checklist

Recommendations to reduce the environmental impact of operating theatres

Anaesthesia

RoyalCollege of Surgeons

Royal College Of Physicians And Surgeons Of Glasgow

SURGEONS Ill OF EDINBURGH

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Consider local/regional anaesthesia where appropriate (with targeted 0 2 delivery only if necessary)

2 Use TIVA whenever possible with high fresh gas flows (5-6 L) and, if appropriate, a low 0 2 concentration s Switch to reusable equipment (e.g. laryngoscopes, underbody heaters, slide sheets, trays)

3 Limit Nitrous Oxide (N,O) to specific cases only and if using: check N,O pipes for leaks or consider decommissioning the manifold and switching to cylinders at point of use; introduce N2 0 crackers for patient-controlled delivery.

4 If using inhalational anaesthesia: use lowest global warming potential (sevoflurane better than isoflurane better than desflurane); consider removing desflurane from formulary; use low-flow target controlled anaesthetic machines; consider Volatile Capture Technology.

6 Minimise drug waste ("Don1 open it unless you need it", pre-empt propofol use)

Preparing for Surgery

7 Switch to reusable textiles, including theatre hats, sterile gowns, patient drapes, and trolley covers

8 Reduce water and energy consumption: rub don't scrub: after first water scrub of day, you can use alcohol rub for subsequent cases; install automatic or pedal-controlled water taps.

9 Avoid clinically unnecessary interventions (e.g. antibiotics, catheterisation, histological examinations) lntraoperative Equipment

10 REVIEW & RATIONALISE: surgeon preference lists for each operation -separate essential vs. optional items to have ready on side; single-use surgical packs -what can be reusable and added to instrument sets? what is surplus? (request suppliers remove these); instrument sets -open only what and when needed, integrate supplementary items into sets, and consolidate sets only if it allows smaller/fewer sets (please see guidance).

REDUCE: avoid all unnecessary equipment (eg swabs, single-use gloves), "Don1 open it unless you need it"

REUSE: opt for reusables, hybrid, or remanufactured equipment instead of single-use (e.g. diathermy, gallipots, kidney-dishes, light handles, quivers, staplers, energy devices)

REPLACE: switch to low carbon alternatives (e.g. skin sutures vs. clips, loose prep in gallipots)

RECYCLE or use lowest carbon appropriate waste streams as appropriate: use domestic or recycling waste streams for all packaging; use non-infectious offensive waste (yellow/black tiger), unless clear risk of infection; ensure only appropriate contents in sharps bins (sharps/drugs); arrange metals/battery collection where possible.

REPAIR: ensure damaged reusable equipment is repaired, encourage active maintenance

POWER OFF: lights, computers, ventilation, AGSS, temperature control when theatre empty

DISCLAIMER: These suggestions are based upon current evidence and broadly generisable, however, specific environmental impacts will depend upon local infrastructure and individual Trusts' implementation strategies.

Declaration Of Climate Emergency

The Royal College of Surgeons of Edinburgh, the Royal College of Surgeons of England, the Royal College of Physicians and Surgeons of Glasgow and the Royal College of Surgeons in Ireland acknowledge that climate change and anthropogenic environmental degradation pose a major threat to both human and planetary health. We have reached and overstepped several planetary boundaries within which humanity can survive and thrive, and this calls for decisive, collaborative and urgent action.

Our colleges strive to promote patient health and wellbeing, and climate change poses a direct and indirect threat to this. As such, it is within our charge to protect patients’ health by urgently minimising the environmental impact of everything we do within our institutions and among our membership activities.

With this declaration, the colleges accept their duty to provide leadership and guidance among the surgical community in tackling the environmental impact of surgical care, and commit to do so urgently at local, regional and national levels.

Check it out

For further details about the RCSEd declaration, checklist and compendium visit bit.ly/sustainablesurgery or use the QR code.