The OR Goes Green

Hospitals produce enormous quantities of waste and consume energy 24/7. Forward-thinking providers make improving environmental performance a priority because it is the right thing to do, and also because waste reduction and energy conservation increases efficiency and cost-effectiveness. Operating rooms (ORs), with disproportionately large environmental footprints, are one place where a few thoughtful changes can make a huge impact.

According to Practice Greenhealth, an organization devoted to helping hospitals reduce their environmental impact, about half of the OR budget in a typical hospital is spent on supplies. ORs produce between 20 and 30 percent of a typical hospital’s waste and generate approximately 40 percent of the typical hospital’s revenue. Reasoning that all these factors made the OR a sensible focus of environmental efforts, the organization began a “Greening the OR” initiative in 2010 to disseminate best practices for green interventions in the OR.

ORs present many opportunities for improved environmental practices, says Kaeleigh Sheehan, project manager for Practice Greenhealth’s Greening the OR initiative. As a first step, administrators should include environmental considerations as a part of all purchasing and design decisions, and developing a knowledgeable green team to assist the process.

Many interventions that the firm recommends are adjustments to systems or processes, such as adopting reusable surgical gowns and basins, reformulating OR kits to prevent unnecessary opening of single-use devices, reducing the use of blue wrap and recycling it, as well as examining medical waste policies to ensure that items that need not be disposed of as infectious waste are placed in standard waste or recycling containers.

Read on for other interventions that are technology based.

Energy-Smart Operating Suites

Advocate Illinois Masonic Medical Center, a 408-bed hospital in Chicago, has been an Energy Star facility for many years, says Facilities Manager Tom Baumstock. As part of its ongoing effort to increase energy efficiency, the hospital last year swapped the halogen surgical lighting fixtures in its ORs for LED fixtures. Energy usage has dropped significantly in the OR, and that is not solely because the three- or four-watt LED bulbs use less energy to produce light than the replaced 200-watt halogen bulbs. LED bulbs also burn much cooler than halogen bulbs, he explains, which allows the hospital to raise the temperature settings in the ORs by several degrees.

“Before, the surgeons would complain about being hot with the bright lights on their backs, so we would adjust the temperature in the room for the surgeon’s comfort. But, the nurses would be freezing, and we would have to use devices to warm the patient,” Baumstock says. Since the LED system has been installed, the OR is kept at 70 degrees, up from 64 degrees prior to the lighting switch. However, the hospital estimates about $74,000 in savings per year due solely to less need for patient warming devices.

The LED lights provide a light quality that is closer to daylight than the halogen fixtures that had been in use, and the surgeons appreciate the enhanced brightness and clarity, Baumstock says. There are other benefits as well. The LED fixtures weigh less than the previous fixtures, making them easier and safer for physical plant staff to handle, he says. And, each bulb has a life span of 25,000 hours, making the LED system more reliable than the halogen system.

The facility sees significant savings by reducing the need for physical plant engineers to replace bulbs—at approximately $41 per hour, the labor costs of bulb replacement are significant. In addition, the OR cannot be used until the bulb is replaced, which means cases may have to be rescheduled or cancelled. Baumstock says the facility has not had to replace a bulb in the year since they were installed. “The financial benefit just from the reliability aspect is huge,” Baumstock reports.  

HVAC systems also are huge energy drains in ORs. Regulations require frequent air changes, and comfort and safety of the patient and staff require strict temperature control. In some facilities, HVAC systems in ORs run continuously; in others, the systems run all night. Dialing back the energy when ORs are not in use can result in significant energy savings.

There are several options available for hospitals interested in making OR HVAC systems more efficient. Providence St. Peter Hospital in Olympia, Wash., reduced its energy use by installing separate HVAC occupancy sensors (one for ventilation and temperature, one for lights) in two of its digitally controlled ORs. When the rooms are not in use, air changes per hour are reduced to mirror the air change frequency in the rest of the hospital. The room is dark and the temperature is kept warmer until people enter the room.

These measures reduced energy by 25,000 kWh and 2,460 Therms, and saved the hospital more than $4,000 per year in energy costs.

Protecting people & the planet

Over a decade ago, Stanford University Medical Center in Palo Alto, Calif., reintroduced reusable surgical instruments, moving away from disposable instrumentation and its heavy impact on the waste stream. Stanford also has implemented technological innovations in its onsite sterile processing department, with protection of the environment and of the health and safety of patients and employees foremost in mind.

Formaldehyde, often used for medical instrument disinfection, can cause short-term irritation of the eyes, lungs and mucus membranes, and is a known carcinogen. Ethylene oxide, another disinfecting agent widely used for disinfection, is flammable, carcinogenic and mutagenic and irritating to the lungs and mucus membranes.

As an alternative to chemical disinfection, Stanford uses steam sterilization whenever possible, and has sought out safer, more environmentally friendly chemicals for those circumstances when steam is not an effective or appropriate method, says Krisanne Hanson, Stanford’s director of sustainability.

Stanford uses no formaldehyde products for sterilization. “We are not 100 percent free of ethylene oxide, but we are close,” Hanson says. If steam disinfection is not an option, less toxic alternatives to ethylene oxide, such as paracetic acid, low temperature hydrogen peroxide or ozone plasma are effective. The provider uses low temperature hydrogen peroxide in most cases where steam disinfection is not feasible, she says.

Stanford also employs reusable hard cases for surgical instrument disinfection as much as possible, to reduce the amount of blue wrap it contributes to the waste stream.

In another innovation designed to protect patients and employees as well as the environment—and the hospital’s bottom line—Stanford has improved its fluid management systems in the 24 operating suites in its main campus and 12 operating suites in its ambulatory surgery center. By introducing reusable suction canisters, the hospital not only eliminates the disposal suction canisters from the regulated medical waste stream but also reduces labor and staff exposure to bodily fluids, Hanson says.

When disposable suction canisters are in use, nurses would have to deposit the used disposable canister in a red bag and deposit the red bag in the appropriate collection area for environmental personnel to transfer to the disposal facility, Hanson explains. The reusable suction canisters eliminate those steps, as the canisters are vacuumed empty and the fluids diverted to the sewage system. Reusable canisters are sterilizeable, and when they must be replaced, the sterilized canisters can be disposed in the regular waste stream.

“This system reduces the supply side environmental footprint by eliminating the manufacture and shipping of the disposable canisters, and the need to transport and dispose of the canisters as regulated medical waste,” Hanson says. “Our facility made a significant capital investment in the reusable canister system and sterilizers and the pay-off in terms of reduced labor and a safer workforce alone has made it worthwhile.”

More and more facilities are likely to reap that pay-off if they put in the green effort.

Change checklist

As part of its Greening the OR initiative, Practice Greenhealth has developed a checklist to assist facilities in implementing changes to make operating suites more environmentally friendly. The checklist covers topics such as establishing a green team, waste reduction and prevention, environmentally conscious purchasing, and environmentally friendly operating room (OR) design and construction.

Practice Greenhealth also has compiled a list of best practices to green the OR. The nine recommended best practices for environmentally responsible surgery are:

  1. Segregating regulated medical waste from other waste products
  2. Diverting and purchasing reprocessed medical devices
  3. Implementing OR fluid management systems
  4. Recycling medical plastics
  5. Reusing gowns, textiles and basins
  6. Employing reusable hard cases for surgical instrumentation
  7. Reformulating OR kits to eliminate items that are opened,
  8. not used and then discarded
  9. Installing OR setback programs for HVAC and lighting
  10. Using hard containers for sharps, rather than disposable containers