Can operating rooms be more sustainable? Creating a framework for change

Amir Ghaferi, M.D., M.S., didn’t always think about how much surgery contributes to greenhouse gas, solid waste and pollution generation. Now, he can’t help but notice it. 

“I’m so attuned to it now. I’ll ask why something we didn’t need to use was opened. The actual cost of the items and the product packaging is huge and at the end of a procedure I’ll pay attention to the bags and bags of garbage from a one-hour case,” Ghaferi says.

Such awareness can be painful, but it’s also a catalyst for change, and Ghaferi has University of Michigan fourth-year medical student Emily Johnson to thank for his sensitive antennae. Johnson was first author on a paper published recently in the New England Journal of Medicine Catalyst that outlined a framework for surgery departments to move toward a “triple bottom line”—considering environmental, financial and social factors in their operations—in order to be more sustainable.  

A problem meets a passion at the right time 

Johnson, an aspiring general surgeon, has always been interested in climate change and sustainability, as her bin of worms busy at work composting kitchen scraps at home can attest. She was floored by the waste and emissions she saw generated on her surgery rotation and was compelled to do something about it to square her personal passion with her professional one. 

“There was this idea in the back of my head that I need to make this field more suitable for me and the things I care about. It didn’t seem like anyone else was doing anything at Michigan, so why not try?” Johnson says.

She did more research and reached out to Ghaferi at the suggestion of general surgery resident Ryan Howard, M.D. 

The timing was fortuitous. Ghaferi, the Surgical Director for the University Hospital’s operating rooms, was looking for ways to contain rising expenses in the operating rooms; they, like certain environmental practices, were on an unsustainable trajectory. 

Johnson laid out the problem with ORs’ links to disproportionate waste and greenhouse gas emissions (the release of anesthetic gases, dependence on single-use devices, and strict heating, ventilation, and air conditioning requirements are largely responsible for the latter), made the case for cost savings associated with attacking the problem and asked what the department could do about it. 

“At the time we were forming a perioperative value analysis team and I thought it would be interesting to build this in as a principle for vetting new products or devices. We decided that we would pursue this concept, and in order to assess the willingness to change, we wanted to gauge what people thought about sustainability within our four walls,” Ghaferi says. 

Taking the temperature of attitudes toward sustainability

Johnson and Ghaferi created a survey to gauge opinions and behaviors related to sustainability and conducted it with OR staff—primarily nurses, surgical technicians and perioperative staff—during a regular meeting of the group. 

The survey targeted surgical staff rather than surgeons because the staff make the day-to-day decisions about what goes on a surgical tray for a given procedure, for example. Johnson was surprised that the responses were as favorable to ideas around sustainability and potential interventions as they were. 

“Overwhelmingly these staff think about sustainability, care about it in their home life and believe it is the responsibility of Michigan Medicine to make the OR more sustainable. It was nice to know we have support on the employee level.” 

In terms of specific initiatives the Department was considering, staff were most supportive of collecting opened but unused sterile items for donation (91.8%), followed by reformatting instrument trays (90.6%), reprocessing single-use devices (82.4%), using reusable personal eye protection (82.4%), and recycling surgical polymers (78.8%), followed by converting blue-wrapped surgical trays to reusable rigid trays (77.7%). 

Reading the room and adjusting the pitch

While Johnson’s personal passion for sustainability can be contagious, she realized it wouldn’t be enough to sway leadership to add it to the existing pillars (cost, patient safety, quality and innovation) of the the value analysis team and use it to vet products.

Having employee buy-in and a case that appealed to the financial bottom line was important, and Ghaferi coached Johnson to think about and present the issue broadly.  

“If you can take single use devices and reprocess them instead of throwing them away, you’re going to save money because you can purchase them back at reduced rates. If you can reduce the number of instruments in a kit, yes you help the environment, but you also cut costs internally,” Ghaferi says.  

Johnson took that tack when pitching the addition of the sustainability pillar to the perioperative value analysis committee. She also knew it was important to make clear this was an initiative with staff support and not just the whim of a transient medical student.  

“I’m only going to be here for four or five years. This process takes time and there might be skepticism that I’m interested now, but I’m going to leave,” Johnson says.

Still, she connected with some surgeons she’d thought might be less receptive to the environmental angle.

“After the meeting, two different surgeons came up to me and one said ‘I never thought about how my decisions could be resulting in more waste and more emissions.’ I realized that maybe it was a lack of information sharing that was the problem,” Johnson said.

Moving from support to action

Initiatives don’t tend to get rolling without support, but support doesn’t guarantee action. Implementation takes time, prioritization and changing practices. And every potential change seems to reveal more complications.

“There’s change management involved here. We worked on trying to purchase reprocessed equipment back and it turns out it may adversely affect existing contracts. We need to figure out how we can negotiate these contracts or create new ones. As a big organization, we have some leverage we can use and our supply chain team is an outstanding group who can help us achieve these goals,” Ghaferi says.

In the case of reprocessed equipment, skepticism about the integrity of the devices is common, even though the devices are subject to a rigorous and heavily regulated sterilization and testing process. In the paper in NEJM Catalyst, Johnson cited a study that found fewer surgical team-reported defects in reprocessed than new equipment. 

The COVID-19 pandemic may have helped demonstrate the efficacy of certain reprocessing procedures; due to an N95 mask shortage, Michigan Medicine sterilized the masks for reuse among employees.

“We were doing that because there was a shortage, but we also showed that it was exceedingly safe. It just goes to show you that it can happen. We stood that process up in no time,” Ghaferi says.

As for support to promote change, there can never be too much, at every level of the organization. 

“There’s always another layer higher above that’s influencing whether you can make these changes. The only way this happens is if a person in power thinks we should make it happen,” Johnson says. 

The President’s Commission on Carbon Neutrality(link is external) gives Johnson hope that sustainability efforts in the health system will be accelerated by the university-wide initiative to move toward net-zero emissions.

Johnson is also seeing signs that the field she’s so interested in might just be shifting in a way that suits her passion. On the residency interview trail, sustainability comes up in discussions because it’s part of her personal statement.

“A lot more people are saying ‘I agree, we’re trying to think about this’” Johnson says.  

As she knows, thinking about a problem is the first step toward change.