The Green Surgery Challenge 2021 was an opportunity for the UK’s surgical community to recognise the value of sustainable healthcare for surgical conditions: to share and promote ways of practising that are less harmful to the environment and our planet and build social sustainability: to continue to transform surgery for the future. 

What is the problem in surgery?

Climate change is having far reaching consequences for planetary health, including within the UK, and is accepted as one of the greatest threats to the health of global populations. In addition, the integrity of our environment is threatened by air pollution, plastic overuse, chemical pollution, water scarcity, soil degradation, deforestation and loss of biodiversity.  

Whilst healthcare organisations work to improve the health of populations, their day to day activities are contributing to climate change and to the impoverishment of the environment. The NHS is responsible for over one third of total public sector carbon emissions. Operating theatres contribute towards this, with energy requirements four to six times that of other hospital areas and as significant users of medical equipment and supplies.  

It’s time for powerful solutions for a sustainable surgical future

The Greener NHS campaign and NHS Net Zero Report highlight the need and opportunity for healthcare to change its activities, processes and systems to address carbon-heavy interventions. The report draws upon The Centre for Sustainable Healthcare’s decade of experience in transforming healthcare for a sustainable future. Specifically, within surgical services there are opportunities for: 

• Preventing and optimising conditions requiring surgical intervention, including peri-operative optimisation. 
• Promoting patient empowerment and patient-centred surgical services. 
• Ensuring lean surgical pathways, including identifying and avoiding unnecessary procedures or unused single-use items in surgery. 
• Promoting low-carbon alternative products and processes in surgery, including reusable instruments, maintenance, repair, and recycling. 
• Raising awareness and changing culture amongst the surgical community. 
• Partnering with other allied healthcare professionals and supporting services to achieve these aims. 

The Green Surgery 2021 Challenge Opportunity 

The challenge launched on 3rd February 2021 at an online event, hosted by the Royal College of Surgeons England (RCSEng) with Ms Victoria Pegna, co-founder of the Sustainability in Surgery working group and the President of RCSEng, Professor Neil Mortensen.  The event included:

• An introduction to green surgery from Professor Mahmood Bhutta & Sustainable Surgery Fellow, Chantelle Rizan, from Brighton & Sussex Medical School
• Information on how to get involved in the challenge by Dr Olivia Bush, Clinical Programme Director at the Centre for Sustainable Healthcare.
• Q&A.

Teams applied to enter the Green Surgery Challenge by submitting an idea for what area of the surgical pathway their team decided to focus on to make it “greener” and more sustainable…and why.  

Green Surgery Challenge Partners 

The Green Surgery Challenge is an adaptation for clinical specialties of the Centre for Sustainable Healthcare’s flagship programme, the Green Ward Competition (an award-winning clinical leadership and engagement programme to improve the environmental sustainability of healthcare). The 2021 challenge was created and delivered through collaboration between a group of supportive partners including:

• The Centre for Sustainable Healthcare 
• NIHR MedTech Co-operative in Surgical Technologies (link is external)
• Royal College of Surgeons, England (link is external)
• Royal College of Surgeons, Edinburgh(link is external)
• The Sustainable Healthcare Coalition (link is external)
• Brighton and Sussex Medical School(link is external) (link is external)
• The Association for Perioperative Practice(link is external)

Green Surgery Challenge Funders and Sponsors 

The Green Surgery Challenge was supported by Gold Funders and Sponsors NIHR MedTech Co-operative in Surgical Technologies and Elemental Healthcare, Silver Sponsors Royal College of Surgeons England and Royal College of Surgeons Edinburgh, Bronze Sponsors the AHSN Network, Vanguard Medical Remanufacturing, and Bowa Medical UK.

How does it work?

Five teams were selected to receive mentoring from sustainable healthcare specialists at the Centre for Sustainable Healthcare over a ten-week period in order to hone a specific question, design a project, implement the project, and measure the outcomes. The teams were encouraged to use sustainable quality improvement (SusQI) methodology to create sustainable transformation.

The Green Surgery Challenge Teams

• Peter Labib, Bryony Ford and their team: Maximising reusable surgical instrument use, including laparoscopic ports, for a sustainable appendicectomy pathway at Derriford Hospital Trust.
• Aaron Quyn, Adam Peckham-Cooper and their team: Innovative, gasless appendicectomy procedure: lean instrument trays: reducing pre-operative urinary catheterisation: for a sustainable laparoscopic appendicectomy pathway at Leeds Teaching Hospital Trust
• Alyss Robinson, Shameen Jaunoo, Mansoor Khan and their team: Reducing blood testing in the pre-operative work-up for laparoscopic cholecystectomy at University Hospitals Sussex NHS Foundation Trust.
• Preetham Kodumuri, Prash Jesudason and their team: Reducing energy use by moving out of the operating theatre: streamlining surgical sets: reducing single-use instruments: for a sustainable carpal tunnel release pathway at Wrexham Maelor and Ysbyty Gwynedd.
• Jasmine Winter Beatty, Jonathan Gan and their team: Substituting local in place of general anaesthesia for inguinal hernia repair and introducing reusable surgical gowns at Imperial College Healthcare NHS Trust.

Team one: Derriford Hospital, University Hospitals Plymouth NHS Trust

The team at Derriford Hospital, University Hospitals Plymouth NHS Trust, focused on reducing the consumption of single-use surgical equipment for their Green Surgery Challenge project.  

Consumables account for one-third of surgical procedure-related emissions and so a reduction has the potential to make a significant impact on carbon emissions in their department and Trust.  

The team was led by Mr Peter Labib, ST6 general surgery registrar and Dr Bryony Ford, Foundation Year 2 doctor; Ms Michelle Winfield, Senior Sister & Clinical Procurement Specialist who was pivotal to the success of the project, liaising with company representatives and the Sterilisation & Decontamination Unit; the project leads were supported by Mr Aditya Kanwar, Consultant Hepatobiliary Surgeon, Mr Grant Sanders, Consultant Oesophagogastric Surgeon, and Mr Walter Douie, Consultant Colorectal Surgeon.

Summary

The team carried out their project using the Sustainable Quality Improvement (SusQI) framework.  First, they introduced their colleagues to the concepts of sustainable healthcare; how the climate crisis has health impacts, and how surgery is contributing to the climate crisis. Following this well-received presentation, the team surveyed their colleagues to find out about surgical practice in their department so that they could identify the hotspots of consumption of single-use surgical instruments.   

In the survey, many colleagues reported frequently opening disposable instruments during laparoscopic appendicectomies, which is one of the most frequently performed procedures in their department (each year, around 500 appendicectomies are performed at Derriford Trust) and nationwide. Surgeons’ reasons for not using the existing ports were also surveyed. The team then carried out an audit that showed that single-use ports and Johann graspers were opened in every case; single-use scissors and Marylands were opened occasionally.   

Ms Wingfield and Mr Labib researched, costed, and procured reusable instruments (including ports with specifications that would address the surgeons’ concerns). Mr Labib and Dr Ford then meticulously modelled the environmental and financial impacts of the change, using carbon footprinting methodology and procurement prices.  The team was then able to propose a revised laparoscopic appendicectomy procedure set that included reusable replacements for the single-use items that are commonly used. They found that the proposed updated appendicectomy set would significantly reduce both the carbon footprint and the financial cost of laparoscopic appendicectomies.  

The appendicectomy set will be changed once formal feedback on the new reusable ports is completed (informal feedback has been positive) and the team will repeat the audit to demonstrate if the changes have successfully reduced consumable use. The social impact will be assessed by surveying the surgical team’s satisfaction with the replacement set. 

In addition to the changes they have made, the team have become influencers and catalysed significant cultural change in their department, division, and in the Trust. Their colleagues have been inspired by the team’s Green Surgery Challenge project to work on changing other surgical sets, there is discussion in the surgical department about switching off air conditioning in elective theatres overnight (this would have the forecast impact of reducing energy usage by up to one third, which alone could allow the department to meet their target of a 20% reduction by 2025 target given the contribution of energy to the overall emissions from theatres), the team is presenting their project to the Trust Board, and one team member has been invited to join the new University Hospitals Plymouth Sustainability Committee. 

Team two: Leeds Teaching Hospital NHS Trust

The Leeds Teaching Hospital NHS Trust team’s Green Surgery Challenge project included four components:

1. Replacing CO2 insufflation with the RAIS device
2. Changing from disposable to reusable gowns and drapes
3. Replacing urinary catheterisation with pre-induction toileting
4. Replacing single-use instruments with reusable instruments in the instrument tray for appendicectomy

These approaches are examples of the third and fourth principles of sustainable clinical practice, ‘lean’ service delivery and low carbon alternatives to existing practices.   

The team was led by Mr Adam Peckham-Cooper, Consultant Emergency General Surgeon and Honorary Senior Lecturer, Mr Aaron Quyn, Consultant General Surgeon, Associate Clinical Professor of Surgery, Deputy Director NIHR Surgical MedTech Co-operative.  The project team included Mr Noel Aruparayil, General Surgery Specialist Registrar, Honorary Research Fellow, Global Health Research Group-Surgical Technologies, Mr Thomas Pike, General Surgery Specialist Registrar, NIHR Clinical Lecturer, Dr Katie Boag, Emergency General Surgery Clinical Fellow, Dr Peter Culmer, Associate Professor in Healthcare Technologies, Engineering Lead NIHR Global Health Research Group-Surgical Technologies and Mr Tim Ho, Medical Student. 

Summary

Medical gases, energy use and consumables are significant contributors to the carbon footprint of surgical procedures.  The team decided to focus on laparoscopic appendicectomy as a particularly resource-intensive procedure that is performed frequently; in the United Kingdom, acute appendicitis has an incidence of 7-12% and is the most common abdominal surgical emergency, resulting in 42,000 appendectomies per year. 

The team carried out their project using the Sustainable Quality Improvement (SusQI) framework.  A holistic review of the laparoscopic appendicectomy process using a process map revealed numerous opportunities to reduce the environmental impact.  The team implemented two key changes, modelled the third change, and made plans for further improvements.

The team listed all the instruments in the current procedure packs and were able to reduce these from 119 to 49, both reducing the number of trays of surgical instruments requiring sterilization and the number of single-use items opened but not used.  These ‘Green Trays’ are now begin used routinely. 

Patients are now also routinely being asked to pass urine before entering the anesthetic room to eliminate the need for urinary catheterization, reducing the use of consumables and potentially improving the patient experience. 

The team also modelled the change in resource use by using a gasless procedure for laparoscopic appendicectomy by carrying out a real-time cadaveric study, simulating the innovative surgical procedure.  The Leeds Global Health Research Group has developed a new device, RAIS (Retractor for Abdominal Insufflation-less Surgery) that mechanically creates a space within the abdomen to allow surgery to be carried out, rather than using insufflated gas.  The procedure was modelled using the standard procedure packs and the green tray, as well as further changes such as re-usable drapes and gowns. 

All these interventions were shown to both reduce the environmental impact of the procedure and reduce cost.  Medical gas use was a surprisingly large contributor to the overall carbon footprint of the procedure. From a global perspective the team think that the RAIS device would expand global surgical access (where access to medical gases is scarce and funds for consumables severely constrained) and contribute significantly towards the UN Sustainable Development Goals (25).  Working with surgeons in low- and middle-income countries also provides an opportunity for reverse innovation, improving sustainable surgical practice in the UK. 

Team three: University Hospitals Sussex NHS Foundation Trust

The Green Surgery Challenge team at University Hospitals Sussex NHS Foundation Trust, focused on streamlining the pre-operative pathway for elective surgery for the project. This approach is an example of the third principle of sustainable clinical practice, ‘lean’ service delivery.  The team focused on pathology testing as this is the single highest volume clinical activity in the NHS and so reducing this activity has the potential to make a significant impact for sustainable healthcare.

The team was led by Dr Alyss Robinson, Mr Shameen Jaunoo and Professor Mansoor Khan.

Summary

The team chose to assess laparoscopic cholecystectomies as it is a common procedure carried out frequently by members of the team; on average 250-300 laparoscopic cholecystectomies are performed in the Trust per year. Patients who have day case laparoscopic cholecystectomies (LC) are required by University Hospitals Sussex (UHS) Trust guidelines to attend on two separate occasions for group and save (G&S) blood tests to be taken.  The rationale is to facilitate urgent perioperative transfusions, if needed, despite clinical experience suggesting that the procedure has a low bleeding risk.  The team decided to investigate the impact on sustainable value of eliminating one G&S test prior to laparoscopic cholecystectomy.

To present their ideas and address any concerns, the team approached colleagues by email, in person and at departmental meetings. They successfully gathered support for their project with a number of the team helping with data collection and engaging other staff.

The team systematically assessed all the elements of sustainable value of the Sustainable Quality Improvement framework:

• Clinical implications and patient safety: Dr Robinson conducted a literature search and audit of all patients who had a laparoscopic cholecystectomy at the Trust since January 2020 to assess the risk of significant perioperative bleeding requiring urgent transfusion.
• Environmental impact: The team calculated the carbon footprint of outpatient G&S tests, including the processing and patient travel, that was surprisingly high as the team found that preoperative tests are carried out at a site located at the greatest distance from main residential areas.
• Social impacts: To understand the social implications of the existing preoperative pathway, the team performed a patient survey.
• Financial impacts: A cost analysis for the G&S tests was performed (finding that costs ranging from £10-24 depending on the Trust) and travel costs for patients was also estimated.

The team have concluded that eliminating the second G&S tests from the preoperative workup for laparoscopic cholecystectomies is a safe intervention that will have carbon and financial savings for the trust when implemented, and be more convenient for patients without compromising their safety or clinical outcomes. This simple intervention could be applicable to a variety of surgical procedures. 

The project was presented to Anaesthetics Governance Meeting in August 2021 with the aim of gaining agreement of anaesthetist colleagues to apply this intervention to several operations.  The team also aim to raise awareness about the carbon footprint of the preoperative process in general as they see further opportunities for streamlining the pre-operative process, especially with the advent of digital pre-operative assessment, including the opportunity for patients to complete their own assessments and even upload some of their own clinical data such as blood pressure, height and weight. The project was also presented to the Trust’s group of ‘Green Ambassadors’ to inspire and encourage them to take action in their own clinical areas and provide an example of sustainable quality improvement in action in their local trust.

Team four: Wrexham Maelor and Ysbyty Gwynedd Hospitals

The Green Surgery Challenge team at Wrexham Maelor and Ysbyty Gwynedd Hospitals, and Betsi Cadwaladr University Health Board in North Wales, focused on the carpal tunnel release pathway as this is the most commonly performed procedure in the field of hand surgery.  They considered the whole pathway and chose interventions that would reduce the consumption of single-use surgical equipment and reduce energy use by moving out of the operating theatre, reducing size of autoclave trays by streamlining the reusable surgical sets and eliminating the need for ward admission.

These approaches are examples of the third and fourth principles of sustainable clinical practice; ‘lean’ service delivery, low carbon alternatives to existing practices and also reduce operational resource use.

The multi-disciplinary team was led by Mr Prash Jesudason and Mr Preetham Kodumuri, Consultant Hand & Orthopaedic Surgeons.  Team members include Iona Williamson, Sterile Services Manager, Teresa Revell, Deputy Team Leader Day Case Unit, Shan Roberts, Theatre Practitioner and Jack Houghton, Specialty doctor in Orthopaedics.

Summary

The team listed all the consumables used and the volume of clinical waste generated whilst performing a CTR.  They used this to identify what changes could be made:

• Single use plastic pots and bowls were abandoned and replaced with reusable plastic receiver,
• Large limb drapes (required for hip or knee replacement but not hand surgery) were replaced with 2 x small 90cm square drapes
• A large number of reusable surgical instruments in the procedure set were reduced, meaning that the containing tray size could be reduced (meaning that more trays can be accommodated in the autoclave per cycle)

The team made these changes, creating a new procedure pack.

The team also gained approval from the theatres manager to carry out CTR in a procedure room rather than theatres (theatres have a high energy requirement, mostly due to the ventilation systems) and for patients to bypass ward admission and come straight to the procedure room. They approached the project using the Sustainable Quality Improvement (SusQI) framework:

• Environmental and financial impact was determined by calculating the carbon footprint and cost of those resources that were eliminated from the pathway.
• Social impact was determined by actively seeking input from patients and employees participating in this green pathway using feedback questionnaires and a pathway folder for suggested improvements. The safety of the pathway was tested with Local Safety Standards for Invasive Procedures (LocSSIP) checklist. At the conclusion of each list, a debriefing meeting was held to examine the day’s events and to identify what went well and what could be improved.

Team five: Imperial College Healthcare NHS Trust

Team four from Imperial College Healthcare NHS Trust, who will be joining the Green Surgery Conference November 4th as one of the Green Surgery Challenge finalists, selected two areas to work on as part of the Green Surgery Challenge; tackling the use of anaesthetic gases by encouraging the use of local anesthesia (LA) with/without sedation for inguinal hernia repair (IHR) instead of general anaesthesia (GA) and reducing the use of single-use consumables by switching from disposable sterile surgical gowns to reusable surgical gowns. These approaches are examples of the third and fourth principles of sustainable clinical practice, ‘lean’ service delivery and  low carbon alternatives to existing practices, whilst also reducing operational resource use.

The project was co-led by Surgical Registrars and Clinical Research Fellows Jasmine Winter-Beatty and Jonathan Gan.  Members of the team were Henry Robb, Surgical Core Trainee,  Simon Dryden, Clinical Research Fellow, Institute of Global Health Innovation,  Patricia Ortega, Bariatric Surgery Fellow, Tabetha Granger, Surgical Core Trainee,  Ben Russell, Foundation Year 1 doctor, Sanjay Purkayastha, Consultant Bariatric Surgeon and Senior Clinical lecturer.  Mike Kynoch, Anaesthetic Consultant, gave specialist advice to the team on anaesthetic practice.

Summary

The team carried out their projects using the Sustainable Quality Improvement (SusQI) framework including assessing outcomes against the elements of ‘sustainable value’, clinical outcomes for the patient and population, environmental impact, social impact and financial resource use.

1) Increasing use of LA (+/- Sedation) instead of GA for open IHR where patients were eligible:

The team identified IHR surgery performed under GA as a potential carbon hotspot in the NHS due to the use of anaesthetic gases, which are also greenhouse gases.  Anesthetic gases are responsible for 42% of carbon emissions related to the surgical procedure. Switching to the use of LA could result in considerable reductions in carbon emissions, with indirect health benefits for the whole population. Additionally, IHR performed under LA may result in improved patient outcomes, financial savings, and a quicker return to daily life and work due to a reduced length of stay (LOS) in hospital.   

The team checked national guidelines for assessing patients’ eligibility to undergo IHR under LA.  The team then discussed the guidance and the benefits of carrying out surgery for IHR under LA with surgical and anesthetic colleagues. Eligible patients were identified by prospectively screening surgical lists, speaking to the consultant responsible for their care to agree eligibility, and then calling patients to offer them the procedure under LA, rather than the GA that they had been listed for originally.

• Clinical outcomes were compared for the groups of patients undergoing inguinal hernia repair under general and local anaesthetic.
• Environmental impacts of the change were calculated by auditing how many IHR were carried out under GA vs LA.  The team then audited the usage of drugs, equipment, anaesthetic agents, and energy use in the patient pathway from anaesthetic induction through to discharge for carrying out IHR under GA and LA; this allowed them to calculate and compare the carbon footprint for the two anaesthetic approaches.
• Financial impact was determined by calculating the cost of pharmaceuticals, equipment, anaesthetic agents, and energy use, as well as the accompanying financial expenditures for carrying out IHR under GA and LA so that a comparison could be made. Additionally, the team compared the average length of hospital stay for IHR under LA and GA, as well as the associated costs to the trust using pre-pandemic 2019 data.
• Simon Dryden led on evaluating Social Impact by devising and conducting patient surveys on the amount of time patients and their caregivers took off from work, any additional income lost due to the hospital stay, and impacts on activities of daily living.

2) Replacing disposable surgical gowns with reusable gowns

Switching from disposable surgical gowns to reusable gowns has the potential to decrease pollution and the production of carbon emissions, and is a way to allow staff to carry out their work in line with sustainability values that are important to most healthcare professionals (this can contribute to improved staff morale) and generate financial savings associated with reduced resource use, waste disposal and transport.

Samples of reusable surgical gowns were procured and made available for theatre staff to use.

• Clinical outcomes: gowns met safety standards for medical use.
• Environmental impact: the team used 2019 procurement data from the Trust and calculated the projected environmental impacts of switching to reusable gowns based on data from peer-reviewed studies.
• Financial impact was determined with assistance from the procurement department who provided the team with key metrics regarding the financial cost of the trust’s current reusable gowns. The suppliers of the team’s current reusable gowns provided a cost per use estimate for the reusable gowns, which included waste disposal and transportation.
• Social impact was determined by distributing surveys to staff to assess their use of reusable gowns. The team supplemented the survey with face-to-face interviews with surgeons, anesthetists and nurses who had tried out the reusable gown samples.

The teams presented their projects at the Green Surgery Conference, highlighting the environmental, social, and financial impact made. The combined projects have projected annual savings of 133.4 tonnes CO2e, which is the equivalent of 38 round-trip flights from London to Hong Kong!

Carbon and financial impact of the green surgery challenge

Team one’s project has forecast annual savings of £34,400 and 0.5 tonnes CO2e/year (based on reducing consumables in the set by 75%). This is the same amount of CO2e as driving 1,434 miles* in an average car (2.5 times from G7 to COP26). 

Team two’s project had a wide range of financial and carbon savings that can be broken down into specific impacts:

• Replacing CO2 insufflation with the RAIS device has forecast savings of £78,000 in procurement costs alone and 107.3 tonnes CO2e/year (based on 50% applicability of the RAIS). This is the same amount of CO2e as driving 307,882 miles* in an average car.
• Changing from disposable to reusable gowns and drapes has forecast savings of 1.9 tonnes CO2e/year (based on 95% applicability). This is the same amount of CO2e as driving 5,451 miles* in an average car.
• Replacing urinary catheterisation with pre-induction toileting has forecast savings of £1128 in costs and 0.36 tonnes CO2e/year (based on 80% applicability). This is the same amount of CO2e as driving 1,032 miles* in an average car.
• Replacing single-use instruments with reusable instruments in the instrument tray for appendicectomy has forecast savings of £9,567 in costs abd 0.74 tonnes CO2e/year (based on 80% applicability). This is the same amount of CO2e as driving 2,123 miles* in an average car.

In total, these projects have a forecast annual saving of £88,695 and 110.3 tonnes CO2e! This is the carbon equivalent of driving 316,488 miles* in an average car (552 times from G7 to COP26).

Team three’s work Eliminating the second G&S tests from the preoperative workup for laparoscopic cholecystectomies has forecast annual savings of  £3,000 for sample processing and 2.5 tonnes CO2e/year. This is the same amount of CO2e as driving 7,173 miles* in an average car (12.5 times from G7 to COP26). 

With approximately 61,220 laparoscopic cholecystectomies(link is external) performed in the UK per year, there could be potential savings of over 600 tonnes CO2e per year, and this approach could be used to address blood bottle shortages in the NHS. 

Team four’s project demonstrated that this ‘green carpal tunnel pathway’ was not only safe but also increased productivity, had a lower environmental impact, a lower economic cost and also reduced time in the hospital for patients. The project has forecast annual savings of £12,641 and 11.6 tonnes CO2e/year (based on 75% applicability). This is the same amount of CO2e as driving 33,285 miles* in an average car (58 times from G7 to COP26). 

Team five’s interventions resulted in significant gains in sustainable value, with environmental and financial benefits. During the project period, the projects saved 1.175 tonnes CO2e and £1,276.82, which leads to a forecast annual saving of approximately 8.5 tonnes CO2e/year and £16,740. If the reusable gowns were spread to the whole trust, it could save 234.7 tonnes CO2e over a year. 

*CO2e comparison: Distance from G7 (Carbis Bay, Cornwall) to COP26 (Glasgow): 573 miles / 922 km. Average car (unknown fuel) GHG emissions: 0.34851kgCO2e/mile.

Would you like to devise your own sustainable quality improvement project?

Join our next Sustainable Quality Improvement Course

This intensive course introduces health professionals and educators to the concept of ‘sustainable value’ and the ‘SusQI’ framework for integrating sustainability into quality improvement. Learning from real examples, participants explore in depth how the framework can be applied in practice to develop preventative, holistic, lean, low carbon care. The course includes 4-6-hours of multi-media self-study, a 4-hour interactive workshop and a follow-up interactive masterclass 1-2 months after the workshop to discuss projects-in-progress.

For more information about running your own green specialty challenge, please contact Hazel Walsh, our Clinical Transformation Programme Manager.

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