Six months ago, a group of University of Utah ophthalmology residents and fellows created a task force to investigate the operations at Moran Eye Center: to identify sources of waste and inefficiency, to understand costs and environmental impacts, and to design initiatives to eliminate these inefficiencies. Our group’s hope was to develop a culture that supports a sustainable future.
With the emergence of the COVID-19 pandemic, our mission was accelerated to face a new reality. We are being forced to employ many of the tactics our task force discussed in our first meetings: reusing supplies traditionally considered disposable, practicing telemedicine, and minimizing unnecessary usage. We are being forced to confront the frightening reality of a system operating beyond its available resources.
Signals of stress on the health care sector were evident before the arrival of a pandemic, though the present circumstances have created a new immediacy and context with which to understand them. Motivated by the need for sustainable health care in the face of global stress, we developed a framework to consider how an academic eye center contributes to waste and environmental degradation.
Focus Areas for a Green Academic Center
We identified four areas on which academic centers could focus: the operating room, clinic, administrative affairs and academic affairs. We investigated these realms with an eye toward maintaining superb patient care while supporting a culture of sustainability. In this article we chose to highlight considerations for the operating room
After initially looking into the possibility of recycling surgical packaging and plastics, we discovered recycling symbols printed on the plastic support inside suture packages. But answers to the question of recyclability of other materials were less clear.
Many of the OR plastics fell into the category of “plastic film” — especially the packages wrapping gloves and devices. This is the same category as plastic bags, which are not recyclable in most areas and can get caught in traditional recycling plants’ machinery. The issue of biohazard contamination came to our attention last year when our main hospital OR contaminated many tons of hospital recyclables in a well-intentioned attempt to recycle OR plastics.
Eye drops are another source of waste. A study in New York estimated that 45.3% of pharmaceuticals in cataract surgery were unused at an annual cost of $195,200 to the sites in the study. The production of this quantity of unused pharmaceuticals is questionable and likely contributes to climate change.
Our eye center’s operating facility discards unused eye drops, which cannot go home with the patients due to regulations against dispensing outside of a regulated pharmacy. Although our residents use a single bottle of proparacaine for all consults seen within one month, we learned that university emergency room physicians open a new bottle of proparacaine for every patient needing an intraocular pressure check. Our team would like to expand our reuse to our peers in the emergency department. Perhaps we can build a natural segue for the reclamation and use of perioperative drops for other patients in the emergency room.
Finally, we looked into the use of disposable instruments and equipment — a now particularly salient topic. Our instrument trays contain, among other things, disposable phaco tips, internal limiting membrane forceps and cauterization tips. Of note, we identified that our Veteran’s Affairs hospital is adopting fully disposable instrumentation. However, literature supports sterilization and reuse of surgical instruments, including phaco tips. Globally, reuse of surgical equipment is common and paramount in the fight against waste.
Until recently, Moran Eye Center used reusable OR gowns, which were replaced with disposable gowns. Reusable gowns soon made a quick comeback, due to the lack of quality of their disposable counterparts. Despite this, it is unknown which has a larger environmental footprint: disposable gowns or reusable gowns (given the unanswered questions regarding shipping costs, water consumption and use of environmentally toxic chemicals for cleaning reusable gowns).
So, what’s next? Our goal is the development of data-driven protocols to reduce waste. Three tenets guide us:
- What sounds like the greenest option may not be. For example, people get gung-ho about reusable gowns that are picked up by a truck, washed and then redelivered by a truck (producing a yet undetermined carbon footprint).
- Sustainability encompasses cost. Initiatives most likely to succeed in the long term will need to be cost-equivalent or produce financial benefit.
- We need cultural buy-in. It can start simply: We encourage everyone to bring a reusable coffee mug to Grand Rounds.
Think about your own carbon footprint. What can you do today in your life as an ophthalmologist? As a global citizen?
Plastic surrounds mail and cannot be recycled.
The Greening of Ophthalmology. Michael Mott. American Academy of Ophthalmology
The Growing Impact of Surgical and Medical Waste. Ruth D Williams, MD, and Alan L Robin MD. American Academy of Ophthalmology.