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Environmental Sustainability and Perioperative Quality Improvement


Key Points

  • Sustainable quality improvement (QI) aims to deliver care that maximizes positive health outcomes through best use of environmental, social, and financial resources.

  • Average global temperatures on earth are rising because of human activity.

  • The US healthcare industry produces 8% to 10% of US greenhouse gases, at a rate of 1.51 tCO 2 /capita, which is about twice as high as other nations with advanced healthcare systems.

  • Perioperative spaces produce a disproportionate share of waste and emissions within hospitals, with evidence indicating the average surgical case produces about 200 kg of CO 2 , equivalent to driving about 500 miles in an average vehicle.

  • Readily achievable objectives, such as anesthetic gas optimization, efficient energy use, and device life prolongation, can significantly reduce the impact of perioperative care on the environment now.

Introduction

Quality improvement (QI) seeks to increase the value of health care by achieving the best outcomes through the best use of resources. Traditionally, this has been limited to financial and social resources. By expanding the definition of “available resources” to include environmental considerations, QI strategies offer a framework for approaching issues of environmental sustainability. Just as QI is currently used to target efficiency, cost, or patient safety, we can target greenhouse gas (GHG) emissions or waste as guiding goals to improve the value of health care. Thus the aim of sustainable QI is to deliver care in a way that maximizes positive health outcomes through best use of environmental, social, and financial resources, as illustrated in Fig. 61.1 .

Fig. 61.1, Sustainable quality improvement. A formula for value within a sustainable quality improvement framework.

Environmental Sustainability

Environmental sustainability can be defined as meeting current needs without compromising the ability of future generations to meet their own. This definition is broad and seeks to encompass all resources necessary for human thriving, including water, land, biodiversity, a stable climate, and others, which are collectively referred to as the planetary boundaries.

Climate Change

Climate change refers to change in average temperatures, precipitation and wind patterns because of rising atmospheric concentrations of GHGs, especially carbon dioxide (CO 2 ). GHGs exist naturally but are also generated by human activities. Atmospheric CO 2 levels have increased by 40% since preindustrial times and are presently at the highest concentrations reached in 800,000 years. Because of these changes, there is virtual certainty that average temperatures on earth are rising and that this increase is because of human activity, primarily from burning fossil fuels. The downstream effects of higher GHG concentrations include intensified hurricanes, heat waves, droughts, precipitation, flooding, and sea level rise. Climate change is only one planetary boundary through which human impact is unsustainable, but currently it is the most urgent threat and will be the focus of this chapter on sustainability.

Climate Change and Human Health

There is strong, growing evidence that climate change harms health. Through temperature-related illness, changes to air quality and respiratory illness, infectious disease-like vector and waterborne pathogens, extreme weather-related injury, malnutrition and food insecurity, and mental health disorders, climate change is already having profound effects on health worldwide.

Climate Change and Health Care

Like all industries, the US healthcare sector contributes to climate change. Health care in the United States produces 8% to 10% of US GHGs, at 1.51 tCO 2 /capita, which is about twice as high as many other nations with advanced healthcare systems like the UK (0.64 tCO 2 /capita) and Canada (0.83 tCO 2 /capita). Through direct and indirect emissions, US health care is responsible for a significant burden of air pollution and public health damages from acidification, smog formation, respiratory disease from particulate matter, ozone depletion, and carcinogenic air toxins, estimated at 470,000 disability-adjusted life years lost annually.

Climate Change and Perioperative Spaces

Perioperative spaces produce a disproportionate share of waste and emissions within hospitals because of anesthetic gas use, electricity requirements, and the perioperative supply chain. Inhaled anesthetic gases are potent GHGs responsible for 30% to 70% of a surgical procedure's total emissions and approximately 1% of all US healthcare emissions annually. Operating rooms (ORs) are more energy intensive than other areas of a hospital, by square foot, because of the electricity intensity of lighting, ventilation, temperature, and sterilization needs. Finally, the perioperative supply chain, which includes all the reusable and disposable instruments, protective equipment, and devices necessary to perform procedures safely, contributes significantly to perioperative emissions. The clearest picture on current emission in surgery to date is a 2017 study from MacNeill et al., which compared perioperative spaces in three countries (UK, Canada, and the US). Totaling direct and indirect emission sources, the average surgical case produces between 146 and 232 kg of CO 2 equivalents, comparable to driving more than 350 miles in an average vehicle ( Fig. 61.2 ).

Fig. 61.2, Greenhouse gas emissions in perioperative spaces. The contribution of each greenhouse gas protocol scope to total perioperative emissions. Contributions from each scope varied between hospitals depending on the source of electricity (i.e., coal, renewable) and inhaled anesthetic gas usage.

Measuring Emissions

The first step to reducing emissions is to recognize and measure current emissions. The Greenhouse Gas Protocol is a formal accounting system used around the world in all industries to measure and report carbon emissions. Application of this framework is explored in Table 61.1 .

Table 61.1
Greenhouse Gas Protocol
Scope Definition Perioperative Application
Scope 1 Direct emissions from an organization Anesthetic gases
Scope 2 Indirect emissions because of electricity consumption Electricity use for heating, ventilation, air conditioning, lighting
Scope 3 All other indirect emissions occurring as a consequence of organization activities Perioperative supply chain, waste disposal

Measures and Approaches

Here we describe several potential areas of focus for perioperative departments seeking to employ sustainable QI approaches to reduce environmental impact.

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