BACKGROUND Anaesthetic gases are an important source of greenhouse gas emissions from operating theatres and can attribute significantly to the carbon footprint of a nation's healthcare system. OBJECTIVE To estimate the magnitude of the climate impact of inhaled anaesthetics in the Netherlands. Furthermore, the goal was to assess the preferences of Dutch anaesthesiologists for anaesthesia techniques, and to explore opportunities for reducing greenhouse gas emissions due to anaesthesia practice. DESIGN A 2019 bottom-up purchase analysis of inhalation anaesthetics used in all of the Dutch hospitals was executed and an online survey was conducted among Dutch anaesthesiologists regarding their preferences for anaesthetic agents. RESULTS Purchasing quantities of volatile anaesthetic agents were obtained from 61 of the 69 hospital organisations in the Netherlands (response rate 88.4%). A total of 12.2 kilotons CO2 equivalent (0.07% of the Dutch healthcare system) was emitted due to inhalation anaesthetics in the Netherlands in 2019. The volume of the in 2019 purchased inhalation volatile anaesthetics was 9.178 l of sevoflurane (93.4%), 404 l of desflurane (4.1%) and 245 l of isoflurane (2.5%). The survey in which 182 anaesthesiologists participated demonstrated that propofol was the first drug of choice of 70% of respondents, desflurane was available in 16% of Dutch hospitals and 83% of anaesthesiologists answered never using desflurane. Nitrous oxide was not used by 63% of respondents, the remaining 27% reported using nitrous oxide only in less than 5% of their cases. CONCLUSION The relatively low emission of greenhouse gases due to inhalation anaesthetics in Dutch healthcare compared to other countries can be explained by the limited use of nitrous oxide and desflurane by Dutch anaesthesiologists and their strong preference for intravenously administered propofol as an anaesthetic.

@en

Objectives
Shoulder arthroplasty has a large environmental impact. Part of the environmental impact is caused by the sterilisation of surgical instruments. This study examines the effect of optimising surgical instrument trays for reverse shoulder arthroplasty (RSA), to reduce the environmental impact.

Methods
An adjusted LEAN 5s method was used to optimise the number of instruments of shoulder arthroplasty specific trays. A Life Cycle Assessment was performed to calculate the CO2-eq.

Results
After careful selection, 139 of the 254 (55%) instruments were removed from the original RSA trays. Out of the 139 removed instruments, 19 were placed in a supplemental tray. The number of base trays was reduced with 3 trays. The estimated impact by reducing these trays from the standard pre-operative setup is a reduction of 28% of the environmental impact annually (524 kg CO2 equivalent).

Discussion
This study confirms the feasibility of optimising instrument trays for RSA, offering a straightforward method to reduce the environmental impact of shoulder arthroplasty. Our results show that strategic instrument selection can contribute to lowering the environmental impact of orthopaedic surgery.@en

Objective: To determine the user experience of wearing comfort of reusable sterile surgical gowns and compare these gowns with conventional disposable surgical gowns. Design: Cross-sectional survey. Setting: An academic hospital in the Netherlands. Population: Gynaecologists, surgeons, residents and operating room assistants (n=80). Methods: Quantitative and qualitative data were obtained via a written questionnaire. Participants provided subjective comments and scored the reusable gown on each individual topic with a score from 1 to 5 (1 = unsatisfactory, 2 = moderate, 3 = good, 4 = very good, 5 = excellent) and compared the reusable gown with the conventional disposable alternative (better, equal or worse). Main outcome measures: Wearing comfort: ventilation and temperature regulation, fit and length, functionality, barrier function and ease of use. Results: The results of the overall scores of the reusable gown are scored as ‘very good’ (mean 4.3, SD ± 0.5) by its users. Regarding comparison of the gowns, more than 79% (lowest score 79%, highest score 95%) of the participants scored the reusable gown equal or higher on six of seven topics. The topic ‘ease of use’ was scored equal or higher by 59% of the participants. Subjective comments provided information on possible improvements. Conclusions: The findings of this study demonstrate that there is professional acceptance regarding the utilisation of reusable surgical gowns. To facilitate broader adoption, it is imperative to foster collaboration among suppliers and healthcare institutions. The reusable surgical gown is an environmentally sustainable, safe and comfortable alternative in the operating room.

@en

Annually, over 300 million surgeries occur globally, requiring numerous surgical instruments. However, many instruments on the tray are returned to the central sterile supply department (CSSD) unused, creating an unsustainable pattern of unnecessary consumption. To address this, we developed a method for optimising surgical instrument trays (SITs) that is straightforward to implement in other hospitals. This optimisation aims to enhance patient safety and sustainability and to improve working conditions and reduce costs. We identified actual instrument usage (IU) in the operating room (OR) and obtained expert recommendations (ERs). Data from both methods were combined in a computer model (CM) to adjust the SITs. The performance of the adjusted SITs was assessed over a year. IU of three different SITs was collected during 16 procedures (mean = 28.4%, SD = 6.4%). Combining IU and ERs resulted in a 36.7% reduction in instruments and a 31.3% weight reduction. These measures contribute to reducing the carbon footprint and enhancing sustainability. During the evaluation of the new SIT contents (n = 7 procedures), mean IU increased from 28.4% (SD = 6.4%) to 46.5% (SD = 11.0%), with no missing instruments during surgery. A one-year follow-up showed no need for further alterations. Combining both methods yields better results than using them individually, efficiently reducing unnecessary items in SITs without compromising patient safety.@en

Background: Surgical site infection (SSI) in the form of postoperative deep sternal wound infection (DSWI) after cardiac surgery is a rare, but potentially fatal, complication. In addressing this, the focus is on preventive measures, as most risk factors for SSI are not controllable. Therefore, operating rooms are equipped with heating, ventilation and air conditioning (HVAC) systems to prevent airborne contamination of the wound, either through turbulent mixed air flow (TMA) or unidirectional air flow (UDAF). Aim: To investigate if the risk for SSI after cardiac surgery was decreased after changing from TMA to UDAF. Methods: This observational retrospective single-centre cohort study collected data from 1288 patients who underwent open heart surgery over 2 years. During the two study periods, institutional SSI preventive measures remained the same, with the exception of the type of HVAC system that was used. Findings: Using multi-variable logistic regression analysis that considered confounding factors (diabetes, obesity, duration of surgery, and re-operation), the hypothesis that TMA is an independent risk factor for SSI was rejected (odds ratio 0.9, 95% confidence interval 0.4–1.8; P>0.05). It was not possible to demonstrate the preventive effect of UDAF on the incidence of SSI in patients undergoing open heart surgery when compared with TMA. Conclusion: Based on these results, the use of UDAF in open heart surgery should be weighed against its low cost-effectiveness and negative environmental impact due to high electricity consumption. Reducing energy overuse by utilizing TMA for cardiac surgery can diminish the carbon footprint of operating rooms, and their contribution to climate-related health hazards.

@en

Objective: To assess the various factors that influence environmentally sustainable behaviour in gynaecological surgery and examine the differences between gynaecologists and residents. Design: An interview study. Setting: Academic and non-academic hospitals in the Netherlands. Population: Gynaecologists (n = 10) and residents (n = 6). Methods: Thematic analysis of semi-structured interviews to determine the various factors that influence environmentally sustainable behaviour in gynaecological surgery and to examine the differences between gynaecologists and residents. By using the Desmond framework and the COM-B BCW, both organisational and individual factors related to behaviour were considered. Main outcome measures: Factors that influence environmentally sustainable behaviour. Results: Awareness is increasing but practical knowledge is insufficient. It is crucial to integrate education on the environmental impact of everyday decisions for residents and gynaecologists. Gynaecologists make their own choices but residents’ autonomy is limited. There is the necessity to provide environmentally sustainable surgical equipment without compromising other standards. There is a need for a societal change that encourages safe and open communication about environmental sustainability. To transition to environmentally sustainable practices, leadership, time, collaboration with the industry and supportive regulatory changes are essential. Conclusion: This study lays the groundwork for promoting more environmentally sustainable behaviour in gynaecological surgery. The key recommendations, addressing hospital regulations, leadership, policy revisions, collaboration with the industry, guideline development and education, offer practical steps towards a more sustainable healthcare system. Encouraging environmentally sustainable practices should be embraced to enhance the well-being of both our planet and our population, driving us closer to a more environmentally sustainable future in healthcare.

@en

Literature proposes numerous initiatives for optimization of the Operating Room (OR). Despite multiple suggested strategies for the optimization of workflow on the OR, its patients and (medical) staff, no uniform description of ‘optimization’ has been adopted. This makes it difficult to evaluate the proposed optimization strategies. In particular, the metrics used to quantify OR performance are diverse so that assessing the impact of suggested approaches is complex or even impossible. To secure a higher implementation success rate of optimisation strategies in practice we believe OR optimisation and its quantification should be further investigated. We aim to provide an inventory of the metrics and methods used to optimise the OR by the means of a structured literature study. We observe that several aspects of OR performance are unaddressed in literature, and no studies account for possible interactions between metrics of quality and efficiency. We conclude that a systems approach is needed to align metrics across different elements of OR performance, and that the wellbeing of healthcare professionals is underrepresented in current optimisation approaches.

@en

Highlights: What are the main findings? Using the HSMEA, it is possible to systematically reduce operating room waste. The HSMEA identifies carbon hotspots of surgical waste based on waste stream analysis. Solutions for improvement are found by applying the six Rs of waste management. What is the implication of the main finding? A reproducible efficient approach to improve operating room sustainability. A structured and practical tool to reduce the environmental impact of surgical solid waste. The purpose of this study was to describe a new method to effectively improve the environmental impact of operating rooms through a systematic approach. A proven successful prospective risk analysis tool to improve the safety of complex healthcare processes (Healthcare Failure Mode and Effect Analysis) was adapted to reduce the environmental impact of surgical waste. For this novel method, named the Healthcare Sustainability Mode and Effect Analysis (HSMEA), a multidisciplinary team, using a structured step-by-step approach, systematically inventories surgical waste, quantifies its environmental impacts, identifies hotspots, and provides solutions for improvement. The five steps of the HSMEA are described (definition of the topic, team assembly, flowchart creation, hazard analysis, actions and outcome measures) and the surgical procedure of a caesarean section was used as a case study to assess the applicability of this method to improve its environmental impact. Applying the HSMEA to caesarean sections resulted in a 22% volume reduction and a 22% carbon footprint reduction in surgical waste. This was achieved by revising the disposable custom pack in order to reduce the overage that was present, and by intensifying waste stream segregation for plastic and paper recycling. The HSMEA is a practical work floor tool to aid in the reduction of the environmental impact of surgical waste that is applicable to all types of operations. It is reproducible, and because it identifies carbon hotspots, it enables an efficient approach to the issue of operating room pollution.

@en

The widespread use of single-use polypropylene packaging for sterilization of surgical instruments (blue wrap) results in enormous environmental pollution and plastic waste, estimated at 115 million kilograms on a yearly basis in the United States alone. Rigid sterilization containers (RSCs) are a well-known alternative in terms of quality and price. This paper deals with two research questions investigating the following aspects: (A) the environmental advantage of RCS for high volumes (5000 use cycles) in big hospitals, and (B) the environmental break-even point of use-cycles for small hospitals. An in-depth life cycle assessment was used to benchmark the two sys-tems. As such a benchmark is influenced by the indicator system, three indicator systems were ap-plied: (a) carbon footprint, (b) ReCiPe, and (c) eco-costs. The results are as follows: (1) the analyzed RSC has 85% less environmental impact in carbon footprint, 52% in ReCiPe, and 84.5% in eco-costs; and (2) an ecological advantage already occurs after 98, 228, and 67 out of 5000 use cycles, respec-tively. Given these two alternative packaging systems with comparable costs and quality, our results show that there are potentially large environmental gains to be made when RSC is preferred to blue wrap as a packaging system for sterile surgical instruments on a global scale.

@en

Background: To assess potential risks of new surgical procedures and devices before their introduction into daily practice, a prospective risk inventory (PRI) is a required step. This study assesses the applicability of the Health Failure Mode and Effects Analysis (HFMEA) as part of a PRI of new technology in minimally invasive gynecologic surgery. Methods: A reference case was defined of a patient with presumed benign leiomyoma undergoing a laparoscopic hysterectomy or myomectomy including in-bag power morcellation; however, pathology defined a stage I uterine leiomyosarcoma. Using in-bag morcellation as a template, a HFMEA was performed. All steps of the in-bag morcellation technique were identified. Next, the possible hazards of these steps were explored and possible measures to control these hazards were discussed. Results: Five main steps of the morcellation process were identified. For retrieval bags without openings to accommodate instruments inside the bag, 120 risks were identified. Of these risks, 67 should be eliminated. For containment bags with openings 131 risks were identified of which 68 should be eliminated. Of the 10 causes most at risk to cause spillage, two can be eliminated by using appropriate bag materials. Myomectomy appears to be more at risk for residual tissue spillage compared to total hysterectomy. Conclusion: The HFMEA has provided important new insights regarding potential weaknesses of the in-bag morcellation technique, particularly with respect to hazardous steps in the morcellation process as well as requirements that bags should meet. As such, this study has shown HFMEA to be a valuable method that identifies and quantifies potential hazards of new technology.@en