Breaking the Routine

The problems with procedure cards

The full research article can be viewed here.

Procedure cards list a surgeon's preferred tools, supplies and setup for an operation, helping to ensure a smooth operation by keeping everyone in the operating room all on the same page.

Too often, however, these cards are outdated with nonessential or redundant supplies. Dr. Shah explains that when doctors finish their residency, they’re often asked what they want on their preference card, and most of the time they just copy what their mentor has on theirs.

“Very few people know how to create a procedure card, and you end up having a lot of waste because you may or may not use exactly what your mentor had,” Dr. Shah explains. She likens the items listed on the procedure card to junk in your house that needs to be cleaned up.

“Taking the time to actually review your procedure is step one. Step two is really asking yourself if you need this or that device, why you’re opening it, and if the hospital really needs to buy a product that may be redundant.”

For example, surgeons may also list their favorite type of disposable surgical device on their procedure card, which results in the hospital purchasing several different products when only one brand is truly necessary to perform an operation.

This lack of coordination and forethought leads to higher direct costs to the hospital and patients, as well as waste that could have been avoided.

For example, about 300,000 appendectomies are performed every year in the United States. Most are simple cases where the appendix can be safely removed without disposable laparoscopic instruments. But these instruments are often opened and never used.

Even if the opened stapler was never touched, it is considered medical waste. As a result, the hospital is wasting money paying for a device no one uses; environmental damage is also caused through disposal by incineration of the plastic and metal in the stapler.

The aggregate cost to health care systems for these unused, opened staplers? A whopping $200 million. This also doesn’t include the resources needed to make the staplers, as well as the production and transportation costs, which cause additional harm to the environment.

Outside of updating providers’ procedure cards, Dr. Shah recommends leaving the stapler sealed and only using it as needed as a simple solution to reduce waste.

Dr. Shah isn’t the first researcher to look at the idea of reducing a hospital’s environmental footprint. While broad policy changes will ultimately have greater impact to reduce costs and waste, she believes that changes at a local level are a good place to start.

Ian Hughes, director of environmental sustainability at Rush, has begun partnering with Dr. Shah to turn her research into reality.

“Having a clinical leader like Dr. Shah to support Rush’s sustainability initiatives from within the operating room is the spark that ignited our Greening the OR initiatives. Aligning her clinical insight and expertise with the supply chain team’s drive for cost savings and efficiency creates a powerful catalyst for positive change.”

Toss out the surgical caps

The full research article can be viewed here.

One of the more confounding topics for Dr. Shah and Hughes is the use of single-use, spun polypropylene surgical caps in the operating room.

A decade ago, the Association of Perioperative Nurses advocated for the change from reusable cotton caps to disposable bouffant caps in the operating room. Despite a lack of evidence to support the change — namely to reduce surgical site infection — many hospitals nevertheless adopted the association’s guidelines.

The switch to single-use caps led to increased costs for hospitals and continues to put a significant strain on the environment. Dr. Shah says single-use products like the bouffant caps are falsely viewed as more sanitary and safer than something reusable.

“The conversation advocating people to wear their cotton cap tends to not get very far,” she explains. “The question of infection control comes up, which we know there’s no difference in SSI prevention between cloth and spun plastic caps. In fact, there are a few studies demonstrating that cloth caps decrease bacterial shedding. But that’s where the conversation stops.”

Aside from the lack of data to support wearing them, single-use surgical caps produce a significant environmental impact and cost hospitals a lot of money.

Based on 2020 data from the Agency for Healthcare Research and Quality, there were roughly 11.5 million ambulatory and 10.3 million inpatient surgeries performed that year. Assuming the surgical suite has a basic number of staff per procedure (one physician, one nurse, one CRNA, one anesthesiologist, two assistants/residents), that conservatively means about 130 million disposable caps were purchased.

Using this data as an estimate, hospitals on the whole purchased 1.3 million boxes of 100-count bouffant caps on average for $10 per box, resulting in an aggregate cost to the health care system of over $13 million.

“Once you use something, you throw it into a bin, it disappears and you don’t think about it,” Hughes says. “Those caps are already going into close-to-full landfills, and millions of these plastic caps are leaching chemicals into the ground and water.”

In their research, Dr. Shah and her colleagues show that reusable cotton caps have overall lower total lifetime CO²e emissions compared to disposable bouffant caps. While cotton caps were found to be more water-intensive than bouffant caps (67.56 L vs. 12.66 L) with the majority of water use secondary to production or manufacturing, reusable cotton caps reduced CO²e emissions by 79% compared to disposable bouffant caps (10 kg versus 49 kg CO²e).

“If a hospital implements a policy to wear reusable caps, then you’re taking those caps out of a landfill and improving the hospital’s bottom line because fewer caps need to be purchased,” Hughes says. “At the same time, you also have an opportunity to reinvest in the local community by sending those cotton caps to Fillmore Linen Service, Rush’s laundry partner on the near West Side. The environmental footprint gets a lot smaller.”

Pulse oximetry probes: A case study

Rush has already achieved success reducing costs and environmental harm through its collection of pulse oximetry probes, which measure the amount of oxygen in the blood. Once collected, these and other single-use devices like tourniquet cuffs, ligasures, trocars and MyoSure are given a new life after what is supposed to be their one and only use before being thrown in the garbage. Instead, they are reprocessed to a “like new” condition and Rush can buy these devices back at a reduced financial and environmental cost.

In 2023, Rush received the Gold Environmental Excellence Award from Stryker Sustainability Services for diverting 24,000 pounds of waste from landfills. Through Stryker's reprocessing and collection programs, the bulk of that waste was provided by the medical center’s collection and reprocessing of pulse oximeter probes.

Nearly 140,000 devices were collected for reprocessing in 2023, saving Rush over $400,000 through the reprocessed device buyback program. Across all facilities participating in the U.S., Rush ranked second overall for pulse oximeter probe collections in 2023.

“Our pulse oximeter collections and reprocessing program has been a huge success thanks to the longstanding support of our amazing nursing, environmental services and procurement teams,” Hughes says. “It has created an everyday opportunity for our staff to actively engage with our landfill diversion initiatives — making a tangible impact on our environmental footprint and our bottom line.

This program also helps change the all-too-common mindset of “take-make-waste” in health care to one of “take-make-remake” — and in doing so, Rush is realizing significant financial and environmental benefits in direct alignment with our organization’s mission to improve human and community health.”