CLINICAL FEATURE KEYWORDS Waste / Recycling / Carbon footprint Provenance and Peer review: Unsolicited contribution; Peer reviewed; Accepted for publication September 2012.

Reducing the carbon footprint of the operating theatre:

a multicentre quality improvement report by T Southorn, AR Norrish, K Gardner and R Baxandall Correspondence address: Tom Southorn, Specialty Registrar, Trauma & Orthopaedics, Norfolk and Norwich Hospital, Colney Lane, Norwich, NR4 7UY. Email: [email protected]

Currently, there are very few provisions for recycling in theatres. We measured the weight of clinical waste for several orthopaedic operations. This waste was then examined and sorted into domestic waste and clinical waste. With staff education it is possible to reduce the amount of clinical waste generated by the operating theatre by roughly 50%. A greater awareness of disposal options leads to a reduction in waste disposed of by incineration. Introduction In December 2011 a special climate and health summit was held in Durban, South Africa. One of the organisations behind the summit recently recommended ten steps towards reducing the carbon footprint of hospitals and health systems (Box 1) (Moynihan 2012). Among their recommendations, the reduction and safe disposal of waste was given high priority. The current trend towards centralisation of specialist interventions, such as percutaneous coronary intervention and trauma care, leads to significantly increased ambulance journeys and an associated rise in carbon footprints (Zander et al 2010). The rising profile of energy use and sustainability within the NHS was highlighted by the NHS Sustainability Day of Action in March 2012. The NHS currently produces approximately 1% of the UK’s annual domestic waste and a quarter of all public sector waste (Moynihan 2012). This amounts to greater than 400,000 tonnes per year and is disposed of at a cost of approximately £73 million (Hutchins 2009). The NHS is also one of the UK’s largest producers of carbon dioxide (CO2), producing 3.2% of the country’s total carbon footprint (McGain et al 2009). Incinerating 1kg of clinical waste produces roughly 3kg of CO2. Of all hospital waste, approximately 20% (Saver 2011) is


50%. In the UK it is thought to be fewer than 10%. Per patient, the UK produces three times the amount of clinical waste of France and nearly twelve times that of Germany (Hutchins 2009).

Prioritise environmental health Substitute harmful chemicals with safer alternatives Reduce and safely dispose of waste Use energy efficiently and switch to renewable energy

The cost of waste disposal varies widely and is dependent on the type of waste in question. Per 1000kg, it costs roughly £750 to dispose of sharps waste, £450 to dispose of clinical waste and £60 to dispose of domestic waste. Costs for recycling waste are very variable but are generally less than those for domestic waste (CH 2010-11).

Reduce water consumption Improve travel strategies Purchase and serve sustainably grown food Safely manage and dispose of pharmaceuticals Adopt greener building designs and construction Purchase safer more sustainable products. Box 1 Ten goals for greening hospitals and health systems (Moynihan 2012)

produced by the operating theatres and it is estimated that each theatre produces about 2300kg a year (Hutchins 2009). In the majority of hospitals in the East of England all of this waste is incinerated. Around the world countries seem to have very different attitudes to waste disposal. In Australia it is thought that 80% of hospitals have some form of meaningful recycling programme. In the USA that figure is roughly

It is common practice in many hospitals in the UK to classify all waste from the operating theatre as ‘clinical waste’ that must be disposed of by incineration. This waste is put into yellow clinical waste bags. A survey of staff attitudes at one hospital in the East of England revealed that this was due to several strong beliefs: the most common were that ’all theatre waste is contaminated’, ’there are no facilities to separate waste’ and ’infection control won’t allow us to separate waste because of the risk of contamination’. In many cases items that members of staff would be able to recycle in their homes are being incinerated instead. Whilst there is little doubt that attempting to recycle contaminated or infectious waste poses a significant threat to health

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Examination of the domestic waste showed that there were no instances of obviously contaminated waste being placed in the incorrect bin

and environment, it is also true that some theatre waste is clean and safe. It has previously been shown that 80% of all theatre waste is created before the patient enters the theatre (Donaldson 2000). It is this waste, that has not come into contact with any patient, that should be classified as clean domestic waste, the obvious exception being sharps. Orthopaedic theatres are amongst the highest producers of waste, due to the large numbers of operating sets and implants required. They also perform large volumes of similar operations, such as hip and knee replacement, which allows a good platform to study the problem and implement change, by way of effective waste separation and recycling. This could have a significant reduction in the carbon footprint of theatre activity as well as a significant cost saving.

Methods The waste for total hip replacement (THR), total knee replacement (TKR) and facet joint injections (FJI) was collected and weighed from two hospitals in the East of England. These procedures were chosen as they are commonly performed in hospitals and, whereas joint replacement operations produce a large amount of waste, facet joint injections produce comparatively less waste. The waste was classified as produced in the anaesthetic room (some waste was produced before the patient arrived, some after), the instrument preparation area (before contact with the patient), the surgical scrub area (where hands are washed and gowns donned – before contact with the patient) and in the operating theatre itself (after contact with the patient).

replaced by black or clear domestic waste bags, as waste from these areas is not contaminated. Labels were placed on the lids of pedal operated bins reminding staff to think about what was being disposed of and whether they were using the correct bin. At the end of each operation the waste was weighed and recorded. Domestic waste was checked primarily to ascertain what proportion could be considered recyclable (paper, plastics, metal, etc. using the criteria for standard local domestic waste recycling) and also to ensure that no contamination of clinical waste had inadvertently occurred. All waste was kept in theatre until after a final swab and instrument count had been performed and was deemed correct. This is generally accepted as best practice. New waste bags were used for each operation to avoid any mixing of waste between patients.

Results Over a two week period, analysis of waste from 18 THRs, 14 TKRs and 12 FJIs revealed that an average total hip replacement created total waste of 12.1kg (+/- 0.25 SD of the mean), total knee replacement created a total waste of 11.6kg (+/- 0.18 SD of the mean) and facet joint injection created a total waste of 1.8kg (+/- 0.17 SD of the mean). After waste separation, 5.8kg (+/- 0.17 SD of the mean) of total hip replacement waste, 5.3kg (+/- 0.18 SD of the mean) of total knee replacement waste and 0.8kg (+/- 0.2 SD of the mean) of waste from the facet joint injection was suitable for domestic waste. Of this domestic waste, 47% was recyclable dry paper and card, a further 47 % was potentially recyclable plastic, and only 6%

was definitely not recyclable (wet paper or card, non recyclable plastic) (Figure 1). Examination of the domestic waste showed that there were no instances of obviously contaminated waste being placed in the incorrect bin. For illustrative purposes, in the UK nearly 180,000 joint replacements are performed every year (NJR 2011). Using our figures, this equates to 2.1 million kg of waste. If, under the traditional system all waste is treated as clinical waste and incinerated this would produce 6.3 million kg of carbon dioxide. If the waste was appropriately separated and recycled, this would reduce carbon footprint by approximately 75%. In addition to the positive environmental impact there is also a strong economic argument. Again, for illustrative purposes, the 180,000 UK joint replacement operations potentially produce 2.1 million kg of clinical waste per year, costing £953,000 to incinerate. If the waste was appropriately separated and only the true clinical waste was incinerated, the cost would be £533,000. This represents a potential saving to the NHS of £420,000 per year, for two operations alone, not including additional savings from recycling. If this were applied to all 4.2 million operative procedures done each year in the UK (RCS 2008) the environmental and economic impact would be substantial.

Discussion Based on the results from this study, a simple change in practice such as we describe can have a significant positive

After the initial collection of data to identify the extent of the problem, we repeated the exercise after highlighting with theatre staff the importance of accurate separation of waste for the purpose of reducing the carbon footprint, clearly identifying which waste could be disposed of in domestic bags and clinical waste bags. In addition, areas such as the instrument preparation rooms and surgical scrub rooms had their yellow clinical waste bags

Figure 1 Breakdown of joint replacement waste by weight

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Reducing the carbon footprint of the operating theatre: a multicentre quality improvement report Continued

impact on the environment as well as cost savings. In addition, based on our sample, we have shown it to be safe – there being no instances of contamination of domestic waste with clinical waste. The process requires no extra staff, only education to highlight the environmental and economic advantages, and accessibility of the correct bags and bins to simplify waste separation and recycling.


This study does have some limitations including its small sample size, however, from the standard deviations seen, there is little deviation in the amount of waste produced between one particular operation and another of the same kind, suggesting that increasing sample size would add little. Other limitations with this proposal include the admirable tendency of clinical staff to ’be on the safe side’, perhaps inappropriately putting clean waste into the clinical waste bin. As a result of this study we feel that this process can be recommended to all NHS trusts and hospitals in the private sector, as well as to GP surgeries and other areas where clinical waste is produced. We also feel that the NHS could use its considerable purchasing power to ensure that equipment and implant manufacturers assess their packaging and ensure that its volume is reduced and made of recyclable materials wherever possible.

Colchester Hospital University NHS Foundation Trust 2010-2011 Estates department costs for waste disposal Internal communication, Colchester

About the authors Tom Southorn MBBS, BSc, FRCS (Tr & Orth)

Donaldson K 2000 Save the planet: Recycling in the OR Available from: www.infectioncontroltoday. com/articles/2000/07/save-the-planet-recycling-inthe-or.aspx [Accessed January 2013]

Specialty Registrar, Trauma & Orthopaedics, Cambridge University Hospitals NHS Foundation Trust, Colchester University Hospital NHS Foundation Trust and The Ipswich Hospital NHS Foundation Trust

Hutchins DC, White SM 2009 Coming round to recycling British Medical Journal 338 b609

Alan R Norrish BSc, MBChir, LLM, PhD, FRCS (Orth)

McGain F, Kayak E, Story D The green anaesthetist Australasian Anaesthesia 67-75

Consultant Orthopaedic Surgeon, Cambridge University Hospitals NHS Foundation Trust

Moynihan R 2012 The greening of medicine British Medical Journal 344 d8360

Kate Gardner MBBS, FRCA

Royal College of Surgeons of England 2008 Surgery and the NHS in numbers Available from: [Accessed October 2012]

Consultant Anaesthetist, Colchester University Hospital NHS Foundation Trust

Saver C 2011 Going green in the OR brings financial, environmental gains Operating Room Manager 27 (6) 1-5

Consultant in Trauma & Orthopaedics, The Ipswich Hospital NHS Foundation Trust

UK National Joint Registry 2011 8th Annual report Available from:

No competing interests declared

Zander A, Niggebrugge A, Pencheon D, Lyratzopoulos G 2012 Changes in travel related carbon emissions associated with modernization of services for patients with acute myocardial infarction: A case study Journal of Public Health 33 (2) 272-9

Richard Baxandall MA, MBChir, FRCS, FRCS (Orth)

Members can search all issues of the BJPN/JPP published since 1998 and download articles free of charge at Access is also available to non-members who pay a small fee for each article download.

Conclusion A simple cost effective change in the way we deal with waste in the operating theatre could have a profoundly positive environmental impact as well as represent a significant cost saving. At our hospitals we now routinely have domestic waste bags in the surgical instrument preparation room and in the surgical scrub room. We also have recycling wheelie bins readily available in theatre corridors to facilitate card, paper and plastic recycling.


June 2013 / Volume 23 / Issue 6 / ISSN 1750-4589

Reducing the carbon footprint of the operating theatre: a multicentre quality improvement report.

Currently, there are very few provisions for recycling in theatres. We measured the weight of clinical waste for several orthopaedic operations. This ...
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