Developing the green operating room: exploring barriers and opportunities to reducing operating room waste

The Australian health care system has an urgent sustainability challenge. It generates 236 million kilograms of waste per year,1 making it one of the largest contributors to waste nationwide. In Australia between 2014 and 2015, 235 000 kg of carbon dioxide was produced per day from the incineration of hazardous waste.2 This is of great concern since the World Health Organization (WHO) declared in 2021 that “climate change is the biggest health threat facing humanity”.3

Operating rooms are a hotspot for greenhouse gas (GHG) emissions as they generate at least 20% of the total waste produced in hospitals.4 Worldwide, the number of operations has been increasing every year by 15% since 1992, resulting in an increase in the amount of annual waste produced.5 Besides the number of surgeries increasing, the other reasons for this dramatic increase in waste is the rise of minimally invasive surgeries, such as laparoscopic and robotic surgeries, the need to improve sterile processing,6 and the use of single-use devices (SUDs).7

All waste increases carbon dioxide emissions.8 However, general non-hazardous waste, which makes up 85% of hospital waste,9 does not contribute directly to GHG emissions unless incinerated.10 Nevertheless, this general waste still contributes to GHG emissions through the manufacturing process10 and through being disposed of incorrectly as infectious waste that requires incineration.11 This review examines the environmental end points of a linear economy of health care waste. Additionally, there is a global call for health care waste systems to transition from a linear to a circular economy.12 As Australia transitions away from coal and towards a renewable energy electricity grid, opportunities for a circular economy of health care waste will emerge. Therefore, this review also examines environmentally preferable purchasing of reusable and reprocessed devices.

There are a variety of frameworks and strategies proposed to reduce operating room waste. In Australia, the 2018 National Waste Policy (NWP)13 provides a framework to guide investments and sustainable action by businesses, governments, communities, and individuals. The National Waste Policy Action Plan (NWPAP), agreed on in 2019, includes five circular economy principles to implement the 2018 NWP: avoiding waste, improving resource recovery, increasing use of recycled material, better managing material flows, and improving information to support innovation, guide investment and enable informed consumer decision making.14 However, translating these general strategies to scalable implementation in health care has its challenges. An audit conducted by the Australian National Audit Office found that the implementation of the NWPAP has been only partly effective.15

A major challenge to scalable waste reduction strategies was the physical limits of recycling, in that nothing is 100% recyclable.16 Another critical challenge is the “tragedy of the commons”,17 in that hospitals might need to invest large amounts of money to reduce operating room waste, even if that individual hospital is not significantly contributing to the problem. A further challenge is that despite policies to promote waste reduction, these are not considered a priority when compared with key ethical concerns such as reducing patient harm.5, 18-20 A final challenge is the presence of an external force in the form of policies that have taken the onus off surgeons to drive sustainable change.7, 21 There is no comprehensive review of these barriers and potential strategies for overcoming them.

Through a review and thematic analysis of the literature, this narrative review assesses the current strategies adopted in the operating room to reduce waste and provides an in-depth analysis of the barriers to scalable waste reduction strategies. It also explores the knowledge gaps in the current NWP and uses this framework to guide policy and practice implications of the findings.