Eyeworld

61 EW RESIDENTS November 2017 the environment: Should green issues drive changes in ophthalmic care? – Yes. Eye (Lond). 2010;24:1309–11. 10. Heeg P, et al. Decontaminated single-use devices: An oxymoron that may be placing patients at risk for cross-contamination. Infect Control Hosp Epidemiol. 2001;22:542–9. Contact information Eliasieh: cteliak@sutterhealth.org another environmentally friendly fiber would further reduce the envi- ronmental impact. 7 This paper demonstrates that there is significant room for im- provement in the environmental footprint of cataract surgeries. Aravind's efforts toward recycling of OR waste should serve as a model for all healthcare professionals and organizations attempting to re- duce their footprint. Indeed, recent literature has highlighted several actions hospitals can take to lower their environmental and economic impact, including installing water saving taps, using technology to better triage patients, purchasing reusable items, and recycling when- ever possible. 8,9 However, it should be noted that many of Aravind's practices, such as flash sterilization techniques and the reusing of surgical gloves with antiseptic gel, would be diffi- cult to apply broadly in the U.S. due to regulations intended for patient safety. Similarly, many U.S. surgical centers opt for single-use disposable (SUD) instruments, which do not require sterilization after every use yet contribute significantly to the amount of waste generated by each case. While the hope is that this may help decrease rates of transmis- sible disease, 10 the paper by Thiel et al. and Aravind's renowned safety record suggest that certain U.S. regulations may not be essential to patient safety. Importantly, there is precedence for implementing some of the con- servation methods outlined in this paper. In 2008, Ascent Healthcare Solutions reported a supply cost sav- ings of $138,142,000 and 4.3 million pounds of medical waste diverted from U.S. landfills by safely repro- cessing SUDs. 2 It may be ethically challenging to perform randomized trials investigating the safety of re- usables, but the process begins with educating surgeons and regulators about these issues. While much of Aravind's emis- sions reductions stem from reusing materials, we must also consider that a typical Aravind OR has two surgeons and four patient beds, with adequate staff to maximize surgeon productivity (and environmental efficiency). This approach, which may be precluded in the U.S. and Europe due to regulations and the realities of staff compensation, could likely be adopted in many devel- oping countries. Similarly, utilizing solar energy may be a relatively simple step that hospitals could take in regions that have adequate solar access across the globe. We are hopeful that a follow-up study at Aravind-Pondicherry will demon- strate the additional environmental benefit of installing solar panels. In summary, we see steps based on Aravind's model that we think could be applied broadly to hospitals throughout the world. These include increased recycling of OR waste, a transition to reusable materials, and cleaner forms of electricity and ener- gy such as solar or wind. As with our clinical decision-making, we should hold ourselves to evidence-based standards determined by a scientific method, rather than relying on our instincts regarding the safety of var- ious OR practices. Moving forward, all participants of the healthcare system will need to make conscious decisions in reducing our environ- mental impact and advocate for system-wide improvements. EW References 1. IPCC. Climate Change 2014: Synthesis Report. Contribution of Working Groups I, II and III to the Fifth Assessment Report of the Intergovernmental Panel on Climate Change [Core Writing Team, R.K. Pachauri and L.A. Meyer (eds.)]. Geneva, Switzerland. 2. Kwakye G, et al. Green surgical practices for health care. Arch Surg. 2011;146:131–6. 3. Eckelman MJ, et al. Environmental impacts of the U.S. health care system and effects on public health. PLoS One. 2016;11:e0157014. 4. US Environmental Protection Agency (US EPA). Tool for the Reduction and Assessment of Chemical and Other Environmental Impacts (TRACI) v 2.1. 2012. 5. Morris DS, et al. The carbon footprint of cat- aract surgery. Eye (Lond). 2013;27:495–501. 6. Ravindran RD, et al. Incidence of post-cat- aract endophthalmitis at Aravind Eye Hospital: Outcomes of more than 42,000 consecutive cases using standardized sterilization and prophylaxis protocols. J Cataract Refract Surg. 2009;35:629–36. 7. PE International. The Life Cycle Assessment of Organic Cotton Fiber – A Global Average. 2014. textileexchange.org/wp-content/up- loads/2017/06/TE-LCA_of_Organic_Cotton-Fi- ber-Summary_of-Findings.pdf. 8. Somner JE, et al. Surgical scrubbing: Can we clean up our carbon footprints by washing our hands? J Hosp Infect. 2008;70:212–5. 9. Somner JE, et al. Eyes, economics and surgery: What can we learn from Aravind? Cataract surgery and environmental sustainability: Waste and life cycle assessment of phacoemulsification at Aravind Eye Care System Cassandra Thiel, PhD, Emily Schehlein, MD, Thulasiraj Ravilla, R.D. Ravindran, MD, Alan Robin, MD, Osamah Saeedi, MD, Joel Schuman, MD, Rengaraj Venkatesh, MD J Cataract Refract Surg. 2017;43(11). Article in press. Purpose: To measure the waste generation and life cycle environmental emissions from cataract surgery via phacoemulsification in a recognized resource-efficient setting. Setting: Two tertiary care centers of the Aravind Eye Care System (Aravind) in southern India. Aravind performs 1,000–1,500 eye surgeries daily and is internationally recognized for efficient surgical processes and excellent outcomes. Design: This observational study utilized waste audits, financial or purchasing data, and interviews with Aravind staff from November 2014 to March 2015. Subjects: This study did not enroll individual patients. Methods: Inventory data, described in Design, was fed into a hybrid environmental life cycle assessment (LCA) framework to quantify the environmental emissions associated with cataract surgery. Main outcomes and measures: Kilograms of solid waste generated and midpoint emissions in a variety of impact categories (for example, kilograms of carbon dioxide equivalents). Results: Aravind generates 250 g of waste per phacoemulsification and nearly 6 kg CO 2 -equivalents in greenhouse gases. This is about 5% of the U.K.'s phaco carbon footprint with comparable outcomes. A majority of Aravind's life cycle environmental emissions occur in the sterilization process of reusable instruments, since their surgical system utilizes largely reusable instruments and materials. Electricity use in the OR and central sterile accounts for 10–25% of most environmental emissions. Conclusions: Surgical systems in most developed countries and specifically their use of materials are unsustainable. Ophthalmologists and other medical specialists can reduce material use and emissions in medical procedures. Systems such as Aravind serve as good examples of effective and efficient patient care.

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