Eyeworld

22 Ophthalmology Business • March 2018 around sterilization practices has cre- ated confusion in ophthalmology. At Aravind the sterilization technique is used between cases with a full cycle at the end of the day. Dr. Thiel said this allows Aravind to stock fewer instrument trays during the day and reduces electricity used in the steril- ization process. "Making a small change to [cataract surgery], if implemented across the country, can make a big difference in the cost and the envi- ronmental footprint," Dr. Thiel said. "Likewise, some of the sustainability lessons we learn by studying cataract surgeries can be applied to other pro- cedures performed in an operating room. Medical practice as a whole needs to be analyzed for efficiency improvements, so that we can reduce waste, reduce spending, and mini- mize our environmental impact." Overall, she added, this research showed that "sustainable healthcare is possible with low environmental emissions, little waste, low costs, and excellent outcomes. We should all be taking steps to reduce our environ- mental footprint." OB References 1. Eckelman MJ, et al. Environmental impacts of the U.S. health care system and effects on public health. PLoS One. 2016;11:e0157014. 2. Thiel CL, et al. Cataract surgery and envi- ronmental sustainability: Waste and lifecycle assessment of phacoemulsification at a private healthcare facility. J Cataract Refract Surg. 2017;43:1391–1398. 3. Morris DS, et al. The carbon footprint of cata- ract surgery. Eye (Lond). 2013;27:495–501. Editors' note: Dr. Sack and Dr. Thiel have no financial interests related to their comments. Contact information Sack: tsack8@gmail.com Thiel: Cassandra.Thiel@nyumc.org exactly the same supplies, Aravind can negotiate for better deals when purchasing supplies." Thiel et al. acknowledged that there are some regulatory barriers in developed countries like the U.S. that prevent straight replication of Aravind's model. Still, Dr. Thiel said there are some things U.S. physicians could consider implementing—and some already have. • If possible, have one surgeon use more than one operating room to improve surgical flow from case to case. • Limit the surgeon's nonsurgical duties. • Reduce the size of custom packs (disposable surgical supply kits) and switch to reusable supplies when available. • Have the team ask the surgeon before they open certain supplies to reduce unnecessary waste. Larger efficiency improvements could require policy changes, Dr. Thiel said. "One example specifically for ophthalmology is the continuous disposal of partially used pharmaceu- ticals," she explained. "At Aravind, eye drops used in surgery are admin- istered to multiple patients until the bottle is empty. In the U.S., because the vials are branded as single-use, the amount remaining after they administer a few drops is thrown out. Even if the drug is something the patient will use at home (like antibi- otics), in most cases, the operating room staff is forbidden from releas- ing that drug to the patient, and it is thrown out. The patient then has to buy another bottle for at-home use." Another regulatory enforcement hurdle faced in the U.S. is short cycle steam sterilization, or what Aravind calls "flash autoclaving," for surgi- cal tools. (Flash autoclaving has a different meaning in the U.S.) Dr. Thiel explained that this is allowed in the U.S. for surgeries performed on the same day the instruments were sterilized, but the terminology system results in 96% fewer carbon emissions than the same procedure taking place in the U.K. (emissions from cataract surgery in the U.K. were already known 3 ). Dr. Thiel said her team is currently researching the carbon footprint of cataract surgery in the U.S. and expect similar results to that seen in the U.K. "Aravind operates with mostly reusable surgical supplies, and they designed safe handling processes and training programs to ensure that the supplies are properly sterilized for each case. They also maximize the materials that they recycle, which earns the hospital some money from their local recycling market," Dr. Thiel said. In addition to reusability of materials, Dr. Thiel said Aravind's environmental success is influenced by other measures as well. "Aravind designed—and contin- ues to redesign—their system with the aim of efficiency. Their goals to reduce costs and increase access, while maintaining quality, also helped to reduce their environmental footprint," Dr. Thiel said. "Aravind has standardized their process so everyone does the same thing every time; it resembles an assembly line. They have also arranged the physical space to optimize the flow of pa- tients. They use two beds per phy- sician, so that one patient is being operated on while the other is being prepared for surgery. These steps allow Aravind to reduce the duration and turnover time of surgery. "Aravind's surgeons only do what surgeons are trained to do— the surgery. Mid-level ophthalmic professionals handle all the pre- and postoperative work the day of sur- gery, thus optimizing the surgeon's time. In contrast, at a typical Amer- ican hospital, the surgeon will often visit with patients in the preoperative room, prepare the patient's surgical site in the OR, and help clean up the patient after the surgery. Additional- ly, because every surgical team uses continued from page 21

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