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The Perioperative Garden of Eden

Leading Edge or Trailing Edge?

Sherman, Jodi D. MD

doi: 10.1213/XAA.0000000000000240
Editorials: Editorial

From the Department of Anesthesiology, Yale University, School of Medicine, New Haven, Connecticut.

Accepted for publication July 24, 2015.

Funding: None.

The author declares no conflicts of interest.

Address correspondence to Jodi D. Sherman, MD, Department of Anesthesiology, Yale University School of Medicine, 333 Cedar St., TMP 3, New Haven, CT 06520. Address e-mail to

Environmental health is critically linked to human health. Modern health care produces significant pollution, which adversely affects human health. The US health sector accounts for 17% of Gross Domestic Product.a Health care is interconnected with industrial activities that pollute our air, water, and soil with particulate matter, toxic metals, persistent organics, and sulfur and nitrogen oxides. In a 2009 landmark study, Chung and Meltzer1 estimated that the US health care sector contributed 8% of the nation’s greenhouse gas emissions. These emissions stem from the entire life cycle (“cradle to grave”) of health care products and services, including health care activities and direct purchases (46%), as well as indirect supply chain activities (54%). Similar reporting from the United Kingdom noted that the National Health Service contributed 3% to 4% of total greenhouse gas emissions, 22% of which stemmed from pharmaceuticals (excluding waste anesthetic gas) and 8% from medical devices.2 Inhaled anesthetics alone accounted for 5% of the UK hospital carbon footprint, equivalent to half the emissions from gas used to heat buildings and water, and 2.5% of the entire health sector greenhouse gas emissions.3 The resource-intense nature of our specialty begs the question what, if anything, are anesthesia practitioners doing to reduce pollution?

To answer this question, in this month’s issue of A & A Case Reports, Ard et al.4 report “A survey of the American Society of Anesthesiologists Regarding Environmental Attitudes, Knowledge and Organization.” This survey is a work product of the American Society of Anesthesiologists (ASA) Environmental Task Force under the direction of the Committee on Equipment and Facilities. Forty-two percent of 5200 randomly sampled ASA members responded. The respondents generally matched survey demographics of the Anesthesia Quality Institute and Physician Characteristics and Distribution in the U.S. 2014. This high survey response rate suggests the importance of the topic to the ASA membership. The study authors found that the majority of respondents demonstrated an interest in sustainability, but lacked knowledge about conservation practices and administrative support for changes in practice.

The majority of ASA respondents supported basic pollution-prevention strategies. Many reported operating room (OR) sustainability practices currently underway at their institutions that include reprocessing equipment (48%), using prefilled syringes (56%), and donating unused equipment and supplies (65%). OR recycling only occurs at 28% of respondents’ facilities; however, >80% reported that they would like to recycle in the OR.4 Given that the survey confirms high interest but only some participation in waste-reduction strategies, what is missing? Only 12% of respondents reported environmental sustainability encouragement from hospital leadership.4 This suggests an opportunity for conscious, systematic waste reduction through perioperative leadership.

Improving the quality and value of patient care through waste reduction is an important and increasingly pressing concern. In “Eliminating Waste in US Health Care”5 and at his 2012 ASA keynote address,b Berwick noted that the urgent need to bring US health care costs into a sustainable range could be achieved through a strategy that reduces wasteful, non–value-added care. Berwick argued that this approach to cost savings could be achieved through systematic, comprehensive, and cooperative waste reduction. Hwang in the book titled The Innovator’s Prescription: A Disruptive Solution for Health Care6 and 2014 ASA keynotec also spoke of waste reduction through better care coordination by moving away from the current “modular approach” in patient care to an “integrated approach.” This new, conservation-minded model of anesthesia practice is called the Perioperative Surgical Home. Although, currently, the Perioperative Surgical Home does not include ecological health as an objective, more efficient delivery of perioperative health care will reduce health care pollution.

Improving quality and value of patient care requires understanding the choices that increase costs and cause more pollution. The survey demonstrated that knowledge about sustainability practices that reduce pollution in anesthesia practice is lacking. For example, approximately one-third (30%) of ASA member respondents reported that they were unaware of environmental impact of inhaled anesthetics,4 despite authoritative articles on the subject.3,7–13 Only 5% reported knowledge of how their clinical management choices affected the environment.4 The authors did not inquire about conscious effort to use lowest fresh gas flows, an obvious strategy to prevent pollution from anesthetic gases.14 Respondents were asked about proper segregation of biohazardous waste. The majority (56%) answered incorrectly.4,d The absence of knowledge is not surprising. Only 8% of respondents from teaching facilities reported that sustainability was part of the medical student or resident curriculum.4 This suggests an opportunity to address a knowledge gap.

Learning objectives for sustainability in health care (Table 1) are already incorporated into the curricula of several specialties in the United Kingdom, with plans to include them into medical school and postgraduate medical education.15,e These learning objectives are complementary to and overlap with those proposed for the Perioperative Surgical Home. A recent editorial in Anesthesiology16 and paired Open Mind articles in Anesthesia & Analgesia17,18 call for changes in the anesthesia curriculum to prepare trainees for expanded roles as anesthesiology and perioperative medicine experts. Proposed expansions include skills development in patient safety and quality assessment, and systems management tools such as Six Sigma and Lean training to achieve improvements in efficiency, cost reduction, and quality. Interestingly, such quality management tools are also commonly used in health care sustainability initiativesf to reduce wasteful practices and to protect patients, workers, and public health from pollution. The goal is the Triple Aim of health care19: better quality care for individuals, better community health, and reduced per capita costs for health care. Although the motivation may appear different between the Perioperative Surgical Home and sustainability, the objective to reduce wasteful practices is the same. It is not surprising that many common pollution prevention practices actually save money.g

Table 1

Table 1

The resource and pollution intensity of perioperative medicine provides substantial opportunities for waste reduction. If not addressed, it also leaves us vulnerable to potential targeting for forced mitigation in the near future. In 2009, the US Environmental Protection Agency issued the Mandatory Reporting of Greenhouse Gases Rule.h This rule requires reporting by facilities that emit >25,000 metric tons per year of carbon dioxide equivalents, stemming from carbon dioxide, methane, nitrous oxide, and fluorinated greenhouse gases. Recently, the White House released the Climate Action Plan,i ahead of the United Nations Framework Convention on Climate Change Conference in Paris in December 2015. This plan promises to cut US greenhouse gas pollution by 26% to 28% below 2005 levels by 2025. Many local municipalities already have committed to more ambitious goals. It is unclear how legislative rulings will eventually impact health care practice. However, it would be prudent for anesthesiologists to be proactive mitigating pollution stemming from anesthesia practice.

In 2010, the American Hospitals Association launched the Sustainability Roadmap,j offering tools and resources to aid health care organizations transitioning to sustainability. More than 1200 hospitals already have pledged to participate in the Healthier Hospitals Initiative,k a national campaign organized by Health Care Without Harm.l The Healthier Hospitals Initiative challenges hospitals around 6 areas of environmental stewardship: cleaner and more efficient use of energy, less waste, safer chemicals, environmentally preferable purchasing, healthier foods, and engaged leadership. Perioperative medicine intersects with all of these areas. The opportunity exists for our profession to take a leadership role in health care’s transition to a more sustainable future.

The ASA membership survey by Ard et al.,4 does a commendable job highlighting that anesthesiologists have an interest in sustainability. However, we are lagging behind the efforts of hospitals, regulators, and scientists in addressing the environmental impact of health care practice. That needs to change. Anesthesiologists were early developers of the field of patient safety.20 Our role as pioneers in patient safety has been recognized widely and lauded. We know how to lead, how to innovate, and how to change practice. Let us follow our own example by being early adoptors, and pioneers, in sustainable health care.

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a The World Bank, Health expenditure, total (% of gross domestic product). Available at: Accessed April 28, 2015.
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b American Society of Anesthesiologists–Anesthesia Patient Safety Foundation Ellison C. Pierce Lecture, “How Anesthesiologists Can Continue to Lead in Patient Safety.” Washington DC, October 13, 2012.
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c American Society of Anesthesiologists Opening Session: “Are You the Anesthesiologist of the Future?” New Orleans, October 11, 2014.
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d Placing regular trash in the biohazardous waste bin through either insufficient knowledge, inattention, or through “overdefining” risk leads to excess pollution and costs. Therefore, proper waste segregation matters. Biohazardous waste must be shipped to one of a handful of special facilities designed for high-temperature incineration of health care waste. Such incineration liberates toxicants including dioxins and heavy metals, and treatment typically costs 5 to 10 times more than regular trash handling.
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e Accessed April 28, 2015.
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f Practice Greenhealth. Available at: Accessed April 28, 2015.
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g J. Moyle, C. DeLoach. The business case for sustainability in surgery. Available at: Accessed April 28, 2015. Many case studies are also available to Practice Greenhealth institutional members.
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h US EPA, Greenhouse Gas Reporting Program. Available at: Accessed August 31, 2015.
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i White House. FACT SHEET: U.S. Reports its 2025 Emissions Target to the UNFCCC. Available at: Accessed April 28, 2015.
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j American Hospitals Association, sustainability road map. Available at: Accessed April 28, 2015.
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k The Healthier Hospitals. Available at:
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l Health Care Without Harm. Available at: Accessed April 28, 2015.
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