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The Development of a Surgical Care and Climate Change Matrix

A Tool to Assist With Prioritization and Implementation Strategies

Ewbank, Clifton MD∗,†; Stewart, Barclay MD; Bruns, Brandon MD§; Deckelbaum, Dan MD; Gologorsky, Rebecca MD; Groen, Reinou MD||; Gupta, Shailvi MD§; Harris, Mark J. MD∗∗; Godfrey, Richard MD; Leppäniemi, Ari MD††; Malone, Debra L. MD§; Newton, Christopher MD; Traynor, Michael D. Jr. MD‡‡; Wong, Evan G. MD; Kushner, Adam L. MD§§,¶¶

Author Information
doi: 10.1097/SLA.0000000000003980
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Even as health care professionals face unprecedented challenges resulting from the SAR-CoV-2 virus and COVID-19, we must look toward a possibly even bigger threat. The global climate continues to undergo change that significantly impacts human and environmental health.1,2 Most of the associated priorities and implementation strategies relate to medical and not surgical conditions.3 However, a recent commentary highlighted some of the issues related to surgical care and climate change and noted, “the intersection of climate change and health is still an inchoate field of study, and how climate change and surgery intersect is even less explored.”4 To address this concern, a working group of surgical care providers developed a matrix to define the problem and identify priority areas of study and intervention. The Surgical Care and Climate Change Matrix, presented here, is based upon the Haddon Matrix developed for injury prevention interventions and a similar matrix developed for global surgery.5,6


A draft matrix was developed and circulated among the working group members and a consensus was achieved. The matrix considers the continuum of patient care from pre-hospital, in-hospital, and post-hospital locations, with interventions focused on prevention, readily achievable responses, and long-term responses at each location (Table 1).

TABLE 1 - Proposed Surgical Care and Climate Change Matrix to Plan Interventions That Mitigate the Impacts of Climate Change on Surgical Practice
Prehospital Hospital Posthospital
Prevention (reduce/reverse) Electric vehicle transportEco-friendly packaging <LBREAK"/>-->Minimize packagingBiodegradable wasteRational expiration datesIncrease urban green spaces Eco-friendly packagingMinimize packagingBiodegradable wasteRational expiration datesShift away from vapor anesthetics, particularly desflurane.Minimize hazardous chemical use Electric vehicle-transportEco-friendly packagingMinimize packagingBiodegradable wasteRational expiration dates
Readily achievable responses ResolutionsLED lightingUpgrade surge capacityReusable equipmentUnderstanding/duplication of critical supply chain ResolutionsLED lightingUpgrade surge capacityReusable equipmentMotion-sensor activated lighting and climate controlRationalize policies regarding room attire (eg, not everyone needs a mask)Food waste composting and water extraction ResolutionsLED lightingUpgrade surge capacityReusable equipment
Long-term responses TelemedicineTask-shiftingRoboticsDronesArtificial IntelligenceLEED certificationBuild hospitals with access to public transportation Task-shiftingSolar/wind energyRoboticsArtificial IntelligenceLEED certificationWaste sorting TelemedicineTask-shiftingRoboticsDronesArtificial IntelligenceLEED certification
LED indicates light-emitting diode; LEED, Leadership in Energy and Environmental Design.


These items mitigate additional impacts on climate change through reduction or even reversal of carbon emissions. Alongside structural changes, we propose an extensive outreach and education effort to change cultural norms. Our efforts will focus on educating the public and all members of the surgical care team about the importance of environmental stewardship. These efforts should be developed at the relevant community level to include appropriate language, cultural, and resource considerations. In the prehospital setting, prevention strategies include use of electric vehicles; converting to compostable packaging; enhancing sterilization and/or reusing select supplies; modifying expiration date rules for items that do not expire; and recognition or conversion to biodegradable waste products. In the hospital setting, carbon emissions can be further decreased by powering down unused operating rooms and using alcohol scrub-in instead of water. Additional reductions in greenhouse gas emissions are possible by switching anesthetic formulations away from certain gases, which, when used for a single hour of surgery, equate to driving nearly 300 miles by car.7 An immediate reduction in waste could be achieved by elimination of single-use plastic bags and plastic beverage containers. In the posthospital setting, the emphasis is again on energy-efficient transport, eco-friendly dressings, and packaging for outpatient care.

Readily Achievable Responses

Readily achievable responses are interventions that can be implemented in less than 1 year with a rapid impact on the local carbon footprint and cumulative effects on climate change. Our first suggestion is to draft resolutions to call for eco-friendly packaging of medical supplies. By applying strong grassroots support from providers, industry may change habits before the need for legislation. Secondarily, conversion to light-emitting diode lighting, as well as motion sensor activated lighting and climate control, can quickly reduce a facility's carbon footprint.

Another readily achievable response is developing surge capacities in prehospital infrastructure and acute and long-term (rehabilitation) health facilities to care for increased patient loads due to climate-related disasters. Disaster plans currently exist for every health facility, but these need to incorporate the increasing risk of climate change-associated events.8 We advocate for enhanced protocols in the event of a facility needing to relocate due to sudden natural disasters and pandemics.

Long-term Responses

Long-term responses to climate change will likely take longer than 1 year to implement. These responses include development and integration of high-fidelity telemedicine, remote care with robotics, drone delivery of supplies, and training of health extenders to perform more complex diagnostics and treatments. The increasing importance of telemedicine is linked in part to the increased danger of travel as a result of climate change. For example, due to later freezing and earlier melting of Arctic ice, many frozen “highways” can no longer safely be used to access health care facilities by ground.9 In addition, continued development of green facilities easily accessible via public transportation will be vital and every effort should be made to see that health facilities are Leadership in Energy and Environmental Design certified.10


All meaningful change starts at the local level, and we invite the surgical community to apply this tool to identify areas for improvement in their own practices and institutions. For example, avoidance of desflurane and occupancy-based ventilation of operating rooms were previously identified as significant modifiable factors of a hospital's surgical carbon footprint.11 Additional study of factors such as these with consideration of both carbon footprint and cost may help guide discussions with administrators. The cost savings of reduced electricity, fuel for transportation, and surgical equipment may provide an additional incentive for institutional change. As surgical care providers concerned with the effects that a changing climate will have upon our patients, health systems, and delivery of surgical care, we feel that now is the time to join together and make changes that support our mission and vision. If all surgical care providers work in conjunction with their professional societies and join with other specialties, we will have the grassroots power to affect change.


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10. LEED green building certification, Available at:, Accessed November 21, 2019.
11. MacNeill AJ, Lillywhite R, Brown CJ. The impact of surgery on global climate: a carbon footprinting study of operating theatres in three health systems. Lancet Planet Health 2017; 1:e381–e388.

climate change; global surgery; Haddon matrix; surgical innovation

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