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SURGICAL PERSPECTIVES

Introduction of the Surgical Providers Assessment and Response to Climate Change (SPARC2) Tool

One Small Step Toward Reducing the Carbon Footprint of Surgical Care

Ewbank, Clifton MD∗,†; Stewart, Barclay MD; Bruns, Brandon MD§; Deckelbaum, Dan MD; Gologorsky, Rebecca MD; Groen, Reinou MD||; Gupta, Shailvi MD§; Hadley, Megan BA∗∗; Harris, Mark J. MD††; Godfrey, Richard MD; Jackson, Jordan 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.0000000000004367
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BACKGROUND

During the global response to COVID-19 we must remain attentive to another looming threat. The global climate continues to undergo rapid change that significantly impacts human and environmental health, and this pandemic has shown how quickly global systems can be disrupted by disaster.1 As we retool our health care systems to meet our changing needs, we have an opportunity to concomitantly address the impact of surgery on climate change. A recent effort by our international Surgical Care and Climate Change collaborative resulted in a matrix illustrating points of maximal leverage from the pre-hospital, in-hospital, and post-hospital locations, with interventions focused on prevention, readily achievable responses, and long-term responses at each location.2 To aid stakeholders during this radical evolution to simultaneously prepare for the mounting climate crisis, we have developed a novel scoring tool to help assess surgical readiness for climate change.

SURGICAL PROVIDERS ASSESSMENT AND RESPONSE TO CLIMATE CHANGE (SPARC2) TOOL DEVELOPMENT

A review of the literature on health care and climate change was performed. A draft tool was then developed and circulated among the working group members and a consensus was achieved. The SPARC2 tool assigns points based on system readiness along the continuum of patient care from pre-hospital, hospital, and post-hospital locations, with interventions focused on prevention, readily achievable responses, and long-term responses at each location (Table 1).

TABLE 1 - Surgical Providers Assessment and Response to Climate Change (SPARC2) Tool
Pre-Hospital Factors 1 2 3 Total
Prevention (reduce/reverse)
 Electric vehicle transport17 kg CO2e/patient3 <25% Of transports <50% Of transports >50% Of transports
 Limit unnecessary air transport6000 kg CO2e/patient3 >10% Air transport 5%–10% Air transport <5% Air transport
Readily achievable responses
 Hospital plan to reduce impact No plan Plan without data Database
 Upgrade critical care surge capacity with local and regional support within 24 hours <20% surge capacity 20–100% surge capacity >100% surge capacity
Long-term responses
 Telemedicine3–22 kg CO2e/patient <5% televisits 5–10% televisits >10% televisits
 Drone transport of supplies/medications6,000 kg CO2e/patient3,9 <5% Drones 5%–10% Drones >10% Drones
 LEED certification Silver or lower Gold Platinum
 Build hospitals with access to public transportation <25% Access to hospital service area 25%–50% Access to hospital service area >50% Access to hospital service area
Hospital Factors 1 2 3 Total
Prevention (reduce/reverse)
 Limit vapor anesthetics particularly desflurane.93–118 kg CO2e/patient >50% Desflurane 5%–50% Desflurane <5% Desflurane
 Reduce disposable surgery components11 kg CO2e/patient >50% Disposable components 5%–50% Disposable components <5% Disposable components
 Reduce disposable laryngoscope use0.33 kg CO2e/patient6 >50% Disposable components 5%–50% Disposable components <5% Disposable components
 Reduce OR packaging and wasteMinimal4 >300,000 kg/y 150,000–300,000 kg/y <150,000 kg/y
Readily achievable responses
 Occupancy-based lighting/HVAC6 kg CO2e/patient7 <25% OR suites with occupancy-based lighting/HVAC 25%–75% OR suites with occupancy-based lighting/HVAC >75% OR suites with occupancy-based lighting/HVAC
 Recyclable sharps containers33 kg CO2e/patient <25% Sharps recycled 25%–75% Sharps recycled >75% Sharps recycled
 Plastic recyclingMinimal4 <25% Plastic recycled 25%–75% Plastic recycled >75% Plastic recycled
Long-term responses
 Renewable energy50–68 kg CO2e/patient5 <25% Renewable energy 25%–75% Renewable energy >75% Renewable energy
 Waste sorting (compost, recycle, landfill)Minimal4 <25% Waste sorted 25%–75% Waste sorted >75% Waste sorted
Post-hospital Factors 1 2 3 Total
Prevention (Reduce/reverse)
 Electric vehicle transport17 kg CO2e/patient3 <25% Of transports <50% Of transports >50% Of transports
 Limit unnecessary air transport6000 kg CO2e/patient3 >10% Air transport 5%–10% Air transport <5% Air transport
Readily achievable responses
 Hospital plan to reduce impact No plan Plan without data Database
 Expedited discharge, transfer to non-hospital care after resolution of acute issue >10% Discharge day(s) after resolution of medical issue 5%–10% Day(s) after resolution of medical issue <5% Day(s) after resolution of medical issue
Long-term responses
 Telemedicine3–22 kg CO2e/patient <5% Televisits 5%–10% Televisits >10% Televisits
Total: ___________
Key: 22–32, unprepared; 33–43, minimally prepared; 44–54, moderately prepared; 55–66, well prepared; HVAC, heating, ventilation, air conditioning; kg CO2e, kilograms of carbon dioxide equivalents; LEED, Leadership in Energy and Environmental Design.

Pre-Hospital Factors

These items frequently occur during patient and equipment transport to the hospital. Our review found the greatest impact on pre-hospital greenhouse gas (GHG) emission to be from air travel. To illustrate, using electric ground transportation would save 17 kg of carbon dioxide equivalents per transported patient (kg CO2e/patient), but sparing air transportation of just 1 patient would save approximately 6000 kg CO2e.3 Interestingly, despite the popularity of minimizing surgical waste and recycling, as well as Leadership in Energy and Environmental Design (LEED) certification of buildings, these initiatives have relatively little impact on overall carbon emissions.4 The SPARC2 tool scores a hospital-wide plan for GHG mitigation and preparation for a response to future threats related to climate change through appropriate critical care capacity and a secure supply chain. The importance of these elements has been clearly demonstrated during the COVID-19 crisis, when hospital capacities and supplies of personal protective equipment have been rapidly depleted in hard hit areas.

Hospital Factors

At the hospital level we recommend reduction of vapor anesthetic use, and desflurane in particular, as this has been strongly associated with increased carbon footprint. Additionally, shifting to reusable surgical and anesthetic components could have a significant impact.5 Use of reusable equipment facilitates a reduction in reliance on “just-in-time" stocking and a potential increase in surge buffer. Another area of opportunity for both reduced carbon footprint and potentially cost savings is occupancy-based operating room heating, ventilation, air conditioning, and lighting systems. Implementation of such an innovation in one hospital reduced annual emissions by 234.3 metric tons of CO2 and saved $33,000/year.6 Similarly, cross-sectional imaging consumes massive amounts of energy, the majority of which is wasted during downtime, another opportunity for improvement.7 Finally, in the long term, it would behoove hospitals to partner with community leaders to increase use of renewable energy. Although this is not always controllable at the hospital level, some grids permit selective use of renewable power. The shift from fossil fuels to renewable power could save an estimated 50 to 68 kg CO2e/patient.8

Post-Hospital Factors

Similar to the pre-hospital location, the post-hospital carbon footprint is largely dependent upon transport modality. We propose a shift toward ground transport, as well as sourcing locally, where possible. We also recommend the use of secure drone deliveries of equipment and medications.9

An additional consideration is the use of telemedicine to address nonemergency issues. Thanks to recent policy changes within Medicare and Medicaid to allow billing for these visits, we have an unprecedented opportunity to save patients the expense and trouble of self-transport to the hospital or clinic, as well as to reduce GHG emissions. The impact of the pandemic-related shift to telecommuting, virtual training, and virtual conferences is yet to be calculated. However, this new work paradigm and its positive environmental impact may be preferable even when the current circumstances resolve.10

CALL TO ACTION

The world is changing rapidly as climate change accelerates, and the sudden global spread of COVID-19 presents unique challenges as well as opportunities to change the way we deliver care. We propose the SPARC2 tool as a first step in the assessment of baseline hospital system readiness for the imminent arrival of further challenges related to climate change. As a united surgical community we can significantly reduce carbon emissions while maintaining, and even improving, the care we deliver to our patients.

REFERENCES

1. Solomon CG, LaRocque RC. Climate change—a health emergency. N Engl J Med 2019; 380:209–211.
2. Ewbank C, Stewart BT, Bruns B, et al. The Development of a Surgical Care and Climate Change Matrix: a tool to assist with prioritization and implementation strategies. Ann Surg 2020; doi: 10.1097/SLA.0000000000003980. Online ahead of print.
3. Brown LH, Canyon DV, Buettner PG, et al. The carbon footprint of Australian ambulance operations. Emerg Med Australas 2012; 24:657–662. https://onlinelibrary.wiley.com/doi/abs/10.1111/j.1742-6723.2012.01591.x
4. McGain F, Burnham JP, Lau R, et al. The carbon footprint of treating patients with septic shock in the intensive care unit. Crit Care Resusc 2018; 20:304–312.
5. Sherman JD, Raibley LA, Eckelman MJ. Life cycle assessment and costing methods for device procurement: comparing reusable and single-use disposable laryngoscopes. Anesth Analg 2018; 127:434–443.
6. Wormer BA, Augenstein VA, Carpenter CL, et al. The green operating room: Simple changes to reduce cost and our carbon footprint. Am surg 2013; 79:666https://www.ncbi.nlm.nih.gov/pubmed/23815997
7. Heye T, Knoerl R, Wehrle T, et al. The energy consumption of radiology: energy- and cost-saving opportunities for CT and MRI operation. Radiology 2020; 295:593–605.
8. 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. https://www-sciencedirect-com.ucsf.idm.oclc.org/science/article/pii/S2542519617301626
9. Thiels CA, Aho JM, Zietlow SP, et al. Use of unmanned aerial vehicles for medical product transport. Air Med J 2015; 34:104–108.
10. Dingel JI, Neiman B. How Many Jobs Can be Done at Home? National Bureau of Economic Research Working Paper Series 2020 doi:10.3386/w26948.
Keywords:

carbon footprint; climate change; quality improvement; surgery

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