In 2018, Stanford Medicine anesthesiologist Praveen Kalra, MD, came across an article about climate change that surprised him. He read that the anesthetic gas desflurane has an outsized environmental footprint: Pound for pound, its greenhouse gas effect is 2,600 times as potent as that of carbon dioxide.
“I had never heard about this,” said Kalra, a clinical associate professor of anesthesiology, perioperative and pain medicine. He used desflurane regularly in Stanford Health Care’s operating rooms. “The more I read, the more I felt a little embarrassed. I thought, if I’m not aware of this, my colleagues may not be, either.”
Global warming threatens the health of billions of people around the world, and Kalra became a physician to improve people’s health, not harm it. He thought it would be wise to stop using desflurane in his own operating rooms because other anesthetic gases work equally well with much smaller environmental effects.
“But the impact would have been low; I’m only one person,” he said, noting that Stanford Medicine has around 300 anesthesiologists, including faculty, residents and fellows. “The real benefit would come if we could all do the same thing.”
Kalra decided to try convincing all his colleagues to stop using desflurane. In doing so, he became part of a green movement now sweeping health care: Last year, Stanford Health Care and Stanford Medicine Children’s Health became two of more than 100 organizations to sign the White House/U.S. Health and Human Services Health Sector Climate Pledge, which commits them to cutting health care-related emissions in half by 2030 and to achieving carbon neutrality by 2050.
About 8.5% of the country’s greenhouse gas emissions come from the health care industry, and U.S. health care has the highest per-patient level of emissions of any country in the world. Leaders across Stanford Medicine are looking for ways to change these trends.
Operating rooms offer an especially stark example of the challenges of making health care sustainable — because while surgery is extremely resource intensive, it helps some of the sickest and most vulnerable patients. Greening the operating room requires a delicate balance: Surgeons, anesthesiologists and their colleagues must maintain patient safety and treatment success, while also scrutinizing their time-tested routines for ways to become sustainable.
To achieve this goal, “green teams” are forming and changing practical details, such as which anesthetic to use, and are gradually altering the culture of surgery by sharing evidence that convinces others to adopt environmentally friendly protocols.
“We’re fortunate in that we have the resources by which we can make sustainability advancements,” said Helen Wilmot, chief facilities and sustainability officer at Stanford Health Care. “People like us are required to put our resources to bear to make these changes.”
Just as academic medical centers have a responsibility to study new medical treatments in clinical trials, such centers also have a duty to pilot methods for sustainable health care, Wilmot said. “Community hospitals and rural hospitals don’t necessarily have the ability to be test cases. We have an obligation to do the work that others can benefit from.”
Climate change hits the health of the most vulnerable groups hardest, another good reason for Stanford Medicine to lead sustainability efforts.
“Children are particularly vulnerable to the impacts of climate change — and Black and brown people as well,” said Dana Hiniker, sustainability program manager at Stanford Medicine Children’s Health. “But there’s also a cost-of-health care argument to be made; the efforts we’re undertaking are huge cost-saving opportunities.”
Like Kalra, many doctors and nurses end up joining the endeavor when they hear facts about the health effects of climate change that surprise them, according to Christy Foster, director of sustainability at Stanford Medicine Children’s Health.
“The number of deaths attributable to U.S. health care pollution is already equal to the deaths from preventable medical errors,” Foster said. “Every time I present that statistic [to our medical teams], I see jaws dropping, and people feel compelled to get engaged.”
One widely cited 2020 study, published in Health Affairs, investigated the impact of pollution generated by the U.S. health care industry in terms of the disability-adjusted life years lost.
The measure, abbreviated as DALY, counts years of healthy life lost to premature death or disability. The study estimated that the U.S. health care industry caused the loss of 133,000-188,000 DALYs in 2018, mostly due to health effects of small-particle air pollution generated when fossil fuels were burned to produce electricity.
Added Foster, “We’re at a moment of realizing that all this research says climate change impacts the patients we take care of, and we have to start doing things differently.”
A new approach to reducing waste
Operating rooms are hubs of hospital activity: They earn up to 60% of a hospital’s revenue; account for 40% to 60% of its supply budget; produce more than 30% of its total waste and two-thirds of its regulated medical waste — such as drugs, sharps and biohazardous materials — that requires special disposal; and consume three to six times as much energy per square foot as any other part of a hospital.
All this activity creates opportunities for green initiatives — such as those spearheaded by surgeons frustrated by how much they throw out, including product packages, unused items such as surgical towels, and single-use versions of devices like blood pressure cuffs that come in reusable options.
“Every time I do a surgical case, we typically throw away, on the low end, four or five large garbage bags of stuff, and in some cases nine or 10,” said Kevin Shea, MD, an orthopaedic surgeon at Lucile Packard Children’s Hospital Stanford, whose commitment to improve sustainability applies to his whole life.
He and his family, for instance, recently installed solar panels on their roof and swapped their gas-powered furnace and water heater for electric heat pump models. He bikes to work most days, and the family uses mainly hybrid electric cars. However, he realized that because surgery uses so much stuff, he could make an even bigger environmental impact at work.
To start, Shea’s team is identifying surgical products with the least-wasteful packaging. For common orthopaedic procedures — such as anterior cruciate ligament reconstruction, a knee surgery — that the team performs hundreds of times per year, buying the same product in cardboard instead of non-recyclable plastic could keep a lot of trash out of landfills.
“We need to start giving feedback to manufacturers saying, ‘We are surgeons — your product users, your customers — and the environmental impact of the packaging choices you make matters to us,’” Shea said, adding that the team of students and surgeons he has built to pursue this project will also share their findings with surgeons at other institutions and encourage them to modify what they use, too.
“We’re always going to have waste to deal with; we do complicated things in the OR,” he said. “But if we can reduce that waste by 40% or 50%, we’ll look back and say, ‘It was worth making those changes.’”
Starting with fewer supplies
Hand surgeon Paige Fox, MD, PhD, associate professor of surgery, recently led a similar push to reduce waste by buying less in the first place. Fox and her colleagues perform about 500 minor hand surgeries a year, primarily carpal tunnel release and trigger finger release procedures.
These surgeries involve cutting a small band of tissue — a ligament or the casing on a tendon — to create space for an irritated tendon or nerve, improving mobility and sensation for patients.
Although the surgeries require a 1- to 2-inch incision, the supply packs Stanford Health Care surgeons used in the past were the same as those provided for much more invasive operations. “We were draping the patient from head to toe in multiple layers of sterile drapes, for instance,” Fox said.
In late 2019, Fox began wondering if she could develop a smaller supply pack for use during minor hand surgeries, which are performed at the Stanford Medicine Outpatient Center in Redwood City.
“It was something I was really excited about, but it had very little traction,” she said, explaining that she was unsure whether her fellow surgeons would want to test new supply packs when they had long assumed their habits added to patient safety. “Then the pandemic hit, everything was disposable, and I felt this backslide.”
She eventually realized the pandemic was creating a silver lining that helped her project: After experiencing 2020’s disruptions in global shipping and manufacturing, her colleagues knew more about supply chains and were invested in improving these once-hidden aspects of hospital operations.
In the spring of 2021, Fox began working with her team, including other surgeons, nurses, scrub techs and operating room leaders, to gauge their openness to the project. She then collaborated with medical-supply vendors to come up with a phased rollout of a supply pack that eliminated the extra plastic, drapes, gowns and equipment needed for bigger surgeries.
Over the following 18 months, Fox and her colleagues tracked surgical outcomes as they switched to using fewer supplies and saw no difference in complications such as infection.
“It’s important for us to demonstrate to patients that it’s just as safe,” she said.
The smaller supply pack, now used by all of Stanford Health Care’s hand surgeons for minor surgeries, contains less than half as much material as the original pack, which weighed almost five pounds, including unneeded sterile drapes, gowns and surgical tools. The switch to the new packs averts nearly three pounds of trash per surgical case and saves $70 in supply costs per case, for a total of more than 1,400 pounds of trash avoided and $35,000 saved each year.
Other projects to reduce waste are underway. For instance, surgical resident Jaclyn Wu, MD, is evaluating supply packs used in common general surgery procedures, such as rectal exams under anesthesia and laparoscopic appendectomies, with the goal of eliminating unnecessary supplies.
“As physicians, the first part of our oath is, ‘Do no harm,’ but if in the practice of medicine we’re generating significant emissions, we’re directly contributing to the problem,” said Wu, adding that she wants to lead sustainability efforts as part of her overall commitment to global health.
“I think to patients it signifies that your doctors and health care system see the bigger picture,” she said.
Updating reuse protocols
Several operating-room leaders are starting programs to reuse as many materials as possible, a high priority because surgery traditionally uses a large volume of single-use items. Stanford Medicine’s adult and pediatric hospitals are piloting programs to recycle blue wrap, the polypropylene fabric that wraps sterile operating room trays. By collecting it during surgery setup and sorting it into its own clean collection bin, the majority of the 36,000 pounds of blue wrap needed each year can be recycled, not sent to landfills.
Both health systems’ operating rooms are being equipped with waste bins that make correctly sorting waste more intuitive. For example, the rooms now have smaller bins for disposing the most hazardous types of drugs, which must be shipped out of state for disposal — an operation with safety benefits but a big carbon footprint and high cost. The small size encourages people to put only the hazardous drugs in these bins, not other items such as plastic waste.
Stanford Medicine Children’s Health is also investigating reusable options for several supplies used in its pre-op area, including pulse oximeters, blood pressure cuffs and tourniquet sensors, which can be wiped clean between patients, potentially saving $8,500 per year per operating room or procedural suite. For Lucile Packard Children’s Hospital Stanford, with 19 operating rooms and two procedural suites, this could mean a total savings of about $178,500 each year.
For medical devices that require complete sterilization — catheters, for instance — the hospitals are shifting toward purchasing products that can be sterilized off-site, by companies that have obtained FDA certification to reprocess medical devices between uses. They’re also evaluating the impact of choices such as laundering surgical towels, including tallying the environmental effect of dirty, soapy laundry water.
It has taken time, but it’s becoming second nature to account for the environmental impact of everything purchased for operating rooms, said Danielle Shoaf, interim director of surgical services at Stanford Medicine Children’s Health, who plays a big role in purchasing decisions.
“I would urge anybody in a similar role to understand that everything they purchase has an impact beyond patient care,” Shoaf said. “Items can be functionally exactly equal, but one choice has a more positive impact on the environment. When looking for new supplies, we always ask, ‘Do you have a recycling program? Do you offer reprocessed items?’ It’s something we’ve built into our culture.”
She added: “It’s a win-win for everyone: It’s better financially for the hospital and contributes positively to the environment without impacting the care we provide our patients. There’s no reason not to do it.”
Succeeding in changing culture
The biggest obstacle to creating greener operating rooms may be surgical teams’ reliance on time-tested routines, checklists and rules to keep patients safe.
“Change always begins with education,” said Kalra, whose campaign to remove desflurane from operating rooms began with a seminar for Stanford Medicine anesthesiologists on its environmental footprint. “My colleagues are an educated, highly intelligent audience, so I had to make it convincing and a bit personal.”
He shared his own philosophy that “the environment is also a patient we cannot neglect,” he said, along with compelling data, including a study from the U.K.’s National Health Service showing that 40% of the carbon footprint of surgery came from anesthetic gases.
He also pointed out that desflurane is twice as expensive as other anesthetic gases and has the highest global warming potential among inhaled anesthetics. Vaporization of one bottle (240 milliliter) of desflurane for anesthesia has the same global warming effect as 886 kilograms of carbon dioxide, he explained.
His colleagues came on board: By mid-2019, desflurane had been eliminated from all Stanford Health Care operating rooms, reducing the organization’s carbon footprint from fluorinated anesthetic gases by 83% and saving $200,000 per year. Fluorinated gases are the main gases used to induce general anesthesia, helping patients “fall asleep,” sometimes in combination with another gas, nitrous oxide.
He also developed a two-week elective rotation for anesthesia residents, equipping them to become leaders in spreading sustainable practices to other hospitals.
Stanford Medicine leaders want the whole health care industry to rethink how to achieve surgical success and safety with a reduced environmental footprint.
“Medicine is a highly regulated environment,” said Wilmot, adding that many regulations were designed with safety, but not sustainability, in mind. “We need to create coalitions with other large organizations and bring regulators to the table to ask about the value of some regulations. We want to bring evidence to regulators that there could be different, more sustainable ways to achieve safety and maintain clinical outcomes.”
In future green operating rooms, said orthopaedic surgeon Shea, one thing will remain constant: Patient well-being will be the top priority.
“Taking care of patients is the North Star for health care, and we never stop navigating by it,” he said. “But we can be careful, thoughtful and proactive about how we navigate, and guide our ship toward that North Star in a better way that includes thinking about the environmental impact of what we do.”
After opening in 2017, Lucile Packard Children’s Hospital Stanford became one of five new hospitals in the world to earn LEED Platinum status, the highest designation for sustainability given by the U.S. Green Building Council. In March 2022, the council also recognized the new Stanford Hospital, which opened in November 2019, awarding it LEED Gold status.
The hospitals were hailed, in part, for designs that feature optimal energy efficiency and water use and acres of drought-tolerant gardens. But neither Stanford Health Care nor Stanford Medicine Children’s Health were new to mitigating health care’s environmental impact — a commitment that continues today.
Both organizations have signed the White House/U.S. Health and Human Services Health Sector Climate Pledge. And Stanford Health Care recently joined the Health Care Climate Council, an industry coalition that seeks to reduce health care’s contributions to climate change.
Here are some of their sustainability initiatives:
Both organizations compost tens of thousands of pounds of kitchen food waste annually and donate surplus meals to community organizations. In fiscal year 2022, 1,480 pounds were donated by Stanford Medicine Children’s Health and 9,664 pounds by Stanford Health Care.
LED fixtures are in place in most areas within the new Stanford Hospital. Lucile Packard Children’s Hospital Stanford is replacing all lighting with LED lights, which will save at least 730,000 kilowatt-hours of electricity — a 48% reduction — in the first year after the project is completed. As of June 2023, 70% of the children’s hospital’s lights had been replaced.
Both hospitals cut water use through water conserving appliances and irrigating with rainwater and water extracted from dehumidifiers and dialysis equipment. The children’s hospital ranks above the 90th percentile of hospitals in water conservation, according to Practice Greenhealth, a sustainable health care organization with members in the U.S. and Canada.