The healthcare industry presents a significant risk to the climate emergency, contributing approximately 4.4% of the world’s total global emissions.1 If the health sector were a country, it would rank fifth among greenhouse gas (GHG) emitters.
The top three regions that produce the greatest pollution, the United States, China, and the European Union, collectively make up 56% of the world’s total healthcare climate footprint.1
Numerous factors contribute to GHG emissions, including transportation and distribution of goods, sanitization practices, supply chain technologies, and waste management.
Overview of medical waste
In the US, surgical specialties account for most healthcare-related GHG production. One often overlooked issue in these specialties is the generation of medical waste. Operating rooms (ORs), including labor and delivery, account for 70% of hospital waste, which makes up over 2.8 billion pounds of waste each year.2,3
Moreover, waste disposal can account for 20% of the annual environmental expenditure of a hospital.2,3 It is estimated that waste production by hospitals has increased annually by a rate of at least 15% since 1992 due partly to increased usage of disposables.3
What is medical waste?
Medical waste can be divided into five main categories: infectious and pathologic, sharps, radioactive, pharmaceuticals, and general waste, which includes unsoiled linens and paper.4,5
Generally, two disposal bags exist at hospital facilities to separate waste. The red bag is for pathologic wastes, while the clear bag contains all noninfectious waste. Radioactive and sharp waste have specific containers for disposal. In the US, operating rooms are estimated to produce between 2,000 and 7,000 tons of waste each day, with the majority classified as biohazardous.2
However, the Centers for Disease Control and Prevention (CDC) estimates that only 1% to 2% of waste may be infectious.2 As hospitals often pay significantly higher disposal costs for biohazard waste, this can lead to substantial environmental and economic burdens.2
The importance of waste management in ophthalmology
Ophthalmology takes the lead among surgical specialties with the highest procedural volumes. With 29 million cataract surgeries reported in 2019 and a projected 50 million in the year 2050, the cataract subspecialty leads the field in surgical waste production.6
One study found that one phacoemulsification procedure in the United Kingdom was equivalent to driving a car 310 miles.7 At the Aravind Eye Care System (AECS), located in southern India, this step would only be 14 miles!8 This highlights that there are opportunities to drastically reduce the carbon footprint of developed nations in the field of ophthalmology.
Furthermore, a survey filled out by 1,300 cataract surgeons and nurses found that 93% of participants agreed that OR waste was deemed excessive, with 78% believing that supplies should be reused.9
Sustainable waste management in ophthalmology benefits the environment and yields economic advantages. By focusing on effective waste reduction and recycling clinics and hospitals can reduce their disposal costs and minimize the volume of waste sent to landfills.
Eco-friendly practices in ophthalmology develop a culture of responsibility and mindfulness among healthcare professionals. It also drives innovation and can create other industries dependent on the waste properly discarded as non-biohazardous.
Sources of ophthalmic waste
Waste can be generated from many sources within the field of ophthalmology, including clinics, hospitals, and surgical centers. Surgical procedures that include surgical instruments, disposable drapes, and single-use intraoperative material and packaging materials are major contributors.
Single-use instruments
A particular concern is single-use disposable instruments and equipment in developed nations that can otherwise be reused. It is estimated that almost 80% of the total waste generated in ORs is linked pre-operatively.10
Stricter infection control guidelines in the US prevent the implementation of the Aravind model of practice, which reuses surgical supplies such as gloves that are sterilized between cases.11 Despite these stringent measures, the rate of post-operative endophthalmitis (POE) continues to be no higher in AECS than in Europe.11
Water
In the field of surgery, sanitation methods often rely on water use. However, using water-based hand scrubs can present notable challenges, especially in regions where water scarcity is a concern.
A study found that in 2 minutes, scrub sinks consumed 15.9L of water.12 Additionally, it is crucial to consider the economic costs associated with using water, especially when alternative practices can achieve similar clinical outcomes regarding infection control.
Prescription drugs
The wastage of prescription drugs is another source of the problem. In the US, prescription drugs constitute approximately 10% of healthcare expenses. However, a study conducted in 2019 revealed that almost half of all medications were discarded after a single use across four different sites.
This wasteful practice resulted in an annual loss of up to $195,000 per site due to unused medication.13 According to Palmer et al., discarded, unused, or partially used eye drops and ointments accounted for $150 per case.13
A 2020 survey conducted by the Ophthalmic Instrument Cleaning and Sterilization (OICS) Task Force on OR waste suggested there is a specific instance of medication wastage that primarily occurs in the OR. The survey found that only 26% of ophthalmologists practicing in the OR send topical medications used during surgeries home with patients.13
Barriers to implementing new medical waste protocols
While many physicians and nurses support the advocacy of medical societies to reduce the carbon footprint of healthcare, several obstacles hinder the progress of this initiative.
One of the biggest contributors to the cost of waste management is a lack of knowledge of proper waste segregation.5,14 This lack of awareness has significant implications, as it has been observed that approximately 90% of biohazard waste does not meet the criteria to be in the biohazard bag in the first place.5
Moreover, when non-biohazardous waste is incorrectly mixed with biohazard waste, it can lead to potential exposures and accidents. Another contributing factor that prevents proper recycling is inconvenient bin locations that can reduce the practice of proper disposal.14 Lack of time and coordination can further make this matter more difficult.14
Considering hospital waste management protocols
Due to hospital protocols, reusing ophthalmic medications on multiple patients can also be an issue. For accreditation purposes, some surgical facilities have been required to discard multiuse eye drop bottles after they have been used on a single patient.
Such were the cases for Utah Valley Regional Medical Center and the Surgical Eye Center of Morgantown. Both organizations later received approval to continue reusing multidose topical bottles after sending their appeals, but the additional steps highlight the need for universal consensus on the practice.
A particular source of wasted medication results from not letting patients take their medication home after surgery. Some reasons contributing to this practice include facility regulations, state regulations, and pharmacy constraints.13 This practice can also affect patient care because it is uncertain if patients will have access to similar medication after discharge due in part to transportation and financial barriers.
Another point of contention that leads to medication wastage is the determination of viability. In many surgical centers and clinics, multidose topical eye drop bottles are used for a duration significantly shorter than the expiration date stated by the manufacturer.
Since confusing policies do not specify expiration dates, particularly for multidose topical eye drops, premature expiration dates are being applied to these medications.
Occupational health and safety considerations
The use of reusable surgical equipment in ophthalmology brings about certain advantages, but it also raises concerns regarding the potential transmission of infectious diseases. An example of such a concern is the risk of acquiring Creutzfeldt-Jakob disease (CJD) due to cross-contamination.15
This risk is particularly significant in vitreoretinal surgery involving delicate neural tissues. While this matter might support the implementation of strict hospital protocols in developed nations like the US, the risks remain unchanged at centers like AECS that uphold strong sanitary practices while prioritizing environmentally conscious protocols.
Multiple policies exist to govern infection control in the US, but many are unproven and limiting to the efforts of environmental sustainability. Despite a larger carbon footprint than AECS, POE rates for the US are comparable at 0.04%.9 Routine intracameral moxifloxacin prophylaxis further reduced POE rates to 0.01% at AECS.9
One of the biggest barriers to implementing more environmentally sustainable practices in ophthalmology includes the need for big data studies at the national level. These can help reconsider policies that unnecessarily lead to high waste production in ophthalmology and make clinical care more effective.
Current waste management practices and innovations in sustainability
The discussion surrounding waste reduction in surgical practice has been amplified by suggestions focused on sustainability.
A systematic review evaluating 43 published articles identified the following green recommendations for surgical practices to reduce waste:5
- Reprocessing single-use medical devices
- Prioritizing environmentally friendly purchasing
- Operative room waste reduction and segregation
- Energy consumption management
- Pharmaceutical waste management
Some hospitals have innovated in waste reduction by reprocessing devices, increasing energy efficiency, eliminating mercury products, developing green buildings, and serving sustainable foods.5
According to a cohort study conducted in Australia, recycling did not result in additional expenses, and there is a potential for the overall impact of recycling to be amplified if the national healthcare system adopts it.16
The “Green Pack” initiative
One of the most effective ways to reduce OR waste has been through the development of Green Packs.2 Each pack includes a set of reusable surgical instruments and supplies. These can also include topical and intracameral medications that are otherwise thrown away after a single use.8
The most useful aspect of Green Packs is that they are tailored for the surgical procedure, leading to minimal waste, unlike current surgical packs, which include more than the necessary equipment. Departments such as the one at Stony Brook have started this initiative, but Green Packs remains a department-specific initiative.
Alternatively, organizations such as EyeSustain offer guidance on sustainable approaches to conducting cataract surgeries.17,18 Companies such as STERIS and MedLine also offer safe solutions for reprocessing and reusing surgical instruments.19,20 It should be noted, however, that the list of items in this category is limited.
The role of sanitation methods
Changing sanitation methods can also help save on water. A major ophthalmic center was able to demonstrate that switching from water-based to alcohol-based hand scrub for surgical preparation was estimated to result in savings of 61,631 liters of water.12
Alcohol-based scrubs were $1,083 less than aqueous soap. The reduction in scrub time was discovered to generate annual savings ranging from $280,000 to $348,000 per operating room.12
Interestingly, antibacterial agents found in hand soaps can also harm the environment after entering rivers and coastal waters. In contrast, alcohol-based scrubs are not as harmful because they do not enter the ecosystem immediately. However, the most notable savings were on OR personnel costs and OR time.
Packaging pros
Another effective practice supported by multiple ophthalmologists is the use of multidose bottles for multiple perioperative patients. A survey by the OICS Task Force found that 98% of the respondents used multidose bottles of topical medications for multiple perioperative patients.13 Those who did not reuse multidose bottles were primarily practicing at hospital outpatient departments.
Advocacy for reusable topical medication has gained significant support over the years. For example, the Chicago and Illinois State Medical Societies introduced the SB579 legislation that provides a method for patients to retain topical medications that have been ordered at least 24 hours pre-operatively and properly labeled.13
Multiple specialty societies within ophthalmology have gone on to endorse this practice.
The environmental benefits of closeby care and telemedicine
Care closer to patients has also reduced carbon emissions by patients who had previously had to travel far for basic follow-up. In the National Health Service system in the United Kingdom, a population-focused planning and delivery model has ensured the expansion of optometric care in low-resourced regions.11 It has also ensured that care is available where patients can access public transport routes with opportunities to walk or cycle.11
Telemedicine has also contributed to the significant advancement of continued care for patients. The “Advanced Eye Screening Unit,” launched by the AECS, helps screen for diabetic retinopathy by utilizing trained technicians and remote live grading by tertiary care staff. A similar approach has been implemented by the LV Prasad Eye Institute (LVPEI) to allow for improved accessibility to diagnosis for rural patients.
In the US, the Joslin Vision Network (JVN) allows teleophthalmology to screen for diabetic retinopathy. The JVN protocols have been widely utilized by the Veteran’s Affairs (VA) health system, the Indian Health Services, the Department of Defense, and several other private and public health systems within the nation.21
With over 120,000 teleophthalmology exams performed at the VA alone, patients who were enrolled in the screening were more likely to have annual screening compared to those enrolled in the traditional screening program.21 A similar pattern has also been noted in patients using the Indian Health Services.21 The convenience of telehealth has improved care and helped reduce the carbon footprint from patient travel.
Conclusions
Waste management in ophthalmology cannot be overlooked with the projected increase of blindness worldwide and climate change. Clinics and hospitals can significantly reduce their environmental impact by implementing effective waste reduction measures through recycling programs, state-level advocacy, proper disposal protocols, water-less scrubs, and telemedicine.
It is vital to raise awareness among healthcare professionals by implementing education initiatives that foster a culture of responsibility and mindfulness for waste generation. With the healthcare sector significantly contributing to global emissions, adopting sustainable waste management strategies can help mitigate the industry’s carbon footprint and minimize waste generation.
