Increasing the environmental sustainability of operating rooms in Canada: an evidence-informed guideline for policy

BACKGROUND: Canada's health care systems contribute about 4.6% of Canada's greenhouse gas emissions and 200 000 tonnes of other pollutants, with operating rooms (ORs) having a substantial environmental impact. In this guideline, we provide actionable recommendations to increase the environmental sustainability of ORs. METHODS: This guideline was developed by the Best Practice in Surgery Group from the University of Toronto, with national representation. We followed the Appraisal of Guidelines for Research and Evaluation (AGREE) Health Services tool, ADAPTE, and Guidelines International Network principles. Given the nature of the evidence, we created a unique grading matrix based on the triple bottom line (people, profit, planet) and did not assess quality of studies. Twenty-four rapid reviews informed the guideline, and we used a modified Delphi approach to reach consensus. We conducted external reviews with various hospitals across Canada. RECOMMENDATIONS: We outline 21 recommendations to improve the environmental sustainability of ORs, grouped into 4 categories: reduce, reuse, recycle, and rethink. The "reduce" category focuses on decreasing unnecessary waste by way of appropriate waste segregation, decreasing pharmaceutical waste, reducing instruments in surgical trays and custom packs, and lowering unnecessary energy use. We also provide recommendations for reducing emissions from inhalational anesthesia. "Reuse" emphasizes replacing disposable items - such as medical devices, textiles, and sharps containers - with reusable alternatives. "Recycle" includes recommendations for traditional and specialized recycling programs. "Rethink" includes strategies with limited direct evidence but considered essential to long-term sustainability, such as donations, alcohol hand rub, and environmentally preferrable purchasing policies. INTERPRETATION: Operating rooms greatly contribute to the environmental burden of the Canadian health care system and these recommendations can help to reduce this impact.