We all know that, since the announcement by the National Health Service in 2020, that it is the ambition of the service to achieve Net Zero emissions by 2045. It is reported that the NHS generates between 4% and 5% of the country’s greenhouse gases and one quarter of all public sector waste. The main contributors of the carbon footprint have been identified as energy use, which accounts for over half of healthcare’s footprint and includes on-site consumption by heating, ventilation and environmental control systems, as well as that used by suppliers in the provision of goods and services. The remainder of the footprint is allocated to the healthcare supply chain through production, transport and disposal of goods and services — particularly food and hospital equipment, surgical instruments, chemicals and medical devices.
Therein lies a responsibility on procurement and clinical staff to take note of and try to avoid high emission products, so that we can make progress towards reducing global greenhouse gas emissions and Net Zero. Determining the life cycle of different elements of an environment, function or treatment undertaken in the healthcare sector is an enormous undertaking. However, a life cycle assessment of individual parts of a service is possible and can be quite enlightening.
Reducing the carbon footprint of products used in the operating theatres will play a huge role in the transition to sustainable models of surgical care.1 Surgery uses a large variety of products and medical devices, many of which are single use and disposed of directly after use, such as gloves, drapes, gowns, tubing and many medical devices — some simple, others complex. This creates a great deal of waste and is rarely reviewed by each procedure. Product reuse, if available, ought to be prioritised, so as to get maximum safe use from each product used. It is important that cultural awareness in the NHS is raised so that theatre departments can contribute meaningfully to carbon reduction.
Not in this country, but in some developed countries, it is acceptable practice to re-use single use devices and an industry has grown up around this service particularly in the US.
Gowns and drapes
Surgical gowns and drapes were initially made from cotton and were reusable. As surgical site infections increased during the 1980s and 1990s more and more disposable drapes and gowns were made available to the NHS and there was much pressure to switch over to more ‘microbially suitable products’. Of course, it had little direct impact on the prevalence of surgical site infections but remains one of the myths which needs to be reviewed. Both the CDC2 and NICE3 have identified that there is little difference between the two with regards to infection.
One of the solutions which particularly appeals to this author, and is worthy of serious consideration by procurement teams and theatre management, is that of serviced provision of sterile theatre gowns and drapes. Immediate advantages of the system are that all of the product belongs to the company, who remove the contaminated items from the hospital site, renew it via a dedicated surgical processing facility, where gowns and drapes are processed, dried, folded, packed and sterilised back to the theatre. All the risk is taken away from the hospital (and therefore the patient) and into the bargain, the hospitals’ waste volume reduces significantly. Identifying the different aspects of this set-up is worth looking at in detail.
Proven performance
The information required by theatre management, surgical teams and procurement is that the items being purchased will do the patient no harm and, in fact, are superior in performance to those that are being superseded. A study undertaken on reusable hospital gowns, both high protection and standard protection gowns was undertaken by The University of Sheffield and the Grantham Centre for Sustainable Futures in 2022.4 The study set out to identify a life cycle assessment of reusable gowns versus a disposable alternative. Results were based on each reusable gown being used thirty times — whereas the gowns are actually used up to 75 times.
The quality of the product meets and exceeds the European Standards by which surgical drapes, gowns and clean air suits are measured, EN 13795. Studies indicate that reusable gowns outperform single use on the key measures of protection, durability, fluid resistance and strength with no measurable increased risk of infection.5 NHS England highlights that reusable gowns have the potential to save the NHS 5.2 kilo Tonnes CO2e, 1.1 kilo tonnes of waste, 31 m litres of water and £9.4m in costs of both surgical and isolation gowns.
The same document also states that 45% can be saved on cost and 69% on carbon compared to single use gowns. Other guidance that is applicable to reusable gowns is for the decontamination of medical devices (HTM01 — 01). This is in addition to the HTM for the management of the process of linen for health and social care (HTM01-04); and ISO 13485, which covers a Quality Management System for Medical Devices. This gives guidance on design, manufacture, installation and services.
Environmentally friendly
If there is to be a switch from single use gowns to re-usable, it is first essential that procurement identifies the volume of gowns used by the Trust, both as a sterile surgical gown or a nonsterile isolation gown, as frequently used in ICU and other highly acute areas of the hospital for procedures, where both the patient and the staff member need to be protected.
The main element of an environmentally friendly service is the lack of clinical waste — which is an expensive aspect of the Trust finances. Volumes of clinical waste are created for each surgical procedure that takes place; it is thought that between 20%-33 % of healthcare waste originates in the hospital’s theatres. An American study reviewed how much waste from each operating room was incorrectly segregated and then was disposed of as hazardous waste, costing many thousands of dollars more for the incineration process.6 There is no reason to suspect that the UK is innocent in this respect and staff should be clear in their management of the recycling process and non-disposal after use, if using a re-usable gown.
It can be noted that when gowns in the managed service reach their 75 uses, they are removed from the process and used to mend areas of gowns which have been identified as in need repair. Users can be sure that each gown and drape has been reviewed over a light table during the packing process and removed for repair if there is a detectable hole. This answers two of the 5 Rs of Refuse, Reduce, Reuse, Renew and Recycle. The significant environmental benefit of reusable surgical gowns has been extensively studied and the results are unequivocable.
Protection and comfort
Fabrics which are used for multi-use gowns are highly engineered microfibre and 3 ply laminates that are breathable and non-linting, benefitting from static control and great tensile strength. The gowns are designed to cover the areas which are in the splash zone by using a second layer of fabric and these are known as High Protection Gowns and would be selected for use by surgeons who estimate that there will be significant amount of fluid during the procedure. The standard gowns are lightweight and designed for ease of movement and heightened levels of performance to reduce the risk of cross infection. The materials are certified and compliant with EN 13795 and have been subjected to rigorous assessment to meet all the relevant criteria.7 When Trusts elect to switch their service, it is recommended8 that they ensure staff who will use the gowns can touch and feel the materials of the proposed products.
An article in the Australian Journal of Surgery found that there were two studies that reported that staff preferred re-usable gowns. Van Niewenhuizen et al 9 found that 79% of theatre staff scored reusable gowns higher on six out of seven criteria including comfort, ventilation and temperature regulation: fit and length, functionality, barrier function and ease of use. A study by Yap et al 10 found that perioperative staff’s hesitancy to adopt reusable gowns was primarily due to a lack of education regarding the environmental impact and safety profile when compared to disposable gowns.
Cost savings
The cost savings implied will depend on the options that service users choose. Local laundry services will already be in use for hospital sheets and bedding and could, in theory, be extended to include operating theatre products such as gowns and drapes. This will obviously need to be discussed with all the parties and the costs included in any move away from disposable items, balanced with the cost of disposal for single use products.
A study of Elis surgical reusable gowns conducted by the University of Sheffield found that waste and offsite disposal costs of single use gowns had a significant impact with potential savings of 22%-26%/ £2,400 to £5,200 for a standard protection gown and 16%-20%/ £3,700 – £7,700 for high protection gowns (modelled on 1000 gown usage per week). The variation is accounted for by the dedicated surgical processing model and logistics.11
The model which this author finds exciting and interesting for the service is the one provided by Elis. They own the product, manage its quality and number of uses, while ensuring that the items are appropriately returned to use, fully sorted, washed according to HTM standards, and checked, packed and sterilised according to HTM decontamination and sterilisation standards. The costs of this managed service, reviewed by Deloitte in 2007, found that a saving of 29% could be achieved by choosing reusable over disposable. Also to be considered is the fact that VAT is reclaimable for the NHS on reusable product. NHS England states that, on average, reusable surgical gowns are 45% cheaper and it reminds potential users of the VAT reclaim.
Conclusion
We have a moral duty to the world to reduce our carbon footprint and in healthcare a particular responsibility to ensure that we minimise the impact that surgery has on the planet. The Green Surgery Report by the Royal Colleges has set the pathway for us, but there are many other ways in which we can immediately ensure that the circular economy of surgical gowns, drapes and tray wraps is made a commitment by Trusts and Operating Theatre Departments around the UK. Companies such as Elis can help by providing a managed service, with a daily delivery service to hospitals, ensuring a sustainable logistics set-up. Reusables seem to be the answer from an environmental perspective, as well as providing a safe and cost-effective solution for end users.
References
1. Brighton & Sussex Medical School, Centre for Sustainable Healthcare, and UK Health Alliance on Climate Change (2023). Green surgery: Reducing the environmental impact of surgical care (v1.1). London: UKHACC.
Accessed at https://ukhealthalliance.org/ sustainable-healthcare/green-surgery-report/
2. Center for Disease Control (2017), Surgical Site Infection (SSI) Prevention Guideline. Accessed at: https://www.cdc.gov/infection-control/hcp/surgical-site-infection/index.html
3. NICE (2020) Surgical Site Infections: prevention and treatment [NG 125].
Accessed at https://www.nice.org.uk/ guidance/NG125
4 Blazejewski T, Rothman R. Life Cycle Assessment (2022), University of Sheffield and Grantham Centre for Sustainable Futures.
5. Cited in NHS England, How to Guide, Reusable Sterile and Isolation Gowns. Accessed at: https://tinyurl.com/mrydsd6a
6. Vozzola E, Overcash M, Griffing E (2020) AORN J Mar;111(3);315-325
7. Blazejewski T, Rothman R. Life Cycle Assessment of Elis Reusable Hospital Gowns (2022)
8. Net Zero and Sustainable Procurement team 2024. Understanding the benefits of a switch from single-use to reusable surgical and isolation gowns. Accessed at: https://networks.sustainablehealthcare.org.uk/resources/hot-guide-reusable-surgical-and-isolation-gowns
9. Nieuwenhuizen K, Friedericy H, Linden S, Willem Jansen F, Eijk (2024). A User experience of wearing comfort of reusable versus disposable surgical gowns and environmental perspectives: a cross -sectional survey. BJOG. Accessed at: https://doi.org/10.1111/1471-0528.17685
10. Yap A, Wang K, Chen E, et al, 2023. A mixed methods study on end-user perceptions of transitioning to reusable surgical gowns. Surg Open Sci 2023:11;33-9 cited in ‘Sustainable shift in surgical practice: embracing reusable gowns,’ 2024. Royal Australian College of Surgeons, ANZ Journal of Surgery, 94(2024) 1457-1459
11. Ibid