The operating room (OR) plays a critical role in today's hospital. A recent study by the McKesson Group estimated that the operating room generates 42% of the hospital's revenue.1 The OR is the primary source of hospital admissions, and drives significant costs related to equipment, supplies, and personnel. The OR also generates huge volumes of waste-between 20 to 30% of a hospital's total waste volume-despite the OR's diminutive spatial footprint. As hospitals across the country have begun to find innovative ways to “green” their operations, case study after case study demonstrates that a focus on environmentally friendly programs can both save money and increase efficiency. And as a more systematic approach to sustainability emerges in healthcare, it only makes sense to seek opportunities for environmental benefits and cost-savings in the hospital's most expensive and wasteful department-the OR.

In April, Practice Greenhealth (PGH)-a nonprofit membership organization for healthcare institutions committed to environmental responsibility-kicked off its Greening the OR Initiative. PGH convened a Greening the OR symposium in Phoenix, AZ. The event was sponsored by the Hospital Corporation of America (HCA), Ascent Healthcare Solutions, and SRI Surgical, and brought together thought leaders, clinicians, administrators, and manufacturers to begin to sketch out which green operational interventions make the most sense in an OR setting. Hospitals presented on an array of different interventions-all tested at their institutions. The day closed with a facilitated discussion that encouraged a common understanding of the barriers to implementation of these interventions and mechanisms to overcome these barriers. The symposium was followed by a three-hour preconference training session at the CleanMed Conference in Baltimore, MD, where more than 60 additional participants brought their ideas to the table about ways to shape the fledgling initiative and pledged their ongoing involvement.

The Greening the OR Initiative is looking at interventions in the OR that reduce environmental impact, reduce cost, increase efficiency, and improve worker or patient safety-or some combination of these. There is a specific focus on reducing the waste and excess in the OR, while developing operational mechanisms to divert or address that waste, and piloting these mechanisms in partnering hospitals. The project is also reaching out to key stakeholder groups relevant to the OR to ensure that all the interventions being discussed are vetted through appropriate channels and driven by all available data. PGH is also welcoming the supply chain to the table, with the recognition that these companies have a key role to play in developing sustainable product and services offerings, and can provide training around the implementation of certain interventions.

The OR is the primary source of hospital admissions, and drives significant costs related to equipment, supplies, and personnel.

Over the past 15 years, the healthcare sector has increasingly moved toward purchasing disposable supplies and equipment-largely as a result of concerns about sterility and hospital-acquired infections. A 2009 study estimated that the disposable medical supply market will increase 4.6% by 2013.2 The Greening the OR Initiative is helping hospitals reexamine the move to disposables. One example is a program to transition from disposable to reusable surgical gowns and basins. Kaiser Permanente (KP) looked at the two product options and compared clinical performance, total cost, and environmental trade-offs. KP found that by switching out just 100,000 gowns from disposable to reusable, they would eliminate nearly 22.5 tons of waste and save nearly $10,000 in waste disposal costs while also simplifying supply chain management by going from 111 SKUs for disposable gowns to four SKUs for reusable gowns. KP's commitment to environmentally preferable purchasing and their focus on looking at the total cost of ownership for products and equipment-including environmental and disposal costs-drove the analysis process. This kind of analysis is an area where the Greening the OR Initiative will be a key resource to the sector and to OR management staff. By collecting case studies from different organizations who have already begun the analysis process, the initiative can provide a forum to discuss the analysis, determine other factors that may affect the outcome, and disseminate a robust model for evaluation and ROI that OR managers need to assess the implementation of these interventions at their sites.

The savings associated with some of these interventions are remarkable. Medical device reprocessing, for example, involves the collection of gently used medical devices which are then disinfected, sterilized, and examined for functionality, safety, and quality by an FDA-regulated third party reprocessor. The reprocessor then sells the reprocessed devices back to the healthcare organization at a significant discount, while also reducing the purchase of new, single-use devices. The program has an outstanding safety record over the past 10 years, and health systems such as HCA and Catholic Healthcare West (CHW) have seen substantial savings. HCA saved $17 million and diverted 94 tons of waste from the landfill in 2009 across its 160 hospitals with less than a 50% device collection rate while CHW saved $6.1 million and diverted 81 tons of waste last year. At a time when healthcare is struggling to cut costs and reinvest savings in quality patient care, programs like this should not be overlooked.

Ongoing attention to climate change and impending climate regulation will also drive key interventions in the OR space related to energy use and waste anesthetic gas (WAG) capture. New technologies such as the use of LEDs in OR surgical lighting can reduce power consumption while also reducing HVAC cooling load. Power booms can also simplify cleaning procedures, manage smoke evacuation, and streamline procedure times-by an average of 10 minutes per procedure.3 WAGs are potent greenhouse gases, accounting for approximately 5% of a hospital greenhouse gas emission. The global warming potential (GWP) of certain WAGs is between 1,900 and 3,700 times the GWP of carbon dioxide.4 New technologies are emerging such as dynamic gas scavenging systems that decrease energy load and reclamation systems that hold the potential to capture, reclaim, and even reuse WAGs in the future.5

Cleveland Clinic has lent its voice to the Greening the OR Initiative, showcasing its innovative program to recycle medical plastics from its Operating Rooms
Image courtesy of Cleveland Clinic

Cleveland Clinic has lent its voice to the Greening the OR Initiative, showcasing its innovative program to recycle medical plastics from its Operating Rooms

The examples cited are just a few of the interventions being looked at by the new initiative. The Greening the OR Initiative is bringing together key stakeholders from across the healthcare sector to collectively develop a set of best practices in the OR that will decrease environmental impact while reducing cost and improving or maintaining worker and patient safety. A guidance document is one key outcome of the project underway, and an array of other activities will take place in the coming months-including the development of a physician/surgeon advisory council, outreach to the nursing and anesthesiology communities, and a series of ongoing discussions with participating hospitals across the United States. PGH hopes the project will demonstrate the value of environmentally friendly interventions that are based on firm data, rigorous analysis, and stakeholder consensus-and sees the OR as the first of many hospital units that can benefit from a department-specific focus on environmental management. Hospitals or OR departments interested in participating can reach out to PGH to get involved and can learn more at PGH has more than 1,000 hospital members nationwide who are changing the way healthcare does business, and are demonstrating that a focus on environmental responsibility can increase patient, worker, and community health and safety.

HD Cecilia DeLoach Lynn, MBA, LEED AP, is Director of Sustainability Education & Training at Practice Greenhealth.

For more information, visit


  1. McKesson Information Systems Inc. and the Healthcare Financial Management Association. Achieving Operating Room Efficiency Through Process Integration.Accessed on May 20, 2010 at:
  2. Specialty Fabrics Review. Demand for Disposable Medical Products to Increase.October 2009. Accessed on May 20, 2010 at:
  3. Johnson Annette C. Technological Advances in Lighting and Booms for the OR: Impact on Infection Control and OR Efficiency.Infection Control Today. July 1, 2000. Accessed on May 20, 2010 at:
  4. Guity A. Presentation for Greening the OR Symposium: Indoor Air Quality, Energy, Lighting, and the OR Environment. Mazzetti Nash Lipsey Burch. April 2010. Available at:
  5. Berry J., et al. Reclaiming waste anesthetic gas: initial clinical trials: 3AP8-3. European Journal of Anaesthesiology.Volume 24.P 32.June 2007.Accessed on May 20, 2010 at:

Healthcare Design 2010 July;10(7):10-12