Is it time to ditch disposables in the operating theatre?

In the modern healthcare setting single use items have become common place, and in many instances have improved infection control between patients. However, this has led to an increased amount of solid waste production via products themselves and increased packaging. I’m sure many of us in practice notice and accept this, albeit with some discomfort.

Much of the waste produced is plastic, derived from fossil fuels and due to either scarcity of correct recycling facilities or contamination with offensive materials it will end up in landfill or be incinerated, adding to the overall environmental impact of health care provision.  In response to this, medical professionals are now asking; are there scenarios where the same hygiene and safety standard can be provided using traditional reusable products?

What products could we consider changing?

From kit to clothing, theatre is a place where disposable items are in high use but there are opportunities for reusable alternatives instead. Examples include:

• Metal surgical kit tins instead of single use sterilisation pouches
• Designated easily disinfected theatre shoes instead of plastic overshoes
• Reusable fabric scrub hats and gowns
• Reusable fabric surgical drapes

Are all reusable products better for the environment?

Disposable surgical textiles such as drapes, surgical gowns and hats are generally made from non-woven plastic polymers, whereas their reusable alternatives are combinations of cotton and polyester. Even when taking into account laundering reusable textiles, multiple life cycle analysis studies comparing resources used in manufacturing and disposal/maintenance have found their use significantly reduces energy consumption, greenhouse gas emissions, blue water consumption and solid waste generation[1]^,[2],[3]. Such studies support that changing to reusable surgical drapes and surgical attire could be an easy and impactful switch for veterinary practices looking to reduce their environmental footprint.

So why are we using disposables?

In a procurement survey of European hospitals, one hospital identified that disposable protective clothing such as surgical gowns accounted for approximately 10% of the single use plastic purchased annually. The increasing reliance on single use surgical textiles is based upon the assumption that reduced contamination potential would reduce surgical site infections[4]. The same assumption is often made within veterinary practice with infection risk cited as the most important factor when choosing reusable fabric vs disposable surgical drapes[5] . Such assumptions are largely unsupported by evidence. Disposables are also seen as more cost effective, however once an initial investment is made, generally in the long term this is also not the case.

Are reusable products safe for my patient?

A recent evidence review found insufficient evidence across human studies to draw a conclusion as to whether drape type influences surgical site infection, and no studies assessing this were available within veterinary literature[6]. Thus we need to weigh up the information we do have and make our own risk assessment.

Many veterinary practices already work with reusable surgical textiles. It’s unlikely these clinics are seeing an inordinate amount of post-operative wound complications given this practice remains common. It’s also worth noting the WHO’s official recommendations for reducing surgical site infections state both sterile disposable and sterilised reusable drape types are an appropriate barrier for the surgical field in human procedures.

During the Covid-19 pandemic, global shortages of PPE forced health care professionals to re-evaluate the use and disposal of PPE products and increase the use of washable cloth gowns. A study performed since then compared performance of reusable and disposable gowns as per the AAMI recommendations, an American rating system for level of protection provided. It found reusable gowns consistently met the stated requirements and performance was not affected by commercial laundering. This was in fact superior to some disposable products that did not meet the stated level of protection when tested and suggests reusable products are appropriate alternatives in terms of performance[7].

How could I approach switching?

The first step would be to talk with your team: what are you using already and why? What concerns about using reusable products might they have?

• If cost is a consideration, reassure your management team that the life cycle analysis also found reusable textiles were cost saving in the long run.
• If infection risk is a concern why not audit your current post-operative complication rate for a routine procedure? Make one change at a time and then reassess this and see if there has been any impact on complication rates. You could consider using reusable products for the cleaner surgeries where significant fluid contamination or bleeding is not expected.

Once you start using reusable textiles, make sure a clear laundering protocol is in place so they are being appropriately washed and sterilised for reuse. Remember reusable does not mean immortal! Woven cloth drapes and gowns are still designed for finite use (often stated as 75-100 in life cycle studies). Keep an eye on any wear and tear and replace them appropriately.

And finally - make it fun! Sourcing cloth scrub hats for the team in prints which reflect them is a great way to jazz up an ops day.

[1] Vozzola, E., Overcash, M. and Griffing, E., 2018. Environmental considerations in the selection of isolation gowns: a life cycle assessment of reusable and disposable alternatives. American journal of infection control, 46(8), pp.881-886

[2] Vozzola, E., Overcash, M. and Griffing, E., 2020. An environmental analysis of reusable and disposable surgical gowns. AORN journal, 111(3), pp.315-325.

[3] Burguburu, A., Tanné, C., Bosc, K., Laplaud, J., Roth, M. and Czyrnek-Delêtre, M., 2022. Comparative life cycle assessment of reusable and disposable scrub suits used in hospital operating rooms. Cleaner Environmental Systems, 4, p.100068.

[4] Gamba, A., Napierska, D. and Zotinca, A. 2021 Measuring and Reducing Plastics in the Healthcare Sector, Heathcare Without Harm. Available from: Measuring and reducing plastics in the healthcare sector | Health Care Without Harm (noharm-europe.org)

[5] Delisser, P.J., Sinnett, D.E., Parsons, K.J. and Friend, E.J., 2012. A survey of surgical draping practices in small‐animal practice in the UK. Veterinary Record, 171(13), pp.326-326

[6] Vasanthakumar, M., 2019. Reducing veterinary waste: surgical site infection risk and the ecological impact of woven and disposable drapes. Veterinary Evidence, 4(3).

[7] McQuerry, M., Easter, E. and Cao, A., 2021. Disposable versus reusable medical gowns: A performance comparison. American journal of infection control, 49(5), pp.563-570.