A Measure of Success

By Kaeleigh Sheehan, Practice Greenhealth Project Manager on May 30, 2014

Greening the OR celebrates four years of environmental achievements!

The University of Maryland Medical Center received the Greening the OR Award
The University of Maryland Medical Center received the Greening the OR Award

The Greening the OR® Initiative began four years ago after Practice Greenhealth members identified the surgical department as a relatively small percentage of the organization’s square footage but a significant contributor to its environmental footprint. A focus on the OR is a great opportunity to not only reduce a facility’s environmental footprint, but also to increase efficiency, increase worker and patient safety, reduce waste, and realize financial savings.


The Greening the OR Symposium celebrates progress and milestones made on the journey to promoting environmentally friendly practices in the operating room and invites new thinking in innovative ideas to overcome our challenges, and strategies that will result in new areas to address to drive further progress. This workshop will be accredited for nursing CEs. For more information, visit PracticeGreenhealth.org/symposium

What began with just 75 hospitals endorsing the Greening the OR Initiative now has over 430 facilities formally signed on and many others currently working to green their operating rooms. It has grown from four original sponsors to 14. The work has spread and is being promoted in various clinical and professional associations such as Association of periOperative Registered Nurses (AORN) and the American Society for Anesthesiologists (ASA), among others. Momentum is building and strategies previously considered "on the edge" of innovative are now shifting to common practice.

As more hospitals integrate these environmentally preferable programs into their surgical suites, the focus has begun to broaden—looking not only at what interventions can reduce environmental impact but also to how well these measures are being implemented. Performing an assessment of original practice, capturing baseline data, tracking and reporting on it to establish how the program is faring, identifying where areas of opportunity might lie, and framing success to justify new programs is incredibly important. Recognizing the importance of measuring performance in this arena, Practice Greenhealth formally included a Greening the OR section into the awards application process this year.

Beyond inclusion in the awards as a whole, a Greening the OR Award was established—with generous sponsorship support from SterilMed. The Greening the OR Award recognizes the exemplary performance of a single institution in addressing environmental impact in the surgical arena.

The University of Maryland Medical Center (UMMC), an 800-licensed bed, Level I Trauma Center and teaching institution with 42 operating rooms located in Baltimore, Maryland, is the recipient of the Greening the OR Award in 2014. UMMC was one of the original endorsing hospitals of the Greening the OR Initiative, highlighting their long-time work using reusable linens in the operating room in one of the Greening the OR case studies published in 2011. Since then, UMMC has continued to lead the way in creating a more sustainable surgical department through clinical leadership and innovation, worked to reduce waste and implement green building elements in the newest addition to their facility—all while gathering and tracking data to highlight their successes.

OR Kit Review

UMMC conducts a robust monthly review of every tote (OR Kit). This process relies heavily on the data collected on item returns. The staff has been very compliant with returning unused items from the totes in designated return bins. These returns are credited back to the medical center and the specific tote and item details are presented at the monthly Surgitrak meeting, which is attended by the vice president of Perioperative Services, directors of Perioperative Services, Materials Management & Sustainability, OR management, and the RN heads of service.

One of the key measures of success that is used is percentage returns. Thresholds are set for each tote (ranging from 2-5 percent), and as returns exceed the threshold, they are evaluated and reformulated until they fall below the threshold. When initially rolled out, the return rate for totes was over 10 percent. In 2012, the return percentage was 1.9 percent, and in 2013 it was reduced to 1.5 percent. Further demonstrating the success of this lean process is the number of items in the kits which averaged 24 in 2012 and were reduced to 21 in 2013. This effort led to an estimated supply savings of over $476,000 and an avoided waste disposal savings of over $24,000 in 2013.

RMW Reduction

By educating and encouraging proper waste segregation prior, during, and post case, UMMC has reduced the regulated medical waste (RMW) from the surgical department. As the percentage of RMW for the Medical Center fell below 20 percent, they began to notice a strong correlation between RMW and OR cases, which makes sense in a facility as large as UMMC (41 ORs and 13 IR/Cath Lab/EP suites).

The OR was a target when trying to further reduce the facility’s overall RMW. Driven by members of the OR green team, the Greening the OR Initiative at UMMC with an emphasis on waste was successful in 2013. One additional metric UMMC established was RMW per OR case. In January 2013, UMMC was averaging 0.038 lb/case and by December 2013 reduced it to 0.0297 lb/case.

In addition to education on proper segregation, the University of Maryland Medical Center utilizes a reusable canister fluid management system, which helps to capture significant amount of fluid waste and divert it from the regulated medical waste stream. Using this system, UMMC was able to divert 20.8 tons from the regulated medical waste stream, save over $10,000 on avoided waste disposal fees, $8,100 on avoided purchase of disposable canisters, and $6,200 on avoided purchase of chemical solidifiers. Beyond these savings, they also identified the intangible benefit of reducing possible staff exposure to bloodborne pathogens.

The original interventions identified four years ago included:

  • Regulated medical waste reduction and segregation
  • Reusable canister fluid management systems
  • Reprocessing of single-use medical devices
  • OR Kit review and reformulation
  • Reusable surgical gowns and basins
  • Medical plastics recycling
  • Reusable rigid containers for surgical instrumentation
  • HVAC setback systems
  • LED surgical lighting and occupancy sensors for lighting

Since then, additional strategies include waste anesthetic gas capture and reclamation; sustainable anesthesia practices, such as reducing the use of nitrous oxide and volatile anesthetic agents; utilizing reusable linens and equipment where possible; reducing water use in associated sterile processing areas, and limiting chemicals of concern within the operating room, among others.

Reprocessing of Single-Use Medical Devices

OR device reprocessing was a major initiative within the perioperative areas of UMMC in 2013. Working with the vendor, individual collection containers were placed in each operating room to enhance collection compliance. This simple yet effective move increased compliance significantly. In 2012, 0.317 tons of single-use devices (SUDs) were collected in the OR and procedural areas. In 2013, this increased by more than six times—to 1.998 tons. To further promote and encourage physicians to use reprocessed devices, a monthly meeting was started to review monthly reprocessing and purchasing behaviors and consistently evaluate where improvement and changes could be made. In 2012, by using reprocessed instead of alternative OEM devices, UMMC spent $330,686 less than it otherwise would have. In 2013, the cost avoidance was $385,335—a 17 percent increase.

Other Waste Minimization Successes

University of Maryland Medical Center has a long history of using reusable surgical linens and basins to reduce the amount of disposable waste coming from the OR. In 2010, UMMC reevaluated this process, and found that using reusable gowns and basins helped them avoid 138,748 pounds of waste annually for an estimated savings of $38,849. The program also saves the hospital an estimated $39,000 by reclaiming surgical instrumentation that was inadvertently sent to the reprocessor along with gowns and table covers.

Transitioning to 68 percent of the surgical cases to rigid sterilization containers has also helped UMMC save almost $5,000 on avoided purchase of sterilization wrap, as well as saved on other unnecessary plastic overwraps, and diverted 0.5 tons of plastic waste from the landfill.

Increasing Energy Efficiency

In 2013, UMMC completed a new building project adding 10 operating rooms to its campus. Each of these 10 ORs are equipped with LED surgical lighting for improved clinical and energy performance. The HVAC system follows American Society of Heating, Refrigeration and Air Conditioning Engineers 170 guidance (to meet but not exceed 20 air changes per hour), and utilizes a setback system when the ORs are unoccupied in order to conserve energy. The facility estimates that through this effort, they’ve saved 62 kBtus/sq ft and $12,000.

University of Maryland Medical Center is an exemplary leader in the Greening the OR effort.


Sterilmed is the proud sponsor of this award.