And the Award Goes to …

By Kaeleigh Sheehan, Practice Greenhealth Project Manager on April 30, 2015

Dartmouth-Hitchcock Medical Center is this year’s Greening the OR Award winner.


OR staff nurse Pat Stockwell demonstrates a recycling bucket used in Dartmouth-Hitchcock Medical Center’s ORs​.

The OR is a large contributor to a health care facility’s environmental footprint, but health systems nationwide are transforming their surgical suites through environmental innovation. This year, Practice Greenhealth is pleased to recognize Dartmouth-Hitchcock Medical Center (D-H) for its outstanding efforts to reduce the environmental impact of the surgical environment.

Located in Lebanon, New Hampshire, D-H is a nonprofit, academic health system and designated Level 1 trauma center with 417 beds and 41 operating rooms. A long-standing leader in driving the health care sustainability movement, D-H is recognized this year for its excellence in the perioperative services department, among other areas.

One of the early enrollees in Practice Greenhealth’s Greening the OR® Initiative, D-H has a comprehensive program that spans everything from waste minimization and recycling to environmentally preferable purchasing and source reduction to energy and water conservation. Its success is due to staff engagement and education, with D-H team members taking the initiative to implement a system-based project to minimize the loss of volatile anesthetic agents, which led to cost savings and reduced impact on the climate.

D-H is working on waste reduction systemwide. With ORs generating such a large portion of a hospital’s waste, particularly expensive regulated medical waste (RMW), focusing on the perioperative department has had a significant impact on D-H’s waste reduction efforts. The OR staff works to properly segregate waste prior to a patient entering the OR as well as during and after a case. The use of reusable canister fluid management systems also significantly reduces the amount of RMW and minimizes staff exposure. D-H has even engaged anesthesia staff in reduction efforts by replacing a stand-alone RMW container with a solid waste container and a small bin for RMW hooked on the side.

To further streamline processes and reduce waste in the surgical department, D-H utilizes reusable hard cases for sterilization of 50 percent of its surgical instruments. D-H saved more than $122,000 from the avoided purchase of sterile wrap and disposal and avoided generating 20 tons of waste. The avoided expense was calculated by using the number of set sterilizations performed and what type of wrap would have been necessary for each instrument set.

One of the early enrollees in Practice Greenhealth’s Greening the OR Initiative, D-H has a comprehensive program that spans everything from waste minimization and recycling to environmentally preferable purchasing and source reduction to energy and water conservation.

D-H also has a comprehensive recycling program in the OR, including plastic film, rigid plastics and blue wrap. In 2014, D-H recycled 33,118 pounds of clean, empty rigids and 8,698 pounds of low-density polyethylene (LDPE) films for a total of more than 20 tons of recycling in the OR. D-H also entered into a custom packs contract and began working with Cardinal Health in a joint endeavor to review every custom pack and remove unnecessary items. In addition, 74 percent of OR kit types were reviewed. The review team identified high-volume cases, representing approximately 75 percent of the total OR volumes, and reviewed each of the 16 surgical services independently with each of the surgeons, looking for opportunities to eliminate items and standardize kits across providers in order to reduce variation.

The OR kit review resulted in removing 2,697 unnecessary items from the packs, saving the organization $858,759 from case carts and $4,719 from the disposal of those items. The team was also able to reduce the overall number of instrument sets from 152 to 111. These changes reduced the annual number of instruments processed each year by 485,489 (91,753 pounds), and the organization saw a savings of $606,861 in annual labor costs. The entire project resulted in a savings of $1,407,339.

D-H also has success with its single-use device (SUD) reprocessing program. In 2014, D-H saw significant growth in collection compliance of multiple noninvasive devices (pulse oximeters, ECG leads, DVT sleeves, blood pressure cuffs) along with an improvement in buy-back compliance of external-fixation devices. The team diverted more than nine tons of SUDs from the OR, Cath/EP labs and patient care areas for a savings of $8,758 in avoided waste disposal costs and $211,726 in the purchase of reprocessed devices.

In addition to being a major waste generator, the OR is a significant energy user. In 2014, D-H began to implement occupancy sensors in ORs as a means to automatically set back the HVAC system when the rooms are unoccupied or unused. Prior to sensor placement, staff would manually turn off lights and set back the air exchange rate in the evenings when the operating rooms were not in use. The engineering team at D-H estimates a savings of 1,706 kBTUs per year and $49,000 in avoided energy costs from automatic setbacks during off hours (six hours per night).

As an additional energy savings measure, LED surgical lights are in use in 24 of D-H’s operating rooms. LED surgical lights have longer life spans, consume less energy and generate less heat. With less heat from the lights, the temperature in an operating room can be set higher while maintaining staff and patient comfort, adding to energy reductions for the cooling system.

D-H was an early leader in connecting the dots between an organization’s operations and its greenhouse gas emissions. D-H developed an Ecological Footprint Calculator in 2009 to help health care organizations broadly assess the impact of their entire operation. D-H identified the impact anesthesia can have on the environment early on. A group of medical residents assessed the use of the three primary anesthetic agents—desflurane, isoflurane and sevoflurane—as well as the flow rates of these gases, then deployed an intervention to minimize the loss of the volatile gases to reduce impact and save money. Desflurane is the most expensive anesthetic agent and also has a significantly higher global warming potential than the other two. The medical residents highlighted the information for the anesthesia team and tracked usage before and after their education efforts. They found a 47 percent reduction in liters of gas used and a 50 percent reduction in costs over several months.

D-H’s work in its ORs to minimize waste, improve recycling, reduce energy use and manage anesthetics has resulted in significant environmental benefits and cost savings for the health system. These efforts are ongoing. The D-H perioperative staff plans to continuously improve its current programs and identify new sustainability opportunities to further reduce its environmental footprint and save money.