Four things otolaryngologists can do right now to reduce costs and environmental impact in your practice.
Amanda E. Dilger, MD, and Neelima "Neelu” Tummala, MD, on behalf of the Environmental Sustainability Task Force
In the United States, healthcare costs have increased substantially over the last decade while reimbursement rates have declined.1,2 This has created an increasingly challenging financial environment for both large healthcare systems and physicians in private practice. Advocacy opportunities such as meeting with your local government officials through the Academy In-District Grassroots Outreach (I-GO) Program and contributing to the ENT PAC* have been well described by our colleagues.3
Here, we outline another approach to reducing operational costs with the additional co-benefit of minimizing your environmental footprint. The U.S. health sector is responsible for about 8.5% of domestic carbon emissions annually, with approximately 30% of these emissions coming from the operating room (OR).4 We highlight four different strategies to directly reduce costs in your practice while also addressing the issue of increasing healthcare-associated waste and pollution.
Don’t miss the authors on the Voices of Otolaryngology podcast for further practical ideas on how to reduce your environmental impact in the episode, "Sustainable ENT: Practical Strategies for the Practicing Otolaryngologist.” Be a part of the conversation and watch the vodcast on YouTube or listen to the podcast.
Reducing Glove Overuse
Gloves are one of the most used disposable products in the healthcare system. Although gloves are recommended for both provider and patient safety in certain clinical scenarios, they have been increasingly overused, particularly in the wake of the COVID-19 pandemic.
The Joint Commission policy on glove use, which aligns with recommendations from the World Health Organization, states that gloves are to be used in patient-care scenarios in which there is contact with blood, body fluids, mucous membranes, and/or non-intact skin. Hand hygiene with hand washing or alcohol-based sanitizer can be used in all other scenarios, including checking vital signs, dispensing medications, and using electronic devices.
Reducing unnecessary glove overuse in outpatient clinics through educational materials and teaching sessions with clinical faculty and staff is an effective way to safely reduce costs and waste.
A recent single-institution study on implementation of hand hygiene educational material in an outpatient otolaryngology and plastic surgery clinic demonstrated a 27% reduction in gloves per visit, with an estimated cost saving of $3,000 per year.5 Another approach is to reduce the unnecessary use of individually packaged sterile gloves. A single institution prospective study of Mohs micrographic surgery found potential savings ranging from $17,580 to $23,440 when using nonsterile gloves for the procedure versus sterile gloves, with no difference in infection rates between the two groups.6
Opting for In-Office Procedures
In certain clinical scenarios, in-office procedures can be a safe, cost-effective, and sustainable alternative to operating room procedures. For example, a 2024 study of in-office versus surgical laryngeal laser procedures for recurrent respiratory papillomatosis found that in-office procedures generated only 13% of the waste compared to surgery for similar pathology.7 For small soft tissue procedures, the use of field sterility (i.e. a single drape, gloves and mask) has consistently been shown to be safe, cost-effective, and less wasteful than the same procedures performed in the OR. One study comparing removal of pediatric benign cutaneous lesions in the operating room versus the clinic found no difference in infection rate between the two sites, with an estimated $57,000 of savings annually when performed in the clinic. The material costs to excise a lesion in the operating room were 193% more expensive compared with removing the same lesion in the clinic.8
Streamlining Surgical Trays and Opting for Reusable Instruments
From a quality improvement standpoint, improving OR efficiency can reap significant monetary and sustainability benefits. One approach is to remove redundant and outdated instruments from surgical trays. This reduces unnecessary water and energy usage during sterilization and facilitates efficiency in the OR by having a more streamlined tray. Less commonly used instruments can be removed from trays and peel-packed, so that they are readily available when needed. A single institution quality improvement study removed instruments used less than 40% of the time from major otolaryngology, otolaryngology plastics, direct laryngoscopy and microdirect laryngoscopy trays. The novel instrument trays had projected savings of $228,338 over a three-year period. The study also found a 100% surgeon satisfaction rating with the streamlined trays.9-11
In addition, the recent advent of disposable intubating laryngoscopes has contributed to increased waste and higher costs. When opting for single-use over reusable scopes, the benefits and convenience of single-use scopes should be considered against the associated financial and environmental costs of reusable laryngoscopes. A single-institution life cycle assessment study, which accounts for the entire “cradle to grave” costs of an instrument, extrapolates that over a one-year period (60,000 intubations), reusable laryngoscopes, when sterilized and utilized appropriately, could save anywhere from $675,000 to $869,000 per year.
Collaborating with Anesthesia Colleagues
There are many opportunities to collaborate with our anesthesia colleagues to decrease the carbon footprint of the OR while reducing cost and providing safe, high-quality care. A high-yield example thoroughly discussed in the American Society of Anesthesiologists Environmental Sustainability Guidelines is reducing the use of inhaled anesthetic gases, particularly desflurane, when clinically appropriate.12 Desflurane costs nearly twice as much as sevoflurane and has an outsized global warming potential compared to other anesthetic gases. One single institution study showed that avoidance of desflurane was associated with savings of over $200,000 over a three-year period. The use of total intravenous anesthetic (TIVA) as opposed to anesthetic gases significantly reduces the carbon footprint of surgical cases, with studies suggesting potential clinical benefits with TIVA, including decreased nausea and vomiting in rhinoplasty patients, decreased risk of pulmonary complication in head and neck free flap patients and improved visibility and reduced blood loss in endoscopic sinus surgery.14-16
Interested In Learning More? Get In Touch!
If you are interested in learning more about cost-effective sustainability initiatives and ways to improve efficiency and save money, please contact the authors, Amanda Dilger, MD, at adilger@montefiore.org or Neelu Tummala, MD, at neelima.tummala@nyulangone.org.
*Contributions to ENT PAC are not deductible as charitable contributions for federal income tax purposes. Contributions are voluntary, and all members of the American Academy of Otolaryngology-Head and Neck Surgery have the right to refuse to contribute without reprisal. Federal law prohibits ENT PAC from accepting contributions from foreign nationals. By law, if your contributions are made using a personal check or credit card, ENT PAC may use your contribution only to support candidates in federal elections. All corporate contributions to ENT PAC will be used for educational and administrative fees of ENT PAC, and other activities permissible under federal law. Federal law requires ENT PAC to use its best efforts to collect and report the name, mailing address, occupation, and the name of the employer of individuals whose contributions exceed $200 in a calendar year.
References
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Eckelman MJ, Huang K, Lagasse R, Senay E, Dubrow R, Sherman JD. Health Care Pollution And Public Health Damage In The United States: An Update. Health Aff (Millwood). 2020 Dec;39(12):2071-2079. doi: 10.1377/hlthaff.2020.01247. PMID: 33284703.
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Perelman VS, Francis GJ, Rutledge T, Foote J, Martino F, Dranitsaris G. Sterile versus nonsterile gloves for repair of uncomplicated lacerations in the emergency department: a randomized controlled trial. Ann Emerg Med. 2004 Mar;43(3):362-70. doi: 10.1016/j.annemergmed.2003.09.008. PMID: 14985664.
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Nuzzi LC, Greene AK, Meara JG, Taghinia A, Labow BI. Surgical Site Infection After Skin Excisions in Children: Is Field Sterility Sufficient? Pediatr Dermatol. 2016 Mar-Apr;33(2):136-41. doi: 10.1111/pde.12523. Epub 2015 Feb 26. PMID: 25727412.
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Yalamanchi P, Miller JE, Prout S, Matthews E, Spagnol C, Harrington S, Chang HF, Spector ME, Casper KA, Malloy KM. Association of Operating Room Costs With Head and Neck Surgical Instrumentation Optimization: A Surgeon-Led Quality Improvement Initiative. JAMA Otolaryngol Head Neck Surg. 2022 May 1;148(5):402-407. doi: 10.1001/jamaoto.2022.0032. PMID: 35266982; PMCID: PMC8914886.
Yalamanchi P, Miller JE, Prout S, Matthews E, Spagnol C, Harrington S, Chang HF, Spector ME, Casper KA, Malloy KM. Association of Operating Room Costs With Head and Neck Surgical Instrumentation Optimization: A Surgeon-Led Quality Improvement Initiative. JAMA Otolaryngol Head Neck Surg. 2022 May 1;148(5):402-407. doi: 10.1001/jamaoto.2022.0032. PMID: 35266982; PMCID: PMC8914886.
Shital D. Patel, Rachel Smith-Steinert. Greening the operating room, one procedure at a time. J Clim Change Health, 2021;2:2667-2782. doi: 10.1016/j.joclim.2021.100014.
Lu VM, Phan K, Oh LJ. Total intravenous versus inhalational anesthesia in endoscopic sinus surgery: A meta-analysis. Laryngoscope. 2020 Mar;130(3):575-583. doi: 10.1002/lary.28046. Epub 2019 May 3. PMID: 31050818.
Sagalow ES, Estephan LE, Kumar AT, Hwang M, Krein H, Heffelfinger R. Recovery Benefit With Total Intravenous Anesthesia in Patients Receiving Rhinoplasty. Otolaryngol Head Neck Surg. 2023 Sep;169(3):489-495. doi: 10.1002/ohn.319. Epub 2023 Mar 11. PMID: 36906818.
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