Goals
Our clinical spaces are working towards two goals:
- Reduce emissions from inhaled anesthetics through best practices
- Increase landfill diversion and reduce landfill waste through implementing reusable equipment and a more efficient workflow
- Consider product reprocessing as a sustainability criteria for sustainable procurement, including:
- Striving for new contracts to specify that at least 20% of disposables should be purchased reprocessed as approved by the FDA when available and operationally feasible.
Recent Accomplishments
Green Anesthesia
Inhaled anesthetic agents are potent Greenhouse gases (GHGs). Less than 5% of anesthetic agents are metabolized by patients, with the vast majority of the anesthetic gases routinely vented into the atmosphere as GHGs. Inhaled anesthetics attribute to 5% of overall emissions of the National Health System (NHS) in the UK and 51% of Operating Rooms' (ORs) emissions for a large academic hospital based on carbon mapping.
UCSF has been spearheading scope 1 emissions reduction from inhaled anesthetics through the elimination of desflurane, an inhaled anesthetic agent with the highest Global warming potential and utilizing low flow anesthesia. To support the low flow anesthesia practice, we implemented a Clinical Decision Support (CDS) tool within the Epic Anesthesia Information Management System (AIMS) to alert providers when the Fresh Gas Flow (FGF) is high (> 0.7 L/min for sevoflurane) during the maintenance phase of anesthesia. Through that, we reduced emissions from sevoflurane by 83%, which is equivalent to removing 219 cars from the street of San Francisco. Through the UC carbon neutrality initiative, UCSF facilitated other UC health systems to implement a similar CDS cool to reduce their emissions from inhaled anesthetics.
Figure 1. Emissions from inhaled anesthetics (excluding nitrous oxide) from 2018 to 2021 in metric tons of CO2
Detailed OR Waste Audit
The operating suite is one of the most resource-intensive areas in the hospital and generates about 20~30% of total hospital waste. UCSF had conducted several detailed OR waste audits in order to have a granular understanding of the components of OR waste so that targeted interventions can be implemented to reduce waste in each category. Landfill surgical waste generated at UCSF ranges from 28 lbs for a laparoscopic appendectomy to 55 lbs for a large spinal fusion case. Among the waste, 31% originated from single-use surgical textiles, such as surgical gowns, towels, drapes, table cover, etc., sterilization wrap for instrument trays account for 12% of the waste, supply packaging account for 13%, and patient positioning account for 4% of the waste. Since that, UCSF has been targeting its efforts to implement reusable surgical textile and reusable gel pad for patient positioning for OR waste reduction.
Single Use Device Reprocessing
UCSF Health is working towards increasing the number of reprocessed single use items in patient care.
Reprocessing of single-use devices (SUD's) is the practice of inspecting, cleaning, function testing, sterilizing, and packaging so that they can safely used again. Reprocessing of SUD's is regulated by the FDA, and goes through rigorous testing processing to ensure that it is equivalent to the Original Equipment Manufacturer (OEM) devices for its clinical use.
Some benefits of using reprocessed items include: waste diversion from the landfill, waste disposal cost avoidance, and less expensive buy-back costs.
In FY 24, UCSF Health collected 116,602 pounds of single-use devices for reprocessing, saving $52,303 in waste avoidance costs.
Blue Wrap Recycling
Blue wrap is a type of polypropylene fabric that wraps sterile instruments in the OR. While blue wrap is an essential item in a healthcare setting, it contributes significantly to our hospitals waste stream. In fiscal year 2023, the UCSF Health Medical Centers disposed of 10 tons of blue wrap in the landfill.
Blue wrap is typically disposed of before the patient is in the operating room, making it free of any biohazardous waste and a suitable candidate for recycling. However, our waste hauler, Recology, cannot recycle polypropylene fabrics.
In 2024, we partnered with an external recycling vendor to begin recycling our blue wrap. The vendor collects the blue wrap, pelletizes it and turns it into new plastic products. See the dashboard below for metrics on blue wrap collection in Fiscal Year 2025 since the launch of our new recycling program:
In Progress
Multi-use Anesthesia Breathing Circuits
UCSF Health is ushering in a new era of sustainability by adopting multi-use anesthesia breathing circuits, a device that delivers oxygen and inhaled anesthesia gases to patients during surgery.
The FDA-cleared reusable breathing circuits, also known as ‘Multi-use Patient Circuits,’ can be used for up to 24 hours in the operating room when used in combination with a hydrophobic HME filter, rather than being disposed of after each patient. While the practice of reusing breathing circuits has been proven to be safe and is wildly used in other countries across all income spectrums, the US has yet to adopt it broadly.
This systemwide adoption will further strengthen UCSF Health’s commitment to reducing landfill waste, minimizing reliance on single-use devices, and promoting data-driven, evidence-based practices to build resilient health systems.
This change rolled out in December 2024 at the Mission Bay Campus in the adult operating rooms and will be rolling out across the five surgical sites. The systemwide change is projected not only to eliminate 8.2 tons of plastic landfill waste but also to contribute to annual cost savings per surgical case without compromising patient safety.
Read the full story here: UCSF Launches New Sustainable Model for Anesthesia
Reducing Emissions from Metered Dose Inhalers
Metered-dose inhalers are a widely used medication delivery system for treating asthma, chronic obstructive pulmonary disease (COPD), and other respiratory diseases. However, there are significant climate impacts that are associated with them, due to the use of hydrofluoroalkane (HFA) propellants. Each puff of the medication from the inhaler releases a hydrofluorocarbon gas that is 1430 to 3000 times more potent when compared to carbon dioxide.
There are more climate-friendly alternatives with a different delivery system for these types of medication without propellants, including dry-powder Inhalers (DPIs) and soft-mist inhalers (SMIs). Nonetheless, they are currently not widely adopted in the US due to limited options and a lack of formulary coverage.
At UCSF Health, we are currently undergoing a preliminary assessment of emissions calculation from different types of inhalers used, for both inpatient dispense and outpatient prescriptions. In addition, conducting stakeholder interviews to help us better understand what the barriers are and establishing an MDI Task Force that involves pulmonologists, pharmacists, ICU attendings, and pediatricians to implement system-wide actions to reduce emissions from MIDs, including prescribing with appropriate indications, and more environmentally friendly alternatives.
Decommissioning Piped Nitrous Oxide
Rising awareness of the environmental impact of Nitrous Oxide ((N2O) coupled with increased use of alternative anesthetics have decreased the demand for N2O as an anesthetic agent in ORs. In response to the current climate health crisis and the University of California’s ambitious carbon neutrality initiative, UCSF Health plans to eliminate central piped N2O at the new outpatient surgical center at Mission Bay campus and the new hospital at Parnassus Heights, as well as remove the existing nitrous pipe system from the current hospital facilities. Smaller gas cylinders that are installed at the back of the anesthesia machine, known as E-cylinders, will be used in the operating rooms to supply N2O when needed. UCSF Health will reduce the amount of N2O that is released into the atmosphere by approximately 83% from its facilities by taking these steps in modifying hospital infrastructure. UCSF Health is currently in the process of decommissioning piped N2O across all operating rooms.
Case Study: UCSF Health System's Sustainability Journey: Pioneering New Practices to Minimize Nitrous Oxide Emissions
Reusable Surgical Textile
To target the largest component of the OR waste, UCSF has partnered with Standard Textile to source reusable surgical gowns, towels, and mayo stand covers in hopes to transition away from the single-use surgical textile products in the OR. Previously, UCSF successfully implemented reusable isolation gowns in 2020 and diverted 64 tons of waste each year. To ensure end users’ satisfaction and successful implementation, a survey that assessed providers and staff's concerns about reusable textiles was administered, and pilots at multiple surgical sites were carried out with great satisfaction. UCSF is expected to roll out a reusable and disposable hybrid program later in 2022.
