Interventions to achieve environmentally sustainable operating theatres: an umbrella systematic review using the behaviour change wheel

Abstract

Introduction: The healthcare sector is a major contributor to the climate crisis and operating theatres (OTs) are one of the highest sources of emissions. To inform emissions reduction, this study aimed to (i) compare the outcomes of interventions targeting sustainable behaviours in OTs using the Triple Bottom Line framework, (ii) categorise the intervention strategies using the five Rs (reduce, recycle, reuse, refuse, and renew) of circular economy, and (iii) examine intervention functions (IFs) using the Behaviour Change Wheel (BCW).

Methods: Medline, Embase, PsychInfo, Scopus, and Web of Science databases were searched until June 2023 using the concepts: sustainability and surgery. The review was conducted in line with the Cochrane and Joanna Briggs Institution's recommendations and was registered on PROSPERO. The results were reported in line with Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) (Supplemental Digital Content 1, http://links.lww.com/JS9/D210 ) guidelines.

Results: Sixteen reviews encompassing 43 life-cycle analyses, 30 interventions, 5 IFs, and 9 BCW policy categories were included. 28/30 (93%) interventions successfully led to sustainability improvements; however, the environmental outcomes were not suitable for meaningful comparisons due to their using different metrics and dependence on local factors. The 'reduce' strategy was the most prolific and commonly achieved through 'education' and/or 'environmental restructuring'. However, single-session educational interventions were ineffective. Improving recycling relied on 'environmental restructuring'. More intensive strategies such as 'reuse' require multiple intervention functions to achieve, either through a sustainability committee or through an intervention package.

Conclusion: Policymakers must examine interventions within the local context. Comparing the outcomes of different interventions is difficult and could potentially be misleading, highlighting the need for a tool integrating diverse outcomes and contextual factors. 'Reduce' strategy guarantees environmental and financial savings, and can be achieved through 'Education' and/or 'environmental restructuring'.

Figure 1

PRISMA diagram demonstrating the screening and inclusion process. Of the 129 studies, 45 were duplicates, leaving 84 articles which were subjected to title and abstract screening against our inclusion and exclusion criteria. Of these, 23 met our criteria and were subjected to full-text screening. Of these, 7 articles were excluded leaving 16 studies eligible for inclusion in the final review.

Figure 2

Percentage of included studies appearing in multiple reviews.

Figure 3

Matrix chart mapping sustainability concepts and IFs. Most studies aimed to ‘reduce’ (n=14) and ‘recycle’ (n=6). Multiple IFs (education + environmental restructuring without (n=4) or with (n=1) enablement) were successful in reducing surgical waste (n=5) followed by ‘education’ and ‘environmental restructuring’ which were successful single interventions (4 and 3, respectively), while ‘environmental restructuring’ was the single most intervention employed to increase recycling in surgery (n=5).