Health Policy and Advocacy Committee

Firearm Violence Prevention

Facts on Pediatric Firearm Violence in the United States

Firearms are the leading cause of death in children and adolescents ages 1 through 19 years old (Figure 1). Firearm violence can be against others (assault/homicide), self (self-harm/suicide), or unintentional. Since 2013, there has been a steady rise in firearm-related deaths, with a marked rise in firearm homicides between 2019 and 2021, while suicide deaths by firearm have risen at a slower rate (Figure 2). Unintentional firearm deaths remain a small, but tragic portion of pediatric firearm deaths at 0.1 to 0.3 deaths per 100,000 children and adolescents, with the CDC reporting 3,216 deaths between 1999 and 2021.

Figure 1: Death rates in children 1-19 years old by mechanism
Firearm-related injuries have been the leading cause of death since 2020
Figure 2: Firearm deaths in children 1-19 years old by intent

Deaths due to firearm-related injuries impact communities throughout the United States to varying levels, demonstrating differences in gender, age, urbanicity, and race (Figure 3). Firearms in the home increase the rate of unintentional firearm deaths, firearm suicides, and firearm homicides in children and teens. In 2021, homicide accounts for 64% of all firearm-related deaths in children ages 10 to 19 years old with similar trends seen by gender, age, and most urbanicity and races. However, rural communities and non-Hispanic whites have higher rates of suicide. Black youth are dying from firearm-related homicides at a rate of over 30 per 100,000 children, far exceeding any other demographic (25x that of non-Hispanic white children).

Figure 3: Firearm death intent and A. gender B. urbanicity C. age and D. race/ethnicity based on 2021 data from CDC Wonder

While unintentional firearm deaths represent only a small portion of all pediatric firearm deaths, when combined with the number of children who survive unintentional firearm injuries, the full extent of unintentional firearm injuries is much greater (Figure 4). Children as young as 3 years old have the manual dexterity and strength to pull a trigger. Telling children not to touch a firearm has been shown to be an ineffective method to prevent unintentional firearm injuries. Note that similar to motor vehicle crash literature, it is prudent to avoid the term ‘accident’ as this implies the deaths are not preventable.

Figure 4: Comparison of shooting intents between fatal and non-fatal pediatric firearm injuries (Source: Naik-Mathuria BJ et al., 2023)

Statistics source: Giffords Law Center

Resources for Pediatric Surgeons

Prevention Opportunities at Trauma Centers

Primary Prevention

Primary prevention of firearm violence is a proactive approach aimed at preventing firearm-related injury. This strategy primarily involves education and awareness programs targeted at children and adolescents, teaching them about the dangers and consequences of firearm violence.

Safe firearm storage counseling and awareness

Research has shown that physician counseling on safe storage practices, coupled with distribution of firearm safety devices, can improve storage behavior. Direct counseling by physicians, however, is not commonly practiced, likely due to lack of time and comfort with the topic. Opportunities exist for trauma centers to participate in this effort simply by raising awareness: placing posters, through social media, gun lock giveaways, or safety device distribution

Gun safety pamphlet

Screening and Counseling Around Firearm Injury Risk

The SaFETy Score screens in four domains of firearm violence risk (Serious fighting, Friend weapon carrying, community Environment and firearm Threats) to predict future two year firearm violence (both victimization and aggression) (Goldstick JE et al., 2017). Scores range from 0 to 10, with increasing scores correlated with increasing levels of risk. It is currently the only validated screen for future firearm violence risk.

SaFETy score

Emergency departments and primary care settings have started to implement the SaFETy Score to identify youth at high risk for interpersonal firearm violence. A recent model for universal screening for firearm injury and mortality prevention (FIMP) was published which maintains this approach by screening all ED patients ages 12 and older for firearm injury risk, with exceptions for patients who are too sick or refuse.

Universal screening model for firearm injury and mortality prevention, implementing the SaFETy Score as part of the screening process (Sathya C, Harrison L, Dauber K, Kapoor S, 2022)

In addition to screening for firearm violence risk, universal preventative counseling has been suggested as a way to increase knowledge and promote safe changes. Preventative counseling often incorporates the “5A’s (Ask, Advise, Assess, Assist and Arrange)” model, which was shown to improve quality, content and comfort delivering firearm safety counseling. When applied to firearm safety counseling, trainees report improved comfort with counseling.

The 5A’s model applied to firearm safety counseling (Hoops K, McCourt A, Crifasi CK, 2022)

The AAP and Brady Campaign developed the ASK (Asking Saves Kids) campaign, which recommends that all parents, including non-firearm owning parents, ASK about the firearm storage in the homes their children visit. Additional campaigns include Means Matter and BeSMART. For firearm-owning parents, it may be helpful to share that studies consistently show that children as young as 5 years old know more about the firearms in their own homes than parents realize. Among teens participating in a national survey, 34% reported they could access a loaded firearm within 5 minutes and 51% within 1 hour. (Salhi C et al., 2021). Importantly, even among parents who think they have adequately secured their firearms, 22% of teens reported loaded firearm access within 5 minutes and 37% within 1 hour.

Resources for Clinicians

Suicide Prevention and Interpersonal Violence

Legislation and Policy

Extreme Risk Protection Orders (ERPOs), also known as "Red Flag Laws," are legal orders that allow law enforcement officers, and sometimes family members and other concerned parties, to petition a court to temporarily remove firearms from individuals who are deemed to be a significant danger to themselves or others. The goal of ERPOs is to prevent potential gun violence and protect the individual and those around them.

What are Child Access Protection (CAP) laws? CAP laws are legislations designed to mandate secure firearm storage to prevent child access, imposing penalties for non-compliance. These laws are supported by studies, including Azad et al (2020), which analyzed the implications of negligent firearm storage and its thresholds, providing insights into defining potential criminal liability and clarifying legislation to prevent firearm injuries among children and adolescents

Gun policies and patient outcomes (Rand 2024)

Hospital Based Violence Prevention Programs (HVIPs)

Resources for Patients & Families

Pertinent Articles

Food Insecurity

Information for Pediatric Surgeons

Keywords: food security, food insecurity, hunger, children, SNAP, Supplemental Nutrition Assistance Program, Special Supplemental Nutrition Program for Women, Infants and Children, WIC, National School Lunch and School Breakfast Programs

Introduction

Food insecurity may, at first, seem like an irrelevant topic for pediatric surgeons.

However, understanding the existence of certain negative health outcomes, such as obesity, that stem from food insecurity is of direct importance to policy makers, healthcare professionals and surgeon advocates.

Nutrition is critically important for positive surgical outcomes, but minimal information exists about the prevalence or impact of food insecurity on pediatric surgical patients [1].

Surgeon advocates are poised to impact food insecurity through support of:

i. The National Strategy to improve population health through better nutrition.

ii. The American Academy of Pediatrics vision to support food security for all [2].

iii. The APSA vision to provide the highest quality of care to all children, patients and families.

Recent research in the fields of economics, internal medicine, nutrition, public health, and social work, examines the association of food insecurity and health.

Definition

Since 1946 and the introduction of the Food Stamp program by President Roosevelt, food policy has been managed by the United States Department of Agriculture (USDA).

The USDA defines food insecurity as “a household-level economic and social condition of limited access to enough affordable, nutritious food that supports health” [3].

It further defines a food-insecure household as one in which "access to adequate food is limited by a lack of money or other resources” [4].

Food insecurity affects an estimated 1 in 6 American children and is part of an interconnected cycle of adverse childhood experiences that include poverty, lack of housing, inadequate access to health care, reduced education opportunities, and exposure to violence [5].

Measuring Food Insecurity

The USDA measures food insecurity through responses to a series of 18 survey questions and statements administered to 45,000 households in the Food Security Supplement of the Census Bureau Current Population Survey (CPS-FSS) (www.ers.usda.gov/publications/eib-economic-information-bulletin/eib113.as...

Eight of the 18 items are focused on children and include questions such as:

“Did you or the other adults in your household ever cut the size of meals as there was not enough money to buy food?”

“Did any of the children not eat for a whole day because there was not enough money for food?”

Based on survey responses, the USDA divides households into categories:

i) high food security

ii) marginal

iii) low

iv) very low (8 or more affirmative responses)

For most research and policy discussions, the categories of low and very low food secure are combined into a category of food insecure.

Food Insecurity in Households with Children

Food insecurity is a worsening problem[4]

Between 2001 and 2007, the rate of food insecurity was steady at about 11% for all households and 18% for those with children. After the Great Recession in 2008, the rate rose to 14.6% overall and 18% for households with children. Between 2008 and 2013, the rate remained unchanged.

In 2013, almost 50 million Americans (14.3%) were food insecure and about one third were considered to have “very low food security” [1].

Between 2013 and 2021, food insecurity decreased to a rate of 10.2% for all households, but in 2022 it suddenly rose to 12.8% [4].

The increased rate is possibly the result of:

i. A rise in food prices of 9.9%, the fastest pace in 40 years.

ii. Several COVID-19 pandemic enhancements to the federal safety net EXPIRED:

Adverse Health Outcomes[3]

Multiple adverse health outcomes strongly correlate with food insecurity [6][7].

Most papers use binary comparisons of children in food-insecure households (those with 3 or more affirmative responses to items on the CPS-FSS) to children in food-secure households (those with zero, one or two affirmative responses) [3].

Articles that examine the rate of adverse health outcomes and food insecurity [3]

Adverse outcome

Age (yrs)

Increased rate factor

Reference

Birth defects - cardiac

At birth

24% reduction if better diet

Botto et al. (2015) [8]

Anemia

12-15

2-3

Eicher-Miller et al. (2009)[9]

Aggression, anxiety

4-8

2

Melchior et al. (2012)[10]

Poor general health

< 3

2-3

Cook et al. (2006)[7]

Asthma

10-15, 16-21

1.4-2.6

Kirkpatrick et al. (2010)[11]

Suicide ideation

14-25

2.3

McIntyre et al. (2013)[12]

Worse oral health

2-18

2

Chi et al. (2015)[13]

Children from food-insecure households are at higher risk of hospitalization, critical illness, and chronic diseases [14]. Data from Children’s Health Watch, a sentinel study of over 40,000 children younger than 4 years at 5 urban hospitals, found that children from food insecure households are more likely to have a mother who reported concerns about child development on a validated evaluation form [7].

A compelling picture of food insecurity and negative health outcomes is emerging based on a wide variety of datasets [1].

Limitations exist, however, in that bias is difficult to minimize. One cannot directly infer causality between food insecurity and a poor outcome as other factors, such as income, may confound and impact both the state of food insecurity and the health outcome under evaluation.

Advocacy and Policy Information

i. White House Conference on Hunger, Nutrition and Health

Wednesday, September 28, 2022: the first White House Conference on Hunger, Nutrition, and Health in over 50 years.

· Hosted by President Biden

· Elected officials, Activists, Advocates, Business Leaders, Philanthropists, Faith Leaders

· Objective: End hunger and increase healthy eating and physical activity by 2030, so that fewer Americans experience diet-related diseases like diabetes, obesity, and hypertension.

· Fact sheet $8 billion in new commitments as part of the Conference’s call to action.

· White House Challenge to End Hunger .

ii. APSA Vision and Mission

Understanding how pediatric surgeons can impact food insecurity aligns with:

· The national vision to end hunger, as well as our organizational vision that all children receive the highest quality surgical care.

· Our organizational mission to provide the best surgical care to our patients and families by supporting an inclusive community through education, discovery and advocacy.

iii. AAP Food Insecurity Resources [2]

· AAP Policy Statement: Promoting Food Security for All Children [2]

www.pediatrics.org/cgi/doil 10.1542/peds.2015-3301 001: 10.1542/peds.2015-3301

· The American Academy of Pediatrics, in cooperation with the Food Research and Action Center, developed a toolkit titled Addressing Food Insecurity- A toolkit for Pediatricians- February 2017[2]

iv. Supplemental Nutrition Assistance Program (SNAP) [2]

After the Great Depression, President Franklin Roosevelt’s administration recognized the need for the government to help feed hungry Americans and created the Food Stamp program. This program represents the first change in food policy.

While assistance to families through today’s version of the Food Stamp program, now called the Supplemental Nutrition Assistance Program (SNAP), and the program for Women Infants and Children (WIC), increased during the pandemic, many Americans remained hungry. The SNAP relief bill was expanded during COVID, but did not significantly expand eligibility beyond some children under six and some college students. Unemployment benefits were not considered income for some applicants.

In 2022, the WIC division of SNAP served 39% of all infants born in the United States (USDA ERS - Food & Nutrition Assistance- accessed January 21, 2024).

SNAP provides food benefits to low-income families to supplement their grocery budget and support their health and well-being. The program reduces poverty and alleviates food insecurity [6]. Any reduction in the state of food insecurity may reduce the health consequences that derive from a lack of healthy food. For over 50 years, the SNAP program has successfully reduced food insecurity [2].

To Qualify:

SNAP Advocacy Efforts [2]:

i. Many food banks lack the capacity, staffing and systems to effectively distribute food. Expanding SNAP can decrease waste and redundancy in the USDA food bank programs. SNAP allows users to shop at local grocery stores instead of waiting in long lines at food banks that were never designed for the present demand.

ii. Advocates do NOT support changing SNAP to a block grant program which would designate a specific amount with no responsiveness to changes in economic needs that may occur during a recession.

iii. Pediatric surgery office: learn to refer patients to the SNAP program (see Feeding America).

iv. For every $1.00 taxpayers invest in SNAP, they get a return of more than $1.50.

v. SNAP expansion would provide an opportunity to invest in rural America. Rural Americans use SNAP at a higher percentage than urban Americans.

vi. SNAP expansion provides economic opportunity for family farms and agricultural jobs [2]. SNAP decreases waste, increases demand, and supports a competetive price for agricultural products.

v. Feeding America
vi. Food Research and Action Center (FRAC)

The Farm Bill is a comprehensive package of legislation passed once every five years that has a direct impact on agriculture, food systems, and consumers. It covers programs ranging from crop insurance for farmers to healthy food access for low-income families. The Farm Bill has different sections — known as titles — that can change over time. The 2018 Farm Bill had 12 titles.

Out of those 12 titles, Title Four, is the most relevant for anti-hunger advocates. The Nutrition Title covers the Supplemental Nutrition Assistance Program (SNAP), as well as a variety of smaller nutrition programs to help low-income individuals and families afford food.

vii. Obesity

Despite efforts to curb obesity among children for over a decade, prevalence rates continue to rise. There is a need for population-wide strategies to achieve healthy growth of all children [9]. A study by Chandran in JAMA Pediatrics provides evidence and support for the National School Lunch Program and School Breakfast program (NSBP) to achieve this [15].

These programs, enacted via the National School Lunch Act of 1946, have long existed. Recent concerns were raised that the poor quality of food served within these programs contributed to rising obesity rates [16].

In response, Congress enacted the Healthy,Hunger-Free Kids Act (HHFKA) in 2010, which called for a revision of school nutrition standards [12]. The HHFKA aimed to strengthen nutritional standards of the NSLP to include more whole grains, fruits, vegetables, and low-fat dairy products in alignment with nutrition expert guidelines.

It established age-specific recommendations for serving sizes and nutritional standards for food and beverage products sold outside of school meal programs, such as the snacks from vending machines and school stores [17].

The Chandran study underscores the important impact of the NSLP on reducing excess weight gain among lower-income children, who are among the most vulnerable for food insecurity, obesity, and obesity-related chronic diseases [16]. The HHFKA appears to reduce obesity for the entire cohort. The study lends support for the program’s influence on BMI for school-aged children nationwide [17].

The Healthy Hunger-Free Kids Act is a feasible policy avenue to reduce disparities in childhood food insecurity that promote obesity [17].

Pediatric surgeons with an interest in advocacy can learn more about this policy and its positive impact for children through the following sites:

The Economic Burden of Adverse Childhood Experiences [5]

Adults with ACE such as food insecurity have more harmful behaviors and worse health outcomes. One study found that the national economic burden of ACE-related adult health conditions is over 14 trillion dollars annually or $88000 per affected adult and $2.4 million over their lifetimes [5].

Information that quantifies the childhood burden of food insecurity may ultimately support investment strategies to improve the health and wellness of the greater population.

FreshRx- A Pediatric Surgeon develops a Farm to Table Program

Dr. Marshall Stone MD

Fresh Rx, a non-profit organization (501c3), aims to address food insecurity through innovative programs that provide access to healthy fresh produce and nutrition education as a vital combination to assist patients and families in making the connection between food and wellness.

https://www.freshrx.org/

The structure, supporting local family-owned farms that use organic practices, strives to build a sustainable, healthy community.

The Fresh Rx Program includes pediatric patients with a variety of medical conditions, including obesity and cancer, who screen positive for food insecurity. They are referred by other health professionals.

The patients and families are enrolled in a 16-week program that provides locally sourced fruits, vegetables, eggs, and legumes. Every week they receive the Fresh Rx educational newsletter which highlights the nutritional benefits of fresh fruit and vegetables. It provides simple recipes, cooking techniques, as well as physical and mental wellness resources. The patients and families complete a health assessment form at entry, end of program, and three-month follow-up.

At program completion patients report significant improvements in the amount of vegetable consumption, physical activity, memory, and sleep patterns. They also maintain an interest and commitment to eating a healthy diet at 3-month follow-up. An active diet intervention program where children and their parents are educated on healthy food choices, and provided weekly fresh produce, can have a significant impact on patient well-being and healthy food choices.

For pediatric surgery patients these changes could have a significant impact on long-term outcomes.

Pediatric Surgeons and Food Insecurity

The FreshRX Toolkit

Fresh Rx has developed a toolkit as a guide for other institutions.

A Personal FreshRX story - Kane’s journey

Fresh Rx is available to offer support through partnerships with other nonprofits or institutions interested in starting a similar type of program. For more information or inquiries for the Fresh Rx program

Please contact: Eilish Murphy at eilish@freshrx.org (561-436-2763) or visit the website, FreshRx.org.

References

Patient Autonomy

APSA Supports Equal Access for Reproductive Health Services

APSA supports our colleagues who provide critical maternal and fetal care. All people, in consultation with their physician, should have equal access to the full range of reproductive health services, including abortion.

The American Pediatric Surgical Association (APSA) joins the many medical and surgical organizations in support of our colleagues who care for pregnant patients. As pediatric surgeons, we believe that pregnant patients should be allowed to decide what is in the best interests of their own health and the well-being of their family. We believe the patient-physician relationship is important and should remain private. We believe that equitable access to high quality and safe prenatal care, including reproductive services and abortion, should be prioritized regardless of economic or geographic status.

Reproductive Rights Toolkit

Welcome to the APSA Advocacy Committee’s toolkit regarding reproductive rights in the post-Dobbs era. Here you will find a curated selection of links pertaining to each category along with a brief description.

Please email svmannava@gmail.com with any questions or concerns about the information displayed.

Current Abortion Laws

Interactive Map: US Abortion Policies and Access After Roe | Guttmacher Institute

The Guttmacher Institute is a research and policy organization with numerous resources on reproductive health for patients, providers, and policymakers. This link provides:

State by State Guides to Abortion | U.S. Abortion Laws by State (abortionfinder.org)

This link from Abortion Finder provides:

Abortion Laws by State – Center for Reproductive Rights

This link from Center for Reproductive Rights provides:

State legislation tracker | Guttmacher Institute

The Guttmacher Institute is a research and policy organization with numerous resources on reproductive health for patients, providers, and policymakers. This link provides state-by-state information regarding:

Medication Abortion | Guttmacher Institute

The Guttmacher Institute is a research and policy organization with numerous resources on reproductive health for patients, providers, and policymakers. This link provides state-by-state information regarding medication abortion.

Where Restrictions on Abortion Pills Could Matter Most in the U.S. – The New York Times (nytimes.com)

This link provides an interactive platform with up-to-date information on abortion pill rulings nationwide. Access to this link is limited to NYT subscribers but can be viewed as part of the “ten free articles per month” allowance on the NYT website.

Lawyers for Good Government | Reproductive Health Digest

Lawyers for Good Government (L4GG) coordinates pro bono programs and advocacy efforts to promote equity. This newsletter is updated on a biweekly basis and contains information on state laws and regulations as they evolve in real time.

Resources for Healthcare Professionals

Legal Help for Current and Prospective Abortion Providers

The National Women’s Law Center is an organization that works closely on authoring legislation on women’s rights issues including equal pay and abortion rights. This link provides information on:

If/When/How Technical Assistance & Public Education

If/When/How is a nonprofit organization comprised of lawyers and advocates aiming to improve access to reproductive healthcare. This link provides:

How to Talk about Abortion | ACOG

The American College of Obstetricians and Gynecologists (ACOG) provides practice guidelines and educational materials to support women’s health. This link will open a list of links curated by ACOG related to:

Reproductive Health Access Project | (reproductiveaccess.org)

The Reproductive Health Access Project (RHAP) trains primary care physicians to ensure access to reproductive health for communities. This link provides factsheets and info which can aid physicians and other professionals prior to counseling patients.

Resources for Patients

Guide for Patients Seeking Abortion Care | ACOG

The American College of Obstetricians and Gynecologists (ACOG) provides practice guidelines and educational materials to support women’s health. This link will open a list of links curated by ACOG regarding:

Crisis Pregnancy Center Information and Resources | ACOG

The American College of Obstetricians and Gynecologists (ACOG) provides practice guidelines and educational materials to support women’s health. This link will provide information regarding:

Where Can I Get an Abortion? | U.S. Abortion Clinic Locator (abortionfinder.org)

Abortion Finder is a website which synthesizes information from public health experts, researchers, and advocates regarding abortion care. This link will provide:

Judicial Bypass: Contact the Helpline | Repro Legal Helpline

Repro Legal Helpline is a service run by If/When/How – this is a non-profit organization comprised of lawyers and advocates aiming to improve access to reproductive healthcare. This link provides:

Abortion Defense Network

This resource provides support to patients who need legal help related to abotion care.

Get Involved in Advocacy

Abortion Is Essential Health Care | ACOG

The American College of Obstetricians and Gynecologists (ACOG) provides practice guidelines and educational materials to support women’s health. This link provides

This link is currently only accessible to ACOG members but may be accessed via email request to the organization

Reproductive Health Coalition – American Medical Women’s Association (amwa-doc.org)

The American Medical Women’s Association (AMWA) is a multi-specialty organization interested in advancing women in medicine and improving women’s health. The Reproductive Health Coalition (RHC), cofounded by AMWA and Doctors for America (DFA), is collection of health professional associations and allied organizations who meet weekly to discuss and develop strategies to protect clinicians in their ethical obligation to provide comprehensive reproductive healthcare to patients.

This link will provide a sign-up form to join the RHC and receive meeting invites and access to meeting minutes. AMWA membership is NOT required to join the RHC.

Advocacy | ACS (facs.org)

The American College of Surgeons (ACS) Advocacy page providers news on advocacy, legislation on relevant issues, and opportunities to become a surgeon advocate.

SurgeonsVoice | Advocacy Center (quorum.us)

SurgeonsVoice is a national advocacy program for surgeons, providing tools and access to make an impact in Congress. This website provides direct links to write to legislators regarding issues relevant to surgeons and their patients. This website also provides a guide to becoming an effective advocate.

Adolescent Health Care: Access and Advocacy

This link from the American Academy of Pediatrics (AAP) outlines information about barriers to sexual and reproductive health services for adolescents. It also details opportunities for healthcare professionals who wish to become involved in reproductive rights advocacy at the federal and state levels.

Sustainability

Mission Statement of the APSA OR Sustainability Subcommittee

To improve child wellbeing, augment health equity and prioritize planetary health by mitigating the climate impact of delivery of surgical care through research, education, advocacy, and policy change.

Need for Environmental Sustainability in the OR

The current climate crisis

The role of healthcare industry on greenhouse gas emissions

The role of operating rooms on greenhouse gas emissions

The role of pediatric surgeons

OR Sustainability Toolkit

For surgeons interested in championing OR sustainablity initiatives at their local institutions, we propose a Toolkit to help.

Steps to Create a “Greening the OR” Plan

  1. Create a multidisciplinary team
  2. Assess the current environment and conduct a needs assessment
  3. Identify key strategies and set goals
    1. Start with projects that are “low hanging fruit”
  4. Incorporate QI principles such as PDSA or DMAIC into project implementation and evaluation
  5. Celebrate wins and share results!High Impact Interventions

Key "Greening the OR" Team Members

  1. Surgeon champion (SC)
    1. Lead projects related to surgical practices
    2. Secure support from colleagues and leadership
  2. Anesthesia champion (A)
    1. Lead projects related to anesthesia practices
    2. Secure support from colleagues and leadership
  3. Nurse champion (N)
    1. Lead projects related to nursing roles
    2. Garner nursing staff buy-in and solicit feedback
  4. Hospital leadership (HL)
    1. Obtain executive sponsorship
    2. Provide support through funding and capital
  5. Engineering (E)
    1. Technical support for projects involving buildings and facilities
  6. Sterile processing (SP)
    1. Assistance with projects focused on altering content of surgical trays
    2. Assessment of sterile processing practices
  7. Supply chain (SC)
    1. Transition to environmentally preferred purchasing where possible
  8. Waste management (WM)
    1. Optimization of current waste streams
    2. Transition to alternative waste streams with lower environmental impact
  9. Infection control (IC)
    1. Assurance that patient safety protocols are in place and regulations met
  10. Students and trainees (ST)
    1. Assistance with implementation, data collection and dissemination

High Impact OR Sustainability Interventions

These interventions are organized from the estimated greatest to least environmental impact. The cost implications of each intervention will vary greatly dependent on hospital or health systems current resources and infrastructure.

Intervention

Key team members

Studies and implementation guides

Potential cost savings*

“Low hanging fruit” – interventions that require little to no upfront investment

Avoidance of high impact inhaled anesthetics (desflurane, nitrous oxide) – may include strategies such as increased use of regional or IV anesthetics

A, S, SC

Practice Greenhealth

Zuegge 201913

$2,593 (per OR/year) $322,405 (per hospital/year)

Surgeon preference card and surgical instrument tray review and revision – scheduled at a regular interval

S, N, SC, SP

Farrokhi 201514

Thiel 201915

Van Demark 201816

Nast 201917

Malone 201918

Lonner 202119

Knowles 202120

Cichos 201921

Fu 202122

$6,752-$302,307 (per hospital/year)

Powering down OR equipment when rooms are unoccupied – may be manual or automated (if available)

N, A, S, E

Wormer 201323

$36,851 (per hospital/year)

Use of waterless scrub (e.g. Avagard) instead of traditional water based scrub

S, N, IC

Wormer 201323

$2,233 (per hospital/year)

Appropriate waste segregation into available streams - sharps, red bag or regulated medical waste, municipal solid waste

N, S, A, WM

Stonemetz 201124

Wormer 201323

Wyssesek 201625

Fraifeld 202126

$28,734-$694,141 (per hospital/year)

Intermediate –requires a moderate amount of financial investment and/or buy-in from leadership

Increased use of telemedicine for outpatient clinic visits

S, HL

Miah 201927

$67,022 (per outpatient surgical clinic/year)

Revision of existing manufacturer purchased disposable surgical packs

S, N, SC

Practice Greenhealth

$1,098 (per OR/year)

Use of rigid sterilization containers as an alternative to blue wrap

N, SP, SC

Practice Greenhealth

Marchand 202028

$1,742 (per OR/year) $252,248 (per hospital/year)

Transition to reusable surgical devices and operating room equipment

S, N, A, SC, IC

Practice Greenhealth

Conrardy 201029

Wormer 201323

$2,411 (per OR/year)

$14,895-$55,828 (per hospital/year)

Replacement of incandescent light bulbs with LED

N, E

Practice Greenhealth

$121 (per OR/year)

Transition to reprocessed surgical devices and equipment

S, N, SC, IC

Practice Greenhealth

$6,206 (per OR/year)

Implementation of recycling programs

N, S, A, WM

Bliss 199530

Wormer 201323

Albert 201531

Babu 201832

Azouz 201933

$867-$189,071 (per hospital/year)

Advanced –projects that will require significant financial investment and buy-in from leadership

Reducing the air circulation rates in ORs hour on nights and weekends – if an automated system is not in place, it would likely need to be installed

N, E, IC

Practice Greenhealth

$2,500 (per OR/year)

Closed fluid management systems (e.g. Neptunes or other means of direct disposal of fluid waste into sewage systems)

N, E, IC

Practice Greenhealth

$3,389 (per OR/year)

S=surgeon champion, A=anesthesia champion, N=nursing champion, HL=hospital leadership, E=engineering, SP=sterile processing, SC=supply chain, WM=waste management, IC=infection control

*Estimates are primarily based on adjusted to 2020 pricing in USD using OECD rates to convert from local currency to USD.34 Practice Greenhealth is a subscription only service, and these cost estimates are the averages from their member organizations’ annual reports. The exact details of what was included for specific cost analyses is not available through Practice Greenhealth. The peer reviewed sources all include details on how cost savings were determined, but often did not include estimates of capital investment required.

“Low hanging fruit” – these are interventions that require little to no upfront investment

Intermediate– these may require some investment or purchasing of new equipment

Advanced– these are projects that will require significant investment and buy-in from leadership

Masterplans for Selected High Impact Sustainability Projects

At the 2025 APSA Annual Meeting, the OR Sustainability Subcommittee hosted a Workshop featuring four high impact projects completed by our members. This workshop discussed specific plan details and examined strategies to overcome common obstacles with content experts who had implemented the projects. Below, we provide masterplan handouts from the workshop for others who may be interested in pioneering similar projects.

Energy Conservation with HVAC Setback

Reducing Carbon Emissions from Pediatric Anesthesia

Lean OR Trays

Recycling in the OR

Organizations focused on environmental sustainability in healthcare

Select literature and publications

Health and Human Services Climate Pledge

https://www.hhs.gov/sites/default/files/pledge-form-healthcare-sector-stakeholder-event.pdf

Expert in the Room Series

Each quarter, the Sustainability Committee invites a speaker to discuss their experience in sustainability efforts in the operating room and their hospital.

4-12-2023

Dr. Muratore leads our first APSA Sustainability Subcommittee Expert in the Room series. He discusses innovative programs at Boston Medical Center such as green roof, gardens, OR sustainability initiatives, and much more.

7-20-2023

Dr. Gander gives our second Expert in the Room. Follow along as he describes the many innovations at UVA Health.

References

1. Atwoli L, Baqui AH, Benfield T, et al. Call for emergency action to limit global temperature increases, restore biodiversity, and protect health. Lancet 2021;398:939e41. https://doi.org/10.1016/S0140-6736(21)01915-2.

2. Paris Agreement to the United Nations Framework Convention on Climate Change. Dec. 12, 2015

3. Allen MR, Mustafa Babiker, Yang Chen, Heleen de Coninck, Sarah Connors, Renée van Diemen, Opha Pauline Dube "Summary for policymakers." In Global Warming of 1.5: An IPCC Special Report on the impacts of global warming of 1.5\C above pre-industrial levels and related global greenhouse gas emission pathways, in the context of strengthening the global response to the threat of climate change, sustainable development, and efforts to eradicate poverty. 2018.

4. Karliner J, Slotterback S. Healthcare’s climate footprint, how the health sector contributes to the global climate crisis and opportunities for action. Produced by Health Care Without Harm 2019.

5 (3). Chung JW, Meltzer DO. Estimate of the carbon footprint of the US health care sector. JAMA. Nov 11 2009;302(18):1970-2. doi:10.1001/jama.2009.1610

6 (4). 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). Dec 2020;39(12):2071-2079.

7 (5). MacNeill AJ, Lillywhite R, Brown CJ. The impact of surgery on global climate: a carbon footprinting study of operating theatres in three health systems. The Lancet Planetary Health. 2017;1(9):e381-e388. doi:10.1016/s2542-5196(17)30162-6

8 (6). Guetter CR, Williams BJ, Slama E, et al. Greening the operating room. Am J Surg. Oct 2018;216(4):683-688. doi:10.1016/j.amjsurg.2018.07.021

9 (7). Kwakye G, Brat GA, Makary MA. Green surgical practices for health care. Arch Surg. Feb 2011;146(2):131-6. doi:10.1001/archsurg.2010.343

10 (8). Ahdoot S, Pacheco SE, Council On Environmental H. Global Climate Change and Children’s Health. Pediatrics. Nov 2015;136(5):e1468-84. doi:10.1542/peds.2015-3233

11 (9). Eckelman MJ, Sherman J. Environmental Impacts of the U.S. Health Care System and Effects on Public Health. PLoS One. 2016;11(6):e0157014. doi:10.1371/journal.pone.0157014

12. Ragavan MI, Marcil LE, Garg A. Climate Change as a Social Determinant of Health. Pediatrics. May 2020;145(5)doi:10.1542/peds.2019-3169

13. Zuegge KL, Bunsen SK, Volz LM, et al. Provider Education and Vaporizer Labeling Lead to Reduced Anesthetic Agent Purchasing With Cost Savings and Reduced Greenhouse Gas Emissions. Anesth Analg. Jun 2019;128(6):e97-e99. doi:10.1213/ANE.0000000000003771

14. Farrokhi FR, Gunther M, Williams B, Blackmore CC. Application of Lean Methodology for Improved Quality and Efficiency in Operating Room Instrument Availability. J Healthc Qual. Sep-Oct 2015;37(5):277-86. doi:10.1111/jhq.12053

15. Thiel CL, Fiorin Carvalho R, Hess L, et al. Minimal Custom Pack Design and Wide-Awake Hand Surgery: Reducing Waste and Spending in the Orthopedic Operating Room. Hand (N Y). Mar 2019;14(2):271-276. doi:10.1177/1558944717743595

16. Van Demark RE, Jr., Smith VJS, Fiegen A. Lean and Green Hand Surgery. J Hand Surg Am. Feb 2018;43(2):179-181. doi:10.1016/j.jhsa.2017.11.007

17. Nast K, Swords KA. Decreasing operating room costs via reduction of surgical instruments. J Pediatr Urol. Apr 2019;15(2):153 e1-153 e6. doi:10.1016/j.jpurol.2019.01.013

18. Malone E, Baldwin J, Richman J, Lancaster R, Krontiras H, Parker C. The Impact of Breast Lumpectomy Tray Utilization on Cost Savings. J Surg Res. Jan 2019;233:32-35. doi:10.1016/j.jss.2018.06.063

19. Lonner JH, Goh GS, Sommer K, et al. Minimizing Surgical Instrument Burden Increases Operating Room Efficiency and Reduces Perioperative Costs in Total Joint Arthroplasty. J Arthroplasty. Jun 2021;36(6):1857-1863. doi:10.1016/j.arth.2021.01.041

20. Knowles M, Gay SS, Konchan SK, et al. Data analysis of vascular surgery instrument trays yielded large cost and efficiency savings. J Vasc Surg. Jun 2021;73(6):2144-2153. doi:10.1016/j.jvs.2020.09.043

21. Cichos KH, Hyde ZB, Mabry SE, et al. Optimization of Orthopedic Surgical Instrument Trays: Lean Principles to Reduce Fixed Operating Room Expenses. J Arthroplasty. Dec 2019;34(12):2834-2840. doi:10.1016/j.arth.2019.07.04

22. Fu TS, Msallak H, Namavarian A, et al. Surgical Tray Optimization: a Quality Improvement Initiative that Reduces Operating Room Costs. J Med Syst. Jul 6 2021;45(8):78. doi:10.1007/s10916-021-01753-4

23. Wormer BA, Augenstein VA, Carpenter CL, et al. The green operating room: simple changes to reduce cost and our carbon footprint. Am Surg. Jul 2013;79(7):666-71.

24. Stonemetz J, Pham JC, Necochea AJ, McGready J, Hody RE, Martinez EA. Reduction of regulated medical waste using lean sigma results in financial gains for hospital. Anesthesiol Clin. Mar 2011;29(1):145-52. doi:10.1016/j.anclin.2010.11.007

25. Wyssusek KH, Foong WM, Steel C, Gillespie BM. The Gold in Garbage: Implementing a Waste Segregation and Recycling Initiative. AORN J. Mar 2016;103(3):316 e1-8. doi:10.1016/j.aorn.2016.01.014

26. Fraifeld A, Rice AN, Stamper MJ, Muckler VC. Intraoperative waste segregation initiative among anesthesia personnel to contain disposal costs. Waste Manag. Mar 1 2021;122:124-131. doi:10.1016/j.wasman.2021.01.006

27. Miah S, Dunford C, Edison M, Eldred-Evans D, Gan C, Shah TT, Lunn P, Winkler M, Ahmed HU, Gibbons N, Hrouda D. A prospective clinical, cost and environmental analysis of a clinician-led virtual urology clinic. The Annals of The Royal College of Surgeons of England. 2019 Jan;101(1):30-4.

28. Marchand KB, Taylor KB, Salem HS, Mont MA, Marchand RC. Surgical Tray Optimization and Efficiency: The Impact of a Novel Sealed Sterile Container and Instrument Tray Technology. Surg Technol Int. Nov 28 2020;37:349-355.

29. Conrardy J, Hillanbrand M, Myers S, Nussbaum GF. Reducing medical waste. AORN J. Jun 2010;91(6):711-21. doi:10.1016/j.aorn.2009.12.029

30. Bliss LM, Ecklund, J. M., & Riley, J. B. Recycling of Renewable Resources in Extra corporeal Circulation Technology. Journal of Extracorporeal Technology 1995;

31. Albert MG, Rothkopf DM. Operating room waste reduction in plastic and hand surgery. Plast Surg (Oakv). Winter 2015;23(4):235-8. doi:10.4172/plastic-surgery.1000941

32. Babu MA, Dalenberg AK, Goodsell G, Holloway AB, Belau MM, Link MJ. Greening the Operating Room: Results of a Scalable Initiative to Reduce Waste and Recover Supply Costs. Neurosurgery. Sep 1 2019;85(3):432-437. doi:10.1093/neuros/nyy275

33. Azouz S, Boyll P, Swanson M, Castel N, Maffi T, Rebecca AM. Managing barriers to recycling in the operating room. Am J Surg. Apr 2019;217(4):634-638. doi:10.1016/j.amjsurg.2018.06.020

34. Sullivan GA, Petit HJ, Reiter AJ, Westrick JC, Hu A, Dunn JB, Gulack BC, Shah AN, Dsida R, Raval MV. Environmental Impact and Cost Savings of Operating Room Quality Improvement Initiatives: A Scoping Review. Journal of the American College of Surgeons.:10-97.

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