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:

• A regularly updated interactive map with thorough information on each state’s current policies and statistics

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

This link from Abortion Finder provides:

• A regularly updated interactive map with information on each state’s current abortion policies.

Abortion Laws by State – Center for Reproductive Rights

This link from Center for Reproductive Rights provides:

• An interactive map with regularly updated state-by-state information on abortion laws
• Guide to legal terminology used in discussion of abortion laws

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:

• Abortion laws: based on gestational age, genetic anomaly, etc.
• Laws regarding crisis pregnancy center funding
• Laws specific to Medicare/Medicaid and private insurance

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:

• Steps to request additional information about legal assistance or guidance related to abortion care
• Obtaining toolkit resources regarding legal resources (email providerintake@nwlc.org for info on this)

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:

• An intake form for healthcare providers curious about how abortion laws will affect their work
• Repro Legal Helpline number: 844-868-2812

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:

• Debunking myths related to abortion, ectopic pregnancy, and gestational development
• Tips for talking about abortion with other colleagues and patients

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:

• Frequently asked questions about abortion care
• Finding an abortion provider or clinic

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:

• Identifying and avoiding crisis pregnancy centers

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:

• A search tool to find an abortion provider in the patient’s local areas

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:

• Information for patients younger than 18 who are seeking abortion but wish to avoid parental involvement
• Helpline phone number (844-868-2812) and intake form

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

• Access to additional links curated by ACOG with recommendations on how to become involved in advocacy

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

• Global warming is the current greatest threat to global public health. In September of 2021, over 200 medical journals endorsed a joint statement urging leaders to act.¹
• Global temperatures have already risen 1°C above pre-industrial times.²Greenhouse gases (GHGs) released by anthropogenic activities are the primary contributor to climate change.
• The Paris Climate Agreement sets a goal of limiting warming to 1.5°C above preindustrial levels.² To achieve this, the Intergovernmental Panel on Climate Change has identified a need to reduce emissions by about 45% from 2010 levels by 2030, reaching net zero around 2050.³

The role of healthcare industry on greenhouse gas emissions

• The healthcare industry is responsible for 4.4-4.6% of worldwide GHG emissions.⁴
• The United States (US) is responsible for about a quarter of all global healthcare related GHG emissions, which is more than any other nation.⁴
• Within the US, the healthcare sector accounts for about 8-10% of national GHG emissions.^5,6
• 82% of US healthcare emissions come from the production of goods and services procured through the supply chain, followed by purchased energy (11%) and direct emissions from healthcare operations (7%).⁶
• The US Department of Health and Human Services (HHS) put forth a voluntary pledge for healthcare organizations to at minimum reduce organizational emissions by 50% by 2030 and to achieve net zero by 2050.
• As of June 20th, 2022, 61 of the largest US hospital and health sector companies had signed the HHS Health Care Sector pledge.

The role of operating rooms on greenhouse gas emissions

• ORs can be up to three to six times more energy intensive than the remainder or the hospital.⁷
• Operating facilities produce 50–70% of waste across the hospital.^8,9
• Operating rooms at institutions in Canada, the US, and the United Kingdom (UK) demonstrated that annual carbon dioxide equivalents (CO2e) emissions from the institutional OR suites ranged from 3,200,000 to 5,200,000 kg CO2, or the equivalence of 7.9 to 12.9 million miles driven by the average gasoline powered vehicle.⁷

The role of pediatric surgeons

• Children are particularly vulnerable to the effects of climate change including weather disasters, heat stress, decreased air quality, climate-sensitive infections, and food/water security.¹⁰
• Social and environmental determinants of health are inextricably linked as climate change disproportionally impacts the most marginalized.^11,12
• Efforts to protect children and future generations through climate change mitigation align with the APSA mission of saving lifetimes.

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.

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

• Surgeon preference card and surgical tray review with removal of items used < 80% of the time
• Education regarding appropriate available waste streams: most hospitals have at minimum municipal solid waste, regulated medical waste or “red bag” waste, and sharps
• Avoidance of high environmental impact inhaled anesthetics (desflurane, nitrous oxide)
• Use of regional or IV anesthetic techniques when appropriate
• Use waterless scrub as an alternative to traditional surgical scrub
• Moving operations away from paper to electronic

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

• Transition to reusable surgical devices and equipment. Examples include suction cannisters, pulse oximetry probes, basins and pitchers, trocars, positioning devices, blood pressure cuffs, tourniquets, and sharps containers
• Transition to reprocessed surgical devices and equipment. Examples include ultrasound and electrophysiology catheters and cables; endoscopic devices and arthroscopic and laparoscopic instruments; orthopedic bits, saws, burrs and blades, and external fixation components; deep vein thrombosis compression sleeves; tourniquets/BP cuffs, infusion pressure bags; pulse oximetry sensors; balloon inflation devices, femoral compression devices
• Transition to rigid sterilization containers as an alternative to blue wrap
• Replacement of incandescent lights with LED
• Implementation of recycling programs
• Revision of existing surgical packs with removal of items used < 80% of the time
• Increasing use of telemedicine and efforts at care coordination to reduce patient travel
• Transitioning to office base procedures to decrease OR resources

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

• Putting systems in place that power down ORs when rooms are not in use (ie. motion sensors)
• Reducing the air circulation rates in ORs hour on nights and weekends when rooms are not in use
• Installation of waste anesthetic gas scavenging and recycling technologies
• Retrofitting existing structures and building new structures in adherences to LEED (Leadership in Energy and Environmental Design, US Green Building Council) certifications
• Transition to closed fluid management systems that can directly discharge fluids into the sanitary sewer (ie. Stryker Neptune fluid management system)
• Supporting the hospital/healthcare system to sign on to the Department of Health and Human Services Health Care Sector Climate Pledge

Organizations focused on environmental sustainability in healthcare

• Practice Greenhealth:
  • https://practicegreenhealth.org/topics/greening-operating-room/greening-or
• Health Care Without Harm
  • https://noharm.org/
• Healthcare climate action works
  • https://healthcareclimateactionworks.com/

Select literature and publications

• Leading on Climate Change: How Healthcare Leaders Stop Global Warming by Neal Hogan
• Healthcare Without Harm. Health care’s climate footprint how the health sector contributes to the global climate crisis and opportunities for action. 2019.
• 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
• Senay E, Cort T, Perkison W, Laestadius JG, Sherman JD. What Can Hospitals Learn from The Coca-Cola Company? Health Care Sustainability Reporting. NEJM Catalyst. 2022;3(3)doi:10.1056/cat.21.0362
• 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
• Yates EF, Bowder AN, Roa L, et al. Empowering Surgeons, Anesthesiologists, and Obstetricians to Incorporate Environmental Sustainability in the Operating Room. Ann Surg. Jun 1 2021;273(6):1108-1114. doi:10.1097/SLA.0000000000004755

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.

References