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Environmental sustainability guidance - Outpatient ENT metal instruments

30 November 2024


The importance of environmentally sustainable practice in healthcare is increasingly recognised, with the UK General Medical Council advising doctors to “Choose sustainable solutions when you’re able to, provided these don’t compromise care standards”[1].

ENT uses more instruments than many other surgical specialties in the outpatient setting. There has been a trend towards using single use individually packaged medical instruments. In a survey at the 2024 ENT UK Spring Meeting, 46% of ENT Surgeons reported using single use instruments only, 43% a combination of reusable and single use instruments, and 11% only reusable instruments.


  • We recommend using reusable metal instruments
  • We recommend preparing, reprocessing and using ENT outpatient instruments in tray sets
  • There is no indication for use of gloves in ENT examination except when there is risk of exposure to blood, body fluid, or non-intact skin.

Reusable versus single-use metal instruments

A life cycle analysis of scissors comparing reusable to single use found an 80% lower ecological impact[2] with reusable (except for water use which increases due to the use of autoclave for sterilization)[3],[4]. Repair of reusable metal instruments (rather than disposal) can further reduce carbon by 20%[5]. These data translate to metal instruments used in ENT.


Packing of instruments for sterilisation and use

Reusable instruments in ENT usually undergo reprocessing in autoclaves because this technology is readily available, but in fact almost all ENT outpatient instruments only need to undergo high level disinfection (rather than sterilization) because they do not breach skin or mucosa during use.

This means it is safe to keep instruments in trays throughout their use. Washing instruments collectively in trays (rather than individually) improves efficiency in machine loading for autoclaves, saving energy and water use4. The number of instruments per tray depends on the size of the tray and the type of instruments. Instruments that are commonly used should stay on communal instrument trays, and the only instruments that should be packaged separately are those that are rarely used[4].

After decontamination, instruments can be kept in their trays and individual instruments picked out in clinic and used as needed. If used instruments do not come into contact with clean instruments, there is little risk of cross-contamination.


Personal Protective Equipment

There is no indication to wear gloves or aprons for the majority of ENT outpatient procedures. Unnecessary use of gloves creates financial and carbon cost[6],[7] and has been associated with poorer compliance with hand hygiene. When gloves are put on too early or removed too late, they can increase the risk of microorganism transmission between equipment and patients[8].

NHS standard infection control precautions recommend glove use only when hands may come into direct contact with blood and/or other body fluids, non-intact skin, or mucous membranes[9] (as a mechanism to reduce the number of pathogens on hands before they are cleaned). For example, it may be appropriate to wear a single glove when palpating inside the mouth.  Hand hygiene with soap and water or hand sanitiser is more effective in infection prevention than wearing gloves, and associated with lower impact on the environment, given that such decontamination is necessary in addition to wearing gloves3.

Aprons should not be worn unless there is a risk of contact with, or splash of, bodily fluids (which is the purpose of an apron).


Summary

For use of instruments in ENT outpatients, the most environmentally sustainable approach is to use reusable surgical instruments, which are stacked in trays during decontamination and use.  Individually wrapped instruments are only necessary when they are used infrequently and so may need to be stored long-term, or for the occasional instrument or instrument set that penetrates skin or mucosal barriers (for example for minor operations) in which case it should be sterile. 

Gloves should not be worn for ENT procedures unless there is expected direct contact of the hands with blood, bodily fluids or mucosal surfaces.  Aprons are only appropriate if there is a risk of contact with, or splash of, bodily fluids.


References

  1. GMC website – professional standards learning materials.
    https://www.gmc-uk.org/professional-standards/learning-materials/sustainability-questions-and-answers, accessed 26/07/2024

 

  1. Ibbotson, S., Dettmer, T., Kara, S. et al. Eco-efficiency of disposable and reusable surgical instruments—a scissors case. Int J Life Cycle Assess 18, 1137–1148 (2013). https://doi.org/10.1007/s11367-013-0547-7

 

  1. Green Surgery: Reducing the environmental impact of surgical care
    https://www.rcseng.ac.uk/-/media/Files/GreenSurgeryReport2023.pdf

 

  1. Rizan C et al. Minimising carbon and financial cost of steam sterilsation and packaging of reusable surgical instruments. Br J Surg. 2022 Feb 2;109(2):200-210

 

  1. Rizan, C., Brophy, T., Lillywhite, R. et al. Life cycle assessment and life cycle cost of repairing surgical scissors. Int J Life Cycle Assess 27, 780–795 (2022).
    https://doi.org/10.1007/s11367-022-02064-7

 

  1. Wilson J, Bak A, Loveday HP. Applying human factors and ergonomics to the misuse of nonsterile clinical gloves in acute care. Am J Infect Control. 2017;45(7):779-86.

 

  1. Loveday HP, Lynam S, Singleton J, Wilson J. Clinical glove use: Healthcare workers’ actions and perceptions. J Hosp Infect. 2014;86(2):110-6. 324.

 

  1. Lindberg M, Skytt B, Lindberg M. Continued wearing of gloves: A risk behaviour in patient care. Infect Prev Pract. 2020;2(4):100091

 

  1. NHS England. Chapter 1: Standard infection control precautions [Internet]. 2023 [cited 2023 Mar 23].
    https://www.england.nhs.uk/national-infectionprevention-and-control-manual-nipcm-for-england/ chapter-1-standard-infection-control-precautions-sicps/


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