Reducing the environmental impact of surgery on a global scale: systematic review and co-prioritization with healthcare workers in 132 countries

Abstract Background Healthcare cannot achieve net-zero carbon without addressing operating theatres. The aim of this study was to prioritize feasible interventions to reduce the environmental impact of operating theatres. Methods This study adopted a four-phase Delphi consensus co-prioritization methodology. In phase 1, a systematic review of published interventions and global consultation of perioperative healthcare professionals were used to longlist interventions. In phase 2, iterative thematic analysis consolidated comparable interventions into a shortlist. In phase 3, the shortlist was co-prioritized based on patient and clinician views on acceptability, feasibility, and safety. In phase 4, ranked lists of interventions were presented by their relevance to high-income countries and low–middle-income countries. Results In phase 1, 43 interventions were identified, which had low uptake in practice according to 3042 professionals globally. In phase 2, a shortlist of 15 intervention domains was generated. In phase 3, interventions were deemed acceptable for more than 90 per cent of patients except for reducing general anaesthesia (84 per cent) and re-sterilization of ‘single-use’ consumables (86 per cent). In phase 4, the top three shortlisted interventions for high-income countries were: introducing recycling; reducing use of anaesthetic gases; and appropriate clinical waste processing. In phase 4, the top three shortlisted interventions for low–middle-income countries were: introducing reusable surgical devices; reducing use of consumables; and reducing the use of general anaesthesia. Conclusion This is a step toward environmentally sustainable operating environments with actionable interventions applicable to both high– and low–middle–income countries

EL FERROL (La Coruña) (Ría). Cartas náuticas. 1894 (1893). 1:13.100

Escala también dada en forma gráfica, de 3000 metros y 2 millas. Coordenadas del este de la bola (Capitanía General) referidas al meridiano de San Fernando (0 2°02'24''/N 43°28'55''). Orientado con lis, señalándose, además, la variación magnética observadaOrografía por normales y puntos acotadosIndica sondas batimétricas expresadas en metros, veriles, calidad del fondo, faros (iluminados en rojo y amarillo) y enfilacionesToponimia de los accidentes geográficos, núcleos de población y fortificaciones que defienden la ríaPresenta el plano de la ciudad y puerto de El FerrolNotas explicativas sobre las sondas, la variación de la aguja, las mareas y la velocidad de la corrienteEn el margen superior: "25 A"Inserta: "Plano general de la ría y puerto de El Ferrol". Escala 1:40000, también dada en forma gráfica, de 2000 metros y 1 mill