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

The big pictures: sources of national competitiveness in the global movie industry

The competitive dynamics of the global film industry are not frozen in time. The Motion Picture Association of America (MPAA) studios have pursued an utterly transparent strategy of buying out or otherwise dominating their domestic and international distribution chains, while generally avoiding cooperation with other nations’ producers. This strategy has gone unchallenged largely because other nations and film production companies have lacked perspective on their own position and potential in the global film industry. With keener use of existing tools, including co-production, these countries can establish themselves. For instance, Canada, having co-production treaties with both mainland China and Hong Kong while no other nation has co-production treaties with either, has uniquely positioned its film industry to enter the Chinese mass market either directly or via Hong Kong’s free trade without the crippling import expenses that other foreign producers face. However, Canada’s producers to date have made less creative use of the co-production treaty with China, using it to more easily access low-cost animation inputs