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

A trama da crítica democrática: da participação à representação e à accountability The conceptual web of democratic critique: from participation to representation and accountability

Este artigo atenta para deslocamentos conceituais ocorridos entre "representação política", "participação" e "accountability" na crítica interna à democracia ao longo das últimas décadas, bem como examina sua ressignificação recíproca na definição de nova trama conceitual da crítica democrática. O conceito de accountability parece oferecer, hoje, o registro normativo para lidar com as exigências de legitimidade nas experiências de representação política extraparlamentar. Argumenta-se também, que as circunstâncias históricas que propiciaram a polaridade negativa ou capacidade crítica à "participação", no campo da teoria democrática, não apenas mudaram, mas tornaram inadequada sua especifi cação analítica para a compreensão das experiências de inovação democrática em curso.<br>In the last decades there has been a surprising conceptual shift between the role of three concepts - political representation, participation and accountability - in the internal criticism of democracy. This article sheds light on that shift by examining the reciprocal redefi nition of meaning between those concepts and the shape of a new conceptual network for democratic critique. Nowadays, internal critique of democracy has been developed from the stand point of representation theories, which used to be traditionally related to the defense of democracy. Participatory democracy models, once the main stand point for criticizing democracy, either lost influence or where integrated to more sophisticated deliberative democratic models. We argue that this state of affairs is due to a conceptual worthy dissociation between representative government and political representation. This dissociation works under democratic and pluralistic assumptions, thus, it is sensible to legitimacy challenges faced by extra-parliamentary political representation. In this scenario, accountability appears as a normative concept useful for dealing with those challenges. We argue as well that the democratic critical leverage of the concept of participation relied on historical circumstances that are not longer in place, rendering standard defi nitions of participation inaccurate for the understanding of ongoing experiences of democratic innovation