Introduction
Climate change has a devastating impact on human civilization. Healthcare systems
contribute 4%–5% of the total greenhouse gas emissions globally [1 ], of which the USA contributes 7.9%, second only to the Netherlands [2 ]. Within the healthcare sector, gastrointestinal (GI) endoscopy is the third largest
contributor to waste generation [3 ].
The four major GI societies in the USA – the American Association for the Study of
Liver Diseases (AASLD), the American College of Gastroenterology (ACG), the American
Gastroenterological Association (AGA), and the American Society for Gastrointestinal
Endoscopy (ASGE) – created a strategic plan for environmentally sustainable endoscopy
advocacy to curtail the environmental impact of GI endoscopy with the following domains:
clinical setting, education, research, society efforts, intersociety efforts, industry,
and advocacy [4 ].
Within endoscopy, the use of disposable, single-use instruments such as biopsy forceps
is ubiquitous owing to concerns about cross-contamination and the spread of infection
with reusable forceps, which leads to increased waste generation. Careful consideration
while using endoscopic accessories and pre-procedure planning have been recommended
to minimize waste generation [5 ]. To establish an environmentally conscious endoscopy practice, we designed a quality
improvement initiative to reduce the use of multiple disposable instruments in colonoscopies
by gastroenterologists in a large tertiary healthcare center.
Methods
The study was conducted at a large tertiary healthcare academic center in the USA.
Patients undergoing screening or surveillance colonoscopies were included in the study.
To ensure the standardization of adequate quality, only patients with Boston Bowel
Preparation Scale (BBPS) scores of ≥7 were included.
We collected baseline data regarding the patient’s age and sex, the number of polyps
removed, and the number and type of instruments used during polypectomies in screening/surveillance
colonoscopies for 8 weeks before the intervention. Colonoscopies for all other indications
were excluded from this study.
Our intervention involved a discussion of green endoscopy initiatives during our monthly
meeting with the gastroenterology faculty in an open-ended forum, followed by their
implementation in day-to-day practice during our monthly administrative meeting. The
meetings took place 3 days apart. In particular, during the course of the two meetings,
we presented data showing the contribution of healthcare in general, and gastroenterology
in particular, towards the global carbon footprint. We discussed the GI Multisociety
Strategic Plan on Environmental Sustainability, specifically the “clinical practice,”
“education,” “research,” and “advocacy” domains, to encourage gastroenterologists
to reduce waste and make environmentally conscious decisions during their day-to-day
practice. We especially highlighted the need for appropriate patient selection and
strong adherence to endoscopy guidelines for the resection of polyps to prevent excessive
use of single-use instruments, and “team briefs” when applicable. The final decision
to use the preferred device was at the endoscopist's discretion after discussing best
practice for polyp resection based on the US Multisociety Task Force (USMSTF) and
European Society of Gastrointestinal Endoscopy (ESGE) guidance.
The intervention involved six practicing gastroenterologists with varied experience
in independent practice (<2 years, n=2; 2–5 years, n=2; >5 years, n=2). All of the
gastroenterologists were performing over 500 colonoscopies per year. They were unaware
that the use of instruments during colonoscopies was being monitored to prevent the
Hawthorne effect. Data on patient’s age and sex, the number of polyps removed, and
the number and type of instruments used during polypectomies in screening/surveillance
colonoscopies was recorded for 6 weeks after the intervention.
The differences between the pre-and post-intervention use of accessories were analyzed
using chi-squared tests for categorical values and odds ratio (OR) to demonstrate
the association of the exposure and the intervention, with a level of significance
of P <0.05. The statistical software STATA 14.2 (Stata Corp., College Station, Texas,
USA) was used to perform the analysis.
Results
Over 14 weeks, 210 patients were included in the pre-intervention group and 112 in
the post-intervention group. The populations before and after the intervention were
comparable regarding indication, demographics, and number of polyps found ([Table 1 ]).
Table 1 Characteristics of the pre- and post-intervention groups.
Pre-intervention
Post-intervention
P value
Age, mean (SD), years
56.9 (11.0)
55.3 (13.0)
0.47
Male:female ratio
0.42
0.46
0.45
Polyps per colonoscopy, mean (SD)
1.8 (2.4)
1.6 (2.0)
0.44
At baseline, 34% of colonoscopies required no intervention, 32% required one tool
(either biopsy forceps or a snare), and 33% required multiple tools. After the intervention,
we observed a significant increase in the use of just one tool (17 percentage point
increase; P =0.003) and a decrease in the use of multiple tools (16 percentage point decrease;
P = 0.002) ([Table 2 ]; [Fig. 1 ]). Endoscopists were more likely to use only a single tool for polypectomy during
the entire case compared with multiple tools after the intervention (OR 3.0, 95%CI
1.6–5.5; P =0.005).
Table 2 Comparison of pre- and post-intervention findings.
Pre-intervention colonoscopies, n (%)
Post-intervention colonoscopies, n (%)
Difference, percentage points (95%CI)
P value
No tools
72 (34%)
38 (34%)
0
>0.99
Single tool (biopsy forceps or snare)
68 (32%)
55 (49%)
17 (5.79 to 27.89)
0.003
• Biopsy forceps only
60 (29%)
43 (38%)
9 (−1.64 to 19.87)
0.10
• Snare only
8 (4%)
12 (11%)
7 (1.21 to 14.39)
0.01
Multiple tools
70 (33%)
19 (17%)
16 (5.98 to 24.8)
0.002
Fig. 1 The use of tools for screening/surveillance colonoscopies before and after the intervention.
A statistically significant post-intervention reduction was found for the use of multiple
tools.
Discussion
In this quality improvement study performed at a single tertiary care center, a notable
shift in practice occurred favoring the use of a single tool over multiple tools in
colonoscopies following an environmentally conscious intervention. We observed threefold
higher odds of choosing a single tool over multiple tools during colonoscopies after
an open-ended environmentally conscious initiative, thereby reducing the waste generated
by endoscopy. While direct waste generation after colonoscopy was not measured in
this study, Rex et al. recently examined the impact of one-device colonoscopy among
379 screening and surveillance patients [6 ]. The authors showed that universal cold snaring of lesions ≤10 mm saved 35 and 47
cold forceps per 100 screening and surveillance patients, respectively.
Lopez-Munoz et al. [7 ] performed a thermochemical analysis to understand the composition of common endoscopic
instruments, such as biopsy forceps, snares, and clips, along with the carbon emissions
from their production, transportation, and incineration. Snares produced 0.41 kgCO2 equivalents (range 0.38–0.44), which was similar to forceps at 0.41 kg CO2 equivalents (range 0.31–0.47). Carbon emissions varied significantly based on the
manufacturer and incineration, highlighting the emission burden of these single-use
accessories.
There are multiple factors involved in the carbon footprint of GI endoscopy, which
include, but are not limited to, landfill and plastic waste from performance of the
procedure, electrical power use, the treatment of waste generated during the endoscopy
(both disposable and nondisposable), the manufacturing, processing, and delivery of
the endoscopes and instruments, and travel for the procedures [8 ]
[9 ]. Many of these factors are not however immediately modifiable, like greenhouse gas
emissions related to the manufacturing of the endoscopes.
Modifiable factors include changes of practice for procedures such as screening/surveillance
colonoscopy and single-tool/device use, strong adherence to guidelines for the performance
of endoscopy when best needed, and on-site waste segregation. To prevent the excessive
use of single-use disposable instruments, pre-procedure planning, effective communication,
and “team briefs” and “huddles” have been proposed [5 ]
[10 ]
[11 ]. Concerted efforts should be made to reduce unnecessary polypectomies of benign
polyps by the use of optical diagnostic imaging, such as narrow-band imaging, during
polypectomies [12 ]. Through our quality improvement project and in line with the ESGE guidelines, the
use of snares should be encouraged over forceps, even for diminutive polyps, for complete
resection and to conserve tool usage [13 ].
In addition to these methods, our study demonstrated that quality improvement initiatives
centered around improving awareness regarding waste generation and the practice of
sustainable endoscopy can significantly reduce waste in endoscopy. Additionally, leadership
at institutional, national, and international levels is critical in mitigating the
effects of climate change, including the establishment of practical guidelines, strategic
plans, and consensus statements by GI societies, which can be helpful to hospital
leadership at an institutional level, as well as to individual practitioners, in making
their practice more environmentally sustainable [5 ]. This is especially critical given the results of the recent LEAFGREEN survey [14 ], where gastroenterologists were surveyed about climate change and sustainability.
Over 400 gastroenterologists responded to the survey. The most important factors in
reducing the environmental impact of GI endoscopy identified in the survey included
a reduction in single-use instruments and appropriate patient selection; however,
a lack of knowledge was identified as a barrier to achieving sustainable endoscopy
practice, highlighting the need for education-based interventions for gastroenterologists
in this area. The ESGE and European Society of Gastroenterology and Endoscopy Nurses
and Associates (ESGENA), in a joint position statement in 2022, also highlighted the
need to add education and training about the environmental sustainability of endoscopy
into GI curricula [15 ].
The strengths of our study include its relative ease of reproducibility among community
gastroenterologists, tangible results, low cost of the intervention, and possible
positive impact of a Hawthorne effect. Limitations noted were that it was a single-center
study with a small sample size, and its short-term goal assessment. We also did not
assess the impact on total waste generation. Further long-term studies are needed
to ensure that the reduction in instrument use does not lead to detrimental outcomes,
such as incomplete resections and the development of interval cancers.
In conclusion, this prospective study found a significant change in practice patterns
favoring the use of a single tool over multiple instruments for polypectomies during
screening colonoscopies after an environmentally conscious intervention. This low
cost environmentally sustainable intervention can be applied to reduce endoscopy waste.
