Surgical Carbon Footprint Auditing Tool for Less Emissions (SCALE): an evidence-based nationwide cross-sectional assessment to reduce the environmental impact of the operating room

Background: The healthcare sector significantly contributes to global carbon emissions, and operating rooms (ORs) are particularly resource-intensive environments. ORs are therefore potentially impactful targets for emission reduction. Growing knowledge of carbon footprint hotspots in surgery should be integrated into a systematic approach to mitigate the environmental impact of ORs. Materials and methods: We developed the Surgical Carbon Footprint Auditing Tool for Less Emissions (SCALE), an evidence-based model combining published life cycle assessments with real-world surgical practice to quantify OR-related carbon emissions and high-impact mitigation strategies. A questionnaire assessing qualitative and quantitative aspects of surgical practice was distributed to 60 Dutch hospitals. Collected data were incorporated into the model to calculate the carbon footprint and mitigation potential of individual ORs. Ten priority interventions were provided to each surgical center. All data were combined to establish a national baseline. Results: Forty surgical centers (594 ORs) completed the questionnaires. The model consisted of defined variables on surgical practice in five categories, including less-emitting alternatives for carbon footprint calculations: (1) organization and reporting, (2) energy, (3) anesthetics, (4) medical products, and (5) decontamination. Implementation of sustainable practices could reduce emissions by 76.3%, saving a mean of 729.9 kg CO 2 -eq/week per OR. The six most impactful interventions, accounting for over 95% of the achievable reduction, were the transition to renewable energy, phase-out of nitrous oxide and desflurane, use of vapor capture technology and end-tidal control, adoption of heat recapture technology, and use of reusable sterile gowns. Conclusion: SCALE provides a framework to reduce the carbon footprint of surgical practice by identifying effective measures at the hospital and national levels in the Netherlands. By prioritizing these high-impact strategies, SCALE facilitates progress toward sustainable healthcare. Given the urgency of the climate crisis, yielding rapid and substantial environmental gains with these interventions is crucial.