AT4 Tourniquet System

Infection control in theatre – must it cost the earth?

The covid pandemic exacerbated the problem presented by the need to use disposable medical and healthcare items to protect against infection whilst also needing to reduce the environmental impact of waste.  

Never had PPE been so essential or used in such quantities – it was a vital shield that was, at times, frighteningly hard to source – relegating concerns about its disposal down the priority list. 

But we know it is an issue that will not go away – and without being too dramatic, one we must address, for the sake of our planet. 

Some of the statistics 

  • £33.3 million – the cost of bagged waste disposal for those NHS organisations in England that participated in the Royal College of Nurses 2017 Freedom of Information Follow up Report on Management of Waste in the NHS.

  • 79,272 tonnes – the amount of waste potentially being incinerated into the atmosphere on an annual basis, with a high percentage being made from, or at least containing elements made from, plastics.

  • 1.07 billion – the items of PPE issued to the NHS and care homes in Scotland between 1st March 2020 and 5th May 2021

Single-use medical devices 

In the operating theatre, single-use medical devices have long been viewed as an essential part of the armoury in minimising the risk of surgical site infections (SSIs) - particularly during the pandemic with the heightened awareness of cross-contamination and potential transmission of COVID-19. 

Even now we know so much more about the virus, practitioners – and risk assessors – continue to be cautious, so how can we address this seemingly insoluble conundrum? 

Tourniquet cuffs – an area where a change in approach could help 

Tourniquet cuffs are used to maintain a bloodless surgical field in many orthopaedic and trauma procedures – and there are two main types: 

  • Disposable (single-use sterile) – for use where the cuff needs to be sited in close proximity to operative site, where a contaminated case is involved or the patient is highly susceptible to infection 

  • Traditional, reusable – for use where there are no surgical restrictions  

Some healthcare providers can be risk averse and therefore choose the single-use option for every procedure…. understandable perhaps when the cost for treating a patient who develops a surgical site infection (SSI) is estimated to be between £10,000 and £100,000 for a deep-incision SSI.3 

But what does that mean in terms of waste, environmental impact – and also in purchase and disposal costs? 

All tourniquet cuffs are produced from, or at least contain elements of, plastic and when it comes to disposal, nearly all will be classified as infectious (yellow bagged) waste to be incinerated. 

They will therefore be contributing to the 25 megatonnes of carbon dioxide equivalent produced by the UK health service each year (this was the figure for 2019 – the most recent available, according to the Lancet Planetary Health) 4, where one tonne of clinical waste generates up to three tonnes of CO². 

In the UK, there are in excess of 2,300 tourniquet inflation devices in use. Based on a conservative usage estimate of four procedures, four times a week, forty-eight weeks of the year, then each tourniquet has the potential to create 192kg of waste in single-use tourniquet cuffs per annum. 

So in single-use tourniquet cuffs alone, that’s a potential of: 

308,774 ft² or 28,614 m² of waste equivalent to four football pitches worth of single-use tourniquet cuffs per annum…. 

… or in terms of weight, it’s around 384,000kg – or 384 tonnes – per annum…. 

…producing 1,152 tonnes of CO² – equivalent to 768 return flights between Paris and New York… 

…and £182,400 in annual disposal costs (an average based on 2017 figures) … 

In terms of individual numbers, it adds up to around 1,697,400 single-use tourniquet cuffs a year, with a purchase cost of £19,521,100 – or £11.61 per procedure. 

But there is another possibility – using a reusable tourniquet on a limited-use basis 

This compromise solution is a reusable tourniquet cuff to be used on a case number or time limited basis: it can mitigate a significant element of the risk of using reusable cuffs, while dramatically reducing waste. 

Perhaps the most practical option is ‘day use’ – where a new tourniquet cuff is used for the first procedure of the day and disposed of after the last. 

It obviates the end-of-list requirement for tourniquet cuff cleaning and disinfection, while still reducing the risk of cross-contamination (the root cause of an SSI or COVID-19 transmission). Waste (including incineration and the release of harmful pollutants entering the atmosphere) and therefore the disposal costs, are also both reduced. 

Using the previous formula of estimates, the potential annual improvements of limited-use cuffs could be: 

  • 441,600 tourniquet cuffs- 255,800 reduction 

  • £8,390,400 in purchase costs- £11,130,700 saving 

  • £52,400 in disposal costs- £130,000 saving 

  • 110,400kg in waste- 273,600kg or 274 tonnes reduction 

  • 80,331 ft² / 7463 m² in waste- 228,443 ft² / 21,223 m² reduction 

  • 330 tonnes of CO²- 822-tonne reduction 

  • £4.97 per procedure- £6.64 saving per procedure 

And while their use is not as widespread as it could be, there is precedent: according to 2019 figures, 187 hospitals in the UK operated with 29,240 limited-use tourniquet cuffs and – again using the 4x4x48 usage formula - that means there were around 116,960 procedures undertaken, which, based on the 2013/14 data, would mean around 9.7% of all trauma and orthopaedic procedures undertaken. 

Given there has been no question raised about safety or infection rates, this suggests that an approach of using a combination of limited-use and single-use tourniquet cuffs where necessary – has proved to be safe and effective – as well as offering a major contribution to sustainability. 

To find out more information on the AT4 Tourniquet System or Tourniquet cuffs.


  1. Freedom of Information Follow up Report on Management of Waste in the NHS 

  1. BBC News 5th May 2021 

  1. Hospital Times ISSN 2398-5070 9th December 2020 

4 The Lancet Planetary Health – ARTICLES | VOLUME 5, ISSUE 2, E84-E92, FEBRUARY 01, 2021 

Health care's response to climate change: a carbon footprint assessment of the NHS in England - The Lancet Planetary Health 

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