Central Line
Episode Number: 134
Episode Title: Sustainable ORs
Recorded: May 2024
(SOUNDBITE OF MUSIC)
VOICE OVER:
Welcome to ASA’s Central
Line, the official podcast series of the American Society of Anesthesiologists,
edited by Dr. Adam Striker.
DR. ADAM STRIKER:
Welcome to Central line.
I'm host and editor Dr. Adam Striker. Today we're going to talk about
sustainability in the OR with Drs. Praveen Kalra and Matthew Meyer. We've done
a few episodes on environmental sustainability, but it is an important topic.
It's a prescient one. It's an evolving issue and something that we do want to
keep a finger on the pulse of. So Drs. Kalra and Meyer, we’re happy to welcome
you both to the show, and I'm anxious to hear more about the issue. If you
don't both don't mind, introduce yourself. Talk a little bit about how you got
involved with this issue, and then we'll start delving into some of the nitty
gritty. Dr. Kalra, why don't we start with you?
DR. PRAVEEN KALRA:
So thank you Dr. Striker,
for inviting me to the podcast. I am Praveen Kalra. I am the clinical associate
professor of anesthesiology at Stanford. I'm also the medical director of
sustainability at Stanford Health Care. I am very fortunate to be the part of
the organization where leadership commitments to sustainability have been
phenomenal. I practice adult anesthesia, and I became a fellow of the American
Society of Anesthesiology last year. I'm also one of the members of ASA
Committee on Environmental Health, as well as the member of the Task Force of
California Society of Anesthesiology on environmental Sustainability.
DR. STRIKER:
Great. Dr. Meyer?
DR. MEYER:
Thanks. So I'm an
associate professor of anesthesiology at the University of Virginia, co-chair
of the UVA Health Sustainability Committee. And this has become more and more
of a passion of mine, because I've realized that our health care processes have
such a large impact on the environment and consequently have an impact on our
patient health, that in many ways, this is my way of not just taking care of
the patients inside the operating room, but helping to take care of them
outside the operating room to.
DR. STRIKER:
Wonderful. Well, you
know, I think probably most of our listeners understand at this point the
importance of sustainability in the operating room. But I'd like to why
sustainability in the OR matters. Dr. Meyer, why don't you start talking about
the environmental impact of our current processes and maybe just lay out the
framework of this issue is as we get going with this discussion.
DR. MEYER:
Sure. So if we're
focusing on the operating room, the operating room is clearly a resource
intensive part of the hospital. And, you know, we can all just appreciate that
by the activity, the finance, the things that run through it.
The first part,
especially as anesthesiologists, for us to realize, is that we have a far
outsized impact on specifically greenhouse gas emissions that come from a
health system. You know, estimates are somewhere around 5% of total health
system emissions might come just from volatile anesthetic gases, specifically
calling out desflurane and nitrous oxide as the two largest sources of the gas.
But all of our volatile anesthetics are terrible greenhouse gases. So, you
know, anesthesiologists have have that, which is both empowering and also a
real big issue that we need to address and really only we can address as our
own society and our own practitioners.
The importance of
sustainability in the operating room is really it's such an important part of
the hospital. I'm clearly very biased, but the operating room is where a lot of
people focus. It's a earns a lot of focus from the C-suite. People pay
attention to the finances as they come in and out, and they also pay attention
to what the people in the operating room are asking, both surgeons,
anesthesiologists, operating room nurses, and all the other sundry people that
are there. We have a lot of opportunity to influence the operations of the
hospital. And so if we can really drive some sustainable thinking inside of the
operating room, we have an opportunity to seed that thought throughout the
health system. And that's both a spread throughout other departments and other
units, as well as up into the C-suite to get buy in and to get them to invest
in some of the items that are outside of the influence of a clinician, but
equally as important in managing the pollution of the hospital. And that
includes system wide recycling, composting, the type of energy that comes into
the health system.
So it's got to start
somewhere. The operating room is a wonderful place to do, and you really have,
like Dr. Kalra and many others, some wonderful anesthesiologists who are really
leading this movement.
DR. STRIKER:
Well, I do want to
circle back to talk about the hospital's role overall. Before we get to that,
though, Dr. Kalra, I want to just delve into a little bit on the impact of
anesthetic gases. If I'm not mistaken, you have a pharmacy background. Can you
talk a little bit about this? Put your chemistry hat on or your pharmacist hat
on, and maybe talk about the impact of the anesthetic gases, what we might not
be aware of, and what we should be looking for going forward.
DR. KALRA:
Absolutely. When we talk
about the impact of anesthetic gases on climate change, we have to delve a
little bit deeper into their physical and chemical properties. So broadly
speaking, anesthetic gases can be divided into two categories. One of them are
fluorinated anesthetic gases. Most of our aims are anesthetic gases ending with
anes like isoflurane, sevoflurane, and desflurane. They are those fluorinated
ether aesthetics. And then comes nitrous oxide. They both contribute to global
warming. But when it comes down to ozone depletion, the biggest contributor is
nitrous oxide. And the reason is because nitrous oxide is released into the
environment from multiple sources: from agriculture, from fossil fuels, as well
as from the fertilizers used in the agriculture. Medicinal Nitrous oxide is
literally responsible for around 5% of the total nitrous oxide emission.
Now, when we talk a
little bit about anesthetic gases, we have to understand some of their
properties. The first property is about global warming potential. This is how
much a given mass of gas contributes to global warming over a specified period
of time, as compared to carbon dioxide. And we we presume that we take into
account that the global warming potential of carbon dioxide is one. So
everything we are talking about is in comparison to CO2. So for a drug like
anesthetic gas, like desflurane, it is 2600 times more potent than carbon
dioxide. The other properties we have to understand is the Mach value, which is
a marker of potency. Higher the MAC value, lower the potency. So for an
anesthetic gas like desflurane, it is used in 6% concentration, meaning it's releasing
far more number of molecules into the environment. When we are using at one
Mach value to compare apples to apples with one Mach of Sevoflurane, which has
a mach of 2% versus isoflurane roughly around 1%.
The third property is
about their in vivo metabolism. Desflurane is the gas which is least
metabolized among all these fluorinated ethers.
Number four aspect is
going to talk about their atmospheric lifetime. Desflurane is also the longest
lifetime among all fluorinated anesthetic gases.
So in a nutshell, you
think about a gas which has the highest global warming potential, releasing
maximum number of molecules, longest atmospheric lifetime. You know, you add
all these properties and then you create something which is not good for the environment.
So these are some of the ways we can talk about it. And the other aspect is if
we compare our anesthetic gases contribution to global warming in comparison to
auto emissions, using desflurane anesthetic at one liter fresh gas flow will
generate the same carbon footprint as someone who drove 320km. And if you
compare it with Sevoflurane, that number is roughly around 6.5km. And if you
compare it with ISO, it's roughly around 14km. And if we are using nitrous
oxide, that number is 95km. So absolutely, these numbers, you know, are pretty
significant depending upon how much anesthetic you are using and at what fresh
gas flows in.
DR. STRIKER:
This might be a good
time to ask this question is a follow up. Given those numbers,
anesthesiologists that are listening to this and are trying to make sense of
what to do with these numbers. You know, I imagine they're thinking, I got to
do something to anesthetize my patients. I need to use something. I want to use
something that I think is effective, that may be safe. I think a volatile agent
is is appropriate. How do they make sense of the idea that they're using
something that is potentially harming the environment, but is actually serving
a very important purpose in the task of anesthetizing a patient? In other
words, we can all make sacrifices with driving less, or maybe not flying as
much and making sacrifices in our daily life that may impact the environment.
But in terms of an anesthetic, which I'm providing care for a patient so they
can have surgery, how does that practitioner make sense of all this? What is
the rank and file anesthesiologist, or the run of the mill anesthesiologist out
there, or someone on the ground level, what do we want them to do with this
information?
DR. KALRA:
So I believe that every
hospital, every anesthesiologist, should be able to deliver anesthetic gases in
a very clean, sustainable manner simply by following three principles. Using
low fresh gas flows. Removing Desflurane from their formulary because it's not
really needed as an anesthetic gas. We have other safer options. And switching
from pipelines to deliver nitrous oxide to portable cylinders. These three
simple interventions can significantly reduce the carbon footprint of medical
gases, uh, of any hospital. Now, that is one aspect of delivering anaesthetics.
The other aspect I would
like to talk about is pharmaceuticals. We have been using total intravenous
anesthetics and they have been extremely effective in providing anesthetic.
They are safe. And and that could also be a part of the discussion. Uh, broadly
speaking, pharmaceuticals are responsible for 18 to 20% of the scope three
emissions coming from it. When we divide our emissions, scope one, two and
three are medical gases come under scope one emissions, which is basically
coming directly from the facility. But pharmaceuticals comes under the supply
chain and which is responsible for bulk of the emissions coming from
healthcare. And within that scope, almost one fifth comes from pharmaceutical.
I was a pharmacist
before I joined medical school. I want to emphasize something. A pharmaceutical
is a chemical first, pollutant second, and a therapeutic agent third. This is
the order in which we have to look at a pharmaceutical. For example,
manufacturing an active pharmaceutical compound is extremely resource intensive
and material intensive process. Because of the number of steps we have to make
such a complicated compound, there is lack of awareness among healthcare
providers about what does it take to create this pharmaceuticals. In other
words, if we know the LCAs of some of these pharmaceuticals, how much carbon
emissions are generated in creating these pharmaceuticals, and also what is the
impact of these pharmaceuticals on the environment? And when we talk about it,
we have to look at their PBT scoring, which is stands for persistence,
bioaccumulation and toxicity. So to answer that, we also need to know that part
of information. We do have information about some of our anesthetic agents and
the communist agents which we use in the operating room, for example propofol.
It has a global warming potential of 21g/g of propofol. Compare that with
Sevoflurane, which has a global warming potential of 350 times more potent, or
Desflurane, which is 2600 times more potent on a molecule per molecule basis
for desflurane as compared to carbon dioxide. So so total intravenous
anesthetics impact, especially for the drugs which we are talking about is
less, especially propofol. But definitely there is a lot of information which
we are not aware about it, uh, especially the carbon emissions generated in
creating these compounds and also its impact on the environment.
DR. MEYER:
A detail in there that I
think is is really important, just going back to what the average
anesthesiologist can do, which is low fresh gas flows. And the ASA just had a
statement out on this October 18th, 2023, and I'm just going to read verbatim
from it because, you know, this is the official statement and it's nice to
finally see it in writing. “Most adult patients under anesthesia can be managed
with a fresh gas flow of 0.5l per minute without adding significant burden to
the anesthesia professional.” And then it says “with vigilance flows can often
be decreased further.” So practicing low flow anesthesia, especially with sevoflurane
really minimizes that footprint. So if you've got someone who wants to deliver
care, they think a volatile anesthetic is the best option. Use low flows and
get there pretty quickly. You know, don't leave it at ten liters of flow for
the first 20 or 30 minutes of the case. You know, drop it down right off. You
have to be attentive. But it's, it's it's well within our grasp. And then in
regards to using tiva or propofol, I think there's a lot of benefit from a
greenhouse gas perspective. But there is a question as to, you know, sort of
the pharmaceutical waste. And I tell you, I'm as attentive as I can be to it,
and I still end up hanging a gram of propofol sometimes and, and being left
with 800mg of it, despite my best intentions to try to use as much of the drug
as possible. So I think really trying to think through how if you're going to
use a drug, using as much of it as is clearly clinically appropriate, but being
very conscientious about the manner in which you deliver these medications.
DR. STRIKER:
Gotcha. Yeah. So now,
maybe I'm oversimplifying this summary here, but trying to translate it to most
of our listeners, the idea is not necessarily endorsement of one technique or
the other, not necessarily the prohibition of one technique or another, but the
idea that all practitioners should be aware of the environmental impact and
hopefully take measures to minimize the environmental impact of these agents.
Is that fair?
DR. MEYER:
I think that's fair. I
will go on the record saying that I don't use Desflurane, and I haven't
necessarily found the need for it. And I wrote about this, I think it was
published about four years ago. Desflurane should disappear, little tongue in
cheek, but pretty much my feelings on that drug. I'm open to the conversation.
If someone can show me the moment when desflurane is the perfect drug, by all
means. I don't think it should be completely abolished, but I haven't used it
in a long while, and I try to take the very best care of my patients I possibly
can.
DR. KALRA:
And I think at Sanford
Healthcare we receive our some sort of a carbon emissions footprint through
practice greenhealth. And by eliminating Desflurane from our ORs, it decreased
our carbon emissions from fluorinated anesthetic gases by 83%. So that was a
huge change. And currently we are switching our pipelines to portable cylinders
for nitrous oxide. And we have already accomplished this objective at two of
our facilities. And we have shown 80 to 96% reduction in our carbon emissions
coming from nitrous oxide. So definitely these are two, relatively speaking,
easier interventions. Very I would say low hanging fruits, which can be done in
addition to using low fresh gas flow as Dr. Meyer.
DR. STRIKER:
Well, this is a great
segue to the next part of the discussion that I want to get into, which is the
role of of the hospital and health systems in general. Dr. Meyer, why don't you
take us through some examples of how hospitals overall as organizations can
make a difference?
DR. MEYER:
Thanks. So we have a
problem in the world right now. And we focused a lot of the initial
conversation upon greenhouse gases and climate change. And that is definitely
one part of it. But I really see that largely as a symptom of the bigger
problem, which is that we are over consuming our resources and and really
polluting our earth in ways that we don't quite understand, and ways that, you
know, once we throw it off, equilibrium are only going to bring harm to our
health. You know, healthy people do not come from unhealthy environments.
Healthy animals do not come from unhealthy environments. You know, that's true.
So, you know, when I sit here and look at the opportunity we have inside of
health systems, I just get so excited. US health care sector is about 18% of
the US GDP. It's about 5% of global GDP. It is a huge amount of influence on
the global economy.
Health systems are set
up not to deliver medicine but to make patients healthy, make people healthy.
If we could make people so healthy that we didn't have to deliver health care,
that would be the best way that we could do this. But that's not in the
near-term future. So we have to work within the system we have. We need to
realize that as the environment changes, as we pollute more, as all these
diseases that we're discovering are associated with the toxins that we have
placed into our environment, you know, and I include in this endocrine
disrupting chemicals, microplastics. I mean, we're just scratching the surface
on what these items are doing, and we've just added them in the last 50 years.
I expect that we're
going to have new diagnoses and different numbers of diagnoses that come
through our door. So that means that the impact of the environmental pollution
is going to feed back and really congest and potentially stress a health system
that already, you know, really didn't pass its stress test of Covid. So I see
the opportunity.
This is an opportunity
for health systems to start thinking more sustainably. Sustainable medicine is
great medicine. This is where you start to think about all the resources you
have and how you can allocate your resources more effectively. This bleeds through
into a lot of institutional priorities. We're talking high value health care.
We're talking about efficient stewardship of resources. These are concepts that
are very appealing to a lot of the people that are working in the mission
driven field, such as basically all the clinical orders, and a lot of the
people who are on the administrative side of health care have chosen to be in
health care because they want to do something better. This is a perfect
opportunity to seed sustainable thought into the global economy.
How do you do that?
Almost each health system at this point is really taking its own path if it's
thinking about it. Some aren't doing much and some are doing tremendous
amounts. My hope my goal is I truly believe that there should be someone
sitting in the C-suite holding the title of Chief sustainability officer and
bringing the sustainable perspective into every decision that's asked at that
level. Now, it doesn't need to be the only consideration. It shouldn't be the
only consideration, but it should be right there, along with financial
decisions, financial thought, you know, and I like to think about the financial
thought is thinking about what we're going to do with the resources we've
already accumulated. And the sustainable thought is, how are we going to
protect the opportunity to gain such resources in the future? So I think there
is incredible potential for the health systems to galvanize the the larger
movement to make this a healthier place for all of us. And that's my hope. And
and I love the fact that the ASA is starting to engage with this.
DR. STRIKER:
And just a quick follow
up. If you are an individual working in your anesthesiology department, you're
passionate about this issue. You want to make this your focus as a contribution
to your group and your organization. And you walk out of the operating room
environment and you see practices outside the operating room that are perhaps
even dwarfing what the operating room does in terms of waste or environmental
contamination, what have you. And I'll give an example, is in the cafeteria
where tons of of waste is generated, and I imagine even more so than the
operating room in certain institutions. What would you have them do? What is
the best way to go about it if the organization doesn't have a chief
sustainability officer?
DR. MEYER:
It's a grassroots
movement at that point, and honestly, that's largely where I work from a lot of
the time. Go talk to the person running the cafeteria. Figure out who the
champion might be. You picked a great one. Food waste is a tremendous
contributor to greenhouse gases and overconsumption, and we do a lot of it. But
it's a matter of of finding your friends. And there's a lot of people out
there. This is something that's very meaningful to people. I mean, my reason, I
have two young children. I want to leave the world better for them. Like that's
the goal of this is, you know, I was always taught to never leave a place
except for in better condition than when you found it. And that's the goal. And
there's a lot of people who subscribe to that. This concept of sustainability has
sometimes been over politicized, but when you boil it down to the air we
breathe, the water we drink, the food we eat, it's something that we can all
agree on. We all notice that this is important, and you would be surprised the
minute you start talking about this who raises their hand to help out?
DR. STRIKER:
Well, let's dovetail on
that, Dr. Kalra. What are challenges you've experienced in trying to advance
sustainability efforts? Do you have any successes or failures?
DR. KALRA:
There’s certainly far
more awareness now among health care professionals than what it was five years
ago when I started on addressing some of these challenges. I think changing the
culture is often the hardest thing, and the way to approach it is following the
mantra of three C's: connect, convey, and convince. So when I started this
journey, I tried to make a case for sustainability. Why it is so essential for
delivery of our services. And conveying your message with latest literature and
education what is available. It helped me in convincing our colleagues to make
that switch. And the thing is, we can all make these changes individually in
our operating rooms, but that impact is going to be almost minimal or
negligible. But if all of us make those changes, the impact is significant. And
as we have shown with multiple projects, for example, removing Desflurane from
our ORS, we reduce our carbon emissions by 33%. Now switching from nitrous
oxide fuel to portable cylinders for nitrous oxide in two hospitals, 80 to 96%
reduction. We address bio hazardous waste in our setting by simply custom
designing the band and with educational materials provided, as well as posters
we showed a reduction in our bio hazardous waste. Similarly for pharmaceutical
waste, as Dr. Meyer talked about – propofol. We actually ran a pilot project
in. We have around 14 operating rooms, so out of a total of 75 operating rooms
where we basically provided education and we said, okay, we are going to make
just three switches. Number one, reduce the size of the propofol bottle from
100 ccs to a smaller level. We provided a calculator, how much propofol you
need for the duration of the case, and encouraging everyone to use syringe
pumps instead of average pumps. And by making these three interventions, we
could reduce our pharmaceutical waste to propofol by two thirds. It can be
done. And I would probably say that the concept of best patient outcomes must
include optimizing our resources and pollution prevention. And and I think that
is that is something we really have to ask ourselves, because we know that the
number of surgeries are increasing. So is the amount of waste. Robotic
surgeries generate 30% more waste than other approaches to surgery. Teaching
hospital, academic hospitals generate more waste than non teaching hospitals just
because of the teaching nature of the hospital. And our current method of
delivering health care is simply going to be unsustainable. And I think our
mantra has to be remove what we can, reuse what we must reduce what we should
sort of a thing. So that way we can address other aspects of waste generations.
Anesthesiology as a specialty
is uniquely positioned because there is no other aspect in health care which
can quantify carbon emissions. Most of the surgical specialties deal with waste….
We can also contribute in reducing our waste, as well as also making a
significant impact on hospital carbon footprint by reducing our anesthetic
gases footprint. So I think we are uniquely positioned to do both. Whereas
other surgical specialties, they they can pretty much do, most likely with
waste reduction.
DR. STRIKER:
Okay, a follow up on
this. When we've talked about environmental sustainability on this podcast, and
it's an issue that we've talked about in the ASA over the years when starting
up the Environmental Sustainability Task Force and whatnot. But I think the
elephant in the room is infection control and prevention. And that has to lead
to what you're talking about, which is the generation of a significant amount
of waste. What do you say to address that specific concern? Because I imagine
it's easier for hospitals or organizations, decision makers, to go down the
road of single use devices and and avoid reprocessing, given the regulatory
bodies or potential liability of infection control or contamination, if you
will, that those are issues they just want to avoid. And that that I think is a
considerable driver of a lot of these practices. So how do you look at that
specific issue?
DR. KALRA:
So the way I look at it
is I would have really hoped that the Inflation Reduction Act, which has
emphasized a lot on energy emissions reduction in the healthcare industry, they
should have focused a little bit on addressing the reprocessing industry. For
example, when we talk about plastic waste typically used in health care, most
of the past is PVC, which is unfortunately not recyclable. If you burn it,
incinerate it, it generates carbon emissions, plus all those toxin gases like
dioxin gas and chlorine dioxide. Plus it also has Dehp, which also acts as the
endocrine disruptor. I would have certainly hoped our medical devices industry
taking a proactive role in encouraging taking some of these devices to
reprocess. There is actually a conflicted model, to some extent, that these
devices has been tested multiple times, can be used significant number of times
without any compromise on the quality. Um, definitely involving infection
control prevention team in your hospital is a key when you are trying to address
reusables, and we are actually partnering with them in some of our projects.
For example, we are trying to evaluate reusable anesthesia circuits in our
setup and see if this is something of feasibility we can explore. So we are
partnering with them. We are seeking their feedback and try to address that.
But the truth, to the extent that recycling is honestly not a solution to
decrease plastic waste. It comes very low in the hierarchy of plastic waste
reduction. The three big things are remove, reduce and reuse and reprocess. And
then I think we have to look at some of those things until we really find some
sort of biodegradable plastics or other technological advances to address this
problem. But for now that is a key. And of course, partnering with them is
extremely vital for a project to be a success.
DR. MEYER:
I really like that
question because you're hitting right at the regulatory bind that we definitely
feel like we're in. There's a couple of points that I want to make. The first
is that sometimes the way in which health systems implement regulations and Joint
Commission standards are really to the lowest common denominator and
oversimplified, rather than appreciating and allowing the nuance that some of
these regulations and standards permit. So I think one of the issues is to
really go back to the the standard and read it and make sure that we're
applying it in a way that's not as wasteful as it can be.
One of the other aspects
is that we need to start to think about what the global health, the public
health impact is of all this waste, because yes, we have pushed ourselves to
this mentality that even one infection is wrong. And granted, if it's me, if
it's my family, I do not like that infection. No one does. But the reality is,
is that we are never going to be perfect. We are humans. We're going to be as
good as we possibly can, but we are never going to be perfect. And at some
point you reach a limit as to when you know another layer of plastic is going
to do any good. There's some evidence out there that calls into question, I
would say, at least some of the practices we have for gowning when we go into
rooms. I think we need to really bring some of that evidence to the forefront
and weigh it and see if some of our practices can be peeled back.
I also want to talk
about the global public health impact of plastics. I mentioned this earlier. We
are just beginning to scratch the surface on the impact of chemicals in our
environment that we know are inside of our body, as well as the plastics that
we're starting to have in our body. There is a wonderful study was out of
Europe and it was carotid endarterectomy. They looked the plaques that they
took out there, about 250 patients, 150 of those patients had micro or
nanoplastics inside of their plaque that was taken out. The odds ratio was four
and a half times for the population to have either MI, a cerebrovascular
accident or death. So a composite outcomes. There were four and a half times
more likely to have the composite outcome if they had the microplastics inside
their plaque. And when you dug into that chart, there were actually seven deaths
in the study. There were six deaths of those patients in the group that had the
microplastics nanoplastics in their plaque, and only one death in the the group
that did not have the microplastics in their plaque. I do not know if the
microplastics are causing these symptoms, but they are the very least
associated with significantly worse health outcomes. And we have to care about
that as much, or at least equally to the infections that are happening in the
hospital. They are both harming our people and we just don't we we're able to
measure the infections a lot easier, and we're just starting to understand this
other phenomenon. But we know that this this other phenomenon in terms of
endocrine disrupting chemicals, microplastics, particulate matter in the air we
breathe are associated with significant health effects for everyone. So I think
we need to start talking about that, too. And again, that brings me back to the
idea. Like someone needs to be elevating these, this conversation into the
decision making into the C-suite.
DR. STRIKER:
A lot of really
interesting points brought up that push pull with infection control and
prevention and then deferring to other priorities. It's certainly a topic that
is going to need a lot more attention and coverage than than we can do here,
but it's certainly a big question in my mind that needs to be further addressed
significantly. Well, there's a lot more to talk about on this topic, so please
stay with us for a short break.
(SOUNDBITE OF MUSIC)
DR. SCOTT WATKINS:
Hi, this is Doctor Scott
Watkins with the ASA patient safety editorial board. Medication and medical
supply shortages threaten the safety and quality of patient care. Clinicians
and clinical practices should be proactive and develop a plan for dealing with
shortages before they occur. Establishing a direct line of communication with
supply chain personnel, considering an emergency stockpile, and staying
informed of impending shortages using FDA resources are all good places to
start. During times of medication or supply shortages, clinics need processes
and protocols for managing scarce resources in reducing waste and tracking and
reporting any complications that result from substitute medications or
supplies. It is important that clinicians receive education whenever substitute
or unfamiliar medications or supplies are introduced into clinical practice to
reduce the possibility of errors. Clinicians can ensure that they continue to
provide the right care to the right patient at the right time, regardless of the
limitations imposed by the supply chain by taking a proactive approach to
medication and supply shortages.
VOICE OVER: For more
patient safety content, visit asahq.org/patientsafety.
DR. STRIKER:
Welcome back. We're
talking with Drs. Kalra and Meyer about environmental sustainability in the
operating room and our health care organizations. Dr. Meyer, I want to ask you,
how are we doing overall, we've talked about what we can do. We've talked about
maybe what we should do. How are we doing currently as a specialty as health
care organizations overall? How far are we along with all this?
DR. MEYER:
We're doing better than
we were five years ago, but we're not doing enough. I applaud the fact that a
lot of major institutions have jumped in with both feet recently. You have the
National Academy of Medicine with its Climate Collaborative for decarbonizing
the US health sector. You have the Joint Commission that has a unfortunately
voluntary but fortunately sustainable healthcare certification. And then you
also have CMS is starting to look into what it looks like to start to gather
data on greenhouse gases. We need to move faster. We have one Earth and we are
already starting to sense the weather perturbations of climate change. We're
starting to understand the impact of some of these chemicals on oncological
processes, the air pollution, on mortality, like there's serious issues at
play.
That said, I'm an
optimist. I think many of us physicians are. We're a little grumpy maybe at
times, but we're optimists, right? We can make this better. And that's why I'm
so excited about the opportunity of health care. We care about health. Our
whole purpose of being doctors, nurses, clinicians of all stripes, our whole
purpose is to try to make the patient in front of us better. And by reducing
our impact on the world, using less plastic, less pharmaceuticals, still
treating them clinically appropriate, but thinking more efficiently, we have
the opportunity to have an impact on so many other patients.
We also, through the
mere size of the health sector in the US, again, about 5% of global GDP. We
have the opportunity to drive sustainable practices into our vendors, who drive
them into their subcontractors, who apply them when they prove themselves to be
more efficient and potentially lower cost into the rest of the global health
care sector. So the answer is better than we were not good enough need to do
more. But I think I think we can. And I will tell you that when I talk, usually
the people that come up to me are younger than me and like significantly
younger than me. They're medical students, they're residents. Those are the
people that this really seems to resonate with. And that gives me a ton of
hope. So the leaders of hospitals that are listening here, the youth are
coming, and this is incredibly important to them. So I believe that the most
sophisticated health systems that are going to place themselves at the
forefront to be leading are the ones that are already engaging with climate,
health and sustainable health care.
DR. STRIKER:
Well, Dr. Kalra, what
are other countries or institutions doing that we can learn from here?
DR. KALRA:
I believe a lot of
institutions are doing well. The key thing, it doesn't matter where you are in
the journey towards sustainable health care. The right time is now because we
are in a catching up mode right now. We did realize that this is a problem and
we need to work faster and try to address that. And I think I agree with Dr.
Meyer’s examples of, you know, CMS making these proactive efforts of
voluntarily signing up to tell what is the carbon footprint about reducing
greenhouse gas emissions. This is a decarbonization resilience initiative. Then
there is a human and health services pledge. So leadership does matter a lot.
And leadership at Stanford Health Care we signed these pledges and we made
certain commitments that we are going to address our carbon emissions from
scope one and scope two by 50% by 2030. And hopefully with decommissioning of
nitrous oxide, we will be able to achieve those objectives by next year, a few
years ahead of the schedule and addressing our energy use intensity waste reduction
as some of our priorities. So I think there's a lot we need to do. We are at
definitely at a better place than where we were five years ago. And I think
also if hospitals were scrambling and trying to be on the edge, thinking about
it is an expensive intervention that they don't know how to handle.
I think there's a lot of
good material available that can help them in addressing how to get started.
For example, Greening the OR document endorsed by our American Society of
Anesthesiologists, an excellent resource available for all the
anesthesiologists to do how they can practice in a clean, sustainable manner.
There's a lot of information available on health care without harm. Practice
greenhealth as some of the resources. So definitely we can do it. And in order
for sustainability as a business model to be sustainable, hospitals looked at
this, it has to be profitable. Because if it is not profitable for the
hospital, then it is considered as a subsidy, and subsidies by definitions are
temporary. If the market shifts, if the leadership changes or economies
collapse, then they disappear. But if sustainability can be a central factor in
all the decision making in the C-suite, and that's something we have evolved
because our leadership believed that this is a central figure for us to achieve
clean healthcare delivery. And if it creates a value higher than the cost, then
I think everyone agrees to it that yes, it is good for the people, it's good
for the planet, and it is also profitable for the hospital.
DR. STRIKER:
You know, it's a topic
we've covered on this podcast a lot, and I know the ASA has certainly stressed
this in a number of avenues, is the involvement of anesthesiologists in
hospital leadership and corporate structure to some degree in every group, just
because of what you're talking about, you know, having input at those levels
when these decisions are made is so vital. You know, just being involved with
administration is key to helping foster these, these causes or decisions that
affect our patients, whether it's this or anything involving anesthetic care.
It doesn't have to be just environmental sustainability. The safety can be
efficacy. Whatever what you're saying highlights why it's so important for us
to be involved with, with administrative structure in our respective
organizations.
DR. KALRA:
And I will also add one
thing that per capita emissions coming from health care in United States is
roughly around 1700 kilograms of carbon dioxide emissions per capita. And the
point between maximal health system performance and minimal cost and minimal
greenhouse gas emissions are actually can be accomplished at 400kg carbon
dioxide emissions per capita. So definitely we are spending far more than that
to provide health care. And definitely our health care in any developed
countries is not considered as with better lifetime expectancy - actually in
US. You can say it's not your genetic code which determines your life
expectancy, it's your zip code. Because zip code determines the quality of air
you breathe, the water you drink, those sort of things. And and I think another
way to also emphasize is on preventive health care services, because that has a
far lesser carbon footprint than tertiary level energy intensive services,
which are, of course, energy hungry services. And they have extensive carbon
footprint. So definitely part of the discussion also has to be on preventive
health care services. So that way we don't really have to provide those energy
intensive intervention tools because at some point they come into the category
of utility versus being beneficial.
DR. STRIKER:
Dr. Meyer, what other
resources exist that you'd like to talk about that can help anyone implement
sustainability in the operating room? Or where can others go to find more
information? Because we've covered a lot here in this episode, and there's a
lot of detail and a lot more to delve into for anybody interested. So where
would you suggest practitioners interested in this go?
DR. MEYER:
We have certainly
covered a lot and there's a lot to cover. And I really I'm thankful that you've
given us the opportunity to have such an important and broad ranging
conversation. So this conversation speaking about sustainable healthcare is
just never complete without mentioning two organizations which are really sort
of attached at the hip. One of them is Healthcare Without Harm, and the other
one is Practice Green Health. Those are the two organizations that have really
catalyzed a lot of this movement. And so there's resources available online.
Practice Greenhealth - there is a membership to access the largest number of
resources. Check your hospital. About 1600 hospitals in the US and Canada are
members, so there's a 1 in 4 chance that your institution's already a member of
it, and then you just need to get your membership activated and go. And you're
going to find so much in terms of case studies. There's a pretty good amount of
literature that's already been written on this. Pretty much everybody, if you
just hit, you know, greening the, you know, ICU, greening the, you know, OR,
greening the renal suite, you're going to get something. So that's sort of the
cheap way of googling or PubMeding. AHRQ, agency for healthcare related
research and quality, they are the, I would say, the agency associated with the
NIH. That really seems to be tackling the concept of sustainable health care. So
you can go there for some resources. IHI, Institute for Health Care Innovation,
they also have a subset of information available on sustainable healthcare. And
then the best part about this is just contact someone that's interested in
this. There are so many good anesthesiologists that are literally at the top of
this field. I won't name them here. You've got one of them, you know, opposite
me on this interview. There's tons of others you can reach out to me. It's a
very collegial field. I don't care if I win the game. I want us to win the
game. And by winning the game, I mean creating, you know, making Earth continue
to be beautiful place to live. And, you know, a place where we're thrilled to
be for everyone. So it's a great outcome. And so we're willing to share our
resources, plug you in, get you into the network. And then those two
organizations I mentioned at the front, Healthcare Without Harm and and Practice
Green Health. They host a great conference with both doctor Kalra and I were at
last week, which is called Clean Med. And it's a great place to also network
with both clinicians as well as industry leaders who are really invested in
this. There's others. Again, just reach out to someone we're really happy to
share.
DR. STRIKER:
Well that's great. Thank
you so much to both of you for joining us on this episode. You're right.
There's a lot of resources out there. I know the ASA now publishes quite a bit
on environmental sustainability through different mechanisms, and of course, is
doing a lot of work with the committee and task force. And so there I think
there's a lot of resources either on the ASA website in addition to to what you
guys have have already outlined. But thank you both for joining us. This is a
huge topic. It's an evolving one. There's a lot of work to be done. Obviously,
there's a lot of questions that need to be answered for a lot of people.
There's a lot more to delve into as time goes on and as this topic becomes, you
know, more and more visible to a lot of practitioners, especially in the world
of medicine, not just anesthesiology. So thank you both for joining us today.
DR. KALRA:
I want to thank ASA for
giving us this opportunity to share our journey and towards sustainable health
here at our institution. And I agree with Dr. Meyer. We are in this together.
And if we apply a principles of Hippocratic Oath, first do no harm. We can
actually take care of our patients and planet, and that is our principle on
which we want to provide health care.
(SOUNDBITE OF MUSIC)
DR. STRIKER:
Well, that's a great
place to leave it. Dr. Kalra, Dr. Meyer, thank you again for joining us.
DR. KALRA:
Thank you.
DR. MEYER:
Thank you so much for
having us.
DR. STRIKER:
And to our listeners,
thanks for tuning in to this episode of Central Line. Please tune in again next
time and we'll talk soon. Take care.
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