Clinical sustainability: environmental stewardship at the bedside

Transcript

• 00:03- Hello, good afternoon all
• 00:05and welcome to our sixth and final session
• 00:08of the 2020 virtual CleanMed series.
• 00:11Our session today is clinical sustainability,
• 00:15environmental stewardship at the bedside.
• 00:18And on behalf of Health Care Without Harm
• 00:20and Practice Greenhealth,
• 00:22we are very pleased to bring you this session
• 00:24in partnership with the Yale Center
• 00:26for Climate Change and Health.
• 00:28My name is Shanda Damaris,
• 00:30and I'm a Member Engagement Manager
• 00:32with Practice Greenhealth,
• 00:34as well as a cardiovascular nurse by background.
• 00:37And it is my pleasure today to be moderating this session
• 00:39for many, many folks across the country.
• 00:42So welcome.
• 00:43I also want to recognize my colleague, Dr. Amy Collins
• 00:46for her efforts in co-developing this session.
• 00:49So thank you for joining us.
• 00:53We would like to thank Kaiser Permanente
• 00:55for supporting our virtual series this year.
• 00:58And while of course, we're looking forward
• 01:00to future years when we can connect in-person,
• 01:03we do recognize the challenges that our communities,
• 01:06and of course our health professional audience
• 01:09in particular, is facing these days.
• 01:11And so that's why we are excited to let you know
• 01:14that CleanMed 2021,
• 01:16will be an even larger all-digital experience.
• 01:20So we'll share more details in the coming months.
• 01:23And we certainly look forward to your participation
• 01:26in a safe, exciting, and virtual CleanMed 2021.
• 01:32So a quick look at our agenda today.
• 01:35Just of note, the session will be recorded
• 01:38and it will be made available to attendees afterwards;
• 01:43in addition, all audience members are on mute.
• 01:46And so if you have questions
• 01:48or discussion you'd like to have during the session,
• 01:51please do feel encouraged to do that in the chat box.
• 01:54Myself and Dr. Amy Collins will be monitoring that together.
• 02:00So it is my pleasure to introduce our colleagues
• 02:04that will be on the line to say with us.
• 02:06First off will be Dr. Jodi Sherman;
• 02:09and Dr. Sherman is a Practicing Anesthesiologist
• 02:13and Medical Director of Sustainability
• 02:15at The Center for Sustainable Health Care,
• 02:18at Yale-New Haven Health System.
• 02:21She also holds among many other roles,
• 02:23the associate professor title
• 02:25at Yale School of Medicine and Public Health.
• 02:30Dr. Jonathan Slutzman will also be joining us today.
• 02:33And Dr. Slutzman
• 02:34is a Practicing Emergency Medicine Physician
• 02:37at Massachusetts General Hospital,
• 02:40and an instructor at Harvard Medical School.
• 02:43Dr. Slutzman has a diverse background
• 02:45in health care environmental research
• 02:47and environmental engineering.
• 02:51And joining us virtually today by prerecorded session,
• 02:56Dr. Cassandra Thiel, is an Assistant Professor
• 02:59at NYU Wagner Graduate School of Public Service.
• 03:03And she teaches in the department of population health
• 03:06and ophthalmology at NYU Grossman School of Medicine.
• 03:11So with that, I'm honored to hand this over
• 03:13to Dr. Jodi Sherman, who will kick us off.
• 03:27- Well thank you for inviting me
• 03:29to participate in the session.
• 03:31I am a practicing anesthesiologist
• 03:33and have been doing a lot of work
• 03:35in environmental health sector footprinting
• 03:37for the past decade.
• 03:38And we thought it'd be useful
• 03:40for me to start the presentation
• 03:42with a higher level view of emissions and drivers
• 03:47in health care sustainability.
• 03:49For disclosures, the Yale Program
• 03:51on Health care Environmental Sustainability,
• 03:52does receive funds
• 03:53from the Association for Medical Device Reprocessors.
• 03:58So why is sustainability in health care?
• 04:00Well, pollution is a leading cause of morbidity
• 04:02and mortality globally, responsible for 9 million
• 04:06or 16% of premature deaths annually.
• 04:09health care itself is a leading emitter
• 04:12of environmental emissions.
• 04:13And reducing health care pollution
• 04:15can improve the quadruple bottom line,
• 04:16meaning better care for the most people at the least cost,
• 04:21and to greatest staff satisfaction.
• 04:23And engaging health professionals,
• 04:25which are respected leaders in communities and globally
• 04:29around the issue of health care pollution prevention,
• 04:32can be key for societal transformation
• 04:34by affecting public policy
• 04:36and by touching all the patients that we interact with.
• 04:40So it's important to recognize
• 04:41that globally the health sector footprint is quite large.
• 04:444.6% of global greenhouse gas emissions
• 04:49come from health care.
• 04:50That's an enormous quantity of emissions
• 04:54and a big responsibility,
• 04:56and when our commitment is to first do no harm.
• 04:59The U S health sector is an outlier,
• 05:00while only 4% of the global population,
• 05:04we are responsible for about 1/4
• 05:05of global health care greenhouse gas emissions.
• 05:09On the left, this is from the Lancet Commission
• 05:11on Climate Change and Health countdown angle report.
• 05:15We see that per capita health care greenhouse gas emissions,
• 05:20as a function of per capita GDP, the U S is an outlier.
• 05:24The bubble width
• 05:25represents a fraction of GDP spent on health care.
• 05:30So we spend more than twice as much in the U S
• 05:32on health care, but we do not have the best health outcomes
• 05:35for that investment.
• 05:37And if we look on the right, these are trends over time.
• 05:40This direction in health care is going globally,
• 05:43is not sustainable.
• 05:44We see one outlier here and that's Greece
• 05:46and this has to do with economic instability,
• 05:50and in part related to the Syrian refugee crisis
• 05:54which has very much challenged their health care system.
• 05:58And this is just to bring up an important point
• 06:01that we can reduce emissions by providing less care;
• 06:04that's not what we're at all suggesting.
• 06:08We need to improve access
• 06:10to basic and good quality care globally,
• 06:13and it has to be done sustainably.
• 06:16So delving deeper into the U S,
• 06:18the U S health care sector emits 9-10%
• 06:21of total national greenhouse gas emissions
• 06:23and similar fractions of criteria air pollution.
• 06:27So understanding what that means for public health,
• 06:31the public health damages from the U S health sector,
• 06:34around 614 disability adjusted life years lost annually.
• 06:38That's especially due to air pollution
• 06:39and also greenhouse gas emissions,
• 06:41but that's from total environmental emissions
• 06:43using life cycle assessment modeling.
• 06:46This amount of damages in the same order of magnitude,
• 06:50as the 44,000- 88,000 deaths
• 06:53due to medical errors first identified
• 06:56or quantified by the Institute of Medicine
• 06:59and their famous to err is human report
• 07:01that came out in 1999.
• 07:03This put patient safety on the map for health care.
• 07:07This completely transformed the lens
• 07:10through which we provide health care.
• 07:12It is all done through the lens of patient safety.
• 07:15On average, 10 years of life are lost
• 07:17for those medical error premature deaths.
• 07:18So that's why we're in the same order of magnitude.
• 07:21To this point, we've been ignoring the public health impacts
• 07:25of health care pollution.
• 07:27What we're saying is that pollution prevention
• 07:29is a new patient safety movement.
• 07:31This is just as important as protecting our patients
• 07:34from the care that we give,
• 07:35we also must protect public health.
• 07:39Delving in further the relative emissions
• 07:42that we're within health care those emissions come from;
• 07:45a lot of it comes from travel;
• 07:46both staff, patients, visitors.
• 07:48A lot of it comes from the energy
• 07:50that is required to run facilities.
• 07:55This is from the National Health Sector.
• 07:56If you're not, national health service,
• 07:58if you're not aware of the sustainable development unit
• 08:00out of England, do you are heavily encouraged
• 08:03to look at their reports.
• 08:06Importantly here a takeaway
• 08:08is that 2/3 of the health sector emissions
• 08:10are coming from procurement;
• 08:11and heavily coming from pharmaceuticals
• 08:14and other chemicals as whether,
• 08:16as well as consumable medical equipment.
• 08:18Numerous studies have shown
• 08:19more than 60% of health care's greenhouse gas emissions
• 08:23are coming from the supply chain;
• 08:26especially energy and upstream manufacturing.
• 08:28And so health care administrators and clinicians,
• 08:31we control which devices and which drugs
• 08:34and how many that we use.
• 08:35Whereas manufacturers and regulators
• 08:37really influence embedded emissions
• 08:40and what goes to marketplace.
• 08:42So we have different ways to leverage our voice.
• 08:48And specifically in health care, we have a problem,
• 08:50particularly in the U S;
• 08:52so this concept of a candy store culture,
• 08:55where all the resources with rare exception
• 08:58of things like expensive implant devices,
• 09:01everything seems free.
• 09:02So there's very little accountability to which
• 09:04and how much that we use.
• 09:05So this is a big part of the problem
• 09:06that we face in the United States.
• 09:09Another issue is infection control.
• 09:12Preventing infection is fundamental
• 09:14to everything that we do in health care.
• 09:16It is part of that safety, that patient safety lens
• 09:19that we view all our patient care through.
• 09:23It is fundamental to what we do.
• 09:25It is all our jobs to prevent infection.
• 09:28It costs our health system a lot.
• 09:31And when we have an additional care
• 09:33that is required to take care of patients
• 09:35who have health care acquired infections,
• 09:37that also increases costs
• 09:38as well as the pollution footprint.
• 09:41And of course it's the right thing
• 09:42to do to prevent infections.
• 09:44But the problem is that our efforts to prevent infections
• 09:46are driving this trend
• 09:48toward excessive single use disposable device uptake
• 09:51as well as drug waste.
• 09:54And so this is an important area that we need to address.
• 09:57Focusing on one type of infections,
• 09:59this is surgical site infections.
• 10:01Taking a historical view,
• 10:03if you were to go back a couple 100 years
• 10:05and you had a major surgery,
• 10:07you had about a 95% chance of getting an infection
• 10:11and maybe a 40% chance of survival.
• 10:14If we track the trends over time,
• 10:16we see the greatest change happening
• 10:18between 1860s, 1880, 1900.
• 10:22This happened along with some of Weiss and pastor
• 10:25and (indistinct) and Lewin Hook with germ theory,
• 10:28the microscope to actually prove the germs existed
• 10:31and then creating aseptic and antiseptic practices.
• 10:34So this was the greatest contribution
• 10:36to preventing infection and improving survivability
• 10:39in this case, after surgery.
• 10:43And then you see a slowing of the curve
• 10:45and another bump happening between 1930 and 1940.
• 10:48This was the introduction of antibiotics
• 10:50into our surgical protocols.
• 10:53And so that was the other great detriment.
• 10:55And then over time, you're seeing improvements
• 10:57in policies and procedures around our protocols
• 11:00for antibiosis and aseptic techniques.
• 11:05And so we are gradually approaching zero here.
• 11:08So we have less than a 5% chance
• 11:10of getting a surgical site infection,
• 11:12and a greater than 95% survival rate.
• 11:15So if we were to continue to look at this curve,
• 11:18we're asking tonically approaching zero.
• 11:20This is the infection rate,
• 11:22but what we're doing is we're trying to get to zero.
• 11:24And the question is whether or not that's realistic,
• 11:26because at the same time
• 11:27we're throwing more and more disposables at the problem,
• 11:30more and more cleaning chemicals;
• 11:31at the same time we're throwing more and more resource
• 11:34trying to get to zero,
• 11:36we're also increasing this hidden to date;
• 11:39hidden indirect disease burden from health care pollution.
• 11:43So we can't ignore that anymore.
• 11:45So ideally we find this nexus here,
• 11:49it's very hard to get there, but that's the aspiration.
• 11:52And we really have to question
• 11:54whether or not getting to zero is the right goal.
• 11:57And so causes of infection are multifactorial.
• 12:00The most important thing
• 12:01is aseptic and antiseptic practices;
• 12:04most notably hand washing.
• 12:06Patient health status is also important.
• 12:08So patients who have diabetes and immunocompromised
• 12:11are a greater risk.
• 12:12Exposure site, the type of the organism, its virulence,
• 12:16how much of that organism is introduced into the patient,
• 12:19and then preventive antibiotics and so forth.
• 12:22So the bottom line is that all these things contribute
• 12:25to health care acquired infections.
• 12:28And the most important thing we need to do
• 12:30is wash our hands.
• 12:31We don't do enough of it, even here in the United States.
• 12:34The World Health Organization
• 12:36has a big initiative around this,
• 12:39but we're not gonna cure the problem
• 12:40in sufficient hand washing.
• 12:42And we're not gonna cure diabetes
• 12:44by throwing more and more disposable devices at the problem.
• 12:47So we really need to look more deeply into these practices.
• 12:52And as we've learned with COVID,
• 12:53we've become so dependent on single use disposable;
• 12:56not only devices for patients,
• 12:58but our personal protective equipment or PPE.
• 13:00So here you're seeing reusable and disposable face masks,
• 13:05impermeable gowns, or semipermeable gowns.
• 13:08And in this case, video laryngoscopes
• 13:10or a type of device we use to put in breathing tubes.
• 13:13We're so dependent on single use disposables;
• 13:16and with COVID, the supply chain has been interrupted.
• 13:19So decreasing the amount of supplies we can actually obtain.
• 13:22At the same time, we've seen massive surges in demand.
• 13:25And so we've had no choice but to,
• 13:28and the question is why we weren't using more reusables
• 13:30to begin with, which by and large
• 13:34have lower environmental footprints
• 13:36and sometimes even are even cost beneficial.
• 13:39But we were caught with our pants down
• 13:40with the COVID pandemic;
• 13:41to the point where we've had to reuse,
• 13:45extend the life of reused reusable devices,
• 13:47and sometimes not so safely.
• 13:49There is a third party procedure
• 13:56called medical device reprocessing,
• 13:57which is an entire market that can clean
• 14:00and return reusable devices,
• 14:03sorry, single use disposable devices for safe reuse.
• 14:05And in fact, we've had to figure out
• 14:08under the Emergency Use Act,
• 14:09how to safely extend and reuse these devices.
• 14:11And we've done so safely
• 14:14to the point where it begs the question,
• 14:16what's the difference between a reusable
• 14:18and disposable devices, if we can reuse disposables,
• 14:22not always, but in sometimes safely?
• 14:24So what is a disposable device?
• 14:26Well, this is a actually a label that comes from industry.
• 14:29So single use disposable does not mean it can't be reused.
• 14:33It means that whoever cleans it
• 14:35assumes the risk of its functionality.
• 14:38Hospitals tend to not want that risk.
• 14:40So they've externalized that procedure,
• 14:43but only 2-3% of approved devices are currently reprocessed.
• 14:48So we have to rethink and come up with better solutions
• 14:53to bolster the resiliency of our supply chain,
• 14:58which also improves environmental mission.
• 15:03So we need to move from a linear health care economy,
• 15:06which is essentially, take-make waste
• 15:08where we extract materials, make them, use them,
• 15:11and then eventually throw them away.
• 15:13Principles of the circular economy are things like recycling
• 15:17which is probably the last thing that we wanna do.
• 15:20We wanna keep things in use and reuse them,
• 15:22repurpose them for alternative uses when we can't,
• 15:25refurbish them, and most importantly,
• 15:28we need to reduce the things that we use,
• 15:31and we need to redesign them
• 15:32so that they are easier to clean.
• 15:33So these are principles of the circular economy.
• 15:38And so the intergovernmental panel on climate change
• 15:41came out with a special report in 2018,
• 15:45basically saying that two degrees centigrade,
• 15:48which is the aspiration of the Paris Accord is not enough.
• 15:52We really need to limit our emissions
• 15:54to get to 1.5 degrees max average temperature increase.
• 16:00We've already seen one degree centigrade warming.
• 16:03This is the curve for business as usual.
• 16:05These are with the current policies and pledges,
• 16:08so even our current policies aren't enough
• 16:11to get us to the Commitment, to the Paris Climate Accord,
• 16:15and really we need
• 16:16to get to one and half degrees centigrade pathway.
• 16:21And the reason is to reduce the,
• 16:23it's not that we can stop climate change,
• 16:25but it's to reduce the worst harms that are predicted
• 16:28to occur, are already occurring,
• 16:30but especially predicted by the year 2100.
• 16:32We are likely to reach 1.5 degrees centigrade
• 16:35between 2030 and 2052.
• 16:38And really what it's going to take
• 16:40to get us to limit to one and a half degrees centigrade
• 16:42average temperature rise,
• 16:44is to cut our emissions by 45% by 2030,
• 16:48and get to net zero by 2050.
• 16:50And those of us who are committing the,
• 16:52contributing the most, especially in the U S,
• 16:55but not exclusively, we have to get there much faster.
• 16:58This is on average.
• 17:00This is possible within the laws of physics and chemistry,
• 17:03but really what it's going to take is political will.
• 17:07If you're not aware, you should know
• 17:08that the national health service
• 17:09has committed to get to net zero.
• 17:11They have a legal mandate,
• 17:12but they have actually made a public announcement.
• 17:15They're the largest health care organization in the world.
• 17:19They're the largest employer in Europe,
• 17:22and after the U S military and the Chinese military,
• 17:26the third largest employer in the world.
• 17:28So in order to get to net zero,
• 17:30we have to measure our missions.
• 17:31We have to know where they're coming from,
• 17:33and we need to have a plan of action
• 17:35to address where these are coming from.
• 17:38So improving the electricity source.
• 17:44I mentioned that most of the emissions
• 17:45coming from our supply chain
• 17:47are in the manufacturing process.
• 17:48So obviously decarbonizing our electricity grid,
• 17:51getting off fossil fuels.
• 17:52It's one of the most important things we need to do.
• 17:55And I invite you to read their reports which is 86 pages,
• 17:59and cannot be done justice in this talk.
• 18:02So, but where do we go from here?
• 18:03So importantly, we have to quantify the pollutants
• 18:06from all our clinical activities.
• 18:08We need to include environmental emissions
• 18:10in the total cost of ownership
• 18:11as part of our overall decision-making.
• 18:14Public health needs to be elevated
• 18:17to the level of importance of patient safety.
• 18:20And it has to be right up there
• 18:21with what we mean by quality and value and care.
• 18:23And this needs to be leveraged through accountability;
• 18:26for example, through mandated pay for performance.
• 18:29So the value equation typically used by health care managers
• 18:34includes taken from the triple aim,
• 18:36that the outcomes for patients and populations
• 18:39need to be maximized.
• 18:41Financial costs need to be minimized,
• 18:43when needs to be factored in there
• 18:44are environmental missions in the social costs of care.
• 18:48We haven't even talked about social costs,
• 18:49things like not harming the communities
• 18:52that have the manufacturing plants
• 18:55and make our devices paying livable wages.
• 18:58So these also need to,
• 19:00so unlivable wages need to be minimized,
• 19:02or the social impacts need to be minimized.
• 19:04So earlier I mentioned the quadruple care.
• 19:06I don't have a picture for that.
• 19:07So famously there's the triple aim
• 19:10but the quadruple, the fourth leg of that has to do
• 19:14with staff satisfaction, that staff care about these issues.
• 19:18And so a summary of take home points,
• 19:19not all of which I've been able to touch upon,
• 19:21but that clinicians were driving health care pollution.
• 19:24We are the ones who decide how much to use, which to use,
• 19:28it is well-known we over diagnose, we over-treat.
• 19:31We fail to prevent disease.
• 19:33We fail to end, we failed to treat patients at end of life
• 19:37in ways that they want,
• 19:39and in ways that are inexpensive and minimize pollution.
• 19:43So that's a big area that we need to address.
• 19:45There's this problem of candy store culture
• 19:47and lack of accountability.
• 19:49And there's excess in our infection control practices.
• 19:53We need to engage one another,
• 19:55that this is about public health.
• 19:56This is about patient safety.
• 19:58They are one in the same.
• 20:00Not all clinicians can get involved
• 20:02and care about things like making their cafeteria
• 20:06more nutritious and more locally sustainable.
• 20:10Not every clinician can get involved
• 20:12with trying to make their facilities more energy efficient,
• 20:15but every one of us cares deeply and will get involved
• 20:19in how we take care of our patients.
• 20:20So we need to engage one another
• 20:22and how we take care of our patients.
• 20:24Our choices matter,
• 20:25while I have not been able to address in this talk,
• 20:27you will be hearing from the next two speakers
• 20:30about using metrics to be able to discern
• 20:35what's environmentally preferable
• 20:36in terms of drugs, devices in clinical care pathways;
• 20:39and how we put that all together.
• 20:41This process requires data.
• 20:43It requires more industry transparency.
• 20:46So the value-based payment model,
• 20:50particularly in the United States,
• 20:52needs to factor in resource conservation
• 20:55as how we hold one another accountable.
• 20:57That resource conservation
• 20:59is part of what we mean by quality care.
• 21:02This could not have been highlighted
• 21:04more than with the COVID pandemic.
• 21:06We have a moral responsibility to conserve resources
• 21:09and we can be held accountable to it
• 21:11through our payment models.
• 21:13We need to track our resource utilization
• 21:15and our emissions at the health care organization level,
• 21:18at the practice and practitioner level.
• 21:20This can be done.
• 21:22We need to add environmental performance metrics
• 21:24to the merit-based incentive payment system.
• 21:25This is through (indistinct) and Medicare and Medicaid.
• 21:28This is how we're gonna drive change.
• 21:30We need to address public policy
• 21:32and regulatory drivers of waste and disposability.
• 21:35Many of us feel very powerless
• 21:37based on our institutional practices
• 21:39or departments of public health or regulations.
• 21:42We can challenge them.
• 21:43We have the ability to do that.
• 21:46It's hard, but we can't throw up our hands.
• 21:48We have to get involved.
• 21:49And then certainly haven't talked about prevention.
• 21:52Self-care for us as physicians, but also for our patients;
• 21:55whole foods, plant-based diet,
• 21:57exercise, active transport, social, spiritual connections,
• 22:00green spaces this is all part of what has to happen
• 22:03in the transformation of care to prevent diseases.
• 22:06And certainly we need to address
• 22:08the social determinants of health.
• 22:09If we can't lift our population out of poverty
• 22:14to address basic economic needs
• 22:19and give basic access to health care,
• 22:21we're never gonna solve this problem.
• 22:23So we've got a lot of work to do today,
• 22:25but I'm certainly optimistic.
• 22:26And I thank you very much for your time.
• 22:33- Terrific, thank you so much Dr. Sherman.
• 22:36We sincerely appreciate it.
• 22:38All right, I am happy to hand over the helm
• 22:41to Dr. Jonathan Slutzman, who will be up next.
• 22:52- Thank you Shanda.
• 22:53And thank you Jodi.
• 22:55It's always a pleasure to follow you as best I can.
• 22:59So my task here today
• 23:01is to give you the super fast brief overview
• 23:06of health care sustainability science.
• 23:09For those of you who are fans
• 23:10of the reduced Shakespeare Company,
• 23:12this is health care sustainability science, abridged.
• 23:15Of course, if you have any questions,
• 23:17please ask, and we'll try to answer them afterwards.
• 23:21As a disclosure, I have received travel funding from 3M,
• 23:25but won't be discussing any specific items in this talk.
• 23:29So what is sustainability science?
• 23:31It's a research field.
• 23:33It's one where we look specifically
• 23:35at the interactions between the natural environment
• 23:38and social systems,
• 23:40and how those impact the challenge of sustainability,
• 23:46defined as meeting the needs of the present generation
• 23:50while preserving the abilities of future generations
• 23:53to meet their own needs.
• 23:55There are a number of tools within sustainability science.
• 23:59The one that I'm gonna highlight the most,
• 24:01and you heard Jodi mention it a little bit already,
• 24:04is life cycle assessment;
• 24:07which is a very powerful research tool that can be used
• 24:12to quantify the environmental impact,
• 24:15both upstream and downstream of a product or a process
• 24:19from cradle to grave;
• 24:20from raw material acquisition, through transportation,
• 24:24manufacturing, more transportation, use, reuse,
• 24:28reprocessing, and ultimately disposal.
• 24:31The idea being that if you want to compare different options
• 24:34whether it's single use disposables to durable equipment,
• 24:38or different surgical procedures
• 24:42that achieve the same clinical outcomes,
• 24:45then you can do it in a holistic way,
• 24:47in a whole body perspective;
• 24:51the same way that we should be making our decisions
• 24:54as we care for our patients.
• 24:56So this is the super-duper five-second version
• 24:59of how to do a life cycle assessment.
• 25:02I promise you,
• 25:03it will not qualify you to do it after this talk,
• 25:05but at least it'll give you a sense
• 25:07for what we'll be talking about in a few of the studies
• 25:11that I'll be reviewing shortly.
• 25:13There are four stages to a life cycle assessment.
• 25:16The first is the goal and scope definition.
• 25:18Meaning I'm going to sit down and decide,
• 25:21what am I including in my system or out of my system.
• 25:25And what are the purposes for the study at hand?
• 25:28There's a very, very different way of doing it.
• 25:30If you're an end-user
• 25:32talking about purchasing one particular product
• 25:35versus another product, versus a manufacturer perhaps,
• 25:39who's deciding in the production process
• 25:42which ways to do things.
• 25:44The next is the inventory analysis.
• 25:46That's where you would add up all of the emissions
• 25:51coming out of a product or a process,
• 25:54or the material inputs going into a product or a process,
• 25:58which leads to the impact assessment
• 25:59where we translate those material flows
• 26:03into some sort of normalized impact
• 26:08on different environmental qualities.
• 26:13And there are different categories of impacts
• 26:15that you might wanna include.
• 26:16Some that you might have heard of
• 26:18would be climate change potential,
• 26:20or ozone depletion potential or human health impacts.
• 26:24And then throughout the whole process
• 26:27comes interpretation analysis.
• 26:29It's a somewhat iterative approach
• 26:31that as you're doing it you're continuing
• 26:33to see what you're getting
• 26:34and how you can improve the process.
• 26:38So with that behind us,
• 26:39I'm going to give a really, really tiny taste
• 26:45of the spectrum of sustainability science in health care.
• 26:51Each of the four studies that I'll be discussing
• 26:55are published in peer reviewed publications.
• 26:58And I believe that all of them
• 27:00are even in the last handful of years.
• 27:04We're gonna start at the highest level here
• 27:06where Jodi Sherman and Matt Eckelman.
• 27:08You heard from Dr. Sherman just a couple of minutes ago,
• 27:12did this study with Matt Eckelman at Northeastern University
• 27:16trying to quantify what are the environmental impacts
• 27:19of the entire U S health care system.
• 27:21And if you've ever quoted the number
• 27:23that about 10% of U S greenhouse gas emissions
• 27:27come from health care,
• 27:28this is the source for that data point.
• 27:31And what Sherman and Eckelman did, was what we call
• 27:35an environmental economic input-output life cycle assessment
• 27:40where they took data,
• 27:43economic data on spending patterns essentially,
• 27:47for U S health care, and used translation tables,
• 27:52their economic input-output tables
• 27:55that try to connect a dollar spent in one particular field,
• 28:00where does that then go?
• 28:02And what are the emissions potentially associated with that?
• 28:05For example, if you spend $10 on ground transportation
• 28:10or you spend $100 on pharmaceuticals,
• 28:14or $1000 on durable medical equipment,
• 28:19what are the emissions associated with that?
• 28:21And those kinds of data are great
• 28:24for looking at very large scale systems.
• 28:29You can imagine that what I just described before
• 28:32of doing a life cycle assessment,
• 28:33adding up all of the inventory components
• 28:36for your product or your process, can be quite tedious
• 28:39even for a simple small scale item
• 28:42like the pad of paper that's sitting on your desk right now
• 28:45for you to take notes.
• 28:47There are a lot of steps that go into that.
• 28:49So imagine trying to do that
• 28:51for a health care system as a whole,
• 28:52it is prohibitively complex.
• 28:56So that's where economic input-output comes along.
• 28:59And you get these really interesting results
• 29:02where you can look at over time,
• 29:06in this case, the greenhouse gas emissions associated
• 29:08with the U S health care system as a whole.
• 29:11And what you can see is that, for the 11 years,
• 29:15that Sherman and Eckelman studied,
• 29:19both the proportion of total U S greenhouse gas emissions
• 29:24from health care has increased
• 29:25as well as the absolute number.
• 29:27So a number of industries actually decreased over that time,
• 29:31but health care continued to grow,
• 29:32and it shows the extent of the challenges
• 29:36that we in health care face.
• 29:38So if you look beyond greenhouse gas emissions
• 29:41and see that there are other output categories
• 29:47or environmental impact categories;
• 29:49you can get these kinds of results
• 29:51where you have an absolute number in some normalized unit.
• 29:55For example, if we look at the,
• 29:57let's say ODP here is ozone depletion potential,
• 30:04it's measured in kilograms of CFC 11 equivalence,
• 30:07and you can see what the health care total is
• 30:10versus the national total.
• 30:12And then the fraction that health care represents
• 30:15including the global warming potential up at the top,
• 30:18which is that 9.8, nearly 10% number.
• 30:22So let's move down from what this might have been,
• 30:26let's say the 50,000 foot study,
• 30:27and go down to about 10,000 feet.
• 30:30And here we have a study by McNeil Lily-White and Brown
• 30:34of carbon footprinting of operating theaters.
• 30:38This study was done by some Britains and some Canadians.
• 30:44So they call it an operating theater,
• 30:47where I come from they're operating rooms,
• 30:49but this was done looking at three different hospitals
• 30:53on three different continents.
• 30:55Vancouver General Hospital,
• 30:56the University of Minnesota Medical Center,
• 30:58and the John Radcliffe Hospital
• 31:02in the U K National Health Service.
• 31:04And what they did was looked at the scope one, scope two,
• 31:08and scope three emissions
• 31:10from the operating room complex at each of these hospitals.
• 31:14It turns out that they're not terribly different in size,
• 31:17so we can compare the numbers closely enough
• 31:22for our purposes.
• 31:23And in scope one, they had direct emissions
• 31:26of anesthetic gases, scope two were purchased energy,
• 31:32or they actually moved their onsite energy generation
• 31:36for heating into the scope tWo number of it.
• 31:39It made sense for their purposes,
• 31:40and it doesn't change the total.
• 31:42Although many people would consider that in scope one.
• 31:45And then scope three,
• 31:46they considered the supply chain for the operating rooms.
• 31:51And what they did was this hybrid
• 31:54greenhouse gas footprinting study,
• 31:56where they apply readily accessible
• 32:03and accepted greenhouse gas emission factors
• 32:07for their anesthetic gases and their energy generation
• 32:14based on grid and fossil fuel burning emissions.
• 32:20And then for the scope three emissions,
• 32:22which are the hardest to quantify,
• 32:24they basically did waste audits,
• 32:27and extrapolated to a year of waste generation
• 32:29from the (indistinct),
• 32:32separated into the predominant material
• 32:34which not surprisingly was mostly a variety of plastics,
• 32:38and then apply the factors for those.
• 32:41And what you see is that they're pretty large differences
• 32:45in the greenhouse gas emissions footprints
• 32:48from these three different sets of operating rooms
• 32:51with the number that jumps out, the biggest to me,
• 32:55is the huge difference in scope one emissions
• 32:58between these three hospitals with Vancouver General
• 33:01and the University of Minnesota, being fairly comparable;
• 33:05but the John Radcliffe Hospital being immensely lower.
• 33:07And that is, if you look in the top left table,
• 33:11predominantly driven by zero deaths fluorine use
• 33:16at John Radcliffe Hospital,
• 33:17it's just not available on formulary.
• 33:19And Dr. Sherman can wax poetic
• 33:21about the benefits of doing that at your own hospital.
• 33:25This kind of a method is really useful,
• 33:28for again, a larger scale study,
• 33:31but you can quibble a bit about that,
• 33:34that scope three emissions number,
• 33:36which as I said, is really challenging to quantify.
• 33:40So let's move down from the 10,000 foot level
• 33:42to more the 1000 foot level.
• 33:45And look at a process life cycle assessment
• 33:48where somebody would look at the individual components
• 33:52of a product or a process, and add that up,
• 33:56and get the emissions associated with that.
• 33:58Here we have another study by Dr. Sherman and Eckleman
• 34:01with Lewis Radley, assisting in the middle there.
• 34:04This is a life cycle assessment
• 34:06and a life cycle costing assessment of laryngoscopes.
• 34:12It's possible that at many of your facilities,
• 34:15you've seen a transition
• 34:16from reusable, durable laryngoscope, handles and blades,
• 34:20to some combination of disposable blades
• 34:24and potentially disposable handles as well.
• 34:27And as Dr. Sherman said,
• 34:28this is based on the potential for infection control
• 34:32with variable benefits.
• 34:34But let's answer the question
• 34:35of what are the environmental impacts?
• 34:37So the first figure that you see,
• 34:40is that the scope of boundary
• 34:45of what was included in the study
• 34:48and the different phases of the life cycle assessment
• 34:50that we talked about initially,
• 34:52and then the bottom of the lab boxes
• 34:54is the costs that were included.
• 34:57So here we have some results.
• 34:58Again, similar to that large scale,
• 35:0150,000 foot total health care system study,
• 35:06you have the same impact categories.
• 35:08You're just looking at a different set of options,
• 35:11and this is comparative rather than temporal.
• 35:14So we're not looking at the same system over time.
• 35:17We're looking at different options within a system.
• 35:19And these results are scaled so that the lowest impact
• 35:23is one, and the others are multiples of that.
• 35:26So you can see that in almost all categories,
• 35:31the multi-use blades, and multi-use handles
• 35:36under high level disinfection,
• 35:38have the least environmental impacts
• 35:40with single use disposable devices,
• 35:43in some cases hundreds of times
• 35:46more impactful on the environment.
• 35:48And you can make really pretty charts
• 35:50that show you just visually strikingly
• 35:52how different these are;
• 35:54but what's most striking about this study, I think,
• 35:57is the life cycle costing piece.
• 35:59And this chart right here, you're seeing the emissions.
• 36:03So these are greenhouse gas emissions.
• 36:05And then you can go to the next chart
• 36:07which is the same options in the same order,
• 36:12but here we're looking at the costs.
• 36:13And it's worth noting that the ones
• 36:16that are the most environmentally impactful,
• 36:19also happen to be the ones that are the most expensive.
• 36:23So this is not necessarily a case
• 36:25where we're gonna save money
• 36:26by using single use disposables,
• 36:28by not spending money on reprocessing.
• 36:32This is a case where doing the right thing environmentally
• 36:35will often help your financial bottom line as well.
• 36:40So we've gone from the 50,000 foot level
• 36:42to maybe the 10,000 foot level to the 1000 foot level.
• 36:47And now we're gonna go to ground level,
• 36:49and do some dumpster diving.
• 36:51This is from an emergency department waste audit.
• 36:56This is the most recently published of the studies
• 36:58that we're reviewing today.
• 37:00And this is one of mine,
• 37:01done with Sarah Sue at Brown and Cassie Thiel here,
• 37:05you're gonna hear from in just a minute or so,
• 37:07Mike Mellow at Brown, and then I was leading this study.
• 37:11We did perhaps one of the simplest
• 37:14kinds of health care sustainability studies there is,
• 37:17which was taking all of our trash and dividing it,
• 37:22and measuring it, quantifying it and reporting it.
• 37:26And this was the first time
• 37:27that a North American Emergency Department
• 37:30really did a dedicated waste audit.
• 37:33These numbers represent 100%
• 37:36of the waste generated from our emergency department
• 37:40in 24 hours, with the exception of pharmaceutical waste;
• 37:44which is complicated, why we didn't do that
• 37:46but it's actually a really small number for our facility.
• 37:50And the take home message is,
• 37:52that over the course of one day,
• 37:54we generated about 1400 pounds of waste.
• 37:59The vast majority of which was plastic.
• 38:01And if we extrapolate that over a year,
• 38:04we're talking about somewhere around 225 tons of waste,
• 38:11just from one emergency department.
• 38:15The disposing of that waste for one day, just the disposal,
• 38:20not the upstream impacts, but just the disposal,
• 38:23is equivalent to driving your average car 7,700 miles;
• 38:28which for some people
• 38:29is actually more than a year of driving;
• 38:32is just disposing of one day of our waste.
• 38:36So it can be quite impactful.
• 38:38And then as you saw from the McNeil Study,
• 38:41these waste audit numbers can then be an input
• 38:44for additional footprinting studies.
• 38:46So our key takeaways:
• 38:47sustainability science can identify many things
• 38:50that we can do that can have marginal environmental benefits
• 38:53and an aggregate can be quite significant.
• 38:55And some of the things we identify
• 38:56can be pretty big on their own.
• 38:59However, these larger scale economy-wide shifts.
• 39:02like Dr. Sherman mentioned, energy source changes in U K,
• 39:05can have a much larger impact.
• 39:07And that I want you to take away
• 39:09that life cycle assessment is an extremely powerful tool
• 39:12for making these evidence-based clinical procurement
• 39:16and other decisions when it comes to
• 39:18what is best for us environmentally.
• 39:20And with that,
• 39:21I will say thank you and turn it back over to Shanda.
• 39:27- Excellent, thank you so much Dr. Slutzman.
• 39:29This has been terrific.
• 39:32All right, so now I am eager
• 39:34to get Dr. Cassandra Thiel session up and rolling here.
• 39:41And so she is not able to join us today unfortunately,
• 39:44but we will hear her Zoomed in.
• 39:50- [Cassandra] All right.
• 39:52Well, thank you very much for having me.
• 39:54I'm sorry I can't be there in person,
• 39:55but I'm glad to be able to share some of the work
• 39:58that myself and colleagues have done in ophthalmology
• 40:01to work on sustainability in clinical care pathways.
• 40:05Let me (faintly speaking) slides.
• 40:08So why are we looking at ophthalmology?
• 40:11It's a really interesting specialty.
• 40:12One, they perform a lot of surgeries
• 40:15and surgeries are resource intensive and quite wasteful.
• 40:18This is just one of my favorite studies,
• 40:20is from a Neurosurgical Department out of California,
• 40:22but they monitored How many of their supplies
• 40:25they were throwing out without being used.
• 40:27And found it was about 13% of their total supply costs,
• 40:29were completely unused.
• 40:31If they could somehow not waste those materials,
• 40:33they would save about $3 million a year in their department.
• 40:36And this is very common across all surgeries,
• 40:39even within ophthalmology.
• 40:40So it's a good area to focus on.
• 40:42Another reason we're looking at ophthalmology
• 40:44is because it's a large specialty.
• 40:46So they performed cataract surgeries
• 40:47kind of their bread and butter.
• 40:49And basically everyone needs cataract surgeries,
• 40:51if you live long enough.
• 40:52It's one of the most performed procedures worldwide.
• 40:55And in the U S,
• 40:55we spend a lot of money on cataract surgeries.
• 40:58About 1/2 of that spend is coming from Medicare,
• 41:00and cataract surgeries alone account for 12%
• 41:02of Medicare's budget.
• 41:04So this is a really big reach within a specialty,
• 41:08and beyond that it's actually growing, right?
• 41:10So we have more people, they're getting older,
• 41:13and we're also trying to expand capacity into regions
• 41:16where they previously didn't really
• 41:17have a lot of ophthalmologists or access to eyecare.
• 41:21So this has a lot of potential for change.
• 41:24And that was one of the exciting reasons
• 41:26to look at ophthalmology specifically.
• 41:29So what do we know about what's going on ophthalmology?
• 41:32Well, there was a study that was published 2013
• 41:34out of the U K,
• 41:35it was on carbon footprint of cataract surgery.
• 41:38The most common form of cataract surgery
• 41:39in developed countries
• 41:41is called phacoemulsification or phaco.
• 41:44And so they looked at phacoemulsification
• 41:46and found that it emits about 180 kilos
• 41:48of carbon dioxide equivalence.
• 41:50So these are the greenhouse gas emissions.
• 41:52That's a good one to a British person living for a week.
• 41:54And this is first surgery
• 41:55that lasts anywhere from 30 minutes to an hour typically.
• 41:59Over 1/2 of those emissions
• 42:00were coming from procurement of supplies,
• 42:02which is not surprising
• 42:03for those of us who study life cycle assessments
• 42:06or carbon footprints of surgical procedures.
• 42:09A lot of the footprint comes from the supplies.
• 42:12And of course in the U K, similar to the U S,
• 42:14a lot of the supplies are single use and disposable.
• 42:16So this led to some interesting thoughts.
• 42:21My first thought was,
• 42:22okay, so we have these developing countries
• 42:24where everything, or sorry,
• 42:25developed countries where everything
• 42:27is kind of on a single use disposable end of the spectrum,
• 42:30but there's gotta be other places in the world
• 42:32where that's not the case.
• 42:33But these surgeries are conducted everywhere.
• 42:35Not everyone can afford
• 42:37to use supplies in the same way that we do.
• 42:39And so this took me to a health care system
• 42:43called Aravind Eye Care, it's in Southern India.
• 42:46They're very notable.
• 42:47There's actually a Ted talk on them
• 42:48if you wanna learn more about what they do,
• 42:51they really developed out of financial efficiency models.
• 42:55So their founder initially thought,
• 42:58if McDonald's can make hamburgers so cheap
• 43:00for everyone around the world,
• 43:01why can't we make cataract care,
• 43:04just as cheap for everyone around the world?
• 43:07So their mission is really geared at providing eye care
• 43:09for people who can barely afford it.
• 43:11And so they've designed a surgical center here
• 43:15that is very efficient, but is looking at reducing costs
• 43:19to the point where they can be a profitable health systems.
• 43:21They don't rely on donations, they're consistent.
• 43:25But where people can pay either the market rate
• 43:27or anything below that down to zero.
• 43:31So I think it's about 2/3 of their surgeries
• 43:34or 1/2 of their surgeries are free or reduced rate.
• 43:37And with the people who pay the full rate,
• 43:39they're actually a profitable model.
• 43:41And so it was really based out of finances,
• 43:44how they develop their efficiency.
• 43:45But I went there to look at, of course, the resource use;
• 43:48because that does tie into that financial efficiency.
• 43:51So here you can see their operating room,
• 43:53a little different from in the U S,
• 43:55we have four beds and two surgeons.
• 43:58So one surgeon operates on two beds.
• 44:00Typically they're operating on one bed
• 44:01while the other one's being prepped.
• 44:03They'll flip all the equipment over, operate on that one,
• 44:05while the first one is being kinda cleaned up
• 44:09and the next patient is brought in
• 44:10and they just go back and forth between the beds.
• 44:12So this really reduces their overhead.
• 44:15And you can also see
• 44:16that they have a lot of reusable supplies here.
• 44:19This is prior to COVID,
• 44:20things have changed a little bit during the pandemic;
• 44:23but essentially they have all reusable masks,
• 44:25gowns, head coverings, drapes,
• 44:29all of that stuff is reusable.
• 44:31So they've really cut down on the resource efficiency
• 44:34or resource use.
• 44:35And you may be wondering now, well,
• 44:38that's all well and good,
• 44:39but what about infection control practices?
• 44:42And that's where Aravind was particularly interesting
• 44:45to look at because they have really good metrics
• 44:48for their complication rates, rates of success,
• 44:51post-surgery, and they're actually better than the U S
• 44:54in quite a few metrics.
• 44:56So that last one there, the rates of endophthalmitis
• 44:58that's an eye infection that is not very common,
• 45:01but it's one of the worst outcomes
• 45:03you can get in a cataract surgery.
• 45:05And you can see the rates for that
• 45:06are much lower than the U S.
• 45:07So this is a really interesting place to look,
• 45:10because they're clearly doing their surgeries well,
• 45:13but in a very different way
• 45:14from how we do things in the U S.
• 45:16So while I was there and monitored their waste generation,
• 45:19this is just one visual for how different things are.
• 45:21And we have one phaco in the U S on the left,
• 45:25it's the garbage produced there;
• 45:27and 93 phacos are ovens on the right.
• 45:30So a huge difference in the amount of materials
• 45:33that we're using in each of these surgeries.
• 45:36This is look at the carbon footprint.
• 45:38So this is comparing Aravind to that U K based study.
• 45:42And what you'll notice is that,
• 45:43of course, the U K has a much higher footprint
• 45:45than Aravind does for the same procedure.
• 45:49So it's like driving car 500 kilometers in the U K,
• 45:52versus 25 kilometers in Aravind.
• 45:55And it's just really interesting to note this, right?
• 45:57We have the data now to show the resource use
• 46:00and these are just some ways to visualize it.
• 46:02So Aravind has some really interesting takeaways
• 46:05that we could potentially bring back
• 46:06to more developed countries.
• 46:09The first one is really about their physical layout.
• 46:11So they paid very close attention
• 46:13to setting up their operating rooms,
• 46:15in a way that would optimize for the surgeries themselves.
• 46:19So it's set up a lot like an assembly line.
• 46:21It may be uncomfortable for a lot of patients in America,
• 46:24at least to go through this;
• 46:25in India, didn't seem to be a problem at all
• 46:27but the patients are always the ones who are waiting.
• 46:30It's never the surgeons or the surgical teams,
• 46:33because they're the high value item.
• 46:35So patients are kind of ushered through the system.
• 46:38They're given their preoperative drugs.
• 46:40They go through anesthesia
• 46:42prior to going to the operating room.
• 46:44They are led into the operating room and let out.
• 46:46But the surgeons always have
• 46:48someone available to operate on.
• 46:50And it's part of that is the physical layout,
• 46:52the flow of the patients through that system.
• 46:55They also engage in what's called task shifting.
• 46:57So this is basically,
• 46:59they've trained a lot of young women actually,
• 47:02there's a different story on that end of the spectrum.
• 47:03But young women from the community
• 47:05are trained up basically as nurses,
• 47:08they call them mid-level ophthalmic professionals;
• 47:11and they handle a lot of these other tasks
• 47:14so that the surgeon can focus just on cataract surgeries.
• 47:18So the woman in the center here is their scrub nurse,
• 47:21the two in green, in the darker green,
• 47:24they're the ones bringing the patients in and out.
• 47:25They do the preoperative work and the post-operative work.
• 47:28Because you don't necessarily need a surgeon
• 47:30to do those things.
• 47:31So this allows the surgeon
• 47:32to just do cut to close cases all day in.
• 47:37Standardization is another thing
• 47:39that Aravind has gotten very good at.
• 47:42They have standardized
• 47:42of course, the pathway steps for the patients.
• 47:45So every patient's doing the same thing
• 47:46all the way through the surgery.
• 47:49They standardized the instrumentation.
• 47:50I think this is really important,
• 47:51because in the U S we see a lot of variability
• 47:53in what materials are used during the surgery,
• 47:57even if we have custom packs or standardized kits.
• 48:00So every surgeon might use a different proportion
• 48:03of those things.
• 48:04And even for reusable items
• 48:06that can lead to a lot of wasted effort,
• 48:07because we have to clean the whole kit,
• 48:09even if it's not used.
• 48:11So Aravind has standardized those instruments phase
• 48:13and pretty much every surgeon uses almost everything
• 48:16that's in there every time;
• 48:18which leads to this third part of standardization,
• 48:20which is the surgical approach.
• 48:22So there's very little variation
• 48:23between surgeons on how they operate,
• 48:26which means it could be a little bit boring
• 48:27for the surgeons themselves, right?
• 48:29They're able to do the surgery in about five to 10 minutes
• 48:32instead of the half hour to an hour, it takes here.
• 48:35So you can imagine if you're operating on 40 people a day,
• 48:38doing the same procedure over and over,
• 48:39it could get a little bit boring.
• 48:40But the benefit of that
• 48:42is that everyone on surgical team
• 48:44knows exactly what's happening.
• 48:46And with that standardization,
• 48:48I think that actually improves your outcomes as well.
• 48:51Another thing they focus on of course
• 48:53is reducing their waste.
• 48:55Waste is just money thrown out the door.
• 48:57And to do this, they maximize reuse,
• 49:00and that includes their drugs.
• 49:01Their drugs are all multi-dose.
• 49:03So they're not throwing out partial bottles.
• 49:05They're using them on multiple patients,
• 49:07as long as they're safe.
• 49:10And they're able to basically reduce
• 49:12how much garbage they're producing,
• 49:14and also minimize how much material
• 49:16they're bringing into each surgery.
• 49:19Finally, and this is the most important,
• 49:21they're maintaining their safety.
• 49:23So they can't maintain,
• 49:24they can't actually achieve their mission, right?
• 49:26Of a high value eyecare for low costs,
• 49:29if their surgeries are not doing anything good
• 49:32for their patients.
• 49:33If the patients are leaving worse than they came in,
• 49:35and then there's no point in doing this at all.
• 49:37And that's probably the ultimate waste, right?
• 49:39Is surgeries that don't go well.
• 49:40So they're really careful about maintaining safety,
• 49:44about making sure that everything
• 49:46that needs to be sterilized between cases is sterilized,
• 49:49and that's really key to their model for its success.
• 49:54So to go back into the U S,
• 49:56we see a lot of variability in our cases.
• 49:59So this is just to look at surgical supply costs
• 50:01for phacoemulsification of five different U S facilities.
• 50:04And you can see a wide range in cost of supplies,
• 50:07whether it's kind of the purple stuff on the bottom,
• 50:09which are the the single use supplies,
• 50:11or if it's drugs or the IOLs, inocula lens
• 50:14that they're replacing the cataract with.
• 50:18Here's our ovens costs, so much, much smaller of course.
• 50:22We wanted to focus a little bit more on the drugs here
• 50:24in the U S because it was a contentious point
• 50:28for a lot of the surgeons we were talking to,
• 50:29may find they were throwing away
• 50:30so much of it unnecessarily.
• 50:33So we went in to four different medical centers
• 50:37in the Northeastern U S,
• 50:38and just measured how much of these drugs were thrown out
• 50:40after every cataract case.
• 50:43And here are our findings, right?
• 50:44So the eyedrops in particular,
• 50:45were heavily wasted between patients.
• 50:48So these are, they'll put a couple drops on a patient's eye
• 50:50and then they have to throw out the whole bottle.
• 50:52Even if the bottle is labeled as multi-dose,
• 50:54as is the case with dilating drops,
• 50:56even if the bottle is something that the patients
• 50:58would be using after their surgery,
• 51:00as this case of antibiotics.
• 51:03And you can see for eyedrops,
• 51:04that almost 80% of the drugs are thrown out
• 51:07at two of our sites.
• 51:09This has financial cost, right?
• 51:10You pay for those drugs at those two sites
• 51:13that threw out the most, that's $190,000 worth of drugs
• 51:16to run out each year from cataract surgeries.
• 51:19That would pay for an additional 53 cataract surgeries
• 51:21at each location, if we somehow didn't throw them out.
• 51:25On the environmental side, of course,
• 51:26we're manufacturing and delivering these drugs,
• 51:29and that has a carbon footprint.
• 51:31So the two sites that wasted the most
• 51:33are throwing out about 105,000 metric tons of CO2 unused.
• 51:38We've already admitted those and we're not even using them.
• 51:41That's like driving a car between Alaska and Florida,
• 51:4351,000 times a year.
• 51:45And these are just like a single site.
• 51:47That's throwing away these drugs
• 51:48in their cataract surgeries.
• 51:50So there's a lot of waste happening here.
• 51:53This led us to conduct a national survey, right?
• 51:55We're wondering if what we're observing in our surgeons
• 51:58is universally true,
• 51:59where they're frustrated with the amount of waste.
• 52:01So we surveyed
• 52:03members of the top four ophthalmological societies,
• 52:06and had about 5%
• 52:08of the U S ophthalmological population respond.
• 52:12And the major conclusion,
• 52:13is yes, they're concerned about climate change.
• 52:15Yes, they're concerned about how much trash
• 52:17is generated in the operating rooms.
• 52:19We asked them very specific questions about what drugs
• 52:22or supplies they would consider reusing or multi-using.
• 52:26And there was actually a surprising number
• 52:27who were comfortable with that,
• 52:29that they would prefer reusable over disposable.
• 52:32But they felt that there was too many regulatory barriers
• 52:35to doing so, is a liability issue more than anything else.
• 52:39So they wanted more discretion to reuse,
• 52:41and they also wanted manufacturers
• 52:42to do more to consider the carbon footprint.
• 52:45So these are some really interesting takeaways
• 52:47that led for two of the ophthalmological sites
• 52:50to join the medical society consortium
• 52:53on climate and health.
• 52:54So they're engaging a little bit more
• 52:56on this political side.
• 52:58So overall, what I love for you to take away
• 53:00from this particular presentation
• 53:02is that low resource settings may be a great place
• 53:04to look for more efficient resource use.
• 53:06And the surgeries are conducted all over the world.
• 53:08There are sites globally that are doing this very well,
• 53:11but with a very different resource use profile.
• 53:14Not every place can afford to throw away supplies
• 53:16like we do here in the U S.
• 53:17And so if you're looking for ways to change that,
• 53:19there are great examples already out there.
• 53:24And I think another of this
• 53:26is that we're all individually passionate about this,
• 53:29but at some point we have to build this up to a larger level
• 53:33and engaging with your professional societies
• 53:34is a great way to leverage those collective voices.
• 53:37It helps to gather the data of course,
• 53:38to have carbon footprinting data, perhaps even surveys
• 53:42to show how widespread this interest is.
• 53:45But engaging those professionals societies
• 53:46is a really great way to try to create political change
• 53:51much more quickly.
• 53:53And finally, I like to say this,
• 53:54'cause a lot of physicians are a little anti-industry
• 53:58and I can understand why.
• 53:59But industry is part of this puzzle as well.
• 54:02So the people who manufacture these devices
• 54:03also set the instructions for use
• 54:05and influence regulation on them.
• 54:07And you're not gonna change the system
• 54:08without engaging industry as well.
• 54:10So these are some of the major things
• 54:12that I think could really help any specialty
• 54:15who's looking to change their carbon footprint
• 54:17and make health care more clinically sustainable.
• 54:20So I have a few funding support shown here,
• 54:24that I'd like to thank,
• 54:26and of course, lots of research partners.
• 54:28So I will leave it at that.
• 54:29If you do have any questions, please feel free to email me.
• 54:33I may be on maternity leave for the next few months,
• 54:35but I will try to get back to you.
• 54:37Thank you.
• 54:44- Fantastic, and apologies again
• 54:47for not having Dr. Cassandra Thiel in person with us,
• 54:51but we are very grateful
• 54:52that she was able to do that ahead of time.
• 54:55All right, so as we close out the session here,
• 54:59we really only have a short moment to do a Q&A.
• 55:06And so I want to open up the question
• 55:10for maybe a 60 second answer
• 55:12for each of our panelists on the line.
• 55:16How have you been able
• 55:17to incorporate environmental sustainability
• 55:21into your relationships with patients or colleagues,
• 55:26to really spread this as part of the culture
• 55:29within your health system,
• 55:30or roles with other organizations?
• 55:33So that culture and that relationship component.
• 55:35Maybe 60 seconds each.
• 55:39- I'm happy to go first.
• 55:41As an anesthesiologist,
• 55:43it's less a conversation I have with my patients.
• 55:46It's just not something that comes up.
• 55:49But I have it every single day with my colleagues.
• 55:51And basically my observation
• 55:53is driven every single research question
• 55:55that I've addressed.
• 55:59Just as an example, the question about reusable
• 56:01versus disposable laryngoscopes that came about
• 56:04because there was a sweeping trend
• 56:05toward disposable laryngoscopes
• 56:07that was (indistinct) evidence-based.
• 56:09It came from a loophole in the regulations,
• 56:13and how it was interpreted by the joint commission.
• 56:17And so after doing,
• 56:19not only LCA looking at the emissions and costs,
• 56:23we also, I also had to do a careful review
• 56:26in the infection control literature,
• 56:27and there was nothing to substantiate the transition.
• 56:30So that has been an ongoing battle.
• 56:32And that is just one device out of thousands.
• 56:35But as a conversation I have every day,
• 56:36I work in a teaching institution every day.
• 56:39My residents are drilled on both resource conservation
• 56:43and environmental preferable practices,
• 56:45where we have data in my specialty
• 56:48because of my research collaborations.
• 56:50We have a lot of information,
• 56:51but that's not true of many specialties.
• 56:55- Thank you Dr. Sherman
• 56:57- I would add
• 56:58that it's challenging in the emergency department
• 57:01to have long conversations about topics
• 57:04that are not directly germane to the care at hand,
• 57:07but with my patients, certainly patients
• 57:11who come in with asthma exacerbations,
• 57:14or respiratory illnesses, or heat exposure,
• 57:18or plenty of other conditions,
• 57:20I'll frequently mentioned that;
• 57:22if you're wondering why this is happening,
• 57:24allergens are a lot worse now than they used to be.
• 57:27And heat exposure is an important factor.
• 57:31And then certainly with my colleagues,
• 57:33both on the clinical side and the administrative side,
• 57:36I have conversations at least daily
• 57:40about the environmental impact that we have
• 57:44and how it's harming our patients.
• 57:45So it's a big factor in our clinical care.
• 57:51- Thank you so much Dr. Slutzman.
• 57:54So as we wrap up here together everyone,
• 57:57I just wanna share gratitude again
• 57:59for my colleague Dr. Amy Collins,
• 58:01in the preparation for this session;
• 58:03of course, our presenters today;
• 58:05Dr. Jodi Sherman, Dr. Jonathan Slutzman
• 58:08and Dr. Cassandra Thiel.
• 58:10And if you're interested in learning more,
• 58:11check out these websites and resources,
• 58:14especially the Physician Network
• 58:16and the Nurses Climate Challenge.
• 58:19And as a reminder,
• 58:20this session will be posted on the website linked below.
• 58:23And if you have further questions after this session,
• 58:26feel free to reach out to either myself
• 58:28or Dr. Amy Collins.
• 58:31Thank you again for joining us
• 58:32all during this challenging time in health care,
• 58:35and we are so grateful to have so many allies in this work.
• 58:38Stay safe, stay healthy, and thank you all.
• 58:42Bye now.