Clinical sustainability: environmental stewardship at the bedside

November 18, 2020

Information

As part of the CleanMed Virtual Series, on October 29, 2020, Dr. Jodi Sherman, Director of the Yale Program on Healthcare Environmental Sustainability, joined Health Care Without Harm and colleagues Dr. Cassandra Thiel (NYU Grossman School of Medicine) and Dr. Jonathan E. Slutzman (Harvard Medical School) for an exploration of clinical sustainability as an important strategy in advancing climate-smart health care.

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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.