Sustainability in Medicine and Anesthesia

Lauren Berkow, MD Associate Professor

Anesthesia and Critical Care Medicine Johns Hopkins School of Medicine

Disclosures Member, Masimo Corporation Scientific

Advisory Board Member, Teleflex Medical Scientific

Advisory Board

NO relevant conflicts of interest related to this lecture

Lecture Objectives

Discuss how sustainability and Medicine are connected

Describe how sustainability impacts physicians and patients

Share examples of sustainability initiatives in medicine and anesthesia

To encourage the audience to get involved!

Barriers/Obstacles to Physician Engagement

Lack of education and knowledge Physicians are already too busy…. Where is the data? Show me the

evidence.. Clinical priorities Educational Priorities

Barriers/Obstacles to Physician Engagement

Lack of education and knowledge Physicians receive no formal education on climate

change or sustainability NOT part of the medical school curriculum Physicians are already too busy…. Focused on patient care Pressure to increase efficiency Focused on educating residents

Why Should Physicians Care? Sustainability Initiatives: Save hospitals money Protect the environment Improve patient health and healing Improve staff health and well being

Remember as physicians, we vowed to “First, do no harm”

Show Me the Data….

American Thoracic Society Member Survey on Climate Change and Health

Mona Sarfaty et al. Ann Am Thoracic Soc 2014 Dec 23 epub

89% of members believe that climate change is occurring

65% responded that they felt it was relevant to patient care

The majority reported health impacts of climate change: Increase in chronic disease severity (77%) Increased allergic symptoms (58%) More severe weather injuries (57%)

Climate Change and Disease Increasing prevalence of asthma has been linked

to the increase in urban air pollutants (nitrogen dioxide, ozone, diesel exhaust)

Extreme weather linked to increased levels of pollen and allergens in the environment

Patterns of allergens appear to be changing-may impact the patterns of respiratory disease as well as their severity Amato et al. Climate change, air pollution and extreme events leading

to increasing prevalence of allergic respiratory diseases. Multidiscip Respir Med 2013;8: 12.

Environmental Footprint

• Healthcare is 17% of the U.S. GDP or $2.4 Trillion – Expected to grow to 20% of

GDP by 2017 or $4.3 Trillion

• Hospital workforce: 4.1 million

• 24/7 operations

• Able to maintain during power outages, natural disasters and emergencies

Energy • 2nd most intensive user of energy in the commercial sector • $8.8 billion on energy/year • More than 2.5 times the energy intensity and CO2 emissions of

commercial office buildings; producing over 30 lbs. of CO2 emissions per square foot

• Average energy $ for a hospital are 2% of gross revenues

Water • Hospitals often one of top 10 consumers of water in community • Between 120,000 and 140,000 gals/day/hospital • That’s 250-300 billion gal/yr for U.S. hospitals

Waste • Hospital Waste > 5.9 Million Tons/Year

Environmental Footprint

1. Improve Environmental Health and Patient Safety

•Design and operate healthier facilities

•Support use of safer chemicals / transition to green chemistry

•Purchase safer and more sustainable products and materials

•Promote nutritious, sustainable food choices

Dell Children’s Medical Center World’s 1st LEED Platinum Hospital

2. Reduce Healthcare’s use of Natural Resources and Generation of Waste

•Reduce consumption of energy / transition to renewable energy

•Minimize waste / decrease incineration

•Address pharmaceutical waste

•Improve transportation strategies

3. Institutionalize Sustainability and Safety

•Make sustainability and safety a strategic priority

•Promote environmental health literacy internally and through community programs

•Invest in sustainability research and innovation

•Engage in public policy to promote sustainability

Food and Sustainability Food Imbalance:

Increase in poor nutrition and malnutrition in some areas

Overabundance of food and unhealthy food choices in other areas, leading to obesity

Consequences of food production: Meat production generates more greenhouse gas

emissions compared to plant or poultry products Use of antibiotics in meat production a large

contributor to antibiotic-resistant infections Dora et al. Indicators linking health and sustainability in the post-2015

development agenda. Lancet 2014 June 9 epub ahead of print. Landers et al. A review of antibiotic use in food animals: perspective, policy and potential. Public Health Rep 2012;127:4-22.

Environmental benefits of recycling Promotes sustainable use of natural

resources Saves energy Reduces pollution Stimulates green technology Decreases need to build landfills and

incinerators

17

Lots of things can be recycled in the Hospital:

Supply packaging Paper plastics

Blue Wrap Empty glass medication vials Batteries

Australian Survey of Anesthesiologists

Surveyed physician attitudes towards recycling

95% supported increase in recycling Perceived barriers: Inadequate recycling facilities (49%) Negative staff attitudes (17%) Inadequate information about

recycling (16%) McGain et al. A survey of anesthesiologists’ views of operating room recycling. Anesth Analg 2012;114: 1049-54.

Ecological responsibility U.S. Hospitals generate 6 million tons of waste

annually (10-15% is Red Medical Waste) Pharmaceuticals leach into the environment

and have been detected in drinking water PVC and DEHP (in lots of our plastic

equipment)-DEHP and dioxin (byproduct of PVC incineration) are known carcinogens

Scavenged anesthetic gases can act as greenhouse gases-stay in the atmosphere a long time (2-10 years) Ryan S, Sherman J. Ecological responsibility in anesthesia

practice. International Anesthesia Clinics 2010; 48: 139-151.

Why is Greening the OR Important? • The Operating Room has a large footprint: 30% of the supplies used in the

hospital Generates 20-30% of hospital waste High use of plastics (30% of OR waste) Largest producer of Red Bag Medical

Waste (RMW) RMW disposal costs 4 times more than

clear bag waste

Why is Greening the OR Important?

Healthcare responsible for 8% of greenhouse gas emissions Inhalational Anesthetic Gases and

Nitrous Oxide are greenhouse gases Scavenged Anesthetic Gas waste

vented to the atmosphere and not regulated

Relative global warming impact of 1 MAC-hour of 3 inhaled anesthetics at 2 L fresh gas flow

Ryan SM & Nielsen CJ Global warming potential of inhaled anesthetics: application to clinical use. Anesth Analg 2010;111:92-98.

Compound Lifetime (y) GWP20 Carbon dioxide15 1

Sevoflurane 1.2 349 Isoflurane 3.6 1401 Desflurane 10 3714 Nitrous oxide15 114 289

Tropospheric Lifetime and 20-Year Global Warming Potential of Inhaled Anesthetics

8 MAC-hours of desflurane at 1-2 L FGF = 58-116 days of auto emissions 8 MAC-hours of sevoflurane at 2 L FGF = 4.8-9.6 days of auto emissions

How can we reduce our carbon footprint?

Consider inhalational anesthetics with lower green house gas potential (isoflurane)

Consider use of IV agents (propofol)

Use Low flows-less waste vented to the atmosphere

Consider anesthetic gas waste collection devices that reduce the amount vented to the atmosphere

An added Bonus:

Isoflurane is less expensive than Sevoflurane and Desflurane Low flow usage can decrease overall

inhalational gas usage This green initiative can also save

your hospital money!

What about Propofol? Pros

Less greenhouse gas emissions than inhalational anesthetics

Cons Does require use of

plastic tubing Disposal of unused

propofol liquid not without risk:

Potential water and land contamination

The Three Rs…. REDUCE

Draw up/open only what will be used to reduce waste

REUSE Reprocessing

RECYCLE Many items can be recycled in

the OR: Plastic-

wrapping/packaging, paper, cardboard, anesthesia circuits

Blue Wrap

The Disposable vs. Reusable Debate

Disposables Re-usables • Often billable to patient • No need for cleaning or

sterilization Potential cost savings

• No cross-contamination risk

• More landfill waste! May release toxins if

incinerated • Solution:

Recycling reprocessing

Often higher cost Require cleaning and

sterilization Water and energy use Provider time Toxicity of cleaning

agents? Cross contamination

concerns Do NOT add to landfill

Reprocessing Reprocessed items reduce waste and are less

expensive to purchase than new items Process closely regulated by FDA Many single use surgical items can be reprocessed: Laparoscopic equipment pulse oximeter probes Sequential compression sleeves Tourniquets Electrophysiology catheters Orthopedic equipment

Reprocessing: The Data Items to be reprocessed

sent to manufacturer or third-party reprocessor

Items cleaned and disinfected/sterilized, re-assembled and quality tested

Sold back at lower cost than purchasing item new

40-60% cost of new item Significant reductions in

waste Significant cost savings to

hospitals Are they safe? No judgments against

reprocessors for failed product or patient injury to date

No legal or insurance claims to date

Decades of peer-reviewed literature and clinical experience

Shuman EK, Chenoweth CE. Reuse of medical devices: implications for infection control. Infect Dis Clin North Am. 2012 Mar;26(1):165-72.

Cradle to Grave Concept Looks at entire life

cycle of products Manufacturing Transport Usage Disposal

Environmental impact of all steps considered

Cradle to Grave Concept • Life cycle assessment often not applied

to medical supplies • Expensive to perform • Industry resistance to provide data-fear

of their device being labeled “ecotoxic” • Reusable items may be more favorable if

disposal and toxicity of disposable items factored in…

McGain et al. Workplace sustainability: the “cradle to grave” view of what we do. Anesth Analg. 2012 May;114(5):1134-9.

Example: OR Gowns Argument for disposable Argument for Reusable

Less risk of cross contamination and spread of infection

Reduction in HAIs 2014 study: found lower

bacterial contamination levels with disposable gowns-BUT did not compare similar barrier levels of the gowns

Less impact on landfill More favorable life cycle

assessment The level of contamination

of the surgical procedure plays a much bigger role in HAI than the OR gown used

Evidence to date poor quality

Ward et al. Glove and gown effects in intraoperative bacterial contamination. Ann Surg. 2014 Mar;259(3):591-7.

Pharmaceuticals and the Environment

Medications assigned a PBT score

Persistence, Bioavailability, Toxicity (PBT)

Assigned up to 3 points for each Propofol has a PBT score of 9

Must be incinerated to avoid water and land contamination

Pharmaceutical waste has contaminated our water supply and soil

Environmental Hazards of Common Medications

Medication Persistence(P)

Bioaccumulation(B)

Toxicity (T)

PBT Total

Propofol 3 3 3 9

Fentanyl 3 3 2 8

Labetalol 3 0 3 6

Ondansetron 3 0 3 6

Midazolam 3 0 2 5

Ketorolac 3 0 1 4

Metoprolol 3 0 1 4

Lidocaine 3 0 0 3

Morphine unknown unknown

unknown

unknown

Succinylcholine

unknown

unknown

unknown

unknown

Pharmaceuticals and the Environment

Studies have found drugs in drinking water and wastewater in 24 states Antibiotics, anti-convulsants, mood

stabilizers found Why? Over-prescribing and over-use of

medications Disposal of medications by patients Usually flushed down the toilet!

Disposal of medications by hospitals Leaching from landfills

How can we reduce pharmaceutical waste?

How can we help? Prefilled syringes to reduce waste Draw up only what you intend to administer Don’t empty unused medications into sinks or

toilets-they enter the water supply eventually Prescribe only truly needed medications Educate patients not to flush unused medications

Dispensary of Hope Collects unused medications/samples and provides

them to patients in need

Syringe Management Use prefilled syringes-less waste Also JCAHO compliant if prelabeled! Draw up only what will be administered Reduces waste and disposal of vials,

syringes Reduces amount of unused medication

requiring disposal Saves money Positive effects during medication

shortages

Physician Cost Awareness Most physicians unaware of medication costs…. Wax et al. 2008

Surveyed anesthesiologists re costs Most over- or underestimated costs despite having

the information available on their departmental website

Hadjipovlou & Bailey 2010 similar survey of anesthesia providers Underestimated costs of expensive drugs,

overestimated costs of in-expensive drugs

PVC and DEHP DEHP: Di(2-ethylhexyl) phthlate, used to make

PVC plastic soft and pliable DEHP present in IV tubing, catheters, blood bags,

etc Concern that it may leach into solutions Many products now DEHP-free Potential health risk, especially to male neonates

2002: FDA released public health notification on DEHP, recommend DEHP-free products when available

Many countries advocating DEHP-free products

Why PVC is Bad…. Requires lots of chlorine and electricity

to manufacture PVC components are carcinogens, heavy

metals added to stabilize PVC Rarely recycled Releases dioxin when incinerated or

placed in landfills

Some examples of sustainability

initiatives in the OR…

The first successful waste reduction effort….

Red Blood Cell Usage in the OR Partnered with our Hematology/Blood

Bank department 20-80 units of blood wasted monthly in

the operating room

The first successful waste reduction effort….

Our Results!

Heitmiller et al. Blood wastage reduction using Lean Sigma technology. Transfusion 2010; 50: 1887-96.

Red Blood Cell Usage Results Red blood cell wastage reduced by 61% $800,000 in cost savings Wastage of blood in the operating room reduced

to almost zero Did not take into account: Savings from reduction in use of tubing,

plastic Savings from reduction in red bag waste

The Next Project: Low Flow Anesthesia

Stage 1: data collection from the electronic medical record about inhalational gas selection and flow rates

Stage 2: Education about low flow and appropriate usage

Stage 3: removal of Sevoflurane vaporizers from low use areas (available upon request)

Stage 4: Data collection post-intervention

$694,181

$632,461

$551,186

$467,908 $477,000

$0

$100,000

$200,000

$300,000

$400,000

$500,000

$600,000

$700,000

$800,000

2009 2010 2011 2012 Annualized

Dol

lars

Fiscal Year

Gas Expense per FY

Our Results!

Ideal Utilization (Low Flows) greatly Improved for Desflurane

50

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Baseline May-11 Jun-12 Dec-12

Perc

enta

ge

Month

Desflurane Ideal Utilization

And For Sevoflurane-Low Flow and Short Case Duration

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Baseline May-11 Jun-12 Dec-12

Perc

enta

ge

Month

Sevoflurane Utilization all OR's

≤ 2 hours

≥ 2 hours

Total misuse: trash in the wrong place!:

Background information

Johns Hopkins Hospital generates 15 million pounds of trash each year

Trash is separated based on the classification of infectious waste (red bag) or clean waste (clear bag).

Red bag waste costs 6 times more to dispose of than regular clear bag waste

Red bag waste requires incineration which is harmful to the environment

Purpose and Goals To develop a culture

of: Sustainability in

the peri-operative environment

Waste reduction to promote cost savings

Environmental stewardship in the peri-operative environment

5 components: Red Bag Trash

Reduction Recycling Reprocessing Supply waste

reduction Linen waste

reduction

3/23/2016 54

Pre-Interventions 50% of the trash at Johns Hopkins was

red bag waste-more than 4 TIMES the national average

In FY11, we documented $242,548 in wasted supplies from the operating room

No recycling existed inside the operating room

Barrier #1: Lack of Knowledge Pre-intervention, we quizzed our residents

and faculty on their knowledge of what should be placed in a red medical waste bag… They performed VERY poorly! This was not a surprise, based on our

surveillance:

Clear Lack of Knowledge Anesthesia providers asked 7

questions related to what should go into a red waste bin Only 16% of respondents got all

correct The majority of respondents got

50% of the questions wrong!

Another Barrier: Size and Scope 1200 bed hospital Over 300 anesthesia providers 200 anesthesia attending physicians 75 anesthesia residents 40 CRNAs

60 operating rooms in Five different buildings

Multiple remote anesthetizing locations

First Step: Education

Keep RECYCLING simple YES NO • Paper • Plastic • Cardboard • Anesthesia circuits/masks • Nasal cannulas • Green O2 masks • LMAs and ETTs • Oral airways • Empty glass vials

• Gloves • Gowns: yellow or blue • Caps, masks, shoe covers • Blue table drapes • Blue OR bed covers • Gauze/lap pads • Chux

• anything saturated with blood

Second Step: Implementation Signage in ORs Phase 1: red bag use reduction Phase 2: recycling bins in the OR Added linen bins in the OR to reduce

linen waste Added reprocessing bins in OR and

PACU (for pulse oximeters)

Resident Recycling Survey 56 participants (75 residents in program) 86% recycle at home 95% aware of the OR recycling initiative Do you actively participate? 95% said yes Do you feel it makes a positive impact? 50% “agreed strongly”, 50% “somewhat agree”

Do you feel the recycling initiative is?: Simple: 44.6% confusing: 51.8% A waste of time: 3.5%

Resident Recycling Survey Perceived Barriers:

Bins not easily accessible to the anesthesia team

Available bins in operating rooms not consistent

Affects efficiency in the OR Takes additional time and effort

during an already busy day

Results! Reduction in number of red bag

trash cans in the OR More recycling in the OR

(previously there was none!) Increased use of reprocessed items Pulse oximeters Surgical supplies Pneumatic sequential devices

Johns Hopkins Hospital: 2012-3 Sustainability Success Report

40% reduction in product costs

JHM savings for 2011 over 1.2 million dollars

Reduced Regulated Medical Waste from 33.62% in January 2010 to 10.63% of total waste in January 2013

Recycling increased to 15%

Saved $1.9 million from reprocessing surgical supplies in 2013

Total savings since the introduction of the Stryker Reprocessing Program is $5,439,608

$0.00

$500,000.00

$1,000,000.00

$1,500,000.00

$2,000,000.00

$2,500,000.00

2010 2011 2012 2013

Reprocessing Savings

Savings

$1.35 M

5.44 M

2.53 M

$0.1 M

Sustainability Initiatives Savings 2010-2013 $9.42 Million

Waste

Reprocessing

Print Mgmt

Furniture

2014 vs 2011 Recycling up almost 16%

RMW down over 20%

15%

Healthier Hospital Initiative Less Waste Recycling Challenge = > 15%

Key Green National Benchmark for Hospitals with 500-1000 Beds

Green Efforts for the Perioperative Provider

Join the recycling and reprocessing efforts in the OR…or start them!

Collect unused supplies for medical missions Improve efficiency and reduce waste Draw up only medications and supplies to

be used Recycle whenever possible

Reduce Anesthetic Gas Waste Use low flow anesthesia

Other Things you can do… Donate to medical missions: REMEDY www.remedyinc.org MedShare International www.medshare.org Operation Giving Back

www.operationgivingback.facs.org

What can be donated: Unused surgical supplies (sponges, gowns,

gloves) Used medical equipment

Ongoing Challenges • Tracking! Lots of data to analyze Need to convert data into forms

people will understand and respond to Data needs to be measured and

accessible to have an impact

The Leader in Sustainability Management Software

1. Automatically imports most data (no more spreadsheets!) – Credible data directly from the utility/vendor

2. Benchmarking, dashboards, scorecards, and reporting – Benchmark your facility nationally and within your system – Consistent system-wide reporting

3. All sustainability metrics (energy, waste, water, and food) tracked in one place

4. Supports multiple users in easy to use web based format

5. Designed specifically for hospitals

Ongoing Challenges • Compliance! The OR is a busy place-takes time to

recycle • Space constraints • Additional trash/recycling bins added to an

already cluttered operating room • Education Drift Education needed for new providers Reminders needed for all providers

Pearls For Success • Find Champions “in the trenches” Nursing, support staff, residents, faculty

• You also need a Champion at the leadership level

• Start Slow-one implementation at a time • Education is Key! Increase awareness LOTS of signage and reminders

• Culture Change is slow-be patient!

Resources! American Society For Anesthesiology

(ASA) Environmental Task Force Greening the OR document on ASA

website http://www.asahq.org/For-

Members/Clinical-Information/Greening-the-Operating-Room.aspx

Practice Greenhealth www.practicegreenhealth.org CleanMed Annual Meeting May 17-19, 2016, Dallas Texas

Summary Healthcare is a large contributor to

waste and global warming There are many steps we can take in the

operating room to reduce waste and protect the environment: Low flow anesthesia Recycling and reprocessing

These steps are almost always also cost saving!

Thank You For Your Attention!