Achieving Ecological Sustainability In Anesthesiology

Believe it or not, damages from health-sector pollution are on the same order of magnitude as lives lost each year from preventable medical errors. Therefore, striving to keep patients safe should include efforts to protect public health.

“Ironically, the health sector is one of the worst polluting industries,” said Jodi Sherman, MD, assistant professor of anesthesiology at Yale School of Medicine, in New Haven, Conn. “You cannot have healthy people on a sick planet.”

Ecological sustainability in health care is an emerging field, and “anesthesiologists are already demonstrating leadership,” said Dr. Sherman, adding that anesthesiologists are well suited to tackle sustainability. “Among environmental hot spots in health care, the operating room [OR] is highly resource-intensive and a very large contributor to the pollution footprint. Anesthetic gases are of particular concern.”

Moreover, anesthesiologists interface with most other specialists in the delivery of clinical care, and also interact with members of hospital administration and support staff in the actual operational function of the hospital itself.

“Therefore, we have the opportunity to take a leadership role and influence and embed sustainability as a core patient care value,” said Dr. Sherman, who has been working on reducing health care pollution since her residency at Stanford University 10 years ago.

More than one-third of the carbon footprint stemming from an average OR surgical procedure derives from anesthetic gases, according to Dr. Sherman, and up to 5% of a hospital’s greenhouse emissions can come from inhaled anesthetics. “The good news is that there are many simple things to reduce these emissions,” Dr. Sherman said.

Focus of ASA Task Force

Strategies advocated by the American Society of Anesthesiologists (ASA) Environmental Task Force to reduce pollution have been collected and listed in the ASA’s Anesthesia Sustainability Checklist (see sidebar).

For inhaled anesthetic gas management, strategies include avoiding the two high-impact inhaled anesthetics desflurane and nitrous oxide. “Instead, administer either sevoflurane or isoflurane when possible,” said Dr. Sherman, who serves as co-chair of the task force.

Making a habit of using low fresh gas flows, and using noninhaled intravenous and regional techniques when clinically feasible, will also reduce inhaled anesthetic atmospheric waste. Technology for waste anesthetic capture/destruction is an important opportunity to further reduce emissions.

Anesthesiology Sustainability Checklist

By the ASA Environmental Task Force

www.asahq.org/?resources/?resources-from-asa-committees/?greening-the-operating-room

Reduce Inhaled Anesthetic Atmospheric Waste

Utilize low fresh gas flows

Avoid high impact inhaled anesthetics: Desflurane, Nitrous Oxide

Consider intravenous and regional techniques

Invest in WAG trapping (for volatiles only) or WAG destroying (all inhaled anesthetics, including Nitrous Oxide) technology for the Anesthesia Machine

Reduce IV Pharmaceutical Waste

Use prefilled syringes

Use appropriate sized vials for an individual patient

Dispose of unused medications and vials according to regulations (and not exceeding)

Reduce Anesthesia Equipment Waste

Only open equipment intended for immediate use

Consider purchase of reusable or reprocessed equipment over disposable

Reprocess or recycle suitable disposable equipment

Adjust stock levels to minimize discarding expired items

Reformulate prefabricated kits to eliminate unnecessary items

Reformulate anesthesia supply carts to eliminate unnecessary items

Donate expired or unused open equipment

Solid Waste Segregation

Segregate waste according to type (pharmaceutical, solid, biohazard, etc.)

Avoid default of placing all waste into a biohazard or sharps bins

Recycle batteries

Consider intraoperative recycling program for clean plastics, paper and cardboard

Use reusable sharps containers

Linens

Consider reusable linens

Minimize excessive use of reusable and disposable towels and blankets

Electronics

Avoid excess electronics without proven benefit to patient care

Use a certified sustainable electronics recycling vendor to dispose of old equipment

When negotiating equipment upgrades/contracts, request vendors take back old equipment for refurbishment and donation, or request vendor use a certified sustainable electronics recycling vendor

Leadership

Develop/join a Sustainability Committee at a department, hospital, or society level and advocate for a sustainability officer

Collaborate with hospital leadership to embed pollution prevention as part of the core business mission, to improve the health of our patients, employees and the surrounding community

Become involved in environmental preferable purchasing

Educate staff regarding the health, safety, and cost benefits of environmental projects

Evaluate new equipment, facility, and behavior options for improved sustainability

Consider strategic sustainability research projects that will lead to financial and environmental savings for the hospital

“It is not just what we throw away that matters,” Dr. Sherman said. “It is also the resources that go into the manufacturing, transportation and the use of supplies—in other words, the entire life cycle of a product. So reducing waste overall is a critically important strategy.”

Surprisingly, the most damaging phase of inhaled anesthetics is the disposal process. “These drugs are essentially blown off of hospital rooftops and into the air, as there are no regulations controlling their outdoor emissions,” Dr. Sherman said.

Fortunately, there is commercially available technology to capture volatile anesthetics and to destroy nitrous oxide. “The question then becomes, should we all be adopting this technology?” Dr. Sherman said.

Anesthesiologists can become environmentally responsible by championing conservation of resource management. “This includes reducing waste and using more reusable devices when safe to do so, or reprocessing those devices,” Dr. Sherman said. “Essentially, instead of using in-house central sterilization and supply departments, third-party vendors take the disposable devices, clean and test them to guarantee their safety, and then resell them at a discounted price.”

To further reduce anesthesia equipment waste, “only open up stuff that you need,” Dr. Sherman said. Adjusting stock levels to minimize the number of expired items and reformulating anesthesia supply carts to remove unnecessary items are also helpful.

Several printed articles demonstrate that anesthesiologists routinely discard 30% to 70% of intravenous drugs. “Vial sizes are frequently much larger than needed for an individual patient, so many of our drugs are being disposed as unused,” Dr. Sherman said. As a result, some institutions have changed to prefilled syringes, which are provided by either a third-party vendor or an in-house pharmacy.

“Although this strategy has not been broadly adopted because it requires cost shifting, a comprehensive cost analysis has been lacking,” Dr. Sherman said. “Prefilled syringes are safer, though, and have been advocated for by the Anesthesia Patient Safety Foundation (APSF) since 2010.”

Solid waste segregation is another key metric for sustainability. “We have many different waste streams in the OR. The more hazardous the waste is, the more expensive and more polluting it is to treat, so taking the time to properly separate trash actually does matter,” said Dr. Sherman, who is the environmental compliance officer for Yale’s Department of Anesthesiology.

Another targeted area is linens. Reusable surgical linens have been shown to produce less pollution. Regardless of whether linens are reusable or disposable, “we need to minimize their use—for example, the number of cotton blanket turnovers on a single patient in their perioperative stay,” Dr. Sherman said. “There is no evidence that a patient’s heat is conserved more by having a blanket fresh out of the warmer versus not, and frequent changeovers are costly and energy- and water-intensive.”

In addition, replacing old electronics such as monitors with the latest models “is not necessarily useful,” Dr. Sherman said. When disposing of old equipment or negotiating new equipment contracts, specify the services of a certified sustainable electronic recycling vendor.

Anesthesiologists can step up to the plate in many ways, including starting or joining a sustainability committee at the department, hospital or community level. They also can become active in medical device procurement committees and add environmental preferable purchasing concerns to decision making.

“Moreover, you can get involved on a higher administrative level, or give talks at your own facility,” Dr. Sherman said.

This past summer, Yale’s Department of Anesthesiology launched a free smartphone app called Yale Gassing Greener, which provides a calculator to help educate clinicians about the environmental impact of inhaled anesthetics. The app also offers an optional research data collection tool. “By sharing inhaled anesthetic procurement volume data, a user can receive a free, personalized benchmark report on the inhaled anesthetic carbon footprint performance of her facility,” Dr. Sherman said.