# Healthcare Sustainability - Transforming Clinical Practice in the Face of Climate Change

https://www.youtube.com/watch?v=4uB0MujR_V4

[00:05] Good morning everyone, I'm Joel Katz at Brigham and Women's Hospital.
[00:11] And on behalf of my colleagues, Dr. Eileene Reynolds at the Beth Israel Deaconess Medical Center and Dr. Jose Flores at Massachusetts General Hospital, I would like to warmly welcome you to the October installment of our combined Harvard Medical Grand Rounds.
[00:29] We have a great group of panelists today who I'm about to introduce.
[00:33] But I want to remind participants throughout the presentation to please submit your questions through the chat function, the question function in the webinar.
[00:44] Today's distinguished speakers are, in order, Dr. Greg Fury, who is the medical director for climate and sustainability at Brigham and Women's Hospital and an instructor in medicine at Harvard Medical School.
[01:03] He will be followed by Dr. Pry Mahotra.
[01:06] Who is the senior medical director for infection control and Hospital epidemiology at the Beth Israel Deaconess Medical Center and an assistant professor of medicine at Harvard Medical School?
[01:17] And our final panelist today will be Dr. Winnie Armand, uh, who is the associate director for the center for environment and health at Massachusetts General Hospital and an assistant professor of medicine at Harvard Medical School.
[01:33] And today our panelists will be talking about a critical, uh, National Health Emergency, uh, Health Care sustainability: transforming clinical practice in the face of climate change.
[01:48] Thank you very much, Dr. Fury.
[01:52] Great, thank you so much.
[01:55] Um, we really appreciate the opportunity to have the opportunity to speak to the group.
[01:58] I'm just pull up my slides here.
[02:06] All right, well, thank you again, um.
[02:11] So first of all, I just wanted to mention that none of us have any conflicts to disclose.
[02:15] And then I just wanted to go over our objectives for today, which are to recognize the US Health sector's substantial contribution to climate change using data from Mass General Brigham's greenhouse gas inventory.
[02:26] To highlight some important sources of healthcare emissions and to understand how clinical activities drive carbon emissions and represent opportunities for mitigation through the use of two examples relevant to Internal Medicine: single-use versus reusable products and low-carbon asthma care.
[02:43] Um, and so, uh, I'm going to be starting off by providing an overview.
[02:48] And then I'm going to turn it over to Dr. Motra and Dr. Arman to provide a deeper dive into two examples that illustrate how clinicians are approaching the challenge of reducing the environmental impact of clinical care and where there's alignment and tension with other priorities in clinical medicine.
[03:04] So I know this is familiar to many of you, but I still think it's important to start with a brief recap of climate science.
[03:10] Um, so the concentration.
[03:13] Of CO2 in Earth's atmosphere shown here at 417 parts per million in 2022 is unprecedented in the past 800,000 years.
[03:22] The previous highest concentration during that time was here at 300 parts per million.
[03:26] And the science is clear that this rise is due to human activity, primarily the combustion of fossil fuels, deforestation, and our agricultural practices.
[03:36] And that's shown here, uh, the rise in atmospheric CO2 concentration shown in blue tracks closely with CO2 emissions shown here in gray.
[03:46] And as you're all aware, rising CO2 concentrations, depicted by the gray line here, are highly correlated with rising average global temperatures due to the greenhouse effect in which solar radiation is trapped inside the Earth's atmosphere.
[04:02] And as becoming increasingly clear with each successive extreme weather event, both locally and globally, the implications for health are really sobering.
[04:11] And that's why recently for the.
[04:14] First time ever, over 200 medical journals, including some pretty reputable ones, published a joint editorial in which they stated that the greatest threat to global public health is the continued failure of world leaders to keep the global temperature rise below 1.5 degrees C and to restore nature.
[04:32] And of course, the health effects of climate change are not limited to the impacts of extreme weather events.
[04:37] This is a figure from The New England Journal showing how increasing levels of CO2 and short-lived climate pollutants are driving rising temperature, rising sea levels, and increasing extreme weather events.
[04:49] And through various exposure pathways, they are having direct and indirect effects on human health that affect essentially every organ system in the body.
[04:58] And importantly, the magnitude of those effects and their distribution among populations are influenced by a number of demographic, socioeconomic, and environmental factors.
[05:08] And it's critical to point this out because we know that climate change disproportionately affects the health of vulnerable.
[05:15] Many believe that climate change is the greatest Public Health Challenge of our time.
[05:20] I argue it is also the greatest Health Equity crisis that we currently face.
[05:24] And for those of us in healthcare, here's the paradox: we're a major part of the problem.
[05:30] If the global Health sector were a country, it would be the fifth largest emitter in the world, and the US would be the 13th.
[05:38] And why?
[05:39] Maybe you aren't aware of those statistics.
[05:41] I suspect that many of you intuitively sense that the health sector has a substantial environmental impact.
[05:46] Think about the Longwood Medical Area, three quaternary care centers operating 24 hours a day, a major Cancer Center, schools of medicine and public health, biomedical research labs, and a power plant all within a three block radius.
[05:58] And then there's another campus very similar to that right across town.
[06:02] The environmental footprint of these facilities is immense and it's exerted through many different pathways.
[06:08] For example, through the manufacture and disposal of all the products we use, transportation, agriculture, water use, all which are.
[06:17] Associated with significant greenhouse gas emissions as well as other types of pollution.
[06:21] And of course, there's emissions just from generating the energy necessary to power, heat, and cool these facilities.
[06:30] As healthcare professionals, I'd say this should make us uncomfortable.
[06:33] Healthcare-associated pollution, including contributions to climate change, adversely and inequitably affects human health.
[06:39] In fact, a recent study estimated that pollution from the US healthcare system, including contributions to climate change, is responsible for 244 to 531,000 disability-adjusted life years annually.
[06:52] That's the same order of magnitude as preventable medical errors.
[06:56] Into 'To Err Is Human', the report that catalyzed the entire quality and safety movement and completely changed the way we practice medicine today.
[07:04] And I hope we can agree that contributing to death and disease through the environmental impacts of our operations is fundamentally at odds with our mission.
[07:11] If we agree it's our professional responsibility to 'first, do no harm', then we have a moral obligation.
[07:18] To address healthcare's significant environmental impacts.
[07:22] So today we're going to focus primarily on greenhouse gas emissions, although there're clearly other forms of healthcare associated pollution that harm human health.
[07:29] So this diagram is from a recent carbon footprinting analysis of the UK's National Health Service which shows sources of emissions using a typical framework for greenhouse gas accounting that divides emissions into scope one, scope two, and scope three.
[07:44] Scope one refers to emissions that are produced directly by facilities, including combustion of on-site fossil fuels, release anesthetic gases and refrigerants, and emissions from an organization's vehicle fleet.
[07:55] Scope two emissions are those attributed to energy purchased by an organization but not produced by it, so electricity and steam primarily.
[08:06] And then last, scope three emissions are those attributable to the supply chain, waste streams, water use, construction, transportation.
[08:13] Importantly, greenhouse gas emissions include not only CO2 but...
[08:18] Also other gases that are commonly used in modern medicine that have far greater heat trapping potential than CO2, such as inhaled anesthetics and the propellants and meter do inhalers.
[08:27] So what are the main sources of emissions from Healthcare?
[08:31] This is data from the from an analysis of the entire US Health sector showing scope one, two, and three emissions from 2010 to 2018.
[08:41] Most recently in 2018, US Healthcare associated emissions represented 8 and a half% of total US greenhouse gas emissions and our per capita emissions from the US healthcare sector are the highest in the world.
[08:54] Notice that our energy consumption, or Scopes one and two, contribute less than a fifth of total emissions.
[09:02] Scope three emissions represent the vast majority and that's a finding that's been seen consistently in studies of the health sector.
[09:07] Importantly, this analysis doesn't include contributions from meter do inhalers or anesthetic AES, nor does it include substantial impacted biomedical research that's conducted at many academic medical centers like.
[09:20] Ours, so as you can imagine, in order to reduce healthcare's contribution to climate change, we need to understand sources of emissions at a more granular reel.
[09:30] And to that end, many organizations that are seeking to reduce their carbon footprint, MGA MGB, recently completed an inventory of its greenhouse gas emissions, including all clinical research and administrative operations.
[09:45] And consistent with studies of other health systems, scope one emissions account for about 9% of our total footprint and scope two for about 7%.
[09:56] The vast majority, 84%, is due to scope three, and the largest contributor is purchased goods and services, or the carbon associated with the manufacturer and transport of all the supplies we used to deliver care and conduct research.
[10:09] This is followed by capital goods, including construction and renovation of buildings, but also large expenditures on durable equipment such as MRI machines.
[10:18] Other notable categories.
[10:20] Include Upstream Fuel and energy.
[10:22] These are emissions that are associated with the extraction, production, and transportation of the energy that we consume and would presume we go down if we were less dependent on fossil fuels.
[10:32] Employee commuting and patient travel also make up substantial contribution.
[10:38] So if we look more closely at uh purchase goods and service, we can see that Pharmaceuticals used in the impatient setting represent about 10% of our footprint.
[10:46] And importantly, this doesn't include emissions from Pharmaceuticals that are sent to retail pharmacies in the outpatient setting.
[10:54] In that study of the NHS that I mentioned, emissions associated with prescriptions um just from primary care were greater than those from all the medications administered in the hospital.
[11:02] And a main driver of that are um within Primary Care are meter dose inhalers which we'll hear more about shortly.
[11:11] And then much of the remainder of this category is made up of all the consumable products we use.
[11:15] And that's driven at least in part by a continual shift in medicine towards Reliance on.
[11:21] Single use disposable items, we're going to hear more about that as well in a bit.
[11:25] Um, you'll notice that this inventory excludes emissions that are associated with our investment holdings, and those are also likely a substantial contributor but not represented here.
[11:36] So this analysis begins to provide us with some high level insight into the sources of our emissions and serves as a starting point for implementing initiatives to address our carbon footprint.
[11:45] But many questions remain.
[11:48] For example, what are the relative contributions of different clinical service lines or types of research programs, of um, of different diagnostic and treatment approaches, and of the specific products that we use?
[12:00] Moving forward, we'll be working to generate even more granular data that helps us prioritize for, um, and approaches to intervention.
[12:07] Unfortunately, there's accelerating interest in this field and so that data is coming.
[12:15] There is one thing that is clear, however, and that is that there's no single solution to healthcare sustainability.
[12:18] We're going to need to implement a suite of changes as.
[12:22] Highlighted by this wedge diagram that outlines how the NHS plans to achieve Net Zero emissions across all scopes.
[12:30] I'm not going to go through this in detail, but I want to point out that the interventions fall broadly into four categories, specifically decarbonization of the electrical grid and transportation, changes in healthcare utilization and delivery, implementation of local sustainability solutions, and decarbonization of supply chain and circularity.
[12:51] And we're going to talk about these last three briefly.
[12:53] So it seems obvious, but it's important to point out that clinical care is the primary driver of healthcare environmental impact.
[12:59] It's relevant because we know that hundreds of billions of dollars of US healthcare spending is waste.
[13:04] I'm not talking about trash, which healthcare also produces a lot of, but rather unnecessary care that comes not only with a high financial cost but an extraordinary environmental cost as well.
[13:14] We could dramatically reduce our environmental impact by reducing the volume of clinical care that we provide through things like.
[13:23] Improve disease prevention and advanced care planning at the end of life by avoiding resource delivering care and resource intensive settings like the emergency department or hospital through better chronic disease management.
[13:35] Caring for ambulatory sensitive conditions in the outpatient setting or increased use of telehealth for ambulatory care that doesn't require in-person visits and by minimizing low value care such as unnecessary testing, procedures, or treatments.
[13:51] And we in Internal Medicine have the opportunity to have a huge impact here because our clinical decisions have so much influence on downstream healthcare utilization.
[14:02] Of course, much of the care that we provide is appropriate.
[14:06] The challenge for us is to figure out how we can deliver high quality care with minimal environmental impacts through implementation of local sustainability solutions.
[14:13] And some examples would include using renewable energy and increasing energy efficiency, using environmentally favorable products like reusable as opposed to single use when.
[14:24] Appropriate environmentally preferred purchasing programs, reprocessing certain single-use devices, utilizing low-carbon clinical pathways, minimizing professional travel including, uh, interviews for all of our trainees, reducing and properly sorting our waste, offering plant-forward food options, um, and expanding employee commuting and remote work programs.
[14:48] And while optimizing healthcare utilization and delivery and implementing local sustainability solutions are critical, we also need to recognize that the majority of healthcare-associated emissions are due to the supply chain and therefore out of our direct control.
[15:03] And while we can reduce the amount of stuff we use in healthcare, we'll never get that to zero.
[15:07] To achieve net-zero emissions, healthcare systems will need to encourage and work with their suppliers to decarbonize their own operations, designed for sustainability and increased product circularity, or the ability to continuously reuse products or recycle the component materials.
[15:24] And it's an ambitious goal, but a critical one.
[15:26] That's true of all the strategy I've just discussed.
[15:30] Ultimately to make progress, health systems will need strong executive leadership on this issue.
[15:34] Our experience has been that robust clinician engagement has been a powerful tool for driving that change.
[15:41] Um, so with that, I'm going to conclude and turn it over to my colleague Dr. Meoa to help us understand some of the challenges associated with pursuing circularity while simultaneously ensuring patient safety.
[15:50] Thank you.
[15:57] Thank you so much, Dr. Fury.
[16:01] It is my pleasure to be here today to talk to you about environmental sustainability and the infection control perspective.
[16:09] Next slide.
[16:13] So I want to start by acknowledging the tension that clearly exists between infection prevention and environmental sustainability.
[16:19] Transmission-based precautions, personal protective equipment, and the principles of disinfection and sterilization are true.
[16:27] Are truly the corner stones of our work in infection prevention and control or IPC.
[16:32] And oftentimes IPC may support the use of disposable items to decrease or eliminate transmission risk of pathogens.
[16:41] But yet we must also weigh that the healthcare sector, as we just heard, remains an incredibly carbon intensive sector.
[16:48] And the addressing climate impact requires multilateral and multi sector change.
[16:53] Next slide.
[16:55] And so I want to take you on a journey where we think about how medical devices and PPE are case studies for acknowledging this tension and what I hope is a thought-provoking exercise and hopefully more than that for all of us.
[17:09] And so to begin the conversation about medical devices, we need to understand the appropriate context in which infection prevention experts think about disinfection and disinfection of medical devices.
[17:21] So this figure shows us the Spalding criteria or Spalding hierarchy.
[17:27] You can see at the bottom of this figure.
[17:29] We have non-critical instruments.
[17:31] These are instruments or devices that come into contact with intact skin or perhaps the built environment around us.
[17:38] These require what we call low-level disinfection, which is typically achieved through the use of a hospital germicidal wipe.
[17:45] In the next section, we have semi-critical instruments.
[17:48] These are devices that come into contact with mucous membranes, and they require something called high-level disinfection.
[17:58] High-level disinfection is a chemical process that typically achieves up to a log six reduction in microorganisms or pathogens to prevent transmission of organisms.
[18:10] Examples of semi-critical devices include scopes, typically endoscopes, bronchoscopes, and also endocavitary probes.
[18:17] And lastly, we have critical devices.
[18:20] These are devices that come into contact with normally sterile body tissues, oftenly seen in the operating room, and they require true [sterilization].
[18:30] Sterilization next slide.
[18:34] So historical key events in healthcare, I believe, have shaped and refined how we think about the Spaulding criteria and infection prevention and flu and influenced our attitude in infection prevention control towards cleaning and disinfection.
[18:51] Not surprisingly, the HIV epidemic gave us insight into transmission of blood and bodily fluids and the use of standard precautions as well as transmission-based precautions.
[19:01] One less discussed seminal event, I believe, is the outbreaks of carbapenem-resistant Enterobacterales which occurred between 2012 and 2015.
[19:13] In that time frame, there were about 25, if not more, outbreaks that were recorded of this very resistant organism that was likely thought to be due to ineffectively disinfected or inadequately cleaned duodenoscopes.
[19:27] And it.
[19:30] It was during this time period that there was significant morbidity and mortality that was discovered due to these events, including patient harm and patient deaths.
[19:38] It launched an FDA and CDC investigation into two scope manufacturers.
[19:43] The FDA also launched intensive postmarketing surveillance programs.
[19:48] And I believe that it created increased regulatory might and power for hospital accreditation programming to think about and bring the domains of disinfection sterilization to infection prevention teams in acute care.
[20:05] And then lastly and not surprisingly, the COVID-19 pandemic has again brought cleaning and disinfection to the forefront.
[20:13] Next slide.
[20:13] So it was the series of events that I believe brought to bear our current marketplace, which is that out of necessity we spurred innovation and we created a single-use market which many believe is here to stay.
[20:29] So in 2019 we had the advent of.
[20:32] dados Scopes created with disposable
[20:35] parts and at BMC we in fact helped to
[20:38] Pioneer one of the first completely
[20:39] disposable jados Scopes not surprisingly
[20:43] shortly after that due to issues
[20:45] discovered with the reprocessing
[20:47] instructions for bronchoscopes a crop of
[20:51] disposable bronchoscopes were created
[20:53] and then again in April 2022 after the
[20:56] FDA released issues with reprocessing
[20:59] uh Urologic endoscopes there's now
[21:02] increas of use of disposable Urological
[21:05] Scopes next
[21:08] slide and so this is not to say that
[21:11] reusable devices don't also have their
[21:13] own tradeoffs including environmental
[21:16] costs so recall that to actually clean
[21:19] and disinfect these devices
[21:21] appropriately there is time and labor
[21:24] and real expertise that goes into
[21:26] following what I would consider to be
[21:28] very dense instructions for use that are
[21:31] sometimes hundreds of pages to
[21:33] adequately disinfect uh reusable
[21:36] equipment for the actual machines that
[21:38] help us to do the reprocessing of these
[21:40] devices they require real estate Capital
[21:43] costs preventative maintenance and there
[21:45] also are additional environmental
[21:47] concerns for reasonable devices
[21:49] themselves such as the water use energy
[21:51] use chemical use and of course the
[21:53] manufacturing and material cost most
[21:56] recently the FDA and the EPA have
[21:59] jointly investigated uh the use of
[22:02] ethylene oxide which is a very common
[22:04] sterilant but unfortunately now found to
[22:06] have uh occupational risk with uh
[22:10] long-term exposure and only recently has
[22:13] the FDA decided to invest in
[22:16] understanding different ways of
[22:18] innovating medical device
[22:20] sterilization not from creating a single
[22:22] use Market but from actually recreating
[22:25] different chemical technologies that can
[22:27] help us sterilize I more devices in
[22:29] different ways next
[22:32] slide and so to carefully weigh all of
[22:35] this we need data which is scarce one of
[22:38] the methodologies that might be
[22:40] considered for assessing environmental
[22:43] impact is something called the life
[22:45] cycle analysis as you'll see in this
[22:47] diagram the life cycle analysis is a
[22:50] methodology that is used to help assess
[22:52] environmental impact in a in a cycle in
[22:56] something that we call the Cradle to the
[22:57] Grave so thinking about the
[23:00] environmental impact of the raw material
[23:03] extraction needed for the materials to
[23:05] create devices for the environmental
[23:08] impact used in the production
[23:10] manufacturing and distribution of those
[23:12] devices the environmental impact of the
[23:15] use of those devices and then finally in
[23:17] the recycling and in the final disposal
[23:20] of every single element that went into
[23:23] creating those devices and so we do have
[23:26] some studies in this first study
[23:29] looking at uh the life cycle assessment
[23:32] of single use versus reusable lingos
[23:34] Scopes by Sherman and colleagues it's
[23:36] not surprising that we see an increased
[23:38] amount of carbon equivalence of single
[23:40] use lenos Scopes I'm sorry uh versus
[23:43] reusable lingos Scopes however in this
[23:46] next study we find that there's
[23:48] significant environmental and financial
[23:51] impact of the personal protective
[23:53] equipment that's used to reprocess
[23:54] flexible bronchoscopes and yet in
[23:57] another study comparing the carbon
[24:00] footprint of single use versus reuse boy
[24:02] reros Scopes we find that the carbon
[24:04] footprint is comparable and so it's
[24:07] important to understand that all Studies
[24:09] have limitations but we need studies
[24:11] that require and have the same rigor
[24:14] single Center lcas might have different
[24:16] conclusions than larger Center lcas and
[24:19] so I believe in aggregate two scale
[24:22] large life cycle analysis assessments
[24:24] with decision analyss are required to
[24:27] help us weigh envir environmental and
[24:29] financial impact next
[24:31] slide moving away from medical devices I
[24:35] wanted to focus on personal protective
[24:37] equipment as another Frontier in
[24:39] understanding this tension so many of
[24:41] you might be familiar with the now
[24:43] emerging literature of discontinuation
[24:46] of contact precautions for patients
[24:48] colonized with methylin resistant Focus
[24:51] orius or vyent resistant andus at our
[24:55] own institution we discontinued the use
[24:57] of contact proc for MRSA and V colonized
[25:00] patients several years ago and not
[25:03] surprisingly we found that there was
[25:04] significant decrease in the monthly
[25:07] expenditure for gowns by 61% and by
[25:10] gloves by
[25:12] 16.3% without there being a significant
[25:14] increase incidence in the rates of
[25:16] nosocomial MRSA or VRE next
[25:20] slide in this modeling life cycle
[25:23] analysis looking at reusable gowns done
[25:26] by Bola and colleagues they found in a
[25:29] modeling study that using uh reusable
[25:33] gowns decreased energy consumption by
[25:36] 28% greenhouse gas emissions by 38% and
[25:40] solid waste Generation by
[25:42] 93% next
[25:45] slide and yet we have to acknowledge
[25:47] that there is a tension here that
[25:49] requires us to understand also what is
[25:52] happening in different sectors including
[25:55] Regulators manufact manufacturers which
[25:58] offer different pricing incentives and
[26:00] so how do we carry the weight of this
[26:03] environmental and patient risk taken
[26:06] together it's my belief that the answer
[26:08] here lies in Risk ratification and
[26:11] nuance and that we need to do this
[26:13] together so for example in the most
[26:16] recent American Association of medical
[26:18] insation and American National standards
[26:21] Institute standard 91 there is now a
[26:24] classification to understand that there
[26:26] may be higher risk scopes that perhaps
[26:29] not all Scopes are created equally and
[26:32] that some scopes with elevator
[26:34] mechanisms or complex designs may
[26:37] require more intensive clean and
[26:39] disinfection may require uh a harder
[26:42] look at whether or not sterilization
[26:44] might be a possibility or May in fact be
[26:48] required that perhaps this is one area
[26:50] where single use design may be
[26:53] appropriate in another example looking
[26:56] at the covid-19 pandemic we found
[26:59] then in crisis standards of care use of
[27:01] elastomeric respirators often actually
[27:05] provided a reusable and sustainable
[27:07] alternative to single use PPE and at the
[27:11] heart of both of these examples is the
[27:14] support of the critical concept of the
[27:16] circular economy and what is the
[27:18] circular economy the circular economy is
[27:21] something that allows us to think about
[27:23] products similar to the LCA from
[27:26] resource to recovery to waste so when we
[27:29] think about production are there
[27:31] opportunities to think about rethink
[27:33] reduce and redesign so for example are
[27:36] there different ways in which Scopes can
[27:39] be designed are there more than one just
[27:41] disposable part that can be used for a
[27:43] scope and then secondly in thinking
[27:46] about
[27:47] reuse is there an opportunity to think
[27:49] about different materials that can be
[27:51] used for Scopes such that they might
[27:54] become heat tolerant and sterilization
[27:56] methodologies could then be used for
[28:00] Scopes next
[28:02] slide and so all of this is to say that
[28:05] I think we're at a very critical time to
[28:08] forge collaboration this includes with
[28:11] Partners in institutional wstream and
[28:14] wstream Regulation and understanding
[28:17] their corporate social responsibility
[28:19] platforms it includes also thinking
[28:21] about the national organizations around
[28:23] us like practice green health and the
[28:26] solutions that they may offer for health
[28:28] and lastly and most importantly thinking
[28:31] about the local initiatives that might
[28:34] be occurring at our own Healthcare
[28:35] institutions I know of course I am
[28:37] indebted to our environmental
[28:39] sustainability colleagues here at
[28:41] BMC next
[28:43] slide and so how do we create
[28:45] situational awareness together I believe
[28:48] environmental sustainable polar care
[28:50] managers can share their goals obstacles
[28:53] and Visions with their colleagues in
[28:55] infection prevention control and work
[28:58] with infection prevention control as
[29:00] well as environmental health and safety
[29:02] and establishing Partnerships for Waste
[29:04] Management and recycling our colleagues
[29:07] in procurement and supply chain can
[29:09] ensure that infection prevention control
[29:12] as well as Sterile Processing
[29:14] departments have reviewed requirements
[29:16] for in-house devices related to cleaning
[29:19] and disinfection Sterile Processing
[29:22] departments can share and discuss any
[29:24] operational or regulatory changes and
[29:26] updates and can identify opportunities
[29:30] for using third-party reprocessing
[29:32] organizations or other potential
[29:34] partners and lastly clinicians all of us
[29:37] can involve infection prevention control
[29:40] and clinical engineering when making
[29:42] decisions about tring new equipment or
[29:44] thinking about what we are using in our
[29:46] own facilities and I know you'll hear
[29:48] more about how clinicians can make an
[29:51] impact in this area next so lastly how
[29:54] do we Embrace future change together I
[29:57] believe that infection prevention
[29:58] control experiences can influence policy
[30:01] and regulation but require joint
[30:03] restratification together with all of us
[30:06] environmental sustainability and
[30:08] infection prevention teams should
[30:10] collaborate on initiatives to create a
[30:12] comprehensive approach especially when
[30:14] partnering with other sectors and that
[30:17] further data is needed to assess the
[30:19] Global Financial and environmental
[30:21] impact as well as tradeoffs of single
[30:23] use equipment and lastly that National
[30:26] and Global Partnerships can Propel
[30:28] sustainability efforts and infection
[30:30] prevention it's my privilege now to hand
[30:33] this over to Dr
[30:35] Armand thank you Dr mirocha and a
[30:38] sincere thanks to all the department
[30:40] chairs for the privilege of being here
[30:42] and also Dr mle for his past and ongoing
[30:46] support I suspect that many of you feel
[30:48] the urgency as I do about the climate
[30:50] crisis and perhaps you also hope as I do
[30:53] that we can work together to address
[30:55] this crisis even through our work as
[30:57] physician
[30:59] I will discuss the mitigation of
[31:00] healthcare emissions through clinical
[31:02] practice focusing on asthma
[31:05] care so why focus on asthmacare you
[31:08] already heard from Dr Fury that our
[31:10] current meter dose inhalers or mdis
[31:13] contain potent greenhouse
[31:15] gases if we look again at the UK
[31:18] National Health Services Pathway to Net
[31:20] Zero you see that shifting to low carbon
[31:23] inhalers is not an insignificant piece
[31:25] of their road map the UK K NHS estimates
[31:29] that about 3% of their Health Systems
[31:32] carbon footprint is attributable to
[31:34] mdis the UK and us are similar in terms
[31:39] of the proportion of inhalers prescribed
[31:41] as mdis and a first pass of our MGB data
[31:45] suggests that our own MDI footprint is
[31:48] on the same order of
[31:51] magnitude in the US the emissions from
[31:53] MDI sold in one year are equivalent to
[31:56] driving 500 ,000 gas powerered vehicles
[31:59] for an entire year and though we see
[32:02] other targets for mitigation
[32:03] realistically most of us here on this
[32:06] call are not in a position to greatly
[32:08] influence our Hospital Energy Efficiency
[32:11] or the supply chain but asthmacare and
[32:14] inhalers are very much our wheelhouse in
[32:16] the department of medicine and where we
[32:18] can have significant
[32:20] impact next slide patient education
[32:24] prevention and advocacy are tremendously
[32:26] important in asthma care but outside the
[32:28] scope of this portion of the talk I'll
[32:30] focus on
[32:31] prescribing and specifically next slide
[32:34] we'll talk about the use of short acting
[32:37] beta agonists which I will refer to as
[32:39] Savas and discuss low carbon inhalers as
[32:42] well as treatment optimization next
[32:45] slide so let's start with gwps by way of
[32:49] background global warming potentials
[32:51] this is a quantification of how much one
[32:53] ton of gas will warm the planet over a
[32:56] given period top typically 100 years
[32:59] relative to that from one ton of carbon
[33:01] dioxide next
[33:03] slide our current MD use two HFA gases
[33:08] as propellants they have gwps over 1,000
[33:12] to 3,000 fold greater than carbon
[33:14] dioxide they are better than our prior
[33:17] cfc's that were phased out of the older
[33:19] inhalers and the goal is to phase out
[33:21] these hfas through the kagali amendment
[33:24] to the Montreal
[33:26] protocol next slide there are two gases
[33:29] with lower gwps being investigated it's
[33:32] not clear if they will be approved and
[33:35] the hfo which looks great on paper with
[33:37] a very low gwp is a past chemical and
[33:41] little is known about the environmental
[33:43] accumulation and potential toxicity and
[33:45] if they come to Market they will surely
[33:47] be costly next
[33:50] Slide the other consideration with
[33:53] respect to gas propellants used in
[33:55] inhalers is a quantity in this table
[33:58] you'll see the various albuterol
[33:59] formulations the two available for
[34:01] ambulatory use prental and venine have
[34:04] the same number of actuations per
[34:06] canister and the same amount of
[34:08] medication delivered per actuation yet
[34:11] they differ almost three-fold in size
[34:13] essentially attributable to the amount
[34:15] of propellant
[34:17] used next slide we will come back to
[34:20] this infographic later but note that
[34:23] there's almost a three-fold difference
[34:26] in carbon emissions with a top Arrow
[34:28] denoting the large canister of Albuterol
[34:30] and the bottom Arrow denoting a small
[34:32] canister of Albuterol with a large
[34:35] canister each puff of Albuterol can be
[34:37] likened to driving one mile in a gas
[34:39] powerered
[34:39] car next
[34:41] slide so returning to our thoughtful
[34:44] prescribing strategies for low carbon
[34:46] asthma care if you are prescribing Savas
[34:49] choose a small canister whenever
[34:51] possible and consider limiting the
[34:53] number of canisters and refills
[34:55] dispensed with each prescription
[34:58] not only might this help avoid waste but
[35:01] it could also sound the alarm for
[35:03] uncontrolled asthma and Trigger further
[35:04] patient evaluation when there are
[35:07] frequent refill requests remember one
[35:09] canister 200 actuations is enough to
[35:12] deliver almost four inhalations per week
[35:15] over the course of the year so patients
[35:17] using much more than one canister a year
[35:20] are not well
[35:21] controlled next slide now I'm going to
[35:24] shift gears and talk about the carbon
[35:26] footprint of pis or dry powed inhalers
[35:29] as compared to the MD please don't get
[35:32] bogged down into the details of this
[35:34] slide but the Tome point is that the
[35:36] Cradle to grave life cycle analysis of
[35:39] carbon emissions of mdis in red are
[35:42] about 20 to 40-fold greater than the
[35:44] dpis marked in green next
[35:48] slide what's more patients actually
[35:50] prefer the dpis this German study which
[35:53] was not industry sponsored taught
[35:55] patients how to use 10 different devices
[35:57] devices as identified in this bar graph
[36:00] by 10 different colors patients then
[36:02] selected their preferred device and
[36:04] multi-dose dpis were preferred over the
[36:07] mdis single do dpis and Soph Mist
[36:11] inhalers next slide not only that when
[36:15] given the choice 60% of patients would
[36:18] consider switching from an MDI to DPI
[36:21] for environmental reasons as noted in a
[36:23] different study
[36:25] survey next slide please so how might a
[36:28] DPI compare to mdis in real world
[36:32] patient care The sford Lung Study um was
[36:35] a 12-month Primary Care study of
[36:37] patients who had symptomatic asthma who
[36:39] were on maintenance IC inhal
[36:41] corticosteroids or IC lava combination
[36:45] they were randomized to either a
[36:47] combination of fluos vantol which is
[36:49] known as Brio ellipta DPI or to continue
[36:52] their usual care with their primary care
[36:55] physician next slide
[36:58] um a subsequent analysis showed that the
[37:00] patients that were on mdis that were
[37:02] switched to dpis rep they reported
[37:05] improved symptoms for the asthma control
[37:08] test and they required one fewer savba
[37:11] canister over the course of the year and
[37:13] they had one half the carbon emissions
[37:16] as compared to the usual Care
[37:19] Group this suggests that there is no
[37:21] clinical harm and in this study perhaps
[37:24] even clinical benefit and certainly
[37:26] dramatic reduction in carbon footprint
[37:29] with the switch from an MDI to
[37:31] DPI so for our second prescribing
[37:34] strategy for low carbon asthma care
[37:36] consider transitioning to a DPI if
[37:38] appropriate for an individual including
[37:40] when there is clinical
[37:42] equipoise but there may not always be
[37:45] clinical equipo next slide and treatment
[37:48] options abound with nearly 100
[37:50] formulations for asthma
[37:52] care so how do we how do we choose how
[37:55] do we navigate asthma therapy with all
[37:57] these
[37:58] choices next slide please well we know
[38:01] that using Sabas too much is not good
[38:04] asthma care in the sabinaa study we see
[38:06] this increased mortality signal even at
[38:09] three canisters of saba per year
[38:11] intuitively that makes sense thinking
[38:14] that the more severe disease drives more
[38:16] worse outcomes along with increased need
[38:19] for Saba however the opposite is true
[38:22] for inhaled corticosteroids with more
[38:24] severe disease the more IC used yet the
[38:27] lower the risk of asthma exacer
[38:29] exacerbations this suggests that there
[38:32] might be something inherently
[38:33] detrimental with Saba
[38:35] overuse using results from the Sabina
[38:38] study the S Sabina carbon study
[38:41] calculated greenhouse gas emissions for
[38:43] asthma care in its entirety including
[38:47] hospitalizations Ed visits clinic visits
[38:49] and
[38:50] medications patients with uncontrolled
[38:53] disease had a three-fold higher carbon
[38:55] footprint compared with patients with
[38:57] controlled
[38:58] disease and of that footprint 99% almost
[39:02] all of it came from medications not the
[39:04] hospitalizations and 63% came from Sabas
[39:08] alone the beauty here is that all of our
[39:11] goals align patients do better with
[39:14] controlled asthma which also leads to
[39:16] lower health care costs this has been
[39:18] well documented and controlled asthma we
[39:21] see lowers carbon
[39:24] emissions so now how do we minimize Sava
[39:27] use the international Gina guidelines
[39:30] since 2019 has included steps based on
[39:33] single maintenance and reliever therapy
[39:36] which often we refer to as smart or
[39:38] Mart smartt uses a combined inhaled
[39:42] corticosteroid with fotol forol is a
[39:45] long acting beta Agonist which has
[39:47] immediate onset so it has unique
[39:50] properties for both maintenance and
[39:53] rescue note that this way of using this
[39:56] medication is off label note also that
[39:59] in this preferred track one there is no
[40:02] savba
[40:03] use next slide please in the alternative
[40:07] non-preferred track 2 a strategy coined
[40:10] partic or air is used and I'll let you
[40:13] read the acronym at the bottom this
[40:15] strategy involves using an IC whenever a
[40:19] rescue Sava is
[40:21] used the us-based
[40:24] Napp guidelines has a stepwise approach
[40:28] that is somewhat similar but includes
[40:30] smart um is a little bit different but
[40:32] it does include smart as the preferred
[40:35] in step three and
[40:37] four next
[40:39] slide as promised we uh return to this
[40:42] infographic and if we are prescribing
[40:45] along the preferred Gina track one in
[40:48] the US buzan for motorol is only
[40:51] available as a meter dose inhaler and
[40:53] the one with a more potent greenhouse
[40:55] gas HFA 227
[40:59] um unfortunately the simoc cour turbul
[41:02] DPI which you see down at the bottom
[41:04] with a very small footprint is not
[41:06] available in the US even though this
[41:09] formulation was primarily used in the
[41:11] trials and is available in Canada the UK
[41:13] and much of
[41:16] Europe overall trials demonstrated that
[41:19] using smart compared to Conventional
[41:22] therapies led to a ballpark 35% relative
[41:26] relative reduction in Asthma
[41:29] exacerbations as well as a 20 to 40%
[41:32] reduction in inhaled corticosteroid use
[41:34] over the course of the year now we don't
[41:37] have any real world data on carbon
[41:39] emissions comparing smart directly with
[41:41] the Alternatives but remember that our
[41:44] prior analyses have demonstrated the
[41:46] trifecta of better asthma control
[41:48] leading to lower health health care
[41:50] costs and lower carbon
[41:54] emissions next slide if circumstances
[41:58] require prescribing along genena track 2
[42:01] using partic or air strategy this means
[42:04] adding a second IC inhaler to use along
[42:08] with a rescue savba as marked by the two
[42:10] red arrows and the Red
[42:13] Bracket there is um there are many dpis
[42:16] for IC so that combination marked by the
[42:19] green bracket would be an option for
[42:21] track two with lower carbon
[42:24] emissions in the prepare trial author by
[42:27] Brigham's Dr Israel patients had an 80%
[42:31] adherence with the additional IC inhaler
[42:34] with rescue use I'd say this 80% is
[42:37] probably at best in the real world given
[42:39] that adherence may be better in a
[42:41] clinical trial and that the all or most
[42:43] of the time adherence was self-reported
[42:46] which gen which generally overestimates
[42:48] actual
[42:49] use uh there is a new drug coming to
[42:52] town air Supra uh next slide please air
[42:56] Supra combines butol with budenoside and
[42:58] has been FDA approved if air Supra is
[43:02] Affordable that certainly simplifies
[43:04] genot trct 2 and would achieve 100%
[43:07] adherence by definition it will be
[43:10] interesting to see if this 20 plus per
[43:13] increase in adherence translates to even
[43:15] better patient
[43:16] outcomes so for our third uh final
[43:20] prescribing strategy um consider using
[43:23] smart next slide please for better
[43:26] treatment optimization
[43:27] and Asthma control uh I'm going to tag
[43:30] onto this third strategy strongly
[43:33] advocating for us access to Affordable
[43:36] smart low carbon inhaler options by
[43:39] which I mean simic cour DPI at this
[43:42] point in
[43:43] time there may be barriers to these
[43:46] three strategies including limited
[43:48] access to low carbon and preferred
[43:51] inhaler devices as we discussed limited
[43:54] information at point of care about cost
[43:56] and coverage
[43:57] and limited time it takes a lot of
[43:59] effort to query refill requests to
[44:02] educate patients and to transition them
[44:04] to different
[44:06] regimens but there are resources that
[44:09] help uh with these barriers and I
[44:12] believe there are opportunities for even
[44:14] improved Solutions through more advocacy
[44:17] and more multi-disciplinary
[44:19] collaborative work and more system and
[44:21] process
[44:23] improvements next slide while addressing
[44:27] ing the climate crisis is daunting and
[44:30] bigger than any one of us there is a
[44:32] growing movement to empower Physicians
[44:35] to take action individually and
[44:37] collectively here are a few of the
[44:39] organizations that provide resources and
[44:42] advocacy including from the government
[44:45] academic institutions nonprofits and
[44:48] physician Grassroots organizations you
[44:50] will be welcome so thank you for your
[44:53] attention and uh we look forward to a
[44:56] discussion with your your questions and
[45:03] comments thank you uh very much to all
[45:05] the panelists that was a really sobering
[45:08] session but also one that really gives
[45:10] us a direction as to what we might be
[45:13] able to do collectively as a community
[45:15] to try to solve a problem that affects
[45:17] us all and particularly our patients as
[45:19] healthcare providers so thank you for
[45:21] all the background information and I
[45:22] think it'll be very useful not only for
[45:25] uh our conversations with patients and
[45:27] colleagues by list of our institutional
[45:29] measures that we take so we have one
[45:31] initial question I have one of my own
[45:32] but I will ask one from Dr Reynolds
[45:34] question is have you have there been any
[45:37] EMR Solutions so something you could put
[45:38] in Epic perhaps um where you would try
[45:41] labeling medications with say green and
[45:45] red labels similar to what happens in
[45:48] the grocery store for example to say
[45:50] what is healthy and what is not healthy
[45:51] what is sustainable not sustainable so
[45:53] that when somebody's ordering is not
[45:54] only paying attention to you whether it
[45:57] is covered by Insurance you know whether
[45:59] it's a a preferred um you know the
[46:02] formulary Etc but also what is more
[46:04] sustainable for example on the inhalers
[46:08] Etc yeah I'd be happy to answer that
[46:11] question um I'm not aware of any
[46:14] particular initiatives like that and I
[46:16] think one of the challenges is that we
[46:19] we just lack the necessary data to be
[46:21] able to include that information in the
[46:24] EHR um in many ways and honestly it
[46:27] starts above that kind of at the level
[46:29] of supply chain um where people who are
[46:32] making decisions about the products that
[46:33] we're purchasing just don't have access
[46:36] to information about the environmental
[46:38] impact of the different products that we
[46:39] use and ideally that is a place that we
[46:42] would get to but it involves a kind of
[46:43] labor intensive process of conducting
[46:46] lcas life cycle analysis of all these
[46:49] products so that we can actually have
[46:51] really kind of rigorously obtain data
[46:53] that allows us to compare between the
[46:55] products um that is an area that I think
[46:57] that is one of the direct I think one of
[47:00] the areas in which we find um think
[47:03] people who are advocating around
[47:05] Healthcare sustainability really moving
[47:07] is trying to encourage our suppliers to
[47:09] begin investing um in um Gathering that
[47:14] data so it's so we don't have it at the
[47:17] moment but I think that is ultimately a
[47:18] priority in the future I guess is
[47:21] related to another question that just
[47:22] came in um I suppose that sort of um
[47:25] labor intensive study of the various
[47:28] medication options would also be
[47:30] necessary for for example pressuring or
[47:33] at least influencing the FDA about their
[47:36] approval of products in a way that would
[47:38] also make those assessments um so that
[47:41] then the FDA might be able to go back to
[47:43] to Big Pharma or to insurers and make uh
[47:46] better products as
[47:48] well yeah and I think the follow up I I
[47:51] agree I think that is one of the
[47:53] mechanisms that we could be using in
[47:56] order to encourage device manufacturers
[47:59] and pharmaceutical companies to be
[48:00] supplying that information is really to
[48:02] just make it part of the regulatory
[48:04] process um and I would say there that is
[48:07] one of the areas in which um there are
[48:09] there is like um pretty significant
[48:11] advocacy work going on currently just
[48:14] the followup here from the from Dr
[48:15] Silver who has the question was whether
[48:17] the FDI the FDA might require uh life
[48:20] cycle data for example every time a
[48:22] medication is submitted for approval
[48:24] then that you know that for manufacturer
[48:25] would be on the hook for providing that
[48:27] sort of information exactly yeah and I
[48:29] think that's where we're hoping things
[48:30] are going to go great wonderful another
[48:34] question great talk by all the speakers
[48:36] from uh Dr Matthew along the line lines
[48:39] of labeling products is red or green or
[48:41] you could choose Your Colors by the way
[48:43] uh can Health Systems request their
[48:45] vendors to disclose the carbon footprint
[48:49] of the companies that provide such
[48:53] products uh I'm going to answer this to
[48:57] I'm not trying to take away from my
[48:59] fellow panelists but only because I'm
[49:01] involved in some of this work through an
[49:03] organization called the US Healthcare
[49:04] climate Council which um our um
[49:07] hospitals are a member of and we are
[49:10] actively working on that right now which
[49:12] is how can we begin to um encourage or
[49:16] pressure our suppliers to begin
[49:19] disclosing their own carbon emissions um
[49:22] many of these are kind of large
[49:23] companies and so I think there's hope
[49:25] that with this new sec ruling that's
[49:27] going to require large um corporations
[49:29] to disclose their carbon emissions some
[49:32] of that will be done for us um but I do
[49:35] think that in combination with other
[49:38] Health Systems as well as our group
[49:39] purchasing organizations through which
[49:41] we buy much of the stuff we use in um uh
[49:46] in delivering care that we are going to
[49:48] be able to begin pressuring companies to
[49:51] supply that information and not only
[49:53] their own footprint but also um
[49:56] declaring that they are going to commit
[49:58] to a specific strategy to reduce their
[50:00] own emissions by a certain um amount
[50:03] over a certain time frame ideally in
[50:05] line with something called the
[50:06] science-based target initiative which is
[50:09] um kind of a globally accepted standard
[50:11] for achieving and maintaining uh Global
[50:15] temperature rise less than one and a
[50:16] half degrees Celsius over the next
[50:21] Century uh I have a question for Dr
[50:23] motra and maybe it's a comment and Then
[50:25] followed by a question um it has to do
[50:27] with the decision to discontinue contact
[50:30] precautions for MRSA and VRE
[50:32] colonization I understand you know that
[50:34] is not the practice ad Mass General um
[50:37] and it's a little bit of a area of
[50:40] controversy perhaps where some of the
[50:42] individual studies may show that there's
[50:43] no difference but you know maybe they're
[50:45] not they're they're not looking at all
[50:46] the relevant outcomes you know for
[50:48] example for infection and there's a
[50:51] guidelines from the multisociety for
[50:53] prevention MSA that does recommend the
[50:55] use of contct precautions and then a
[50:57] recent study in the VA across the entire
[51:00] system so very large where hospitals
[51:03] were given the choice of different
[51:04] levels of precaution whether you simply
[51:07] discontinu you use active surveillance
[51:09] or contact precautions for colonization
[51:11] contact precautions for infection and
[51:13] then the hospitals that had the lowest
[51:15] rates of reinfection were the ones that
[51:16] applied the most stringent so I think it
[51:18] is a little bit of a point of contention
[51:21] um and the evidence is still being
[51:23] gathered I guess one naive question I
[51:26] would have is what is the relevant the
[51:29] the relative carbon footprint of the use
[51:32] of disposable PPE versus the old way in
[51:35] which we would have something that would
[51:36] simply be washed so it would be cloth BP
[51:40] and then that would be used and put in a
[51:41] hamper and then eventually wash you know
[51:43] which one actually generates the worst
[51:44] carbon footprint it's a great question
[51:47] and you're rightly identifying that um
[51:50] there is still a fair amount of
[51:52] controversy related to the use of
[51:54] contact precautions or discontinuous
[51:56] contact precautions for patients
[51:58] colonized with MRSA or V and you are
[52:01] right also identifying that uh you know
[52:04] there are multisociety guidelines that
[52:06] still do support um the practice having
[52:10] said that there's an equal number of
[52:12] studies in both directions and this is
[52:14] uh heatly debated at basically every
[52:17] single Society for healthcare
[52:18] epidemiology conference now I'd say the
[52:20] last five years in Sharing each
[52:23] experience and institution's data about
[52:25] the discontinuous ation of contact
[52:28] precautions I will say that as I noted
[52:31] you know really there's just that one
[52:33] modeling study that I showed that uh
[52:35] compared reusable uh gowns versus single
[52:38] use gowns but to your point a complete
[52:41] life cycle analysis not just at one
[52:44] facility perhaps but by region would
[52:46] need to take into account the entire
[52:49] laundering that would be required and it
[52:51] is required for reusable gowns so I
[52:53] think there's two separate questions
[52:54] there one is specific Ally about the use
[52:57] of gowns in general for contact
[52:59] precautions which we can heatly debate
[53:01] and I would I would always add and I
[53:03] take every opportunity to give a plug
[53:05] for hand hygiene hand hygiene hand
[53:07] hygiene um but then I will also say that
[53:10] separate as a question looking at
[53:12] reusable versus single use gowns or
[53:14] disposable gowns I think there's a lot
[53:16] more data that we could collect okay so
[53:20] maybe uh to follow up on on this
[53:21] conversation a little bit uh maybe
[53:23] everybody can comment but start with you
[53:25] Dr mahotra
[53:27] Dr rynolds asked you know there is um
[53:29] hospitals are under different pressures
[53:31] um and for example they need to document
[53:33] lower rates of reinfection to be able to
[53:36] meet metrics that payers demand and and
[53:38] quality assessor demand and The Joint
[53:40] Commission Etc you know we're about to
[53:42] have a jco visit this this winter and so
[53:44] we need to really make sure that we are
[53:46] fulfilling those and so you have that as
[53:49] a must fulfilled measure and then you
[53:51] have the sort of aspiration on the
[53:53] ethical side of things that is maybe a
[53:54] little more ethereal um and difficult to
[53:57] convince and so as a hospital
[53:58] administrator how do you prioritize you
[53:59] know which one to pay attention to and
[54:01] can we kind of thread that
[54:03] needle I think the reality is is we have
[54:05] no choice but to try and thread that
[54:07] needle so yes absolutely I'm I count me
[54:11] in the camp of individuals who are
[54:13] beholden to uh regulatory standards who
[54:16] are involved in Joint Commission
[54:17] pressures who are involved with
[54:19] understanding in particular how
[54:21] disinfection and sterilization are at
[54:23] the Forefront of Hospital accreditation
[54:25] programming particularly when it becomes
[54:28] to patient safety and preventable harm
[54:30] but I think it would be remiss if we
[54:32] didn't also make the case that not
[54:35] thinking about climate health is another
[54:37] area where we are letting preventable
[54:39] harm occur and so I think um there are
[54:42] regulatory entities including the Joint
[54:44] Commission who are understanding this
[54:46] and who are testing different
[54:49] methodologies of incorporating
[54:50] sustainability metrics into their own uh
[54:53] processes and observations and have
[54:55] recognized a fair amount of waste that
[54:58] is included in the infection prevention
[55:00] standards that exist so I think in
[55:02] reality we need to weigh all of this
[55:04] together um it may take and it will take
[55:07] time and I think that at certain
[55:10] opportunities at certain times one might
[55:13] supersede the other um but I think
[55:15] that's much of what happens in how we
[55:16] practice in
[55:18] healthcare so another question connected
[55:20] with that um that the last statement how
[55:23] we practice in healthcare um I don't
[55:25] know about your respective hospit
[55:26] hospitals um but in our hospital it's
[55:29] quite common in the medical service that
[55:30] every patient automatically gets a blood
[55:32] draw every day because you need to know
[55:34] what the potassium and The Bu and
[55:36] creatinine and the CBC is on every
[55:38] patient every day and I imagine that the
[55:41] carbon footprint generated by daily
[55:43] blood DRS that are maybe unnecessary is
[55:46] substantial um do you think that would
[55:48] be a potential area for intervention
[55:49] what you know how would you try to
[55:50] change the
[55:54] culture I can address that I I think
[55:57] that as actually Dr Fury mentioned the
[56:00] importance of looking at whether we are
[56:02] practicing low value care versus high
[56:04] value care and and just I think
[56:07] hopefully with time it'll be ingrained
[56:09] into the culture I think right now it's
[56:12] um uh a work in progress because I think
[56:14] there are so many other tensions and and
[56:17] just to the traditions of what how a
[56:20] medicine is practice and I believe Dr
[56:22] Fury you can speak to this there was a
[56:24] resident uh Peter Tren who actually did
[56:26] a study he'll pass it to you about the
[56:28] the issue with blood draws on a daily
[56:30] basis yeah so there's actually there's a
[56:33] group of residents at the briam who are
[56:34] interested in this specific question and
[56:36] so they have actually um in partnership
[56:39] with Dr Kats they have been leading a um
[56:44] essentially a trial looking at providing
[56:46] an educational initiative at the
[56:48] beginning of residents um uh block on a
[56:52] particular service within within
[56:54] internal medicine and
[56:57] and uh
[56:59] essentially providing some information
[57:01] about low value care but also really
[57:03] tying it to this environmental question
[57:06] and using and using that to see whether
[57:08] it motivates change and so I I think
[57:12] it's an it's a specific example looking
[57:15] at precisely the question you refer to
[57:17] about kind of low value care and
[57:19] necessary lab tests but there are many
[57:21] many examples of this and I think we
[57:23] need to begin quantifying the potential
[57:25] impact of glow value
[57:26] um from an environmental perspective not
[57:28] just a financial perspective and to I
[57:31] think your other question that is one
[57:33] way of really driving change at the
[57:35] health system level because there's huge
[57:38] expenditures here and if we can provide
[57:40] further incentive for reducing cost of
[57:42] care um then that's a compelling
[57:45] argument for for leadership of our
[57:47] hospitals and one potential solution
[57:49] mention in the in the Q&A here is that
[57:51] perhaps we should be using pediatric
[57:52] tubes I mean that maybe that would have
[57:54] an impact if you really need that blood
[57:55] dry could use P too
[57:58] so great so another sort of general
[58:00] question how you motivate people maybe
[58:01] we can close the session with this you
[58:03] know some people will I think the people
[58:05] that are hard to convince you know some
[58:07] people you will never convince on the
[58:08] French but then the people that are sort
[58:10] of hard to motivate are people who say
[58:11] you know fine we can do this but really
[58:13] the biggest toits are outside the United
[58:15] States or they are in other places and
[58:17] so what we do in healthcare is only
[58:18] going to be you know spit in the bucket
[58:21] so how do you really motivate those
[58:22] people to show that even our piece is
[58:24] important I just learned yet recently
[58:26] for from the pope of all people who just
[58:28] issued some letter on climate change
[58:29] that who said that while it is true that
[58:31] say China produces more carbon emissions
[58:33] than the US per capita per capita a US
[58:37] resident produces twice as much carbon
[58:40] than than a Chinese resident so how
[58:41] would you motivate
[58:43] people I would just add on to that that
[58:46] to consider the fact that yes China may
[58:49] have large emissions but a lot of it is
[58:51] manufacturing of things that we're
[58:52] purchasing so if you look at our supply
[58:54] our footprint of 80 plus% a lot of that
[58:57] is because we're purchasing things that
[58:59] are made
[59:00] elsewhere that's a great
[59:03] answer well I of anybody else has one
[59:06] last few words otherwise we'll have Dr
[59:08] Reynolds close the
[59:12] session I want to thank our three
[59:14] speakers today uh Dr Fury Armand and
[59:17] morota what a great um motivating
[59:21] conversation uh gave me all sorts of
[59:24] ideas and motivations around my own
[59:26] practice that I hope to be able to
[59:30] implement um we are excited for next
[59:33] month's Harvard medicine Grand rounds it
[59:35] will be held on November 2nd from 8 to 9
[59:38] as usual it uh will feature doctors hyra
[59:41] war rishy wera and Jason wasi who will
[59:45] be speaking about implementation
[59:47] challenges in cardiovascular disease
[59:50] transforming promise into
[59:53] progress uh hope to see you all on
[59:55] November 2nd
[59:56] have a great week and weekend