Leadership for Environmentally Friendly Health Care2018.cleanmedeurope.org/CME18 presentations/CME18_A4_Sherman.pdf · Leadership for Environmentally Friendly Health Care Jodi Sherman,

Leadership for Environmentally Friendly Health Care

Jodi Sherman, MDAssociate Professor of AnesthesiologyAssociate Professor of Epidemiology in

Environmental Health SciencesYale University A&A 2012 art

Take Home Points• Clinicians driving healthcare pollution

– over/diagnose, over/treat, prevention failure– Candy store culture– infection control excess

• Engage clinicians through practice management– Protecting patients AND public health– Clinical choices matter: compare environmental impacts of

alternative drugs, devices, and clinical care pathways – Compare practitioners to each other

• Value-based payment model and sustainability– Resource conservation is integral to quality and value of care– Track resource utilization by practice/practitioner– Add environmental performance metrics to Merit-based

Incentive Payment System

@GreeningDoc #ClinicallySustainable #CleanMedEurope

‘Kid in a Candy Store’ Culture

Patient safety movement

• 1999 Institute of Medicine report

• 44,000-88,000 people die each year in the US due to medical errors

• A leading cause of death

PatientPublic safety movement

• US health care public health damages from pollution 614,000 DALYs (especially air + GHG)

• Similar in magnitude as the 44,000-88,000 deaths due to medical errors

• Pollution prevention the new patient safety movement

Eckelman, Sherman, PLoS ONE 2016Eckelman, Sherman, Am. J. Public Health 2017

Relative National GHG emissions, and clinical contribution

Eckelman, Sherman, MacNeill (PLOS Med 2018)

SDU, 2012

Example that choices matter:GHG Emissions and Operating

Theatres in Three Health Systems

MacNeill AJ, et al., Lancet Planetary Health 2017

One hour of anesthetic like driving a car….miles (EPA 2012 USA fuel efficiency average, 23.9 mpg)

1-MAC-hour Sevoflurane2.2%

Isoflurane1.2%

Desflurane6.7%

N2O*0.6-MAC-hr

0.5 L/min XXXX 4 93 29

1.0 L/min 4 7 189 57

2.0 L/min 8 15 378 112

5.0 L/min 19 38 939 282

10.0 L/min 38 74 1,876 564

Courtesy S. Ryan

Flow rate and type of inhaled drugs matters

What aboutNon-inhaled Anesthetics?

• Regional/Peripheral Nerve Blocks

• Neuraxial

• Total Intravenous Anesthesia (TIVA)

10

Results - Cradle-to-gate GHG emissions per kg API

30061506

799444

171144140

103968276

373634292322211211

0 500 1000 1500 2000 2500 3000 3500

Dexmedetomidine

Hydromorphone

Phenylephrine…

Ketamine

Fentanyl

Glycopyrrolate

Ropivacaine HCl

Lidocaine

Neostigmine…

Sugammedex

Cradle-to-gate GHG emissions in kg CO2 eq.

Parvatker, Tunceroglu, Sherman, Coish, Zimmerman, Eckelman

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Comparison in Anesthetic Procedures

Clinical Pathways

• MAC: Monitored Anesthesia Care• PNB: Peripheral Nerve Block• GIH: General Inhaled• TIVA: Total Intravenous

Anesthesia• Mixed: A combination of IH and IV

0.0 10.0 20.0 30.0 40.0 50.0 60.0

MAC

PNB+(TIVA/MAC)

TIVA

MIXED

PNB+GIH

GIH

GHG emissions (kg CO2 eq.)

Global Warming for Anesthetic Clinical Pathways

IV (used)

IV (wasted)

Source: GE Healthcare

Field study with data from clinical procedures Results used as a guide for clinicians

Sherman, Tunceroglu, Parvatker, Sukumar, Dai , Eckelman

IV drug waste in the OR

• 30-80% wasted

• Yale, approximately $2 million OR drug waste (top 20 drugs)

• 22,514 kg CO2eq annually

• = 54,778 miles driven (around earth 2x)

• Just at Yale-New Haven Hospital

Tunceroglu, Parvatker, Zimmerman, Eckelman, Sherman

Using the EHR point-of-service ordering system to influence decision-making

Goal to incorporate pollution data

Mock drug performance report

Integrates administration, waste, cost and pollution emissions data

The Team!• Matt Eckelman, PhD and Abhijeet

Parvatker, PhD Candidate, Northeastern University Civil & Environmental Engineering

• Husein Tunceroglu, MD Yale School of Medicine

• Robert Dubrow, MD, PhD, Yale School of Public Health, Climate Change and Health Initiative

• Julie Zimmerman, PhD, Yale Center for Green Chemistry and Green Engineering

• Robert Lagasse, MD, Professor and Director of Quality Management & Perioperative Safety, Yale Anesthesia

Thank you! [email protected]