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Healthcare is a major contributor to global carbon emissions and waste, with the OR serving as the largest polluter in the healthcare sector. Inhaled anesthetic agents, which are essential to providing safe and comfortable surgery, are responsible for the majority of the greenhouse gas footprint from the operating room, and an estimated five percent of a hospital’s total GHG emissions. Some anesthetic gases have a larger environmental footprint than others. It is estimated that sevoflurane remains in the atmosphere contributing to warming for 1.4 years, desflurane for 14 years, and nitrous oxide for 114 years. Luckily, there are many clinically sound opportunities to address the environmental impact of anesthetic gases.
At this session on environmentally sustainable anesthetic practices, Drs. Anita Rao and Peter Menikefs:
1. Describe the scope of the problem
2. Review best practice guidelines for “Greening the OR”
3. By using local data, demonstrate how the implementation of greening practices leads to monetary savings
4. Share how clinical staff can advocate for a more environmentally-friendly workplace
Les soins de santé contribuent largement aux émissions de carbone et aux déchets au niveau mondial, le bloc opératoire étant le plus grand pollueur du secteur des soins de santé. Les agents anesthésiques inhalés, qui sont essentiels pour assurer une chirurgie sûre et confortable, sont responsables de la majeure partie de l’empreinte de gaz à effet de serre de la salle d’opération et, selon les estimations, de 5 % des émissions totales de gaz à effet de serre d’un hôpital. Certains gaz anesthésiques ont une empreinte environnementale plus importante que d’autres. On estime que le sévoflurane reste dans l’atmosphère et contribue au réchauffement pendant 1,4 an, le desflurane pendant 14 ans et l’oxyde nitreux pendant 114 ans. Heureusement, il existe de nombreuses possibilités cliniquement valables de s’attaquer à l’impact des gaz anesthésiques sur l’environnement.
Lors de cette session sur les pratiques anesthésiques durables, les docteurs Anita Rao et Peter Menikefs :
1. Décrire l’ampleur du problème
2. Examiner les lignes directrices des meilleures pratiques pour “écologiser la salle d’opération”
3. En utilisant des données locales, démontrer comment la mise en œuvre de pratiques d’écologisation conduit à des économies monétaires.
4. Expliquer comment le personnel clinique peut plaider en faveur d’un lieu de travail plus respectueux de l’environnement.
Presentation contents | Contenu de la présentation :
0:00 Intro and Learning Objectives | Introduction et objectifs d’apprentissage
6:41 Sustainability in the Operating Room | La durabilité dans la salle d’opération
12:10 Pillars of Operating Room Sustainability | Les piliers de la durabilité du bloc opératoire
12:20 Waste Management Strategies | Stratégies de gestion des déchets
12:25 Waste Reduction Strategies | Stratégies de réduction des déchets
14:13 Pharmaceutical Waste Reduction Strategies | Stratégies de réduction des déchets pharmaceutiques
17:18 Reuse: Reusables vs Disposables | Réutilisation : Réutilisation : produits réutilisables et produits jetables
25:08 Recycling | Recyclage
27:14 PVC 123 Recycling Program | Programme de recyclage PVC 123
29:20 Device Remanufacturing (Stryker Sustainability Solutions) | Remise à neuf des appareils (Stryker Sustainability Solutions)
31:23 Fluid Waste Management | Gestion des déchets liquides
34:43 Energy Management | Gestion de l’énergie
41:46 Anesthetic Gases | Gaz anesthésiques
41:53 Desflurane
56:14 Minimal Flow Anesthesia | Anesthésie à débit minimal
1:00:28 TIVA vs Gas Carbon Burden | TIVA vs Gaz Carbon Burden
1:02:29 Nitrous Oxide | Oxyde nitreux
1:05:41 The Sustainability Moment | Le moment de la durabilité
1:07:35 Cost Savings | Économies de coûts
1:09:42 Summary | Résumé
1:11:25 Questions and Answers | Questions et réponses
So, some of the objectives, um, the first thing is recognizing that our our employer the health care sector is a major contributor to greenhouse gases, and waste in general, and you can just, if you just, take two minutes and just watch what you’re doing at any given day, it’s pretty obvious to
See. Um and um we’re also going to uh review some of the uh sort of best practices or guidelines that can help us improve our our workspace and our and our influence. And you can actually find
Out that uh while you’re doing this stuff you can actually save the system a lot of money. It’s not all about costs; there’s some uh pretty significant numbers that we can show you of how we
Can save the system money and um learn how to be advocates and spread the good word. That’s part of what we’re doing here today. Um the I’ve been to a number of talks of late it seems to be which is a
Good thing uh sustainability in the environment it seems to be a very hot topic these days in healthcare. I went to one last night and uh I went to an event last night and the keynote speaker was about uh sustainability and these one two three references you hear them at almost everyone um
And that’s because they’re important. Uh the World Health Organization says that climate change is the single biggest um health threat to humanity. Pretty important. Um if the health care sector were a country, we’d be number five in the world in terms of emissions and and whatnot. Ah and
Um if you could sort of remember this number, cause we’re going to go a little further into this, the healthcare sector itself is worth is uh makes up about five percent of greenhouse gases. Just healthcare itself in Canada, which I think is even more than the airline industry. It’s twice,
Twice as much as the airline industry. If you think of like flying a plane as being really a big pollutant, well we’re big polluters. I’ll let you take this ah. So, before the big cop in Glasgow, COP26 um the WHO came out with uh some recommendations and one of them, number four,
So in a in a list of recommendations was for countries to build low-carbon sustainable climate resilient health systems. And as part of, ah, the health program at, in, Glasgow that was led by the UK, the World Health Organization, and the large greening organization Healthcare without Harm,
Canada actually signed on to this pledge to become low-carbon sustainable and climate resilient. So, we have actually pledged that we would follow a path towards greening our health care system. So, where do we stand um right now? Now, this is a very general slide, and some of you may have
Seen this slide before. This is in particular to um to the health care sector, but we need to get here to avoid the worst effects in 2100 um for the climate crisis no more than 1.5 degrees above pre-industrial levels. Right now, um we are aiming towards 2.5 to 2.9. That’s with current policies.
That’s if we actually maintain the pledges we already–sorry 2.1–maintain the pledges we have, but currently we’re going towards 2.5 to 2.9. So, really, this is a call to action for everyone who’s involved in any industry and personally to try and decrease their carbon um emissions. So,
We need a 50 percent reduction today. And it really underlines why we call it a crisis. So um so where are we? So, in Canada, we like to think of ourselves as very nature friendly and green – um this is per capita greenhouse gas emissions,
And this is not just for the health care sector. So, um Saudi Arabia number one almost a 25 tons per capita. The average is 7.5 tons um in the world we are number two. So we’re at 24 tons per
Capita. So, this is quite shocking; we’re higher than um the states and higher than Australia. And ah Australia has a very dirty energy grid with a lot of coal. And if we think of sort of “pure countries” on the um we’ve got Germany and England, who are, the UK, which are quite,
You know, half the amount. So, we’re not doing something right, and in order to um meet anywhere near our targets our own health care per capita GHGs (greenhouse gases) have to decrease. So that’s total. So, as Canadians, we’re pretty bad in the world, where are we with our
Climate foot—ah health care uh footprints so HFCs: [NOTE: on the slideshow it is HCF ((healthcare climate footprint)) but presenter says HFCs] healthcare climate footprint per capita. And um the big orange up there in North America that stands for um like well over one ton,
And we um are the worst polluters. So Healthcare climate footprint as well, we are one of the worst. We’re not the worst; there are some smaller countries and, of course, the states their healthcare climate footprint is significantly higher as a percentage of their total. Um so the
Big emitters: Australia, Canada, Switzerland, United States. These are the top emitters, so we need to do something because our we have high quality care but there are many other countries that have high quality healthcare as well but they’re not producing as much carbon as we are.
I call this, the little bit, the ah force for the trees principle or ah slide. Um, in any given circumstance, when we are in the operating room treating an individual, for example, um we’re trying to do
What’s best for that person’s health but in the grand scheme of things when all the offshoot of some of the actions that we take make their and our environment worse — we’re missing the forest for the trees. So, we’re obliged as practitioners of health care to not only think about the patient
In front of us, but to think of everybody else and and the land around them in terms of how we’re going to behave to make sure that not only is that person’s health good right now but down the road.
So, I will look a little bit at uh our setting in the operating room. Um, this is the cover of anesthesiology from December 2021. Um and this is an artist, ah, she’s Dutch ah I’ll butcher her last name — I don’t remember it’s Maria um something. And um she was having reconstructive
Breast surgery after an initial mastectomy. So it was like a six to eight hour surgery, and she asked the OR team to collect all the waste um that occurred during her procedure. And this was just one surgery. Um visually this really — I mean look at those gloves just that
Alone — to think that that there’s that many gloves that are just going right to the landfill. Um. And uh so, I, I think that was a very uh meaningful slide to me. Um the OR is um very intensive in terms of energy use, CO2 emissions, and uh and ah waste creation,
And 20 to 33 percent of any hospital setting, uh it, you know, it comes down to the OR. So um, we have to focus where we work and some of the things that you can see every day in an OR,
We have to sort of figure out ways to improve it, whether it comes to reducing, reusables, eliminating waste. Remember, remember that five percent figure where the health care is five percent of emissions? Well five percent of that is just anesthetic gases. It’s a pretty shocking
Number and um five percent as in effects on carbon uh on, ah, as a greenhouse gas and whatnot. Um, I’ll keep going here? Sure. Um, so, there are guidelines out there, and a couple few months ago when we started doing this presentation six months ago,
ASA and the NHS — the NHS in the UK is uh way ahead of everybody, well, way ahead of us in terms of some of the initiatives that they’ve done and they’ve been sort of a good benchmark and a place
To to look for information – um but finally uh in January, everybody gets the guidelines to practice every January, you’re waiting by the –well, what would be the, used to be the mailbox, but now is the electronic version um for the guide– annual guidelines to practice, and this year the Canadian
Anesthesiologist Society finally put out guidelines with ah Section 10. Practically, I have it memorized now. Um of putting out some real statements about um about how to practice and practice in sort of a thoughtful way when it comes to sustainability. And some of the key points
Here um emphasis on reusables, uh responsible use of volatiles, ah especially going to low ah low flows or minimal flows. Um and there’s a statement that makes us really happy: the use of desflurane and nitrous should be eliminated or minimized. Ah environmentally friendly techniques
Like regional versus general anesthesia, and basically coordination of recycling programs and whatnot. So we were very very pleased ah when ah we saw that this was finally coming out and now we have our own Canadian standards to go by. So I’m just going to talk about this is um
Dr Andrea MacNeill’s study from U, ah UBC. And it involved three hospitals: one in British Columbia, one in the states, and one ah in the UK, but there — she had a breakdown of the OR emissions from
Vancouver General. This is the most robust carbon footprinting study in um that’s been done to date. Now, this data is over 10 years old — this is not what Vancouver General looks like now, but if you haven’t eliminated desflurane in your operating room this could look like what your OR does now.
So, this is a proportion of the carbon footprint: anesthetic gases were 63 percent. So, if you’re still using a high percentage of desflurane in your operating room that is by far the biggest carbon burden and emissions from your activities of providing surgical care. Supply
Chain and waste is 20 percent, and that includes all of our equipment, surgical equipment, and seizure equipment, um and pharmaceuticals which is a huge source of um carbon emissions in both their production and in their disposal. And energy is only 17 percent. So, when we think of where we’re
Spending our carbon budget a lot of it is felt to be the envelope of say an institution — actually in healthcare it’s the activities that go on inside the building not the building itself. So, I think this is really important, and this is where us, as anesthesiologists, need to focus
And need to alter our um professional activities. And I’ll, I’ll take you back to that picture of the woman who had surgery. And you think of all that waste that’s in that picture, and it, to me,
Again, that picture just has, says so many things about how much how consumptive what we do is, but as soon as you use desflurane that stuff almost, not strong, it’s not trivial, but that makes just such a huge difference. It’s so profess — in such a profound effect that something like
Desflurane has. Um so um we’re going to break down um topics within the OR into three areas, and um the first one of which is just waste management itself. We could spend hours on this. Um so in terms of the basics: reduce, reuse, recycle. Um, we’ll start off with some reduction
Strategies. Yeah. So uh one of the things that us as anesthesiologists a lot of our procurement is actually pharmaceuticals. So, drugs are — we use a lot of drugs and we dispose of a lot of drugs and, more importantly, we waste a lot of pharmaceuticals.
So um one of the things we waste is our resuscitation drugs. So as residents we’re often taught, and so was I, that you have everything prepared at the beginning of the day. And some of those get tossed, some of them never get used, like atropine, um but you toss them at the end
Of the day because they’ve already been drawn up. So, there are some strategies for reducing um uh pharmaceuticals particularly and things like pre-filled syringes. So some of you may have the um either pharmacy prepared for in-house or the vendor um made pharmaceutical like the ephedrine
And phenylephrine syringes. So, there is some data to show that those save drugs because you’re not, you’re not drying up a big bag. Also simple things like putting expiry dates, where the pharmacist will actually look at the drugs that are about to expire: single dose files, because if
You have a big multi-dose file, um you might use just one dose for one patient and throw it away, and there’s there’s a — not only are there carbon emissions there are other environmental externalities like ecotoxicity on the disposal of those. Now, having said that “reduce” is very
Challenging in the OR because as opposed to other places we really have to be concerned with infection control and sterility. So, we can reduce as much as possible but there are some limitations. There are there are some other things about just pharmaceuticals in general. We spend a
Lot of money on pharmaceuticals, so it’s not just carbon emissions; so, an entire hospital pharmacy budget, anesthetists are 10 to 13 percent. So, if you think of all your inpatient wards, your ambulatory, your chemotherapy, we use a lot of drugs even compared to the ICU. So,
Um we it’s on us to also be financially responsible with our drugs. And the most uh wasted drug is ephedrine and atropine. So, these are things that we drop every day. So the other thing with – I, I should have said this earlier– with the ah pre-packaged drugs is they’re a little
Bit safer because you’re not drawing them up yourself; they’re actually produced elsewhere so when you’re tired or it’s late at night you’re not drawing these up you’re taking them off the shelf. So they have the advantage of patient safety as well as reducing drug waste. I like to add,
Um, and I say this in the OR, I’ve used atropine once in 23 years. Once in 23 years. Don’t draw up atropine. So, what do we do with – where, where do our pharmaceuticals go? So some some of us don’t have pharmaceutical bins and they go right into the general garbage.
And the general garbage is landfilled in in most places in Ontario, it’s landfilled. So they that pharmaceutical waste actually leeches into our soil and it leeches into our waterways. There is actually no provincial or federal legislation governing our pharmaceutical waste. There is for some classes of pharmaceuticals; so
Um there is some development on getting, making guidelines for what to do with our waste but the breast [best] practice is incineration of actual drug. But if you have empty vials, they can actually go into the garbage and not into the pharma bin. So the pharma bins are all
Incinerated, but if you have an empty vial it can just go into the main garbage. Um, incineration is quite carbon intensive. I’m just going to ask cause we’ve worked at our respective hospitals for a long time and we don’t know sometimes what goes on out in the real world. From your
Experiences of being at U of T, are there receptacles for drugs like waste? There are. Depends on the site. It depends on the site, yeah. Okay, and are you putting um a half-filled syringe into it or are you dumping the drug in like a juice or? Juicing. All right,
Good to know. And then that gets incinerated into it. Incinerated. Yeah cause like, you know, we have a lot of, I think, at my hospital, at St Joe’s, we have a lot of progressive stuff but propofol goes into the garbage and that’ll just end up in the streams and the waters and whatnot.
Moving on. um so in terms of uh more R’s uh reuse: reusables versus disposables. um this is something that probably when I started practice or maybe around there a bit before, there was a lot, there was a lot more reusable, reusable laryngeal masks and then the the
Disposables came along and they were awesome and they are awesome except that they’re awful for the environment. And so now we’re looking for ways to get back into reusables. Um and it’s a challenge; there’s no question. there is a financial upfront um cost to our hospital, our system. You have to
Know how to process them and and handle them and not lose them uh you know laryngeal masks, when you use reusables it’s amazing how they disappear, especially after you’ve been using disposables for a long time and so, um, it it has to be a very well coordinated reviewed process and there are
Many layers involved from purchasing right down to how it gets handled um in terms of being cleaned and whatnot in various parts of the hospital. Full lifestyle — life cycle analysis is important, um. you’re still making an laryngeal mask out of silicon and someday that’s going to go into the
Waste and that has to ah be considered as well. Um, so, ah, any of you seen reusable laryngeal masks? They’re out there, somewhere? Oh okay good. Um and versus the disposables ah this is just like an obvious one. My, ah, I’ll give you a tiny story. After years of using disposable, ah, Dr
Ali Abbas who’s a real sustainability guy at our place worked hard, hard, hard and last summer we went live with a reusable laryngeal mask program — I think we spent $30 000 on it which was a pretty significant commitment from the hospital and within a month half of them disappeared.
Even though we had planned everything, it just — and so we’re back to the drawing board. But we do have support from our, from our hospital to try again in the future but, very sort of, kind of heartbreaking after all that effort and it’s a leap of faith too from the hospital say
Yes we’re going to invest in this because we think it’s right. And then we kind of lost them all, and whatever. I’ll let Anita take this. Watch your face. Yeah, okay, me. I’m gonna go on this side,
If that’s okay. So so um life cycle assessment for reusable versus disposable LMAs: reusable LMAs are made of silicon and the disposable ones are made out of PVC. So this is a um a study comparing the
Two from uh the States. And you can — even if you don’t know what these categories mean or where they are, the dark blue line here is the disposable and the um lighter blue line is reusables for 40 uses. Having said that, that’s what the manufacturer says, 40 uses, but there are
Studies to show that you can use a reusable LMA, they’re safe and they’re effective for well over that, up to 100 uses. So global warming, we’re at 65 percent um acidification so that’s both soil and water. You’re at just over 20 percent compared to the disposable. The one thing I really like to
Point out is that there are some hidden effects of disposables and reusables that are not obvious unless you do a life cycle assessment. And this is the carcinogens so the production of carcinia– the release of carcinogens and the production of disposables is so much higher than it is
For a reusable. And when you think of how many LMAs are produced in the world per year that’s very significant. So, environmentally, for sure, um reusables are better. And ah, go to the next slide, but what about cost? So there’s always an upfront cost when
You have reusables but in general reusables are almost always cheaper than disposables or if not comparable, when you consider purchase and disposal costs. So, I couldn’t get the price from my institution currently of a reusable LMA but I estimated with inflation the last time we used
Them was 2005. So if you use 40 uses, um they’re ah somewhere between um like 10, 11, 25 depending on how much it costs to manufac– to sterilize them, which is probably an overestimate but I
Put two dollars and fifty cents. But you can go up to 100 uses, and that really brings down the cost. So it depends on your um institution, what they’ll allow you to do. So, it’s comparable –that’s what
It comes down to. This does not account for a loss which does happen in a lot of places. So when you’re assessing reduce– reusables we do, we assess them on something called the triple bottom line, which is also um ah an idea that’s used in many other industries. But
For our purposes we can think of it as clinical performance, so I don’t know if any of you had, well you’ve had the chance to use the reusables they function just as well as the disposables, your environmental impact, and your cost. And I would always put clinical performance number one,
Right? Patient safety would be number one. So um strategies for reusables. So uh Peter talked about some of the challenges they’ve had, but one of the challenges we have at our hospital is really to demystify the risk perception of disposables and reusables. So the reason that disposable LMAs were first
Brought into the hospital, the history is actually quite interesting, in the 1990s there was a lot of concern about Jacob Kreitzfeld Disease and that potentially there could be transmission if there was um some contact with the tonsils or any other lymphoid tissue. That was the original rationale
For getting into disposables, and then they were just um because the upfront cost is lower and that’s what the manufacturers started making. So, there, you do need to um change the culture. You need to engage clinicians, and that’s something that’s sometimes challenging but often with supply
Chain disruptions now we’re being asked to trial a lot of different products and we’re being given disposables. So you really need to engage with those trials in your hospital — be part of the process, and say you want reusables. You need full life cycle assessments. Sometimes you get fulls,
Sometimes the reusables can be more carbon intensive or there are there are um more pollutants, and you really need um your medical device and reprocessing department to be engaged with them, to know what’s possible what’s not possible and how to do it efficiently. Speaking of disposables, um
They’re all over the place, you see them. And they need not be as such, look at that K Basin, it’s plastic, it’s usually going to go in the garbage maybe if you’re lucky it’s recyclable. Um that
Needs to be made out of metal and reused over and over and over again. Um, the Spider-Man glasses, I never use these things just some gauze, tape, you know it’s ah probably a lot cheaper than that. Dis– disposable bronchoscopes came in during the pandemic, um, you know, ah maybe
There was a short-lived time in place but ah we can’t be, we can’t be moving forward in healthcare if we’re doing stuff like that. This is just some obvious easy picking stuff. Um so uh recycling is the third of the three R’s. Um it is really the, it’s sort of the last hope.
I mean the first two are really where the money is but if there are certain things that can’t be uh reduced or reused or whatever then we got to go to recycling. And you know what it’s like,
It’s hard to recycle in an OR. Um there might be bins, and I work so hard to protect my bin and then somebody comes along and throws a rubber glove in or a bloody whatever and I’m
Like “argh” anyway. Um it’s hard. But it can be done, um a lot of education is required because half the time, number one, people like don’t know what to recycle it’s just like at home, is this recyclable? is it not recyclable? And the other thing is what happens when it leaves
The OR. If it’s just, if they all go to the same bin and then in the dumpster, then all that effort of recycling gets lost. So it’s not the best way but there are strategies out there and, again,
With ongoing education, this is um this is a a positive step. The last one I’m just going to point out, this is sort of an interesting one. Studying recycling and waste in the OR, often the best way to recycle is right at the beginning before there’s there’s patient waste,
Blood, what not; the nurses, the scrub nurse, they set up their stuff, I set up my stuff, you put in recycling whatever’s recyclable you tie the bag you’re done. And it’s a little bit of like uh you know perfection being the enemy of good. You know, we
Don’t practice this but it is kind of interesting because as the case goes on somebody loses focus and there goes your gloves into my recycling bin and etcetera. Um, this is a great program
Um I gotta toot the horn of St. Joe’s this was the first in North America brought on by my colleague Ali Abbas. He found a place in Australia I believe that did this, and Ali has worked with the
Institute, the vinyl Institute of Canada, there’s Anita there, we have these in our ORs. You, all we capture is um IV bags and green disposable masks. That’s most of what we capture, and there’s been great buy-in actually in our OR. Things like recycling are difficult, this is pretty easy.
And um we now um redirect a huge percentage of our IV IV bags ah in the OR. And this is just just some of the numbers. Um St. Joe’s will go through, a roughly, this many units in any year and
Um, let’s see, if you think about what it costs to do um to break down or throw a bag out in terms of waste and biohazard and whatnot we’re saving a lot of money. And ah, there, 80
000 pounds of waste diverted in one year at St Joe’s and Humber. Sorry, okay, what do you do with the bags? where do they go? uh they are collected by, is it the Institute? the a vinyl Institute of Canada? So, it’s storage plastics, it’s a local recycler in Southern Ontario. He collects them,
His company collects them. And they are a hundred percent reclaimed so unlike some of the recycling initiatives you may have seen news reports that maybe only nine percent or a small percentage actually gets recycled, um PVCs is completely recyclable and it gets broken down and sold
Into pallets to make things like garden hoses. So we know that this is actually getting recycled. Yeah, so, if you want to make a difference where you are or where you’re going to be in six months or where you’re going to be five years from now, PVC one, two, three just look
It up — it’s a great program. And we’re happy to give you the contacts for the recycler as well. Is it just in Ontario? Is it just in Ontario. Um it’s uh they are trying to expand to other provinces. This is another great program, a Stryker Sustainability, again just Google it,
Stryker’s Sustainability Solutions, and what they do is they collect or we collect and we give it to them um energy devices as we call them these techno things that anesthetists don’t have, you know those expensive staplers at the ligatures yeah ligatures. Those kind of things
Um and the way it works is again you call them up, they set it up, no cost, in fact, you save money. So our um waste uh company is Daniels they bring in these big bins that are
You know we’ll call them lime green or whatever and we pitch all sorts of things into them and then they take that away and they sort out whatever is Stryker or stryker-like or these various companies and it gets shipped off to a reprocessing reclamation factory in the U.S.
Um and we buy it back at reduced cost. and um again you’re saving bits from going into the the landfill. Again, a really great program at no cost to your facility um. So these are some numbers. Um I’m just gonna add with Stryker, there’s no sorting so it actually replaces the
Uh yellow instrument bin. So you don’t– there is so it’s not like a recycling where you have to think about where things go. The only thing that they ask is not to put sharps in, um which is they can use our anesthesia sharps container for that. But it’s so it’s actually completely
A turnkey program. So um just this is uh just the numbers for one year at St. Joe’s. Um you can see them there uh 63 bins collected, 600 devices which is a thousand pounds that didn’t go in landfill
And ah we bought a bunch back and we saved $45 000, so, you know we’re not just doing good for the environment here we’re saving money and we know that all administrators like to save money when you’re running on a tight budget. Uh fluid managemen, that’s you. This is me. So this is
Um so, again, we are on the anesthesia side but we are part of the perioperative team, so, this does concern us when it comes to the environmental impact of the OR. So, a lot of waste is actually fluid waste so suction irrigation, your glycine that goes through your turps,
Um any ascites, body fluids, so 25 percent of biomedical waste is from suction containers, and biomedical waste does have to be handled differently from general waste. Now this biomedical waste that some, a lot of it can actually go just down the regular sanitary sewer
Like it was in your your waste in um at home. Um and many of us will seen see the most common sort of waste management for fluid in the GTA is the suction canisters. So you put the suction in
They have the big plastic canister, they take it out, they throw it out for every case, so it has to be disposed of so either it’s disposed of with these kind of toxic solidifiers that are
Put in to make a gelatinous or somebody has to open it up and put it down the drain which does um make the person who’s doing it the EVS staff vulnerable to splashes. So there are other options, and one of them is our fluid management systems where the fluid is contained
Directly into a receptacle or a centralized system and goes to the sewer. Now this um they there is a capital investment involved in these, and some of them you’ll have seen like the Neptune systems, the sort of the Rovers that go around and when they’re suctioning up from certain surgical
Procedures they’ll go into the Rover and some of those actually have reusable canisters in them so you can they can be taken out, they still have to be um dumped by someone, but they’re actually I shouldn’t say that some of them are automated and some of them are manually have to be uh
To be um put into the sanitary sewer. So there, but the the gold standard and there are many new hospitals coming out in the GTA is a centralized fluid system where you take your suction canister when you’re suctioning someone at the end of the case and it goes directly to the wall and
That gets directly disposed of. So there’s, it’s a safety issue for employees as well as ah saving plastic. so um there are retrofits now, they’re expensive but in the end they can um save money. So I’ll just show some pictures because it’s a little bit hard to conceptualize all of these.
Um, so sorry, return on investment between one and three years unless occupational exposure, and then the next slide. So this is the one, the traditional open, the one that a lot of us will have. These are the Neptune, like the closed systems, I think you’ve probably seen them for
Some of the surgical procedures, and this is the wall to sewer. That’s like the gold standard, and I know we’re getting a new build, you’re getting a new build, and so this is something that we’re pushing for. Energy. Yeah. Yes, Energy Management. So we’re now moving section two of uh OR.
Um, so, this is often this is something that often you might not think of, I never really thought of this before until recently, um the OR is very consumptive uh in terms of energy three to six times the hospital as a whole. Ventilation Services uh ventilation systems uh obviously
Um are are important in the OR, um and if you think about um how, so these things are measured in turnovers and most ORs are 20 air volume turnovers per hour during running time. And if you don’t reduce that at night it’s still going on and on and on. And if
You consider that most ORs are empty for at least half of any given week, you’re wasting a lot of energy. And so the what to do here is as you’re either building, you’re planning your new hospital or you you’re retrofitting your current one, you need to put in consider putting in systems
That are just like smart likes that are like, you know, based on movement and presence of people. Um and here’s a rough estimate it costs about $125 000 a year just for energy in the OR, a standard block of ORs, and this can easily be reduced by two-thirds in
Some cases. And it basically involves um these systems that are readily available um for retrofit or going forward that basically reduce the um amount of turnover and adjust for humidity and whatnot um the in the literature of the Cleveland Clinic which is 10 sites um save
Two million dollars in a year by ah putting in these OR ah HVAC setbacks where you on aff, on off hours you go from 20 exchanges an hour to six. Um, so again not obvious stuff but um but
When you but if you delve a little bit deeper you find that this is ah a good way to save. Question from the floor. So just a quick question on the topic of energy management. I’ve heard that
Bair Huggers are a big contributor to consumption in the OR. Is there a green alternative? Oh, ah, put a blanket on him. You know what I think it’s I, I, I don’t have I mean Anita might have more
Sophisticated um um answer uh. In, was it this past fall or a year ago fall, where there was a study that came out from Australia about the spinal versus general anesthesia, I don’t know if you saw this study, but they did a study where they’re trying you’d think that spinal anesthesia
Or regional anesthesia would be cheaper than than um than general anesthesia and not cheaper but better for the environment and their conclusion was that ah it’s about the same, I think that’s what they said, keeping in mind that in Australia a lot of energy is created through coal. So that,
You know, but um one of the things in that study that I noticed was how much energy is used from the Bair Hugger or body warmers just plugging that thing in and it running you know for a three-hour
Case um so I don’t have a great answer for you but I can tell you I’ve like really pulled back on using them and um like covering the patient with blankets as much as possible which has its own cost in terms of processing and whatnot um but I’m not familiar with anything that’s
More economical than that, and, again, you have to be selective I mean you know in in a 75 year old who has some coronary disease you don’t want them shivering when they wake up but if they’re 25 years old, you know, you’re making choices. About, just an add-on question to that,
On temperature management ah for little kids, you know, you sometimes crank the OR temperature to like 25 degrees just to keep the kid warm. Yes. Has there ever been any investigation to how much energy that takes up? Uh probably, and but I don’t think that that’s particularly
Different than uh in, in a non-OR setting, and the energy for heating is the energy for heating. Um and again I’m just going to go back and say, that is necessary for that patient and the facilities, the energy and heating, is a fraction of the um carbon emissions from everything else,
From the supply chain, the anesthetic gases, so we want to look on where we can make big impacts to carbon reduction and for keeping a patient warm if it’s necessary for patient good patient care that has no patient safety effects, those, those are the kinds of interventions we’re looking for,
But keeping a child warm is essential so I would say don’t use the nitrous though as a carrier gas in that patient. That’s where that’s where you get your your savings. I just want– I can talk about a little bit about the H, because I love HVAC, so ah so
Um we have been trying for a year to try and get an HVAC pilot at my hospital. It’s actually a little bit complicated because there’s a lot of stakeholders involved: there’s facilities, there’s clinical staff, and um there’s also emergency cases like if you turn your HVAC down what do
You do if you use a block of of ORs for emergency cases or if you don’t always use the same OR. So we have three sites, and one of our sites is a standalone orthopedic center that is never used
For emergencies. Now there had to be some upgrades made for that so we we wanted to try a pilot, so we found the perfect OR and that’s a brachytherapy suite that’s only used for elective cases, so um we had to engage with ah the clinical staff to make sure that we
Knew what their schedule was and with facilities and, in fact, they came in, facilities was very excited about this because it shows great energy savings for them, um, and they tested our OR; we were at 39 air exchanges per hour and we only needed to be at
20. And that’s because you can’t always know what the booster fan like how many air exchanges you’re getting and we draw– when we dropped it, we were at 5.9 and um with the current system 5.9 is not
6, so Canadian Standards Association was 6, so we had to make some upgrades, and we just launched our pilot, and we’re going to get data within a couple of months to see how much energy we’re saving. That OR is probably used for 30 percent of the time for the entire week. No weekends,
No nights, ends at four, and not every day. So we will get huge energy savings from that. It can be done, can sometimes not be done with old infrastructure, and it’s not worth um the capital investment to do that or the carbon emissions. This capital investment and carbon
Emissions go together, so something to think about for new builds. So anyway, that’s all I’ll say about HVAC but if anyone’s interested in HVAC please come talk to me. Um anesthetic gases. This is uh where our this is where our focus uh has to be as anesthetist.
Um and in our eyes and our view this is pretty straightforward. Um hydrofluorocarbons, really bad, we know that. We, we know it increasingly in recent years um, and um, if you, so, gases, for instance, are measured by this global warming potential and if
It’s if you take a ton of carbon dioxide um that will create a greenhouse gas effect and of 1, versus desflurane, 2540. And carbon dioxide is bad for the environment, they’re accumulation, we know that, and desflurane is way worse for the duration that it sits in the atmosphere and
The duration ah for how long it does its bad job of absorbing heat and whatnot. Um sevoflurane is much better and isoflurane is um not great but uh still better than desflurane. Um so, this one, I love this slide, this comes from the Canadian Journal if you’ve seen it before if you
Imagine driving a car or sorry if you imagine giving an anesthetic at 1 Mac for 1 hour at 1 liter a minute which is probably a little higher than I want you to do or I, I’d do, um that’s the equivalent emissions of six and change with sevo kilometers, ISO nitrous,
Desflurane. it’s, this is, this is where the money is, right here. This is why we should not be using desflurane. Um so burn that into your brain because I know I have. But that’s just, it, when you’re, when you’re at a cocktail party and you want to make a difference 6.5 sevo,
320 desflurane. I know it’s a fun cocktail party. Question. Yes, a question about the nitrous. So um using nitrous like just initially during an inhalational induction for like, you know, what could likely be less than a minute not and then
Not continuing is that uh obviously the the number shows that it’s not you know carbon wise, but is it reasonable if people do that as long as you’re not running like for prolonged periods of time. So
Um, we can talk, we’re going to get to nitrous in a couple of minutes, do you want to wait until, because I can address that and maybe a bit better and also how the nitrous is getting
To your machine because that in itself is a problem there’s a lot of leakage in our hospital. Um, this is my hospital. So I, I just want to show a graph of how much we saved. So we started a stepwise QI initiative in 2019. So we started with education and at every
Rounds our Chiefs would say who’s still using desflurane, and what cases are you using it for. Um and then the pandemic hit, of course, and we were doing a lot of cases and they weren’t rounds but we still continued and in um 2021 we actually removed the vaporizers — from
Early 2021, we removed the vaporizers from the OR and ah locked up the uh desflurane, sorry desflurane, the vape – the desflurane vaporizers in the AAA room and if you really wanted it you had to go and get it. Also in May of 2021, we dropped our fresh gas flows
On auto controller and Asus machines from 1 to 0.5 liters per minute. so that was for sevo as well, and then we completely eliminated desflurane in February 2022. So um with those two interventions,
We went from 826 tons of carbon emitted per year — the blue is all desflurane, so 757 – to um, now, we still had a tiny bit of desflurane left because we we took out we eliminated desflurane
100 percent the end of February so we were at 82.7 tons. So, 10-fold reduction and we saved $125 000 because desflurane is less potent so it costs more money per patient. So um so that’s pretty significant. And I can tell you I stopped using desflurane probably about 15
Years ago because of cost, just cost. Um and then I saw the other angle of this being the environmental impact and again, this is, this is profound. This is like a 90 percent reduction in in CO2 emissions or if you will or the equivalent. Um by just converting from des to sevoflurane.
So that’s why we believe so strongly about this. So a couple of the questions that we often get is for specific clinical conditions, right, and one of them is Bariatrics. So, um, all of you will have done bariatric surgery or we’ve certainly all had patients who were obese, and
Um we know from other studies outpatient studies in general that desflurane does not um shorten the throughput from PACU to the Ambulatory Surgery to to home. Um, but what about with special populations. So the morbidly obese or um bariatric surgery, um there are studies that definitely show
A timed extubation in the OR is faster, and time to eye-opening and time to stating your name. So there are, but there are some interesting studies if you look at how the methods of the studies, is they compare desflurane to sevoflurane and like this study where they say the modified
Aldrete scores higher admission to PACU but not at discharge. So that means they’re no better at discharge in the time, I do write this here, but the time is not significantly different. But um their conclusions where it desflurane is, because you’re extubated quicker,
It is better. Ah they turned off their desflurane and sevoflurane at the end of the last stitch. So um they waited till the surgery is completely over and then they turned both drugs off at the
Same time. Well, I, I don’t know but I can’t get through my day if I turn my sevo off at the last stitch. I lose my last case. So that’s a little bit strange. That study was supported by Baxter
Um so, you know, it’s biased. So there, there are uh there’s an again this is a different study, volatile turned off at the end of wound closure with no tapering. I, I don’t know who does that. So and then when you look at the differences do these differences make uh make any clinical
Difference? Well there’s no re-intubations because they were still partially anesthetized with sevo, so there’s no patient safety issues. Um now there is one more study, I think it’s on the next slide, where they titrated the BIS to 60, 60 to 70 in the last 15 minutes and they’re not different
In both groups. So extubation orientation, so if you’re using a drug the way it should be used you’re not going to get any differences so the recovery was the same after sevo and des with careful titration. I, I don’t know about this cognition, thing, this was a little bit strange,
But the mini-mental and the CV sevo group was 11 minutes earlier than des. I, I’m not sure if that’s a red herring but um as far as efficiency, which is people will say in safety for bariatric surgery, probably no difference um from this study. I’m just going to add, so, um, Anita and
I have a little bit of a traveling road show and we’re moving around the GTA and even beyond that to places that want to hear our our talk and and again it’s a greening the OR, but we’re really
Trying to say to anesthetists is please stop using desflurane. And you know depend depending on where you’re depending on where you go, there’s always going to be some resistance and some people like oh I haven’t used it in 15 years and other people will be like, you know, no why, you know, I,
I need to use it. There are cases, there’s this, and and again you haven’t been doing anesthesia as long as some of these people and so when you get set in a way, you start to you know be comfortable
In a situation and and and I understand the reluctance to change. And when I look at this information and if you, if, back on the previous study, if you look at the times for desflurane, they are faster than sevoflurine, right, for a lot of things but in the end, if you think about,
Even if it is a little bit faster and whatnot because again I haven’t used in 15 years it’s fast desflurane on and off is really fast and every five minutes of turning over cases definitely matters, um, when you’re trying to get through an eight-hour day and get all the cases done. The,
In the end, I say to myself but is it really worth it? If you look at how horrible desflurane is to the environment compared to sevoflurane, to me, there’s no question that any possible marginal benefit that you might get in specific cases for desflurane is not worth it to me, in cost and
Environmental impact. Just a quick question here, I think a lot of us have heard chatter about waste anesthetic scavenging systems. Yeah. They seldom see them used in hospitals uh is that technology ready for clinical practice? Is it cost effective? That’s a, that’s a really great questions. One
Question that we get frequently. So waste anesthetic gas capture, there are a couple of companies in Canada that that do it. Right now um one of them is ah the aim is actually to capture and to recycle the gases for use they only have a drug identification number for desflurane not sevo
Yet. Um we don’t uh exactly have published data on the capture rates, so how much is being captured, how much is going into fugitive losses, um as well as good life cycle assessments on the energy and infrastructure, how much energy and infrastructure is being used to capture
Gases um versus the gases going out into the atmosphere and what I would say is desflurane is a no-go. It should not be produced, it should not be used, even if a drop of it escapes gas capture, it doesn’t make any sense. Eventually, it will eventually get into the atmosphere no matter how
Many times you recycle it. Low flow sevoflurane at 0.5 or even lower fresh gas flow, I’m not, we don’t know we don’t know what the life cycle assessment is about the whole infrastructure. If that comes out even if it’s destroyed and not recycled that it’s better than as as in a
Publicly funded system, we should invest in those. So, it’s it’s yet to be known. It’s, it’s fantastic we’ve toured one of these facilities, it’s fantastic technology; it’s really amazing, but what happens after the capture um still remains to be seen. And what are
The rates of capture. Yeah, so where are we in the ditch the desk campaign as we call it. Ah we’ve got some we’ve got some pretty good victories here there’s some um pretty solid names uh on here. um we we recently found out, we were trying to to date these things,
Was it Connor that was dating them? Yeah, so Connor was helping us trying to put a, a, a date on the various hospitals and we thought it was sort of like uh Sudbury was first or something and then we recently got in touch with somebody from West Perry Sound Health Center. It
Turns out there is no East or Central Perry Sound health centre and they got rid of it 14 years ago, because they got all new gas machines and had to decide do we buy both kinds of vaporizers
And they’re like nah desflurane is no good. So they’re by far, the ah leaders in Ontario not that it’s a competition but so this is — it’s a bit of a competition. Okay, well. And I think, I think Kingston Health Sciences and Queens just won so they’re getting rid of it as an
Active. Yeah we just heard uh that the hospital’s in Kingston and there’s a bunch of hospitals around them they’re all working together. We, this list is not quite complete um but um you know if you think of how many hospitals there are in the province ,we’re chipping away, we’re spreading
The good word, the nice thing about this list is that if you look at some of the Heavy Hitters here like Sunnybrook, Sick Kids, all of UHN, uh Saint Mike’s is almost there, they’re, we’ve we’ve we’ve
Worked on them they’re almost there but this is a, if you add these up, this is a huge percentage of all the operating rooms. I mean, this might only be, you know, a single digit percent of
All the hospitals in the province but if you add up how big some of these places are this is this is pretty impressive. And so we hope to grow this list ah with spreading ah the good word.
Um so, what do we do? Well, our suggestion is get rid of it from formulary. Don’t make it accessible. If possible, don’t have it behind the counter, get rid of the vaporizers, whatever steps you can do, but if you can’t get to that agreement, things like Anita’s group did like
Whittle it down to two vaporizers, lock it in the RT or RA room, and if you need it it’s a little bit that like over-the-counter, behind the counter — if you need it you got to do that walk
And get it and and that’s a certain barrier. Use it for specific cases, making the meeting guidelines where it might be better. Um but in the end, we ah maybe this is going to just get legislatively banned because you can see we’ve we heard about Scotland recently that was all
All over the news that they’ve just decided the whole country forget it. Um, and the NHS is moving towards that and the EU in general. So maybe you know maybe our work is going to be done for us by
Uh by legislatures and whatnot. Minimal flow. Yes minimum flow anesthesia. And I hope this is not a topic of conversation anymore because this um we had to talk a lot about this before the new CAS guidelines came out but the CAS guidelines have said use low flow anesthesia, don’t use
Desflurane, and in other words sevoflurane is safe to use on low flow. There is no issue with plasma fluoride um or compound A. So there was actually in the meta-anal– there’s a meta-analysis by um by Dr Sondekoppam, who’s um a big ah environmental advocate from Alberta, and he showed that there
Was no impact on renal function in multiple studies and no difference in creatinine clearance. Um so the reason this whole idea of sevoflurane, we need 2 litres ah fresh gas flow from um per minute um comes from um is, it is only in North America. It’s in the product monograph,
And Germany, the UK, Ireland, France, they don’t have any defined fresh gas flow recommendations, so there’s a couple of things we’re never going to get that product monograph changed. There’s no incentive for for ah the manufacturers to do that and it’s expensive and you know there’s it’s a lot
Of paperwork. So we have to come up with our own guidelines to do that and the CAS has done that so if anyone is using two litres thinking that there that there’s an issue with compound A, it’s wrong and they’re not in accordance with Canadian guidelines. I’m just going to ask
Are you familiar with this 2-litre thing in sevoflurane? Oh yes. From the floor. Like their their Baseline is 2 litres and like some of their cases are obviously very long and they have a million operating rooms,
But I’ve heard that they are trying to go down to 0.5 as their like default that it would go to um but it sounds like it’s like a really hard thing to do for some reason is it like how do
They actually do that, like change the settings on it. So the the biomedical engineers will just go in and change the programming uh we we did it in a couple hours I guess, our biomedical technician.
Okay, so hopefully — but do you mean, do you mean the default on the ah tidal control is two liters? Yes. Exactly, yeah that’s correct. And do people run 2 litres? Yes. The default on their end
Tidal control is 2 litres not 1 litre even. Yeah it’s um it’s it’s it’s not (crowd chuckles) that it’s it’s not that hard to change. Okay. Yeah. That’s reassuring hopefully it’ll change soon, yeah. But. They’re aware of it. But hopefully it’s the barrier is just they never got around to it
Because just to give it a little bit I think you were shaking your head, you’ve never heard of this before, going back let’s say 15 years ago when sevoflurane was becoming more, or 20 years ago, 25 years ago, when sevoflurane was coming out on the market there was concerns about
Um the um breakdown products, something called compound A and part of it had to do with the soda lime that was being used and creating by-products that were somehow ah harmful so the recommendation was, well, if you don’t go under 2litres a minute of fresh gas flow you’ll just sort of flush it
Out, and this quickly became debunked I, they, also there was a there’s been a general change with the soda lime ah and the basicity of it and but people really hang their hats on it and
You go around the province and you’ll still see people you peek in the OR and they’re like oh my god 2 litres a minute, please stop, this has all been debunked it doesn’t exist anymore but people are resistant to change. So ASA, CAS, World Federation of Societies of Anesthesiologists,
Minimum flow is safe. That’s what comes down to, you you’re not in compliance with guidelines. So back to CAS, January 2023 desflurane and nitrous oxide should be eliminated or minimized to the extent possible given local resources location in the clinical context, 1 litre a minute,
Maybe even half a litre. And in fact, if you go off in tidal control you can get down to 300 CC’s a minute. Yeah. If you really want to(crowd chuckles), if you really want to do that. So one
Of the things we get asked about a lot is uh TIVA versus um ah volatile anesthetics. Maybe we just shouldn’t be using volatile anesthetics at all and in fact TIVA’s a great anesthetic so what is the carbon burden of TIVA versus volatiles and what are the environmental impacts. So
Um actually the uh the energy to um power the pump is actually what are most of the carbon emissions that come from TIVA from the REMI and propofol and so there is a good uh life cycle assessment for
Carbon emissions and it’s the next slide that has propofol which you can’t see on the graph because the carbon emissions are so low, now this is an old um, this is the study is a bit old, and it
Includes nitrous as a carrier gas just so you’ll understand this is actually worse than if the desflurine and sevo were used on their own. And UM the production of propofol and the production of the gases is the blue line so it’s not a lot per juice it’s mostly the direct emissions. Now
Sure propofol is a lot less carbon intensive than desflurane or sevoflurane but this was not a full life cycle assessment it does not consider other environmental impacts such as water toxicity, soil toxicity, eutrophication, land acidification, all of these things are important, what we do know is
Propofol is toxic and even when it’s released from the patient’s body the metabolites of propofol are toxic so I don’t know the answer I think still if propofol is better for your patient, if it’s a young woman who’s potentially going to get nauseated, Tiva is probably a better choice
But environmentally we don’t know the answer to that. And think about how much propofol goes into the garbage, lots. Yeah we waste 50, 50 percent of the propofol we drop we waste. um nitrous, so I, I’m just going to go to that uh question that Connor asked before.
Um so nitrous is terrible for the environment in fact in all other industries over a certain level nitrous is actually regulated how much release um for for medical use it’s not because it’s felt that it’s necessary. Now medical uses and that’s for everything so obstetrics, dental is
Only about 1 percent of total nitrous contribution to the atmosphere and it is on the WHO’s list of essential medications, however, it is an ozone destroying gas and it’s subject to the Montreal Protocol and the Kigali Amendment and um but ah do we need it in anesthesia is the question. And
Um the CAS says no, the ASA says no, and most importantly I think it’s the next slide is the World Federation of Societies of Anesthesiologists in 2021, if you read this paper which is fantastic, actually asks high resource countries to please not use nitrous
And save it for low resource countries. Nitrous is cheap that we know that worldwide surgical care needs to improve in low resource countries, leave the nitrous for them we should not use it. The other thing that’s getting a lot more attention um is how much nitrous leaks from
A hospital and how much actually ends up at the patient, and so there’s a lot of infrastructure to getting nitrous to clinical use everywhere in the hospital. Centralized nitrous comes from a tank or comes from these large cryogenic tanks somewhere in the hospital and have yet to find out where
In mine and it’s piped all through the hospital and these pipes leak, the big tank leaks and the cryogenic tanks leak, 90 percent of nitrous is leaked out before it even gets to your machine. So we keep filling up these tanks and it just keeps going to the atmosphere for no reason
It’s just like running a hose in your yard, so even more than using it as a carrier gas, you’re just you need 10 times that amount before it even gets to you. So multiply what you’re using by 10;
9 or 10 depending on on, so um we don’t need nitrous. World Federations of an, Societies of Anesthesiologists said please don’t use it, I know people use it in Pediatrics, um it can be done with sevo; anesthesia can be done with sevo. So uh now we have
Been trying to get nit, uh desflurane banned, um the Ontario the OMA actually endorsed Ontario’s anesthesiologists to try and put a carbon price on anesthetic gases, if that happened um desflurane would just not be used. It would it would be too expensive, this is the only OMA
Endorsed statement on the environment, this came out in 2021. Anita worked hard to get this done, finally got them to agree. And UM the next one is, this is Peter’s, it came out published last month. Yeah, one day when we were probably hanging out debating what’s the best pizza in the West
End (Anita chuckles), Anita and me which we do all the time. Uh yeah, we came up with this idea and this is something that I’ve started to do and we’re trying to spread the good word, I don’t know
If any of you have seen me do this, but um I tack this on ah at the end of the timeout just before we get started when everyone’s paying attention: nurses, surgeons, residents, whatever, and I say sustainability moment or green timeout, and I usually say something like
Please don’t put gloves in the recycling bin, please don’t put things, please don’t put non-blood-soaked sponges in the yellow um bio bag um, and ah cheap and safe is better than expensive and safe. And it’s just a reminder to everyone in
The OR um, that we all have a little bit to do and um I’ve found very quickly that yeah there’s you know you often get a little bit of a laugh from somebody but it’s it’s it is interesting how
How people really buy in. And what happens is it circulates, nurses start to police the recycling on that side of the room like I placed mine on my side and and the surgeons will start to to think
About stuff like this. So it literally takes 10 seconds it’s just a reminder um if I’m with the same team all day long I’m not doing it every case but I’m certainly going to start my day that way,
If there’s a changeover of personnel I’ll throw it in as a reminder um and um yeah Green pause, green timeout, the sustainability moment — call it what you will just uh take it out there and propagate it until it becomes worldwide just like the surgical checklist.
And, are we done oh yeah so we’ve saved the planet and now we’re saving money doing the same thing. These are all essentially initiatives led by Anita at Trillium Health Partners away we go let’s look at how much money we’re saving. So 125,000 um from anesthetic gases which I keep telling my
Chief that’s what I’m using my second index budget for (crowd laughs) um the inter-surgical circuits, these are the the ah week-long circuits as opposed to changing I think Sick Kids after every patient and sun and Sunnybrook and in some places after every day. These are Healthcan approved for one
Week we’re going to save 37,000, um we just put them in this year so that’s projected. Bring your own reusable bag so those toxic patient bags, belongings bags, that are made of plastic have you ever seen them um if you go out into surgical check-in they’re very heavy duty plastic we’re
Going to save just by decreasing 50 percent of those bag distributions in elective surgeries alone 466 tons of carbon, remember one person in Canada puts out 24.5 for the entire year so this is a lot of carbon just from plastic bags, $19,000 is what we’ll save. PVC 123, we diverted 2.6 tons
In the first year um it’s not a lot of money it’s a few thousand dollars, ah Stryker device recycling 1.2 tons diverted that’s over two years and we saved $145,000. Reusable gowns this is actually um the Ottawa Hospital data, um 117 tons of CO2 will be saved and they’re about the same
Size as us so I’m using those numbers, and we’ve just started our transition, we’re doing trials now, eleven thousand, and HVAC setbacks, I’m very excited this is going to be big savings, once we
Get our data in a couple of months. So um this is how you pitch it to your administration about why people need protected time to do this and um why there are cost savings in greening interventions. So, are we uh the second last slide I don’t remember what the last one is,
Um, so in summary, you’ve seen a lot of good stuff here great for the environment, cost savings, um but there needs to be coordination. You need to put together a team, you need people that listen, you need people up in administration. Um there are tools out there, CASCADES
Has lots of stuff to help us, and now Ontario’s anesthesiologists, that’s us, environmental sustainable working group, join us. Um the Canadian Coalition of Green Health, PEACH is another one there’s stuff out there on the internet, readily available,
Um and we have to engage our leaders and we have to be leaders in this kind of stuff so put together a green team. At St Joe’s, we got a perioperative green team. Um and pick projects ah this has to be from physicians, administrators, to custodial, to medical device RD, reprocessing,
Reprocessing whatever everybody’s got to be involved um to make changes. Do you have to do Qi projects in residency? Kind of maybe, you could if you wanted to, okay. You have to do something.
Well that’s what I mean, you have to do, you have to do something and QI is think these are easy. Find a project find something that you don’t like at one of the teaching hospitals and you will
Find somebody that will listen and be a mentor and if not just call us and we’ll mentor you, you or we’ll find somebody to mentor you for a QI project based on environmental sustainability. And that’s it. If anyone has any questions? So,
Just a quick question, so at the start of the talk you mentioned reusable LMAs and then came back at the end to reusable circuits. Ah what else might we be able to reuse them or not yet? The obvious ones are reusable gowns um in the OR. We have reusable gowns at St Joe’s
Um but drapes drapes are really very much in the um non-reusable pretty much I don’t know that there’s many places that use reusable drapes um but that would be an obvious big one and then you
Know, but along that line, so because I started to ah see things in the OR more than I used to, we’re doing sinus surgery and it’s a disposable drape and you know you set up, you get your circuit in
Under the drape, and then they lay out this like full length quilt of a drape and it’s six feet long and I said to our charge nurse, well why not just like a little halter top type thing or you
Know what they use in cataracts is just a little thing, why we have four more feet of of disposable drapes. So even if you can’t go in that direction you know there’s always things that can be done.
What other reusable things that you can think of? So for anesthesia reusable masks I think there’s some places that use disposable masks exclusively not just for special populations like MH um and — Certainly when I started the circuit mask when you’re inducing anesthesia those
Were all reusables. And um ah definitely during the pandemic we saw some supply chain disruptions and those centers that had a lot more reusables like isolation gowns, they weren’t subject to the same supplies chain disruptions, so masks is one of them,
Is you could run out of anesthesia masks if all of a sudden they have a hurricane in a place where they produce them and and ah that’s not just a theoretical concern right, that happened in Puerto
Rico where they do make a lot of um reusable medical equipment and it was in short supply. I got two questions. So first one, is are there any surgeons on these green committees? Uh all of them. Yeah. So in in ours, we’ll have surgery, anesthesia, nursing, MDRD,
Um and uh and nurses from different areas, so the PACU is a huge champion and EVS staff, so we have EVS Champions. Like the Cascade thing in your group like it’s all it sounds like it’s Ontario anesthetists and is there ASA? Is there a surgical– So we we are we’re Ontario’s
Anesthesiologists environmental sustainable working group so we’re anesthetists. But there are groups out there I don’t have the names or the tags of them but in our travels and our journeys we certainly have found some very enthusiastic surgeon champions, there’s — around around the GTA and around the province. There’s several there’s several groups
That include surgeons and the OMA, the Green is Health Medical interest group has surgeons. And then my second is like from my experience I think I don’t know I’m not gonna speak for everyone but I think a lot of residents are very mindful of kind of anesthesia being green like
I don’t think I’ve seen a resident use desflurane ever um and a lot of the younger staff are similar I was going to ask how do you find the kind of uptake from your, the old, like the older
Colleagues because I think in my experience I would like I don’t like to use a stylet and I don’t like to use disposable laryngoscope blades like the McGrath if it’s not indicated and then
A lot of older staff would be like no no no you every time you have to use this, every time you have to use this, and it’s I’m kind of there as a resident and be like yeah okay fine. Yeah
You know what I mean you’re (chuckles) you’re for the next little while you’re you’re you’re on the one hand you’re kind of somebody’s above you and if they say, you know, it’s hard, but you know, you’re the future, I’m old. You’re the future and you’re
Gonna take these ideas and you’re gonna propagate them and you’re going to teach them to Residents in the future whereby someday desflurane is going to be like a story to tell um so you’re right now during residency you know you’re you’re still kind of caught in between but
We’re doing our best to uh to create change in the reality is that if older staff keep on hearing it over and over again from us and you and whatnot well you know sometimes they’re going to change their ways. I think the momentum’s changed a bit, the more awareness people have about the
Climate crisis in general the more people are engaged and willing to make a change. So if you educate about what the actual waste imprint is or what the actual carbon footprint is um your staff who’s been doing it the same way for a long time may be willing to change.
So because we all have things we care about, right. And ah so and those will all be in jeopardy. And has there been any things looking at what people’s kind of green mentality is outside of the OR versus inside because I feel like kind of I worked
In the UK for a while and a lot of people there were very pushing for it and there were a lot of people that were like well I don’t recycle at home so why would I do it at work and it’s like okay,
Well, fair enough so you’re kind of a lost cause. Yeah you know what you’re gonna I mean obviously you’re gonna be faced with that kind of, you know, the standard if I ever call anybody on oh please
Don’t put the gloves in my recycling bin or please open the gloves, what’s the standard answer, rather than you know a lot of times it’s you know sometimes it’s like oh yep you’re right but a lot of times it’s it’s defensive it’s like oh that doesn’t get recycled anyway, you know, but if
We can’t, if we don’t try, then we’ll just end up with the status quo and you saw from the numbers, from temperatures, and whatnot what the status quo gets you. I, I think that’s the reason why we
Have to advocate for system change. So we have to do it as a systems level it’s like a QI paradigm, right, education will only get you so far, you need to actually have a stepwise um a
Program where you get to that forcing function, where you just say you know, you, you don’t have a choice of throwing that gown in the garbage because guess what we have reusable gowns. So, I would say if you if you want to make a change certainly you can on your day-to-day effort,
But if you want to get involved and make a systems change that is where your real change will be. Uh this is back to the question about disposable items, so the individual item I throw out the most is syringes. I imagine 50 years ago they had glass syringes and they gave medications with
That is there any different, well, but when I suggest that people look at me crazy. Is there any reason why you can sterilize surgical equipment which is in regular contact with blood and you can’t sterilize a syringe which most of the time doesn’t even contact blood but contacts
IV fluid uh you know five feet up the line. It’s a great question, I, I, you know the only uh uh the only people I’ve seen that use the glass syringes but they but they’re disposable are the dentists.
So I I don’t I don’t know the answer to that, I don’t know the answer to that. It almost seems like one area where we’re deliberately have a blind spot because we just don’t we just don’t know, but you’re right, they ah IV, IV banks used to be glass too.
Um just a quick question, you know, we work with hundreds of staff over residency so we see a lot um sometimes we try, I’ll try and bring something up and say hey have you ever thought about using[sevo in this kind of case yada yada and trying to approach a conversation, um often what
I hear back is they say you know, James, we’re doctors, we treat the patients in front of us, I don’t treat the environment. How do you, do you have any tips on how to approach that conversation? Wow. So um so treating the patient in front of you is aligned with treating the
Environment, right, so um it is our responsibility as physicians to be accountable to the health of our community as well. And so you can say that it may not get you very far but you’ll be working on your own soon um you can also direct them to our Ontario’s anesthesiologist uh statement which
Says exactly that, that as a profession we have to be responsible for community health as well because we’re physicians, we’re not just anesthesiologists, um and there is no detriment in anything we’ve said, we’ve shown the studies, there’s no patient safety issues
With using sevoflurane versus desflurane for every patient population but of course I can say that it’s hard to say that when someone’s evaluating you and how you’re performing so. Um, yeah, so another question. I guess like um the big, I guess my takeaway is like desflurane
Is very bad but there’s already been like a lot of change like positive change and probably trending like most hospitals will probably adapt this this model, seems that way, so like let’s say you check
That off and that’s like the big one, what’s like the next uh biggest change you can make in terms of bang for your buck like especially not these finite things. I love the way you’re thinking cause I, I agree with you like I’m so tired talking. We spend too much time talking about
Desflurane where we really shouldn’t like it’s a, it’s a closed case. It’s done, we’re tired of it. But you know there’s no question there are, it’s kind of like if you spend all your time talking
About recycling, and recycling is I mean it’s okay but it’s not really where the money is. We’re not gonna save the planet, we’re not going to recycle our way to the future, right, so in terms of bang
For the buck in terms of stuff that we’ve talked about here I mean reusables is gotta be a huge one. Getting away from disposable stuff and the energy ones too uh like you know if the HVAC HVAC
Setbacks and stuff, if you can cut the amount of electricity that we need every day in the OR um to recirculate air, humidify, heat, cool um that’s a huge one. I I think the the one
Thing that we have a lot of agency over that I want to change and this is my my goal for my project for this year is nitrous mitigation. So um I think the numbers that we show for des,
When we actually get the numbers for nitrous may even be higher, because how much we’re they’re just going it’s just leaking into the air. And so I would say that is a huge project and requires
A lot of stakeholders but that would be the next one and I think what we should be doing is there’s multiple hospitals being built in the GTA, no centralized nitrous pumping. If we can somehow get attention to that and it’s all over the UK they’re they’re
Just stopping nitrous use, um and they use a lot for LND and we’re not taking nitrous away from people we’re just taking the centralized sources away because you can uh you can have nitrous for LND but you can use the tanks, they don’t leak like centralized supply. So we’re not saying
Don’t use nitrous, we’re saying just don’t use centralized supply. We are saying in anesthesia don’t use it as a carrier gas because it’s not needed but nitrous is needed in some places. Um the other question I have is around like disposals. I find there’s a lot of like even, even
In my own products I find I get confused about like where to put certain things. Is there any um infographics that have been used to like indicate things like which is and obviously different hospitals like you mentioned some have the medical waste, and the sharps waste,
And a garbage, and a recycling that’s like best practice but then many places don’t have any of that stuff. So like how do we figure that out. So I love infographics because we’re constantly being
Asked to can you put something on the wall, can you do this, can do that but then it changes two weeks later and then it’s difficult to keep up and even with recycling like at St Joe’s what we can
Recycle right now at St Joe’s is different than it was four or five years ago ah because of changes it changes in the market. Soft plastics, you know, your your syringe you separate paper and plastic and it used to be separate both in the garbage, both in recycling, now it’s separate paper,
Recycle plastic coverage because there’s no market for that. Um our my our colleague Alia Abass uh has put together this huge slide slideshow just in the last couple days of how to handle um OR waste particularly biohazard stuff um that even I didn’t know like I, if you had, in theory,
If you have a like a gauze that has blood on it I thought it was supposed to go in the yellow bin but in fact it’s only supposed to go in the yellow bin if it’s soaked. I didn’t know that. Um and so
It’s hard, so do I have something easy for you, I don’t think I have anything easy for you but if we continue to develop our Cascades websites, their environmental sustainability website, these various sources and if you tinker around and just look at the ASA or whatever there are things
On there um that provide a, provide a, a good guide but we all need help with this because you know we’re supposedly specialists in this and I’m just learning stuff all the time about this kind of stuff. One more question, one more question. Sounds good, this should be a quick one. Um so
First of all just to clarify like when we have ah like a glass vial of medication once we draw it that empty vial can just go into the garbage, correct? Except, yes, so your propofol vial goes into the garbage. Yes. Not, not sharps, it’s not sharp, only sharps go in sharp; however,
If you rip the lid off of it the bottle can go in recycling, the lid goes in garbage. Okay perfect, and I guess just as a second point, I’m sorry that was just to confirm my understanding,
So I didn’t say something uh dumb from my second part. But that that is my understanding and that’s why I was doing it and I’ve had a few people you know both anesthesiologists, surgeons, custodians, nurses, tell me that that is a sharp because once it goes into the garbage it can smash
And you know they kind of make me feel guilty because you could potentially harm the people that because I don’t throw these things out right so. Every place, every place has a different set of guidelines but in general, so for I’m a glass syringe person when it comes to epidurals I don’t
Use the plastic syringe I always use a glass syringe that comes in our kits that’s garbage. Again at our facility, that’s garbage and maybe from facility to facility it changes a bit but that’s that’s what we use and so, you know, when you if you peek inside the sharps container and
You see syringes and gauze and it should just be Fentanyl and needles, almost exclusively, that should really be the only thing that’s in in ah your sharps container. And you know the big thing about these things is that the cost to incinerate those stuff, that stuff is incredible,
The cost incinerate the yellow bags, the bio stuff, is huge compared to regular old garbage and… yeah yeah in a way you know at home glass, you know your recycle glass or it goes in the garbage it’s you know it’s not incinerated sharp style. So again I’ll continue my practice and
Just take any feedback. As long as it’s consistent with your local policy interestingly we have three centres, in one centre the pro- they want the propofol and the sharps at the other two it can
Go in the garbage. So it is it it you still have to follow the local EVS guidelines but in general there’s no uh issue with a tiny bit of profile in the garbage as opposed to the pharma bin,
I know that was slightly different than your question but yeah. No, no it’s very helpful. Is there any um anything with Xenon in the future because I know it’s really expensive, but it’s like… Good, good, yeah good question. You see it at conferences, I’ve been
Seeing it at conferences for 20 years I’ve got the Xenon thing. I, I don’t know much about it it really it it was it was one of those things years ago where it was like this is the future
And it just here we are, we’re still looking for the future. So I, it’s never made adequate inroads that I’ve seen adequately. Uh I mean there will be some innovations in anesthesia um we don’t have a lot of innovations in anesthesia in general, but I, I mean it’s possible that we’ll
Come out with some you know non-GHG anesthetic gases — there are some innovations, memsorb, um like a new CO2 uh it’s it’s more of a filter than it is like an absorbent which really has no waste whatsoever instead of those thousands of kilos of soda lime, and baralyme,
Spherasorbs that you throw away but it’s uh there may be some things coming but I think the climate crisis demands that we don’t really look to innovation that we really do something today. So potential easy and on in the future but for now low flow sevo or tiva Okay, that’s it.