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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
11
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! Jodi.Sherman@yale.edu
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