Several years ago Praveen Kalra, MD, was doing research to prepare a talk about anesthesia when he read a report that stunned him: It said that each year, emissions from anesthetics used in surgeries harm the climate as much as the carbon dioxide emissions from 1 million cars.
“Wait, is this true?” wondered the Stanford University Medical Center (SUMC) anesthesiologist. Kalra knew that most anesthesia gases are not metabolized by the patient, but instead are exhaled and captured in ventilation systems that expel the gas out of the building and into the atmosphere. But he had not known the extent of the environmental damage. He dug for more information and found another unpleasant surprise: One of the common anesthetics used at SUMC, desflurane, produces greenhouse gas emissions at a rate 2,500 times higher than carbon dioxide.
Kalra led an effort for the California medical center to eliminate desflurane in favor of far less environmentally damaging anesthesia drugs such as sevoflurane. That change eliminated 1,200 tons of greenhouse gas emissions in 2020, Stanford Health Care reports.
As hospitals increase efforts to reduce their carbon footprints, the SUMC experience illustrates the creative ways they are making progress, in addition to high visibility, high impact projects like switching to solar power and installing energy-efficient windows. While such major investments are essential, they must be supplemented by countless changes in the most fundamental ways that hospitals carry out their business — like re-sterilizing unused surgical tools and using hot water from a city’s woodchip incinerator to heat buildings.
Creative thinking is especially important after 61 of the nation’s largest hospitals, health sector companies, and nonprofits, including the AAMC, joined the Biden administration’s Health Sector Climate Pledge last month to reduce their greenhouse gas emissions by 50% by 2030 and to reach net-zero emissions by 2050.
Meeting that pledge will have a big environmental impact, given the health sector’s outsized contribution to greenhouse gas emissions around the world. A 2019 report, Health Care’s Climate Footprint, led by the international nonprofit Health Care Without Harm, concluded that “if the health sector were a country, it would be the fifth-largest emitter [of greenhouse gases] on the planet.” The biggest contributor is the United States, accounting for 27% of the global health care carbon footprint, the report said.
Hospital systems that have been working to reduce their greenhouse emissions shared their lessons about what works, in terms of both physical changes and new approaches for working with staff and communities.
Look for small wins
Pilot projects: The Ohio State University (OSU) Wexner Medical Center in Columbus has diverted 50 tons of plastic annually by converting to reusable containers for “sharps” — items with sharp points and edges such as needles, syringes, and fingerstick devices to draw blood. OSU has thousands of sharps containers in exam rooms, operating rooms, and other places, and as with most hospitals, the routine practice had been to discard each container when it was full, for safety and sanitary reasons.
The medical center sustainability team worked with a multidisciplinary internal group to use reusable sharps containers in some rooms. The contents of the new containers were safely disposed of through a vendor, then the containers were cleaned and put back in circulation. Each container can be used up to 600 times, Dial says.
“We use a pilot approach to test things because the downside is minimal and the upside potential is great,” says Aparna Dial, OSU’s senior director of sustainability and strategic services.
The test was so effective that the change was expanded across the medical center, Dial says. Last year, OSU reports, this process kept more than 150,000 dispensers out of landfills.
Low-cost changes: Ian Hughes, sustainability manager at Rush University Medical Center in Chicago, admits that when talking about how to save the planet from climate change, controlling air conditioning valves “is not super sexy.” But it pays off quickly.
Rush recently examined the valve systems that run various functions such as heating, air conditioning, and humidity, which are primarily controlled by sensors and valves tied to a building automation system. The center found lots of small problems, like valves getting stuck closed and automation systems not turning certain functions on and off in the most efficient way. For example, a sensor that can open a damper to let in cool outside air wasn’t correctly detecting that the indoor air had gotten too warm. At the same time, a sensor that did detect the warm inside temperature would turn on the air conditioning.
“We had systems fighting themselves,” Hughes says. “If valves and sensors aren’t working as well as they should be, that’s energy literally being wasted.”
Rush is fixing and replacing valves, updating control settings, and insulating pipes and valves, Hughes says. Aside from lowering energy use and thus greenhouse gas emissions, Hughes projects that many of the changes will pay for themselves in reduced energy costs in less than two years.
Power: A key strategy for success has been collaborating with local businesses and government. A few years ago, the city of Burlington, Vermont, approached the University of Vermont Medical Center (UVMMC) with an idea: Capture the waste steam and heat that’s created when the city burns woodchips at a generating station, use it to warm water, and pipe the water to the medical center to help heat buildings. UVMMC liked the idea but the cost was prohibitive, recalls Stephen Leffler, MD, president and chief operating officer of the medical center.
Then other local businesses joined the project, which spread out the cost among the participants. The city and the local power company moved forward last year with plans to construct the system.
“Look for partnerships within your community,” Leffler says. “The steam project is feasible because the city, the medical center, and some other local businesses all want to do it.”
Supplies: Dial, of OSU, co-chairs the environmental advisory council for a group purchasing organization (GPO) of 1,500 health systems across the country. The council established guidelines for purchasing products that meet sustainability standards — i.e., the products meet certain standards involving the materials from which they are made (such as no PVC) and their recyclability. The scale of purchasing power by those combined health systems makes it economically feasible for suppliers to provide products that meet the standards.
“Once we have the standards, we can influence the marketplace to drive up demand so that suppliers respond,” says Dial. She reports that 99% of the products purchased through the GPO meet the sustainability standards.
Rethink what gets thrown out
In operating rooms (ORs), it’s routine practice for staff to open most of the devices and supplies that are on hand for a procedure — such as pads and extra IV tubing — even if some of the items are unlikely to be used. This understandable precaution to have items ready to pick up creates a lot of waste, as many of the items are packed for sterility and cannot be repackaged on the spot.
“Opened and unused supplies are a constant source of waste in every OR case,” says Helen Wilmot, chief facilities and sustainability officer at Stanford Health Care, which includes SUMC.
Stanford Health Care works with clinicians to avoid overstocking supplies that are underutilized in surgeries, Wilmot says. The University of California Davis Medical Center asks medical staff to consider if some items can be safely left off the medical carts for specific procedures so that they are less likely to be opened during preparation, according to Brad Simmons, chief administrator of UC Davis Health.
In addition, UC Davis Health collects selected single-use devices and returns them to authorized vendors to be cleaned, tested, sterilized, and repackaged. In fiscal year 2022, the medical center’s OR collected 10.25 tons of single-use devices for reprocessing, according to UC Davis Health.
In the OR, the blue plastic wrap that keeps medical instruments sterile is a major waste product because it is not a type of plastic that can be handled at most commingled recycling plants, but instead needs to go to a specialty recycler. UVMMC and UC Davis Health contracted with companies to recycle the wrap into a variety of products, including bedpans, basins, and personal tote bags. Last month, UC Davis Health reports, that initiative prevented about 1,000 pounds of blue wrap from going to landfills.
Sometimes, the nuts and bolts of reality impede grand plans. Remember the push a few years ago to eliminate plastic straws?
“We wanted to eliminate plastic straws entirely,” says OSU’s Dial. “We wanted to go to compostable straws.”
But some patients need to use bendable straws because of mobility limitations, especially when they are in bed.
“We couldn’t find a compostable bendable straw,” Dial recalls. So the OSU medical center switched to compostable straws in certain areas, but keeps plastic bendable straws for patients who need them.
“Patient care is the most important thing,” Dial says.
Work with all staff
The straw compromise reflects the recognition among sustainability managers that they cannot develop new procedures on their own then pass the burden on to already overburdened hospital staff. To get full buy-in from staff and to make sure that the conservation ideas can work on the wards, hospitals develop teams and working groups from all areas to help craft, test, and carry out ideas.
That planning includes determining what support the staff will need in order to follow the new procedures, such as making it easy to order supplies that meet environmental standards and providing administrative help.
“You have to give them project management support,” says Wilmot at Stanford Health Care. “You can’t put it all on their backs.”
Sustainability managers have also found that the changes will be more widely and enthusiastically implemented if they are seen as more than just part of a cultural fad. While people want to help the environment, lecturing them about doing the right thing doesn’t produce fundamental changes in the business culture and processes.
“If you approach this as catastrophizing [about the environment], it will turn people off,” Wilmot says.
“Figure out what people care about,” advises Dial at OSU. “Perhaps sustainability or climate change is not the hook to start with. Perhaps it’s efficiency, or cost savings, or community engagement.
“It always starts with building trust and relationships.”
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