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Issues of the Environment: Combating greenhouse gas emissions in Michigan Medicine's surgical rooms

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Dr. George Mashour
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Dr. George Mashour

Overview

  • Michigan Medicine Anesthesiology delivered anesthesia services for more than 100,000 surgical cases last year. But alongside the lifesaving and life-enhancing care patients receive comes an unwanted consequence: release of greenhouse gases and ozone-depleting agents into the atmosphere. The U.S. health sector is responsible for about 8-10% of the nation's greenhouse gas emissions. (Source: https://www.npr.org/sections/health-shots/2019/05/06/716415598/effects-of-surgery-on-a-warming-planet-can-anesthesia-go-green; https://medicine.umich.edu/dept/anesthesiology/news/archive/202204/department-anesthesiology-launches-initiative-minimize-field’s-impact-climate-change)
  • A brand-new initiative by the Department of Anesthesiology at Michigan Medicine aims to reduce greenhouse gas emissions resulting from the use of anesthetics during surgery and minimize its impact on climate change. The Green Anesthesia Initiative (GAIA) aims to implement environmentally sound health care practices while continuing to protect public health and provide excellence in patient care.
  • GAIA aims to reduce the department’s greenhouse gas emissions from anesthetic gases by 80% over a three-year period. Phase one, which will begin this quarter, will focus on:

    • Switching to anesthetics with a lesser carbon footprint, such as sevoflurane.
    • Eliminating use of desflurane.
    • Reducing use of isoflurane and N20.
  • Desflurane and sevoflurane are two gases commonly used to keep patients unconscious during surgery, but damage from desflurane is much worse. Dr. Mashour points out that administering sevoflurane for an hour has an approximate environmental impact of driving a gas vehicle 20 miles while an hour of desflurane is estimated to equate to 400 miles.
  • Phase two will focus on the use of low-flow practices with a goal to reduce current flows by 25%, reducing the release of anesthetic in the environment and minimizing anesthesia delivery costs
  • Phase three seeks to broaden the initiative’s impact — both within the department and beyond — as leadership further commits to reducing the amount of anesthesia waste and diverting as much as possible from landfills.
  • Dr. George Mashour, Robert B. Sweet Professor and Chair of Anesthesiology at Michigan Medicine, believes cutting greenhouse gas emissions from surgery is an important step in doing no harm. He says, “I believe that we can, and should, be doing better as a department and as a field to be good stewards of our environment,” said Mashour, the Robert B. Sweet Professor and Chair of Anesthesiology. “Fortunately, unlike many other industries and fields, making smarter environmental choices as an anesthesiology department does not necessarily entail tectonic shifts or disruption. Rather, it requires intentionality about our anesthetic and clinical care choices — and we do have attractive options.”

Department of Anesthesiology launches initiative to minimize the field’s impact on climate change

Michigan Medicine Anesthesiology delivered anesthesia services for more than 100,000 surgical cases last year. But alongside the lifesaving and life-enhancing care patients receive comes an unwanted consequence: release of greenhouse gases and ozone-depleting agents into the atmosphere.

The Department of Anesthesiology has launched a new initiative to reduce its greenhouse gas emissions and minimize its impact on climate change. The Green Anesthesia Initiative (GAIA) aims to implement environmentally sound health care practices while continuing to protect public health and provide excellence in patient care.

Department Chair George Mashour, M.D., Ph.D., said the impact of health care on the climate has been the subject of intense discussion — but the field of anesthesiology is poised to make positive changes.

“I believe that we can, and should, be doing better as a department and as a field to be good stewards of our environment,” said Mashour, the Robert B. Sweet Professor and Chair of Anesthesiology. “Fortunately, unlike many other industries and fields, making smarter environmental choices as an anesthesiology department does not necessarily entail tectonic shifts or disruption. Rather, it requires intentionality about our anesthetic and clinical care choices — and we do have attractive options.”

Mashour and GAIA leads David Hovord, MB BChir, and Prabhat Koppera, M.D., formally introduced the initiative Thursday during a department-wide virtual town hall.

GAIA aims to reduce the department’s greenhouse gas emissions from anesthetic gases by 80% over a three-year period. Phase one, which will begin this quarter, will focus on:

  • Switching to anesthetics with a lesser carbon footprint, such as sevoflurane
  • Eliminating use of desflurane
  • Reducing use of isoflurane and N20

Administering sevoflurane for an hour has an approximate environmental impact of driving a gas vehicle 20 miles while an hour of desflurane is estimated to equate to 400 miles. Hovord said the GAIA planning team considered factors beyond environmental impact and patient care when determining these first steps — including provider adaptability, impact on the learner experience, and potential costs — and that he anticipates further collaboration as the initiative develops.
“How do we get from here to there? This is the million-dollar question in any kind of problem like this,” Hovord said. “We want this to be locally led — provider-focused and provider-led. We want to put the data out there and let the frontline providers be heard, be a part of the decision-making process about how we proceed forward.”

Phase two will focus on the use of low-flow practices with a goal to reduce current flows by 25%, reducing the release of anesthetic in the environment and minimizing anesthesia delivery costs. This phase will include a significant educational element for all providers to encourage the use of low-flow anesthetic care when clinically appropriate and to provide additional training as necessary to minimize patient safety risks.

Phase three seeks to broaden the initiative’s impact — both within the department and beyond — as leadership further commits to reducing the amount of anesthesia waste and diverting as much as possible from landfills. Plans for this phase include:

  • Creating anesthesia site-specific workgroups to develop additional solutions in support of GAIA’s carbon emissions reduction goals
  • Developing a consortium with other health care systems to influence environmentally preferred purchasing practices

Koppera said this final phase highlights the need for collaboration in addressing one of the most pressing issues of our time.
“This is an opportunity for us to be leaders and change advocates for the other divisions that use these agents to investigate their own use of them and then make a decision based on a very holistic approach,” Koppera said. “We can be leaders amongst our colleagues, both within anesthesia and at the local level at the university, as well as among other academic anesthesia departments across the nation.”

GAIA’s project team includes faculty, staff, and learners from across the department’s clinical sites, as well as staff from Michigan Medicine representing pharmacy ordering, environmental sustainability and safety.

“As Michigan Medicine becomes more engaged in the University of Michigan’s commitment to pursuing more environmentally sustainable strategies, the Department of Anesthesiology is poised to be a vital contributor and leader, thanks to the GAIA team,” Mashour said. “I look forward to working with GAIA leaders, all our anesthesiology team members, and colleagues across Michigan Medicine in the coming years as we strive to do what is right for our patients and our planet.” (Source *directly quoted* https://medicine.umich.edu/dept/anesthesiology/news/archive/202204/department-anesthesiology-launches-initiative-minimize-field’s-impact-climate-change)

Operating rooms are the climate change contributor no one's talking about

In April 2021, during the Leaders Summit on Climate, President Biden announced his goal to drastically reduce the United States’ greenhouse gas emissions by 2030.

Victor Agbafe was watching the address on TV. The University of Michigan Medical School student, who is also studying law at Yale, immediately texted a few mentors, including Michigan Medicine integrated plastic surgery resident Nicholas Berlin, M.D., M.P.H., M.S.

The question that emerged from their messages was a crucial one: What role can the medical community, which accounts for about 8.5% of America’s greenhouse gas emissions, play in these climate change reduction efforts?

A year later, research that Agbafe and Berlin led outlines some answers. Their paper outlines how surgery, particularly cancer surgery, contributes to climate change and suggests some solutions to combat the problem, from reducing waste to rethinking how surgical care is delivered.

“In general, these ideas are good for our planet,” Agbafe said. “But also, surgery unfortunately plays a disproportionate role in the carbon output and the waste we produce in medicine.”

Operating rooms are a massive source of greenhouse gas production for hospitals, representing 70% of their waste and generating three to six times as much carbon as the rest of health systems.

Cancer care is an obvious target for greener efforts within surgery, Berlin notes, because it often involves intense levels of care over a short period of time.

Plus, minimally invasive surgeries that require a lot of energy, including robotic-assisted operations, have become common treatments for cancers ranging from colorectal and uterine cancer to head and neck cancer. A robotic-assisted hysterectomy, for example, produces as much carbon as driving more than 2,200 miles in a car — the equivalent of a road trip from Ann Arbor, Mich., to Los Angeles.

“If we can lower our greenhouse gas output, we have a chance to extend the lifespan of our patients and expand access to timely care,” Agbafe said. “And we think it’s really important that the surgical community is proactive at being at that table.”

What to do differently

One of the most feasible changes to make in this space would be around waste reduction, Agbafe said.

This might be as simple as making sure that anything thrown away before or during surgery is properly categorized and labeled since it’s estimated that over 90% of OR waste does not meet the necessary standards for the type of trash it ends up in. (The red waste bags in ORs are intended only for items that have been exposed to bodily fluids and are much more expensive to dispose of than clear disposal bags.)

Hospitals could also consider switching to some reusable or reprocessed devices and surgical gowns since there is no link between reused tools and hospital-acquired infections.

Some of the pair’s other suggestions involve optimizing ORs’ energy use. Agbafe and Berlin point to the American Society of Healthcare Engineering’s recommendations to install energy-efficient lighting, schedule preventive maintenance and minimize air flow into rooms that aren’t being used as easy ways to green the systems.

The surgical supply chain could be more efficient, too, they write. Estimates suggest that 87% of the surgical instruments laid out for an operation are rarely used, so coming up with standardized lists of the necessary tools for surgeries that occur regularly could cut down on cost, waste and the energy needed to sterilize and repackage those instruments.

Moving more manufacturing of surgical supplies closer to hospitals — or choosing to source from suppliers that are locally based — could also reduce the OR’s carbon footprint.

“Given some of the geopolitical events that have been going on right now in Ukraine and with China and the competition there along with the effects of pandemic is creating an increasing emphasis on resiliency within supply chains,” Agbafe said. “So this idea of localizing our operating room supply chains is something that there’s a lot of political energy and momentum within the public to move towards.”

From gas to (more sustainable) gas

Some sustainability shifts may come even sooner at Michigan Medicine.

For instance, the Department of Anesthesiology recently launched the Green Anesthesia Initiative, or GAIA for short. Its mission: become more environmentally conscious about the types and rates of anesthesia its providers use, another area Agbafe and Berlin say is ripe for improvement.

“This is a topic of fairly intense discussion right now in the field, and I’ve been thinking about it for a while,” said George Mashour, M.D., Ph.D., the chair of the Department of Anesthesiology and the Robert B. Sweet Professor of Anesthesiology at the University of Michigan Medical School. “Unlike other industries, I don't think that we require massive disruption in order to make progress because, fortunately, we have options.”

Several inhaled gases regularly used for anesthesia are A-list offenders when it comes to greenhouse gas production. Nitrous oxide, commonly known as laughing gas, is a greenhouse gas, a direct ozone depleter and does not dissipate from the atmosphere for more than a century after it’s produced.

However, the inhaled anesthetic sevoflurane has much less of an environmental impact than nitrous oxide and other common inhaled agents, so Mashour says it would be a good alternative.

“The overall goal is to shift away from some of these egregious culprits and start making better choices about which drug we use and then also how we use it,” Mashour said.

“The contributions in terms of greenhouse gas effect or ozone-depleting action partly relate to how much is getting pumped out into the atmosphere and that relates directly to how high we have our fresh gas flow,” he added. “If we have, for example, 10 liters going, we’re blowing a lot of anesthetic into the scavenging and waste and atmospheric systems that doesn’t need to be there.”

To that end, Mashour’s colleagues in the Department of Anesthesiology are already leading a national initiative to try to reduce anesthetic gas flow rates through the Multicenter Perioperative Outcomes Group, another quality initiative that includes health centers from across the country.

Mashour plans to roll out other elements of GAIA over a three- to- five-year period.

“We could be doing better,” he said. “Right now, we’re starting the conversations, getting people on board and making structural choices in the department to help make it easy for people to do the right thing.” (Source: *directly quoted* https://labblog.uofmhealth.org/industry-dx/operating-rooms-are-climate-change-contributor-no-ones-talking-about)

Transcription

David Fair: This is 89 one WEMU, and welcome to another edition of Issues of the Environment. I'm David Fair, and you may be just as surprised as I was to find out that more than 100,000 surgical cases at Michigan Medicine last year required anesthesia services. That's a lot of procedures. I was just as surprised to learn that these kinds of care services produce an undesirable environmental consequence. It seems the process includes the release of greenhouse gases and ozone depleting agents in the atmosphere. In fact, in a recent NPR report, it was noted that 8 to 10% of all greenhouse gases in the U.S. come from the health sector. Our guest today is Dr. George Mashour, and he is the chair of anesthesiology at Michigan Medicine, and his department has decided to do something to better address environmental impacts. Thank you so much for making time today.

Dr. George Mashour: Thank you for inviting me.

David Fair: Since this is new information to me, I'm betting it may also be new information to others. How long have those in your profession known there was an issue with creating greenhouse gas emissions?

Dr. George Mashour: That's a great question, David. And we've been seeing this in the literature, and there have been a number of individuals who have been trying to draw this to our attention. But I'll have to admit and confess that this was not something that had fully resonated with me. I think as I was starting to understand the profound effects that the health care sector can have on the environment and becoming chair of the department, I started reflecting more critically about what we could be doing better. So, I think it's been out there for a while, but now our department is really trying to face these uncomfortable facts and develop a plan to try to try to do what we can do to make sure that our anesthetic care is environmentally sustainable.

David Fair: And kind of to better understand what we're dealing with, what about the gases being used in the process of delivery allows for these emissions?

Dr. George Mashour: Yes. So, unlike many sectors that might have indirect contributions, we have a very direct contribution to climate change because the anesthetic agents that we use are greenhouse gases. They've helped form that blanket insulating the earth. And, in some cases, they also directly deplete the ozone layer. And I think what was really interesting for me to think about and to try to raise awareness about is that anesthetics that, in the clinical setting, are relatively indistinguishable. They might have some specific features, have widely divergent environmental profiles. So, for example, sevoflurane is a commonly used ether. Its global warming potential is 130. And, remember, carbon dioxide is the reference of one. It's atmospheric lifetime is about a year. By contrast, desflurane, which is a very similar drug clinically, that has a global warming potential of 2540 and an atmospheric lifetime of 14 years--so, very similar drugs in the clinical setting. We can use both of them safely, but very divergent in terms of the environmental impact. One more example, nitrous oxide. What you might know is laughing gas. The only inhaled anesthetic that's been in clinical use, continuous use, since the 1840's when anesthesia started. Its atmospheric lifetime is 110 years. And that's really remarkable because we like it clinically, because it's very short acting. And yet, its impact on the environment is long standing. So, we make these direct contributions, and that's both troubling. But it's also good news because it means that, through intentionality and through smarter choices, we can start to mitigate our effect on the environment.

David Fair: So, I think when most of us think about greenhouse gas emissions, the first thing that come to mind are cars, SUVs, and trucks, kind of the transportation sector. You mentioned the difference in environmental impact between sevaflurane and desflurane. If we were to put it in terms of miles driven, is there an equation to be made there?

Dr. George Mashour: Yes. And I don't have the numbers off the top of my head, but, yes, we can translate that. And, for example, the comparison I just made of desflurane and sevaflurane. Desflurane would be associated with, you know, hundreds more miles over the course of hours compared to the use of sevaflurane. So, we can translate this. We've done it in the past, but I think the numbers speak for themselves.

David Fair: Issues of the Environment and our conversation with Dr. George Mashour continues on 89 one WEMU. He is chair of anesthesiology at Michigan Medicine, and he is the Robert B. Sweet professor at the University of Michigan. Now, we've talked about the problem, and you've touched upon how we're going to go about some of the solutions. The Green Anesthesia Initiative aims to reduce the emissions 80% over a three-year period, and it's been designed as a three-phase process. So, what comes in the first phase?

Dr. George Mashour: Well, the first phase is just starting to make smarter choices. I think the good news that I want to share with anybody who's listening is that we don't have to compromise safety. And patient safety is of paramount importance at Michigan Medicine and, certainly, in the Department of Anesthesiology. So, really, this is just about making choices. And unlike a lot of fields where you have to have major disruption, we actually have alternatives. And so, the initial goals are to start using agents that have a lower global warming potential. So, we often use ethers such as isoflurane. We occasionally use desflurane. We are going to be shifting to the use of sevaflurane, which has a much more favorable environmental profile. We're also going to be shifting away from the use of nitrous oxide. Again, the drug has been around a long time. It's safe. It has a lot of clinical benefits. But we don't need it to deliver safe care. And we're concerned about the fact that a decision to use nitrous oxide today could have an impact on the environment lasting more than a century. So, making more intentional choices, shifting to the anesthetics that are actually very safe. Sevaflurane is the most current ether on the market. And not just in terms of what drugs we use, but how we use them, because the amount of gas emission that we're creating is directly proportional to how high the flows are. So, when we deliver these ethers to a patient, we're delivering them in oxygen at a certain flow rate. We could deliver it at ten liters a minute or something much lower.

David Fair: And you can still keep us patients asleep and out of pain through the surgical process?

Dr. George Mashour: Absolutely. We don't have to compromise safety or our anesthetic practice. And that's really the good news. It's just about being thoughtful and intentional about those flow rates. And this is something that we're actually trying to extend to the national level through a major organization that we lead at the University of Michigan called the Multicenter Perioperative Outcomes Group, or MPOG--more than 50 sites across the US. And trying to raise awareness and trying to improve the quality of our care, not only from patient safety, which, again, is of paramount importance, but also environmental safety.

David Fair: So, we can talk about the fact that you have alternatives that are just as safe in patient care and better for the environment. The industry of insurance--not always as thoughtful as perhaps you are being. Can you use those alternatives and allow us to still be fully covered in these processes?

Dr. George Mashour: Yes. These are drugs that are in common use again. The good news here is we could just make choices about drugs that we already use to a greater or lesser extent. In some cases, you know, a drug might be a little more expensive, a little less expensive, but certainly within the framework of current support systems and the health system, the insurance system. So, we don't really see any problems there. And the other thing is, too, when it comes to costs, that also relates to how much we use. And that ties in also with that flow rate, how much we're allowing to get consumed and to get out into the atmosphere.

David Fair: Once again, this is Issues of the Environment on WEMU. And, Dr. George Mashour, after the first phase is completed, do you need to analyze the results before you fully design phase two and phase three, or is that already set forth?

Dr. George Mashour: So, absolutely. Whenever we have any kind of quality improvement cycle, we want to develop a plan, we want to implement it. We want to gather data, analyze it, and see what's working and see where it's not working. So, we'll definitely be doing that as we move forward. Some of the future plans are qualitatively distinct because that's not going to solve the whole problem. You know, we use a lot of plastic devices. There's waste involved. And we want to think about how we can be more thoughtful and intentional in that regard. And then, in the final stages, there's thinking more broadly, thinking at the national level, thinking more ambitiously, how can we start to partner with industry, be more intentional about the kinds of devices that are being developed, and see if we can have a broader, more sustained effect through that kind of partnership.

David Fair: And is phase one now underway or about to launch?

Dr. George Mashour: We're underway. There's a lot of enthusiasm and excitement in our department. And even just starting to talk about this and think about this has changed practice. So, this will be a multi-stage process in itself, but it's underway, and we're looking forward to doing the best that we can to keep our patients safe and also to keep our environment safe.

David Fair: Thank you so much for the time and sharing the information today. Doctor. I appreciate it.

Dr. George Mashour: Thank you.

David Fair: That is Dr. George Mashour. He is the Robert B. Sweet professor at the University of Michigan and chair of anesthesiology at Michigan Medicine. For more information on today's conversation, visit our website at WEMU dot org. Issues of the Environment is produced in partnership with the Office of the Washtenaw County Water Resources Commissioner, and we bring it to you every Wednesday. I'm David Fair, and this is 89 one WEMU FM Ypsilanti.

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