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The American Society of Anesthesiologists is an educational, research and scientific association of physicians organized to raise and maintain the standards of the medical practice of anesthesiology and improve the care of the patient.


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May 1, 2013 Volume 77, Number 5
Environmental Sustainability: Protecting Patients, Staff and the Community Charlotte Bell, M.D. Chair Committee on Equipment and Facilities Member, Committee on Patient Safety and Education

T. Kate Huncke, M.D., Co-chair ASA Task Force on Environmental Sustainability Member, Committee on Equipment and Facilities

Susan M. Ryan, M.D., Ph.D., Co-chair ASA Task Force on Environmental Sustainability Member, Committee on Equipment and Facilities

The phenomenal increase in the number, magnitude and duration of weather disasters in the past few years has been an obvious challenge to patient safety in health care institutions and to the health of the larger community. Media descriptions of hospital staff protecting and even evacuating critical patients during power interruptions with loss of usual transportation options are gripping to watch. Those who were instrumental in managing these disasters during and after hurricanes in New Orleans and New England, tornadoes in the Midwest and other less-publicized events will not soon forget patients at risk and the overwhelming problems for immediate management and long-term recovery, despite our ubiquitous committees on disaster preparedness.

What is less obvious from popular media descriptions is the impact of our daily choices in health care operations, and specifically our practice of anesthesiology, on the global environment. These more mundane activities of our routine practice affect not only the safety of patients within the hospital setting, but also the safety of staff who work there every day and the health and safety of the surrounding community. Hospitals are typically one of the largest local industries and, as such, directly affect and significantly impact energy resources, local waste management, fresh water supplies and air contamination.

Hospital trash is equal to about 2 million tons per year, about 85 percent of which is municipal waste, and about 5 percent is hazardous. Health care over the last several decades has turned to disposables to prevent cross contamination between patients, but as a result we now generate excessive waste, which ends up in landfills. Landfill has been linked to serious health problems due to seepage of toxic materials into the soil, air and water. Fortunately, advances in landfill engineering mitigated some of these problems, but methane release from landfill continues to have an effect on global warming, since it acts as a greenhouse gas.

Similarly, our efforts to properly treat and dispose of regulated medical waste to prevent infectious contamination to the community have also been linked to serious health problems. Medical waste incineration, thought to be a quick and easy way of disposing of infectious material, was found to produce and release toxins and carcinogens such as mercury, dioxins and furans into the atmosphere. Because of the unhealthy air quality and respiratory complaints from communities surrounding medical facilities, the Environmental Protection Agency in 1997 set emission standards for medical incinerators. This led to eventual closure of most onsite hospital incinerators in the United States. Medical incineration for disposal of regulated medical waste, or red bag waste, now takes place at modern facilities with special gas cleaning equipment to comply with emission standards. The medical industry is cooperating, too, by removing from construction mercury and certain plastics that produce dioxins when incinerated.

In an effort to reduce the cost and waste of disposables, several companies have developed tools that can be recycled or reprocessed, such as pulse oximeter sensors, laryngoscope blades and laryngeal mask airways. Although less waste is produced, reprocessing itself comes with an environmental cost. Therefore, much study and discussion still need to take place in order to determine best practices for our specialty in general and each institution in particular. The Food and Drug Administration (FDA) weighed in on this subject with the Medical Device User Fee and Modernization Act of 2002 (MDUFMA), which details the conditions for reprocessing. In 2008, a report on reprocessing of single-use devices by the Government Accountability Office (GAO) was presented to the House of Representatives with the conclusion that reprocessing does not present an elevated health risk. Subsequently, most institutions have undertaken some level of reprocessing as a cost-effective measure, which also decreases some disposable waste.

Historically, most of the plastic we use in our practice is PVC (polyvinylchloride), although this is decreasing in direct patient contact in items such as intravenous fluid bags. Nevertheless, large amounts of PVC still exist in our capital equipment and building materials, such as carpeting, tile, shower curtains, etc. The entire cradle-to-grave manufacturing process of PVC involves the release or “waste” of mercury, dioxin, lead, cadmium and vinylchloride monomers – all potent carcinogens. In recognition of the importance of removing carcinogens from facilities whose main mission is health care, Kaiser Permanente (and a few other notable institutions) focused on alternatives to PVC. For example, all carpeting in new Kaiser hospitals contains only polyvinylbuterate backing, eliminating a huge source of PVC and thereby decreasing exposure to patients, staff and visitors.

The pharmaceuticals used routinely in our practice also add to our eco footprint. Anesthetic gases are scavenged and vented into the atmosphere. Our choice of which inhaled anesthetic to use, and how high our fresh gas flows remain through a case, will change the amount of greenhouse gases we send into the air. Nitrous oxide, for example, stays in the atmosphere for more than 100 years and impairs the ozone layer as well as functioning as a greenhouse gas. Although most nitrous oxide contamination of the atmosphere is a result of industrial use, our ability as physicians to show leadership in avoiding use can have a major impact on other sources. Desflurane has approximately 20-50 times the climate eco footprint of sevoflurane or isoflurane, and depends heavily on fresh gas flow practices.1-3 Minimizing fresh gas flows is one technique that can be universally adopted to decrease our environmental impact when using inhaled techniques.4

Environmentally, oral and parenteral pharmaceuticals are given a number from 0-9, called the PBT score (three points each for Persistence, Bioavailability and Toxicity). Wasted propofol, with a PBT of 6, must be incinerated to avoid the potential contamination of water and land resources. In a recent study, propofol waste approaches 50 percent,5 partially because of the difficulties in obtaining propofol in small aliquots due to current drug shortages. The use of prefilled syringes is one technique advocated to decrease waste of propofol as well as other medications common in our workplace. Unfortunately, the recent problems with serious infections caused by contamination at compounding facilities, as well as the expense of compounding, have made these choices more difficult. At the present time, the use of prefilled syringes must be decided at each individual institution after careful consideration of local compounding resources, infection statistics and opportunities for waste management.

Because our anesthesiology practices typically involve care in multiple areas of the health care institution, we often sit at the table when new facilities (or remodeling of older facilities) is planned. It is important to be aware that health care buildings use twice the energy per square foot as office buildings as well as using more water resources and contaminating more ground water. By incorporating green features early in the design process, operational costs are lowered, resulting in overall cost benefits. These features include LED and natural lighting, porous concrete for parking areas to decrease runoff of contaminated water, eliminating PVC, adding green roofs and utilization of solar photovoltaic panels. Studies have shown that medical errors decrease, worker productivity increases and patient hospital stays decrease with more natural light.6 Windows that open have been advocated as a method of decreasing air contamination within hospitals. Although fewer germs exist in hospital buildings than in nature, the pathogenicity of hospital organisms is far greater, placing patients at greater risk. Dilution by outdoor air is a technique that may improve the indoor environment.

Anesthesiologists have been the strongest advocates for patient safety. In addition, we are particularly expert at understanding the complexity of systems – in our understanding of the complex physiology and interactivity of multiorgan systems during anesthesia as well as the complexities of system interactions that take place to make operating rooms highly functional organizations. Environmental sustainability is a critical piece of both patient care and organization function, and it demands an understanding of risks and benefits, patient safety and infection, human factors and economic costs. Anesthesiologists are uniquely able to understand these components of system complexity and succeed at incorporating environmental protection as part of patient safety. It is not insignificant that by doing so, we are also protecting ourselves and other staff in the workplace as well as the greater community served by large health care institutions.

We have several tasks before us in order to achieve these goals. We need to find ways to reduce our consumables (and therefore our consumption of resources) while minimizing risks to patients of potential infection. We need to become knowledgeable consumers by determining our anesthesia eco footprint specific to each facility. We need to become knowledgeable purchasers. All the major purchasing organizations used by hospitals offer environmentally preferable purchasing (EPP). This change in purchasing habits will also drive the development of new products, such as the carpeting without PVC backing developed specifically for the Kaiser system. We need to understand the impact of our anesthetic drugs on climate, including atmosphere and fresh water resources, and consider changes that protect these natural resources while still offering the best possible care to our patients.

All of these tasks will require more studies to determine best clinical practice and optimization of health care economics. We need leadership in science, purchasing and design to get to the next steps. As a starting point, the ASA Task Force on Environmental Sustainability developed an extensive resource available on the ASA website to provide information on environmental sustainability in our practice as well as a manual that provides step-by-guides on initiating programs in your facility and links to other online and written resources.7

Charlotte Bell, M.D. is Attending Anesthesiologist, Milford Anesthesia Associates, Milford, Connecticut.

T. Kate Huncke, M.D. is Clinical Associate Professor and Vice Chair, NYU Department of Anesthesiology, NYU Langone Medical Center, New York, New York

Susan M. Ryan, M.D., Ph.D. is Clinical Professor of Anethesia and Critical Care, Emeritus, Department of Anesthesia and Perioperative Care, University of California, San Francisco.

1. Sulbaek Andersen MP, Nielsen OJ, Wallington TJ, Karpichev B, Sander SP. Assessing the impact on global climate from general anesthetic gases. Anesth Analg. 2012;114(5):1081-1085.
2. Sherman J, Le C, Lamers V, Eckelman M. Life cycle greenhouse gas emissions of anesthetic drugs. Anesth Analg. 2012;114(5):1086-1090.
3. Ryan SM, Nielsen CJ. Global warming potential of inhaled anesthetics: application to clinical use. Anesth Analg. 2010;111(1):92-98.
4. Feldman JM. Managing fresh gas flow to reduce environmental contamination. Anesth Analg. 2012;114(5):1093-1101.
5. Mankes RF. Propofol wastage in anesthesia. Anesth Analg. 2012;114(5):1091-1092.
6. Ulrich RS. View through a window may influence recovery from surgery. Science. 1984;224(4647):420-421.
7. Huncke TK, Ryan SM, Hopf HW, et al.; Committee on Equipment and Facilities. Greening the operating room: reduce, reuse, recycle and redesign. American Society of Anesthesiologists website. Published in 2012. Accessed March 13, 2013.

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