Climate Change and Healthcare Pollution: Balancing Patient Safety and Public Health with Jodi Sherman, MD

June 02, 2023

Information

May 24, 2023

Climate Change and Healthcare Pollution: Balancing Patient Safety and Public Health

Jodi Sherman, MD

Director, Yale Program on Healthcare Environmental Sustainability (Y-PHES)

Associate Professor of Anesthesiology, Yale School of Medicine

ID10005

To CiteDCA Citation Guide

00:00Welcome everybody to the final
00:02evening ethics seminar at the Yale
00:04Program for Biomedical Ethics.
00:06The final one for this year.
00:07Of course we'll be back in in September,
00:11but for tonight,
00:12I want to introduce Doctor Sherman.
00:13But just before I do that to remind
00:15you folks who are here and you focus
00:17on zoom to let you know how it
00:19works is after a brief introduction,
00:20I'll turn it over to Doctor Sherman.
00:22She'll speak for 45 minutes plus minus.
00:25After that, we're going to have time for
00:28some discussion questions you guys have.
00:30And the folks on Zoom,
00:31you can send questions in through
00:33the Q&amp;A portion of Zoom,
00:35not through chat, but through Q&amp;A.
00:37I'll be reading those questions to to Jody
00:40and we will, I'll moderate a session.
00:43We'll have here a discussion and we'll
00:45finish sometime between 6:00 and 6:30.
00:47We'll see, Well, we won't go past 6:30,
00:50we'll see how we do.
00:51So with that said,
00:53let me introduce tonight's speaker,
00:55Jody Sherman is Associate Professor
00:57of Anesthesiology at the Yale
00:58School of Medicine.
00:59And associate professor of Epidemiology
01:01and Environmental Health Sciences
01:03and the founding director of
01:05the Yale Program on Healthcare,
01:06Environmental Sustainability in
01:08the Yale Center on Climate Change,
01:10and Health.
01:11Doctor Sherman also serves as the
01:13Medical Director for Yale New Haven
01:16Health Center for Sustainable Healthcare.
01:18She's an internationally recognized
01:19researcher in the emerging field of
01:21sustainability and clinical care.
01:23Her research interest is in life
01:25cycle assessment of environmental
01:27emissions human health impacts.
01:28And economic impacts of drugs,
01:30Devices, clinical care pathways,
01:32and Health systems.
01:34Her work seeks to establish
01:36sustainability metrics paired with
01:37health outcomes and costs to help
01:40guide clinical decision making,
01:41professional behaviors,
01:42and organizational management toward
01:44more ecologically sustainable practices.
01:46To improve the quality, safety,
01:48and value of clinical care,
01:50and to protect public health.
01:52She collaborates with environmental
01:54engineers, epidemiologists,
01:55toxicologists, health economists.
01:57Health administrators,
01:58health professionals and most
02:00importantly bioethicist tonight, right.
02:03Come on.
02:04And when I could go on the the her
02:07credentials are quite impressive
02:09and I just heard today that you
02:11were just made coeditor of the
02:14British Journal of Anesthesiology.
02:15Is that right?
02:18Of a special issue. Got you.
02:20Well that's not nothing. Okay.
02:22I just got this hot hot off the presses.
02:24But a little if I got a little wrong,
02:25I apologize.
02:28Jody trained at the Stanford University,
02:31where she was a resident,
02:32did a fellowship at University
02:34of California at San Francisco.
02:36She did her internship at Columbia
02:38and received her MD at SUNY
02:40Downstate College of Medicine.
02:41So we're really fortunate,
02:43and I'm a little bit embarrassed to
02:45say that this is such a colossally
02:46important topic and not one that
02:48we've really addressed yet in the
02:50program for biomedical ethics.
02:51So I think, and this is on me,
02:53I think we're a little late to the party,
02:55but I'm glad to be here.
02:57And we are so pleased that
02:57you've made time for us tonight.
02:59Thanks a lot, Jody.
03:02Well,
03:09thanks so much for that kind introduction.
03:12I have disclosures,
03:13I do have grant funding from the
03:15Canadian Institutes of Health Research,
03:17Commonwealth Fund and I do serve
03:19as faculty for the Institute
03:22for Healthcare Improvement.
03:23So for learning objectives for today,
03:25I hope you'll be able to identify
03:27relationship between healthcare
03:28pollution and disease burden,
03:30summarize some of the latest
03:32healthcare pollution findings.
03:34Importantly,
03:34discuss some ethical conflicts and hopefully
03:37describe opportunities for investigation,
03:39practice improvement and regulatory reform.
03:42So like many people in this emerging space,
03:47my interest started during my
03:49residency training where was so much
03:51fun to be able to do my specialty of
03:53anesthesiology take care of patients.
03:56And at the same time,
03:56it was blatantly obvious that
03:58there's a problem.
03:59We're using so much stuff,
04:01we're wasting so much stuff used and unused.
04:03Throwing it away must be causing
04:05some harm to the environment.
04:08And so really it's I asked a
04:10question what is best practice for
04:13both patients and public health,
04:15and there was little to no information
04:17which started me on my career journey.
04:20And so I thought it would help
04:22me to review some of the core
04:24principles of bioethics.
04:25I actually was a philosophy
04:26major as an undergrad,
04:27but it's been quite some time since.
04:29I delve into these core concepts,
04:32Of course applying them to medical ethics.
04:34But beneficence a duty to help the
04:36patient advance their own good and to
04:38act in their pay in their best interest,
04:41autonomy,
04:41they do need to honor the patient's
04:43right to make their own decisions
04:45and to be selfdetermining.
04:47Non malfeasance or the duty
04:48to do no harm to the patient,
04:50which is really what we most
04:51think about when we think about
04:53the Hippocratic Oath and justice.
04:54A duty to be fair and how the care is
04:58provided and how resources are allocated.
05:01What about public health ethics?
05:03This is something I definitely
05:05was not taught in medical school.
05:06There are some very variabilities to it.
05:09It distinguishes itself by emphasizing
05:12communitarian values and social justice.
05:15And balancing individual autonomy
05:16and the economy.
05:17Good remains central,
05:18but does not begin with emphasis
05:20on individual interests.
05:22So beneficence of potential benefits
05:25to individuals and society should be
05:28maximized and potential harms minimized.
05:30Non malfeasance includes harm to
05:32both patients and public health
05:34and should be avoided.
05:35Autonomy, duty to honor,
05:37rights of self, determination.
05:38But this includes members of the community,
05:41not just the patients.
05:42And justice,
05:43maximizing public utility of all affected,
05:46which raises questions of equality versus
05:49equity and intergenerational rights.
05:52And I start thinking further
05:54because I work very intently in
05:57healthcare administration.
05:58Corporations are entities too.
06:00Or so does, say, our 17th Amendment.
06:04I actually had a hard time
06:07finding these same principles.
06:08Applied to corporate ethics,
06:10But they're there, just in different forms.
06:12But it's defined as application of
06:15ethical values to business behavior
06:16relative to both conduct of individuals
06:19and the organization as a whole.
06:22Applies to any and all
06:23aspects of business conduct,
06:24from boardroom strategies and how companies
06:27treat their employees, how they treat
06:29their producers and their suppliers.
06:31Their sales techniques and accounting
06:33practices and so try to stretch them
06:35to the same principles of beneficence,
06:37so that maximizing benefits to shareholders.
06:41But I would ask what timeline
06:43because there's a difference.
06:44If it's a short timeline,
06:45then great is good for your shareholders.
06:48If it's a longer timeline,
06:49sustainability or business is also the
06:52same as sustainability of the planet.
06:54And I think there are differences between
06:57publicly and privately held corporations.
06:59Autonomy.
06:59I couldn't really make a stretch here.
07:01Maybe the audience has some ideas now.
07:03Not non malfeasance, of course.
07:05Duty to do no harm to the company,
07:07whether it's reputation, finances,
07:09harm being sustainability as well.
07:12And then justice.
07:12I already elucidated some of those on
07:15how it's applied, including to fair,
07:17fair treatment of employees,
07:18whether it's wage promotions,
07:20diversity, equity, inclusion,
07:21being fair with the customer suppliers.
07:25And to the community and I think
07:27we might even consider structing
07:30that to ecosystems in nature.
07:32Of course there's a concept
07:34of environmental ethics
07:38and how we define that I think
07:41is is up for conversation.
07:44So, but why sustainability in
07:48healthcare pollution is the
07:50leading cause of morbidity and
07:52mortality responsible for 9,000,000.
07:54Premature deaths annually,
07:55or 16% of all premature deaths,
07:59is due to pollution.
08:02Healthcare itself is a leading
08:04emitter of environmental pollutants.
08:05It's against our mission to do no harm.
08:08Reducing healthcare pollution can
08:09improve the triple bottom line,
08:10the best care for the most
08:12patients at the least cost.
08:14And why I got involved in this work
08:16as a healthcare professional is that
08:19engaging each other in this industry.
08:24Really can be key for public
08:26policy and societal transformation.
08:27Healthcare is an enormous part
08:29of our economy. We are well
08:31respected members of the community.
08:32Now we do talk a lot or I you'll hear
08:34me talking a lot about climate change,
08:36carbon dioxide equivalents greenhouse gases,
08:39these this is from Rockstrom
08:42and Stefan Whitney.
08:45The describes the planetary ecosystem in
08:48terms of boundaries and 9 dimensions.
08:52Where we are outside the planet's
08:56ability to regenerate itself,
08:58threatening life on Earth.
08:59Climate change is just one of those concerns,
09:02of course, and biodiversity loss,
09:03which is closely related to land use?
09:06We are in the midst of the
09:08sixth great mass extinction,
09:09probably heard calls for 30 by 30,
09:11or protecting 1/3 of untouched
09:15natural systems by 2030.
09:17And of course,
09:18nitrogen and phosphorus loading,
09:19for example, through fertilization.
09:21So for, excuse me,
09:23agricultural fertilization.
09:24So we're already well beyond the planet's
09:28ability to regenerate itself in these
09:30areas and really have to act fast.
09:33Gray are areas where we don't
09:35have enough scientific data yet.
09:37Doesn't mean we're not outside
09:39the boundaries.
09:40But importantly,
09:42we can reduce these problems
09:45by providing less care.
09:47That's not the goal.
09:49Obviously,
09:49we want to provide better care
09:52and more care for the most people.
09:54And so there's this concept of the
09:57social foundation that we want
09:58to be above the the foundation,
10:00so no one's left behind but below.
10:04The ecological system is so-called
10:07donut economics.
10:08So even those talk will be
10:10mostly about climate change.
10:11I would be neglectful if we didn't
10:13talk somewhat about plastics.
10:15Most plastic is actually
10:16derived from fossil fuels,
10:18so their sources and their business
10:21interests are very similar.
10:22If we consider if we
10:24continue business as usual,
10:26there will be more plastic volume
10:28than fish in the ocean by 2050.
10:30And it's not just what's
10:31floating on the surface.
10:32If you've heard of the great
10:34gyres or the garbage patches or,
10:36you know,
10:37there was a.
10:39Very well known 18 year old who developed a
10:41device that safely skims a surface ocean.
10:43That's not going to solve this issue.
10:46There's plastic at the bottom of the
10:49ocean and in fact there's no place
10:52that's untouched by plastic pollution.
10:54And of course the fossil fuel drive plastic,
10:57which is about 95% or more of all
11:00our plastic doesn't go anywhere.
11:01It just breaks down into smaller
11:03and smaller pieces.
11:03And so we've got micro
11:06nanoplastic pollution problem.
11:07I literally can't keep up
11:08with the evidence on this.
11:09Every time I do a slide a talk,
11:13I end up adding more and more
11:15on to this list.
11:17Plastic is ubiquitous in our tap
11:19water and table salt around the world.
11:22Found in human stool,
11:23Found in wild animal stools and
11:26remote places on the planet.
11:28Found in human blood, Found in placentas.
11:30Found in breast milk,
11:31found in sperm, Found in lungs.
11:34And now the nanoplastics are
11:36found in the brain have breached
11:39the blood brain barrier.
11:41This is being called the plasticine error.
11:45And it's not just obstructive concerns.
11:49These plastics are laden with chemicals,
11:53and so there's a cocktail
11:57chemical contaminants,
11:59many of which are known neurotoxins.
12:02Endocrine disruptors, carcinogens.
12:04And so we are constantly
12:08being exposed to all this.
12:11And so industrial chemicals
12:15are not regulated the same as
12:17pharmaceuticals and pharmaceuticals.
12:19You you have to demonstrate safety before
12:22releasing something to the marketplace.
12:24The opposite true is of chemicals.
12:26There's more than 100,000
12:28industrial chemicals in existence.
12:30There is no requirement to prove safety
12:32before releasing them into the marketplace.
12:35The the trouble is that with 100,
12:39you know, 100,000 chemicals out there,
12:41how do you prove harm?
12:43It's a it's the same exact
12:45story as a tobacco story,
12:47and there's been a movement toward
12:49the precautionary principle,
12:49which is prove proving safety first
12:52before releasing to the marketplace.
12:55And then the healthcare sector,
12:57I never thought about this in my training,
12:58but the healthcare sector is a
13:01leading purchaser of chemicals.
13:03On the right is an image from the
13:05famous Body Burden study from
13:06the environmental working Group.
13:08This started the whole biomonitoring field.
13:12There was A at the time.
13:14This is now, gosh, at least 15 years ago,
13:17if not actually more than 20 years ago.
13:18I'm dating myself a very small study
13:21looking at new board newborn cord.
13:24Samples across the United States
13:28for 267 chemicals of concern.
13:30Out of those 100,000,
13:32virtually every single chemical
13:33is found in every single one
13:35of those blood cord samples.
13:37So in other words,
13:38babies are being born polluted.
13:40There's a massive experiment being
13:42conducted on all of us without consent.
13:46So I am going to shift to climate change.
13:48It will be the bulk of this talk.
13:50Climate change is called a health emergency.
13:56An urgent action.
13:57There's still a window where we can act.
13:59Urgent action is required to secure a fair,
14:03equitable and livable future for all.
14:05It's not that we're going to go away,
14:07but civilization will look very
14:08differently if we don't change things.
14:11We're already seeing harm from 1.2 degrees
14:15average centigrade surface temperature
14:18change compared to preindustrial baseline.
14:22So if we'll get historic emissions.
14:25Business as usual.
14:26We're seeing a four to five
14:29degree centigrade average change,
14:31which is not compatible with human life.
14:34Our current policies to mitigate
14:35bring us between 3:00 and 4:00.
14:38Pledges get us somewhere between 2.6 and 3.2,
14:41the Paris agreement,
14:42so even though there was global
14:45consensus on signing this.
14:47Not all national policies actually
14:49get us to that.
14:50And really,
14:51the scientific community says we need
14:53to limit warming to 1 1/2 degrees
14:55centigrade in order to avert the worst
14:58predicted harms to civilization this century.
15:01And in fact, this is possible than
15:02the laws and chemistry and physics.
15:04It requires unprecedented
15:06scale and timeline of action.
15:09And in fact,
15:10there's there's some really
15:11great lessons from the COVID.
15:1219 pandemic,
15:13where the global community came together,
15:15shared scientific information,
15:17shared resources.
15:19We actually can do this.
15:20This is a matter of political will.
15:23And so nobody's death certificate is
15:24going to say climate change on it.
15:26So direct effects of climate change,
15:28including more storms and floods,
15:30droughts, heat waves,
15:32wildflowers, these are wildfires.
15:34These are direct effects of climate change.
15:37Indirect effects are things
15:39like poor water quality,
15:41air pollution and physical harm
15:47through from storms and then physical
15:51displacement of populations,
15:53causing political instability,
15:55which we're actually already seeing.
15:58And not everyone is affected equally,
16:00so those most vulnerable are often.
16:05Harmed the worst and the
16:07least capable of adapting,
16:09and so some of the known health
16:11impacts from all of these include,
16:14of course, mental illness,
16:17problems with food and and water nutrition,
16:21worsening allergy seasons,
16:24worsening cardiovascular
16:26serovascular disease,
16:27of course infectious diseases,
16:28and so forth.
16:31Climate change also impacts health systems.
16:34In addition to seeing altered healthcare
16:36patterns of increased disease burdens,
16:38there's structural risks to our our
16:41buildings or utilities or physical
16:44infrastructure supply chain interruptions.
16:47There's a lot of similarities
16:49with with the COVID-19 pandemic,
16:52and a lot of lessons to be taken as well.
16:56And in fact, we're already saying this.
16:58There's increased numbers of billion dollar
17:02storms in the United States every year,
17:05both from wildfires and from hurricanes,
17:08flooding. These are already dated.
17:10Hard to even keep up with it all on the left,
17:12of course. Hurricane Sandy,
17:14which we felt certainly here in New Haven.
17:17I live just off the Grand St.
17:19at the time,
17:20right on the Quinnipiac River.
17:22My whole street was flooded and was
17:24evacuated by the National Guard.
17:26And of course you're seeing some
17:28famous images here of NYU Langone
17:30being evacuated on the right,
17:31of course the campfires which leveled
17:34the the the Paradise Fire also
17:38leveled the Adventist Health Center.
17:41You're seeing it being evacuated
17:42literally an hour before it caught fire.
17:45So we're already seeing these disruptions.
17:47And then, of course,
17:48supply chain disruptions.
17:49Hurricane Maria, most famously,
17:51people across the United States
17:53were aware of saline shortages,
17:55but also there were drug shortages.
17:57This led to patient safety concerns from
18:01substituting less desirable medications,
18:04changing protocols,
18:05cancellation of elective cases
18:07due to these shortages.
18:09And then of course,
18:10my specialty of anesthesiology was also.
18:13Specifically affected the
18:14small vials if you pivocain,
18:16which are used for spinal anesthesia
18:18for commonly used for emergency
18:21C sections were completely out.
18:24Ironically,
18:24we had to substitute 30ML vials which
18:28we cannot easily safely split split
18:31between patients without creating new
18:33systems and so we had this paradox of
18:36throwing away 99% of this drug when
18:40we had shortages of the smaller one.
18:43And so Healthcare is a major
18:45contributor to this problem.
18:47Our organizations run 24/7,
18:49they have hightech therapeutic
18:51and diagnostic equipment.
18:53Our industry is very unique
18:55requirements for infection prevention.
18:58We have a regulatory complexity
19:00and business models that Dr.
19:02wasteful unnecessary utilization of
19:04resources and we have a culture of excess
19:08and where disposability is normalized.
19:11And of course,
19:12we have a social mission
19:12to our individual patients.
19:14So we feel that we're doing good
19:15in the world and we are doing
19:16good at the world in the world.
19:18But what about public health?
19:19What about the harm we're causing at the
19:22same time that we're helping patients?
19:24And so this is our work with The Lancet
19:26Countdown in health and Climate change.
19:28Globally,
19:28the healthcare sector emits 5.2% of
19:32total global greenhouse gas emissions.
19:35Healthcare is an enormous part
19:36of our economy, 10% globally,
19:3820% of United States.
19:411/4 of these global emissions
19:42come just from the United States,
19:45even though we're only we only
19:47have 4% of the population,
19:50so we have the highest per capita
19:52healthcare greenhouse gases in the world.
19:54Now if we had the best
19:55healthcare system in the
19:56world, that might somehow justify
19:58those emissions, but we don't.
20:001/4 of services globally in 1/3
20:02in the United States are deemed
20:05inappropriate or low value wasteful.
20:07Half the world Box likes lacks
20:09access to essential health services.
20:11In the United States.
20:13Half of Americans are on or under insured,
20:1711% totally uninsured.
20:18And we can see if we plot per
20:21capita healthcare greenhouse gas
20:23emissions against some measure
20:25of healthcare system quality.
20:28We've used many measures now
20:29and the story is the same.
20:31Here you're seeing the I HME's
20:33Healthcare Access and Quality Index.
20:36You can see the United States is
20:38by no means the best performing
20:40health system in the world,
20:41despite having the highest
20:43greenhouse gas emissions.
20:45But there's a good news in this
20:47story here and that there is
20:49room to improve and reduce our
20:52emissions while maintaining or
20:53even improving healthcare quality.
20:55To break even point is around
20:58400 kilograms per capita,
20:59and so right now we're about four times that.
21:02But there there is a positive story here.
21:06But if we look at the disease
21:08burden from healthcare,
21:09to help trying to contextualize
21:11the scope here,
21:13we've estimated that healthcare pollution,
21:14both greenhouse gas and non
21:16greenhouse gas pollution,
21:17together cause an estimated 388,000
21:20disability just of life here's lost annually,
21:23especially from particulate matter.
21:25And the biggest source of particulate
21:28matter and greenhouse gas emissions
21:30emissions is fossil fuel combustions.
21:32Clean up our energy and we'll do a lot here.
21:36This harm is similar.
21:37Magnitude is death due to medical
21:39errors as first reported by the
21:41Institute of Medicine in 1999 in
21:42the famous to Errors Human report,
21:44which found 44 to
21:4944 to 98,000.
21:51I believe it was premature deaths
21:54due to medical errors or ACT.
21:56The actuaries say it's about
21:5810 years of life lost.
22:00For each of those deaths,
22:01and if you multiply that by ten,
22:03we're in the same order of magnitude
22:05as harm from healthcare pollution.
22:07And if there's no other take away,
22:09it's this that pollution prevention
22:11is the new patient safety movement.
22:14Everything we do in Healthcare is
22:16through the lens of patient safety.
22:17Since this report came out,
22:19we thought we were doing good beforehand
22:21and we learned not Harm is just as big
22:24from healthcare pollution and it cannot
22:27be ignored and in order to impact.
22:29You have to know where there's emissions
22:31coming from and several studies including
22:34our own paint a similar picture.
22:36About 2/3 of healthcare
22:38come from the supply chain.
22:40The goods and services that we use to
22:43deliver care about 5% for anesthetic gases
22:46and pressurized metered dose inhalers.
22:49Building energy and transportation are are
22:51other big areas but the biggest one here.
22:54Is the supply chain,
22:56especially pharmaceuticals and chemicals,
22:58medical devices and supplies and food,
23:02and the two ways to impact
23:04or mitigate these emissions.
23:05One is to address waster and
23:07efficiency in the system.
23:08Clinicians, administrators, regulators.
23:10We control consumption of resource.
23:13The other big way to reduce emissions
23:15is to use stuff and services with
23:18less embodied emissions in them.
23:21Manufacturers,
23:21regulators they control will
23:22go to marketplace,
23:24although we have some agency and
23:26some of the things that we select.
23:28So I'm going to shift gears and
23:29talk about the problem with
23:31healthcare acquired infections.
23:32This is one of the harms that
23:34it is our duty to prevent.
23:37There are about 700,000 healthcare
23:39acquired infections annually in acute
23:41care hospitals in the United States and
23:43it's the number one adverse event globally.
23:45About 75,000 premature deaths annually,
23:48the United States causing costing between
23:506 and $7 billion from excessive care.
23:55And this data is already old,
23:57so I would imagine it's even
23:59larger than that.
24:00It is our duty, obviously,
24:02to prevent harm from healthcare
24:05required infections.
24:06Unfortunately,
24:06this is driving a trend toward
24:09excessive use of single use
24:11disposal devices and drug waste.
24:14And anyone who's in the clinical care spaces
24:17knows exactly what I'm talking about here.
24:20So I'm going to give you an example
24:22from the perioperative space,
24:24although this is just one type of infection,
24:26surgical site infection,
24:27we go back a couple 100 years.
24:30If you had a major surgery,
24:31you had about 95.
24:32Percent chance of getting an infection.
24:34About a 40% chance of survival.
24:37Along comes my hero is somewhat wise
24:39and then of course pastor and listor.
24:41So germ theory.
24:44Of course Lou and Hook in the
24:47microscope and and the ability to see
24:50those terms and to do pasteurization
24:52have aseptic antiseptic techniques
24:55and most important things that have
24:58happened in the history of medicine.
25:00To decrease infections and
25:03increase survivability,
25:05the next blip you see here
25:06in the curves is
25:07from the introduction of antibiotics
25:09between World War One and World War Two,
25:11the next greatest invention
25:14in the history of medicine.
25:17And so now you're seeing as we refine
25:20our antibiotics and treatments over
25:22time or asymptotically approaching 0,
25:26and now you have less than a 5%
25:28chance of getting infected and
25:30greater than 95% chance of survival.
25:31But we have a problem here if
25:34you blow up that portion of the
25:35curb as we're trying to get to 0,
25:37we're throwing more and more and
25:39more stuff trying to get to 0 and
25:43we're ignoring the increasing harm,
25:44the increasing indirect.
25:46Burden of disease from all
25:48the stuff we're using,
25:50all the stuff we're throwing away.
25:52And we really have to ask this question,
25:54is IF0 healthcare acquired infections?
25:57Are they realistic and we cannot
26:00ignore the indirect damages.
26:02Now of course causes of
26:04infection are multifactorial.
26:05The two most important things
26:07to prevent infection are staff
26:09discipline and a something,
26:11an antiseptic technique,
26:13especially washing our hands,
26:15which we know we don't do enough of.
26:17And then of course,
26:18the patient health status,
26:18are they immunocompromised?
26:19You have diabetes,
26:21they have immune disorders,
26:22Do they have cancer?
26:24Of course, exposure site types
26:26and quantities of inoculation,
26:27those two matter as well.
26:29But we know we've got a problem.
26:30We don't wash our hands enough and
26:33we're not going to cure hand washing
26:36or diabetes by throwing more and
26:38more disposables at the problem.
26:40And we also have another problem and that
26:43is what we've learned through the pandemic.
26:45And that our supply chains are
26:48very vulnerable to interruption.
26:50We require so much stock to be
26:52coming in and out because of our
26:55reliance on single use disposal.
26:57The supply chains are very fragile.
27:00On the left are this is the United States on.
27:02On the left you're seeing
27:04some nurses in Brooklyn,
27:05NY, on the right in England,
27:07in the UK These are hard images
27:10to look at and of course.
27:13Our global supply chain,
27:15and it benefits us in many ways
27:17because it can reduce production
27:19costs and storage costs,
27:21reduces local pollution in some countries,
27:23but it actually increases
27:24pollution in other countries.
27:26And we know that there are unfair
27:27wages in other countries and unfair
27:29labor practices in other countries.
27:31So there's a real question about it.
27:33Is it just?
27:34And there's also a lack of
27:36transparency of suppliers.
27:38And so we do know who our
27:39direct suppliers are,
27:40but it is well known that it
27:44is very rare that second tier,
27:47third tier suppliers are transparent.
27:50And any vital hub in this web
27:54can take the whole system down,
27:57which is what happened partially
27:59would happen with the pandemic.
28:00And whether it's climate change or pandemics,
28:02the risks are the same.
28:04Now part of the problem we have
28:07in the Healthcare is over cleaning
28:09over sterilization critical items.
28:12Things that normally contact
28:13sterile tissue need to be sterile.
28:16Some uncritical items are those
28:18that contact mucous membranes are
28:20not intact skin.
28:21They do not need to be sterile.
28:22Things that you put in your
28:24mouth do not need to be sterile.
28:26Obstetrics procedures.
28:29Colorectal procedures and two procedures.
28:32Many of those are not sterile techniques and
28:35many of them do not require sterile devices.
28:39And then non critical items.
28:40Things that touch intact skin are
28:42blood pressure cuffs or pulse oximeter.
28:44Probes are bed linens.
28:46These are things that are pillows.
28:48These are things that are
28:50disposable or patient.
28:51Gowns are are are clinician gowns.
28:54These are things that are disposable.
28:55It's it's really rather insane.
28:58I'm going to give him one example
28:59from my own practice now.
29:01We use thousands of medical
29:03devices every day in a hospital.
29:05I call this a bit of a Canary.
29:06This is laryngoscope.
29:07Of course we used to put in a breathing tube,
29:09has two parts,
29:11the tongue blade and the handle.
29:14There has been some,
29:15so the tongue blade goes in the mouth.
29:17So that's a semi critical device that
29:19must be at least high level disinfected.
29:22So that goes down to the central
29:25sterilization department for processing.
29:27The handle, something we hold on
29:29to is considered low risk,
29:31and so low risk items are
29:33cleaned at the point of use.
29:35But there has been a loophole in
29:38CDC designation of this handle.
29:41There's been conflicting designations
29:43by professional societies,
29:45and so the CDDC leaves it to
29:49industry to decide, well,
29:52industry by their own declarations.
29:55Are not infection prevention specialists.
29:57They can say how to clean something.
30:00They can't say what level of risk it is.
30:03And so,
30:04but industries jumped all over
30:06this and so now there is saying
30:09that these are intermediate risk
30:11devices and must go down to
30:14central sterilization and supply.
30:15Or alternatively you can buy their
30:18single use disposable device.
30:20And so there's this wave.
30:22Of moving to single use of
30:25social devices across the country
30:28because of this regulatory risk.
30:29And so there's this concept of greenwashing.
30:32There are many different aspects to it,
30:34but in general it's a practice of
30:36making unwarranted or exaggerated
30:37claims of sustainability or
30:39environmental preference and an
30:41attempt to gain market share.
30:43This particular device was presented to
30:47our Peri Operative Manager as a green device.
30:51Because it could be recycled.
30:53Well, that is questionable,
30:55but nonetheless, I didn't.
30:57And also cheaper,
30:58but I didn't take anyone's word for it.
31:00So we got together with their
31:02engineering students and it was
31:03called the Life Cycle Assessment.
31:05LCA is a modeling tool for quantifying
31:07the total resource inputs and
31:09environmental burdens over the
31:10life cycle of a product or process.
31:13We tend to think about stuff
31:15as we're using it.
31:16We think less about what goes into
31:19manufacturing it and even less about
31:21the natural resource extraction that
31:23even preceded the manufacturing.
31:25And we might think about something,
31:28what happens to something when
31:29we throw it away.
31:30But unless you consider all
31:31of these things together,
31:32you can't make very fair you
31:35can't make any assessment
31:36of environmental performance.
31:38And so LCA considers the entire system the
31:42the hotspots are not always intuitive.
31:45And importantly, even though we I talk and
31:46we talk a lot about greenhouse gas emissions,
31:49carbon emissions, it's not the only
31:51environmental pollutant of concern.
31:53There are multiple environmental
31:54impacts and we have to be careful.
31:55We're not shifting one problem to another.
31:58So this is a method of quantifying
32:00emissions for design and decision support.
32:03And so very briefly we did an LC of the.
32:07Reasonable disposable laryngoscope.
32:08So for the single use disposables,
32:11the SUD's we consider raw
32:12material extraction all the way,
32:14manufacturing,
32:15packaging and then eventually throwing
32:17away and compare that to reusable.
32:20Now importantly,
32:21especially if you're reading the literature,
32:23you don't have to know how to interpret it.
32:25The handle was rated for 4000 uses,
32:28so one disposables compared to 1/4
32:32thousandth of a reusables manufacturing.
32:36And packaging and transportation to
32:40one use in cleaning and repackaging
32:43and one four thousandth of the device
32:46being thrown away in one package.
32:48So you have to do a fair comparison.
32:50We also looked at cost.
32:51We considered refurbishment.
32:53We consider labor costs and disposal fees.
32:56Now there's a lot of information here.
32:58I just want you to squint at it.
33:00There are some clear things to
33:02take away here.
33:02The Gray is a disposable and
33:05the green are the reusable.
33:07So even though the vendor told us
33:09that it was more costeffective and
33:11more environmentally friendly to you
33:13because we could recycle that device,
33:16that is not what we found.
33:17The disposable device several times,
33:21the emissions of all different scenarios
33:24and how to clean the reusable and.
33:27It also increased our cost by about $700,000,
33:32just our one department.
33:33The other take away here is the waste phase.
33:37Now the manufacturer said it's green,
33:40you can recycle it.
33:41Actually all those components are
33:43not recyclable and you have to go
33:45to a vendor willing to take it,
33:47which would be about 1000 miles away.
33:50But for the sake of argument,
33:52so the red here is the average US waste mix,
33:55so a fraction is.
33:57Recycle The fraction is incinerated
33:59in a fraction of landfill.
34:01For the sake of argument,
34:02we said what if we could 100%
34:04recycle this device, which we can't.
34:06But what if we could?
34:07That's what this bar is representing.
34:09And what this means is that we
34:13cannot overcome the higher emissions
34:16of these devices by recycling.
34:17We cannot recycle our way out of this issue.
34:21And in fact,
34:22we need to ask ourselves what a
34:24singleuse disposal device is.
34:25There is an industry called reprocessing,
34:27which third party takes some of
34:29our disposal devices, cleans them,
34:31test them, send them back,
34:32sells them back at a fraction of the cost.
34:35And it's important to know that
34:37singleuse disposal is an industry
34:39designation, is not a regulatory designation.
34:41It does not mean that a device
34:44can't be reused.
34:45What it does mean is that
34:47whoever cleans it assumes
34:49that it's going to function
34:51as originally intended.
34:52And so there's this concept of
34:54the circular economy that should
34:55become carbon common parlance.
34:57What we have is a linear economy,
34:59a take, make waste,
35:00where we extract resources, we make stuff,
35:02we use it very briefly and we throw it away.
35:05The circular economy comes
35:06from nature and nature.
35:07There is no such thing as waste.
35:10The waste product of 1 system
35:11is a feedstock for another.
35:13And that is the the the foundation of this.
35:16Approach.
35:17So we want to retain and reuse
35:19things as much as possible,
35:21repair and refurbish them as needed,
35:23repurpose them when they can't be
35:25used for their original intention.
35:26The last thing you want to do is recycle.
35:28It's better than nothing.
35:30But even that might even
35:32be called into question.
35:33And of course we need to redesign things.
35:36We need to redesign products and
35:38services where fewer embodied
35:39materials and chemicals and energy.
35:41We need to design things for reuse.
35:43They have a modular design so
35:45they're easy to disassemble,
35:46clean and reassemble.
35:47And we need systems for recovering
35:49and repurposing materials.
35:51We need to address policy drivers
35:53of manufactured obsolescence.
35:54I'm going to shift gears and talk
35:56about a couple of medication examples.
35:59I mentioned that 5% of health sector
36:03emissions are coming from inhaled
36:05anesthetics and meter dose inhalers.
36:08Meter dose inhalers used for
36:10reactive airway disease.
36:10You see people puffing.
36:13Those inhalers have a propellant
36:16that actively pushes the medication
36:19into the patient's lungs.
36:21One Albuterol inhaler.
36:23Because of those,
36:25the gases in the delivery device is
36:28equivalent of driving 200 miles.
36:30There are 55 million devices sold
36:32annually in the equivalent of more
36:34than a half million cars on the
36:36road just in the United States.
36:38There are multiple device
36:40alternatives with 110th,
36:41120th the emissions,
36:43most notably dry powered inhalers,
36:44softness inhalers.
36:45Of course not every patient can use these,
36:49we can't get to 0 metered dose inhalers,
36:52but we do know that Sweden is now
36:54about 12% metered dose inhalers,
36:57the USUK around
37:0070%. So we have room to move on this.
37:05So choosing, we talked about making choices.
37:08Lower embodied carbon as one of
37:12our approaches to mitigation.
37:14So inhale anesthetics is another area.
37:17These are not.
37:18These medications are not metabolized.
37:19They're exhaled by the patient.
37:21They're essentially blown off the
37:23hospital rooftop where they are potent
37:25greenhouse gases and some of them are
37:27destructive to the ozone layer and
37:30their emissions are uncontrolled.
37:31This is another study we did.
37:32Again, I just want you to squint at it.
37:34These top three drugs you see here,
37:37Destroine, Isoflorine and Cevoflorine.
37:39Deaths Rain is at least 20 times
37:41the emissions of isoflorine and
37:43cevoflorine on a life cycle basis.
37:46The pink hair.
37:47So you see the the other thing is if you
37:49use in combination with nitrous oxide,
37:51which is common,
37:53nitrous oxide emissions are.
37:55Close to those of deserine and clinical
37:58clinical equipment quantities.
37:59And so if you add them to
38:01Isopylane and Cebo chlorine,
38:03they make those combinations worse.
38:06And then this one that you
38:07can hardly see here,
38:08propofol,
38:08it's not a typo,
38:10it's an intravenous medication and the
38:13life cycle greenhouse gas emissions
38:15are several orders of magnitude
38:18fewer than the inhale metaesthetic.
38:21So here's an opportunity where choices exist.
38:24Choose a lower carbon approach.
38:27And so of course there are other
38:29things we use in anesthesia,
38:30general inhale with the patient being asleep,
38:33we could do regional or peripheral
38:34nerve block whether we numb up an arm,
38:36for example for a limb surgery
38:40or here you're seeing a patient
38:41getting an injection to have either
38:43a spinal or epidural.
38:44Those are types of regional
38:46anesthesia or total intravenous,
38:48meaning you could have general
38:50anesthesia but performed.
38:51Surely through intravenous drugs.
38:52And again, if you just squint at this,
38:54we hypothesize any anesthetic approach,
38:57you know,
38:58because it's not just those drugs
38:59we use lots of drugs and supplies,
39:00medications,
39:01any anesthetic approach that use
39:03inhale anesthetics would be a worse
39:06approach from an environmental perspective.
39:08And that's what we found.
39:11Similarly,
39:11different approaches to surgery.
39:14This study looked at different
39:17approaches to hysterectomy,
39:18looking at open procedures and
39:21abdominal procedure versus a vaginally
39:24assisted abdominal procedure.
39:26Compared with minimally invasive
39:28laparoscopic robotic procedures
39:29and some of the takeaways here,
39:32the purple or the inhaled anesthetics.
39:33Inhaled anesthetics is responsible
39:35on average for about 50% of
39:38perioperative emissions.
39:40The other big offenders here are the
39:44single use consumable instruments
39:47and linens and the minimally invasive
39:50procedures are using a lot more of these.
39:55Obviously environmental performance
39:56is not how we're going to select our
39:59approach to a surgical procedure.
40:01That said.
40:02There are no better clinical outcomes
40:05from robotic versus laparoscopic procedures.
40:08So that's something to pay attention to.
40:10These large bars here represent the
40:13emissions of the anesthetics or
40:16or impacted by anesthetics because
40:18some of the patients in these
40:20studies had intravenous anesthesia
40:21versus the inhaled gases and and I
40:24already told you that there's four
40:26orders of magnitude difference.
40:27That's why you're seeing those error bars.
40:30Here's another interesting study
40:31comparing the same procedure
40:32performed in different countries.
40:34So variation in practice,
40:36particularly this is cataract surgery.
40:38So if you look at the emissions
40:40from the same surgery performed
40:42in the UK versus II has,
40:48you know, two fold fewer emissions
40:51for the same procedure on the right,
40:54you're seeing all the trash from one
40:56cataract surgery in the United States.
40:58And on the bottom bottom,
41:00similar amount of trash from 93
41:02cataract surgeries performed in the UK.
41:05Now of course we also have to
41:06ask about clinical outcomes.
41:08While this study didn't look at that,
41:09other studies have shown that the
41:12clinical outcomes are are very similar.
41:15Now, it's a low risk procedure,
41:16but it really begs the question
41:18of what we're doing differently,
41:21why we're doing it differently.
41:22And also, it's not just about the global
41:25S learning from us how to do better care.
41:27It's about us learning from
41:29them how to do better care.
41:31And so we also have a problem with even
41:34when we're delivering the right care,
41:36using too much stuff,
41:38using, doing too many tasks,
41:40too many medications.
41:41We really have to match the patient
41:43complexity to the preparedness
41:45and the stuff that we use.
41:46Simple cases, simple stuff,
41:48complex cases, complex stuff.
41:50If we over prepare we create waste and
41:53if we under prepare we create risk.
41:56So it really is about finding
41:58that balance And another topic,
42:00we're almost done here that I
42:03really want to dresses this idea
42:05of inappropriate care.
42:06We know we do too many tests to we
42:09prescribed too many medications,
42:11we do too many procedures.
42:13We prolong death at end of life
42:15most of our spending and is at end
42:18of life and much of it not wanted.
42:21And so how we act as clinicians,
42:24the micro level meaning in our
42:25personal practice we need to adhere
42:28to evidence based practice that means
42:30de adopting old ways of doing things
42:32being on top of new ways of doing things.
42:34Here at Yale New Haven Hospital,
42:36we have the Care Signature program,
42:38which really makes it easy for us to do
42:41the most streamlined current best practices.
42:45So we need to avoid technology
42:47and indication creep as well,
42:48something new and shiny for
42:51one specific indication.
42:53Once it becomes available,
42:54then people start using things liberally.
42:56That creates a lot of waste.
42:59We need to focus more on
43:00shared decision making,
43:01providing care that is wanted by the patient.
43:04And also that also means educating
43:06our patients and not providing
43:08unnecessary care because they want it.
43:11The famous example, of course,
43:12being antibiotics for childhood
43:15ear infections,
43:16most of which are viral in nature.
43:20Of course parents feel bad.
43:21They want a solution, they want a pill,
43:23but the pill is not the answer.
43:24And so education is really important.
43:27And so shared decision making is not
43:29only just providing care that is wanted,
43:32it means not providing.
43:33Unnecessary care just because it is wanted.
43:37So at the meso level that means
43:39acting within our organizations,
43:40better care, coordinate in coordination,
43:42avoiding duplication of care,
43:44working to create institutional
43:46structures to promote best
43:48practices within our departments,
43:50within our institutions.
43:51And again this idea we can develop
43:54protocols for D adopting low value
43:57care and on the macro level.
43:59Of course universal healthcare
44:01access will will be one of the
44:04things to advocate for here,
44:05but also addressing clinical care guidelines,
44:08standards of care education,
44:10addressing payment models to
44:12discourage low value care.
44:13So there's ways of us getting
44:15involved on the national level
44:17and even international level.
44:19And so of course as an acute care provider,
44:23this is not my area,
44:24but I would be remiss if I
44:25didn't talk about prevention
44:27and crime disease management.
44:28Things like green spaces,
44:30encouraging active transportation,
44:31more physical activity,
44:32more Whole Foods,
44:33plant based diet,
44:34addressing the social determinants of
44:37health and affordable primary care
44:39moving upstream to prevent people
44:41from needing care to begin with is
44:44essential for mitigating healthcare harm.
44:46That said, if we.
44:48Expand and do the same things to more
44:51patients in the name of of prevention.
44:53We will not be solving the problem,
44:56We'll be worsening the problem.
44:57So it really is about care transformation.
45:00Some good news,
45:01some good things that are happening globally.
45:03Nationally,
45:03the scientific community is called
45:05for having emissions by 20-30,
45:08getting to net 0 by 2050.
45:10On the left,
45:11you're seeing the National Health
45:12Service was the first in the world to
45:16regulate. Carbon reduction on of their
45:20national of their nation with that
45:23involve involved all their national
45:25systems including the health system.
45:27So they've been measuring their emissions
45:30since 28 and they have a whole greener
45:33NHS program is what it's called to
45:35strategically mitigate my team as part
45:37of the part of the analytics here.
45:39So if you figure what are all the
45:42things we can do to mitigate emissions.
45:45And and phase them in strategically,
45:48how long will it take to get to net zero?
45:51And that's really what this plan is
45:53all about. So the NHS has led this.
45:55They got together with COP 26 and with
45:59the UNF Triple C and The Who created a
46:03global movement of committing to low carbon,
46:06resilient health systems.
46:07The White House has a similar
46:09mandate under executive order
46:11affecting all federal health systems.
46:14The Joint Commission has developed
46:16an environmental standard to help to
46:19help move hospitals in this direction
46:21of accounting and mitigation.
46:22The National Academy of Medicine
46:24has a action collaborative and
46:26decarbonizing the US health sector.
46:28The
46:30SEC has proposed rules that would require
46:33accounting by all accounting and mitigation
46:36by all publicly traded organizations.
46:38Of a certain size.
46:40This all requires decarbonization
46:42targets and timelines.
46:44We can't just have them, you know,
46:45I'd like to say a merry band of
46:48volunteers who start a recycling program.
46:50We have to have clear targets and timelines.
46:53We have to be very strategic about this,
46:55which means we have to have robust
46:58benchmarking methods and tools,
47:00and we have to consider interventions that
47:03are both feasible and impactful together.
47:06Addressing waste and inefficiency
47:07and reducing embodied emissions
47:09and our goods and services.
47:11And we have to be careful
47:13to avoid greenwashing,
47:13both intentionally and unintentionally.
47:15And so my colleague and I on Doctor Anna
47:19McNeill is a surgeon at the University
47:22of British Columbia have developed
47:24a planetary healthcare framework.
47:26You've heard these principles in my talk,
47:28but I'll just present them.
47:31The key principles include reducing emissions
47:33and body within healthcare services.
47:35Conclusive electrification
47:36combined with clean energy,
47:39switching to a circular economy
47:41and being better resource stewards,
47:43matching supply with demand,
47:44meaning we have to address
47:46inappropriate care,
47:46which is a huge problem in
47:48our country and globally,
47:50but we certainly recognize here in
47:51the United States and moving upstream
47:53to reduce demand for healthcare to
47:55begin with through health promotion,
47:56disease prevention and addressing
47:58the social determinants of health.
48:00And when we think about value in the
48:02triple bottom line of the best care for
48:04the most patients at the least cost,
48:05least cost isn't just financial,
48:07it also means least environmental
48:09and social harms.
48:10And that's what we mean by high value care.
48:14And so there's now a concept of
48:16planetary health and there is a
48:19an update to the Hippocratic Oath
48:21or which has already been updated.
48:29Sorry, I'm. I'm blanking.
48:31On 1948, the Hippocratic Oath was updated
48:34by the World Medical Association,
48:37but it has just undergone a new proposed
48:40update to account for planetary health.
48:43I encourage everyone to read this,
48:45and in fact, I think medical
48:47students should recite it during
48:48their White Coat Summers ceremonies.
48:50And with that,
48:52I will pause and take questions.
49:00Thank you doctor. Sherman let me
49:02see how we can figure out what the
49:04how are we going to do this week.
49:06Karen how do you want to
49:08set up for questions Karen.
49:13OK all right. So we we so that the
49:17folks on on there we have nothing
49:19on zoom you just have the folks
49:20here I'm going to do a little walk
49:22in here with this you've got that.
49:24OK. So I'm going to take the.
49:27Take the first question if I can Jody,
49:32we, you know the the specter,
49:35the importance of public health,
49:37it was raised in in conversations I
49:39think that we had prior to this and
49:41what's the importance of your work.
49:42I guess what I'm trying to,
49:44what I'm trying to get around to is
49:45it seems to me that to fix this it's
49:47got to be a public health solution
49:49which is to say that I'm pretty much,
49:50I'm pretty much I know that I need the
49:54disposable kit for me and everybody
49:56else should use the other one.
49:58And I think that probably a lot
50:00of people feel that way.
50:01Do you know what I mean?
50:02That that there has to be,
50:04I don't want to sound authoritarian
50:07about this,
50:07but one gets a sense there has to be
50:09kind of a higher authority that says, no,
50:10this is what we're going to do, right?
50:12Because particularly, you know,
50:13in a society that's so values
50:15individualism so much that to say,
50:17well, we're going to do this for
50:19the benefit of the planet,
50:20that's a hard sell.
50:20We're going to do this for
50:22the benefit of the group.
50:22That's a hard song unless someone's kind
50:24of overseeing the benefit of the group.
50:25But I think everybody's pretty clear
50:27that everybody else ought to cut back
50:29on their emissions except for me.
50:31So.
50:31So is there a strong initiative
50:34on a national level in terms of
50:36public health to make these things
50:37happen in the hospital?
50:39Right. Well, I think there's a few
50:42issues that you've highlighted and want.
50:45We cannot sacrifice individual
50:47patient safety for public health.
50:50That is also. A moral issue, right.
50:55So we cannot do harm to our patients.
50:58So right now it's about using
51:01environmental information to be
51:03part of the decision making.
51:05Not the first thing or the only thing,
51:06but part of what goes
51:08into our decision making.
51:09And two things.
51:10Firstly, that requires evidence.
51:12We need to know what's more or less harmful.
51:14That requires disclosure by industry.
51:18That requires.
51:20Funding for research and that requires
51:24disclosure standards and we also
51:26need guidance of what to do in the
51:29absence of information in the terms
51:32in in terms of infection control.
51:34There are things that we know are
51:36safe to do and then there's a lot of
51:38stuff that we have no information on.
51:39But the default is let's just
51:42throw everything away and just
51:44like it's our responsibility to
51:46not prescribe antibiotics for a
51:48probable viral ear infection.
51:50And we also have to be mindful of
51:53inappropriate use of disposable goods.
51:55And I also hear you suggesting
51:59the need for regulation.
52:02And I would say that's true because in fact,
52:05nationally,
52:06you asked what's happening nationally,
52:07the White House has a a
52:10pledge to decarbonize healthcare.
52:14They've had about over 100.
52:17Corporations and health organizations have
52:19since signed on to this White House pledge,
52:23which is to have emissions by
52:2520-30 get to net 0 by 2050,
52:27which is the international
52:29scientific mandate and is
52:32possible and requires commitment.
52:35But unfortunately,
52:36voluntary pledges are not enough.
52:38So I have published on and I've
52:40in fact testified in front of
52:42Congress that we need mandatory
52:44reporting and mitigation.
52:47Thank you. You know,
52:48your analogy to antibiotics with
52:49viruses is of course a very good one.
52:51Antibiotics for viruses,
52:52we should we cut that out?
52:54That'll cut out some waste.
52:55But I was, I thought you were going
52:56to go in a different direction,
52:57which is that even though for my patient,
52:59I think you know what a third generation
53:02Cephalosporin will really do the job here,
53:05that nevertheless I feel a responsibility
53:07because of the overall concern
53:08of antibiotic resistance not to
53:10go directly perhaps to that third
53:12generation Cephalosporin to the latest.
53:14And greatest antibiotics,
53:15but to use something that's simple
53:17because we worry so much about
53:19creating resistance strengths to
53:20the more developed antibiotics.
53:22So it's the same sort of thing.
53:23So I think within the medical
53:24culture we've had some upbringing
53:27in the idea that well,
53:28it may be fine for this patient,
53:30but in fact in the long run
53:32it's going to do harm.
53:33Well,
53:33and that's also the virtue
53:35of decision support tools,
53:36including nudges in our
53:38electronic health record that
53:40point us to better first choices.
53:43Point us, don't restrict us, but point us.
53:46And that's also why we need
53:48decision support tools,
53:49why the work of care signature is really,
53:51I think a shining star of our organization.
53:54Thank you, I I've always had the
53:56sense it's a psychological thing
53:58and and I may be off based on this.
54:01I wonder what you're thinking.
54:02But sometimes when I do things
54:04or when I see things I have,
54:06I fall back and it was somebody must
54:08have the right this the first time.
54:10I used the whole freaking kit
54:11for one quick procedure and
54:13then threw the whole thing away.
54:14Except the sharps I threw away
54:15over here and everything else.
54:17I thought, well, someone,
54:18somebody who knows more than
54:19me and authority has figured
54:20out that this is the best way.
54:22For us to do this,
54:22which is to throw away all this
54:24stuff every time we do a procedure
54:25and and or when you use you know
54:27a complicated device to administer
54:29medication and throw the whole designs away,
54:31the disposable, the Ringoscopes.
54:32I I couldn't believe it when I saw it.
54:33I said well really this is the
54:35best thing overall,
54:35all right.
54:36There's the sense that somebody
54:38in authority overseeing this as a
54:39side of this is really what's best.
54:41And my fear is and I don't mean
54:43to be cynical,
54:44actually don't my fear is that they
54:46figured out this is what's best in
54:47the short run for the bottom line.
54:49And perhaps also for infection prevention.
54:51I think a lot of this is that
54:52in the short run,
54:53this is what's best for the bottom line.
54:54And that's we're all about the
54:56short run and we're all about the
54:58bottom line because some of the
54:59stuff that we throw away in the
55:02practice of medicine is just amazing.
55:04It amazes me.
55:05So I always thought that somebody's
55:06figured out that this is the best way,
55:07but not so well.
55:09I don't believe somebody's
55:10figured out it's the best way.
55:11I think much of it is manufactured
55:15obsolescence by industry.
55:18Regulatory loopholes,
55:19lobbying to obfuscate and preventing,
55:26not putting forth accurate information,
55:29misleading information.
55:30And then of course there
55:32you're absolutely right.
55:34It's a lot of it is about convenience.
55:36But if you actually do the analytics now,
55:39when when we first made this switch to
55:42disposable lingoscopes in our department.
55:44I went to our para operative manager
55:45and he started touting about how
55:47much money it was going to save and
55:48how was better for the environment.
55:50And I said show me the data.
55:51And I actually I didn't believe it.
55:53So that's why we did our own study.
55:55He was presenting data presented by industry.
55:58Now of course we do have our own
56:02internal value analytics teams,
56:04but I will say this that.
56:07If it doesn't pass the sniff test,
56:10I I I personally investigate
56:12and I would say it's not always
56:15true that reusables are cheaper.
56:17It's not always true that
56:19reusables are safer.
56:20It's not always true that reusables
56:22are better for the environment.
56:24But by and large,
56:26all the research that has been
56:28done has shown that to be true
56:30and we really cannot sit back and
56:33just let this trend go unfettered.
56:35It really has to be looked at
56:38critically and in fact there is so much
56:40money and opportunity to be saved,
56:42but we have to look for it
56:44and instead the easy way out,
56:45just like it's easy to to take our
56:47buyer to go coffee and throw the cup
56:50away versus carrying our cup with us.
56:52It's just more convenient.
56:54It takes less time,
56:55takes less human resource.
56:57That doesn't mean it's better
56:58for our bottom line.
56:59In fact,
57:00creating more jobs in our local community
57:02supports the social determinants
57:04of health and and prevents harm
57:06and need for healthcare services.
57:08So really have to look broader
57:10than what's most immediate.
57:12Thank you. We have,
57:13there's a question back,
57:14we got a few questions in the house.
57:15So I'm going to run with the
57:17microphone so that the folks
57:18on Zoom can hear you as well.
57:22I think this is critically important
57:24and I'll trump your cynicism with mine.
57:27You mentioned the bottom line.
57:29My question is better for the bottom line.
57:30The question is whose bottom line?
57:33And my frustration is that it's politics
57:36and profit that really rule today,
57:38and I don't know how science that
57:41we in science can overcome that.
57:44Well, I I will tell you that
57:46there are some shining stars,
57:48some healthcare organizations shining stars.
57:51And we're actually different
57:52than other industries.
57:53Other industries are really motivated in
57:55this space and many are already do carbon,
57:57carbon accounting and mitigation,
57:59looking for greener solutions for
58:01real because they have reputational
58:04risks because there are many
58:07studies now that show that.
58:09Potential employees want this and
58:12they will absolutely choose between
58:15job opportunities based on the
58:17corporate responsibility profile
58:19of a of a particular industry,
58:23a particular organization.
58:26So, but there are some shining stars
58:29and organizations and I will tell
58:31you that those that are shining
58:33stars either have a religious
58:35mission where they understand that.
58:37Protecting planetary health
58:38is a matter is a moral issue,
58:40a matter of ethics,
58:41and we're part of the environment.
58:43It shouldn't have to be a moral stretch.
58:45We cannot survive unless that
58:47the environment is thriving.
58:49But those who recognize it as a
58:52moral issue tend to be those that
58:55are religious based organizations.
58:58The other shining stars are
59:01those that have tied.
59:03Executive pay to environmental performance
59:13can you you
59:14you presented some wonderful data
59:17and I'm interested in what the the
59:20status is of you the you of your
59:24ability to use this data to persuade
59:26health institutions, hospitals,
59:28health systems to make the changes that.
59:32Seem to be pretty obvious and available.
59:37Do Do the institutions respond #1, #2?
59:42Are there enough of you that are making
59:45the case to the institutions that they need
59:48to be changing and that there are ways
59:51to change that are readily accomplishable?
59:53Where where do things stand just in
59:57terms of moving health institutions?
01:00:00In the directions that you'd like to see,
01:00:03Yeah, thanks for that question.
01:00:05There are not enough professionals
01:00:07in that being paid in the space.
01:00:10I will say that most of the work is
01:00:13being done on a voluntary basis,
01:00:15which isn't going to go far enough,
01:00:18as I like to say, a merry band of volunteers.
01:00:20You can't, can't get it done
01:00:22with a merry band of volunteers.
01:00:24So the Agency for Healthcare Research
01:00:26and Quality has put forth a primer
01:00:29on how to measure and get started.
01:00:31I was one of the authors on that.
01:00:34This goes along with a brand new Office
01:00:37of Climate Change and HealthEquity,
01:00:40which is also collaborated with the
01:00:41White House and the White House pledge.
01:00:44And I will say that.
01:00:47Organization.
01:00:47So I I told you 2 main ways to
01:00:49reduce emissions is number one is
01:00:50to reduce waste and efficiency.
01:00:52Whichever 1 can get behind,
01:00:53you're going to save money doing that.
01:00:55And then there's sort of a question,
01:00:56why haven't when we've been able
01:00:58to get it done.
01:00:59I think that it's a very complex issue.
01:01:02A part of it is what motivates us as
01:01:05individuals providing the care, right.
01:01:07So if so, I, for instance,
01:01:10have a fixed salary,
01:01:12the organization makes or loses money
01:01:14based on my behaviors doesn't really affect.
01:01:17Me in a way that is is felt so.
01:01:20I mean I care about it,
01:01:21but I would say most providers don't care
01:01:23about care about that as a motivation.
01:01:26However,
01:01:26if you start presenting their pollution
01:01:28data to them and start educating them
01:01:30on the fact that they are causing harm,
01:01:33I guarantee you they will
01:01:34be motivated to waste less.
01:01:35So one is simply getting enough
01:01:39awareness and and education around
01:01:42why it's important to prevent waste.
01:01:45The other on environmentally
01:01:48preferable drugs and devices,
01:01:49part of it is that there is are limited
01:01:53things that are known to us as clinicians.
01:01:56There's a lot of information being
01:01:59put forth by suppliers now and it's
01:02:01really hard to sort through all that.
01:02:04But importantly is to start by doing
01:02:08organizational missions, measurement.
01:02:10This is pretty straightforward.
01:02:13And with that information,
01:02:14any organization can make a strategic
01:02:17plan based on where their hot
01:02:19spots are and based on what's most
01:02:21feasible for that organization.
01:02:23And it's kind of,
01:02:24there are some similarities,
01:02:25Inhale, anesthetics, meter,
01:02:27dose inhalers, those are hot spots.
01:02:29But every organization has to start
01:02:31with benchmarking its emissions.
01:02:33And I guarantee you once they
01:02:35start saying it's not hard to do,
01:02:36they'll identify hotspots,
01:02:37which by the way are hotspots that
01:02:40they're probably already thinking about
01:02:42anyway and there are opportunities for
01:02:44them to save money and those things.
01:02:46So I have a couple of online questions,
01:02:48then we're going to get to yours also.
01:02:51One is something I was actually
01:02:52thinking about Jennifer Miller's work,
01:02:53but I say she's already chanted.
01:02:54We'll get to her in a couple minutes.
01:02:56One is a question is who are the
01:02:58best stakeholders to be asking?
01:03:00Show me the data to encourage the suppliers.
01:03:02To design for improve
01:03:04environmental performance,
01:03:05who should be asking for these
01:03:06data that the physicians,
01:03:07for example, is it the consumers?
01:03:10Yeah, well, it's actually,
01:03:11it starts with the SEC, that's for sure.
01:03:14So there are proposed rules by the
01:03:16SEC to mandate on this reporting.
01:03:18It's already happening in Europe.
01:03:20So we're behind the times and a
01:03:22lot of the corporations we work.
01:03:24With our global entities,
01:03:26so even if the SEC doesn't
01:03:28come on board quickly,
01:03:30the the global corporations are
01:03:31being pressured in this direction
01:03:33and that is that they need to measure
01:03:35and mitigate their own emissions.
01:03:37That's part of it.
01:03:38Because if they decarbonize or
01:03:40is 1 expression what's embodied
01:03:42in the stuff that they provide,
01:03:44that's going to help everyone and
01:03:46also create a knowledge base that
01:03:48that other organizations like
01:03:50healthcare organizations can use.
01:03:52The other part of that is that there
01:03:54has to be mandated reporting on the
01:03:56level of products and standards around that.
01:03:58Just like we have food and nutrition labels,
01:04:01there needs to be similar labels at
01:04:02the level of the product and then
01:04:05also has to come from regulators.
01:04:07Thank you. Ask your question next, please.
01:04:10Thanks for the presentation.
01:04:12Doctor Jody and Doctor Sherman,
01:04:14I guess I'm thinking about in the
01:04:16context of a lifecycle analysis
01:04:19when you have, you know 2.
01:04:23Two procedures that have clinical equipoise,
01:04:25but you have clinicians that are
01:04:27trained or who have been fed this
01:04:29idea that you know we need to be
01:04:31able to reduce hospital acquired
01:04:33infections And you know there's a very
01:04:36compelling argument that a singleuse
01:04:39device leads to like lower risks.
01:04:42I'm wondering to what extent
01:04:44there needs to be like research
01:04:48paired with this LC Air like.
01:04:50How how can you convince A clinician
01:04:53beyond showing them the lowered
01:04:56ecological impact of a reasonable
01:04:59outcome to believe like I don't know
01:05:02that clinically it would be like equal
01:05:04and when they have so much almost
01:05:06marketing that goes against that narrative,
01:05:08Sure, that's a great question.
01:05:11Part of the challenge with
01:05:13healthcare acquired infections
01:05:14is that they are multifactorial.
01:05:17You would literally need.
01:05:19I forget it has been estimated,
01:05:21but you know something like millions of
01:05:24cases to prove one infection related
01:05:27to a particular device outside of,
01:05:30you know, obvious things like
01:05:33central line infections for example.
01:05:36So it it makes it very difficult
01:05:39if not impossible.
01:05:40And so we are actually calling
01:05:42for creating standards on on how
01:05:44we define and how a report risks.
01:05:47Related to we can't.
01:05:49We can't report the infection,
01:05:50but we can report realist risks.
01:05:52I mean, we can report infections,
01:05:54but in terms of causality,
01:05:56we we can't always identify what it is.
01:05:58So we're now calling for experts
01:06:00to come together and develop
01:06:02a system of reporting risks to
01:06:05better identify those cases.
01:06:07But there's also a rational approach.
01:06:09If you're not doing a sterile procedure,
01:06:12you do not need sterile devices.
01:06:15That's a pretty simple thing.
01:06:17There are situations where we know,
01:06:19for example,
01:06:20longer drapes prevent central line
01:06:23infections versus shorter drapes.
01:06:25There are some things that we know about,
01:06:26but we also have to use our judgment
01:06:29and we have to be better stewards,
01:06:32stewards of our resources.
01:06:34And there's this concept of de adoption
01:06:37de adopting old ways of doing things
01:06:39that are not supported by evidence.
01:06:41That requires education,
01:06:43both at the undergraduate,
01:06:44graduate, postgraduate level.
01:06:46That requires culture change.
01:06:48That requires everyone recognizing
01:06:51that excessive use of things
01:06:55has its own risk involved.
01:07:01So another question from the Zoom world.
01:07:03But before I get to that question,
01:07:07which is from Jen Miller, who works
01:07:09at has developed a pharma scorecard.
01:07:12And she's one of our faculty here,
01:07:13essentially has to do with ethical
01:07:15principles and bioethical practices.
01:07:16Or essentially a company
01:07:18receives a a a scorecard,
01:07:20an ethical scorecard, if you will.
01:07:23And then they have their incentivized
01:07:25then to improve the ethical practices
01:07:27of that pharmaceutical company.
01:07:29And I wonder if there's an analogy
01:07:30to be drawn, which is to say,
01:07:32could we have a scorecard?
01:07:33You mentioned this about having like
01:07:35we have warnings on here's how many
01:07:38calories this particular drink has in it.
01:07:40If we have similar things on the
01:07:43label about exactly how much impact
01:07:45this has had on the environment,
01:07:47about the whether it's the
01:07:48greenhouse gas emissions, etcetera,
01:07:49etcetera,
01:07:50it said to have us an analogous
01:07:52scorecard for the pharma companies
01:07:54or for other companies.
01:07:55But then I want to get to
01:07:57Jen's question also after,
01:07:58yeah, well, there is such a thing.
01:08:00It's called ESG,
01:08:01environmental social governance.
01:08:02This is what the SEC is working on and would
01:08:05apply to large pharmaceutical corporations.
01:08:08In that there is a standardized method
01:08:12of measuring and required transparency
01:08:16on environmental performance,
01:08:17meaning, you know, in part,
01:08:19greenhouse gas emissions,
01:08:20social performance,
01:08:21meaning what harm we're doing in.
01:08:26Harm we're doing in the world and also
01:08:28our responsibility to diversity, equity,
01:08:30inclusion and fair pay and also governance,
01:08:33meaning what governance structures
01:08:35do we have to moderate and systems
01:08:37in place to oversee that and to
01:08:40oversee performance improvement.
01:08:42There is a standardized,
01:08:43standardized method of measuring
01:08:45that and transparent reporting
01:08:47and that is what the SEC is doing.
01:08:50That's what ESG reporting is all about.
01:08:54The next question please from Zoom,
01:08:55which is great talk is the first comment.
01:08:57If the 25 largest pharma companies
01:08:59by market cap asked you to identify
01:09:02your top three to five recommendations
01:09:04for how they could reduce their
01:09:07negative environmental impact,
01:09:09what would you say? And within that,
01:09:10so that your three to five recommendations
01:09:12for the big pharma companies,
01:09:14but also is there a shining star or a
01:09:16shining practice in the pharmaceutical sect?
01:09:22Well, there is a new group called SMI,
01:09:26the Sustainable Medications Initiative,
01:09:28which is a collaboration amongst
01:09:32pharmaceutical companies to develop a methods
01:09:35of measuring and reporting emissions.
01:09:38So I'd say that that is a a positive thing.
01:09:42I do continue to worry about greenwashing.
01:09:46So in terms of top, top practices,
01:09:48there's a challenge because of course.
01:09:51These are forprofit corporations who
01:09:54are incentivized to sell more stuff.
01:09:57Everybody benefits,
01:09:58even pharmaceutical companies from lean
01:10:00practices reducing waste and inefficiencies.
01:10:03So that that is something that that benefits.
01:10:06We need to move toward greener design.
01:10:09That means green chemistry as well.
01:10:11So there's a whole movement happening in
01:10:13that regard and that's great to move away
01:10:16from forever chemicals to design things to.
01:10:18To have a function but to also break
01:10:20down as part of what green chemistry
01:10:22and green pharmacy is all about.
01:10:24But I would say one thing that
01:10:26really has to well, two things.
01:10:27I would say the list could go on,
01:10:30but one of the things that we struggle
01:10:33with is that package sizes are much
01:10:35bigger than we need and as a result
01:10:39we cannot split packages between
01:10:41patients in the hospital environment.
01:10:44There are either infection concerns.
01:10:47Or regular regulatory concerns.
01:10:49If, for example,
01:10:50one patient's insurance has paid
01:10:51for something and they've only
01:10:53used a fraction for it,
01:10:54we are forced to throw it away,
01:10:55which is obscene.
01:10:58So pharmaceutical companies really need
01:11:01to make things and packages that are
01:11:05the right size and need to be priced.
01:11:10Appropriately,
01:11:11sometimes they they they price things.
01:11:13Even larger packages can be
01:11:15cheaper than smaller ones.
01:11:16There's a lot of gaming in the system there.
01:11:18They really need to package things
01:11:20appropriate in appropriate size.
01:11:22The other is that we need to address
01:11:25Best Buy dates or expiration dates.
01:11:28They're somewhat arbitrary in the
01:11:32sense that they there's out to a.
01:11:35Particular period of time where
01:11:37medications are proven to be stable
01:11:41and lack any bacterial growth
01:11:43or or viral or or fungal growth,
01:11:47but they don't necessarily take
01:11:49it out to the the end point and
01:11:52so addressing Best Buy dates is
01:11:57another important strategy.
01:11:58I will say that I don't think any
01:12:00of these are going to come from
01:12:02the Pharmaceutical industry.
01:12:02I think it has to be regulated.
01:12:05Thank you. Other questions from inside
01:12:08the Do you have a question, Karen?
01:12:10No, Yes, this gentleman here
01:12:18thanks Doctor Sherman,
01:12:19not to spark a polemic discussion,
01:12:22but how has Yale New Haven,
01:12:25our own institution responded to a
01:12:28lot of research topics or anything and
01:12:30have they implemented any policies?
01:12:34Regarding, I mean any sustainable practice,
01:12:38what we do, the Yale New Haven Health System
01:12:41has a Center for sustainable healthcare.
01:12:43We do have a systemwide executive
01:12:46committee and each delivery network has
01:12:48a green team that meets regularly to
01:12:51discuss how to implement these changes.
01:12:55We were the first healthcare organization in
01:12:58the world to get rid of deaths rain, which
01:13:01is the worst offending inhale anesthetics.
01:13:04We did that back in 2013,
01:13:06saved our organization $1.2 million
01:13:08that year, just this hospital alone.
01:13:11Yale, New Haven at York Street campus,
01:13:13save the equivalent of 360 cars
01:13:15off the road annually.
01:13:16By getting rid of that drug.
01:13:18We actually started a global movement.
01:13:21Dust, dust,
01:13:21rain is now banned in Scotland this year,
01:13:24as of next year and England
01:13:25it will be banned.
01:13:27By 2026 it will be banned in Europe.
01:13:30So that's one shining accomplishment.
01:13:33We have are doing a lot of green
01:13:37energy planning for our new
01:13:40construction and retrofitting.
01:13:41So those are a couple of the
01:13:43examples of what we've done.
01:13:47Yeah. So somewhat related questions.
01:13:49So if a department like emergency medicine,
01:13:52you know, I I don't see that
01:13:53we're doing anything right now.
01:13:54So if a department wanted to start
01:13:58doing something other than getting our
01:14:00married group together or something,
01:14:02what would be the best way of
01:14:05starting to make some changes in a in,
01:14:08in a way that could be actionable,
01:14:10measurable things like that?
01:14:13Well, I will say that we don't have
01:14:17resource to give project managers to all
01:14:20departments to implement these things.
01:14:22So really I'd say every department needs
01:14:24to start its own green team and not in
01:14:26the sense of merry band of volunteers,
01:14:28but to identify those projects that
01:14:32are obvious to you as professionals.
01:14:35That are opportunity for reducing
01:14:37waste and if there is information on
01:14:40how to reduce embodied emissions,
01:14:42that's great too.
01:14:43But you know kind of like the
01:14:45Choosing Wisely campaign is really
01:14:47dependent on specialties to OfferUp
01:14:50what the solutions are.
01:14:52I think that's true in our own
01:14:54organization we don't have
01:14:55project managers to give to each
01:14:57department has to come from from.
01:14:58From you all and then you have to
01:15:01propose what needs to be done and I
01:15:05would encourage emailing the Center
01:15:09for Sustainable Healthcare to put
01:15:11forth ideas and and what what it
01:15:13would take to implement them or at
01:15:14least to start the conversation.
01:15:19Thank you so much for that wonderful
01:15:22presentation. I wanted to ask you
01:15:23if perhaps you could speak a
01:15:24little bit more on a topic
01:15:26that's near and dear to my heart,
01:15:27which is whole food plant based nutrition.
01:15:31You know Full disclosure as a
01:15:33cardiologist you know that the
01:15:35evidence continues to mount that
01:15:36you know in terms of cardiovascular
01:15:38health and also cancer prevention.
01:15:39You know we we know that a plant
01:15:41forward at least a predominantly
01:15:43whole food plant based diet has a
01:15:44lot of different health benefits.
01:15:46And we also know that you know that
01:15:49like even though The Who has said that
01:15:51processed meat is a carcinogen and
01:15:53red meat is a probable carcinogen and
01:15:55we know that that just beef alone,
01:15:57taking aside all the other dietary
01:15:59elements is responsible for way more
01:16:01carbon emissions than other foods.
01:16:03So it's sort of is baffling that
01:16:05something that that foods that are
01:16:08carcinogens are probable carcinogens
01:16:09and major carbon major carbon emitters.
01:16:14Are still featured very prominently
01:16:15in in the
01:16:16food that we serve.
01:16:17So perhaps you can talk about more
01:16:19about what their impact is and
01:16:22how how what you think is the
01:16:24path forward to having not only
01:16:26healthier offerings that support
01:16:28our mission of beneficence and non
01:16:30maleficence on an individual level
01:16:32but also on a on a planetary level.
01:16:35Yeah, thanks for that.
01:16:37So actually beef alone accounts for 1%
01:16:40of our National Health sector emissions.
01:16:42And it's not just what we feed our patients,
01:16:43it's what we feed our staff.
01:16:45And so there is a lot that can happen.
01:16:47There's actually a lot
01:16:48that has already happened.
01:16:49I don't know how long you've
01:16:50been with the organization,
01:16:51but there's a lot that has
01:16:53already happened to reduce the
01:16:54amount of meat that is offered
01:16:57both the patients and the staff.
01:16:59I'm also particularly concerned of
01:17:01all the single use disposables.
01:17:03That's another issue.
01:17:05How to improve it I think is is
01:17:07to get involved and and become
01:17:08a leader in that space.
01:17:10I will say that we did have another
01:17:13passionate person on this topic
01:17:14several years ago who decided
01:17:16to really clean up our patient
01:17:19menus and it failed pretty quickly
01:17:21because patients didn't enjoy it.
01:17:24Particularly give you an example of that
01:17:26kids when they're not feeling well,
01:17:27they want their their fish to another
01:17:29fish to they want their chicken fingers,
01:17:32they want their French fries.
01:17:34Whatever can't can bring them comfort
01:17:36and get some some calories and then
01:17:38really matters So and I think that you know,
01:17:41there's some truth to that in adults as well.
01:17:43Obviously we don't want to be causing harm,
01:17:46but there is something about
01:17:48patient comfort that matters.
01:17:50And so there are health systems that
01:17:54have been very successful by having
01:17:58really outstanding chefs preparing meals.
01:18:02There's a problem if we're outsourcing
01:18:03a lot of that to company that
01:18:05provides it for us,
01:18:06but then also is a cost mitigation strategy.
01:18:09So it's it's an area that needs improvement,
01:18:13but also not a simple one.
01:18:15It's not a simple saying let's
01:18:17just get rid of all the red meat,
01:18:19right.
01:18:20Thank you, Dr. Sherman.
01:18:22Next question away from the Zoom,
01:18:24you mentioned CDSS, please say more
01:18:26about developments and decision support.
01:18:29Is there enough data to make recommendations?
01:18:32What work is going on to create such systems?
01:18:35How do you envision there being?
01:18:36There's a lot of questions in
01:18:37wrapping this one question scene.
01:18:39So how do you We'll go,
01:18:40I'll go through them all and then
01:18:41we can take a little bit of it.
01:18:42How do you envision they're being
01:18:44implemented and used, for example,
01:18:46as part of the health record,
01:18:48as part of treatment recommendations,
01:18:50etcetera?
01:18:51Are there CDSS for selecting devices
01:18:54or are such systems being developed?
01:18:58These questions don't need
01:18:59to each be addressed,
01:19:00but I'm hoping for more comments
01:19:02about what's going on and
01:19:03what's needed in this area,
01:19:05specifically the CD Hasso you
01:19:06explain to us what that is.
01:19:08So a clinical decision support
01:19:10system is I think what they meant.
01:19:14So I said, you know there are actually
01:19:16a few things that we know are more or
01:19:19less polluting and in terms of drugs,
01:19:21you know it's one thing if you have you
01:19:24know there you have clinical equity poised.
01:19:27But you still need those options.
01:19:29And so for example,
01:19:30in the case of metered dose inhalers,
01:19:32we're working on a clinical decision
01:19:35support tool that nudges providers
01:19:37to select other types of inhalers
01:19:39before prescribing that one.
01:19:41So that's an example.
01:19:44In the case of inhaled anesthetics,
01:19:48not exactly it's it is a point of care tool.
01:19:52We have fresh gas alerts that tell us
01:19:54when we're using excessive flows of
01:19:56gas more than the patients require.
01:19:58That's another example.
01:19:59In terms of choosing between medical devices,
01:20:02there would not be a decision
01:20:04supports tool in that regard that
01:20:06really is not for clinicians,
01:20:08it's the kind of thing that.
01:20:10Procurement officers require that data
01:20:12to help them choose who to contract with,
01:20:15who not to contract with,
01:20:17and it's just one factor of many
01:20:19that goes into that decision making.
01:20:21So I don't know so much that it is a
01:20:24a tool so much as it is an algorithm.
01:20:27But one thing I do think that really
01:20:29needs to happen is that we need a
01:20:32better means of accounting of all the
01:20:34stuff that we're prescribing and using.
01:20:36Some of that is is captured in the
01:20:38patient record, some of it is not.
01:20:40But of the things that are captured
01:20:42in the patient record,
01:20:43we can use electronic health systems
01:20:46to allow us to assess variation
01:20:49between practitioners,
01:20:51accounting for differences in
01:20:53patients and differences in clinical
01:20:55outcomes to identify outlying.
01:20:57Providers that have more excessive OR,
01:21:01or, or not doing best practices.
01:21:04An example has to do with number of
01:21:08surgical trays that are used for.
01:21:10I'm going to give an example of
01:21:12a total knee replacement,
01:21:13which is something we've discussed
01:21:14with the orthopedic surgery team.
01:21:16So that's a way that electronic health
01:21:20records can be used to track information,
01:21:22identify best practices,
01:21:24identify outliers.
01:21:26Who can then be shown data to reflect
01:21:30as one means of behavior modification?
01:21:34Thank you. There's one last question
01:21:35which I'll answer, which is,
01:21:36are the recording and slides available to us?
01:21:39The recording will be,
01:21:40there'll be a recording of the of the
01:21:42presentation which will be available
01:21:44on our website in a few days.
01:21:45And I think in the chat you saw
01:21:47the CME information was presumably
01:21:49everyone could see this.
01:21:50You want me to go ahead and say it?
01:21:52That's what all that pointing the stuff is.
01:21:54Go ahead and say it.
01:21:55All right, here we go.
01:21:55So for today,
01:21:57the number you would you would text is 2 O
01:22:0334429435. That's the same
01:22:04for all the Yale CME2 O
01:22:0834429435. And then the code
01:22:10for today's section is
01:22:1336153. Joey's going to see if she
01:22:15can get to some CME credit for this
01:22:17excellent talk she just attended.
01:22:18Let me just grab this real quick.
01:22:20Thank you very much.
01:22:22Doctor Sherman, this was a really,
01:22:26really depressing a presentation.
01:22:28It was also a really,
01:22:29really necessary presentation and and
01:22:31beautifully I beautifully got a line for so.
01:22:34So thank you very much.
01:22:35A lot of work to be done.
01:22:36A small token of our appreciation.
01:22:38Please join me on connecting.
01:22:44OK, so we're all set.
01:22:45We're all set for this academic
01:22:46year in fact. We'll be back.
01:22:47First week in September,
01:22:49so you'll be getting emails about that.
01:22:50And keep an eye on our website.
01:22:52Thank you all very much.
01:22:53And with that we can go ahead
01:22:54and end the webinar and
01:22:55end tonight's session here.
01:22:56Thanks everybody.