Faculty Bibliography

Importance/UNASSIGNED:Pharmaceutical products, including unused portions, may contribute to financial and environmental costs in the United States. Because cataract surgery is performed millions of times each year in the United States and throughout the rest of the world, understanding these financial and environmental costs associated with cataract surgery is warranted. Objective/UNASSIGNED:To investigate the financial and environmental costs of unused pharmaceutical products after phacoemulsification surgery. Design, Setting, and Participants/UNASSIGNED:This descriptive qualitative study included 4 surgical sites in the northeastern United States (a private ambulatory care center, private tertiary care center, private outpatient center, and federally run medical center for veterans). Prices and data for use of services and pharmaceuticals were obtained for the tertiary care and outpatient centers from January 1 through April 30, 2016; for the ambulatory care center from June 1, 2017, through March 31, 2018; and the federal medical center from November 1, 2017, through February 28, 2018. Data were collected from routine phacoemulsification surgical procedures without vitreous loss or other complications. Volume or weight of medications remaining after surgery was measured. Total and mean costs of medications per case and month were calculated. Environmental effects were estimated using economic input-output life cycle assessment methods. Data were analyzed from December 1, 2017, through June 30, 2018. Main Outcomes and Measures/UNASSIGNED:Cost of unused pharmaceutical products (in US dollars) and kilogram equivalents of carbon emissions (carbon dioxide [CO2-e]), air pollution (fine particulate matter emissions of ≤10 μm in diameter [PM10-e]), and eutrophication potential (nitrogen [N-e]). Results/UNASSIGNED:A total of 116 unique drugs were surveyed among the 4 centers. Assuming unmeasured medications had no materials left unused, a cumulative mean 83 070 of 183 304 mL per month (45.3%) of pharmaceuticals were unused by weight or volume across all sites. Annual unused product cost estimates reached approximately $195 200 per site. A larger percentage of eyedrops (65.7% by volume) were unused compared with injections (24.8%) or systemic medications (59.9%). Monthly unused quantities at the ambulatory care center (65.9% by volume [54 971 of 83 440 mL]), tertiary care center (21.3% [17 143 of 80 344 mL]), federal medical center (38.5% [265 of 689 mL]), and outpatient center (56.8% [10 691 of 18 832 mL]) resulted in unnecessary potential emissions at each center of 2135, 2498, 418, and 711 kg CO2-e/mo, respectively. Unnecessary potential air pollution between sites varied from 0.8 to 4.5 kg PM10-e/mo, and unnecessary eutrophication potential between sites varied from 0.07 to 0.42 kg N-e/mo. Conclusions and Relevance/UNASSIGNED:This study suggests that unused pharmaceutical products during phacoemulsification result in relatively high financial and environmental costs. If these findings can be substantiated and shown to be generalizable in the United States or elsewhere, reducing these costs may be of value.

Healthcare is a critical service sector with a sizable environmental footprint from both direct activities and the indirect emissions of related products and infrastructure. As in all other sectors, the "inside-out" environmental impacts of healthcare (e.g., from greenhouse gas emissions, smog-forming emissions, and acidifying emissions) are harmful to public health. The environmental footprint of healthcare is subject to upward pressure from several factors, including the expansion of healthcare services in developing economies, global population growth, and aging demographics. These factors are compounded by the deployment of increasingly sophisticated medical procedures, equipment, and technologies that are energy- and resource-intensive. From an "outside-in" perspective, on the other hand, healthcare systems are increasingly susceptible to the effects of climate change, limited resource access, and other external influences. We conducted a comprehensive scoping review of the existing literature on environmental issues and other sustainability aspects in healthcare, based on a representative sample from over 1,700 articles published between 1987 and 2017. To guide our review of this fragmented literature, and to build a conceptual foundation for future research, we developed an industrial ecology framework for healthcare sustainability. Our framework conceptualizes the healthcare sector as comprising "foreground systems" of healthcare service delivery that are dependent on "background product systems." By mapping the existing literature onto our framework, we highlight largely untapped opportunities for the industrial ecology community to use "top-down" and "bottom-up" approaches to build an evidence base for healthcare sustainability.

OBJECTIVES/OBJECTIVE:To determine the carbon footprint of various sustainability interventions used for laparoscopic hysterectomy. METHODS:We designed interventions for laparoscopic hysterectomy from approaches that sustainable health care organizations advocate. We used a hybrid environmental life cycle assessment framework to estimate greenhouse gas emissions from the proposed interventions. We conducted the study from September 2015 to December 2016 at the University of Pittsburgh (Pittsburgh, Pennsylvania). RESULTS:The largest carbon footprint savings came from selecting specific anesthetic gases and minimizing the materials used in surgery. Energy-related interventions resulted in a 10% reduction in carbon footprint per case but would result in larger savings for the whole facility. Commonly implemented approaches, such as recycling surgical waste, resulted in less than a 5% reduction in greenhouse gases. CONCLUSIONS:To reduce the environmental emissions of surgeries, health care providers need to implement a combination of approaches, including minimizing materials, moving away from certain heat-trapping anesthetic gases, maximizing instrument reuse or single-use device reprocessing, and reducing off-hour energy use in the operating room. These strategies can reduce the carbon footprint of an average laparoscopic hysterectomy by up to 80%. Recycling alone does very little to reduce environmental footprint. Public Health Implications. Health care services are a major source of environmental emissions and reducing their carbon footprint would improve environmental and human health. Facilities seeking to reduce environmental footprint should take a comprehensive systems approach to find safe and effective interventions and should identify and address policy barriers to implementing more sustainable practices.

PURPOSE/OBJECTIVE:To measure the waste generation and lifecycle environmental emissions from cataract surgery via phacoemulsification in a recognized resource-efficient setting. SETTING/METHODS:Two tertiary care centers of the Aravind Eye Care System in southern India. DESIGN/METHODS:Observational case series. METHODS:Manual waste audits, purchasing data, and interviews with Aravind staff were used in a hybrid environmental lifecycle assessment framework to quantify the environmental emissions associated with cataract surgery. Kilograms of solid waste generated and midpoint emissions in a variety of impact categories (eg, kilograms of carbon dioxide equivalents). RESULTS:Aravind generates 250 grams of waste per phacoemulsification and nearly 6 kilograms of carbon dioxide-equivalents in greenhouse gases. This is approximately 5% of the United Kingdom's phaco carbon footprint with comparable outcomes. A majority of Aravind's lifecycle environmental emissions occur in the sterilization process of reusable instruments because their surgical system uses largely reusable instruments and materials. Electricity use in the operating room and the Central Sterile Services Department (CSSD) accounts for 10% to 25% of most environmental emissions. CONCLUSIONS:Surgical systems in most developed countries and, in particular their use of materials, are unsustainable. Results show that ophthalmologists and other medical specialists can reduce material use and emissions in medical procedures using the system described here.

BACKGROUND:Health care providers worldwide are rapidly adopting electronic medical record (EMR) systems, replacing paper record-keeping systems. Despite numerous benefits to EMRs, the environmental emissions associated with medical record-keeping are unknown. Given the need for urgent climate action, understanding the carbon footprint of EMRs will assist in decarbonizing their adoption and use. OBJECTIVE:We aimed to estimate and compare the environmental emissions associated with paper medical record-keeping and its replacement EMR system at a high-volume eye care facility in southern India. METHODS:We conducted the life cycle assessment methodology per the ISO (International Organization for Standardization) 14040 standard, with primary data supplied by the eye care facility. Data on the paper record-keeping system include the production, use, and disposal of paper and writing utensils in 2016. The EMR system was adopted at this location in 2018. Data on the EMR system include the allocated production and disposal of capital equipment (such as computers and routers); the production, use, and disposal of consumable goods like paper and writing utensils; and the electricity required to run the EMR system. We excluded built infrastructure and cooling loads (eg. buildings and ventilation) from both systems. We used sensitivity analyses to model the effects of practice variation and data uncertainty and Monte Carlo assessments to statistically compare the 2 systems, with and without renewable electricity sources. RESULTS:e per patient), a level comparable to the paper record-keeping system. Energy-efficient EMR equipment (such as computers and monitors) is the next largest factor impacting emissions, followed by equipment life spans. Multimedia Appendix 1 includes other emissions impact categories. CONCLUSIONS:The climate-changing emissions associated with an EMR system are heavily dependent on the sources of electricity. With a decarbonized electricity source, the EMR system's GHG emissions are on par with paper medical record-keeping, and decarbonized grids would likely have a much broader benefit to society. Though we found that the EMR system produced more emissions than a paper record-keeping system, this study does not account for potential expanded environmental gains from EMRs, including expanding access to care while reducing patient travel and operational efficiencies that can reduce unnecessary or redundant care.

Concurrent increases in global cancer burden and the climate crisis pose an unprecedented threat to public health and human well-being. Today, the health care sector greatly contributes to greenhouse gas emissions, with the future demand for health care services expected to rise. Life cycle assessment (LCA) is an internationally standardized tool that analyzes the inputs and outputs of products, processes, and systems to quantify associated environmental impacts. This critical review explains the use of LCA methodology and outlines its application to external beam radiation therapy (EBRT) with the aim of providing a robust methodology to quantify the environmental impact of radiation therapy care practices today. The steps of an LCA are outlined and explained as defined by the International Organization for Standardization (ISO 14040 and 14044) guidelines: (1) definition of the goal and scope of the LCA, (2) inventory analysis, (3) impact assessment, and (4) interpretation. The existing LCA framework and its methodology is described and applied to the field of radiation oncology. The goal and scope of its application to EBRT is the evaluation of the environmental impact of a single EBRT treatment course within a radiation oncology department. The methodology for data collection via mapping of the resources used (inputs) and the end-of-life processes (outputs) associated with EBRT is explained, with subsequent explanation of the LCA analysis steps. Finally, the importance of appropriate sensitivity analysis and the interpretations that can be drawn from LCA results are reviewed. This critical review of LCA protocol provides and evaluates a methodological framework to scientifically establish baseline environmental performance measurements within a health care setting and assists in identifying targets for emissions mitigation. Future LCAs in the field of radiation oncology and across medical specialties will be crucial in informing best practices for equitable and sustainable care in a changing climate.

Background: Delivering healthcare requires significant resources and creates waste that pollutes the environment, contributes to the climate crisis, and harms human health. Prior studies have generally shown durable, reusable medical devices to be environmentally superior to disposables, but this has not been investigated for pulse oximetry probes. Objective: Our goal was to compare the daily carbon footprint of single-use and reusable pulse oximeters in the emergency department (ED). Methods: Using a Life Cycle Assessment (LCA), we analyzed greenhouse gas (GHG) emissions from pulse oximeter use in an urban, tertiary care ED, that sees approximately 150 patients per day. Low (387 uses), moderate (474 uses), and high use (561 uses), as well as cleaning scenarios, were modelled for the reusable oximeters and compared to the daily use of single-use oximeters (150 uses). We calculated GHG emissions, measured in kilograms of carbon dioxide equivalents (kgCO2e), across all life cycle stages using life-cycle assessment software and the ecoinvent database. We also carried out an uncertainty analysis using Monte Carlo methodology and calculated the break-even point for reusable oximeters. Results: Per day of use, reusable oximeters produced fewer greenhouse gases in low-, moderate-, and high-use scenarios compared to disposable oximeters: 3.9 kgCO2e, 4.9 kgCO2e, 5.7 kgCO2e vs 23.4 kgCO2e, respectively). An uncertainty analysis showed there was no overlap in emissions, and a sensitivity analysis found reusable oximeters only need to be used 2.3 times before they match the emissions created by a single disposable oximeter. Use phases associated with the greatest emissions varied between oximeters, with the cleaning phase of reusables responsible for the majority of its GHG emissions (99%) compared to the production phases of the single-use oximeter (74%). Conclusion: Reusable pulse oximeters generated fewer greenhouse gas emissions per day of use than their disposable counterparts. Given that the pulse oximeter is an ubiquitous piece of medical equipment used in emergency care globally, carbon emissions could be significantly reduced if EDs used reusable rather than single-use, disposable oximeters.

BACKGROUND/UNASSIGNED:Delivering healthcare requires significant resources and creates waste that pollutes the environment, contributes to the climate crisis, and harms human health. Prior studies have generally shown durable, reusable medical devices to be environmentally superior to disposables, but this has not been investigated for pulse oximetry probes. OBJECTIVE/UNASSIGNED:Our goal was to compare the daily carbon footprint of single-use and reusable pulse oximeters in the emergency department (ED). METHODS/UNASSIGNED:e), across all life cycle stages using life-cycle assessment software and the ecoinvent database. We also carried out an uncertainty analysis using Monte Carlo methodology and calculated the break-even point for reusable oximeters. RESULTS/UNASSIGNED:e, respectively). An uncertainty analysis showed there was no overlap in emissions, and a sensitivity analysis found reusable oximeters only need to be used 2.3 times before they match the emissions created by a single disposable oximeter. Use phases associated with the greatest emissions varied between oximeters, with the cleaning phase of reusables responsible for the majority of its GHG emissions (99%) compared to the production phases of the single-use oximeter (74%). CONCLUSION/UNASSIGNED:Reusable pulse oximeters generated fewer greenhouse gas emissions per day of use than their disposable counterparts. Given that the pulse oximeter is an ubiquitous piece of medical equipment used in emergency care globally, carbon emissions could be significantly reduced if EDs used reusable rather than single-use, disposable oximeters.