Faculty Bibliography

A circular economy involves maintaining manufactured products in circulation, distributing resource and environmental costs over time and with repeated use. In a linear supply chain, manufactured products are used once and discarded. In high-income nations, health care systems increasingly rely on linear supply chains composed of single-use disposable medical devices. This has resulted in increased health care expenditures and health care-generated waste and pollution, with associated public health damage. It has also caused the supply chain to be vulnerable to disruption and demand fluctuations. Transformation of the medical device industry to a more circular economy would advance the goal of providing increasingly complex care in a low-emissions future. Barriers to circularity include perceptions regarding infection prevention, behaviors of device consumers and manufacturers, and regulatory structures that encourage the proliferation of disposable medical devices. Complementary policy- and market-driven solutions are needed to encourage systemic transformation.

Healthcare is a major emitter of environmental pollutants that adversely affect health. Within the healthcare community, awareness of these effects is low, and recognition of the duty to address them is only beginning to gain traction. Healthcare sustainability science explores dimensions of resource consumption and environmental emissions associated with healthcare activities. This emerging field provides tools and metrics to quantify the unintended consequences of healthcare delivery and evaluate effective approaches that improve patient safety while protecting public health. This narrative review describes the scope of healthcare sustainability research, identifies knowledge gaps, introduces a framework for applications of existing research methods and tools to the healthcare context, and establishes research priorities to improve the environmental performance of healthcare services. The framework was developed through review of the current state of healthcare sustainability science and expert consensus by the Working Group for Environmental Sustainability in Clinical Care. Key recommendations include: development of a comprehensive life cycle inventory database for medical devices and drugs; application of standardized sustainability performance metrics for clinician, hospital/health system, and national levels; revision of infection control standards driving non-evidence-based uptake of single-use disposable devices; call for increased federal research funding; and formation of a Global Commission on the Advancement of Environmental Sustainability in Healthcare. There is urgent need for research that informs policy and practice to address the public health crisis arising from healthcare pollution. A transformational vision is required to align research priorities to achieve a sustainable healthcare system that advances quality, safety and value.

INTRODUCTION/BACKGROUND:Healthcare contributes 10% of greenhouse gases in the United States and generates two milion tons of waste each year. Reducing healthcare waste can reduce the environmental impact of healthcare and lower hospitals' waste disposal costs. However, no literature to date has examined US emergency department (ED) waste management. The purpose of this study was to quantify and describe the amount of waste generated by an ED, identify deviations from waste policy, and explore areas for waste reduction. METHODS:We conducted a 24-hour (weekday) ED waste audit in an urban, tertiary-care academic medical center. All waste generated in the ED during the study period was collected, manually sorted into separate categories based on its predominant material, and weighed. We tracked deviations from hospital waste policy using the hospital's Infection Control Manual, state regulations, and Health Insurance Portability and Accountability Act standards. Lastly, we calculated direct pollutant emissions from ED waste disposal activities using the M+WasteCare Calculator. RESULTS:The ED generated 671.8 kilograms (kg) total waste during a 24-hour collection period. On a per-patient basis, the ED generated 1.99 kg of total waste per encounter. The majority was plastic (64.6%), with paper-derived products (18.4%) the next largest category. Only 14.9% of waste disposed of in red bags met the criteria for regulated medical waste. We identified several deviations from waste policy, including loose sharps not placed in sharps containers, as well as re-processable items and protected health information thrown in medical and solid waste. We also identified over 200 unused items. Pollutant emissions resulting per day from ED waste disposal include 3110 kg carbon dioxide equivalent and 576 grams of other criteria pollutants, heavy metals, and toxins. CONCLUSION/CONCLUSIONS:The ED generates significant amounts of waste. Current ED waste disposal practices reveal several opportunities to reduce total waste generated, increase adherence to waste policy, and reduce environmental impact. While our results will likely be similar to other urban tertiary EDs that serve as Level I trauma centers, future studies are needed to compare results across EDs with different patient volumes or waste generation rates.

Cataract surgery is the most commonly performed medical procedure in the world but there continues to be a large, unmet requirement for more surgery, with cataract still accounting for one third of all global blindness. A great deal of progress has been made in increasing cataract surgical rates or productivity, and associated cost containment. However, there is currently no audit tool which facilitates capture of routine cataract surgical productivity, solid waste, carbon, and cost-related data which could be used for global benchmarking, learning, and improvement. The Eyefficiency tool, discussed here, develops a universal Life Cycle Assessment (LCA) methodology for cataract surgery to identify opportunities for sites to minimize the footprint of cataract surgical services and increase access to cataract surgery for patients worldwide. Here, we describe the LCA approaches tested for use in Eyefficiency, with the goals of creating an easy-to-use, open source tool that is also easy to maintain and update. Given those goals, the development team chose to use a hybrid LCA approach with UK-based process and environmental extended input"“output inventories. The carbon results of the Eyefficiency tool are compared to previous studies at two of Eyefficiency's pilot test sites. Though Eyefficiency's carbon calculator may only provide order of magnitude accuracy, it offers cataract surgical providers everywhere in the world an opportunity to benchmark their costs, throughput, waste generation, and carbon emissions. Eyefficiency enables ground level ownership in sustainable pathways for the most common medical procedure worldwide.

Waste auditing is important for effectively reducing the medical waste generated by resource-intensive operating rooms. To replace the current time-intensive and dangerous manual waste auditing method, we propose a system named iWASTE to detect and classify medical waste based on videos recorded by a camera-equipped waste container. In this pilot study, we collected a video dataset of 4 waste items (gloves, hairnet, mask, and shoecover) and designed a motion detection based preprocessing method to extract and trim useful frames. We propose a novel architecture named R3D+C2D to classify waste videos by combining features learnt by 2D convolutional and 3D convolutional neural networks. The proposed method obtained a promising result (79.99% accuracy) on our challenging dataset.Clinical Relevance-iWaste enables consistent and effective real-time monitoring of solid waste generation in operating rooms, which can be used to enforce medical waste sorting policies and to identify waste reduction strategies.

BACKGROUND: Environmental sustainability is a growing concern to healthcare providers, given the health impacts of climate change and air pollution and the sizable footprint of healthcare delivery itself. In 2017, 17.9% of the United States (US) Gross Domestic Product, or $3.5 trillion, was from the healthcare sector (1). In addition,10% of US greenhouse gas emissions (GHGs) and 9% of air pollutants that adversely affect the lives of the public(2,3) come from the healthcare sector. Though many studies have focused on environmental footprints of operating rooms, few have quantified emissions from inpatient stays.
METHOD(S): This study analyzes resources required for care activities of a regular inpatient unit (Unit 4500) with 49 beds and 14,427 bed days and a medical intensive care unit (MICU) with 12 beds and 2,536 bed days in a tertiary, private hospital in Brooklyn, NY, USA. Through the use of hybrid Environmental Life Cycle Assessment (LCA), average emissions associated with resource use in an inpatient setting for one calendar year and per bed day were quantified. Retrospective data collected included purchasing of supplies, pharmaceutical, utilities (gas, water, electricity), and linens used over a calendar year, and staffing levels in both units. A 5-day period of manual waste auditing in each unit was also conducted.
RESULT(S): Unit 4500 generates 5.5kg of solid waste and 65kg CO2-e per bed day, shown in the Figure. The MICU generates 7.1kg of solid waste and 168kg CO2-e per bed day. Most emissions originate from purchase of consumable goods, building energy consumption, purchase of capital equipment, food services, and staff travel.
CONCLUSION(S): As expected, the MICU generates more solid waste and GHGs per bed day than Unit 4500. With resource use and emissions data, sustainability strategies, like energy efficiency upgrades, renewable energy sources, minimizing single-use consumables, and optimizing care pathways, can be effectively targeted and tested. Medical device and supply manufacturers should also aim to minimize life cycle waste and GHGs.(Figure Presented)

In an online survey of more than 1300 cataract surgeons and nurses, 93% believed that operating room waste is excessive and should be reduced; 78% believed that we should reuse more supplies; 90% were concerned about global warming; and 87% wanted medical societies to advocate for reducing the surgical carbon footprint. The most commonly cited reasons for excessive waste were regulatory and manufacturer restrictions on reuse or multiple use of devices, supplies, and pharmaceuticals. More than 90% believed that profit, liability reduction, and failure to consider carbon footprint drive manufacturers to produce more single-use products; more than 90% want more reusable products and more regulatory and manufacturer discretion over when and which products can be reused. Assuming comparable cost, 79% of surgeons preferred reusable over disposable instruments. In order of decreasing consensus, most were interested in reusing topical and intracameral medications, phacoemulsification tips, irrigating solutions/tubing, blades, cannulas, devices, and surgical gowns.

Background: The healthcare sector contributes 10% of US greenhouse gas emissions (GHGs). Given the adverse health effects associated with GHGs, healthcare sector workers have a moral imperative to reduce these GHGs. Life Cycle Assessment (LCA) is a tool used to quantify environmental emissions associated with a product or process, including natural resource extraction, manufacturing, packaging, transportation, use, and disposal of materials. To quantify GHGs and help guide pollution prevention strategies, we applied LCA to the process of preparing a biopsy in a surgical pathology laboratory.
Design(s): A detailed analysis of the processing of a biopsy was performed at a large surgical pathology laboratory, and grouped into 11 steps. Each supply item, reagent, and capital equipment was catalogued, along with the number of individuals involved, and average duration of each step. Supply items were weighed and primary material types noted. The lifespan of each reusable item was estimated, and post-use treatment pathways, including disposal, were noted. Reagent quantity was allocated to a single case based on total bottles used in the lab over one week. Watt meters and equipment power ratings were used to estimate the energy consumption of capital equipment. A lifecycle inventory and impact analysis were performed to estimate GHGs. The LCA was performed comparing two scenarios as a sensitivity analysis: (1) a patient case with a single biopsy jar and (2) a patient case with three biopsy jars.
Result(s): The largest proportion of total GHGs was from processing the cassette(s) on the tissue processor (Leica ASP 300S), which contributed 0.085kg of CO2-equivalents (kg CO2e) for scenario 1 and 0.224 kg CO2e for scenario 2, or, in both scenarios, 31% of total emissions, of which 25% was attributable to production of reagents used. The second largest contributor to GHGs was receiving and accessioning the case in the lab, which contributed 0.051kg CO2e or 19% of total emissions in scenario 1, and 0.151kg CO2e or 21% of total emissions in scenario 2, attributable mostly to the jars being single use items. Sensitivity analysis showed that GHGs can range between -18% and +4% for scenario 1, and between -15% and +10% for scenario 2.
Conclusion(s): This study evaluates the processing of a surgical pathology biopsy using an LCA. Understanding the process steps that contribute to GHGs is essential for determining which parts of the healthcare sector could be effectively targeted for reducing emissions