Transcription:
Sustainable Ophthalmology: Waste Management in the OR

Melanie Cole (Host): Welcome to Better Edge, a Northwestern Medicine Podcast for physicians. I'm Melanie Cole. And joining me today is Dr. David Palmer. He's a Clinical Associate Professor of Ophthalmology at Northwestern Medicine, and he is here to highlight sustainable ophthalmology waste management in the OR.

Dr. Palmer, thank you so much for joining us. As I said off the air, I absolutely love this very important topic today. So as we get into it, shed light for us on the environmental costs of waste generation associated with ophthalmic surgery. Tell us what's going on in that department.

Dr David Palmer: Well, thank you, Melanie, for inviting me. And as an overview in the US healthcare sector, about 8.5% of all greenhouse gas emissions relate to what we do in our healthcare industry, and that could amount to up to 5 billion pounds of waste per year that we put into landfills. And within hospitals, the operating rooms themselves account for about 30% to 35% of hospital waste. And a lot of the waste is a biohazard-type waste, about two thirds of that.

Among our operating room procedures and why ophthalmology is important in this topic is cataract surgery is the highest volume surgical procedure actually in the United States and generally worldwide. And what I've observed and other colleagues of mine have observed is that topical medication waste that we apply within the operating room to our patient's eyes is excessive. And this has led to some evidence-based studies, which have looked into the quantification of the costs of this waste in addition to greenhouse gas emissions.

And I can tell you about two papers that highlight this. One of which, appeared in GEM Ophthalmology in 2019, which examined four Northeastern healthcare facilities. And the authors found that about 50% of the items used in the operating room were discarded. Two-thirds of these were eye drops and they were discarded by weight and volume at a loss of about $150 a case. And when you look at how many cataract surgeries there are per year in the United States, which was approximately 4 million and extrapolate that out, that's over 560 million of medications that we discard annually, which could be actually provided to our patients for post-op use. And this waste, of course, goes into our landfills, potentially contaminating our water supplies and it adds greenhouse gas emissions and the cost of the disposal to the facilities themselves.

Another study I'll reference is one from the Utah Valley Regional Medical Center in Provo, Utah, that was published in GEM Ophthalmology in 2014, and they found that over $300 in medications were discarded per cataract surgery case. So, the money does add up and adds cost and, generally, waste in our environment.

Greenhouse gas emissions is a hot topic right now and there are a number of companies actually looking and quantifying these emissions. And these emissions or carbon footprints are divided into three areas. The highest emissions are from the procurement of supplies and materials. In ophthalmology and cataract surgery, in particular, 55% of this procurement is for medications and other supplies and medications account for 20% of this. Building and energy use is about 35% and travel about 10%.

And to give you some perspective on this, in terms of car emissions and the number of miles driven to achieve these cataract surgery procedures, there's a study actually done in the United Kingdom and cataract surgery there was the equivalent of driving a car, in terms of greenhouse gas emissions, 310 miles. And another study came out from South India, the Aravind Eye Care System, which showed the equivalent of waste or greenhouse gas emissions at only 14 miles, which is about 1/20 of what we have here in the United States and the United Kingdom. And looking at the differences, it was due mainly to more efficient use of supplies, reduced materials, the reuse and recycling capabilities, which here in the United States we may not have access to and supply chain efficiency because they actually, in the South India Hospital, make their own lens implants and a lot of their own materials and equipment.

And as an extrapolation of this, the greatest greenhouse carbon footprint in the operating room is actually from unused pharmaceuticals. And this is just actually provided to me from a study that was done by one of these greenhouse gas carbon tech companies called Zasti, and I have no financial ties to it, but they are looking not only at cataract surgery within our field, but they're looking now into other subspecialty surgeries such as retina and they have another high volume procedure quantity in their operating rooms. So, that gives you an overview.

As far as what disposables are most highly discarded, the Zasti company found that drapes, gowns and syringes were the main products. And we are actually now working as an OR Waste Task Force to national task force in which I'm a member and I actually also co-chair a subcommittee on surgical pharmaceutical waste. We're looking at ways to work with industry actually to reduce the size of the drapes, maybe reduced number of gowns, or at least the number of gowns ordered per operating room. And we're also working with industry to try to have them relabel single use instruments into multi-use because so many of these instruments are discarded and not necessarily recycled. So, this has opened up an avenue for so many studies and has expanded, not only within our field, but in other fields. And not only nationally here, but it's also gone internationally into Europe. So, that gives you an overview and I hope that's answering your question on ophthalmic surgery and waste generation.

Melanie Cole (Host): Well, it certainly does. And you got to my second question too, which makes you awesome. But this is such an incredible topic, Dr. Palmer. It really is something that I think needs to be looked at across the healthcare spectrum. But what are some of the barriers or challenges in adopting sustainable practices in ophthalmology specifically?

Dr David Palmer: One of the barriers is addressing the issues from not only the local level, but also the state level and maybe the national level. I have a case I can refer to, and I mentioned that a number of us have observed a number of these drugs being discarded unnecessarily. And what got me actually interested in this area initially was hearing from a colleague at another institution about how they applied medication to a patient who had cataract surgery because of some mild discomfort. And the ophthalmologist in question, the surgeon, gave that medication to the patient for post-discharge use. And the hospital actually cited him for doing something that was beyond and contradictory to their hospital policy.

So when I heard about this and this is an Illinois ophthalmologist, I looked into our state Pharmacy Practice Act policies and discovered in fact the policies were in place but that in fact, for this particular institution, and later I heard from others, circumvented these policies by creating their own internal policies. So I've, for a number of years, been affiliated and associated with our Chicago Medical Society and Illinois State Medical Society, and wrote a resolution that addressed this issue called Topical Operating Room or Emergency Room Medications for Post-discharge Patient Use, which was eventually adopted in 2019. And this not only gained the support of ophthalmologists in this state, but also dermatologists, ENTs, plastics and emergency room physicians who also found these same problems within their environments.

And within this time, two surveys were published on the attitudes of ophthalmologists concerning operating room waste. And one was national, appearing in Journal of Cataract & Refractive Surgery in July of 2020. And the other was actually local, that was distributed by the Illinois Society of Eye Physicians and Surgeons, and this appeared in the Journal of Cataract & Refractive Surgery in August of 2020, which was co-authored by three Northwestern Memorial Physicians, one of which is my department chairman, Dr. Nicholas Volpe. Another is a former resident, Dr. Nicholas Hackett, and myself. And the common themes were that roughly 60% to 70% of patients couldn't take home their topically applied medications that they applied in the operating room.

And the factors, and these are some of the barriers you were asking me about, were insufficient pharmacy staffing, no medication counseling could happen because of the insufficient staffing and the medications were unlabeled and therefore discarded. They needed to be labeled with certain criteria for the patients to be taken home. But unfortunately, the pharmacies were not able to perform this task. In general, between these two surveys, over 90% percent thought that there are strict state regulatory agency and facility protocols and manufacture directions for use that limit our discretion to reuse these supplies. Again, these are barriers that you asked about. The general sense of that operating room waste is excessive and global warming is a concern, that drops should be use multi-dose in multiple patients. And in Illinois in particular and many other states, our State Pharmacy Acts do not allow multiple dosing on multiple patients.

So, another barrier is that we need to inform our state legislature that this law or these policies are contributing to more waste and cost and need to be readdressed and modified. And in fact, I'm now working with our state medical society to help modify our Practice Act in this regard. It's gone through two phases, one through the Illinois Council of Hospital Pharmacist, the other is the Illinois Hospital Association, and it's now in the hands of our Illinois Department of Public Health. This has to go under their review into a committee review and then has a 90-day commentary period. But hopefully, they will modify the language to allow our eyedrops to be used multi-dose, so we can reduce our waste and save costs and reduce our environmental strain.

The barriers to patients are that they may have trouble repurchasing their drops post-discharge, because these drops have already been charged to them and then they leave and have to go to a pharmacy and they may not have the funds to do so. They may have transportation barriers, and social and home supports could be also be barriers to them. And when you look at this as an entirety, if the patients aren't getting their medications, you can imagine that their quality of care is negatively impacted, and our surveys indicated that this is a result of them not getting their medicines leading to increased inflammation and infection risk if they can't continue their drops postoperatively.

So, these are some of the barriers that we have identified in this process. And to further help counter these barriers, the state resolution, by the way, was then sent to our state legislature and passed into law as a Public Act 102-0155. This is July of last year, July 1st actually. And the success of this was based on negotiations with our state society with the Council of Hospital Physicians, our Illinois Hospital Association stakeholders and identifying legislative champions in the House, in the Senate and acquiring multi-specialty society support. Without any of these entities helping, this may not have passed.

And eventually, American Academy of Ophthalmology Topical Waste Reduction Act legislative template was developed based on the Illinois law so that other states who don't have this policy in place could use it to enact their own. So again, the Illinois law hopefully counter barriers other states are experiencing in this regard. The resolution, by the way, was also introduced into the American Medical Association House of Delegates interim meeting in November of 2021. And in addition to permitting the dispensing of the stock medications for our patients post-discharge, it also called for the safe use of multidose medications on multiple patients. Again, this is a barrier we have currently in Illinois, but we want to make this a national concern. This was eventually adopted at that meeting and it was supported by major eye multi-specialty societies, including our major academy organizations, Society for Refractive Surgery or Glaucoma Society and Outpatient Ophthalmic Surgical Society and also climate-oriented specialty organizations. And these organizations are comprised not only of physicians, but also of lay people in various states that are very informed on environmentalism. One of them happens to be here in the Midwest called the Great Lake States Consortium, and this passed their scrutiny. And again, the AMA passage would not have been possible without their help.

Data was also collected by a committee that I had mentioned, our Operating Room Waste Task Force, and our surgical pharmaceutical waste task force. And this data was then compiled and then eventually written up as a position paper and published in a paper I co-authored in the Journal of Cataract and Refractive Surgery in September of this year endorsed by our major eye organizations, and this had three recommendations to help those bypass barriers in their own institutions. One of them is to use multi-dose topical drops safely on multiple patients. The other is that multi-dose topical drugs can be used up to the manufacturer's expiration date. And that the topically applied partially used medications I referenced earlier should be allowed home with patients. And importantly, this was endorsed by not only your IR organizations, but also the FDA, CMS, the CDC, the Joint Commission, and several accreditation organizations, one called the AAAHC and the other AAAASF, ASORN and the CMS Survey and Certification Group. This group, if you're not familiar with it, actually does surveys of various surgical facilities and they have a worksheet. And on this worksheet, they check off a number of items that air compliance or non-compliance. And what they have thought over many years is that eye drops are conflated with injectable medicines, which have only a 28-day expiration date. And the organizations I mentioned all said, "No, no, that's not true. These manufacturers have listed expiration dates on each bottle. And those are the actual expiration dates, not 28 days." So, our OR Waste Task Force and our academy actually approached CMS in a Zoom call and they in fact changed their survey infection control worksheet to exclude eye drops has a 28-day expiration date maximum, and in fact are now using the manufacturer's expiration date. So, organizations like ours, advocacy like ours, can actually change policies at the government level.

Eventually, to help everybody try to counter these barriers that I've mentioned, our eye organizations have created a website called EyeSustain, and it's at www.eyesustain.org. And this is a sustainability resource, launched just April of this year. And within this website are sections that will highlight the interests of individuals who look at this website. One section is clinic sustainability. Another is global sustainability. Another is drug waste in which I'm actively involved. There are industry initiatives within the site and also general climate change initiatives. And we are now collecting and collating information on each of these areas. So that if you or anybody else wishes to access this and learn more about these topics and the barriers and how to counter them, that can easily be accessed and examples and remedies provided on this website.

So, you asked about what actions we could take about these barriers, and I mentioned a few. At this hospital level, and this includes Northwestern and others, not only in Illinois, but elsewhere nationally, this may require modifications of the state Pharmacy Practice Acts and, by the way, facility policies, which may limit what we can do as physicians in applying these drops to multiple patients, even if the state law existed. The P&T, which is the Pharmacy and Therapeutic Committee, needs to be on board with this, as does the Risk Management Office, by the way, which is important because, you know, there's a concern that using drops on multiple patients can possibly be associated with eye infections including endophthalmitis, which is an infection of the eye that can occur internally post-cataract surgery. And we hope to bring evidence-based information to them, again endorsed by all these different regulatory organizations, that in fact this is a safe use of these products.

Another barrier that occurred within our system in particular as well is the EMR system may not be connected to a printer to label the labels correctly. And there may not be enough infrastructure in terms of hardware to actually perform these tasks that are now part of our Illinois law. So, we have been working, the department and myself with the pharmacy services department and the IS, which is the information service team and the administration to streamline this process. And in fact, at Northwestern Central, this is happening. This is of course complicated because Northwestern has multiple sites and the processes have been approved for these sites. But now, the implementation phase is in process and not all sites are actually connected and can print these labels at this time, but I know this is a work in progress and will be done in the near future.

Another barrier within the hospital, and this is only after we get allowance to use multi-dose medications, is a section 340B plan medication policy that is actually overseen by the government. And essentially Northwestern, which is an eligible 340B facility, can purchase medications at a reduced cost, because of their eligibility status and seeing a number of individuals who are underserved or uninsured. And these medications can only be used in eligible patients as outpatients. Well, it turns out that in the operating room, every patient we see is an eligible patient, but there are strict criteria on meticulously tracking the number of drops we give for patient for accurate accountability to maintain 340B plan eligibility. And even though it's not happened necessarily in Northwestern at this point, this is happening in states where multi-dosing is allowed and workarounds are necessary to make sure their hospitals don't lose their 340B plan eligibility. So, the nursing staff has to be very well-trained to document the number of drops per patient. And each drop, by the way, has a certain monetary amount. So if it's three drops, those three drops are actually charged to the patient. And if it's found that these bottle are either underused, then the hospital can not be any longer eligible to receive them at reduced cost.

Another barrier and final one is finding champions in each state and facility to advocate for the sustainability policies and legislative changes that we were talking about. Thankfully at Northwestern, we have a very energetic, ambitious staff. And within my department, number of individuals are very interested in this topic, who have been extremely helpful in this regard. But overall, we do need more advocacy. And what I found not only speaking with residents within Northwestern but elsewhere, is that the younger ophthalmologists are an amazingly energized force and very attuned to sustainability in medicine in general, and certainly within our department in ophthalmology. And I keep stressing to them that they should maintain that advocacy, follow the footsteps of predecessors and previous state laws and policies, but that they really need to be very persistent yet patient in adopting these sustainable practices. the laws that I've mentioned and the policy changes that I've alluded to in this conversation have taken at least three years. So, it's not a very quick process, but with persistence, it certainly can be a very happy outcome.

Melanie Cole (Host): Well, it certainly can. What a complex issue, but you've laid it out so very clearly, Dr. Palmer. And thank you for telling us about the interventions that you recommend for reducing that environmental impact of ophthalmic surgery while maintaining the safest and highest quality clinical outcomes.

As we wrap up, final thoughts. What's next as a leader in sustainable surgery movement? You are the man to tell us. Where do you see this going? Briefly, just tell us what's next.

Dr David Palmer: Here at Northwestern, we've created standardized medication order sets and instrument trays for each ophthalmology specialist to limit the waste and the number of instruments that have to be sterilized. At the outpatient level in one of our outpatient centers in Glenview, the department is actually looking at modifying its hospital policy on using clinic dilating drops up to the manufacturer expiration date, which is currently only at 28 days. And from a general sustainability effort within the hospital system, we are working with the NMHC Sustainability Committee, which is comprised of managers from the construction project and property operations offices on remodeling and expansion projects within the department.

In response to your question about what I'm doing as a leader in the Sustainable Surgery Movement, what's next? As a leader, I've also been interacting with many wonderful individuals within my field nationally. And with the support of ophthalmologists within our department, our state societies, and our national and international eye organizations and their task forces. Our next steps generally are basically to engage in network and education and learn from global ophthalmic community in the United States also and overseas, such as with our European partners and I mentioned our partners in India. We would collaborate with one another, looking at not only the cataract subspecialty within our field, but other subspecialties to reduce our carbon footprint and medication waste.

Related to this, we are on our task force interfacing with industry representatives and already we've addressed the DFUs, which are the directions for use, to basically eliminate the paper instructions and place QR codes on the packaging to reduce the weight and size of the packaging itself. With industry, we're looking into relabeling instruments from single use to multi-use. We're encouraging industry to use biodegradable materials for their packaging, and we're looking at doing future research with them by maybe modifying their supply chain processes.

And we're also collaborating with other medical specialties and climate-related organizations in our leadership roles in organizations such as the Multi-specialty Society on Climate and Health of which, by the way, the Academy and American Society of Cataract and Refractive surgeons are members. And examples of collaboration include Columbia University's Global Consortium on Climate and Health Education, Climate Action Work Groups, Healthcare Without Harm and Practice Greenhealth of which Northwestern Medicine is a member organization. And conferences within our hospital system, we've had grand rounds on this topic that's been highly supported by my department chairman, Dr. Nicholas Volpe.

As leaders, we are hoping to support advocacy and education about the public health impact of climate change. I mentioned many of your young ophthalmologists are very much involved. They wish to incorporate more climate change education within medical school, residency and fellowship training. And even at the post-graduate level, at the attending staff level, we really need to disseminate this information further and further. Because healthcare, as I mentioned earlier in this conversation, comprises such a great deal of our carbon footprint.

And finally, I will mention that what we can do at meetings, not only at Northwestern but also nationally and even internationally are to introduce the concept of environmentalism by reducing the carbon footprint to reuse our water bottles. One meeting has reduced the red meat consumption because cattle contribute quite a bit to greenhouse gas formation. They limit vehicle travel to and from hotels to the meeting sites. We're also using electronic schedules, mobile apps instead of printed booklets for the attendees at the meetings to again save on print and the waste of paper.

So, I hope that answers your question about what we are doing as leaders in this movement and what comes next.

Melanie Cole (Host): It certainly does. And what amazing work you are doing, Dr. Palmer. I applaud everything you were discussing here today. So much work still needs to be done, and I hope that you will come back on and join us and give us updates as we learn more. Thank you so much again for joining us and sharing your incredible expertise in this topic that is so important not only for ophthalmology, but also, as you say, across the healthcare spectrum and onward.

To refer your patient or for more information, please visit our website at breakthroughsforphysicians.nm.org/ophthalmology. That concludes this episode of Better Edge, a Northwestern Medicine Podcast for physicians. Please always remember to subscribe, rate, and review this podcast and all the other Northwestern Medicine podcasts. I'm Melanie Cole.