Melanie Cole, MS (Host): Welcome to Better Edge, a Northwestern Medicine podcast for physicians. I'm Melanie Cole. And today, we're talking about ophthalmology sustainability practices, current efforts, and future direction for sustainability at Northwestern Medicine. We have a panel for you with Jeff Good, he's the Chief Sustainability Executive at Northwestern Medicine; and Dr. David Palmer, he's a Clinical Associate Professor of Ophthalmology at Northwestern Medicine.

Thank you both for being with us today. And I'd like to start off this episode by providing a brief background on your roles at Northwestern Medicine. And Jeff, your title is so interesting. Can you tell us what you do?

Jeff Good: Sure. I've been with Northwestern Medicine for a little over 15 years. And most of that time, in oversight of operational areas, across the health system, both downtown on the Northwestern Memorial Hospital campus, but also in some system function role. In the fall of 2023, the organization, understanding the importance of our responsibility, to our environment and to our community, created a new role for the health system. And I transitioned into that role in September of 2023.

And, you know, while the organization has done initiatives and efforts and projects around sustainability across the health system, the organization felt it was time to have executive oversight to ensure that we're putting together strategic plans around what we want to achieve, start to develop goals and prioritize efforts to reach those goals. So, it's a new role, a new role for me, and I'm excited to be in it.

Melanie Cole, MS: That's so interesting. What an interesting job that you have. Now, Dr. Palmer, you and I have spoken before, and I'd like to ask you to shed light for us on the environmental costs and waste generation associated with ophthalmic surgery. What part of ophthalmology has the greatest carbon footprint.

Dr David Palmer: Sure. Well, thank you for the invitation. And as an overview, U.S. healthcare annually emits about 8.5% of our greenhouse gases in this country and, unfortunately, deposits about 5 billion pounds of waste. And within hospitals, the generation is about 30-35% of a hospital's waste in the operating room. And it does contribute to greenhouse gas emissions. And you ask for a breakdown of the types of procedures, and the generation of the carbon footprint, about 55% of this carbon footprint or greenhouse gas emissions is from supply procurement, which includes raw material mining, manufacturing, packaging the product, delivery, the use, and the disposal. About 35% is building and energy, and 10% from travel.

Now, cataract surgery, which is my specialty, is the highest volume surgical procedure in the United States and really the world, generating a great deal of waste, which contributes to this carbon footprint that we just discussed. There's a study actually, looking at the cost and waste of medications, and it was found in this study that two-thirds of the medications are discarded because mainly patients could not go home with them post-surgery, even if needed for post-operative care. And this amounted to about $150 of waste per cataract procedure. And with 3.8 million cataract surgeries in the U.S., you can imagine that hundreds of millions of dollars of these medications are actually discarded. And the estimated greenhouse gas emissions from these discarded medicines is, in one study, equivalent to driving a gas-powered car between Alaska and Florida up to 50,000 times each year. So, it's pretty great amount. In another study, greenhouse gas emissions were generated overall from a single cataract surgery, the equivalent of driving a car 311 miles. Now, these are estimates based on what is thought to be the carbon emissions, but It's great. And this is just from one procedure out of many performed in the world.

The other issue is many of our supplies that we use in the operating room, our gowns or drapes or covers are polypropylene sourced from fossil fuels, contributing to these greenhouse gas emissions. And the end result of these emissions is the effect on climate change and health. And maybe you and your listeners have read that last year was the hottest year in recorded history over the last 150 years. And this higher temperature and environmental pollutant that is the result of the fossil fuel emissions and such contributes to ocular problems such as glaucoma, retinovascular disease, macular degeneration, cataracts, dry eyes, inflammation, and insect-borne diseases, which aren't prevalent here as much as they are maybe in the rest of the world, but you've heard of West Nile virus, that is one. And controlling these greenhouse gas emissions will hopefully mitigate these medical problems.

Melanie Cole, MS: Dr. Palmer, that is just fascinating. And I remember when we were talking about take-home eyedrops and the waste involved and you explained that so very well. So Jeff, tell us about the current efforts that have been implemented to promote sustainability at Northwestern Medicine based on what Dr. Palmer was just saying, which is stunning to hear those statistics. What is Northwestern doing?

Jeff Good: I'll let Dr. Palmer talk specifically if he'd like to comment further on the take-home drops. I think more broadly, we as an organization, in the early part of this journey, I think in terms of being a coordinated office of sustainability, in our first steps, over the course of the next couple of months, is to identify what our baseline carbon footprint is. So, we're going to be working with a consultant to help us across our entire health system define what is our starting point. Where are we starting from in terms of our greenhouse gas emissions? Where are we on our waste, our water consumption, to set that baseline and begin to develop that plan that says, "All right, what are our targets? Where do we want to be in the next 5, 10, 15 years in terms of our reduction in greenhouse gas emissions? And how are we going to get there?" So, that's a lot of the work that we'll be undertaking over the next several months.

With that said, we don't want to slow down any ongoing initiatives. There are what people call their green teams that exist around the health system that have been doing recycling of the inpatient booties that patients are given. We were the first in the nation to partner with Baxter in an IV bag recycling project. We're going to not only continue those things, but look to expand them across the health system so that we continue to make progress while we're trying to develop that larger and longer term strategic plan. So, those are just a few things there.

Melanie Cole, MS: Dr. Palmer, how have the Northwestern Medicine sustainability efforts been really integrated into the daily operations as Jeff was just telling us what he's looking forward to and how they're beginning? Tell us about the Department of Ophthalmology. And what are some of the protocols that your department has implemented inside or outside the OR?

Dr David Palmer: Well, you and Jeff mentioned the initiative taking home eyedrops from the operating room and, you know, this was based on a law that was passed here in Illinois in July of 2021, which inevitably became a template for other states in the country to follow, and that is to basically label the medications that are used from the operating room post-surgery according to the Pharmacy Practice Act protocol for our state and other states, so that patients can in fact take them home instead of discarding these medicines.

And Northwestern, we created a beta testing site to see how Epic can be utilized from the ordering process to the labeling process in a very streamlined fashion. And with the efforts of the admin teams, pharmacy teams, of course, Epic and IT, and a lot of interchange that took about two years, this beta test actually became very successful and was implemented, and this was at Grayslake Hospital, and then eventually, also implemented at the Northwestern downtown campus. I don't know and maybe, Jeff, you can answer this, if other sites within the Northwestern system have implemented this as well. But not only is this applicable to ophthalmology, but any other specialty that uses topical drops or salves or any other medicines in the operating room is certainly eligible to send their medicines home with their own patients using the same system. So, that's one thing that Northwestern implemented very successfully.

As far as ophthalmology, our department chairman, Dr. Nicholas Volpe, is very supportive of our sustainability efforts. And in fact, what started this whole process off was his initiative in asking me to conduct a grand rounds on cost, waste, and policies of operating room procedures, specifically cataract surgery. So, he has really been the catalyst that has evolved into this process that Jeff and I are discussing, for me personally. In the clinic, we separate waste into landfill and recycling bins. We are usually utilizing alcohol-based scrubs in our offices, not soap and water. We're using our sharps containers that are delivered by our regulated medical waste hauling company, so we don't have to keep purchasing new sharps containers. Motion detectors for lighting have been installed. The hospital system has recently lowered its computer power at night. And we are also very soon going to be initiating a contact lens recycling program through a third party.

 And within the operating room, there has been a lot of discussion, not only in our specialty, but others about standardizing your surgical trays. And in one study looking at ophthalmology specifically when vitreoretinal surgeons did this and they used maybe 80-85% of their instruments and put them on the tray, leaving the other 15% as pick items, they saved about $10,000 to $15,000 a year. And there's another study that was even more impressive by neurosurgeons, I think at UC San Francisco, and they saved almost $2.9 million a year standardizing the surgical trays. So, this is something that our department has already implemented by subspecialty within our field. We're also using alcohol-based scrubs to save water. And we're also looking very astutely at the scheduling efficiencies and surgical block times to make our efforts also more efficient.

Jeff Good: And I think just to build on what Dr. Palmer was talking about with respect to the eyedrops, it is an opportunity we've now successfully piloted it at a couple of our facilities. And now, it's an opportunity to expand that. And I think as we think bigger picture over the coming months and years, sitting down with surgeons like Dr. Palmer and others, to better understand what are the needs in the operating room? How can we reduce amount in our pre-surgical packs that get opened for every case? And what in those packs is used less than X percent of the time? If it's only used a very small percentage of the time, how can we pull that out so it's not wasted and have it available, but just not wasted to the extent that we do?

And Dr. Palmer and I have had conversations about the surgical drapes that are used. And in many cases, a drape has to go practically head to toe. That's not required in ophthalmic surgery. So, how do we work with vendors? How do we get our colleagues comfortable with a more appropriate sized drape that's going to continue to provide sterility in the environment? We clearly don't want to have an opportunity for an increase in infections, but where we can do it safely, but reduce the amount of waste, that goes to the landfills.

Dr David Palmer: And I would also add, Jeff, that we can also expand that beyond ophthalmology. I mean, we look at anesthesia, right? And the recapture of gases or maybe throwing away the propofol and other anesthetics that are used intravenously into what's called a cactus bin. Even air circulation in the operating room may differ per subspecialty. And in reading about this, ophthalmology requires maybe a turnover of 20 times per hour, but other specialties may need more. And maybe a good way is to temper the air circulation times based on the specialty using that OR.

Melanie Cole, MS: Isn't this the most fascinating conversation, and what seems to me, the viewer here, insurmountable. But you gentlemen are really targeting these practices that are creating this carbon footprint and we applaud you for it. And now Jeff, tell us, because I'm listening, how do you engage and educate staff and providers about these sustainability practices, some of these challenges you've been discussing and what you guys are doing? Tell us about some of those interventions that you recommend and how is everybody reacting to it.

Jeff Good: And I think this is one of those where we're still early in that journey. And we've had within our intranet, and we have internal employee communications that go out, there have been a few of the sustainability success stories that have been out there. I envision us really increasing the amount of communication around the efforts that we're making. One, because some of it is generational. There's a younger generation that has a high value on our impact on the planet. But it isn't solely generational. It is something that all of us as employees of Northwestern Medicine, but really as citizens of this world, need to be aware of.

So, we're going to really work on increasing the amount of communication that we do. We're going to be standing up a website within our intranet at some point in the future where resources and tips will be available to our employees. And it's even been suggested that other academic medical centers may have links on their intranet site that allows employees to make suggestions. "Hey, have we thought about doing X," or "I noticed something in my workspace that is an opportunity for improving." And those are some of the ways that we envision reaching our employees.

But beyond that, we want to reach the community. We want to have a public-facing site that reports our progress. Once we establish our baseline and our goals, it's part of our mission. I've tried to, as we're developing this office of sustainability, to tie it back to our mission. And our mission is to improve the healthcare quality of our community. And part of that is to do it and deliver our care in a more sustainable way. There's no doubt that the impact of greenhouse gas emissions and its impact on climate change in our communities that are particularly in under-resourced communities are disproportionately impacted by climate change. Dr. Palmer mentioned a few of those things earlier. So, we have a responsibility to our community. And so, we're going to have public-facing reports and information for the community to be able to see our commitment and how we're progressing towards that.

Dr David Palmer: And I'd also like to add, if I can, our Academy of Ophthalmology, the American Society of Cataract and Refractive Surgery, and the European Society of Cataract and Refractive Surgery has developed a website called iSustain, isustain.org. And basically, the site is a warehouse of anything that is related to sustainability in our field that is evidence-based, including podcasts such as this, and the site is divided into several segments. One of them is drug waste. Another is industry initiative, waste in the clinic and research labs, global green practices, and also the public health impact of climate change. And it sounds like this site, in particular, could actually be a nice complement to what you're planning to do with the Northwestern's website.

Melanie Cole, MS: I'd like to give you each a chance for some final thoughts here. And Dr. Palmer, as we look to the future of sustainability at Northwestern Medicine specifically, are there new initiatives, goals on the horizon you would like other providers to know about? And if they are thinking about implementing some of these initiatives in their own practices, what advice would you have for them?

Dr David Palmer: Well, certainly, I think the first step is to have an awareness and a sensitivity to what is going on in the environment. And as Jeff succinctly indicated, we are contributing greenhouse gas pollutants to areas where there are, unfortunately, populations so socioeconomically depressed that really can't do much about this. So, it's our effort to try to change all of that. So, that is one thing on the horizon.

The other is, I mentioned the iSustain website, but there's a voluntary iSustain surgery pledge that has seven steps that I think would be very beneficial to Northwestern as one system, and other systems in particular. And Jeff mentioned educating surgeons and the surgical staff about sustainability and the impact of oral waste. He also mentioned talking about reevaluating our surgical packs to minimize our waste. We made reference to multi-dosing bottles of topical medicine on multiple patients when possible and allowing the patients to take home their eyedrops, applicable to other specialties as well outside of ophthalmology.

Jeff also mentioned the necessity of reducing our full-drape patient gowns to maybe a smaller gown. And to that, there was a journal article in the British Journal of Ophthalmology. And this is out of the Aravind Eye Care System, which is the largest eye care system in the world. That's very first world. And they actually looked at the drapes. They looked at reusing supplies, equipment, having two patients in the OR at once, having gloves on for 10 cases and then discarding them. And the infection rate compared to what we do in this country is identical to better. So, there are things we can learn internationally that may be applicable based on FDA and CDC scrutiny to us here.

The other is to assess options for reusable versus single-use products. And the AMA just recently, in fact, passed a resolution calling for more research and safety into this area. And again, that's another future prospect for research at the hospital. And assessing the feasibility of alcohol-based scrubs, which we're already using, and maybe even going to WHO standards, which instead of using a scrub brush and water for the first case, immediately goes to an alcohol-based scrub.

And the last thing is to institute or update recycling strategies. And again, this involves educating the staff and MDs on waste sorting so that our regulated medical waste and landfill waste is not intermingled. And this is because regulated medical waste is a lot more expensive to haul away.

The other is and maybe, Jeff, you can speak more about this, is the Joint Commission just offered a Voluntary Sustainable Healthcare Resource Center and Certification Program, which is another prospect to look at our critical examination of material purchases. You know, many companies create tools and equipment that are wrapped in plastic. And maybe these boxes and such are not compostable. So, to actually go to companies that are very much environmentally oriented and seeing what kind of supplies and processes that they use to reduce our environmental waste and cost and greenhouse gas emissions.

And the other is at conferences and clinics, and Northwestern hosts many of them, is to limit attendee travel from the hotel using bus shuttles, no plastic bottles of Styrofoam or plasticware, using personal water bottles and compostable utensils. And this has worked very successfully now at our major eye meetings, both in this country and internationally. And maybe even to use more plant-based foods and less red meat, which is not only healthier, but these products are differed in terms of greenhouse gas emissions and that animals and the grazing contributes more to overall environmental greenhouse gas emissions.

I talked about research with projects on safety and efficiency and efficacy of instruments. We talked about how climate change can affect populations. And then the other that perhaps we can talk further about is to use telehealth initiatives to follow patients. And this would not only also increase their quality of care, but also reduce travel and associated greenhouse gases from that travel.

Jeff Good: And just to comment on Dr. Palmer's mention of the Joint Commission's voluntary certification, we can envision a world probably not in the too distant future where accrediting bodies will not be voluntary anymore in terms of asking about what we're doing from a sustainability standpoint. And it could be accrediting bodies, it could be rating agencies. This, for Northwestern Medicine, is all about doing the right thing and potentially getting ahead of what may be some requirements down the road. But first and foremost, it's about doing the right thing for our community and our environment in general.

Melanie Cole, MS: This is really, in my opinion, such an important topic and such an important discussion and really what these podcasts are intended to do. And Jeff, the last word to you as a leader in sustainable surgery, in sustainable practices, I would like you to speak to the listeners. What would you like them to take away, the key messages and the important work that you and Dr. Palmer and all of your colleagues are doing at Northwestern Medicine?

Jeff Good: It has been a fascinating few months for me in this role, I think the real key takeaway is that we all play a role, every single one of us. And one of the things is we think about structuring our organization to activate various initiatives in the months and years ahead. There are some organizations that structure themselves with an office of sustainability that has a big team, that's helping drive performance in those various initiatives from a central office or central location.

As I'm thinking about the future of how we structure ourselves, to me, it seems really important to have individuals that are in their operational areas that are focused on sustainability. It's just part of what they do. Having someone from a central office telling a department how to do it, to me, just isn't as effective as having it be part of the culture and part of what an individual does in his or her job every single day.

So, to go back where I started, it really is important we all think about what our individual impact is and how we can make a difference and support the changes that we need to do ahead of us.

Melanie Cole, MS: Rock on. Thank you both so much for joining us today and really giving us an eye-opening awareness of sustainability practices and the importance of them in not only the hospital setting, but in the community in general. So, thank you both so much. And to refer your patient or for more information, please visit our website at breakthroughsforphysicians.nm.org/ophthalmology to get connected with one of our providers and to learn more.

And that wraps up this episode of Better Edge, a Northwestern Medicine podcast for physicians. Please remember to subscribe, rate, and review this podcast and all the other Northwestern Medicine podcasts. I'm Melanie Cole. Thanks so much for joining us today.