Green endoscopy: Practical strategies to reduce environmental impact in GI practice

Background: Health care is a significant contributor to global greenhouse gas (GHG) emissions.

Hospitals, specifically operating rooms and procedural areas are the primary source of health carehealth care-related waste. The U.S. takes the global lead for health care waste production, generating over 3.5 million tons of medical waste every year (1, 2). GHG emissions are produced not only from this waste, but also from facility energy usage and the energy required for supply chain: the energy required to produce necessary health care tools and supplies, to transport and utilize them.

If global health care were a country, it would be the fifth largest emitter of GHG in the world, making up for about 4.4% of total global emissions (3). Sustainability efforts to improve emissions and reduce waste within health care are vital to reduce GHG emissions, mitigate the effects of global warming, protect patients from climate change associated health care ramifications, and offer potential cost savings for the institution. A topic of increased interest and attention, we, as a health care field, must mobilize stakeholders to enact change; according to the Lancet, “climate change is the greatest threat to public health” (4). 

How to convince stakeholders: There are plenty of opportunities for gastroenterologists, ambulatory surgery centers, endoscopy units, and outpatient clinics to implement changes that reduce GHG emissions. Ideally, a stewardship team is set up in each unit to oversee the implemented changes, but also to collect data and report on metrics, particularly cost saving measures and interventions. As not everyone in your clinical administration will prioritize GHG emission reduction, it is extremely important to meet stakeholders where they are.

Highlighting the opportunity for cost saving is extremely important to garner support and buy in. Starting with cost saving measures is important to establish “proof of concept” after which additional interventions that may be cost neutral and potentially costly can be considered at a later time.

Educational seminars on these interventions and why they matter are also opportunities to educate peers who may not know. Petre et al conducted a study in 2019 interviewing 426 anesthesiologists who reported that despite a 97.5% interest in recycling efforts, only 30.2% did, and the largest reason cited was lack of support (63.5%) and inadequate information and education on the matter (62.8%) (5). This highlights the fact that health care workers are interested in improving their GHG emissions but often lack the resources and support to do so. The reality is that reducing certain types of health care waste saves money.

What we can do practically in the GI unit: Given the fact that they are the primary sources of waste and emissions, procedural areas and operating rooms (OR) are prime targets for reducing waste and improving GHG emissions from any health care facility. Listed here are opportunities to improve an endoscopy unit’s carbon footprint: 

1. Reprocessing: A combination of infection control, revenue opportunity, and difficult logistics with reprocessing had moved the field of medicine largely towards single use disposable medical devices. Non-invasive items like pulse oximeters, sequential compression device (SCD boots), and electrocardiogram (EKG) leads are often utilized as “single use” and disposed, immediately going to landfill. Industry partners now offer the opportunity sell back these items for reprocessing, with an opportunity to generate revenue for the hospital (6,7). The items are cleaned and tested for functionality and quality control. Hospital systems can decide if they would like to purchase reprocessed items (or not). This opportunity serves as a great “starter” option for hospital systems who are interested in improving GHG emissions and waste while generating revenue for the hospital system.

2. Waste allocation: Regulated medical waste (RBW) also known as “red bag waste” is potentially infectious or hazardous hospital waste that can serve as a potential threat to the handler of the waste or the population living within proximity to the allocated landfill. As such, it is handled in specific (red) bags and often driven far distances to be incinerated. Not only does this waste cost more money to be handled and disposed of compared to landfill waste (8,9), but the incineration process is hazardous to the community local to the incineration site. Known carcinogenic compounds, also thought to impact reproductive capabilities known as dioxins, are byproducts of this incineration process. The CDC has designated an appropriate amount of RBW to be 3-5% of a hospital’s waste, but due to poor education on what exactly goes into the red bins, many health care providers overutilize the red bins, placing unnecessary items into them (10). Educational initiatives on appropriate use of the red bins and associated sharps containers can be offered free of charge by sustainability working groups within the hospital or ambulatory facility, creating opportunities to reduce costs and divert items from incineration. Gastroenterology-specific guidelines have been published to guide gastroenterologists on what items within our field warrant placement within the red bins and sharps containers (11). Generally, containers with free-flowing blood or blood products, items completely saturated with blood, and soiled materials from patients on contact precautions are some examples of gastroenterology procedural waste items that require placement into the red bins (12). It is equally as important to educate clinicians on the items that do not go into the bin, including gowns, gloves, and gauze unless grossly bloody (dripping with blood) (12).

3. Reduction in unnecessary procedures: While often not the most popular item for providers who work in private practice or productivity-based systems, the reality is that each procedure of the average 18 million endoscopies performed annually within the United States has a carbon footprint, and not all of them are necessary. Reducing interventions such as endoscopy through non-invasive screening methods like stool testing for colon cancer screening in average-risk individuals, for example, provide excellent opportunities to reduce the carbon footprint of endoscopy.

4. Non-sterile water: There is no direct evidence proving the need for sterile water during routine endoscopy (13). Tap water, while suitable for drinking within the United States, has not been utilized routinely for endoscopic procedures, despite sterile water’s higher carbon footprint and lack of necessity within the non-sterile gastrointestinal tract. There is an ongoing push within the community of sustainability advocates within the field of gastroenterology to normalize the use of tap water for lavage during routine endoscopy. (14).

5. Reusable gowns: Despite performing mostly non-sterile procedures, many endoscopy units fall under the “peri-operative’ designation where sterile technique is standard of care. As such, single use sterile gowns, sterile gloves, and sterile gauze are often utilized for gastroenterology procedures. These items come with additional bulky plastic packaging meant to maintain sterility. Reusable gowns are an excellent opportunity to reduce the GHG emissions from an endoscopy unit and reduce costs. A hospital system that transitioned to reusable gowns reported a $60,000 decrease in cost and 50,000 pound reduction in waste (10,12).

6. Endoscopic decontamination/processing: Reusable scopes require decontamination. Alternative, ecofriendly, green options for cleaning solutions offer excellent options to reduce carbon emissions and chemical waste.

7. Resect and discard: Not all pathology specimens require formal pathology evaluation to change clinical management of a patient. An example being hyperplastic polyps within the distal, left colon. Additional interventions include separately sending tubular adenomas throughout the colon that have identical pit patterns suggesting their degree of adenomatous change. The “resect and discard” method for removing pre-cancerous small lesions with predicable pathology results an excellent opportunity to reduce the carbon footprint of an endoscopic

8. Non-invasive screening methods: See above, “Reduction in unnecessary procedures.”

9. Recycling: Recycling non-soiled rigid plastic waste can divert it from landfill (15,16). Bulky plastic packaging meant to maintain often unnecessary sterility for tools that do not require it (i.e. endoscopic forceps, snares, etc.) are often non-recyclable. Collaborating with industry to push for biodegradable packaging or recyclable packaging remains an opportunity to reduce waste and emissions (16). In the interim, working within your health care facility to recycle rigid plastic and cardboard boxes remains an opportunity to reduce waste.

10. Double-sided printing: Hospitals continue to print an exorbitant amount of paperwork despite the development of electronic medical record systems with abundant patient access. Recycled paper is an additional opportunity for reduced GHG emissions. (17).

11. Lighting: Most ambulatory surgical centers and endoscopy units within the U.S. operate with a fixed schedule. Placing light emitting diode (LED) lighting, ideally with motion sensors creates an opportunity to reduce emissions created by unnecessary lighting of units during “off hours. If such upgrades are not possible, enacting a “lights off initiative” during “off” hours is an alternative opportunity to reduce emissions and associated energy costs (12).

Conclusion: Climate change is indeed a factor in patient care. Improving our efforts in reducing health care associated carbon emissions serve our patients and our communities, all while offering potential cost saving opportunities to the hospital administration. Straight forward, attainable opportunities to achieve this goal, as outlined in this paper, present an opportunity to enact necessary change, serving planet Earth and our patients. 

References

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