PHC Med Staff

• There is an urgent need for transformation in health care to address healthcare system contributions to environmental unsustainability. A blend of leadership, mandates and grassroots action can achieve significant, impactful change.
• Health care organizations can lead with strategies that integrate environmental sustainability into frontline clinical care and recognize it as a dimension of care quality.
• Canada is actively participating in global efforts to develop low-carbon, sustainable, and resilient health systems.
• Networks like CASCADES focus on mobilizing knowledge and supporting sustainable healthcare innovations in Canada.
• The Lancet Commission on Sustainable Healthcare and initiatives led by institutions like UBC and Yale are establishing a research and policy agenda for transforming to sustainable health systems and positioning healthcare professionals at the forefront of addressing the climate crisis.

• Publicly funded entities like health care are mandated to report their emissions annually and purchase carbon offsets, aiming for carbon neutrality for reported emissions, mainly from utilities and transportation.
• Efforts are underway at Providence reduce building emissions from utilities, which make up the majority of emissions. PHC achieved a 9.3% reduction by 2022 and is aiming for a 50% reduction by 2030. Further reductions can be achieved with the new, greener hospital facility.
• Providence is encouraging medical staff and staff involvement in environmental stewardship, to build a community of sustainability and planetary health with:
• An invitation to join the Planetary Health and Environmental Sustainability/Stewardship team, a cross-disciplinary environmental stewardship team created in 2023.
• Small grants for research specifically aimed at planetary health.
• Supports to become a green plus leader through the environmental Energy Environmental Sustainability Team in the Lower Mainland – training, resources and a website called bcgreencare.ca.

• Health care is hindering success in stemming the flow of oil – and adding to the flow.
• Efforts can be made to minimize low-value care: unnecessary and high cost practices that consume resources and energy and have an environmental impact without significantly benefiting patient health, preventing disability or improving life years.
• High-Value Healthcare: Health care practices and guidelines that focus on care that optimizes health outcomes and minimizes environmental impact.
• Examples of eliminating/reducing low-value care
  • Reducing LDH Testing show to reduce emissions, impactful oil use reduction.
  • Reducing TSH testing (where considered to be low value)
  • Vitamin D testing for example, is is increasing exponentially because of guidelines and patient preferences. The guideline, patient and ordering doctor should consider whether high value.

• Dr Wong is leading work to improve food quality and food experience for vulnerable seniors at Holy Family hospital in long term care and rehabilitation.
• Used a QI lens/methodology to measure food consumption and food waste, the food experience, and reduce food complaints.
• Recognized at the BC Quality Forum, this work included:
• A significant reduction in dinner entrée waste: Utilizing meal tray tickets to monitor food consumption and further work to achieve a 50% reduction in dinner entrée wastage among cognitively intact residents.
• Testing of vegetarian lunch options (vegetarian week for lunch entrées) which showed an increase in food wastage, and provided valuable lessons on the logistics of menu changes, food service operations, and the importance of patient choice in achieving improvements.
• Moving forward: Collaborative efforts with VCH and Fraser Health towards sustainable dining and more sustainable menu options in the BC lower mainland.
• Dr Wong’s Food Working Group has been engaging staff, patients and residents including through the Celebrate Plant power and World Food Day events. The group is open to present to interested colleagues/groups to spread awareness.

• Heart disease management is evolving, with patients with devices like pacemakers to address rhythm issues.
• There are three main pathways for patient follow-up: regular check-ups, suspicion of device malfunction, or emergencies such as sudden cardiac arrest, each traditionally requiring in-person visits that contribute to a larger carbon footprint.
• The remote monitoring program aims to minimize the need for transportation and in-person visits.
• It allows for data transmission from patients’ devices to health care providers through a secure system, either via a dedicated device or a smartphone, to achieve timely and efficient care without the need for physical clinic visits.
• Leveraging remote monitoring technology will not only to improve patient care and experience, but also to contribute to reducing carbon emissions.
• Requires ongoing research to quantify the benefits and promote sustainability.

• Significant impact of anesthetic gases on carbon footprint: A landmark study in the Lancet in 2017 highlighted that desflurane, the main anesthetic agent health care in two facilities, contributed up to a 63% of the operating room carbon footprint, compared to only 4% in a center that did not use it.
• Desflurane requires 3x the mass for the same clinical effect as sevoflurane, has a longer atmospheric lifetime (14 years), and a global warming potential 2500 times that of CO2. Sevoflurane and nitrous oxide have significantly lower (but still notable) impacts.
• Attempts to voluntarily reduce desflurane use by 50% at PHC were more successful with the removal of canisters and vaporizers, for a 50-80% reduction.
• Nitrous oxide, used predominantly in maternity services, has a long atmospheric lifetime and high global warming potential.
• There are also issues related to wastage from central supply systems and leaks for gas flow. Transitioning from a central supply to portable cylinder units is proposed as a solution.
• Additional recommendations include exploring alternatives to general anesthesia like regional anesthesia, and adopting innovative technologies for capturing, reducing and recycling anesthetic gases.

• Operating rooms contribute significantly to environmental waste, with the amount of waste from a single surgery comparable to what a family of four generates in a week, primarily due to the use of single-use plastics.
• Practical steps include initiatives like marking unused suction tubing and anesthesia circuits as clean for reuse (using green “I am clean” stickers) and informing cleaning staff to not take those away but instead use for the next patient.
• Exploration of reusable breathing circuits that only require filter changes between patients are and consideration.
• Despite the simplicity of these kinds of waste-reduction concepts, implementing them in the context of hospital operations presents challenges, requiring commitment and creativity.
• The importance of sharing and adopting waste reduction strategies among other institutions globally will foster a community of practice dedicated to minimizing environmental impact in health care settings.

• There are opportunities to improve prescribing practices and reduce waste for inhalers used by patients when they are admitted to hospital, and throughout their health care journey.
• Pressurized Metered Dose Inhalers significantly contribute to greenhouse gas emissions, highlighting the need for climate-conscious prescribing practices.
• PHC dispenses 5000-6000 dispensers in acute care on an annual basis as single patient use. Unfortunately, every dispenser is only used to about 15% or less resulting in 85% wastage.
• Programs that allow for multiple patient use of these dispensers through cleaning and disinfection have shown success.
• This extends the dispensers’ life cycle to they can be used for multiple patients until they are fully used– instead of discarded, resulting in significant waste.
• PHC is looking to establish a program to reinitiate the recycling of these inhalers in a collaboration with PHC and VCH pharmacy, and with eventual expansion across the region.
• Resources for Low-Emission Inhalers:
  • CASCADES has released a playbook for both inpatient and outpatient settings to promote climate conscious inhaler prescribing practices.
  • BCinhalers.ca provides information for patients and prescribers on low carbon emission inhalers, including PharmaCare coverage and instructional videos.

• Heparin production: Annually, 1.1 billion pigs are slaughtered to produce heparin for global use, a process that is not efficient and raises ethical and environmental concerns.
• Re-evaluating heparin use in patient care: The current medical culture of administering heparin to hospital patients to prevent blood clots is often unnecessary, as many patients have a low risk of developing such complications.
• A strategy to align heparin prescriptions more closely with patients’ actual risk levels (provided by pharmacist) aims to significantly reduce unnecessary heparin use, thus lessening its environmental and ethical impact.
• Strategies for reducing heparin exposure include implementing guidelines for prescribing through pharmacist-led screening.
• Strategies have proven effective, drawing lessons from antimicrobial and opioid stewardship programs.
• The heparin stewardship initiative in PHC started in March 2023 has led to a 53% reduction in heparin use on medicine and geriatric hospital units.
• Adoption includes monthly education lectures to physicians, residents, and students.

Question 1) What can you do/what are you doing in your clinic/Division/Dept/Other area?

Opportunities for Action:

• Reduce usage of paper reports and recycle more.
• Take advantage of virtual care when possible.
• Install more cooling and heat pumps that reclaim wasted heat and reuse it to heat the building.
• Turn off scanners and MRI machines at night.
• Minimize big panel lab work.

Big Picture Items:

• Talk more about planetary health and environmental sustainability.
• Learn the best practices in your department.
• Integrate environmental sustainability as a part of the onboarding process and curriculum for medical students.

Question 2) What supports do you need/were helpful to allow you to do this (start & implement your related project, idea, change)? From the organization, div/dept, other?

Opportunities for Action:

• Use smaller metered-dose inhalers (MDI) canisters without so much wastage.

Big Picture Items:

• Collect more data on ordering, impact and hire someone who can help us understand these impacts.
• Utilize a bottom-up cultural shift where solutions come from technicians.
• Make Planetary Health and Environmental Sustainability a more well-established concern.

Question 1) What can you do/what are you doing in your clinic/Division/Dept/Other area? 

Opportunities for Action:

• Take desflurane canisters to recycling.  
• Remove supplies you don’t want people to use or make it difficult to get them.  
• Turn off equipment and lights when not in use. (Except computers managed by regional IT/HSSBC)
• Revise order sets in chemistry to help other departments reduce or eliminate options and offer better options. 
• Move more towards online and reduce our paper consumption. 
• Minimize unnecessary bloodwork.  
• Simplify the drugs patients are on (drugectomies). 

• Purchase better drapes that can be reused and recycled.  

• Purchase cloth drapes to reuse.  

• Purchase and use washable gowns. 

• Get data on cloth vs paper and which is environmentally better.   

• Switch from big plastic contains to vacuum sealed bags (current pathology lab initiative). 
• Work on processes with Exceleris to reduce the paper labs, which they get paid to send.  

• Engage them to stop sending paper;  
• As individual practitioners, refuse to accept paper, as a group, by considering hiring someone to support physicians for form distribution.  

• Reduce defibrillator pads for patients in the EP (electrophysiology) lab – data shows that most of the time the pads are not being used.  
• Stop using paper on the tables that must be wiped down anyways.  
• Take out just the amount of sodium bicarbonate you need. 
• Reduce usage of Styrofoam in the OR and replace it with reusable gel pads.  
• Discuss with operations the OR setup being thrown in the garbage when it is unused (nobody can monitor if it was not tampered with) and if this approach is evidence-based.   
• Move laparoscopics to reusable/permanent trocar.   

Big Picture Items: 

• Have employment groups approach this issue collectively. 
• Lead the way in figuring out what is necessary.  
• Work with IPAC champions to debunk some stories about safety.  
• Get the organization on board to support through procurement – make the large-scale change.  

• Check if endoscopy devices switching from multi use to single use is due to an industry narrative to drive profits or if there is actual data to support it.  
• Give each department their data on where they are generating the most waste to target their efforts.  
• Obtain a green assessment of the vendors as part of the procurement process.  

Question 1) What can you do/what are you doing in your clinic/Division/Dept/Other area?  

Opportunities for Action:

• Use tap water not sterile water during colonoscopy.  
• Reduce unnecessary tests by individualizing cases and not offering every single patient the same tests.  
• Utilize dashboards to help clinicians monitor trends in use of tests.  
• Eliminate daily blood work orders; instead look at the patient’s most recent results and then determine which tests need to be ordered/re-ordered.  
• Use virtual care if feasible, and if the patient has substantial travelling time.  
• Reduce the amount of pre-op testing and streamline the process so a patient can get all necessary tests accomplished in one visit.  
• Continue with MedSafer trial to reduce medication use especially in elderly patients.  
• Ensure the pharmacy divides medication into smaller vials to reduce medication wastage.  
• Utilize smaller MDIs

• Understanding current guidelines and sourcing containers with fewer doses.
   

• Big Picture Items: 
• Examine Cerner PowerPlans that encourage over-ordering of tests/procedures.  
• Get funding for MFA – funded committee that helps to start planetary health initiatives.  

• Use playbooks from CASCADES, etc.  

Opportunities for Action:

• Track food wastage at SPH. Measurements being done (biannual food wastage results). Data not available yet. 
• Get more data re: food wastage – Why aren’t patients eating the food? (mostly due to not feeling well). 
• Don’t wait to start measurements.  
• Label food with carbon footprint (is this already being done by Food Services)?  
• Celebrate Plant Power event events at PHC wards with physician champions: Posters, samples to be given 
• Engage staff: posters, materials, education 
• More plant-based menu items in maternity ward, especially for GDM (gestational diabetes mellitus) patients 
• Batch (same day) discharges so some meals do not end up being delivered. 

Be aware of limitations to changes: 

• Food services repatriated from a private provider to in-house.
• Sites available for food tasting-needs dietitian discussion and approval
• Legislative constraints: legislation allows certain amount of calories, water intake.

Educate/ raise awareness among staff & patients 

• Try to cut down on high carbon food. 
• Explore ways for families & friends to provide more foods to avoid wastage. (However, must be cleared with dietitian, staff.)

Explore more food choices 

• Acute care menu
• Ask patient meal preference (less wasteful).
• Timing of choice
• Psychiatry interested

Explore food options 

• More fresh fruits & vegetables.
• Different recipes.
• More plant-based foods incorporated at an institutional level. Gradual with partial vegan; Not completely vegetarian but gradually changing to complete vegetarian.
• More plant-based menu items.
• More comfort foods (tomato soup, mac & cheese, chicken noodle soup).
• More tasty foods for patients.

Explore timing of meals 

• Synchronising meals and ordering the day before or day of?
• Cancelling meals not needed e.g. when patient is away for specialist appointment.

Explore additional support opportunities  

• Spread Quality Improvement (SQI) funding for team-based Food QI project available
• Green Leaders training
• Food Working Group on the EST – meets monthly every second Thursday