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Becker’s Healthcare Podcast
Eliminating Nitrous Oxide and Advancing Sustainable Care in the OR with Dr. Arash Motamed
00:16:15
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- [00:00]
A
Welcome to the Becker's Healthcare Podcast. I'm Mariah Taylor, assistant editor, and I'm thrilled to have Aresh Moutamid, anesthesiologist and medical Director of Sustainability with keck Medicine of USC, on the podcast today. Dr. Mutamid, thank you so much for joining me. I'm really excited to learn more about how you're discontinuing nitrous oxide in the or. But before we jump into that, I'd love if you could introduce yourself a little bit and tell us a little bit more about why you discontinued nitrous oxide.
- [00:31]
B
Well, hi, Maria. Thank you for having me on your podcast. It's my pleasure to be here today. I'll start off with my story and involvement with nitrous oxide. It started off with a pretty casual conversation with a colleague of mine who works at a competing medical center. He was the one that first let me know what the problem with nitrous oxide is. And for those who may not know, it's also known as the laughing gas. It's a type of an anesthetic inhalation, all that has been used for over a century, but really started to gain a lot of popularity in the latter half of this past century and has some really great benefits in terms of quick onset, quick offset, and also very available and inexpensive. But what he told me at that time, which is really the start of my journey in discontinuing nitrous oxide from our medical center, was a majority of the nitrous oxide that's in the central pipelines and the hospitals leaks into the atmosphere. When they've done studies to look at that, they say anywhere from 75, up to 95% of the nitrous oxide leaks, typically at the areas of the connections. And there's really no way to prevent this. And what's interesting about it is what it means is that the nitrous actually never has any clinical impact. It just goes straight into the atmosphere. Then the next question is, well, why do we care about it? We do, because nitrous oxide is a fairly potent greenhouse gas, about 300 times as potent as carbon dioxide. So it really has a big impact. And on top of it, it does also deplete the ozone layer. Then one other thing with it is it lasts for a pretty long amount of time in the atmosphere, about 100 years or so in some ways. Some of the first nitrous oxides that were being used as anesthetics are still somewhere in our atmosphere. Most of it had gone unused in terms of clinical benefit. To the patient. Now, we know the patient still gets the amount that we want the patient to get, but majority of it just leaks before it ever gets to the patient. So knowing that and, you know, my involvement with our sustainability efforts at Keck, I felt compelled that we need to look at this and we need to figure out a way to better address it and hospitals. Nitrous oxide commonly comes in two forms, so either cylinders that gets attached to the anesthesia machine, or central pipes that again gets connected to the anesthesia machine. Almost all the times, if a place has the central pipes, that's what they use, and the cylinder is used as a backup should there ever be any issues with central supply. So what we wanted to do was look at our usage at our medical center and decide whether it makes sense to discontinue it. The challenge with doing that one is education and making sure that everyone has awareness as to why we're doing what we're doing. But also it's partnering with our colleagues at facilities, because as an anesthesiologist, I know nothing about the central pipelines, how they work and how they function. Also, at the end of the day, this is a medication that anesthesiologists have used for many decades. There is clinical comfort when established habits, that is, take some time to get them to see and understand and look at other alternatives. So that's the basics of the beginnings of how we got involved with getting rid of nitrous oxide.
- [04:23]
A
Excellent. And how did you build a credible business and clinical case for this initiative? And then on top of that, how did you get both hospital leadership and frontline physicians aligned on it?
- [04:35]
B
Yeah, that's a really great question. I think goes to heart of any type of initiative we try to do. It really needs to be collaborative and you need to have the buy in, because otherwise it's just not going to go anywhere. What I decided to do in this particular instance was initially, our department in anesthesia is about almost 200 individuals, combination of physicians, CRNAs and residents. And I picked about 20 of them who either have leadership roles or, you know, are otherwise still fairly influential or have, you know, a lot of experience and expertise. And I polled them and my first question to them was, you know, are there any types of cases that we do where nitrous oxide is really the only type of anesthetic we should use for? Because if that answer comes, comes back as yes and a fair amount, then it's a different question. But, you know, as an anesthesiologist myself, I know the answer is no. And that was the response that I got, which was great. So then it led to the next question on the next round of surveys that we did, which was, since we know that it's not a must have, can we have the option of a fully getting rid of everything that we have, two, discontinuing the central pipeline and just having the cylinders as backup should anyone need it, or three, removing everything but having a few cylinders somewhere in the building as backup should anyone need it. And we'll bring it up and connect it to the machine. And it was interesting that through that process and of course as these surveys are happening, there's education with the department in forms of grand rounds to let them know what the impact of nitrous oxide is. But most of the group felt comfortable moving towards an approach where we remove everything from the OR so it's not there ready to be used. But we'll have cylinders available should we ever be in a need where someone feels like that that is the best thing for their patient at that point in time. We reserved four cylinders where we keep all the gas cylinders in our hospital and created a pathway that is easy to a phone number to dial and the person comes in and helps set it up. And what was really interesting was in the last three years at our Keck Hospital and two years at Norris Cancer Hospital, not a single time has anyone needed to make that phone call, which essentially made us the only institution that I know of in the US that has fully removed nitrous oxide from both central supply and the cylinders.
- [07:22]
A
That's incredible. What were some of those key learnings you had when you were moving this from a concept into execution?
- [07:31]
B
One of the interesting things that came up that we did not know was the way the nitrous is set up to the machine. Once you discontinue it, that machine could no longer do itself check and would give a lot of errors so it would be non functional. We first had tried this on one of our spare machines just to see what happens. Once we realized that that's a problem, we needed to connect with the manufacturer and have one of their representatives come in because they needed special codes to go in there and change the machine check so that it doesn't alarm and it can still do its self check and it can still function. That was an interesting learning point. But one of the other things that could potentially sometimes I think in other institutions also be viewed as barrier is the term that gets frequently when it comes to removing nitrous oxide from central supply or central pipelines is decommissioning. And decommissioning can mean different things to different people, as I have learned. And it could be anything from we're just not using the pipes to we need to go into the building and we need to remove pipes, which, of course, is not only a construction nightmare, but also fairly expensive and, you know, regulatory challenges that, you know, may come with it. Our approach to decommissioning was not to do any of that. It was to simply stop having nitrous oxide in those central pipelines. And then our team with the facilities management actually came up with a really brilliant and unique idea which I think can be used by other hospitals as well, which is to fill that pipes with nitrogen, which is also another gas that helps preserve the integrity of the pipes, should there be some other use for them down the line for some other form of gas. But at the same time, it's also inexpensive, and it doesn't have any negative environmental impact.
- [09:25]
A
That's amazing. Some really interesting problem solving and, you know, issues that probably nobody had thought about before you tried. So I'm curious if we take kind of a step back and when you're evaluating sustainability initiatives as a whole, how are you balancing the environmental impact with the financial performance, clinical outcomes, all the operations, operational feasibility? And then how are you measuring the success beyond just emissions numbers?
- [09:50]
B
Yeah, that's the. That's the tough question that we try to figure out, actually, with every single project that we do. We're fortunate in that at our institution, there has been, you know, support to the sustainability program. So we have a chief of sustainability and a sustainability program manager. And along with me and my role, what we try to do with all of these initiatives is partner with the various stakeholders at our hospital, whether it's obtaining data or whether it's talking with supply chain to try to figure out what the impact is, both financially and to some of the contracts, because the hospitals may be tied to certain contracts. So we can't just suddenly go and say, this is what we want to do. And then, of course, the. I would say both, you know, the return on investment from an environmental point of view or from a cost point of view. There are projects that, you know, will be very expensive with maybe not so much significant environmental impact in terms of reducing carbon footprint. And then there's projects that are exactly opposite. So in our approach, so one, we collect as much data as we can to before, during, and after. And we have committees that meet very regularly on a monthly basis with all the various individuals within the health system that play a role in one form or another, and the care that we deliver to make sure everyone's on board with the projects. And it makes sense. Of course, clinicians are very much involved and we really listen to their input. And that's part of my role, is to bring them on board and make sure nothing that we do ultimately has a negative impact on patient care. But what we try to do, I would say, on a very high level, is most of the projects that we decided to tackle earlier on were the types of projects that would achieve both. And that's, I think, one of the other misconceptions with a lot of these efforts to reduce the carbon footprint of care delivery is everyone just assumes it's going to be expensive. And when you look at, you know, how can we better be better for our environment, the number one thing everyone just says is, you know, reduce waste. Reducing waste is obviously, you know, financially beneficial as well as well, you know, in addition to reducing the negative impact of the on the environment and in health systems, there is a fair amount of waste. And when you look at health systems, specifically the academic medical centers, I mean, part of that cost of education also becomes excess waste for all of us, who, myself as an anesthesiologist in the operating room, we do see that all the time. And part of it is just the practice of medicine and helping teach somebody else and helping somebody else become a clinician. But I think the other part of it is we've historically, as an entity, never truly looked at how much waste we generate and what the impact is. And now we know that healthcare is one of the, you know, leading industries when it comes to greenhouse gas emissions. You know, studies have said, at least in the US anywhere from 8 to 10% and we're much higher compared to other institutions outside of the country.
- [13:13]
A
Absolutely. And I know here at Becker's we've seen a lot of hospitals that are starting to move forward with sustainability initiatives in a lot of different ways. But I'm curious, from your experience, where do you see the biggest untapped opportunities for hospitals to reduce their environmental footprint?
- [13:30]
B
Yeah, I think from my point of view, the biggest untapped opportunity is still lack of education. I think, again, using myself as the example of it, the first time I went into a grand rounds where some individual was talking about the impact of care delivery on carbon footprint was my aha, moment of I need to get involved and what do I need to do? And I think that is there's still a great opportunity there. And clinicians really need to be involved. There are some hospitals or healthcare systems where they're doing a fair amount in terms of reducing energy usage or water usage, but the clinicians haven't been fully engaged. Educating and connecting both the hospital administrative side and the clinical side together, I think really makes a big difference from our point of view. You know, once, once we got that group together, the projects, just one feeds the other. You know, when we started our monthly or group talking about how can we, you know, do better in the periop setting, I remember the first session I had, you know, afterwards I'm like, oh my God, I have nothing to say. Next month I just went over everything I had to say. Now it's at a point two years later where there's not enough time to keep talking about all the different things that people want to do. The different folks in the hospital, whatever their role or responsibility is, are the ones that come to us with the ideas we have. One of the individuals at our hospital that does patient transport is the one that came up with idea of how to try to create bins for the significant battery waste that we have in hospital. For all the devices that we use. The ideas flow once you have that set up and you know, you have the key individuals involved. So I think from my point of view, the biggest barrier is that first step. And once you take that first step, it just ends up feeding itself and at the end of the day gets us to a place where we deliver better care. Because in my view, the best care you can deliver is also the most sustainable one where the patient does well and they don't have to come back to the hospital again or be readmitted to the hospital or have a prolonged hospital stay. And as we do that, we're able to deliver more care and actually do it in the most cost effective way. So for me, that mentality is just very much aligned with value care that we aspire to deliver absolutely.
- [16:03]
A
Well, this has been such an informative discussion. Thank you for taking the time to join me today and share more about everything you're doing.
- [16:10]
B
Thank you so much. I appreciate being here.