How ID Can Lead Sustainability Efforts in Health Care

Buddy Creech: [00:00:12] Hey, everybody, this is Buddy Creech. And this is another episode of Let’s Talk ID. Today, I’m really excited about a conversation that, quite frankly, I’m excited about learning some new things about. And that’s about the future of our society as it relates to the impact of climate change and the need for sustainability efforts, not just within our specialty and in our local hospitals, but really in the medical field at large. And so I’m joined by two folks who have identified this as something important to them and are really leading our efforts in the pediatric ID society to address these issues of sustainability. Preeti Jaggi is director of antimicrobial stewardship at Children’s Healthcare of Atlanta. And she’s been an early leader in this within our society, putting together those who are interested in figuring out how to reduce medical waste and how to address these fundamental issues of climate change. And Shreya Doshi, who is a third-year pediatric infectious diseases fellow at Children’s National Hospital in Washington, DC, and she’s also pursuing an MPH in global and environmental health at GW. Together, they formed Sustainabil-ID, which is a committee of PIDs which currently has over 200 members on its listserv. And this initiative focuses on evaluating the environmental impact of healthcare practices through an infectious diseases lens, and exploring methods to modify those practices for the benefit of children and their planet. To the both of you. Thank you for being here and welcome. I’m excited to learn today because honestly, this is probably new to me and it may be new to many of our listeners. So Preeti, do you want to talk a little bit about – I love origin stories. I love trying to figure out where people got to where they are. So can you walk us through a little bit about how this came about.
Preeti Jaggi: [00:01:59] So I have always been really drawn to spending time in nature and been really concerned about climate change as an individual since really the 1990s. I remember seeing an Earth Day special on TV-
Buddy Creech: [00:02:13] Awesome.
Preeti Jaggi: [00:02:13] with Robin Williams and Bette Midler and thinking, wow, this is like really important. And I started making my family recycle. And it’s always been something that’s of interest to me. And just as time has gone on, I have been recognizing that climate change is really important for for human beings and, you know, really thinking about it as a really in the future kind of problem. And as time has gone on, it’s been more and more clear to me that climate change is a health issue and it’s especially important to children. I think becoming a mother has also been really, really important to me, seeing my kids and thinking about their future. So really, it’s been something that has been kind of interest to me for a long, long time. As you start thinking about climate change and its impact on health. It feels sometimes, you feel a bit powerless in this problem. But, you know, ultimately we really need to decrease greenhouse gas emissions. That’s source control that we love in ID. As I’ve become more have spent more time doing antibiotic stewardship, realizing that there are ways that we can make health care delivery less impactful to the planet, we do contribute substantially to the greenhouse gas emissions in the United States, and there are lots of ways that we can change the things that we do every day in order to decrease those greenhouse gas emissions.
Buddy Creech: [00:03:27] What a great response. And if for no other reason, I’ve now checked Bette Midler and Robin Williams off of my podcast bingo card for the morning, so this is really good. Shreya, talk to me a little bit about why this environmental sustainability issue might be relevant to ID. I mean, you’re a third-year fellow, you’re about to launch, and this is becoming a part of what you’re most interested in. So why ID specifically? What is our specific role in addressing some of these issues?
Shreya Doshi: [00:03:57] When we think of one health concept and we think how the wellness of the planet, the nature, animals and humans is all interconnected. I feel like infectious disease is sees that connection of that interconnectedness more than any other specialty. Because when you think of some of the diseases that are surging this year, like dengue, we’re seeing record breaking cases in the Americas. We’re seeing a lot of increase in general when it comes to resistance. And Candida auris or coccidiomycosis or tick-borne illnesses are extending their boundaries now. I feel like this concept of one health is so important to ID, and when I think of ID, I think of us as system wide thinkers, problem solvers. So we have a history of looking at problems through a different lens, be it antimicrobial resistance or stewardship, or even if you look at how infection prevention and control started. So we have expertise in collaborating with different people within the hospital and finding problems for system wide solutions. Hence, I think we’re very well suited and perfectly positioned to, you know, bring better solutions to healthcare sustainability and mitigate the impact of climate change.
Buddy Creech: [00:05:24] Yeah, that’s super helpful. I mean, our cardiologists, our orthopedic surgeons don’t really have to think about whether there’s a white footed mouse or a cat or a whatever animal it might be, or which tick species is is circulating in a given area. And we do have that responsibility. And maybe this is a chance to say, regardless of how political this issue around climate change can be, can be made and how sometimes divisive that can be at a sort of a national level. What we’re talking about is not the political aspects of this. We’re just talking about the fact that in an undeniable way, diseases that were limited to one geographic area are no longer limited to that area. And whether we like that or not, and whether we might, might even disagree, on I guess we could disagree on the origin story of that too, maybe, at the end of the day, it’s happening and we’ve got to figure out a way to fight back about that or to address that, maybe not fight back. Maybe that’s not the right word, but to address that issue, because the reality is ticks and deer and birds and whatever the animal, they don’t know where the Kentucky Tennessee border is.
Buddy Creech: [00:06:34] They don’t know where the District of Columbia begins and ends. Turns out I don’t either. So I’m not that much different than a roving dog in the Maryland area. But my point there is that things are changing, weather patterns are different, and we just have to be mindful of that. So I don’t want to get ahead of myself. But the first thing that I start thinking about, within ID that we’re directly responsible for, I mean, you’re going to have to educate me on this, but the first thing I think of is the fact that when I was on service last week, I wore so many gowns. I mean, all the gowns. I wore all the gown. And I took one off, threw it away, and if for some reason I had to go back into the room, well, I put another one on and threw it away. Like that seems like an enormous amount of waste. Do you want to talk a little bit about, I don’t know what the scale of that is, but that seems like a lot. And it seems like we’re often the ones generating the need for that through our infection prevention activities.
Preeti Jaggi: [00:07:30] So first of all, I want to just point out that infection prevention is a very good effort. If we can prevent somebody from having another surgery, that’s because of a health care acquired infection. You know, obviously that is the best thing for the patient. That’s the best thing for the planet too, because that requires a lot of resources to do that extra surgery. I start seeing infection prevention a little bit along the lines of how we sort of started viewing antibiotic stewardship, where we were for many years, just thinking about the benefits of the antibiotics and not the drawbacks, the harms of those antibiotics. And I think we’re just starting the conversation now about what’s the tradeoff here between some of the environmental impact and the prevention aspect. And so we need more science in this area to say, what can we do a risk and benefit to show these things? We know that there are some drawbacks to using gowns, in the sense that people don’t go in the room as much to assess the patient. And we know there are tons and tons of gowns and masks and gloves and all of those things that are thrown into landfill, which it goes to very often low-income communities. And that becomes methane, which is a very potent greenhouse gas. And it also stresses the whole health care system. You just even think about your EVS workers going in there to collect all that. So I think there’s a lot of work that needs to be done and trying to sort of really look at very carefully both the benefits and the risks, so that we can really hone that down to do high quality infection prevention. And I think that conversation is just starting right now.
Buddy Creech: [00:08:58] Well, and you’re even giving me words around this where I need to not, I probably need to think less about throwing something away, and I’m really thinking about I mean, I’m just moving it from one place to another. I’m moving it in bulk. That’s an eyesore at the very least. It does disadvantage those who are already disadvantaged and creating an amazing burden there. Or if we don’t throw it away, if we don’t move it, we’re changing it into something that’s not good for our environment. So this is really, really helpful for me. What are the other areas besides sort of environmental? Well, I guess it’s all waste. But other than infection prevention, I’m trying to think about other places where we might see opportunities to intervene?
Shreya Doshi: [00:09:40] So I just wanted to set the stage for this with some statistics. So if you look at the US total greenhouse gas emissions from every different industry. The healthcare industry contributes about 8.5%, which is like a huge chunk. And then if you think of the world’s healthcare emissions from every country, like if you add all of those up, then the healthcare industry would be the fifth largest contributor, just behind, you know, the first few countries. So those statistics just make us want to reflect and think about how we can change things within our infectious disease practices. So some other ways are I think a huge one is antimicrobial waste, especially in the era of drug shortages, because we have drug shortages for so many antibiotics all the time. We’ve both done studies and so have some other folks, that at pediatric hospitals especially, antimicrobial waste is huge, because we prepare antibiotics generally 4 to 5 hours in advance because it’s called batch processing because you want to meet the demand for like a 300-bed hospital. Now, when you do that and you already have your vancomycin prepared for a 15-kilo child or your zosyn prepared for a 20-kilo child, we are preparing specific doses. And when things change on rounds so your orders get modified, all these drugs that are already prepared go to trash and they’re actually incinerated in some places, autoclaved in some places. I think the ones that I have looked at, they’re incinerated. And that means you require more energy to do that incineration also. So there’s thousands of unused antimicrobial doses that are going to waste. So that’s one area. And there’s many other areas that could be related to lab waste. Doing more telehealth, you could incorporate environmental sustainability into your quality improvement projects. Recently, we had somebody come and talk to us on sustainability about how HIV care is related to climate and health, as well as how some of the drugs have a larger footprint carbon footprint than other. No matter what you’re doing within it, there is a role for sustainability.
Buddy Creech: [00:12:03] Yeah. You know, there’s this acronym that you all have written about that I think originated in Providence. This idea of “we act,” where there’s waste, there’s energy and water use, there’s things related to agriculture and the food cycle. The C is for chemicals and pharmaceuticals, and then the T is for transportation. And I think one of the wins that we’ve probably seen post Covid has been that we may be at a higher clip than others, because we are so non-procedural, can engage in telemedicine and some employee commuting. We can reduce some of the carbon footprint of our patients when we’re doing follow up visits where they where they get their local labs, you know, three miles from their home rather than 100 miles to us. That’s a big difference when it’s to scale. So Preeti, what do you think are the low hanging fruit that if we just had, I don’t know if someone gave you the keys to the kingdom and said, you’ve got 36 months to make a big difference in some of our major healthcare systems, what would be like your top, I don’t know, top three, top something? What would you focus? What would be the lowest hanging fruit?
Preeti Jaggi: [00:13:15] All right. There’s a lot there. Okay. So I’m thinking both in the hospital. So sustainability is bigger than just ID alone. So let’s talk about ID first. Telemedicine is really, really important. We did a paper where we looked over, I believe a three-year period, we saved our patients about 31,000 miles of driving.
Buddy Creech: [00:13:36] Good grief.
Buddy Creech: [00:13:36] And you think about they have to pay for parking. They have to pay for gas. They have time. They have to take care of care of their other children. For moms and dads, this can be really, really helpful. I have done telemedicine where people are bringing their child out of daycare. They’re in the car and I’m talking to them and I’m seeing how the kid is doing. And then they go back and the mom can go to work. This is a really there’s some social benefits there as well. So I think telemedicine is really huge diagnostic stewardship for us. We did a paper also about the environmental savings of microbiology lab waste from diagnostic stewardship efforts, like Brightstar. And we can save even an endotracheal tube culture that they have to kind of work up in the lab, a quote unquote positive culture, which we know are of dubious clinical value, is about the equivalent of driving 0.4 miles in a gas-powered vehicle. So every culture. So when you start incorporating this into your work, I think that can be really, really helpful. Pharmaceutical waste is a really, really helpful. A patient doesn’t need to get 50mg/kg of ceftriaxone or 75mg per kilo.
Preeti Jaggi: [00:14:40] They can get it in between. Some places are doing banned dosing. So you say we give you. So we have like a stock of you know ten different doses. And we can then reuse that. That’s what an adult hospital would do. They can reuse it if it wasn’t used. We don’t do that because we have very, very specific dosing. How we dose amoxicillin, you know it’s 7.2 mls bid for a patient. That is very confusing for the mom. So why don’t we use chewable amoxicillin tablets that has band dosing. There’s lots of things in the pharmacy. We are really experts in pharmaceutical stuff right. With ID I started we started working on IV to PO conversion and we started expanding, not just antibiotics but famotidine. Do you need IV famotidine? You know, probably not. And that is also accessing the line. And that can impact CLABSI or PIVIEs. So I think there’s just so much there. There’s also other things we need to do. We need to collaborate with our colleagues. Anesthesia, there’s a lot of efforts to decrease unnecessary anesthetics. That’s a bit bigger than ID, but we are really good at diagnostic and high-quality care. So we can start expanding that concept to broader than just antibiotics. And I think actually when we think about IV to enteral conversion, that’s a huge impact on some of the things that are integrally tied to our work, like CLABSI and peripheral IV extravasation.
Buddy Creech: [00:16:02] Well, and the downstream effect of decreased plastic use and decreased, I mean, all of the tubing changes and all of the electricity needed to run a pump. I generate my own electricity when I swallow. So no, no carbon footprint there. I love this. So that almost begs the question of should we in our hospitals, in our departments of pediatrics, maybe within a handful, if not many of our divisions? For things we care about, we often designate some type of champion or go to person who’s thinking about these things. And I would assume that Shreya, you probably play some type of role like this as a fellow because we love to dump stuff on fellows. That’s our favorite thing to do. I would imagine you serve as sort of like a point of contact so that if there’s something coming up that’s sustainability or sustainability adjacent, you’re probably going to be the one who gets the email. Is that is that something we should think about doing at a local level?
Shreya Doshi: [00:17:00] Yes. Like if we want to start, we should start locally. Preeti and I did a survey recently of ID practitioners and ask them if they are involved in their hospital sustainability council or committee. And it turns out a very small percentage, about 8% of ID providers were actually involved at their hospital or sustainability committee. And this is really important for us to get involved, because a lot of times people want to make changes, but they want collaboration with infection prevention, with our antibiotic stewardship team, to make these changes, which will result in sustainability savings. So I think it’s really important for us to get involved at the hospital level and then subsequently at the society level at all our various ID societies as well.
Buddy Creech: [00:17:52] So Preeti, how do we know that what we’re doing is making a difference? Now, some of this stuff may just make a difference if we decide that if you don’t have a draining wound, we’re not going to put contact precautions in place for somebody with MRSA. Okay. That’s just good infection prevention practice. And it has the benefit of also reducing waste. But the things we do now aren’t going to have a necessary impact maybe for years. There are other things besides the impact on the on the climate that we can measure in this. Are other people doing this well in terms of how to measure the sort of the value that this brings to a health care system?
Preeti Jaggi: [00:18:30] Yes. I think that the best actual example is what is being done in the UK. They have the Centre for Sustainable Healthcare Value and they actually have green team projects, and they help people measure their greenhouse gas savings from, you know, decreasing unnecessary IV cannulation in the emergency department, telemedicine for HIV care. They basically will help them. You can look at miles driven savings. We partnered with a sustainability company to just look at how our trash like the driving, and then the amount of landfill, that methane gas that is created from the landfill waste. So you can start measuring the process so you know, you’re not going to measure the effect of climate change on infectious diseases. You’re going to measure the process, which is how much can I decrease waste. How does that translate to greenhouse gas emissions? Or you could just, you know, just really measure the amount of waste, like that’s okay. This is someplace where we need to collaborate with others. We have reached out to, they’re are sustainability professionals out there. Many hospitals have sustainability teams. There are medical directors of sustainability that partner with their operations people, and they have FTE for this in some hospitals. So I see our role, this is a missed opportunity in my opinion, if ID professionals do not integrate ourselves into this because joint Commission has a voluntary certification on sustainability that may become mandatory, we know how that works. We have that with stewardship. We would be missing a huge opportunity for FTE. In my opinion, if we don’t start thinking about this, if we are the experts and we are integral, you kind of have to be, you have to have knowledge about how to prevent infections and how to use do diagnostic and treatment stewardship wisely in order to do this work. And we already know that. Why would we let somebody else do this? Like that would be, to me, a huge mistake.
Buddy Creech: [00:20:33] Yeah, this is really great. I mean, the two of you, I’m going to just as a shameless plug for the JPIDS article from June of 2024, where the two of you and your co-author looked at some of this. I mean, 15 pounds of solid waste in an ICU per day, which would be the equivalent of 350 miles in a gas-powered car. I mean, that’s an enormous daily burden, but that’s not the only thing we’re talking about, right? The sustainable healthcare value also takes into account the, you’ve spoken to this, the social impact of what we do, the environmental impact of what we do and the financial piece. And so when you take telemedicine, can we provide good care? Yes. Is it better than being in person? No. Unless you take into account no missed days from work or reduced days off from work, the financial impact that has for a family, and then the environmental impact of not driving 100 miles to a referral center. Now all of a sudden, telemedicine wins for certain situations. And that’s pretty interesting. Shreya, what’s your sense of where, maybe this is one of my last questions, where do you think our current set of trainees are in this? I mean, we go into these generational waves and every generation has a different, sometimes a different focus. Right? There’s some almost cohort effect, where some of us came up during a time where we stopped ordering CBCs every single day on our patients, even though the generation before us had daily CBCS. And that’s just generationally, we just kind of change that. Do you see this as a as a potential place for recruitment and of connecting with some things that are, are maybe junior trainees and medical students are really interested in?
Shreya Doshi: [00:22:22] Absolutely. I think that climate change and sustainability are going to be the theme of this current generation. And there’s been several surveys out there which show that the younger generations are more concerned, more stressed, more anxious about climate change, and they want to do something about it. So I think this our interest as a society and as a specialty, our interest in climate change and sustainability, is going to help recruit more students if we make the right moves in the next few years. I feel like if we give sustainability and climate change a little more importance, like make it a part of a culture change or think differently about it, incorporate it in all our existing values and missions. We can definitely use that and leverage that opportunity to recruit new students who are interested in this.
Buddy Creech: [00:23:21] I love this. I love this. Well, I can tell you right now, I’m so excited to start this start this conversation with you all, and I would love to have you back. As we start to see real, real change happening in some of our medical centers. I mean, the things I’ve taken away from this would be that that when we measure healthcare value, there’s a lot of domains that go into that. And I want to really be conscious of that. It doesn’t mean that I’m going to ignore infection prevention practices when I go into a room and say, hey, I’m reducing waste. But what it does mean is I’m going to ask questions. And as a group, we can think about best practices, not doing things just because that’s the way we’ve done them, but really trying to think about how we leverage new technologies, how we think about the social and financial and environmental impact of what we do. I love this idea of pharmaceutical dosing banding, so that we get a little less anxious about whether we have 71.7mg of a drug. I bet you they’ll be okay with 70 or 75 or, God forbid, even 67. I bet they would do okay. Sometimes we’re a victim of our own precision, and that’s okay. It sounds like there’s a lot of people already in this space that are interested, and I really want to promote that. So, Preeti, if folks are interested in what this looks like, certainly on the pediatric side, we can point them to the sustainability section on the PIDS website. There’s an email that can get you onto the listserv. And on the adult side, we certainly want to make sure folks are engaged through IDSA and through the efforts that are there. And the work that you’re doing through sustainability is simply not pediatric only. It is really for everybody. So I really want to make sure folks are going to that. That’s great. Preeti, last words from you? If somebody was really focused on traffic and zoned out for 2 to 3 minutes while I was talking, what’s your biggest takeaway that you want folks to hear from today?
Preeti Jaggi: [00:25:19] Think small but of a system. Like if you’re concerned about climate change, think about what you are doing every single day and pair up with a buddy and think about one system that you could change and start. Don’t think too big because you can’t do everything but thinking about one small system, not something individual, but one small system, and start working on that. And you can reach out to us because there may be some publication opportunities as well. There are things that people are doing to reduce single use plastics. There are things that people are doing to reduce solid waste. Some of these infection prevention practices, folks are just telling people like, when do you not need the protective equipment? When is it appropriate not to use it? Think small and just start somewhere and we will cheer you on because we know even if it’s not published, it is worthwhile. It is worthwhile for all the entire world’s children for you to do something.
Buddy Creech: [00:26:16] I mean, this is our version of kaizen, right? We’re going to take some small changes and know that they’re going to result in some big impact over time. I’m thankful for the both of you. Thank you for spending your time like this. If you have any questions around this, please contact us at IDSA or PIDs or SHEA. We would love to talk more about this. If you’re interested in being in the listserv, visit the PIDS website. Look for Sustainabil-ID. There will be a link there to join the listserv so that you can be up to date on these things that are happening. Thank you to the both of you. Join us next time as we think about how ID can not only impact our patients, but even those disciplines around us, and maybe eventually, even our planet. Thanks for joining us at Let’s Talk ID. Take care.
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