Episode 50: Hospitals and Sustainability with Julie Moyle (Practice Greenhealth)

Episode Intro Notes

What We’ll cover

• Footprint of hospitals

• Why hospitals care

• Areas of impact and cool initiatives

• Coronavirus & medical waste

• What you can do

• About Julie Moyle

footprint of hospitals

• Hospitals make up a significant part of our economy and communities, and their sweeping operations have a large environmental footprint.

  • First, let’s talk economy. Healthcare alone represents 18% of the U.S. economy and 10% of the global economy. Pretty staggering. 

  • Next, let’s talk community. Hospitals play a big role in their local communities and spend a lot of money on social causes important to them . 

    • More than half of U.S. healthcare organizations spent between 5 to 10% of total operating expenses on community benefits including charity care, unreimbursed costs for government programs and subsidized health services. 

    • Increasing amounts of money are being spent on things outside the walls of the hospital as well because they are realizing that can mean better health outcomes for the surrounding population..

      • For example, consider an issue like air quality. If hospitals are successful in improving air quality for the populations they serve, that will mean less cases of asthma and other respiratory illnesses coming through the hospital. That’s why Kaiser Permanente launched a $200 million Thriving Communities Fund to address housing stability and homelessness. Funding went toward procuring new housing as well as repairs to existing housing units to remove toxic substances such as mold and lead paint.

  • The climate impact of healthcare is also substantial. Healthcare Without Harm published in September 2019 the first-ever global estimate of healthcare’s carbon footprint. It found healthcare’s carbon footprint is 4.4% of global emissions. That’s the equivalent of 514 coal-fired power plants and if the global healthcare sector was a country, it would be the fifth largest emitter on the planet.

    • A big part of this footprint is due to needing around the clock heating and cooling.

    • The United States is the world’s highest emitter of health care greenhouse gases, accounting for 27% of the global health care footprint. China is number two at 17%. 

    • The U.S. footprint is also not great per capita. It produces 57 times more emissions per person than does India. 

    • Now, going back to that 4.4% of global emissions number, 71% of that is Scope 3, which are beyond its direct operations and relate to the production, transport, and disposal of goods and services. This explains why one-quarter of all health care emissions are generated outside of the country where the health care product is ultimately consumed.

      • More on scope 3 emissions in episode 25.

    • And, importantly, it’s not just greenhouse gases. U.S. health care is also responsible for 9% of the country’s air pollution, 12% of acid rain emissions, and 10% of smog-forming emissions.

why hospitals care

• Addressing climate change is directly related to the mission of hospitals--to keep people healthy. As natural disasters hit, diseases spread, and the other calamitous effects of climate change take place, people’s health is put at risk. As just discussed, hospitals can play a major role in the fight to avoid these effects given their economic, community, and environmental footprint.

  • There is a strong connection between environmental sustainability and the health of the population. In fact, preventable environmental factors are responsible for an estimated 23% of all deaths globally, according to the World Health Organization, including 26% of deaths among children under the age of 5. Crazy that essentially 1 in 4 child deaths are 1) preventable and 2) where the source is environmental issues.

  • Hospitals also care about sustainability because it can impact their ability to operate and to get needed supplies. Let’s dive more into this ability to operate.

    • If there’s more severe natural disasters, it could lead to closures at times when we need hospitals the most, like right now as we address the Coronavirus. 

      • The catastrophic California wildfires in 2017 led to the Santa Rosa Medical Center closing for weeks since it had to clean and re-stock and since two hundred employees had just lost their homes. During the closure, people in the area found themselves struggling with smoke-related illness and trying to manage their medical needs without having their hospital to turn to.

      • Another example comes from Hurricane Sandy in 2012. The NYU Langone Medical Center in Manhattan was ready for up to a 12-foot storm surge. The problems started when the surge hit 14 feet. Buildings filled with water, the power grid went down, and the backup generators sputtered and stopped. Suddenly doctors and nurses were racing to evacuate more than 200 patients, carrying them down staircases lit by flashlights and ferrying them by ambulance to other area hospitals.

    • In addition to building closures, there can be supply disruptions because of natural disasters.

    • Consider when Hurricane Maria hit Puerto Rico in 2017. It disrupted supply chains across the U.S. because Puerto Rico manufactured IV bags for the rest of the country, and the plants were severely damaged in the storm. For months, nurses had to resort to standing at the patient bedside slowly injecting medications by syringe instead of letting the medication drip in from an IV bag.

areas of impact and cool initiatives

• There are a couple big areas of impact that hospitals can address. We’re going to go over each of those and some cool initiatives hospitals have implemented to reduce those impacts.

  1) Energy

  • The Environmental Protection Agency has ranked inpatient health care as the second largest commercial energy user in the United States. Energy use in hospitals includes lighting, electrical equipment, and air circulation; let’s break these down.

    • The Cleveland Clinic, which is working to become carbon neutral by 2027, has demonstrated several ways to reduce energy use.

      • The Cleveland Clinic switched all lightbulbs from fluorescent lights to lower-energy LEDs. This change saved energy, but it also importantly improved light quality and saved $2.5 million a year with a short four year payback. Plus, employees now devote far less time to changing light bulbs since they burn out less frequently. I think this may be a win-win-win-win.

      • The Cleveland Clinic didn’t stop there. It also addressed its 50,000 medical grade computers, which took up a lot of energy since they were constantly fully on so that doctors and nurses could access them without delay. They installed software that would automatically put them to sleep—but keep essential services on standby– when they weren’t being used. This generated a savings of $400,000 each year.

      • A third change at the Cleveland Clinic to save energy was its largest energy use--air circulation. To control infection risk, patient rooms are required to have six complete air exchanges per hour, and operating rooms, the most energy intensive part of the hospital, need 15 to 20 per hour. All that air has to be filtered, humidified or dehumidified, and heated or cooled. An energy audit uncovered many operating rooms at the Cleveland Clinic were doing 30 or more air exchanges an hour without any medical benefit and even when the operating rooms were not being used. It installed a system that adjusts the air exchanges based on whether operating rooms are in use, and exchanges only as much air as is necessary. And you guessed it, monetary savings resulted too--$2 million a year.

      • Overall, the Cleveland Clinic, which has 15 LEED certified buildings, has reduced its energy use intensity (energy per square foot) by 19%, which has led to $50 million in savings.

  • Gunderson Health System in the Midwest is another leader. It is energy independent at its 100 sites, using energy produced on-site or locally such as through its dairy biogas project.

    • It has received so much interest from other healthcare institutions that it actually started a separate energy consulting business.

  • Another example is the Children’s Hospital of Pittsburgh, which was designed to have many windows so natural light alone is sufficient during the day. 

  • Beyond the use of the energy, there’s also the energy’s source. The Healthcare Without Harm report says more than half of health care’s carbon footprint comes from energy use and recommends a “transition to clean, renewable energy and transportation.”

    • The University of California system is doing its part, having pledged to become 100% reliant on clean electricity for its campuses and medical centers by 2025.

  • There’s an added benefit of being more energy efficient beyond the energy savings and reduced emissions.  Lower energy usage means the backup generator can power the hospital for a longer time if the power grid goes down.

  2) Food Procurement and Disposal

  • General procurement is a way to drive change. Practice Greenhealth collected and compiled extensive sustainability data from 327 U.S. hospitals. The 2019 data showed millions of dollars spent on sustainable and safer products including $121 million on furniture and furnishings that avoid target chemicals of concern.

  • Now, let’s talk specifically regarding food procurement and disposal. University of California San Diego (UCSD) is a leader in this area.

    • It composts or donates excess food, and UCSD medical centers want to reduce food-related emissions 25% by 2030. One way it's doing that is reducing the amount of meat, dairy, and eggs that it buys and instead offering more vegan and vegetarian options.

  • Another leader in food procurement and disposal is Kaiser Permanente. It set the goal of buying 100% of its food from local or sustainable producers by 2025. In 2017, 28% of Kaiser’s food budget went toward sustainable food, with its hospitals collectively hosting more than 50 seasonal markets and farm stands a year.

  3) Construction

  • This is important since there are a little over 6,000 hospitals in the United States and China has the most with 69,000 hospitals. That’s thousands of, often times, sprawling buildings that take a lot of material to build and how they are built can dictate their footprint.

  • One principle to construct sustainably is when building, make it resilient.

    • The Partners Healthcare Spaulding Rehabilitation Hospital in Boston is 30 inches above the 500-year flood mark. Even if it somehow were to flood, it was built such that the damage would be minimal and the rest of the hospital could be occupied and operate.

  • Another principle for sustainable construction is when renovating, try to consolidate and reduce your footprint.

    • Boston Medical Center spent $400 million to consolidate, renovate, and install energy efficiency improvements. As a result, its sprawling campus shrank by 400,000 square feet. After the renovation, its patient volume went up 20 percent. Still, even with seeing more patients, because of the consolidation and renovation, its energy and operations savings top $30 million annually.

    • Another example from Boston Medical Center is that it installed a rooftop farm on an existing building. This rooftop farm provides 6,000 pounds of fresh, local produce to its cafeteria, the green roof reduces heating and cooling costs, and it doubles the expected life of the roofing materials.

    • More on the impact of working with existing buildings is in episode 31.

  4) Gases (areas of impact and cool initiatives)

  • Unused anesthetic gases alone may make up 5 percent or more of a hospital’s carbon footprint. That’s because commonly used anesthetics like desflurane are 1500 times more powerful at trapping heat than carbon dioxide. Unfortunately, a significant amount of this gas is not used by the patient and then has the potential to escape to the atmosphere if not properly managed and mitigated. More than 95 percent of gases that are administered to patients are never metabolized. 

    • The impact of the gases can be reduced in a number of ways including using alternatives to desflurane and investing in new equipment or retrofitting existing ones to better manage and reduce wasted gas.

  5) Material Use and Waste

  • Overall hospitals generate over 5 million tons of waste each year. 

  • Let’s first talk plastic. Practice Greenhealth estimates that 25% of the waste that a hospital generates is plastic. A single hysterectomy, an operation to remove a woman’s uterus, can produce 20 pounds of waste, most of which is plastic. Single-use plastic is attractive for hospitals because it’s cheap, durable, easily tossed out, and each new fresh plastic container or covering offers a newly sterile environment. Still, there are some single use plastic applications that could be replaced.

    • Equipment like surgical basins used to wash equipment during surgery, blood pressure cuffs, and pulse oximeters could be reused and would reduce waste.

    • Another example is the needle counter box, which is used to facilitate correct count and disposal of needles and blades during surgical procedures. NewGen Surgical has developed a sustainable needle counter box, eliminating 93% of the plastic waste associated with a product used in nearly every operating room procedure.

    • An additional plastic item that could be replaced is the “blue wrap.” This is a sheet of polypropylene that covers sterilized tools that is removed and discarded before surgeries. Some hospitals are experimenting with replacing the blue wrap with reusable sterilization containers that can be made clean just like the instruments they contain. Others have a recycling program with it, as the University of Vermont has recycled 50 million tons of blue wrap since 2010.

  • Ultimately, there will always be biohazard waste that can’t be recycled, but according to the World Health Organization, about 85% of hospital waste is noninfectious, the bulk of which is recyclable. This tracks with the finding that up to 90 percent of waste that is placed in biohazard containers is non-hazardous and does not require incineration. Today, only a fraction of that recyclable waste actually enters the recycling stream.

    • Many hospitals do have lofty ambitions here. Kaiser Permanente has a goal of recycling or reusing all of its non-hazardous waste by 2025.

• And that’s it for our five buckets. For more examples of cool initiatives and leading hospitals, we encourage you to check out the hospitals listed in Practice Greenhealth’s 2020 Environmental Excellence Award, its highest honor.

• Now, let’s talk cost of the kind of sustainability initiatives we just detailed. All these cool initiatives may sound expensive, and some are, but considering them in the initial design of the hospital can dramatically reduce their costs.

  • The Spaulding Rehabilitation Hospital that was discussed earlier and built to withstand significant floods, took a variety of other actions to be a climate-resilient hospital, and it claims that the additional cost for all of this resiliency was just 1.5% of the total cost of the building.

  • Overall, one study found that energy and water reductions and more efficient purchasing in operating rooms could save U.S. hospitals $5.4 billion over 5 years, and $15 billion over 10 years.

    • Looking at one hospital, the University of California in San Francisco found that by eliminating unused items from surgery, the neurosurgical department could save up to $2.9 million per year in supply costs. 

• Still, the up-front cost is an issue for many hospitals. Not-for profit hospitals have slim margins– in 2018 the median operating margin was 1.7 percent. These hospitals can start small and set up revolving funds where the money saved from reduced energy savings is then used to fund more initiatives. They could also look to share costs via government grants or incentives from the local utility. Other options include issuing green bonds and having local climate initiatives like tree planting groups do activities at their facilities.

coronavirus and medical waste

• One reason we wanted to cover this topic now is that the coronavirus pandemic has brought the state of our hospitals front and center.

• • From a sustainability point of view, what’s gotten the most amount of attention is the levels of medical waste this pandemic is creating.

    • Wuhan, China saw first hand how dramatically these levels can increase. In Wuhan, daily medical waste volumes after the outbreak were six times the normal amount. The Chinese Government responded by deploying dozens of portable waste treatment facilities. At the virus' height in China, medical waste facilities in 29 cities were at or near capacity.

    • Waste treatment companies in the U.S. say that they are seeing increased volumes from hospitals, but there is reason to think this won't become a crisis.

      • For one, companies like Stericycle that steam-sterilizes infectious trash before sending it to the landfill says that it has extra capacity because elective surgeries and dental visits are for the most part not taking place right now. Also, coronavirus generates less waste than other crises like Ebola in which body fluids were a big contributor. U.S. federal regulators have advised equipment contaminated with bodily fluids needs to be sterilized or disinfected before sending to landfill but that otherwise the waste from COVID-19 patients can be considered regular trash. Some still worry if sanitation workers can safely handle such gloves, masks, etc.

  • There’s also financial ramifications as the higher profit elective surgeries are put-off and the expensive ICU (intensive care unit) beds fill up. Hospitals, especially non-profit ones, are feeling these effects and may have less capital to deploy for sustainability initiatives.

  • We also discussed how natural disasters can impact the supply chain. Hospitals will likely look at what they needed most during this crisis and determine if there are more stable, less single-use supply chains they can create so we don’t have shortages like we’ve seen with N-95 masks.

  
  

  What You Can Do

• Ask your hospital how they manage their waste. 

  • You could make sure they are aware of the free guide from Healthcare Plastics Recycling Council called HospiCycle on how hospitals can implement a plastics recycling program.

  • See if the hospital you frequent has a sustainability program or is part of a collective trying to drive change together like the Washington Health Care Climate Alliance in Washington State or the Boston Green Ribbon Commission, whose 20 hospitals have collectively reduced greenhouse gas emissions by a third since 2011.

  • Encourage those looking for sustainability jobs or a trade to consider HVAC, electricity, and programming. Hospitals need people with these skills to help identify energy efficiency improvements. As demand accelerates generally, some 115,000 smart building jobs across the United States could go unfilled by 2022 because of the lack of trained workers.

about julie moyle

• Julie is the perfect person to interview since she works as a nurse in a hospital and works with hospitals across the United States in her role with Practice Greenhealth.

• She has been an operating room nurse for many years and currently is a staff nurse at Avista Adventist Hospital Ambulatory Surgery Center in Boulder, Colorado.

• She’s been with Practice Greenhealth for five years and serves as a Member Engagement Manager.