Latest / Becker’s Healthcare Podcast / Eliminating Nitrous Oxide and Advancing Sustainable Care in the OR with Dr. Arash Motamed

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Eliminating Nitrous Oxide and Advancing Sustainable Care in the OR with Dr. Arash Motamed · Becker’s Healthcare Podcast

• 0:00
  Welcome to the Becker's Healthcare podcast. I'm Mariah
• 0:03
  Taylor, assistant editor, and I'm thrilled to have
• 0:05
  Arash Motamed,
• 0:07
  anesthesiologist
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  and medical director of sustainability
• 0:10
  with Keck Medicine of USC
• 0:13
  on the podcast today. Doctor motamed, thank you
• 0:16
  so much for joining me. I'm really excited
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  to learn more about how you're discontinuing
• 0:21
  nitrous oxide in the o r. But before
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  we jump into that, I'd love if you
• 0:25
  could introduce yourself a little bit and tell
• 0:27
  us a little bit more about why you
• 0:28
  discontinued nitrous oxide.
• 0:31
  Well, hi, Maria. Thank you for having me
• 0:33
  on your podcast. It's my pleasure to be
• 0:34
  here today. I'll start off with, you know,
• 0:37
  my story and involvement with nitrous oxide.
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  It started off with a pretty
• 0:42
  casual conversation with a colleague of mine who
• 0:46
  works at a competing medical center,
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  and he was the one that first let
• 0:51
  me know what the
• 0:53
  problem with nitrous oxide is. And for those
• 0:55
  who may not know, it's also known as
• 0:57
  the laughing gas. It's a type of an
• 0:59
  anesthetic inhalational
• 1:01
  that
• 1:02
  has been used for over a century, but
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  really started to gain a lot of popularity,
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  in the latter half of this past century,
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  and has some really great benefits in terms
• 1:15
  of quick onset, quick offset,
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  and also, you know, very available
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  and inexpensive.
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  But what he told me at that time,
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  which is really sort of the start of
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  my journey in discontinuing nitrous oxide from our
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  medical center, was
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  a majority of the nitrous oxide that's in
• 1:34
  the central pipelines and the hospitals leaks into
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  the atmosphere. So when they've done studies to
• 1:39
  look at that, they say anywhere from seventy
• 1:41
  five up to ninety five percent of the
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  nitrous oxide leaks,
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  typically at the areas of the connections.
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  And there's really no way to prevent this.
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  And, you know, what's interesting about it is
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  what it means
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  is that the nitrous actually
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  never has any clinical impact. It just goes
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  straight into the atmosphere. And then the next
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  question is, well, why do we care about
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  it? We do because
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  nitrous oxide is a fairly potent
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  greenhouse gas,
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  about 300 times,
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  as potent as carbon
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  dioxide. So it really has a big impact.
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  And on top of it, it does also
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  deplete the ozone layer. And then one other
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  thing with it is it lasts for a
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  pretty long amount of time in the atmosphere,
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  so about hundred years or so. So in
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  some ways, some of the first nitrous oxides
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  that were being used as anesthetics are still
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  somewhere in our atmosphere,
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  and most of it had gone unused in
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  terms of,
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  clinical
• 2:38
  benefit to the patient. Now we know the
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  patient still gets the amount that we want
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  the patient to get, but majority of it
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  just leaks before it ever,
• 2:47
  gets to the patient.
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  So knowing that and, you know, my involvement
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  with our sustainability
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  efforts at Keck, I felt
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  compelled that we need to look at this
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  and we need to figure out a way
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  to better address it. And and,
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  hospitals, nitrous oxide commonly comes in two forms.
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  So either cylinders that gets attached to the
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  anesthesia machine
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  or central pipes that, again, gets connected to
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  the anesthesia machine.
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  Almost all the times, if a place has
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  the central pipes, that's what they use, and
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  the cylinder is used as a backup, you
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  know, should there ever be any issues with
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  central supply.
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  So what we wanted to do was look
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  at our usage at our medical center and
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  decide, you know, whether it makes sense to
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  discontinue it.
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  The challenge with doing that, you know, one
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  is,
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  education and making sure that everyone has
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  awareness as to why we're doing what we're
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  doing, but, also,
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  it's
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  partnering with our, colleagues at facilities because, you
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  know, as an anesthesiologist,
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  I know nothing about, the central pipelines, how
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  they work, and how they function.
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  And, also, you know, at the end of
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  the day, this is a medication that anesthesiologists
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  have used for
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  many decades. So there is clinical comfort,
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  and when established habits that is,
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  takes some time to,
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  get them to see and understand and look
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  at other alternatives. So that's
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  the
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  basics of the beginnings of how we got
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  involved with, getting rid of, nitrous oxide.
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  Excellent. And how did you build a credible
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  business and clinical case for this initiative?
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  And then on top of that, how did
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  you get both hospital leadership and frontline physicians
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  aligned on it?
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  Yeah. That's a that's a really great question,
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  and I think goes to heart of any
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  type of initiative we try to do.
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  It really needs to be collaborative, and you
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  need to have the buy in because, otherwise,
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  it's just not gonna go anywhere.
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  What,
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  I decided to do in this particular instance
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  was,
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  initially,
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  I,
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  you know, our department in anesthesia is about
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  almost 200,
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  individuals,
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  combination of physicians, CRNAs, and, residents.
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  And I picked
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  about 20 of them who
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  either have leadership roles or, you know, are
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  otherwise still fairly influential or have, you know,
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  a lot of experience and expertise,
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  and I pulled them. And my first question
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  to them was, you know, are there any
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  types of cases that we do where nitrous
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  oxide is really the only
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  type of anesthetic we should use for? Because
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  if that answer
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  comes back as yes and a fair amount,
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  then it's a different question. But, you know,
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  as an anesthesiologist myself, I know the answer
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  is no.
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  And that was the response that I got,
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  which was great. So then it led to
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  the next question on on the next round
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  of surveys that we did, which was,
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  since we know that, you know,
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  it's not a must have,
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  can we have the option
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  of,
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  a, fully getting rid of everything that we
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  have?
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  Two,
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  discontinuing
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  the central pipeline and just having the cylinders
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  as backup should anyone need it?
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  Or three,
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  removing everything, but having a few cylinders somewhere
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  in the building as backup should anyone need
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  it, and we'll bring it up and connect
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  it to the machine.
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  And it was interesting
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  that, you know, through that process and, of
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  course, as as these surveys are happening, there's,
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  you know, education,
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  with the department and forms of, you know,
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  grand rounds,
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  to let them know what the impact of
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  nitrous oxide is. But most of the group
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  felt comfortable moving towards
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  an approach where we remove everything from the
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  OR. So it's not there ready to be
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  used,
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  but we'll have cylinders available should we ever
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  be in a need where someone feels like
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  that that is the best thing for for
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  their patient at that point in time. So
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  we reserved four cylinders,
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  where we keep all the the gas cylinders
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  in our hospital and created a pathway that,
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  you know, is easy to follow and a
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  phone number to dial, and the person comes
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  in and helps set it up. And what
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  was really interesting
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  was,
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  in the last
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  three years at our Keck Hospital and two
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  years at Norris Cancer Hospital, not a single
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  time has anyone needed to make that phone
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  call,
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  which essentially made us,
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  the,
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  only institution that I know of in The
• 7:14
  US that has fully removed nitrous oxide from
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  both central supply and the cylinders.
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  That's incredible.
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  What were some of those key learnings you
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  had when you were moving this from a
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  concept into execution?
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  So one of the,
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  interesting
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  things that came up that we did not
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  know was
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  the way the nitrous is set up to
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  the machine. Once you discontinue it, that machine
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  could no longer do its self check and
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  would give a lot of errors, so it
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  would be nonfunctional.
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  So we first had tried this on one
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  of our spare machines just to see what
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  happens. And once we realized that that's a
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  problem, we needed to
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  connect with the manufacturer,
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  and have one of their representatives come in
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  because they needed, you know, special codes to
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  go in there and change the machine check
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  so that it doesn't alarm and it can
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  still do itself check and it can still
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  function. So that was an interesting learning point.
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  But one of the other things that was,
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  could potentially sometimes I think in other institutions
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  also be viewed as barrier is the term
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  that gets used frequently when it comes to
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  removing nitrous oxide from central
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  supply or central pipelines is decommissioning.
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  And decommissioning can mean different things to different
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  people as as I have learned, and it
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  could be anything from we're just not using
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  the pipes to we need to go into
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  the building and we need to remove pipes,
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  which, of course,
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  is not only a construction nightmare, but also
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  fairly expensive and, you know, regulatory challenges that,
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  you know, may come with it. Our approach
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  to decommissioning
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  was not to do any of that. It
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  was to simply
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  stop having nitrous oxide in those central pipelines.
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  And then our the our team with, the
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  facilities management actually came up with a really
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  brilliant and unique idea, which I think can
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  be used by other hospitals as well, which
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  is to fill that pipes with, nitrogen,
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  which is also another gas that helps preserve
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  the integrity of the pipes should there be
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  some other use for them down the line,
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  for some other form of gas. But at
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  the same time, it's also inexpensive, and it
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  doesn't have any negative environmental impact.
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  That's amazing. Some really interesting problem solving and,
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  you know, issues that probably nobody had thought
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  about before you tried.
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  So I'm curious if we take kind of
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  a step back. And when you're evaluating
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  sustainability initiatives as a whole, how are you
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  balancing the environmental impact with the financial performance,
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  clinical outcomes, all the operational feasibility,
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  and then how are you measuring the success
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  beyond just emissions numbers?
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  Yeah. That's the that's the tough question that
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  we try to figure out. Actually, with every
• 9:55
  single project that we do, we're fortunate in
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  that,
• 9:58
  at our institution,
• 10:00
  there has been, you know, support to the
• 10:03
  sustainability
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  program.
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  So we have a chief of sustainability and
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  a sustainability program manager.
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  And along with, you know, me and my
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  role, what we try to do with all
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  of these initiatives is partner with the various
• 10:15
  stakeholders
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  at our hospital,
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  you know, whether it's, you know, obtaining data
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  or whether it's talking with supply chain
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  to try to figure
• 10:25
  out what the impact is
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  both financially
• 10:28
  and to the some of the contracts because,
• 10:30
  you know, the hospitals may be tied to
• 10:32
  certain contracts, so we can't just suddenly go
• 10:33
  and say this is what we wanna do.
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  And then, of course, the
• 10:38
  I would say both, you know, the return
• 10:39
  on investment from an environmental point of view
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  or from a cost point of view.
• 10:44
  There are projects
• 10:45
  that, you know, will be very expensive with
• 10:48
  maybe not so much,
• 10:50
  significant environmental
• 10:52
  impact in terms of reducing carbon footprint, and
• 10:55
  then there's projects that are exactly opposite. So
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  in our approach so one, we collect as
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  much data as we can,
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  to before, during, and after. And we have
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  committees,
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  that meet very regularly on a monthly basis
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  with all the various,
• 11:11
  individuals,
• 11:12
  within the health system that play a role
• 11:14
  in one form or another and the the
• 11:17
  care that we deliver to make sure everyone's,
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  on board with the projects and it makes
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  sense.
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  Of course, clinicians,
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  are very much involved in we, you know,
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  we really listen to their input, and that's
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  part of my role is to bring them
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  on board and make sure, you know, nothing
• 11:33
  that we do ultimately has a negative impact
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  on patient care.
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  But what we try to do, I would
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  say, on a very high level is most
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  of the projects that we decided to tackle
• 11:43
  earlier on were the types of projects that
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  would achieve both. And that's, I think, one
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  of the other misconceptions with a lot of
• 11:50
  these efforts to reduce the carbon footprint, of
• 11:53
  care delivery is everyone just assumes it's gonna
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  be expensive.
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  And when you look at, you know, how
• 11:58
  can we better be better for our environment,
• 12:00
  the number one thing everyone just says is,
• 12:02
  you know, reduce waste.
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  Reducing waste is obviously, you know, financially beneficial
• 12:08
  as well as well, you know, in in
• 12:10
  addition to,
• 12:11
  reducing the negative impact of the on the
• 12:15
  environment. In in
• 12:17
  health systems,
• 12:18
  there is a fair amount of waste. And
• 12:21
  when you look at health systems, specifically the
• 12:24
  academic medical centers and part of that cost
• 12:26
  of education
• 12:28
  also becomes access waste. So, you know, for
• 12:30
  all of us who, you know, myself as
• 12:31
  an anesthesiologist
• 12:32
  in the operating room, we do see that
• 12:35
  all the time. And part of it is,
• 12:38
  just the
• 12:39
  the practice of medicine and helping teach somebody
• 12:43
  else and helping somebody else become,
• 12:46
  a clinician. But I think the other part
• 12:48
  of it is we've historically, as an entity,
• 12:51
  never
• 12:52
  truly looked at how much waste we generate
• 12:54
  and what the impact is. And now we
• 12:56
  know that health care is one of the,
• 12:58
  you know, leading industries when it comes to,
• 13:02
  greenhouse gas emissions. You know, studies have said,
• 13:05
  at least in The US, anywhere from eight
• 13:07
  to 10%,
• 13:08
  and we're much higher compared to other institutions
• 13:10
  outside of the country.
• 13:12
  Absolutely. And I know here at Becker's, we've
• 13:15
  seen a lot of hospitals that are starting
• 13:17
  to move forward with sustainability initiatives in a
• 13:20
  lot of different ways.
• 13:21
  But I'm curious from your experience, where do
• 13:24
  you see the biggest untapped opportunities for hospitals
• 13:27
  to reduce their environment footprint?
• 13:29
  Yeah. I I think from my point of
• 13:31
  view, the the biggest untapped opportunity is still
• 13:34
  lack of education.
• 13:36
  I I think, you know, again, using myself
• 13:39
  as as the
• 13:41
  example of it. The first time I went
• 13:43
  into a, grand rounds where some individual was
• 13:46
  talking about the impact
• 13:48
  of care delivery on carbon footprint was sort
• 13:50
  of my moment of, you know, I need
• 13:52
  to get involved, and what do I need
• 13:53
  to do? And I think that is there's
• 13:56
  still a great opportunity there, and
• 13:58
  clinicians really need to be involved. There are
• 14:01
  some,
• 14:02
  hospitals or health care systems where they're doing
• 14:04
  a fair amount,
• 14:06
  in terms
• 14:07
  of reducing energy usage or water usage, but
• 14:11
  the clinicians haven't been fully,
• 14:14
  engaged. So
• 14:16
  educating and connecting both the hospital,
• 14:21
  administrative side and the clinical side together, I
• 14:24
  think, really makes a big difference from our
• 14:26
  point of view. You know, once once we
• 14:28
  got that group together, the project's just one
• 14:31
  feeds the other. You know, when we started
• 14:33
  our monthly OR group, talking about how can
• 14:36
  we, you know, do better in the peri
• 14:38
  op setting,
• 14:39
  I remember the first session I had, you
• 14:41
  know, afterwards, I'm like, oh my god. I
• 14:43
  have nothing to say next month. I just
• 14:44
  went over everything I had to say.
• 14:46
  And now it's at a point, you know,
• 14:48
  two years later where there's not enough time
• 14:50
  to keep talking about all the different things
• 14:52
  that people wanna do.
• 14:54
  The different folks in the hospital, whatever their
• 14:56
  role and responsibility is, are the ones that
• 14:59
  come to us with the ideas.
• 15:01
  We have one of the individuals at our
• 15:02
  hospital that,
• 15:04
  does patient transport is the one that, you
• 15:06
  know, came up with idea of how to
• 15:07
  try to create bins for,
• 15:10
  the the significant battery waste, that we have
• 15:14
  in hospital for all the devices that we
• 15:15
  use. So the idea is slow once you
• 15:18
  have that set up,
• 15:20
  and, you know, you have the key individuals
• 15:23
  involved. So I think from my point of
• 15:24
  view, the biggest barrier is that first step.
• 15:26
  And once you take that first step, it
• 15:28
  just ends up feeding itself. And at the
• 15:30
  end of the day, gets us to a
• 15:31
  place where we
• 15:33
  deliver better care because in my view, the
• 15:35
  best care you can deliver is also the
• 15:37
  most sustainable one where the patient does well
• 15:39
  and they don't have to come back to
• 15:40
  the hospital again or be readmitted
• 15:43
  to the hospital or have a prolonged hospital
• 15:45
  stay.
• 15:46
  And,
• 15:47
  as you we do that, we're able to
• 15:49
  deliver more care and actually do it in
• 15:51
  the most cost effective way. So for me,
• 15:54
  that mentality is just very much aligned with
• 15:57
  value care that we, you know, aspire to
• 16:00
  deliver.
• 16:01
  Absolutely.
• 16:02
  Well, this has been such an informative discussion.
• 16:05
  Thank you for taking the time to join
• 16:06
  me today and share more about everything you're
• 16:08
  doing.
• 16:09
  Thank you so much. I appreciate being here.