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How Antimicrobial Stewardship Can Impact Sustainability · The SHEA Podcast

• 0:08
  SPEAKER_02: Hello and welcome everyone to the Shea podcast series.
• 0:11
  SPEAKER_02: Today we're going to be discussing two of my favorite topics: an microbial stewardship and sustainability.
• 0:18
  SPEAKER_02: My name is Layla Hodad.
• 0:19
  SPEAKER_02: I'm an ID physician and the director of antimicrobial stewardship at University Hospitals Peace Western in Cleveland.
• 0:26
  SPEAKER_02: And I'm pleased to be the host and moderator of this episode.
• 0:30
  SPEAKER_02: Today we have the privilege of talking with two amazing experts.
• 0:34
  SPEAKER_02: We first have Dr.
• 0:35
  SPEAKER_02: Prefi Jaggy, who comes from Emory University, where she's a professor of pediatrics and serves in their Peace Infectious Diseases Division.
• 0:44
  SPEAKER_02: We also are joined by Dr.
• 0:47
  SPEAKER_02: Emily Spivak from University of Utah Hospital in the Salt Lake City VA.
• 0:52
  SPEAKER_02: Dr.
• 0:52
  SPEAKER_02: Spivak is a professor of medicine and director of the stewardship programs at Utah Health and the VA.
• 0:58
  SPEAKER_02: So welcome, Dr.
• 0:59
  SPEAKER_02: Jaggy and Dr.
• 1:00
  SPEAKER_02: Spivak.
• 1:01
  SPEAKER_02: Welcome.
• 1:02
  SPEAKER_02: I'm grateful that you were able to join us today.
• 1:05
  SPEAKER_02: Excited to get your thoughts on the intersections between stewardship and sustainability, which there's lots of growing interest in this area.
• 1:14
  SPEAKER_02: So to get us started thinking about how stewardship might play a role in this space, I just wanted to have you talk a little bit about where you currently see waste in general and in all senses of the term, I guess, in antimicrobial prescribing currently.
• 1:31
  SPEAKER_02: And both of you have written about this concept.
• 1:33
  SPEAKER_02: Dr.
• 1:33
  SPEAKER_02: Jaggy, do you want to start us off talking a little bit about your observations of antimicrobial waste in pediatrics?
• 1:41
  SPEAKER_00: Sure, thank you so much.
• 1:44
  SPEAKER_00: So I am the director of the antimicrobial stewardship program at Children's Health Care of Atlanta.
• 1:49
  SPEAKER_00: And we have been doing a lot of prospective audit and feedback in our program.
• 1:56
  SPEAKER_00: We don't do as many restrictions on antimicrobials, but rather audit and feedback.
• 2:01
  SPEAKER_00: And then one of the things that we noted at our hospital is in pediatrics, we have weight-based dosing.
• 2:08
  SPEAKER_00: So we have very specific doses of drugs, unless the child's at a maximum weight for an adult appropriate dose.
• 2:15
  SPEAKER_00: And one of the things we noted actually from one of our nurses was boy, Dr.
• 2:20
  SPEAKER_00: Jaggy, we return a lot of drugs back to the pharmacy.
• 2:24
  SPEAKER_00: We take it, we put it in, but you know, send it back to the pharmacy.
• 2:27
  SPEAKER_00: And then we went to the pharmacy one day and noted that there was just a lot of drugs being returned to the pharmacy, which has to be either incinerated or autoclaved.
• 2:37
  SPEAKER_00: And I believe in our area, we are incinerating it.
• 2:40
  SPEAKER_00: So that takes a lot of energy.
• 2:42
  SPEAKER_00: So we started running a report, validated it and figured out the drugs that were wasting.
• 2:49
  SPEAKER_00: And we wasted a lot of drugs, about 80 doses a day.
• 2:55
  SPEAKER_00: And most of it was were common antimicrobials, especially ampicillin, which is more frequent dosing in pediatrics.
• 3:02
  SPEAKER_00: And so in order to counteract this, we are doing some automatic IV to PO conversions in our hospital.
• 3:09
  SPEAKER_00: We're also working on giving decision support to providers about going to an oral drug.
• 3:15
  SPEAKER_00: And the other thing that I also noted is it's not just antibiotics, it's a lot of other drugs as well.
• 3:20
  SPEAKER_00: Anytime we have a weight-based dosing in pediatrics, uh that's probably an opportunity for there to be waste.
• 3:27
  SPEAKER_00: Um, and then it got me also kind of looking at batch times in the pharmacy.
• 3:32
  SPEAKER_00: Our pharmacy has three times a day batch time.
• 3:35
  SPEAKER_00: So we just started making providers aware of when you need to put a hold on a medication, let's say after noon on a certain day, if you think the patient's gonna go home, uh, because that's a way to save that drug from being uh discarded on the day of discharge, which is about uh, I think it was about one-fourth of our drugs were being discarded on the day of discharge of the patient.
• 3:59
  SPEAKER_02: Yeah, wow, that's amazing.
• 4:00
  SPEAKER_02: Um, we we kind of noticed something similar to um not even just with the waste base weight-based dosing, but um just drugs that expire on the shelf.
• 4:11
  SPEAKER_02: Uh, you know, if it's like a compounded drug, like you said, you they you know has a very short uh shelf life.
• 4:18
  SPEAKER_02: But other drugs I it sounds like from my pharmacy staff just get tossed and or or they may not even know when the the dates are, so they have to toss them.
• 4:27
  SPEAKER_02: So lots and lots of waste from that perspective.
• 4:30
  SPEAKER_02: And Dr.
• 4:31
  SPEAKER_02: Spiga, you actually uh quantify the impact of antibiotic prescription waste.
• 4:36
  SPEAKER_02: Could you talk a little bit about what your study looked at and some of your findings?
• 4:42
  SPEAKER_01: Yeah, so just to before that, just say like in adults, I think people probably know this, but there's a a lot of movement, and I would just say the adult clinical infectious diseases sort of area, but also that feeds into stewardship and trying to understand really what is the necessary antibiotic duration and route for a lot of things, meaning there's a push toward shorter durations and more PO antibiotics.
• 5:05
  SPEAKER_01: And so as I've done stewardship for what feels like a long time now and started to think about different ways to actually move the needle and impact providers and motivate providers.
• 5:15
  SPEAKER_01: That's how I got interested in sort of thinking about a different argument, a different spin, and a different way to like make people feel like they're having an impact and think about well, what are the emissions that we might be avoiding?
• 5:27
  SPEAKER_01: So at the same time, I got interested in this.
• 5:29
  SPEAKER_01: I've been working with Pete's ID colleagues here at the University of Utah on developing, which we've now done, an urgent care stewardship uh program focused on improving prescribing for respiratory infections in our urgent cares, and you know, seeing essentially the thousands and thousands of encounters and the amount of you know, scripts that could be avoided for things that really aren't questionable, these tier three antibiotics for like bronchitis and cough and URI, et cetera.
• 5:57
  SPEAKER_01: I was, I thought, like, hey, that's a way to maybe think about quantifying emissions that are not, there's no argument really.
• 6:05
  SPEAKER_01: They're completely avoidable.
• 6:06
  SPEAKER_01: And so I had the idea to go to our outpatient pharmacy and think and ask them, can you give me all the stuff, what's eventually trash, that you give somebody uh with an outpatient prescription?
• 6:18
  SPEAKER_01: So, like the paper bag, the plastic bottle, the sort of paper leaflet that goes with it.
• 6:23
  SPEAKER_01: And I worked with our sustainability group here to just have them educate me very generally on like healthcare emissions, life cycles.
• 6:31
  SPEAKER_01: And I said, I have this idea to quantify this waste just in pounds, but also calculate emissions from this trash when the patient is done with it and they throw it away.
• 6:44
  SPEAKER_01: And that was just the and they said, Oh, yeah, that's actually not very hard to do.
• 6:47
  SPEAKER_01: You're missing a whole part of emissions in like the producing of the drug, just as long as you acknowledge that, though.
• 6:54
  SPEAKER_01: And um, so that led to them teaching me essentially how to quantify the emissions and just taking the weight of all the trash times the number of prescriptions.
• 7:03
  SPEAKER_01: I first was going to do it just for our urgent cares.
• 7:05
  SPEAKER_01: I did it for them and presented it as you know, in one of our stewardship educational meetings to them.
• 7:10
  SPEAKER_01: Um, but we had the idea like, let's go bigger and use CDC estimates of unnecessary ambulatory prescriptions in the US across all age groups from 2022 and quantify there.
• 7:23
  SPEAKER_01: And that's what we did in what was published in Ashie, where we estimated based on just again, it's just very simple calculations, that in one year in the US alone, unnecessary outpatient antibiotic prescriptions equate uh or uh offset or produce emissions equal to if you were able to drive a car around the uh around the center of the earth, which is about 24,000 miles, I think, uh 194 times.
• 7:49
  SPEAKER_01: So it's like once you see those numbers, you're like, oh my goodness, this is and it's completely unnecessary scripts, like never really should have gotten one.
• 7:57
  SPEAKER_01: So there's like so much opportunity in adults to do that thinking about shorter durations, diagnostic stewardship, thinking about unnecessary prescriptions there, etc.
• 8:06
  SPEAKER_02: Yeah, and I mean it's amazing too, because it's these are pieces of it that as providers we don't even really think about or see, you know, we put it in order and then something happens and you don't like think about all the the other steps.
• 8:20
  SPEAKER_02: And you mentioned like the you know, the manufacturing end and then the shipping and then all of the the things that you know happen between the pharmacy and the patient.
• 8:29
  SPEAKER_02: So I think that's really amazing work that you did.
• 8:31
  SPEAKER_02: So thanks for talking about that.
• 8:33
  SPEAKER_02: So you know, with that problem in mind and and you know the scope of this issue, uh I wanted to talk a little bit more about how stewardship programs can help mitigate the impact of antimicrobial waste.
• 8:49
  SPEAKER_02: And you guys both started to mention a couple of projects that you've done in your own institutions, but just in general, like anything, what are things in particular that are maybe low-hanging fruit that stewardship programs can address, you know, like right away?
• 9:05
  SPEAKER_00: Well, I do think that the IV to PO conversion is really, really important.
• 9:11
  SPEAKER_00: And I also think that we have as stewards a lot of experience in antibiotic stewardship doing this, which can be expanded to other drug classes.
• 9:21
  SPEAKER_00: We're doing a big IV to PO conversion project at our hospital, and we're working on antiepileptics because the same principles and antibiotic stewardship of going to enter all treatment can be actually applied to antiepileptics.
• 9:34
  SPEAKER_00: And I actually didn't know that even with antiepileptics, there's some good pediatric data to show that, you know, that can be done safely in certain uh with certain criteria met.
• 9:43
  SPEAKER_00: So I think using our expertise to help um thinking about what we're actually also doing, you know, these um H2 blockers like Fomodidine in our hospital.
• 9:52
  SPEAKER_00: That's a low-hanging fruit to be able to go to NRL because you also save a lot of plastic waste.
• 9:57
  SPEAKER_00: You save nursing time, you don't need a flush when you need to give it oral medication.
• 10:02
  SPEAKER_00: So I think thinking about what we are doing, kind of expanding it to other areas is a great way to think about that.
• 10:10
  SPEAKER_00: And when I think about going from stewardship to sustainability, I think of stewardship as being really specific, antibiotic stewardship, steward, stewards of antibiotics, like uh Dr.
• 10:20
  SPEAKER_00: Alexander Fleming said, you know, we want to save penicillin from being misused to save antibiotic resistance later.
• 10:27
  SPEAKER_00: But sustainability is thinking about resources as a whole.
• 10:31
  SPEAKER_00: So it's almost like an expansion of stewardship.
• 10:33
  SPEAKER_00: So this is like the indigenous wisdom saying, you know, save our resources today so that people in seven generations from now will have those same resources.
• 10:42
  SPEAKER_00: And when I think about resources, I think about it not it's plastic waste, it's time.
• 10:46
  SPEAKER_00: How much time do our pharmaceutical technicians spend in preparing these drugs, our nurses spend in giving these drugs?
• 10:54
  SPEAKER_00: So trying to kind of get that idea of all the resources involved.
• 10:57
  SPEAKER_00: And then that doesn't even account for the the energy and all the stuff that has to be done to make those materials.
• 11:04
  SPEAKER_00: So I think just using that, the stewardship as a framework to expand to sustainability can be just so powerful, and there's just so much work to do in the US healthcare system.
• 11:14
  SPEAKER_01: I love that because you, I mean, as we all know, we are not the only sector that uses the word stewardship, right?
• 11:20
  SPEAKER_01: Like out here, there's a lot of environmental groups and they are stewards of the land.
• 11:24
  SPEAKER_01: And my kids at school are taught to be, you know, stewards of uh, you know, stewards of the environment, stewards of society.
• 11:30
  SPEAKER_01: And so yeah, it's almost like we are just you could take off the antimicrobial and a stewardship program, and healthcare would really steward all the resources, whether that's like you're saying time, you know, the the the things that we use.
• 11:42
  SPEAKER_01: Another example that just popped into my mind, which I'm like, oh gosh, I need to do this with this resident who's already asked me about this project, the blood culture shortage.
• 11:50
  SPEAKER_01: I mean, we cut our blood culture usage here in half over the summer, in half, and uh there's no harm, you know, our positivity rate went up just a teeny bit, just showing like there's still so much under, but that's another way to show, like in our usage of diagnostics tests, which we've all talked about, right, Preeti, and people are starting to look at diagnos, you know, sort of um urine cultures and sort of the waste associated with unnecessary use of urine cultures.
• 12:18
  SPEAKER_01: But there's so many examples in healthcare, as you're pointing out.
• 12:21
  SPEAKER_01: But I think like using shortages, that's another way to measure maybe what you avoid in a shortage situation to say, oh, that maybe that was unnecessary.
• 12:31
  SPEAKER_01: We could quantify um the waste and emissions associated with that as well.
• 12:36
  SPEAKER_00: And I think in infectious disease, we are really good cognizant of antibiotic stewardship, but radiology diagnostic stewardship, stewardship of testing.
• 12:46
  SPEAKER_00: You know, I sometimes think about the encephalitis patient that comes in and, you know, you really need the HSV test, and then you can proceed to other testing.
• 12:54
  SPEAKER_00: But like what's going to actually make a difference to the patient?
• 12:57
  SPEAKER_00: So really thinking critically about our diagnostics.
• 13:01
  SPEAKER_00: I think we even have room to, you know, how improve our own medical care, not just the other providers in the hospital.
• 13:08
  SPEAKER_00: Um, we're looking at our patients with an intracranial abscess and how many MRIs we're ordering because we think that there's some opportunity to decrease the MRI use in in children.
• 13:19
  SPEAKER_00: Oftentimes we need to sedate them.
• 13:20
  SPEAKER_00: So you're also then saving the greenhouse gas emissions with the inhaled anesthetics for uh procedure.
• 13:26
  SPEAKER_00: So or a diagnos, uh, an imaging test, which requires energy and greenhouse gases for the anesthesia.
• 13:33
  SPEAKER_00: And it's safer for the patient.
• 13:35
  SPEAKER_00: So, you know, all of those things are really important.
• 13:38
  SPEAKER_01: Yeah, I mean, it just makes me think there's more.
• 13:40
  SPEAKER_01: I we did some work because our echo lab was overstretched on reducing echoes.
• 13:45
  SPEAKER_01: Essentially, I helped create some like diagnostic tree algorithms embedded into Epic to really like guide people, like they had to answer questions and you know, and get to the answer and their answers, no, like you really shouldn't have an echo in this patient.
• 13:57
  SPEAKER_01: I didn't quantify any energy usage or time, but that's another, I mean, everything we do almost, uh, there's some there's some energy usage potentially translating to emissions that can be factored in.
• 14:10
  SPEAKER_01: Uh, hospitals here a couple of years ago did a project looking at trying to reduce usage of telemetry.
• 14:16
  SPEAKER_01: At the time, that would have been a great, another great example of thinking of all the pieces that are used um in in telemetry, uh, put unnecessarily putting patients on telemetry, could have quantified that as well.
• 14:27
  SPEAKER_00: Interesting.
• 14:28
  SPEAKER_00: Yeah, and all the beeping too for the patient, right?
• 14:30
  SPEAKER_00: Like that's another thing you don't even think about.
• 14:33
  SPEAKER_00: So in the UK, they talk about the sustainable healthcare value, which is the the true value of healthcare are best clinical outcomes with the least social, environmental, and financial harms.
• 14:47
  SPEAKER_00: And I really think if you start looking at anything that we do with that framework and even just labeling the social harms that are occurring, it's so powerful.
• 14:56
  SPEAKER_00: It's not necessarily something you can quantify, but it is something that you start thinking about.
• 15:00
  SPEAKER_00: Like if I give a chronic medication and I tell the patient, I'm gonna give you a three-month supply versus a one-month supply, that's two less trips that they have to make to the pharmacy to go get the drug.
• 15:12
  SPEAKER_00: And maybe they don't have a car.
• 15:13
  SPEAKER_00: You know, there's things that we're not thinking about in the social realm and thinking about it as stratifying it by socioeconomic resources that I think that if you start thinking about everything that we do with that framework, it just becomes really fun.
• 15:26
  SPEAKER_00: You can be very creative and thinking about how you can do more with less resources.
• 15:34
  SPEAKER_02: So funny, as you were saying that, I was just thinking about um, you know, like I get some of my prescriptions by mail, and I just got one and it comes in this big giant like bubble package every single time, and I'm like, no, you know, or couldn't they have waited and put it with the other ones or something, or you know, could they have done something different?
• 15:51
  SPEAKER_02: But um, but anyway, this is this is really great how this this conversation is kind of headed.
• 15:55
  SPEAKER_02: I was kind of hoping to get into this space where you know, how does stewardship fit into you know you know, we we were so focused on antibiotics and antibiotic stewardship, just as you guys were saying.
• 16:08
  SPEAKER_02: But it really makes sense for us to kind of lead this effort, I think, as as stewards, since we're connected to everything in in some way, you know, we have connections to kind of every different field and and different types of resources used, and it really seems like it's a natural fit.
• 16:28
  SPEAKER_02: And then having kind of some of the leadership and quality experience as well.
• 16:32
  SPEAKER_02: Along those lines, you know, do you guys have any thoughts about is there more specific leadership skills or training or certifications that stewards might want to think about if they want to have a more active role in healthcare sustainability in their institutions?
• 16:51
  SPEAKER_01: I'm gonna let Precy answer that because I want to learn from her.
• 16:56
  SPEAKER_01: Because that's a question that I have for myself.
• 16:58
  SPEAKER_01: I mean, I think we're a natural fit, as we're all like sort of nodding to each other on the screen here, uh, to take on these roles because we have all the relationships.
• 17:07
  SPEAKER_01: We know how to like, we just know how everything works, I think, in healthcare and how to reduce usage and the tools that you use to guide people to do, as you were saying, uh, more with less.
• 17:18
  SPEAKER_01: But I'd love to hear your your thoughts on like how do you gain more skills and knowledge about this sort of sustainability work in healthcare to maybe sort of, I don't want to say credential yourself, but get your give yourself a better application or a better tools to get into those roles.
• 17:33
  SPEAKER_00: Yeah, this is interesting to me because I feel like this is a little bit how stewardship started, antibiotic stewardship started, where it was kind of starting from nothing, right?
• 17:41
  SPEAKER_00: So it's it's not that it's starting from nothing, but I think clinicians getting involved in the sustainability space is relatively new.
• 17:49
  SPEAKER_00: So for me, a lot of this, whatever I have done has been um, I took a class.
• 17:55
  SPEAKER_00: So Emery has a pretty good climate and health curriculum.
• 17:58
  SPEAKER_00: So I took some of these online classes or they were just video recordings.
• 18:03
  SPEAKER_00: And I did a pro I did another training through I think Columbia.
• 18:07
  SPEAKER_00: They had a just about climate and health, just to give myself some information.
• 18:10
  SPEAKER_00: They talked a lot about air pollution and how that's harmful to health.
• 18:13
  SPEAKER_00: So I had to kind of get myself up to speed there.
• 18:15
  SPEAKER_00: And then just reading whatever I could find and then going to clean med was really helpful for me.
• 18:21
  SPEAKER_00: And when I think about sustainability in general, there's also a lot of opportunity to do advocacy in your institution.
• 18:29
  SPEAKER_00: So that's really, really helpful to do as well because there's some, you know, the food waste that we incur, that just knowing where where are these emissions coming from is really helpful to learn about.
• 18:41
  SPEAKER_00: There's been a the New England Journal of Medicine's doing some work in that space.
• 18:45
  SPEAKER_00: There's a really nice article in there about just where are the emissions coming from.
• 18:50
  SPEAKER_00: And then I just kind of really started with the intersection of what my work was, which was antibiotic stewardship and preserving, you know, eliminating waste or decreasing waste.
• 19:02
  SPEAKER_00: And I just kind of started there.
• 19:04
  SPEAKER_00: And I think that it just kind of grows organically from there.
• 19:07
  SPEAKER_00: And then the other thing that's been fun for me is talking with other providers.
• 19:11
  SPEAKER_00: And I think the idea of sustainability with providers is really motivating.
• 19:15
  SPEAKER_00: Like my clinicians love the idea like of them preventing waste.
• 19:19
  SPEAKER_00: Like the surgeons, they see a lot of waste.
• 19:21
  SPEAKER_00: So it's been a great, one of my best buds in sustainability here is a trauma surgeon.
• 19:26
  SPEAKER_00: So working with them about what they see, other drugs, thinking about other drugs.
• 19:32
  SPEAKER_00: I have been trying to really hard to get a sustainability group at our hospital, which has been a little difficult.
• 19:37
  SPEAKER_00: We're building a new hospital.
• 19:38
  SPEAKER_00: There's a lot of efforts going into that, but we're hoping to kind of build that.
• 19:42
  SPEAKER_00: So I think there's two efforts.
• 19:44
  SPEAKER_00: You can work on doing some advocacy in your own hospital.
• 19:49
  SPEAKER_00: Uh, UPMC did a really nice um, they did a petition uh with a ton of people in their facility, and then they got a sustainability program going after they told their leaders this is what we want.
• 20:01
  SPEAKER_00: And then just kind of doing what trying to bring it into what you're doing every day is a really good thing.
• 20:06
  SPEAKER_00: And there are some medical directors now of sustainability.
• 20:10
  SPEAKER_00: Uh, so that is something new.
• 20:12
  SPEAKER_00: And who better to do that than the OG sustainability people, which are stewards, antibiotic stewards?
• 20:17
  SPEAKER_00: Because we really have a lot of experience in this area.
• 20:20
  SPEAKER_00: And uh I think this we are kind of a natural fit for that area, and there's a lot of ability to prevent um financial loss too.
• 20:28
  SPEAKER_00: So you can save a lot of money doing sustainability.
• 20:31
  SPEAKER_00: So I think that's a good sell for hospital administrators.
• 20:36
  SPEAKER_01: Can I ask Bruti a question?
• 20:38
  SPEAKER_01: Do you do anything within the medical school around sustainability?
• 20:43
  SPEAKER_01: Because I think that's maybe another way to get involved with it.
• 20:46
  SPEAKER_01: I'm sort of saying that and questioning that.
• 20:48
  SPEAKER_01: So the project that I was talking about that I did um also came about because I had a second-year medical student who had I had lectured to them about antibiotics, and she wanted to do a project with me.
• 21:00
  SPEAKER_01: She had rounded with me, and I these things happen at the same time.
• 21:03
  SPEAKER_01: And I'm like, well, I have this idea about this project about you know, waste and emissions with unnecessary antibiotics.
• 21:09
  SPEAKER_01: And she went crazy.
• 21:10
  SPEAKER_01: She's like, I love that.
• 21:11
  SPEAKER_01: That's so exciting.
• 21:12
  SPEAKER_01: I definitely want to do that with you.
• 21:14
  SPEAKER_01: And she presented it at Shea and everything.
• 21:16
  SPEAKER_01: I think that's another area to get involved with, and just curious if you've done stuff within the med school.
• 21:21
  SPEAKER_00: Yeah, I think the medical school is a great um avenue.
• 21:24
  SPEAKER_00: I've actually done some work with some undergraduate students as well.
• 21:28
  SPEAKER_00: One was on the microbiology waste of diagnostic stewardship, decreasing uh healthcare's climate impact and microbiology waste.
• 21:36
  SPEAKER_00: I have a student looking at um peripheral IV extravization and the drugs associated with that, and antibiotics are a big one for that.
• 21:42
  SPEAKER_00: So, also another way to show that you know, IV to oral conversion is a good idea.
• 21:47
  SPEAKER_00: Mostly when you do these projects, a lot of it's weighing the supplies, and then you can do some greenhouse gas calculations.
• 21:54
  SPEAKER_00: You can't do a full life cycle analysis, but undergrads and medical students, they uh they love this stuff.
• 22:00
  SPEAKER_00: It's opportunity to potentially publish, which is great for them.
• 22:04
  SPEAKER_00: And also an opportunity for them to see about how they can, you know, get involved in decreasing it makes you mindful of the waste that occurs in healthcare.
• 22:13
  SPEAKER_00: So I think that's a great opportunity.
• 22:16
  SPEAKER_00: And people generally can do it.
• 22:18
  SPEAKER_00: It doesn't take a ton of time.
• 22:20
  SPEAKER_00: It's more just like seeing, monitoring waste and things like that, and then weighing the supplies.
• 22:27
  SPEAKER_01: And it's also maybe a way to get people interested in ID.
• 22:30
  SPEAKER_01: Yes.
• 22:31
  SPEAKER_01: Just trainees, et cetera.
• 22:32
  SPEAKER_01: I mean, again, get them passionate about ID, thinking about it in a different way, I think, than we classically have tried to sell infectious diseases, maybe as a as a career.
• 22:42
  SPEAKER_00: I definitely think that's an opportunity.
• 22:44
  SPEAKER_00: We are starting a climate and health uh resource optimizer track.
• 22:48
  SPEAKER_00: So we call it Climate Hero, ID Climate Hero.
• 22:51
  SPEAKER_00: And that is trying to use the experience we've gained in stewardship and infection prevention to try to extend it towards healthcare sustainability.
• 23:00
  SPEAKER_00: So I'm hoping that will also attract fellows because in pediatric ID, we are definitely needing to attract fellows.
• 23:08
  SPEAKER_00: But what a great way to feel like you can make an impact in the greatest global threat to public health is climate change.
• 23:17
  SPEAKER_00: 200 medical journals simultaneously published that on the same day.
• 23:20
  SPEAKER_00: And it's great to be able to see a, you know, we can we can decrease that because we know that in healthcare, it's 8.5%.
• 23:27
  SPEAKER_00: Healthcare delivery in the United States is associated with 8.5% of the greenhouse gas emissions in our country.
• 23:34
  SPEAKER_00: That's almost one in 10.
• 23:36
  SPEAKER_00: So we have this ability to decrease our emissions in healthcare and probably create a lot of ripple effects in other areas.
• 23:43
  SPEAKER_00: So we can do this.
• 23:45
  SPEAKER_00: And we have started from antibiotic stewardship from scratch.
• 23:48
  SPEAKER_00: And I think we can really move this area forward in sustainability.
• 23:53
  SPEAKER_01: Isn't the estimate also that if US, I believe it's just US healthcare were a nation, we would be the fifth largest emitter in the world.
• 24:01
  SPEAKER_00: Correct.
• 24:01
  SPEAKER_00: Yeah, that's what I understand as well.
• 24:04
  SPEAKER_00: It's astounding.
• 24:05
  SPEAKER_00: It's astounding.
• 24:06
  SPEAKER_00: And when we think about global public health, if we decrease our emissions in the United States, we have global public health benefits.
• 24:14
  SPEAKER_00: So it's it's thinking globally, acting locally.
• 24:17
  SPEAKER_00: You don't have to travel anywhere for that.
• 24:19
  SPEAKER_00: You just do what you're doing every day in a better way.
• 24:22
  SPEAKER_02: It's amazing to think about how far reaching some of these concepts can go and you know what we can really accomplish as stewards in in our capacity.
• 24:33
  SPEAKER_02: So that's really inspiring.
• 24:35
  SPEAKER_02: Um, thank you for that outstanding discussion.
• 24:38
  SPEAKER_02: I've learned so much from both of you, and our audience has as well.
• 24:42
  SPEAKER_02: Any other final comments that either of you want to make?
• 24:46
  SPEAKER_00: I would also just invite our infection prevention colleagues.
• 24:51
  SPEAKER_00: We definitely need you.
• 24:53
  SPEAKER_00: We need to be safe, deliver safe medical care and prevent infections, but we also need to decrease the waste that is associated with healthcare delivery.
• 25:02
  SPEAKER_00: So I think the area of sustainability really, really needs infection preventionists.
• 25:08
  SPEAKER_00: We need your expertise.
• 25:09
  SPEAKER_00: So I would definitely not want to silo this to stewardship.
• 25:13
  SPEAKER_00: I think this is all infectious disease providers that can really contribute to this.
• 25:18
  SPEAKER_00: So I guess that's all I wanted to mention as well.
• 25:21
  SPEAKER_01: Yeah, and I like how you said all ID providers, because I don't mean to call out ID, but I guess I can't because I'm one of the problem.
• 25:28
  SPEAKER_01: I think when we see patients and we're so cautious, sometimes individually in like seeing and treating patients.
• 25:35
  SPEAKER_01: And I think unfortunately, ID practice in and of itself sometimes is not the most stewardship-friendly, you know, area of medicine.
• 25:44
  SPEAKER_01: And we're talking about the sort of day-to-day clinical practice of ID.
• 25:47
  SPEAKER_01: And I really think uh infectious diseases needs to sometimes uh we need to wake up and really realize the risks and benefits and sort of as your the life cycle of how we treat patients and you know, look at literature and realize that we really should be doing less, I think, in all areas of infectious diseases, less diagnostics, less antibiotics, less IV antibiotics, shorter durations.
• 26:09
  SPEAKER_01: Um, and you know, a lot of clinical ID would have a big impact on sustainability as well.
• 26:14
  SPEAKER_01: I think if we really kind of try and do it, we need to be doing less.
• 26:19
  SPEAKER_02: That's wonderful.
• 26:20
  SPEAKER_02: Well, thank you both, Dr.
• 26:21
  SPEAKER_02: Jaggy and Dr.
• 26:22
  SPEAKER_02: Spivak.
• 26:24
  SPEAKER_02: What an amazing conversation.
• 26:26
  SPEAKER_02: Thank you all for listening in to this episode of the Shade podcast.
• 26:30
  SPEAKER_02: And check back for more episodes launching soon.