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

Transcript

Eliminating Nitrous Oxide and Advancing Sustainable Care in the OR with Dr. Arash Motamed · Becker’s Healthcare - Clinical Leadership 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
• 0:08
  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
• 0:18
  to learn more about how you're discontinuing
• 0:21
  nitrous oxide in the o r. But before
• 0:23
  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.
• 0:40
  It started off with a pretty
• 0:42
  casual conversation with a colleague of mine who
• 0:46
  works at a competing medical center,
• 0:49
  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
• 1:05
  really started to gain a lot of popularity,
• 1:09
  in the latter half of this past century,
• 1:13
  and has some really great benefits in terms
• 1:15
  of quick onset, quick offset,
• 1:18
  and also, you know, very available
• 1:21
  and inexpensive.
• 1:22
  But what he told me at that time,
• 1:23
  which is really sort of the start of
• 1:27
  my journey in discontinuing nitrous oxide from our
• 1:29
  medical center, was
• 1:31
  a majority of the nitrous oxide that's in
• 1:34
  the central pipelines and the hospitals leaks into
• 1:37
  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
• 1:44
  nitrous oxide leaks,
• 1:45
  typically at the areas of the connections.
• 1:49
  And there's really no way to prevent this.
• 1:51
  And, you know, what's interesting about it is
• 1:53
  what it means
• 1:55
  is that the nitrous actually
• 1:57
  never has any clinical impact. It just goes
• 1:59
  straight into the atmosphere. And then the next
• 2:01
  question is, well, why do we care about
• 2:03
  it? We do because
• 2:05
  nitrous oxide is a fairly potent
• 2:08
  greenhouse gas,
• 2:10
  about 300 times,
• 2:12
  as potent as carbon
• 2:14
  dioxide. So it really has a big impact.
• 2:16
  And on top of it, it does also
• 2:17
  deplete the ozone layer. And then one other
• 2:20
  thing with it is it lasts for a
• 2:22
  pretty long amount of time in the atmosphere,
• 2:24
  so about hundred years or so. So in
• 2:26
  some ways, some of the first nitrous oxides
• 2:29
  that were being used as anesthetics are still
• 2:31
  somewhere in our atmosphere,
• 2:33
  and most of it had gone unused in
• 2:35
  terms of,
• 2:37
  clinical
• 2:38
  benefit to the patient. Now we know the
• 2:40
  patient still gets the amount that we want
• 2:42
  the patient to get, but majority of it
• 2:44
  just leaks before it ever,
• 2:47
  gets to the patient.
• 2:49
  So knowing that and, you know, my involvement
• 2:52
  with our sustainability
• 2:53
  efforts at Keck, I felt
• 2:56
  compelled that we need to look at this
• 2:58
  and we need to figure out a way
• 2:59
  to better address it. And and,
• 3:01
  hospitals, nitrous oxide commonly comes in two forms.
• 3:04
  So either cylinders that gets attached to the
• 3:07
  anesthesia machine
• 3:08
  or central pipes that, again, gets connected to
• 3:11
  the anesthesia machine.
• 3:13
  Almost all the times, if a place has
• 3:15
  the central pipes, that's what they use, and
• 3:17
  the cylinder is used as a backup, you
• 3:19
  know, should there ever be any issues with
• 3:21
  central supply.
• 3:23
  So what we wanted to do was look
• 3:25
  at our usage at our medical center and
• 3:27
  decide, you know, whether it makes sense to
• 3:29
  discontinue it.
• 3:31
  The challenge with doing that, you know, one
• 3:34
  is,
• 3:35
  education and making sure that everyone has
• 3:38
  awareness as to why we're doing what we're
• 3:40
  doing, but, also,
• 3:42
  it's
• 3:44
  partnering with our, colleagues at facilities because, you
• 3:48
  know, as an anesthesiologist,
• 3:49
  I know nothing about, the central pipelines, how
• 3:52
  they work, and how they function.
• 3:55
  And, also, you know, at the end of
• 3:56
  the day, this is a medication that anesthesiologists
• 4:00
  have used for
• 4:01
  many decades. So there is clinical comfort,
• 4:05
  and when established habits that is,
• 4:09
  takes some time to,
• 4:11
  get them to see and understand and look
• 4:13
  at other alternatives. So that's
• 4:15
  the
• 4:16
  basics of the beginnings of how we got
• 4:18
  involved with, getting rid of, nitrous oxide.
• 4:22
  Excellent. And how did you build a credible
• 4:25
  business and clinical case for this initiative?
• 4:27
  And then on top of that, how did
• 4:29
  you get both hospital leadership and frontline physicians
• 4:33
  aligned on it?
• 4:34
  Yeah. That's a that's a really great question,
• 4:36
  and I think goes to heart of any
• 4:38
  type of initiative we try to do.
• 4:41
  It really needs to be collaborative, and you
• 4:42
  need to have the buy in because, otherwise,
• 4:43
  it's just not gonna go anywhere.
• 4:45
  What,
• 4:46
  I decided to do in this particular instance
• 4:50
  was,
• 4:51
  initially,
• 4:51
  I,
• 4:52
  you know, our department in anesthesia is about
• 4:55
  almost 200,
• 4:57
  individuals,
• 4:58
  combination of physicians, CRNAs, and, residents.
• 5:02
  And I picked
• 5:04
  about 20 of them who
• 5:06
  either have leadership roles or, you know, are
• 5:08
  otherwise still fairly influential or have, you know,
• 5:11
  a lot of experience and expertise,
• 5:13
  and I pulled them. And my first question
• 5:16
  to them was, you know, are there any
• 5:18
  types of cases that we do where nitrous
• 5:20
  oxide is really the only
• 5:23
  type of anesthetic we should use for? Because
• 5:26
  if that answer
• 5:27
  comes back as yes and a fair amount,
• 5:29
  then it's a different question. But, you know,
• 5:31
  as an anesthesiologist myself, I know the answer
• 5:33
  is no.
• 5:35
  And that was the response that I got,
• 5:37
  which was great. So then it led to
• 5:39
  the next question on on the next round
• 5:41
  of surveys that we did, which was,
• 5:43
  since we know that, you know,
• 5:46
  it's not a must have,
• 5:48
  can we have the option
• 5:50
  of,
• 5:51
  a, fully getting rid of everything that we
• 5:53
  have?
• 5:54
  Two,
• 5:55
  discontinuing
• 5:56
  the central pipeline and just having the cylinders
• 5:59
  as backup should anyone need it?
• 6:01
  Or three,
• 6:03
  removing everything, but having a few cylinders somewhere
• 6:07
  in the building as backup should anyone need
• 6:09
  it, and we'll bring it up and connect
• 6:11
  it to the machine.
• 6:12
  And it was interesting
• 6:14
  that, you know, through that process and, of
• 6:16
  course, as as these surveys are happening, there's,
• 6:18
  you know, education,
• 6:20
  with the department and forms of, you know,
• 6:22
  grand rounds,
• 6:23
  to let them know what the impact of
• 6:24
  nitrous oxide is. But most of the group
• 6:27
  felt comfortable moving towards
• 6:29
  an approach where we remove everything from the
• 6:31
  OR. So it's not there ready to be
• 6:33
  used,
• 6:34
  but we'll have cylinders available should we ever
• 6:37
  be in a need where someone feels like
• 6:39
  that that is the best thing for for
• 6:40
  their patient at that point in time. So
• 6:42
  we reserved four cylinders,
• 6:45
  where we keep all the the gas cylinders
• 6:47
  in our hospital and created a pathway that,
• 6:49
  you know, is easy to follow and a
• 6:51
  phone number to dial, and the person comes
• 6:53
  in and helps set it up. And what
• 6:56
  was really interesting
• 6:57
  was,
• 6:59
  in the last
• 7:01
  three years at our Keck Hospital and two
• 7:03
  years at Norris Cancer Hospital, not a single
• 7:06
  time has anyone needed to make that phone
• 7:08
  call,
• 7:09
  which essentially made us,
• 7:11
  the,
• 7:12
  only institution that I know of in The
• 7:14
  US that has fully removed nitrous oxide from
• 7:17
  both central supply and the cylinders.
• 7:22
  That's incredible.
• 7:23
  What were some of those key learnings you
• 7:25
  had when you were moving this from a
• 7:27
  concept into execution?
• 7:30
  So one of the,
• 7:32
  interesting
• 7:33
  things that came up that we did not
• 7:35
  know was
• 7:36
  the way the nitrous is set up to
• 7:38
  the machine. Once you discontinue it, that machine
• 7:40
  could no longer do its self check and
• 7:43
  would give a lot of errors, so it
• 7:44
  would be nonfunctional.
• 7:46
  So we first had tried this on one
• 7:49
  of our spare machines just to see what
• 7:50
  happens. And once we realized that that's a
• 7:52
  problem, we needed to
• 7:53
  connect with the manufacturer,
• 7:56
  and have one of their representatives come in
• 7:58
  because they needed, you know, special codes to
• 8:00
  go in there and change the machine check
• 8:02
  so that it doesn't alarm and it can
• 8:03
  still do itself check and it can still
• 8:05
  function. So that was an interesting learning point.
• 8:08
  But one of the other things that was,
• 8:11
  could potentially sometimes I think in other institutions
• 8:13
  also be viewed as barrier is the term
• 8:17
  that gets used frequently when it comes to
• 8:19
  removing nitrous oxide from central
• 8:22
  supply or central pipelines is decommissioning.
• 8:25
  And decommissioning can mean different things to different
• 8:27
  people as as I have learned, and it
• 8:30
  could be anything from we're just not using
• 8:32
  the pipes to we need to go into
• 8:34
  the building and we need to remove pipes,
• 8:36
  which, of course,
• 8:38
  is not only a construction nightmare, but also
• 8:41
  fairly expensive and, you know, regulatory challenges that,
• 8:44
  you know, may come with it. Our approach
• 8:46
  to decommissioning
• 8:48
  was not to do any of that. It
• 8:50
  was to simply
• 8:51
  stop having nitrous oxide in those central pipelines.
• 8:55
  And then our the our team with, the
• 8:58
  facilities management actually came up with a really
• 9:01
  brilliant and unique idea, which I think can
• 9:04
  be used by other hospitals as well, which
• 9:05
  is to fill that pipes with, nitrogen,
• 9:09
  which is also another gas that helps preserve
• 9:12
  the integrity of the pipes should there be
• 9:15
  some other use for them down the line,
• 9:17
  for some other form of gas. But at
• 9:19
  the same time, it's also inexpensive, and it
• 9:21
  doesn't have any negative environmental impact.
• 9:25
  That's amazing. Some really interesting problem solving and,
• 9:27
  you know, issues that probably nobody had thought
• 9:30
  about before you tried.
• 9:31
  So I'm curious if we take kind of
• 9:33
  a step back. And when you're evaluating
• 9:35
  sustainability initiatives as a whole, how are you
• 9:38
  balancing the environmental impact with the financial performance,
• 9:42
  clinical outcomes, all the operational feasibility,
• 9:45
  and then how are you measuring the success
• 9:47
  beyond just emissions numbers?
• 9:50
  Yeah. That's the that's the tough question that
• 9:53
  we try to figure out. Actually, with every
• 9:55
  single project that we do, we're fortunate in
• 9:57
  that,
• 9:58
  at our institution,
• 10:00
  there has been, you know, support to the
• 10:03
  sustainability
• 10:03
  program.
• 10:05
  So we have a chief of sustainability and
• 10:07
  a sustainability program manager.
• 10:09
  And along with, you know, me and my
• 10:11
  role, what we try to do with all
• 10:13
  of these initiatives is partner with the various
• 10:15
  stakeholders
• 10:16
  at our hospital,
• 10:18
  you know, whether it's, you know, obtaining data
• 10:20
  or whether it's talking with supply chain
• 10:23
  to try to figure
• 10:25
  out what the impact is
• 10:27
  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.
• 10:36
  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
• 10:42
  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
• 10:57
  in our approach so one, we collect as
• 11:00
  much data as we can,
• 11:02
  to before, during, and after. And we have
• 11:06
  committees,
• 11:07
  that meet very regularly on a monthly basis
• 11:09
  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,
• 11:19
  on board with the projects and it makes
• 11:22
  sense.
• 11:23
  Of course, clinicians,
• 11:25
  are very much involved in we, you know,
• 11:28
  we really listen to their input, and that's
• 11:29
  part of my role is to bring them
• 11:31
  on board and make sure, you know, nothing
• 11:33
  that we do ultimately has a negative impact
• 11:35
  on patient care.
• 11:37
  But what we try to do, I would
• 11:38
  say, on a very high level is most
• 11:41
  of the projects that we decided to tackle
• 11:43
  earlier on were the types of projects that
• 11:46
  would achieve both. And that's, I think, one
• 11:48
  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
• 11:55
  be expensive.
• 11:56
  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.
• 12:04
  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.