Instrument and Supply Variability: An Opportunity to Reduce the Carbon Footprint of the Operating Room.

INTRODUCTION: Reducing costs and carbon footprints are important, parallel priorities for the US health-care system. Within surgery, reducing the number of instruments that are sterilized and disposable supplies that are used for each operation may help achieve both goals. We wanted to measure the existing variability in surgical instrument and supply choices and assess whether standardization could have a meaningful cost and environmental impact. METHODS: We analyzed surgeon preference cards for common general surgery operations at our hospital to measure the number of sterilizable instrument trays and supplies used by each surgeon for each operation. From this data, we calculated supply costs, carbon footprint, and median operative time and studied the variability in each of these metrics. RESULTS: Among the ten operations studied, variability in sterilizable instrument trays requested on surgeon preference cards ranged from one to eight. Variability in disposable supplies requested ranged from 17 to 45. Variability in open supply costs ranged from $104 to $4184. Variability in carbon footprint ranged from 17 to 708 kg CO2e. If the highest-cost surgeon for each operation switched their preference card to that of the median-cost surgeon, $245,343 in open supply costs and 41,708 kg CO2e could be saved. CONCLUSIONS: There is significant variability in the instrument and supply choices of surgeons performing common general surgery operations. Standardizing this variability may lead to meaningful cost savings and carbon footprint reduction, especially if scaled across the entire health system.

Transition to Reusable Surgical Gowns at a Hospital System.

This quality improvement study investigates the feasibility of transitioning back to reusable surgical gowns at a US tertiary hospital system and projected corresponding cost savings and solid waste reduction.

Pharmacological and Endoscopic Interventions for Prophylaxis of Post-Endoscopic Retrograde Cholangiopancreatography Pancreatitis.

Background: Post-endoscopic retrograde cholangiopancreatography pancreatitis (PEP) represents the most common serious complication after endoscopic retrograde cholangiopancreatography (ERCP). Rectal non-steroidal anti-inflammatory drugs (NSAIDs) and pancreatic duct stenting (PDS) are the prophylactic interventions with more evidence and efficacy; however, PEP still represents a significant source of morbidity, mortality, and economic burden. Chronic statin use has been proposed as a prophylactic method that could be cheap and relatively safe. However, the evidence is conflicting. We aimed to evaluate the impact of endoscopic and pharmacological interventions including chronic statin and aspirin use, on the development of PEP. Methods: A retrospective cohort study evaluated consecutive patients undergoing ERCP at John H. Stroger, Jr. Hospital of Cook County in Chicago from January 2015 to March 2018. Univariate and multivariate analyses were performed using logistic regression. Results: A total of 681 ERCPs were included in the study. Twelve (1.76%) developed PEP. Univariate, multivariate, and subgroup analyses did not show any association between chronic statin or aspirin use and PEP. PDS and rectal indomethacin were protective in patients undergoing pancreatic duct injection. Pancreatic duct injection, female sex, and younger age were associated with a higher risk. History of papillotomy was associated with lower risk only in the univariate analysis (all P values < 0.05). Conclusion: Chronic use of statins and aspirin appears to add no additional benefit to prevent ERCP pancreatitis. Rectal NSAIDs, and PDS after appropriate patient selection continue to be the main prophylactic measures. The lower incidence at our center compared with the reported data can be explained by the high rates of rectal indomethacin and PDS, the use of noninvasive diagnostic modalities for patient selection, and the expertise of the endoscopists.

Knowledge Gaps in Anesthetic Gas Utilization in a Large Academic Hospital System: A Multicenter Survey.

Inhaled anesthetics account for a significant portion of the greenhouse gases generated by perioperative services within the healthcare systems. This cross-sectional study aimed to identify knowledge gaps and practice patterns related to carbon dioxide (CO2) absorbents and intraoperative delivery of fresh gas flows (FGF) for future sustainability endeavors. Secondary aims focused on differences in these knowledge gaps based on the level of training. Surveys were distributed at five large academic medical centers. In addition to site-specific CO2 absorbent use and practice volume and experience, respondents at each institution were queried about individual practice with FGF rates during anesthetic maintenance as well as the cost-effectiveness and environmental impact of different volatile anesthetics. Results were stratified and analyzed by the level of training. In total, 368 (44% physicians, 30% residents, and 26% nurse anesthetists) respondents completed surveys. Seventy-six percent of respondents were unaware or unsure about which type of CO2 absorbent was in use at their hospital. Fifty-nine percent and 48% of respondents used sevoflurane and desflurane with FGF ≥1 L/min, respectively. Most participants identified desflurane as the agent with the greatest environmental impact (89.9%) and a greater proportion of anesthesiologists correctly identified isoflurane as a cost-effective anesthetic (78.3%, p=0.02). Knowledge gaps about in-use CO2 absorbent and optimal FGF usage were identified within the anesthesia care team. Educational initiatives to increase awareness about the carbon emissions from anesthesia and newer CO2 absorbents will impact the environmental and economic cost per case and align anesthesia providers toward healthcare decarbonization.

Bilateral Superficial Trigeminal Nerve Blocks are not More Effective than a Placebo in Abolishing Post-operative Headache Pain in Pituitary Transsphenoidal Neurosurgery: A Prospective, Randomized, Doubleblinded Clinical Trial.

BACKGROUND: Pituitary neurosurgery executed via the transsphenoidal endonasal approach is commonly performed for pituitary adenomas. Reasons for prolonged hospital stay include postoperative headache and protracted nausea with or without vomiting. Bilateral superficial trigeminal nerve blocks of the supra-orbital V1 and infra-orbital V2 (SION) nerves performed intra-operatively as a regional anesthetic adjunct to general anesthesia were hypothesized to decrease 6 hours postoperative morphine PCA (patient-controlled analgesia) use by patients. METHODS: Forty-nine patients, following induction of general anesthesia for their transsphenoidal surgery, were prospectively randomized in a double-blinded fashion to receive additional regional anesthesia as either a block (0.5% ropivacaine with epi 1:200,000) or placebo/sham (0.9% normal saline). The primary endpoint of the study was systemic morphine PCA opioid consumption by the two groups in the first 6-hours postoperatively. The secondary endpoints included (1) pain exposure experienced postoperatively, (2) incidence of postoperative nausea and vomiting, and (3) time to eligibility for PACU discharge. RESULTS: Of the 49 patients that were enrolled, 3 patients were excluded due to protocol violations. Ultimately, there was no statistically significant difference between morphine PCA use in the 6 hours postoperatively between the block and placebo/sham groups. There was, however, a slight visual tendency in the block group for higher pain scores, morphine use p=0.046, and delayed PACU discharge. False discovery rate corrected comparisons at each time point and then revealed no statistically significant difference between the two groups. There were no differences between the two groups for secondary endpoints. CONCLUSION: It was found that a 6-hour postoperative headache after endoscopic trans-sphenoidal pituitary surgery likely has a more complicated mechanism involving more than the superficial trigeminovascular system and perhaps is neuro-modulated by other brain nuclei.

Epstein-Barr Virus-Positive Lymphoepithelioma-Like Carcinoma in Celiac Disease.

Lymphoepithelioma-like carcinoma (LELC) is a rare lymphoproliferative malignancy that has been described in many organs over the years. LELC in the duodenum has rarely been described in literature. This article aims to present a rare cause of melena in a young man and the diagnostic challenge that ensued to throw more light on this rare disease. In this article, we describe a 43-year-old man who presented with melena and weight loss and was subsequently diagnosed with LELC after multiple endoscopic biopsies. The patient was also found to have celiac disease in association with his LELC.

Reducing Volatile Anesthetic Waste Using a Commercial Electronic Health Record Clinical Decision Support Tool to Lower Fresh Gas Flows.

BACKGROUND: Volatile anesthetic consumption can be reduced by minimizing excessive fresh gas flows (FGFs). Currently, it is unknown whether decision support tools embedded within commercial electronic health record systems can be successfully adopted to achieve long-term reductions in FGF rates. The authors describe the implementation of an electronic health record-based clinical decision support tool aimed at reducing FGF and evaluate the effectiveness of this intervention in achieving sustained reductions in FGF rates and volatile anesthetic consumption. METHODS: On August 29, 2018, we implemented a decision support tool within the Epic Anesthesia Information Management System (AIMS) to alert providers of high FGF (>0.7 L/min for desflurane and >1 L/min for sevoflurane) during maintenance of anesthesia. July 22, 2015, to July 10, 2018, served as our baseline period before the intervention. The intervention period spanned from August 29, 2018, to December 31, 2019. Our primary outcomes were mean FGF (L/min) and volatile agent consumption (mL/MAC-h). Because a simple comparison of 2 time periods may result in false conclusions due to underlying trends independent of the intervention, we performed segmented regression of the interrupted time series to assess the change in level at the start of the intervention and the differences in slopes before and after the intervention. The analysis was also adjusted for potential confounding variables. Data included 44,899 cases using sevoflurane preintervention with 26,911 cases postintervention, and 17,472 cases using desflurane with 1185 cases postintervention. RESULTS: Segmented regression of the interrupted times series demonstrated a decrease in mean FGF by 0.6 L/min (95% CI, 0.6-0.6 L/min; P < .0001) for sevoflurane and 0.2 L/min (95% CI, 0.2-0.3 L/min; P < .0001) for desflurane immediately after implementation of the intervention. For sevoflurane, mL/MAC-h decreased by 3.8 mL/MAC-h (95% CI, 3.6-4.1 mL/MAC-h; P < .0001) after implementation of the intervention and decreased by 4.1 mL/MAC-h (95% CI, 2.6-5.6 mL/MAC-h; P < .0001) for desflurane. Slopes for both FGF and mL/MAC-h in the postintervention period were statistically less negative than the preintervention slopes (P < .0001 for sevoflurane and P < .01 for desflurane). CONCLUSIONS: A commercial AIMS-based decision support tool can be adopted to change provider FGF management patterns and reduce volatile anesthetic consumption in a sustainable fashion.

A mixed-methods study on end-user perceptions of transitioning to reusable surgical gowns.

Background: Perioperative services contribute up to 70% of the US hospitals' solid waste generation. While surgical textiles are more environmentally friendly than their disposable counterparts, many US institutions have converted to disposable surgical wear in the last few decades. End-users' perception surrounding reusable textiles is currently unknown. Methods: Perioperative staff at the University of California San Francisco (UCSF) were surveyed to assess perceptions of reusable surgical gowns to guide potential implementation. The instrument included eight close-ended questions drawn from prior studies and a free-response section. The survey was piloted before dissemination. Descriptive statistics and qualitative inductive theme analysis were applied. Results: 205 participants or 19.8% of the workforce responded. 77.6% perceived reusable surgical gowns as better for the environment, while 34.1% were unsure or believed that switching to reusable surgical gowns would increase surgical site infections. If given an option, 39.8% preferred reusable gowns, 30.7% preferred disposable gowns, and 25.4% had no preference. Qualitatively, four themes were identified concerning reusable gowns' 1) functionality and safety, 2) user comfort, 3) environmental concern, and 4) cost, which hindered end-user buy-in. Laundering water utilization in a drought-prone area was of particular concern. Conclusions: While most perioperative staff in a US tertiary hospital believed reusable surgical gowns were environmentally friendly, ambivalence towards transitioning to reusable gowns stemmed from uncertainty in reusable textiles' environmental benefits, safety profile, and cost savings. These perceptions may prevent successful implementation of reusable surgical gowns and suggest a need for staff education and context-specific environmental impact analyses. Key message: End-user perceptions on transitioning to reusable surgical gowns are mixed and revolve around uncertainty in their environmental benefits, cost, and functionality, which may hinder their successful implementation.

A race to net zero-early lessons from healthcare's decarbonization marathon.

Climate change poses a threat to healthcare systems; at the same time, healthcare systems contribute to a worsening climate. Climate-induced disasters are predicted to increase both the demand for healthcare services while also posing a threat to the integrity of healthcare systems' infrastructures and supply chains. Many healthcare organizations have taken initiatives to prepare for such disasters through implementing carbon emission-reduction practices and infrastructure reinforcement, through globally recognized frameworks and strategies known as Scopes 1, 2, and 3, and decarbonization. We explored the efforts of these early adopters to understand how they are thinking about and addressing climate change's impacts on healthcare. Through a process of reviewing the peer-reviewed literature, publicly available published documents, annual sustainability reports, conference presentations, and participation in a national decarbonization collaborative, we (1) provide a diverse set of examples showcasing the variety of ways healthcare systems are responding; (2) identify a set of emergent key themes to implementing decarbonization practices, such as the role of an organizational culture of iterative improvement and building systems of cross-organizational collaboration; and (3) synthesize the identifiable set of driving factors for long-term sustainability of these decarbonization efforts.

Climate change poses a threat to healthcare systems, while, at the same time, healthcare systems contribute to climate change. Disasters caused by climate change are expected to increase demand for healthcare services and affect healthcare infrastructure and supply chains. Some healthcare organizations have taken steps to prepare for these challenges by implementing carbon-reduction practices and infrastructure reinforcement. To do this, they are using globally recognized frameworks for reducing carbon emissions. Researchers studied these early adopters and their efforts to address climate change in healthcare. They reviewed a variety of published documents, annual sustainability reports, and conference presentations and identified key themes for implementing these carbon-reduction practices. They also identified driving factors for the long-term sustainability of these efforts. This research can help healthcare organizations better prepare for and address the challenges posed by climate change.

An Accessible Clinical Decision Support System to Curtail Anesthetic Greenhouse Gases in a Large Health Network: Implementation Study.

BACKGROUND: Inhaled anesthetics in the operating room are potent greenhouse gases and are a key contributor to carbon emissions from health care facilities. Real-time clinical decision support (CDS) systems lower anesthetic gas waste by prompting anesthesia professionals to reduce fresh gas flow (FGF) when a set threshold is exceeded. However, previous CDS systems have relied on proprietary or highly customized anesthesia information management systems, significantly reducing other institutions' accessibility to the technology and thus limiting overall environmental benefit. OBJECTIVE: In 2018, a CDS system that lowers anesthetic gas waste using methods that can be easily adopted by other institutions was developed at the University of California San Francisco (UCSF). This study aims to facilitate wider uptake of our CDS system and further reduce gas waste by describing the implementation of the FGF CDS toolkit at UCSF and the subsequent implementation at other medical campuses within the University of California Health network. METHODS: We developed a noninterruptive active CDS system to alert anesthesia professionals when FGF rates exceeded 0.7 L per minute for common volatile anesthetics. The implementation process at UCSF was documented and assembled into an informational toolkit to aid in the integration of the CDS system at other health care institutions. Before implementation, presentation-based education initiatives were used to disseminate information regarding the safety of low FGF use and its relationship to environmental sustainability. Our FGF CDS toolkit consisted of 4 main components for implementation: sustainability-focused education of anesthesia professionals, hardware integration of the CDS technology, software build of the CDS system, and data reporting of measured outcomes. RESULTS: The FGF CDS system was successfully deployed at 5 University of California Health network campuses. Four of the institutions are independent from the institution that created the CDS system. The CDS system was deployed at each facility using the FGF CDS toolkit, which describes the main components of the technology and implementation. Each campus made modifications to the CDS tool to best suit their institution, emphasizing the versatility and adoptability of the technology and implementation framework. CONCLUSIONS: It has previously been shown that the FGF CDS system reduces anesthetic gas waste, leading to environmental and fiscal benefits. Here, we demonstrate that the CDS system can be transferred to other medical facilities using our toolkit for implementation, making the technology and associated benefits globally accessible to advance mitigation of health care-related emissions.

Predictors of poor bowel preparations and colonoscopy cancellations in inpatient colonoscopies, a single center retrospective study.

BACKGROUND: An adequate bowel preparation prior to colonoscopy is a major quality-limiting factor that determines both the diagnostic and therapeutic yield of a colonoscopy. Colonoscopy is considered the gold standard for colon cancer screening and it is the primary approach to the workup of hematochezia, diarrhea and iron deficiency anemia (IDA). Several modifiable factors of bowel prep adequacy have been identified, that account for around 25% of inadequate bowel preparations in outpatient colonoscopies. However, the literature is sparse when examining the factors associated with inadequate preparations and procedure cancellations in an inpatient hospital setting. We aim to identify factors that affect bowel preparation adequacy and procedure cancellations among diagnostic colonoscopies performed during hospitalization. METHODS: We retrospectively reviewed the electronic medical records of 1,500 consecutive patients who had a diagnostic colonoscopy as an inpatient at a tertiary level hospital over a 2-year period. All patients were administered a clear liquid diet the day prior to the colonoscopy. Patients were then instructed to drink 4 L of polyethylene glycol (PEG, Golytely) between 5 am to 9 am on the day of the procedure. The clinical course of each case was followed to identify quality of preparations, cancelled procedures and the reasons for cancellations. We applied univariate and multivariate logistic regression analysis to identify variables to predict cancellation and poor preparation. RESULTS: A total of 1,029 patients were included in the study. 194 (18.8%) patients had colonoscopy cancellations and 268 (26.0%) had poor bowel preparations. Multivariate analysis revealed these factors to be associated with colonoscopy cancellations: education at the graduate school level [odds ratio (OR) =1.93, P=0.04], Hispanic ethnicity (OR =0.47, P<0.01), hemoglobin level <10 g/dL (OR =1.41, P=0.05) and if the colonoscopy was done for other indications (OR =0.53, P=0.04). Factors associated with poor bowel preparation on multivariate analysis, were dementia (OR =2.44, P=0.02), gastroparesis (OR =3.97, P=0.01) and inpatient opioids use (OR =1.69, P=0.04). CONCLUSIONS: The rate of colonoscopy cancellations and poor bowel preparations in inpatient colonoscopies were high, and we were able to identify predictors of inadequate colon preparation and procedure cancellations. Exploring more individualized colon preparation regimens based on personal risk factors could reduce the number of inadequate and cancelled colonoscopies in an inpatient setting.

Surgeons' perspectives on operating room waste: Multicenter survey.

BACKGROUND: Waste is endemic in the U.S. health care system. Operating rooms are a source of significant solid waste. Surgeons are integral to many decisions in the operating room. METHOD: Online survey of surgeons at 2 major academic centers in the United States assessing perspectives on intraoperative waste and willingness to work to actively reduce intraoperative waste. RESULTS: We received responses from 219 surgeons: 90% agreed or strongly agreed that waste of sterile surgical items is an issue, and 95% agreed or strongly agreed to a willingness to change the operating room workflow to reduce waste. Surgeons estimated 26% of single-use, sterile supplies opened for surgery were unused at the end of the case. The barriers to waste reduction cited most frequently were: (1) lack of awareness of waste, (2) lack of concern for waste, and (3) lack of time to address the waste. CONCLUSION: Surgeons understand there is significant waste in the operating room and are willing to change their workflow to reduce waste. Changes in operating room practices that reduce waste will be beneficial to health systems' finances and their efforts to improve population health through a reduction in consumption and pollution. Efforts should be directed toward reducing operating room waste with an initial focus on the elimination of unnecessary waste of sterile surgical supplies. Further work is needed to determine the precise sources of perioperative waste and what initiatives can be implemented to reduce this burden while maintaining high-value patient care.

The Cook Score: A Novel Assessment for the Prediction of Liver-Associated Clinical Events in a Diverse Population.

BACKGROUND AND AIMS: Transient elastography (TE) provides accurate quantification of liver fibrosis. Its usefulness could be significantly amplified in terms of predicting liver-associated clinical events (LACE). Our aim was to create a model that accurately predicts LACE by combining the information provided by TE with other variables in patients with chronic liver disease (CLD). METHODS: We retrospectively reviewed the electronic medical records of patients who underwent liver elastography, at John H. Stroger Hospital in Cook County, Chicago, IL. The incidences of LACE were documented including decompensation of CLD, new hepatocellular carcinoma, and liver-associated mortality. Significant predicting factors were identified through a forward stepwise Cox regression model. We used the beta-coefficients of these risk factors to construct the Cook Score for prediction of LACE. Receiver-operating characteristic (ROC) curves were plotted for Cook Score to evaluate its efficiency in prediction, in comparison with MELD-Na Score and FIB-4 Score. RESULTS: A total of 3097 patients underwent liver elastography at our institution. Eighty-eight LACE were identified. Age (hazard ratio (HR) 1.04, p = 0.002), aspartate aminotransferase to alanine aminotransferase ratio (HR 2.61, p < 0.001), platelet count (HR 0.98, p < 0.001), international normalized ration (INR) (HR 17.80, p < 0.001), and liver stiffness measurement (HR1.04, p < 0.001) were identified as significant predictors. The Cook Score was constructed with two optimal cut-off points to stratify patients into low-, intermediate-, and high-risk groups for LACE. The Cook Score proved superior than MELD-Na Score and FIB4 Score in predicting LACE with an area under curve of 0.828. CONCLUSION: This novel score based on a large robust sample would provide accurate prediction of prognosis in patients with chronic liver disease and guide individualized surveillance strategy once validated with future studies.

Awake spinal surgery: simplifying the learning curve with a patient selection algorithm.

OBJECTIVE: There is a learning curve for surgeons performing "awake" spinal surgery. No comprehensive guidelines have been proposed for the selection of ideal candidates for awake spinal fusion or decompression. The authors sought to formulate an algorithm to aid in patient selection for surgeons who are in the startup phase of awake spinal surgery. METHODS: The authors developed an algorithm for selecting patients appropriate for awake spinal fusion or decompression using spinal anesthesia supplemented with mild sedation and local analgesia. The anesthetic protocol that was used has previously been reported in the literature. This algorithm was formulated based on a multidisciplinary team meeting and used in the first 15 patients who underwent awake lumbar surgery at a single institution. RESULTS: A total of 15 patients who underwent decompression or lumbar fusion using the awake protocol were reviewed. The mean patient age was 61 ± 12 years, with a median BMI of 25.3 (IQR 2.7) and a mean Charlson Comorbidity Index of 2.1 ± 1.7; 7 patients (47%) were female. Key patient inclusion criteria were no history of anxiety, 1 to 2 levels of lumbar pathology, moderate stenosis and/or grade I spondylolisthesis, and no prior lumbar surgery at the level where the needle is introduced for anesthesia. Key exclusion criteria included severe and critical central canal stenosis or patients who did not meet the inclusion criteria. Using the novel algorithm, 14 patients (93%) successfully underwent awake spinal surgery without conversion to general anesthesia. One patient (7%) was converted to general anesthesia due to insufficient analgesia from spinal anesthesia. Overall, 93% (n = 14) of the patients were assessed as American Society of Anesthesiologists class II, with 1 patient (7%) as class III. The mean operative time was 115 minutes (± 60 minutes) with a mean estimated blood loss of 46 ± 39 mL. The median hospital length of stay was 1.3 days (IQR 0.1 days). No patients developed postoperative complications and only 1 patient (7%) required reoperation. The mean Oswestry Disability Index score decreased following operative intervention by 5.1 ± 10.8. CONCLUSIONS: The authors propose an easy-to-use patient selection algorithm with the aim of assisting surgeons with patient selection for awake spinal surgery while considering BMI, patient anxiety, levels of surgery, and the extent of stenosis. The algorithm is specifically intended to assist surgeons who are in the learning curve of their first awake spinal surgery cases.