Episode #61: Resilience and Sustainability: Preparing Healthcare for the Future with Dr. Elizabeth Cerceo

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I'm your host, Dr. Albert Rizzo, the chief medical officer of the American Lung Association.

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Today's topic strays away from our usual respiratory focus to address a broader topic that spans the healthcare industry. That is the importance of resiliency and sustainability in the healthcare industry. In these days of extreme weather events and resultant floods and wildfires, not to mention the consequences of epidemics such as the recent CO 19 pandemic, the nation's healthcare industry is at the front line of helping our citizens maintain their health.

In the healthcare industry, resilience is the capacity of individuals, organizations, or systems to adapt and thrive in the face of these challenges, stresses, and disruptions while maintaining high quality care. It involves preparing for, absorbing, recovering from, and adapting to various stressors. In the healthcare industry, sustainability focuses on creating and maintaining systems that improve, maintain, or restore health while minimizing negative environmental impacts and promoting the health and well-being of both current and future generations.

Both resilience and sustainability in the healthcare industry are significant topics on their own. Today we can only hope to raise our listeners’ awareness of these topics to improve their understanding of today's reality in the industry.

Our guest today is well suited to give us an introduction to this topic. Dr. Elizabeth Trucheo is professor of medicine and director of climate health at the Cooper Medical School of Rowan University in New Jersey. She is co-chair for physician engagement and women in medicine and serves as the associate program director for the internal medicine residency.

In this role, she develops novel curricula, including comprehensive research, advocacy, and climate health curricula. She is the chair of a climate health task force for the medical society of New Jersey and chair of the health and public policy for the American College of Physicians, New Jersey chapter, in which role she has been advocating for sustainability efforts for healthcare systems by creating a task force for healthcare sustainability in the medical society consortium on climate and health. She co-chairs two committees, one on education and one on climate smart healthcare.

Thank you for being with us today.
Thank you so much for the kind introduction.
You're welcome.

So let's start out with resilience. As I mentioned, I have heard this topic broken down into the individual, the organizational or hospital or clinic, and the broader system which includes the hospitals along with public health agencies. Do you think it's a good way to discuss this and what would be some of the factors contributing to resilience in these sectors of healthcare?

So, you know, I think there's been more and more in the news and in common conversation about what resilience means for hospitals. People often partition it into the resilience piece and the sustainability piece. And for those of us who are deeply embedded in this work, we see it as two sides of the same coin really.

But resilience means that you can keep your doors open and you can keep on treating patients, which we all want to do when there's a climate disaster or even if you think about it more broadly, because resilience also has to do with workforce if there are pandemics or other disasters that maybe are not even climate driven.

So that resilience kind of also comes in a couple of flavors. It's the infrastructure. Are your buildings constructed in a way that can weather that hundred-year storm or sustain the winds that are going to be coming in the next three or four decades? But then it’s also some of the softer infrastructure. Can you mobilize? Do you have the supply chain resilience, or do you only have that just-in-time three-day supply chain that so many health systems right now have?

Do you have the person power? We saw when there are events like in Lahina or with tropical storm Helen in North Carolina, healthcare professionals are often dealing with their own disasters. And so, how do you mobilize people who are already dealing with their own personal disasters to care for the injured and the sick?

All of this has to be thought of and really approached in a very deep way before a disaster happens. That means not just keeping those conversations within the four walls of your institution, but branching out and talking to community organizations, talking to local and state government and even regional consortia.

It really is something that, as you can imagine, has so many levels of complexity. So yes, that resilience does have to do with the buildings and with talking with engineers and architects in advance, but there's so much more to it than that. And it really is worthwhile putting in the effort upfront.

There have been some estimates — because I know that all health systems, not just now but for years, many are operating on shoestring budgets — but there really is an economic argument to a lot of this. There are some estimates that hospital damages from extreme weather can range from about $600,000 up to $2 billion. And the World Health Organization actually estimates that for retrofitting, you could invest as little as 1% of the value of a hospital and possibly protect up to 90% of a hospital's assets. So it really is important from an investment perspective to think about resilience in that lens as well.

I'm struck by what you said with regard to — I mean, did the CO 19 pandemic teach us anything? We saw burnout, we saw beds not being available, ventilators, a lot of the supply chain you mentioned. What do you see as a learning from that? And if we have learned, are we continuing to listen to our learnings?

Oh, that's a good question. There were a lot of lessons that I think many of us pulled out. Some having to do with supply chain resilience. Some having to do with how we can decrease some of our use so that we're not wasting. Some of us, you know, like a Lean Six Sigma methodology, making sure that we're utilizing the resources that we have and that we're also pulling on assets from the local community.

Even thinking about how we can partner with other hospitals and other health systems to share resources. One way that we kind of backtracked a little bit though has to do with PPE. So, you know, that the personal protective equipment is now everywhere. There are a lot of efforts in — it started, I believe, in the UK — but there are global efforts with gloves-off campaigns because now people are putting gloves on for everything.

When I go to the grocery store, people have gloves on. And if you talk to hand hygiene experts, they will tell you that it doesn't help hand hygiene because when people put on those gloves, they're not sanitizing their hands. They're not cleaning them and so it's actually worse for patients and we're using so many resources. It's very costly and of course all of those are ending up in landfills and the rubber has to come from somewhere. So there are rubber plantations where this has to be churned out from. So that's just one example where we maybe could have learned some lessons but then we also took a couple steps back.

Interesting. That's an interesting point.

So I think you may have mentioned this but I guess then really what is the goal and the actual benefit from the healthcare industry in being resilient?

A lot of it really does come down to the patients. You were talking in the very beginning about how this is maybe seen to be kind of like a separate parallel aspect to patient care. And I honestly see it as entwined.

A lot of this has to do with the fact that we as a healthcare system produce in the US 8.5% of our greenhouse gas emissions. And those greenhouse gas emissions and the resultant fossil fuel pollutants, the particulate matter 2.5 and the ozone and sulfur dioxide, nitrogen dioxide, all of these things that as pulmonologists you're all very, very well acquainted with — all of these impacts have direct effects on our patients.

So I see our efforts in sustainability as a direct preventive health measure to try to go upstream to keep our patients healthier and to keep populations healthier. In terms of resilience, again, this is a matter of being able to treat our patients, being able to keep our doors open when patients need us the very most.

Great. So, my next question maybe you've touched on a little bit as well, but we're going to turn to sustainability. I understand this can be viewed as the healthcare industry trying to balance environmental, social, and economic needs in delivery of their healthcare while still being aware of the needed resilience you mentioned already. Can you speak to what this balancing means and areas of focus for the healthcare industry at this point in time?

Yeah. So, you know, maybe just to step back and do some basics in terms of sustainability. When we're thinking about sustainability, we often talk about three scopes of emissions: scope one, scope two, and scope three.

Scope one emissions are those emissions that are coming right from your healthcare center. So that might be anesthetic gases, it might be ambulances. Scope two is your purchased electricity. And scope three is everything else. That means your medications, all that PPE from COVID, research, investments, transportation.

And so, as you can imagine, scope three is a big chunk of a hospital's emissions. So as we're trying to tackle all of those, we need to think about where the emissions are coming from and where our immediate scope of influence can actually affect change. And so very often scope one or maybe scope two are where we'll hone in on first because those are some aspects that we can directly impact.

So if we talk about scope one, for example with anesthetic gases, I'll use desflurane as an example because desflurane is a potent greenhouse gas. We often don't think about it as that but our anesthesia colleagues have actually been way ahead of us on this. They've been doing research in this field for a while. Desflurane is about 2,540 times more potent than carbon dioxide and it's also more expensive.

A case of desflurane costs about a little upwards of $13 a case whereas sevoflurane — which is not fabulous, it's about 140 times more potent than carbon dioxide — is about 60 cents. So, orders of magnitude difference. Health systems that have made that change and have tried to deemphasize desflurane in favor of IV anesthetics have saved a lot of money and have not experienced any adverse patient outcomes.

Seattle Children's Hospital, for example, saved about $175,000 annually by removing desflurane unless it was specifically requested. They also cut down on their nitrous oxide flows because nitrous oxide is also about 300 times more potent than carbon dioxide. So these are your win-win situations where you can save a health system money and you're also decreasing the environmental output.

You really look for those win-win situations.

We also need to reframe a lot of the value proposition. We traditionally will think about value just in terms of outcomes over costs, and we need to broaden that. We need to think about outcomes for the patient that we're treating but also for populations, and we need to expand cost so that it's the planet and its populations and its people — all of those things put together.

I think just broadening our lens really changes the conversation.

I've heard the term carbon footprint a lot, and some industries actually measure that and determine whether or not they can send people on trips and use airlines if they've reached a certain limit. Do you see health care systems looking at things like the carbon footprint, or at least putting it in that term?

And a lot already have. And I love that you mentioned the travel aspect because, you know, that is something that is such an easy way — because air travel is so carbon intensive — it's a very easy way for us to cut down on our carbon footprint. There have been some great studies that have modeled trying to prioritize virtual meetings.

We do the same thing with telehealth too. If we can offer telehealth to our patients, there have been some really interesting studies. I think there was a study out of California, I believe, that was saying that it saves patients on average about 11 or 12 miles in terms of their travel, but then of course there's a carbon savings and there's also a time savings.