Hello and welcome back to the Anesthesia Patient Safety Podcast. My name is Alli Bechtel, and I am your host. Thank you for joining us for another show. We are getting ready to discuss the February 2024 APSF Newsletter articles. For our show today, we are returning once again to the October 2023 Newsletter to talk about the increased dependence on single-use items during anesthesia patient care and moving towards a more sustainable model.
Before we dive into the episode today, we'd like to recognize Fresenius Kabi, a major corporate supporter of APSF. Fresenius Kabi has generously provided unrestricted support to further our vision that "no one shall be harmed by anesthesia care". Thank you, Fresenius Kabi - we wouldn't be able to do all that we do without you!"
Our featured article today is from the October 2023 APSF Newsletter. It is, “Sustainable Anesthesia: Limiting Waste, Maximizing Resiliency” by Molly Herr and Leal Segura. To follow along with us, head over to APSF.org and click on the Newsletter heading. Fourth one down is the Newsletter archives. Then, scroll down until you get to October 2023. From here, scroll down until you get to our featured article today. I will include the link in the show notes as well.
Before we get into the article, we are going to meet the author. Let’s take a listen.
[Herr] “Hi, my name is Molly Herr and I'm a pediatric anesthesiologist at the Mayo Clinic in Rochester, Minnesota. My other roles include being chair of the Mayo Clinic Rochester Sustainability Subcommittee and I serve as a member of the ASA's Committee on Environmental Health.”
[Bechtel] To kick off the show today, I asked Herr why she wrote this article. This is what she had to say.
[Herr] “It is becoming increasingly apparent that sustainability in healthcare is of the utmost importance. We're seeing human health being affected by climate change now, but we also need to realize that healthcare itself is having an impact on climate. This is due to healthcare's associated enormous greenhouse gas emissions and its heavy reliance on single use disposable devices.
For anesthesiology practices to remain resilient and safe in a new era of supply chain shortages and to improve public health, we need to decrease waste and increase reusable device use where we can. In this article, we wanted to emphasize that properly cleaned, reprocessed devices are proven safe and should be maximized for improved sustainability and planetary health.”
[Bechtel] Thank you so much to Herr for helping to kick off the show today and raising this important call to action related to anesthesia patient safety and planetary health. And now, it’s time to get into the article.
First, we need to understand the scope of the problem. Have you noticed that we are using a lot of single-use devices during our anesthesia practice? Examples include laryngoscopes, video laryngoscopes, blood pressure cuffs, medical gowns, operating room hats and attire, and pulse oximetry probes which are used for one patient and then thrown away. Four years ago, in the United States, the disposable medical device market was a $66.9 billion dollar industry which has been growing at a compound annual growth rate of 16.7%.
So, why are we using so many single use devices? Manufacturers highlight the ease and safety of single-use products. Others claims that infection control is easier with single use devices. Many health care organizations have turned to single-use devices rather than tackle the ambiguity and changes in processing requirements for medical equipment and be at risk for citations by accrediting bodies.
One of the lessons that we learned during the pandemic was that over reliance on disposable devices may lead to significant supply shortages if the supply chain is disrupted. There is a “just in time” mentality used by health care systems to keep costs low by maintaining relatively low supplies and reordering short-term supplies only when needed. Many anesthesia professionals in the United States have witnessed frequent and significant shortages of equipment, supplies, and medications over the past three years. This has led to scrambling for alternative equipment and supplies and then needing to use second- or third-line devices or medications which is a big threat to anesthesia patient safety due to the frequent introduction of new and unfamiliar supplies. If we are going to learn from these product shortages and supply chain disruptions, then we need to evaluate disposable device usage.
We haven’t even talked about the environmental concerns yet, but this is something that we have talked about before on this podcast. Anesthesia care has a rather large environmental footprint as we are learning. This has led many health care systems to try to decrease waste and greenhouse gas emissions produced from surgical procedures and anesthetic care. The authors provide methods that can be used to improve sustainability and supply chain resiliency with evidence-based analysis of product safety, infection risk, and greenhouse gas emissions related to product manufacturing, use, and disposal. This is a critical patient safety topic since maximizing the use of reusable products decreases the risk of shortages. Plus, reusable products means less waste and the potential for significant cost benefits for health care systems. That’s right cost benefits. And now that I have everyone’s attention, let’s keep going with the article.
Modern anesthesia practices must be sustainable, resilient, and cost-effective and this requires understanding product costs and resource utilization. Are you responsible for product purchasing for your anesthesia practice? Are you evaluating life cycle costing and life cycle assessments? Check out Table 1 in the article to review these important terms.
· Life Cycle assessment is an internationally standardized modeling tool evaluating the cradle-to-grave environmental impact associate with all states of a product’s life. This includes raw material extraction and processing, manufacturing, distribution, use, and eventual waste or recycle.
· Life Cycle Costing is the process of compiling costs of ownership over the lifetime of a product.
The next step is to consider waste management in terms of the environmental impact patient and community safety, and cost benefit. Check out Figure 1 in the article for a picture of the Waste Hierarchy. This is a tool that healthcare leaders can use when evaluating product purchases. For the Waste Hierarchy, from the most preferable to the least preferable is: Rethink, Reduce, Reuse, Recycle, Dispose. The authors provide the example of a properly cleaned, re-used pulse oximetry probe has a lower impact on the environment and is cheaper than a recycled or discarded probe.
There are significant benefits to successful waste management which include improved community health by decreasing landfill waste and incinerated waste and improved planetary health by decreasing fossil fuel usage, carbon dioxide emissions, and the energy required for the manufacture, transport, and disposal of single-use products.
Let’s see if we can address some of the arguments against reusable products such as the relationship between surgical site infections and reusable products. Surgical site infections are a threat to patient safety with increased hospital length of stay, increased risk of readmission, and increased morbidity and mortality. Single-use devices may offer easy infection control, but properly cleaned reusable devices do not increase the risk for surgical site infection. The Center for Disease Control and Prevention has requirements for device disinfection and sterilization based on the Spaulding Device Cleaning Classification. Check out Table 2 in the article which provides the details of this system of cleaning techniques and reprocessing methods depending on the devices, patient contact, and the infection risk. Keep in mind that all medical equipment should be cleaned according to the manufacturer’s instructions for use which can help to ensure device safety and longevity. For the Spaulding Device Cleaning Classification there are different levels, infection risk, description, examples, and required processing methods. The highest level is critical with high infection risk for devices that enter sterile areas including the vascular system. This includes surgical instruments and implants and these must be cleaned with sterilization and high-pressure steam. The next level down is semi-critical with moderate infection risk for devices that contact mucous membranes or broken skin. This category includes laryngoscope blades, rigid and flexible endoscopies, and video laryngoscope blades which require high-level disinfection with chemical reprocessing, vaporized hydrogen peroxide, and glutaraldehyde. The final category is non-critical with low infection risk for devices that contact intact skin. This includes laryngoscope handles, blood pressure cuffs, stethoscopes, and video laryngoscope handles which need to be cleaned with lower-level disinfection such as with wipe disinfection, sani-cloths, 70% isopropyl alcohol, and quaternary ammonium. Interestingly, organizations do not agree about laryngoscope handle cleaning so these may be categorized as either noncritical or semi critical.
This is an important area where anesthesia professionals can help to keep patients safe while decreasing the environmental impact and waste associated with anesthesia care. We are going to review commonly used disposable and reusable anesthesia products.
When you think of anesthesia equipment, the first things you think about are probably laryngoscope handles and blades, right? Are you using reusable or disposable ones at your institution?
There is significant environmental and cost savings associated with the use of reusable equipment while maintaining patient safety with proper cleaning. Let’s dive a little deeper into this. In the Spaulding Classification, laryngoscope handles are either low or moderate risk which means they need to be cleaned with either low-level disinfection with chemical wipes or high-level disinfection with chemical reprocessing. The required cleaning depends on the recommendations from different professional organizations, but with either cleaning method there is still an environmental benefit in favor of the reusable handles and blades.
Check out the 2018 Anesthesia and Analgesia article by Sherman and colleagues, “Life cycle assessment and costing methods for device procurement: comparing reusable and single-use disposable laryngoscopes.” I will include this citation in the show notes and we are going to take a closer look at the data from this article now.
The researchers report the following:
· A disposable metal handle produces more than 20 times more greenhouse gas emissions than a high-level disinfected reusable steel handle with an estimated life span of 4,000 uses.
· From an environmental perspective, the reusable stainless steel handle treated to high-level disinfection is the way to go whereas the single use handles are the worst option.
· For blades, the reusable steel togue blade treated to high-level disinfection standards is the best option, unless you choose to sterilize these reusable blades which increases the greenhouse gas emissions by almost 400%. But, even with sterilization of the reusable blades, there is significantly less greenhouse gas emissions than the single-use products.
We covered the environmental benefits for reusable handles and blades, but what about the costs?
Here are the costs per use according to the article by Sherman and colleagues:
Reusable handle with low-level disinfection = 58 cents per use
Reusable handle with high-level disinfection 98 cents per use
Reusable handle with sterilization 2 dollars and 39 cents per use
Single use handle 10 dollars and 66 cents per use
For institutions that perform more than 60,000 intubations each year, this means a potential cost savings of over $500,000 by switching to reusable handles.
We can’t just intubate with the handle though, so what about the blades?
Reusable tongue blade with sterilization = $2.10 per use
Reusable tongue blade with high level disinfection = $0.69 per use
Single use blade = $5.11 per use
In the above scenario, switching to reusable blades may translate into a cost savings of about $200,000.
There is no data that supports the benefits of single use laryngoscopes compared to reusable devices cleaned to the standard of the Spaulding Classification criteria and the manufacturer’s instructions for use. Infection control is still an important threat to patient safety, and we cannot let down our guard. There are case reports of infection transmission in neonatal intensive care units due to laryngoscopes that were not disinfected properly. There are older studies that report contamination with low or very low quality of evidence and inconsistent cleaning protocols. There is more data in favor of properly cleaning laryngoscope handles to decrease infection transmission though. Check out the 2009 study by Call and colleagues, “Nosocomial contamination of laryngoscope handles: challenging current guidelines.” The investigators examined laryngoscope handles that had been cleaned with low-level techniques and found no pathogenic bacterial or viral colonies and rare to few nonpathogenic bacterial colony growth. Interestingly as the study progressed, there was decreased bacterial colony growth from the handles which likely represents increased performance of the cleaning protocol by the anesthetic technicians. Keep in mind that the impact of this level of bacterial contamination on the laryngoscope handles is not known at this time. What we do know is that 50% of sterile fields are contaminated with a few hours even in an empty operating room and bacteria have been cultured from newly opened sterile trays. Plus, anesthesia professionals are using reusable and single use laryngoscope handles without sterile gloves so both types of devices may be opened, touched, and contaminated during OR setup. With reusable devices, it is important to complete high-quality cleaning and reprocessing protocols prior to use.
We have only cracked the surface on the environmental and cost saving benefits from using reusable devices instead of single use devices and with appropriate cleaning protocols, we can uphold our commitment to infection control and patient safety. We hope that you will tune in next week as we continue the conversations. We’ll be highlighting blood pressure cuffs, gowns, OR Hats and arm coverings, and pulse oximetry probes.
If you have any questions or comments from today’s show, please email us at podcast@apsf.org. Please keep in mind that the information in this show is provided for informational purposes only and does not constitute medical or legal advice. We hope that you will visit APSF.org for detailed information and check out the show notes for links to all the topics we discussed today.
There is still time to submit an article for the June 2024 APSF Newsletter, but the deadline is fast approaching on March 10th. You can feel free to submit a manuscript at any time too. Type of articles may include review articles, case reports, questions and answers articles, letter to the editor, rapid response, and editorials. Check out the Guide for Authors over on the APSF website for more information. You may be the next APSF newsletter article author and before you know it we will be talking about your article her eon the podcast. So, what are you waiting for?!?
Until next time, stay vigilant so that no one shall be harmed by anesthesia care.
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