Is COVID a turning point for sustainability in hospital supply chains? [PODCAST]

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“Scarcity has, in many ways, defined the COVID-19 experience in the U.S., from shortages in personal protective equipment to ICU ventilators and hospital capacity, to COVID test kits, to drugs like Remdesivir in hard-hit states. These shortages have added impetus and new dimensions to existing conversations around health care supply chains, some of which had originally stemmed from a climate-conscious, sustainability lens. As suggestions are put forth to re-evaluate hospital supply chain design, from procurement to waste disposal, this momentum can be harnessed to achieve the dual aims of bolstering pandemic preparedness and improving sustainability in the health care sector.

COVID-19 illustrates the need for greater resiliency within health care’s supply chain. Dependence on expansive global networks for raw materials, manufacture, and distribution of critical health care supplies created a pathway prone to breakdown during a worldwide pandemic. Of note, this pathway is similarly vulnerable to the climate crisis, as worsening natural disasters can disrupt critical junctures of the U.S. supply chain.”

Genevieve Silva is a medical student. Cassandra Thiel is an assistant professor, NYU Langone Health’s Departments of Population Health and Ophthalmology.

They share their stories and discuss their KevinMD article, “Is COVID a turning point for sustainability in hospital supply chains?”

This episode is sponsored by Tradeoffs, available on your favorite podcast platform.

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Hosted by Kevin Pho, MD, The Podcast by KevinMD shares the stories of the many who intersect with our health care system but are rarely heard from.

Transcript

Kevin Pho: Hi, and welcome to the show, where we share the stories of the many who intersect with our health care system but are rarely heard from. My name is Kevin Pho, founder and editor of KevinMD. Here on the show we have Genevieve Silva and Cassandra Thiel. Genevieve is a medical student. Cassandra is an assistant professor at NYU Langone Health’s Departments of Population Health and Ophthalmology. Together they wrote the KevinMD article “Is COVID a turning point for sustainability in hospital supply chains?” Genevieve and Cassandra, welcome to the show.

Cassandra Thiel: Thanks for having us.

Kevin Pho: So we’ll get into your article in a little bit, but I’m going to ask each of you for your stories and journeys to where you are today. Genevieve, why did you go first?

Genevieve Silva: So I’m currently a third-year medical student at the University of Pennsylvania. But my journey toward being really interested in climate and health began pretty much from the beginning of undergrad, when I started getting involved in my school’s program on climate change communication. I interned at an environmental advocacy organization, and I completed my senior thesis work around environmental justice implications of fracking fluid. Throughout that journey, I became really, really aware of the intersections between climate change, environmental impacts, and human health.

As I paralleled my interest in medicine and matriculated to the University of Pennsylvania School of Medicine, I got really involved with health care sustainability groups on campus and a national group called Medical Students for a Sustainable Future. This group led me to Dr. Thiel’s lab. I was really drawn to it because she was working directly at the intersection of how the health care field itself contributes to emissions and waste and how it can become more sustainable. When the COVID pandemic hit, it was right around my summer when I was looking for a research internship, and that really brought us all together and got us thinking about the intersection of health care sustainability and also the COVID pandemic, which led to the article that we wrote together.

Kevin Pho: And Genevieve, has climate change been incorporated in any way during our formal medical training?

Genevieve Silva: While we haven’t necessarily had a formal course around climate change, it’s something that some of my classmates and I have really been working toward, and we’ve had some very productive conversations with administration around looking for ways to incorporate connections in our subspecialty blocks and in some of our social determinants of health courses, and ways that we can link climate to health. Administration has been largely receptive, so that’s something that we’re hoping will improve in the future.

Kevin Pho: Thank you. Cassandra, can you briefly share your story and journey to where you are today?

Cassandra Thiel: Sure. My background is actually in civil engineering, civil environmental engineering. While I was a doctoral student at the University of Pittsburgh, I met a surgeon who was very concerned about how much garbage she was making, and this got me started on a journey looking into health care and resource utilization and the environmental footprint from our health care services. So my lab at NYU Langone Health is really focused on using these engineering tools to quantify emissions from health care services. A lot of the studies we do are baseline assessments of, like, the carbon footprint from providing a specific surgery.

Jenny joined my lab one summer ago, so 2020, and of course we were in the middle of the COVID pandemic. Here in New York we had a really large outbreak going on, and it was, of course, a little scary. We had lots of PPE shortages, and every hospital was kind of on their own trying to figure out where they could source these single-use supplies from. This intersects, of course, with sustainability quite a bit, because those single-use supplies have a really large environmental footprint. So we started talking more about resilience and these supply chain issues, and started thinking about all the ways that the COVID pandemic would probably reshape our hospital supply chains and how we can start incorporating sustainability into that as those changes were occurring.

Kevin Pho: Now, before I ask Jenny to go into the article, give us a sense of the scope, because I really, honestly, didn’t really think about it before I read your article. Give us a scope of the carbon footprint of our health care system.

Cassandra Thiel: Yeah. So nationally, the U.S. health care sector is responsible for between 8 to 10 percent of our carbon footprint. It depends on the estimates and the assumptions that they’re making, but that’s all health care activities, so pharmaceutical production, hospital care, the transportation associated with moving patients around, and those kinds of things. It’s a lot. That’s nearly 10 percent of our greenhouse gas emissions, which is a huge number, because we emit a lot of greenhouse gases in the U.S.

So if health care in the U.S. were a country, it’d be the 13th-largest emitter in the world, ahead of many other countries. So there’s a lot of work that we can do as health care professionals to mitigate our impact, which should then also improve health outcomes for our patients and just people all over the world.

Kevin Pho: And we’ll certainly talk more about that in the interview. Both of you wrote the KevinMD article “Is COVID a turning point for sustainability in hospital supply chains?” Genevieve, for those who didn’t get a chance to read your article, can you just walk my audience through it and share the story about why you and Cassandra decided to write it?

Genevieve Silva: So, as was just being said, the health care system in the U.S. contributes a significant amount of the country’s greenhouse gas emissions, and a recent study actually found that 64 percent of those emissions from the U.S. health care system come from the supply chain itself, and that includes production, transport, and disposal of goods and services. As Dr. Thiel and I were thinking about putting together this article, we realized that as the COVID pandemic has escalated, the utilization of resources and waste and supply chain disturbances has really escalated as well.

So the point of this article was really to think about how we can harness this energy and momentum that currently exists in the health care system around rethinking supply chains, now that we’ve seen how easily they can be disrupted by disasters like the COVID pandemic, and how that momentum can be utilized toward also making changes in the supply chain that will make it more environmentally sustainable moving forward, to kind of achieve a dual aim of both reducing health care’s greenhouse gas emissions and also making its supply chain more robust to future disturbances, like, God forbid, a future pandemic or whatever else may impose a threat to the supply chain.

So in this article, to address that question, we go through a few different ways in which supply chains are currently being updated, in ways that could be further updated with tweaks to make them more sustainable. We talk about consolidating production to be more local, giving examples of certain health care systems that did in-house production of COVID tests, for example, when COVID testing was otherwise unavailable, when resources were strained. While this was helpful during the COVID pandemic, it would also be helpful long term in terms of reducing emissions from transporting supplies, to create resources long term after the COVID pandemic has passed.

We also spoke about making procurement more sustainable. There are multiple resources that exist from organizations like Practice Greenhealth that list suppliers that utilize more environmentally sustainable practices than others. Hospitals during the COVID pandemic began vetting vendors for various reasons, and that kind of practice can be translated into also vetting vendors for their environmental sustainability. In addition, we spoke about supply sharing among health care systems, which was previously not so much standard practice but also increased during the pandemic, which can also, again, help reduce costs and greenhouse gas emissions associated with bringing in supplies from afar.

Finally, we wrapped up the article by talking about how we can just overall work to reduce the need for instant supply chain ramping up by creating a system that overall just emphasizes reuse of supplies more than generation of new supplies. Third-party reprocessing is a method by which we can do this, as well as increasing technology around demand forecasting and automation of tracking inventory in hospitals.

Kevin Pho: And Cassandra, when I hear about hospital supply chains, it’s several steps removed from what I see as a physician. So can you share, like, a story or a case study to make a hospital supply chain more tangible to the clinicians?

Cassandra Thiel: There are so many supplies that we rely on to provide care, and we don’t think about it because they’re usually there and available for us. So, you know, if I’m going into, let’s say, a cataract surgery (I’ve done a lot of work in ophthalmology), we have the PPE, our gowns and gloves and masks and head caps and all those kinds of things. Those are usually all single use and disposable. And then we have our surgical supplies, so, you know, cannulas, and, I don’t know, there are even disposable blood pressure cuffs and stethoscopes, right? So all these single-use supplies come in. We have, of course, reusable supplies, which also have to be manufactured somewhere but then are typically sterilized in-house in our central sterile departments, which are fun places to check out for anyone who hasn’t seen them.

All these supplies have to be manufactured somewhere. Usually they’re manufactured all over the world. Gloves, of course, we know a large number of them came from China, which is part of the reason we had shortages, that their manufacturing was shut down as the initial outbreaks occurred, and sent all over the world. You know, really huge global supply chains. And we use them, hopefully once, and then they get thrown away, and their disposal makes them end up in our communities in various ways. Usually for the U.S. it’s landfilling or incineration, but all of these steps and stages have emissions. You know, we’re burning fossil fuels to get these goods manufactured and transported wherever they’re going.

In addition, because they’re manufactured brand new every single time, that puts us a little bit at risk, especially when we suddenly need a lot of, say, PPE and they’re hard to source, and we need more than we ever have in the past, right? So you have both a supply and a demand issue, which I think most clinicians would have felt last year especially. That shortage of PPE was really tangible. Just a few months before the COVID pandemic, I could go into an operating room and grab as many gloves as I wanted, and no one cared, and then all of a sudden they were under lock and key.

It’s just, all the supplies are very crucial, and it’s something that, because it had worked in the past, we didn’t have to think about. Our concern moving forward is that with climate change there will be a lot more disruptions to supply chains. We saw it with Hurricane Maria hitting Puerto Rico, which interrupted the supply of IV bags. These kinds of things will become more and more common, so we really have to rethink how we’re using these resources and where we’re sourcing them from.

Kevin Pho: Cassandra, I work for a community hospital in a relatively small town. Now, as to solutions to these issues, does it have to be at a policy level, or are there things that individual hospitals can do?

Cassandra Thiel: I think it’s a little bit of both. Of course, we would love to see regional or national policies that help us maybe stockpile gear and manage those stockpiles well. But I think local hospitals also have a role to play, perhaps with your group purchasing organizations, if you’re contracting with a GPO. But you can certainly work on your procurement and the contracts that you have worked out with suppliers. You can start looking for more reusable goods, for example, because then you own those products. So there are reusable isolation gowns, for example, and you could have your own stock of those and set up ways to sterilize and clean them, and that typically has a lower environmental footprint than buying brand new and disposing of them over and over again.

But also, as Jenny mentioned in our article, just having better track of your inventory can be very helpful, right? So that supplies don’t expire and have to be disposed of without having been used. And even before expiration, there are a lot of supplies, particularly in operating rooms, even in patient units, where we end up throwing the supplies away because of some weird issue. You know, maybe they were opened up and not used but the patient was in the room, or maybe they fell on the floor because we overstocked a cabinet. Those kinds of things are definitely something that you can work on at the local level to just reduce what you’re bringing into those spaces.

Kevin Pho: We’re talking to Genevieve Silva and Cassandra Thiel. Genevieve is a medical student. Cassandra is an assistant professor at NYU Langone Health’s Departments of Population Health and Ophthalmology. Together they wrote the article “Is COVID a turning point for sustainability in hospital supply chains?” Genevieve, what are some things that medical students and physicians can do on an individual basis to bring more attention to that intersection between climate change and health care?

Genevieve Silva: I think that part of what both med students and physicians can do is just bring the conversation more to the general awareness of their colleagues in health care systems. I think it’s something that’s not thought about as often as it could be. Just making your colleagues aware, whether there’s an opportunity to speak at a conference or to share an article about the amount of waste that’s being generated daily by hospitals, because it’s very significant, could just really get in the backs of people’s minds and make someone maybe think twice before opening up a second kit just to check what’s in it and then having to throw it away just because it’s been opened, even though it’s unused. Things like that happen so frequently in the hospital, and they are, just as Dr. Thiel was saying, easy ways to avoid waste.

I’d also say that there are a lot of really great toolkits out there by organizations like the Medical Society Consortium on Climate and Health, Practice Greenhealth, and Health Care Without Harm. These are all organizations that have published resources for physicians and med students to use for both advocacy and education, which include information to use in patient conversations as well as things like slide decks to use in presentations to colleagues. So there are a lot of ways you can get involved, and I definitely encourage anyone who’s interested to get involved.

Kevin Pho: And I’m going to ask each of you your take-home messages to the KevinMD audience. Cassandra, why do you start with you?

Cassandra Thiel: Yeah, I think my take-home message is, you know, it’s very clear after the COVID pandemic that the health care supply chain needs work. We’re not resilient. It’s not sustainable. Now that we’re kind of not fully recovered from COVID but able to step back and reassess things, now is the time to really work on the supply chains and make them more sustainable, make them more resilient.

Kevin Pho: And Genevieve, what’s your take-home message that you want to leave with the KevinMD audience?

Genevieve Silva: I would echo what Dr. Thiel said. I think the supply chain disruptions that we saw from the COVID pandemic really illustrate how important it is to be preemptive and proactive with anticipating threats to the health care system. Climate change is poised to create so many escalating threats over the next few decades that now is really the time to take action to bolster health care supply chains, both in terms of resilience and also in terms of not contributing to escalating climate change, by making them more environmentally sustainable.

Kevin Pho: Genevieve, Cassandra, thank you so much for sharing your time and insight, and thanks again for being on the show.

Genevieve Silva: Thank you for having us.

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