Episode #193 Sustainable and Safe Anesthesia Care

March 13, 2024

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Welcome to the next installment of the Anesthesia Patient Safety podcast hosted by Alli Bechtel.  This podcast will be an exciting journey towards improved anesthesia patient safety.

Our featured article again today is from the October 2023 APSF Newsletter. It is, “Sustainable Anesthesia: Limiting Waste, Maximizing Resiliency” by Molly Herr and Leal Segura.

Thank you so much to Molly Herr for contributing to the show today.

We are covering the following equipment today:

  • Blood pressure cuffs
  • Surgical and isolation gowns
  • Operating room hats and arm coverings
  • Pulse oximetry probes

Here are the citations to the articles that we talked about today:

  • McQuerry M, Easter E, Cao A. Disposable versus reusable medical gowns: a performance comparison. Am J Infect Control. 2021;49:563–570. PMID: 33091509
  • Haskins IN, Prabhu AS, Krpata DM, et al. Is there an association between surgeon hat type and 30-day wound events following ventral hernia repair? Hernia. 2017;21:495–503. PMID: 28631104

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© 2024, The Anesthesia Patient Safety Foundation

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 hope you tuned in last week when we started the conversation about the trend towards increased dependence on single-use items during anesthesia patient care in the past two decades and how we can begin moving towards a more sustainable model.

Before we dive into the episode today, we’d like to recognize GE Healthcare, a major corporate supporter of APSF. GE Healthcare has generously provided unrestricted support to further our vision that “no one shall be harmed by anesthesia care”. Thank you, GE Healthcare – 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.

Last week, we addressed the scope of the problem of single use devices which are a billion-dollar industry, have a significant impact on waste, and are not safer for patients as long as proper cleaning protocols are used for reusable devices.

Armed with evidence-based analysis of product safety, infection risk, greenhouse gas emissions, and cost, it is possible to improve sustainability and supply chain resiliency in your anesthetic practice while keeping patients safe from infection and saving money.

Last week, we highlighted the environmental impact and financial implications of reusable compared to single use laryngoscope handles and blades. If you are currently using single use devices, this may be a good time to discuss product purchasing going forward and make plans for switching to reusable devices with proper cleaning protocols. We are picking up right where we left off!

Did you know that taking into consideration the lifetime costs of reusable laryngoscopes including reprocessing and device attrition, a reusable handle only needs to be used 4-5 time to generate a cost benefit compared to a single use handle and a reusable blade only needs to be used 5-7 times compared to a single use blade. Rest assured that after the first year of clinical practice, there are considerable cost savings for hospitals that make the switch even after the initial investment and with any cleaning protocol. What we learned the hard way from the Covid-19 pandemic is that reusable products not only will save hospitals money, but they may also save lives by protecting health systems from critical device shortages. During the pandemic, there was a massive shortage of single-use plastic video laryngoscope blades in the face of an increased demand. As a result, hospitals had to reprocess the blades internally or through a third-party reprocessing company in order to meet the demand. We also learned that reprocessing these single-use devices can be performed safely. The FDA regulates external third-party reprocessing so that devices are restored to their original quality, function, and sterility while maintaining safety warranties. This process also confers a cost savings over purchasing new equipment.

Now, let’s talk about some other equipment that is a part of routine anesthesia care. Have you placed a blood pressure cuff on a patient today? Was it a reusable one or single use? Evaluating the life cycle data reveals that reusable BP cuffs have a much lower environmental impact than disposable cuffs. In fact, reusable BP cuffs are environmentally better in every clinical setting with a wide variety of cleaning protocols with almost 40 times fewer greenhouse gas emissions than disposable cuffs over their lifetime. Once again, we see the cost savings as well. The life cycle cost analysis reveals that reusable BP cuffs are much cheaper than disposable cuff over their lifetime in outpatient and procedural areas. There is no data to support an increased risk of infection related to reusable cuffs either.  Keep in mind that if reusable cuffs are not properly disinfected, they may be contaminated by bacteria. This can also happen with single use cuffs if they are contaminated by the hands of health care workers. This highlights the importance of proper cleaning protocols and handwashing. These devices fit into the non-critical category on the Spaulding classification which requires low-level disinfection between patients.

What about all those surgical and isolation gowns that are used during surgery, anesthesia care, and throughout the hospital? Did your hospital have any gown shortages during the Covid-19 pandemic? Reusable gowns are less vulnerable to supply disruptions and can help keep patients and healthcare professionals safe. Healthcare providers had to use garbage bags for PPE during the pandemic due to the supply shortages and making the change to reusable gowns can help prevent this from happening again.

There are additional benefits for reusable gowns including improved infection protection and cost savings due to their durability and sustainability. Check out the 2021 article by McQuerry and colleagues, “Disposable versus reusable medical gowns: a performance comparison.” I will include this citation in the show notes as well. This was a study that compared Level 1, 2, and 3 disposable and reusable medical gowns in terms of ability to protect against infection across the product’s lifespan by evaluating water resistance, hydrostatic pressure, and durability assessments for breaking, tear, seam strength, piling resistance, dimensional stability, and air permeability, colorfastness, and fabric hand. New disposable gowns were tested, and reusable gowns were tested after 1, 25, 50, and 75 time laundered. The results revealed that lower-level disposable gowns did not meet the industry standard, this is the Association of Advancement Instrumentation PB70 Performance Specifications, for impact penetration water resistance. Level 1, 2, and 3 disposable gowns all did not meet the standard American Society of Testing and Materials performance requirements for breaking strength. Do you know what did meet the performance standards? That’s right, the reusable gowns met both performance requirements throughout the life cycle of 75 washings.

Other benefits of the reusable gowns are the decreased environmental impact with life cycle assessments reveal the following with the use of reusable surgical gowns depending on the specific analysis.

Decreased natural resource energy consumption by 28-64%

Decreased greenhouse gas emissions by 30-66%

Decreased blue water use by 41-83%

And decreased solid waste generation by 84-93%. Have you heard of the term blue water consumption? This is water that is removed from the water supply and not returned.

Now, let’s talk about another frequently used item in the operating rooms and anesthesia care areas, OR hats and arm coverings. The guidelines have changed over the past 10 years and current recommendations are for clean, but not mandatory disposable head wear. This is a patient safety concern as well since published evidence supports equivalent or possibly better infection protection with reusable hats compared to disposable ones with a significantly reduced impact on the environment. Many anesthesia professionals remember the 2015 guidelines on OR attire to reduce surgical site infection risk by the Association of perioperative Registered Nurses. These guidelines required the use of disposable bouffant hats and long sleeves for all non-scrubbed personnel in the OR and were accepted by accrediting bodies including the Centers for Medicare and Medicaid Services even though there was no definitive evidence to support the recommendation. As a result, there was a series of published studies that revealed no infection benefit with the use of disposable hats compared to reusable hats. Let’s dive a little deeper into the study by Haskins and colleagues published in 2017, “Is there an association between surgeon hat type and 30-day wound events following ventral hernia repair?” I will include this citation in the show notes as well. The study included 70 surgeons who performed more than 6000 ventral hernia repair surgeries which showed no significant different in surgical site infection related to the surgeon wearing a disposable or reusable hat. Other studies revealed that airborne particle contamination was lower with cloth “skull” hats compared to the disposable bouffant and that passive microbial shedding was significantly higher with the disposable bouffant compared to disposable skull hats and other cloth hats. Actually, it was the disposable bouffant hats that were the most permeable and had the largest pore size. Based on these new studies, the current guidelines from the American Society of Anesthesiology, American College of Surgeons, and the Association of periOperativeRegistered Nurses confirm the lack of scientific evidence showing any association between head covering type, extent of hair coverage, and SSI, and it is recommended to wear clean surgical coverings during procedures. Despite this, the use of disposable hats and gowns remains quite common even though there is no improved infection control, and they are more expensive. A study of over 12,000 matched pairs of surgical patients compared strict attire of disposable bouffant, disposable beard covers, and disposable long-sleeved jacked in non-scrubbed operating room staff after adoption of the 2015 AORN guidelines and revealed no improvement in the surgical site infection risk with significant increased costs, 10-20 times per person entering the operating room.

Our final devices are pulse oximetry probes. Many anesthesia practices use disposable pulse oximetry probes. Evaluation of individual patient safety related to disposable pulse ox probes compared to reusable ones reveals the following:

Lack of data showing any difference in the safety profile and accuracy

No data showing increased infection risk with properly cleaned reusable probes compared to disposable ones.

Another important consideration is that reusable pulse ox probes may improve patient safety in resource-poor countries due to increased availability. Did you know that pulse oximetry has been on the World Health Organization’s Surgical Safety Checklist since 2007, but 15% of operating rooms in resource-poor settings do not have this critical monitor. In addition, reusable pulse ox probes decrease waste and improve resource utilization while helping to improve community and planetary health. But wait, there’s more…

There are clinical benefits and cost savings with reusable probes. Reusable probes likely provide equivalent monitoring without safety concerns and with decreased costs which emerges once the monitor is used 22 times. For example, in an emergency department with 55,000 annual visitors, the annual cost savings was over $100,000 with reusable pulse ox probes.

We made it to the end of the article. The use of disposables is a threat to patient safety with hospitals at risk for supply chain shortages leading to implementation of inferior, unfamiliar, and costly replacement devices. The authors leave us with this summary and call to action. There is no evidence that single-use devices with low or intermediate infection risks provide better or safer care when compared to properly cleaned reusable devices. Anesthesia professionals must be leaders and consider sustainability standards, greenhouse gas emissions, lifetime costs, and supply chain resiliency as well as device quality, safety, and ease of use when purchasing devices for anesthesia care.

[Bechtel] Before we wrap up for today, we are going to hear from Herr once again. I also asked her what she hopes to see going forward. Here is her response.

[Herr] “The future for sustainability and anesthesiology holds promise as the medical community increasingly recognizes the importance of environmental responsibility. We’re aiming to decrease or eliminate the use of the most environmentally harmful agents, desflurane and nitrous oxide, minimizing their carbon footprint. Innovations in equipment design and sterilization and cleaning processes contribute to reduce waste generation.  Collaborative efforts among health care providers, manufacturers, and policy makers are fostering the integration of sustainable practices into standard protocols.

As awareness grows, education and training programs are likely to emphasize the environmental impact of anesthesia practice, shaping a new generation of healthcare professionals more attuned to environmental considerations. Ultimately, I see a future with anesthesiology as a leader in green healthcare practices, prioritizing both patient well-being and environmental sustainability.”

Thank you so much to Herr for contributing to the show today. This is an inspiring article. What devices are you using at your institution, disposable or reusable ones? We hope you are making the switch to reusable devices. Let us know if you are team reusable devices by tagging us on X @APSF.org. If you have a story about making the switch to reusable devices at your institution, we want to hear it. Send an email to [email protected] and we can feature it on the podcast! If you have any questions or comments from today’s show, please email us at [email protected]. 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.

Until next time, stay vigilant so that no one shall be harmed by anesthesia care.

© 2024, The Anesthesia Patient Safety Foundation