Welcome to the Becker's Healthcare podcast. I'm Mariah
Taylor, assistant editor, and I'm thrilled to have
Arash Motamed,
anesthesiologist
and medical director of sustainability
with Keck Medicine of USC
on the podcast today. Doctor motamed, thank you
so much for joining me. I'm really excited
to learn more about how you're discontinuing
nitrous oxide in the o r. But before
we jump into that, I'd love if you
could introduce yourself a little bit and tell
us a little bit more about why you
discontinued nitrous oxide.
Well, hi, Maria. Thank you for having me
on your podcast. It's my pleasure to be
here today. I'll start off with, you know,
my story and involvement with nitrous oxide.
It started off with a pretty
casual conversation with a colleague of mine who
works at a competing medical center,
and he was the one that first let
me know what the
problem with nitrous oxide is. And for those
who may not know, it's also known as
the laughing gas. It's a type of an
anesthetic inhalational
that
has been used for over a century, but
really started to gain a lot of popularity,
in the latter half of this past century,
and has some really great benefits in terms
of quick onset, quick offset,
and also, you know, very available
and inexpensive.
But what he told me at that time,
which is really sort of the start of
my journey in discontinuing nitrous oxide from our
medical center, was
a majority of the nitrous oxide that's in
the central pipelines and the hospitals leaks into
the atmosphere. So when they've done studies to
look at that, they say anywhere from seventy
five up to ninety five percent of the
nitrous oxide leaks,
typically at the areas of the connections.
And there's really no way to prevent this.
And, you know, what's interesting about it is
what it means
is that the nitrous actually
never has any clinical impact. It just goes
straight into the atmosphere. And then the next
question is, well, why do we care about
it? We do because
nitrous oxide is a fairly potent
greenhouse gas,
about 300 times,
as potent as carbon
dioxide. So it really has a big impact.
And on top of it, it does also
deplete the ozone layer. And then one other
thing with it is it lasts for a
pretty long amount of time in the atmosphere,
so about hundred years or so. So in
some ways, some of the first nitrous oxides
that were being used as anesthetics are still
somewhere in our atmosphere,
and most of it had gone unused in
terms of,
clinical
benefit to the patient. Now we know the
patient still gets the amount that we want
the patient to get, but majority of it
just leaks before it ever,
gets to the patient.
So knowing that and, you know, my involvement
with our sustainability
efforts at Keck, I felt
compelled that we need to look at this
and we need to figure out a way
to better address it. And and,
hospitals, nitrous oxide commonly comes in two forms.
So either cylinders that gets attached to the
anesthesia machine
or central pipes that, again, gets connected to
the anesthesia machine.
Almost all the times, if a place has
the central pipes, that's what they use, and
the cylinder is used as a backup, you
know, should there ever be any issues with
central supply.
So what we wanted to do was look
at our usage at our medical center and
decide, you know, whether it makes sense to
discontinue it.
The challenge with doing that, you know, one
is,
education and making sure that everyone has
awareness as to why we're doing what we're
doing, but, also,
it's
partnering with our, colleagues at facilities because, you
know, as an anesthesiologist,
I know nothing about, the central pipelines, how
they work, and how they function.
And, also, you know, at the end of
the day, this is a medication that anesthesiologists
have used for
many decades. So there is clinical comfort,
and when established habits that is,
takes some time to,
get them to see and understand and look
at other alternatives. So that's
the
basics of the beginnings of how we got
involved with, getting rid of, nitrous oxide.
Excellent. And how did you build a credible
business and clinical case for this initiative?
And then on top of that, how did
you get both hospital leadership and frontline physicians
aligned on it?
Yeah. That's a that's a really great question,
and I think goes to heart of any
type of initiative we try to do.
It really needs to be collaborative, and you
need to have the buy in because, otherwise,
it's just not gonna go anywhere.
What,
I decided to do in this particular instance
was,
initially,
I,
you know, our department in anesthesia is about
almost 200,
individuals,
combination of physicians, CRNAs, and, residents.
And I picked
about 20 of them who
either have leadership roles or, you know, are
otherwise still fairly influential or have, you know,
a lot of experience and expertise,
and I pulled them. And my first question
to them was, you know, are there any
types of cases that we do where nitrous
oxide is really the only
type of anesthetic we should use for? Because
if that answer
comes back as yes and a fair amount,
then it's a different question. But, you know,
as an anesthesiologist myself, I know the answer
is no.
And that was the response that I got,
which was great. So then it led to
the next question on on the next round
of surveys that we did, which was,
since we know that, you know,
it's not a must have,
can we have the option
of,
a, fully getting rid of everything that we
have?
Two,
discontinuing
the central pipeline and just having the cylinders
as backup should anyone need it?
Or three,
removing everything, but having a few cylinders somewhere
in the building as backup should anyone need
it, and we'll bring it up and connect
it to the machine.
And it was interesting
that, you know, through that process and, of
course, as as these surveys are happening, there's,
you know, education,
with the department and forms of, you know,
grand rounds,
to let them know what the impact of
nitrous oxide is. But most of the group
felt comfortable moving towards
an approach where we remove everything from the
OR. So it's not there ready to be
used,
but we'll have cylinders available should we ever
be in a need where someone feels like
that that is the best thing for for
their patient at that point in time. So
we reserved four cylinders,
where we keep all the the gas cylinders
in our hospital and created a pathway that,
you know, is easy to follow and a
phone number to dial, and the person comes
in and helps set it up. And what
was really interesting
was,
in the last
three years at our Keck Hospital and two
years at Norris Cancer Hospital, not a single
time has anyone needed to make that phone
call,
which essentially made us,
the,
only institution that I know of in The
US that has fully removed nitrous oxide from
both central supply and the cylinders.
That's incredible.
What were some of those key learnings you
had when you were moving this from a
concept into execution?
So one of the,
interesting
things that came up that we did not
know was
the way the nitrous is set up to
the machine. Once you discontinue it, that machine
could no longer do its self check and
would give a lot of errors, so it
would be nonfunctional.
So we first had tried this on one
of our spare machines just to see what
happens. And once we realized that that's a
problem, we needed to
connect with the manufacturer,
and have one of their representatives come in
because they needed, you know, special codes to
go in there and change the machine check
so that it doesn't alarm and it can
still do itself check and it can still
function. So that was an interesting learning point.
But one of the other things that was,
could potentially sometimes I think in other institutions
also be viewed as barrier is the term
that gets used frequently when it comes to
removing nitrous oxide from central
supply or central pipelines is decommissioning.
And decommissioning can mean different things to different
people as as I have learned, and it
could be anything from we're just not using
the pipes to we need to go into
the building and we need to remove pipes,
which, of course,
is not only a construction nightmare, but also
fairly expensive and, you know, regulatory challenges that,
you know, may come with it. Our approach
to decommissioning
was not to do any of that. It
was to simply
stop having nitrous oxide in those central pipelines.
And then our the our team with, the
facilities management actually came up with a really
brilliant and unique idea, which I think can
be used by other hospitals as well, which
is to fill that pipes with, nitrogen,
which is also another gas that helps preserve
the integrity of the pipes should there be
some other use for them down the line,
for some other form of gas. But at
the same time, it's also inexpensive, and it
doesn't have any negative environmental impact.
That's amazing. Some really interesting problem solving and,
you know, issues that probably nobody had thought
about before you tried.
So I'm curious if we take kind of
a step back. And when you're evaluating
sustainability initiatives as a whole, how are you
balancing the environmental impact with the financial performance,
clinical outcomes, all the operational feasibility,
and then how are you measuring the success
beyond just emissions numbers?
Yeah. That's the that's the tough question that
we try to figure out. Actually, with every
single project that we do, we're fortunate in
that,
at our institution,
there has been, you know, support to the
sustainability
program.
So we have a chief of sustainability and
a sustainability program manager.
And along with, you know, me and my
role, what we try to do with all
of these initiatives is partner with the various
stakeholders
at our hospital,
you know, whether it's, you know, obtaining data
or whether it's talking with supply chain
to try to figure
out what the impact is
both financially
and to the some of the contracts because,
you know, the hospitals may be tied to
certain contracts, so we can't just suddenly go
and say this is what we wanna do.
And then, of course, the
I would say both, you know, the return
on investment from an environmental point of view
or from a cost point of view.
There are projects
that, you know, will be very expensive with
maybe not so much,
significant environmental
impact in terms of reducing carbon footprint, and
then there's projects that are exactly opposite. So
in our approach so one, we collect as
much data as we can,
to before, during, and after. And we have
committees,
that meet very regularly on a monthly basis
with all the various,
individuals,
within the health system that play a role
in one form or another and the the
care that we deliver to make sure everyone's,
on board with the projects and it makes
sense.
Of course, clinicians,
are very much involved in we, you know,
we really listen to their input, and that's
part of my role is to bring them
on board and make sure, you know, nothing
that we do ultimately has a negative impact
on patient care.
But what we try to do, I would
say, on a very high level is most
of the projects that we decided to tackle
earlier on were the types of projects that
would achieve both. And that's, I think, one
of the other misconceptions with a lot of
these efforts to reduce the carbon footprint, of
care delivery is everyone just assumes it's gonna
be expensive.
And when you look at, you know, how
can we better be better for our environment,
the number one thing everyone just says is,
you know, reduce waste.
Reducing waste is obviously, you know, financially beneficial
as well as well, you know, in in
addition to,
reducing the negative impact of the on the
environment. In in
health systems,
there is a fair amount of waste. And
when you look at health systems, specifically the
academic medical centers and part of that cost
of education
also becomes access waste. So, you know, for
all of us who, you know, myself as
an anesthesiologist
in the operating room, we do see that
all the time. And part of it is,
just the
the practice of medicine and helping teach somebody
else and helping somebody else become,
a clinician. But I think the other part
of it is we've historically, as an entity,
never
truly looked at how much waste we generate
and what the impact is. And now we
know that health care is one of the,
you know, leading industries when it comes to,
greenhouse gas emissions. You know, studies have said,
at least in The US, anywhere from eight
to 10%,
and we're much higher compared to other institutions
outside of the country.
Absolutely. And I know here at Becker's, we've
seen a lot of hospitals that are starting
to move forward with sustainability initiatives in a
lot of different ways.
But I'm curious from your experience, where do
you see the biggest untapped opportunities for hospitals
to reduce their environment footprint?
Yeah. I I think from my point of
view, the the biggest untapped opportunity is still
lack of education.
I I think, you know, again, using myself
as as the
example of it. The first time I went
into a, grand rounds where some individual was
talking about the impact
of care delivery on carbon footprint was sort
of my moment of, you know, I need
to get involved, and what do I need
to do? And I think that is there's
still a great opportunity there, and
clinicians really need to be involved. There are
some,
hospitals or health care systems where they're doing
a fair amount,
in terms
of reducing energy usage or water usage, but
the clinicians haven't been fully,
engaged. So
educating and connecting both the hospital,
administrative side and the clinical side together, I
think, really makes a big difference from our
point of view. You know, once once we
got that group together, the project's just one
feeds the other. You know, when we started
our monthly OR group, talking about how can
we, you know, do better in the peri
op setting,
I remember the first session I had, you
know, afterwards, I'm like, oh my god. I
have nothing to say next month. I just
went over everything I had to say.
And now it's at a point, you know,
two years later where there's not enough time
to keep talking about all the different things
that people wanna do.
The different folks in the hospital, whatever their
role and responsibility is, are the ones that
come to us with the ideas.
We have one of the individuals at our
hospital that,
does patient transport is the one that, you
know, came up with idea of how to
try to create bins for,
the the significant battery waste, that we have
in hospital for all the devices that we
use. So the idea is slow once you
have that set up,
and, you know, you have the key individuals
involved. So I think from my point of
view, the biggest barrier is that first step.
And once you take that first step, it
just ends up feeding itself. And at the
end of the day, gets us to a
place where we
deliver better care because in my view, the
best care you can deliver is also the
most sustainable one where the patient does well
and they don't have to come back to
the hospital again or be readmitted
to the hospital or have a prolonged hospital
stay.
And,
as you we do that, we're able to
deliver more care and actually do it in
the most cost effective way. So for me,
that mentality is just very much aligned with
value care that we, you know, aspire to
deliver.
Absolutely.
Well, this has been such an informative discussion.
Thank you for taking the time to join
me today and share more about everything you're
doing.
Thank you so much. I appreciate being here.