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GREENHEALTH NEWSCleanMed a Success!Health Care Without Harm’s Healthy Food inHealth Care (HFHC) program has issued its thirdMenu of Change report, tracking the progressof the health care sector toward healthyand sustainable food service operations andhighlighting the work being done to advancethese efforts nationally and in regional pilots.“The health care facilities and professionalshighlighted in this report are making the criticalconnection between their missions to protecthealth, the food they serve, and the food systemthat produces it,” says Emma Sirois, nationalco-coordinator of the Healthy Food in HealthCare Program. “We are inspired by the amazingprogress of facilities and individuals containedin this report.”The report includes the results of a recentHFHC nationwide survey of hospitals that areengaged with HCWH in developing healthyfood programs.The HFHC program works with hospitals acrossthe country to help improve the sustainability oftheir food services. To learn more and to view thereport, visit healthyfoodinhealthcare.org.CleanMed, the nation’s premier conference on health care and sustainability, marked its 10th event thisyear by drawing its highest attendance since the conference began in 2001. More than 900 health careleaders converged in Boston to discuss best practices, learn from each other, and preview innovative newtechnologies. Sessions and workshops provided the opportunity for attendees to discuss health care’smost pressing sustainability issues: reducing toxins and chemicals of concern; sourcing and purchasingenvironmentally preferable medical products; providing patients, staff, and families with sustainable,local food choices; reducing energy and water use; and better waste management through recycling,reprocessing of medical instruments, and smarter supply chain management.shutterstock.com/ Kasia BialasiewiczGood for You4Greenhealth  June/July 2013“We hear from our members that the bestthing about CleanMed is the opportunity tolearn new things and to make connectionswith other professionals, from those withadvanced sustainability initiatives through tothose who are just beginning the journey,”says Laura Wenger, the executive director ofPractice Greenhealth.The keynote speaker, journalist Bill McKibben,spoke on the global effects of climate change andthe issue’s importance to the health care sector.Don Berwick, the former administrator ofMedicare and Medicaid who served for 22years as the CEO of the Institute for HealthcareImprovement, also gave a keynote address, alongwith announcing his run for Massachusetts’governorship in 2016. He discussed the role of health care and how it is a human right for all, and that HealthCare Without Harm and Practice Greenhealth are redefining the health of society. Berwick also discussedaddressed myriad ways hospitals can provide the health care the country wants and needs, at an affordablecost, by making changes in the health care system and using new treatment and prevention strategies.Planning for CleanMed 2014 is already underway. The conference will be held May 12-16 atthe Global Center for Health Innovation in Cleveland, Ohio. For more information, visit cleanmed.org.

shutterstock.com/ AperitiviCalifornia HospitalAssociation Supports HHIPractice GreenhealthConsulting ServicesThe Healthier Hospitals Initiative (HHI) announced that the California HospitalAssociation has signed on as a Supporting Organization of HHI, a collaborativeof leading health care institutions united to incorporate environmentally friendlypractices into daily operations for improved health of patients, staff, andcommunity; to reduce the sector’s environmental impact; and to save money.“With HHI, hospitals use their collective experience and proven strategiesto lead their communities in developing mitigation and resiliency programs forresponding to environment-related health issues,” says Gary Cohen, president ofHealth Care Without Harm and founder of HHI. “To achieve widespread adoption,we must come together with the support of organizations like the CaliforniaHospital Association to show this is both a sound business decision and the rightthing to do for improved public health and reduced environmental impact.”“The California Hospital Association’s vision is an optimally healthysociety,” says C. Duane Dauner, president and CEO. “TheHealthier Hospitals Initiative plays an importantrole in helping to realize that visionby encouraging better environmentalstewardship, as well as promoting the healthand wellness of patients and staff in Californiahospitals. The collective stewardship efforts ofCalifornia’s more than 400 hospitals and healthsystems will propel California to lead the nationtoward an optimally healthy society.”The leading hospital systems, supportingorganizations, and health care facilitieswork together to accelerate the use ofproven sustainability practices in sixkey “Challenge” areas: EngagedLeadership, Healthier Food, LeanerEnergy, Less Waste, SaferChemicals, and SmarterPurchasing.Success will bemeasured and trackedwith aggregatedata that canbe sorted bystate or hospitaltype—data that willbe of great use fordemonstrating success.Two sustainability-consulting firms—Resource Recycling Systems and SOSPartners—have joined forces with Practice Greenhealth’s SustainabilityConsultant Program. Designed to provide new options to meet your needs forin-depth consulting and taking the guesswork out of identifying the best fit foryour organization, the program gives you access to these high performers thathave demonstrated commitment to Practice Greenhealth values and approach.With customized recommendations for your facility using real-time informationonsite, Practice Greenhealth consultants are trusted sources.Resource Recycling Systems and SOS Partners both met the program’scriteria, including a review of services, customer interviews for qualityassurance, and ongoing exit surveys that provide insightful results.Resource Recycling Systems is a full-service sustainability consulting andimplementation firm that aligns with hospitals and health care systems to fullyincorporate sustainability into their existing strategies and cultures.SOS Partners is a cutting-edge sustainability planning and implementationconsulting firm that helps hospitals meet their environmental goals.For more information, visit www.practicegreenhealth.org.Learn more about the Healthier Hospitals Initiative athealthierhospitals.org.Pharma Waste WebsiteDeveloped by the University of Wisconsin Extension Solid and HazardousWaste Education Center and the Wisconsin Department of NaturalResources, the Pharmaceutical Waste Reduction website offers asearchable database of drugs for which there are documented studiesof successful waste reduction strategies. The site describes otherstrategies facilities might try and offers a process for determining whichstrategies to try first, based on each facility’s individual priorities. Healthcare facilities and researchers are invited to expand the tool by sharingproven waste reduction ideas via an online form. Visit uwm.edu/shwec/pharmaceuticalwaste/.“The collective stewardship efforts of California’s more than 400 hospitals and healthsystems will propel California to lead the nation toward an optimally healthy society.”—Duane Dauner, president and CEO, California Hospital Associationpracticegreenhealth.org   Greenhealth5

Greening the orAnesthesia for the EnvironmentA look at theenvironmental impactof anesthetic gases.By Angela Herring, science writer forNortheastern UniversityThe potential health impacts of climatechange are far reaching. Cardiovascular disease,heat-related asthma, and malnutrition due tocompromised food security are just a few ofthe associated risks. The health-care systemin which patients are eventually treated isresponsible for eight percent of the nation’sgreenhouse gas emissions. According to YaleUniversity School of Medicine assistantprofessor of anesthesiology and environmentalcompliance Jodi Sherman and NortheasternUniversity’s civil and environmental engineeringassistant professor Matthew Eckelman, thisall raises the interesting question of how thehealth-care industry itself is affecting our healththrough direct and indirect changes in ourenvironment.Sherman and Eckelman look at the lifecycle of various products and processes—fromproduction to destruction—to determine theiroverall environmental impact on a systems level.In a paper presented in the journal Anesthesia &Analgesia, Sherman and Eckelman performedlife-cycle assessments of the major anestheticgases used in the health care industry: nitrousoxide, desflurane, isoflurane, and sevoflurane, aswell as a liquid anesthetic alternative, propofol.“Any life-cycle assessment,” Eckelmansays, “is a series of tradeoffs among differentenvironmental impacts.” The health care systemis designed to reduce human mortality andmorbidity, but it is also important to understandthe indirect or unintended effect s that health carehas on the environment and public health. “Thehealth care sector is increasingly concerned withsustainability issues,” he says.The paper’s results show the relativeenvironmental profile of each anestheticalternative, and the important conclusionthat the combined environmental impact ofproduction, transportation, waste disposal, andother life-cycle events pales in comparison tothe impact of the anesthetic gases alone.“Anesthetic gases like nitrous oxide and thethree halogenated ethers are greenhouse gasesthemselves,” says Eckelman, “and they’re quiteSave the DateGreening the ORSymposiumSeptember 4, 2013The 1st annual Greening the ORSymposium celebrates progress andmilestones made on the journey topromoting environmentally friendlypractices in the operating room andinvites new thinking in innovativeideas to overcome our challenges, andconcepts that will result in new areasto address to drive further progress.6Greenhealth  June/July 2013www.shutterstock.com/ wavebreakmediaCAMLS Center for AdvancedMedical Learning and Simulation,Tampa, Florida

Desflurane, an anesthetic gas, has a 100-year global warmingpotential more than 2,500 times that of carbon dioxide.potent.” Desflurane, for example, has a 100-yearglobal warming potential more than 2,500times that of carbon dioxide, he says.Only small amounts of the gases are actuallymetabolized by the body. “The rest are usuallyvented out of the top of the hospital.” Inaddition to the anesthetic itself, these agentsrequire a carrier gas, which can be oxygencombined with either air or nitrous oxide, saysEckelman. In cases where nitrous oxide is used, alarge portion of the impact comes from emissionsof the carrier gases.Based on the research results, which putdesflurane at the top of the list in terms of life-cycle greenhouse gas emissions, Eckelman andhis team made a series of recommendations forboth doctors and hospitals. Within medical andcost considerations, they suggest doctors shouldavoid desflurane where possible; use oxygen asa carrier gas instead of nitrous oxide; minimizefresh gas flow rates; and employ IV anestheticalternatives in applicable cases—propofol’senvironmental impacts are negligible comparedto the inhaled anesthetics.The paper, which links health andsustainability, is part of a general internationaleffort to bring life-cycle assessment to bear onvarious aspects of health care practice.Life Cycle Greenhouse Gas Emissions of Anesthetic DrugsBy Jodi Sherman MD, Cathy Le, Vanessa Lamersand Matthew Eckelman PhDWhen mitigating anesthetic gases, there are practical environmental impactstrategies. Desflurane and N2O should be restricted to cases where they mayreduce morbidity and mortality over alternative drugs. Clinicians should avoidunnecessary high fresh gas flow rates for all inhaled drugs. Although reducingfresh gas flow rates increases the requirement for CO2 absorbent and itsconcomitant footprint, this is unlikely to offset the benefits of reducing volatiledrug and N2O use. Charcoal absorbers may be placed within the anesthesiacircuit to capture volatile waste anesthetic gas.Unfortunately, charcoal does not permanently remove the volatile drug.Volatile anesthetics diffuse into the atmosphere from charcoal absorbers in amatter of days, so they do not prevent emissions. Inhalation anesthetics arenot generally included in climate change mitigation strategies because theyare deemed “medically necessary.” Current Occupational Safety and HealthAdministration and Joint Commission regulatory language revolve aroundprotection of worker safety through methods such as prevention of excessiveexposure from handling, checking machines for leaks, and fire prevention. TheAmerican Society of Anesthesiologists-approved guidelines for waste anestheticgas management recommend “discharging safely to the outside atmosphere.”There is currently no waste anesthetic gas policy limiting discharge of anestheticgases into the atmosphere.Technologies on the near horizon include photochemical air purification. Thisapproach can theoretically destroy all waste anesthetic gases. Alternatively,current volatile waste anesthesia gas capturing systems can reclaim volatilegases for reuse rather than discharge waste into the atmosphere. The DynamicGas Scavenging System designed at Vanderbilt University is a cryogeniccondensing system built into the exhaust system of multiple operating rooms.This system is activated only when the patient exhales. Because the vacuumpump is only intermittently active, the system has minimal impact on heating,ventilation, and air conditioning energy usage. Deltasorb is an alternativetechnology consisting of a canister that snaps into existing scavenging circuits.It uses a sieve-like filtering matrix that adsorbs volatile anesthetic gas. Thecanisters are returned to the vendor where the captured anesthetics can beextracted, liquefied, and processed into medical grade anesthetics (Blue-ZoneTechnology, Toronto, Canada). The Food and Drug Administration is presentlyconsidering approval for reprocessed volatile drugs, which may also finduse in veterinary medicine. Propofol has the least overall impact on GHGemissions, even assuming a 50 percent wastage rate, disposable plastics forIV administration, and the energy requirements of the infusion pump. The highproportion of wasted propofol may have environmental impacts other than GHGemissions.Some quantity of unprocessed propofol likely makes its way into theenvironment, where it has moderate persistence. It is unknown what coursethe metabolites take within ecosystems or whether these are harmful. Thereis significant uncertainty in this analysis, particularly regarding the synthesisof propofol and the volatile drugs. Our results, therefore, should be interpretedwith caution. Future research would benefit from commercial-scale synthesisdata from pharmaceutical companies. Nevertheless, from our results it appearslikely that techniques other than inhalation anesthetics, such as IV anesthesia,neuraxial, or peripheral nerve blocks, would be least harmful to the climate.Finally, there are also important human health considerations from reducingGHG emissions. The World Health Organization estimates climate-relatedmortality at 0.3 percent of all annual deaths (150,000/year) and expects thisnumber to increase. For example, the incidence of cardiovascular disease andasthma may increase due to the emissions from coal-fired power plants andthrough temperature changes, and infectious diseases may spread more readilydue to altered habitats resulting from climate change. Clinical decisions shouldconsider the full environmental and human health impacts from anesthetic use.Excerpt from Anesthesia & Analgesia, May 2012, Volume 114 Number 5practicegreenhealth.org   Greenhealth7

Greening the Supply ChainIlluminating SustainabilityBy Beth Eckl, director of PracticeGreenhealth environmentalpurchasing program, andJason R. Tuenge of PacificNorthwest National LaboratoryFor more information onPractice Greenhealth’s EPPSpecifications and Resource Guide,visit www.practicegreenhealth.org8Greenhealth  June/July 2013Lighting consumes close to 35 percentof the electricity used in commercial buildingsin the United States and affects other buildingsystems through its electrical requirements andthe waste heat that it produces. Upgradinglighting systems with efficient light sources,fixtures, and controls can reduce lighting energyuse, improve the visual environment, and affectthe sizing of HVAC and electrical systems.Light-emitting diode (LED) technology hasbeen demonstrated to surpass conventionallighting technologies in terms of energyefficiency, longevity, versatility, and color quality.According to a recent forecast, LED lighting willrepresent 74 percent of lumen hour sales in theU.S. market by 2030. Over a 20-year period it’sestimated that use of LEDs will result in 25billion in savings and a greenhouse gas emissionreduction of roughly 1,800 million metric tonsof carbon.One area in hospitals where upgrading toLEDs makes sense is the operating room, whichneeds high levels of luminance and is potentiallya huge draw on the electrical system. TheDepartment of Energy’s Hospital Energy Alliancecame together to explore the benefits of LEDtechnology for surgical lights, looking at theenergy savings relative to tungsten-halogen.LED lighting in the operating room is provingto be a good choice for its superior energyefficiency, reduced heat, low maintenance, andlonger life. Chris Walters, product manager forSteris Corporation, explains, “LEDs radiatemuch less heat than incandescent bulbs, so thesurgeon and staff are more comfortable, which iscritical in long procedures.”Another benefit of LED lighting is the purewhite light it generates. Unlike halogens, whichneed filters and coatings to produce a whiterlight, LEDs are already white and are muchmore consistent than their halogen counterparts.Halogen lamps typically have a low luminousefficacy; LED lights typically have a higherefficacy depending on the product brand.Halogen lights are also typically rated 1,000 to3,000 hours, while LED surgical task lights arerated 25,000 to 40,000 and are expected to failby gradually fading in brightness.LED lights also may mitigate shadows castby surgical staff. In a typical LED light head,www.shutterstock.com/ MarafonaEnergy efficientLED surgical lightingproves to be a winin the OR.

LED lighting has several benefits in the OR,including its superior energy efficiency, reducedheat, low maintenance, and longer life.www.shutterstock.com/ Gergely ZsolnaiEnergy EfficientAccording to the American HospitalAssociation, there are more than 49,000operating rooms across the country. JohnD’Angelo of the Cleveland Clinic estimatesthere are 100 surgical lamps distributedamong the 30 operating rooms in his hospitalnetwork, and in use roughly 2,100 hours peryear. Assuming these figures are typical,there are approximately 163,000 surgicallamps in the U.S. The Pacific NorthwestNational Laboratory reviewed the majorsurgical luminaries and rated initial efficacyof LED lighting to be three times moreenergy efficient than halogen lights.each LED creates a spot. These individual spotsare then overlapped so no matter how manyLEDs are blocked during the surgery, the spotremains the same—round and consistent. Thishelps surgeons from being distracted by shadowpatterns. Another clinical benefit in the OR isthe color adjustment, but staff using the lightsshould ultimately determine color quality.At the moment, LED surgical lights cancost up to two times more than halogen lights,so when justifying the purchase of the moreexpensive LED, look at total cost of ownershipusing energy and replacement bulb cost savings.But the more compelling arguments are theclinical benefits that LED technology provides,which can lead to better patient outcomes. Ifcost is a major concern, W

The Spaulding Hospital on Boston's waterfront takes restorative care to a new level. Test of Time 16 The Joel Schnaper Memorial Garden in New York City is a rooftop oasis of healing for its patients. Healing environments JuNE/July 2013 Kalpana Kuttaiah Bruce Buck/Dirtworks PC practicegreenhealth.org GREENHEAlTH 1