The importance of sustainable practices in the cardiac catheterization lab (CCL) and its impact on the environment and climate change were explored by Alasnag et al in a recent paper in JACC: Cardiac Interventions.1

KEY FINDINGS

  • CCLs contribute to high use of energy and other resources that lead to a substantial carbon footprint. The interventional cardiology community and all CCL stakeholders benefit from taking steps toward a more ecologically sustainable CCL practice.
  • Solutions toward a more sustainable CCL include reducing, reusing, and recycling, tracking CCL resource use, and improving management of supply chain inefficiencies.

As explained by the authors, the health care sector accounts for a considerable amount of greenhouse gas emissions. Hospital waste accounts for a majority of all waste from the health care sector, with waste in CCLs contributing to approximately half of material waste. CCLs are also intense users of energy via supply chain inefficiencies, unnecessary waste, and a lack of effort in reuse and recycling.

Unfortunately, little attention has been brought to this topic and no standards yet exist for evaluating CCL sustainability. Thus, this article aims to analyze the biggest contributors to CCL waste and inefficiencies, recognize practical solutions, and identify areas of improvement.

Supply chain inefficiencies are a key factor when discussing CCL sustainability and are caused by limited physical storage capabilities, poor inventory management and product waste, ineffective information technology systems, and stringent financial controls. These inefficiencies lead to product shortages, inferior care, decreased revenue, and increased expenses. Managing supply chains with efficiency throughout the entire cycle is therefore pivotal to both the financial and environmental sustainability of a health care institution.

With this in mind, the authors suggest a few practical strategies and solutions to implement. The first strategy is to implement a way to track CCL resource utilization, waste, and carbon output, potentially by incorporating these variables into already existing quality improvement metrics tracking. Tracked variables could include measured landfill output, captured recyclables, other device/equipment use, and procedure cost. Observations regarding overall trends and heterogeneity across institutions could point to practices that most effectively decarbonize CCLs. However, the authors note that the ultimate goal is measurement of CCL carbon output and emissions, which allows for appropriate benchmarks and decarbonization targets. CCLs should also have a process in place to manage acute shortages, preferably via an interdisciplinary team.

The second strategy is to use a practice of reducing, reusing, and recycling as a framework to identify  ways to increase sustainability and carbon neutrality. The goal for reducing usage begins with aiming for as close to 0% waste as possible. However, as cited in the article, because > 1 million CCL procedures are performed in the United States annually, a 25% to 50% reduction in material consumption would significantly reduce waste overall.

Practical ways to decrease usage involve reducing or eliminating the use of paper (eg, paper packet inserts or paper instructions for use) and replacing them with electronic versions, as well as conducting a paper use audit. However, FDA may need to reassess current safety requirements and standards before changes could be implemented.

Regarding reuse, the authors suggest replacing single-use items with those that could be reused or resterilized, such as reusable gowns, resterilizable surgical options, or exclusion of unnecessary instruments in cath packs. This will require a discussion about the safety of resterilization and evaluation of infection control standards, as well as input and approval from FDA.

Recycling, especially in plastic disposable packaging, is also key. Unfortunately, many United States hospital systems lack recycling practices. As an alternative option, product manufacturers can  facilitate recycling buy-back programs. Conversation among all stakeholders is needed to identify best practices in recycling.

Overall, to address the increasing health care carbon footprint, scalable solutions are needed in all areas, including the CCL. It is imperative to acknowledge that CCLs currently make a hefty contribution to GHG emissions and its many untoward effects. It is time that the interventional cardiology community identify and adopt methods of improvement, such as tracking and measuring CCL resource utilization, waste, and carbon output; optimizing supply chain management; and employing strategies to reduce, reuse, and recycle. A “greener” future relies on making environmental sustainability a priority for all health care professionals and will need collaboration between all CCL stakeholders, noted the investigators.

1.  Alasnag M, Ahmed B, Jones T, et al. Cardiac catheterization laboratory sustainability: what it is and why it matters. JACC Cardiovasc Interv. 2023;16:2034-2039. doi: 10.1016/j.jcin.2023.06.004

Cardiac Intervention Today Asks…

Study investigator Bina Ahmed, MD, FACC, FSCAI, with Cottage Cardiovascular Associates at Cottage Health in Santa Barbara, California, provided additional insight.

Your review found that there were only three articles in PubMed dedicated to CCL environmental sustainability. What would you attribute to the lack of attention on this topic?

I think a lot of it has to do with limited awareness and education about the health care industry’s carbon footprint. There has been a larger movement to identify ways to decarbonize health care globally, but the response and uptick has been sparse in the United States over the last decade. In addition, I think as providers, it is challenging to factor in the waste and carbon output of our efforts while we are taking care of our patients. And finally, there may be a sense that the efforts on the individual scale will have no effect on the larger problem. This can be a very overwhelming issue to think about. 

The paper identifies several practical steps to take toward sustainability. What are the biggest roadblocks for implementing these solutions?

The first roadblock has to do with acknowledging and understanding the many reasons we need to be more ecologically sustainable in the cath lab. For most of us, this is not on our radar. Second, the supply chain is a complicated maze. Materials travel from all parts of the world to a handful of distribution centers. Many more complicated steps follow to eventually have the materials and equipment on our shelves. To try and make any change can feel overwhelming due to the complexities of process and often is the biggest hurdle. Third, the movement is missing its champions. For this to gain the needed traction, hospital and physician leadership will be essential.

Your paper stresses that sustainability is a collective responsibility for the CCL physicians/leadership as well as industry, societal leadership, and regulatory. How would you suggest an individual physician can raise awareness of this topic to the relevant leadership and their fellow physicians? What are some ways to raise general awareness among the community?

Any member of the cath lab team—be it physician, nurse, tech, or trainee—can champion the start of a more sustainable cath lab practice. Many institutions and hospitals already have operating room (OR) green teams that can be a helpful resource. Cath conferences are a good platform to educate and discuss the importance and need of sustainability in the cath lab. Another important aspect is ensuring the support of hospital leadership through education on the topic and the potential benefits of a more ecologically sustainable health care system. Though cath labs and ORs are high-yield areas to target for decarbonization, for the necessary impact, the hospital system as a whole will need to commit to lowering overall health care–related emissions. There are several resources available to educate and guide the needed transitions (Healthcare without Harm, Practice Greenhealth, etc). Similarly, national societies like the American Heart Association, the American College of Cardiology, and the Society for Cardiovascular Angiography and Interventions should consider a sustainability task force that evaluates appropriate decarbonization assessments and targets for CCL practice. Moving forward, benchmarking CCL sustainability as a quality metric will ensure that every cath lab has guidance on how to be more sustainable.