Happy World Environment Day (June 5 2024)!  Our guests celebrate by discussing sustainability in healthcare and infectious diseases.  Join Drs. Shreya Doshi, Preeti Jaggi, Pam Lee, and Shira Abeles as they raise awareness about the ways ID professionals can help reduce the negative environmental impact of the way we provide healthcare to our patients!

Here is the JPIDS/OFID Supplement Introduction from Drs. Doshi and Jaggi: Healthcare Environmental Sustainability Through an Infectious Diseases Lens

The second article mentioned is: Healthcare Sustainability to Address Climate Change, Call for Action to the Infectious Diseases Community

The Sustainabil-ID group mentioned in the podcast can be found on Twitter/X @sustain-ID as well as via email at sustainabilityiddocs@gmail.com

Episodes | Consult Notes | Subscribe | Twitter | Merch | febrilepodcast@gmail.com

Febrile is produced with support from the Infectious Diseases Society of America (IDSA)

Hi

everyone.

Welcome to Febrile, a cultured podcast about all things infectious disease.

We use consult questions to dive into ID clinical reasoning, diagnostics, and antimicrobial management.

I'm Sara Dong, your host and a MedPeds ID doc.

We are bringing you today's episode in honor of World Environment Day, which will be June 5th, 2024.

World Environment Day is led by the United Nations Environmental Program and held annually on June 5th, since 1973.

It is the largest global platform for environmental public outreach, and we're using this as an opportunity to talk about sustainability and infectious diseases.

First of all, welcome the mastermind behind most of this episode, Dr.

Shreya Doshi.

Shreya is a second year pediatric ID fellow at the Children's National Hospital in D.

C.

She's focused on diagnostic stewardship and healthcare sustainability.

She is co founder of the Sustainabil-ID Group, which you'll hear more about in this episode, a group dedicated to research integrating environmental sustainability into ID.

And she is also co editor of an upcoming supplement in J PIDS and OFID on healthcare sustainability and ID.

Hi, this is Shreya.

Next, let's meet Dr.

Preeti Jaggi.

Preeti is currently a Professor of pediatrics at Emory University School of Medicine and the Medical Director of Antimicrobial Stewardship at the Children's Healthcare of Atlanta.

She is the chair for Georgia Clinicians for Climate Action.

She is also partners with Shreya on the two things I mentioned, the Sustainabil-ID group and the J PIDS OFID supplement.

She sees parallels between the advances in antimicrobial stewardship and healthcare quality improvement that could be applied to decreasing emissions in healthcare settings.

Hi, this is Preeti.

Thank you so much for having me.

Now we meet Dr.

Pam Lee.

Pam is an ID specialist at Harbor UCLA Medical Center.

Much of her training took place in LA County's Department of Health Services, and as such, she is deeply committed to providing healthcare for LA's safety net populations.

She is an IDSA SHEA 2023 2024 LEAP Fellow (Leaders in epidemiology, antimicrobial stewardship, and public health).

She also co leads the healthcare sustainability team for the California based advocacy group Climate Health Now.

Hi everyone, I'm so excited to see you all again after just seeing you last week in person at Clean Med.

This is great.

And last but not least is Dr.

Shira Abeles.

Shira is an I.

D.

specialist and Medical Director of Sustainability at UC San Diego Health.

She also serves as Medical Program Director of Antimicrobial Stewardship and Associate Medical Program Director of Infection Prevention and Clinical Epidemiology.

Her research focuses on evaluating methods for curbing unnecessary antibiotic use in healthcare settings, as well as assessing the clinical impacts of various infection prevention interventions.

Hi, this is Shira.

Thanks for having me.

Uh, so as everyone's favorite cultured podcast, on Febrile, we like to ask our guests to share a little piece of culture, really just something non medical that you enjoy or that has brought you happiness.

Uh, so I'd love to hear about some things that you guys are interested in.

I thought about this question for so long and I was so excited to answer it, but the thing I want to talk about is the pizza scene in Long Beach, California.

It's amazing.

The Washington Post named one of our pizza vendors the best pizza in the country, so I highly recommend it.

I would say that that place is called Speak Cheesy, but there are about, I don't know, five or six other places in Long Beach that are just outstanding pizza.

Happy to give more recommendations.

Love it.

Um, how about you, Shira?

What brings me joy is being in the great outdoors, so going on hikes and being by the ocean here in San Diego.

And what about you, Preeti?

Uh, I really like to cook and I recently took a Thai cooking class, which was a lot of fun and I learned about the three musketeers of Thai cooking as taught by my Thai teacher.

And it was lemongrass, kaffir lime leaves, and galangal.

And that was kind of fun.

I made some pad thai after that class.

Very nice.

And I can attest to, uh, Preeti's cooking because she's been nice enough to have me over.

All right.

And closing us out, Shreya.

I'm from Mumbai and I love singing Bollywood songs and listening to old Bollywood songs all the way from the 1950s to now.

So whenever I hear, um, an older song, it, it brings me joy.

Love it.

We got some good variety today.

Well, I'm really excited.

You guys are all here to talk a little bit about sustainability in healthcare and specifically in ID, but we will start with a little sort of clinical case, a consult call.

Um, so I'll just mention a case and then maybe ask Shreya to comment.

You're called about a young girl who just returned from travel to Pakistan about two weeks ago.

ID is consulted for her illness, which includes a fever, headache, diarrhea, and muscle aches.

I'm going to kind of skip forward.

You know that her blood culture results have returned with extremely drug resistant (or XDR) Salmonella typhi, and her isolate demonstrates resistance to ampicillin, ceftriaxone, trimethoprim sulfamethoxazole, chloramphenicol, and ciprofloxacin.

Uh, so she is treated with a course of meropenem and I suspect that you kind of had this diagnosis guess early on based on the case scenario and her travel history, um, but maybe you can tell us a little bit about taking care of this patient and, um, maybe some quick learning points about XDR salmonella.

Yeah, this is a wonderful 10 year old girl.

And as you mentioned, XDR.

So just to tell some of our learners, what does that mean?

Extremely drug resistant typhoid means that you're resistant to all four drugs that we typically use for the treatment, which includes ampicillin, ceftriaxone, Bactrim (trimethoprim-sulfamethoxazole), um, and, uh, chloramphenicol.

And the reason why this case really was so interesting to me is because I saw her in the first week of my fellowship in the background of, um, Pakistan just having its worst floods ever, with two thirds of the country being submerged under floodwaters, which really got me thinking if I wanted to take my research in this direction.

And some other interesting things about typhoid in general are that the number of XDR cases, XDR typhoid cases in the U.

S.

are increasing even in non travelers.

This has been reported by a CDC group which later published that article in OFID as well, that even in non travelers, they are seeing a rise.

And a little more about typhoid, it is waterborne.

So extreme events like this where you have floods definitely exacerbate the number of cases and worsen outbreaks.

Some other things and general advice that you can always tell your patients while traveling is to maintain good hand hygiene and try to get the vaccine prior to traveling if possible.

And I liked how you started to mention how this impacted, you know, the way you were thinking about perhaps your fellowship projects and your career.

Maybe you can dig into that a little bit deeper and talk about some of the other things that came to mind as a result of seeing this case.

Yeah, I was just fascinated by how a problem that's already so bad, so this patient required a carbapenem for treatment because none of the drugs that I previously mentioned would work for her and it just got me thinking what it's going to do, uh, what the flood, the catastrophic floods that were going on at that time that she had just

returned from were going to do to a problem that's already such a massive problem, and that's when I decided that, you know, I would like to do something, uh, in this zone.

Some other examples of waterborne illnesses that are worsened by climate change include, um, you know, Shigella, Vibrio cholera, Cryptosporidium, and many, many others.

And I wanted to point out that even though Um, you know, in this case, this is happening somewhere far away, there is this perception of a psychological distance, but it is indeed happening here as well.

Also, it seems like a problem of the future, but it's also already happening right now.

The WHO has a concept of One Health that has a goal of achieving optimal health outcomes, recognizing the interconnection between people, animals, plants, and their shared environment.

So I really like that concept and I think that, uh, you know, in infectious diseases, it's a really important, uh, concept.

So, this is, the case is how I got interested in climate change, the problem, but when I was speaking with my mentor, Rana, and she introduced me to Preeti, that's how I got interested in healthcare sustainability, which is the solution.

And I, from doing Puscast, see lots of the articles that have been coming out trying to describe and talk about climate change, and I think a lot of people probably feel like that's pretty overwhelming, and maybe you can give I'm going to give people some perspective on ways that ID physicians could get involved in helping with prevention of climate change.

Thanks for that question.

I think when it comes to climate change, people either think about adaptation, things that we can do to prevent illness that are going to be caused by climate change.

But I think the other thing that's really, really important is mitigation.

And for us to be thinking globally about the world's people, but acting locally to decrease our own greenhouse gas emissions.

And so I think that's a way we can shift from, boy, this sort of terrifying problem to, to specific things that we can do.

So we know that the healthcare industry is part of the problem.

If we look at it from the U.

S.

perspective, about 8.

5 percent of our carbon emissions or greenhouse gas emissions are associated with healthcare delivery in the United States.

And if you look at all of healthcare in the entire globe, about 25 to 27 percent is from the United States.

We have the largest per capita emissions.

And if we think about the problems that are associated with healthcare associated emissions, it's about 470, 000 daily adjusted life years lost from healthcare's pollution.

So anything that we can do to decrease our greenhouse gas emissions while we are delivering healthcare is a way for us to decrease healthcare pollution and prevent illness in people.

So I think that's a good way of sort of thinking about that.

And we'll start talking about some specific ways that we can do that.

Yeah, so just to kind of add on to what Preeti just said, a lot of these emissions that we're talking about and a lot of the pollution as well comes from the healthcare supply chain.

So that means things that are either upstream manufacture, downstream disposal, it can include things like pharmaceuticals, chemicals, as well as some, I guess, less intuitive things like the food that we consume, our patients consume, that is required for our hospitals to function.

And so what that really means functionally is that we do make choices or we experience the impact of other people's choices that can really impact the effect of health care upon the environment.

And in a lot of ways, the environmental consequences of health care, since, many of them do come from the supply chain are embedded in the ways that we practice medicine.

And the way that came into play for me with my infectious disease career was really in the field of infection prevention and control.

And that was sort of a, an interesting transition for me, you know, like a lot of people during COVID, I ended up doing infection prevention and control because they were like, Hey, you're an ID.

So clearly, you know, about this.

And I found that, you know, a lot of the things that we were doing, that I was talking to our infection prevention nurses about involved things like single use switches, so taking things that had been reusable and for infection prevention and control reasons, switching them to single use disposable, and that was just very counter to the way that I lived my personal life.

I was, you know, the person who brought her little containers to bring takeout home because I didn't want to take a box from the restaurant or when we had conferences at work, I would, like, bring my plate and my reusable silverware because I didn't wanna use the plastic things that they had there.

So to go from that to, like, in my career?

Being like, oh, suddenly everything is trash was just kind of upsetting to me.

And as I learned more about healthcare sustainability, I found that that really was, it wasn't a me problem.

That was something that people all over the country were experiencing.

They felt that infection prevention and control was sort of a barrier to implementing more sustainable practices in their workplaces.

And I think that, you know, sometimes that's fair, sometimes that's unfair.

I think there are times that we could probably be a little bit more sustainable, and there's times when we, ourselves, as Infection Prevention and Control, don't have a lot of other options, right?

Don't have a reasonable option available to us, or we have regulations that we have to follow that require us to enforce practices that generate more waste.

So it's a, it's an interesting space.

I think what, you know, we all just went to this conference CleanMed last week, uh, and Preeti and I gave a talk, and it was really fascinating hearing some of the questions that people gave to us as infectious disease physicians.

We weren't even doing a talk about infection prevention and control, but a lot of the questions were about infection prevention.

They were things like, how do we get infectious disease physicians engaged in this problem?

Or, I don't think this is that much of an exaggeration, one of the questions was, how do we talk to infectious disease?

And I think Preeti and I were both a little taken back, we were like, what do you mean?

Like, we're here, just talk to us.

Like, we are as invested in this problem as many of you, or perhaps even more invested, right?

Because as Shreya mentioned, we see the consequences of climate change, of global warming, in our daily practice.

So we are very, very invested in this issue.

And I think one of my key takeaways from that conference was that there is this need for infectious disease physicians, especially those of us that do some degree of infection prevention and control, to be very active in this space.

And I think that we are quite well suited to it, as uh, as Shira is a great example of.

Yeah, Shira,.

I had heard that you have a pretty unique position as a medical director of sustainability.

And I think I would love to, and I'm sure the listeners would love to hear about what types of things that you, uh, work on and focus on in that role.

Thanks so much.

Yeah.

It's such a lucky position to have the privilege of serving in.

So, I would say my role is really to elevate sustainability system wide and kind of create a space to allow for all the physicians, clinicians, pharmacists, nurses, the, the clinicians itself to have a, have a voice and, and a place to shine in the role of sustainability and planetary health.

Um, we've had a sustainability team at UC San Diego for a while, but it was really the idea to create a link to the clinical practice to really show the full circle of the impact that, um, greenhouse gases and chemicals of concern have on health.

And, and to align and show and highlight how, um, sustainability is aligned with the goals of promoting health.

And with just all the challenges that we anticipate in terms of climate change in the future kind of highlighting how we have to build resiliency, working toward sustainable methods and reusable items can also build resiliency for the challenges to come.

So I think, my role as Medical Director of Sustainability is really to highlight all the work that needs to be done and it really is gathering the voices of clinicians.

We have people from cardiothoracic surgery, transplant surgery, nephrology, pharmacy, nurse educators, nurses on the floors, um, infectious disease physicians, you know, allergy immunologists, just from the whole breadth of healthcare who are really focused on this.

And so, creating a space where we can exchange ideas, promote each other, highlight the work being done, and connect it so closely with the clinical mission of healthcare.

So, that's the role I play.

I think people are also interested in how I got this role, and it was somewhat making this role.

And that came from initially being really excited about leadership positions within infectious diseases.

So I started off as a medical director of antimicrobial stewardship, which is a much more common position.

Um, and then right before COVID hit, I also took a position as the associate medical director of our infection prevention program.

And it was really, you know, working around the clock with leadership, especially through COVID, that allowed me to make relationships and form connections and really understand how a system works and how complex a healthcare system is and all the different roles and just

how valuable all the different perspectives are and that you really need that understanding, um, to make changes in the healthcare system.

Um, and just, um, to respond to Pam's great comments, you know, I, I think what I'm coming to understand is when people say, well, we're doing this because of infection prevention, there's a lot of layers behind that, right?

The, the facility has to support, you know, practices to support renewable, um, supplies.

Our procurement needs to be involved.

Our nurses need to be involved, right?

Um, the environmental services needs to be involved.

It's, it's, It's, it's a whole system, right?

It's an ecosystem that needs to be engaged and focused on making this change.

And so, some of it is also education on how, okay, we want to make this change.

How are we going to make it?

What are the barriers and getting everyone involved and focused and saying, we all want to do this.

It's going to take work and investment, you know, and how do we get there?

And a lot of what sparked this, I have had the pleasure of working with a couple of folks on the call, but, um, the other thing we really wanted to point out with this episode is that J PIDS and OFID have partnered to bring a collection of articles to raise

awareness about different aspects of how our field and ID can help reduce the negative environmental impact when we are providing care.

And so I was hoping that maybe you guys could introduce that series, which just launched its introduction articles, um, but also more about your efforts in this space and the "Sustainabil-ID", uh, group that you've been working on.

Yeah.

I'm so happy to talk about this.

Um, so Sustainabil-ID or sustainability, uh, is a group where we meet monthly and invite researchers to talk about various topics at the intersection of infectious diseases and healthcare sustainability.

Now, there's this super awesome thing called IDDI (ID Digital Institute).

Um, Sara, you may know about it.

Uh, that's where I learned how to write a mission statement.

And the mission statement for Sustainabil- ID says that it's a collaborative for infectious diseases physicians, pharmacists, public health personas, and trainees to discuss integrating environmental sustainability into all things infectious diseases.

So that's more about the group and it has really grown over the past one year, um, since we started it and more and more people are showing interest, which is great.

And we are hoping to eventually formalize this committee into our societies.

So just to give an example, one of the speakers, um, who came to our, uh, Sustainabil- ID meeting spoke about how to green your lab.

So you could do that in many different ways.

For example, increasing the temperature for the freezer from minus 70 to minus 80 degrees, using low flow faucets, low power settings and conducting regular waste audits in your lab.

Um, and the series of articles by JPIDS and OFIDs is going to be released sequentially over the next few months.

And it's really based on many different topics, including pharmaceutical or antibiotic waste, outpatient telemedicine, specific actionable steps you can take regarding infection prevention and control, greening your labs, and it has a global health perspective as well.

So we're really excited about this.

We've got about 30 authors from all over who are contributing to this.

Very cool.

So we'll link, we'll link the first article, definitely in the Consult Notes, and then people can stay tuned for the future ones.

And, you know, I think that perhaps there are some people who are listening, who are less familiar with some of the concepts that you guys have been talking about in sustainability, but a lot of things may seem familiar or overlap with how we think about stewardship.

And I think it'd be very helpful to see if you could help us compare what is similar or different when we use those terms stewardship and sustainability.

That's a great question.

So I've been practicing antimicrobial stewardship since about 2012, and I think about stewardship as really being defined as involving careful management of resources, so using resources wisely.

And when we think about sustainability, it expands upon this concept of stewardship to really include more of the resources than we would, might think about very specifically with antibiotic stewardship, but it's really trying to use the idea that we want to meet today's needs without sacrificing the ability of future generations to meet their own needs.

So, in antibiotic stewardship, or in stewardship in general, you might be thinking really specifically about a specific resource.

And I think sustainability is more of a holistic concept that it's really involving all of our decision making and really recognizing that we have limited resources, we have limited financial resources, limited natural resources, and then also that many of the things also take social impacts, and so we're trying to really consider all of that in health care sustainability.

So there's a lot of overlap, I think, between stewardship and sustainability, but sustainability is more holistic.

And we can think about a lot of different ways that antibiotic stewardship and sustainability are really, go hand in hand.

We talk about, you know, for instance, converting from intravenous antibiotics to oral antibiotics in antibiotic stewardship.

And if you think about that more holistically, it saves a lot of plastic waste.

It saves a lot of nursing time to, you know, be checking on those IVs.

It saves finances.

So I think that's a way that you can think about antibiotic stewardship really overlapping a lot with sustainability.

Um, and I think, you know, Pam started to talk about this a little bit, like some of the challenges or, or, or sort of perceived barriers when we think about infection prevention and control.

Um, I'd love to expand on that a little bit.

Yeah, you know, like I mentioned, we're, infection prevention and control is just seen as a really key barrier when you talk to a lot of people who do healthcare sustainability projects.

And I think that's really unfortunate for a number of reasons.

I think that the main concern often comes from the widespread use of single use plastic devices and supplies, which, yes, are indisputably widely used in infection prevention and control.

But again, I do want to stress, and Shira mentioned this as well, that sometimes we're kind of driven to these measures, right?

We either don't have a reusable or reprocessible option available or there are things like serious outbreak situations that can cause patient harm during which it feels like there is no other option in order to prevent sort of the harm cascade from proceeding.

And the other component to it though is that there do exist certain, you know, inflexible, sometimes outdated or non evidence based, uh, and maybe a little bit overly conservative regulations that can also drive a good amount of waste within the healthcare system.

So I think where I and Shira and many others in this space would like to see things moving is for the infection prevention and control community to take some steps towards acknowledging the wasteful nature of some of our recommendations and trying to identify ways that we can adjust those practices to prioritize planetary health.

And obviously we can't change everything overnight, but I do think that we can start maybe with some local actions as well as advocacy at higher levels.

So an example of that is is I work with the L.

A.

County Department of Public Health and we've recently taken some steps to support our health care facilities that do not use contact precautions for MRSA and VRE.

So as many people listening to this probably know, these contact precautions have been a matter of debate within the I.

D.

and Infection Prevention Community for I would say decades.

And there are a lot of facilities that do not use contact precautions for MRSA and VRE in part due to concerns about the efficacy as well as potential harms to patients as well as things like impacting patient flow or even, you know, health care workers are occasionally not in favor of those precautions as well.

So, you know, for those reasons, in L.

A.

County, we actually held a series of webinars where we discussed contact precautions used for MRSA and VRE.

We talked about sort of the evidence for, evidence against.

We also had people from facilities that had discontinued contact precautions used for those organisms come on the webinars and share their experiences.

And then we also talked about things like decolonization, hand hygiene, sort of these horizontal infection prevention and control practices that might be able to support facilities that feel like they are thinking about stopping contact precaution use for those organisms but not quite there yet.

So sort of trying to bolster the other facets of your infection prevention and control program as you consider decreasing contact precaution use.

And I really got involved in this because of my interest in sustainability, you know, personal protective equipment contributes to a significant amount of healthcare waste and in LA County at least, when you quantified it, it's about 200 gowns per week for each patient who is in contact precautions for those organisms.

So it's a, it's a pretty significant amount of, of typically single use gowns and gloves that go into patient care for those patients.

And again, for a practice that many consider outdated, inefficacious, and possibly causing patient harm.

So I think that's a great example of a sort of local initiative that we've taken.

And, you know, I do want to say it wasn't necessarily started purely for environmental reasons, but it has some great environmental co benefits to it.

You know, here we don't isolate for MRSA, VRE, or even ESBL.

You know, our challenge is we want to switch from disposable gowns to launderable gowns that could be reused like some of other institutions do.

And so we've been working on that transition for about a year now, right?

It sounds like an easy thing, right?

We always presume, why, why can't we just do this?

But first we had to find gowns that would be acceptable to providers, you know, particularly nurses who are the most, you know, going in and out of the rooms.

So we wanted something convenient, something that would fit everyone.

And so it was clear that our laundry vendors did not hold a gown that was going to meet those needs.

And so we had to negotiate getting gowns specifically made.

How would we purchase those.

You know, then we have to change the culture, right?

We need to figure out the logistics of how the flow of gowns will go through the floors.

And so when we had done an educational session with the nurses through our nurse educators, you know, proposing using launderable gowns for sustainability purposes, you know, as an organization, we could save 44 tons of waste each year by doing this switch, which is pretty remarkable.

There was a lot of support, but when you get down to the nitty gritty, who's going to walk and resupply, who's going to stock it, who's going to bring it down, where's the space for these bins now because it's not just going to go into the trash, who's going to pick it up, blah, blah, blah.

Then all of a sudden, right, it's taking a lot of work and we are so focused, we send 44 tons of waste every year.

This is, this is worth doing.

We are doing this.

Um, we're going to keep working toward it, but it just kind of highlights all the little pieces that you don't necessarily think of when you're like, well, this, let's just switch gowns.

It's a great idea.

So, we're still a work in progress and still have that goal very clear, um, because it'll make a big impact.

Um, and we hope that by doing that in our community, that other hospitals around will see, Okay, we've advanced a way for appropriate, you know, easy to use gowns to be available in our community with the local laundry business in San Diego and then kind of promote this and hopefully it'll flow through the county, but work in progress.

Can I just interject to say there's so many examples even outside of infectious diseases.

So for example, one hospital replaced all their, um, use and throw pulse oximeters with reusable ones.

There were environmental savings, cost savings, um, and it was a good decision because it did not change their infection rates.

It's always awesome to hear these different examples and I do wonder, are there other things that you guys would recommend that for the audience or members of our ID community, what are things that they can consider helping with, advocating for, um, obviously

they could join Sustainabil- ID as a group, but, um, any other insights or, or things that you guys, uh, would like to mention?

Yes, I think there, there are lots of things that you can get involved in.

Um, I kind of like the mnemonic that they coined at the Providence Health System.

Um, for the areas that we want to target in sustainability, and the mnemonic they use is WE ACT, which I like a lot, and WE ACT stands for, the W stands for waste, the E is for energy, the A is for anesthetics and anything along the agricultural food cycle.

The C is for chemicals, pharmaceuticals, chemicals and pharmaceuticals, and the T is for transportation.

So there's a lot of intersection between what we do in infectious disease and these areas.

And I think, you know, we've talked a lot about waste.

And I just wanted to remind people about why waste is a problem.

Uh, Waste in a landfill is methane, and methane is a greenhouse gas.

It is a very potent greenhouse gas, so that's why we want to reduce it.

And we know that plastics are originating from fossil fuels, and also plastics are, we're starting to see some medical issues with plastics, where we are finding them in our tissues and our blood, and they've just found them in atheromas in people.

And so I think that's a real big problem too.

And plastics are something that we use a lot when we're, we're taking care of patients.

So, um, some of the ways I'll just give you a couple of examples of how some things that I think kind of intersect with, at least what I do, waste.

One of the things that we targeted in our pediatric hospital was pharmaceutical waste.

So these are drugs that are being prepared, delivered to the floor, and the patient either leaves or we change the antibiotic.

And we waste a considerable amount of antibiotics that are prepared in these syringes.

Get up to the floor and then they have to go back and they have to be either incinerated or autoclaved and that requires a lot of energy.

So the E is for energy and when we think about a lot of regulated medical waste, it also requires extra energy because you have to do something with that waste to treat it before it can go into a landfill.

So another example is a lot of work has been done in diagnostic stewardship to decrease needing to send a urine culture that might be unnecessary, an endotracheal tube culture.

We just figured out that, um, we just went through a greenhouse gas analysis for the disposal of an endotracheal tube culture, which we all know is very dubious clinical value.

And that, that's about the equivalent, just to dispose of it, of about 0.

4 to 0.

5 miles of driving in a gas powered vehicle.

So you might be able to kind of use that take of sustainability when you talk to your providers and stewardship because I think people really do care about this a lot.

So the A is for anesthetics and anything around the food cycle.

So anesthetics are really, really important because they are greenhouse gases.

So there are lots of people that are working on, our anesthesia colleagues are actually working on decreasing the greenhouse gas footprint of the type, the way that they use anesthetics.

But we, in infectious disease, if we do good infection prevention and good stewardship we are going to prevent unnecessary surgeries, unnecessary procedures to be done.

So I think that's a really great thing.

And then I know our radiology colleagues in pediatrics are looking at a rapid MRI that has no contrast and has decreased the need for anesthesia for a lot of kids getting an MRI for possible osteomyelitis.

So it's just a great way to say, Oh, look, you can actually decrease the need for the anesthetics.

Um, and then the C is for chemicals and pharmaceuticals.

And so we know one, one really big thing that you can do is to go from IV.

to oral medications wherever possible.

So when we're talking about that, maybe we even think about that for other drugs that are not antibiotics, but there's a lot of work that can be done there.

And then the T's for transportation, um, and transportation can be in many forms, it's employee commuting, it's commuting to our meetings.

Most of the, um, greenhouse gases associated with the meeting are actually getting to the meeting, transportation to a meeting.

So, um, I'm gonna, I'm thinking about trying to do a watch party of, of a meeting virtually where I sign up and get some other people to see it because that's going to be a really good way to decrease greenhouse gas emissions as well.

So in the article that we wrote, we kind of tried to tie in some infectious disease specific ways of working on that WE ACT, um, mnemonic.

And then if you think about WE ACT together, it's really for advocacy.

So the other thing that providers can do is you can try, if you're in a hospital system, you can try to be asking your leaderships to, to, to join the Health and Human Services Climate Pledge, which is working on decreasing our greenhouse gas emissions in our hospitals.

There's also a joint commission certification for sustainability.

So those are a couple of things that you can ask for because there are definitely things that your leaders need to be working on, such as decreasing food waste and composting, you know, those kinds of things that are going to be needed to be done on a system level.

Preeti, that's a great summary of some thought provoking points.

And I always go back to think how you said that this is how stewardship started about 20 years ago.

Um, so, you know, along those lines, I think we have we have a request to the Infectious Diseases Society, you know, to create some educational modules both for climate change and for healthcare sustainability, but also to create more funding and publication opportunities for sustainability and, you know, within each ID society.

So, whether it's PIDs or IDSA, we are hoping that sustainability can be a subcommittee where people can lead more research and talk about it.

As well as, uh, you know, more ID physicians can have leadership jobs, um, like, like Shira has.

I'd also throw SHEA in there, right, since we're talking about the infection control piece.

So, one of the things that I think we can all do as well, because many of us are working in quality improvement, is to fold in an environmental component into quality improvement work we're already doing.

This is kind of, uh, something that has been done in the United Kingdom where they have a sustainable quality improvement framework, which is looking for best clinical outcomes with the least social, environmental and financial impacts.

So, uh, we can start folding in some of these environmental costs to some of the things that we're improving.

A lot of quality improvement, actually, is healthcare sustainability.

So I think that's something that we can start folding into our quality improvement projects.

And we are going to be starting a pediatric, uh, infectious disease track at Emory Children's Healthcare of Atlanta, which is called the ID Climate HERO track.

And HERO stands for Healthcare Resource Optimizer.

So we're going to be working on sort of the intersection between Infection prevention and antimicrobial stewardship and how we can apply that more broadly to healthcare sustainability.

I think those are great points and, and that was a big step for our sustainability team.

We do report to our quality team and I think it made me realize we also see a huge role and, and a co benefits with our health equity work, our DEIJ, um, because so much, the overlap is with kind of environmental justice and those issues which you find, um, right in your own, you

know, uh, area where you work, so we have a lot of local interest in environmental justice here and that allows for a lot more engagement.

I will say just another to add to other things you can do, along with all the wonderful things Preeti said, would be kind of thinking about how you can start talking to patients in your clinical spaces as well, because just like everyone was saying in the beginning, we're seeing kind of impacts of climate change in our clinical practices, and so

reflecting that to patients in even just the smallest ways, um, I think helps bring awareness kind of even more broadly to the challenges ahead and the importance of the work.

Yeah, I think that's a great point, Shira.

I think that our health equity colleagues can be such powerful partners in this space, partially because they've been doing a lot of this work themselves for a long time, right?

I think that, you know, as we as we think about really framing climate change, global warming, pollution as health issues, bringing patients in as partners is really important.

And I think there's, there's some interesting corollaries to that.

So, uh, the Center for Climate Change Communication has done some really interesting studies just asking the American public, what do you think about when you think about climate change?

And most people don't think about health.

They think about like the polar bear on like, et It's melting, you know, glacier or whatever, which is very sad, but it also feels very distant.

It feels like, oh, you know, I've only ever seen a polar bear in the zoo, and I'll probably keep seeing them in zoos.

You don't necessarily think about, like, your patients, right?

And the impact on their health, but I think it's really important that we do frame these things as human health issues, and I think it's also important that we consider that a lot of these things are happening now, right?

With changes in vector epidemiology, with the issues with antimicrobial resistance that we've talked about a little bit.

But I think what you can take away from that is that there can also be solutions and benefits that can occur more in the short term.

So one of the things I love to talk about with pollution is there have been studies looking at what happens to cities when they host Olympics.

Because when the Olympics happen, the cities really go all in on decongesting and making sure that people, that they have a good public transit infrastructure set up for people who are visiting the Olympics.

And what they've seen in cities like Beijing and Atlanta is that there are immediate health benefits to that.

So you see decreases in the amount of emergency room and urgent care visits for things like asthma, COPD, even coronary artery disease.

So it's really fascinating to me, and I think it's also a pretty powerful message that the things that we do today can impact health in the short term.

I also just love talking about it because I love the Olympics, and we're going to have an Olympics in Los Angeles, so I'm, uh, I'm excited to hopefully see some improvements in our air quality as that rolls around.

In the 1996 Olympics, pediatric asthma rates dropped by 40 percent.

That's amazing.

Yeah.

Of the Olympics.

This has been so wonderful.

I, I've learned a lot and I always like to close out the episodes by just leaving it open actually to see if there's anything that we've missed that you want to make sure to add or just sort of big take homes, um, other sort of calls to action for the audience.

So if you wanna join us, um, on our Sustainabil-ID meetings, uh, right now we're meeting on the first Friday of the month at 4:00 PM est.

And our, uh, email, uh, will be mentioned in the Consult Notes, but it is sustainabilityiddocs@gmail.com.

Uh, thank you.

I would say if anyone's interested, hopefully there's something like a green team or sustainability team that you can connect with at your facility and just get a start, hopefully, with all the great ideas from the other guests here today.

People have a lot of take homes and kind of re examining.

Why they're not recommending, you know, daily blood cultures or urine cultures and kind of rethinking the impact that those have in the cascading kind of waste that can and harm that can come out of those things.

So I, I came away with new knowledge and ideas from you guys, so I really appreciate this.

Well, Shira, you're one of the OGs in this space, so, you know, we've all learned from you for sure.

Uh, yeah, I think there have been a lot of really good ideas that have come out of this, the antibiotic stewardship, diagnostic stewardship, of course, infection prevention, you know, sustainability like infectious disease.

It is infiltrated into every single part of healthcare, so I think that if you really start thinking about how you can integrate that into your daily practice, you'll honestly end up with more ideas than you know what to do with.

Um, I did want to plug our public health website.

I forgot to mention that when I was talking about the contact precautions bit.

But, uh, we did make a public facing website for the L.

A.

County Department of Public Health on our MRSA VRE contact precautions project.

It actually has links to recordings of all of our webinars as well as the PowerPoint slides as well.

And there's also contact information if anyone else would like to expand this to their own counties.

I was really impressed when we went Clean Med, uh, because I thought it was, uh, it's a, it's a conference that's all about healthcare sustainability.

And it was really interesting because it was an interesting group of people, including manufacturers and clinicians.

And I, It was just wonderful.

I have never had so much fun looking at exhibitors and saying, you know, somebody looking who's I tried on a reusable gown and people who are talking about, uh, reusable pulse oximeters and how you could autoclave in your own facility.

And there's so many nuances and there's a lot of learning from people from different fields, engineers, manufacturers, sustainability experts.

So if you're really interested, that was a wonderful, that was my first time attending CleanMed, but I thought that was really, really eyeopening and you could hear different, um, people talking about how they are meeting these, um, health and human services climate pledges, and it was so, so inspiring.

That's another great point.

And I'll say too, just cause some of the focus in that conference was on the kind of stress of climate change and the impacts of stress.

Stress on climate and climate's causing of stress.

And I will say, I definitely have suffered from stress about climate change and doing the work is one of the greatest privileges and therapies for, for being concerned about kind of the future of the planet.

Getting involved, um, has really helped manage that.

And so just another reason to get involved for those of you who are, who are concerned, but hopefully for everybody who's listening.

And we're so well suited to it, right?

And I think that's one of the amazing things about being an ID.

We're so aware of how, what our patients do, what they eat, where they live impacts their health.

And this all ties back in because we really, we do need to think about planetary health when we think about patient health as well, right?

Because we, we cannot have healthy patients on an unhealthy planet.

So, you know, I think about this problem of climate change and health and being, it's such a big, big problem.

And when I think about my colleagues in infectious disease, I get so, so inspired about how in the past we ran towards this new epidemic of HIV.

We do not shy away from antibiotic resistance.

You can think about antibiotic resistance as being this sort of existential threat.

We ran towards it.

We've made tremendous strides.

We have made so much strides in infection prevention, preventing healthcare associated infections, saying, Hey, it's not right that a person goes into a hospital and comes out worse than when they went in.

We ran towards that problem, and we helped.

And how much we worked, collectively, when the COVID pandemic happened.

So, when I think about this problem and who would be best suited to run towards this enormous problem, I can think of nobody better than Infectious Disease Professionals who don't do it for the money, who are so, so, so dedicated.

Who are, have their heart in the right place and where this concept of One Health came from was in the 1800s when we started realizing that zoonotic infections affect humans.

And I think that, you know, that comes out of the sort of idea of an infectious disease.

So, we can do this.

And I think we can use the skills that we've developed in from past problems that we have attacked and really address this head on, and I can think of nobody better than infectious disease professionals to, to really tackle this.

Thank you again to Shreya, Preeti, Shira, and Pam for joining Febrile today.

Please make sure to check out the JPIDS OFID publications.

You'll find the introduction from Shreya and Preeti entitled, Healthcare Environmental Sustainability Through an Infectious Disease Lens, which is available now, as well as the first article in the series, Healthcare Sustainability to Address Climate Change, Call for Action to the Infectious Diseases Community.

Don't forget to check out the website, febrilepodcast.

com, where you will find the consult notes, which are written supplements to the episodes with links to references, our library of ID infographics, and a link to our merch store.

Febrile is produced with support from the Infectious Diseases Society of America, IDSA.

Please reach out if you have any suggestions for future shows or want to be more involved with Febrile.

Thanks for listening.

Stay safe and I'll see you next time.