Sleep Medicine's Path to Environmental Sustainability – Sleep Review

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Sep 13, 2023 | Future of Sleep | 0 |
When I brought home a WatchPAT ONE, I assumed that disposing of the single-use home sleep test would require driving to the local hazardous waste collection center. This dreaded errand entails emptying my car trunk (which contains a surprisingly hefty haul, ranging from a stroller to a spare dog leash), then sacrificing a weekend morning, the only time the center is open for drop-offs, to make the trip.
So I was pleasantly surprised when a card inside the box directed me to www.itamar-medical.com/greenprogram to print a prepaid label to ship the device back to its maker, ZOLL Itamar, no trunk-emptying or 40-minute roundtrip drive needed.
The WatchPAT ONE Green Program was launched two years ago after inquiries from multiple customers about recycling options. ZOLL Itamar gives prepaid shipping to patients in the United States, Canada, and the United Kingdom and passes the returned devices to a commercial recycler. “When we launched WatchPAT ONE, we did not anticipate questions about recycling,” says Melih Alvo, senior director of commercial marketing at ZOLL Itamar. “But as disposable devices became more popular, we decided it was the right time to develop a program that aligns with our commitment to our customers, patients, and the environment.”
I applaud ZOLL Itamar for keeping it simple. “It wasn’t just about the right company for the recycling but also the easiest program for the return shipments,” Alvo says. In the United States, the package goes into a standard outgoing USPS mailbox. In addition to any environmental benefits, the program’s ease makes it accessible to people in underserved communities—who might otherwise be unable to properly dispose of e-waste.
This experience inspired me to find out how sleep medicine could do more to facilitate environmental sustainability. 
A great place to start, I learned, is before a diagnostic or therapy device is ever prescribed. Reducing waste upfront is where the impacts can begin.
Surgical kits, including likely those used by ENT/sleep surgeons, are an environmental offender in this area. They frequently include every item the surgeon might possibly need, and then some. One medical center found average instrument use rates to be 13% for otolaryngology, 15.5% for plastic surgery, 18.2% for bariatric surgery, and 21.9% for neurosurgery.¹ When Providence St. Vincent Medical Center in Portland, Ore, re-engineered its processes in 2020 to efficiently manage surgeon preference cards, it removed 39,506 products and 9,411 instrument sets from its supply—which reduced its annual CO₂ equivalent by 834 metric tons and water consumption by 820,000 gallons (and saved it over $1 million).² 
“We’re starting to find a growing interest both from clinicians and from sustainability teams in trying to redesign procedure packs to only include the necessary items, which will save clinicians’ time, cut costs, and curb emissions,” says Bhargavi Sampath, MPH, a senior research associate at the Institute for Healthcare Improvement and co-author of Reducing Healthcare Carbon Emissions: A Primer on Measures and Actions for Healthcare Organizations to Mitigate Climate Change.²
Another way to mitigate pollution is to reduce the emissions intensity, the kilograms of CO₂ equivalent emitted per product, or “kind of like the calorie count of the stuff that we use,” says Jodi D. Sherman, MD, founding director of the Yale Program on Healthcare Environmental Sustainability and a co-author of Reducing Healthcare Carbon Emissions: A Primer on Measures and Actions for Healthcare Organizations to Mitigate Climate Change. “A solution that ticks both boxes”—lowering emissions intensity and lowering waste at the start—“is to move back to reusables,” Sherman says, “especially if we were recently reusing them and still have the remnants of the infrastructure in place. People say it’s just easier to use disposable. It may be easier, but that’s not the right way.” 
Several studies comparing disposable versus reusable equipment show that single-use disposables typically result in severalfold higher energy use and greenhouse gas emissions on a life-cycle basis.³
According to Daniel J. Vukelich, Esq, CAE, president and CEO of the Association of Medical Device Reprocessors (AMDR), device reprocessing is an option for some categories of single-use devices, including pulse oximeter and EKG leads. US Food and Drug Administration-regulated reprocessing refers to the cleaning, testing, and repackaging of “single-use” medical devices for clinical reuse. It is done at commercial reprocessing facilities, not within medical centers themselves. “The devices are reprocessed to the exact same standards and safety required of new devices,” Vukelich says.
Sleep disorders centers can purchase reprocessed devices and/or offload their single-use devices to commercial reprocessors. “The use of reprocessed single-use devices can reduce greenhouse gas emissions, cost, and waste, and they strengthen supply chain resilience,” Vukelich says. (The AMDR lists its members’ contact information on its website, which is a great place to start.)
Another avenue, one that Practice Greenhealth, a fee-based membership and networking organization for sustainable healthcare, and its health system members advocate for is driving market transformation of supply chains. “Collectively, the healthcare sector has tremendous purchasing power,” says John Ullman, MS, MBA, safer chemicals and procurement director at Health Care Without Harm and Practice Greenhealth. “Clinicians and sleep managers should engage their procurement departments and, as necessary, other key stakeholders in their facilities to push manufacturers to incorporate sustainability into their products and operations.” 
Indeed, there is so much opportunity to go green in sleep medicine, and we can and should start immediately. “Patient care is, of course, the priority, and part of that includes being cognizant of the lasting impact our medical waste has on the planet our patients live on,” says Alison Lehane, MD, a research scholar in pediatric surgery at Lurie Children’s Hospital and a general surgery resident at Wake Forest Medical Center. Lehane helped conduct life cycle assessments of Lurie’s medical instrument use to better grasp where overall impact can be decreased without negatively impacting patient care. “We have just as much of a duty to our patients when it comes to the environmental impact created in taking care of them,” she says.
References
1. Stockert EW, Langerman A. Assessing the magnitude and costs of intraoperative inefficiencies attributable to surgical instrument trays. J Am Coll Surg. 2014 Oct;219(4):646-55.
2. Sampath B, Jensen M, Lenoci-Edwards J, et al. Reducing healthcare carbon emissions: A primer on measures and actions for healthcare organizations to mitigate climate change. (Prepared by Institute for Healthcare Improvement under contract no. 75Q80122P00007.) AHRQ Publication No. 22-M011. 2022 Sept.
3. MacNeill AJ, Hopf H, Khanuja A, et al. Transforming the medical device industry: Road map to a circular economy. Health Aff (Millwood). 2020 Dec;39(12):2088-97.
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Sree Roy is editor of Sleep Review.
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