Editor’s note: Jodi Sherman is an associate professor of anesthesiology at Yale School of Medicine and is the director of the Yale Program on Healthcare Environmental Sustainability. She also serves as the medical director for the Yale New Haven Health System Center for Sustainable Healthcare. We spoke to her on patient safety and sustainable healthcare.

Sarah Mossburg: Welcome Dr. Sherman. Please tell us about yourself and describe your role.

Jodi Sherman: I am a practicing anesthesiologist at Yale University, in the Yale New Haven Health System. I have an academic position as associate professor of anesthesiology in the School of Medicine and have a secondary appointment as an Associate Professor of Epidemiology in Environmental Health Sciences in the School of Public Health. There I run a research program on healthcare environmental sustainability that lives within the Yale Center for Climate Change in Health. I also serve as Medical Director of Sustainability for the Yale New Haven Health System, where I’m tasked with trying to help implement change in how our organization is run. One role is clinical practice, one role is clinical research, and my third role is clinical administration.

Sarah Mossburg: The impact of climate change is regularly in the news right now. For example, wildfires, poor air quality, the extreme heat experienced across the country this year in the southwest and west, flooding, and severe storms. I think that more and more people are really seeing it affect their day-to-day lives in very tangible ways. Climate change is becoming a priority for many organizations. As an expert on sustainable healthcare and climate change, we’re hoping you could talk to us about some ways that climate change is impacting health from a patient safety lens.

Jodi Sherman: Let’s take a step back and say that both climate change and air pollution stem from fossil fuel combustion, and that patients and population are harmed by both. Energy is a root driver, and clean energy transformation needs to be addressed at the policy level. Climate change and pollution are harming health now, affecting healthcare access and quality, and both are expected to worsen.

At a systems level, we are seeing more weather-related damage and impact to health systems, such as from severe storms and wildfires, which leads to displaced populations and hospital overcrowding, as well as disruptions to healthcare delivery. This mismatch of population needs and hospital locations and staff available to deliver care then delays essential care and shifts financial burdens and income between healthcare facilities, as patient populations are displaced. All of this results in higher healthcare costs and reduces access, equity, and quality of care.

Sarah Mossburg: In your work on this topic, you have mentioned preventable harm, morbidity, and mortality from cardiovascular and pulmonary diseases as ways that climate change impacts patient safety. Could you speak to that here?

Jodi Sherman: Right, so in addition to weather-related injuries and disruption of healthcare delivery, more frequent climate change-related extreme heat stress and air pollution are causing exacerbations of chronic obstructive pulmonary disease (COPD), as well as acute cardiovascular and cerebrovascular events. Also, we’re seeing acute renal failure with more frequent and extreme heat days, particularly among agricultural workers, which impacts food security. These are some of the ways that environmental harm is impacting health.

So far, we’ve discussed how climate change and pollution are impacting health and care delivery, but the flip side is how healthcare delivery is contributing to pollution and climate change. The healthcare industry is a leading polluter, particularly in the United States. The U.S. healthcare system is responsible for nearly 9% of national greenhouse gases and similar fractions of toxic air emissions like fine particulate matter (PM2.5), which is one of the primary toxicants implicated with acute respiratory events as well as cardiovascular and cerebrovascular events.

Healthcare pollution causes indirect harm. Nearly 400,000 disability-adjusted life years are lost due to U.S. healthcare pollution annually, which is commensurate with harm from medical errors as first reported by the Institute of Medicine in the landmark 1999 To Err Is Human report that sparked the patient safety movement. Now, all healthcare organizations have patient safety structures in place and care is delivered through a safety lens.

Before To Err Is Human, we thought we were doing a good job. We didn’t realize that we weren’t doing as good a job as we should, or as we could have been doing. The patient safety movement was about trying to take a systematic approach to measuring and improving patient safety and preventing medical harm. The same now has to happen for healthcare pollution. Healthcare pollution prevention is the new patient safety movement.

An important difference between climate change-related patient harm and medical errors is whether harm from a specific action can be attributed to a specific patient. With medical errors, we’ve harmed a patient in a knowable way from healthcare delivery. Harms from pollution and climate change are indirect, occurring outside the walls of our buildings. Harms are externalized from an organization and are presently left unaccounted for. Because these indirect harms are distant geographically and in time, our contributions to climate change and pollution from healthcare have a different effect on our awareness and our motivation to try and do better. But we can measure emissions and harm from healthcare delivery, and we can no longer ignore our responsibility to prevent it.

Sarah Mossburg: Is there anything else that people involved in healthcare—patients, clinicians, administrators—should know about climate change and healthcare?

Jodi Sherman: Well, I think importantly, we all need to see that this isn’t some future thing. This is happening now. We are already seeing the harm from a rapidly changing climate. We are rapidly approaching our planetary system’s tipping points, and every bit of prevention matters. We can’t kick the can down the road and leave the next generation to figure out how to solve the issue. I think many administrators think this issue is important, but they don’t prioritize it because they’re too busy putting out the other fires. We’re still dealing with staff shortages and financial losses from the pandemic. The short story is that we cannot afford the luxury of picking one crisis at a time to solve. The climate crisis is happening now. It’s a health and healthcare crisis too, and we need to deal with these issues simultaneously, whether we like it or not.

The good news is that some of the same solutions address different problems. For example, budget savings and pollution prevention can both be achieved by reducing waste. We’ve known for years and years that we have a problem with inefficient, wasteful consumption of healthcare resources, particularly in the United States. There’s an ongoing question of why we haven’t fixed it before. Administrators are motivated by cutting costs, but clinicians and staff in the trenches are not motivated in the same way. But if they were to understand and were provided information on the fact that their way of providing care to patients is contributing to harming patients and environment health, if they had some real tangible information on that, I think they would be very much motivated to reduce waste and pollution.

Sarah Mossburg: Somewhat along those lines, in your research and writing, you’ve noted that in some ways patient safety initiatives have contributed to wasteful practices in healthcare. Could you briefly talk about that and share what you think are some ways that patient safety could better align with sustainable environmental practices?

Jodi Sherman: All safety initiatives are very well-intentioned. However, many of them are done in silos without consideration for indirect impacts or shifting burdens. We may solve one problem, but then we may be creating others. For example, with infection prevention and control, there’s been this aspiration for zero harm that created an attitude that no resource should be spared for trying to prevent even one infection. Let’s throw more and more disposables at the problem. “When in doubt, throw it out.”

However, there are so many instances where the risk of infection transmission is low or minuscule. The approach of using more disposables may be stemming from someone who’s trying to do good, and has some idea that it might be helpful, but isn’t considering how disposables increase pollution, costs, decrease supply chain resilience—as experienced during the pandemic—and also create an equity issue if we run out of disposable supplies, which is also a patient safety issue.

Of course, the argument is that if a patient gets infected, that’s wrong, and it’s going to increase cost, pollution, and waste. This is very true, and we should never prioritize environmental protection over preventing a healthcare-acquired infection. But we need to look at the evidence or weigh the risks in the absence of evidence. If there is a very low risk, then we should not simply err on the side of throwing things away because we’re causing actual harm to environmental health, hurting the fiscal bottom line, and decreasing access to limited resources.

Another example where wasteful practices could be reduced is end-of-life care. We really need to do a much better job of having necessary hard conversations early on with patients and family members about their wishes, and effectively communicating expectations around what quality of life is possible. During the pandemic, we were so resource-constrained that we developed new policies and procedures to clearly communicate if there was no chance at recovery and to switch early on to comfort care. The bottom line is whether we feel supply chain shortages or not, there are supply chain shortages all the time. Because we’re in a very wealthy country, we can access resources whereas other health systems, other countries, cannot. The reality is there are not enough resources to go around to meet all the needs. It is impractical to assume that we have unlimited resources and that we can continue to do everything under the sun. For those of us who take care of patients, we must recognize a lot of the care that we provide at the end of life is unwanted. Unnecessary care is hurting people and the environment. So really, we need to address a big problem of how we deal with end-of-life care both as providers and as consumers of healthcare.

Sarah Mossburg: Could you expand on the overuse and underuse of services that may impact the sustainability of healthcare?

Jodi Sherman: A fundamental issue in how to transform care delivery to make it more sustainable is to address the issue through the lens of appropriateness of care. Inappropriate care, low-value care, is care that is unneeded, unwanted, ineffective, or inappropriate in its consumption of resources.

The starting point is if a patient doesn’t want care, then we surely should not provide it. That’s fundamental. The flip side of that is that just because a patient wants something doesn’t mean they should get it. If it’s not going to benefit them in terms of their health and well-being, then they should be counseled against it. The biggest example of care that fits this category is antibiotic treatment for viral ear infections in children. Historically, antibiotics were doled out anyway to appease worried parents. Now, there’s a big effort to get pediatricians and family doctors not to give antibiotics just because parents want them. AHRQ is a leader in this effort toward better antibiotic stewardship.

Similarly, even if patients want a diagnostic test, medication, or procedure, it is our duty to be resource stewards and counsel them against and simply not offer what’s not going to help them. To do a diagnostic test just for the sake of knowing, is not a good enough reason if it’s not going to change treatment. On the provider side, just because we want to know or we want to feel better by doing something, if it’s not going to change outcomes in ways that patients want, then we should not do it. We need to be aware that part of our job is to be resource stewards to protect public health.

Sarah Mossburg: You mentioned that the use of disposable medical supplies is another example where resource stewardship may reduce the impact of healthcare on climate change. Could you say more about the impact of disposable medical devices?

Jodi Sherman: First, just because something is labeled as a single-use disposal does not mean it can’t be reused. That message is important. What a single-use disposable label means is that whoever cleans it is responsible to ensure that the device functions as originally intended. That legal risk has driven a lot of hospitals to just start throwing stuff away. A third-party industry sprang up that collects a lot of these devices and cleans, refurbishes, and resells these devices following an FDA-approved process for a limited number of reuses. This practice is very safe. The Government Accountability Office was tasked by Congress to investigate the safety of so-called reprocessed single-use devices and found no difference in safety between the reprocessed and new devices. Reusing devices safely can reduce costs, reduce pollution, and increase supply chain resilience.

Sarah Mossburg: Acting on climate change will improve patient safety at the public health level. How do we achieve more complete vision of patient safety that encompasses individual and public levels?

Jodi Sherman: Well, there are two general ways to think about pollution mitigation, one of which we’ve talked a lot about, and that is reducing waste. The other way is selecting materials, procedures, and pathways that have less embodied emissions.

Two of the most common examples of embodied emissions in healthcare are inhaled anesthetics and metered-dose inhalers used to treat reactive airway disease. There are four common inhaled anesthetic drugs. If you look at equipotent doses of these drugs, two of them are outliers in terms of how much embodied carbon is in them. Desflurane, for example, has 45 times the emissions, or embodied carbon, as an equivalent clinically effective amount of sevoflurane. They have slightly different physiologic effects, but they achieve the same thing. So, there is nothing unique about the drug desflurane that cannot be achieved with the drug sevoflurane, and we can safely avoid it on environmental grounds.

Similarly with metered-dose inhalers, the ones that are pressurized have a greenhouse gas that actively delivers the drug. There are alternative delivery devices. One device is called a dry powder inhaler. Instead of a gas that pushes the drug into the patient, the patient has to suck the drug into the lungs. Not every patient can do that, so there is a role to play for pressurized metered-dose inhalers. However, right now the pressurized metered-dose inhalers have about 20 times the embodied emissions than the non-pressurized ones. The global leader in this area is Sweden. Of all their inhaler prescriptions, about 12% of them are pressurized metered-dose inhalers. In the United States, about 75% of inhaler prescriptions are pressurized metered-dose inhalers. These numbers tell us we can be much more selective in the inhalers that we prescribe in the United States.

Sarah Mossburg: What is Sweden doing differently?

Jodi Sherman: They are encouraging clinicians to be more environmentally selective in how they prescribe. They have something called the Wise Choice List. The Wise Choice List is a priority list of medications based on an environmental index that takes into account the persistence, bioaccumulation, and toxicity of medications. Clinicians are provided with this guidance tool to encourage environmentally preferable selections when they have a choice. It’s not to say they can’t prescribe the more environmentally harmful drugs if patients need them, but rather it encourages them to be more judicious. That’s one thing that they’ve done that has helped them to be more successful.

Sarah Mossburg: You said earlier that almost 9% of U.S. emissions are related to healthcare, and your work has really begun to quantify how healthcare organizations have contributed to climate change. How do we know how much healthcare contributes to emissions? What can we do about it?

Jodi Sherman: Hospitals and healthcare systems are like miniature cities: they procure supplies, water, food, and energy; they provide services and transportation; and they produce waste and sewage. All these things consume materials and generate emissions. To understand where to effect a change, one needs to understand where the emissions are coming from in the system. That means auditing all the stuff going into a system and all the stuff coming out of the system. Beyond our utility bills, we can’t easily physically measure all the stuff going into and out of a system, add it up, and come up with a footprint, but we can use financial ledgers to perform environmentally extended input-output assessment. If you know everything that a hospital is spending money on, all the supplies that you’re buying, and all the gasoline you’re buying for your vehicle fleets, then you can estimate the environmental footprint at the level of an organization.

After we have that information, we can use environmental engineering models to estimate the related emissions. Then, we understand where the pollution hot spots are. Things that you spend more money on are typically those that have higher emissions, but it’s not one for one. They may have different emissions intensity.

We can mitigate emissions in two ways: reduce waste and select things that have less emissions intensity. The challenge of selecting options with less emissions is that there are very limited areas where we have that information. There has to be a lot more research in both these approaches—waste mitigation and environmentally preferable practices. That is a part of why we need AHRQ to continue to emphasize the connections among climate change, healthcare pollution, and patient safety. After you start categorizing all the flows of materials and energy across care delivery, and all the associated costs and emissions, you can develop your hotspot priority areas. Then, you can strategize how to mitigate those things based both on feasibility and impact, while also accounting for patient outcomes.

Sarah Mossburg: One thing that you mentioned in one of your articles is that as opposed to single-use disposable medical devices, reusables tend to be less polluting, often cheaper, and a strategy for improving resilience. What does that mean, “a strategy for improving resilience?”

Jodi Sherman: Well, the perfect example just came out of the pandemic during which there was a global shortage of single-use disposable PPE, such as contact precaution gowns and N95 respirator masks. Many studies have compared the life cycle emissions of disposable and reusable gowns. These studies demonstrate that reusables are several times better in terms of energy, chemical and water utilization, and greenhouse gas emissions on a lifecycle basis. Most health systems went to disposables years ago, although there isn’t any evidence of improved patient outcomes for this transition. During the pandemic, between disruptions in production and transportation of supplies, and surges in need, we ran out. In contrast, if we had reusables, then we would not have run out. We would have more supply resilience, by serving as our own material suppliers.

Does that mean everything should be reusable? No. Some things are difficult to clean, for example syringes and IV catheters. Obviously, we’re not going to clean and reuse those. Part of a resilient system necessitates not relying on any one supplier, including ourselves. Some things should remain disposable, but by and large, most things are becoming disposable these days and it’s not from a safety perspective. It’s increasing supply chain risk and harming environmental health. We need to move back to more reusables as the default, and we must require good evidence to support the decision to choose disposables for only select reasons.

Sarah Mossburg: How do you see quality, patient safety, and climate change interacting in healthcare administration?

Jodi Sherman: I would say that working to reduce healthcare’s contribution to pollution and climate change fits within the quality agenda. Pollution mitigation is part of patient safety, preventing harm to public health. The quality aspect has to do with how we deliver safe, high-value care, effective care, and at the same time mitigate pollution and risk, and maximize access. All quality improvement projects should include pollution impacts and resource stewardship as part of what they evaluate, as part of harm avoidance and equity. If you’re going to change or add a product or service, then you should assess not only what it will cost your organization fiscally, but also what it going to cost your organization environmentally.

Sarah Mossburg: In 2022 you were one of the authors of a primer on reducing healthcare carbon emissions published by AHRQ. The primer includes measures and proposed system-level interventions to reduce the impact of healthcare organizations on climate change. What important takeaways should healthcare professionals think about after reviewing the primer?

Jodi Sherman: I hope one of the most important takeaways from that document is that we need more governance structure and accountability to do this work. Sustainability transformation requires some investment and coordination to develop strategic plans and to implement projects that reduce healthcare pollution. And as discussed earlier, this can identify and address waste, as well as motivate staff engagement around change. Implementing change is very challenging in the current financial crisis. The way to motivate organizational leaders to change is by conveying that there are financial savings to be had. The first step is education to overcome perceived challenges.

Sarah Mossburg: How can patient safety researchers and practitioners contribute to decreasing the impact of healthcare on climate change?

Jodi Sherman: I think that they need to learn how to incorporate sustainability metrics into routine patient safety research and practice. The most common sustainability measure is carbon or greenhouse gas emissions. This isn’t the only type of pollution of concern; however, it is the one that is relatively easy to quantify and one that people are most familiar with. Patient safety researchers and practitioners should look at consumption and waste (used and unused) resources in every single project, even if they don’t know what the emissions are.

Sarah Mossburg: Thank you, Dr. Sherman. This has been a really interesting conversation and a really important topic. We really appreciate your time.

Jodi Sherman: I’m honored that you chose to work with me.

Funding: Dr. Sherman’s work on this project is partially supported by the Commonwealth Fund.