Goals: 1. Dispel the misconceptions associated with single use disposable devices, equipment, and supplies 2. Describe the differences between linear and circular supply chains 3. Apply risk reduction principles, including comprehensive cost-benefit assessments to purchasing decisions

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SAFE AND SUSTAINABLE: BALANCING INFECTION
CONTROL AND ENVIRONMENTAL HEALTH
HARRIET W. HOPF, MD
PROFESSOR OF ANESTHESIOLOGY
ADJUNCT PROFESSOR OF BIOMEDICAL ENGINEERING
UNIVERSITY OF UTAH
UCLA Visiting Professor March 2022

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FINANCIAL DISCLOSURES
• Educational Consultant, Ambu, Inc. 2020-2021
(educational videos on filters in anesthesia circuits)
• Member, ASA Committees on Equipment & Facilities
and Occupational Health, Ad Hoc Committee on
Environmental Health

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I acknowledge that the land I work
on, which is named for the Ute Tribe,
is the traditional and ancestral
homeland of the Shoshone, Paiute,
Goshute, and Ute Tribes
I acknowledge that the Tongva peoples
as the traditional land caretakers of
Tovaangar (Los Angeles basin, So.
Channel Islands) and pay my respects to
the Honuukvetam (Ancestors), 'Ahiihirom
(Elders), and 'Eyoohiinkem (relations) past,
present and emerging.
Jessica Wolf/UCLA

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OBJECTIVES
• Dispel the misconceptions associated with single
use disposable devices, equipment, and supplies
• Describe the differences between linear and
circular supply chains
• Apply risk reduction principles, including
comprehensive cost-benefit assessments to
purchasing decisions

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WHO News Headline

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PPE HAS A LARGELY LINEAR SUPPLY CHAIN
• PPE are mostly single use
disposables (SUD)
• Health systems optimize
efficiency w just-in-time delivery
of standard order
• SUDs reduce space,
equipment, & personnel
needed for reprocessing

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COVID-19 EXPOSED LINEAR SUPPLY CHAIN VULNERABILITY
• PPE demand skyrocketed
• Just-in-time supply was depleted
quickly & could not be replenished
– Standing orders insufficient
– Resource delivery, manufacturing, &
product shipment interrupted &
delayed, even for standing orders
– Lack of facilities, staff, expertise for
reprocessing

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• How did we get to a linear
supply chain in perioperative
equipment and supplies?
• What does that mean for
patient outcomes, cost,
availability, and the
environment?
• What are potential solutions?
This Photo by Unknown Author is licensed under
CC BY-NC-ND

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DRIVERS OF SINGLE USE DISPOSABLES
• Perception of reduced infection risk
• Perception of reduced cost
• Reduced institutional complexity
– Reduced need to staff & manage reprocessing & storage
• Reduced liability from human error
• Reduced chance of accreditor citation
• More profitable for manufacturers
– Less expensive components
– No need to seek approval for reprocessing
– Sell more units

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U.S. HEALTH CARE GHG EMISSION CONTRIBUTIONS
• 80% from supply chain
– Pharmaceuticals & chemicals
– Medical devices & supplies
– Food
• Administrators, clinicians, & regulators
control consumption
• Manufacturers & regulators control
supply
– Design & manufacture
– Raw materials
– Transportation
• Public health harm equivalent to that
of medical errors
Medical devices & supplies

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U.S. HEALTH CARE GHG EMISSION CONTRIBUTIONS
• 80% from supply chain
– Pharmaceuticals & chemicals
– Medical devices & supplies
– Food
• Administrators, clinicians, & regulators
control consumption
• Manufacturers & regulators control
supply
– Design & manufacture
– Raw materials
– Transportation
• Public health harm equivalent to that
of medical errors

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REDUCING INFECTION RISK

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THE CHALLENGE

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DEMONSTRATING INFECTION PREVENTION BENEFIT
Thiel CL, Sherman JD, Hopf HW. AMA Surg. 2020;155:453–454.

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DIMINISHING RETURNS
Copyright © 2021 International Anesthesia Research Society

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SPAULDING CLASSIFICATION
• Critical items
– contact normally sterile tissues
– must be sterilized
• Semi-critical items
– contact mucous membranes or non-intact skin
– require high level disinfection
• Non-critical items
– contact only intact skin
– intermediate or low level disinfection
Courtesy of Dr. Jodi Sherman

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SPAULDING CREEP DRIVES SUD ADOPTION
• Recent guidelines treat laryngoscopes as single unit
• Hospital systems reprocess both components as semi-critical
to avoid negative findings during accreditation reviews
• Transition to SUD to reduce complexity
• Driver is perception of reduced infection risk & reduced cost
– Evidence does not support reduced infection risk
– What about cost?

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LIFE CYCLE ANALYSIS

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PROJECTED ANNUAL LARYNGOSCOPE COSTS
Copyright © 2021 International Anesthesia Research Society

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PROJECTED ANNUAL GHG EMISSIONS
Copyright © 2021 International Anesthesia Research Society

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TEXTILES (GOWNS, DRAPES, ETC.)
Overcash M. Anesth Analg. 2012; 114:1055–66.
Single Use Textiles Reusable Textiles
• Equivalent performance
• Lower cost
• Lower environmental impact
Solid
Waste
750%
CO2
200-
300%
Water
250-
300%
Energy
200-
300%
Cloth is three-way win

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FROM ZERO HARM TO RISK REDUCTION
• Patient safety view of infection control emphasizes
“Zero Harm”
– ”No cost too high to prevent one infection.”
• Zero harm: unattainable + unintended
consequences
– Risk reduction: attainable + balances consequences
• Environmental harm = unintended consequence
– Risk reduction: assess infection risk + environmental harm

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RESPONSE TO DISRUPTION: CIRCULAR ECONOMY
• Prolonged use, re-use, &
reprocessing of PPE
– Not designed for reprocessing
• Transition to reusables
– Capacity for reprocessing had
to be (re)built
• Expansion of local
manufacturing capacity
• Innovation
– Elastomeric masks
– Snuba masks
https://www.uschamberfoundation.org/blog/post/circular-economy-toolkit-small-businesses

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LINEAR VS CIRCULAR ECONOMY
• No evidence SUDs infection risk (w exceptions)
• Acquisition cost but per use cost even w/o
considering environmental health impact
• Just-in-time SUDs institutional complexity but
vulnerability to disruption
• liability from human error in current regulatory climate
• liability from accreditor citation in current regulatory
climate
• Profitable for manufacturers & little incentive for
creative engineering in current regulatory climate
Urgent need to reframe our approach

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SUMMARY
• Infection control protects patients & health care professionals
• SUDs have few advantages, but increase cost, environmental
impact, & supply chain vulnerability
• A circular economy requires commitment, regulatory changes,
comprehensive cost-benefit analysis, & biomedical innovation
– COVID-19 pandemic underscores the urgency