Hello, welcome to a discussion on green endoscopy and climate change. Why do we need to adapt our practice and how can we do it? My name is Eden Essex and I will be the announcer for this session. This session is being recorded and will be available to you in the near future via GILeap, ASG's online learning platform. By registering for this event, the program will be automatically populating your GILeap account. Contact the ASG office if you need assistance accessing your account. You will be able to submit questions and comments throughout the event via the Q&A box. Please do use the Q&A box and not the chat box to keep us organized. A roundtable discussion with audience Q&A will be held at the conclusion of the presentation. Now it is my pleasure to introduce our moderators for the session, Dr. Seth Crockett and Doug Rex. Dr. Seth Crockett is an associate professor of medicine at Oregon Health and Sciences University. He specializes broadly in gastroenterology and digestive diseases with a particular interest in screening and prevention of colon cancer. Dr. Crockett serves on the ASG Sustainable Endoscopy Task Force. Dr. Doug Rex is a distinguished professor of medicine at Indiana University School of Medicine, Chancellor's Professor at Indiana University, Purdue University, Indianapolis, and Director of Endoscopy at Indiana University Hospital in Indianapolis. Dr. Rex is the immediate past president of ASGE. During his presidency, he established the ASG Sustainable Endoscopy Task Force and initiated the establishment of the GI Multisociety Task Force on Climate Change. I will now hand the proverbial floor over to Dr. Rex. Hey, everybody. Thank you so much for joining us. And thanks, Eden, for your introductions and Seth for co-moderating. And we've got some very nice presentations from Rahul and Rabia and Lyndon that are going to be very informative. Thanks to all those who are joining us online to listen in. Appreciate your interest in this topic that is increasingly capturing our attention. So let's get right into it. Our first speaker is Dr. Rahul Shimpi, who is an assistant professor of medicine at Duke and his clinical focus is on esophageal disorders. He's the co-founder and medical director of the Esophageal Center at Duke, and he's a member of our ASGE Sustainable Endoscopy Task Force. And he's going to give us an overview on endoscopy and climate change. Welcome, Rahul. All right. Thanks, Doug. Thanks, Eden. I have the honor of starting off the talk to this webinar. I'd like to start off by thanking the ASGE for inviting me to participate. This is really a topic which I think is vitally important to any of us who do endoscopy, endoscopists, nurses, technicians. So my talk is going to focus pretty briefly on an overview of the role that GI endoscopy has in climate change. And I should start off by saying that I have no disclosure relevant to this talk. All right. So I'm going to start this off by making a somewhat bold statement. It might be controversial to some, probably not for most of the attendees, but the unfortunate truth is that climate change is real. It's largely a result of the buildup of greenhouse gases in our atmosphere. And this then leads to numerous environmental consequences, as I've listed here, many of which have devastating impact on our ecosystems, our environment, and ultimately in our daily lives. Climate change has had a profound deleterious effect on the health of humanity itself. Climate change directly affects many determinants of health, and these include things such as access to clean water, food security, access to health care. Respiratory and cardiovascular diseases, which are directly related to climate change, are on the rise. You see that number, about 8 million deaths are directly attributed to air pollution each year alone. And this impact actually extends to digestive diseases as well. So the change in ecology and vectors and diminished access to clean water has led to things like hepatitis outbreaks, as well as an increased risk of certain diarrheal diseases. Food insecurity and malnutrition may also contribute in terms of obesity and fatty liver disease. And there's really a disproportionate impact of the health effects of climate change on those of lower socioeconomic status, the uninsured, the elderly, and those with chronic medical conditions. When you take all of this into account, it's really not very hard to understand why a lot of experts believe that climate change is actually the single greatest global health threat of the 21st century. So climate change, again, is largely related to the presence of greenhouse gases in the atmosphere. A greenhouse gas is any gas which accumulates in the atmosphere, which absorbs and re-emits heat, and thus contributes to global warming. Greenhouse gases mainly consist of carbon dioxide and methane, but there are actually others. So let's start with a couple of definitions here that I think are important. When we talk about the environmental effects of an activity, we use the term carbon footprint. So the carbon footprint is a measure which comprises the total all greenhouse gas emissions. And so these are both direct and indirect emissions of that activity. And then the next definition is that we measure carbon footprint in CO2 equivalents, which are also known as CO2e. And CO2e is a direct measure of the contribution of a particular activity to global warming. We categorize greenhouse gas emissions into three different groups, and these are known as scopes. So scope one are direct sources of emissions. Scopes two and three are indirect sources of emissions. When we think about scope one emissions, think about things that we do in the endoscopy unit, such as CO2 insufflation, leakage of anesthesia gases, any direct on-site fuel combustion that occurs, and importantly emissions from fleet vehicles. So scope two emissions are those emissions that are related to purchased energy that's generated from combustion of fossil fuels, and this is going to be the primary source of energy for power in most of our endoscopy units. And then scope three emissions are those generated somewhere along the supply chain. So if you look beyond just the direct sources of emissions, so beyond just scope one emissions, the indirect sources actually contribute substantially to the environmental impact of endoscopy, and overall scope one has the lowest overall impact, whereas scope three is thought to account for about 70 percent of the ultimate overall emissions impact in health care. So delivering health care is actually enormously environmentally impactful. I guess it's a bit of a cruel irony that even as we in health care are providing care to our patients, we're actually a huge part of the problem when it comes to climate change, which then as I've discussed does have significant health impact, so it's really one of the ultimate vicious cycles. Health care alone accounts for nearly four and a half percent of greenhouse gas emissions globally. If we looked at health care as an individual country, it would be the number five global emitter. This is probably not a surprise to anybody, but the U.S. is the global number one health care emitter, and that's both in absolute and per capita terms. And then if you took the U.S., China, and the EU, that as an entity comprises more than 50 percent of the global health care carbon footprint. All right, so let's turn to an activity that is near and dear to our hearts and that we spend much of our time involved in, GI endoscopy. So endoscopy actually has very substantial environmental impact. We're a very resource intensive specialty. We obviously have high caseloads, so all of the items and activities I've listed there are integral components involved in performing endoscopy, and each of these also contributes to some extent to our carbon footprint. Along every single step of the way when we perform procedures, be it pre-procedurally, intra-procedurally, or post-procedurally, there is potentially significant environmental impact. Waste is another important component in endoscopy's environmental impact. So waste is a substantial contributor to greenhouse gas emissions, and this includes contributions related to the disposal and incineration of waste, as well as landfill related emissions. Endoscopy is actually thought to be the third greatest source of medical waste in the hospital. Each single endoscopic procedure generates over 2.1 kilos of waste, and much of that is plastic waste. This is a really sort of eye-opening table from an editorial by Swat Nagayan, which lists all the waste generated during a single endoscopic procedure, and look at all that plastic. So this overall leads to more than 13,000 tons of plastic waste generated from endoscopy per year in the U.S., and unfortunately most of that plastic waste does end up in landfill. So of the overall waste generated during endoscopy, about two-thirds goes into landfill. About 28 percent is disposed of as regulated medical waste, and actually less than 10 percent is recycled, and it's estimated that more than a third of that waste actually could be recycled. Much of the regulated medical waste that's disposed of as landfill, or could be disposed of as landfill, and not as regulated medical waste, and that's an important point, because regulated medical waste is either autoclaved or incinerated, and is the most environmentally impactful category of waste with the highest carbon emissions. So this slide is to try to put endoscopy's climate impact into numbers that we can maybe more easily digest, and these numbers come from an analysis published by Keith Seale and colleagues in 2021. So in this they examine the total carbon emissions generated by both energy consumption and waste disposal in endoscopy. So one endoscopy generates about 4.2 kilograms of CO2 emissions, and if we use the estimate of about 18 million total endoscopies performed in the U.S. per year, that equates to a total of over 85,000 metric tons of CO2 emissions from endoscopy alone. So putting that into terms that maybe are a little bit more easily grasped, that number is the equivalent of nearly 10 million gallons of gasoline consumed, is the equivalent of about 95 million pounds of coal burn, or is the equivalent of driving an average car over 200 million miles. And I think as staggering as those numbers are, and they're pretty staggering, they're actually gross underestimates because they don't really account for scope three emissions, which as I've already said is the category of emissions with the highest overall environmental impact, again about 70 percent of emissions overall. All right, so wrapping up, I hope in the last few minutes I made a few important points. So climate change is real, and it does have an enormous impact on the health of people on our planet. Healthcare has a huge carbon footprint, and endoscopy specifically, you know, the business that we're in, above many other specialties, is a substantial contributor. I do think some of this is the cost of doing business. I mean, there's just no way of getting around the fact that endoscopy by its very nature is, and will continue to be, at least to some extent, a highly environmentally impactful activity. But I think that knowing what our environmental impact is in endoscopy, I think we should all feel obligated to look at how we can try to mitigate that impact. And it's really not all doom and gloom. I mean, we do have some really good opportunities to reduce our impact along every step of the way. So this includes changes and innovations that we can make during endoscopic procedures themselves, in the post-procedure setting, and actually, perhaps most excitingly, pre-procedurally, or in the supply chain aspect of endoscopy. And we're going to be spending some time discussing some of these opportunities throughout the rest of this webinar. So I'll stop there. Thank you very much. But thank you, Rahul, for a really comprehensive yet concise overview. And I think that helps set the stage for the other talks we're going to hear this evening. It's now my pleasure to introduce Dr. Rabia De La Tour, who's an Assistant Professor of Medicine at NYU School of Medicine and the Director of Endoscopy, as well as the Chief Sustainability Officer at Bellevue Hospital. Dr. De La Tour currently serves on a GI multi-society task force on climate change. And Rabia is going to tell us about what we can do to lower waste and the carbon footprint of endoscopy, the easy and the not so easy. Rabia, the audience is yours. Thank you so much for having me. Can you guys hear me all right? We can. Okay, great. All right. I wanted to thank the ASG and Drs. Crockett and Rex for having me today and Eden for all of your wonderful help in setting this up. So I'm going to be talking to you about what you can do as an endoscopist or someone who works within a GI suite or ASC to improve your carbon footprint. And there's multiple things you can do. So we already alluded to this, but this is basically a picture of the three different types of emissions that we emit from the healthcare sector, essentially. And scope three has the largest box because it's the biggest contributor. And there is actually the greatest room here for improvement in things that we can do as clinicians and essentially boots on the ground. And so I just wanted to include this slide. So when you're talking about your plan in terms of how you can improve the carbon footprint, this goes from a macro level to a micro level to everyday things we can do in the endoscopy unit. Since we're talking about it, I wanted to bring up things that on a administrative large scale, the hospital can do. So in terms of the healthcare addition plan, there's a global roadmap for healthcare decarbonization. And that includes trying to move over to a hundred percent clean renewable energy and renewable energy sources are like your wind energy, your solar energy. And those are basically things that do not come from fossil fuels. Fossil fuels are basically the sources of energy like natural gas and coal that are from fossils from millions of years ago that basically turned into energy sources that if you burn them, you can derive energy from. So our goal is to switch to a hundred percent clean renewable energy, like the things I talked about, wind, solar, geothermals, what have you. They're much better for the environment and they don't emit greenhouse gases. Another thing that they can do is invest in zero emission buildings and infrastructure, transition to zero emission, sustainable travel and transport, provide healthy sustainable food for the, not only the patients, but also for staff, incentivize and produce low carbon pharmaceuticals, implement circular healthcare and sustainable healthcare management, and establish greater health system effectiveness. The reason why I'm rushing through this slide is because this stuff isn't really up to us, right? This is up to the people in within the ESG department that are hired by your hospital who typically have engineering degrees and whatnot. So I'm going to breeze through some of these and then talk more about what we can do. But one of the biggest concerns people have about switching over to more sustainable practices is that they're worried it will cost money. And this is a really wonderful slide from Practice GreenHealth that basically says that sustainable procurement in healthcare can lead to significant cost reductions, supporting uninterrupted operations, attracting top talent, let people, you know, not to say like myself, but like there are people out there who really care about this and want to work in a place that has really good ESG practices. And you can also drive cutting edge innovation using this and address inequities in health hazards within the supply chain and also the impact of healthcare and the inequity that results in the people who are most affected by the greenhouse gas emissions that are created when let's say you incinerate your garbage at a site that tends to be in a low income area. So these are all really important things to recognize that by switching over to sustainable practices within your ASC, your endo unit, and your ORs, you can actually save a lot of money if you follow guidelines from organizations like this. So what's the plan in terms of the GI edition, right? So we went macro level, and now we were talking more micro. In terms of GI societies, there's a lot of advocacy research and education that we can do. For example, this webinar, the different societies have actually already come together and created a really great paper that I was fortunate enough to be a part of to discuss this, and we're working on more things. I also really strongly feel that we should work with industry and not against them, because a lot of people feel that industry is one of the major producers of a lot of these through not only the items that they make and the expiration dates that they have, but also just through creation of a lot of their devices that are often single use. But it's important that we work with industry to try to combat this really important issue that's going to impact all of us. It's also within medical societies joining together and uniting to basically create plans to decarbonize their health industries. And there's a lot of really great papers on this. I actually wrote an ACG practice management toolbox about how to improve your endoscopy unit's carbon footprint with very practical things you can do. If you're interested, you could take a look at that, but we're going to talk about some of those things today. So this is a slide I'll probably spend the most amount of time on, and it's really the things that you can do in your endoscopy unit in order from the most impactful to the least, from left to right. Because as you knew, reducing is the most impactful thing you can do, then reusing, and lastly, recycling. So in terms of things that you can do within your endo unit, your ASC, your hospital, telemedicine is a great option. Remote consulting is environmentally preferable. Its success is highly context specific, obviously. And so patient selection and engagement are critical. But we saw during the pandemic a huge swap in the way that we actually operate, and we've seen the opportunity to make telemedicine a viable option for patient care. And then one of the biggest things we can do is to avoid unnecessary procedures. Now, my colleague recent said in the last set of slides that it's somewhat the cost of business, but we're doing a better job, I believe, in improving this. So appropriately reducing the number of unnecessary endoscopic procedures performed is likely to be the single most effective route to mitigation of our impact. And it's axiomatic to think that the greatest waste is a procedure that did not need to be performed. But the decarbonization cannot end with this step because demand for endoscopy, as we all know, rises every year. And it's also a big income generator for most centers. So the concept of reducing this is quite scary to a lot of people. So one of the things we've done is avoid over surveillance. I think the newest colon polyp surveillance guidelines will definitely help with this as we change with the change moving to seven to 10 year surveillance intervals versus a five to 10 year for patients with the lowest number of adenomas. And there's also non-invasive stool tests and colon capsule endoscopy already in use, but more pressure on the healthcare sector to improve sustainability efforts. These are interventions that can add benefit. And then things like cytosponge could also play a role in risk stratifying patients and better identifying who needs actual endoscopy. Other things you can do to reduce our plant-based menus in your hospital, and also offering those for your patients and your staff. Double basin washers are another option because you can wash two scopes at a time. Environmentally friendly cleaning solutions, waste allocation education. And I'll talk about this, making sure that you put the right things in the regulated medical waste bins, those red bins and those sharps bins, because a lot of unnecessary stuff goes in that. Not only does it cost more for you to get rid of that waste, which needs to be driven far places and incinerated oftentimes, but it's also much worse for the environment. More for the OR preference cards so that unnecessary things aren't opened in your endoscopy unit. Switching your lights to LED light bulbs will save you money and also better for the environment. And then reducing travel. In terms of reusing, you can reprocess a lot of items and you can often make money by sending these back for reprocessing. And then you can choose whether or not you want to buy reprocessed, let's say, pulse oxes versus selling them back and having another hospital buy them. You can also compost your food. We can use reusable gowns. And I'll talk about this more, but one of the problems with the GI suite is that we often get put under the peri-op umbrella. And so a lot of our practices end up being focused on sterility when we don't obviously perform sterile procedures. And so that's a huge problem for us. And this goes back to billing, but ultimately we need to push the envelope about changing some of these things so that we can better serve the environment and also our patients in turn. You can reuse scope buttons. You can reuse washcloths. You can get biodegradable packaging, something we can work with industry on. I donate all of my expired medical goods instead of throwing them in the garbage where they go straight to landfill. And we can reuse surgical and medical products. And then lastly is recycling, right? This is the lowest impact thing you can do in terms of a carbon footprint, but you can still do it. And as long as you don't sell your recycling stream and keep things simple within your unit, you can really have a great impact. So you can recycle your plastic, your metal, your cardboard, and disposable scopes if indicated, if you're using those in your unit. Okay. So just briefly about regulated medical waste. So those bins in your procedure rooms, in your ORs, this is basically waste that is meant to protect not only the handler of the waste, because it may be sharp and poke through the bag, or it may have blood or other materials that are dangerous to the handler of the waste, but also for the landfills that they go into. And the problem with this waste is that the CDC indicates only about three to 5% of the waste in the hospital should go into red bags, but some people have as much as 70% of their waste going into these. And the issue is that they're driven long distances to often be incinerated, and they give off very dangerous chemicals when that happens. And obviously that impacts the people who live around the incineration sites. So it can be very, not only costly, but also very dangerous for the people who live around those sites. So it's important to reduce the things that should not go in there. And I often see it in my hospital, someone sees a red bin, they just throw their gown gloves in it because they're too lazy to walk to the actual garbage bin. And that's just horrible. So educating about this is one of the biggest impact things you can do. And it's basically saving you money, it's free to educate, and it's something that you can do low hanging fruit. This is just showing you that these dioxins that are given off when you burn this regulated medical waste is very dangerous. It has a long half-life. It is ubiquitous in our food supply chain and can cause a lot of health problems for the people who are exposed to it. And 45% of these come from medical waste incinerators. In terms of reducing waste, again, you can see here at our hospital, regulated medical waste costs $830 per ton to get rid of, solid waste $122, and recycling $86. So with each different option that's better for the environment, it costs less. So this is a great way to save money and do good for the environment and for the people who live around these sites who often are invisible to us, we don't think about them. This is an example of something we're working on for the ASGE and actually breaking down, sharps containers are actually under the umbrella of regulated medical waste and going through step-by-step things that actually need to go in sharps containers versus things that don't, or in red bins. So for example, people often throw bloody gauze into a red bin, right? But it doesn't actually need to go in there unless it's dripping with blood, freely flowing blood, which in GI almost never happens. So that's a perfect example of just educating people on putting the right things in these bins and the right sharps in the bin specifically too. So going through this list, this is a busy slide, which you obviously don't have to read, but it's very nuanced and it actually changes state to state. So it's hard to create like a national guideline on it, but we're working on it. I made a video on regulated medical waste and red bag education for my hospital, and it's on our learning modules. And it's something that hopefully we'll get out to GI societies as well. In terms of single use disposables, this is also another low hanging fruit that you can do at your hospital center. I think, unfortunately, because of infection prevention being such a big driver within medicine in general, that's led to a lot of things being single use that I don't necessarily feel need to be. And sometimes it feels like the pendulum has swung a little bit too far. So single use disposables make up a large portion of hospital trash. And many of these have reusable options like gowns, surgical equipment, pulse oxes, SCD boots. And so it's really important to recognize that there's companies out there that will actually take these back and pay you for them. And if you're not in the business of wanting used pulse ox, because you feel like it's not as good quality, you can buy new ones. But you can sell these to Stryker and other companies like that to make money for your hospital and actually just do a great thing for the environment. We reprocess a lot of different things at our hospital. Like I said, like I mentioned earlier, pulse oxes, SCD boots, and EKG leads. And part of my job as chief sustainability officer is going around the hospital and basically re-educating people on these bins, the presence of these bins, and making sure whenever a new staff is onboarded that they know about this and they don't just throw it in the garbage. We also donate our expired medical devices. A lot of stuff in GI, I do advanced endoscopy. And so we have some very expensive tools and toys that we use, but they have an expiration date. Now the expiration date itself is up for debate, I feel, but you know, it's usually the plastic packaging that expires, not the metal stent that you're going to put in someone's bile duct. And so unfortunately, because they do expire, and this is an FDA regulation, once they expire, they go in the garbage. And if you don't have a good inventory system, a lot of stuff can expire. And so we actually donate it to companies that accept them and then redistribute them to developing countries where they don't have such stringent rules about expiration. It's also important moving along that chart I showed you that you can recycle. Now at my hospital, we started with a recycling pilot because we know how human beings are in the hospital. The goal is patient care, right? It's not always doing the best thing for the environment, but what if you can marry those things? So we basically started a recycling pilot and we asked that only these plastic bottles that are used for every single OR case were recycled. And you can recycle things that have the one, two and five label at the bottom, but we basically started simple and then grew from there. And now we're recycling in almost every single OR and all rigid plastics, not just those things. So you can start small and grow. And the goal is basically not to sully your stream. So you don't want garbage going into that because that can ruin the whole bag. Here's some examples of non-recyclable plastics that we use. So it's important to know that if you do a recycling program, you can't recycle everything. It needs to have the proper label. All right. Just briefly wanted to talk about in-person versus remote or hybrid conferences. So basically there's been some studies done looking at the fact that logically speaking, obviously remote conferences are better for the environment, but as we all attend, you know, DDW next month, we know that sometimes air travel is unavoidable, right? So there are things that you can do to try to offset your carbon footprint. So JetBlue offers carbon offsets with every flight. It's included in the purchase price. And obviously, you know, I'm not paid by JetBlue or Stryker or anything. So these are just ideas I'm throwing out there, but you can purchase carbon offsets separately for different airlines. You can consider Zoom or combining trips, obviously not so much a problem for most gastroenterologists, but avoid private jets. And then you can also pick options with lower CO2 emissions. So these are all things that you can do. And a study was done in Canada, looking at basically the location of your meeting has a big impact on different carbon emissions. So choosing big city centers is better than choosing the exotic location like Toronto versus Banff. So it's important to know that of course, you know, people want to go to a conference in a beautiful location like Hawaii, but it's probably not the best thing for the environment because most practitioners are not going to be living there. So it's just things to consider. Plant-based diets are great for the environment. We actually have a wonderful clinic at Bellevue to educate our patients on this, but it's a great option for all the meals that are prepared for patients in a hospital setting. So like meatless Mondays is a great option because most red meats have huge carbon footprint. So it's really important to consider that. And then switching all your light bulbs over to LED light bulbs. Not only will you save money, but it's also much better for the environment and then turning off lights or having those motion detectors. It's really important for hospitals to switch over to these if they can. Here's just some work that we've done at our hospital with sustainability and, you know, some awards that we've won for our work. And some of the research that we're doing is not so glamorous, but it's really important work to basically contribute to the education and the papers on sustainability that exist. So thank you so much for your time and attention. And I'll pass it over to my colleague. That was, that was fabulous. You've got to appreciate the enormous knowledge that you have and have developed as a sustainability officer for a hospital, which I think even that job is fascinating. We'd like to hear more about that. I wish my hospital had one of those. So we're going to go on to our next and final talk, which is by Lyndon Hernandez. Lyndon holds a clinical faculty appointment at the Medical College of Wisconsin. He provides management for all general digestive disorders as well as pancreatic disease. And he also currently serves on the ASGE sustainability endoscopy task force. So Lyndon, take it away. Good evening. Single-use devices have increasingly permeated the medical device industry for the past 20 years and is projected to grow in the coming years. The primary driver is that perception that single-use devices are safer than reusable devices, promising zero or near zero infection rates. There are two other factors contributing to its use, multi-drug resistant organisms detected in contaminated duodenoscopes. And the pandemic also accelerated the use of disposable PPEs. Various incentives converge towards the use of single-use devices. Hospitals want to minimize liability as well as the labor and material costs of reprocessing. We also want to minimize human error in reprocessing. Manufacturers do not want to be associated with infectious outbreaks. Regulatory bodies such as the FDA requires proof that a product can be safely reprocessed, but very little requirement for marketing devices as a single-use. Accreditation bodies such as the Joint Commission traditionally favors single-use devices due to its perceived safety. Endoscopists are incentivized towards zero infection, often without regard for environmental impact. So after 2013, when the first duodenoscope infection was published, we noted an increase in patient infections from contaminated duodenoscopes, noting a peak incidence in 2015. Soon after that, the FDA mandated manufacturers to perform post-market surveillance studies, optimize high-level disinfection protocols, and work on duodenoscope designs to improve the cleaning of the elevator mechanism. Fortunately, since 2015, the number of infections declined by 62 percent, down to 95 reports in 2017. We await further infection updates from the FDA after the 2019 data. After 2019, first the fully disposable duodenoscope was introduced. Then the following year, duodenoscope with a disposable implant. What are the materials used for GI endoscopes and accessories used during endoscopy? Let's briefly look at the material composition of endoscopes and accessories and how they affect the environment. Among accessories used for endoscopies, polymers such as plastic are the predominant material. It is important to note that most of these components, namely plastic and metal, goes to local landfills, and only a minority is recycled. So among duodenoscopes, most of the carbon emissions and energy consumption from manufacturing is actually not from metals and plastic, but from that semiconductor embedded in each scope. Thus, as we shall see later, there is a higher environmental cost for using single-use duodenoscopes, especially in a high-volume setting. So how do we decide between single-use and reusable equipment? We have seen several publications on green endoscopy offering tips on how to reduce one's carbon footprint. Certainly, these are valuable references and it also raises awareness. However, when it comes to implementation, there is no single solution that will fit the needs of all endoscopy units. Therefore, the key is prioritizing at a local context. What we need is a framework that can be used for decision-making when choosing between single-use and reusable equipment. We need to find the intersection of reducing carbon footprint, if possible without added cost, and should be easy to implement. First, we need to decide what a successful outcome will be. What's our goal? Reducing carbon footprint or it can be reducing waste. Second would be cost. It can be budget neutral or it can be cost savings. We will have an example in the next slide. Implementation is the most critical component for most units. Most people falter and we will discuss that. Here are some examples of accessories and endoscopes that are available as single-use or reusables. In the pre-procedure area, gowns, blood pressure cuffs, EKG leads, water containers such as single-use, for single-use that pertains to sterile water. Intra-procedure, this will include esophageal dilators, endoscope valves, or buttons. Let's look at gowns as an example. There is preliminary data showing that the environmental advantages of reusable gowns over disposables, considering laundry and wastewater treatments. Using reusable gowns could reduce greenhouse gas emissions by up to 66% and solid waste, 84%. In our area, a single disposable gown, for example, will cost about $3 while a reusable gown will cost about $1. In our unit, the choice was obvious. We chose reusable gowns. This won't make sense in facilities where it is logistically difficult to implement. Rabia mentioned this regarding surgical units. For example, the hospital surgical department may already be using single-use gowns, and so switching to a reusable gown in the endoscopy unit will be challenging. This brings back our emphasis to implement according to the local context. Another important caveat is to work as a team. Involve the entire endoscopy team, including managers, technicians, your procurement officers. Start with a question, generate your goal. Let the answers grow from the ground up. Giving a mandate from top to bottom will result in poor execution. Now let's go to endoscopes. Rahul mentioned about the study by member R on waste generation endoscopy. There are two ways to look at environmental impact, waste generation and carbon emissions. In an audit of two US medical centers, each endoscopy generated about 2.1 kilograms of disposable waste. And as you know, the majority went to landfill. The authors also projected that if all procedures were performed in single use endoscopes, the net waste mass would increase by 40%. Another outcome to consider beside waste is carbon footprint and public health outcomes. In our preliminary modeling, we compared the greenhouse gas emission and public health impact of reusable dual endoscope versus single use dual endoscopes. We considered in our model, reprocessing waste and the energy used to manufacture these devices. In our model, we estimated that single use devices emits carbon dioxide that is 24 to 47 times higher than reusable dual endoscopes. In fact, most of the greenhouse gas emission of single use dual endoscopes comes from manufacturing the semiconductor embedded in each scope. Thus a reasonable approach for using single use dual endoscope is to individually consider the risk of acquiring multi-growth resistant infections. There is an inherent tension between the goal of zero infection rates versus net zero carbon footprint. However, these are not completely opposing goals and it is possible to give the best endoscopic care to our individual patients and also become aware of how our actions affect our environment and public health. So in summary, we need to use a framework considering the environmental goals, cost and ease of implementation. We need to generate ideas as a team and choose the best option. Ultimately, what we need is close collaboration with our partners in industry. We need the rigorous accounting and public disclosure materials to calculate the carbon footprint of our endoscopic equipment. Thank you. I will thank you, Lyndon, for that thought provoking presentation. And we're gonna now head into our Q&A session so people can start thinking about questions and putting them in the Q&A. Doug, are we ready to start the discussion? Yeah, I think we are. I see a question in the chat box from Ashley Faux saying that it would be nice to kind of have a step-by-step roadmap for folks that are getting started. So maybe you guys could comment on that. Robbie, does your ACG toolbox address that? And I'd sort of like to know what are the structural kinds of things that you need to really get going? Very interested that you're the Chief Sustainability Officer for the hospital and you're talking about working in lots of departments outside of endoscopy. We may have some medical directors here in freestanding endoscopy units. So what about setting up a structure to get started either on the hospital? Is that a common thing, a sustainability officer for a hospital? No, it's definitely not. And I think my work within sustainability for over five years now really helped pave the way for that opportunity that I essentially manufactured and pushed for because it's something I wanted to do and I was willing to do it without a title, but they just formalized it. So it's something I have been working on. But to answer your original question about a roadmap, I definitely would start, I think whenever you're dealing with any sort of sea change within policies and processes within a hospital setting, you want to start with the lowest hanging fruit. And when it comes to administrators, those tend to be things that are free or potentially save money because once you start with that low hanging fruit, you can kind of convince them and say, okay, we have proof of concept, this worked, now let's push the envelope and try for the next best thing. And so I wrote a great paper for, and I'm going to call it great because I think it's great, for the ACG toolbox that basically is 10 things you can do to improve the carbon footprint of your endoscopy unit. And honestly, these are very practical things that anybody could really do. Most of them are free or save money. And so I highly recommend taking a look at that, but you can start very small. Like we're going to ask the people in our printing department to do double-sided printing. It's the small things that I think will then snowball into having a total different outlook on sustainability. So I say, start small. Very good. I would add our ASG task force, which includes Lyndon and Rahul and Rabia as a guest member is in the process of putting out a few papers. One sort of a framing paper to cover some of the concepts that were discussed tonight. And another paper kind of directed at just that, how to get started if you're interested, but not really sure where to start or to the initial steps that you could take. Lyndon, you were mentioning that, you felt it was important to not have it sort of be from the top down, but rather to try to engage people at all levels. What does that look like in, I mean, I'm in Indiana. It's kind of a, it's a little bit of a reddish state, not too much worrying going on here about carbon footprints. How does that, how do you build interest and importance in the whole group to get everybody involved? And so I tried to identify people who might be interested in this topic. So these are, this might be a nurse, this might be a manager, techs, who might feel will be open to this topic. And then I start asking questions. How do you feel about reducing our use of the red bin? You might, I might want to angle it as a way of reducing costs, because in our unit, we pay per volume for the red bin. So I first angle it by reducing costs and usually managers will listen. And then later on, we can, we'll talk about a little bit about sustainability, but I think if you engage the people who might be interested and you start it in a point of view of reducing costs, from there it will grow organically. Very good. Seth, got anything? We do have a question in the Q&A from Gerard Eisenberg. How can we share best practices in different organizations, ASCs, hospital-based endoscopy? Could the ASG use GI LEAP or their website to be used to share these practices? And I guess, maybe to extend this a little bit further, what can GI societies do to help with this work? And Rabia, maybe you can speak to that being part of this kind of multi-society task force. I think there's multiple tenets to what we can offer. And I think it starts with raising awareness in education, right? So when it comes to trying to create a change of opinions, that's the easiest thing to do. And also the most practical thing to start with. And offering then the next step after you kind of create what we did, our multi-society task force basically put out an opinion paper on what we think changes should be. I think the next step then is going to very practical things that you can do within your endoscopy unit, your ASC or your OR. And also including then cost-saving possibilities. Because ultimately, we'd be foolish not to acknowledge the fact that ASCs are business, right? They need to make money. They need to stay afloat. And not acknowledging that and pretending like, oh, we only care about patient care. Like we do care about patient care, but a lot of private practices need to make money. They need to make ends meet. They need to pay their employees. So putting your head in the sand and not acknowledging that is really difficult. So putting out basically papers is the best thing that as societies you can do in research is the best thing that we are doing and people will continue to do, I hope, because this is a really burgeoning field of academic research within I think all aspects of medicine. And I truly feel that the people doing this research really care. They're not just looking for a niche. They actually care about this subject and want desperately for us as a healthcare society to improve and do better for our patients just in a different way other than patient care. Are there guides about, I'm interested in, what plastics are recyclable? And I know we have the markings on them, but what are the fundamental differences between recyclable plastic and plastic that is not? And are there differences, like say, are we seeing sort of across a class of devices, all the sneers are one thing, all the biopsy forceps are another? Are there sometimes differences between vendors where a particular vendor does make a device that has recyclable plastic in it? Or how does that go? I can let Rabia speak to this because I'm sure she has a lot more insight than I do. I think a lot of the endoscopic tools that we use are mixed materials. I think they're very hard to recycle. Generally, plastics, number one and two, when we're talking about plastics are recyclable. Plastic, number five, which makes up our sterile water bottles as can be recyclable. It depends on your recycling partner as to whether they'll actually accept number five plastics for recycling. But I think one of the big issues with a lot of our endoscopic equipment is it's mixed materials. Okay. Any insights in terms of vendors? I know that some of them have set goals for zero carbon emissions by a particular date and so on, but any kind of sense within the endoscopy community about which ones of our vendors are doing particularly well, actually making progress in powering their factories with wind or solar, et cetera? I don't personally have any insight. I'm hoping they're all making big moves behind the scenes. It would seem like an important thing that possibly we could exercise some leverage in our discussions, even at the society level to encourage them. If that accounts for 70% of the carbon emissions, that having them set honest goals and trying to do that is an important part of what we're trying to do. Yeah, I mean, I will say that the sustainability officer, the business community is far ahead of healthcare in that regard that a lot of these big corporations do have sustainability officers and departments looking at it. But I think the GI societies are able to sort of exert some pressure on the hospital systems about their energy sources and pursuing renewable energy. And so that's perhaps one way where kind of GI societies can exert their collective influence. We have a couple other questions in the Q&A that I just wanted to get to. Julie Sun asked thoughts or experience with the human waste management systems, such as the Neptune. I don't know if any of the panelists have had experience with that. And Harshit Kara asked amongst the various committees at ASGE and other GI societies, is there an opportunity to create a green endoscopy committee where physicians or directors can share ideas and learn from each other's experience? So I think that we're trying to move towards that, at least on the ASGE side, starting with this task force, but with an eye towards perhaps eventually becoming a full-fledged committee. I'm not as aware in other societies of similar activities, but perhaps some of the other panelists are, I don't know. Each of the societies is basically, after our committee joined and wrote, we're working on different projects. Each of the societies has kind of taken ownership of what they plan to do. And it's not easy to try to push forward. Some societies are more supportive than others. So I think that the opportunity is really ripe if you're interested to create a leadership opportunity, not only for yourself, but for like-minded individuals like right now. So strike while the iron's hot. If there's no organization that exists within the society that you like to work in, I think now would be a great opportunity to do that. I know that personally we're working on one within the ACG. I know that ASG is super active, but I don't know about the other ones. I don't know if they have actually taken that leap to formalize a group. So it's a great opportunity for someone who's passionate about this. I think all four of the GI societies certainly had enough interest to participate in this multi-society task force. And so, just like all of us are at a different place in the whole thing, as we can see from the people who think it's very important to reduce their carbon footprint to those who think it's moderately important, there's still some variation, maybe a little bit between the societies, but everybody's got some level of interest, I think, to participate. And hopefully that's gonna increase as time goes on, of course. Well, I think we're coming to the end of the hour. I wanna thank all our wonderful speakers tonight for a very informative discussion. I certainly learned some things, and I hope those in the audience did too, about an increasingly important aspect of our work as endoscopists that we're just beginning to sort of wrap our brains and arms around. Doug, any final comments? Well, I wanna thank all the panelists for your leadership in this area, and for really some practical tips and guidance that we can all take away from this. And I appreciate all the audience joining us, because I know a lot of you share these interests. Some of you are medical directors, and you've at least got an inkling here. So I appreciate you taking the time and getting some tips that you can use to get started. I kind of feel the same way about it. So I found this to be incredibly valuable. Some resources have been mentioned that I think all of us can look into. So this has been a very productive thing, and I hope we can have more sessions like this, and grow the audience, and encourage everybody to get involved in this very important and new area. It's kind of in our infancy here, except for Dr. Rabia, who's like full, and our other ASG Task Force members who are into this. But we all wanna join you and share your interests. So this has been great. Thanks, everybody. Thanks, Eden, for organizing this. Appreciate everybody's time and effort. Well, thank you. And to our audience, I want you to know, we will be issuing some more resources in the near future. Dr. Crockett mentions a paper series that will be coming out. I will be sure to email you all directly. I'm gonna consider you a high interest group, and I will keep you apprised of those things. So we do wanna thank our presenters, our moderators, and you, our audience. As a reminder, a recording of this session will populate your GILeap account when it is available. This concludes the presentation on green endoscopy and climate change. We hope this information is useful to you and your practice.

green endoscopy

sustainability

waste reduction

recycling practices

materials impact

telemedicine

patient care

carbon emissions

best practices