Hi everybody, so welcome to our event tonight, we, this is our lessons in green endoscopy so we're really glad we're going to learn from each other tonight, and it's going to be an exciting evening it we do want this to be interactive So bear in mind that you can put questions in the chat there. We encourage you to raise your hand and go off mute and share your experience as well so we're going to get as much out of this as we give to each other so for those of you on the quality side I say quality is a team sport, sustainable endoscopy is a team sport. So, cameras on cameras off whatever you want to do is great but we're all here to learn from each other so with that said I'm going to hand it over to Dr. Pol All right, everyone. Let's get started and welcome everyone, it would be great if you could show yourself and unlock your cameras, it would be just nicer to have like a communication with people you see, but of course it's up to you if you want to do it or not so welcome everyone. So, this is our first ASG discussion forum around lessons learned in green endoscopy and we thought we're going to have a forum like this where we have some interaction and see what we've learned so far, so I'm looking forward to our exchange over the next hour. Hi, I'm Michael Pol, I'm a gastroenterologist at the VA Red Rare Junction in Vermont, I also work at Dartmouth-Hitchcock Medical Center in New Hampshire so I'm exposed to two endoscopy units. I'm also chairing the ASG Task Force on Sustainable Endoscopy and the Multi-Society Task Force on Environmental Sustainability. My co-facilitator is Sonali Pachaduri who is a gastroenterologist at Mass General Hospital. She's also the Associate Director of the Safety and Quality Committee there, and she's a member of the ASG Committee on Sustainable Endoscopy. So, I thought in the beginning to just get started, I'd like to just have some introductory slides so let me just pull up my slides here. So, that's how, by the way, how I got motivated to think about sustainability, because I was just so fed up with seeing all the waste that we generate in endoscopy every day. And what you can see here is the amount of waste that we generated in one room of our advanced, in one advanced endoscopy room during a day. This was taken during an audit, a waste audit that we performed some time ago on an endoscopy unit, and the average waste that is being generated in endoscopy is about 2.1 kg per endoscopy. It's more for advanced procedures, a little less for routine procedures. Now, that has an impact, not just, you know, for our landfills, but on the greater scale for actually the world, not just our endoscopy, but healthcare. And eventually it will affect pollution, plastic pollution above all, but there are also other effects on the so-called planetary boundaries. And the thing that we are most concerned about, or many of us, is climate change and global warming. Of course, when we have so many consumables that are single use, they generate also emissions and they contribute to global warming, greenhouse gas emissions. The healthcare sector actually generates about 8.5% of all greenhouse gases that are generated in the US. So it's a major contributor to greenhouse gases in this country. So the question is, what can we do about it? And the Multistudy Task Force came together and generated this kind of strategic plan on environmental sustainability. It covers seven domains or categories and kind of puts out like an outline, a pathway towards a sustainable GI practice, not just endoscopy, but GI and hepatology. And in each of those areas, clinical, education, research, and so forth, we laid out some milestones that can be achieved over a five-year time horizon. So, but even with those milestones, the question is, how are we really doing this in our endoscopy and how can we really get something happen, make something happen and get practical? And there are a lot of, or increasing number of papers out there that just generate some statements that we should be, you know, have less waste and should be in general more green. But the question is really, how are we doing this? And so in our task force, we have started to create some manuals. So for you in the endoscopy unit, take on and trying to implement things in your endoscopy unit. And this is a series of papers. The first one is how to get started, was published a year ago. The second one actually was just published, just came online today. So appropriate management of endoscopic waste. We will have the next one is reduce. And then the one day after is about reusable items and then energy conservation. So those serious papers are intended to give you something practical, like a manual that you can use in your endoscopy unit to implement. So, but then still the question is, does it work? And then we thought, I'm just going to skip a couple of slides here. Then we thought we should just have, see how that works in practice. And so there were a number of endoscopy units that wanted to participate in the green pilot site project. And eventually, eight were started to participate in this. And this started in January of this year, or February of this year. And so today is, we will have a representative who will share the experience of one endoscopy unit, what happened during this pilot site project. And so I'm curious to hear about that too. But the main task here is really main, main question is really what worked well, what didn't work well, what can we improve and how can others learn from this? So Sonali is the leader or the chair of the screen pilot site project, and I'll give it over to Sonali and she can maybe then also introduce our first speaker on this. And by the way, if you have questions, you can put them into the chat and we will have enough time I hope for discussion. Thanks Heiko. As he said, my name is Sonali and I'm excited to try to get a lot of this conversation going. So just a couple of outlines for our discussion today. The goal is, you know, as Heiko said, not a typical webinar. We really want this to be a group discussion. So for the first few planned sites, we'll have one site discuss their project. And what I'd ask for all of you is to put up questions in the chat, you know, be open about what your thoughts are and questions and suggestions. And then also share if you've had similar experiences. You can write in the chat, you can raise your hand and maybe we'll be able to, you know, unmute and really make this a conversation. After or during, if you have a story that you want to share for your project, please let us know by writing in your chat, new project, just three to five words. And we'll, you know, make sure you get a chance to share your story and see what other questions people have. I'm putting here just, you know, kind of a framework for how we'll try to tell our story. So we'll say like the goal of the project, I have in bold what ended up happening so far, and what were the lessons learned. And then maybe we'll try to follow up with some of the other questions regarding what were the barriers and who was leading and stuff like that. So we can get a good sense of, you know, what works and what could be improved in future iterations of trying to do the project. So I'll leave this up and I'll ask one of our first sites. Oh, I'll just mention we had these eight fantastic sites who are doing really, you know, they're really invested in some of the things that they're doing on their sites. Stephanie is here to share what happened at her site. And if the other sites are available, feel free to, you know, chat and we'll try to add you on next. Otherwise, I'll give little blurbs as we ask for other people to tell their stories. So I'll kick it off to Stephanie and tell us what was happening at her site, who will kind of, you know, practice using this model of telling us what happened and the lessons learned. Hi there. My name is Stephanie. I'm a staff nurse at an endoscopy unit at Stony Brook Hospital in New York. So I started on our unit three years ago, and then there was like zero, any green initiatives at all. We didn't recycle any plastic, any cardboard. There was really nothing going on. So when I got there, I was kind of shocked that we use the huge amount of cardboard and plastic and we were just throwing it all in the garbage. So that kind of sparked some thoughts for me. And then my manager joined the green initiative and together we kind of started making our unit more green. So we have like two main projects that we were trying to tackle. The first one was successful. So the first one was linen reduction on our unit. And then the second one was more recycling with plastics and cardboard. So the linen reduction, basically, our goal was to reduce pounds of linen that our unit was laundering. So we were having patients come in on a stretcher, I mean, on a chair, basically, that was dressed with linen and then having them walk into the room for their endoscopy on a new stretcher with more linen. So this is what they had been doing for like years. And such a simple fix was to just have the stretchers in the pre-procedure intake with linen on it and then transferring the patient on that stretcher into the room for the procedure. So that basically would half the linen for the day that we were using. So that was our overall goal was to reduce it. The metrics that we measured were pounds of linen being taken from our unit. And then the cost for the current state, I guess we didn't really realize there was anything wrong with it because that's how we had always done it. So the plan was to try and implement it for a week and see what everyone thought of it and then go from there. We did have some barriers, which was resistance to change, which is always a barrier, I feel like. So, you know, people thought maybe it wasn't going to work or it was too bulky to have a stretcher in the pre-procedure area. So our boss kind of like stated it as a trial to see how it would go just to kind of get everyone in agreement to it. And then once we did it for a week, everyone was like, wow, this is such a good change. And we're using less linen. We're making less stretchers. Like it just overall was a really successful project. So with the numbers, I don't know the exact numbers off the top of my head, but we did see that there was a decrease in pounds of laundered linen from our unit. And that's how we do all of our pre-procedures now. We just have them come on a stretcher and then go straight into the room. So that was our first small project that was a success. So we were really happy with that. And then our second one was more of recycling all the cardboard and plastic that we use, like all the sterile water bottles, saline bottles, stent boxes, everything that we use every single day was going in the garbage. So the goal was basically to start recycling these eligible items. We had to find out if there was even a recycling contract on our unit, I mean, in our hospital. So after touching base with the hospital linen department and housekeeping department, we found out that we do actually recycle in our hospital, but our unit just didn't. We didn't have any bins. No one was collecting anything on our unit. So we just didn't really know about it. So that was definitely something that was helpful is that there was already a process in place in the hospital. So one thing that we needed was collection bins. So there wasn't even the ability to collect recycled items because all we had was garbage. So we got recycling bins for plastic, for cardboard. And then we reached out to, there is a recycling committee on our hospital, but it's only a few people. I think it's like four or five people. So we reached out to them, basically how we can get our recycled items to them. And we got, I printed out all these labels for the bins and then we started recycling plastics, cardboards. And so far it's been successful. There have been a lot of barriers. People are skeptical of recycling to begin with because people like to say it all ends up in a landfill. So things like that, people don't want to walk out of the rooms and put it into a recycling bin. There's not a lot of room in the actual procedure rooms for recycling bins. So they're in the hallway right now, which is kind of another barrier. It's taking up space. It's bulky. So there are definitely some barriers that we're running into. And then finding out what exactly can be recycled, what can't. What else? Those are like the main barriers, but so far we have been recycling a lot and people are more involved and excited about it, that we have the abilities and it's still a work in progress. And they do actually track the amount of plastic and cardboard that the hospital recycles. So it is good to see those numbers and get excited that we're contributing to that now. So that's pretty much it for our projects, one in progress and one kind of completed. But if anyone has any questions or if I missed anything, let me know. Yeah, thanks, Stephanie. Those are really great updates. Vipak asks, thanks for sharing. How did you overcome the barriers? I think he means perhaps about recycling. So one thing that- You mentioned a couple of things that people are skeptical about recycling to begin with, for example. Yes, so that I think was a big one because people actually laugh. They're like, oh, you think that's so funny. You think that's actually going somewhere. And it hurt my feelings a little bit, but I was like, all right. So I called, I asked the recycling committee, who do we recycle to? So the first one was a place called Long Island Waste. I think it's called Long Island Waste Systems. So I called their facility and I asked them, like, what is the process of you picking up our cardboard? Like, what do you do with it? They told me that every day they come, they pick up all of our cardboard dumpsters. They bring it back to their facility and they actually sell it to people that use cardboard recycling. And then I also reached out to them about, it was a separate company that does plastic and they pick up our plastic and they melt it into pellets and they also sell it to companies that make items out of recycled plastic. So once I spoke to them about the process and I went down to our loading dock and I saw the actual recycling bins where trucks were picking them up day by day, I came back to the unit and I told everyone, I said, hey, like, there's trucks picking up all this plastic. There's trucks picking up all this cardboard. They wouldn't be doing that if it was just going in a landfill because they're wasting their time and resources. So I took pictures of everything. I showed it to everyone. And I do want to take a tour of the facilities eventually that the plastic is going to and that the cardboard is going to. I didn't reach out to see if I could do that yet, but I feel like that would be very helpful to maybe take like a picture or a video to say like, hey, this is our plastic and this is where it was going. Like seeing is believing almost. So that's kind of my goal if I can get there eventually. I remember the last time we spoke. Oh, sorry. You were saying you were going to like follow a truck or like to go see it. So it sounds like you're able to at least see the trucks and bring that information back. So that's great. All I'll say is, Stephanie, you're a hero. I mean, you know, if these individual efforts like these, I think they make all the difference. I mean, clearly you didn't have to do these things. And I feel if every endoscopy unit had a person like you, like, you know, it would be a different place. So thank you for sharing. Thank you so much. I appreciate that. Lynn says, I am impressed by your fortitude in confirming the recycling. I think that was really helpful. So at any point, if anyone has any questions, go ahead and put in the chat. If anyone has any other stories to tell, go ahead and put in the chat. Sunali, I have a comment. So Stephanie, it was great. Thanks for sharing and inspiring. So I have not thought of linen. And we have our task forces and we talk a lot of different things. But linen is one of the opportunities, at least in your unit. So thanks for inspiring this idea also. I agree that there's a lot of skepticism about recycling. And there's actually good data how often recycling doesn't work. More than 90% of what we think is recycled is actually not recycled and ends up in the landfill. The more it is important to understand who the recycling partner is, as you figured out, and understand exactly what can be recycled. And that might vary between hospitals because it depends on the recycling partner. And we did in our assessment, we found out that about 30 or 35% or so of all the materials that we use are potentially recyclable. It doesn't mean that you can recycle them. So one typical thing is, for instance, those plastic bags that are often used for packaging material. They are recyclable, but a lot of companies don't recycle them. But a few things that are really recyclable by every company is like cardboard and typical plastic. Let me just briefly share something, maybe also an inspiration for others, that fits the topic. In the paper that just came online, we included practical steps to green your endoscopy unit, appropriate management of endoscopic waste. We include some practical things, and you can see here a suggested poster of what goes into the hazardous waste bin, what goes into the sharps, what goes into landfill, and what goes into recycling. But you can see on the yes cardboard, paper, plastic bottles, it's pretty self-explanatory, but the disclaimer is here per local guidance. So you may have to adjust that recycling one and we are working on this currently in our unit to try to adjust this to what we can recycle. But also for other disposal of waste, hazardous waste for instance in our audit we figured or we had about 28% was hazardous waste and after we understood what goes where we actually reduced it to less than 5% of hazardous waste. So I encourage you to read in here there's also very detailed guidance what goes where and anyway I thought that kind of fits what you were just sharing so thank you. Yeah I read a couple of comments from the chat here so Fadi says did you get any pushback in regards to taking plastic that has been inside procedure rooms probably for infection control and such? We did definitely get pushback about that so I asked the recycling committee of the hospital about that and they stated that as long as it's not coming touch coming in contact with the patient or their bodily fluids then it would be safe to recycle it. So all of our sterile water bottles we probably go through 100 of them a day alone don't touch the patient so those were a big commodity. We use like e-traps for our polyps the box that that comes in is 100 plastic and recyclable and that doesn't touch the patient and scent boxes like when you open it you know the cardboard so things that you can kind of like get out of the field quickly it seemed like were able to be recycled as long as it didn't have blood or saliva or anything on it. Yeah it's great you're able to get that confirmation from your hospital. Kevin adds plastic bags can be taken home at least for use as trash bags can then buy fewer trash bags. Yeah fair enough there's a lot of stuff in the unit that we probably don't end up using. I wanted to circle back a little bit on actually Stephanie you can add to this as well from some of the other sites that have participated as pilot sites recycling really has been a very common topic or goal and there have been a myriad of barriers coming from not having the strains for collection in their hospitals to also like people working really hard to sort it to then realize it wasn't getting kept sorted later. So it's really great that you were able to confirm where your stuff was going and get that buy-in from your group to believe it because of all the things that Heiko said and even what some of the other sites had seen in their own practice. Deepak adds based on ASGE guidelines we would encourage you to consider using tap water instead of sterile water for endoscopic procedures. So yes coming soon is a paper that kind of discusses this. Thanks Deepak for bringing that up and hopefully we'll be able to encourage more sites to use tap water instead of sterile water if able to at your institution and such. I just had one more comment Sonali on the linen. One of the things that we have been battling is for the increased linen use is we often use our towels and blankets as support you know instead of wedges for the patients to just position them well and we have been trying to get away from it and that has been a battle too but I once counted that we used close to 36 times in our three endoscopy rooms different kind of you know blankets or towels to to just position the patient. You know we lose our wedges because they go on the stretchers and they don't come back but that's also I think is a complete waste because once you use them you end up putting them in for cleaning and you know it's just like linen wear so I don't know if others have noticed the same thing or not. Yeah anyone feel free to add. I'll also just read Badi's question. How about the manufacturer's IFU recommending sterile water? Deepak do you want your probably best position to address that? We don't you know we have discussed with our Olympus representatives we have been using tap water for you know for almost you know for a few years we have not had any problems using tap water and Olympus has no studies to say that you know tap water is unsafe as far as you know I know. I think it's what your institution or what individual endoscopy unit you know interprets the you know IFUs as you know we have not had any problems. I think that the two things one is for the endoscope and the second is for the patient. For the patient I can you know I can very categorically state that it does not increase patient risk. The second is about endoscopes and whether it obviates your warranty and other things you know that remains for an individual endoscopy unit to decide. Maybe I can respond to that too because Fadi and I were both at BAs and the BA is very strict on following the manufacturer's guidelines and so that is the main reason if the manufacturer says in the IFU in their manual we need he need to use sterile water then we have to use sterile water. However because for instance this current circumstance of the shortage of IV fluids and sterile water let Olympus at least for the Olympus endoscopes to state an official declaration or letter that we can digress from that IFU statement and that actually at our VA allows now to and I think this VA wide actually there is a statement from the BA that we don't have to adhere to the guidance of using sterile water. How to make that happen is a different question. So one possibility is if your institution allows that is to use a sterile water bottle in the in the morning and then fill it up with tap water filter tap water. It's still a waste of sterile water in the beginning. There is reusable water bottles that is that are distributed by Olympus two liter and also the CO2 water bottles 250 cc's. You just have to be which we just learned you just have they have to be congruent with the water pump. So if you have an Olympus water pump then you can have Olympus bottle if you don't have an Olympus water pump it's going to be an issue. So there are those unforeseen little challenges you think you can now use tap water but no it doesn't work. But that is just the current situation that we actually have an opportunity with the shortage as crazy as it sounds to revisit some of our practices that actually would support green or sustainable endoscopy. Same for IV fluids there's no benefit or no no data is actually data to the contrary to support routine use of IV fluids and and others can share stories about that. Michael I'll just say you know you know this is Fadi this is very important that you bring up these points and I think you know Heiko and Sonali in their positions I mean this is the kind of things that you know every every institution is slightly different endoscopy units interpret rules differently we do things slightly differently and we can just pull our resources together to show like no difference in outcomes when we do things slightly differently and I think that would help push sustainability to the next level. So if you have for anybody on this call like if you have questions like these you know please bring it up you know say to Heiko, Sonali and that gives us more ideas how to to study them. I should introduce that Deepak is one of our task force members and has a lot of experience in working on these sorts of projects. Linden another task force member mentions that they use tap water at eight of their ASCs where they use care water for the first patient and then tap water thereafter and so that is something in practice at some sites you'll have to see if it's something that's doable at your site. While we're waiting for you all to say what stories you want to add I'll maybe add a couple of points and bring in some stories from some of our other sites. Thank you Stephanie for kicking off a great conversation on two different projects and please feel free you know feel free to participate as we go. So the IV fluids question that recently came up I think that's a great topic to just bring up because this is something that we were all thinking about I did ask our pilot sites to see what they were doing at different sites and then we as a task force to ask each other what we were doing at different sites and I think out of those conversations we did learn that there were sites not routinely using IV fluids and just hep blocking the IV for patients and giving flushes and only using IV fluids as needed. This has been very minimally studied there are a couple of basically like a poster from several years ago but there aren't any great studies comparing the need for IV fluids or on-demand versus routine use but I think you know in the past couple of weeks since the unfortunate hurricane and limit in Baxter's supply many of us have found that we're using IV fluids in less than five percent of patients if we're just hep blocking and then only using it as needed for hypertension or other clinical needs. So this is a great example of how we did learn from each other in the beginning and hopefully we'll be able to share our story and encourage other sites to consider doing something similar and not just get through this crisis moment in terms of supply but also lean into a likely more sustainable practice and use us IV fluids. I'll bring to that another story that came from our discussions in the pilot sites. So we have several VAs and some of them had shared that in order to check the channel before using the scope that there was a policy in their institution that they had to run the biopsy forceps through the channel to check it and they would have to do this for every scope for every patient and then they couldn't use the biopsy forceps you know again between patients so they would just have to throw it away after that. So you know for some patients you end up using it for biopsies after but even if you don't end up using it later you literally just had to waste it after checking the channel and so I didn't know this. This isn't something we did at our site and this is something that you know a couple of sites said that they do so this is something that we're looking into for you know Eden and the rest of some of the support in the task force to see if there's a way we can get to the you know the top of where this guidance comes from and try to encourage a change in practice so that it's not going to be in the policies at individual sites. So we only learned of that by talking about it in our conversations from the pilot sites. I thought that was really interesting and hopefully be able to make some headway. If anyone has any examples of how they got past that at their site that'd be great because then we can learn from it. As I'll mention again put any examples in the chat if you'd like. I'll share another story from one of our sites. So at their site they were throwing away liquid waste you know the waste from the liquid waste you know from endoscopy into the biohazard bags because it's considered biohazard obviously but they were able to convince their hospital to buy the solidifier so they can throw it into regular trash and it was actually you know smart on their part that they did it as a financial decision. They said it was you know three to four dollars per liter for biohazard but it's only a penny for regular waste and they were able to kind of draw out what the savings would be for the hospital, get the buy-in to buy the solidifier and they've been doing so since. So they went from counting about 30 large biohazard bags a day which we all know are more expensive and toxic to the environment to only four small bags a day and they made this change with buy-in from their hospital and save them money and so that was really a helpful change that they've been able to to maintain. How much is a solidifier? That's a good question. I don't think I know I don't remember the dollar amount but they worked out the numbers and it was like by far you know financially helpful to switch over and they found a supplier that was able to give them the amount that they needed and stuff like that and this was at one of the VA sites. So now this is about 50 cents a bottle per jar. Thank you. A lot less than the biohazard cost per liter I guess. Any other questions or thoughts on that one? Oh yeah Stephanie you have your hand raised. I guess I don't really know the exact difference of like being able to put something in the biohazard versus the garbage like what do you know the exact guidelines for that? Yeah I can tell you about that. So these are OSHA guidelines and actually feces is not considered biohazard by OSHA. So if you have liquid blood in there then it has to be biohazard. If it's just feces it's not biohazard. Anything that can release liquid when compressed is a biohazard. So if you if you have blood in a gauze that's not biohazard but if you can squeeze blood out of something then that's biohazard. So it's but if you go to OSHA guidelines and it's called blood-borne pathogen guidelines and they have it in a lot of detail out there. I think let me add to this. I think that's a very important topic because most of what at least we in our units had in terms of biohazard or hazardous or regulated medical waste was those effluents from the colon or the stomach. So the liquid that you suction out from the suction canisters. Again only if it's really bloody it's considered a biohazard. Otherwise feces or stomach secretions are not considered other potentially infectious material. That's the official term. And as Deepak was saying if you can squeeze out blood then it's it's kind of soaked in blood that that would be a biohazard. But most of the time you see it's brown or yellowish it's not bloody. So the thing is that you cannot just throw liquid material into the landfill trash. You have to use a solidifier. It's based on the Department of Transportation regulations. So therefore solidifiers have to be put in there. Now this is also not a great solution but it's better than putting into the hazardous waste and have it incinerated or autoclaved. So the better solution would be if you had a sanitary drain in your endoscopy unit and you could take the canisters and empty them in there and ideally you have reusable canisters. Now some people or some units use the Neptune. The Neptune also seems okay now we have something that we can put into a sanitary drain but per patient you have to use a plastic adapter that's also contributing to waste and you have to use the tubing which is actually often a longer tubing than usual tubing because the Neptune is somewhat away from the processor. And so that also contributes to waste. So whether this is really environmentally beneficial we are not sure. So I think the current probably best way is to put the solidifier into the canisters and put this into the landfill waste. Fadi asks how about solidified colonic effluent after a cold polypectomy? There's always invisible blood but the amount of blood from that is pretty small compared to the amount of material and so that so if it's being solidified it probably isn't considered the infectious material. No that doesn't count Fadi. It's just a little bit of blood in there. It's like if you have someone who bleeds from an ulcer in the stomach and you suction this into the canister that's hazardous. You cannot put this in the landfill. Deepak? Yeah I know I was just saying another interesting statistic is that these biohazard these canisters are autoclaved or they're subjected to heat treatment and I was reading that for every suction canister the amount of water used in decontaminating things about 30 liters per canister. So you know you know there's a lot of apart from financial savings for the institution there's also a lot of other heat and water wastage when you subject them to unnecessary heat treatment. Think about it. I calculated it could be like you know like a few hundred gallons of water from you know every day endoscopy just to autoclave these things. Yes thank you Deepak. It's true the autoclave I mean it depends also how your institution handles its trash. There are sites where do things locally versus send it off to a company and so that can also impact the amount of energy being wasted and such but all of it is is definitely much more intensive than if you're able to throw it out other ways. Fadi also asked running back to a different topic unfortunately running a forceps or a tool down the channel before procedures is also in the IFU but it doesn't have to be forceps as our ADR is greater than 60 percent. Well we have switched to using dedicated cold snares to check colonoscopies and forceps for EGD so basically trying to limit the number of times you have to use two instruments instead of one. Is that right Fadi? Yeah that's great. Still unfortunate because sometimes you probably still don't need it so we'll try to see if there's a solution to that in terms of making a change to the IFU because that's still not something that all sites do even if it seems to be in the IFU for some VAs but you know in the meantime I guess you're trying to minimize the amount of duplicate or multiple devices being used. Great. Now I have a proposal so I just want to point out or just acknowledge that on this forum here there are physicians, there are nurses, there are techs and it's not just you know one group's issue so it's we're all involved with this the entire endoscopy team and we could include those who purchase things and those who do scheduling and so there's a lot more people who are involved in the day-to-day practice of GI endoscopy and so I want to encourage or ask you know what in your specific responsibility or your field do you see requires change or what do you think could be changed right so you as a nurse what do you think can you change and that could be even the pre-endoscopy area in the procedure room the post-endoscopy area or as a tech what do you see can be changed and my personal impression is that I as a physician I actually know much less than the techs and the nurses in the room and and so so the question is what are the the ideas that you have what do you think are is an issue that you think as a nurse the tech should be changed what ideas have you had in the past that you think would be worthwhile implementing what what changes are relevant well what do you think is relevant but that's a very interesting discussion too what's really relevant does it have to be a major carbon footprint reduction or anything like that but but just to encourage you to what is the change that you think you see in your environment is worthwhile changing and maybe you haven't dared saying it you haven't dared you know sharing the idea yet but but maybe tomorrow you will or right now you I encourage you to speak up and say it so so I just want to kind of broaden this the discussion maybe in terms of what you think is worthwhile changing and and get some some more voices heard here so do you have do we have any endoscopy techs who are who have ideas, who have seen things that might be worthwhile changing. Because I think they really know a lot. It looks like Urim is going to say something. I work with Dr. Pohl at the White River Junction of VA. And I'm really excited that Dr. Pohl is bringing this idea, because I just joined VA and trying to do the recycling program for, I think we've been running it for a year, a year and a half, Dr. Pohl. And we reduce so much waste, as Stephanie was saying earlier, by recycling the water bottles, the plastic from the polyp traps, and so many different things that were actually all of it went to the landfill and we've been recycling since. And it's a great effort that, as a team, we're all participating in that, and more to come as far as the sterile water thing that Dr. Pohl is working with, the SPS. And I think it's a great sum to look forward to. Less waste. Thanks, Urim. Well, so we did have the ability to do breakout sessions where we can come up in small groups and people can discuss maybe for five minutes or so in their groups what brought them into this conversation and what they're looking to change and maybe their own stories. What do you think, Heiko? Should we break out into doing that for a little bit? Why don't we do it? And don't be discouraged. Just click on Join and then see what happens in your communication. And then we'll come back after, let's say, six minutes. Eden, would that work? Everyone has about two minutes. So it's a group of three. Everyone has like two minutes to talk. And then why don't we exchange some ideas, and then we come back in six minutes, and then we'll see what happens. Okay? The room will have an auto timer. Yeah, you will be automatically kicked out of the room again once the six minutes are up. So we're going to just throw you into the rooms now. How's it going? Good. So what facility do you work in? I'm at SHUM in Montreal. Oh, wow. Very cool. I was with curiosity following the last meetings, this whole IV fluid discussion. We don't give IV fluid at all. You don't for any procedures? Well, just as needed. We don't give it routinely. Like if they have low blood pressure? Yeah, exactly. We give them for like every procedure, even if it's like five minutes. It's crazy. It sounds funny. Yeah. I was listening today. I'm from Germany originally, and I transitioned 10 years ago here to Canada. And I was listening to a podcast, and they admit, and I remember that from practicing there, they admit after every EMR, they admit patients, right? And they were like discussing that, and we sent them all home. And I had to think of this IV fluid for you guys. And then we don't do that. And it's like if you stop it, all of a sudden it seems so scary. Yeah. Yeah. I feel like if I propose that in my unit, there would be a lot of pushback for that. But do you have like separate anesthesia, or do the nurses give the anesthesia there? We have one nurse for the verse at fentanyl. We have one nurse who manages the sedation and assists the procedure. So that might be where our difficulty is, because we have like a CRNA and an anesthesiologist. So they automatically give IV fluids, and they're using propofol usually, which always decreases people's blood pressure. So I feel like they have the fluids running while using a propofol drip almost. That's interesting. So when I practiced in Germany, everyone, like every sedation was propofol, like 99%. And we also never gave IV fluids, only as needed. Oh, really? Was it just pushes of propofol? Well, it was typically like the residents would give it. If you had a resident for the case, a trainee or so, we had the internal medicine residents, and so on rotation, they would give it. But there was no standard IV fluid. It was always propofol mono. And if there was longer procedures, like you would have as perfusion. And then I guess we would give some, you know, some if there would be like a long procedure, and, you know, you really go up with a sedation. But it's so interesting how these things are practiced so differently. Yeah. And that's really interesting. I'm going to I think I'll ask like the anesthesiologist to see what they say about like the idea of not using fluids. I feel like they're going to be very new. Yeah, exactly. But it's interesting to hear that you don't a lot of places don't, especially like the patients being NPO or have done the prep, like you kind of think that they might be a little dehydrated and might need the fluid. But I guess it's not really that big of a deal unless it's like you said. For example, like I said, we have an EGD, a standard colonoscopy. Right. Really, really matters. Yeah. I was listening to this podcast today, and then they were talking about duodenal EMR. And if it's like less than one centimeter, you can send the patient home. And if it's bigger than one, you can keep them in hospital. It doesn't matter for us. Stephanie and Daniel. I ended up in the same room. And the third one was couldn't unmute him or herself. And so it left. So we just thought we'd join you because we heard. We're talking that every country is doing things differently. And with this IV fluids, it seems so interesting listening to that, that you guys are scared of that, stopping it. You don't even use an encounter. We don't. As needed, right? If someone has a drop in blood pressure, we start giving it. But other than that, it's like 98% of all versed fentanyl are without. And then we had the discussion that maybe you guys have propofol. But I remember from Germany, we also never gave IV fluids. Yeah. And had always propofol. Yeah. Did you want me to bring everybody back? I'm sorry, Stephanie. I didn't mean to cut you off. I've gone longer. After six minutes, Eden, yes. But Stephanie, you wanted to say something. Oh, I was going to say another factor is maybe we have like anesthesiologists and CRNAs, so it adds another factor of like billing and supply use and things like that. So they automatically use fluids on everyone. But I don't know if they would be receptive to not using it. I don't know. I'm going to ask them and see what they say. You're muted, Sinan. Thank you. What are they doing now with the IV fluid shortage? Everyone still gets like a liter of fluid. But with the shortage, there was discussion about not using it for endoscopies, but no one really implemented it. My gosh. Wow. Yeah. We implemented it for a few days in our endoscopy unit at the VA. And then after three days, it was all of a sudden stopped because the head nurse said, you can't do this. It has to go through the moderate sedation or whatever sedation committee. So now we have a conversation on November 8th in our sedation committee, which I will participate in, and we'll see what we can do. That's so long from now. That's crazy. Any form of data. I mean, if we in Canada do it completely differently, you know, without medical fees. So, Sonali, there are studies on this. I saw there was like a 16%. Yeah. Right. 16% same hypotensive, and there's no increase in additional use of IV fluids. And more than 80% or so who were hypotensive responded to IV fluids. So there's no benefit of giving routine IV fluids. I think there were two randomized studies. One I reviewed in detail. One of them is like a poster. So I think it wasn't, or maybe the one I saw was only a poster. It wasn't really converted to a full paper. You guys should evaluate that now. You should take the test. Basically, you get your patient randomized right now kind of by fate. It's almost a before and after. None of our patients are getting fluids right now. No, but you have this cohort right now, right? You have like fate that just randomized a huge cohort into not receiving fluids. Yeah. What I just learned is we have been trying to collect that data. We have it for people with RN sedation, but we don't have that data for our Mac cases because it runs through anesthesia and they're not collecting it the same way. So I'm trying to figure out cases. Oh, sorry. And monitored anesthesia care. So cases with anesthesia in the room using propofol with their medications. You could do a really cool study if you find, if you get access to that data multi-center. Right. All of a sudden have like a hundred thousand, you know, where you have like 50,000 receiving standard, you know, IV fluid and 50,000 don't. Right. That would be a really cool study. Hope we can get that data. So welcome back, everybody. We were just talking about IV fluids briefly. So we just have a few minutes, but we're hoping we can take this moment and kind of just learn from what you all did in your breakout room. So I'll quickly just ask in order of groups for maybe 30 seconds, recount a couple of things you discussed in your small groups. And of course, everyone, please do write your comments or thoughts in the chat. So breakout room one, what did you guys discuss? And anyone from the group can unmute. Oh, that was Stephanie and I, the room. Oh, the room didn't work. Room number two. So that was Lyndon and Monica. Monica. I learned a lot from Monica. Monica, would you like to share your experiences? Yeah. Lyndon and I were just talking about our two very different hospital systems. You know, ours is a community hospital practice. With Kevin Skoll and Lyndon have a very large. Multi-site ASC. And just getting some ideas of accountability of number of devices used for procedure, which I thought was an interesting idea. As well as we were just sharing some stories about how we've been able to dramatically reduce printer use. With Kevin Skoll, just shout out to Kevin Skoll as a member of the committee. Really pushing for us to use and give patients reports through the portal rather than printing them and giving it to them. Which I think has really improved what we have our utilization at our unit. Great. Thanks so much, Monica. And good to see you again. Group number three. So that's autumn, Kevin and Joanne. Anyone. I would be happy to let the other two speak if they would like to. If not, I'll give a quick summation. So very briefly I'm on the task force and neither of those people that I shared the room with were even physicians, which was very interesting for me. And the one thing we talked about was the benefit of having a team of people. Doctor nurse tech from all over. Being sort of the nucleus of trying to make the changes. So at least hopefully it's a buy-in at all levels. Things that they learned some of the things that I was doing and I actually sound found some things that they were doing. Interesting. We did talk about the IV fluid thing, of course. And everybody's having a different experience with it, but. Overall. The group was very, very useful for me. All right. Great. Kevin. Let's go to group four and we'll say the last alphabetical first name will be. Can be the speaker. So it's not Deepak and. So Chetty is the last Dr. Or. I'm sorry if I'm not saying your right name. Yes. Hi. Yeah, we talked about a few things in our group. Deepak. A lot of good points about. What's the committee has been doing. The one thing that. I think it's very important. I grew up in Nigeria, for example. And, you know, I practice abroad as well. And I know that in the developing world, when we talk about, you know, Green endoscopy, it goes far beyond. What we could do here in the U S. In most of the world, people still reuse. It's in fact, can we use, you know, biopsy for steps. I think that she may have. I think it's very important. And I think it's very important for us. We are proceeding with that. These accessories that we use. Right. You know, we can talk about linens and. Well, but. Accessories. That we use at such a high volume. And, you know, Can we get to a point where companies can begin to make them again so that they're not single use. Because, you know, It's a great thing that the committee is doing, but if we can get to the heart of the matter, it is that. More expensive. We use more frequently. Accessories and talk about those. The other thing that Deepak, you know, Which, you know, we discussed as well was in other parts of the world. The scope is not just for the nobility of it. Right. It's a good course. Yes. But it's also a matter of just, you know, You know, Being. To be able to afford. Yeah. The cheaper it is to provide care to people, the more they can access it and pay for it. And so the more we can come up with. That's. Sustainable. Reduces costs. We went for everyone. That's all I have. Thank you all. That's a lot of great comments. Appreciate that just for time. Thank you. Thank you. I'll move on to group six, whoever the last. First name is. Tabitha you're left your partner left. So that you're holding the torch. Well, I feel terrible to say, but I don't think we connected at all. I turned on muted and said hello and sent a message, but. That we. Well, we didn't talk, but. Yeah. Well, thanks. Yeah. Sorry, Tabitha. Thanks for letting us know about the experience though, because this is our first time. So thanks for. Was your group seven to report out and then we'll we'll kind of wrap up. Yeah. It was spotty on talkie and when Lou, so maybe when. If when still on the line. Yeah, I am. So we talked about using the coast near. And the biopsy forceps for the upper, which I need to. Probably starting. Doing for my unit. And then when also talked about the solidifier, because we here at the Connecticut VA have this. And then we also talked about, you know, how much we paid to use it and put it in the regular trash. We're saving a lot of money. It was like 90 cents per tube. And then we also talked about. Trying to get a recycling. More for our unit. So. Well, a lot of good information. That's all. That's a lot of stuff. You guys discuss this in short time. That's great. Okay. I think we're, we're beyond our time anyway, but. I don't think I need to show any slides yet. Well, Thank you all for joining. This is great. Hopefully everyone got to hear about something they didn't know from someone else in our conversations. A lot of great projects. I hope you realize, or, you know, this feeds into. What you may already known, which is that there are a lot of people working on this. And I think it's important for us to, you know, share with each other. And the more we share with each other, the better off we are. So we can really make progress together. So thank you all for the work that you do. I think Ian has just a couple of wrap up slides here. Yes. So. Sure do. Thanks. Dr. Paul Chowdhury and Dr. Paul. So it's a great discussion. We do have a sustainable endoscopy webpage, which is available on our website as well. So if you want to check that out, you can go to our website and click on that link. And you'll be able to get it published literally hot off the. Presses or article in presses. And this is our waste paper. It is now currently available there. It is open access. So you should be able to get it. And if you have GIE, you can get it right through GIE as well. Thank you. And then I will throw it back to Dr. Paul and Dr. Paul Chowdhury to any other final remarks. I just want to thank everyone. For joining and, and joining this experiment of exchanging experience. And ideas. I think I'd like to have that again and make that maybe something that. Also people feel like they want to share and, and understand what others have done and work for others and learn from them and from each other. So thank you for joining us today. And thank you to all of our panelists. And thank you to Dr. Paul and Dr. Paul Chowdhury. For all the kind of resources that we, but even has just mentioned. It's really very useful. I think. So Nellie, any final words from you. If you have feedback or, you know, how we can do this. Differently or better or the same in the future, please do let us know. And we'll try to, you know, feed off of that and come up with other ways. We can continue these sorts of conversations. Thanks.

Sustainable Endoscopy

Environmental Impact

Waste Management

Healthcare Sustainability

Endoscopic Waste

Greenhouse Gases

Recycling Initiatives

Community Collaboration

Sustainability Strategies