Challenges to live in a green hospital,

Transcription

1 C O N F E R E N C E Challenges to live in a green hospital, role of the anaesthesiologist. O n 2 5 t h J a n u a r y f r o m 5 p m a t t h e C r o w n e P l a z a h o t e l, D u b a ï, U A E h e l d b y D r H a n a n e A m i r a n d D r P h i l i p p e M a c a i r e

2 Challenges to live in a green hospital, role of the anaesthesiologist. Every day physicians are saving lifes in hospital. These hospitals have also to participate to save our planet by a better management of their wastes and by a sustainable and fair choice to buy recyclable devices. Every day 54% of the hospital wastes could be recycled : papers, plastics, metals, glasses. Medical devices containing PVC also contain Phtalates. Phtalates are used as softeners in PVC and are dangerous for Health; they are forbidden in kids toys and their use is to be restricted in Europe in medical devices by the new requirements of The European Directive 2007/47/CE in application since March We can find phtalates in perfusion bags, IV tubes, endotracheal tubes circuits of respirators.. And because Phtalates is damaging for Health, it cannot be recycled. Replacement solutions exist such as Polypropylene that is 100% recyclable and easy to recycle. After medical use it can be recycled to plastics in car industry applications and at the end finish in cement for building. This new management will reduce the Hospitals Costs and the Hospitals wastes Why morphine could be the worse pain killer. The Morphine is considered by everyone as the best pain killer. In fact it is not in many fields. Based on international publications we will show that it is not the best pain killer, that it delays the rehabilitation, it decrease the immune response in many situations. It is a global new approach to the pain treatment. S p e a k e r s H a n a n e A M I R, M D d e n t a l s u r g e r y, Specialized in medical information, strategy for quality in healthcare. High diploma in Health economics, risk management and evaluation methods. Initiative in change management, Human resources in public health. Ex-expert consultant (cabinet ALTAO) in healthcare managment: architecture, IT, organisation. P h i l i p p e M a c a i r e M D Founder and past Chairman of the foundation ALRF for regional anaesthesia and analgesia, Founder and Partner of the society AFARCOT for anaesthesia in orthopedic and traumatology. Publications in international journals, books, and medias on regional anaesthesia techniques, concepts in ambulatory surgery and in telemedicine for pain management. Consultant in anesthesiology and pain in Rashid Hospital Trauma Center. Breathe easy, we ve got you covered

3 TAKING THE CHANCE TO MAKE OUR HOSPITALS GREEN

4 Moving towards a Green Hospital Saving lives Saving Earth Saving Money

5 Waste production : An American hospital of 600 beds generates waste of* 7000 tons /day 2.5 million /year (last estimate) 10% of the energetic consumption of the country In Australia: A Public sector hospital produces waste equivalent of 200,000 households!* A city can spend up to $ 10 million per annum disposing of solid waste from its public hospitals!** * Jo Ciavalglia, Bucks country courrier times, April 2008 **Dr Forbes Mc Gain, Anasthesist, DEA, Doctors for the environment Austarlia 2010

6 Energy consumption 300 bed mid sized hospital uses the energy equivalent of 5000 households* 60% of the CO2 emissions are coming from goods and services while only 22% from powering the building and 18% from the staff and patient travel* * Sustainable hospitals Response to victorian climate change green paper, 2009,

7 Waste Categories Organics; 2% Glass; 5% Metals; 2% Others; 10% Paper; 36% Plastics; 12% kitchen; 33% Paper kitchen Plastics Others Glass Organics

8 Waste Categories Observations: recyclable and not recyclable contaminated and infectious waste cost the most but are minor comparing to the solid waste!!!? Plastic,paper and glass are considered the areas where recycling can be most effective

9 Waste Separation The key to minimization and effective management of health care waste is segregation and identification of the waste. Segregation is always the responsibility of the waste producer and takes place close to where the waste is generated and is maintained in storage areas and during transport.

10 Waste Separation

11 Recycling Waste Recycling is a common method for reducing waste disposal at health care facilities. Recycling diverts waste from the landfill, reducing waste disposal costs and, in some instances, generating revenue from the sale of recyclable materials. In addition, recycling provides the facility with an opportunity to be a good

12 What goes Where

13 Plastics Polypropylene Vs Polyvinylchloride PP is the most neutral plastic ( only Hydrogen and carbon) PVC has 30% of its weight chloride, a dangerous substance for the environement) PVC need a large amount of lead to stabilise it, while PP is a relatively safe gas PVC is a waste by product of the petroleum industry that used to be burned off into the atmosphere contributing to greenhouse gas emissions the more polypropylene used in products helps in reducing greenhouse gas emissions.

14 Polypropylene Oil conservation ( non renewable source of energy) Conserving energy while treating it Decrease discharge of green house gaz Latest worlwide regulations not using phthalates in plastic product to increase their flexibility, transparency, durability, and longevity

15 Phthalates Phthalates in the environment are subject to biodegradation and photo degradation, and anaerobic degradation. Because phthalate plasticizers are not chemically bound to PVC, they can easily leach and evaporate into food or the atmosphere. Phthalate exposure can be through direct use or by indirect means through leaching and general environmental contamination

16 Phthalates the health care industry began shifting to single use versions, often made from inexpensive plastics to a better quality plastic disposables mostly because of the high fertility risks caused by phtalates

17 Leaders Responsibility Ethics ENVIRONMENTAL AND HEALTH CONCERNS Costs FINANCIAL ISSUES

18 Leaders Responsibility Whole system thinking change End user consideration ( staff and patient ) Team work with the research and development in the companies

19 RECOMMONDATIONS Product evaluation commitees for an intelligent purchasing decisions on whole life cycle and environmental costs Encourage product, locally sourced with minimal packaging Purchase of recycled disposables

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21 Is morphine still the best pain killer? Philippe B Macaire Senior Consultant Anesthesiology and Pain Management Rashid Hospital Trauma centre Dubai Health Authority - DUBAI UAE Sept 2009

22 Morphine = Gold standard in pain PCA morphine Post op pain Cancer pain Chronic pain Did we progress during the past 15 years? Kehlet H, ASRA 2009 Sept 2009

23 Morphine: Other side of the medal Meta analysis inclusion critera : PNB vs opioids Post op analgesia 19 articles Max. VAS pain scores PNB = Peripheral nerve blocks = Regional Anesthesia Regional analgesia > opioids Richman J et al Anesth analg 2006 Mean VAS pain scores

24 Morphine: Other side of the medal Side effects Catheters Reg Anest Nausea 38/182 Vomiting (20,9%) Sedation 12/45 (26,7%) Pruritus 11/113 (9,7%) Opioids 95/195 (48,7%) 23/44 (52,3%) 29/109 (26,6%) Odds ratio < 0,001 0,278 < 0,012 0,332 < 0,001 0,297 Richman J et al Anesth analg 2006

25 Ex : Major shoulder surgery Interscalen catheter 60 patients. Shoulder surgery / Block Post-op PCA Morphine IV : morphine 0.5mg/h, Bolus 2 mg / 20 mn PCA interscalen : Ropivacaine 0.2% 5ml/h Bolus 4 ml / 20 min Regional analgesia > opioids Borgeat Brit J Anaesth 1998

26 In traumatology Calcaneum fracture Pre op sciatic block Post op sciatic block douleur = urgence vitale PCA opioids 30 patients Morphine Used over 24 hours VAS pain scores Cooper J Journal of ortho Trauma. 2004

27 In traumatology Calcaneum fracture Pre op sciatic block Post op sciatic block douleur = urgence vitale PCA opioids VAS and morphin consumption Cooper J Journal of ortho Trauma. 2004

28 In traumatology Fascia Iliaca Block Vs Morphin in hip fracture douleur = urgence vitale Foss N anesthesiology 2007

29 In traumatology Fascia Iliaca Block Vs Morphin in hip fracture Foss N anesthesiology 2007

30 In trauma on accident site Schiferer A., AA 2007

31 In traumatology Ederly patient + Hip fracture Intensive program douleur = urgence vitale Conventional program Anagesia: Femoral catheter Anesthesiologist at the door Nutrition program Fluid and Oxygen urinary cath protocol Anagesia: opioids anesth pre op Nutrition urinary cath systematic Pedersen SJ et al J Am Geriatr Soc. 2008

32 In traumatology Ederly patient + Hip fracture douleur Intensive Conventional = urgence P vitale Complications 20% 33% =.002 Hospitalisation 9.7 days 15.8 days < months mortality 12% 23% =.02 Pedersen SJ et al J Am Geriatr Soc. 2008

33 In traumatology Escorte study Rosencher N., Journal of thrombosis and haemostasis 2006

34 RA and traumatology douleur = urgence vitale Benjamin T. Flagel et al surgery 2005

35 Post op rehabilitation? TKA / GA n= 56 patients 72 h Post op analgesia Intensive physiotherapy 10-12h/day PCA Morphin KT epidural Kt femoral Capdevila X et al Anesthesiology 1999

36 Post op rehabilitation? VAS values 24 and 48 h after TKA : PCA* Fem Epi PCA* Fem Epi Capdevila X et al Anesthesiology 1999

37 Post op rehabilitation? Flexion targets after TKA: 40 at D1 and 50 at D2 PCA morphin Femoral KT Epidural KT 24 h 48h 24 h 48h 24 h 48h 30 (10-40)* 40 (32-40)* 40 (34-40) 50 (48-50) 40 (40-40) 50 (45-50) * P < 0,05 (25th 75th) percentiles Capdevila X et al Anesthesiology 1999

38 Post op rehabilitation? Knee flexion after TKA PCA morphin Femoral KT Epidural KT Day 5 discharge Day 5 discharge Day 5 discharge PCA* Fem Epi 60 (50-70)* 80 (65-90)* 80 (65-85) 90 (70-95) 85 (75-100) 90 (77-100) * P < 0,05 (25th 75th) percentiles Capdevila X et al Anesthesiology 1999

39 Post op rehabilitation? Side effects : Dysthesia : Epidural * Hypotension : Femoral ² < Epidural * Urinary retention : morphine ² < Epidural * PCA* Fem Epi Nausea : morphine * Peripheral nerve block > Axial block > Morphine Capdevila X et al Anesthesiology 1999

40 Post op rehabilitation? Author Year Type Results in favor of regional analgesia Capdevila 1998 TKR Targets of physio + less side effects Singelyn 1998 TKR Targets of physio + less side effects Chelly 2001 TKR Time to walk time to discharge Ilfeld 2005 Shoulder Targets of physio Horloker 2005 TKR/THR Time to walk time to discharge Ilfeld 2008 THR Time to reach criteria of discharge Ilfeld 2008 TKR Time to reach criteria of discharge Peripheral nerve block > Morphine Sept 2009

41 Post op rehabilitation? After Colorectal surgery Beaussier Anesthesiology Less morphine use - 43% - Better quality of sleep - Earlier return to normal abdominal function - Reduction of hospital stay Sept 2009

42 Post op rehabilitation? After C section Rackelboom T Obst Gynecol Oct 2010

43 Post op rehabilitation? Khoo Annals of surgery2007 Sept 2009

44 Post op quality of life Author Year Type Results in favor of Blocks Macaire 2001 foot Quality of life- analgesia at home Capdevila Macaire 2006 Foot Shoulder Reason of activity limitation less with blocks Martin 2008 TKR Daily life activities Ilfeld 2008 Shoulder Analgesia at home Sept 2009

45 Morphine and oncology. Stress or surgery process promote T developt» Shamgar Ben Eliyah : Int. J. Cancer 1999 Post op pain is a mediator of T promoting effect in rats» Gayle P : Pain 2001 Attenuating of tumor promote effect by surgery by RA in rats» Sahra ben Youssef Anesthesiology 2001 Morphine stimulate angiogenesis and promote breast tumor growth» Kalpna G : Cancer research 2002

46 Oncology surgery Author Year Type of study Study Result Barbara 2008 RetroS Prostatectomy for cancer Christopherson 2008 RetroS Colon cancer + Metastasis Less recurrence in the Group Epidural + GA Vs. Opioids + GA [Meta - ] + [Epidural] = OR Y Exadaktylos 2006 RetroS Breast Cancer Less recurrence with paravertebral block Vs. opioids De Oliveira 2010 RetroS Ovarian cancer Peri operative epidural => Less Tumor recurrence Vs. opioids

47 Why practice of RA is so poor? S. Klein et al. Anesth Analg 2002

48 Educational program in UAE Training centre in Regional anaesthesia and analgesia Intensive course in RA Post graduated diploma in RA 2010/2011 Sept 2009