Hello, everyone. Welcome to the RS&E webinar on environmentally sustainable radiology. My name is Dr. Kate Hanneman. I'm a Cardiothoracic Radiologist at the University of Toronto, and I'm the chair of the Sustainability Committee at RS&E. And I'm really pleased to be joined by Dr. Sean Lillen today, who works at the University of San Francisco and is a member of the same RS&E Sustainability Committee. It's really a pleasure to be here today to talk to you a little bit about sustainability in radiology. Before we get started, though, I'd like to take a few minutes to go over a few items. So this webinar will be recorded and it will be available on demand in the RS&E course catalog. You will also have access to some supplemental resource guide and resources, including recommended readings on sustainable radiology that will be available to all registrants. There will be time for you to ask questions after our two presentations today. And we really hope this will be engaging. So please feel free to engage with us in the chat box and you can put your questions in the Q&A. And we'll be sure to get to as many of those as we can afterwards. We do have time allocated for that. And again, please feel free to ask any questions in the chat box as well. And there are a couple of slides that include important CME information. And so we'll just take a moment to allow each of you to read those for yourself. And so the first slide is on disclosures. So please take a moment to read this. The next slide is on accreditation and designation statements, and you can read those as well. This slide is on how to claim CME after the course. You can visit the RS&E course catalog, visit my courses, and you'll be able to complete the evaluation and then obtain CME. And this is the RS&E disclaimer statement, which you can review. And finally, here are the learning objectives for the webinar today. And we will get started without further ado. Thank you so much. Today, I have the pleasure to be talking to you about planetary health and radiology. And this will hopefully lay the groundwork for some of the actions that Dr. Bowling will talk about in the second half of the webinar. I have no relevant financial disclosures. In today's, specifically in my talk, what I want to talk about is the intersection of planetary health and radiology. We'll review the environmental impact of imaging and the delivery of care and discuss some of the climate response pathways. So, again, in broad strokes, what are some of the ways that we can think about actions or strategies to improve sustainability within radiology? We'll start with the intersection of planetary health and radiology. And I think this is really one of the most fundamental things. And people ask, and I asked myself this a couple of years ago, you know, really, how does sustainability relate to us as radiologists or anyone who works in medical imaging? And often we're thinking about patient health in the context of our jobs as radiologists. We're often thinking about optimizing diagnostic performance, for example, on an individual study. We can also think about our role in terms of improving population health. So maybe we can think about offering coronic asthma score screening in an underserved community. We can expand this even to global health. And of course, RSMA has several global health initiatives in terms of improving access to imaging and improving skills globally. And then we can even take this one step further. So expand and think about planetary health. And this is really a concept that's emerged over the last decade that recognizes the interconnectedness of everything on Earth. Not only life, humans and animals and so forth and other forms of nature, but also the non-living components. And so some of the obvious non-living components that we want to think about how they interact with us as humans and human health would be climate and weather. But also the non-living components include the consequences of human actions and pollution and so forth. And so all of this is very interconnected and really brings us back to kind of the fundamental concept of climate change, which really is often kind of the main concept that we're thinking about when we're talking about environmental sustainability. It's not the only one. But I really wanted to start here by laying the groundwork of why this is something we should think about and care about. And of course, this might bring you all the way back to your high school science class. I know it does for me. And if you think about greenhouse gases, these exist naturally in our environment. And really what they what when we talk about climate change or global warming, often we're referring to the fact that we have had increased concentration of greenhouse gases in our atmosphere. So normally some of the sun's radiation would be absorbed on Earth. And this is, of course, what allows us to have a hospitable environment in order to sustain life. But some of them should be reflected back either by the Earth's surface or by atmospheric layers. And human activities, which is predominantly burning fossil fuels, other things like deforestation also contribute, act to increase the concentration of these greenhouse gases, mostly carbon dioxide, but there are many others, methane and fluorinated gases or a few other notable greenhouse gases. These basically form a blanket around the Earth effectively, and they trap greenhouse gases or trap sun's radiation rather that would have normally reflected back. So this basically acts to increase average global temperatures. But this is really one part of the triple planet crisis. And it's important, but it's not the only one. So we also have at the same time, all of these interconnected factors can result in biodiversity loss. And this, of course, can be some things that are quite obvious, like loss of species and diversity. But we might think about this as it links to human health in terms of our ability to have hospitable living environments, not to support the world's population, and of course, in order to feed the world's population. And then we can think about air pollution. So air pollution is distinct from greenhouse gases. But when we burn fossil fuels, we often co-emit or increase both of them in the atmosphere. And we'll learn in a little bit how air pollutants can also impact human health. And of course, those are in our environment. So these are all very closely related concepts. And so then I think it's important to think about what are the downstream effects? So the average increase in global temperatures by themselves are important, but it's these downstream effects, how all of the interconnected weather and climate systems are impacted, that really has quite a tremendous impact on human life. This includes flooding, both due to increased precipitation, but also due to rising sea levels. And this is really important, of course, in coastal cities. And of course, nations that have large populations of islands, increased frequency and severity of storms, both tornadoes and hurricanes, forest fires, of course, very near and dear to many of our hearts, both in Canada and the U.S. and elsewhere. We're already entering another forest fire season here in Canada. And of course, the tremendous loss of life that can occur immediate after or during the forest fire is really important. But then there are more insidious effects that can happen downstream from exposure to the wildfire smoke that we're really only continuing to learn about. And then extreme heat. So this is distinct from global warming, talking about those average changes in global temperatures. But really, this is the increased frequency of extreme ambient temperature, which refers to outdoor temperature. Mostly extreme heat, of course, can have devastating impacts on human life. Both children and older populations are particularly vulnerable. But we also know that extreme cold can happen due to climate change, again, related to these changing patterns. And I picked the heart here because I'm a cardiac radiologist. But of course, you can pick essentially any organ system. And really, there is a tremendous amount of literature showing us data on how these environmental impacts and exposures adversely impact human life, both morbidity and mortality. And again, this affects almost all organ systems, even musculoskeletal related to traumas. Of course, there's neurologic findings in terms of increased stroke and so forth, but also mental health effects. And this is quite well demonstrated. It's really important to acknowledge that there is a very clear link between sustainability and health equity. We know that populations who are already the most vulnerable tend to be impacted the most by many of these exposures. And on the other hand, they have tended to contribute the least to the rising levels of greenhouse gases. So this has the potential to widen pre-existing health equities and in fact, potentially create new ones. So in addition to all of these health effects that we've talked about, again, this is really grounding the discussion on why this is important to us as physicians and health professionals. We also need to recognize that these health impacts will drive increased health utilization and that will include medical imaging. And so really, this is, of course, very interconnected to the fact that these environmental exposures adversely impact human health of the patients and the populations we serve. But also us and our families, of course, are within the medical imaging community. And this will impact the delivery of health care, not only increased demand, but potentially cause higher costs, potentially reduced access, which may be related to physical impairment in getting to health systems, destruction of property during extreme weather events, for example. And both of those can contribute to lower quality of care. So really important, again, that we think about how do we improve this and how do we address this. Here's one example of an extreme weather event that impacted radiology specifically. And where I've referenced specific articles, I've tried to include QR codes so they're easy for you to access. And these papers will also be included in the supplemental guide that will be provided at the end. So here's some data from a hurricane, of course, that was very destructive in Puerto Rico, Hurricane Irma and Maria. And really, there was, of course, tremendous loss of life and loss of electricity across the island. You can imagine how that would impact the delivery of health care at the same time that there is a surge in the need for health care and along with reduced ability to deliver it. So, of course, in radiology, because we're very technology dependent, we really need to think about this proactively and thinking about preparedness plans. This is data from one of the publications from our group, where we looked at the impact of environmental exposures on demand or utilization for medical imaging here in the emergency department as kind of a good indicator of short term, the impact of short term environmental exposures on patients who come to the emergency department. We already knew there was already literature that showed that environmental exposures like high temperatures cause increased patient visits in the emergency department. It was unclear whether that would actually translate to increased imaging. There's the potential that patients might come to the emergency department in part to seek shelter. And in this paper, we showed that there is an immediate actual significant increase in imaging utilization from the emergency department with higher temperatures. And these are relatively modest increases. This, of course, is local data from Toronto, and so it does get quite warm here in the summer. Certainly, you know, nowhere near as hot as you might experience in some of the southern US. And this increase in imaging actually persists over several days. So here I'm showing you lag days in the bottom. And we saw a similar effect for poor air quality. So PM2.5 is a marker of fine particulate air pollution, and there's actually a tremendous amount of literature on the adverse health effects of this. But here showing that on poor air quality days, and these are really modestly poor air quality, actually below some of the international guidelines for what would be acceptable for air quality, you can see, again, the significant increase in imaging utilization that persists for several days. So not only on the day when you might have smog or wildfire smoke, as we experienced quite profoundly in 2023, but we know that we can have poor air quality for multiple reasons. So again, one of the things we need to think about as radiologists in terms of preparedness planning. Okay, so now we talked a lot about, you know, what are the health effects, how does this impact us as radiologists, but at the same time, we need to grapple with the fact that the actual delivery of healthcare contributes to global greenhouse gases and emissions and environmental sustainability. So we have fairly good estimates of healthcare, the delivery of healthcare globally contributes to about 4% of global greenhouse gas emissions. And that may not seem like a large number, but it's really quite staggering if you think about that in the context of the entire fossil fuel industry, the entire airline industry, for example. And the percent is probably higher in many developed countries. And of course, there's a range of estimates. And radiology plays an outsized contributor to that, probably because we are very technology dependent, again, and we know that our imaging equipment can be quite energy intensive. So the energy is one large component. We also generate a large amount of waste. Most commonly, we think about this in the setting of interventional procedures, but even just delivery of diagnostic imaging generates a tremendous amount of waste from the delivery of contrast and the tubing that's required, hospital gowns, if you're using disposable gowns and cups to give oral contrast and so forth. And really, it's quite remarkable, the waste audits that have been done in radiology departments have been quite staggering. We also rely quite substantially on finite resources. And this can be really challenging when there are geopolitical issues that might potentially disrupt supply chains. And we're no stranger to that within recent contrast media shortages that, of course, the radiology community has had to respond to. And of course, some of these environmental disruptions can potentially further impact that and our ability to deliver care. So here's just kind of a summary to try to bring this all together. We talked a lot about, you know, planetary health and how that impacts human health. Again, here's the human heart. But of course, you can pick any organ system. And that will, of course, drive increased utilization of health care resources, but also directly impact our ability to deliver care, including medical imaging. And then at the same time, the delivery of care, so actually providing health care services and, of course, delivery of radiology imaging and services also contributes to rising greenhouse gas levels. And so this is really the circularity and the interconnectiveness of the planetary health concept. I want to introduce you to the concept of scope emissions. I think this is really useful, both in terms of reading the literature and trying to understand what's going on. And this is a useful framework. It just tries to conceptualize where the emissions are coming from in the delivery of care. And here I've tried to put this in the context of radiology departments, but you could think about it within your entire health system. So scope 1 emissions are direct emissions. Those are generated on site. So if you were burning fossil fuels in a boiler system within your health care facility, that would be an example. If you are doing a lot of procedures or imaging under GA, particularly relevant in pediatric hospitals, for example, inhaled anesthetic gases are greenhouse gases themselves. And so that would be considered a scope 1 emission. Scope 2 are indirect emissions. And so this includes all of the electricity that we consume to run our imaging equipment and, of course, our packs and stations and monitors and so forth. We often think about that because that's, in some ways, easy to measure because, of course, we have to pay the electricity bill and many of us have electric cars. And so you might understand what a kilowatt hour is. But then there's scope 3 emissions. And so these are all the other indirect emissions that are not related to energy and electricity. And the circle is big. There's a lot of things in here, but it is also a big circle because it is a huge component of the emissions within health care and within radiology. We don't have great radiology specific estimates yet, or many of them rather, but we know that it's probably about three quarters of the emissions generated within the delivery of health care. And so a common way to think about this is kind of like the entire supply chain, both upstream and downstream. So the production of all of the imaging equipment, the food, the contrast, and so forth, RIT systems, data storage, and so forth. And then downstream, all of the waste that we generated, that's all part of scope 3. So again, it's a lot. We're trying to understand, well, really, what is the magnitude of the problem of the environmental impact of delivering radiology services? And there's some data from our group. We are a large academic center, and we just try to quantify all of the emissions from the delivery of diagnostic imaging. Interventional imaging has some layers of complexity in terms of, of course, the emissions vary quite substantially depending on the procedure. So here's an estimate of the amount of emissions just from diagnostic imaging within one radiology department. And this was equivalent to over 3,000 metric tons of carbon dioxide per year, just from the use phase. So just from actually acquiring the images and so forth. And this is comparable to the energy that's required for over 400 single family homes. Again, one imaging department. So you can imagine how this can scale up quite rapidly and really impact the environment. Here is when we try to quantify this in terms of both number of tests and emissions per modality. And you can see that MRI is an outsized contributor, and this has been confirmed in other studies now, contributing 41% of emissions in our study, but only 12% of the number of imaging studies. And CT, again, 34% of emissions, but only 24% of the number of tests that were performed. Here's a beautiful study that I would encourage you to look at. This is a much more comprehensive life cycle analysis performed in the US, published last year in radiology, of an entire radiology department. And again, what they found was MRI was a large contributor, but 48% of emissions. And so we'll hear from Dr. Woolen, I'm certain, because this is an area of expertise that he has. But also, if you look at the literature, you'll see there's been a tremendous amount of interest in trying to improve sustainability of MRI. And really, this is obviously a huge potential opportunity for us. Here's beautiful data from another radiology study that basically mapped when images were being acquired on both CT and MRI scanners to the energy use. And what they showed was there was a substantial amount of energy that is wasted in non-productive states. So either when the technologist is getting the patient on the table, idle time between scans, and even overnight and on weekends, if scanners are left in a very high energy, high power state, like a ready to scan state, when we know, of course, they could be powered down. We talked about contrast a bit before. So in addition to the kind of plastic tubing and all the material that's required to actually inject it, the contrast itself is really important. Of course, it requires resources like iodine and gadolinium, which need to be extracted and have their own environmental impact. But we also now know, and there's increasing recognition, that the contrast is largely excreted within patients urine within 24 hours. And this can be detected back within waterways. And in the case of gadolinium-based contrast agencies, chelates are very stable, of course, by design. We don't want gadolinium dissociated in patients' bodies, but it actually is not effectively removed by traditional wastewater treatment and so can actually be detected back into municipal water supplies. And so there's a large amount of interest in trying to understand both the ecologic impacts of these contrast contaminants. And on the flip side, of course, trying to understand how we might be able to minimize those. A lot of what we talked about already has been mostly in terms of using our imaging equipment and so forth. But really important to think about all of the upstream components of the production phase. And this really is all the way from raw material extraction to putting the components together, manufacturing, production, transporting it. We now know that many imaging units are flown across between continents, and there's other options that may have lower emissions, might take longer, like seafreight, for example, and a large amount of interest in exploring those. And then even installing the equipment within our imaging centers. And you can see here that the estimates of emissions per modality also vary quite substantially. So production phase emissions are higher for MRI versus ultrasound, and that probably makes intuitive sense when we think about the size of imaging equipment. Of course, MRI units also require, many of them rather require helium, and there's been a tremendous amount of interest in low and no helium systems as well, as that is also a finite resource. So really, there's been a large interest in shifting away from the traditional linear economy, where we would manufacture something, transport it over, use it, and then it would go into a landfill, to a circular economy. And I really wanted to introduce this concept to you because, again, you might hear this if you're thinking or reading about environmental sustainability. And really, this tries to think about the various steps at which we could potentially decrease our environmental footprint. And so, again, we're not a one-stop shop. We have many opportunities. And I really like the concepts of repairing and refusing and repurposing things. And you can really be quite creative of the ways that we can ultimately decrease the amount of waste that we generate. And this brings us back to the triple bottom line concept for sustainable imaging, where not only do we want to optimize health outcomes for patients over the dollar cost, but we want to minimize that environmental impact and, of course, improve social standing as well. And finally, in the last couple of minutes, we'll just very briefly introduce you to the concept of climate response pathways. And a lot of the interest in radiology today in terms of improving sustainability has been focused on mitigation, which is essentially reducing our environmental impact. And this is incredibly important. This absolutely needs to be the cornerstone of any sustainability actions that we take. And so, this might be reducing the amount of electricity we're consuming. On the downstream side is thinking, again, about those health impacts and the impacts on our ability to deliver care. And this refers to adaptation and building resiliency to the effects of climate change. And these need to occur in parallel. So, we cannot do adaptation alone, but it does need to occur in parallel with mitigation. A related concept is resilience. And so, this is actually one step further from adaptation, and it is really building capacity to not only adapt to changing environment, but also to predict it and potentially to bounce forward. So, if something happens or we have an environmental exposure, maybe we can think about redesigning our radiology systems to be more efficient or to provide better care for underserved populations. And so, again, mitigation is kind of reducing our environmental impact, and then adaptation is on the downstream side. And again, we want to think about all of them. And then I think we really want to think about the opportunity as radiologists to understand some of these health effects. So, imaging is a tool to understand the environmental health effects of climate change or other environmental exposures, heat exposure, poor air quality, and so forth. And so, again, we're no stranger to using imaging to understand what's going on at the pathophysiologic level, and here we can just think about a different type of exposure. I wanted to show you some examples, and hopefully this will inspire you if you're interested in research. So, here's an example of a study that used MRI to look at the impact of air pollution, and they showed that longer or higher air pollution exposure was associated with decreased cortical thickness in the brain, measured, of course, by MRI. Here's a cardiac MRI study looking at long-term air pollution exposure and showed that there was a significant increase in ventricular volumes with higher exposures, and that's not ideal. Here's a study that looked at heat exposure. So, this is over short-term exposures and looked at myocardial blood flow characterized by PET and showed that higher temperatures, so as patients might experience in a heat wave, for example, there was a significant impact on myocardial blood flow. And finally, we can think about environmental exposures beyond climate. So, here's the impact of microplastics, which of course we've heard a lot about in recent years, mostly based on tissue samples. But here is a beautiful study that looked at a novel PET tracer and showed that they were able to detect microplastics. So, again, a couple examples just to show how imaging can actually be leveraged as a tool. And I really think it's important for us to reframe things from a problem, which of course we do have, to a potential opportunity to understand the health effects of these environmental exposures, to reinforce our role as radiologists, as healthcare professionals, and at the same time to be prepared and build resilience, as we talked about before. All of these actions really need to occur in a very, you know, kind of multidisciplinary setting. Many of these changes, and we'll hear from Dr. Will in a minute, cannot be done in isolation. So, we really need to engage multidisciplinary green teams. It's really important that we do this in a very collaborative way. So, again, not shaming people, but trying to think about creative solutions in terms of actions we can take, and of course making sure you celebrate the successes once you've implemented some of the actions we can take to improve sustainability within radiology. And with that, I will pause and we'll turn things over to Dr. Willen, who will be talking to us about some actions we can take to improve sustainability. Dr. Willen, thank you. Yeah, thanks, Kate, for the great talk. And, you know, again, my name is Dr. Willen. I'm one of the faculty at UCSF, and I'm going to be talking about strategies to improve sustainability in radiology. Yeah, these are my financial disclosures. And so, you know, this is not a scene of a movie. This is the Golden Gate Bridge shrouded by orange due to nearby forest fires. And what we can see is that climate change affects the communities that we live in. And similar recent natural disasters like this have occurred throughout the world. Now, as physicians, we're already seeing the consequences with worsening respiratory conditions, heat-related illness, and broader threats to public health. And what's become obvious is that climate change impacts health. The World Health Organization estimates that between 2030 and 2050, climate change is expected to cause approximately 250,000 additional deaths per year from malnutrition, malaria, diarrhea, and heat stress alone. And healthcare delivery impacts climate change. Globally, if the healthcare sector were ranked as a country, it would rank fifth. And the healthcare sector generates 4.4% of global greenhouse gas emissions. And the United States healthcare sector generates 10% of the country's CO2 emissions. And this is primarily due to the technology and resources we use to practice medicine. And the environmental impact of radiology is hard to ignore. 850 people consume the same amount of energy in a year as three CTs and four MRIs. 48% of a hospital's energy comes from the radiology department. And 1% of global emissions are from MRI and CT alone. So how do we think differently? How do we close the gap between healthcare and other industries? And how do we change our operations to reduce energy consumption? And so what I want people to take from this talk are five simple changes in your radiology department can help your bottom line and the environment. The five changes I'm going to talk about today are to power down your equipment on weekends and evenings when not in use, create efficient scanning operations, optimize HVAC settings, switch to reusables, and upgrade equipment when possible. And throughout this talk, I may present cost savings, but all of the cost savings also have environmental savings. So the first change is to turn equipment off at night and on weekends when not in use. And this is a simple energy efficiency technique a lot of us use in our homes. We'll often turn off lights in unoccupied rooms or our television when we're not watching it. And this is simply applying it to healthcare. And so anytime we start a project, it's always important to do an impact analysis. And by that, I mean it's important to look at all the different radiology equipment to see where the highest energy consumption is occurring. And this can help us decide where to dedicate resources and time to start a project. And so if we look at this figure of data accumulated from different sources in the literature with the annual energy consumption on the y-axis and the different imaging equipment on the x-axis with the number of devices that I found from the literature. What we can see is that MRI and CT consume the most energy. And a single MRI is equivalent to nearly 12 US ohms, and a single CT is equivalent to nearly 3 US ohms. And now I want to focus on a – powering down a high-energy device, medium, and low-energy device. So if we look at the savings per device, if we power down a high-energy device such as MRI, we can power it down by 25 to 33 percent with the remaining energy being used to cool. And this would result in a savings of almost $3,800. A medium device such as CT can be powered down by 80 percent and save a little over $2,000. And powering down a low-energy device such as a workstation can be powered down 100 percent and save around $100. So turning off the highest-energy-consuming devices save the most. And what this shows is that powering down MRI equipment would be a good place to start. However, the savings scale up. You're not going to power down just a single device. And so if we think of a theoretical practice, powering down 24 MRIs can save almost $91,000. Powering down 14 CDs can save a little over $28,000. And powering down 185 workstations can save a little over $19,000. And cumulatively, this can result in a total savings of a little over $138,000. What this shows is that what makes good environmental sense can also make good business sense. The second change is to create efficient scanning operations. And so essentially doing the same amount of clinical work with less equipment. And when I first thought about an MR scan appointment, I thought about the cut sheet that I look at for the protocol for the scan. But the appointment actually consists of more than just the scanning-specific process. It also is all of these non-scan-related activities. This is essentially connecting the coils, placing the IV for the patient, connecting the IV, giving the patient instructions, taking the patient on and off the scanner, and answering patient questions for a patient-centered exam. And this all takes time. And so really an average appointment time slot at our institution was 45 minutes. And so each of these areas can be targeted to decrease the scan appointment time. So if we look at, again, our theoretical practice of 24 MRIs operating 351 clinical days for 12 hours per day, and we use different acceleration methods such as deep learning reconstruction to decrease our sequence time by 50%, again, this doesn't decrease the time in between the sequences or the non-scan-related activities. We can decrease our scan appointment from 45 minutes to 35 minutes. And this will likely be done for the operational benefits such as gaining imaging slots and potential revenue from those slots. But it also has several environmental benefits. And so because we're decreasing the time in the active scanning mode, which has the highest power consumption and essentially having more time in the idle mode or lower power states, we actually decrease the energy consumption by also increasing the number of scans. And so this decreased energy can save a little over $66,000 and decrease the greenhouse gas emissions by 355 megatons of CO2 equivalents. But we also decrease the need for new MRI equipment. So if we look at the number of imaging slots gained, this is equivalent to almost six MRIs. And so if we prevented the installation of six MRIs over 10 years, this can save almost 9.2 kilotons of CO2 equivalents if we use the data from the life cycle analysis published by Dr. Thiel in radiology. So the third change is to optimize heating, ventilation, and air conditioning at night and weekends when not in use. And again, this is another common technique we use in our homes. A lot of us will have smart thermostats that will keep the temperature optimized to keep us comfortable while we're home, but also regulate the temperature to save energy when the house is unoccupied. And this idea really came from this paper by Chu and team that did a life cycle analysis of an interventional radiology practice over five days. And a life cycle analysis essentially looks at each component of the process to see where the most greenhouse gases are emitted. What they found is that the climate control system has the highest source of an environmental impact. And I actually found this interesting because I used to always think it was the production and transportation of single-use supplies such as wires, coils, and imbalization materials, but it's actually the climate control system. And why I like this as a potential intervention is that over half of the energy is consumed when the room is unoccupied. And here the arrows show the proportion when the room is not in use and when the room is in use. And so if we look at the climate control system, it really has two main modifiable components. The air changes per hour for procedure rooms are required to be at 20 air changes per hour and a normal room is around six air changes per hour. This is primarily to keep the room sterile during the procedure, but it doesn't need to be at this high rate when the room is not in use. Similarly, the temperature is usually kept lower during procedures, usually around 60 degrees. A normal room might be around 70, and this is primarily to keep the proceduralists comfortable and also to decrease the chance for infection. But again, it doesn't need to be at this high rate when the room is not in use. And so if we look at decreasing the air changes per hour needed for IR procedures to a normal room when unoccupied, this can save a little over $3,000 annually. And optimizing 10 IR procedure rooms can save $32,000 annually. However, not all of the greenhouse gas emissions come from energy consumption, only about half. And so now I'd like to switch on these last two interventions to look at ways we can decrease our solid waste in our radiology to practice. One of these is to eliminate unnecessary waste and switch to reusables when possible. And a lot of us do this in our home without knowing it by using metal forks that are reusable instead of using single-use forks and so on. And so if we look at a procedure packet for an ultrasound-guided biopsy for a kidney transplant, and we open this up, several of these items are consistently used for every procedure, such as the sterile blue towels, sterile gauze, the needle stop, the different needles and syringes for lidocaine administration. But several of these items are consistently thrown away on every case, such as the islet drape, the hemostats, plastic tray, and white towels. And so essentially by reorganizing this packet to only have the supplies used for the procedure, we can eliminate this waste stream. It's also important to switch to sterilizable, reusable items when possible. Disposables increase costs in physical waste, and unused disposables at UCSF Neurosurgery accounted for $968 per case, almost $243,000 per month, and $2.9 million per year. And if we look at switching from a single-dose injector to a multi-dose injector for iodinated contrast, this would result in contrast waste reduction by 73% to 100%, and plastic waste reduction by 85% to 93%. But it also has operational and financial benefits with an annual savings of almost $500,000 and time savings per scan at 41 seconds. And the final change that I want to talk about is upgrading old equipment instead of buying new equipment. And what I mean by that is if we look at this old, outdated MRI scanner that has hardware that doesn't really meet the function that's needed for clinical operations, and we strip this MRI external casing and old hardware essentially down to the magnet, and then we rebuild it back up with modernized hardware such as RF amplifiers, coils, and gradients, and also new casing, we essentially have an upgraded MRI unit. And compared to buying a new MRI, circular systems reduce the need for new raw material, shorter time to upgrade, usually about two to three weeks, and cost less, usually reduce the cost by 25% compared to buying a new MRI. What I hope I've shown is that simple changes to save operational costs also decrease greenhouse gas emissions from energy production and decrease the need for equipment. For instance, the example I demonstrated earlier with a practice savings of nearly $138,000, it would also save the energy to power 139 homes and the equivalent carbon emissions of 155 gasoline-powered passenger vehicles driven for one year. Similarly, multi-dose contrast inductors reduce the amount of contrast waste and plastic while also having financial and operational benefits as well. And so, what I hope I've shown is that five simple changes in your radiology department can help your bottom line and the environment. These five changes that I talked about are turning equipment off at night and weekends when not in use, optimizing HVAC settings, creating efficient scanning operations, eliminating waste and switching to reusables, and upgrading old equipment. Thank you and happy to answer any questions. Thanks so much, Sean. That was phenomenal and I love how you brought it all back or brought it to five points. It was just so approachable. So, that was fantastic. Just a reminder to all the participants, you're welcome to put any questions in the Q&A box. It's probably the best spot and easiest for us to monitor them, and if you have any challenges addressing that, of course, you can use the chat function as well. But Sean, I really wanted to – I loved your approach to trying to simplify things and the analogy to turning your lights off when you leave on the weekend. I often think about it in the same way, or even overnight, of course, we wouldn't leave our TV blaring and leave everything on in our homes, and I think that's so intuitive. One of the things I found is that step is so obvious in terms of powering things down, but can be actually somewhat logistically challenging. I just wanted to get your perspective on your experience with this and maybe just for context and to realize that with older equipment, it might take a bit longer to come up to a ready-to-scan stage. It might impact the technologist's workflows, and so I just wanted to hear what kind of challenges you've experienced with that and how you've overcome them. Yeah, I know. With any policy, the difference between kind of knowing the best method and having it implemented for consistent use is always different, right? One of the challenges that we ran into is that some of our MRI machines, especially some of our research units, need to transfer data overnight to allow kind of our research arm of our institution to continue, and so there are some solutions. For example, for that one, we were able to go to the low-power mode instead of the system-off state, which allowed transferring data, which helped. Again, that's essentially powering down the MRI but then leaving the computer console powered up to where you could still transfer data or do software updates by the vendor if needed. And there's other kind of challenges. I think you mentioned the power cycling time, and depending on the unit, this could range anywhere from five minutes to, I guess, I think I've heard of one being up to 15 minutes, which none of ours are that long, but I think somebody had mentioned that to me one time that one of their MRIs takes that long to power down. One of the ways is to try to have automated power down and power up times, working with the vendor to be able to do that. And if it's an older unit that's not able to do that, kind of having the technologist power things down at the end of their shift and right when they arrive as they're setting things up to start the power cycle back up. And I found that to be effective as well. But again, anytime you're relying on an individual to power things down or up, it's never going to be 100%. Thank you. That was a really important perspective in a way. I think it does depend on the department and the age of the company. So we'll share that 15 minutes. You seem out of the range of impossibility based on some of the equipment you have. And one of the things I've actually learned with CT is some of the QA or QI that needs to happen intermittently, that can impact the technologist workflow and so forth. So I really think it's so important when we're thinking about making these changes, the best intentions really need to have all the players as part of the plan from the beginning. And really to try to understand. I think your point about. Yeah, I definitely think. Oh, yeah. Go ahead. Yeah. Go ahead. Yeah, I was going to say that, you know, I think you made a really good point that a lot of these different solutions, they're going to look slightly different between institutions, right? You know, one of the big things of implementation science is get to know the people that work at the place that you're implementing this change. Get to know the frontline worker opinions, the different technologists like MRI leadership, you know, different players and, you know, the local application individuals that are working on the machines and to strategize and come up with a plan that works for everyone. Because, again, you know, a plan that works at UCSF might look slightly different at another hospital. And I'm with you. And that totally ties in with what I was going to say is, you know, I think you talked about, you know, in your research scanners, maybe you can't go to the fully, you know, power down state, but but at least, you know, a lower energy state, because now, of course, you know, there's multiple in your papers have described that so beautifully is better than nothing. And so I think, you know, sometimes people get so frustrated. And I've heard this, especially with the powering down comment, you know, like there's push back from admin or technologists because of some of these potential impacts. And so it's like, you know, making a small incremental change, you know, especially if you're applying it across multiple units, really can can scale up quite quickly. So I think I think that's really important that when there's not one size fits all. And I know, you know, I've shifted a bit in my thinking about that, you know, to align more with what you're thinking. I really always wanted to think about, like, let's prioritize, let's do the highest impact things first. And I agree with you. I think it looks different to different centers. And I think the most important thing is that we inspire people to make one change that that's a move towards sustainability. Maybe it's not the biggest impact one to start with, but it's the one you can achieve. That is incredibly motivating. So, you know, even eliminating one single use thing might feel small. But again, the cumulative impact can be quite large. Yeah. You know, with any movement or quality improvement process, getting an early win can really help motivate the team and to later on build the energy to create big wins. I'm with you. And I think there's that concept of kind of, you know, sharing the wins and trying to quantify it. And I know we're both researchers. And so, you know, that obviously often aligns with that thought pattern. But I think even for non-researchers and certainly outside of academic centers, somehow trying to show what the impact of an intervention is, is really important. And I don't mean it has to be a formal research study or even a QA, which could align with QA as well, but somehow trying to even say how many, you know, units of plastic or whatever are, you know, diverted from waste, even if you can't convert it to a greenhouse gas, for example, like that's powerful in and of itself. Yeah, definitely. I don't see any questions in the chat box or Q&A. But again, if anyone has any, please feel free to put them there. I have a number of things I want to ask Sean, so I'll keep chatting for a bit. And Sean, of course, if you have anything you want to ask, please feel free to chime in. But I wanted to get your thoughts on, you know, the HVAC component. And I'm so glad you brought that up because I know the papers that came out, particularly in interventional suites were so, like, again, also, I think you share the same sentiment that I felt like I was like, wow, like this is quite remarkable that this is such a large component of it. And that also seems so achievable. So I wanted to hear if you if you have worked on this at UCSF and what you've done. I know people have talked about, you know, the motion sensors and so forth and how you've achieved that. Yeah, well, it's actually not you know, this actually originated from the operating rooms. And so at UCSF, there are some of the environmental and facilities people that did a large initiative looking at our, you know, operating, which are much larger scale than our interventional radiology rooms. I think they have, you know, maybe 30 operating rooms. So you can imagine that scales up quite a bit. And then, you know, maybe only one or two of those might be needed at night for emergency surgeries. And so essentially having the amount of energy for this very high air change rate is quite quite intensive. And so what they did initiative to kind of modulate those, I believe, with room sensors to power them down to normal room rates when they're unoccupied. And that, you know, that has substantial, you know, institutional savings. You know, but again, I can't take credit for that one. That was our UCSF facilities and, you know, sustainability section that, you know, had implemented that. So but again, you know, applies to our radiology, you know, procedure rooms as well. And so. I think that's another great point is that the knowledge sharing we can learn from other specialties. And I think obviously I think we've definitely learned a lot from surgery across the board in terms of reducing single use supplies and the procedure packs and age factors you talked about. So really important, you know, that we, you know, maybe don't reinvent the wheel. And I think radiology as a community that really has done a good job with knowledge transfer. And I think, you know, hopefully we're sharing a lot of the things we've learned as well and that will inspire others. Yeah, you know, I agree. It's, you know, why recreate the wheel if you don't have to, if there's other specialties or leaders, you know, in your hospital system to share knowledge back and forth to overall have a larger impact for the health care system. I think that's that's the important component. So. Yeah, absolutely. And in terms of communicating both the wins, but also I think in terms of engaging key stakeholders to motivate some of these changes. One of the things I've been thinking a lot about recently, I know there's been recent discussion and webinars and so forth, has been the role of patients and the patient voice. And have you had an experience at UCSF in terms of patient facing communications for sustainability initiatives and, you know, how they might perceive it? And I know we have survey data, not specific in radiology that I'm aware of, at least yet from from patients, but certainly across health care data I've seen indicates that patients would prefer a sustainable change if it won't negatively impact the care they receive. And so I because we both talked about the health effects of climate changes and sustainability and environment in general, in terms of motivating many of these initiatives, which I think is really important that we always kind of keep that central as health care professionals. Just wanted to get your sense on how you think we can engage patients if, you know, kind of doing the work in the background is enough or should we be directly engaging with them? Yeah, I mean, I know Dr. Rito-Marie, he's done a lot of work on starting an initiative to look at, you know, patients' voices and then using those to help inform environmental sustainability policies. And I think that's really part of the way of the future is to, you know, hear the voices of our patients and to then use that information to help, you know, inform their care and our policies within the health care system. And, you know, I think one of the things that he had mentioned was that, you know, patients would choose a provider that was practicing more sustainability or health care system. And so I think that really could inform how, you know, different hospitals would approach this kind of situation. But I have to admit, I haven't done as much, you know, personal looking into that particular topic, but still inspired by the idea of the patient voice informing some of the future sustainability initiatives. Yeah, it's something I'm really interested in as well and obviously have learned from Reid and others and kind of interested in thinking about, you talked about efficient scanning as well. And, you know, when a patient who's come from multiple MRIs notice, like, hey, my appointment's now 20 minutes when it was 45 minutes or whatever, because that's a big jump as an example. You know, whether communicating, you know, we're able to achieve the same diagnostic accuracy, but we save this much energy and, you know, this is the net positive benefit with it. That might be something that was perceived positively. And again, I think it's really important that we don't compromise quality of care, of course, in these initiatives. Yeah, yeah. No, I think like, you know, you know, not, you know, no sort of like in change for sustainability policy should affect our ability to provide excellent, you know, quality, you know, health care. And, you know, I think that's, of course, the top mission of, you know, hospitals is to, you know, help the patients that, you know, come into the hospitals to provide, you know, the excellent care they come in for. We can do it with like less resources and more sustainable. I think that's, that's a win. So. Yeah, absolutely. And, you know, the other one you talked about was, of course, the financial wins. And I think these like the co-benefits or however you want to phrase it can be so powerfully motivating to, you know, maybe motivate the change in the first place, of course. And I think energy is so intuitive in that, like, we know if you use less electricity, there is a dollar cost savings. And I'll just share, like, one of the things we found, but even showing that there is going to be less electricity use and even modeling out the actual dollar cost of that would be, which I have learned is quite nuanced and interesting with like the different dollar costs at like different times of day. And I'm like, oh, OK, leave that concept aside. You know, the, what I found is that the budget line for electricity is like, you know, obviously such a larger health system budget line not directly aligned or controlled by like the leadership team who would be more impacted by like these types of actions we're taking in our departments. And so trying to marry those two and like, you know, convince one group that there is this net benefit that they're not seeing directly in their budget line was actually, you know, a surprising challenge. And perhaps it shouldn't have been surprising. Yeah, you know, and another, you know, kind of like unspoken, you know, part of it as well as by reducing our energy consumption and or like our amount of waste that we produce, like it shepherds our resources for like a growing, you know, growing patient base that we're probably going to have in the future. And I expect health care systems are going to continually have to supply health care to more patients. And so by using less resources, it also allows us to have, you know, more available to treat larger populations. And so and also, you know, like, you know, energy is becoming more scarce as well. You know, there's the idea of switching to like greener energy resources, but to facilitate that happening, the whole health care system really needs to consume less energy to get it down to a level that can support, you know, green infrastructure. And so I think, you know, there's, you know, there's other kind of, you know, ideas of like being able to like reduce. Obviously, the cost is always great. You know, reducing the amount of emissions is great. But also, I think like enabling potential delivery of health care to a larger amount of people and also, I guess, decreasing, you know, decreasing energy consumption to enable, you know, using, you know, greener infrastructure. So. I'm with you. I feel like there's almost an infinite number of things we can do. And again, I think it gets back to reframing it as, yes, there is a problem, but absolutely we have an opportunity to have such a huge positive benefit that I think reframing it as an opportunity can be hopefully motivating. Thank you for being here and for chatting. I don't see any open questions and unless you have any last words, maybe we'll close things. No, yeah. No, I think this is great. And, you know, I really enjoyed, you know, doing this talk with you. Likewise. It's always a pleasure to chat with you. And I swear every time you talk, I learn something new. So thank you. And to all our participants, thank you for being here and for this feed that we'll be viewing on demand. I really appreciate it. You'll receive a notification from the RS&A in the next couple of days on how to access the recording and the supplemental resource guide in the RS&A course catalog. And be sure to check the RS&A website for upcoming educational events and webinars. Thank you to the RS&A team for inviting us. And thank you again, Sean, for being here. Take care, everyone.

sustainable radiology

planetary health

environmental impact

scope emissions

greenhouse gas

energy-saving protocols

interdisciplinary collaboration

reusable materials

healthcare quality