Learning to treat the climate emergency together: social tipping interventions by the health community

Accelerating the decarbonisation of local and national economies is a profound public health imperative. As trusted voices within communities around the world, health professionals and health organisations have enormous potential to influence the social and policy landscape in support of decarbonisation. We assembled a multidisciplinary, gender-balanced group of experts from six continents to develop a framework for maximising the social and policy influence of the health community on decarbonisation at the micro levels, meso levels, and macro levels of society. We identify practical, learning-by-doing approaches and networks to implement this strategic framework. Collectively, the actions of health-care workers can shift practice, finance, and power in ways that can transform the public narrative and influence investment, activate socioeconomic tipping points, and catalyse the rapid decarbonisation needed to protect health and health systems.

Consensus on Prioritisation of Actions for Reducing the Environmental Impact of a Large Tertiary Hospital: Application of the Nominal Group Technique

Hospitals are the largest greenhouse gas producers within the Australian healthcare sector due to the large amounts of energy, resource utilization, equipment and pharmaceuticals required to deliver care. In order to reduce healthcare emissions, healthcare services must take multiple actions to address the broad range of emissions produced when delivering patient care. The goal of this study was to seek consensus on the priority actions needed to reduce the environmental impact of a tertiary Australian hospital. A nominal group technique was utilized within a multidisciplinary, executive-led environmental sustainability committee to find consensus on the 62 proposed actions to reduce the environmental impact of a tertiary Australian hospital. Thirteen participants joined an online workshop during which an educational presentation was delivered, 62 potential actions were privately ranked according to two domains of 'amenability to change' and 'scale of climate impact' and a moderated group discussion ensued. The group achieved verbal consensus on 16 actions that span staff education, procurement, pharmaceuticals, waste, transport and advocacy on all-electric capital works upgrades. In addition, the individual ratings of potential actions according to each domain were ranked and shared with the group. Despite a large number of actions and varied perspectives within the group, the nominal group technique can be used to focus a hospital leadership group on priority actions to improve environmental sustainability.

Aerosol Generation During High Intensity Exercise-Implications for COVID-19 Transmission

BACKGROUND AND AIM

COVID-19 can be transmitted through aerosolised respiratory particles. The degree to which exercise enhances aerosol production has not been previously assessed. We aimed to quantify the size and concentration of aerosol particles and evaluate the impact of physical distance and surgical mask wearing during high intensity exercise (HIE).

METHODS

Using a prospective observational crossover study, three healthy volunteers performed high intensity cardiopulmonary exercise testing at 80% of peak capacity in repeated 5-minute bouts on a cycle ergometer. Aerosol size and concentration was measured at 35, 150 and 300 cm from the participants in an anterior and lateral direction, with and without a surgical face mask, using an Aerodynamic Particle Sizer (APS) and a Mini Wide Range Aerosol Spectrometer (MiniWRAS), with over 10,000 sample points.

RESULTS

High intensity exercise generates aerosol in the 0.2-1 micrometre range. Increasing distance from the rider reduces aerosol concentrations measured by both MiniWRAS (p=0.003 for interaction) and APS (p=0.041). However, aerosol concentrations remained significantly increased above baseline measures at 300 cm from the rider. A surgical face mask reduced submicron aerosol concentrations measured anteriorly to the rider (p=0.031 for interaction) but not when measured laterally (p=0.64 for interaction).

CONCLUSIONS

High intensity exercise is an aerosol generating activity. Significant concentrations of aerosol particles are measurable well beyond the commonly recommended 150 cm of physical distancing. A surgical face mask reduces aerosol concentration anteriorly but not laterally to an exercising individual. Measures for safer exercise should emphasise distance and airflow and not rely solely on mask wearing.

Violence in intensive care: a point prevalence study

Introduction: Violence in the intensive care unit (ICU) is poorly characterised and its incidence is largely extrapolated from studies in the emergency department. Policy requirements vary between jurisdictions and have not been formally evaluated. Methods: A multisite, single-time point observational study was conducted across Australasian ICUs which focused on the incidence of violence in the previous 24 hours, the characteristics of patients displaying violent behaviour, the perceived contributors, and the management strategies implemented. Unit policies were surveyed across a range of domains relevant to violence management. Results: Data were available for 627 patients admitted to 44 ICUs on one of 2 days in June 2019. Four per cent (25/627) displayed at least one episode of violent behaviour in the previous 24 hours. Violent behaviour was more likely in individuals after a greater length of stay in hospital (incidence, 2%, 4% and 7% for day 0-2, 3-7 and > 7 days respectively; P = 0.01) and in the ICU (2%, 4% and 9% for day 0-2, 3-7 and > 7 of ICU stay respectively; P < 0.01). The most common perceived contributors to violence were confusion (64%), physical illness (40%), and psychiatric illness (34%). Management with chemical sedation (72%) and physical restraint (28%) was commonly required. Clinicians assessed an additional 53 patients (53/627, 9%) as at risk of displaying violence in the next 24 hours. Of the 44 participating ICUs, 30 (68%) had a documented violence procedure. Conclusion: Violence in the ICU was common and frequently required intervention. In this study, one-third of ICUs did not have formal violence procedures, and in those with violence procedures, considerable variation was observed.

Health, financial and environmental impacts of unnecessary vitamin D testing: a triple bottom line assessment adapted for healthcare

OBJECTIVE

To undertake an assessment of the health, financial and environmental impacts of a well-recognised example of low-value care; inappropriate vitamin D testing.

DESIGN

Combination of systematic literature search, analysis of routinely collected healthcare data and environmental analysis.

SETTING

Australian healthcare system.

PARTICIPANTS

Population of Australia.

OUTCOME MEASURES

We took a sustainability approach, measuring the health, financial and environmental impacts of a specific healthcare activity. Unnecessary vitamin D testing rates were estimated from best available published literature; by definition, these provide no gain in health outcomes (in contrast to appropriate/necessary tests). Australian population-based test numbers and healthcare costs were obtained from Medicare for vitamin D pathology services. Carbon emissions in kg CO2e were estimated using data from our previous study of the carbon footprint of common pathology tests. We distinguished between tests ordered as the primary test and those ordered as an add-on to other tests, as many may be done in conjunction with other tests. We conducted base case (8% being the primary reason for the blood test) and sensitivity (12% primary test) analyses.

RESULTS

There were a total of 4 457 657 Medicare-funded vitamin D tests in 2020, on average one test for every six Australians, an 11.8% increase from the mean 2018-2019 total. From our literature review, 76.5% of Australia's vitamin D tests provide no net health benefit, equating to 3 410 108 unnecessary tests in 2020. Total costs of unnecessary tests to Medicare amounted to >$A87 000 000. The 2020 carbon footprint of unnecessary vitamin D tests was 28 576 kg (base case) and 42 012 kg (sensitivity) CO2e, equivalent to driving ~160 000-230 000 km in a standard passenger car.

CONCLUSIONS

Unnecessary vitamin D testing contributes to avoidable CO2e emissions and healthcare costs. While the footprint of this example is relatively small, the potential to realise environmental cobenefits by reducing low-value care more broadly is significant.

Vented Individual Patient (VIP) Hoods for the Control of Infectious Airborne Diseases in Healthcare Facilities

By providing a means of separating the airborne emissions of patients from the air breathed by healthcare workers (HCWs), vented individual patient (VIP) hoods, a form of local exhaust ventilation (LEV), offer a new approach to reduce hospital-acquired infection (HAI). Results from recent studies have demonstrated that, for typical patient-emitted aerosols, VIP hoods provide protection at least equivalent to that of an N95 mask. Unlike a mask, hood performance can be easily monitored and HCWs can be alerted to failure by alarms. The appropriate use of these relatively simple devices could both reduce the reliance on personal protective equipment (PPE) for infection control and provide a low-cost and energy-efficient form of protection for hospitals and clinics. Although the development and deployment of VIP hoods has been accelerated by the coronavirus disease 2019 (COVID-19) pandemic, these devices are currently an immature technology. In this review, we describe the state of the art of VIP hoods and identify aspects in need of further development, both in terms of device design and the protocols associated with their use. The broader concept of individual patient hoods has the potential to be expanded beyond ventilation to the provision of clean conditions for individual patients and personalized control over other environmental factors such as temperature and humidity.

Everyone's a winner if we test less: the CODA action plan

In this era of 'Choosing Wisely,' we present a four-step action plan to reduce unnecessary pathology testing and the associated patient harm (blood loss through repeated phlebotomy), economic cost and environmental impact. The authors are experts from the CODA group; a medical education and health-promotion charity that aims to build on the Choosing Wisely initiative to provide meaningful and sustainable actions to reduce the carbon footprint of healthcare, globally. Pathology testing is expensive and carbon-intensive, with as many as half of all tests being not clinically indicated. Reducing unnecessary testing is the only effective way to decrease the carbon footprint and other associated costs, as opportunities to reuse and recycle pathology specimens are limited. The four key steps for action are (i) auditing local practice; (ii) defining unnecessary testing including developing a clinical guideline for rational ordering; (iii) educating stakeholders; and (iv) measuring the impact of the intervention through re-audit. This proven method is designed to be used in any healthcare setting around the world; having a small group of passionate 'champions' is thought to be as important as strong clinical governance and more important than access to sophisticated equipment. Electronic medical record systems and other technological solutions offer new ways to help establish a sustainability mindset and reduce unnecessary testing. The Codachange.org/coda-earth/ website provides a dynamic crowdsourcing platform through which we can collectively learn to meet the diverse needs of our international medical community. Self-reported outcomes are gamified through collaborative feedback, amplification via social media and the ability to earn rewards, be uploaded to the CODA website, or added to the template as a success story. By combining our existing local networks with the emerging international CODA community, we can initiate meaningful change now and enter the era of environmental stewardship.

The carbon footprint of hospital diagnostic imaging in Australia

BACKGROUND

Pathology testing and diagnostic imaging together contribute 9% of healthcare's carbon footprint. Whilst the carbon footprint of pathology testing has been undertaken, to date, the carbon footprint of the four most common imaging modalities is unclear.

METHODS

We performed a prospective life cycle assessment at two Australian university-affiliated health services of five imaging modalities: chest X-ray (CXR), mobile chest X-ray (MCXR), computerised tomography (CT), magnetic resonance imaging (MRI) and ultrasound (US). We included scanner electricity use and all consumables and associated waste, including bedding, imaging contrast, and gloves. Analysis was performed using both attributional and consequential life cycle assessment methods. The primary outcome was the greenhouse gas footprint, measured in carbon dioxide equivalent (CO₂e) emissions.

FINDINGS

Mean CO₂e emissions were 17·5 kg/scan for MRI; 9·2 kg/scan for CT; 0·8 kg/scan for CXR; 0·5 kg/scan for MCXR; and 0·5 kg/scan for US. Emissions from scanners from standby energy were substantial. When expressed as emissions per additional scan (results of consequential analysis) impacts were lower: 1·1 kg/scan for MRI; 1·1 kg/scan for CT; 0·6 kg/scan for CXR; 0·1 kg/scan for MCXR; and 0·1 kg/scan for US, due to emissions from standby power being excluded.

INTERPRETATION

Clinicians and administrators can reduce carbon emissions from diagnostic imaging, firstly by reducing the ordering of unnecessary imaging, or by ordering low-impact imaging (X-ray and US) in place of high-impact MRI and CT when clinically appropriate to do so. Secondly, whenever possible, scanners should be turned off to reduce emissions from standby power. Thirdly, ensuring high utilisation rates for scanners both reduces the time they spend in standby, and apportions the impacts of the reduced standby power of a greater number of scans. This therefore reduces the impact on any individual scan, maximising resource efficiency.

FUNDING

Healthy Urban Environments (HUE) Collaboratory of the Maridulu Budyari Gumal Sydney Partnership for Health, Education, Research and Enterprise MBG SPHERE. The National Health and Medical Research Council (NHMRC) PhD scholarship.

Action guidance for addressing pollution from inhalational anaesthetics

Climate change is a real and accelerating existential danger. Urgent action is required to halt its progression, and everyone can contribute. Pollution mitigation represents an important opportunity for much needed leadership from the health community, addressing a threat that will directly and seriously impact the health and well‐being of current and future generations. Inhalational anaesthetics are a significant contributor to healthcare‐related greenhouse gas emissions and minimising their climate impact represents a meaningful and achievable intervention. A challenge exists in translating well‐established knowledge about inhalational anaesthetic pollution into practical action. CODA is a medical education and health promotion charity that aims to deliver climate action‐oriented recommendations, supported by useful resources and success stories. The CODA‐hosted platform is designed to maximise engagement of the global healthcare community and draws upon diverse experiences to develop global solutions and accelerate action. The action guidance for addressing pollution from inhalational anaesthetics is the subject of this article. These are practical, evidence‐based actions that can be undertaken to reduce the impact of pollution from inhalational anaesthetics, without compromising patient care and include: removal of desflurane from drug formularies; decommissioning central nitrous oxide piping; avoidance of nitrous oxide use; minimising fresh gas flows during anaesthesia; and prioritising total intravenous anaesthesia and regional anaesthesia when clinically safe to do so. Guidance on how to educate, implement, measure and review progress on these mitigation actions is provided, along with means to share successes and contribute to the essential, global transition towards environmentally sustainable anaesthesia.

Principles of environmentally-sustainable anaesthesia: a global consensus statement from the World Federation of Societies of Anaesthesiologists

The Earth's mean surface temperature is already approximately 1.1°C higher than pre-industrial levels. Exceeding a mean 1.5°C rise by 2050 will make global adaptation to the consequences of climate change less possible. To protect public health, anaesthesia providers need to reduce the contribution their practice makes to global warming. We convened a Working Group of 45 anaesthesia providers with a recognised interest in sustainability, and used a three-stage modified Delphi consensus process to agree on principles of environmentally sustainable anaesthesia that are achievable worldwide. The Working Group agreed on the following three important underlying statements: patient safety should not be compromised by sustainable anaesthetic practices; high-, middle- and low-income countries should support each other appropriately in delivering sustainable healthcare (including anaesthesia); and healthcare systems should be mandated to reduce their contribution to global warming. We set out seven fundamental principles to guide anaesthesia providers in the move to environmentally sustainable practice, including: choice of medications and equipment; minimising waste and overuse of resources; and addressing environmental sustainability in anaesthetists' education, research, quality improvement and local healthcare leadership activities. These changes are achievable with minimal material resource and financial investment, and should undergo re-evaluation and updates as better evidence is published. This paper discusses each principle individually, and directs readers towards further important references.

Quantitative evaluation of aerosol generation during manual facemask ventilation

Manual facemask ventilation, a core component of elective and emergency airway management, is classified as an aerosol-generating procedure. This designation is based on one epidemiological study suggesting an association between facemask ventilation and transmission during the SARS-CoV-1 outbreak in 2003. There is no direct evidence to indicate whether facemask ventilation is a high-risk procedure for aerosol generation. We conducted aerosol monitoring during routine facemask ventilation and facemask ventilation with an intentionally generated leak in anaesthetised patients. Recordings were made in ultraclean operating theatres and compared against the aerosol generated by tidal breathing and cough manoeuvres. Respiratory aerosol from tidal breathing in 11 patients was reliably detected above the very low background particle concentrations with median [IQR (range)] particle counts of 191 (77-486 [4-1313]) and 2 (1-5 [0-13]) particles.l-1 , respectively, p = 0.002. The median (IQR [range]) aerosol concentration detected during facemask ventilation without a leak (3 (0-9 [0-43]) particles.l-1 ) and with an intentional leak (11 (7-26 [1-62]) particles.l-1 ) was 64-fold (p = 0.001) and 17-fold (p = 0.002) lower than that of tidal breathing, respectively. Median (IQR [range]) peak particle concentration during facemask ventilation both without a leak (60 (0-60 [0-120]) particles.l-1 ) and with a leak (120 (60-180 [60-480]) particles.l-1 ) were 20-fold (p = 0.002) and 10-fold (0.001) lower than a cough (1260 (800-3242 [100-3682]) particles.l-1 ), respectively. This study demonstrates that facemask ventilation, even when performed with an intentional leak, does not generate high levels of bioaerosol. On the basis of this evidence, we argue facemask ventilation should not be considered an aerosol-generating procedure.

Carbon emissions and hospital pathology stewardship: a retrospective cohort analysis

BACKGROUND

As healthcare is responsible for 7% of Australia's carbon emissions, it was recognised that a policy implemented at St George Hospital, Sydney to reduce non-urgent pathology testing to two days per week and on other days only if essential, would also result in a reduction in carbon emissions. The aim of the study was to measure the impact of this intervention on pathology collections and associated carbon emissions and pathology costs.

METHODS

The difference in the number of pathology collections, carbon dioxide equivalents (CO₂ e) for five common blood tests, and pathology cost per admission were compared between a 6-month reference period and 6-month intervention period. CO₂ e were estimated from published pathology CO₂ e impacts. Cost was derived from pathology billing records. Outcomes were modelled using multivariable negative binomial, generalised linear, and logistic regression.

RESULTS

In total, 24,585 pathology collections in 5,695 patients were identified. In adjusted analysis, the rate of collections was lower during the intervention period (rate ratio 0.90, 95% CI, 0.86 to 0.95; P<0.001). This resulted in a reduction of 53 g CO₂ e (95% CI, 24 to 83g; P<0.001) and $22 (95% CI, $9 to $34; P=0.001) in pathology fees per admission. The intervention was estimated to have saved 132kg CO₂ e (95% CI, 59 to 205kg) and $53,573 (95% CI, 22,076 to 85,096).

CONCLUSIONS

Reduction in unnecessary hospital pathology collections was associated with both carbon emission and cost savings. Pathology stewardship warrants further study as a potentially scalable, cost-effective, and incentivising pathway to lowering healthcare associated greenhouse gas emissions. This article is protected by copyright. All rights reserved.

Net zero healthcare: a call for clinician action

Health professionals are well positioned to effect change by reshaping individual practice, influencing healthcare organisations, and setting clinical standards, argue Jodi Sherman and colleagues