European Society of Anaesthesiology and Intensive Care consensus document on sustainability: 4 scopes to achieve a more sustainable practice

Environmental sustainability in intensive care: An international survey of intensive care professionals'views, practices and proposals to the European Society of Intensive Care Medicine

BACKGROUND

The intensive care unit (ICU) is a high-resource area, generating more waste and greenhouse gas (GHG) emissions than standard hospital wards. Environmental sustainability is important for healthcare professionals worldwide, prompting scientific societies to call for urgent action. To respond to this global need, the European Society of Intensive Care Medicine (ESICM) conducted an international survey assessing intensive care professionals' attitudes and practices towards environmental sustainability.

METHODS

Intensive care professionals completed an online survey between 21 October 2023, and 5 January 2024. The survey, featuring 21 questions assessing attitudes and practices towards environmental sustainability and proposals for actions from ESICM, was disseminated during the 36th ESICM Congress via National Intensive Care Societies and ESICM's social media.

RESULTS

We received 635 responses from 48 countries. Four hundred seventy (80 %) respondents acknowledged a responsibility to be aware of the environmental impact of intensive care practice, and 372 (63.5 %) disagreed or were uncertain about their knowledge level to guide practice. Four hundred thirty-seven (84 %) lacked formal training on making sustainable choices. Ninety-five per cent used non-sterile gloves in ICUs, and 63 % were willing to reduce use to support sustainable practices. Two proposed actions for ESICM to improve environmental sustainability were increasing knowledge on ecology (91/187, 49 %) and raising awareness in the field (36/187,20 %).

CONCLUSION

This survey highlighted the need for scientific societies, notably ESICM, to provide robust support and structured education on environmental sustainability. Intensive care professionals acknowledged the environmental impact of intensive care and seemed eager to invest in their education on this topic.

The carbon footprint of general anaesthesia in adult patients: a multicentre observational comparison of intravenous and inhalation anaesthetic strategies in 35,242 procedures

BACKGROUND

General anaesthesia is a significant contributor to healthcare-related greenhouse gas (GHG) emissions. Previous studies have compared non-optimised anaesthesia strategies (desflurane, nitrous oxide, or both) to evaluate the impact of green initiatives on reducing the carbon footprint of anaesthesia. However, modern halogenated anaesthesia techniques, including low fresh gas flow and target-controlled inhalation anaesthesia (TCIA), offer potentially more environmentally friendly alternatives. Thus, we aimed to compare the GHG emissions of total intravenous anaesthesia (TIVA) with these newer techniques.

METHODS

This multicentre study compared GHG emissions per hour of general anaesthesia in adult surgical patients between three anaesthetic strategies: TIVA with propofol, sevoflurane in TCIA mode, and manually optimised sevoflurane. The study was conducted in three French university hospitals, each using one anaesthesia strategy. The quantity of anaesthetic drugs used was obtained from pharmacy procurement records and converted to carbon dioxide equivalents (CO2e). The primary outcome was the total GHG emissions per hour of anaesthesia for each strategy, including sevoflurane, propofol, and syringe consumption.

RESULTS

TCIA, manually optimised sevoflurane, and TIVA strategies were used in 7873, 15 461, and 10 717 anaesthetics, respectively. The carbon footprint of the principal anaesthetic drugs per hour of anaesthesia was significantly lower in the TIVA strategy, at 0.4 kg CO2e per hour, compared with 3.1 kg CO2e per hour in the TCIA strategy and 3.8 kg CO2e per hour in the manually optimised sevoflurane strategy.

CONCLUSIONS

TIVA with propofol was the most effective approach for minimising greenhouse gas emissions in anaesthesia practices. However, if TIVA were used exclusively globally, it could lead to issues such as stock depletion, plastic pollution, and water contamination.

A nationwide approach to reduction in anaesthetic gas use: the Dutch Approach to decarbonising anaesthesia

Anaesthetic gases account for ∼3% of the carbon footprint of the entire healthcare sector and up to 63% of the emissions originating from surgical care. Transitioning to predominant use of total intravenous anaesthesia (TIVA) has been proven a safe and effective strategy to reduce this footprint, yet its adoption has been slow in most countries. Interventions at the national level have been limited to regulatory action (e.g. banning of desflurane) and publication of nonbinding recommendations and best practices. We describe a new approach that we used to drive sustainable change and apply it to the debate between TIVA and inhalation anaesthesia at the national level. The Dutch Approach is founded on a bottom-up, self-regulatory model grounded in evidence-based practices. Patient safety studies, a national inventory of anaesthetic drug use, and in-depth interviews with anaesthetists were combined in developing a national guideline. Meeting the two main concerns among anaesthetists, patient safety and professional autonomy, the guideline requires all Dutch anaesthetic practices to adopt a local protocol whose main message is 'TIVA when possible, inhalation anaesthesia when necessary'. Central to the approach was the integration within the national quinquennial quality control audits. Adoption and implementation will be monitored and evaluated in an ongoing research project.

The implementation of intrathecal morphine for caesarean delivery into clinical practice, and assessment of its impact on patient-reported quality of recovery using the ObsQoR-10-Dutch scale: A single-centre cohort study

BACKGROUND

Optimising a mother's quality of recovery following caesarean delivery is of paramount importance as it facilitates maternal care of the newborn and affects physical, psychological and emotional well being. Intrathecal morphine (ITM) reduces postoperative pain and may improve quality of recovery: however its widespread use is limited.

OBJECTIVE

To assess the effects of implementing ITM for caesarean delivery on postoperative quality of recovery.

STUDY DESIGN

Single-centre observational before-after study.

SETTING

Tertiary university hospital, the Netherlands, January 2023 until April 2024.

STUDY POPULATION

Patients who underwent caesarean delivery under spinal anaesthesia.

INTERVENTION

Patients recruited before implementation of ITM ( n  = 55) received patient-controlled intravenous analgesia with morphine or continuation of epidural analgesia previously used for labour ('pre-ITM group'). Patients recruited after implementation of ITM ( n  = 47) received ITM 100 μg and oral morphine tablets 10 mg as needed ('ITM group').

OUTCOMES

Primary outcome was the score on the Obstetric Quality of Recovery (ObsQoR-10-Dutch) questionnaire (0 to 100). Secondary outcomes included ObsQoR-10 subscores, length of stay, opioid consumption and self-reported general health score (0 to 100).

RESULTS

Protocol adherence for ITM was 98%. Quality of recovery improved significantly [ObsQoR-10 scores pre-ITM 65 ± 16 vs. ITM 74 ± 13 points, mean difference 9.0 (95% CI, 3.1 to 15] points, P  = 0.002], with improvement in pain scores, physical comfort, independence and psychological wellbeing. In multivariate analysis, the improvement was 6.3 (95% CI, 0.37 to 12.2] points, which was statistically significant but did not reach the predefined threshold for clinical relevance. There was, however, an improvement in self-reported general health score (57 ± 18 vs. 68 ± 17, P  = 0.002), median [IQR] length of hospital stay (41 [36 to 51] vs. 37 [32 to 49] h, P  = 0.032) and median [IQR] opioid consumption (52 [35 to 73] vs. 0 [0 to 0] mg, P  < 0.001).

CONCLUSIONS

Implementing ITM for caesarean delivery resulted in moderate improvements in obstetric recovery and reduced opioid consumption. Cautious interpretation is warranted given the nonrandomised design of this implementation study. Our findings support the use of ITM in a multimodal analgesia strategy for patients undergoing caesarean delivery.

Environmental responsibility in resource utilization during the practice of regional anesthesia: a Canadian Anesthesiologists' Society Delphi consensus study

PURPOSE

Regional anesthesia (RA) is often perceived to be more environmentally sustainable than alternative forms of anesthesia. Nevertheless, the principles of sustainable RA remain ill-defined in the presence of variability of resource utilization within RA practice. Many infection prevention practices are based on low-level evidence, and recommendations vary internationally. We sought to conduct an evidence review and Delphi consensus study to provide guidance on aspects that lack high-quality evidence in RA practice to reconcile responsible resource stewardship and infection prevention in RA.

METHODS

We conducted a three-round modified Delphi process. After distributing an initial free-text questionnaire to all collaborators, we created structured questions, followed by two rounds of anonymized voting. We defined strong consensus as ≥ 75% agreement and weak consensus as ≥ 50% but < 75% agreement.

RESULTS

Forty-six experts agreed to take part in the study and 36 (78%) completed all the voting rounds. Regional anesthesia practice parameters with strong consensus included hand hygiene using alcohol scrub rather than soap and water, sterile gowns being unnecessary for single-injection RA techniques, only minimal equipment in the premade packs, and goal-directed use of sedation and supplemental oxygen.

DISCUSSION

We obtained consensus on the safe and environmentally responsible practice of RA for both single-injection and indwelling catheter techniques and identified areas of research focus. While more robust evidence is being generated, clinicians may use these findings as a guide to infection prevention and environmental sustainability in their anesthesia practice.

Unlocking opportunities to transform patient care: an expert insight on limitations and opportunities in patient monitoring

BACKGROUND

Current patient monitoring technologies are crucial for delivering personalised and timely care and are critical in achieving the best health outcomes while maintaining high care standards. However, these technologies also present several challenges affecting patients and healthcare professionals.

INFORMATION OVERLOAD

Healthcare providers often deal with excess data, making it challenging to identify the most critical patient information quickly. This may lead to delays in necessary interventions and potentially poorer patient outcomes.

ALARM FATIGUE

Many patient monitoring systems trigger frequent false alarms. This high incidence can cause healthcare providers to become desensitised, potentially leading to slower response times or overlooked important alerts.

INTEGRATION CHALLENGES

Current systems often need more seamless integration with other healthcare technologies, making it difficult for healthcare providers to have a cohesive view of the patient's health. This lack of integration can impair care coordination and increase workloads. This paper presents the findings from a group of experts who described the state of the art of patient monitoring and discussed potential solutions and new pathways for developing these technologies.

Intravenously Administered Nonsteroidal Anti-Inflammatory Drugs in Clinical Practice: A Narrative Review

Intravenously administered nonsteroidal anti-inflammatory drugs (NSAIDs) constitute a crucial component of multimodal analgesia strategies in surgical settings. This narrative review aims to provide an up-to-date evaluation of the efficacy, safety, and clinical use of intravenous (IV) NSAIDs for perioperative pain management in adults and children. The NSAIDs and selective COX-2 inhibitors (coxibs) approved in Europe for the short-term symptomatic treatment of acute, moderate perioperative pain via IV infusion in adults and/or children have been influenced by US and global guidelines and practice: the drugs primarily reviewed here are ibuprofen, ketorolac, ketoprofen, naproxen, paracetamol, and acetylsalicylic acid. Furthermore, intravenous ibuprofen is authorized for the short-term symptomatic treatment of fever. In contrast to intravenous ketoprofen, intravenous ibuprofen is authorized for administration to children over 6 years of age or weighing more than 20 kg. Overall, IV ibuprofen had a more favorable profile with regard to peri- and postoperative opioid sparing and pain relief. Oral ibuprofen and IV ibuprofen have similar levels of efficacy, although IV ibuprofen has a shorter onset of action and is required in patients who are unable to take oral medications. The frequency of significant adverse events appears to be similar for ibuprofen and paracetamol. Systematic reviews and meta-analyses report that intravenous NSAIDs reduce postoperative opioid consumption by approximately 20-60%, improving pain management with fewer opioid-related side effects. In indications in infants, the choice of medication is limited, and the oral route is not always feasible; IV formulations of ibuprofen are preferred in this setting. Topics for further research should include head-to-head trials of IV NSAIDs.

[Sustainability-national and international initiatives in intensive care and emergency medicine]

BACKGROUND

Climate change with global warming, natural disasters, species extinction and soil erosion is doubly relevant for medicine: On the one hand, heat waves, floods and other natural disasters lead to new disease patterns to which healthcare systems must adapt. On the other hand, the global healthcare system itself contributes to these effects, as it is estimated that the CO2 footprint of all healthcare facilities accounts for around 5% of global greenhouse gas emissions.

OBJECTIVES

National and international initiatives to promote sustainability concepts in intensive care and emergency medicine.

MATERIALS AND METHODS

Research on homepages of national and international (specialist) societies dealing with intensive and emergency care medicine and corresponding PubMed search (sustainability and climate change and emergency or intensive care medicine).

RESULTS

Six of the 12 national specialist societies surveyed have taken initiatives on sustainability, notable among them the initiative of Arbeitsgemeinschaft der Wissenschaftlichen Medizinischen Fachgesellschaften (AWMF) for a new registration of the S1 guideline "Sustainability in intensive care and emergency medicine". On the international scene, the activities of the Australian and New Zealand Intensive Care Society (ANZICS) with numerous publications on the topic of sustainability in intensive care medicine and the practical guide "A beginners guide to sustainability in intensive care medicine" as well as the European Society of Anaesthesiology and Intensive Care (ESAIC) with a consensus paper on sustainability should be highlighted.

CONCLUSIONS

At the national level, initiatives on sustainability (guidelines, working groups, forums) are emerging and are attracting increasing attention and activity. The umbrella organization of German Intensive Care Medicine, the Deutsche Interdisziplinäre Vereinigung für Intensiv- und Notfallmedizin (DIVI), has so far shown no (discernible) activity; there is an urgent need for action here, and health policy and the German Medical Association should also become (even) more involved in reducing the CO2 footprint in the healthcare sector. Internationally, there are a number of societies and institutions that are promoting the topic of "sustainability", although a stronger focus on the area of intensive care and emergency medicine would also be desirable here.

Environmental impact of the enhanced recovery pathway in colorectal surgery: A simulation study

AIM

Most of the literature on the environmental impact of surgery has analysed operating theatre practice in terms of its contribution to global warming (by greenhouse gas effects). The aim of this study was to assess the overall environmental impact of a complete perioperative pathway with and without implementation of an enhanced recovery programme (ERP).

METHOD

We compared two scenarios: an ERP scenario and a conventional scenario (CONV) for colorectal surgery. We carried out a lifecycle analysis for perioperative procedures, devices and consumables. We measured the impact on 17 environmental variables in addition to global warming.

RESULTS

The overall environmental impact of ERP was 6% lower than that of conventional care. The reduction of impact due to ERP ranged from 5% for greenhouse gas emissions (18 kg CO2 equivalent less per intervention) to 27% for water consumption (3 m3 less). The stages that had the most impact on the environment were the preoperative stage (essentially owing to patient travel) and the intraoperative stage with the surgical part (medical devices representing 83.3% of the impact of the procedure) and the anaesthesia part (halogenated gases and ventilation representing 54.9% of the impact of anaesthesia care).

CONCLUSION

This study found an ERP approach to be more eco-responsible than conventional care. This is an additional benefit of ERP implementation. The impact of ERP implementation might be further reduced by action on the preoperative and intraoperative stages.

Bacterial contamination and greenhouse gas emissions: A randomised study of reuse versus single-use of infusion-set components for intravenous anaesthesia

BACKGROUND

Reusing anaesthesia infusion-set components may reduce the climate impact from plastic waste and discarded medications. Infusion-set contents can be shielded from patient contact by single use of an infusion line fitted with dual antireflux valves, preventing retrograde entry of microorganisms, and eliminating the risk for patient-to-patient cross-contamination. However, infusion-set contamination from compromised aseptic handling could affect quality of care.

INTERVENTIONS

To determine the prevalence of infusion-set bacterial contamination and compare the climate effects, we randomised operating rooms scheduled for total intravenous anaesthesia to handle procedures by infusion-set reuse or single-use. Both methods used dual single-use antireflux valves.

OUTCOMES

The primary outcome was infusion-set bacterial contamination assessed by aerobic culture of infusion-set fluid collected after each procedure. The secondary outcome was CO 2 emissions (CO 2 -eq) estimated by life cycle assessment of component and medication use. To assess feasibility of detecting an inter-method difference in bacterial contamination, an interim analysis was planned after including at least 150 procedures per group.

RESULTS

After allocating 54 operating rooms per method, 189 and 159 procedures of reuse and single use were included. Reuse permitted a median of three procedures per infusion set (range 1 to 8). Positive cultures occurred in two procedures per method [mean (95% CI)]; prevalence 1.15% (0.03 to 2.27); relative risk of reuse versus single use 0.84 (0.12 to 5.93), P  = 0.861. As prespecified, inclusion was stopped due to futility. The median (95% CI) per-procedure climate emissions were 0.43 (0.41 to 0.47) and 1.39 (1.37 to 1.40) kg CO 2 -eq for reuse and single-use respectively; difference -0.96 (-0.99 to -0.93), P  < 0.0005. The main sources for climate emissions were production of infusion-set components and waste handling.

CONCLUSIONS

We conclude that the prevalence of bacterial contamination was low for both methods. A much larger study would be needed to detect an inter-method difference. Reuse of infusion-set components allowed significantly reduced intravenous anaesthesia climate emissions.

Influence of nitrous oxide added to general anaesthesia on postoperative mortality and morbidity: a systematic review and meta-analysis

BACKGROUND

Nitrous oxide (N2O) is a common adjuvant to general anaesthesia. It is also a potent greenhouse gas and causes ozone depletion. We sought to quantify the influence of N2O as an adjuvant to general anaesthesia on postoperative patient outcomes.

METHODS

We searched Medline, EMBASE, and Cochrane Central for works published from inception to July 6, 2023. RCTs comparing general anaesthesia with or without N2O were included. Risk ratios (RRs) and standardised mean differences (SMDs) were calculated, along with 95% confidence intervals (CIs), using a random-effects model. Outcomes were derived from the Standardised Endpoints for Perioperative Medicine (StEP) outcome set. Primary outcomes were mortality and organ-related morbidity, and secondary outcomes were anaesthetic and surgical morbidity.

RESULTS

Of 3305 records, 179 full-text articles were assessed, and 71 RCTs, totalling 22 147 patients, were included in the meta-analysis. Addition of N2O to general anaesthesia did not influence postoperative mortality or most morbidity outcomes. N2O increased the incidence of atelectasis (RR 1.62, 95% CI 1.24 to 2.12) and postoperative nausea and vomiting (RR 1.27, 95% CI 1.15 to 1.40), and decreased intraoperative opioid consumption (SMD -0.19, 95% CI -0.35 to -0.04) and time to extubation (MD -2.17 min, 95% CI -3.32 to -1.03 min).

CONCLUSIONS

N2O did not influence postoperative mortality or most morbidity outcomes. Considering the environmental effects of N2O, these findings confirm that current policy recommendations to limit its use do not affect patient safety.

SYSTEMATIC REVIEW PROTOCOL

PROSPERO CRD42023443287.

[Reconciling Sustainability and Hygiene in the Healthcare Sector]

In the course of climate change, doctors will not only be confronted with heat-related consequences, but also with the emergence of infectious diseases caused by previously tropical pathogens in temperate climate zones.Fortunately, the topics of sustainability and climate change are also becoming increasingly important in discussions in the healthcare sector, which accounts for 4.4% of global greenhouse gas emissions. The topic of hygienically safe sustainability in healthcare facilities is highly complex due to the large number of possible adjustments, but also offers a great deal of potential.Numerous measures can be implemented without any restrictions in terms of hygiene requirements or occupational safety.It is not always the large investments that make their contribution to reducing CO2-emissions - many smaller measures can also be implemented without high costs, but with great sustainability potential. Similar to hand hygiene compliance, behavior modification by each individual plays a decisive role in the implementation of such projects. There is great practical savings potential, for example, in the indication-based use of disposable medical gloves, the hygienically safe handling of medication or the decision between reusable and disposable medical products, just to name a few items discussed in the article.

Scoping review for the SAGES EAES joint collaborative on sustainability in surgical practice

BACKGROUND

Surgical care in the operating room (OR) contributes one-third of the greenhouse gas (GHG) emissions in healthcare. The European Association of Endoscopic Surgery (EAES) and the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) initiated a joint Task Force to promote sustainability within minimally invasive gastrointestinal surgery.

METHODS

A scoping review was conducted by searching MEDLINE via Ovid, Embase via Elsevier, Cochrane Central Register of Controlled Trials, and Scopus on August 25th, 2023 to identify articles reporting on the impact of gastrointestinal surgical care on the environment. The objectives were to establish the terminology, outcome measures, and scope associated with sustainable surgical practice. Quantitative data were summarized using descriptive statistics.

RESULTS

We screened 22,439 articles to identify 85 articles relevant to anesthesia, general surgical practice, and gastrointestinal surgery. There were 58/85 (68.2%) cohort studies and 12/85 (14.1%) Life Cycle Assessment (LCA) studies. The most commonly measured outcomes were kilograms of carbon dioxide equivalents (kg CO2eq), cost of resource consumption in US dollars or euros, surgical waste in kg, water consumption in liters, and energy consumption in kilowatt-hours. Surgical waste production and the use of anesthetic gases were among the largest contributors to the climate impact of surgical practice. Educational initiatives to educate surgical staff on the climate impact of surgery, recycling programs, and strategies to restrict the use of noxious anesthetic gases had the highest impact in reducing the carbon footprint of surgical care. Establishing green teams with multidisciplinary champions is an effective strategy to initiate a sustainability program in gastrointestinal surgery.

CONCLUSION

This review establishes standard terminology and outcome measures used to define the environmental footprint of surgical practices. Impactful initiatives to achieve sustainability in surgical practice will require education and multidisciplinary collaborations among key stakeholders including surgeons, researchers, operating room staff, hospital managers, industry partners, and policymakers.

Effects of fatigue on anaesthetist well-being and patient safety: a narrative review

The elements that render anaesthesia a captivating profession can also foster stress and fatigue. Professionals considering anaesthesia as a career choice should have a comprehensive understanding of the negative consequences of fatigue and its implications for clinical performance and of the available preventive measures. Available evidence suggests that factors unrelated to patient characteristics or condition can affect clinical outcomes where anaesthetists are involved. Workload, nighttime work, and fatigue are persistent issues in anaesthesia and are perceived as presenting greater perioperative risks to patients. Fatigue seems to negatively affect both physical and mental health of anaesthetists. Existing evidence justifies specific interventions by institutions, stakeholders, and scientific societies to address the effects of anaesthetist fatigue. This narrative review summarises current knowledge regarding the effects of fatigue on anaesthetist well-being and patient safety, and discusses potential preventive solutions.

Heideveld-Chevalking A, Kristensen K, Huibertina Davida van Tuyl L, Põlluste K, Weynants C, Garel P, Sousa P, Talving P, Marx D, Žaludek A, Romero E, Rodríguez A, Orrego C. Improving quality and patient safety in surgical care through standardisation and harmonisation of perioperative care (SAFEST project): A research protocol for a mixed methods study

INTRODUCTION

Adverse events in health care affect 8% to 12% of patients admitted to hospitals in the European Union (EU), with surgical adverse events being the most common types reported.

AIM

SAFEST project aims to enhance perioperative care quality and patient safety by establishing and implementing widely supported evidence-based perioperative patient safety practices to reduce surgical adverse events.

METHODS

We will conduct a mixed-methods hybrid type III implementation study supporting the development and adoption of evidence-based practices through a Quality Improvement Learning Collaborative (QILC) in co-creation with stakeholders. The project will be conducted in 10 hospitals and related healthcare facilities of 5 European countries. We will assess the level of adherence to the standardised practices, as well as surgical complications incidence, patient-reported outcomes, contextual factors influencing the implementation of the patient safety practices, and sustainability. The project will consist of six components: 1) Development of patient safety standardised practices in perioperative care; 2) Guided self-evaluation of the standardised practices; 3) Identification of priorities and actions plans; 4) Implementation of a QILC strategy; 5) Evaluation of the strategy effectiveness; 6) Patient empowerment for patient safety. Sustainability of the project will be ensured by systematic assessment of sustainability factors and business plans. Towards the end of the project, a call for participation will be launched to allow other hospitals to conduct the self-evaluation of the standardized practices.

DISCUSSION

The SAFEST project will promote patient safety standardized practices in the continuum of care for adult patients undergoing surgery. This project will result in a broad implementation of evidence-based practices for perioperative care, spanning from the care provided before hospital admission to post-operative recovery at home or outpatient facilities. Different implementation challenges will be faced in the application of the evidence-based practices, which will be mitigated by developing context-specific implementation strategies. Results will be disseminated in peer-reviewed publications and will be available in an online platform.

Healthcare in the era of climate change and the need for environmental sustainability

ABSTRACT

Climate change is an existential threat to humanity. While the healthcare sector must manage the health-related consequences of climate change, it is a significant contributor to greenhouse gas emissions, responsible for up to 4.6% of global emission, aggravating global warming. Within the hospital environment, the three largest contributors to greenhouse gas emissions are the operating theatre, intensive care unit and gastrointestinal endoscopy. Knowledge of the health-related burden of climate change and the potential transformative health benefits of climate action is important to all health professionals, as they play crucial roles in effecting change. This article summarises the available literature on the impact of healthcare on climate change and efforts in mitigation, focusing on the intrinsic differences and similarities across the operating theatre complex, intensive care unit and gastrointestinal endoscopy unit. It also discusses strategies to reduce carbon footprint.