The financial and environmental costs of reusable and single-use plastic anaesthetic drug trays

The impact of radical prostatectomy on global climate: a prospective multicentre study comparing laparoscopic versus robotic surgery

BACKGROUND

More than 4% of the global greenhouse gas emissions are generated by healthcare system. Focusing on the environmental impact of minimally invasive surgery, we assessed and compared the CO2 emissions between Robot-assisted (RALP) and Laparoscopic Radical Prostatectomy (LRP).

METHODS

In patients prospectively enrolled, we evaluated the age, surgical and anesthesiologic time, postoperative intensive care unit and hospital stay, blood transfusion, pre- and postoperative hemoglobin and Gleason score, open conversion need, and complications (Clavien-Dindo classification). We assessed the life cycle to estimate the energy consumption for surgical procedures and hospital stays. We reported the materials, CO2 produced, and fluid quantity infused and dispersed. Disposable and reusable materials and instruments were weighed and divided into metal, plastic, and composite fibers. The CO2 consumption for disposal and decontamination was also evaluated.

RESULTS

Of the 223 patients investigated, 119 and 104 patients underwent RALP and LRP, respectively. The two groups were comparable as regards age and preoperative Gleason score. The laparoscopic and robotic instruments weighed 1733 g and 1737 g, respectively. The CO2 emissions due to instrumentation were higher in the laparoscopic group, with the majority coming from plastic and composite fiber components. The CO2 emissions for metal components were higher in the robotic group. The robot functioned at 3.5 kW/h, producing 4 kg/h of CO2. The laparoscopic column operated at 600 W/h, emitting ~1 kg/h of CO2. The operating room operated at 3,0 kW/h. The operating time was longer in the laparoscopic group, resulting in higher CO2 emissions. CO2 emissions from hospital room energy consumption were lower in the robot-assisted group. The total CO2 emissions were ~47 kg and ~60 kg per procedure in the robot-assisted and laparoscopic groups, respectively.

CONCLUSIONS

RALP generates substantially less CO2 than LRP owing to the use of more reusable surgical supplies, shorter operative time and hospital stay.

How to choose between single-use and reusable medical materials for sustainable nursing: Methodological lessons learned from a national study

AIM

To demonstrate and reflect upon the methodological lessons by which healthcare organizations can address questions of environmental sustainability related to single-use healthcare materials.

DESIGN

A cross-sectional multi-centre study in hospitals was performed, followed by an exploratory analysis of the sustainability of commonly used healthcare materials.

METHODS

A hospital survey was conducted to collect the procurement data for single-use medical materials. Based on consumption and cost, five single-use medical materials with sustainable alternatives were selected using different reuse strategies. Single-use and reusable materials were assessed through an exploratory literature review and document study based on four parameters: environmental sustainability, safety, cost and efficiency.

RESULTS

A pragmatic method emerged from this study, providing healthcare facilities with tools to select environmentally sustainable alternatives to replace single-use options. First, an inventory of single-use medical materials consumed was collected. Next, single-use materials were prioritized for further study based on criteria such as cost, volume of the material, feasibility and input of stakeholders. We then analysed the prioritized single-use materials and their alternatives based on life cycle assessments or available information on their different life stages. Finally, we assessed safety, costs and efficiency related to the process following the use of the medical material.

CONCLUSION

This pragmatic method can guide healthcare institutions in making the most sustainable choices of medical materials and achieving sustainability goals within their institutions and nationwide.

IMPACT

Patient care involves a large consumption of single-use medical materials with considerable environmental impact. A pragmatic method was developed to guide healthcare institutions in making the most sustainable choices regarding the use of single-use healthcare materials. Healthcare institutions, ideally represented by a green team including nurses and other relevant professionals, can use this method to reduce the use of single-use medical materials, thereby yielding positive outcomes for the entire population.

PATIENT OR PUBLIC CONTRIBUTION

No patient or public contribution.

Go Green in Neuroradiology: towards reducing the environmental impact of its practice

Raising public awareness about the relevance of supporting sustainable practices is required owing to the phenomena of global warming caused by the rising production of greenhouse gases. The healthcare sector generates a relevant proportion of the total carbon emissions in developed countries, and radiology is estimated to be a major contributor to this carbon footprint. Neuroradiology markedly contributes to this negative environmental effect, as this radiological subspecialty generates a high proportion of diagnostic and interventional imaging procedures, the majority of them requiring high energy-intensive equipment. Therefore, neuroradiologists and neuroradiological departments are especially responsible for implementing decisions and initiatives able to reduce the unfavourable environmental effects of their activities, by focusing on four strategic pillars-reducing energy, water, and helium use; properly recycling and/or disposing of waste and residues (including contrast media); encouraging environmentally friendly behaviour; and reducing the effects of ionizing radiation on the environment. The purpose of this article is to alert neuroradiologists about their environmental responsibilities and to analyse the most productive strategic axes, goals, and lines of action that contribute to reducing the environmental impact associated with their professional activities.

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

Climate change is a defining issue for our generation. The carbon footprint of clinical practice accounts for 4.7% of European greenhouse gas emissions, with the European Union ranking as the third largest contributor to the global healthcare industry's carbon footprint, after the United States and China. Recognising the importance of urgent action, the European Society of Anaesthesiology and Intensive Care (ESAIC) adopted the Glasgow Declaration on Environmental Sustainability in June 2023. Building on this initiative, the ESAIC Sustainability Committee now presents a consensus document in perioperative sustainability. Acknowledging wider dimensions of sustainability, beyond the environmental one, the document recognizes healthcare professionals as cornerstones for sustainable care, and puts forward recommendations in four main areas: direct emissions, energy, supply chain and waste management, and psychological and self-care of healthcare professionals. Given the urgent need to cut global carbon emissions, and the scarcity of evidence-based literature on perioperative sustainability, our methodology is based on expert opinion recommendations. A total of 90 recommendations were drafted by 13 sustainability experts in anaesthesia in March 2023, then validated by 36 experts from 24 different countries in a two-step Delphi validation process in May and June 2023. To accommodate different possibilities for action in high- versus middle-income countries, an 80% agreement threshold was set to ease implementation of the recommendations Europe-wide. All recommendations surpassed the 80% agreement threshold in the first Delphi round, and 88 recommendations achieved an agreement >90% in the second round. Recommendations include the use of very low fresh gas flow, choice of anaesthetic drug, energy and water preserving measures, "5R" policies including choice of plastics and their disposal, and recommendations to keep a healthy work environment or on the importance of fatigue in clinical practice. Executive summaries of recommendations in areas 1, 2 and 3 are available as cognitive aids that can be made available for quick reference in the operating room.

How a hospital pharmacist can contribute to a more sustainable operating theater

Healthcare sectors, particularly operating theaters, are major consumers of resources. Given today's climate-related issues, its seems vital that the different healthcare professionals in operating areas become aware of their roles. This is pronouncedly the case for hospital pharmacists, who fulfill cross-sectional functions in the proper use and management of healthcare products and sterile medical devices. The objective of this review of the literature is to identify the actions a hospital pharmacist can take to impel evolution toward ecologically responsible care in the operating theater. Seven areas in which a pharmacist can assume a leading, supporting or composite role in rendering an operating theater ecologically responsible have been highlighted: purchasing, procurement and storage, harmonization of practices, modification of practices, professional attire, waste elimination and research/teaching. The active participation of all healthcare professionals, including the hospital pharmacist, is essential to the development of a sustainable approach to healthcare.

Methods to Include Environmental Impacts in Health Economic Evaluations and Health Technology Assessments: A Scoping Review

OBJECTIVES

The environmental impacts of healthcare are important factors that should be considered during health technology assessments. This study aims to summarize the evidence that exists about methods to include environmental impacts in health economic evaluations and health technology assessments.

METHODS

We identified records for screening using an existing scoping review and a systematic search of academic databases and gray literature up to September 2023. We screened the identified records for eligibility and extracted data using a narrative synthesis approach. The review was conducted following the JBI Manual for Evidence Synthesis and reported according to the Preferred Reporting Items for Systematic Reviews and Meta Analyses Extension for Scoping Reviews checklist.

RESULTS

We identified 2898 records and assessed the full text of 114, of which 54 were included in this review. Ten methods were identified to include environmental impacts in health economic evaluations and health technology assessments. Methods included converting environmental impacts to dollars or disability-adjusted life years and including them in a cost-effectiveness, cost-utility, or cost-benefit analysis, calculating an incremental carbon footprint effectiveness ratio or incremental carbon footprint cost ratio, incorporating impacts as one criteria of a multi-criteria decision analysis, and freely considering impacts during health technology assessment deliberation processes.

CONCLUSIONS

Methods to include environmental impacts in health economic evaluations and health technology assessments exist but have not been tested for widespread use by health technology assessment agencies. Further research and implementation work is needed to determine which method can best aid decision makers to choose low environmental impact healthcare interventions.

Reusable laryngoscope blades: a more eco-responsible and cost-effective alternative

INTRODUCTION

Consumption of single-use medical devices has increased considerably, contributing to the excessive wastage produced during surgical procedures. The present study aimed to describe a methodology to assess the transition from single-use blades (SUB) to reusable laryngoscope blades (RUB) and to assess the ecological and economic impact of the switch.

METHODS

The ecological analysis was based on the life cycle assessment method. Based on 30 operating rooms in a single tertiary university hospital, the economic analysis compared the usual SUB supplier with four RUB suppliers considering different costs: blade purchasing and depreciation, reprocessing, logistics and waste management.

RESULTS

In 2021, 17,200 intubations were performed requiring about 147 RUBs. Switching from SUB to RUB led to an annual saving of 26.5 tons of CO2eq (global warming impact), equivalent to 120 000 km by car. It avoids the extraction of 6.6 tons Oileq (petroleum) and 579 kg of copper (mineral resources) per year. This action also leads to a land occupation reduction of 626 m2 per year and water savings of 221.6 m3 per year. The average cost per intubation varies from 3.16 [3.15-3.16] for SUB to 2.81 [2.77-2.85] for RUB, representing an average saving of 0.35 per intubation leading to 5783.50 annual gain [5074.00-6192.00]. RUB are preferable from 3 and 86 uses from an ecological and economic viewpoint, respectively.

CONCLUSION

In a model of 17,200 intubations /year, switching SUD to RUB would save 26.5 tons of CO2eq and 6.6 tons of Oileq with 5783.50 annual gain. RUBs are ecologically and cost-effective after 3 and 86 uses, respectively.

Guidelines for reducing the environmental impact of general anaesthesia

OBJECTIVE

To provide guidelines for reducing the environmental impact of general anaesthesia.

DESIGN

A committee of ten experts from SFAR and SF2H and SFPC learned societies was set up. A policy of declaration of competing interests was applied and observed throughout the guideline-writing process. Likewise, it did not benefit from any funding from a company marketing a health product (drug or medical device). The committee followed the GRADE® method (Grading of Recommendations Assessment, Development and Evaluation) to assess the quality of the evidence on which the recommendations were based.

METHODS

We aimed to formulate recommendations according to the GRADE® methodology for three different fields: anaesthesia vapours and gases; intravenous drugs; medical devices and the working environment. Each question was formulated according to the PICO format (Population, Intervention, Comparator, Outcome). The literature review and recommendations were formulated according to the GRADE® methodology.

RESULTS

The experts' work on the synthesis and application of the GRADE® method led to the formulation of 17 recommendations. Since the GRADE® method could not be entirely applied to all of the questions, some of the recommendations were formulated as expert opinions.

CONCLUSION

Based on strong agreement between experts, we produced 17 recommendations designed to guide reducing the environmental impact of general anaesthesia.

Implementation approaches to improve environmental sustainability in operating theatres: a systematic review

Operating theatres consume large amounts of energy and consumables and produce large amounts of waste. There is an increasing evidence base for reducing the climate impacts of healthcare that could be enacted into routine practice; yet, healthcare-associated emissions increase annually. Implementation science aims to improve the systematic uptake of evidence-based care into practice and could, therefore, assist in addressing the environmental impacts of healthcare. The aim of this systematic search with narrative synthesis was to explore what implementation approaches have been applied to reduce the environmental impact of operating theatre activities, described by implementation phases and methodologies. A search was conducted in EMBASE, PubMed, and CINAHL, limited to English and publication since 2010. In total, 3886 articles were retrieved and 11 were included. All were in the exploratory phase (seven of 11) or initial implementation phase (four of 11), but none were in the installation or full implementation phase. Three studies utilised a recognised implementation theory, model, or framework in the design. Four studies used interprofessional education to influence individuals' behaviour to reduce waste, improve waste segregation, or reduce anaesthetic gases. Of those that utilised behaviour change interventions, all were qualitatively successful in achieving environmental improvement. There was an absence of evidence for sustained effects in the intervention studies and little follow-up from studies that explored barriers to innovation. This review demonstrates a gap between evidence for reducing environmental impacts and uptake of proposed practice changes to deliver low-carbon healthcare. Future research into 'greening' healthcare should use implementation research methods to establish a solid implementation evidence base. SYSTEMATIC REVIEW PROTOCOL: PROSPERO CRD42022342786.

Innovations towards achieving environmentally sustainable operating theatres: A systematic review

INTRODUCTION

The NHS accounts for 5.4% of the UK's total carbon footprint, with the perioperative environment being the most resource hungry aspect of the hospital. The aim of this systematic review was to assimilate the published studies concerning the sustainability of the perioperative environment, focussing on the impact of implemented interventions.

METHODS

A systematic review was performed using Pubmed, OVID, Embase, Cochrane database of systematic reviews and Medline. Original manuscripts describing interventions aimed at improving operating theatre environmental sustainability were included.

RESULTS

675 abstracts were screened with 34 manuscripts included. Studies were divided into broad themes; recycling and waste management, waste reduction, reuse, reprocessing or life cycle analysis, energy and resource reduction and anaesthetic gases. This review summarises the interventions identified and their resulting effects on theatre sustainability.

DISCUSSION

This systematic review has identified simple, yet highly effective interventions across a variety of themes that can lead to improved environmental sustainability of surgical operating theatres. Combining these interventions will likely result in a synergistic improvement to the environmental impact of surgery.

The degradation of single-use plastics and commercially viable bioplastics in the environment: A review

Plastics have become an integral part of human life. Single-use plastics (SUPs) are disposable plastics designed to be used once then promptly discarded or recycled. This SUPs range from packaging and takeaway containers to disposable razors and hotel toiletries. Synthetic plastics, which are made of non-renewable petroleum and natural gas resources, require decades to perpetually disintegrate in nature thus contribute to plastic pollution worldwide, especially in marine environments. In response to these problems, bioplastics or bio-based and biodegradable polymers from renewable sources has been considered as an alternative. Understanding the mechanisms behind the degradation of conventional SUPs and biodegradability of their greener counterpart, bioplastics, is crucial for appropriate material selection in the future. This review aims to provide insights into the degradation or disintegration of conventional single-use plastics and the biodegradability of the different types of greener-counterparts, bioplastics, their mechanisms, and conditions. This review highlights on the biodegradation in the environments including composting systems. Here, the various types of alternative biodegradable polymers, such as bacterially biosynthesised bioplastics, natural fibre-reinforced plastics, starch-, cellulose-, lignin-, and soy-based polymers were explored. Review of past literature revealed that although bioplastics are relatively eco-friendly, their natural compositions and properties are inconsistent. Furthermore, the global plastic market for biodegradable plastics remains relatively small and require further research and commercialization efforts, especially considering the urgency of plastic and microplastic pollution as currently critical global issue. Biodegradable plastics have potential to replace conventional plastics as they show biodegradation ability under real environments, and thus intensive research on the various biodegradable plastics is needed to inform stakeholders and policy makers on the appropriate response to the gradually emerging biodegradable plastics.

Anaesthesia and environment: impact of a green anaesthesia on economics

The excessive growth of the health sector has created an industry that, while promoting health, is now itself responsible for a significant part of global environmental pollution. The health crisis caused by climate change urges us to transform healthcare into a sustainable industry. This review aims to raise awareness about this issue and to provide practical and evidence-based recommendations for anaesthesiologists.

Inclusion of Environmental Spillovers in Applied Economic Evaluations of Healthcare Products

OBJECTIVES

Climate change and environmental factors have an impact on human health and the ecosystem. The healthcare sector is responsible for substantial environmental pollution. Most healthcare systems rely on economic evaluation to select efficient alternatives. Nevertheless, environmental spillovers of healthcare treatments are rarely considered whether it is from a cost or a health perspective. The objective of this article is to identify economic evaluations of healthcare products and guidelines that have included any environmental dimensions.

METHODS

Electronic searches of 3 literature databases (PubMed, Scopus, and EMBASE) and official health agencies guidelines were conducted. Documents were considered eligible if they assessed the environmental spillovers within the economic evaluation of a healthcare product or provided any recommendations on the inclusion of environmental spillovers in the health technology assessment process.

RESULTS

From the 3878 records identified, 62 documents were deemed eligible and 18 were published in 2021 and 2022. The environmental spillovers considered were carbon dioxide (CO₂) emissions, water or energy consumption, and waste disposal. The environmental spillovers were mainly assessed using the lifecycle assessment (LCA) approach while the economic analysis was mostly limited to costs. Only 9 documents, including the guidelines of 2 health agencies presented theoretical and practical ways to include environmental spillovers into the decision-making process.

CONCLUSIONS

There is a clear lack of methods on whether environmental spillovers should be included in health economic evaluation and how this should be done. If healthcare systems want to reduce their environment footprint, the development of methodology which integrates environmental dimensions in health technology assessment will be key.

[Prioritized utilisation and reprocessing of reusable equipment in anaesthesiology deparmtents : Recommendations on how to reduce CO2 emissions from anaesthetic equipment]

Currently, few robust data are available to provide estimates of the environmental footprint and in particular the CO₂ emissions of medical devices; however, existing life cycle assessments largely indicate that reusable materials have more favorable emissions and environmental footprints compared to disposable items. Thus, the challenge for every anesthesiology department is to identify items that can be used as reusable products for ecological and other reasons.A prerequisite for the use of reusable items is hygienically correct reprocessing and packaging. Here, a distinction must be made between noncritical, semicritical and critical medical devices, depending on the type of use. In addition, a distinction must be made between categories A-C, depending on the complexity of the reprocessing.In this narrative review article common reusable items used in anesthesiology are categorized and a standardized decision algorithm for reprocessing routes is proposed. Special attention is also given to the packaging of medical devices, which can contribute to the ecological footprint to a relevant extent.This article further explains the framework under which reprocessing can take place and analyzes the current state of knowledge on the life cycle assessment of reprocessing reusable devices.This requires the special commitment of clinically active anesthesiologists to include ecological aspects in the decision to use disposable or reusable items. In the medium term, comprehensible ecological key numbers should be provided on every medical device to make the ecological costs of the articles understandable in addition to the monetary costs.

Operation clean up: A model for eco-leadership and sustainability implementation

Healthcare contributes to environmental harm. Trainee-led Research and Audit in Anaesthesia for Sustainable Healthcare (TRA₂SH) is an Australasian network focused on sustainable anaesthesia practice. TRA₂SH hypothesised that trainee-led audits alongside education presented on a scheduled national day, called Operation Clean Up, can improve engagement with sustainability initiatives. This paper aims to describe the first two years of Operation Clean Up in terms of goals, achievements and data collected so far. Environmental themes for Operation Clean Up were chosen based on available evidence (life cycle analyses and observational studies). The first Operation Clean Up (OCU 2020) focused on reducing the unnecessary use of single-use disposable absorbent pads (known as 'blueys' in Australia, 'greenies' in New Zealand). OCU 2021 included: refuse desflurane, reduce bluey use, reuse drug trays, and recycle paper and cardboard. TRA₂SH provided an information pack to trainees who presented educational material to their department and fed back procurement figures to quantify each item. Descriptive statistics were used to analyse de-identified pooled data submitted to a centralised database.Eight departments submitted data for OCU 2020 and six provided follow-up data. Bluey use was reduced from a median of 37 to 34 blueys per ten surgical encounters. Fifteen departments submitted pre-campaign data for OCU 2021 with follow-up data to be collected during OCU 2022. Baseline data showed a median bluey use of 31 per ten surgical encounters. Volatile-related emissions were calculated; desflurane's proportion was 70% of these emissions yet was 11% of volatile procurement. Two participating departments removed desflurane from their formulary following OCU 2021. Operation Clean Up is a practical model for implementing sustainability initiatives using trainees as eco-leaders.

The impact of switching from single-use to reusable healthcare products: a transparency checklist and systematic review of life-cycle assessments

BACKGROUND

Replacing single-use products with reusable ones may reduce the environmental impact of healthcare. This study aimed to broadly assess the environmental effects of that substitution.

METHODS

A systematic review of comparative cradle-to-grave life-cycle assessments (LCAs) of single-use and reusable healthcare products was conducted. The main outcomes assessed were changes in the environmental impact that resulted after switching from single-use to reusable products. As no standardized transparency checklist was available, one was developed here using DIN ISO 14040/14044. The final checklist included 22 criteria used to appraise the included studies.

RESULTS

After screening, 27 studies were included in the analysis. The healthcare products were assigned to four categories: invasive medical devices, non-invasive medical devices, protection equipment and inhalers. The outcomes revealed a reduction in mean effect sizes for all environmental impacts except water use. Non-invasive medical devices have greater relative mitigation potential than invasive devices. On average, information on 64% of the transparency checklist items was reported. Gaps included the reporting of data quality requirements.

CONCLUSIONS

Switching to reusable healthcare products is likely to reduce most impacts on the environment except water use, but the effect size differs among product categories. Possible study limitations include location bias, no systematic search of the grey literature and small samples for some impacts. This study's strengths are its approach to product categories and developed transparency catalogue. This catalogue could be useful to inform and guide a future process towards creating a standardized transparency checklist for the systematic reviews of LCAs.

HealthcareLCA: an open-access living database of health-care environmental impact assessments

Anthropogenic environmental change negatively effects human health and is increasing health-care system demand. Paradoxically, the provision of health care, which itself is a substantial contributor to environmental degradation, is compounding this problem. There is increasing willingness to transition towards sustainable health-care systems globally and ensuring that strategy and action are informed by best available evidence is imperative. In this Personal View, we present an interactive, open-access database designed to support this effort. Functioning as a living repository of environmental impact assessments within health care, the HealthcareLCA database collates 152 studies, predominantly peer-reviewed journal articles, into one centralised and publicly accessible location, providing impact estimates (currently totalling 3671 numerical values) across 1288 health-care products and processes. The database brings together research generated over the past two decades and indicates exponential field growth.

Environmental impact of single-use, reusable, and mixed trocar systems used for laparoscopic cholecystectomies

Introduction

Climate change is one of the 21^st century’s biggest public health issues and health care contributes up to 10% of the emissions of greenhouse gases in developed countries. About 15 million laparoscopic procedures are performed annually worldwide and single-use medical equipment is increasingly used during these procedures. Little is known about costs and environmental footprint of this change in practice.

Methods

We employed Life Cycle Assessment method to evaluate and compare the environmental impacts of single-use, reusable, and mixed trocar systems used for laparoscopic cholecystectomies at three hospitals in southern Sweden. The environmental impacts were calculated using the IMPACT 2002+ method and a functional unit of 500 procedures. Monte Carlo simulations were used to estimate differences between trocar systems. Data are presented as medians and 2.5^th to 97.5^th percentiles. Financial costs were calculated using Life Cycle Costing.

Results

The single-use system had a 182% higher impact on resources than the reusable system [difference: 5160 MJ primary (4400–5770)]. The single-use system had a 379% higher impact on climate change than the reusable system [difference: 446 kg CO₂eq (413–483)]. The single-use system had an 83% higher impact than the reusable system on ecosystem quality [difference: 79 PDF*m²*yr (24–112)] and a 240% higher impact on human health [difference: 2.4x10^-4 DALY/person/yr (2.2x10^-4-2.6x10^-4)]. The mixed and single-use systems had a similar environmental impact. Differences between single-use and reusable trocars with regard to resource use and ecosystem quality were found to be sensitive to lower filling of machines in the sterilization process. For ecosystem quality the difference between the two were further sensitive to a 50% decrease in number of reuses, and to using a fossil fuel intensive electricity mix. Differences regarding effects on climate change and human health were robust in the sensitivity analyses. The reusable and mixed trocar systems were approximately half as expensive as the single-use systems (17360 € and 18560 € versus 37600 €, respectively).

Conclusion

In the Swedish healthcare system the reusable trocar system offers a robust opportunity to reduce both the environmental impact and financial costs for laparoscopic surgery.

The environmental impact of surgery: A systematic review

BACKGROUND

Climate change is a significant public health threat. Health care comprises 10% of greenhouse gas emissions in the United States, where surgery is especially resource intensive. We did a systematic review to assess and summarize the published evidence of the environmental impact of surgery.

METHODS

We searched Medline, Embase, Web of Science, and GreenFILE databases for publications that report any environmental impact measure by all surgical subspecialties, including anesthesia. Inclusion criteria were published in English, original research, and passed peer review. Because data were heterogeneous and the aim was broad, we conducted a qualitative summary of data. Where possible, we compare impact measures.

RESULTS

In the study, 167 articles were identified by our search strategy and reviewed, of which 55 studies met criteria. Eight were about anesthesia, 27 about operating room waste, and 6 were life cycle assessments. Other topics include carbon footprint and greenhouse gas emissions. Nine papers fell into 2 or more categories. Overall, the operating room is a significant source of emissions and waste. Using anesthetic gases with low global warming potential reduces operating room emissions without compromising patient safety. Operating room waste is often disposed of improperly, often due to convenience or knowledge gaps. There are environmental benefits to replacing disposable materials with reusable equivalents, and to proper recycling. Surgeons can help implement these changes at their institution.

CONCLUSION

Although there is a clear need to lower the carbon footprint of surgery, the quality of research with which to inform protocol changes is deficient overall. Our attempt to quantify surgery's carbon footprint yielded heterogeneous data and few standardized, actionable recommendations. However, this data serves as a starting point for important future initiatives to decrease the environmental impact of surgery.

Building sustainable and resilient surgical systems: A narrative review of opportunities to integrate climate change into national surgical planning in the Western Pacific region

Five billion people lack access to surgical care worldwide; climate change is the biggest threat to human health in the 21st century. This review studies how climate change could be integrated into national surgical planning in the Western Pacific region. We searched databases (PubMed, Web of Science, and Global Health) for articles on climate change and surgical care. Findings were categorised using the modified World Health Organisation Health System Building Blocks Framework. 220 out of 2577 records were included. Infrastructure: Operating theatres are highly resource-intensive. Their carbon footprint could be reduced by maximising equipment longevity, improving energy efficiency, and renewable energy use. Service delivery Tele-medicine, outreaches, and avoiding desflurane could reduce emissions. Robust surgical systems are required to adapt to the increasing burden of surgically treated diseases, such as injuries from natural disasters. Finance: Climate change adaptation funds could be mobilised for surgical system strengthening. Information systems: Sustainability should be a key performance indicator for surgical systems. Workforce: Surgical providers could change clinical, institutional, and societal practices. Governance: Planning in surgical care and climate change should be aligned. Climate change mitigation is essential in the regional surgical care scale-up; surgical system strengthening is also necessary for adaptation to climate change.

Ecoresponsible actions in operating rooms: A health ecological and economic evaluation

BACKGROUND

In the current context of climate change, actions must be taken to improve the hospital's ecological footprint, particularly in the operating room, which is a major consumer of medical devices.

METHODS

This prospective pilot study assessed the ecological and economic impacts of sustainable actions targeting medical devices designed by a multidisciplinary working group and implemented in the 24 operating rooms of a University Hospital over one year. The ecological analysis was based on the life cycle assessment method and categorized in seven impacts. The economic impact was assessed by a micro-costing analysis and divided in four main expense items: human and material resources, logistics, and waste management.

RESULTS

In total, 13 actions were implemented with the aim of reducing waste volume, improving waste sorting, and increasing eco-responsible purchases. In one year, these 13 actions allowed avoiding the emission of 203 tons eq CO₂. The environmental and human toxicity benefits were 707.8 and 156.2 tons of 1.4 dichlorobenzene, respectively. Concerning non-renewable resources, these actions avoided the extraction of 9 tons of oil (petroleum) and 610 kg of copper per year. These actions led to a land occupation reduction of 1071.3 m²year and to water saving of 552 m³. From the economic side, the implementation of these actions brought a gain of €3747.9 for the first year and of €5188.2 for the following years.

CONCLUSION

The integration of sustainable measures in operating rooms leads to important ecological benefits and also generating savings. This more eco-responsible approach should be considered in all healthcare establishments that generate a significant annual volume of waste.

Ecodesign approach for pharmaceutical packaging based on Life Cycle Assessment

Packaging ecodesign can contribute to improve the environmental performance of pharmaceutical products. The main goal of this article is to present an ecodesign approach based on Life Cycle Assessment (LCA) for pharmaceutical packaging, assessing opportunities to improve the packaging environmental performance, and providing ecodesign recommendations to the pharmaceutical sector. The proposed ecodesign approach consists of five phases. I) The most representative packaging of medicines in the market (blister, bottle, and sachet), with different sizes, materials and weights, were investigated. II) Three ecodesign strategies were selected to analyze with LCA: i) weight and/or volume reduction, ii) alternative types of packaging, and iii) transportation with less environmental impact. III-IV) A cradle-to-gate life cycle model has been implemented, including transport to pharmacies. Alternative transportation modes (truck, train, airplane, and ship) and different packaging production locations have been considered. Thirteen environmental categories have been analyzed. V) Ecodesign recommendations for improving the environmental performance of pharmaceutical packaging are presented in two stages: i) specific recommendations based on LCA, illustrated in sheets with examples of ecodesign, quantifying the environmental impact reduction of an ecodesign solution compared to the original; and ii) generic recommendations for different packaging life cycle phases. Ecodesign recommendations highlight the use of smaller-size packaging, avoiding superfluous elements and empty spaces, which reduces material and production costs, and transportation impacts; the selection of modes of transportation with less environmental impact, considering the packaging production location; and the use of electric vehicles for pharmacy distribution. This ecodesign approach based on LCA allows quantifying environmental impacts robustly to support the incorporation of environmental information from the design, material selection, and packaging production to distribution till the final consumer. This article emphasizes the importance of developing specific packaging ecodesign based on LCA to improve environmental performance and provide more informed recommendations to stakeholders.

Environmental impact and life cycle financial cost of hybrid (reusable/single-use) instruments versus single-use equivalents in laparoscopic cholecystectomy

BACKGROUND

Hybrid surgical instruments contain both single-use and reusable components, potentially bringing together advantages from both approaches. The environmental and financial costs of such instruments have not previously been evaluated.

METHODS

We used Life Cycle Assessment to evaluate the environmental impact of hybrid laparoscopic clip appliers, scissors, and ports used for a laparoscopic cholecystectomy, comparing these with single-use equivalents. We modelled this using SimaPro and ReCiPe midpoint and endpoint methods to determine 18 midpoint environmental impacts including the carbon footprint, and three aggregated endpoint impacts. We also conducted life cycle cost analysis of products, taking into account unit cost, decontamination, and disposal costs.

RESULTS

The environmental impact of using hybrid instruments for a laparoscopic cholecystectomy was lower than single-use equivalents across 17 midpoint environmental impacts, with mean average reductions of 60%. The carbon footprint of using hybrid versions of all three instruments was around one-quarter of single-use equivalents (1756 g vs 7194 g CO₂e per operation) and saved an estimated 1.13 e^-5 DALYs (disability adjusted life years, 74% reduction), 2.37 e^-8 species.year (loss of local species per year, 76% reduction), and US $ 0.6 in impact on resource depletion (78% reduction). Scenario modelling indicated that environmental performance of hybrid instruments was better even if there was low number of reuses of instruments, decontamination with separate packaging of certain instruments, decontamination using fossil-fuel-rich energy sources, or changing carbon intensity of instrument transportation. Total financial cost of using a combination of hybrid laparoscopic instruments was less than half that of single-use equivalents (GBP £131 vs £282).

CONCLUSION

Adoption of hybrid laparoscopic instruments could play an important role in meeting carbon reduction targets for surgery and also save money.

Reducing the Environmental Impact of Sterilization Packaging for Surgical Instruments in the Operating Room: A Comparative Life Cycle Assessment of Disposable versus Reusable Systems

The widespread use of single-use polypropylene packaging for sterilization of surgical instruments (blue wrap) results in enormous environmental pollution and plastic waste, estimated at 115 million kilograms on a yearly basis in the United States alone. Rigid sterilization containers (RSCs) are a well-known alternative in terms of quality and price. This paper deals with two research questions investigating the following aspects: (A) the environmental advantage of RCS for high volumes (5000 use cycles) in big hospitals, and (B) the environmental break-even point of use-cycles for small hospitals. An in-depth life cycle assessment was used to benchmark the two systems. As such a benchmark is influenced by the indicator system, three indicator systems were applied: (a) carbon footprint, (b) ReCiPe, and (c) eco-costs. The results are as follows: (1) the analyzed RSC has 85% less environmental impact in carbon footprint, 52% in ReCiPe, and 84.5% in eco-costs; and (2) an ecological advantage already occurs after 98, 228, and 67 out of 5000 use cycles, respectively. Given these two alternative packaging systems with comparable costs and quality, our results show that there are potentially large environmental gains to be made when RSC is preferred to blue wrap as a packaging system for sterile surgical instruments on a global scale.

Carbon Footprint of General, Regional, and Combined Anesthesia for Total Knee Replacements

BACKGROUND

Health care itself contributes to climate change. Anesthesia is a "carbon hotspot," yet few data exist to compare anesthetic choices. The authors examined the carbon dioxide equivalent emissions associated with general anesthesia, spinal anesthesia, and combined (general and spinal anesthesia) during a total knee replacement.

METHODS

A prospective life cycle assessment of 10 patients in each of three groups undergoing knee replacements was conducted in Melbourne, Australia. The authors collected input data for anesthetic items, gases, and drugs, and electricity for patient warming and anesthetic machine. Sevoflurane or propofol was used for general anesthesia. Life cycle assessment software was used to convert inputs to their carbon footprint (in kilogram carbon dioxide equivalent emissions), with modeled international comparisons.

RESULTS

Twenty-nine patients were studied. The carbon dioxide equivalent emissions for general anesthesia were an average 14.9 (95% CI, 9.7 to 22.5) kg carbon dioxide equivalent emissions; spinal anesthesia, 16.9 (95% CI, 13.2 to 20.5) kg carbon dioxide equivalent; and for combined anesthesia, 18.5 (95% CI, 12.5 to 27.3) kg carbon dioxide equivalent. Major sources of carbon dioxide equivalent emissions across all approaches were as follows: electricity for the patient air warmer (average at least 2.5 kg carbon dioxide equivalent [20% total]), single-use items, 3.6 (general anesthesia), 3.4 (spinal), and 4.3 (combined) kg carbon dioxide equivalent emissions, respectively (approximately 25% total). For the general anesthesia and combined groups, sevoflurane contributed an average 4.7 kg carbon dioxide equivalent (35% total) and 3.1 kg carbon dioxide equivalent (19%), respectively. For spinal and combined, washing and sterilizing reusable items contributed 4.5 kg carbon dioxide equivalent (29% total) and 4.1 kg carbon dioxide equivalent (24%) emissions, respectively. Oxygen use was important to the spinal anesthetic carbon footprint (2.8 kg carbon dioxide equivalent, 18%). Modeling showed that intercountry carbon dioxide equivalent emission variability was less than intragroup variability (minimum/maximum).

CONCLUSIONS

All anesthetic approaches had similar carbon footprints (desflurane and nitrous oxide were not used for general anesthesia). Rather than spinal being a default low carbon approach, several choices determine the final carbon footprint: using low-flow anesthesia/total intravenous anesthesia, reducing single-use plastics, reducing oxygen flows, and collaborating with engineers to augment energy efficiency/renewable electricity.

EDITOR’S PERSPECTIVE

Regulating Environmental Impact of Medical Devices in the United Kingdom—A Scoping Review

Medical devices are highly regulated to ensure safety and efficacy of the products and minimize the risk of harm to users and patients. However, the broader impacts of these devices on the environment have scarcely been questioned until recently. The United Kingdom National Health Service intends to achieve a “net zero” emissions service by 2040 and has identified specific targets to achieve through this process. However, medical device manufacturers do not see sufficient incentives to invest in reducing greenhouse gas emissions unless enforced by legislation. Furthermore, there is little evidence on the legislation required to reduce emissions from medical devices. This study addresses the relationship of medical device regulations and the environmental impact of the devices throughout their lifecycle. A scoping review was conducted on academic literature on the topic, followed by a critical review of the current medical device regulations and associated guidelines in the United Kingdom. The challenges to regulating environmental impact of medical devices were identified under seven themes. These challenges were contextualized with the National Health Service target of achieving zero emissions by 2040. The review indicates that current guidelines support single-use disposal of devices and equipment as the best approach to prevent pathogen transmission and landfilling and incineration are the most used waste management strategies. Manufacturers need to be guided and educated on reducing their emissions while ensuring the development of safe and effective devices.

Before/after intervention study to determine impact on life-cycle carbon footprint of converting from single-use to reusable sharps containers in 40 UK NHS trusts

OBJECTIVES

To compare global warming potential (GWP) of hospitals converting from single-use sharps containers to reusable sharps containers (SSC, RSC). Does conversion to RSC result in GWP reduction?

DESIGN

Using BS PAS 2050:2011 principles, a retrospective, before/after intervention quantitative model together with a purpose-designed, attributional 'cradle-to-grave' life-cycle tool, were used to determine the annual greenhouse gas (GHG) emissions of the two sharps containment systems. Functional unit was total fill line litres (FLL) of sharps containers needed to dispose of sharps for 1-year period in 40 trusts. Scopes 1, 2 and 3 emissions were included. Results were workload-normalised using National Health Service (NHS) national hospital patient-workload indicators. A sensitivity analysis examined areas of data variability.

SETTING

Acute care hospital trusts in UK.

PARTICIPANTS

40 NHS hospital Trusts using RSC.

INTERVENTION

Conversion from SSC to RSC. SSC and RSC usage details in 17 base line trusts immediately prior to 2018 were applied to the RSC usage details of the 40 trusts using RSC in 2019.

PRIMARY OUTCOME MEASURE

The comparison of GWP calculated in carbon dioxide equivalents (CO₂e) generated in the manufacture, transport, service and disposal of 12 months, hospital-wide usage of both containment systems in the 40 trusts.

RESULTS

The 40 trusts converting to RSC reduced their combined annual GWP by 3267.4 tonnes CO₂e (-83.9%); eliminated incineration of 900.8 tonnes of plastic; eliminated disposal/recycling of 132.5 tonnes of cardboard and reduced container exchanges by 61.1%. GHG as kg CO₂e/1000 FLL were 313.0 and 50.7 for SSC and RSC systems, respectively. A sensitivity analysis showed substantial GHG reductions within unit processes could be achieved, however, their impact on relevant final GWP comparison varied <5% from base comparison.

CONCLUSIONS

Adopting RSC is an example of a sustainable purchasing decision that can assist trusts meet NHS GHG reduction targets and can reduce GWP permanently with minimal staff behavioural change.

[New challenges for anesthesia due to the climate change]

BACKGROUND

The climate crisis is the most serious threat to global health in the twenty-first century. In western countries 5-10% of all greenhouse gas emissions originate from the healthcare sector and the main contributing factors are energy-intense departments (intensive care units, operating suits and prehospital emergency services).

OBJECTIVE

The aim of this review is to provide background knowledge and practical ideas to achieve climate-neutral hospitals.

MATERIAL AND METHODS

Narrative review with information on the topics of (I) volatile anesthetics as greenhouse gases, (II) energy supply in hospitals and (III) solid waste management.

RESULTS AND CONCLUSION

(I) Volatile anesthetics are highly potent greenhouse gases, especially desflurane has a major global warming potential. Total intravenous anesthesia (TIVA) with propofol or regional anesthetic techniques have a much lower impact on the climate. (II) Using sustainable energy sources as well as initiating energy sparing techniques, such as light-emitting diodes (LED) and motion sensors, can reduce CO₂ emissions. (III) Waste can be managed by the reduce, reuse, recycle, rethink and research concept. Doctors should actively contribute to reach the climate goals.

Operating in a Climate Crisis: A State-of-the-Science Review of Life Cycle Assessment within Surgical and Anesthetic Care

BACKGROUND

Both human health and the health systems we depend on are increasingly threatened by a range of environmental crises, including climate change. Paradoxically, health care provision is a significant driver of environmental pollution, with surgical and anesthetic services among the most resource-intensive components of the health system.

OBJECTIVES

This analysis aimed to summarize the state of life cycle assessment (LCA) practice as applied to surgical and anesthetic care via review of extant literature assessing environmental impacts of related services, procedures, equipment, and pharmaceuticals.

METHODS

A state-of-the-science review was undertaken following a registered protocol and a standardized, LCA-specific reporting framework. Three bibliographic databases (Scopus®, PubMed, and Embase®) and the gray literature were searched. Inclusion criteria were applied, eligible entries critically appraised, and key methodological data and results extracted.

RESULTS

From 1,316 identified records, 44 studies were eligible for inclusion. The annual climate impact of operating surgical suites ranged between 3,200,000 and 5,200,000 kg CO2e. The climate impact of individual surgical procedures varied considerably, with estimates ranging from 6 to 1,007 kg CO2e. Anesthetic gases; single-use equipment; and heating, ventilation, and air conditioning system operation were the main emissions hot spots identified among operating room- and procedure-specific analyses. Single-use equipment used in surgical settings was generally more harmful than equivalent reusable items across a range of environmental parameters. Life cycle inventories have been assembled and associated climate impacts calculated for three anesthetic gases (2-85 kg CO2e/MAC-h) and 20 injectable anesthetic drugs (0.01-3.0 kg CO2e/gAPI).

DISCUSSION

Despite the recent proliferation of surgical and anesthesiology-related LCAs, extant studies address a miniscule fraction of the numerous services, procedures, and products available today. Methodological heterogeneity, external validity, and a lack of background life cycle inventory data related to many essential surgical and anesthetic inputs are key limitations of the current evidence base. This review provides an indication of the spectrum of environmental impacts associated with surgical and anesthetic care at various scales. https://doi.org/10.1289/EHP8666.

Moving towards green anaesthesia: Are patient safety and environmentally friendly practices compatible? A focus on single-use devices

OBJECTIVE

Discuss if the use of disposable or reusable medical devices leads to a difference in terms of hospital-acquired infection or bacterial contamination. Determine which solution is less expensive and has less environmental impact in terms of carbon footprint, energy and water consumption and amount of waste.

METHODS

We carried out a narrative review. Articles published in English and French from January 2000 to April 2020 were identified from PubMed.

RESULTS

We retrieved 81 articles, including 12 randomised controlled trial, 21 literature reviews, 13 descriptive studies, 6 experimental studies, 9 life-cycle studies, 6 cohort studies, 2 meta-analysis, 4 case reports and 8 other studies. It appears that pathogen transmission in the anaesthesia work area is mainly due to the lack of hand hygiene among the anaesthesia team. The benefit of single-use devices on infectious risk is based on weak scientific arguments, while reusable devices have benefits in terms of costs, water consumption, energy consumption, waste, and reducing greenhouse gas emissions.

CONCLUSION

Disposable medical devices and attire in the operating theatre do not mitigate the infectious risk to the patients but have a greater environmental, financial and social impact than the reusable ones. This study is the first step towards recommendations for more environmental-friendly practices in the operating theatre.

Transforming The Medical Device Industry: Road Map To A Circular Economy

A circular economy involves maintaining manufactured products in circulation, distributing resource and environmental costs over time and with repeated use. In a linear supply chain, manufactured products are used once and discarded. In high-income nations, health care systems increasingly rely on linear supply chains composed of single-use disposable medical devices. This has resulted in increased health care expenditures and health care-generated waste and pollution, with associated public health damage. It has also caused the supply chain to be vulnerable to disruption and demand fluctuations. Transformation of the medical device industry to a more circular economy would advance the goal of providing increasingly complex care in a low-emissions future. Barriers to circularity include perceptions regarding infection prevention, behaviors of device consumers and manufacturers, and regulatory structures that encourage the proliferation of disposable medical devices. Complementary policy- and market-driven solutions are needed to encourage systemic transformation.

Environmental sustainability in anaesthesia and critical care

The detrimental health effects of climate change continue to increase. Although health systems respond to this disease burden, healthcare itself pollutes the atmosphere, land, and waterways. We surveyed the 'state of the art' environmental sustainability research in anaesthesia and critical care, addressing why it matters, what is known, and ideas for future work. Focus is placed upon the atmospheric chemistry of the anaesthetic gases, recent work clarifying their relative global warming potentials, and progress in waste anaesthetic gas treatment. Life cycle assessment (LCA; i.e. 'cradle to grave' analysis) is introduced as the definitive method used to compare and contrast ecological footprints of products, processes, and systems. The number of LCAs within medicine has gone from rare to an established body of knowledge in the past decade that can inform doctors of the relative ecological merits of different techniques. LCAs with practical outcomes are explored, such as the carbon footprint of reusable vs single-use anaesthetic devices (e.g. drug trays, laryngoscope blades, and handles), and the carbon footprint of treating an ICU patient with septic shock. Avoid, reduce, reuse, recycle, and reprocess are then explored. Moving beyond routine clinical care, the vital influences that the source of energy (renewables vs fossil fuels) and energy efficiency have in healthcare's ecological footprint are highlighted. Discussion of the integral roles of research translation, education, and advocacy in driving the perioperative and critical care environmental sustainability agenda completes this review.

The anesthesiologist and global climate change: an ethical obligation to act

PURPOSE OF REVIEW

Pollution and global warming/climate change contribute to one-quarter of all deaths worldwide. Global healthcare as a whole is the world's fifth largest emitter of greenhouse gases, and anesthetic gases, intravenous agents and supplies contribute significantly to the overall problem. It is the ethical obligation of all anesthesiologists to minimize the harmful impact of anesthesia practice on environmental sustainability.

RECENT FINDINGS

Focused programs encouraging judicious selection of the use of anesthetic gas agents has been shown to reduce CO2 equivalent emissions by 64%, with significant cost savings. Good gas flow management reduces nonscavenged anesthetic gas significantly, and has been shown to decrease the consumption of volatile anesthetic agent by about one-fifth. New devices may allow for recapture, reclamation and recycling of waste anesthetic gases. For propofol, a nonbiodegradable, environmentally toxic agent, simply changing the size of vials on formulary has been shown to reduce wasted agent by 90%.

SUMMARY

The 5 R's of waste minimization in the operating room (OR) (Reduce, Reuse, Recycle, Rethink and Research) have proven benefit in reducing the environmental impact of the practice of anesthesiology, as well as in reducing costs.

Why be sustainable? The Australian and New Zealand College of Anaesthetists Professional Document PS64: Statement on Environmental Sustainability in Anaesthesia and Pain Medicine Practice and its accompanying background paper

Healthcare’s environmental sustainability is increasingly an area of research and advocacy focus. The Australian and New Zealand College of Anaesthetists (ANZCA) has produced a professional document, PS64, Statement on Environmental Sustainability in Anaesthesia and Pain Medicine Practice, and a background paper, PS64 BP. The purpose of the statement is to affirm ANZCA’s commitment to environmental sustainability and support anaesthetists in promoting environmentally sustainable work practices. This article presents the main features of PS64 and its background paper, and the associated supporting evidence. The healthcare sector is highly interconnected with activities that emit pollution to air, water and soils, considerably adding to humanity’s collective ecological footprint. As anaesthetists, we are uniquely high-carbon doctors due to our work anaesthetising with greenhouse gases (particularly desflurane and nitrous oxide) and our exposure and contribution to large amounts of resource and energy use and waste generation in operating theatres. Discussion is made of the improving research base of anaesthetic life-cycle assessments—that is, cradle-to-grave studies of how much energy, water and so on a product or process requires throughout its entire life. Thereafter, reducing, reusing and recycling as well as water use are examined. Ongoing research efforts within environmentally sustainable anaesthesia are highlighted. Environmentally sustainable anaesthesia requires scholarship, health advocacy, leadership, communication and collaboration. The focus is placed on practical initiatives within PS64 and the background paper that can be achieved by all anaesthetists striving towards more sustainable healthcare practices that reduce waste, reap financial benefits and improve health.

Life cycle assessment as decision support tool for environmental management in hospitals: A literature review

BACKGROUND

Life cycle assessment (LCA) is an environmental accounting tool aimed at determining environmental impacts of products, processes, or organizational activities over the entire life cycle. Although this technique already provides decision-makers in other sectors with valuable information, its application in the health care setting has not yet been examined.

PURPOSE

The aim of this study was to provide a comprehensive overview of scientific research on the application of LCA in hospitals and its contribution to management decision-making.

METHOD

We perform a systematic literature review by searching a range of databases with synonyms of "LCA" in combination with the term "hospital" in order to identify peer-reviewed studies. The final sample of 43 studies were then subjected to a content analysis.

RESULTS

We categorize existing research and show that single and multi-indicator LCA approaches are used to examine several products and processes in hospitals. The various approaches are favored by different scientific communities. Whereas researchers from environmental sciences perform complex multi-indicator LCA studies, researchers from health care sciences focus on footprints. The studies compare alternatives and identify environmental impacts and harmful hotspots.

PRACTICE IMPLICATIONS

LCA results can support health care managers' traditional decision-making by providing environmental information. With this additional information regarding the environmental impacts of products and processes, managers can implement organizational changes to improve their environmental performance. Furthermore, they can influence upstream and downstream activities. However, we recommend more transdisciplinary cooperation for LCA studies and to place more focus on actionable recommendations when publishing the results.

Instilling a culture of cleaning: Effectiveness of decontamination practices on non-disposable sphygmomanometer cuffs

Background

Sphygmomanometers and their cuffs are non-critical items that can act as a fomite for transmission of pathogens which may cause healthcare-associated infection (HAI), leading to an argument that disposable equipment improves patient safety.

Aim

The aim of this study was to demonstrate that decontamination decreased in microbial contamination of non-disposable sphygmomanometer cuffs, providing evidence to negate the need to purchase, and dispose of, single-patient-use cuffs, reducing cost and environmental impact.

Methods

A pre-post intervention study of available sphygmomanometer cuffs and associated bedside patient monitors was conducted using a series of microbiological samples in a rural emergency department. A Wilcoxon signed-rank test analysed the effect of the decontamination intervention. To further examine the effect of the decontamination intervention, Mann-Whitney U-tests were conducted for each aspect.

Findings

Contamination was significantly higher before decontamination than afterwards (Z = -5.14, U = 55.0, P < 0.001, η2 = 0.61 inner; Z = -5.05, U = 53.5, P < 0.001, η2 = 0.59 outer).

Discussion

Decontamination of non-disposable sphygmomanometer cuffs decreases microbial load and risk of HAI, providing evidence to negate arguments for disposable cuffs while being environmentally sensitive and supportive of a culture of patient safety and infection control.

Life Cycle Assessment and Costing Methods for Device Procurement: Comparing Reusable and Single-Use Disposable Laryngoscopes

BACKGROUND

Traditional medical device procurement criteria include efficacy and safety, ease of use and handling, and procurement costs. However, little information is available about life cycle environmental impacts of the production, use, and disposal of medical devices, or about costs incurred after purchase. Reusable and disposable laryngoscopes are of current interest to anesthesiologists. Facing mounting pressure to quickly meet or exceed conflicting infection prevention guidelines and oversight body recommendations, many institutions may be electively switching to single-use disposable (SUD) rigid laryngoscopes or overcleaning reusables, potentially increasing both costs and waste generation. This study provides quantitative comparisons of environmental impacts and total cost of ownership among laryngoscope options, which can aid procurement decision making to benefit facilities and public health.

METHODS

We describe cradle-to-grave life cycle assessment (LCA) and life cycle costing (LCC) methods and apply these to reusable and SUD metal and plastic laryngoscope handles and tongue blade alternatives at Yale-New Haven Hospital (YNHH). The US Environmental Protection Agency's Tool for the Reduction and Assessment of Chemical and other environmental Impacts (TRACI) life cycle impact assessment method was used to model environmental impacts of greenhouse gases and other pollutant emissions.

RESULTS

The SUD plastic handle generates an estimated 16-18 times more life cycle carbon dioxide equivalents (CO2-eq) than traditional low-level disinfection of the reusable steel handle. The SUD plastic tongue blade generates an estimated 5-6 times more CO2-eq than the reusable steel blade treated with high-level disinfection. SUD metal components generated much higher emissions than all alternatives. Both the SUD handle and SUD blade increased life cycle costs compared to the various reusable cleaning scenarios at YNHH. When extrapolated over 1 year (60,000 intubations), estimated costs increased between $495,000 and $604,000 for SUD handles and between $180,000 and $265,000 for SUD blades, compared to reusables, depending on cleaning scenario and assuming 4000 (rated) uses. Considering device attrition, reusable handles would be more economical than SUDs if they last through 4-5 uses, and reusable blades 5-7 uses, before loss.

CONCLUSIONS

LCA and LCC are feasible methods to ease interpretation of environmental impacts and facility costs when weighing device procurement options. While management practices vary between institutions, all standard methods of cleaning were evaluated and sensitivity analyses performed so that results are widely applicable. For YNHH, the reusable options presented a considerable cost advantage, in addition to offering a better option environmentally. Avoiding overcleaning reusable laryngoscope handles and blades is desirable from an environmental perspective. Costs may vary between facilities, and LCC methodology demonstrates the importance of time-motion labor analysis when comparing reusable and disposable device options.

Financial and environmental costs of reusable and single-use anaesthetic equipment

BACKGROUND.

An innovative approach to choosing hospital equipment is to consider the environmental costs in addition to other costs and benefits.

METHODS.

We used life cycle assessment to model the environmental and financial costs of different scenarios of replacing reusable anaesthetic equipment with single-use variants. The primary environmental costs were CO 2 emissions (in CO 2 equivalents) and water use (in litres). We compared energy source mixes between Australia, the UK/Europe, and the USA.

RESULTS.

For an Australian hospital with six operating rooms, the annual financial cost of converting from single-use equipment to reusable anaesthetic equipment would be an AUD$32 033 (£19 220), 46% decrease. In Australia, converting from single-use to reusable equipment would result in an increase of CO 2 emissions from 5095 (95% CI: 4614-5658) to 5575 kg CO 2 eq (95% CI: 5542-5608), a 480 kg CO 2 eq (9%) increase. Using the UK/European power mix, converting from single-use (5575 kg CO 2 eq) to reusable anaesthetic equipment (802 kg CO 2 eq) would result in an 84% reduction (4873 kg CO 2 eq) in CO 2 emissions, whilst in the USA converting to reusables would have led to a 2427 kg CO 2 eq (48%) reduction. In Australia, converting from single-use to reusable equipment would more than double water use from 34.4 to 90.6 kilolitres.

CONCLUSIONS.

For an Australian hospital with six operating rooms, converting from single-use to reusable anaesthetic equipment saved more than AUD$30 000 (£18 000) per annum, but increased the CO 2 emissions by almost 10%. The CO 2 offset is highly dependent on the power source mix, while water consumption is greater for reusable equipment.

Steam sterilisation's energy and water footprint

Objective The aim of the present study was to quantify hospital steam steriliser resource consumption to provide baseline environmental data and identify possible efficiency gains. We sought to find the amount of steriliser electricity and water used for active cycles and for idling (standby), and the relationship between the electricity and water consumption and the mass and type of items sterilised. Methods We logged a hospital steam steriliser's electricity and water meters every 5min for up to 1 year. We obtained details of all active cycles (standard 134°C and accessory or 'test' cycles), recording item masses and types. Relationships were investigated for both the weight and type of items sterilised with electricity and water consumption. Results Over 304 days there were 2173 active cycles, including 1343 standard 134°C cycles that had an average load mass of 21.2kg, with 32% of cycles <15kg. Electricity used for active cycles was 32652kWh (60% of total), whereas the water used was 1243495L (79%). Standby used 21457kWh (40%) electricity and 329200L (21%) water. Total electricity and water consumption per mass sterilised was 1.9kWhkg-1 and 58Lkg-1, respectively. The linear regression model predicting electricity use was: kWh=15.7+ 0.14×mass (in kg; R2=0.58, P<0.01). Models for water and item type were poor. Electricity and water use fell from 3kWhkg-1 and 200Lkg-1, respectively, for 5-kg loads to 0.5kWhkg-1 and 20Lkg-1, respectively, for 40-kg loads. Conclusions Considerable electricity and water use occurred during standby, load mass was only moderately predictive of electricity consumption and light loads were common yet inefficient. The findings of the present study are a baseline for steam sterilisation's environmental footprint and identify areas to improve efficiencies. What is known about the topic? There is increasing interest in the environmental effects of healthcare. Life cycle assessment ('cradle to grave') provides a scientific method of analysing environmental effects. Although data of the effects of steam sterilisation are integral to the life cycles of reusable items and procedures using such items, there are few data available. Further, there is scant information regarding the efficiency of the long-term in-hospital use of sterilisers. What does this paper add? We quantified, for the first time, long-term electricity and water use of a hospital steam steriliser. We provide useful input data for future life cycle assessments of all reusable, steam-sterilised equipment. Further, we identified opportunities for improved steriliser efficiencies, including rotating off idle sterilisers and reducing the number of light steriliser loads. Finally, others could use our methods to examine steam sterilisers and many other energy-intensive items of hospital equipment. What are the implications for practitioners? We provide useful input data for all researchers examining the environmental footprint of reusable hospital equipment and procedures using such equipment. As a result of the present study, staff in the hospital sterile supply department have reduced steam steriliser electricity and water use considerably without impeding sterilisation throughput (and reduced time inefficiencies). Many other hospitals could benefit from similar methods to improve steam steriliser and other hospital equipment efficiencies.

The Environmental footprint of morphine: a life cycle assessment from opium poppy farming to the packaged drug

OBJECTIVE

To examine the environmental life cycle from poppy farming through to production of 100 mg in 100 mL of intravenous morphine (standard infusion bag).

DESIGN

'Cradle-to-grave' process-based life cycle assessment (observational).

SETTINGS

Australian opium poppy farms, and facilities for pelletising, manufacturing morphine, and sterilising and packaging bags of morphine.

MAIN OUTCOME MEASURES

The environmental effects (eg, CO₂ equivalent ('CO₂ e') emissions and water use) of producing 100 mg of morphine. All aspects of morphine production from poppy farming, pelletising, bulk morphine manufacture through to final formulation. Industry-sourced and inventory-sourced databases were used for most inputs.

RESULTS

Morphine sulfate (100 mg in 100 mL) had a climate change effect of 204 g CO₂ e (95% CI 189 to 280 g CO₂ e), approximating the CO₂ e emissions of driving an average car 1 km. Water use was 7.8 L (95% CI 6.7- to 9.0 L), primarily stemming from farming (6.7 L). All other environmental effects were minor and several orders of magnitude less than CO₂ e emissions and water use. Almost 90% of CO₂ e emissions occurred during the final stages of 100 mg of morphine manufacture. Morphine's packaging contributed 95 g CO₂ e, which accounted for 46% of the total CO₂ e (95% CI 82 to 155 g CO₂ e). Mixing, filling and sterilisation of 100 mg morphine bags added a further 86 g CO₂ e, which accounted for 42% (95% CI 80 to 92 g CO₂ e). Poppy farming (6 g CO₂ e, 3%), pelletising and manufacturing (18 g CO₂ e, 9%) made smaller contributions to CO₂ emissions.

CONCLUSIONS

The environmental effects of growing opium poppies and manufacturing bulk morphine were small. The final stages of morphine production, particularly sterilisation and packaging, contributed to almost 90% of morphine's carbon footprint. Focused measures to improve the energy efficiency and sources for drug sterilisation and packaging could be explored as these are relevant to all drugs. Comparisons of the environmental effects of the production of other drugs and between oral and intravenous preparations are required.

Is non-woven fabric a useful method of packaging instruments for operation theatres in resource constrained settings?

INTRODUCTION

Studies have highlighted the advantages and disadvantages of woven and non-woven fabrics. The present study assessed the change in resterilisation proportion after introduction of non-woven fabric for packaging of instruments and to evaluate the cost-effectiveness of non-woven fabrics compared with woven fabrics.

MATERIALS AND METHODS

The present study is a secondary data analysis of resterilisation data collected from November 2009 to August 2013. We calculated the proportions (and their 95% confidence intervals) of resterilisation done every month. The proportion over time was compared using a Chi-square test for trend. We used linear regression analysis to adjust for the number of surgeries performed every month. We also compared the cost of woven and non-woven fabrics.

RESULTS

Of the total 117,335 surgical packets prepared during the study period, 1900 were resterilised; thus, the overall proportion was 1.62% (95% CI: 1.55% to 1.69%). The resterilisation proportion was 8.95% (95% CI: 7.73% to 10.17%) in November 2009 and was 0.38% (95% CI: 0.16% to 0.62%) in August 2013 (P < 0.001). After adjusting for the total number of surgeries conducted every month, we found that the number of packets resterilised reduced every month (per month reduction: -1.97, 95% CI: -2.76 to -1.18). The total cost (initial preparation and resterilisation) for 100 units of woven fabric is INR 6359.41 per month (confidence limit estimates: 6228.20 to 6430.62) and for non-woven fabric was INR 6208.50 (confidence limit estimate: INR 6194.90 to 6223.35) (P < 0.01).

CONCLUSIONS

The introduction of non-woven spunbond-meltblown-spunbond fabrics did reduce the proportion of resterilisation of packaged instruments. The decline was sharp and sustained over time, even after accounting for the change in the number of procedures. Furthermore, though the switch from woven to non-woven fabric was cost-effective in our situation, it may not be directly translated to other scenarios.