The carbon footprint of a renal service in the United Kingdom

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.

Climate change and its impact on infectious diseases in Asia

ABSTRACT

Climate change, particularly increasing temperature, changes in rainfall, extreme weather events and changes in vector ecology, impacts the transmission of many climate-sensitive infectious diseases. Asia is the world's most populous, rapidly evolving and diverse continent, and it is already experiencing the effects of climate change. Climate change intersects with population, sociodemographic and geographical factors, amplifying the public health impact of infectious diseases and potentially widening existing disparities. In this narrative review, we outline the evidence of the impact of climate change on infectious diseases of importance in Asia, including vector-borne diseases, food- and water-borne diseases, antimicrobial resistance and other infectious diseases. We also highlight the imperative need for strategic intersectoral collaboration at the national and global levels and for the health sector to implement adaptation and mitigation measures, including responsibility for its own greenhouse gas emissions.

A carbon calculator: the development of a user-friendly greenhouse gas measuring tool for general dental practice (Part 2)

The need to reduce carbon emissions and limit global warming to 1.5 °C has spurred various sectors towards net-zero emission goals. This paper introduces a specialised carbon calculator for dental practices to compute and monitor their carbon footprints (CFPs). The carbon calculator is developed using recent carbon modelling, utilising methodologies and data from estimating the average NHS dental practice's CFP. It employs both spend-based and activity-based carbon accounting methods, simplifying carbon emission estimation. It offers dental practices a user-friendly, rudimentary, cost-free tool to determine their baseline CFP and track sustainability progress. It includes conversion factors for patient travel, procurement and waste management, enabling practices to input data and generate personalised CFP charts. It also acknowledges assumptions and uncertainties related to procurement and waste management, emphasising the availability of personalised consultancy services for more precise carbon footprinting. This carbon calculator supports environmental sustainability in dental practices as an accessible starting point. By raising awareness of their CFP, it encourages progress in 'green dentistry' and promotes environmental responsibility in oral healthcare. The calculator is freely downloadable and part of a broader 'green dentistry' initiative. Continuous carbon emission measurement and monitoring are crucial for a sustainable future, with this tool aiding dental practitioners in their environmental contributions.

Considerations for environmental sustainability in clinical radiology and radiotherapy practice: A systematic literature review and recommendations for a greener practice

INTRODUCTION

Environmental sustainability (ES) in healthcare is an important current challenge in the wider context of reducing the environmental impacts of human activity. Identifying key routes to making clinical radiology and radiotherapy (CRR) practice more environmentally sustainable will provide a framework for delivering greener clinical services. This study sought to explore and integrate current evidence regarding ES in CRR departments, to provide a comprehensive guide for greener practice, education, and research.

METHODS

A systematic literature search and review of studies of diverse evidence including qualitative, quantitative, and mixed methods approach was completed across six databases. The Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) guidelines and the Quality Assessment Tool for Studies with Diverse Designs (QATSDD) was used to assess the included studies. A result-based convergent data synthesis approach was employed to integrate the study findings.

RESULTS

A total of 162 articles were identified. After applying a predefined exclusion criterion, fourteen articles were eligible. Three themes emerged as potentially important areas of CRR practice that contribute to environmental footprint: energy consumption and data storage practices; usage of clinical consumables and waste management practices; and CRR activities related to staff and patient travel.

CONCLUSIONS

Key components of CRR practice that influence environmental impact were identified, which could serve as a framework for exploring greener practice interventions. Widening the scope of research, education and awareness is imperative to providing a holistic appreciation of the environmental burden of healthcare.

IMPLICATIONS FOR PRACTICE

Encouraging eco-friendly travelling options, leveraging artificial Intelligence (AI) and CRR specific policies to optimise utilisation of resources such as energy and radiopharmaceuticals are recommended for a greener practice.

Sustainable surgical practices: A comprehensive approach to reducing environmental impact

This paper presents a comprehensive overview of the environmental impact of surgical procedures and highlights potential strategies to reduce the associated greenhouse gas emissions. We discuss procurement, waste management, and energy consumption, providing examples of successful interventions in each area. We also emphasize the importance of adopting the Green Theatre Checklist as a useful tool for clinicians aiming to implement sustainable surgical practices.

Identifying Environmental Impact Factors for Sustainable Healthcare: A Scoping Review

The healthcare industry has a substantial impact on the environment through its use of resources, waste generation and pollution. To manage and reduce its impact, it is essential to measure the pressures of healthcare activities on the environment. However, research on factors that can support these measurement activities is unbalanced and scattered. In order to address this issue, a scoping review was conducted with the aims of (i) identifying and organizing factors that have been used to measure environmental impact in healthcare practice and (ii) analyzing the overview of impact factors in order to identify research gaps. The review identified 46 eligible articles publishing 360 impact factors from original research in PubMed and EBSCO databases. These factors related to a variety of healthcare settings, including mental healthcare, renal service, primary healthcare, hospitals and national healthcare. Environmental impacts of healthcare were characterized by a variety of factors based on three key dimensions: the healthcare setting involved, the measurement component or scope, and the type of environmental pressure. The Healthcare Environmental Impact Factor (HEIF) scheme resulting from this study can be used as a tool for selecting measurable indicators to be applied in quality management and as a starting point for further research. Future studies could focus on standardizing impact factors to allow for cross-organization comparisons and on expanding the HEIF scheme by addressing gaps.

The Environmental Impact of Spine Surgery and the Path to Sustainability

STUDY DESIGN

Narrative literature review.

OBJECTIVE

The aim of this study was to review published literature discussing sustainable health care and to identify aspects that pertain to spine surgery.

SUMMARY OF BACKGROUND DATA

In recent years, research has investigated the contribution of surgical specialties to climate change. To our knowledge, no article has yet been published discussing the impact specific to spinal procedures and possible mitigation strategies.

METHODS

A literature search was performed for the present study on relevant terms across four electronic databases. References of included studies were also investigated.

RESULTS

Spine surgery has a growing environmental impact. Investigations of analogous specialties find that procurement is the single largest source of emissions. Carbon-conscious procurement strategies will be needed to mitigate this fully, but clinicians can best reduce their impact by adopting a minimalist approach when using surgical items. Reduced wastage of disposable goods and increased recycling are beneficial. Technology can aid remote access to clinicians, and also enable patient education.

CONCLUSIONS

Spine-surgery-specific research is warranted to evaluate its carbon footprint. A broad range of measures is recommended from preventative medicine to preoperative, intraoperative, and postoperative spine care.

LEVEL OF EVIDENCE

5.

Climate and the Nephrologist: The Intersection of Climate Change, Kidney Disease, and Clinical Care

Climate change is upon us, and it will have a major effect on both kidney disease and the nephrology practice. But the converse is also true: our treatment of kidney disease has an effect on the climate. Much attention has focused on how rising temperatures can lead to acute and CKD and health exacerbations in patients with established kidney disease. Climate change is also associated with rising air pollution from wildfires and industrial wastes and infectious diseases associated with flooding and changing habitats, all of which heighten the risk of acute and CKD. Less well recognized or understood are the ways nephrology practices, in turn, contribute to still more climate change. Hemodialysis, although lifesaving, can be associated with marked water usage (up to 600 L per dialysis session), energy usage (with one 4-hour session averaging as much as one fifth of the total energy consumed by a household per day), and large clinical wastes (with hemodialysis accounting for one third of total clinical medicine-associated waste). Of note, >90% of dialysis occurs in highly affluent countries, whereas dialysis is much less available in the poorer countries where climate change is having the highest effect on kidney disease. We conclude that not only do nephrologists need to prepare for the rise in climate-associated kidney disease, they must also urgently develop more climate-friendly methods of managing patients with kidney disease.

COVID-19 measures as an opportunity to reduce the environmental footprint in orthopaedic and trauma surgery

Background

Climate change and its consequences on our everyday life have also tremendous impacts on public health and the health of each individual. The healthcare sector currently accounts for 4.4% of global greenhouse gas emissions. The share of the emissions in the health care system caused by the transportation sector is 7%. The study analyses the effect of video consultation on the CO₂ emissions during the Covid-19 pandemic in an outpatient clinic of the department of orthopaedics and traumatology surgery at a German university hospital.

Methods

The study participants were patients who obtained a video consultation in the period from June to December 2020 and voluntarily completed a questionnaire after the consultation. The type of transport, travel time and waiting time as well as patient satisfaction were recorded by questionnaire.

Results

The study comprised 51 consultations. About 70% of respondents would have travelled to the clinic by car. The reduction in greenhouse gas emissions of video consultations compared to a face-to-face presentation was 97% in our model investigation.

Conclusion

The video consultation can be a very important part of the reduction of greenhouse gas emissions in the health care system. It also saves time for the doctor and patient and can form an essential part of individual patient care.

Application of job shop scheduling approach in green patient flow optimization using a hybrid swarm intelligence

With the increasing demand for hospital services amidst the COVID-19 pandemic, allocation of limited public resources and management of healthcare services are of paramount importance. In the field of patient flow scheduling, previous research primarily focused on classical-based objective functions, while ignoring environmental-based objective functions. This study presents a flexible job shop scheduling problem to optimize patient flow and, thereby, minimize the total carbon footprint, as the sustainability-based objective function. Since flexible job shop scheduling is an NP-hard problem, a metaheuristic optimization algorithm, called Chaotic Salp Swarm Algorithm Enhanced with Opposition-Based Learning and Sine Cosine (CSSAOS), was developed. The proposed algorithm integrates the Salp Swarm Algorithm (SSA) with chaotic maps to update the position of followers, the sine cosine algorithm to update the leader position, and opposition-based learning for a better exploration of the search space. generating more accurate solutions. The proposed method was successfully applied in a real-world case study and demonstrated better performance than other well-known metaheuristic algorithms, including differential evolution, genetic algorithm, grasshopper optimization algorithm, SSA based on opposition-based learning, quantum evolutionary SSA, and whale optimization algorithm. In addition, it was found that the proposed method is scalable to different sizes and complexities.

Redesigning Kidney Care for the Anthropocene: A New Framework for Planetary Health in Nephrology

Climate change is one of the greatest threats to human health in the 21st century. The human health impacts of climate change contribute to approximately 1 in 4 deaths worldwide. Health care itself is responsible for approximately 5% of annual global greenhouse gas (GHG) emissions. Canada is a recent signatory of the 26th United Nations Climate Change Conference (COP26) health agreement that is committed to developing low carbon and climate resilient health systems. Kidney care services have a substantial environmental impact and there is opportunity for the kidney care community to climate align clinical care. We introduce a framework of redesigned kidney care and describe examples of low carbon kidney disease management strategies to expand our duty of care to the environment which completes the triple bottom line of optimal patient outcomes and cost effectiveness in the Anthropocene.

Renal health benefits of sustainable diets in Japan: a review

Global warming may reduce food production and force people to adopt dietary habits of inadequate quantity or quality. Such dietary habits could trigger chronic kidney disease through inappropriate nutrition or lifestyle diseases. Livestock farming and other types of food production are responsible for many greenhouse gases. These problems are being emphasized as a diet-environment-health trilemma to be addressed on a global scale, with various methods being proposed toward its resolution. Diets like plant-based and low-protein diets not only potentially prevent the progression of chronic kidney disease, but are also rational from an environmental preservation perspective. Evidence from Japan on resolutions for this trilemma is sparse, but one concrete proposal is the use of traditional Japanese diets like washoku, the Okinawa diet, and the traditional Buddhist diet. However, traditional Japanese diets also have several problems, such as excessive salt content and caloric deficiencies, and need to be modified and incorporated into the current lifestyle. The progression of chronic kidney disease needs to be prevented with appropriate dietary treatment and environmental friendly manner.

Carbon footprint modelling of national health systems: Opportunities, challenges and recommendations

Health care presents significant contributions towards climate change. An awareness of a health systems carbon footprint provides a quantification of its environmental impact, an understanding of carbon intensive areas to target with reduction measures and a means of mapping trends in emissions over time. Attempts at calculating the carbon footprint of national health systems are few, predominantly of developed nations, and are limited by data availability and methodological inadequacies. There is a need to mobilise countries to understand the role of health care in contributing towards climate change and for them to start engaging in ongoing calculations of their national health system carbon footprints. There is also a need to improve data availability and information systems to allow for such calculations, especially in developing countries where there may be differences in carbon hotspots. Finally, there is a need for continued improvements in the carbon footprint modelling methodology of health systems as data collection and available emission factors, especially of health care specific products and supply chain emissions, improves. Health systems need to join the global fight against climate change.

Climate change is a significant threat to global health.

Health systems contribute to climate change.

Carbon footprint modelling allows focused decarbonisation of health systems.

Improvements in health care data collection for carbon modelling is needed.

Analyzing the Carbon Footprint of an Intravitreal Injection

Purpose

To estimate the carbon footprint of a single intravitreal injection in a hospital-based intravitreal service.

Methods

Greenhouse gas emissions attributable to the delivery of an intravitreal injection were calculated using a hybrid lifecycle analysis technique. Data were collected regarding procurement of materials, patient travel, and building energy use.

Results

Carbon emissions associated with a single intravitreal injection, excluding the anti-VEGF agent, were 13.68 kg CO2eq. This equates to 82,100 kg CO2eq annually for our service. Patient travel accounted for the majority of emissions at 77%, with procurement accounting 19% for and building energy usage for 4% of total emissions. The omission of items considered dispensable from injection packs would reduce carbon emissions by an estimated 0.56 kg per injection – an annual saving of 3,360 kg CO2eq for our service. Similar savings, if extrapolated to a country the size of the United Kingdom, could yield annual carbon savings of 450,000 kg CO2eq. For context, a single one-way economy transatlantic flight produces 480 kg CO2eq per person.

Conclusion

Wasteful practice in healthcare increases greenhouse gas production and drives climate change. The healthcare sector should be a leader in sustainable practice promotion and changes to high volume procedures have the largest impact on emissions. Long-acting agents offer the greatest future potential for meaningful reductions.

Sustainability in dialysis therapy: Japanese local and global challenge

Human-induced climate change is considered the greatest health threat of the 21st century. The health effects of climate change are becoming increasingly apparent, and there is substantial evidence indicating increased risk of kidney injury due to heat illness and other climate change-related meteorological abnormalities. On the other hand, healthcare itself is responsible for environmental burdens and has been estimated to generate between 3 and 10% of total national CO2 equivalent emissions. Dialysis has been estimated as one of the major contributors to healthcare’s carbon footprint. Especially in Australia and the UK, nations that have high awareness regarding environmental research, “Green Nephrology” has emerged as a new discipline. From both of these countries, a series of papers have been produced outlining the carbon footprint of hemodialysis, the results of surveys of specialists’ awareness of environmental issues, and proposals for how to save resources in dialysis therapy. Following on from this, several national and international nephrology societies have committed themselves to a range of initiatives aiming at “greening” the kidney sector. In Japan, where water and electricity supplies currently are stable, we occasionally are reminded of the potential for shortages of water and energy and of waste disposal problems. These issues particularly come to the fore in times of disasters, when hemodialysis patients need to be evacuated to distant dialysis facilities. Irrespective of the current state of resource availability, however, continuous efforts and the establishment of resource-saving procedures as a part of Japanese culture are highly desirable and would contribute to environmentally friendly healthcare. Japan needs to build awareness of these issues before the country faces a catastrophic situation of resource shortages. This review is intended as a call to action regarding environmental sustainability in kidney healthcare in Japan and the world.

Assessment of environmental sustainability in renal healthcare

The health effects of climate change are becoming increasingly important; there are direct effects from heatwaves and floods, and indirect effects from the altered distribution of infectious diseases and changes in crop yield. Ironically, the healthcare system itself carries an environmental burden, contributing to environmental health impacts. Life cycle assessment is a widely accepted and well-established method that quantitatively evaluates environmental impact. Given that monetary evaluations have the potential to motivate private companies and societies to reduce greenhouse gas emissions using market mechanisms, instead of assessing the carbon footprint alone, we previously developed a life cycle impact assessment method based on an endpoint that integrates comprehensive environmental burdens into a single index-the monetary cost. Previous investigations estimated that therapy for chronic kidney disease had a significant carbon footprint in the healthcare sector. We have been aiming to investigate on the environmental impact of chronic kidney disease based on field surveys from the renal department in a hospital and several health clinics in Japan. To live sustainably, it is necessary to establish cultures, practices, and research that aims to conserve resources to provide environmentally friendly healthcare in Japan.

Carbon footprint reduction associated with a surgical outreach clinic

BACKGROUND

Healthcare systems generate substantial carbon footprints that may be targeted to decrease greenhouse gas emissions. Outreach clinics may represent tools to assist in this reduction by optimizing patient related travel. Therefore, we sought to estimate the carbon footprint savings associated with a head and neck surgery outreach clinic.

METHODS

This study was a cross-sectional survey of patient travel patterns to a surgical outreach clinic compared to a regional cancer treatment centre from December 2019 to February 2020. Participants completed a self-administered survey of 12 items eliciting travel distance, vehicle details, and ability to combine medical appointments. Canadian datasets of manufacturer provided vehicular efficiency were used to estimate carbon emissions for each participant. Geographic information systems were used for analyses.

RESULTS

One hundred thirteen patients were included for analysis. The majority of patients (85.8%) used their own personal vehicle to travel to the outreach clinic. The median distance to the clinic and regional centre were 29.0 km (IQR 6.0-51.9) and 327.0 km (IQR 309.0-337.0) respectively. The mean carbon emission reduction per person was therefore 117,495.4 g (SD: 29,040.0) to 143,570.9 g (SD: 40,236.0). This represents up to 2.5% of an average individual's yearly carbon footprint. Fewer than 10% of patients indicated they were able to carpool or group their appointments.

CONCLUSION

Surgical outreach clinics decrease carbon footprints associated with patient travel compared to continued care at a regional centre. Further research is needed to determine possible interventions to further reduce carbon emissions associated with the surgical care of patients.

Carbon footprint of a hemodialysis unit in Morocco

Climate changes have a major influence on the overall health of the population. They are directly linked to the emissions of the greenhouse gases (GHG). The extent of GHG emission in relation to hemodialysis has been measured by several studies all over the world. Up to this date, no similar study has been conducted in Morocco. Therefore, the objective of our study is to conduct a review of the GHG emissions and to evaluate its specificities in order to establish a targeted action plan to reduce the ecological impact of hemodialysis in Morocco. To do this, we sought the help of a certified audit firm. Carbon Footprint tool (L'outil Bilan Carbon), established in Morocco in collaboration with Mohammed VI Foundation for the Protection of the Environment, was used to analyze the results collected for the year 2019. Our unit (conventional hemodialysis 3 × 4 hours, 424 m² , 24 generators, 80 patients, and 29 nursing staff) generates 408.98 tonnes of CO₂ equivalent per year (t CO₂-eq per year) or 5.11 TeqCO₂ per patient per year. The largest contributors to GHG emissions are electrical energy consumption (28%), equipment purchase and services (27%), and staff and patients travel (22%). The use of renewable energy for the operation of hemodialysis centers can be a realistic solution to reduce the ecological impact of this type of healthcare in Morocco.

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.

Life cycle environmental emissions and health damages from the Canadian healthcare system: An economic-environmental-epidemiological analysis

BACKGROUND

Human health is dependent upon environmental health. Air pollution is a leading cause of morbidity and mortality globally, and climate change has been identified as the single greatest public health threat of the 21st century. As a large, resource-intensive sector of the Canadian economy, healthcare itself contributes to pollutant emissions, both directly from facility and vehicle emissions and indirectly through the purchase of emissions-intensive goods and services. Together these are termed life cycle emissions. Here, we estimate the extent of healthcare-associated life cycle emissions as well as the public health damages they cause.

METHODS AND FINDINGS

We use a linked economic-environmental-epidemiological modeling framework to quantify pollutant emissions and their implications for public health, based on Canadian national healthcare expenditures over the period 2009-2015. Expenditures gathered by the Canadian Institute for Health Information (CIHI) are matched to sectors in a national environmentally extended input-output (EEIO) model to estimate emissions of greenhouse gases (GHGs) and >300 other pollutants. Damages to human health are then calculated using the IMPACT2002+ life cycle impact assessment model, considering uncertainty in the damage factors used. On a life cycle basis, Canada's healthcare system was responsible for 33 million tonnes of carbon dioxide equivalents (CO2e), or 4.6% of the national total, as well as >200,000 tonnes of other pollutants. We link these emissions to a median estimate of 23,000 disability-adjusted life years (DALYs) lost annually from direct exposures to hazardous pollutants and from environmental changes caused by pollution, with an uncertainty range of 4,500-610,000 DALYs lost annually. A limitation of this national-level study is the use of aggregated data and multiple modeling steps to link healthcare expenditures to emissions to health damages. While informative on a national level, the applicability of these findings to guide decision-making at individual institutions is limited. Uncertainties related to national economic and environmental accounts, model representativeness, and classification of healthcare expenditures are discussed.

CONCLUSIONS

Our results for GHG emissions corroborate similar estimates for the United Kingdom, Australia, and the United States, with emissions from hospitals and pharmaceuticals being the most significant expenditure categories. Non-GHG emissions are responsible for the majority of health damages, predominantly related to particulate matter (PM). This work can guide efforts by Canadian healthcare professionals toward more sustainable practices.

The impact of surgery on global climate: a carbon footprinting study of operating theatres in three health systems

BACKGROUND

Climate change is a major global public health priority. The delivery of health-care services generates considerable greenhouse gas emissions. Operating theatres are a resource-intensive subsector of health care, with high energy demands, consumable throughput, and waste volumes. The environmental impacts of these activities are generally accepted as necessary for the provision of quality care, but have not been examined in detail. In this study, we estimate the carbon footprint of operating theatres in hospitals in three health systems.

METHODS

Surgical suites at three academic quaternary-care hospitals were studied over a 1-year period in Canada (Vancouver General Hospital, VGH), the USA (University of Minnesota Medical Center, UMMC), and the UK (John Radcliffe Hospital, JRH). Greenhouse gas emissions were estimated using primary activity data and applicable emissions factors, and reported according to the Greenhouse Gas Protocol.

FINDINGS

Site greenhouse gas evaluations were done between Jan 1 and Dec 31, 2011. The surgical suites studied were found to have annual carbon footprints of 5 187 936 kg of CO₂ equivalents (CO₂e) at JRH, 4 181 864 kg of CO₂e at UMMC, and 3 218 907 kg of CO₂e at VGH. On a per unit area basis, JRH had the lowest carbon intensity at 1702 kg CO₂e/m², compared with 1951 kg CO₂e/m² at VGH and 2284 kg CO₂e/m² at UMMC. Based on case volumes at all three sites, VGH had the lowest carbon intensity per operation at 146 kg CO₂e per case compared with 173 kg CO₂e per case at JRH and 232 kg CO₂e per case at UMMC. Anaesthetic gases and energy consumption were the largest sources of greenhouse gas emissions. Preferential use of desflurane resulted in a ten-fold difference in anaesthetic gas emissions between hospitals. Theatres were found to be three to six times more energy-intense than the hospital as a whole, primarily due to heating, ventilation, and air conditioning requirements. Overall, the carbon footprint of surgery in the three countries studied is estimated to be 9·7 million tonnes of CO₂e per year.

INTERPRETATION

Operating theatres are an appreciable source of greenhouse gas emissions. Emissions reduction strategies including avoidance of desflurane and occupancy-based ventilation have the potential to lessen the climate impact of surgical services without compromising patient safety.

FUNDING

None.

INCORPORATING ENVIRONMENTAL OUTCOMES INTO A HEALTH ECONOMIC MODEL

OBJECTIVES

Traditional economic evaluations for most health technology assessments (HTAs) have previously not included environmental outcomes. With the growing interest in reducing the environmental impact of human activities, the need to consider how to include environmental outcomes into HTAs has increased. We present a simple method of doing so.

METHODS

We adapted an existing clinical-economic model to include environmental outcomes (carbon dioxide [CO2] emissions) to predict the consequences of adding insulin to an oral antidiabetic (OAD) regimen for patients with type 2 diabetes mellitus (T2DM) over 30 years, from the United Kingdom payer perspective. Epidemiological, efficacy, healthcare costs, utility, and carbon emissions data were derived from published literature. A scenario analysis was performed to explore the impact of parameter uncertainty.

RESULTS

The addition of insulin to an OAD regimen increases costs by 2,668 British pounds per patient and is associated with 0.36 additional quality-adjusted life-years per patient. The insulin-OAD combination regimen generates more treatment and disease management-related CO2 emissions per patient (1,686 kg) than the OAD-only regimen (310 kg), but generates fewer emissions associated with treating complications (3,019 kg versus 3,337 kg). Overall, adding insulin to OAD therapy generates an extra 1,057 kg of CO2 emissions per patient over 30 years.

CONCLUSIONS

The model offers a simple approach for incorporating environmental outcomes into health economic analyses, to support a decision-maker's objective of reducing the environmental impact of health care. Further work is required to improve the accuracy of the approach; in particular, the generation of resource-specific environmental impacts.

The carbon footprints of home and in-center peritoneal dialysis in China

OBJECTIVE

The provision of healthcare itself is associated with abundant greenhouse gas (GHG) emissions. This study aims to determine the carbon footprints of peritoneal dialysis (PD) with the different modalities and treatment regimes.

METHODS

A total of 68 subjects performed with PD treatment were enrolled in this study. Emissions factors were applied to data that were collected for energy consumption, travel, and procurement.

RESULTS

The carbon footprints generated by the provision of PD treatment for the individual patient were calculated and normalized to a 2-l PD dialysate volume. The fixed emissions were higher in patients who received PD therapy in center than at home, mostly attributing to the consumption of electricity. Conversely, PD treatment performed in center yielded less variable emissions than that of at home, which resulted from reduced constituent percentage of waste disposal and transportation. Collectively, packaging consumption mostly contributed to the total carbon footprints of PD.

CONCLUSION

This study for the first time demonstrates the delivery of PD is associated with considerable GHG emissions, which is mainly attributed to packaging materials, transportation, electricity, and waste disposal. These results suggest that carbon reduction strategies focusing on packaging consumption in PD treatment are likely to yield the greatest benefits.

Evaluating sustainability: a retrospective cohort analysis of the Oxfordshire therapeutic community

BACKGROUND

Therapeutic communities (TCs) could reduce the health care use of people with personality disorder (Davies S, Campling P and Ryan K, Psychiatrist 23:79-83, 1999; Barr W, Kirkcaldy A, Horne A, Hodge S, Hellin K and Göpfert M, J Ment Health 19:412-421, 2010) and in turn reduce the financial and environmental costs of services. Our hypothesis is that 3 years following entry to a TC service, patients have reduced subsequent health care use and associated reductions in financial costs and carbon footprint.

METHODS

A retrospective 4-year cohort study examined changes in health care use following entry to the Oxfordshire TC service. Comparative analysis was undertaken on a treated (n = 40) and a control group (referred but who declined treatment; n = 45). Financial costs and carbon footprint of health care use were calculated using national tariffs and standard carbon conversion factors. Mean changes in these outcomes were compared over 1, 2 and 3 years and adjusted for costs and carbon footprints in the year prior to joining the TC service.

RESULTS

Compared to baseline, the group receiving TC care had greater reductions in financial costs and carbon footprint associated with A&E attendances (p = 0.04) and crisis mental health appointments (p = 0.04) than the control group. There were significantly greater reductions in carbon footprint for all secondary health care use, both physical and mental health care, after 3 years (p = 0.04) in the TC group.

CONCLUSIONS

TC services may have the potential to reduce the financial cost and carbon footprint of health care.

Development of certified environmental management in hospital and outpatient haemodialysis units

INTRODUCTION

The environmental impact of haemodialysis is very high. Institutional activity in this sense is important, even in the production of references. Voluntary environmental management systems (EMS), environmental management and auditing systems (EMAS) and the International Organization for Standardization standards (ISO 14001) are important tools for environmental protection, together with legislation, taxation and tax benefits.

OBJECTIVES

To determine the degree of implementation of EMS in hospital units and outpatient haemodialysis in the Spanish National Health System to provide a group of reference centres in environmental management in this healthcare activity.

METHODS

Development of a list by autonomous communities showing hospital and outpatient dialysis units using an EMAS and/or ISO 14001 in 2012-2013. The sources of information were the Spanish National Catalogue of Hospitals, Spanish Registry of Healthcare Certification and Accreditation, European and regional EMAS records, world ISO registrations, dialysis centre lists from scientific societies and patients, responses from accredited entities in Spain for environmental certification and the institutional website of each haemodialysis centre identified.

RESULTS

Of the 210 hospitals with a dialysis unit, 53 (25%) have the ISO 14001 and 15 of these also have an EMAS). This constitutes 30% of all hospital dialysis chairs in Spain: 1,291 (of 4,298). Only 11 outpatient clinics are recorded, all with the ISO 14001.

DISCUSSION

There is no official documentation of the implementation of EMS in dialysis units. Making this list provides an approach to the situation, with special reference to haemodialysis because of its significant environmental impact.

The carbon footprint of acute care: how energy intensive is critical care?

OBJECTIVES

Climate change has the potential to threaten human health and the environment. Managers in healthcare systems face significant challenges to balance carbon mitigation targets with operational decisions about patient care. Critical care units are major users of energy and hence more evidence is needed on their carbon footprint.

STUDY DESIGN

The authors explore a methodology which estimates electricity use and associated carbon emissions within a Critical Care Unit (CCU).

METHODS

A bottom-up model was developed and calibrated which predicted the electricity consumed and carbon emissions within a CCU based on the type of patients treated and working practices in a case study in Cornwall, UK.

RESULTS

The model developed was able to predict the electricity consumed within CCU with an error of 1% when measured against actual meter readings. Just under half the electricity within CCU was used for delivering care to patients and monitoring their condition.

CONCLUSIONS

A model was developed which accurately predicted the electricity consumed within a CCU based on patient types, medical devices used and working practice. The model could be adapted to enable it to be used within hospitals as part of their planning to meet carbon reduction targets.

The carbon footprint of cataract surgery

BACKGROUND

Climate change is predicted to be one of the largest global health threats of the 21st century. Health care itself is a large contributor to carbon emissions. Determining the carbon footprint of specific health care activities such as cataract surgery allows the assessment of associated emissions and identifies opportunities for reduction.

AIM

To assess the carbon footprint of a cataract pathway in a British teaching hospital.

METHODS

This was a component analysis study for one patient having first eye cataract surgery in the University Hospital of Wales, Cardiff. Activity data was collected from three sectors, building and energy use, travel and procurement. Published emissions factors were applied to this data to provide figures in carbon dioxide equivalents (CO2eq).

RESULTS

The carbon footprint for one cataract operation was 181.8 kg CO2eq. On the basis that 2230 patients were treated for cataracts during 2011 in Cardiff, this has an associated carbon footprint of 405.4 tonnes CO2eq. Building and energy use was estimated to account for 36.1% of overall emissions, travel 10.1% and procurement 53.8%, with medical equipment accounting for the most emissions at 32.6%.

CONCLUSIONS

This is the first published carbon footprint of cataract surgery and acts as a benchmark for other studies as well as identifying areas for emissions reduction. Within the procurement sector, dialogue with industry is important to reduce the overall carbon footprint. Sustainability should be considered when cataract pathways are designed as there is potential for reduction in all sectors with the possible side effects of saving costs and improving patient care.

Mainstreaming carbon management in healthcare systems: a bottom-up modeling approach

Increasing greenhouse gas emissions threaten human health and the environment. In response, healthcare managers face significant challenges in balancing operational decisions about patient care with carbon mitigation targets. We explore a bottom-up modeling framework to aid in the decision-making for both carbon and cost in healthcare, using data from a case study in Cornwall, UK. A model was built and run for secondary healthcare, specifically outpatient clinics, theater lists, beds, and diagnostic facilities. Five scenarios were tested: business-as-usual; service expansion; site closure; water temperature reduction; and theater optimization. The estimated emissions from secondary healthcare in Cornwall ran to 5787 T CO(2)eq with patient travel adding 2215 T CO(2)eq. Closing selected sites would have reduced this by 4% (261 T CO(2)eq), a reduction less than the resulting increases in patient transport emissions. Reducing hot water temperatures by 5 °C and improving theater usage would lower the footprint by 0.7% (44 T CO(2)eq) and 0.08% (5 T CO(2)eq), respectively. We consider bottom-up models important tools in the process of estimating and modeling the carbon footprint of healthcare. For the carbon reduction targets of the healthcare sector to be met, the use of these bottom-up models in decision making and forward planning is pivotal.

The impact of rural hospital closures on equity of commuting time for haemodialysis patients: simulation analysis using the capacity-distance model

Background

Frequent and long-term commuting is a requirement for dialysis patients. Accessibility thus affects their quality of lives. In this paper, a new model for accessibility measurement is proposed in which both geographic distance and facility capacity are taken into account. Simulation of closure of rural facilities and that of capacity transfer between urban and rural facilities are conducted to evaluate the impacts of these phenomena on equity of accessibility among dialysis patients.

Methods

Post code information as of August 2011 of all the 7,374 patients certified by municipalities of Hiroshima prefecture as having first or third grade renal disability were collected. Information on post code and the maximum number of outpatients (capacity) of all the 98 dialysis facilities were also collected. Using geographic information systems, patient commuting times were calculated in two models: one that takes into account road distance (distance model), and the other that takes into account both the road distance and facility capacity (capacity-distance model). Simulations of closures of rural and urban facilities were then conducted.

Results

The median commuting time among rural patients was more than twice as long as that among urban patients (15 versus 7 minutes, p < 0.001). In the capacity-distance model 36.1% of patients commuted to the facilities which were different from the facilities in the distance model, creating a substantial gap of commuting time between the two models. In the simulation, when five rural public facilitiess were closed, Gini coefficient of commuting times among the patients increased by 16%, indicating a substantial worsening of equity, and the number of patients with commuting times longer than 90 minutes increased by 72 times. In contrast, closure of four urban public facilities with similar capacities did not affect these values.

Conclusions

Closures of dialysis facilities in rural areas have a substantially larger impact on equity of commuting times among dialysis patients than closures of urban facilities. The accessibility simulations using thecapacity-distance model will provide an analytic framework upon which rational resource distribution policies might be planned.

The follow-up of renal transplant recipients by telephone consultation: three years experience from a single UK renal unit

Although telephone consulting is increasingly used by clinicians seeking to balance rising caseloads, heightened patient expectation and the desire to ensure continued improvements in the quality, convenience and accessibility of the care they provide, its use to provide care to renal transplant recipients has not previously been described. Climate change is a major global public health threat. However, the provision of healthcare itself has a significant environmental impact. A transformation to lower carbon clinical care must be achieved without detriment to the quality of the patient care. This article reports the use of telephone consultation clinics to provide follow-up to renal transplant recipients over a three-year period. The benefits of this service to patients, providers and the environment are outlined, the existing literature regarding the provision of virtual care to patients with kidney disease is reviewed, and the possibilities of more widespread adoption are discussed.