Climate responsibilities in intensive care medicine-let's go green! An introduction to a new series in Intensive Care Medicine

A Randomized Noninferiority Trial to Compare Enteral to Parenteral Phosphate Replacement on Biochemistry, Waste, and Environmental Impact and Healthcare Cost in Critically Ill Patients With Mild to Moderate Hypophosphatemia

OBJECTIVES

Hypophosphatemia occurs frequently. Enteral, rather than IV, phosphate replacement may reduce fluid replacement, cost, and waste.

DESIGN

Prospective, randomized, parallel group, noninferiority clinical trial.

SETTING

Single center, 42-bed state trauma, medical and surgical ICUs, from April 20, 2022, to July 1, 2022.

PATIENTS

Patients with serum phosphate concentration between 0.3 and 0.75 mmol/L.

INTERVENTIONS

We randomized patients to either enteral or IV phosphate replacement using electronic medical record-embedded program.

MEASUREMENT AND MAIN RESULTS

Our primary outcome was serum phosphate at 24 hours with a noninferiority margin of 0.2 mmol/L. Secondary outcomes included cost savings and environmental waste reduction and additional IV fluid administered. The modified intention-to-treat cohort comprised 131 patients. Baseline phosphate concentrations were similar between the two groups. At 24 hours, mean ( sd ) serum phosphate concentration were enteral 0.89 mmol/L (0.24 mmol/L) and IV 0.82 mmol/L (0.28 mmol/L). This difference was noninferior at the margin of 0.2 mmol/L (difference, 0.07 mmol/L; 95% CI, -0.02 to 0.17 mmol/L). When assigned IV replacement, patients received 408 mL (372 mL) of solvent IV fluid. Compared with IV replacement, the mean cost per patient was ten-fold less with enteral replacement ($3.7 [$4.0] vs. IV: $37.7 [$31.4]; difference = $34.0 [95% CI, $26.3-$41.7]) and weight of waste was less (7.7 g [8.3 g] vs. 217 g [169 g]; difference = 209 g [95% CI, 168-250 g]). C O2 emissions were 60-fold less for comparable phosphate replacement (enteral: 2 g producing 14.2 g and 20 mmol of potassium dihydrogen phosphate producing 843 g of C O2 equivalents).

CONCLUSIONS

Enteral phosphate replacement in ICU is noninferior to IV replacement at a margin of 0.2 mmol/L but leads to a substantial reduction in cost and waste.

Cost awareness among intensivists in their daily clinical practice: a prospective multicentre study

BACKGROUND

Better cost-awareness is a prerogative in achieving the best benefit/risk/cost ratio in the care. We aimed to assess the cost-awareness of intensivists in their daily clinical practice and to identify factors associated with accurate estimate of cost (50-150% of the real cost).

METHODS

We performed a prospective observational study in seven French ICUs. We compared the estimate of intensivists of the daily costs of caring with the real costs on a given day. The estimates covered five categories (drugs, laboratory tests, imaging modalities, medical devices, and waste) whose sum represented the overall cost.

RESULTS

Of the 234 estimates made by 65 intensivists, 70 (29.9%) were accurate. The median overall cost estimate (€330 [170; 620]) was significantly higher than the real cost (€178 [124; 239], p < 0.001). This overestimation was found in four categories, in particular for waste (€40 [15; 100] vs. €1.1 [0.6; 2.3], p < 0.001). Only the laboratory tests were underestimated (€65 [30; 120] vs. €106 [79; 138], p < 0.001). Being aware of the financial impact of prescriptions was factor associated with accurate estimate (OR: 5.05, 95%CI:1.47-17.4, p = 0.01). However, feeling able to accurately perform estimation was factor negatively associated with accurate estimate (OR: 0.11, 95%CI: 0.02-0.71, p = 0.02).

CONCLUSION

French intensivists have a poor awareness of costs in their daily clinical practice. Raising awareness of the financial impact of prescriptions, and of the cost of laboratory tests and waste are the main areas for improvement that could help achieve the objective of the best care at the best cost.

[Sustainability in intensive and emergency care : A nationwide survey by the German Society of Medical Intensive Care and Emergency Medicine]

BACKGROUND

The impact of climate change on humans is well known. However, the health care system is also a relevant contributor, accounting for up to 5-7% of global greenhouse gas emissions, and work should be adapted to be more sustainable.

AIM

The survey investigated whether sustainability plays a role in hospitals and specifically in the field of emergency and intensive care. Concrete measures and which hurdles are already recognized were also inquired.

MATERIALS AND METHODS

The "AG Nachhaltigkeit" (working group on sustainability) of the "Deutschen Gesellschaft für Internistische Intensivmedizin und Notfallmedizin" (DGIIN) conducted an electronic survey among the staff of intensive care units, emergency rooms, and ambulance services in Germany.

RESULTS

In all, 218 survey results were included in the analysis: 108 (50%) participants were from the nursing sector and 98 (45%) belonged to the medical staff. The majority of participants work in an intensive care unit (181 [83%]) followed by intermediate care unit (52 [24%]). A total of 104 (47%) participants indicated that their workplace had already implemented sustainability measures. However, when asked whether decision-makers in the workplaces incorporate sustainability into their decisions, management scored highest with only 20%. Potential for improvement is seen in energy and waste management, among others.

CONCLUSION

The survey results show that (1) employees are highly motivated to address the issue of sustainability and to implement measures, (2) the potential to establish a resource-saving and environmentally friendly hospital is far from being exhausted, and (3) it must become a priority that decision-makers in the hospital propagate sustainability, make processes transparent, and support the motivation of employees on the subject of sustainability. In addition, this process must be supported by politicians and health insurance companies.

How environmental impact is considered in economic evaluations of critical care: a scoping review

PURPOSE

Health care is a major contributor to climate change, and critical care is one of the sector's highest carbon emitters. Health economic evaluations form an important component of critical care and may be useful in identifying economically efficient and environmentally sustainable strategies. The purpose of this scoping review was to synthesise available literature on whether and how environmental impact is considered in health economic evaluations of critical care.

METHODS

A robust scoping review methodology was used to identify studies reporting on environmental impact in health economic evaluations of critical care. We searched six academic databases to locate health economic evaluations, costing studies and life cycle assessments of critical care from 1993 to present.

RESULTS

Four studies met the review's inclusion criteria. Of the 278 health economic evaluations of critical care identified, none incorporated environmental impact into their assessments. Most included studies (n = 3/4) were life cycle assessments, and the remaining study was a prospective observational study. Life cycle assessments used a combination of process-based data collection and modelling to incorporate environmental impact into their economic assessments.

CONCLUSIONS

Health economic evaluations of critical care have not yet incorporated environmental impact into their assessments, and few life cycle assessments exist that are specific to critical care therapies and treatments. Guidelines and standardisation regarding environmental data collection and reporting in health care are needed to support further research in the field. In the meantime, those planning health economic evaluations should include a process-based life cycle assessment to establish key environmental impacts specific to critical care.

[The CO2 footprint of intensive care medicine-let's go green]

Climate change and global warming are facts, and actually they are a hot topic for politics, economics, and societies. Global healthcare contributes approximately 5% of worldwide anthropogenic emissions, and this fact might produce an ethical dilemma between the Hippocratic principles of 'beneficence' (promotion of health) and of 'non-maleficence' (avoiding reinforcement of the climate crisis). Intensive care medicine has continuous high staff activity, resource use, and energy demands, and it is clear that intensive care medicine must become green to commence with practical measures to reduce their intensive care unit (ICU) carbon footprint. In this article several strategies are introduced, beginning with the creation of green teams on the ICUs from the bottom. Furthermore, systematic recycle programs, and the assessment and control of energy use are required to make ICUs more sustainable. Strategies for avoiding futile treatment combined with a choose wisely philosophy might contribute to such projects. Immediate engagement of all healthcare staff, particularly those who work in the ICU, is necessary to join the 'race to zero carbon emissions'.