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

Climate change and resilience for antimicrobial stewardship and infection prevention

PURPOSE OF REVIEW

This review covers recent research regarding the challenges posed by climate change within the areas of antimicrobial stewardship and infection prevention, and ways to build resiliency in these fields.

RECENT FINDINGS

Infectious disease patterns are changing as microbes adapt to climate change and changing environmental factors. Capacity for testing and treating infectious diseases is challenged by newly emerging diseases, which exacerbate challenges to antimicrobial stewardship and infection prevention.Antimicrobial resistance is accelerated due to environmental factors including air pollution, plastic pollution, and chemicals used in food systems, which are all impacted by climate change.Climate change places infection prevention practices at risk in many ways including from major weather events, increased risk of epidemics, and societal disruptions causing conditions that can overwhelm health systems. Researchers are building resilience by advancing rapid diagnostics and disease modeling, and identifying highly reliable versus low efficiency interventions.

SUMMARY

Climate change and associated major weather and socioeconomic events will place significant strain on healthcare facilities. Work being done to advance rapid diagnostics, build supply chain resilience, improve predictive disease modeling and surveillance, and identify high reliability versus low yield interventions will help build resiliency in antimicrobial stewardship and infection prevention for escalating challenges due to climate change.

Considering planetary health in health guidelines and health technology assessments: a scoping review protocol

BACKGROUND

This protocol outlines a scoping review with the objective of identifying and exploring planetary health considerations within existing health guidelines and health technology assessments (HTA). The insights gained from this review will serve as a basis for shaping future Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) guidance on planetary health.

METHODS

We will adhere to the JBI methodology for scoping reviews. We will conduct a comprehensive search and screening of results in all languages across various databases including MEDLINE, EMBASE, CINAHL, Global Health, Health Systems Evidence, Greenfile, and Environmental Issues. Additionally, we will supplement this search with resources such as the GIN library, BIGG database, Epistemonikos, GRADE guidelines repository, GRADEpro Guideline Development Tool Database, MAGICapp, NICE website, WHO websites, and a manual exploration of unpublished relevant documents using Google incognito mode. Two independent reviewers will screen and assess the full texts of identified documents according to the eligibility criteria. The following information from each full text will be extracted: document title; first author's name; publication year; language; document type; document as a guideline or HTA; the topic/discipline; document purpose/study objective; developing/sponsoring organization; the country in which the study/guideline/HTA report was conducted; definition of planetary health or related concept provided; types of planetary health experts engaged; study methods; suggested methods to assess planetary health; use of secondary data on planetary health outcomes; description for use of life cycle assessment; description for assessing the quality of life cycle; population/intended audience; interventions; category; applicable planetary health boundaries; consideration of social justice/global equity; phase of intervention in life cycle related to planetary health addressed; the measure of planetary health impact; impact on biodiversity/land use; one health/animal welfare mention; funding; and conflict of interest. Data analysis will involve a combination of descriptive statistics and directed content analysis, with results presented in a narrative format and displayed in tables and graphs.

DISCUSSION

The final review results will be submitted to open-access peer-reviewed journals for publication when they become available. The research findings will also be disseminated at relevant planetary health conferences and workshops.

SYSTEMATIC REVIEW REGISTRATION

Open Science Framework ( https://osf.io/3jmsa ).

Environmental impact of hybrid (reusable/single-use) ports versus single-use equivalents in robotic surgery

Given the rise in robotic surgery, and parallel movement towards net zero carbon, sustainable healthcare systems, it is important that the environmental impact of robotic approaches is minimised. The majority of greenhouse gas emissions associated with robotic surgery have previously been associated with single-use items. Whilst switching from single-use products to hybrid equivalents (predominantly reusable, with a small single-use component) has previously been found to reduce the environmental impact of a range of products used for laparoscopic surgery, the generalisability of this to robotic surgery has not previously been demonstrated. In this life cycle assessment, use of hybrid 5 mm ports compatible with emerging robotic systems (143 g CO2e) was found to reduce the carbon footprint by 83% compared with using single-use equivalents (816 g CO2e), accompanied by reductions in fifteen out of eighteen midpoint environmental impact categories. For endpoint categories, there was an 81% reduction in impact on human health and species loss, and 82% reductions in resource depletion associated with using hybrid robotic 5 mm ports. Whilst the carbon footprint of 5 mm hybrid ports compatible with emerging robotic equipment was 70% higher than previous estimates of ports appropriate for conventional laparoscopic approaches, the six-fold reductions seen with hybrids in this analysis point to the generalisability of the finding that reusable or hybrid products have a lower carbon footprint when compared with single-use equivalents. Surgeons, procurement teams, and policy makers should encourage innovation towards clinically safe and effective robotic instruments with maximal reusable components.

Carbon footprint of hospital laundry: a life-cycle assessment

OBJECTIVES

To assess greenhouse gas (GHG) emissions from a regional hospital laundry unit, and model ways in which these can be reduced.

DESIGN

A cradle to grave process-based attributional life-cycle assessment.

SETTING

A large hospital laundry unit supplying hospitals in Southwest England.

POPULATION

All laundry processed through the unit in 2020-21 and 2021-22 financial years.

PRIMARY OUTCOME MEASURE

The mean carbon footprint of processing one laundry item, expressed as in terms of the global warming potential over 100 years, as carbon dioxide equivalents (CO2e).

RESULTS

Average annual laundry unit GHG emissions were 2947 t CO2e. Average GHG emissions were 0.225 kg CO2e per item-use and 0.5080 kg CO2e/kg of laundry. Natural gas use contributed 75.7% of on-site GHG emissions. Boiler electrification using national grid electricity for 2020-2022 would have increased GHG emissions by 9.1%, however by 2030 this would reduce annual emissions by 31.9% based on the national grid decarbonisation trend. Per-item transport-related GHG emissions reduce substantially when heavy goods vehicles are filled at ≥50% payload capacity. Single-use laundry item alternatives cause significantly higher per-use GHG emissions, even if reusable laundry were transported long distances and incinerated at the end of its lifetime.

CONCLUSIONS

The laundry unit has a large carbon footprint, however the per-item GHG emissions are modest and significantly lower than using single-use alternatives. Future electrification of boilers and optimal delivery vehicle loading can reduce the GHG emissions per laundry item.

The IDEAL framework for surgical robotics: development, comparative evaluation and long-term monitoring

The next generation of surgical robotics is poised to disrupt healthcare systems worldwide, requiring new frameworks for evaluation. However, evaluation during a surgical robot's development is challenging due to their complex evolving nature, potential for wider system disruption and integration with complementary technologies like artificial intelligence. Comparative clinical studies require attention to intervention context, learning curves and standardized outcomes. Long-term monitoring needs to transition toward collaborative, transparent and inclusive consortiums for real-world data collection. Here, the Idea, Development, Exploration, Assessment and Long-term monitoring (IDEAL) Robotics Colloquium proposes recommendations for evaluation during development, comparative study and clinical monitoring of surgical robots-providing practical recommendations for developers, clinicians, patients and healthcare systems. Multiple perspectives are considered, including economics, surgical training, human factors, ethics, patient perspectives and sustainability. Further work is needed on standardized metrics, health economic assessment models and global applicability of recommendations.

Evaluating the Environmental Impact of Radiation Therapy Using Life Cycle Assessments: A Critical Review

Concurrent increases in global cancer burden and the climate crisis pose an unprecedented threat to public health and human well-being. Today, the health care sector greatly contributes to greenhouse gas emissions, with the future demand for health care services expected to rise. Life cycle assessment (LCA) is an internationally standardized tool that analyzes the inputs and outputs of products, processes, and systems to quantify associated environmental impacts. This critical review explains the use of LCA methodology and outlines its application to external beam radiation therapy (EBRT) with the aim of providing a robust methodology to quantify the environmental impact of radiation therapy care practices today. The steps of an LCA are outlined and explained as defined by the International Organization for Standardization (ISO 14040 and 14044) guidelines: (1) definition of the goal and scope of the LCA, (2) inventory analysis, (3) impact assessment, and (4) interpretation. The existing LCA framework and its methodology is described and applied to the field of radiation oncology. The goal and scope of its application to EBRT is the evaluation of the environmental impact of a single EBRT treatment course within a radiation oncology department. The methodology for data collection via mapping of the resources used (inputs) and the end-of-life processes (outputs) associated with EBRT is explained, with subsequent explanation of the LCA analysis steps. Finally, the importance of appropriate sensitivity analysis and the interpretations that can be drawn from LCA results are reviewed. This critical review of LCA protocol provides and evaluates a methodological framework to scientifically establish baseline environmental performance measurements within a health care setting and assists in identifying targets for emissions mitigation. Future LCAs in the field of radiation oncology and across medical specialties will be crucial in informing best practices for equitable and sustainable care in a changing climate.

Reducing the carbon footprint in carpal tunnel surgery inside the operating room with a lean and green model: a comparative study

The primary aim of our study was to assess the environmental impact of moving from a standard to a lean and green model for a carpal tunnel decompression. We objectively measured the clinical waste generated, the number of single use items and the number of sterile instruments required for a standard procedure, and then moved to smaller instrument trays, smaller drapes and fewer disposables. These two models were compared for waste generation, financial costs and carbon footprint. Information prospectively collected on seven patients in the standard model and 103 patients in the lean and green model in two hospitals over a 15-month period, demonstrated a reduction in CO2 emissions of 80%, clinical waste reduction of 65%, and an average aggregate cost saving of 66%. The lean and green model can deliver a safe, efficient, cost-effective and sustainable service for patients undergoing carpal tunnel decompression.Level of evidence: III.

Environmental sustainability related to dental materials and procedures in prosthodontics: A critical review

This article aims to review the status, challenges, and directions of environmentally sustainable oral healthcare by focusing on the dental materials and procedures used in prosthodontics. Sustainable development is a global priority and requires a systemic, integrative approach from all sectors of society. The oral healthcare sector is responsible for substantial greenhouse emissions throughout its value chain, including raw material extraction, industrial production, supply distribution, clinical practice, and management of waste. Of all dental specialties, prosthodontics has been one of the main generators of carbon emissions by fabricating a single product such as dentures or crowns in multiple steps. Dental prosthetic procedures involve chemicals and materials such as polymers, ceramics, metals, gypsum, and wax, which are often used in large quantities and for a single use. Thus, environmental risks and socioeconomic burdens can result from residuals and improper disposal, as well as waste and the embedded costs of unused materials retained by manufacturers, retail suppliers, dental laboratories, and dental clinics. To mitigate the environmental impact generated by conventional prosthodontics, we urge awareness and the adoption of sustainable good practices in the daily routine of dental clinics and laboratories. Capacity building and investment in a circular economy and digital technology can reduce the carbon footprint of prosthetic dentistry and improve the quality of life for present and future generations.

Evaluating Carbon Footprint of Proton Therapy Based on Power Consumption and Possible Mitigation Strategies

PURPOSE

There is increasing concern about rising carbon dioxide (CO2) emissions and their hazardous effect on human health. This study quantifies the energy utilization of proton therapy, assesses the corresponding carbon footprint, and discusses possible offsetting strategies toward carbon-neutral health care operations.

METHODS AND MATERIALS

Patients treated between July 2020 and June 2021 using the Mevion proton system were evaluated. Current measurements were converted to kilowatts of power consumption. Patients were reviewed for disease, dose, number of fractions, and duration of beam. The Environmental Protection Agency calculator was used to convert power consumption to tons of CO2 equivalent (CO2e) for scope-based carbon footprint accounting.

RESULTS

There were 185 patients treated and a total of 5176 fractions delivered (average, 28). Power consumption was 55.8 kW in standby/night mode and 64.4 kW during BeamOn, for an annual total of 490 MWh. BeamOn time was 149.6 hours, and BeamOn consumption accounted for 2% of the machine total. Power consumption was 52 kWh per patient (breast, highest at 140 kWh; prostate, lowest at 28 kWh). Annual power consumption of the administrative areas was approximately 96 MWh, for a program total of 586 MWh. The carbon footprint for BeamOn time was 4.17 metric tons of CO2e, or 23 kg per patient course (breast cancer, 60 kg; prostate, 12 kg). The annual carbon footprint for the machine was 212.2 tons CO2e, and for the proton program, 253.7 tons CO2e, with an attributed footprint of 1372 kg CO2e per patient. The corresponding CO2e offset for the program could be 4192 new trees planted and grown for 10 years (23 trees per patient).

CONCLUSIONS

The carbon footprint varied by disease treated. On average, the carbon footprint was 23 kg of CO2e per patient and 253.7 tons of CO2e for the proton program. There are a number of reduction, mitigation, and offset strategies possible for radiation oncologists that should be explored, such as waste minimization, less treatment commuting, efficient energy use, and renewable electricity power use.

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.

Main Challenges of Incorporating Environmental Impacts in the Economic Evaluation of Health Technology Assessment: A Scoping Review

Health technology assessment (HTA) provides evidence-based information on healthcare technology to support decision making in many countries. Environmental impact is a relevant dimension of a health technology's value, but it has been poorly addressed in HTA processes in spite of the commitment that the health sector must have to contribute to mitigating the effects of climate change. This study aims to identify the state of the art and challenges for quantifying environmental impacts that could be incorporated into the economic evaluation (EE) of HTA. We performed a scoping review that included 22 articles grouped into four types of contribution: (1) concepts to draw up a theoretical framework, (2) HTA reports, (3) parameter designs or suitable indicators, and (4) economic or budgetary impact assessments. This review shows that evaluation of the environmental impact of HTAs is still very incipient. Small steps are being taken in EE, such as carbon footprint estimations from a life-cycle approach of technologies and the entire care pathway.