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

Advancing sustainability in healthcare: A scoping review of global recycling practices in operating rooms

The healthcare sector, particularly operating rooms (ORs), generates significant waste, contributing to global environmental pollution. This scoping review aimed to assess global recycling practices in ORs across various surgical specialties, identifying key barriers and strategies for improvement. A comprehensive literature search using PubMed and Embase and PRISMA reporting guidelines yielded 35 studies for inclusion. The findings indicate that up to 74 ​% of OR waste, particularly preoperative waste, is recyclable. However, implementation of recycling programs is hindered by regulatory constraints, lack of education, leadership challenges, and logistical difficulties. Successful initiatives involve targeted recycling efforts, such as focusing on specific materials like blue wrap and polyethylene terephthalate plastics, supported by leadership engagement and standardized guidelines. The review highlights the necessity of a multifaceted approach, including regulatory reform, education, and strategic partnerships with manufacturers, to overcome these barriers. Incorporating robust recycling practices in ORs offers an opportunity for healthcare systems to align waste management with broader environmental sustainability goals, ultimately reducing environmental impact while enhancing resource efficiency.

The green ICU: how to interpret green? A multiple perspective approach

Mitigating environmental impacts is an urgent challenge supported by (scientific) intensive care societies worldwide. However, making green choices without compromising high-quality care for critically ill patients may be challenging. The current paper describes a three-step approach towards green intensive care units. Starting with the measurement of environmental sustainability, intensive care units can identify hotspots, quantify the environmental impacts of products and procedures, and monitor sustainable progress. Subsequently, a multidisciplinary approach is proposed to improve environmental sustainability, including a collaboration of procurement specialists and healthcare professionals, using co-creation and green teams as efficient grassroots change agents. A context-specific approach for enhancing sustainable healthcare practices is key in order to fit local regulatory requirements and create support of professionals. A final step is to share results and create momentum, including publishing initiatives and participating in online (inter)national networks. Based on the core sustainability principles, this three-step approach towards green ICUs provides a valuable tool to professionals worldwide to facilitate change towards environmentally responsible intensive care units.

The climate crisis - actions to prioritize for anaesthesiologists

PURPOSE OF REVIEW

Climate change is the biggest threat to human health and survival in the twenty-first century. Emissions associated with healthcare contribute to climate change and there are many personal and professional actions that can reduce carbon emissions. This review highlights why action is necessary and what anaesthetists and healthcare workers can do.

RECENT FINDINGS

Encouraging continuing research regarding sustainable anaesthesia and expanding education at all levels to include climate action is key. Professionally, actions include limiting use of single-use equipment, reducing reliance on volatile gas inhalational anaesthesia, and adopting low fresh gas flow techniques. Personal actions such as climate-conscious travelling, spending, and eating are important, especially when shared to create climate positive movements.

SUMMARY

This article shows that, while patient safety and quality of care must remain healthcare's top priority, considering the climate implications of care is part of that duty. Many actions that reduce the carbon impact of care simultaneously improve the quality of care and reduce financial cost. More research into sustainable healthcare is needed. Departments and hospitals and must create environments in which climate conversations are welcomed and can result in positive advancements.

Assessment of bacterial positivity rate changes in anesthesia machine internal circuits within recovery rooms and associated risk factors

OBJECTIVE

The objective of this study is to investigate bacterial proliferation within the internal circuits of anesthesia machines in post-anesthesia care units (PACUs) following the implementation of the new protocol, where 'a single dedicated external circuit is used for each individual patient.' This measure was introduced during the COVID-19 pandemic, in alignment with a novel prevention and control strategy.

METHODS

Using the observational technique, we analyzed anesthesia machines in PACUs between July and September 2022. The internal circuits of the anesthesia machines were disinfected every two weeks. Samples were obtained from the internal circuits on the 3rd, 5th, 7th, 10th, 12th, and 14th day following disinfection for bacterial culture. Changes in the positivity rate of bacteria in the internal circuits over time were analyzed using the generalized estimating equation. The anesthesia machines were divided into the positive group (n = 9) and the negative group (n = 41) based on the sampling results on the 14th day after disinfection. Risk factors for positive bacterial culture results in anesthesia machines in PACUs were analyzed using single-factor modified Poisson analysis and multi-factor modified Poisson regression analysis.

RESULTS

The positivity rates of the internal circuits of anesthesia machines in PACUs on the 3rd, 5th, 7th, 10th, 12th, and 14th day following disinfection were 10%, 14%, 12%, 20%, 16%, and 18% respectively. There were no statistically significant differences when the positive rates of the next five time points and the third day were compared (P > 0.05). Risk factors for the contamination in the internal circuits of anesthesia machines was the number of elderly patients and the overall surgical use duration, with the difference was statistically significant (P < 0.025).

CONCLUSION

Amid the COVID-19 pandemic, characterized by the adoption of new prevention and control protocols, the disinfection interval for internal circuits of anesthesia machines in PACUs may potentially be extended. However, the emphasis of disinfection should still be placed on those anesthesia machines that have been used for a longer cumulative surgical duration and by a higher number of elderly patients over 60 years old. This approach ensures that resources are allocated effectively.

Potential impacts of optimised care pathways on carbon impact of anaesthesia consultation-A monocenter prospective study

BACKGROUND

Global warming presents major public health challenges, with healthcare transportation significantly contributing to carbon dioxide equivalent emissions (eCO2). While the greenhouse effects of anaesthetic gases are well-documented, the eCO2 of pre-anaesthesia consultations remains underexplored. This study aims to evaluate and propose strategies to reduce the carbon impact of these consultations at a Tertiary University Hospital.

METHODS

In a prospective, observational study over one month, data were collected from patients attending pre-anaesthesia consultations. ECO2 emissions from transportation and electricity were calculated. To reduce emissions, several modifications to the care pathway were investigated, including teleconsultation, remote consultation, grouping of consultations, carpooling, and the promotion of public transport. The effects of current and optimised care pathways were then compared.

RESULTS

Data from 213 patients showed that 75% attended the hospital solely for pre-anaesthesia consultations, mostly by car (82%). The mean eCO2 per consultation was 22.4 kgCO2 (95% CI: 14.6-30.2). Implementing optimisation strategies in 65% of cases could reduce emissions to 5.6 kg CO2 (95% CI: 0.2-10.9) per consultation, leading to a 74% reduction and an annual saving of 274 t of eCO2.

DISCUSSION

Our study highlights the potential for significant reductions in the eCO2 of pre-anaesthesia consultations. The adaptation of the care pathway would largely involve grouping consultations and developing teleconsultations. These potential savings in greenhouse gas emissions are in the same order of magnitude as not using desflurane in the operating theatre and could be the next step towards greener anaesthesia.

Switching to reusable operating theatre equipment: lessons learnt from sterile light handle projects in two Australian hospitals

BACKGROUND

Replacing single-use operating theatre equipment with reusables might be one strategy for reducing the carbon footprint of operating theatres. However, in Australia, where the energy mix is predominantly fossil-fuel-based, the re-sterilization of reusables may increase the carbon footprint. We analyzed the financial and environmental impacts of introducing reusable operating theatre light handles in two NSW hospitals.

METHODS

The effects on cost, waste, and carbon footprint of replacing disposable light handle covers with reusable handles in each hospital were analyzed over 12 months using procurement, waste and sterilization data, and life cycle assessment.

RESULTS

Energy requirement for sterilization of reusable handles, increasing alongside weight of the handle, resulted in higher carbon footprint than using disposable covers. At one hospital, using a heavy handle increased carbon emissions sixfold, while the cost of handle sterilization exceeded the cost of disposable covers, resulting in 11% higher cost per use. At the other hospital, using a lighter handle increased carbon emissions by 40% per use, while sterilization cost was less than the cost of disposable covers, resulting in 14.8% lower cost per use. Scenario modelling indicated that sterilizing handles as part of a hollowware set rather than as individual items would significantly reduce cost and carbon footprint. At both hospitals, associated clinical waste was essentially eliminated.

CONCLUSION

Judicious replacement of disposable covers with lightweight yet durable reusable handles can reduce costs, but increases carbon footprint in the current Australian energy context. Adopting predominantly renewable energy and more efficient sterilization practice would mitigate this.

Improving sustainability and mitigating the environmental impact of anaesthesia and surgery along the perioperative journey: a narrative review

Climate change, environmental degradation, and biodiversity loss are adversely affecting human health and exacerbating existing inequities, intensifying pressures on already strained health systems. Paradoxically, healthcare is a high-polluting industry, responsible for 4.6% of global greenhouse gas emissions and a similar proportion of air pollutants. Perioperative services are among the most resource-intensive healthcare services and are responsible for some unique pollutants. Opportunities exist to mitigate pollution throughout the entire continuum of perioperative care, including those that occur upstream of the operating room in the process of patient selection and optimisation, delivery of anaesthesia and surgery, and the postoperative recovery period. Within a patient-centred, holistic approach, clinicians can advocate for healthy public policies that modify the determinants of surgical illness, can engage in shared decision-making to ensure appropriate clinical decisions, and can be stewards of healthcare resources. Innovation and collaboration are required to redesign clinical care pathways and processes, optimise logistical systems, and address facility emissions. The results will extend beyond the reduction of public health damages from healthcare pollution to the provision of higher value, higher quality, patient-centred care.

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.

Diagnostic Excellence in the Context of Climate Change: A Review

Climate change is leading to a rise in heat-related illnesses, vector-borne diseases, and numerous negative impacts on patients' physical and mental health outcomes. Concurrently, healthcare contributes about 4.6% of global greenhouse gas emissions. Low-value care, such as overtesting and overdiagnosis, contributes to unnecessary emissions. In this review, we describe diagnostic excellence in the context of climate change and focus on two topics. First, climate change is affecting health, leading to the emergence of certain diseases, some of which are new, while others are increasing in prevalence and/or becoming more widespread. These conditions will require timely and accurate diagnosis by clinicians who may not be used to diagnosing them. Second, diagnostic quality issues, such as overtesting and overdiagnosis, contribute to climate change through unnecessary emissions and waste and should be targeted for interventions. We also highlight implications for clinical practice, research, and policy. Our findings call for efforts to engage healthcare professionals and policymakers in understanding the urgent implications for diagnosis in the context of climate change and reducing global greenhouse gas emissions to enhance both patient and planetary outcomes.

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.

Routine Use of Videolaryngoscopy in Airway Management

Tracheal intubation is a fundamental facet of airway management, for which the importance of achieving success at the first attempt is well recognized. Failure to do so can lead to significant morbidity and mortality if there is inadequate patient oxygenation by alternate means. The evidence supporting the benefits of a videolaryngoscope in attaining this objective is now overwhelming (in adults). This has led to its increasing recognition in international airway management guidelines and its promotion from an occasional airway rescue tool to the first-choice device during routine airway management. However, usage in clinical practice does not currently reflect the increased worldwide availability that followed the upsurge in videolaryngoscope purchasing during the coronavirus disease 2019 pandemic. There are a number of obstacles to widespread adoption, including lack of adequate training, fears over de-skilling at direct laryngoscopy, equipment and cleaning costs, and concerns over the environmental impact, among others. It is now clear that in order for patients to benefit maximally from the technology and for airway managers to fully appreciate its role in everyday practice, proper training and education are necessary. Recent research evidence has addressed some existing barriers to default usage, and the emergence of techniques such as awake videolaryngoscopy and video-assisted flexible (bronchoscopic) intubation has also increased the scope of clinical application. Future studies will likely further confirm the superiority of videolaryngoscopy over direct laryngoscopy, therefore, it is incumbent upon all airway managers (and their teams) to gain expertise in videolaryngoscopy and to use it routinely in their everyday practice..

Developing the green operating room: exploring barriers and opportunities to reducing operating room waste

The Australian health care system contributes 7% of the national greenhouse gas emission footprint and generates massive waste streams annually. Operating rooms are a particular hotspot, generating at least 20% of the total hospital waste. A systematic search of several global academic databases was conducted in mid-2022 (articles from 1992 to 2022) for peer-reviewed research relevant to waste management in the operating rooms. We then used thematic analysis to enumerate and characterise the strategies and barriers to sustainable waste management in the operating room. The waste reduction strategies focused on avoidance of high carbon products; correct waste segregation and reduced overage; reusing, reprocessing, and repurposing devices; and improved recycling. The first barrier identified was a constrained interpretation of the concept of "first do not harm", ingrained in surgeons' practices, in prioritising single-use surgical products. The second barrier was ineffective or insufficient waste education. The third barrier was the immediate cost of implementing waste management compared with the long term realisation of environmental and economic benefits. The last barrier to implementing institutional practice change was the lack of policies and regulations at the local hospital, federal and international levels. We also evaluated the knowledge gaps in current surgical waste research, including lack of benchmarking data and standardised regulations concerning reusable or reprocessed devices, as well as the methods used to promote pro-sustainability behavioural change.

Does Reusable Instrumentation for Four-Anchor Rotator Cuff Repair Offer Decreased Waste Disposal Costs and Lower Waste-Related Carbon Emissions?

INTRODUCTION

Orthopaedic surgery is culpable, in part, for the excessive carbon emissions in health care partly due to the utilization of disposable instrumentation in most procedures, such as rotator cuff repair (RCR). To address growing concerns about hospital waste, some have considered replacing disposable instrumentation with reusable instrumentation. The purpose of this study was to estimate the cost and carbon footprint of waste disposal of RCR kits that use disposable instrumentation compared with reusable instrumentation.

METHODS

The mass of the necessary materials and their packaging to complete a four-anchor RCR from four medical device companies that use disposable instrumentation and one that uses reusable instrumentation were recorded. Using the cost of medical waste disposal at our institution ($0.14 per kilogram) and reported values from the literature for carbon emissions produced from the low-temperature incineration of noninfectious waste (249 kgCO 2 e/t) and infectious waste (569 kgCO 2 e/t), we estimated the waste management cost and carbon footprint of waste disposal produced per RCR kit.

RESULTS

The disposable systems of four commercial medical device companies had 783%, 570%, 1,051%, and 478%, respectively, greater mass and waste costs when compared with the reusable system. The cost of waste disposal for the reusable instrumentation system costs on average $0.14 less than the disposable instrumentation systems. The estimated contribution to the overall carbon footprint produced from the disposal of a RCR kit that uses reusable instrumentation was on average 0.37 kg CO2e less than the disposable instrumentation systems.

CONCLUSION

According to our analysis, reusable instrumentation in four-anchor RCR leads to decreased waste and waste disposal costs and lower carbon emissions from waste disposal. Additional research should be done to assess the net benefit reusable systems may have on hospitals and the effect this may have on a long-term decrease in carbon footprint.

LEVEL OF EVIDENCE

Level II.

Cost Awareness of Anaesthetic Consumable Items Among the National Health Service (NHS) Staff and the Financial Impact on the NHS

Background The financial burden of running the National Health Service (NHS) is high. Staff members should be aware of the cost of the equipment they use to enable efficient use of resources, reduce waste, and control spending. However, limited financial education at undergraduate and junior stages has contributed to relatively poor knowledge among healthcare workers at all levels. Anaesthetics is a speciality which uses a large amount of equipment; therefore, we aim to assess the cost awareness among staff for commonly used consumables. Furthermore, we aim to assess staff members' attitudes towards the financial and environmental impact of the equipment they use and whether this would change their practice. Methodology An electronic survey was sent to staff members from the anaesthetic department of the Medway NHS Foundation Trust during a one-month period. Respondents were asked to estimate the cost of 19 commonly used anaesthetic consumables, with an estimate categorised as correct if it was within 20% of the actual cost. At the end of the survey, there were five questions for respondents to answer regarding the financial and environmental impact of their current healthcare practice and possible alternatives. Results There were 69 respondents within the anaesthetic department from a variety of roles. Overall, only 9.37% of items were estimated correctly, with cheaper items commonly being overestimated and more expensive items being underestimated. Overall, 60% of respondents said the cost of an item would influence their use. The overwhelming majority claimed that the environmental impact was a concern, and most would favour recyclable/reusable alternatives. Conclusions Cost awareness among anaesthetic staff for commonly used equipment is poor. More education and training are necessary in this area as limited knowledge of service costs restricts the ability to make cost-efficient choices which are needed in the current NHS.

A Cost and Waste-Savings Comparison Between Single-Use and Reusable Pulse Oximetry Sensors Across US Operating Rooms

BACKGROUND

Operating room (OR) expenditures and waste generation are a priority, with several professional societies recommending the use of reprocessed or reusable equipment where feasible. The aim of this analysis was to compare single-use pulse oximetry sensor stickers ("single-use stickers") versus reusable pulse oximetry sensor clips ("reusable clips") in terms of annual cost savings and waste generation across all ORs nationally.

METHODS

This study did not involve patient data or research on human subjects. As such, it did not meet the requirements for institutional review board approval. An economic model was used to compare the relative costs and waste generation from using single-use stickers versus reusable clips. This model took into account: (1) the relative prices of single-use stickers and reusable clips, (2) the number of surgeries and ORs nationwide, (3) the workload burden of cleaning the reusable clips, and (4) the costs of capital for single-use stickers and reusable clips. In addition, we also estimated differences in waste production based on the raw weight plus unit packaging of single-use stickers and reusable clips that would be disposed of over the course of the year, without any recycling interventions. Estimated savings were rounded to the nearest $0.1 million.

RESULTS

The national net annual savings of transitioning from single-use stickers to reusable clips in all ORs ranged from $510.5 million (conservative state) to $519.3 million (favorable state). Variability in savings estimates is driven by scenario planning for replacement rate of reusable clips, workload burden of cleaning (ranging from an additional expense of $618k versus a cost savings of $309k), and cost of capital-interest gained on investment of capital that is freed up by the monetary savings of a transition to reusable clips contributes between $541k (low-interest rates of 2.85%) and $1.3 million (high-interest rates of 7.08%). The annual waste that could be diverted from landfill by transitioning to reusable clips was found to be between 587 tons (conservative state) up to 589 tons (favorable state). If institutions need to purchase new vendor monitors or cables to make the transition, that may increase the 1-time capital disbursement.

CONCLUSIONS

Using reusable clips versus single-use stickers across all ORs nationally would result in appreciable annual cost savings and waste generation reduction impact. As both single-use stickers and reusable clips are equally accurate and reliable, this cost and waste savings could be instituted without a compromise in clinical care.

Defending and Defining Environmental Responsibilities for the Health Research Sector

Six planetary boundaries have already been exceeded, including climate change, loss of biodiversity, chemical pollution, and land-system change. The health research sector contributes to the environmental crisis we are facing, though to a lesser extent than healthcare or agriculture sectors. It could take steps to reduce its environmental impact but generally has not done so, even as the planetary emergency worsens. So far, the normative case for why the health research sector should rectify that failure has not been made. This paper argues strong philosophical grounds, derived from theories of health and social justice, exist to support the claim that the sector has a duty to avoid or minimise causing or contributing to ecological harms that threaten human health or worsen health inequity. The paper next develops ideas about the duty's content, explaining why it should entail more than reducing carbon emissions, and considers what limits might be placed on the duty.

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.

Including environmental and social sustainability in the planning process of healthcare services: A case study of cancer screening programs in an inner area in Italy

Healthcare systems plan their activities to achieve efficiency and effectiveness, without addressing environmental and social sustainability. This paper describes a new approach adopted in Italy to plan and deliver health prevention services in an inner area of the Tuscany region (in Italy) to guarantee proximity of care and environmental and social sustainability. The project examines the design and delivery of cancer screening programmes using a mobile screening unit to maximise social benefits while minimising environmental waste. A cost analysis was developed to estimate the difference in CO2 equivalent emissions, travel costs, and productivity losses, comparing the current screening programmes against the introduction of a comprehensive full-service mobile screening unit. The results indicate that the new service model reduces direct non-medical costs incurred by the population and improves environmental sustainability. This alternative can reduce, annually, over 95,000 euros in terms of travel costs and productivity losses, as well as 35 tons of CO2-equivalent travel emissions for a population of 59,000 inhabitants in a mountainous area with around 6000 people involved in the screening programme. The study supports the need to adopt a new planning methodology that considers environmental, social, and financial sustainability jointly in the provision of public health services in rural areas.

Cardiovascular Imaging, Climate Change, and Environmental Sustainability

Environmental exposures including poor air quality and extreme temperatures are exacerbated by climate change and are associated with adverse cardiovascular outcomes. Concomitantly, the delivery of health care generates substantial atmospheric greenhouse gas (GHG) emissions contributing to the climate crisis. Therefore, cardiac imaging teams must be aware not only of the adverse cardiovascular health effects of climate change, but also the downstream environmental ramifications of cardiovascular imaging. The purpose of this review is to highlight the impact of climate change on cardiovascular health, discuss the environmental impact of cardiovascular imaging, and describe opportunities to improve environmental sustainability of cardiac MRI, cardiac CT, echocardiography, cardiac nuclear imaging, and invasive cardiovascular imaging. Overarching strategies to improve environmental sustainability in cardiovascular imaging include prioritizing imaging tests with lower GHG emissions when more than one test is appropriate, reducing low-value imaging, and turning equipment off when not in use. Modality-specific opportunities include focused MRI protocols and low-field-strength applications, iodine contrast media recycling programs in cardiac CT, judicious use of US-enhancing agents in echocardiography, improved radiopharmaceutical procurement and waste management in nuclear cardiology, and use of reusable supplies in interventional suites. Finally, future directions and research are highlighted, including life cycle assessments over the lifespan of cardiac imaging equipment and the impact of artificial intelligence tools. Keywords: Heart, Safety, Sustainability, Cardiovascular Imaging Supplemental material is available for this article. © RSNA, 2024.

Digital technologies to unlock safe and sustainable opportunities for medical device and healthcare sectors with a focus on the combined use of digital twin and extended reality applications: A review

Medical devices have increased in complexity where there is a pressing need to consider design thinking and specialist training for manufacturers, healthcare and sterilization providers, and regulators. Appropriately addressing this consideration will positively inform end-to-end supply chain and logistics, production, processing, sterilization, safety, regulation, education, sustainability and circularity. There are significant opportunities to innovate and to develop appropriate digital tools to help unlock efficiencies in these important areas. This constitutes the first paper to create an awareness of and to define different digital technologies for informing and enabling medical device production from a holistic end-to-end life cycle perspective. It describes the added-value of using digital innovations to meet emerging opportunities for many disposable and reusable medical devices. It addresses the value of accessing and using integrated multi-actor HUBs that combine academia, industry, healthcare, regulators and society to help meet these opportunities. Such as cost-effective access to specialist pilot facilities and expertise that converges digital innovation, material science, biocompatibility, sterility assurance, business model and sustainability. It highlights the marked gap in academic R&D activities (PRISMA review of best publications conducted between January 2010 and January 2024) and the actual list of U.S. FDA's approved and marketed artificial intelligence/machine learning (AI/ML), and augmented reality/virtual reality (AR/VR) enabled-medical devices for different healthcare applications. Bespoke examples of benefits underlying future use of digital tools includes potential implementation of machine learning for supporting and enabling parametric release of sterilized products through efficient monitoring of critical process data (complying with ISO 11135:2014) that would benefit stakeholders. This paper also focuses on the transformative potential of combining digital twin with extended reality innovations to inform efficiencies in medical device design thinking, supply chain and training to inform patient safety, circularity and sustainability.

Environmental sustainability in obstetrics and gynaecology: A systematic review

BACKGROUND

The healthcare sector is responsible for 4%-10% of global greenhouse gas emissions. Considering the broad range of care that obstetricians and gynaecologists provide, mitigation strategies within this specialty could result in significant reductions of the environmental footprint across the whole healthcare industry.

OBJECTIVES

The aim of this review was to identify for what services, procedures and products within obstetric and gynaecological care the environmental impact has been studied, to assess the magnitude of such impact and to identify mitigation strategies to diminish it.

SEARCH STRATEGY

The search strategy combined terms related to environmental impact, sustainability, climate change or carbon footprint, with the field of obstetrics and gynaecology.

SELECTION CRITERIA

Articles reporting on the environmental impact of any service, procedure or product within the field of obstetrics and gynaecology were included. Included outcomes covered midpoint impact categories, CO2 emissions, waste generation and energy consumption.

DATA COLLECTION AND ANALYSIS

A systematic literature search was conducted in the databases of MEDLINE (Ovid), Embase (Ovid) and Scopus, and a grey literature search was performed on Google Scholar and two websites of gynaecological associations.

MAIN RESULTS

The scope of the investigated studies encompassed vaginal births, obstetric and gynaecological surgical procedures, menstrual products, vaginal specula and transportation to gynaecological oncologic consultations. Among the highest yielding mitigation strategies were displacing disposable with reusable materials and minimising content of surgical custom packs. The lowest yielding mitigation strategy was waste optimisation, including recycling.

CONCLUSIONS

This systematic review highlights opportunities for obstetricians and gynaecologists to decrease their environmental footprint in many ways. More high-quality studies are needed to investigate the environmental impact of other aspects of women's and reproductive health care.

Instrument and Supply Variability: An Opportunity to Reduce the Carbon Footprint of the Operating Room

INTRODUCTION

Reducing costs and carbon footprints are important, parallel priorities for the US health-care system. Within surgery, reducing the number of instruments that are sterilized and disposable supplies that are used for each operation may help achieve both goals. We wanted to measure the existing variability in surgical instrument and supply choices and assess whether standardization could have a meaningful cost and environmental impact.

METHODS

We analyzed surgeon preference cards for common general surgery operations at our hospital to measure the number of sterilizable instrument trays and supplies used by each surgeon for each operation. From this data, we calculated supply costs, carbon footprint, and median operative time and studied the variability in each of these metrics.

RESULTS

Among the ten operations studied, variability in sterilizable instrument trays requested on surgeon preference cards ranged from one to eight. Variability in disposable supplies requested ranged from 17 to 45. Variability in open supply costs ranged from $104 to $4184. Variability in carbon footprint ranged from 17 to 708 kg CO2e. If the highest-cost surgeon for each operation switched their preference card to that of the median-cost surgeon, $245,343 in open supply costs and 41,708 kg CO2e could be saved.

CONCLUSIONS

There is significant variability in the instrument and supply choices of surgeons performing common general surgery operations. Standardizing this variability may lead to meaningful cost savings and carbon footprint reduction, especially if scaled across the entire health system.

A long road ahead. A German national survey study on awareness and willingness of surgeons towards the carbon footprint of modern surgical procedures

Background

Climate change may well be the "largest threat" to humankind. Changes to our climate system lead to a decrease in global health. The healthcare sector presents one of the largest carbon footprints across all industries. Since surgical departments have one of the largest carbon footprints within the healthcare sector, they represent an area with vast opportunities for improvement. To drive change, it is vital to create awareness of these issues and encourage engagement in changes among people working in the healthcare industry.

Methods

We conducted an anonymous cross-sectional survey study to assess awareness among surgeons regarding the impact of healthcare systems on climate change. The questions were designed to investigate surgeons' willingness to accept and promote changes to reduce carbon footprints. Participants included surgical professionals of all ages and levels of expertise.

Results

A total of 210 participants completed the survey in full and were included in the evaluation. Sixty percent emphasized a lack of information and the need for personal education. Over 90 % expressed concern for the environment and a strong desire to gain new insights. Provided that clinical performance remains the same, more than 70 % are willing to embrace carbon-friendly alternatives. In this context, all participants accepted the additional time required for training and initially increased personal efforts to achieve equal performance.

Conclusion

Limited awareness and information about carbon footprints were observed in surgical departments in German hospitals. Nevertheless, the vast majority of surgeons across all age groups are more than willing to acquire new insights and adapt to changes in order to reduce energy consumption and carbon dioxide production.

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.

Comparative Life Cycle Assessment Between Single-Use and Reprocessed IPC Sleeves

Purpose

Healthcare has a large environmental footprint, not least due to the wide use of single-use supplies. Reprocessing of medical devices is a well-established, regulated process, and can reduce its environmental impact. This life cycle assessment (LCA) compares the environmental footprint of a single-use and a reprocessed version of otherwise identical intermittent pneumatic compression (IPC) sleeves.

Materials and Methods

The LCA was performed in accordance with the international standard ISO 14044 using the Environmental Footprint 3.0 (EF) method for the assessment. Data were obtained in cooperation with IPC sleeve manufacturers. Where no primary data were available, ecoinvent database records were used. The functional unit is five hospital treatments applying IPC. The robustness of the results was interrogated in sensitivity analyses of the energy mix, the ethylene oxide emissions during reprocessing, and the transport distances. The impact of waste reduction on hospital disposal costs was calculated.

Results

The environmental footprint of reprocessed IPC sleeves was found to be reduced in all categories compared to single-use devices, leading to a weighted normalized reduction of 43% across all categories. In a breakdown of the LCA results, reprocessed IPC sleeves were found to reduce the carbon footprint by 40%, with the treatment of five patients with single-use IPC sleeves creating 7 kg CO2eq, compared to 4.2 kg CO2eq from reprocessed sleeves. Waste disposal costs were also reduced by 90%.

Conclusion

Reprocessing of IPC sleeves provides an environmental and economic benefit in comparison to single-use devices.

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.

Disposable and reusable instruments in dental health practice: A comparison of cost factors in a public provider organization in Queensland, Australia

OBJECTIVES

Choosing between reusable instruments (RIs) and disposable instruments (DIs) for dental care provision requires a careful consideration of costs and their contributing factors, alongside other choice criteria. This study aimed to assess the current use of instruments in the West Moreton Oral Health Service (WMOHS) in Queensland, Australia, with a broader goal of informing future practice in this and comparable organizations.

METHODS

A cost model was developed reflecting costs arising from procurement, reprocessing and disposal, depending on the RI and DI composition of instrumentation. The current practice in WMOHS was compared to modular (RI-only and DI-only) strategies by considering four standard instrument sets (examination, simple extraction, surgical extraction, restoration) and the annual use of instruments in the organization at large. The use of resources (water, electricity) and emissions (waste) were quantified for each strategy. The robustness of findings was explored across a range of scenarios that involved varying instrument prices, lifespans, factors impacting on the cost of reprocessing (labour, water, energy), the cost of waste disposal and couriering.

RESULTS

At the organization level, the current mix of instruments (A$1.28 m per year) was 4% more costly than the lower cost, RI-only alternative (A$1.23 m). However, with lower DI prices or higher labour costs current practice would become the lowest cost option. Results for specific instrument sets varied by service type. DI-only offered the lowest cost option for oral examinations (A$6.29), and the current practice of mixed instrumentation for simple extractions (A$16.56). RI-only sets were less costly in more resource intensive procedures such as surgical extractions (A$40.19) and restorations (A$43.83). In terms of environmental impacts, the use of instruments based on current practice required 37% of water and energy use of an RI-only alternative and generated 36% waste of the DI-only alternative.

CONCLUSIONS

Reusable instruments are generally less costly than DIs, but for specific instrument sets the outcome depends on the type of procedure. In some circumstances, mixed instrumentation can provide the lowest cost alternative. While the WMOHS instrument mix used in current practice does not minimize cost for the provider, it may be justified in light of operational risks, logistics and uncertainty regarding cost factors.

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.

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.

Climate change, health and sustainable healthcare: The role of health economics

Healthcare systems around the world are responding with increasing urgency to rapidly evolving ecological crises, most notably climate change. This Perspective considers how health economics and health economists can best contribute to protecting health and building sustainable healthcare systems in the face of these challenges.

Interventions for sustainable surgery: a systematic review

OBJECTIVE

To systematically evaluate interventions designed to improve the sustainability of surgical practice with respect to their environmental and financial impact.

BACKGROUND

Surgery contributes significantly to emissions attributed to healthcare due to its high resource and energy use. Several interventions across the operative pathway have, therefore, been trialed to minimize this impact. Few comparisons of the environmental and financial effects of these interventions exist.

MATERIALS AND METHODS

A search of studies published up to 2nd February 2022 describing interventions to increase surgical sustainability was undertaken. Articles regarding the environmental impact of only anesthetic agents were excluded. Data regarding environmental and financial outcomes were extracted with a quality assessment completed dependent upon the study design.

RESULTS

In all, 1162 articles were retrieved, of which 21 studies met inclusion criteria. Twenty-five interventions were described, which were categorized into five domains: 'reduce and rationalize', 'reusable equipment and textiles', 'recycling and waste segregation', 'anesthetic alternatives', and 'other'. Eleven of the 21 studies examined reusable devices; those demonstrating a benefit reported 40-66% lower emissions than with single-use alternatives. In studies not showing a lower carbon footprint, the reduction in manufacturing emissions was offset by the high environmental impact of local fossil fuel-based energy required for sterilization. The per use monetary cost of reusable equipment was 47-83% of the single-use equivalent.

CONCLUSIONS

A narrow repertoire of interventions to improve the environmental sustainability of surgery has been trialed. The majority focuses on reusable equipment. Emissions and cost data are limited, with longitudinal impacts rarely investigated. Real-world appraisals will facilitate implementation, as will an understanding of how sustainability impacts surgical decision-making.

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.

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.

Climate-smart Actions in the Operating Theatre for Improving Sustainability Practices: A Systematic Review

CONTEXT

Surgical activity contributes to global warming though the production of greenhouse gases and consumption of resources. To date, no clinical practice guidelines have been made to promote and implement climate-smart actions.

OBJECTIVE

To perform a systematic review of the available actions that could limit CO₂ emission in the operating room (OR) and their potential benefits upon the environment, whilst preserving quality of care.

EVIDENCE ACQUISITION

MEDLINE and Cochrane databases were searched from January 1, 1990 to April 2021. We included studies assessing carbon footprint (CF) in the OR and articles detailing actions that limit or reduce CF.

EVIDENCE SYNTHESIS

Thirty-eight studies met the inclusion criteria. We identified six core climate-smart actions: (1) waste reduction by segregation; (2) waste reduction by recycling, reuse, and reprocessing; (3) sterilisation; (4) anaesthesia gas management; and (5) improvement of energy use. Quantitative analysis regarding the CF was not possible due to the lack of homogeneous data. For climate-smart actions, the analysis was limited by discrepancies in study scope and in the methodology of CO₂ emission calculation. Improvement of education and awareness was found to have an important impact on waste segregation and reduction. Waste management is the area where health care workers could have the strongest impact, whereas the main field to reduce CF in the OR was found to be energy consumption.

CONCLUSIONS

This review provides arguments for many climate-smart actions that could be implemented in our daily practice. Improving awareness and education are important to act collectively in a sustainable way. Further studies are mandatory to assess the impact of these climate-smart actions in the OR.

PATIENT SUMMARY

We performed a systematic review of the available scientific literature to reference all the climate-smart actions proposed to improve the sustainability of surgical activities. Waste segregation, waste reduction and recycling, reuse and reprocessing, sterilisation, anaesthesia gas changes, and improvement of energy use in the operating room were found to be the main areas of research. There is still a long way to go to homogenise and improve the quality of our climate-smart actions.

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.

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.

Environmental Impact of Prostate Magnetic Resonance Imaging and Transrectal Ultrasound Guided Prostate Biopsy

BACKGROUND

Reducing low-value clinical care is an important strategy to mitigate environmental pollution caused by health care.

OBJECTIVE

To estimate the environmental impacts associated with prostate magnetic resonance imaging (MRI) and prostate biopsy.

DESIGN, SETTING, AND PARTICIPANTS

We performed a cradle-to-grave life cycle assessment of prostate biopsy. Data included materials and energy inventory, patient and staff travel contributed by prostate MRI, transrectal ultrasound guided prostate biopsy, and pathology analysis. We compared environmental emissions across five clinical scenarios: multiparametric MRI (mpMRI) of the prostate with targeted and systematic biopsies (baseline), mpMRI with targeted biopsy cores only, systematic biopsy without MRI, mpMRI with systematic biopsy, and biparametric MRI (bpMRI) with targeted and systematic biopsies. We estimated the environmental impacts associated with reducing the overall number and varying the approach of a prostate biopsy by using MRI as a triage strategy or by omitting MRI. The study involved academic medical centers in the USA, outpatient urology clinics, health care facilities, medical staff, and patients.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

Greenhouse gas emissions (CO₂ equivalents, CO₂e), and equivalents of coal and gasoline burned were measured.

RESULTS AND LIMITATIONS

In the USA, a single transrectal prostate biopsy procedure including prostate MRI, and targeted and systematic biopsies emits an estimated 80.7 kg CO₂e. An approach of MRI targeted cores alone without a systematic biopsy generated 76.2 kg CO₂e, a systematic 12-core biopsy without mpMRI generated 36.2 kg CO₂e, and bpMRI with targeted and systematic biopsies generated 70.5 kg CO₂e; mpMRI alone contributed 42.7 kg CO₂e (54.3% of baseline scenario). Energy was the largest contributor, with an estimated 38.1 kg CO₂e, followed by staff travel (20.7 kg CO₂e) and supply production (11.4 kg CO₂e). Performing 100 000 fewer unnecessary biopsies would avoid 8.1 million kg CO₂e, the equivalent of 4.1 million liters of gasoline consumed. Per 100 000 patients, the use of prostate MRI to triage prostate biopsy and guide targeted biopsy cores would save the equivalent of 1.4 million kg of CO₂ emissions, the equivalent of 700 000 l of gasoline consumed. This analysis was limited to prostate MRI and biopsy, and does not account for downstream clinical management.

CONCLUSIONS

A prostate biopsy contributes a calculable environmental footprint. Modifying or reducing the number of biopsies performed through existing evidence-based approaches would decrease health care pollution from the procedure.

PATIENT SUMMARY

We estimated that prostate magnetic resonance imaging (MRI) with a prostate biopsy procedure emits the equivalent of 80.7 kg of carbon dioxide. Performing fewer unnecessary prostate biopsies or using prostate MRI as a tool to decide which patients should have a prostate biopsy would reduce procedural greenhouse gas emissions and health care pollution.

Modeling the Environmental and Financial Impact of Multi-dose vs. Single-dose Iodinated Contrast Media Packaging and Delivery Systems

RATIONALE AND OBJECTIVES

Iodinated contrast media (ICM) is used in computed tomography (CT) imaging to better visualize pathophysiology. ICM is commonly sold in "single-dose" bottles that require any unused volume to be discarded. Multi-dose bottles have been developed as an alternative packaging method. The objective of this study was to compare ICM waste, plastic waste, and the associated financial costs for both the single-dose and multi-dose ICM delivery systems.

METHODS

Institutional data was used to estimate the average ICM administered per CT scan, average ICM wasted per CT scan, and the total ICM volume wasted annually. Waste estimates for the multi-dose bottles were generated by applying the average ICM administered per CT scan to the larger, multi-dose bottle volumes. Single-dose bottles, multi-dose bottles and injection syringes were weighed and used to calculate plastic waste generated by both packaging methods. Financial analysis was performed to compare the cost of supplies for single-dose and multi-dose ICM delivery systems.

RESULTS

We found that 100 mL single-dose ICM bottles waste an average of 19.7 mL per CT scan, representing over 964 L of ICM wasted per year. The multi-dose ICM delivery system was projected to decrease pharmaceutical waste by at least 73% and reduce plastic waste by approximately 93%. We also estimate $494,000 in annual savings using the multi-dose ICM delivery method at our institution.

CONCLUSION

Multi-dose ICM packaging can help conserve ICM, an important pharmaceutical that was only recently severely affected supply chain disruptions. The multi-dose delivery system can also reduce plastic waste and generate substantial financial savings to offset capital investment.

Incorporating environmental and sustainability considerations into health technology assessment and clinical and public health guidelines: a scoping review

Healthcare systems account for a substantial proportion of global carbon emissions and contribute to wider environmental degradation. This scoping review aimed to summarize the evidence currently available on incorporation of environmental and sustainability considerations into health technology assessments (HTAs) and guidelines to support the National In stitute for Health and Care Excellence and analogous bodies in other jurisdictions developing theirown methods and processes. Overall, 7,653 articles were identified, of which 24 were included in this review and split into three key areas - HTA (10 studies), healthcare guidelines (4 studies), and food and dietary guidelines (10 studies). Methodological reviews discussed the pros and cons of different approaches to integrate environmental considerations into HTAs, including adjustments to conventional cost-utility analysis (CUA), cost-benefit analysis, and multicriteria decision analysis. The case studies illustrated the challenges of putting this into practice, such as lack of disaggregated data to evaluate the impact of single technologies and difficulty in conducting thorough life cycle assessments that consider the full environmental effects. Evidence was scant on the incorporation of environmental impacts in clinical practice and public health guidelines. Food and dietary guidelines used adapted CUA based on life cycle assessments, simulation modeling, and qualitative judgments made by expert panels. There is uncertainty on how HTA and guideline committees will handle trade-offs between health and environment, especially when balancing environmental harms that fall largely on society with health benefits for individuals. Further research is warranted to enable integration of environmental considerations into HTA and clinical and public health guidelines.

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.