A pathway to net zero emissions for healthcare

Health Economics in a World of Uneconomic Growth

Multiple, accelerating and interacting ecological crises are increasingly understood as constituting a major threat to human health and well-being. Unconstrained economic growth is strongly implicated in these growing crises, and it has been argued that this growth has now become "uneconomic growth", which is a situation where the size of the economy is still expanding, but this expansion is causing more harm than benefit. This article summarises the multiple pathways by which uneconomic growth can be expected to harm human health. It describes how health care systems-especially through overuse, low value and poor quality care-can themselves drive uneconomic growth. Health economists need to understand not only the consequences of environmental impacts on health care, but also the significance of uneconomic growth, and pay closer attention to the growing body of work by heterodox economists, especially in the fields of ecological and feminist economics. This will involve paying closer heed to the existence and consequences of diminishing marginal returns to health care consumption at high levels; the central importance of inequalities and injustice in health; and the need to remedy health economists' currently limited ability to deal effectively with low value care, overdiagnosis and overtreatment.

Chronic kidney disease and the global public health agenda: an international consensus

Early detection is a key strategy to prevent kidney disease, its progression and related complications, but numerous studies show that awareness of kidney disease at the population level is low. Therefore, increasing knowledge and implementing sustainable solutions for early detection of kidney disease are public health priorities. Economic and epidemiological data underscore why kidney disease should be placed on the global public health agenda - kidney disease prevalence is increasing globally and it is now the seventh leading risk factor for mortality worldwide. Moreover, demographic trends, the obesity epidemic and the sequelae of climate change are all likely to increase kidney disease prevalence further, with serious implications for survival, quality of life and health care spending worldwide. Importantly, the burden of kidney disease is highest among historically disadvantaged populations that often have limited access to optimal kidney disease therapies, which greatly contributes to current socioeconomic disparities in health outcomes. This joint statement from the International Society of Nephrology, European Renal Association and American Society of Nephrology, supported by three other regional nephrology societies, advocates for the inclusion of kidney disease in the current WHO statement on major non-communicable disease drivers of premature mortality.

Toward a Climate-Ready Health Care System: Institutional Motivators and Workforce Engagement

Policy Points The US health care system faces mounting pressure to reduce greenhouse gas emissions and adapt to the impacts of climate change; motivated institutions and an engaged health care workforce are essential to the development, implementation, and maintenance of a climate-ready US health care system. Health care workers have numerous profession-specific and role-specific opportunities to address the causes and impacts of climate change. Policies must address institutional barriers to change and create incentives aligned with climate readiness goals. Institutions and individuals can support climate readiness by integrating content on the health care implications of climate change into educational curricula.

Supporting Decarbonization of Health Systems-A Review of International Policy and Practice on Health Care and Climate Change

PURPOSE OF REVIEW

Healthcare is a significant contributor of carbon emissions, which contribute to climate change. There has been an increased focus on the role healthcare should play in reducing emissions in recent years. This review, completed in September and October 2022, explored national commitments among 73 countries to reduce emissions from healthcare and the policies and delivery plans that exist to support their implementation.

RECENT FINDINGS

Whilst some countries such as Norway, Columbia, and Australia are working to understand current emissions and develop plans to reduce them, few have published delivery plans for meeting national targets. Broader policies and reports published to date provide a clear set of actions that healthcare can take to reduce emissions. However, more research, innovation, and service redesign will be needed to close the gap to net zero healthcare. Some health systems are already taking action to reduce their emissions. However, national incentives, including standardized metrics and reporting, can help drive broader action and pace of delivery.

Human health and the health of Planet Earth go together

The emergence of the planetary health approach was highlighted by the report of The Rockefeller Foundation-Lancet Commission on Planetary Health in 2015 and changed how we comprehend human well-being. The report advocates integrating the health of other living beings and Earth's natural systems as intrinsic components of human health. Drawing on over three decades of experience in respiratory epidemiology and environmental health, this article outlines how my perspective on human health underwent a transformative shift upon reading the abovementioned report. The planetary health approach offers a lens through which human health issues and potential solutions can be understood within the context of the Anthropocene. It addresses the pressing existential challenges arising from humanity's transgression of planetary limits. Embracing the planetary health paradigm within the field of health sciences can catalyze transformative changes essential for cultivating a sustainable and equitable future.

Electricity consumption of anesthesia workstations and potential emission savings by avoiding standby

BACKGROUND

Anesthesiology has a relevant carbon footprint, mainly due to volatile anesthetics (scope 1 emissions). Additionally, energy used in the operating theater (scope 2 emissions) contributes to anesthesia-related greenhouse gas (GHG) emissions.

OBJECTIVES

Optimizing the electricity use of medical devices might reduce both GHG emissions and costs might hold potential to reduce anaesthesia-related GHG-emissions and costs. We analyzed the electricity consumption of six different anesthesia workstations, calculated their GHG emissions and electricity costs and investigated the potential to reduce emissions and cost by using the devices in a more efficient way.

METHODS

Power consumption (active power in watt , W) was measured with the devices off, in standby mode, or fully on with the measuring instrument SecuLife ST. Devices studied were: Dräger Primus, Löwenstein Medical LeonPlus, Getinge Flow C, Getinge Flow E, GE Carestation 750 and GE Aisys. Calculations of GHG emissions were made with different emission factors, ranging from very low (0.09 kg CO2-equivalent/kWh) to very high (0.660 kg CO2-equivalent/kWh). Calculations of electricity cost were made assuming a price of 0.25 € per kWh.

RESULTS

Power consumption during operation varied from 58 W (GE CareStation 750) to 136 W (Dräger Primus). In standby, the devices consumed between 88% and 93% of the electricity needed during use. The annual electricity consumption to run 96 devices in a large clinical department ranges between 45 and 105 Megawatt-hours (MWh) when the devices are left in standby during off hours. If 80% of the devices are switched off during off hours, between 20 and 46 MWh can be saved per year in a single institution. At the average emission factor of our hospital, this electricity saving corresponds to a reduction of GHG emissions between 8.5 and 19.8 tons CO2-equivalent. At the assumed prices, a cost reduction between 5000 € and 11,600 € could be achieved by this intervention.

CONCLUSION

The power consumption varies considerably between the different types of anesthesia workstations. All devices exhibit a high electricity consumption in standby mode. Avoiding standby mode during off hours can save energy and thus GHG emissions and cost. The reductions in GHG emissions and electricity cost that can be achieved with this intervention in a large anesthesiology department are modest. Compared with GHG emissions generated by volatile anesthetics, particularly desflurane, optimization of electricity consumption of anesthesia workstations holds a much smaller potential to reduce the carbon footprint of anesthesia; however, as switching off anesthesia workstations overnight is relatively effortless, this behavioral change should be encouraged from both an ecological and economical point of view.

Carbon footprint of Nepalese healthcare system: A study of Dhulikhel Hospital

Background

Though direct greenhouse gas emissions cannot be observed in health care sectors, there can exist indirect emissions contributing to global climate change. This study addresses the concept of the carbon footprint and its significance in understanding the environmental impact of human activities, with a specific emphasis on the healthcare sector through gate-to-gate (GtoG) life cycle assessment. Transportation, energy consumption, and solid waste generated by hospitals are the primary sources of carbon emissions.

Methods

Different standards, guidelines and parameters were used to estimate emissions from both the primary and secondary data. All steps and sub-steps involved in GtoG were accessed and analyzed within the standard ISO 14040:44 guideline. An extensive review of existing literature was carried out for the evaluation and verification of secondary data.

Results

The total carbon footprint of generators, electricity consumption, transportation activities, LPG cylinders, PV systems was found to be 58,780 kg-CO2-eq/yr, 519,794 kg-CO2-eq/yr, 272,375 kg-CO2-eq/yr, 44,494 kg-CO2-eq/yr, 35,283 kg-CO2-eq/yr respectively and the emissions from non-biodegradable solid waste was found to be 489,835 kg-CO2/yr. Local air pollutants such as PM 10, CO, SO 2, NO X, and VOCs generated by generators and transportation were also estimated. The CH 4 emissions from liquid waste were 1177.344 kg CH 4/BOD yr, and those from biodegradables were 3821.6954 kg CH4/yr.

Conclusions

Healthcare professionals and policymakers can take action to reduce the sector's carbon footprint by implementing best practices and encouraging sustainable behavior. This study can be taken as foundation for further exploration of indirect emissions from healthcare sectors not only in Nepal but also in south Asian scenario.

Reducing the Environmental and Economic Costs of Single-Department Infectious Waste Disposal

PURPOSE

The aim of this study was to demonstrate the efficacy of zero-cost interventions on the reduction of infectious waste (IW) stream production in interventional radiology (IR).

METHODS

This quality improvement initiative was developed using needs identification through department-wide meetings with IR stakeholders (physicians, nurses, and radiologic technologists). Department leadership identified and implemented two interventions to reduce disposal of noninfectious waste (NIW) in the IW stream. First, hospital waste management provided focused education for sorting IW versus NIW to IR staff members. Next, the number of IW bins was reduced, and the IW bins were strategically placed on the perimeter of the room. Radiologic technologists tracked IW and NIW bags per case for 25 case days before the intervention and 175 case days after the intervention. A run chart was created to visualize change over time. Wilcoxon rank sum and signed rank tests were performed to evaluate the difference in IW and NIW bags per case before and after the intervention. A goal of significant reduction in NIW stream production was set.

RESULTS

Before the intervention, the production of IW and NIW bags per case was similar (median, 1.0 [interquartile range (IQR), 0.86-1.31] vs 1.1 [IQR, 0.86-1.40]; P = .20). After the intervention, IW bags per case decreased (median, 1.0 [IQR, 0.86-1.31] vs 0.05 [IQR, 0.00-0.13]; P < .001). Fewer IW bags than NIW bags were produced per case after the intervention (median, 0.05 [IQR, 0.00-0.13] vs 1.53 [IQR, 1.30-1.76]; P < .001).

CONCLUSIONS

Zero-cost interventions, including focused education, stakeholder engagement, and strategic placement of waste bins, can significantly reduce the environmental and economic impact of waste produced in IR.

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.

Barriers and facilitators to sustainable operating theatres: a systematic review using the Theoretical Domains Framework

BACKGROUND

The health sector contributes significantly to the climate crisis. Operating theatres (OTs) in particular are a major contributor of greenhouse gas emissions and waste, and while there are several evidence-based guidelines to reduce this impact, these are often not followed. The authors systematically reviewed the literature to identify barriers and facilitators of sustainable behaviour in OTs, categorising these using the Theoretical Domains Framework (TDF).

MATERIALS AND METHODS

Medline, Embase, PsychInfo, and Global Health databases were searched for articles published between January 2000 and June 2023, using the concepts: barriers and facilitators, sustainability, and surgery. Two reviewers screened abstracts from identified studies, evaluated quality, and extracted data. Identified determinants were mapped to TDF domains and further themes as required. The results were reported in line with PRISMA (Preferred Reporting Items for Systematic reviews and Meta-Analyses) and AMSTAR (A MeaSurement Tool to Assess Systematic Reviews) guidelines.

RESULTS

Twenty-one studies were selected for analysis and assessment (17 surveys and four interview studies) comprising 8286 participants, including surgeons, nurses, and anaesthetists. Eighteen themes across 10 TDF domains were identified. The most common barriers to adoption of green behaviours in OTs were in domains of: 'knowledge' ( N =18), for example knowledge of sustainable practices; 'environmental context and resources' ( N =16) for example personnel shortage and workload and inadequate recycling facilities; 'social influences' ( N =9) for example lack of leadership/organisational mandate or support; 'beliefs about consequences' ( N =9) for example concerns regarding safety. Intention was the most common facilitator, with 11 studies citing it.

CONCLUSIONS

Despite intentions to adopt sustainable practices in OTs, this review identified several barriers to doing so. Interventions should focus on mitigating these, especially by improving staff's knowledge of sustainability practices and working within the environmental context and time pressures. Furthermore, institutional change programmes and policies are needed to prioritise sustainability at the hospital and trust level. Additional qualitative work should also be conducted using behavioural frameworks, to more comprehensively investigate barriers and determinants to decarbonise OTs.

Hearing Loss and Disorders: The Repercussions of Climate Change

PURPOSE

Climate change is considered to be the greatest threat to human health in the 21st century, and its effects are accelerating. Extensive research has clearly demonstrated its increasing impact across the continuum of health conditions. Despite this, there has been limited attention to the ramifications of climate change on hearing loss and hearing disorders. This lack of consideration is somewhat surprising as the environment itself and its changing nature have a substantial effect on hearing.

METHOD

Tackling climate change could be the greatest global health opportunity of the 21st century. To address this issue, this tutorial provides a general introduction to climate change and its three major elements (pollution, infectious diseases, and extreme weather events) and their effects on health. The substantial consequences of climate change for the incidence, development, and exacerbation of hearing loss and disorders are clearly described and detailed.

CONCLUSIONS

The challenge of responding to this very real and escalating threat to hearing requires a combination of prevention, advocacy, and education. These three roles place audiologists in the perfect position to take action on the far-reaching effects of climate change on hearing loss and disorders. To respond to this challenge and to fulfill these roles, several strategies, ranging from the individual level to the global level, are delineated for audiologists to incorporate into their practice.

Factors contributing to the carbon footprint of cataract surgery

The healthcare sector is a significant greenhouse gas emitter. Cataract surgery is a procedure that results in a large amount of carbon dioxide (CO2) emissions. We sought to review the literature for factors contributing to the carbon footprint of this procedure. The literature, although limited, varies greatly by region. The carbon footprint of cataract surgery ranged from approximately 6 kg CO2 equivalents in a center in India to 181.9 kg CO2 equivalents in a center in the United Kingdom. Factors contributing to the carbon footprint of cataract surgery included the procurement of materials, energy use, and the emissions associated with travel. Factors facilitating a lower carbon footprint include the reuse of surgical materials and more efficient autoclave settings. Potential areas for improvement to consider include the reduction in packaging material, the reuse of materials, and potentially reducing travel emissions by performing simultaneous bilateral cataract surgery.

A Review of the Applicability of Current Green Practices in Healthcare Facilities

BACKGROUND

Circular economy (CE) has raised great interest as a concept and as a development model worldwide. This concept aims to provide a substitute for the linear economic model, which was based on production and consumption, continuous growth, and resources depletion. CE allows a greener economy with sustainable development and promotes more balanced societies. The healthcare sector is a major contributor to the climate crisis, with a carbon footprint representing 4.4% of global net emissions. It is thus essential to rethink the applicability of CE in healthcare.

METHODS

We conducted a scoping review guided by the Arksey and O'Malley methodological framework and utilised PRISMA-ScR (Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews) checklist. A systematic search from MEDLINE complete, SCOPUS, and Web of Science databases published between 1992 and 2022.

RESULTS

Through database searching a total of 1018 records were identified and 475 duplicates were removed. From the total search, 543 articles were screened by title/abstract according to the inclusion and exclusion criteria. After screening, 38 full-text articles were selected and assessed for eligibility. Forty-seven additional records were also identified through other sources and screened for eligibility. Other sources included: 12 articles from snowballing of previous papers; 9 articles following peer-reviewers suggestions; 19 reports from relevant organisations in CE and healthcare; two webpage, and one book.

CONCLUSION

Specific areas were identified where hospitals could reduce their greenhouse gas (GHG) emissions and consequently their negative environmental impact, namely through waste management, energy, water, transportation/travel, hospital design, food optimisation, green procurement, and behaviour. Also, lack of staff awareness and knowledge of the environmental impact of healthcare, and hospitals sustainability were identified as major contributors.

Fair pathways to net-zero healthcare

Over the past decade, it has become clear that the health sector is not only at risk from climate change but also a major polluter of greenhouse gases. In November 2021, the World Health Organization and partners launched the COP26 Health Programme for sustainable, climate-resilient and low-carbon health systems, and have since established the Alliance for Transformative Action on Climate and Health to support its implementation. Given the wide variation in health financing, carbon emissions and unmet health needs across the world, fair sharing of the remaining carbon budget and health gains will be critical. In this Perspective, we explore the challenges and opportunities of healthcare decarbonization, outlining the principles of fair pathways to net-zero healthcare that are attentive to health and socioeconomic inequalities within and between countries.

Aspects Regarding Sustainability among Private Dental Practitioners from Bucharest, Romania: A Pilot Study

Oral health professionals' knowledge of sustainability is essential for promoting environmental protection in dental healthcare. This pilot study involved an online survey addressed to 70 dental private practitioners from Bucharest, Romania, to evaluate their awareness of the concept of sustainability in dentistry. The performed statistical analysis revealed that 41.4% of the participants were well aware of sustainability in dentistry, with older participants demonstrating significantly higher levels of such awareness (p = 0.001). Sustainability awareness among participants correlates positively with their knowledge of the negative environmental impacts of dental activity (p < 0.001) and with the concern for sustainable dentistry implementation in their workplace (p = 0.037). Improper biohazardous waste disposal was identified as the primary cause of negative environmental impact of dental practices by 87.1% of participants. Installing high energy-efficient dental equipment was selected as the most important action to implement sustainability in participants' dental practices (64.3%). Overall, 51.4% of the participants reported that the COVID-19 pandemic had a medium impact on their dental activity in terms of sustainability. Our study found that participants have a moderate level of awareness regarding sustainability in dentistry, highlighting the need for education on sustainability for oral health professionals.

Considerations for integrating wearables into the everyday healthcare practice

Wearable technologies are becoming ever more popular as suggested tools for use in modern medicine. Studies evidence their growing pragmatism and provision of objective data for a more informative and personalised approach to patient care. Yet many wearables are one dimensional, despite the underlying technology being common across a large array of tools. That is primarily due to the accompanying software, unmodifiable or black box-based scripts that generally lack accessibility or modification, meaning wearables may often get discarded. Use of wearables for sustainable healthcare needs careful consideration.

'Climate change mitigation is a hot topic, but not when it comes to hospitals': a qualitative study on hospital stakeholders' perception and sense of responsibility for greenhouse gas emissions

OBJECTIVE

Physical and mental well-being are threatened by climate change. Since hospitals in high-income countries contribute significantly to climate change through their greenhouse gas (GHG) emissions, the medical ethics imperative of 'do no harm' imposes a responsibility on hospitals to decarbonise. We investigated hospital stakeholders' perceptions of hospitals' GHG emissions sources and the sense of responsibility for reducing GHG emissions in a hospital.

METHODS

We conducted 29 semistructured qualitative expert interviews at one of Germany's largest hospitals, Heidelberg University Hospital. Five patients, 12 clinical and 12 administrative employees on different levels were selected using purposive maximum variation sampling. Interviews were transcribed verbatim and analysed using the framework approach.

RESULTS

Concerning GHG emissions, hospital stakeholders perceived energy and waste as most relevant emission sources followed by mobility. Climate change mitigation in general was considered as important. However, in their role as patients or employees, hospital stakeholders felt less responsible for climate change mitigation. They saw providing best possible medical care to be the top priority in hospitals and were often concerned that patients' health could be jeopardised by climate change mitigation measures.

CONCLUSION

Perceptions of most important emission sources did not coincide with those in literature, highlighting the need to inform stakeholders, for instance, about pharmaceuticals as important emission source. A frequently perceived conflict between reducing emissions and providing high-quality medical care could be eased, if reducing emissions would not only be justified as a contribution to mitigation, but also as a contribution to preventing ill health-a basic principle of medical ethics.

Evaluating the Short-term Environmental and Clinical Effects of a Radiation Oncology Department's Response to the COVID-19 Pandemic

PURPOSE

During the COVID-19 pandemic, many radiation oncology departments worldwide adopted the use of shorter and more intense hypofractionated regimens. Hospital foot traffic was reduced through virtual care. This study's primary objective was to assess the collective environmental effect of these strategic changes by identifying sources of carbon dioxide equivalents (CO₂e). The rate of radiation-related adverse events from the increased use of hypofractionated treatments was assessed.

METHODS AND MATERIALS

All patients treated with external beam radiation therapy from April 1, 2019, to March 31, 2021, at our single institution were identified (n = 10,175) along with their radiation therapy visits (176,423 fractions) and unplanned visits to the radiation nursing clinic or emergency department. Out-patient hospital and virtual visits (n = 75,853) during this same period were also analyzed. Environmental effect measures, including linear accelerator power usage, patient travel distances, and personal protection equipment consumption were all converted into CO₂e.

RESULTS

The use of curative hypofractionated regimens increased from 17% to 27% during the pandemic year. Carbon footprint was reduced by 39% during the pandemic year (1,332,388 kg CO₂e) compared with the prepandemic year (2,024,823 kg CO₂e). Comparing patients in the prepandemic versus pandemic year, there was a significant reduction in the proportion of hypofractionated patients who needed a visit to either the radiation nursing clinic (39% vs 25%; P < .001) or emergency department (6% vs 2%; P < .001) during and within 90 days of radiation therapy.

CONCLUSIONS

This is the first study to demonstrate the environmental benefits of increased use of hypofractionated regimens and virtual care, while assuring that there was no added acute radiation-related adverse event. Our findings support their continued use as one of many long-term strategies to reduce the environmental footprint of health care delivery.

Climate change and the prevention of cardiovascular disease

Climate change is a worsening global crisis that will continue negatively impacting population health and well-being unless adaptation and mitigation interventions are rapidly implemented. Climate change-related cardiovascular disease is mediated by air pollution, increased ambient temperatures, vector-borne disease and mental health disorders. Climate change-related cardiovascular disease can be modulated by climate change adaptation; however, this process could result in significant health inequity because persons and populations of lower socioeconomic status have fewer adaptation options. Clear scientific evidence for climate change and its impact on human health have not yet resulted in the national and international impetus and policies necessary to slow climate change. As respected members of society who regularly communicate scientific evidence to patients, clinicians are well-positioned to advocate on the importance of addressing climate change. This narrative review summarizes the links between climate change and cardiovascular health, proposes actionable items clinicians and other healthcare providers can execute both in their personal life and as an advocate of climate policies, and encourages communication of the health impacts of climate change when counseling patients. Our aim is to inspire the reader to invest more time in communicating the most crucial public health issue of the 21st century to their patients.

The global temperature-related mortality impact of earlier decarbonization for the Australian health sector and economy: A modelling study

Background

Sustained elevated concentration of GHGs is predicted to increase global mortality. With the Australian health sector responsible for 7% of the nation’s GHG emissions, the benefits and costs of various decarbonisation trajectories are currently being investigated. To assist with this effort, we model the impact earlier decarbonisation has on temperature-related mortality.

Design

We used DICE-EMR, an Integrated Assessment Model with an endogenous mortality response, to simulate Australian GHG trajectories and estimate the temperature-related mortality impact of early decarbonisation. We modelled a linear decline of the Australian health sector’s and economy’s GHG annual emissions to net-zero targets of 2040 and 2050.

Main outcome measure

Deaths averted and monetary-equivalent welfare gain.

Results

Decarbonisation of the Australian health sector by 2050 and 2040 is projected to avert an estimated 69,000 and 77,000 global temperature-related deaths respectively in a Baseline global emissions scenario. Australian economy decarbonisation by 2050 and 2040 is projected to avert an estimated 988,000 and 1,101,000 global deaths respectively. Assuming a low discount rate and high global emissions trajectory, we estimate a monetary equivalent welfare gain of $151 billion if the Australian health sector decarbonises by 2040, only accounting for the benefits in reducing temperature-related mortality.

Conclusions

Earlier decarbonisation has a significant impact on temperature-related mortality. Many uncertainties exist and health impacts other than temperature-related mortality are not captured by this analysis. Nevertheless, such models can help communicate the health risk of climate change and improve climate policy decision making.

Environmental sustainability in orthopaedic surgery

Aims

In the UK, the NHS generates an estimated 25 megatonnes of carbon dioxide equivalents (4% to 5% of the nation’s total carbon emissions) and produces over 500,000 tonnes of waste annually. There is limited evidence demonstrating the principles of sustainability and its benefits within orthopaedic surgery. The primary aim of this study was to analyze the environmental impact of orthopaedic surgery and the environmentally sustainable initiatives undertaken to address this. The secondary aim of this study was to describe the barriers to making sustainable changes within orthopaedic surgery.

Methods

A literature search was performed according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines through EMBASE, Medline, and PubMed libraries using two domains of terms: “orthopaedic surgery” and “environmental sustainability”.

Results

A total of 13 studies were included in the final analysis. All papers studied the environmental impact of orthopaedic surgery in one of three areas: waste management, resource consumption, and carbon emissions. Waste segregation was a prevalent issue and described by nine studies, with up to 74.4% of hazardous waste being generated. Of this, six studies reported recycling waste and up to 43.9% of waste per procedure was recyclable. Large joint arthroplasties generated the highest amount of recyclable waste per procedure. Three studies investigated carbon emissions from intraoperative consumables, sterilization methods, and through the use of telemedicine. One study investigated water wastage and demonstrated that simple changes to practice can reduce water consumption by up to 63%. The two most common barriers to implementing environmentally sustainable changes identified across the studies was a lack of appropriate infrastructure and lack of education and training.

Conclusion

Environmental sustainability in orthopaedic surgery is a growing area with a wide potential for meaningful change. Further research to cumulatively study the carbon footprint of orthopaedic surgery and the wider impact of environmentally sustainable changes is necessary.

Cite this article: Bone Jt Open 2022;3(8):628–640.

Improving the environmental sustainability of paediatric care

Accelerated global warming is directly related to greenhouse gas (GHG) emissions. In order to achieve international and national set targets on reducing GHG emissions, paediatricians should aim to decrease GHG emissions associated with paediatric care, when this is not in conflict with patient outcomes. In this article, we review literature on practical ways to encourage environmentally sustainable paediatric care and identify areas where more evidence is required. Finally, we introduce readers to the principles of sustainable healthcare which may be used to help guide further efforts to reduce the environmental impact of paediatric care.

Turning green: the impact of changing to more eco-friendly respiratory healthcare - a carbon and cost analysis of Dutch prescription data

OBJECTIVES

Dry powder inhalers (DPIs) and soft mist inhalers have a substantially lower global warming potential than pressurised metered-dose inhalers (pMDIs). To help mitigate climate change, we assessed the potential emission reduction in CO₂ equivalents when replacing pMDIs by non-propellant inhalers (NPIs) in Dutch respiratory healthcare and estimated the associated cost.

DESIGN

We performed a descriptive analysis of prescription data from two national databases of two independent governmental bodies. First, we calculated the number of patients with chronic obstructive pulmonary disease (COPD) and asthma that were using inhalation medication (2020). Second, we calculated the number and total of daily defined doses of pMDIs and NPIs including DPIs and soft mist inhalers, as well as the number of dispensed spacers per patient (2020). Third, we estimated the potential emission reduction in CO₂ equivalents if 70% of patients would switch from using pMDIs to using NPIs. Fourth, we performed a budget impact analysis.

SETTING

Dutch respiratory healthcare.

PRIMARY AND SECONDARY OUTCOME MEASURES

The carbon footprint of current inhalation medication and the environmental and financial impact of replacing pMDIs with NPIs.

RESULTS

In 2020, 1.4 million patients used inhalers for COPD or asthma treatment. A total of 364 million defined daily doses from inhalers were dispensed of which 49.6% were dispensed through pMDIs. We estimated that this could be reduced by 70% which would lead to an annual reduction in greenhouse gas emission of 63 million kg.CO2 equivalents saving at best EUR 49.1 million per year.

CONCLUSIONS

In the Netherlands, substitution of pMDIs to NPIs for eligible patients is theoretically safe and in accordance with medical guidelines, while reducing greenhouse gas emission by 63 million kg.CO2 equivalents on average and saving at best EUR 49.1 million per year. This study confirms the potential climate and economic benefit of delivering a more eco-friendly respiratory care.

Climate to COVID, global to local, policies to people: a biopsychosocial ecological framework for syndemic prevention and response in behavioral medicine

Land development, pollution, and waste have affected natural environments, contributing to hurricanes, wildfires, and pandemic infectious diseases like COVID-19. Globalized corporate food systems that produce ultra-refined foods with low nutritional value contribute to both environmental conditions and health conditions like obesity and undernutrition. This has the greatest impact on communities already suffering from elevated health risks driven by economic inequities rooted in racism. These interacting environmental, health, and social conditions represent a syndemic. We outline practical suggestions to address this syndemic of environmental degradation, pandemic infectious disease, chronic disease, undernutrition, and inequity through research and practice at many levels, including individual behavior, local communities, and regional, national and global policy. Collaboration with communities is central to simultaneously tackling interconnected human and environmental health threats. For example, community-led groups have increased access to healthy food in response to pandemic conditions. Building on behavioral medicine's rich foundation of ecological models, communities have partnered with local researchers to address the needs of equitable public transport and reduction of greenhouse gas emissions through multilevel research and practice. Policymakers, researchers, practitioners, and community members should collaborate with each other and across disciplines to find lasting, multiduty solutions to improve physical, psychosocial, and planetary health.

How can we address the ever-pressing need to 'green up' surgical practice in the National Health Service?

Clinical practice has inadvertently changed after the COVID-19 pandemic and currently the need to provide sustainable surgical services is more pressing than ever. The National Health Service has committed to a long-term efficient plan to reduce carbon footprint but there is no detailed plan for surgical practice, the domain that contributes the most to hospital-derived pollution. A series of consecutive steps and measures ought to be taken, starting from a hybrid approach quantifying surgically attributed carbon footprint. Then, a variety of suggested measures can be widely discussed and accordingly applied on a wider or more local level. Appropriate training should always precede implementing new practices to ensure that staff is familiar with these. These measures cover a broad range and should be arranged on a patient-centred basis from preoperative preconditioning to an effective follow-up. The need for more intense research and implementation of enhanced recovery protocols is widely discussed. Also, the necessity of green research and reinvestment of materials and resources is highlighted. A change of philosophy from a cradle-to-grave approach to a repurposing approach is suggested. We are confident that a new era is dawning in surgical practice and teamwork is the key for providing greener surgical services.

Searching for Sustainability in Health Systems: Toward a Multidisciplinary Evaluation of Mobile Health Innovations

Mobile health (mHealth) innovations are considered by governments as game changers toward more sustainable health systems. The existing literature focuses on the clinical aspects of mHealth but lacks an integrated framework on its sustainability. The foundational idea for this paper is to include disciplinary complementarities into a multi-dimensional vision to evaluate the non-clinical aspects of mHealth innovations. We performed a targeted literature review to find how the sustainability of mHealth innovations was appraised in each discipline. We found that each discipline considers a different outcome of interest and adopts different time horizons and perspectives for the evaluation. This article reflects on how the sustainability of mHealth innovation can be assessed at both the level of the device itself as well as the level of the health system. We identify some of the challenges ahead of researchers working on mobile health innovations in contributing to shaping a more sustainable health system.

'Green podiatry' - reducing our carbon footprints. Lessons from a sustainability panel

Background

The eyes of the world will be on COP26 as it meets in Glasgow in November, 2021. Our planet is displaying weather extremes due to climate change which cannot be ignored, and which are deleterious for people’s health. Ironically, healthcare contributes to climate change, contributing approximately 5% of carbon emissions globally. Climate change due to global warming is ‘the biggest global health threat of the 21st century’.

Main body

The Australian Podiatry Association conference held a sustainability panel, hearing perspectives of industry and science, medicine and sport, fashion, and retail. Content unified a broad planet and human health message, which is highly relevant for podiatrists. Key themes included waste as a resource, exercise as evidence-based intervention, responsibility and circular economy recycling principles for end-of-life product (footwear) purchases, and wider ethical considerations of footwear and clothing.

The Anthropocene origin of climate change requires humanity to collaborate and to live more sustainably. Innovation is essential for better energy modes, cleaner air, human health and earth care.

Green Podiatry joins the concerted activity of medical and health groups within Australia. The UK’s NHS is an exemplar in this area, having already reduced healthcare emissions by 35%, and aiming for net zero by 2045, and perhaps sooner.

Conclusion

People are increasingly concerned about climate change, and COP26 is an important and imminent meeting for human and planet health.

This commentary on Green Podiatry directs us all to lighten our carbon footprint. A final, and forthcoming commentary will outline practical ways of positively incorporating climate change communication into the clinical setting.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13047-021-00497-1.

Sustainable medicines use in clinical practice: A clinical pharmacological view on eco-pharmaco-stewardship

Climate change continues to pose a dangerous threat to human health. However, not only is health impacted by this crisis, healthcare itself adds to the problem, through significant contributions to greenhouse gas emissions. In the UK, the National Health Service (NHS) is responsible for an estimated 4% of the overall national carbon footprint. Medicines account for a quarter of this and whilst they are vital for health now, through sustainable use they can also positively influence the environmental health of the future. In this review, we explore how clinical pharmacologists and other health care professionals can practice sustainable medicines use or eco-pharmaco-stewardship. We will discuss current and near future environmental practices within the NHS, which we suspect will resonate with other health systems. We will suggest approaches for championing eco-pharmaco-stewardship in drug manufacturing, clinical practice and patient use, to achieve a more a sustainable healthcare system.

Outcomes of a Climate Change Workshop at the 2020 African Conference on Emergency Medicine

A changing climate will have demonstrable effects on health and healthcare systems, with specific and disproportionate effects on communities in Africa. Emergency care systems and providers have an opportunity to be at the forefront of efforts to combat the worst health effects from climate change. The 2020 African Conference on Emergency Medicine, under the auspices of the African Federation for Emergency Medicine, convened its first ever workshop on the topic of climate change and human health. Structured as a full day virtual course, the didactic sections were available for both live and asynchronous learning with more than 100 participants enrolled in the course. The workshop introduced the topic of the health effects of climate as they relate to emergency care in Africa and provided a forum to discuss ideas regarding the way forward. Lectures and focused discussions addressed three broad themes related to: health impacts, health care delivery, and advocacy. To our knowledge, this is the first workshop for health professionals to cover topics specific to emergency care, climate change, and health in Africa. The results of this workshop will help to guide future efforts aimed at advancing emergency care approaches in Africa with regard to medical education, research, and policy.

African relevance

•

Climate-related extreme weather events are adversely affecting health and health care delivery in African countries.

•

African organisations, cities, and nations have taken positive steps to adapt and build climate resilience.

•

There are opportunities for emergency care professionals and scholars to continue to expand, and lead, climate and health education, research, and policy initiatives on the continent.

A systematic review of food waste audit methods in hospital foodservices: development of a consensus pathway food waste audit tool

BACKGROUND

To understand, monitor and compare the scope of food waste in hospital foodservices, it is essential to measure food waste using a standardised method. The aims of this systematic review were to: (i) describe and critique the methodological features of waste audits used in hospital foodservice settings that measure aggregate food and food-related waste and (ii) develop a consensus tool for conducting a food waste audit in a hospital foodservice setting.

METHODS

Seven electronic databases were searched for peer reviewed literature, and 17 Google Advanced searches located grey literature that described food waste audit methods previously used or developed for hospital foodservices. Study selection and quality assessment occurred in duplicate. Data describing the audit method, its feasibility, and strengths and limitations were extracted and synthesised to develop a consensus tool.

RESULTS

Eight peer reviewed and nine grey literature documents describing a variety of food waste audit methods were found. The most common practices were 2-week data collection (n = 5), foodservice staff collecting data (n = 6), measuring food waste only (n = 11), measuring food waste at main meals (n = 5) and using electronic scales to measure waste (n = 12). A consensus tool was developed that proposes a method for preparing, conducting and analysing data from a food waste audit.

CONCLUSIONS

This review used published evidence to develop the first ever food waste audit consensus tool for hospital foodservices to use and measure food and food-related waste. Future research is needed to apply and test this tool in practice.

Can patient-led surveillance detect subsequent new primary or recurrent melanomas and reduce the need for routinely scheduled follow-up? A protocol for the MEL-SELF randomised controlled trial

BACKGROUND

Most subsequent new primary or recurrent melanomas might be self-detected if patients are trained to systematically self-examine their skin and have access to timely medical review (patient-led surveillance). Routinely scheduled clinic visits (clinician-led surveillance) is resource-intensive and has not been shown to improve health outcomes; fewer visits may be possible if patient-led surveillance is shown to be safe and effective. The MEL-SELF trial is a randomised controlled trial comparing patient-led surveillance with clinician-led surveillance in people who have been previously treated for localised melanoma.

METHODS

Stage 0/I/II melanoma patients (n = 600) from dermatology, surgical, or general practice clinics in NSW Australia, will be randomised (1:1) to the intervention (patient-led surveillance, n = 300) or control (usual care, n = 300). Patients in the intervention will undergo a second randomisation 1:1 to polarised (n = 150) or non-polarised (n = 150) dermatoscope. Patient-led surveillance comprises an educational booklet, skin self-examination (SSE) instructional videos; 3-monthly email/SMS reminders to perform SSE; patient-performed dermoscopy with teledermatologist feedback; clinical review of positive teledermoscopy through fast-tracked unscheduled clinic visits; and routinely scheduled clinic visits following each clinician's usual practice. Clinician-led surveillance comprises an educational booklet and routinely scheduled clinic visits following each clinician's usual practice. The primary outcome, measured at 12 months, is the proportion of participants diagnosed with a subsequent new primary or recurrent melanoma at an unscheduled clinic visit. Secondary outcomes include time from randomisation to diagnosis (of a subsequent new primary or recurrent melanoma and of a new keratinocyte cancer), clinicopathological characteristics of subsequent new primary or recurrent melanomas (including AJCC stage), psychological outcomes, and healthcare use. A nested qualitative study will include interviews with patients and clinicians, and a costing study we will compare costs from a societal perspective. We will compare the technical performance of two different models of dermatoscope (polarised vs non-polarised).

DISCUSSION

The findings from this study may inform guidance on evidence-based follow-up care, that maximises early detection of subsequent new primary or recurrent melanoma and patient wellbeing, while minimising costs to patients, health systems, and society.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry (ANZCTR): ACTRN12621000176864 . Registered on 18 February 2021.

Positive Externalities of Climate Change Mitigation and Adaptation for Human Health: A Review and Conceptual Framework for Public Health Research

Anthropogenic climate change is adversely impacting people and contributing to suffering and increased costs from climate-related diseases and injuries. In responding to this urgent and growing public health crisis, mitigation strategies are in place to reduce future greenhouse gas emissions (GHGE) while adaptation strategies exist to reduce and/or alleviate the adverse effects of climate change by increasing systems' resilience to future impacts. While these strategies have numerous positive benefits on climate change itself, they also often have other positive externalities or health co-benefits. This knowledge can be harnessed to promote and improve global public health, particularly for the most vulnerable populations. Previous conceptual models in mitigation and adaptation studies such as the shared socioeconomic pathways (SSPs) considered health in the thinking, but health outcomes were not their primary intention. Additionally, existing guidance documents such as the World Health Organization (WHO) Guidance for Climate Resilient and Environmentally Sustainable Health Care Facilities is designed primarily for public health professionals or healthcare managers in hospital settings with a primary focus on resilience. However, a detailed cross sectoral and multidisciplinary conceptual framework, which links mitigation and adaptation strategies with health outcomes as a primary end point, has not yet been developed to guide research in this area. In this paper, we briefly summarize the burden of climate change on global public health, describe important mitigation and adaptation strategies, and present key health benefits by giving context specific examples from high, middle, and low-income settings. We then provide a conceptual framework to inform future global public health research and preparedness across sectors and disciplines and outline key stakeholders recommendations in promoting climate resilient systems and advancing health equity.

Environmentally sustainable emergency medicine

Emergency clinicians worldwide are demonstrating increasing concern about the effect of climate change on the health of the populations they serve. The movement for sustainable healthcare is being driven by the need to address the climate emergency. Globally, healthcare contributes significantly to carbon emissions, and the healthcare sector has an important role to play in contributing to decarbonisation of the global economy. In this article, we consider the implications for emergency medicine of climate change, and suggest ways to improve environmental sustainability within emergency departments. We identify examples of sustainable clinical practice, as well as outlining research proposals to address the knowledge gap that currently exists in the area of provision of environmentally sustainable emergency care.

Health Care Sustainability Metrics: Building A Safer, Low-Carbon Health System

As understanding grows of the scale of health care's environmental impacts, so too does interest in measuring and reporting on sustainability as a facet of health care system performance. This article examines important lessons from health care's long experience with performance and quality measurement and reporting that can be applied to the creation of health care sustainability metrics. Although some large health systems such as Kaiser Permanente have invested heavily in environmental stewardship, in the US the focus of health care sustainability measurement and reporting has typically been on corporate social responsibility and climate risk disclosure. The ability of health care organizations to generate data on and control environmental impacts can be limited by legacy infrastructure and complex supply chains. However, just as in other domains of performance, health care sustainability measurement and reporting must proceed from a clear conceptual framework and statement of purpose. Measurement must reflect strategic goals, instead of letting goals become dictated by ease of measurement. Health system leaders now need to set clear and compelling sustainability goals, invest in internationally comparable metrics by which to measure their success, and embed them in their core business.