Sustainability in interventional radiology: are we doing enough to save the environment?

Interventions to achieve environmentally sustainable operating theatres: an umbrella systematic review using the behaviour change wheel

INTRODUCTION

The healthcare sector is a major contributor to the climate crisis and operating theatres (OTs) are one of the highest sources of emissions. To inform emissions reduction, this study aimed to (i) compare the outcomes of interventions targeting sustainable behaviours in OTs using the Triple Bottom Line framework, (ii) categorise the intervention strategies using the five Rs (reduce, recycle, reuse, refuse, and renew) of circular economy, and (iii) examine intervention functions (IFs) using the Behaviour Change Wheel (BCW).

METHODS

Medline, Embase, PsychInfo, Scopus, and Web of Science databases were searched until June 2023 using the concepts: sustainability and surgery. The review was conducted in line with the Cochrane and Joanna Briggs Institution's recommendations and was registered on PROSPERO. The results were reported in line with Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) (Supplemental Digital Content 1, http://links.lww.com/JS9/D210 ) guidelines.

RESULTS

Sixteen reviews encompassing 43 life-cycle analyses, 30 interventions, 5 IFs, and 9 BCW policy categories were included. 28/30 (93%) interventions successfully led to sustainability improvements; however, the environmental outcomes were not suitable for meaningful comparisons due to their using different metrics and dependence on local factors. The 'reduce' strategy was the most prolific and commonly achieved through 'education' and/or 'environmental restructuring'. However, single-session educational interventions were ineffective. Improving recycling relied on 'environmental restructuring'. More intensive strategies such as 'reuse' require multiple intervention functions to achieve, either through a sustainability committee or through an intervention package.

CONCLUSION

Policymakers must examine interventions within the local context. Comparing the outcomes of different interventions is difficult and could potentially be misleading, highlighting the need for a tool integrating diverse outcomes and contextual factors. 'Reduce' strategy guarantees environmental and financial savings, and can be achieved through 'Education' and/or 'environmental restructuring'.

Green radiography: Exploring perceptions, practices, and barriers to sustainability

INTRODUCTION

Previous research has delved into the attitudes and behaviors of diverse professions regarding environmental sustainability. However, there needs to be more research specifically targeting radiographers. This study aims to survey radiographers' perceptions, practices, and barriers to change concerning environmental sustainability in radiology.

METHODS

Institutional ethical approval was obtained (IRB-COHS-FAC-110-2024) and data collection was conducted using Google Forms (Google Inc., Mountain View, CA). The survey targeted 104 practicing radiographers across several countries. Questions were structured around five domains to gather insights into demographics, training in global warming and climate change, perceptions of sustainability and climate change, sustainability barriers, and current radiology practices on sustainability. Data analysis utilized descriptive and d inferential statistics.

RESULTS

One hundred and four radiographers completed the study. Females had a significantly higher attendance rate in environmental protection campaigns (P = 0.01). The majority of respondents (68%) believe in climate change's knowledge and impact on the natural world. Our survey findings demonstrate that 74% of respondents believe there's a need to improve sustainability practices. The most commonly used strategies to decrease energy consumption and emissions were low-energy lighting (60%), real-time power monitoring tools (41%), and energy-efficient heating systems (32%). A significant concern regarding sustainability emerges among respondents: time (50%) and lack of leadership (48%) are prevalent concerns among the identified barriers.

CONCLUSION

Participants are recognising the importance of environmental sustainability in radiology, but lack of leadership, support, authority, and facility limitations hinder their adoption.

IMPACT ON PRACTICE

Radiology must prioritize environmental sustainability by providing resources and training for radiographers and collaborating with healthcare professionals, policymakers, and environmental experts to develop comprehensive strategies for a sustainable healthcare system.

Promoting sustainability activities in clinical radiography practice and education in resource-limited countries: A discussion paper

OBJECTIVE

Urgent global action is required to combat climate change, with radiographers poised to play a significant role in reducing healthcare's environmental impact. This paper explores radiography-related activities and factors in resource-limited departments contributing to the carbon footprint and proposes strategies for mitigation. The rationale is to discuss the literature regarding these contributing factors and to raise awareness about how to promote sustainability activities in clinical radiography practice and education in resource-limited countries.

KEY FINDINGS

The radiography-related activities and factors contributing to the carbon footprint in resource-limited countries include the use of old equipment and energy inefficiency, insufficient clean energy to power equipment, long-distance commuting for radiological examinations, high film usage and waste, inadequate training and research on sustainable practices, as well as limited policies to drive support for sustainability. Addressing these issues requires a multifaceted approach. Firstly, financial assistance and partnerships are needed to adopt eco-friendly technologies and clean energy sources to power equipment, thus tackling issues related to old equipment and energy inefficiency. Transitioning to digital radiography can mitigate the environmental impact of high film usage and waste, while collaboration between governments, healthcare organisations, and international stakeholders can improve access to radiological services, reducing long-distance commuting. Additionally, promoting education programmes and research efforts in sustainability will empower radiographers with the knowledge to practice sustainably, complemented by clear policies such as green imaging practices to guide and incentivise the adoption of sustainable practices. These integrated solutions can significantly reduce the carbon footprint of radiography activities in resource-limited settings while enhancing healthcare delivery.

CONCLUSION

Radiography-related activities and factors in resource-limited departments contributing to the carbon footprint are multifaceted but can be addressed through concerted efforts.

IMPLICATIONS FOR PRACTICE

Addressing the challenges posed by old equipment, energy inefficiency, high film usage, and inadequate training through collaborative efforts and robust policy implementation is essential for promoting sustainable radiography practices in resource-limited countries. Radiographers in these countries need to be aware of these factors contributing to the carbon footprint and begin to work with the relevant stakeholders to mitigate them. Furthermore, there is a need for them to engage in education programmes and research efforts in sustainability to empower them with the right knowledge and understanding to practice sustainably.

Sustainable radiology departments: A European survey to explore radiographers' perceptions of environmental and energy sustainability issues

INTRODUCTION

The environmental impact of radiology and radiotherapy activities is influenced by the energy consumption of equipment, the life cycle of consumables, waste generation, and CO2 emissions caused by staff travel. This study aims to investigate radiographers' perception and knowledge of environmental sustainability issues.

METHODS

An online survey was created and distributed to European radiographers and therapeutic radiographers. The survey questions (n = 43) include demographic data; questions on their perceptions and actions regarding environmental sustainability in healthcare, energy consumption, emissions from staff travel, waste generation from radiological procedures; the role of radiographers in addressing sustainability issues within their departments.

RESULTS

A total of 253 responses were collected from 27 European countries. About their perception on sustainability issues, most participants considered environmental sustainability in healthcare as very important. According to 63.6% (n = 161) of respondents, the energy consumption of radiological equipment is the major source of environmental footprints from radiology activities. Additionally, 44.7% (n = 113) believe that conducting diagnostic examinations remotely could reduce environmental footprints from staff commuting About their actions at workplace, over 70% (n = 192) reported turning off devices after use. Attention to waste recycling is high, but limited to paper, plastic and glass. Contrast agents recycling procedures are implemented by 13% (n = 33). The absence or unawareness of environmental sustainability procedures in the workplace was reported by 66% (n = 167). Radiographers could play an active role in environmental sustainability programs for 243 (96.1%) participants.

CONCLUSION

This study provides a comprehensive overview of European radiographers' knowledge and perceptions concerning environmental sustainability issues. While radiographers recognize the importance of a green radiology department, significant gaps remain in their understanding of eco-friendly initiatives in radiology units' activities.

IMPLICATION FOR PRACTICE

Enhancing radiographers' skills with sustainability expertise could promote a greener culture within radiology departments.

How we can reduce the environmental impact of our operating theatres: a narrative review

Climate change is projected to become the leading cause of adverse health outcomes globally, and the healthcare system is a key contributor. Surgical theatres are three to six times more pollutant than other hospital areas, and produce anywhere from a fifth to a third of total hospital waste. Hospitals are increasingly expected to make operating theatres more sustainable, however guidelines to improve environmental sustainability are lacking, and previous research takes a narrow approach to operative sustainability. This paper presents a narrative review that, following a 'review of reviews' approach, aims to summarize the key recommendations to improve the environmental sustainability of surgical theatres. Key domains of discussion identified across the literature included minimisation of volatile anaesthetics, reduction of operating theatre power consumption, optimisation of surgical approach, re-use and re-processing of surgical instruments, waste management, and research, education and leadership. Implementation of individual items in these domains has seen significant reductions in the environmental impact of operative practice. This comprehensive summary of recommendations lays the framework from which providers can assess the sustainability of their practice and for the development of encompassing guidelines to build an environmentally sustainable surgical service.

Approaches to reduce medical imaging departments' environmental impact: A scoping review

INTRODUCTION

Global warming stands as a paramount public health issue of our time, and it is fundamental to explore approaches to green medical imaging departments/(MID). This study aims to map the existing actions in the literature that promote sustainable development in MID towards the promotion of environmental impact reduction.

METHODS

Following the JBI methodology and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR), this literature search was conducted on MEDLINE, Embase and CINAHL to encompass studies published after 2013. Combinations of keywords and relevant terms related to environmental sustainability, recycling, medical waste, and greening radiology were applied for this review. Three independent reviewers screened abstracts, titles, and eligible full-text. Disagreement was solved through consensus.

RESULTS

38 out of 4630 articles met all inclusion criteria, and four additional articles were identified and added through reference search. A third of the studies included were published after 2022, and most were conducted in developed countries (36/41). Articles focused on computed tomography (9/41), magnetic resonance imaging (6/41), interventional radiology (4/41), conventional radiography (4/41), ultrasound (2/41), mixed modalities (10/41), or not applicable to an imaging modality (6/41). Four principal categories were identified to decrease ecological footprint: energy consumption, waste management, justification and environmental pollution.

CONCLUSION

To minimise the environmental impact of MIDs raising awareness and promoting education is fundamental. Examinations must be justified adequately, energy consumption must be reduced, and waste management practices need to be implemented. Further studies are required to prioritise the most effective strategies, supporting decision-making among stakeholders.

IMPLICATIONS FOR PRACTICE

Several strategies are already possible to implement to reduce the environmental impact of MIDs and improve the healthcare outcomes for patients.

Green radiology: How to develop sustainable radiology

The phenomenon of global warming due to the increased emission of greenhouse gases makes it necessary to raise public awareness about the importance of promoting sustainable practices. The field of radiology is not an exception, as it consumes a large amount of energy and resources to operate equipment and generate images. Green radiology is a sustainable, innovative, and responsible approach in radiology practice that focuses on minimizing the negative environmental effects of the technologies and procedures used in radiology. Its primary goal is to reduce the carbon, water and ecological footprint in our services based on four strategic pillars: decreasing energy, water, and helium usage; properly recycling and/or disposing of waste and residues (including contrast media); minimizing the environmental impact of ionizing radiation; and promoting eco-friendly radiology practices.

Planetary Health and Radiology: Why We Should Care and What We Can Do

Climate change adversely affects the well-being of humans and the entire planet. A planetary health framework recognizes that sustaining a healthy planet is essential to achieving individual, community, and global health. Radiology contributes to the climate crisis by generating greenhouse gas (GHG) emissions during the production and use of medical imaging equipment and supplies. To promote planetary health, strategies that mitigate and adapt to climate change in radiology are needed. Mitigation strategies to reduce GHG emissions include switching to renewable energy sources, refurbishing rather than replacing imaging scanners, and powering down unused scanners. Radiology departments must also build resiliency to the now unavoidable impacts of the climate crisis. Adaptation strategies include education, upgrading building infrastructure, and developing departmental sustainability dashboards to track progress in achieving sustainability goals. Shifting practices to catalyze these necessary changes in radiology requires a coordinated approach. This includes partnering with key stakeholders, providing effective communication, and prioritizing high-impact interventions. This article reviews the intersection of planetary health and radiology. Its goals are to emphasize why we should care about sustainability, showcase actions we can take to mitigate our impact, and prepare us to adapt to the effects of climate change. © RSNA, 2024 Supplemental material is available for this article. See also the article by Ibrahim et al in this issue. See also the article by Lenkinski and Rofsky in this issue.

Go Green in Neuroradiology: towards reducing the environmental impact of its practice

Raising public awareness about the relevance of supporting sustainable practices is required owing to the phenomena of global warming caused by the rising production of greenhouse gases. The healthcare sector generates a relevant proportion of the total carbon emissions in developed countries, and radiology is estimated to be a major contributor to this carbon footprint. Neuroradiology markedly contributes to this negative environmental effect, as this radiological subspecialty generates a high proportion of diagnostic and interventional imaging procedures, the majority of them requiring high energy-intensive equipment. Therefore, neuroradiologists and neuroradiological departments are especially responsible for implementing decisions and initiatives able to reduce the unfavourable environmental effects of their activities, by focusing on four strategic pillars-reducing energy, water, and helium use; properly recycling and/or disposing of waste and residues (including contrast media); encouraging environmentally friendly behaviour; and reducing the effects of ionizing radiation on the environment. The purpose of this article is to alert neuroradiologists about their environmental responsibilities and to analyse the most productive strategic axes, goals, and lines of action that contribute to reducing the environmental impact associated with their professional activities.

Waste analysis and energy use estimation during MR-HIFU treatment: first steps towards calculating total environmental impact

OBJECTIVES

To assess the environmental impact of the non-invasive Magnetic Resonance image-guided High-Intensity Focused Ultrasound (MR-HIFU) treatment of uterine fibroids, we aimed to perform a full Life Cycle Assessment (LCA). However, as a full LCA was not feasible at this time, we evaluated the CO2 (carbon dioxide) emission from the MRI scanner, MR-HIFU device, and the medication used, and analyzed solid waste produced during treatment.

METHODS

Our functional unit was one uterine fibroid MR-HIFU treatment. The moment the patient entered the day care-unit until she left, defined our boundaries of investigation. We retrospectively collected data from 25 treatments to assess the CO2 emission based on the energy used by the MRI scanner and MR-HIFU device and the amount and type of medication administered. Solid waste was prospectively collected from five treatments.

RESULTS

During an MR-HIFU treatment, the MRI scanner and MR-HIFU device produced 33.2 ± 8.7 kg of CO2 emission and medication administered 0.13 ± 0.04 kg. A uterine fibroid MR-HIFU treatment produced 1.2 kg (range 1.1-1.4) of solid waste.

CONCLUSIONS

Environmental impact should ideally be analyzed for all (new) medical treatments. By assessing part of the CO2 emission and solid waste produced, we have taken the first steps towards analyzing the total environmental impact of the MR-HIFU treatment of uterine fibroids. These data can contribute to future studies comparing the results of MR-HIFU LCAs with LCAs of other uterine fibroid therapies.

CRITICAL RELEVANCE STATEMENT

In addition to (cost-) effectiveness, the environmental impact of new treatments should be assessed. We took the first steps towards analyzing the total environmental impact of uterine fibroid MR-HIFU.

KEY POINTS

• Life Cycle Assessments (LCAs) should be performed for all (new) medical treatments. • We took the first steps towards analyzing the environmental impact of uterine fibroid MR-HIFU. • Energy used by the MRI scanner and MR-HIFU device corresponded to 33.2 ± 8.7 kg of CO2 emission.

Sustainability within interventional radiology: opportunities and hurdles

BACKGROUND

Healthcare is a highly polluting industry and attention to the need for making this sector more sustainable is growing. The interventional radiology (IR) department is a relatively unique department in the hospital because of its synergetic use of both imaging equipment and medical instruments. As a result, the interventional radiology department causes a significant environmental burden in terms of energy usage, waste and water pollution. The aim of this study was to explore the current state of sustainability within IR by conducting a survey and interviews among IR specialists in the Netherlands.

RESULTS

The main findings of this study were that there is a high awareness for the need of sustainability within IR, but that there is still limited action. Previous studies point towards the various opportunities in the field of energy, waste and water pollution, yet our study unveils these opportunities are often not implemented because of (1) sustainability not being a priority, (2) a dependency on employees, and (3) factors that simply cannot be changed by an individual IR department or hospital. Generally, our study indicates that there is a willingness to become more sustainable, but that the current system involves a wide range barriers that hinder true change. Furthermore, it seems that no one is currently taking the lead and a leading role from higher management, government, healthcare authorities or professional societies is lacking.

CONCLUSIONS

Despite the hurdles found in our study, IR departments can implement several improvements. An important factor is that sustainability should not lead to lower convenience for employees, which can be ensured by a sufficiently designed waste infrastructure and behavioral nudges. Furthermore, there lies an opportunity in more collaboration between IR departments in knowledge sharing and open innovation.