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Response to Healthcare and ecological economics at a crossroads
... A difficult trade-off must also be made between the use of reusable devices that require water for cleaning and single-use devices (31). ...
... In response to Tsai et al. 4 : We have previously corresponded with Tsai et al. about water use required for cleaning reusable anesthetic equipment, 21 and remain in agreement that water use is an important local environmental consideration. The concerns of Tsai et al. about the limitations of life cycle assessment are also correct, but we note that methodologic techniques are evolving to incorporate life cycle assessment into Herman Daly's ideas about ecological economics, e.g., by Pelletier et al. 22 Nevertheless, we remain focused upon carbon dioxide equivalent emissions as global climate change is an existential threat. ...
... In response to Tsai et al. 4 : We have previously corresponded with Tsai et al. about water use required for cleaning reusable anesthetic equipment, 21 and remain in agreement that water use is an important local environmental consideration. The concerns of Tsai et al. about the limitations of life cycle assessment are also correct, but we note that methodologic techniques are evolving to incorporate life cycle assessment into Herman Daly's ideas about ecological economics, e.g., by Pelletier et al. 22 Nevertheless, we remain focused upon carbon dioxide equivalent emissions as global climate change is an existential threat. ...
... In response to Tsai et al. 4 : We have previously corresponded with Tsai et al. about water use required for cleaning reusable anesthetic equipment, 21 and remain in agreement that water use is an important local environmental consideration. The concerns of Tsai et al. about the limitations of life cycle assessment are also correct, but we note that methodologic techniques are evolving to incorporate life cycle assessment into Herman Daly's ideas about ecological economics, e.g., by Pelletier et al. 22 Nevertheless, we remain focused upon carbon dioxide equivalent emissions as global climate change is an existential threat. ...
... In response to Tsai et al. 4 : We have previously corresponded with Tsai et al. about water use required for cleaning reusable anesthetic equipment, 21 and remain in agreement that water use is an important local environmental consideration. The concerns of Tsai et al. about the limitations of life cycle assessment are also correct, but we note that methodologic techniques are evolving to incorporate life cycle assessment into Herman Daly's ideas about ecological economics, e.g., by Pelletier et al. 22 Nevertheless, we remain focused upon carbon dioxide equivalent emissions as global climate change is an existential threat. ...
... In response to Tsai et al. 4 : We have previously corresponded with Tsai et al. about water use required for cleaning reusable anesthetic equipment, 21 and remain in agreement that water use is an important local environmental consideration. The concerns of Tsai et al. about the limitations of life cycle assessment are also correct, but we note that methodologic techniques are evolving to incorporate life cycle assessment into Herman Daly's ideas about ecological economics, e.g., by Pelletier et al. 22 Nevertheless, we remain focused upon carbon dioxide equivalent emissions as global climate change is an existential threat. ...
... In response to Tsai et al. 4 : We have previously corresponded with Tsai et al. about water use required for cleaning reusable anesthetic equipment, 21 and remain in agreement that water use is an important local environmental consideration. The concerns of Tsai et al. about the limitations of life cycle assessment are also correct, but we note that methodologic techniques are evolving to incorporate life cycle assessment into Herman Daly's ideas about ecological economics, e.g., by Pelletier et al. 22 Nevertheless, we remain focused upon carbon dioxide equivalent emissions as global climate change is an existential threat. ...
... In response to Tsai et al. 4 : We have previously corresponded with Tsai et al. about water use required for cleaning reusable anesthetic equipment, 21 and remain in agreement that water use is an important local environmental consideration. The concerns of Tsai et al. about the limitations of life cycle assessment are also correct, but we note that methodologic techniques are evolving to incorporate life cycle assessment into Herman Daly's ideas about ecological economics, e.g., by Pelletier et al. 22 Nevertheless, we remain focused upon carbon dioxide equivalent emissions as global climate change is an existential threat. ...
... 138 Recently, in times of drought, reducing direct water requirements to clean and sterilise reusable devices has often been ranked of greater short-term importance than reducing one's carbon footprint through avoidance of singleuse devices. 139 Further, as freshwater itself becomes scarcer, there are increasing monetary value and CO 2 e emissions attached to alternative sources such as through desalination. 138 Travel Considerable health benefits arise from less fossil-fuelled travel, both active and public transport. ...
The detrimental health effects of climate change continue to increase. Although health systems respond to this disease burden, healthcare itself pollutes the atmosphere, land, and waterways. We surveyed the ‘state of the art’ environmental sustainability research within anaesthesia and critical care, addressing why it matters, what is known, and ideas for future work. Focus is placed upon the atmospheric chemistry of the anaesthetic gases, recent work clarifying their relative global warming potentials, and progress in waste anaesthetic gas treatment. Life cycle assessment (LCA; i.e. ‘cradle to grave’ analysis) is introduced as the definitive method used to compare and contrast ecological footprints of products, processes, and systems. The number of LCAs within medicine has gone from rare to an established body of knowledge in the past decade that can inform doctors of the relative ecological merits of different techniques. LCAs with practical outcomes are explored, such as the carbon footprint of reusable vs single-use anaesthetic devices (e.g. drug trays, laryngoscope blades, and handles), and the carbon footprint of treating an ICU patient with septic shock. Avoid, reduce, reuse, recycle, and reprocess are then explored. Moving beyond routine clinical care, the vital influences that the source of energy (renewables vs fossil fuels) and energy efficiency have in healthcare's ecological footprint are highlighted. Discussion of the integral roles of research translation, education, and advocacy in driving the perioperative and critical care environmental sustainability agenda completes this review.
Background:
In the past, anaesthetic breathing circuits were identified as a source of pathogen transmission. It is still debated, whether breathing circuits combined with breathing system filters can be safely used for more than 1 day. The aim of this study was to evaluate the transmission risk of bacteria and also viruses via breathing circuits after extended use.
Methods:
The inner and outer surface of 102 breathing circuits used for 1 day and of 101 circuits used for 7 days were examined for bacteria and viruses. Additionally, 10 and 20 breathing circuits each were examined after use on patients with pulmonary virus infection and with multidrug-resistant organism (MDRO) colonisation/infection respectively. Bacteria were detected by standard microbiological procedures; PCR techniques were applied for herpes simplex virus, cytomegalovirus, influenza, parainfluenza and respiratory syncytial virus.
Results:
Endoluminal bacterial contamination of breathing circuits remained unchanged after 7-day vs. 1-day use (5.9% vs. 7.8%) [CI95%: -0.0886-0.0506, pnon-inferiority 0.0260]. Only outside surface contamination with bacteria belonging to environmental species or human flora increased (16.8 vs. 6.9%) [CI 95%: 0.0118 - 0.1876, pnon-inferiority 0.8660]. Viruses occurred on the patient side, but not in breathing circuits. No MDRO occurred in the 20 circuits after use on patients harbouring such germs.
Conclusion:
Endoluminal contamination of breathing circuits with bacteria did not increase after extended use. No viruses were detected in the breathing circuits using filters. Based on our results, the extended use of ABC without exceptions appears safe, if a high level of anaesthesia workplace cleaning is secured.
For most items used in operating rooms, it is unclear whether reusable items are environmentally and financially advantageous in comparison with single-use variants. We examined the life cycles of reusable and single-use central venous catheter kits used to aid the insertion of single-use, central venous catheters in operating rooms. We did not examine the actual disposable catheter sets themselves. We assessed the entire financial and environmental costs for the kits, including the influence of the energy source used for sterilization.
For the reusable central venous catheter kit, we performed a "time-in-motion" study to determine the labor costs and measured the energy and water consumption for cleaning and sterilization at Western Health, Melbourne, Australia. For the majority of the inputs for the single-use kit, we relied upon industry and inventory-sourced databases. We modeled the life cycles of the reusable and single-use central venous catheter kits with Monte Carlo analysis.
Inclusive of labor, the reusable central venous catheter insertion kits cost A) (95% confidence interval [CI], A6.86), and the single-use kits cost $A8.65. For the reusable kit, CO(2) emissions were 1211 g (95% CI, 1099 to 1323 g) and for the single-use kit 407 g (95% CI, 379 to 442 g). Water use was 27.7 L (95% CI, 27.0 to 28.6 l) for the reusable kit and 2.5 L (95% CI, 2.1 to 2.9 l) for the single-use kit. For the reusable kit, sterilization had the greatest environmental cost, and for the single-use kit, the manufacture of plastic and metal components had the largest environmental costs. Different sources of electricity to make the reusable kits patient-ready again affected the CO(2) emissions: electricity from hospital gas cogeneration resulted in 436 g CO(2) (95% CI, 410 to 473 g CO(2)), from the United States electricity grid 764 g CO(2) (95% CI, 509 to 1174 g CO(2)), and from the European electricity grid 572 g (95% CI, 470 to 713 g CO(2)).
Inclusive of labor, the reusable central venous catheter insertion kits were less expensive than were the single-use kits. For our hospital, which uses brown coal-sourced electricity, the environmental costs of the reusable kit were considerably greater than those of the single-use kit. Efforts to reduce the environmental footprint of reusable items should be directed towards decreasing the water and energy consumed in cleaning and sterilization. The source of hospital electricity significantly alters the relative environmental effects of reusable items.
An interdisciplinary working group from the German Society of Hospital Hygiene (DGKH) and the German Society for Anaesthesiology and Intensive Care (DGAI) worked out the following recommendations for infection prevention during anaesthesia by using breathing system filters (BSF). The BSF shall be changed after each patient. The filter retention efficiency for airborne particles is recommended to be >99% (II). The retention performance of BSF for liquids is recommended to be at pressures of at least 60 hPa (=60 mbar) or 20 hPa above the selected maximum ventilation pressure in the anaesthetic system.
The anaesthesia breathing system may be used for a period of up to 7 days provided that the functional requirements of the system remain unchanged and the manufacturer states this in the instructions for use.
The breathing system and the manual ventilation bag are changed immediately after the respective anaesthesia if the following situation has occurred or it is suspected to have occurred: Notifiable infectious disease involving the risk of transmission via the breathing system and the manual bag, e.g. tuberculosis, acute viral hepatitis, measles, influenza virus, infection and/or colonisation with a multi-resistant pathogen or upper or lower respiratory tract infections.
In case of visible contamination e.g. by blood or in case of defect, it is required that the BSF and also the anaesthesia breathing system is changed and the breathing gas conducting parts of the anaesthesia ventilator are hygienically reprocessed.
Observing of the appropriate hand disinfection is very important. All surfaces of the anaesthesia equipment exposed to hand contact must be disinfected after each case.
Background.:
An innovative approach to choosing hospital equipment is to consider the environmental costs in addition to other costs and benefits.
Methods.:
We used life cycle assessment to model the environmental and financial costs of different scenarios of replacing reusable anaesthetic equipment with single-use variants. The primary environmental costs were CO 2 emissions (in CO 2 equivalents) and water use (in litres). We compared energy source mixes between Australia, the UK/Europe, and the USA.
Results.:
For an Australian hospital with six operating rooms, the annual financial cost of converting from single-use equipment to reusable anaesthetic equipment would be an AUD30 000 (£18 000) per annum, but increased the CO 2 emissions by almost 10%. The CO 2 offset is highly dependent on the power source mix, while water consumption is greater for reusable equipment.
Objectives:
Steam sterilization in hospitals is an energy and water intensive process. Our aim was to identify opportunities to improve electricity and water use. The objectives were to find: the time sterilizers spent active, idle and off; the variability in sterilizer use with the time of day and day of the week; and opportunities to switch off sterilizers instead of idling when no loads were waiting, and the resultant electricity and water savings.
Methods:
Analyses of routine data for one year of the activity of the four steam sterilizers in one hospital in Melbourne, Australia. We examined active sterilizer cycles, routine sterilizer switch-offs, and when sterilizers were active, idle and off. Several switch-off strategies were examined to identify electricity and water savings: switch off idle sterilizers when no loads are waiting and switch off one sterilizer after 10:00 h and a second sterilizer after midnight on all days.
Results:
Sterilizers were active for 13,430 (38%) sterilizer-hours, off for 4822 (14%) sterilizer-hours, and idle for 16,788 (48%) sterilizer-hours. All four sterilizers were simultaneously active 9% of the time, and two or more sterilizers were idle for 69% of the time. A sterilizer was idle for two hours or less 13% of the time and idle for more than 2 h 87% of the time. A strategy to switch off idle sterilizers would reduce electricity use by 66 MWh and water use by 1004 kl per year, saving 26% electricity use and 13% of water use, resulting in financial savings of AUD$13,867 (UK£6,517) and a reduction in 79 tonnes of CO2 emissions per year. An alternative switch-off strategy of one sterilizer from 10:00 h onwards and a second from midnight would have saved 30 MWh and 456 kl of water.
Conclusions:
The methodology used of how hospital sterilizer use could be improved could be applied to all hospitals and more broadly to other equipment used in hospitals.
In the presence of single-use airway filters, we quantified anaesthetic circuit aerobic microbial contamination rates when changed every 24 h, 48 h and 7 days. Microbiological samples were taken from the interior of 305 anaesthetic breathing circuits over a 15-month period (3197 operations). There was no significant difference in the proportion of contaminated circuits when changed every 24 h (57/105 (54%, 95% CI 45-64%)) compared with 48 h (43/100 (43%, 95% CI 33-53%, p = 0.12)) and up to 7 days (46/100 (46%, 95% CI 36-56%, p = 0.26)). Median bacterial counts were not increased at 48 h or 7 days provided circuits were routinely emptied of condensate. Annual savings for one hospital (six operating theatres) were US 4846) and a 57% decrease in anaesthesia circuit steriliser loads associated with a yearly saving of 2760 kWh of electricity and 48 000 l of water. Our findings suggest that extended circuit use from 24 h up to 7 days does not significantly increase bacterial contamination, and is associated with labour, energy, water and financial savings.
Steam sterilisation's energy and water footprint
- McGain