Climate adaptive hospital: A systematic review of determinants and actions

Abstract

Introduction

Climate change is among the most renowned concerns of the current century, endangering the lives of millions of people worldwide. To comply with the United Nations Climate Change Conference (COP21), hospitals should be on track to reduce greenhouse gas emissions. Although hospitals contribute to climate change by emitting greenhouse gases, they are also affected by the health consequences of climate change. Despite all the guidance provided, hospitals need more radical measures to confront climate change. The current study was carried out to examine the components of hospitals’ adaptation to climate change and to review measures to confront climate change in hospitals.

Method

This systematic review was designed and carried out in 2020. The required information was collected from international electronic databases including Scopus, PubMed, Web of Science, EMBASE, and Google Scholar. Moreover, Iranian datasets such as Scientific Database (SID), Irandoc, Magiran, and IranMedex were reviewed. No restriction was considered in the methodology of the study. For the relevant thesis, the ProQuest database was also explored. The related sources were examined and the Snowball method was applied to find additional related studies. The research team also reviewed other accessible electronic resources, such as international guidelines and academic websites. The checklist of the Joanna Briggs Institute (JBI, 2017) was employed in order to evaluate the quality of the included papers. The studies published until June1, 2020, were included in the study.

Results

Of 11,680 published documents in the initial search, the full-texts of 140 were read after evaluating the titles and abstracts, of which 114 were excluded due to lack of sufficient information related to countermeasures in hospitals. Finally, the full-texts of 26 studies were reviewed to extract the required components. Two strategies were found, including climate change mitigation and climate change adaptation, with 13 components including water, wastewater, energy, waste, green buildings, food, transportation, green purchasing policy, medicines, chemicals and toxins, technology, sustainable care models, and leadership in hospitals were identified as affecting these measures and strategies.

Conclusion

Considering the significance of climate change and strategies to confront it as one of the current challenges and priorities in the world, it is necessary to develop a framework and model to reduce the effects of climate change and adapt to climate changes in hospitals and other health centers. The identification and classification of the measures and components, influencing hospital adaptability and solutions for reducing the climate change impacts could be the first stage in developing this strategy. This is because it is impossible to create this framework without identifying these factors and their mutual impacts at the first. In the present study, through a systematic review using a comprehensive approach, the related components were explored and divided into two categories, including measures to reduce the effects and measures to adapt to climate change. The results of this study can be useful in developing a comprehensive action model to reduce greenhouse gas emissions and adapt hospitals to climate change.

Introduction

Climate change is one of the biggest known threats of the twenty-first century that threatens the lives of many people around the world. Researchers have warned that continuing the current trend will exacerbate severe climate disasters and related hazards [1, 2]. Hence, “climate action” has been identified as one of the goals of sustainable development to combat climate change and its consequences [3]. Hospitals play a vital role in minimizing the health consequences of climate change by patients’ treatment, taking required steps to reduce carbon emissions from medical services, and promoting the community’s preparedness and participation in the face of climate change [4]. Hospitals are a set of architectural structures, infrastructures, equipment, staff, internal communication networks, guidelines, and treatment protocols that operate systematically in an integrated manner to provide medical services to patients. Non-stop provision of hospital services round the clock is one of the major factors in greenhouse gas emissions. Hospitals consume energy per square foot almost twice more than other office buildings. In 2014, the healthcare sector had an effect of 2.0 gigatonnes carbon dioxide (GtCO2e) emissions globally equivalent to 4.4% of the global net CO2 emissions. This is while many developing countries have not calculated greenhouse gas emissions [5–7]. Hospitals ought to be on schedule to minimize greenhouse gas emissions in order to be in compliance with the United Nations Climate Change Conference (COP21) [8]. The performance of hospitals in the face of climate change brings about both negative and positive consequences. On the one hand, hospitals are sufferers of health impacts caused by climate change and play an essential role in decreasing death rates and the negative consequences of disasters resulted from. On the other hand, their performance also leads to accelerating the climate change process. Healthcare professionals are needed to offer treatment in order to alleviate the effects of climate change, and hospitals, as pioneers of the medical sector, have a significant deal of duty to inspire the community. Today, reducing greenhouse gas emissions is no longer an optional issue. Waste reduction, the efficiency of energy and water, building design, green marketing policies, and active travel plans are some strategies that have been adapted in connection to sustainable development in order to mitigate climate change in hospitals. Adaptation strategies of climate change including anticipation and preparation for the consequences of climate change are required to guarantee that the health care system can be adaptable and strategically powerful in the forthcoming future [9–11]. In regard to hospitals' mitigation efforts, the World Bank has launched the “Climate-Smart Healthcare” system a low-carbon solution in the healthcare sector [12]. The “Global Green and Healthy Hospitals (GGHH)” and “Healthy Hospitals, Healthy Planet, Healthy People” are two independent guidelines focusing on climate change, which have been published by the World Health Organization (WHO) and the Health Care Without Harm institute, respectively. Environmental footprint reduction and environmental activity promotion in hospitals are the objectives that are supposed to be reached by following these guidelines [13, 14]. The “Leadership in Energy and Environmental Design,” or LEED program, has been introduced by The United States Green Building Council (USGBC) in order to decrease environmental consequences during constructing and renovating buildings and to turn hospitals into sustainable structures [15]. Moreover, the Pan American Health Organization (PAHO) has developed the “Smart Hospital Toolkit” as a useful guideline for hospital administrators to access smart healthcare infrastructures by conserving resources, boosting operational efficiency, and lowering carbon emissions [16]. The Green Building Council of Australia (GBCA) has published two rating tools including “Green Star-Health v1” and “Green Star Design & As Built v1.3” to support sustainable planning, design, and construction for health centers [17]. Furthermore, among the first building grading systems linked to environmental consequences in many sectors, the Building Research Establishment's Environmental Assessment Method (BREEAM) has suggested strategies for hospitals in the UK to minimize the emission of greenhouse gases [18]. In recent years, hospitals around the world have taken an approach to take actions that are safe not only for patients but also for their surrounding environment. Despite all the guidance provided, hospitals need more radical measures to confront climate change. The present study was conducted to examine the components affecting hospitals’ measures to confront climate change and to provide strategies in this regard. The results of this study can broaden the scope of current knowledge and help to mobilize resources and accelerate the implementation of hospitals’ measures to adapt to climate change.

Method

Data sources and strategies

This study was a systematic review of journals and documents related to measures and strategies used by hospitals around the world to confront climate change (global warming). The literature search was conducted on the 1st of July 2020. All study reports, books, instructions, guidelines, and dissertations related to this subject were extracted without a time limit and regardless of the study method. The necessary data was gathered from worldwide electronic databases such as Scopus, PubMed, EMBASE, Web of Science, and Google Scholar. Persian documents were found in Iranian databases such as Irandoc, Magiran, IranMedex, and Scientific Database (SID). For relevant theses, the ProQuest database was explored. The retrieved sources and documents were examined and the Snowball method was used to find other relevant studies. Other accessible electronic resources, including international guidelines and instructions and academic web pages, were also evaluated by the study team. The following keywords and related terms were taken from the MEDLINE or the Mesh database and EMBASE indexes. Additionally, prior to the search, academics and professionals were engaged in evaluating words and their types. Except for the studies obtained using the Snowball method, other studies were found using the following strategies and keywords in the titles, abstracts, and keywords:

(Adapt* OR Adopt* OR mitigat* OR Cop* OR resilien* OR accomudat* OR Adjust* OR Acclimat* OR Compatibl* OR "risk reduction" OR cease OR tackle OR address OR fight OR strateg* OR implementation OR action OR effort OR attempt OR policy OR framework OR plan OR approach OR response OR model) AND (Climate change OR Global Warming) AND (hospital* OR healthcar* OR "health care" OR (health AND care*) OR (Tertiary AND Care*)).

The resources extracted from various databases were entered into the EndNote version 8. Then, duplicate documents were removed.

Inclusion criteria

Studies, books, instructions, and guidelines that could be accessed in full text and contained components, factors, measures, strategies, and programs of hospitals around the world to confront climate change (global warming) were included in the study.

Exclusion criteria

Documents and papers related to disasters except for climate change and in any language except for English and Persian. The published documents and papers were subjected to thematic and descriptive analyses. Moreover, the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analysis) checklist assessment tool was taken into account.

Study selection and data extraction

Two separate researchers chose studies and extracted data. The titles and abstracts of the papers were examined in order to choose the ones that met the inclusion and exclusion criteria. The full texts of the chosen documents were then evaluated. Subsequently, two forms were developed: the first one was for inputting general information about the selected papers, such as the type of the study, the name of the first author, the study location, the date of publication, methodology, and objectives of the study; the second one was for extracting the components influencing the strategies and measures used by hospitals to deal with the climate change issue.

Data analysis

The obtained data was analyzed using the thematic analysis approach. Thematic analysis is commonly used to discover, comprehend, evaluate, and report on issues in a collection of interrelated data. Although thematic analysis is a systematic method of data analysis, it is an analysis-based method at the same time [19]. A thematic analysis of the papers was carried out in two stages in this study. To begin, two scientists (AM and AO) extracted data. Then, a group of all the components given in the 26 accessible papers was generated for further examination. Following that, coding was carried out in various subgroups depending on research results. Coding was conducted by a researcher and verified by a second colleague for convenience and accuracy. The disputes over coding were resolved through discussion or, if not resolved, through consultation with a third party.

Results

A total of 16,786 potentially relevant citations were found in this study, of which 15,084 were retrieved from the Scopus, Web of Science, PubMed, and Embase electronic databases, and 1702 from the Google Scholar search engine and other related sources. In the next stage, 5106 duplicate citations were removed and 11,680 unique citations remained in the study, of which 11,540 were excluded from the study due to not meeting the inclusion criteria after studying the titles and abstracts of the studies. Then, the full-texts of 140 studies were fully read and 114 studies were removed due to lack of sufficient information regarding hospitals’ confrontation measures. Finally, 26 documents were finally included in the present study. This study was based on the PRISMA checklist assessment tool (Fig. 1).

Fig. 1.

Flow: diagram of the search and selection of papers

Analysis and critical appraisal

The checklist of The Joanna Briggs Institute (JBI, 2017) was employed in order to assess the quality of the studies [20]. For the various kinds of studies that were included in our research, we obtained several appropriate standards checklists from the webpage (https://jbi.global/critical-appraisal-tools). The Checklist for Analytical Cross Sectional Studies, the Checklist for Systematic Reviews, Checklist for Case Reports and the Checklist for Text and Opinion were utilized to guarantee the reliability, relevance and to decide appropriateness for incorporation within the review. Every critical appraisal tool has different vital points (8, 11, 8 and 6, respectively) to analyze the quality of each study with a ‘Yes’, ‘No’, ‘Unclear’ or ‘not applicable’ response available. ‘Include’, ‘Exclude’ or ‘seek further information’ (JBI, 2017) were the alternatives for overall assessment (JBI, 2017). Two authors evaluated each paper separately, and any discrepancies were resolved via discussion. We scored papers by reviewing the written guide to the questions on the Joanna Briggs Institute Checklist. No studies were excluded based on quality assessment. Table 1 shows the characteristics and objectives of different studies and also the summary of the JBI (2017) critical appraisal according to each chosen paper.

Table 1.

The characteristics of articles and other sources included systematic review

First author	year	Study location	Methodology	Type	Study objective	Quality appraisal
Bharara et al. [21]	(2018)	India	Cross-sectional study	Original article	To become a climate-friendly green hospital according to seven instructions from the WHO on the climate change issue	JBI = 6/8
Agar [22]	(2015)	Australia	Narrative literature review	Original article	To explore the existing scope of “Green” or eco-dialysis methods	JBI = 8/11
Tomson [23]	(2015)	UK	Narrative literature review	Original article	To reduce the carbon footprint of hospital-based care	JBI = 8/11
McGain and Naylor [24]	(2014)	Australia	Systematic review	Original article	To determine the amount of research done on hospital environmental sustainability as well as major concerns that arise for research, policy, and practice	JBI = 10/11
Charlesworth et al. [25]	(2018)	Australia	Expert opinion	Original article	To operationalize environmental sustainability Initiatives in health organizations	JBI = 5/6
Linstadt, et al. [26]	(2020)	USA	Narrative literature review	Original article	To encourage and educate emergency personnel to take action by offering a roadmap to a sustainable health system and a method for establishing a climate-smart emergency department	JBI = 9/11
Aslan and Yıldız [27]	(2019)	Turkey	case report	Original article	To establish how many green applications are implemented in hospitals in Konya, Turkey	JBI = 7/8
Pencheon [28]	(2015)	UK	case report	Original article	To making health care more sustainable	JBI = 5/8
Cook et al. [29]	(2019)	USA	Expert opinion	Original article	To do Climate Actions by nurses: Opportunities to lead national efforts	JBI = 5/6
Guetter et al. [30]	(2019)	Brazil	Narrative literature review	Original article	To decrease the waste of operating rooms and the effect of the approaches on the environment	JBI = 9/11
Jamieson and Wicks [31]	(2015)	Australia	Narrative literature review	Original article	To review environmental sustainability in healthcare systems and to highlight the demand for a policy framework for taking action	JBI = 8/11
Weisz et al. [32]	(2020)	Austria	Cross-sectional study	Original article	To calculate the carbon footprints of health care professionals from Austria and to decompose the emissions of hospitals to a greater extent	JBI = 7/8
Sahamir and Zakaria [33]	(2014)	Malaysia	Literature review	Original article	To analyze the criteria for green assessment for public hospitals in Malaysia	JBI = 9/11
Holmner et al. [34]	(2012)	Sweden	Narrative literature review	Original article	To review and discuss the literature regarding the possible role of health information technology, namely eHealth, in the adaptation and mitigation of climate change	JBI = 8/11
Kumari and Kumar [35]	(2020)	India	Narrative literature review	Original article	To detect the parameters influencing the design quality of green hospitals as well as their future designs	JBI = 9/11
Prada et al. [36]	(2020)	Romania	case report	Original article	To put an emphasis on greenhouse gas emission reduction by devising new strategies for dealing with global warming. The new proposed solutions are related to the energy efficiency of the hospitals in the Eastern part of Europe	JBI = 6/8
Danilov et al. [37]	(2020)	Russia	Literature review	Conference Paper	To concentrate on green healthcare system designs, deeply investigated	JBI = 8/11
Satoshi et al. [38]	(2010)	Japan	Cross-sectional study	Report	To Follow up on the voluntary action plan for global warming in hospitals	JBI = 5/8
Chapman and Chapman [39]	(2011)	Canada	Expert opinion	Viewpoint	To discuss opportunities for giving critical care to decrease the corresponding environmental effects and change the framework	JBI = 5/6
Bouley et al. [12]	(2017)	World bank	Literature review	Guideline	To design resilience and low-carbon approaches for healthcare systems	JBI = 8/11
PAHO [16]	(2017)	Pan American Health Organization	Literature review	Guideline	To help health systems develop a policy framework on smart health equipment	JBI = 9/11
GHHA[14]	(2015)	USA	Literature review	Guideline	To develop a thorough list of subjects related to environmental health for healthcare systems throughout the globe	JBI = 8/11
World Health Organization [13]	(2016)	WHO	Literature review	Guideline	To address the climate change issue in the health sector	JBI = 9/11
Kubba [15]	(2009)	USA	Literature review	Guideline	To promote a greener, more resilient, and prosperous future for health care	JBI = 8/11
Schroeder et al. [40]	(2012)	UK and the USA	Text	book	To promote sustainable healthcare	JBI = 4/6
Nieto-Cerezo [41]	(2019)	UK	Text	book	To design innovative climate change adaptation plans for Hospitals	JBI = 5/6

Descriptive results

The 26 selected documents published by June 1, 2020, were reviewed. Most of them were from the United States (19%), Australia (15%), the United Kingdom (15%), India (7%), and the rest of the studies were from Russia, Canada, Turkey, Japan, Malaysia, Romania, Austria, and Sweden. The studies included 16 original research papers (two of which were review papers), a conference paper, five guidelines, two books, a report, and a viewpoint. Literature review was an essential part of all of the studies.

Thematic results

The reviewed studies indicated the hospitals’ measures to confront climate change. Finally, 13 components including water, wastewater, energy, waste, green buildings, food, transportation, green purchasing policy, medicines, chemicals, and toxins, technology, sustainable care models and leadership were extracted and divided into two general areas of “adaptation” and “mitigation” after merging similar measures. The “mitigation” area included reducing energy consumption, reducing water consumption, reducing hospital waste generation, reducing fossil fuel consumption, chemicals management, cooperation in legislation and implementation of mitigation-related laws. The “adaptation” area included capacity building, technology development and transfer, financial affairs, education and research, monitoring and evaluation, information sharing and support (Tables 2 and 3). Through taking action in the mentioned components, hospitals can reduce environmental risks and greenhouse gas emissions. Some of these components have been mentioned in the accreditation and risk management of hospitals and have also been emphasized by international organizations such as the WHO to control environmental issues and prevent the progress of the current process of climate change. In addition, all Domains and subdomains of hospitals’ climate actions are shown in Supplementary File (Table 2).

Table 2.

Domains and subdomains of hospitals’ climate actions

Water
Subdomain	Action
Water conservation	Develop a water conservation plan and framework aspiring to “net-zero water use” [12, 14–16, 23, 25, 34, 40]
	Implement the policies for measuring and monitoring water-related costs and water consumption, and report them regularly to staff, patients, and the broader public [26, 40]
	Apply novel technologies to maximize water savings [16]
	Reduce Potable Water Use [13–15]
	Design an educational plan about the significance of water conservation for visitors, staff, and patients [16, 39, 40]
	Use safe water storage [12]
	Adjust the standard volume of water for taps, nozzles, and toilets [39]
	Install low-flow and efficient fixtures [35]
	Install pressure-reducing valves if required [40]
	Install aerators and flow reducers on showers plus taps containing motion sensors or automatic shut-off valves if it is required [12, 21, 24, 26, 35, 38, 40]
	Install water-saving instruments including automatic tap timers [24]
	Replace any sorts of electronic devices or facilities with water-saving models [40]
	Repair and improve refrigeration systems [13, 14, 31]
	Locate and repair leaking devices. Reduce leaking regional flow cutting devices (valves, etc.) against water loss [12, 13, 24, 26, 27, 40]
	Install high-efficiency low-flow or dual flush volume toilet tanks [24, 27, 36, 40]
	Install high-efficiency sensor fixtures and waterless urinals in the toilet [35]
	Apply toilet vessels with recessed tanks and dual flaps [36]
	Utilize short showers, rather than bathrooms and shared baths [40]
	Outfit the facility with high-efficiency plumbing fixtures, motion-activated faucets [13, 14, 16, 35]
	Switch from film-based radiological imaging equipment to digital imaging, not applying water and polluting radiological substances [14, 40]
	Use permeable paving in wet climates [12]
	Wash only full loads of dishes and laundry [40]
Water efficiency	Buy and use water-efficient devices [26]
	Install efficient refrigeration and ventilation systems that use less water [15]
	Guarantee efficiencies through monitoring heating and water consumption [31]
	Distinct water supplies; municipal, on-site well, on-site bottled or potable water storage [12]
	Promote habitat [14]
	Utilize native plus drought-tolerant plants; decrease water consumption by xeriscaping (landscaping with no need for supplemental irrigation) [13, 14, 16, 22, 35, 37, 40]
	Use rain water harvesting system for different applications (building services, not requiring drinking water, and garden irrigation) [12–14, 16, 21, 27, 35, 40]
	Mulch landscape plantings to assist in keeping moisture surrounding the root system [16]
	Use Water Efficient Landscaping; do not use Potable Water for Irrigation [15, 37]
	Apply automatic irrigation system [15, 16, 26, 27, 35, 37]
	Apply green roofing [35]
	Analyze water quality regularly [14]
	Use auditing usage, such as installing data- logging meters and sub-metering, tracking water use, track changes over time [21, 26, 40]
	Avoid bottled water when safe alternatives exist [13, 14, 23, 27, 40]
	Observe water safety [12]
	Reuse water effectively [13, 15, 16, 22, 33, 38]
	Run joint projects in association with the community to enhance the quality of and protect water supplies, use novel methods to enhance water delivery, water quality, and wastewater systems for the public [14]
Waste water
Subdomain	Action
Waste water	Discharge wastewater properly in accordance with the law [27]
	Use waste water treatment and recycling [21, 35]
	Use a hi-tech compost system to convert sewage from the hospital to generate bio-methane for being polished into Bio-Natural Gas (BNG). Then, the BNG is utilized in a co-generation plant for the aim of powering water purification systems and hospitals [13, 21, 33, 35]
	Control storm water release management; grey water recapture/ recycling [12–14, 16, 21, 35]
	Run on-site wastewater treatment technologies when municipal services are not accessible (e.g. water recycling from dialysis devices or sterilizers) [12, 14, 24, 40]
	Reverse Osmosis water recycling to sterilize the steam generation department, hospital janitor stations, hospital landscape use, toilet flushers, and hemodialysis (green nephrology network) [21–23]
Waste
Subdomain	Action
Solid waste management	Use options for waste incineration for examples: decrease, re-use, recycle and compost [23]. [14, 16, 23, 40]
	Support officials to create and operate secure landfills for managing non-recyclable waste post-treatment to reduce the potential for underground and soil contamination [14, 16, 40]
	Apply proper construction management to reduce waste [15, 16]
	Get rid of general waste: plastic, glass and cardboard, food waste, non-contaminated wrapping material sent for recycling, non-contaminated paper, aluminum packaging, and steel [16, 21, 30]
	Get rid of waste in the vicinity of the generation point [14]
	Install on-site waste management systems [22]
Medical waste	Dispose of biological waste according to national regulations [16]
	Reduce Regulated Medical Waste (RMW) according to the hospital action plan [16, 29, 39, 40]
	Instruct all healthcare workers to adopt standard precaution and safety measures while handling and disposing of the waste [29, 40]
	Place the waste storage site of the hospital approximately 500 m away from care areas [21, 27]
	Store hazardous waste (containers, sealed floors, water leaks, etc.) properly [27]
	Train staff properly to know what kind of waste is in which specific container [39]
	Follow guidelines and instructions to manage liquid infectious waste [39]
	Perform frequent biomedical waste audits to improve waste segregation and reduction [16, 21]
	Identify the departments using dangerous wastes (flammable, toxic, abrasive, irritating, carcinogenic, mutagenic, environmentally damaging, etc.) to decrease or replace hazardous materials [27]
	Decrease or eradicate the incineration of medical waste [13, 40]
	Treat infectious waste through microwaving instead of autoclaving, incineration, or lime [24]
	Install a sewage treatment plant for managing biomedical waste and recycling [21]
	Design suitable signage for laboratories to determine which disposed materials should be in a clear bag, red bag, or sharps container [39]
	Use wheeled non-motorized trolleys, which do not require any fuel [21]
	Use of recyclable containers to transport hospital waste [39]
	Use labeled containers, i.e., avoid blending medical waste, like infectious waste, with general waste [16]
	Avoid unnecessary or unproven hospital procedures in order to reduce medical waste [30, 31]
	Don’t use injectable medicines where oral treatments were feasible [14]
	Minimize waste in red bags that contain only materials that must be discarded in this way [25, 26]
	Use appropriate sizes and locations for containers and red bags [26]
	Utilize reusable medical devices (e.g. reusable laryngoscopes) rather than disposable pieces of equipment [26, 28, 31]
	Use non-disposable items instead of gowns with single-use textile, drapes with single-use textile, packages with single-use drapes, paddings (foam non-disposable gel pads), or suction tubes ( plastic single-use tubes) [30]
	Apply sharps management: safe handling of sharps and other waste types and injection safety [30, 31]
Waste prevention and reduction	Run a committee for waste management and dedicate a budget for this aim [14, 25, 26, 33, 34, 39, 40]
	Develop a broad program and a written protocol to reduce waste [23, 27, 40]
	Develop and implement “zero waste” policies in the hospital through composting and/or develop and endorse new approaches to decrease waste supplies [23]
	Comply with sustainability legislation [40]
	Implement a comprehensive waste management training program for staff [14, 16, 23, 27, 37, 40]
	Guarantee that handlers of waste are well-educated and got vaccinated, and personal protective equipment is available [14, 23]
	Perform internal controls with waste regulations [27]
	Decrease waste sources to a large degree [16, 26]
	Substitute dangerous substances and reuse or recycle waste where possible [23, 24, 27]
	Follow the existing guidelines for the aims of parsing, spooling, and also storage [26, 27]
	Generate a low amount of waste in nursing practice and separate the waste properly [27]
	Abolish unessential materials such as not needed packaging in products, reducing the presence of unessential opened substances [30]
	Segregate proper waste at the source and store it in a secure location until it is collecting for disposal [14, 30, 40]
	Reduce food waste [26]
	Follow computerized procedures to less paper waste generation and avoid unnecessary printing [16]
Energy
Subdomain	Action
Energy audit	Develop an energy conservation plan and allocate a specific budget for this purpose [13, 16, 34, 38, 40]
	Conduct regular energy audits and monitor energy costs and carbon emissions across the hospital and use the results to retrofit programs [13, 14, 26, 28, 40]
	Manage Energy consumption by applying the building management system (BMS) through monitoring, control, and energy consumption in a data center. The BMS system works as a network between a server and automation controllers (in determined numbers). The automation controllers are interconnected and also communicate with the server via the internet/ethernet [36]
Conserve energy	Turn off equipments if not used and develop a campaign about this issue [22, 26, 29, 30, 39]
	Set printers and computers in sleep mode if not being used [3, 23, 26]
	Power down unessential medical equipment between uses [26]
	Establish plans for low-energy room settings (lights/TV/computers off) [29]
	Install automatic doors to maximize energy saving [21]
	Utilize power bars and timers for equipment employing standby mode to almost zero energy consumption [3]
Energy efficiency	Choose energy-efficient electronic equipment (low energy consumption (class A)) [3, 5, 12, 26, 27, 32, 33, 39]
	Upgrade/replace office or medical equipment to the energy-efficient one (for example, Elevator replacement from the new generation, with up to 50% energy consumption less than the current one [16, 36, 38]
Renewable energy	Use On-site renewable energy sources: • install Solar photovoltaic on rooftop In sun-drenched regions • use Thermal solar energy rather than electrical heaters • install wind turbine if location, building codes, space, wind speed, and existing wind direction, are appropriate Use other renewable energy sources [12–16, 21–24, 26, 28, 29, 32, 36, 39, 40]
	Use solar, wind, hydropower, geothermal, and bioenergy [30]
	Advocate for reinvestment in renewable energy sources [31]
Hospital Staff	Promote energy-saving activities, whether organizationally or not [38]
	Combine awareness programs and occupant education for personnel about energy-saving actions [14, 23, 39]
Thermal	Improve thermo-regulation [29, 31]
	Apply a temperature controller, flexible in timing and the isolation of geographical regions [3]
	Retro-fit heat exchangers [22]
	Rehabilitate the hospital thermally [36]
	Turn down thermostats a few degrees in cool climates or winter, and turn it up in warm climates or summer. Even one centigrade rise in room watch temperature in summer or winter reduces notable energy consumption [13, 14, 24, 35, 39, 40]
Refrigerant Management	Check that all equipment and devices with refrigerant that utilize no CFCs; Phase out/upgrade commonly-used equipment using CFCs [16, 27]
	Have trained professionals service your refrigerant-containing equipment regularly to decrease leaking/release into the atmosphere [16]
	Provide devices with enhanced lifespans and decreased refrigerant charge [15, 16]
Ventilation	Apply passive heating, cooling, and ventilation methods: evaporative cooling, Underground earth-pipe cooling, natural ventilation in hospitals, desiccant dehumidification [12, 21, 27, 34, 35]
	Use combined heat and power units [12, 31]
	Take indoor air quality –active and passive approaches: check regularly and continuously and make corrections to ventilation standards for removing or diluting impurities; upgrade and monitor various parameters of heating, ventilation, and air conditioning (HVAC) systems [24, 26, 32, 37]
	Control air-conditioning temperatures [38]
	Turn off air-conditioning at nighttime and intermediate times [24, 38]
	Install sensors to notify the air-conditioning system to turn off the air conditioning of the room when windows are open by patients for more fresh air [35]
	Rehabilitate heating and ventilation systems with heating pumps within the central heating system [36]
Insulation	Insulate the hospital building thermally with extruded polystyrene, polyurethane foam in the shell of hospital buildings to decrease energy usage [13, 23, 27, 31, 32, 37, 39]
	Apply insulation, a reflective roof, and an energy star reflective roof in exterior walls and the roof to reduce receiving heat in the building [16, 35]
	Retrofitting buildings to reduce the waste of energy [35]
Electricity	Generate electricity locally in both new and existing facilities [31]
	Rehabilitate electrical installations by using new and reliable devices, providing safe service for important consumers [36]
	Use particular energy sources and technologies, namely gas-fired co-generation; co-generation (consisting of power and heat) are beneficial for hospitals [24]
Lighting	Install enough windows to illuminate and maximize daylight [27]
	Install low emittance glass containing an invisible metal coating sandwiched between the layers of glazing, leading to reflective glass. They maintain the structure warm and cool in winter and summer [35]
	Replace halogens and Compact Fluorescent Lamps (CFL) with Light Emitting Diodes (LED) [16, 21, 22, 27, 35, 36]
	Employ occupancy motion sensor switches and energy-efficient lighting in hospital facilities, and use natural light wherever feasible. Solar lights should be installed in hospital parking [3, 12, 13, 16, 21, 24, 26, 31, 32, 35, 38–40]
	Turn off lights near windows during daytime [32]
	Utilize light shelves installed on exterior windows to increase the influence of day lighting on interior areas [37]
	Utilize task lights to produce illumination in task spaces such as labs, wards, and consulting rooms [37]
	Use individual lighting controls to allow modifications to individual patient demand and preferences, in addition to limiting disturbance in multiple-patient areas [16]
Chemical
Subdomain	Action
Chemical Management Policy	Create a chemical management policy with the goal of reducing or eliminating the usage of hazardous chemicals through the purchase of low hazardous/toxic and far environmentally friendly substitutes [14, 16, 21]
	Adopt regulations requiring the disclosure of chemical components in materials and products, and strive to guarantee that all substances have passed basic toxicity tests [14]
reduce or eliminate the use of hazardous chemicals	Join the World Health Organization's (WHO) Health Care Without Harm (HCWH) Global Mercury-Free Health Care Initiative by replacing all blood pressure equipment and mercury thermometers with safe, reliable, and cheap equivalents [14, 21, 26, 27, 39, 40]
	Select and install low-mercury fluorescent lights or mercury-free LED light bulbs [16]
	Select materials containing no or low levels of Persistent Bioaccumulative and Toxic Chemicals (PBTs), such as PVC, CPVC, Volatile Organic Compounds (VOCs) and Semi-Volatile Organic Compounds (SVOCs) as constituent components of interior materials, Dioxins and Halogenated Compounds, Halogenated Fire Retardants (HFR), Brominated flame retardants, heavy metals, phthalates, perfluoro [14–16, 26, 35, 37, 39]
	Buy Di(2-Ethylhexyl)phthalate (DEHP)-free products; DEHP-free products in (urinary collection kits, blood bags, dialysis containers, intravenous tubing, feeding tubes, vascular catheters, chest drain catheters, enteral feeding pump kits, and TPN bags) [26]
	Select composite wood goods that do not include urea–formaldehyde resins [16, 35]
	Do no use foam-filled furniture since it has most likely been treated with various flame retardants [16]
	Do no use paints containing antimicrobial components and, if feasible, select pre-painted metal goods [16]
	Utilize dry chemicals rather than wet ones [16]
anesthetic gas reclamation	Decrease GHG emissions gained from anesthesia gas usage and disposal waste by recapturing and scavenging anesthetic gas [12, 32, 34]
	Employ Blue-Zone technology, which captures, reclaims, and purifies halogenated anesthetic gases [12, 30, 32, 34]
	Utilize Xenon, with minimal toxicity and no negative influence on the environment, as an anesthetic gas [30]
	Promote the appropriate use of nitrous oxide [38]
pesticides	Make sure that pesticides and other substances used on the exterior part of the facility are administered safely by a qualified expert, and only the amounts needed are utilized [16]
	Construct, maintain, and design buildings to be highly pest-resistant [16]
	Remove holes and cracks to protect from pests. Before sealing up gaps between walls and other spaces, lightly dust them with boric acid [16]
	Employ physical barriers to prevent pests from entering and moving (for example doors, door sweeps, windows, and screens at air intakes) [16]
Environmentally Preferable Cleaning	Employ natural cleaning agents whenever and wherever feasible [15, 16]
	Check to see if disposable paper goods, such as hand towels and paper, comprise recycled material [16]
	Employ combined dyes and cleaner/disinfectants carefully and only when absolutely required [16]
	Replace dangerous chemicals such as ethylene oxide and the high-level disinfectant (HDL) glutaraldehyde (general sterilants and disinfectants), and other dangerous compounds with safer equivalents [14, 16]
	Phase out manual disinfection and use automated machine washers/disinfectors to reduce the exposure of personnel to liquid disinfectants [16]
	Assure that the whole sterilizing and disinfection equipment are efficient and beneficial in order to limit chemical usage and disposal [16]
	Purchase soaps without triclosan and triclocarban [26]
Contaminant Reduction	Label appropriately and properly maintain all substances according to the instructions of the manufacturer [16]
	Record the delivery, storage, purchase, and usage of any harmful substances and chemicals kept on-site [16]
	Provide additional containment and security for chemicals kept outside, over the ground, or underground to prevent spills and leaks [16]
	Educate employees on appropriate chemical storage and handling, as well as spill/leak protocols [16]
	Check that there is a policy in place that forbids chemical disposal into drains and that training for staff is included [16]
	Ensure that photochemicals (fixtures, rinse water, developer, and so on) from X-ray equipment are discharged under proper circumstances [27]
	Ensure that chemicals coming out of the laboratory ward are discharged under suitable conditions [27]
	Ascertain that plastics, PBTs, batteries, any material containing PVC, products containing mercury, and flame retardant-treated substances are not incinerated along with other medical wastes, since they discharge carcinogenic and toxic content into the air following incineration [16]
	Incinerate no waste on-site. Provided that the onsite incineration of waste is unavoidable, position the incinerator downwind from the facility and make sure there exist no close air intakes [16]
Green Building
Subdomain	Action
Design	Apply Modern hospital architectural design [23]
	Endorse healthy and green hospital designs and constructions; Work toward building carbon–neutral or carbon-negative hospitals [14, 15, 21, 34, 40]
	Design Dual-skinned buildings [22]
	Avoid thermal bridging [22]
	Apply Enhanced building thermal envelope [12]
	Construct hospitals sensitive to local climate conditions and designed for decreased energy and resource needs [23]
	Consider energy efficiency in the design and planning stages in order to achieve long-term benefits, [24]
	Design for local natural and social settings to better connect the building with the natural environment and the community [14]
	Incorporate sustainable features into designing, construing, and landscaping new buildings, as well as expanding buildings and/or retrofitting projects [13]
	Design Outdoor Places of Respite [15]
	Direct Exterior Access for Patients [15]
	Follow Resilient building design considerations [12, 26]
	Pay attention to building form: critical clinical services should be located above flood levels or out of harm's way, with provisions for patients increasing in number during and after an incident [12]
	Pay attention to Building Exterior: stronger exterior roofs and walls; water- and wind-resistant exteriors [12]
	Pay attention to the quality of the indoor environment (low emissions of volatile organic compounds, thermal comfort) [15, 39]
site	Integrate the hydrology, geology, regional climate, ecosystem, and the particular micro-climates of the site into the green design [35]
	Design sites to choose and utilize a site that increases passive solar heating and cooling [12–15, 22, 35, 39]
	Optimum natural light and shade positioning [21, 22, 39]
	Protect natural supplies (e.g., protecting local ecologies, wildlife habitats, and trees) and decrease land interference and erosion [12–15, 22, 35, 39]
	Utilize wider strategies for sustainability (such as public transportation access, multiple access points, service delivery, and community involvement) when deciding about designing and constructing hospitals [33, 40]
	Maximize Open Space [15]
ventilation	Improving aeration and quality: to eliminate indoor air contaminants, buildings must go through a pre-occupancy flush-out, which involves forcing a significant volume of tempered outdoor air via the ventilation system [35]
	Utilize permanent entry-way dust-collection devices, such as slotted systems, grates, or grilles, at all major entries [37]
	Use E star roof ENERGY STAR qualified roof goods to decrease air conditioning required in the building [35]
	Apply cross ventilation [21]
	Use narrow floor plates for day natural ventilation [12, 14]
	Consider Air-conditioning: Periodic filter cleaning, Optimization of external air intake [38]
	Observe Indoor Air Quality (IAQ) Management Plan Before Occupancy [15]
	Monitor Outdoor Air Delivery [15]
Pollution Prevention	Apply Air pollution level LED display [21]
	Implement Construction Activity Pollution Prevention [15]
	Observe Environmental Quality Management Plan (EQMP) During Construction [15]
	Stick to Light Pollution Reduction [15]
plant	Promote greenification of rooftops and hospital vicinities [26]
	Increase green belt (plantation of more trees, especially at the hospital boundary) [21]
	Provide places in the courtyard for native and adaptive plant species that are unlikely to induce allergic responses [12, 37]
	Use specific indoor plant species that create oxygen while also decreasing indoor foreign and dangerous chemicals such as volatile organic compounds in the air [12, 37]
	Protect and restore natural habitat [14]
material	Consider the life-cycle effect of building materials, such as climatic characteristics and the long-term influence of building materials. The ultimate materials must be non-toxic, offer extra characteristics, and be readily preserved and recycled at the final stage of the life cycle of a building [35]
	Use local and regional building materials (reducing transportation energy) [12, 14, 35]
	Highlight the health consequences of material extraction, use, transport, and disposal when evaluating materials for hospital use; utilize materials that are replenishable; promote human and ecosystem health throughout their life cycle [14, 15]
	Employ salvaged and recycled components, saving energy that would otherwise be spent on new manufacturing [14, 15]
	Encourage the use of toxic-free goods and production methods, and avoid chemicals such as paints and coatings containing lead and cadmium, plus asbestos [14, 15]
	Utilize indoors and flooring producing, absorbing, or re-releasing no indoor contaminants such as dust and volatile organic compounds (VOCs) [37]
	Use permeable paving in wet climates [12]
	Utilize high reflectivity roofing and paving, often known as "green roof" systems, and reflective surface pavement to decrease the effects of urban heat islands [12, 14, 15, 35]
Water reuse management	Incorporate water reuse into building management [22]
	Ensure storm water management systems function [12, 14, 15]
Travel
Subdomain	Action
Promote active and alternative travel	Support healthy and sustainable transport alternatives for both patients and employees (e.g., using cycling, or walking) by the provision of multiple incentives, namely interest-free loans to purchase bikes [12–14, 21, 23, 24, 26, 27, 31–33, 35, 38–40]
	Make individuals aware of the additional benefits of active travel, such as enhanced physical fitness, improved mental well-being, lower illness, and lower staff turnover [40]
	Supply lockers, showers, safe bike storage, improved route lighting, proper signage, and other amenities that support active travel and remove obstacles to it [13–15, 23, 40]
Location of hospital	Pay attention to how much hospital is near public transportation and safe cycling, walking [12–15, 23, 27, 35, 40]
Reduce unnecessary travel	Avoid travel wherever possible, by better using virtual meetings such as teleconference, telemedicine, web-enabled meeting, and videoconference [23, 24, 40]
	Minimize patient, employee, and visitor travel, as well as travel for obtaining medicine, food, equipment, and other services [31]
	Take into account community-based medical services, home care [13, 14]
planning	Advocate for progressive transport strategies [14, 25, 40, 41]
	Create mechanisms to assess, on a regular and systematic basis, the necessity for patients, visitors, and employees to travel [23]
	Establish continuous monitoring procedures to reduce emissions from vehicles utilized for hospitals [23]
	Collaborate with personnel, local communities, other businesses, and transportation providers to create a travel strategy that is unique to your location. Encourage the sharing of facilities and transportation with other persons and local groups to offer alternatives to automobile use [23, 40, 41]
Low Emitting & Fuel Efficient Vehicles	Improve the energy efficiency related to hospital fleet vehicles by utilizing electric, hybrid, or suitable biofuel technology [13–15, 23, 26, 32]
	Implement Green ambulance initiative [21]
	Provide free parking lots for low-carbon vehicles could lead to extra motivation, such as electric or hybrid cars [23]
Fuel	Switching fuel from diesel, fuel oil, and kerosene to more climate-friendly fuel such as CNG and electricity [12, 14, 21, 38]
Food
Subdomain	Action
Healthy Food Program	Change hospitals to a “fast food free zone” [14]
	Remove sugary soft drinks from hospital cafeterias and vending machines [14]
	Change hospital menus and procedures to encourage healthy food use by purchasing locally grown and organic products (fewer animal products and foods that require less transportation) [14, 21, 26, 29]
	Minimize Meat products are served in the hospital [13, 21]
	Support higher plant-based options (fresh fruits and vegetables) in cafeterias and on menus for patients [26]
	Prohibit the use of frozen food [27]
Waste Food	Apply strategies to reduce food waste and beneficially reuse food waste. Include food donations, source reduction, food scrap diversion to animal feed, waste oil conversion to biofuel, and composting [14, 16, 26]
	Decrease using disposable products such as bottled water and non-food service paper goods namely paper towels and napkins. Use high-efficiency dispensing systems to monitor the quantity of the used products [16]
Planning and Implementation	Have a plan to provide healthy and nutritious food for staff and patients, promote community health and protect the environment [40]
	Support and collaborate with local farmers, community-based groups, and food producers to expand the availability of locally produced, sustainably farmed food by purchasing local and organic goods [14, 26, 40]
	Identify the supply chain areas required for food supply, food security [12]
	Develop a step-by-step plan for identifying and procuring sustainable food [14]
	Turn the hospital into a nutrition and healthy food center by hosting farmers' markets for the local community and supporting community gardens on grounds of hospitals [14]
	Label all foods in terms of nutritional features [40]
	Limit the advertisement of harmful foods (particularly to vulnerable individuals) [40]
	Incentivize food-management companies and/or vendors to supply produced food with no synthetic pesticides, hormones, or antibiotics administered to the animals without any diagnosed disease [14]
	Train and communicate with patients and the community about healthy, socially equitable, and environmentally sustainable food practices and procedures in hospitals [14, 40]
	Supply healthy produce grown on the roof for patients and employees [16, 22, 23]
	Place pressure on large food sellers to make staple foods more nutritious [40]
Pharmaceutical
Subdomain	Action
pharmaceutical management	Advocate a comprehensive pharmaceutical waste management program [26, 28]
	Assure that pharmaceutical waste is handled and disposed of according to national and WHO guidelines [14, 16]
	Establish processes for the acquisition, storage, distribution, and disposal of all medicines [14, 16]
	Encourage the unit pharmacy to source from firms with a genuine green policy and to accept unused goods [24, 32, 39, 40]
	Utilize ‘low stock' policies at drugstores to limit the number of drugs that expire before they are distributed [32, 40]
	Support pharmaceutical firms to create more effective drug delivery methods so that pharmaceuticals are received more efficiently, and also chemical excretion is reduced [14]
	Make contracts to guarantee that surplus medicines are returned to the producer [14]
	Encapsulate medicines or make them inert by combining them with concrete are low-cost and efficient methods prior to disposal in a landfill, for low-income countries [40]
	Reduce pharmaceutical packaging [34]
Staff behavior	Reduce the usage of pharmaceuticals through evidence-based prescribing decisions, and employing non-pharmaceutical treatment suggestions, where appropriate [26]
	Train patients about the appropriate disposal of household medication and incentivize them to give unused medication back to the drugstore [14, 26, 40]
	Create training courses for health care practitioners in order to improve their prescribing and the rational use of pharmaceuticals [14, 31, 32, 40]
	Avoid unnecessary prescriptions and over-prescription [16, 32, 40]
	Apply 'starter packs' when starting a new medicine, so that only a little amount of medication is wasted provided that the patient does not accept it [14, 23, 40]
	Utilize low-carbon options, namely effective herbal medications. If possible [40]
	Implement frequent drug reviews: polypharmacy and improper prescribing are widespread among elderly people [23]
	Use the patient’s own drugs during inpatient episodes [23]
	Make sure that patients are willing to take a specific medicine prior to prescribing [23]
Sustainable Purchasing
Subdomain	Action
safer and sustainable products	Adopt a sustainable purchasing strategy that takes into account the environmental and human right consequences of all elements of purchasing, from manufacturing to packaging to final disposal [14, 26, 29]
	Adopt a strategy requiring suppliers to reveal chemical components and safety testing data for product purchases, and prioritize suppliers and goods that fulfill these requirements. Restrict hospital purchasing to items that satisfy these requirements [14]
	Consider the life cycle assessment when comparing the product. Life cycle assessment evaluates the entire environmental effect of a product (from the raw material procurement stage to the final producing stage), whereas life cycle cost assesses the whole product ownership costs from procurement to disposal [24, 26]
	Implement smarter purchasing [31]
	Request that vendors show their approaches for achieving sustainable development and lowering carbon emissions [40]
	Encourage the use of a sustainability scorecard to assess goods [26]
	Participate in an assessment based on hospital value or purchasing committee to promote green purchasing [26]
	Follow ethical procurement guidance [40]
	Follow ecologically friendly purchasing practices and avoid using hazardous materials such as mercury, PVC, and needless disposable goods [14, 16, 39, 40]
Solid Waste Reduction in Purchasing	Support extended producer responsibility and products that create less (or no) waste, are durable, are less disposable, utilize less dangerous raw materials, and have less packaging [14, 29, 35, 39]
Electronics Purchasing	Utilize a sustainable purchasing program for computer and electronic equipment [14]
	Buy energy-efficient goods, decreasing “stand-by” energy consumption [35, 38, 39]
Furniture and Medical Furnishings	Obtain furniture and furnishing made from managed forests or that have no heavy metals, PBTs, PVC, and other hazardous chemicals [16]
	Manage procuring medicines, medical equipment, company products and services, food/catering, and other facility inputs more effectively [12, 16, 28]
Clean and Green Interior Building Materials	Develop a purchasing scheme to obtain cleaning goods and materials that are less hazardous or environmentally friendly than other products while yet preserving the high cleanliness of the facility [16, 29]
	Utilize copper-based interior elements such as light switches, door handles, taps, and worktops. According to research, copper, as a building material, provides a microbial-resistant surface [37]
Influencing the local community	Support local suppliers who adhere to sustainable and ethical standards, as well as those who employ local and regional resources (thereby saving transportation energy) [14, 23, 28, 40]
Material management	Purchase safer, more stable, and environmentally friendly products and materials [40]
	Choose products made with recyclable or degradable materials [27, 39]
Reprocessing	Employ reusable products instead of disposable ones, and buy recycled items [35, 39, 40]
Technology
Subdomain	Action
Telehealth/ telemedicine	Introduce telemedicine to reduce time and travel parameters home patient telemonitoring and guidance [12, 22, 23, 25, 32, 40]
	Consider Emergency response via Telehealth [12]
	Provide health worker advice & collaboration via mobile phones [12]
	Consider consultations via video, e.g., between general healthcare providers and specialists or specialists and patients [12]
	Consider tele-homecare, e.g., remote support of self-management in chronic diseases [34]
	Provide Remote public health or medical training [34]
	Facilitate Virtual visits [34]
	Consider Remote diagnostics, e.g., remote auscultations and teleradiology [34]
	Prescribe electronically [34]
Health records	Convert paper-based records to electronic health records [34, 39]
	Make use of Electronic medical records and referrals [34]
	Use health information technology (HIT) [34]
use of new technologies	Encourage hospital to conduct long-distance meetings by video link rather than via travel [25, 29, 39]
	Boost using information technology in hospitals [40]
Sustainable care models
Subdomain	Action
Transformational changes to models of care in hospital	Enhance public health to reduce the need for healthcare services [14, 25, 27, 31, 32, 40]
	Apply a systemic transformation to strengthen preventive care and health promotion rather than treating illness [14, 25, 27, 31, 32, 40]
	Increase clinicians' involvement and readiness to be leaders in transforming care [31]
	Seek enhanced vaccination programs [31]
	Concentrate on changing unessential acute care to low-carbon health care providers to decrease the burden on hospital settings [32]
	Reduce unnecessary hospitalizations and lengths of stay [23]
	Prevent inefficiencies in health systems [32]
	Implement reforms in national healthcare provision planning [32]
	Focus on living well to minimize acute and specialist intervention [31]
	Provide financial incentives to invest in areas that lead to avoiding the need for hospital care [23]
	Provide funding sources that incentivize further sustainable care models, enabling de-hospitalization and de-medicalization [28]
	Incorporate climate change teaching into curricula for nurses and general practitioners [31]
	Incorporate physical exercise into the daily lives of employees to boost their mental and physical health status [28]
	Endorse the empowerment of patients and suitable participatory self-care [23, 25, 28, 40]
	Provide patients with further responsibility to manage their health [23, 25, 28, 40]
	Enhance patients’ engagement and awareness of their management to improve results, such as decreased needs for hospital care [23, 25, 28, 40]
	Engage the local community completely in many models of care that might be commissioned [23, 25, 28, 40]
	Improve end of life care [23]
	Raise numbers of home dialysis frequently provided. Novel strategies might be needed to inhibit CO2 emissions for each dialyzed patient [24]
	Consider changing medical treatments: implementing new healthcare approaches in hospitals [32]
SURVEILLANCE SYSTEM	Improve monitoring disease-related markers and health levels [31]
	Develop early warning systems [31]
Leadership
Subdomain	Action
manager	Create a committee to run hospital-broad sustainability approaches by evaluating basic emissions, setting priorities, and providing guidelines for environmental solutions [13]
	Assess and monitor progress in reduction initiatives [25, 41]
	Establish an action framework, like a committee to lead organizational-wide sustainability initiatives (to include basic emissions, setting priorities, and writing guidelines for environmental initiatives) [40]
	Build a task force comprised of representatives of different departments in hospital to assist in guiding and implementing initiatives [14]
	Encourage the use of programs, frequently updated and reviewed, for sustainable development management [28]
	Join the Global Green and Healthy Hospitals network to gain access to global networks and resources [25]
	Ensure that strategic and operational programs and budgets represent the commitment of the hospital to being green and healthy [14]
	Determine how to include sustainability strategies into accreditation standards [14]
	Assure that environmentally sustainable activities are consistent with other aims of hospital, which include providing excellent healthcare, enhancing patient experience, improved efficiency, relevancy and consistency, and financial stability [25]
	Endorse energy and environmental design leadership [15]
	Raise public awareness to decrease energy consumption in hospitals [35]
	Advocate climate-smart energy, waste, transportation, water [26]
	Fund research to eliminate impediments to reduction initiative innovations [14]
	Utilize data collection methods and extensive data in order to estimate basic carbon footprints in hospital [25, 26, 40]
	Support information gathering on local climate change impacts [41]
	Encourage leaders to participate in the Health Care Climate Challenge [14, 26]
	Support leadership and engagement across traditional bureaucratic boundaries [31, 33]
	Require sustainability objectives in job descriptions [28]
	Employ sustainability managers [25]
	Produce a “green team” and join this team [27]
	Be a motivating and supporting force for climate-friendly activities of the hospital [27]
	Endorse sustainability initiatives conducted by motivated clinical and non-clinical employees and managers who lack official resources and assistance [25]
	Support nurse scientists who research climate risk reduction, education, and preparation [29]
	Use passive systems whenever feasible to improve redundancy and resilience [14]
	Consider supply chains: specify regions for extra clinical/ food resources [15]
	Raise political awareness amongst professional groups that believe such initiatives are opposed to, or in rivalry with their professional aims [25]
	Advocate for divestment from fossil fuels and investments in sustainable energy sources [31]
Health care staff	Provide climate change-orientated education and motivation for caregivers [27, 29, 31]
	Ensure that mid-level managers, junior nursing, and medical personnel are frequently the most creative and active drivers of sustainability initiatives [25]
	Encourage nurses to join the Nurses Climate Challenge [26]
	Encourage employees to save energy, recycle, and improve the environment [28]
	Provide employees with training in waste safe management and disposal in hospitals [37]
	Reduce waste in nursing practice [27]
	Make certain that hospitals provide smoking cessation assistance to their employees [23, 24]
	Take proactive measures to prevent obesity among its employees [23, 24]
	Pay attention to staff apathy toward unsustainable healthcare activities such as excess lighting, usage, and waste [24]
	Influence the local community by staff commitment to environmental sustainability [23]
	Prepare and share patient education documents about the common health effects of climate change [29]
	Be prepared for more frequent illnesses during times of high heat, severe weather, fires, and floods [29]

Table 3.

Mitigation & adaptation strategy

Mitigation Strategy	Water management	Water conservation planning
		Water efficiency
		Harvest of rain water in order to irrigate the green space
	Waste water management	Hospital sewage treatment before entering the municipal sewage
		Effective hospital sewage treatment technology
	waste management	Solid waste management
		Management of medical and laboratory waste
	energy management	Energy audit
		Energy efficiency
		Utilizing clean and renewable energy
	Chemical management	Chemical and toxin management policy
		Pharmaceutical management
	Materials and resource management	Environmentally-friendly and sustainable materials
		Low Emitting materials
		Removal of mercury and harmful materials
		Attention to the environment when choosing medical equipment and furniture
	Reducing fossil fuel consumption	Access to public transportation
		Low-consumption and low-emission vehicles
		Planning active trips like walking and biking
		Use of suitable fuels such as CNG instead of gasoil, fuel oil, and kerosene
	Green space management	Local regionally-friendly plants
		Creation of green roofs
		Improving existing habitats
		Irrigation of plants with non-drinking water
	Nutrition	Healthy food program
		Modification of hospital menu like less meat consumption
		Purchase of local food products
		Reduction of food wastes
		Increasing the knowledge of the staff of the nutrition unit from water and food borne diseases
	implementation of mitigation laws	Development of low carbon measures
		Attention to employees’ role in climatic actions
		leadership
	Green Purchasing guide	Purchase of durable and sustainable equipment
		Attention to waste reduction when buying equipment
		Purchase of reusable products
	Sustainable care models	Attention to prevention and improving health instead of treatment
		Providing home care services to patients with special conditions
		vaccination of employees and patients
		Creating health database of the area covered by the hospital
		Awareness of the prevalence of heart disease, respiratory and renal diseases in the area covered by the hospital
Adaptation Strategy	Capacity building	Structural, non-structural, as well as functional measures
		Sustainable hospital design
		Employing laboratory networks to rapidly diagnose and control the transmittable diseases that are sensitive to the climate change
		Disease surveillance
		Developing an Incident Command System (ICS) to quickly respond to extreme climate events
		Emergency response plan for a hospital in face of climate change
	Technology development and transfer	Employing modern re-engineering approaches of the processes and updating the current systems
		Modernizing and rehabilitating technologies and processes to reduce energy usage
		ehealth such as Telemedicine
	Financial affairs	allocate the funds to measures against climate change
		Insurance coverage of hospital to enhance resilience
	Education and research	Organizing workshops and conferences on climate actions
		Education to staff to increase their knowledge about climate change
	Assessment, evaluation and monitoring	Detecting and fast treatment of climate change-related diseases
		Development of early warning and monitoring systems for hospitals
		establish a hospital emergency department-based syndromic surveillance system
	sharing information	Sharing the information between hospitals to prevent the parallel works
		Recording incidents and sharing lessons learned among hospitals
		Sharing findings through international conventions by hospitals
	Advocacy	involving people in the approaches to combatting climate change
		Supporting local residents such as purchasing local products

The synthesis limitations

Our synthesis suffers the major limitation of classifying the discovered variables. Concerning the research team’s ideas, it was concluded to manage it by classification of the variables on the basis of their differences and similarities.

Discussion

Evidence shows that climate change has caused an increase in the demand for health care and has created new challenges for hospitals. To address such challenges, hospitals must adopt special strategies to reduce the effect of and adapt to climate change. The present study was conducted to explain the factors affecting hospitals’ actions using a comprehensive approach. The aim of the study was to determine the components affecting hospitals’ measures to fight climate change. Since international documents, especially COPE 21, present two main strategies to combat climate change, the findings of this study showed that these strategies could be classified into two categories: mitigation measures and adaptation measures. Table 3 shows these strategies (Table 3).

Climate change mitigation strategies for hospitals

In terms of water management, a report prepared by the United Nations predicts that by the end of 2030, water shortage in arid and semi-arid regions will lead to the migration of 24 to 700 million people. Lack of proper management and planning regarding water use may lead to irreparable damage in the future. Therefore, several solutions have been proposed for maintaining and controlling water reserves in hospitals as one of the largest water consumers. Applying these simple but practical solutions can markedly help to improve resilience in water management in hospitals. Some of these strategies include water conservation, water productivity, water reuse, rainwater harvesting, and managing, storing and reusing storm water to supply water to the buildings. Employing these strategies is very important when it comes to controlling the effects of water scarcity in the future [42]. Perdomo Gaitan et al. (2020) conducted a case study in Sao Paulo, Brazil to examine the impact of water conservation measures in a university hospital. They found that a combination of the above measures, such as rainwater harvesting systems (RWHS) along with water conservation programs, had many economic, environmental, and social benefits [43].

As for the wastewater, hospitals must collect their wastewater, especially the waste from laboratories, hazardous chemotherapy units, and nuclear medicine units, using separate systems and treat them on site. However, Topbas et al. (2016) conducted a study and reviewed the knowledge and opinions of managers of private and public hospitals about wastewater management in Trabzon Province, Turkey. They showed that only a few hospitals collected wastewater through separate systems. Meanwhile, only 14 of the 23 surveyed hospital managers stated that wastewater management was one of their top priorities. According to their findings, they concluded that it was quite essential to train hospital managers on this subject. It was also found that the Ministry of Health officials should take on the responsibility of training their employees and regulate and implement laws in this regard [44].

In terms of waste management, hospitals are among the main polluters of the environment due to the production of pharmaceutical, chemical, radioactive, and infectious waste material. Although hazardous infectious wastes comprise a small portion of hospital waste, due to their pathogenic potential, they can transmit diseases to humans, such as tuberculosis, cholera, HIV, tuberculosis, hepatitis B, and C through sharp injury. Several studies have focused on inefficient measures concerning hospital waste management. Some of these insufficient measures include improper source separation [45], insufficient use of colored and coded waste bags [46], illegal methods of waste collection, unsafe storage of infectious waste, unskilled manpower, insufficient financial resources and essential training, and poor supervision over waste disposal centers [47]. Hospitals should have comprehensive programs for sustainable management of their waste and achieving zero waste. They must also allocate sufficient funds to these measures.

Cassandra Thiel et al. (2017) examined the views of gynecologists on global warming and medical waste at the University of Pittsburgh Medical Center in Western Pennsylvania, the USA. The results of the survey showed that compared to the general population, they were more likely to believe that global warming was happening and attributed it to human activities (84% vs. 54%). Two-thirds of the surveyed doctors also stated that an excessive amount of surgical waste was produced and that its production increased continually. The majority of the surveyed doctors (95%) supported the efforts to reduce hospital waste and 66% of them were in favor of using reusable tools versus disposable ones. Regardless of their desire for reusable surgical equipment, only 20% of clinicians had access to such devices and technologies [48].

In terms of energy management, hospitals are one of the largest centers of energy consumption due to their constant operation. The adoption of energy-saving techniques has a vital effect on lowering greenhouse gas emissions. Energy-saving initiatives in different areas, energy efficiency, and renewable energy (solar and thermal energy, clean energy, and wind panels,) usage are prominent measures [23]. Some measures that are crucial to energy saving include thermal insulation of buildings, implementation of low-consumption heating and cooling systems, use of natural ventilation and ventilation systems in accordance with the occupancy level of the building, low-consumption equipment, using daylight to save on lighting, low-consumption lighting equipment, regular energy audits, allocating a budget to energy efficiency measures, educating the employees, patients, and their companions through training programs with the purpose of changing their individual behavior [49].

Lawrence H. Brown et al. (2012) conducted a systematic review study to investigate the rate of energy consumption and the environmental impact of health services. They found that although the rate of energy consumption and greenhouse gas emissions per hospital bed was relatively low, it was a significant figure. They also stressed that although reducing energy consumption and greenhouse gas emissions from healthcare centers alone did not solve all the problems of energy shortage and climate change, it could make a significant contribution to decreasing them [50].

Regarding chemical wastes, hospitals are one of the largest consumers of chemicals from chemotherapy for cancer treatment to disinfectants for sterilization. These chemicals potentially have detrimental effects on the environment. Human contact with certain chemicals is strongly associated with an increased incidence of diseases such as reproductive and metabolic disorders, neurological diseases, and some cancers. Hospital staff is at a greater risk due to continuous exposure to these substances. Addressing this issue should be an essential part of the hospitals' mission to prevent people from being harmed. Safe in-hospital chemicals are managed using existing policies related to reducing the purchase of hazardous chemicals and receiving, transporting, storing, handling, and using environmentally safe chemicals [51].

As another aspect of chemical substances management, it is quite crucial to manage drugs that have significant environmental effects. Hospitals play an important role in reducing greenhouse gas emissions by adopting comprehensive programs. Some examples of such programs include preparing a guideline for ranking the drugs based on their environmental effects and making them available to doctors to increase the prescription of drugs with lower environmental effects, preventing over-prescription of drugs, minimizing improper disposal of drugs by returning unused drugs to manufacturers, and educating the patients. Hospital pharmacies can also reduce drug waste and environmental pollution through using or redistributing near-expiry drugs [52].

Joel Kreisberg et al. (2011) conducted a pilot study on the management of unused drugs in a care center in California. In this study, nurses provided patients with postal envelopes that were free of charge to collect unused medicines during discharge and instructed them on how to place these medicines in the postal envelope. They had to first place the tablets and liquids in plastic bags inside the mailer and then send them to a waste incinerator in Texas. During the 6-month study period, 160 of 400 distributed postal envelopes were returned for re-disposal. The total weight of the drugs sent to the incineration center was 107 pounds and the average weight of each posted package was 0.66 pounds. This study showed that the postal system and proper training of medical staff in hospitals could improve drug waste management, but other methods might be needed to improve drug management [53].

Regarding the reduction of fossil fuel consumption, one of the main components in this field is transportation management. Given that a large amount of greenhouse gas emissions in hospitals is due to transportation, there is a clear need to design and implement certain strategies to reduce greenhouse gas emissions. Hospital transportation management includes not only patient and staff transportation but also transportation related to the hospital’s logistics department [54].

Bozoudis et al. (2020) studied the greenhouse gas emissions from the transportation activities of the Athens Military Hospital. They found that the transfer of patients in or out of the hospital had the largest share (85.92%) in the emission of greenhouse gases [55]. After patient transportation, ambulance services, garbage disposal, hospital purchases, and staff transfer had the highest shares in greenhouse gas emissions with 7.52%, 3.65%, 2.43%, and 0.48% of the share, respectively. According to this study, calculation of greenhouse gas emissions is the starting point for planning to reduce greenhouse gas emissions in the transportation sector. Other measures related to transport management include proximity of hospitals to public transport stations such as subways and buses, not using personal vehicles by hospital staff, restrictions on the use of the hospital parking lot to emergencies, supporting active travel plans, providing green ambulances that consume renewable fuels such as biodiesel, and training drivers to reduce fuel consumption [35]. Given that hospital sites are mostly limited spaces and their transportation routes are mostly short, one suggestion could be setting up renewable travel systems in hospitals to transport patients and staff.

Regarding the green purchasing policy component, hospitals are one of the largest consumers of goods with significant environmental impacts. Therefore, hospitals must follow the Sustainable Purchasing Guidelines that cover all ethical and environmental aspects from production to packaging, transportation, and final disposal. It is considered very vital [56]. Green purchasing covers energy, consumables, electronic appliances, food, cleaning products, etc. These criteria also apply to the construction and transportation sectors. Implementing this criterion can reduce energy consumption, pollution caused by production and consumption of products, and the amount of waste [40]. One of the most important parameters for the successful implementation of the green purchasing policy is training the hospital staff, especially those working in the purchasing and procurement department [23, 26].

Salik Uddin Ahmed et al. (2020) investigated the political circumstances needed for the effective adoption of sustainable purchasing in Pakistan's health sector. They gathered information from two separate hospitals and evaluated it by the SPSS program. To better comprehend the issues and establish a policy, they investigated different parameters including equipment prices and country of origin, international standards (environmental effects, energy usage, and safety and quality standards), actual purchasing decisions, and the efficiency of equipment. Their data analysis revealed a positive correlation between equipment prices and quality standards, but no association between the country of origin and equipment efficiencies could be identified by the use of the chi-square test. According to this analysis, a thorough policy framework may be established, which contains the policies of the government and institutes considering a commitment to implementing sustainable purchasing techniques and introducing regulations that evaluate energy, environmental effects, quality, and safety standards for all instrumentation over the procurement process. The policy strategy would aid policymakers and sustainable development planners in implementing sustainable procedures in healthcare sectors [57].

Regarding legislation and law enforcement, leadership is an important component in hospitals, which is policy-making and planning to create a sustainable framework at all levels in the hospital. To achieve the goals of sustainable development in the fight against climate change, a question that arises is, "If the health sector does not take an effective measure and play the leadership role in this fight, are other sectors expected to do so?" [58]. However, there are always some groups in hospitals that believe these measures are contrary to the description of their professional duties [28]. Therefore, it is quite important to take the hospital staff into account at the forefront of the fight against the human damage caused by climate change, as they are the most important implementers of adaptation and mitigation policies in hospitals. Describing the health-related harms of climate change and benefits of using clean energy, and providing appropriate solutions through "climate measures" taken by health workers can lead to an appropriate emotional response to this situation. Discussions about protecting vulnerable groups to reduce poverty and inequality should strongly focus on supporting adaptation measures in hospitals [59]. According to a World Health Organization (WHO) Conference on the development and implementation of climate change preventive and protective measures in 2016, health professionals around the world need to enhance their efforts to protect public health and be more determined in playing the leadership role [59, 60].

David Pencheon et al. (2010) conducted a study entitled "Health sector leadership in mitigating climate change: experience from the UK and NSW". According to the results of this study, due to the health threats posed by climate change at all levels, both private and public institutions need to change their current practices to reduce carbon emissions, and everyone must play a key role in building a healthy future. While the UK healthcare system still faces many challenges in reducing its carbon footprint, there are many examples of leadership in the New South Wales health sector. For example, initiatives such as generating electricity for hospitals using natural gas led to a 15% reduction in electricity consumption in all health centers in the region. The installation of high-energy efficiency lamps also reduced the amount of electricity consumption in the studied hospitals. Another measure was developing transport access guides that displayed how to travel to and from the hospitals using active travel, such as bike lanes, recommended walkways from railway stations, or bus stops. In addition, such guidelines did not display the location of parking lots to discourage the staff and patients from taking their cars and encourage active travel to these destinations instead [61].

Climate change adaptation strategies for hospitals

Increasing the capacity of the hospitals includes measures associated with the hospital safety index (HSI) in structural, non-structural, and functional areas. The goal is to reduce vulnerability to the consequences of climate change-related disasters, establish an accident control system for effective response, strengthen laboratories to better identify infectious diseases related to climate change as soon as possible, and prepare for severe weather events to reduce casualties and injuries.

As for the building component, hospitals produce a significant amount of carbon footprint from the beginning of the construction process until their launch day. Due to the environmental impact of the hospital's building, a large number of "green building" tools have been designed for hospitals. Many ranking tools have been designed to improve innovation and have green hospitals in many countries around the world, especially the United States [15], the United Kingdom [18], Australia [17], and Malaysia [33]. It is important to note that green building strategies are not only applicable to newly built hospitals but also can be applied to old buildings to renovate them to improve their performance in many ways. Some of the items in this regard include referring to national or regional guidelines regarding green building, supporting the design and construction of green and healthy hospitals such as using an appropriate location for construction and materials and considering high-quality environmental materials in the building [40]. Other measures include supporting the use of local materials (reduction of energy consumed for transportation) in the hospital building, using recycled materials and products that are free of toxins [13], and employing a green design for maximum use of clean energy such as solar energy [21].

Zeeshan Ullah and colleagues (2020) published a paper titled "How sustainability in the healthcare industry challenges guidelines and code development: a framework for the design of sustainable hospital structures." They observed that the sustainability concept in the building industry was difficult not just for architects but also for the governing authority responsible for developing construction regulations, guidelines, and standards. All of these criteria must be evaluated in a single framework in order to be useful as part of a comprehensive strategy for designing a completely sustainable construction [62].

Regarding the technological component, several solutions have been proposed. Telemedicine, innovative ways for predicting the incidence of climate-sensitive diseases, promotion of health information technology (HIT), termed e-health, including the online storage of patients' health data rather than paper-based storing, decreasing the hospital waste using modern methods of re-engineering process, and upgrading the existing systems in compliance with proper strategies are some of the strategies to reach hospital adaption goal.

However, the successful function of this technology is mainly dependent on the Information and Communications Technology (ICT) infrastructures of the nations, and states with inadequate infrastructures are required to invest significantly in this technology in order to make benefits from the advantages. One of the provisions of the Sendai Framework for Disaster Risk Reduction is transferring the technology from reach nations to the countries with middle-income and low income [34].

Rachel L Police et al. (2010) performed a systematic review entitled "Adoption and use of health information technology in physician practice organisations". They showed that despite the many benefits, HIT was not used much in medical groups and only 9–29% of the studied organizations stored the patients' medical records electronically. They argued that the biggest reason why HIT was not accepted in medical departments was the initial and ongoing costs of electronic systems. According to this study, lack of adequate training, lack of a receptive culture to the use of HIT, technological problems, and lack of adequate funding hindered its effective use in such organizations. Thus, it is necessary to make more efforts to better understand and overcome these barriers, especially in developing countries [63].

As for financial issues in hospitals, strategies such as forecasting financial resources, allocating budgets to respond to accidents caused by climate change, and insuring hospital staff, equipment, and facilities seem to be essential [64].

In addition, in regard to education and research, holding workshops and seminars in the hospital for all of the staff is an important strategy when it comes to the concept of adaptation. Such a strategy can help increase the staff's awareness, evaluate the performance of the staff and the entire hospital, and consolidate the lessons learned related to previous incidents [65].

An essential part of the fight against climate change is assessment and monitoring, including the syndromic surveillance systems for infectious diseases related to climate change and having a surge capacity program for rapid admission and treatment of these patients, designing a rapid alert system, having a regional health database, having access to information on the region's climate hazards, having databases for the staff and the equipment, ensuring the security of hospital information system, and sharing the information between hospitals [66].

Some examples of advocacy in the hospital setting include buying food from regional sources, supporting farmers and manufacturers, and boosting the engagement of ordinary people and hospital employees in climate change mitigation efforts. In this respect, considering the fact that hospitals serve millions of meals to patients and their families each year, regional hospital food settings are ideal targets for encouraging healthy and sustainable dietary habits. The reduced intake of processed foods and red meat, the increased intake of fruits and vegetables, lowering the risk of non-communicable diseases, and reducing the emission of greenhouse gases, all have substantial environmental benefits [67]. The first step in improving hospital food is to remove fast-food restaurants, sugary drinks, and vending machines from hospitals [68].

Rosario Vidal et al. (2015) compared the amount of greenhouse gas emissions from different diets of patients in a hospital in Spain. According to their findings, the type of the diet had a significant effect on greenhouse gas emissions. They found that the Mediterranean diet had fewer negative effects on the environment than the diets that included more meat, especially red meat. They also reported that preparing guidelines for providing healthy food in hospitals around the world was an effective step in tackling climate change [69]. Therefore, it can be concluded that replacing animal protein-based diets with plant-based diets may affect greenhouse gas emissions. It should be noted that for this change, the protein needs of patients must be taken into consideration.

To further discuss advocacy, some strategies can be adopted in the fight against climate change. Some of these strategies are the component of sustainable care models, including replacing the treatment approach with the preventive approach, promoting the health of the population, informing patients, companions, and the staff about lifestyle modifications such as being more active, having a healthier diet, for example, consuming less meat, supporting patient empowerment and appropriate self-care to prevent recurrent and avoidable hospitalizations, reducing the duration of hospital stay, developing rapid alert systems for climate change-related diseases, and allocating sufficient budgets that encourage sustainable care models [28].

A qualitative study titled "Nurses' perceptions of climate and environmental issues" was performed by Anna AnAaker et al. (2013). In this study, 18 nurses in a Swedish hospital participated in their interviews. Their results revealed that, while the nurses played an important role and duty for mitigating the consequences of climate change, there was a disconnect between climate and environmental concerns and their everyday work, and their sense of responsibility was overwhelmed by the other job requirements. The authors stated that raising the nurses' understanding in this area will result in the development of sustainable care models with a preventative approach, health promotion, and the establishment of a sustainable society [70].

Regarding climate change, preliminary prevention relates to climate change mitigation, while secondary and tertiary prevention pertains to adaption to climate change consequences. Mitigation is the preferred action, however, adaptive options are more pragmatic and feasible from a political standpoint. Mitigating and adapting.

to climate change are complicated issues that need multilevel innovative approaches and solutions across all sectors. From an individual perspective, there is a need to continue to advance population health through health promotion, for example by encouraging active travel or reducing food miles, both of these activities reduce reliance on fossil fuels, improve health, and are, as a co-benefit, less harmful to the environment. At the system level of healthcare delivery there needs to be fundamental changes to models of clinical practice, system governance, the way practitioners work, consumer expectations of health services and the business model of healthcare delivery. It should be noted that control measures (mitigation and adaptation) are flexible and sometimes even complement each other.

Conclusion

Identifying the components and measures related to climate change and the fight against it will enable managers, decision-makers, and policymakers in the field of hospitals to achieve an acceptable level of measures to reduce the speed of climate change by allocating appropriate resources and funds to the measures. Moreover, taking these measures into account in different stages of designing and constructing hospitals can reduce their vulnerability to climate change and provide the necessary guidance for the selection of new and efficient facilities and infrastructure. These components and the related measures can align hospitals with climate change reform policies of the Paris Cop 21 Agreement. In regard to climate change mitigation, one suggestion is adopting energy efficiency measures and using renewable and clean energy in the hospitals such as solar energy by installing solar panels on the roof of the hospital, reducing water consumption, managing health and medical waste such as pharmaceutical waste, providing facilities for cycling or walking to reduce fossil fuel consumption, cooperating in legislation and implementing laws related to the adoption of the green purchasing policy, and providing low-carbon health care services. Besides, as far as climate change adaptation is concerned, surge capacity components must be taken into account. These components include measures in the structural, non-structural, and functional areas in the Hospital Safety Index, sustainable design of the hospital building, improving the laboratories to identify infectious diseases related to climate change as soon as possible, having an Emergency Response Plan (ERP), employing an Incident Command System (ICS), promoting technological developments in hospitals including telemedicine to reduce travels and transportations, using process modernization or improvement to reduce energy consumption, and in-hospital financial proceedings such as allocating funds to climate change-related measures and insuring hospitals against climate change or disasters, developing education and research activities like improving the staff's awareness, improving assessment and monitoring capacities including rapid diagnosis and treatment of climate change-related diseases, designing an in-hospital rapid alert system, sharing information between hospitals to combat climate change, and supporting local food suppliers for providing food for hospitals.

Limitations of the study

One of the limitations of this study was that only articles and documents in English and Persian were reviewed to collect the required data. Therefore, the authors might have missed out on some studies in other languages. Another limitation was that access to the full texts of some articles was restricted, which could be effective in finding the relevant components. In addition, there were a significant number of similar components in different studies, which was the reason why the authors combined some of the similar components.

Abbreviations

CCM

Climate change mitigation

CCA

Climate change adaptation

HSI

Hospital Safety Index

ICS

Incident Command System

PRISMA

Preferred Reporting Items for Systematic Reviews and Meta-Analyses

JBI

Joanna Briggs Institute

Declarations

Conflict of interest

The authors declare that they have no conflict of interest.