Reducing critical care’s carbon footprint with financial and social co-benefits

Climate crisis and health

The consequences of the climate and ecological crisis are increasingly apparent, yet global change is not occurring with sufficient pace or scale to avoid an environmental catastrophe. The COVID-19 pandemic brought the world to a halt in 2020, yet carbon emissions fell only by 7%, reflecting economic inactivity rather than intended decarbonisation (Friedlingstein et al., 2020). This carbon footprint reduction is not sufficient if we are to stay below the targeted 1.5°C warming by the end of this century (Friedlingstein et al., 2020). We need to get this right. We cannot be responsible for our own extinction.

Richard Horton, editor of the Lancet, and other public health leaders called on the World Health Organization (WHO) to declare a ‘Planetary Health Emergency’ (Harmer et al., 2020). International bodies, universities, cities and countries also announced a ‘Climate Emergency’ to convey the urgency of the situation and provide a clear and positive commitment to tackling the climate crisis and its effects on population health. In 2018 alone, 8.7 million premature deaths were directly attributed to pollution from fossil fuel emissions (Vohra et al., 2021). The WHO (2018) projects an additional 250,000 death/annum worldwide between 2030 and 2050 due to other causes associated with climate breakdown, such as malnutrition, malaria, diarrhoea and heat stress. Health care systems need flexibility and sufficient resilience to surge quickly and efficiently deal with heatwaves, mass casualties following natural disasters and outbreaks of infectious diseases (Bein et al., 2020). This increased health care activity from the climate crisis will lead to increased healthcare costs and further greenhouse gas emissions.

Sustainability in health care

‘First do no harm’ – the Hippocratic Oath echoes throughout professional codes of conduct for nurses and allied health professionals. However, current health care practice is actively driving climate change. “Health care’s climate footprint is equivalent to 4.4% of global net emissions [of greenhouse gases] …If the health sector were a country, it would be the fifth-largest emitter planet” (Karliner et al., 2019, p. 4). Consequently, health care providers directly cause detrimental effects to planetary health. In England, the National Health Service (NHS) is tackling this paradox head-on, having launched the For a Greener NHS campaign and produced the landmark paper ‘Delivering a ‘Net Zero’ National Health Service’ (NHS England and NHS Improvement, 2020). With this report, NHS England was the first health care system in the world to commit itself to reach net zero by 2045, across all scopes of carbon emissions. A strategic national commitment demonstrates how the health care sector can lead par example; by mitigating climate change and its downstream consequences, promoting public health through reduced air and water pollution, and creating cost savings from eliminating waste and inefficiency.

The climate crisis demands a change in current education for greater understanding of planetary health and environmental sustainability and its impact on public health. Environmental stewardship needs to be included as a core health care professional responsibility to aid in ecological sustainability changes (Baid et al., 2021). Nursing is the most trusted profession (Ipsos MORI, 2020), which puts every nurse in a unique, privileged position to facilitate widespread transformation. Nurses have the power to educate and lead sustainability initiatives by engaging with patients, colleagues, administrators, managers and policymakers about the threats of the climate crisis on health and global wellbeing and to bring necessary change at an accelerated speed.

Sustainability in intensive care

There is a growing interest for environmental sustainability within the speciality of intensive care. New information is developing from life-cycle analyses and research studies about waste prevention through avoidance, reduction, reuse, recycling and reprocessing clinical supplies (McGain et al., 2020). For instance, the daily carbon footprint of a critically ill patient with septic shock equates to 3.5 times that of a healthy person in America (McGain et al., 2018). Pollard et al. (2014) modelled a prediction of energy consumption in intensive care units based on the types of patients, equipment used and care delivery. They suggested that this model can be tailored to individual hospitals to aid carbon savings. Further research is required to establish a more robust evidence-base for lowering intensive care’s carbon footprint in a financially affordable and socially responsible way.

The most sustainable hospital care minimises unnecessary resource-use in the first place through proactive health promotion instead of relying on reactive management (Sherman et al., 2020). Clinicians might not explicitly intend preventative measures to be sustainability actions, but they reduce the carbon footprint and financial cost by lowering the demand on critical care services. For instance, quality improvement approaches to reduce inappropriate admissions, decrease intensive care unit length of stay or facilitate timely discharge enhance the patient experience while also reducing the environmental and economic impact of care provision. The Centre for Sustainable Healthcare (2017) provided such an example with an entry into their Green Ward Competition that focused on early mobilisation in a cardiac surgery intensive care unit. This project aimed to prevent muscle wasting and over-sedation for improved clinical outcomes while simultaneously considering carbon footprint reduction and financial savings.

Recommendations

The Centre for Sustainable Healthcare’s SusQI framework is a quality improvement model that integrates environmental, financial and social sustainability resource implications for initiatives to improve health care practice (Mortimer et al., 2018). The SusQI framework demonstrates the intrinsic links between the principles of sustainability and quality improvement. The concept of ‘satisficing’ can also be used for addressing environmental sustainability, which is being ‘satisfied’ that quality care is achieved while ‘sufficing’ within the limits of available resources and without putting future ecological, economic or social resourcing at risk (Baid et al., 2021). Table 1 offers links to further information for intensive care professionals interested in carbon footprint reduction.

Table 1.

Sustainability resources for intensive care.

Name	Website	Resource information
GREEN-ICU: GREater ENvironmental sustainability in Intensive Care Units	https://blogs.brighton.ac.uk/sustainablecriticalcare/	Information about research, education and clinical practice related to sustainable critical care practice
Centre for Sustainable Health care	https://sustainablehealth care.org.uk/	Range of sustainability resources including SusQI framework, Critical Care Susnet andGreen Nurse Network
NurSuS TOOLKIT	http://nursus.eu/	Sustainability in nursing teaching materials available in multiple languages
Nurses Climate Challenge	United States and Canada: https://nursesclimatechallenge.org/ Europe: https://eur.nursesclimatechallenge.org/	Resources for nurses and Schools of Nursing to champion sustainability

We strongly recommend that clinicians, educators, managers and researchers actively seek out opportunities for collaborating with hospital estates and procurement teams to improve their intensive care unit’s environmental sustainability.

The time to act is now because “If ever there was a public health emergency of international concern, it is this” (Harmer et al., 2020, p. 3).