Research into sustainable hospital care

‘If we all travelled by train or bike from now on, that would really have a huge impact’
For the first time, research is being done into the climate and environmental impact of individual healthcare trajectories in hospitals. The results, mainly expressed in kilograms of CO2 emitted, provide tools to genuinely make healthcare more sustainable. Intensive care specialist and researcher Hugo Touw: ‘So far, we’ve always taken small steps to make healthcare more environmentally friendly. With this study, we can achieve fundamental solutions.’

The intensive care specialist at Radboudumc, who is also a member of The Green IC committee of the Netherlands Association for Intensive Care, is pretty surprised that he has become a researcher again. He never expected to resume research after completing his PhD. ‘However, I am so concerned about the climate problem that I genuinely need to know how polluting a hospital treatment is. My participation in The Green IC has sharpened my views on this. We need to do far more than introduce washable isolation gowns. We need structural solutions.’

CO2 emission of an open heart operation: 531 kilos

Since 2022, Touw has led the Radboudumc project Making healthcare processes more sustainable. With a grant from the ZonMw programme Climate and Health, he and his colleagues are investigating the environmental and climate impact of individual healthcare trajectories at the accident and emergency department (A&E), in the operating theatre (OR) and on intensive care (IC). They hope to complete the study in 2024, but have already obtained surprising results. For example, the CO2 emission for an open heart operation is 531 kilos, and for a cataract operation 72 kilos. That is equivalent to 4700 km and 730 kilometres of flying, respectively.

With our study, we can precisely calculate which consequences an environmental protection measure has.
Hugo Touw
Intensive care specialist and researcher, Radboudumc

During the COVID-19 pandemic an awful lot of material was discarded

The figures are quite stunning, according to Touw. The COVID-19 period made him aware of just how polluting healthcare is. People can still vividly remember the images of disposable protective suits, face masks and gloves. Even so, people don’t really like to change, which means you need to really convince them. ‘With our study, we can precisely calculate which consequences an environmental protection measure has. That allows us to determine which measures make real sense.’

Design of the research into the A&E, OR and IC

The researchers observe several individual patient trajectories for A&E, the OR and IC. They always observe 10 patients per group. For each trajectory, they subsequently itemise which medication, products and equipment are used and the frequency of use. They also look at the other actions that are performed, such as the cleaning of reusable products.

Next comes the phase in which the team examines the environmental impact of instruments and consumables using the so-called life cycle analysis (LCA, see box). Sometimes these LCAs are already known from databases and/or via the manufacturers. If that is not the case, the researchers perform these analyses themselves or they urge the producers to supply these details. ‘An LCA offers a unique insight into the hotspots and offers an action perspective to make healthcare structurally more sustainable’, explains Touw.

The life cycle approach

Life cycle assessment (LCA) is a method to calculate the environmental impact of a product or service over the entire life cycle, from cradle to grave. For this, various environmental effects are included, such as climate change, damage to the ozone layer, ecotoxicity of water, human toxicity, depletion of raw materials and acidification.

An assessment starts with describing all environmental interventions associated with providing the function of the product or service up to and including its final disposal, such as the use of energy, water, raw materials and the required transport. With the help of special LCA software, the environmental interventions are translated to the contribution to the various environmental effects in accordance with the international LCA method ReCiPe. The total environmental burden can subsequently be expressed in a single numerical score, the so-called Ecopoint score, with the help of weighting factors. An LCA study can also focus solely on the contributions to CO2 emission and therefore the environmental theme of climate change.

450 products were collected for the sustainability analysis of a heart operation

Such a life cycle analysis is nothing new, says Touw. Comparisons between disposable nappies versus washable nappies or disposable cups versus washable cups are often based on such analyses. However, such calculations have not been previously performed for an entire healthcare trajectory. ‘For the heart operation, 450 products were collected and analysed. This is very intensive work for the researchers, who process bin bags full of waste. They sort, count, and weigh everything: clothing, mats, cloths, tubes, drip bags, packaging material, clamps, and so on.’

But what does that 531 kilos for a heart operation consist of?

Touw takes an overview that he regularly shows at presentations about his research. Interestingly, one-fifth of this emission consists of travel movements made by personnel. Touw: ‘And that only concerns the employees of the operating theatre; other Radboud employees have not yet been included in this. If we all travelled by train or bike from now on, that would really have a huge impact.’

De CO2-uitstoot van een openhartoperatie is als volgt verdeeld: 30% OK wegwerpartikelen, 21% energie, 20% reisbewegingen van het personeel, 11% medicatie, 8% patiënttransport, 7% intensive care wegwerpartikelen en 3% herbruikbare producten.
Distribution of the 531 kg CO2 emissions from a heart operation.

The energy consumption accounts for another fifth of the total. At least, Radboudumc runs on green electricity, adds Touw. ‘In our case, the impact of the energy consumption has been reduced to almost nil. All healthcare institutions should start doing this tomorrow, because then you would immediately realise a considerable decrease of your impact on the climate.’

In the case of a cataract operation, it is mainly the patient’s travel movements that cause pollution

The figures are completely different for a cataract operation, the most frequently performed operation in the Netherlands and worldwide. Here the total CO2 emission is 72 kilos and 46.2% of this is made up by the travel movement of the patient. Transporting the patient to and from the hospital therefore forms almost half the environmental impact of a cataract operation.

De CO2-uitstoot van een staaroperatie is als volgt verdeeld: 46,2% patiënttransport, 19,5% reisbewegingen van het personeel, 18% wegwerpartikelen, 4,9% herbruikbare producten, 4,2% energie, 4,1% verpakkingen, 1,6% transport, 1,4% energieapparatuur.
Distribution of the 72 kg CO2 emissions from a cataract operation.

‘I couldn’t have predicted that’, says Touw. ‘With this, we provide an extra argument for performing cataract operations on both eyes at once. Cost-effectiveness research had already revealed that this option is preferable to operations on two separate days. Nevertheless, this does not yet happen at many locations in the Netherlands. ‘I hope that, from now on, these emission figures will become a decisive factor.’

The life cycle analysis is an eye-opener for trainee doctors

The first scientific articles about the environmental and climate impact of heart and cataract operations will be sent to scientific journals this summer. Their research is very topical, as the researchers experience every day. Employees of other hospitals frequently approach the research team. Sometimes they want to do similar research and sometimes they request help with the life cycle analysis. The results are also becoming part of the curriculum of medical education. ‘Now, we’re already teaching our trainee doctors to assess an LCA using concrete examples. For them, the real eye-opener is: if you do it once, you’ll never forget it again.’

Sustainability is also becoming an argument in healthcare choices

And, of course, the project fits really well in the widely felt urgency that something needs to be done about climate problems. The interest in sustainable care is rapidly increasing at the local, regional, national and international levels. Touw cites the Green Deal Working Together towards Sustainable Healthcare and the report Towards Sustainable Devices in Healthcare (see box) as examples. ‘Such agreements and advisory reports emphasise the need for us to examine things more holistically. Sustainability will also become an argument to determine what constitutes qualitatively good care. For example, we can start reducing the number of travel movements in many medical disciplines. Diagnosis and treatment can frequently take place on a single day, and we can do even more digitally.’

The Health Council of the Netherlands advises making devices more sustainable

The government must do more to make the use of medical devices and personal protective equipment in the healthcare sector more sustainable. The Health Council of the Netherlands writes this in its advisory report entitled Towards sustainable devices in healthcare. With this, the Council is referring to a broad range of devices such as gloves, materials for wound care, surgical instruments, medical equipment, diagnostic tests and implants.

According to the advisory report, a shift has occurred in recent decades from reusable devices to devices for single use, also in the case of advanced instruments. Furthermore, excessive use often occurs, and scarcely any thought is given to repairing equipment and reusing parts or materials. The Council formulates 7 concrete recommendations to change this.

Patients should receive information about a treatment’s CO2 emission

According to Touw, things will get really exciting when sustainability considerations also start to play a role in the choices between two treatments. What is the climate and environmental impact of a kidney dialysis at home versus one in a hospital? And what about a case of appendicitis, which could be operated on or treated with medication? What is more sustainable, diagnosis with a CT scan or with an echogram? ‘If the quality of care for both options is identical, it becomes possible to make sustainability considerations the decisive factor. I think we have a duty to provide this information to patients. From now on, the climate impact must be considered for each innovation.’

Sustainable care is care that can be prevented

Touw would like to add another consideration here: the inequality between people. In the Netherlands and worldwide, people with a low income and/or lower social position are more vulnerable to climate problems than people in a better situation. For example, the latter group often has more possibilities to deal with the consequences of air pollution and high temperatures. ‘In hospitals, we see a disproportionate number of patients with a lower income, lower level of education and living in neighbourhoods where there are many problems. Ultimately, sustainable care is mainly care that does not have to be carried out. We therefore need to focus far more on prevention and creating quality of life.’

Citizen assembly about sustainable care

As a consequence of this research, Touw would also like to involve citizens in sustainability projects. The tried and tested method for this is a citizen assembly in which well-informed citizens can help to decide about complex issues. ‘Perhaps then, very different things will be required from a hospital than all of those highly technical things we do now. It could well be the case that less money goes to hospital treatments and more to housing and poverty alleviation. At present, we dare not abandon expensive operations because we think that people in the Netherlands desire this type of care from us. However, I strongly question whether this is actually the case. Especially if you compare this with the health gain that can be far more effectively achieved in other ways.’

That’s rare: a medical specialist who calls for fewer hospital treatments?

No, says Touw resolutely. Think about the oath that each doctor has taken. Doctors promise not to inflict harm, but it’s becoming increasingly clear that the healthcare sector is itself a major polluter. ‘We also need to think about that when realising appropriate care. That is a term everybody talks about, but I always question this by asking: do we provide the care that respects the limits of our planet?

His answer to this question is a firm no’. ‘We do not do enough to achieve the targets set. In 2050, the healthcare sector must be circular and climate neutral. We will only achieve that if we make a considerable investment in research but, unfortunately, relatively little funding is actually available for research.’

Who is Hugo Touw?

Portretfoto van Hugo Touw

Hugo Touw graduated in medicine from the University of Groningen in 2009. He subsequently trained to be an anaesthetist and intensive care specialist at VUmc. Since 2017, he has been an intensive care specialist at Radboudumc in Nijmegen. He gained his doctorate from VUmc in 2019 for a study into recognising critically ill patients by means of continuous monitoring and diagnosing complications with lung ultrasound.

At Radboudumc, he is now a member of the steering group Sustainability and founder of the network Sustainable Care Professionals. He is also a member of the Green IC committee of the Netherlands Association for Intensive Care. Besides his work, Touw is active in the Cellenbroeders foundation. This foundation manages estates around Nijmegen and the lease income is used to combat poverty through structural support of, for example, the food bank. He is active in the national workgroup Care on behalf of the Dutch green political party GroenLinks’.


Image: Flip Franssen
Text: Gonny ten Haaft