What is the environmental impact of a blood transfusion? A life cycle assessment of transfusion services across England.

BACKGROUND: Healthcare activities significantly contribute to greenhouse gas (GHG) emissions. Blood transfusions require complex, interlinked processes to collect, manufacture, and supply. Their contribution to healthcare emissions and avenues for mitigation is unknown. STUDY DESIGN AND METHODS: We performed a life cycle assessment (LCA) for red blood cell (RBC) transfusions across England where 1.36 million units are transfused annually. We defined the process flow with seven categories: donation, transportation, manufacturing, testing, stockholding, hospital transfusion, and disposal. We used direct measurements, manufacturer data, bioengineering databases, and surveys to assess electrical power usage, embodied carbon in disposable materials and reagents, and direct emissions through transportation, refrigerant leakage, and disposal. RESULTS: The central estimate of carbon footprint per unit of RBC transfused was 7.56 kg CO2 equivalent (CO2eq). The largest contribution was from transportation (2.8 kg CO2eq, 36% of total). The second largest was from hospital transfusion processes (1.9 kg CO2eq, 26%), driven mostly by refrigeration. The third largest was donation (1.3 kg CO2eq, 17%) due to the plastic blood packs. Total emissions from RBC transfusion are ~10.3 million kg CO2eq/year. DISCUSSION: This is the first study to estimate GHG emissions attributable to RBC transfusion, quantifying the contributions of each stage of the process. Primary areas for mitigation may include electric vehicles for the blood service fleet, improving the energy efficiency of refrigeration, using renewable sources of electricity, changing the plastic of blood packs, and using methods of disposal other than incineration.

Environmental Impact of a Direct Laryngoscopy: Opportunities for Pollution Mitigation.

OBJECTIVE: To quantify the environmental impact of standard direct laryngoscopy surgery and model the environmental benefit of three feasible alternative scenarios that meet safe decontamination reprocessing requirements. STUDY DESIGN: This is a life cycle assessment (LCA) modeling study. SETTING: Yale-New Haven Hospital (YNHH), a 1541-bed tertiary medical center in New Haven, Connecticut, USA. METHODS: We performed cradle-to-grave LCA of DLS at Yale New Haven Hospital in 2022, including global warming potential (GWP), water consumption, and fine particulate matter formation. Three alternative scenarios were modeled: disinfecting surgical tools using high-level disinfection rather than steam sterilization, substituting non-sterile for sterile gloves and gowns; and reducing surgical towel and drape sizes by 30%. RESULTS: Changes in disinfection practices would decrease procedure GWP by 11% in each environmental impact category. Substituting non-sterile gowns and gloves reduced GWP by 15%, with nominal changes to water consumption. Linen size reduction resulted in 28% less procedure-related water consumption. Together, a nearly 30% reduction across all environmental impact categories could be achieved. CONCLUSIONS: Not exceeding minimum Center for Disease Control (CDC) decontamination standards for reusable devices and optimizing non-sterile consumable materials could dramatically reduce healthcare-associated emissions without compromising safety, thereby minimizing the negative consequences of hospital operations to environmental and human health. Findings extend to other non-sterile surgical procedures. LEVEL OF EVIDENCE: N/A Laryngoscope, 2024.

Environmental and financial impacts of perioperative paracetamol use: a multicentre international life-cycle analysis.

BACKGROUND: Pharmaceuticals account for 19-32% of healthcare greenhouse gas (GHG) emissions. Paracetamol is a common perioperative analgesic agent. We estimated GHG emissions associated with i.v. and oral formulations of paracetamol used in the perioperative period. METHODS: Life-cycle assessment of GHG emissions (expressed as carbon dioxide equivalents CO2e) of i.v. and oral paracetamol preparations was performed. Perioperative paracetamol prescribing practices and costs for 26 hospitals in USA, UK, and Australia were retrospectively audited. For those surgical patients for whom oral formulations were indicated, CO2e and costs of actual prescribing practices for i.v. or oral doses were compared with optimal oral prescribing. RESULTS: The carbon footprint for a 1 g dose was 38 g CO2e (oral tablet), 151 g CO2e (oral liquid), and 310-628 g CO2e (i.v. dependent on type of packaging and administration supplies). Of the eligible USA patients, 37% received paracetamol (67% was i.v.). Of the eligible UK patients, 85% received paracetamol (80% was i.v.). Of the eligible Australian patients, 66% received paracetamol (70% was i.v.). If the emissions mitigation opportunity from substituting oral tablets for i.v. paracetamol is extrapolated to USA, UK, and Australia elective surgical encounters in 2019, ∼5.7 kt CO2e could have been avoided and would save 98.3% of financial costs. CONCLUSIONS: Intravenous paracetamol has 12-fold greater life-cycle carbon emissions than the oral tablet form. Glass vials have higher greenhouse gas emissions than plastic vials. Intravenous administration should be reserved for cases in which oral formulations are not feasible.

Sustainable and Resilient Health Care in the Face of a Changing Climate.

Climate change is a threat multiplier, exacerbating underlying vulnerabilities, worsening human health, and disrupting health systems' abilities to deliver high-quality continuous care. This review synthesizes the evidence of what the health care sector can do to adapt to a changing climate while reducing its own climate impact, identifies barriers to change, and makes recommendations to achieve sustainable, resilient health care systems.

Displaying geographic variability of peri-urban agriculture environmental impacts in the Metropolitan Area of Barcelona: A regionalized life cycle assessment.

Peri urban agriculture (peri-UA) can supply food locally and potentially more sustainably than far-away conventional agricultural systems. It can also introduce significant environmental impacts depending on the local biophysical conditions and resources required to implement it and, on the crops managing practices, which could vary widely among growers. Sophisticated methods to account for such variability while assessing direct (on-site) and indirect (up/down stream) environmental impacts of peri-UA implementation are thus needed. We implemented an attributional, regionalized, cradle-to-gate life cycle assessment (LCA) for which we derive spatially explicit inventories and calculate 14 impacts due to peri-UA using the ReCiPe method. Further, to show the importance of impact assessment regionalization for the environmental assessment of peri-UA, we regionalize eutrophication impacts characterization. We use the Metropolitan Area of Barcelona (AMB) to illustrate these methodological developments. Vegetables and greenhouses, the prevalent peri-UA land uses, had the largest impacts assessed, of all peri-UA land uses. European NPK mineral fertilizer production to cover N demand of these crops drives all impacts. For fruit crops, on-site N emissions drive marine eutrophication impacts and for irrigated herbaceous crops, phosphate runoff drives freshwater eutrophication impacts. Geographic variability of peri-UA metabolic flows and impacts was displayed. Management practices at the plots, which are linked the land use, are responsible for impacts variability. Regionalization of eutrophication impacts highlights the importance of accounting for the biophysical aspects at the geographic scale at which peri-UA takes place, which is a much finer scale than those implemented in current regionalization of impact assessment methods in LCA. This study provides a fundamental baseline needed to assess transition scenarios of peri-UA at an appropriate geographic level of analysis and gives essential knowledge to guide appropriate circular and sustainability strategies for the sector.

i-CLIMATE: a "clinical climate informatics" action framework to reduce environmental pollution from healthcare.

Addressing environmental pollution and climate change is one of the biggest sociotechnical challenges of our time. While information technology has led to improvements in healthcare, it has also contributed to increased energy usage, destructive natural resource extraction, piles of e-waste, and increased greenhouse gases. We introduce a framework "Information technology-enabled Clinical cLimate InforMAtics acTions for the Environment" (i-CLIMATE) to illustrate how clinical informatics can help reduce healthcare's environmental pollution and climate-related impacts using 5 actionable components: (1) create a circular economy for health IT, (2) reduce energy consumption through smarter use of health IT, (3) support more environmentally friendly decision-making by clinicians and health administrators, (4) mobilize healthcare workforce environmental stewardship through informatics, and (5) Inform policies and regulations for change. We define Clinical Climate Informatics as a field that applies data, information, and knowledge management principles to operationalize components of the i-CLIMATE Framework.

Multidimensional Analyses Reveal Unequal Resource, Economic, and Environmental Gains and Losses among the Global Aluminum Trade Leaders.

Disputes around trade inequality have been growing over the last 2 decades, with different countries claiming inequality in different terms including monetary deficits, resource appropriation and degradation, and environmental emission transfer. Despite prior input-output-based studies analyzing multidimensional trade consequences at the sector level, there is a lack of bottom-up studies that uncover the complexity of trade imbalances at the product level. This paper quantifies four types of flows, monetary, resource, embodied energy use, and embodied greenhouse gas (GHG) emissions, resulting from aluminum trade for the four economies with the highest aluminum trade, that is, the United States, China, Japan, and Australia. Results show that the United States has a negative balance in monetary flows but a positive balance in resource flows, embodied energy use, and GHG emissions. China has a positive balance in monetary and resource flows but a negative balance in embodied energy use and GHG emissions. Japan has a positive balance in all flows, while Australia has a negative balance in all flows. These heterogeneous gains and losses along the global leaders of aluminum trade arise largely from their different trade structures and the heterogeneities of price, energy use, and GHG emission intensities of aluminum products; for example, Japan mainly imports unwrought aluminum, and its quantity is 3 times that of the exported semis and finished aluminum-containing products that have similar energy and GHG emission intensities but 20 times higher prices, while Australia mainly exports bauxite and alumina that have the lowest prices, the quantity of which is 25 times that of imported semis and finished products. This study suggests that resource-related trade inequalities are not uniform across economic and environmental impacts and that trade policies must be carefully considered from various dimensions.

Health care's response to climate change: a carbon footprint assessment of the NHS in England.

BACKGROUND: Climate change threatens to undermine the past 50 years of gains in public health. In response, the National Health Service (NHS) in England has been working since 2008 to quantify and reduce its carbon footprint. This Article presents the latest update to its greenhouse gas accounting, identifying interventions for mitigation efforts and describing an approach applicable to other health systems across the world. METHODS: A hybrid model was used to quantify emissions within Scopes 1, 2, and 3 of the Greenhouse Gas Protocol, as well as patient and visitor travel emissions, from 1990 to 2019. This approach complements the broad coverage of top-down economic modelling with the high accuracy of bottom-up data wherever available. Available data were backcasted or forecasted to cover all years. To enable the identification of measures to reduce carbon emissions, results were disaggregated by organisation type. FINDINGS: In 2019, the health service's emissions totalled 25 megatonnes of carbon dioxide equivalent, a reduction of 26% since 1990, and a decrease of 64% in the emissions per inpatient finished admission episode. Of the 2019 footprint, 62% came from the supply chain, 24% from the direct delivery of care, 10% from staff commute and patient and visitor travel, and 4% from private health and care services commissioned by the NHS. INTERPRETATION: This work represents the longest and most comprehensive accounting of national health-care emissions globally, and underscores the importance of incorporating bottom-up data to improve the accuracy of top-down modelling and enabling detailed monitoring of progress as health systems act to reduce emissions. FUNDING: Wellcome Trust.

Transforming The Medical Device Industry: Road Map To A Circular Economy.

A circular economy involves maintaining manufactured products in circulation, distributing resource and environmental costs over time and with repeated use. In a linear supply chain, manufactured products are used once and discarded. In high-income nations, health care systems increasingly rely on linear supply chains composed of single-use disposable medical devices. This has resulted in increased health care expenditures and health care-generated waste and pollution, with associated public health damage. It has also caused the supply chain to be vulnerable to disruption and demand fluctuations. Transformation of the medical device industry to a more circular economy would advance the goal of providing increasingly complex care in a low-emissions future. Barriers to circularity include perceptions regarding infection prevention, behaviors of device consumers and manufacturers, and regulatory structures that encourage the proliferation of disposable medical devices. Complementary policy- and market-driven solutions are needed to encourage systemic transformation.

Health Care Pollution And Public Health Damage In The United States: An Update.

An up-to-date assessment of environmental emissions in the US health care sector is essential to help policy makers hold the health care industry accountable to protect public health. We update national-level US health-sector emissions. We also estimate state-level emissions for the first time and examine associations with state-level energy systems and health care quality and access metrics. Economywide modeling showed that US health care greenhouse gas emissions rose 6 percent from 2010 to 2018, reaching 1,692 kg per capita in 2018-the highest rate among industrialized nations. In 2018 greenhouse gas and toxic air pollutant emissions resulted in the loss of 388,000 disability-adjusted life-years. There was considerable variation in state-level greenhouse gas emissions per capita, which were not highly correlated with health system quality. These results suggest that the health care sector's outsize environmental footprint can be reduced without compromising quality. To reduce harmful emissions, the health care sector should decrease unnecessary consumption of resources, decarbonize power generation, and invest in preventive care. This will likely require mandatory reporting, benchmarking, and regulated accountability of health care organizations.

Life cycle environmental emissions and health damages from the Canadian healthcare system: An economic-environmental-epidemiological analysis.

BACKGROUND: Human health is dependent upon environmental health. Air pollution is a leading cause of morbidity and mortality globally, and climate change has been identified as the single greatest public health threat of the 21st century. As a large, resource-intensive sector of the Canadian economy, healthcare itself contributes to pollutant emissions, both directly from facility and vehicle emissions and indirectly through the purchase of emissions-intensive goods and services. Together these are termed life cycle emissions. Here, we estimate the extent of healthcare-associated life cycle emissions as well as the public health damages they cause. METHODS AND FINDINGS: We use a linked economic-environmental-epidemiological modeling framework to quantify pollutant emissions and their implications for public health, based on Canadian national healthcare expenditures over the period 2009-2015. Expenditures gathered by the Canadian Institute for Health Information (CIHI) are matched to sectors in a national environmentally extended input-output (EEIO) model to estimate emissions of greenhouse gases (GHGs) and >300 other pollutants. Damages to human health are then calculated using the IMPACT2002+ life cycle impact assessment model, considering uncertainty in the damage factors used. On a life cycle basis, Canada's healthcare system was responsible for 33 million tonnes of carbon dioxide equivalents (CO2e), or 4.6% of the national total, as well as >200,000 tonnes of other pollutants. We link these emissions to a median estimate of 23,000 disability-adjusted life years (DALYs) lost annually from direct exposures to hazardous pollutants and from environmental changes caused by pollution, with an uncertainty range of 4,500-610,000 DALYs lost annually. A limitation of this national-level study is the use of aggregated data and multiple modeling steps to link healthcare expenditures to emissions to health damages. While informative on a national level, the applicability of these findings to guide decision-making at individual institutions is limited. Uncertainties related to national economic and environmental accounts, model representativeness, and classification of healthcare expenditures are discussed. CONCLUSIONS: Our results for GHG emissions corroborate similar estimates for the United Kingdom, Australia, and the United States, with emissions from hospitals and pharmaceuticals being the most significant expenditure categories. Non-GHG emissions are responsible for the majority of health damages, predominantly related to particulate matter (PM). This work can guide efforts by Canadian healthcare professionals toward more sustainable practices.

Comparative Life Cycle Assessment of Advanced Wastewater Treatment Processes for Removal of Chemicals of Emerging Concern.

The potential health effects associated with contaminants of emerging concern (CECs) have motivated regulatory initiatives and deployment of energy- and chemical-intensive advanced treatment processes for their removal. This study evaluates life cycle environmental and health impacts associated with advanced CEC removal processes, encompassing both the benefits of improved effluent quality as well as emissions from upstream activities. A total of 64 treatment configurations were designed and modeled for treating typical U.S. medium-strength wastewater, covering three policy-relevant representative levels of carbon and nutrient removal, with and without additional tertiary CEC removal. The USEtox model was used to calculate characterization factors of several CECs with missing values. Stochastic uncertainty analysis considered variability in influent water quality and uncertainty in CEC toxicity and associated characterization factors. Results show that advanced tertiary treatment can simultaneously reduce nutrients and CECs in effluents to specified limits, but these direct water quality benefits were outweighed by even greater increases in indirect impacts for the toxicity-related metrics, even when considering order-of-magnitude uncertainties for CEC characterization factors. Future work should consider water quality aspects not currently captured in life cycle impact assessment, such as endocrine disruption, in order to evaluate the full policy implications of the CEC removal.

Life Cycle Assessment and Costing Methods for Device Procurement: Comparing Reusable and Single-Use Disposable Laryngoscopes.

BACKGROUND: Traditional medical device procurement criteria include efficacy and safety, ease of use and handling, and procurement costs. However, little information is available about life cycle environmental impacts of the production, use, and disposal of medical devices, or about costs incurred after purchase. Reusable and disposable laryngoscopes are of current interest to anesthesiologists. Facing mounting pressure to quickly meet or exceed conflicting infection prevention guidelines and oversight body recommendations, many institutions may be electively switching to single-use disposable (SUD) rigid laryngoscopes or overcleaning reusables, potentially increasing both costs and waste generation. This study provides quantitative comparisons of environmental impacts and total cost of ownership among laryngoscope options, which can aid procurement decision making to benefit facilities and public health. METHODS: We describe cradle-to-grave life cycle assessment (LCA) and life cycle costing (LCC) methods and apply these to reusable and SUD metal and plastic laryngoscope handles and tongue blade alternatives at Yale-New Haven Hospital (YNHH). The US Environmental Protection Agency's Tool for the Reduction and Assessment of Chemical and other environmental Impacts (TRACI) life cycle impact assessment method was used to model environmental impacts of greenhouse gases and other pollutant emissions. RESULTS: The SUD plastic handle generates an estimated 16-18 times more life cycle carbon dioxide equivalents (CO2-eq) than traditional low-level disinfection of the reusable steel handle. The SUD plastic tongue blade generates an estimated 5-6 times more CO2-eq than the reusable steel blade treated with high-level disinfection. SUD metal components generated much higher emissions than all alternatives. Both the SUD handle and SUD blade increased life cycle costs compared to the various reusable cleaning scenarios at YNHH. When extrapolated over 1 year (60,000 intubations), estimated costs increased between $495,000 and $604,000 for SUD handles and between $180,000 and $265,000 for SUD blades, compared to reusables, depending on cleaning scenario and assuming 4000 (rated) uses. Considering device attrition, reusable handles would be more economical than SUDs if they last through 4-5 uses, and reusable blades 5-7 uses, before loss. CONCLUSIONS: LCA and LCC are feasible methods to ease interpretation of environmental impacts and facility costs when weighing device procurement options. While management practices vary between institutions, all standard methods of cleaning were evaluated and sensitivity analyses performed so that results are widely applicable. For YNHH, the reusable options presented a considerable cost advantage, in addition to offering a better option environmentally. Avoiding overcleaning reusable laryngoscope handles and blades is desirable from an environmental perspective. Costs may vary between facilities, and LCC methodology demonstrates the importance of time-motion labor analysis when comparing reusable and disposable device options.

Integrating uncertainties to the combined environmental and economic assessment of algal biorefineries: A Monte Carlo approach.

The economic and environmental performance of microalgal processes has been widely analyzed in recent years. However, few studies propose an integrated process-based approach to evaluate economic and environmental indicators simultaneously. Biodiesel is usually the single product and the effect of environmental benefits of co-products obtained in the process is rarely discussed. In addition, there is wide variation of the results due to inherent variability of some parameters as well as different assumptions in the models and limited knowledge about the processes. In this study, two standardized models were combined to provide an integrated simulation tool allowing the simultaneous estimation of economic and environmental indicators from a unique set of input parameters. First, a harmonized scenario was assessed to validate the joint environmental and techno-economic model. The findings were consistent with previous assessments. In a second stage, a Monte Carlo simulation was applied to evaluate the influence of variable and uncertain parameters in the model output, as well as the correlations between the different outputs. The simulation showed a high probability of achieving favorable environmental performance for the evaluated categories and a minimum selling price ranging from $11gal-1 to $106gal-1. Greenhouse gas emissions and minimum selling price were found to have the strongest positive linear relationship, whereas eutrophication showed weak correlations with the other indicators (namely greenhouse gas emissions, cumulative energy demand and minimum selling price). Process parameters (especially biomass productivity and lipid content) were the main source of variation, whereas uncertainties linked to the characterization methods and economic parameters had limited effect on the results.

Estimated Global Disease Burden From US Health Care Sector Greenhouse Gas Emissions.

OBJECTIVES: To quantify the increased disease burden caused by US health care sector life cycle greenhouse gas (GHG) emissions of 614 million metric tons of carbon dioxide equivalents in 2013. METHODS: We screened for health damage factors that linked GHG emissions to disease burdens. We selected 5 factors, based on appropriate temporal modeling scales, which reflect a range of possible GHG emissions scenarios. We applied these factors to health care sector emissions. RESULTS: We projected that annual GHG emissions associated with health care in the United States would cause 123 000 to 381 000 disability-adjusted life-years in future health damages, with malnutrition being the largest damage category. CONCLUSIONS: Through their contribution to global climate change, GHG emissions will negatively affect public health because of an increased prevalence of extreme weather, flooding, vector-borne disease, and other effects. As the stewards of global health, it is important for health care professionals to recognize the magnitude of GHG emissions associated with health care itself, and the severity of associated health damages.

Life Cycle Assessment and Release Studies for 15 Nanosilver-Enabled Consumer Products: Investigating Hotspots and Patterns of Contribution.

Increasing use of silver nanoparticles (AgNPs) in consumer products as antimicrobial agents has prompted extensive research toward the evaluation of their potential release to the environment and subsequent ecotoxicity to aquatic organisms. It has also been shown that AgNPs can pose significant burdens to the environment from life cycle emissions associated with their production, but these impacts must be considered in the context of actual products that contain nanosilver. Here, a cradle-to-gate life cycle assessment for the production of 15 different AgNP-enabled consumer products was performed, coupled with release studies of those same products, thus providing a consistent analytical platform for investigation of potential nanosilver impacts across a range of product types and concentrations. Environmental burdens were assessed over multiple impact categories defined by the United States Environmental Protection Agency's Tool for the Reduction and Assessment of Chemical and Other Environmental Impacts (TRACI 2.1) method. Depending on the product composition and silver loading, the contribution of AgNP synthesis to the overall impacts was seen to vary over a wide range from 1% to 99%. Release studies found that solid polymeric samples lost more silver during wash compared to fibrous materials. Estimates of direct ecotoxicity impacts of AgNP releases from those products with the highest leaching rates resulted in lower impact levels compared to cradle-to-gate ecotoxicity from production for those products. Considering both cradle-to-gate production impacts and nanoparticle release studies, in conjunction with estimates of life cycle environmental and health benefits of nanoparticle incorporation, can inform sustainable nanoenabled product design.