Guidelines and Recommendations Special Articles 329

M. Schuster1 · H. Richter1 · S. Pecher2 · S. Koch3 · M. Coburn4 Ecological Sustainability § Compiled by the DGAI/BDA Commission on Sustainability in Anaesthesiology in Anaesthesiology and Intensive Care Medicine A DGAI and BDA Position Paper with Specific Recom- mendations*

 Citation: Schuster M, Richter H, Pecher S, Koch S, Coburn M: Ecological Sustainability in Anaesthesio­ logy and Intensive Care Medicine. A DGAI and BDA Position Paper with Specific Recommendations*. Anästh Intensivmed 2020;61:329–338. DOI: 10.19224/ai2020.329

1 Klinik für Anästhesiologie, Intensiv­ Summary be avoided in both the operating theatre medizin, Notfallmedizin und Schmerz­ and intensive care unit without upsetting therapie, Kliniken Landkreis Karlsruhe, This position paper with specific recom­ existing processes. Fürst-Stirum-Klinik Bruchsal, Rechberg­ mendations was commissioned by the klinik Bretten, Akademische Lehrkran­ kenhäuser der Universität Heidelberg DGAI and BDA executive committees in In addition to these measures directly 2 Klinik für Anästhesie und Intensiv­ March 2020 and was compiled by the related to the field of anaesthesiology, medizin, Diakonie Klinikum Stuttgart joint “Commission on Sustainability in this position paper addresses further 3 CharitéCentrum für Anästhesiologie und Anaesthesiology”. areas of concern indirectly associated Intensivmedizin CC 7, Campus Charité with the everyday professional role Mitte & Campus Virchow – Klinikum, With the impending climate disaster in of the anaesthesiologist. As such, the Charité Universitätsmedizin Berlin mind, the aim of this position paper is to paper alludes to the significance of 4 Klinik für Anästhesiologie, Uniklinik delineate with which specific measures RWTH Aachen sustainable mobility with regard to every­- anaesthesiologists can contribute to a day commutes, patient transfers, and consistent and sustained reduction in § Members of the Commission on conferences. Improved energy manage­ Sustainability in Anaesthesiology CO2 emissions and minimise the nega­ (in alphabetical order): ment may commence in the operating tive ecological implications associated Prof. Dr. Thomas Bein, Prof. Dr. Mark theatre and intensive care unit but must 1 with the fields of anaesthesiology and Coburn , Prof. Dr. Herwig Gerlach, ultimately encompass the whole hospital Priv.-Doz. Dr. Susanne Koch2, Dr. Ana intensive care medicine. The paper is as a significant source of CO2 emissions. Kowark, Dr. Ferdinand Lehmann, divided into six sections and, on the Dr. Sabine Pecher, Dr. Hannah Richter, Numerous measures can already be im­ Prof. Dr. Rolf Rossaint, Dr. Charlotte basis of published literature, presents plemented today, and appropriate steps Samwer, Priv.-Doz. Dr. Christian Schulz, the currently available evidence on should be taken at a local level. Last but Prof. Dr. Martin Schuster3 how anaesthesiologists can incorporate not least, the importance of research and (1: Chair DGAI, 2: Instigator, 3: Chair sustainability aspects in their professional BDA) teaching is emphasized as a key factor in sphere of influence. Special attention successfully facing the challenge of eco­ is directed towards the environmental logical sustainability in anaesthesiology effects of drugs used in anaesthesiology and intensive care medicine. and intensive care and their impact on climate change. In that regard, the direct and potent greenhouse gas effects of Preface * Resolution of the Execuitve Commitee of volatile anaesthetics are emphasized. In In March 2020 the Professional Asso­ the DGAI, dated 16.03.2020/of the BDA, consequence, specific recommendations ciation of German Anaesthesiologists dated 24.04.2020. are made on reducing the damaging (BDA) and the German Society of Anaes­ Interest to disclose effects of volatile anaesthetics on the cli­ thesiology and Intensive Care Medicine The authors have no financial or other com­ peting interest to disclose. This recommen­ mate. With regard to consumables, the (DGAI) executive committees assigned dation was unfunded. increasing use of disposable single-use the joint “Commission on Sustaina- items is the subject of critical analysis, bility in Anaesthesiology” the task of Keywords and the need to incorporate the carbon compiling a position paper with specific Guidelines – Anesthesio­ footprint in the selection of products is recommendations. Both executive com­ logy – Sustainability – Climate stressed. As waste has significant direct mittees approved the publication of this

change – CO2 emission and indirect ecological effects, the 5R position paper in its current form during concept is used to show how waste can their sessions on the 16th March 2020 330 Special Articles Guidelines and Recommendations

(DGAI) and 24th April 2020 (BDA). With plemented immediately at a local level the grave”, including the following po­ the publication of this position paper, by anaesthesiologists. However, a good sitions: 1) extraction of raw materials, 2) both BDA and DGAI expressly commit number of measures, including many processing and manufacturing, 3) trans­ themselves to the goal of carbon neutral, with significant leverage, are arduous to port and packaging, 4) use, reutilisation sustainable health care and will there­ implement at a local level alone. As and maintenance, 5) recycling and 6) fore, together with other actors in the such, achieving carbon neutrality in disposal. Water use and release of toxins health care sector, use their influence on anaesthesiology and intensive care are additional important factors besides politics and on the industry to actively medicine over the next three decades CO2 release [15]. further the necessary transformational will require wide-ranging technological process. innovation and significant investment in energy efficient refurbishment and in the A. Drugs Introduction infrastructure of individual hospitals. Major issues such as assuring generation R1: General anaesthesia using volatile The 2018 Intergovernmental Panel on of energy from renewable sources or re­ anaesthetics and/or nitrous Climate Change report was climate alising sustainable transport are tasks for oxide should be maintained in scientist’s warning not to exceed the society as a whole and require political such a fashion that the smallest 1.5 °C limit of global warming. Only a implementation. As a professional and a quantity of anaesthetic possible is rapid and substantial worldwide reduc­ scientific body, we will use our influence discharged into the environment. tion in CO2 emissions over the next few to demand these changes. This requires consistent use of years can avert runaway effects such In the past, close coordination between minimal-flow anaesthesia. as the melting of Antarctic ice masses practising physicians and the industry – R2: Use of desflurane should be or thawing of permafrost soils, which especially in the fields of anaesthesio­ reserved for cases in which it threaten to make the effects of climate logy and intensive care medicine – have appears mandated on medical change uncontrollable [1]. led to a variety of technical innovations grounds. Of those volatile As physicians we are under a special ob­ which have made patient care safer and anaesthetics commonly used, ligation. Over the next decades, climate opened new horizons of clinical possibi­ sevoflurane is the least potent change will lead to a change for the lity for the good of patients. Seen in the greenhouse gas. worse in health care for a great number light of the climate crisis, this close coor­ R3: Use of nitrous oxide should be of people across the planet and pose dination should be further strengthened, avoided unless its use appears grave challenges to health care systems aiming to promote the transformation to mandated on medical grounds. in almost every country [2]. At the same ecologically sustainable patient care. R4: The development, trialling and time, the health care system is itself use of scavenging and recycling responsible for significant emissions of Glossary systems for volatile anaesthetics greenhouse gases, owning 4.4% of glo­ should be expedited. bal greenhouse gas emissions in 2014 CO2e: CO2 equivalents [3]. In response, numerous professional Emissions of greenhouse gases other R5: In contrast to inhalational anaesthesia techniques, total medical bodies have issued their own than CO2 can be converted to CO2 statements alluding to the urgent need to equivalents. This entails calculating the intravenous and regional anaes­ thesia do not intrinsically cause reduce CO2 emissions across the health quantity of CO2 which would exhibit care sector [4–8]. Physicians are called the same effect in the atmosphere as the direct greenhouse gas emissions. upon to adjust their consumer behaviour emission in question by using the mass Use of these techniques to avoid and – in the spirit of divestment cam­ of that emission and its Global Warming greenhouse gas emissions is judi­ paigns – their investment decisions to Potential [13]. cious when they are appropriate prioritise climate protection [9]. from a medical standpoint. GWP: Global Warming Potential R6: Pharmaceutical waste should be As high-tech, resource hungry fields, The Global Warming Potential describes avoided on both economic and anaesthesiology and intensive care me- the substance-specific greenhouse effect ecological grounds. dicine are involved in a significant por- compared to CO2 over a specified length tion of CO2 emissions across the health R7: Pharmaceutical waste must be of time. In general, the interval chosen is care sector [10–12]. In the past few years, disposed of in an appropriate fa­ 100 years (GWP100) [14]. numerous professional anaesthesiologic shion and must not be introduced into the sewage system. As a rule, bodies have published recommenda­ LCA: Life-Cycle Assessment it is appropriate to dispose of tions for anaesthetists on how they can A life-cycle assessment can be used to such waste resulting from anaes- contribute to reducing CO2 emissions determine the actual carbon footprint thesia and intensive care by [5–8]. of consumables, drugs and medical incineration together with other The following recommendations focus procedures. This involves analysing the residual waste. on those measures which can be im­ ecological footprint from “the cradle to Guidelines and Recommendations Special Articles 331

Volatile anaesthetics (VA) and nitrous flurane significantly worsens the carbon anaesthesia cases per annum, the annual oxide exhibit potent greenhouse effects footprint of the volatile agent [21,25]. carbon footprint is equivalent to that of when released into the atmosphere. Both During the maintenance of general up to 200 average citizens in Germany. sevoflurane and desflurane are hydro­ anaesthesia, doubling the flow rate will Avoiding desflurane could obviate 67% fluorocarbons (HFCs), whilst isoflurane, double the emissions from VA [19,21, of emissions attributable to an anaesthe­ enflurane and halothane are chlorofluo­ 24–26]. As such, utilising minimal flow sia department [28]. rocarbons (CFCs) and exhibit additional for maintenance of anaesthesia is to be Various technical solutions for capturing ozone-depleting effects. The same is recommended in any case. A higher fresh rather than emitting VAs and nitrous true for nitrous oxide (N2O) [11,16–19]. gas flow should be reserved for situations oxide are currently in development or VAs show a significantly larger negative in which the depth of anaesthesia needs almost ready for market. Using such impact on the climate than CO2. That to be changed rapidly. Also when initia­ technologies, VAs can be destroyed by impact is recorded as the comparative ting emergence, high flows should only thermal, catalytic or photochemical greenhouse effect in relation to CO2 be used once the vapor has been shut off means, or processed for reuse [24,25, (Global Warming Potential, GWP). To [25]. 29–31]. Today, systems which capture ensure the total atmospheric lifetime of Volatile agents used for general anaes­ nitrous oxide used in obstetrics, destro­ CO2 is taken into account [22], an obser­ thesia are currently discharged into the ying it by means of a thermal catalytic vation period of 100 years (GWP100) is environment in their entirety, causing process, are already in practical use [24, typically selected [17,19–21]. a significant greenhouse effect. World­ 30]. The technical means for reacquiring VAs exhibit their principal greenhouse wide emissions from VA totalled 3 m tons sevoflurane from specially designed ac­ effect during their atmospheric lifetime, CO2 equivalent in 2014, not including tivated carbon filters, making it available instead of uniformly throughout the the effect ascribable to nitrous oxide. for reuse on patients after distillation and 100-year timeframe. Applying GWP100 80% of these emissions were attributable sterilisation, already exist. As such, at will lead to the negative impact of VAs to desflurane alone [11]. In an average some point in the future, VAs could re­ on the climate being underestimated for anaesthesia department, use of VAs will present a test case for licensing recycled the next 10 – 30 years. As such, a GWP be responsible for between 3.5 and drugs. The process of capturing VAs in observation period of 20 years can be 118.3 kg CO2 equivalent per anaes­ carbon filters – as is commonly practised helpful in demonstrating the greenhouse thesia case [27,28]. Assuming 10,000 on intensive care units in Germany – is effect which will set in within the rele­ vant social and political time remaining to battle global warming (Tab. 1) [19]. Table 1 In addition to the greenhouse effect per Global Warming Potentials and atmospheric lifetimes of inhaled anaesthetics (Sulbaek Anderson et al. 2012 [17]). quantity of substance used, the actual quantity of the VA required to reach GWP100 GWP20 Atmospheric lifetime (in years) an adequate minimal alveolar con­ CO2 1 1 30 – 95 (23) centration (MAC) needs to be factored N2O 298 289 114 into the equation. During steady state Sevoflurane 130 440 1.1 and assuming identical flow rates, use Desflurane 2,540 6,810 14 of desflurane for general anaesthesia Isoflurane 510 1,800 3.2 emits approx. 50 times as much CO2 Halothane 50 190 1.0 equivalent as when sevoflurane is used. Enflurane 680 2,370 4.3 This difference becomes all the more apparent when the emissions caused by inhalational agents for maintenance Table 2 of anaesthesia during steady state are Emissions from 6 hours of inhalational anaesthesia during steady state, converted to kilometres converted and expressed as kilometres travelled by car (based on Sherman and Feldman 2017 [24]). travelled by car [17,21,24]. Emissions Minimal-Flow Low-Flow High-Flow- High-Flow- from 6 hours of inhalational anaesthe­ Anaesthesia Anaesthesia Anaesthesia Anaesthesia sia – the equivalent of one working day 0.5 l/min 1 l/min 2 l/min 5 l/min – are set out in this fashion in Table 2, Sevoflurane 2,2% 19.3 km 38.6 km 77.2 km 183.5 km based on GWP100s. The results assume Desflurane 6,7% 898.0 km 1,825.0 km 3,650.0 km 9,067.0 km general anaesthesia during steady state, Isoflurane 1,2% 38.6 km 67.6 km 144.8 km 366.9 km and so do not include the induction and Nitrous oxide (N2O) 280.0 km 550.4 km 1,081.5 km 2,723.0 km emergence phases. Using nitrous oxide 60% as a carrier gas for sevoflurane or iso­ 332 Special Articles Guidelines and Recommendations

insufficient on its own, however, as (based on the earlier Persistence, Bioac- those VAs are released from the filter into cumulation and Toxicity (PBT) Index) R2: Use of reusable fabrics such as surgical gowns, caps and drapes the atmosphere after the filter has been was designed to grade the risk phar­ should be considered. disposed of [24,25]. maceuticals pose to the environment. The score should be consulted whenever R3: Single-use items made of metal With regard to CO2 emissions attribu­ have a particularly poor carbon table to production, distribution and possible when selecting drugs, so as to footprint and replacing them disposal of almost all other drugs com­ ensure the smallest possible impact on with reusable products should be monly used in anaesthetics, precise data the environment. Unfortunately, a signi­ assessed. are lacking such that it is impossible to ficant portion of anaesthesiologic drugs make detailed statements with regard to have yet to be graded [38]. R4: Manufacturers should be called specific drugs. Waste drugs can be introduced into the upon to provide full life-cycle assessments of the carbon As methods such as TIVA or regional environment when they are discarded footprints of medical devices. anaesthesia do not generate direct emi­- improperly via the sewage system – ssions of greenhouse gases, the emissi­ propofol remnants have been found in Single-use items are ubiquitous in ons associated with those methods are hospital wastewater [39]. Propofol has a anaesthesia and intensive care and are significantly lower than from inhalatio­ Hazard Score of 4 (on a scale of 0 to increasingly displacing reusable pro­ nal anaesthesia [24,25,32–34]. the maximum of 9) and is neither biode­ gradable in water nor under anaerobic ducts. The main influencing factors in When considerable drug quantities are conditions [25,33,36,40]. the decision process between single-use discarded, it is expedient to consider and reusable products are quoted as All departments must establish pro­ using smaller vials [25]; up to 20% of concern for hygiene, convenience, and cedures for correct disposal of pharma­ propofol waste, for example, is conside­ cost. Environmental factors have traditi­ ceutical waste and train staff in the red to be avoidable [35]. In some situa­ onally played a lesser role [15]. tions, switching from 50 or 100 ml vials implementation. Life-cycle assessments are available for of propofol to 20 ml vials can reduce Disposal of left-over pharmaceuticals an ever-increasing number of medical the quantity of drug wasted by more “down the drain”, that is via the sewage products. A review of 6 LCAs comparing than 90% [36]. This can, in addition, system, is unacceptable from an eco­ washable, reusable surgical textiles (sur­ be economically viable; wasted drugs logical point of view. As a rule, drugs gical gowns and drapes) with single-use make up for approximately one quarter must be disposed of by incineration. items showed that the reusable textiles of the total cost of drugs [35]. This calls The requisite temperatures vary [25]. featured a 30–50% smaller carbon foot- for a comprehensive review taking other Propofol remnants aren’t destroyed until print. Single-use items require 200– waste (see below) into account. Drugs heated to over 1000 °C for at least 2 300% more energy, 250–330% more kept drawn up ready for use not only seconds [36], whilst most other drugs water and produce 750% more waste cause significant costs when they ulti- used in anaesthesia can be incinerated than reusable items, even when both mately remain unused but also bear a at lower temperatures [25]. The disposal the water and energy requirements for relevant negative ecological impact of pharmaceuticals should be organised washing and sterilising reusable items [36]. 50% of emergency drugs drawn in a pragmatic, error-resistant way: it is are taken into account [41]. up end up being discarded unused [37]. recommended that left-over drugs should This applies to drugs which have to be be emptied into paper towels and placed A comparison between single-use and available for use immediately and with­ together with resiudal waste for incine­ reusable plastic anaesthetic drug trays out delay (such as those for anaesthesia ration. Balanced electrolyte solutions showed the reusable item to be not only for emergency caesarean section) and to without the addition of any drugs can be more ecological but also more economi­ those which require dilution, which may emptied down the drain. cal [42]. For reusable laryngeal masks, a lead to delay and dosing errors (such as significantly smaller negative ecological bolus injections of catecholamines). It impact was shown across all examined is appropriate to consider having these B. Consumables categories of ecological sustainability drugs prefilled into syringes under clean [43]. Utilising single-use laryngoscopes R1: The increasing use of single-use and sanitary conditions by the pharmacy increases the CO2 emissions by 16 to or to purchase prefilled syringes, which disposable consumables in place 25 times when compared with reusable typically have a longer shelf life and can of reusable items should be the stainless-steel devices, especially when therefore reduce waste [15]. subject of critical analysis. An both the laryngoscope blade and the assessment should be undertaken The Swedish Stockholm County Council handle are single-use items [44,45]. to determine in which cases Drug Therapeutic Committee has deve­ Extracting metals from ore is extremely reusable items could present an energy intensive and leads to a very loped an environmental classification alternative. for pharmaceuticals. The Hazard Score large carbon footprint [27,46]. The Ger- Guidelines and Recommendations Special Articles 333

man Society of Hospital Hygiene (DGKH) patient blood management is at waste – which could be dispo­ notes that use of single-use metal inst­ the same time a sound ecological sed of as standard waste or even ruments (laryngoscopes, scissors, needle approach. holders, forceps etc.) is of particular recycled – must not through concern as, in addition to the associated thoughtlessness or laziness be Recycle: significant use of resources, erroneous disposed of as dangerous waste. Approximately 60% of waste generated introduction of such products into the in operating theatres can potentially be Approximately 20–30% of waste ac- sterilisation process poses a significant recycled. A lack of containers and inf­ crued in hospitals is generated in the risk of causing corrosion of other ins­ rastructure, lack of knowledge, laziness operating theatre; 25% of this waste is truments. They go on to point out that and lack of support have been listed generated by anaesthesia, much of it is a good number of single-use products as barriers to effective recycling in the packaging [51,52]. Each theatre case are manufactured under ethically pro­ theatre environment [61]. generates between 7.62 and 16.39 kg blematic conditions in underdeveloped of waste [27]. The 5R concept (reduce, As the largest proportion of packaging countries [47]. As such, single-use metal reuse, recycle, rethink and research) waste is accrued when opening equip- items should be replaced by reusable ment before the patient is brought to products whenever possible. When this was coined to reduce the ever-increasing theatre, contamination of that waste is appears impossible, at the very least quantity of waste produced [50]. practically inconceivable. One option to effective recycling should be implemen­ Reduce: ensure recycling waste remains uncon­ ted. 1 m ton of recycled steel reduces “Doing more with less” is the most ef- taminated is to seal the recycling bags as CO2 emissions by approx. 80% when fective method of sparing resources and soon as the patient is brought into the compared to manufacturing with metal operating theatre [15]. Clearly structured extracted from raw materials [48,49]. producing less waste and is both an ecologically and an economically sus­ programmes facilitate the introduction Using LCAs, the purchasing process can tainable concept [53]. There are a good of recycling programmes and increase incorporate sound ecological factors. number of ways to conserve materials their efficiency. Recycling bins should They can also show ways to implement without risking patient safety or quality be easily accessible and marked with improvements. As energy sources and along the way. clear instructions as to what belongs in transport show significant heterogeni­ them. Involving local recycling compa­ city, LCAs are specific to their respective The following measures can be named as examples: nies and providing recurring training to geographic region. Extrapolations should staff are essential [15]. be regarded with circumspection and • When used in conjunction with manufacturers called upon to provide individual patient filters, ventilator Paper/cardboard, plastic, glass, batteries, national LCAs [15,50]. circuits can be used for 7 days printer cartridges, electronic waste and (except when soiled or used for metal can all be collected in the operat­ contagious patients); several studies ing suite for recycling. Recycling can C. Waste Management have shown that the number of also be cost effective [7]. Approximately pathogens in the circuit was not 30% of theatre waste is made up of R1: The 5R concept of waste increased after 7 days vs 24 hours plastics, including items manufactured management (reduce, reuse, [54–57], leading the DGAI and from polypropylene and PET (single-use recycle, rethink and research) DGKH to recommend this approach textiles, blue sterilisation packaging should be implemented. [58]. Furthermore, the use of wash­ for medical and surgical instruments), R2: An efficient recycling concept able, reusable ventilator circuits polyethylene (plastic tubing, beakers should be shown to be operating should be considered [55]. and trays), polyurethane, PVC (suction in all areas of operating theatre • Pre-packed sets, e.g. for insertion of and oxygen tubing), copolymers and suites and intensive care units. central venous lines or for regional other compositions. Specific details are R3: It is to be required that anaesthesia, and surgical trays often not declared appropriately or at plastic packaging should, when often contain unnecessary plastic, all. Some types of plastic such as PVC possible, be manufactured from gauze or other materials which are require special processing [51]. Recy­ single-type plastic, which can disposed of unused. Upon request, cled plastic requires only 25% of the undergo high-grade recycling. manufacturers can often slim down energy used to produce plastic from new R4: Dangerous waste and the requi­ sets in a cost-effective manner [59]. materials [62]. When different types of site special modes of disposal • The decision to order diagnostic plastic are mixed and recycled together, cause very large emissions of tests should not be taken lightly – however, the resulting products are low- consider, for example, routine blood grade. This has led to calls for packaging CO2. Economical and ecological considerations dictate that other tests in healthy patients prior to to be produced from single-type plastic minor elective surgery [60]. Effective and to be appropriately declared. 334 Special Articles Guidelines and Recommendations

MacNeill et al. (2017) examined the all hospitals to be readily accessible good use. Airborn transport of carbon footprint of three large hospitals by public transport. in Canada, the USA and England. They patients should be critically • For rural areas, ride-sharing plat­ performed a detailed waste audit and evaluated. forms or centres can be developed calculated the CO2 emissions associated R3: With regard to participation in by the hospital for its employees. with the various types of waste. Extrac­ conferences and work related to • Increased provision of work-from- tion of raw materials, material-specific professional associations, public home options and video conferen­ manufacturing, transport and disposal transport should be preferred. cing can reduce commutes. alone (so without regard for additional Inland flights should be avoided Following the introduction of a mobility CO2 emissions from product-specific whenever possible and only concept for commuter traffic, it is likely manufacturing and product packaging) reimbursed as travel expenses in that the improved cycling and pedestrian caused emissions of 3,254 kg CO2e/t well-reasoned exceptional cases; infrastructure and public transport offe­ for plastic, 2,708 kg CO2e/t for steel and a carbon offset for the flight rings will also be used by patients. 895 kg CO2e/t for glass [13, 27]. should then be considered. With regard to emergency services, a Clear definitions of the various types R4: Streaming of conferences, video reorientation towards alternative, non- of waste are required [63,64]. Waste conferencing and webinars fossil fuels (electromobility, hydrogen accrued in hospitals is approx. 30% should be offered as a way to fuel cells) will be unavoidable. An medical waste originating from medical reduce travel and its associated additional option is to critically recon­ treatment and nursing, and approx. 60% carbon footprint. sider the use of systems associated with household-like waste. About 10% of significant fossil fuel requirements – such waste is dangerous, with 3% infectious Reducing the carbon footprint of the as air ambulances – when their use is not and 7% toxic waste such as chemicals health care sector will require a focus mandated on medical grounds. or cytostatic drugs [65]. Infectious waste on mobility; specifically, the following has to be destroyed in specialised inci­ three areas of transport require attention: The significant proportion of emergen­ nerators which, amongst other things, health care employees’ commute to their cies involving emergency physicians but requires additional transport [66,67]. At respective places of work (commuter not actually requiring intervention by the 1,833 kg CO2e/t, incineration of clinical traffic), emergency medical services and physician may suggest that telemedicine and dangerous waste causes the most outpatient transport services (patient might reduce the need to despatch a emissions from waste disposal [27]. If transport), and trips to conferences and physician-staffed, second vehicle to it were appropriately sorted, stored and meetings (educational travel). Reducing emergencies. In general, implementa- transported, the largest proportion of this the carbon footprint of those individual tion of telemedical consultations can waste could, however, be disposed of areas requires that different approaches significantly reduce the carbon footprint: together with municipal waste in ther­ be considered. when the drive to the surgery by car is mal waste treatment plants; furthermore, just 3.5 km or more, teleconsultations a large proportion could potentially be Commuter traffic in particular exhibits are the more climate friendly option recycled [66,67]. As such, the various an average motor vehicle occupancy [69]. rate of 1.2. A study showed employees’ different types of waste need to be The number of large, international con- drive to the place of work to be respon­ sorted, keeping the proportion of clinical ferences with ever more participants sible for 12–39% of the carbon footprint – dangerous waste as small as possible travelling long distances is increasing. of a department of anaesthesiology [28]. [10]. Conference participation causes signi­- Alternative mobility concepts, suited to ficant CO2 emissions associated with respective areas of residence, are requi- D. Mobility journeying, especially over long di­ red if these work-related CO2 emissions stances as is required in some cases. are to be curbed. R1: As mobility related to commuting Participants’ journeys to a single interna­ is responsible for a significant Possible targets for interventions in the tional conference were associated with proportion of the carbon hospital include [68]: a 22,000 t carbon footprint, the equi­ footprint of anaesthesiology • Furtherance of cycling infrastructure valent of the average annual carbon departments, hospitals should together with a sufficient number of footprint of 2000 citizens in Germany develop and promote alternative bicycle parking spaces on hospital [70]. Air travel is especially problematic mobility concepts. grounds; calls for hospitals to be because of the associated emission of connected to bikeways. R2: With regard to prehospital 230 g CO2e per passenger kilometre, • Charging infrastructure for e-mobility. emergency care and critical care by far the largest carbon footprint transport, electromobility and • Commuter ticket schemes can associated with travel. CO2 emissions telemedicine should be put to help promote the switch to public per passenger kilometre for travel by transport. Calls should be made for car and train – 147 g/km and 32 g/km Guidelines and Recommendations Special Articles 335

respectively – are notably lower [71]. (1) In operating suites, heating, ventila­ by up to 50%. In addition to technical Online streaming of conferences should tion and air conditioning are com- solutions, these concepts also integrate be expanded. Streaming of conference monly operational throughout in approaches aimed at optimising user lectures and interactive sessions should every operating theatre, despite the behaviour. Energy saving measures be offered as attractive options, enabling fact that those theatres are often such as these can lead to long-term cost conference participation without travel unoccupied at least 40% of the reductions [73,79]. Each and every hos­ [70]. time. Setback operation in systems pital in Germany should identify their in unused operating theatres (“night options for introducing such measures and implement them. E. Energy management setback” or “unoccupied setback”) – with the exception of required emer­ The cogeneration (CHP) systems com­ gency theatres – can facilitate energy R1: Concepts aimed at reducing the monly used in hospitals in Germany savings of up to 50 % [27,74]. considerable power consumption exhibit a high primary energy yield by (2) First steps with regard to heating and associated with heating, using the heat produced during electri­ air conditioning concern the tempe­ ventilation and air conditioning city generation for heating or cooling the in operating theatre suites and rature curve settings in central control building. High energy yields can, how­ intensive care units should be systems. In operating theatres at high ever, only be achieved during optimum implemented. These might, ambient temperature, every reduction operation of the CHP system. Because for example, include setback of temperature by 1° C can reduce the they currently typically consume fossil operation in systems in operating energy required for heating by 5–8% fuels, these systems should be viewed as theatres unused outside of usual [73]. interim technologies [79,80]. The switch working hours and optimising (3) When considering ventilation, it to a climate-friendly future necessitates the temperature and ventilation can – as a first step – be viable to the use of renewable energy for electri­ settings. review the system and adjust the air city and heating in hospitals. Using wind change rate to suit the room tempe­ power, waterpower, photovoltaics, solar R2: All departments should work rature [73]. In some other European thermal energy, geothermal energy or towards ensuring that their countries, it is already customary to biogas allows for generation of energy hospital evaluates its options with completely deactivate ventilation with a reduced carbon footprint, and regard to energy saving measures, during unoccupied periods [75]. can be devised to be cost efficient [73, energy efficient refurbishment (4) In less frequented areas (storage or 79]. and use of renewable energy sources, implementing those auxiliary rooms, toilets, etc.) it is ex­ options in a timely manner. pedient to control the lighting using F. Research and Teaching motion detectors [76]. R3: A switch to renewable energy (5) The halogen lamps traditionally is essential so as to reduce the R1: The effects of climate change used in operating suites should be carbon footprint of hospitals in on intensive and emergency exchanged for LEDs. This measure Germany. care, and on hospital capacity can reduce the energy consumed for have not yet been adequately lighting by 80% [73,77]. In addition, Both operating theatre suites and inten­ researched. Appropriate research sive care are resource-hungry and use LEDs radiate less heat, which redu­ projects should be developed very large amounts of energy [10,72]. ces the energy required for cooling and supported. [10]. The energy consumption in operating R2: Research pertaining to ecological theatre suites is 3 – 6 times higher than Care for patients on intensive care units sustainability in anaesthesiology that of the rest of the hospital. Of the caused the emission of 88–178 kg CO2e and intensive care medicine power consumed in operating suites, per patient day, with energy consumption should include issues such 90–99% is used for heating, air condi­ (dominated by requirements for heating, as choice of drugs and the tioning and ventilation [27]. ventilation and air conditioning), again optimised use of volatile anaes­ These CO2 emissions can be reduced making up 76–87% of the carbon foot- thetics and medical devices. print [72]. A switch to renewable energy by making savings in energy consumption R3: Conferences, seminars and voca­ is recommended together with optimi­ [27,72,73]. Energy-saving measures in tional education events relating sation of the energy efficiency of the operating theatre suites can reduce to anaesthesiology and intensive building to reduce the carbon footprint energy consumption and with that the care medicine should be plan­ [78]. Holistic energy management con- carbon footprint of the operating suite by ned, organised and implemented 50%, a measure which also significantly cepts can enable hospitals to reduce in an ecologically responsible cuts costs [27]. The following practical their energy requirements by up to 30%, and carbon neutral fashion. steps should be taken: reducing the associated CO2 emissions 336 Special Articles Guidelines and Recommendations

As academic teachers we have a special 5. ASA: Environmental Sustainability. R4: Sustainability in health care responsibility to pass our knowledge of American Society of Anesthesiologists. should be an integral part of https://www.asahq.org/about-asa/gover­ aspects of sustainability in medical care student, postgraduate and nance-and-committees/asa-committees/ on to the next generation of doctors. As speciality training. Each and committee-on-equipment-and-facilities/ such it is essential that sustainability be environmental-sustainability every department is called upon integrated into undergraduate teaching (Accessed on: 03.03.2020) to integrate appropriate content as a fundamental concept. Similar efforts 6. RCoA: Environment and sustainability. into their curricula and continu­ are required to promote knowledge of Royal College of Aneaesthetists; ing medical education. Available from: https://www.rcoa. ecologically, socially and economically R5: Climate -friendly behaviour ac.uk/about-college/strategy-vision/ sustainable patient care through conti­ environment-sustainability (Accessed on: should be encouraged in all nuing medical education and professio­ 03.03.2020) departmental staff by provision nal development. 7. ANZCA: Statement on Environmental of information and training. Sustainability in Anaesthesia and Pain Implementation of the “reduce, reuse, Medicine Practice. Background paper. The WHO has estimated that a further recycle, rethink and research” approach New Zealand: Australian and New unbridled increase in the average tempe­ can further staff awareness in hospitals Zealand College of Anaesthetists 2019 rature as a result of climate change will and show positive effects with regard 8. ESA: The Sustainable Anaesthesia lead to an additional 250,000 deaths to team spirit and progression to sus­ Project. European Society of Anaesthesiology. http://newsletter.esahq. per annum from 2030 to 2050 alone, tainable hospitals, bringing closer the org/sustainable-anaesthesia-project/ caused in part by heat waves and natural requisite large transformations. Whilst (Accessed on: 03.03.2020) disasters [81]. Pulmonary, respiratory, its importance is often underestima­ 9. Abbasi K, Godlee F: Investing in humani­ nephrological and infectious disease ted, the human factor is an essential ty: The BMJ‘s divestment campaign. BMJ will also increase by a relevant margin consideration in the lead up to change 2020;368:m167 as a result of climate change. This will [73]. Training is essential if staff is to be 10. Kagoma Y, Stall N, Rubinstein E, Naudie D: People, planet and profits: the case have a significant impact on required sensitised to the issue. for greening operating rooms. CMAJ capacities for emergency and intensive 2012;184(17):1905–1911 care. Further research is required to References 11. 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