2025/01/01 by Rosie Cervera‐Jackson, Patricia McCready, Stephanie Ireland +4 · 1 voice
Environmental Science · Health Professions · Medicine · #Climate Change and Health Impacts #Healthcare cost, quality, practices #Intensive Care Unit Cognitive Disorders
paper · pdf · doi:10.1111/nicc.13252
openalex publication_date 2025/01/01 · openalex created_date 2025/10/10 · openalex updated_date 2026/07/16
This critical commentary uses a human factors and systems approach to explain target areas, anticipated barriers and enablers for improving environmental sustainability in the critical care units of a large multi-site hospital trust in London, UK. A trust-wide critical care sustainability working group with representatives from each site includes clinical, estates, procurement and waste management staff and the organization's sustainability officer. The working group then used the ‘Onion Model’1 (see Figure 1) to plan environmental sustainability targets and actions. Legislation requires the National Health Service (NHS) in England to reach net zero carbon emissions by 2040, with an interim 80% reduction by 2028–2032.2 National net zero requirements are in place for suppliers, and health care waste guidance has been updated to promote minimizing waste, accurately segregating waste and reducing single-use plastic.3 Health care trusts in England are mandated to have a board-approved Green Plan.4 Financial pressures on the health care system and rising demand from a growing and ageing population are potential barriers,5 although cost savings and ill health prevention can be achieved through environmentally sustainable health care actions.6 Hospitals are anchor institutions that influence and reflect the communities they serve.7 Therefore, social attitudes and behaviours amongst staff, service users and the public towards sustainability will likely influence progress towards environmental targets. Based on survey data, attitudes and behaviours are an enabling influence: In 2023, 64% of adults in Great Britain were somewhat or very worried about the impact of climate change, rising to 75% in London, and 64% of adults have taken action to help tackle climate change over the past year,8 while a separate survey in 2021 showed 87% of staff support the NHS net zero commitment.9 Critical care units use higher amounts of consumables, produce more waste and require larger heating, ventilation and air conditioning (HVAC) rates than hospital ward areas.10 Targets for reducing energy use include transitioning to renewable sources, enhancing metering and monitoring and investing in energy storage solutions to increase self-generated clean power utilization. For the building, upgrades to insulation and HVAC systems, heat recovery mechanisms, LED lighting and automation controls for lighting and temperature optimize energy efficiency. Although improving energy efficiency requires an initial capital investment, it can generate significant cost savings and reduce carbon footprint. Local projects are being planned together by clinical staff with estates and facilities, with advice from infection prevention and control and ventilation experts, to ensure standards for critical ventilation systems are met, and fire safety and regulations for control of substances hazardous to health (COSHH) are maintained throughout any changes.11 Water conservation is another wider workspace target through leak detection, reducing unnecessary usage and wastewater recycling. Critical care units can participate in sub-metering and usage audits to identify opportunities to reduce water use.12 Providing multiple waste streams and monitoring waste generation by type can support ICU staff in reducing the amount of waste incinerated and disposed of in landfills. Reusable sharps bins decrease single-use plastic disposal.13 Collaborating with hospital procurement teams to buy more sustainable products (reusable/recyclable supplies, products with ecolabels, items with less/recyclable packaging and local sourcing) can be more effective than doing this in isolation. An organization-wide inventory system is in place to reduce the number of delivery product transport journeys by enabling bulk ordering supplies, preventing small orders and using an offsite warehouse for storage. Sustainable food practices for staff, patients and visitors are encouraged, such as switching to reusable food ware, minimal packaging and preventing food waste. Incentives for active travel through secure bicycle storage, charging points, public transport between hospital sites, season ticket loans and liaison with local public transit are other trust-wide sustainability initiatives, along with replacing paper patient records with an electronic system. Although 20% of the health care carbon footprint is attributed to buildings, electricity and gas, 80% results from clinical care.14 The critical care workspace can be sustainable while providing a safe and suitable setting that meets national standards.15 An example is to redesign clinical areas to accommodate multiple waste streams, such as recyclable, non-offensive, offensive, infectious, sharps, medication and cytotoxic waste.16 A quality improvement project carried out by clinical staff, health care cleaning staff, the infection prevention and control team and a waste manager could include a waste audit, process mapping exercise and iterative testing/measurement cycles to find the optimum sizes and locations for waste containers. Space limitation and the cost of reconfiguration and purchase of new waste containers are potential barriers to be addressed. Storage and stocking of clinical supplies is another potential target for improving environmental sustainability. Electronic inventory systems can be installed to avoid overstocking and to use items with the earliest expiry dates first. Establishing the optimum frequency for routine replacement of items like suction liners, giving sets, ventilator circuits and urometers, as well as standardizing this across the critical care units, is likely to reduce the volume of single-use items. Similarly, reviewing the contents of sterile kits for central venous catheter insertion or dressings provides an opportunity to streamline and standardize, removing unnecessary items that are frequently discarded or unused. Another target is to increase reusable items, including gowns, individually allocated respirators, eye protection, rewarming blankets and transfer sheets. Success is most likely when storage before and after laundering or cleaning has been well-designed and fits the clinical workflow. Routines for reprocessing or cleaning reusable clinical equipment like bronchoscopes, laryngoscope handles, blood pressure cuffs or ECG leads could also be explored. Adequate maintenance and servicing can extend the lifespan of equipment, and a sustainability assessment can be integrated into local tender processes for new equipment. Energy use can be addressed at the personal workspace level within the critical care unit by routinely switching off equipment that is not in use. Bedside and office computers can be switched off when unoccupied. New routines for switching off clinical equipment like ventilators and infusion pump stacks can be developed following a risk assessment that includes best practices for rechargeable batteries, time required for power-on and maintenance of battery charge while switched off. Clinical scientists can advise on safe protocols that minimize unnecessary energy use from equipment and link with manufacturers for equipment support, maintenance and sustainable procurement. Guidelines, training, team organization, culture and care routines shape decision-making and actions by critical care staff, and there are several targets for improving environmental sustainability. One example is glove use. Gloves are a fossil-fuel-derived single-use product discarded for landfill or incineration.17 Wearing non-sterile gloves outside the indications described in national guidance18 and local policy is common in hospitals and is associated with poor hand hygiene in observational studies.19-21 An organization-wide initiative led by the Infection Prevention and Control department to be glove aware matches a recent joint campaign by the Intensive Care Society, British Association of Critical Care Nurses and Infection Prevention Society (‘Gloves Off in Critical Care’, May 2023). The critical care working group could supplement awareness-raising campaigns with bedside education, audit and feedback, task- and role-specific signage and monitoring glove-order volumes to eliminate unnecessary glove use. Sustainable waste management is an example at the wider organization level (to provide alternative waste streams), the personal workspace level (to reorganize clinical areas so receptacles for each waste stream are available where they are needed), and at the ‘task and people’ level (to encourage staff to segregate waste correctly). These strategies could also include switching off equipment that is not in use, selecting reusable rather than single-use equipment and extending the duration of use for items like ventilator circuits. Another approach at the task/job design/people level is to identify clinical decisions that reflect evidence-based critical care and prevent unnecessary resource use. The 10 Choosing Wisely in Critical Care actions represent clinical excellence by eliminating low-value care.22 For example, reserving diagnostic testing for situations where the result is likely to change clinical management, promoting practices associated with shorter duration of mechanical ventilation and intensive care length of stay, and discontinuing antibiotic treatments as soon as clinically indicated. Other potential clinical targets could include switching intravenous to oral preparations of medications as soon as indicated (e.g. paracetamol, antibiotics and proton pump inhibitors), discontinuing unnecessary prescriptions before discharge from critical care and frequent review of the indication and dose of kidney replacement therapy.23 A clinical practice culture in which stewardship leads to clear targets for starting, stopping and titrating therapies, and effective team communication supports safe titration of therapies between scheduled medical reviews, is likely to benefit patients by limiting low-value care. Using a human factors-systems model to explore targets for improving sustainability has provided a framework for action that fits the context of the critical care units in a large multi-site health care organization. Data sharing is not applicable to this article as no new data were created or analyzed in this study.