http://www.thelancet.com/article/S2542519623000505/pdf

Physicians' views of patient-planetary health co-benefit prescribing: a mixed methods systematic review.

Pathology testing is a very common investigation in the intensive care unit (ICU). Many tests are ordered on a routine basis rather than for a specific clinical indication, resulting in potential patient harm and unnecessary financial and environmental costs. 

Environmental impact of a blood test reduction intervention in adult intensive care units: A before and after quality improvement project.

<h2>Abstract</h2><h3>Background</h3> Blood gas analysis is the most commonly ordered test in the intensive care unit. Each investigation, however, comes with risks and costs to the patient and healthcare system. Evidence suggests that many tests are performed with no appropriate clinical indication. <h3>Objectives</h3> The primary aim of our prospective interventional study was to investigate the proportion of blood gases undertaken with a valid clinical indication before and after an educational intervention. A secondary aim was to examine sleep interruption secondary to blood gas sampling. <h3>Methods</h3> A prospective, before-and-after interventional study was conducted across two metropolitan intensive care units in Melbourne, Australia. Adults aged ≥18 years who were admitted to intensive care were eligible for inclusion. Two observation periods were conducted across a 2-week period in May and September 2022 (Periods 1 and 2), where clinicians were encouraged to record the purpose of blood gas sampling and other relevant data via an electronic questionnaire. These data were reviewed with corresponding electronic medical records. In between these periods, an interventional educational program to inform the clinical rationale for blood gas testing was delivered during July and August 2022, including introduction of a clinical guideline. <h3>Results</h3> There were 68 patients with 688 tests included in Period 1 compared to 69 patients with 756 tests in Period 2. There was no significant difference between the median number of blood gas analyses performed per patient before and after the educational intervention (6.0 tests per patient vs 5.0 tests per patient, p = 0.609). However, there was a significant increase in the percentage of tests with a valid clinical indication (49.0% vs 59.7%, p = 0.0025). The most common indications selected were routine measurement, monitoring a clinical value, change in ventilator settings/oxygen therapy, and clinical deterioration. In addition, there were a large number of patients who were awakened upon drawing of a blood sample for analysis (26.1% for Period 1 and 37.6% for Period 2, p = 0.06). <h3>Conclusion</h3> The implementation of an educational program resulted in a significant increase in the proportion of blood gases performed with an appropriate clinical indication. There was, however, no reduction in the overall number of blood gases performed. 

Blood gas sampling in the intensive care unit: A prospective before-and-after interventional study on the effect of an educational program on blood gas testing frequency.

Healthcare systems are major emitters of greenhouse gases that contribute to climate change. The resulting climate crisis harms human and planetary health and increasingly impacts lives on Earth. Because of their status as high emitters and their social role in society, healthcare systems have a clear obligation to decarbonise. This study investigates how healthcare systems worldwide can lower their greenhouse gas emissions and thereby contribute to global climate action. We performed a systematic literature review, searching PubMed, GreenFILE, Business Source Complete and CINAHL for relevant empirical studies, non-research papers and grey literature published between 1 January 2018 and 28 March 2023. The Greenhouse Gas Protocol applied to healthcare systems guided thematic and descriptive analyses to explore interventions targeted at scope 1, 2 and 3 emissions. The PRISMA guidelines were followed for reporting and synthesising the results. A total of 742 publications were initially identified, 230 of which were included in the systematic literature review, comprising 96 empirical studies, 132 non-research papers and two governmental reports. Numerous conventional and unique decarbonisation actions related to healthcare have been reported in the literature. Eight themes were identified: transportation, anaesthesia, energy, travel, supply chain, clinical practices, planetary health literacy and system changes. This study shows the abundant potential for healthcare decarbonisation while highlighting key uncertainties around decarbonisation in healthcare and providing ambitious recommendations to lower emissions globally. Decarbonisation actions are needed at the personal, organisational and system levels. The health workforce is vital in driving transformative change but needs to be adequately trained and educated about the importance of low-carbon solutions in healthcare. Countries worldwide must exchange knowledge about successful decarbonisation interventions and best practices to push global progress. Looking forward, action plans and audits at the local level combined with large-scale measures and policies are needed to influence the system as a whole. Climate change caused by greenhouse gases, which are mainly emitted via the burning of fossil fuels and biomass in the form of carbon dioxide but also include methane, nitrous oxide and fluorinated gases, harms both human and planetary health. Health effects can be direct and indirect and range from infectious to chronic diseases, mental health impacts, malnutrition and forced displacement. Highly developed healthcare systems are crucial for meeting the rising demand for health services related to the climate crisis. However, healthcare systems worldwide have a large climate footprint, and they themselves contribute to this problem. They emit greenhouse gases directly (scope 1) and indirectly (scopes 2 and 3)—most greenhouse gases are emitted through the global healthcare supply chain (scope 3). We reviewed the literature for possible actions that healthcare workers and decision-makers can take to lower the climate footprint of healthcare systems. We found that healthcare system emissions have abundant potential to decrease, for example, by reducing emissions from transportation, anaesthesia, energy, travel, the supply chain and clinical practices. Practical actions at the personal and organisational levels can be supported by promoting the planetary health literacy of healthcare workers, patients and their caregivers and system changes that need to be implemented at a higher level. The health workforce is vital in driving transformative change but needs to be adequately trained and educated about the importance of low-carbon solutions in healthcare. We recommend that countries worldwide exchange knowledge about successful decarbonisation interventions and best practices to push global progress. Future research is needed to substantiate these decarbonisation efforts. However, the time for action is now—and through this research, we hope to empower everyone to take the necessary steps towards a climate-friendly healthcare system.

Green health: how to decarbonise global healthcare systems

In this era of 'Choosing Wisely,' we present a four-step action plan to reduce unnecessary pathology testing and the associated patient harm (blood loss through repeated phlebotomy), economic cost and environmental impact. The authors are experts from the CODA group; a medical education and health-promotion charity that aims to build on the Choosing Wisely initiative to provide meaningful and sustainable actions to reduce the carbon footprint of healthcare, globally. Pathology testing is expensive and carbon-intensive, with as many as half of all tests being not clinically indicated. Reducing unnecessary testing is the only effective way to decrease the carbon footprint and other associated costs, as opportunities to reuse and recycle pathology specimens are limited. The four key steps for action are (i) auditing local practice; (ii) defining unnecessary testing including developing a clinical guideline for rational ordering; (iii) educating stakeholders; and (iv) measuring the impact of the intervention through re-audit. This proven method is designed to be used in any healthcare setting around the world; having a small group of passionate 'champions' is thought to be as important as strong clinical governance and more important than access to sophisticated equipment. Electronic medical record systems and other technological solutions offer new ways to help establish a sustainability mindset and reduce unnecessary testing. The Codachange.org/coda-earth/ website provides a dynamic crowdsourcing platform through which we can collectively learn to meet the diverse needs of our international medical community. Self-reported outcomes are gamified through collaborative feedback, amplification via social media and the ability to earn rewards, be uploaded to the CODA website, or added to the template as a success story. By combining our existing local networks with the emerging international CODA community, we can initiate meaningful change now and enter the era of environmental stewardship.

Everyone's a winner if we test less: the CODA action plan.

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Everyone's a winner if we test less: the CODA action plan.