Improving environmental sustainability of intensive care units: A mini-review

Table 1 Clinical practices which may aid in reducing the environmental impact of intensive care unit

Category	Clinical practices
Reduce	Avoid unnecessary ICU admissions through accurate triage
	Avoid futile care
	Avoid overdiagnosis
	Avoid over-investigation and routine testing
	Avoid overtreatment
	Avoid overuse of supplemental oxygen
	Avoid routine prophylaxis (e.g., proton pump inhibitors, thromboprophylaxis) for low-risk patients
	Change central venous catheter infusion sets not earlier than 7 d
	Manage supply chain to reduce unused medical waste
	Replace intravenous drug use with oral alternatives
	Avoid unnecessary vehicular transport by utilizing telepresence
	Reduce facility energy consumption for heating, ventilation, and air conditioning, by setting a moderate room temperature
	Improve first-pass success of procedures through better training
	Decarbonize energy sources by using natural rather than artificial lighting
	Reduce paper printouts and forms
	Minimize plastic use
	Reduce healthcare-associated infections and iatrogenic complications
	Stock fewer items inside patient rooms and keep them in supply carts outside patient rooms
	Replace inhalational anaesthetics with total intravenous anaesthesia
	Replace hydrofluorocarbon-containing metered dose inhaler with mesh nebulizer
Reuse	Choose reusable equipment over single-use disposal ones
	Consider single-use device reprocessing
	Extend product lifespans through repairing and upgrading equipment as much as possible
Recycle	Recycle used fluid bags and non-sharps

ICU: Intensive care unit.

Table 2 Published environmental sustainability efforts done in intensive care unit

Category	Method	Outcome	Ref.
Reduce	Redesign pharmaceutical doses and packaging; install waste containers for non-recyclables and chemical wastes; educate staff	Decreased solid waste generation by 39% (13.7 to 8.4 kg/patient/d)	Furukawa et al[47], 2016
Reduce	Four-step action plan: (1) Audit local practice; (2) develop clinical guideline for rational ordering; (3) educate stakeholders; and (4) measure impact through re-audit	Comparing July-December 2017 vs July-December 2018 in a 58-bed ICU, number of ABG tests decreased by 31.3%, saving A$770000, 100 L of blood, and reducing emissions of 1038 kg CO2e (akin to driving 6782 km in an average Australian car). Inappropriate ABG testing decreased by 47.3%, and the number of inappropriate tests per bed-day decreased by 71%, without worsening patient mortality	Walsh et al[48], 2020
Reduce	Relocating in-room disposable equipment to supply carts situated outside the patient rooms, while using small baskets for basic admissions with expected short lengths of stay. Additionally, instead of refilling all items to quota, daily room restocking was customized based on nursing requirements	A Canadian ICU with 16 beds implemented a strategy to reduce the amount of unused equipment waste, resulting in a large 80% decrease. This reduction translated to an approximate annual saving of Can$110000	Yu et al[49], 2021
Recycle	Recycling program in ICU	An Australian ICU produced 540 kg total waste/week in 2008, which reduced to 505 kg after introducing a recycling program in 2013, with 14% of the total waste being recycled	McGain et al[50], 2009; Kubicki et al[51], 2015

ABG: Arterial blood gas; ICU: Intensive care unit.