Environmental sustainability: Overview

Abstract
Background: Pharmacological treatments for critical processes in patients need to be initiated as rapidly as possible; for this reason, it is a standard of care to prepare the main anesthesia and emergency drugs in advance. As a result, 20%-50% of the prepared drugs remain unused and are then discarded. Decreasing waste by optimizing drug use is an attractive strategy for meeting both cost containment and environmental sustainability. The primary end point of this study was to measure the actual amount of drug wastage in the operating rooms (ORs) and intensive care units (ICUs) of a Regional Health Service (RHS). The secondary end point was to analyze and estimate the economic implications of this waste for the Health Service and to suggest possible measures to reduce it.

Methods: This prospective observational multicenter study was conducted across 12 hospitals, all of which belong to the same RHS in the north-east of Italy. Data collection took place in March 2018 and included patients admitted to ICUs, emergency areas, and ORs of the participating hospitals. Data concerning drug preparation and administration were collected for all consecutive patients, independent of case types and of whether operations were scheduled or unscheduled. Drug wastage was defined as follows: drugs prepared in ready-to-use syringes but not administered at all and discarded untouched. We then estimated the costs of wasted drugs for a 1-year period using the data from this study and the yearly regional pharmacy orders of drugs provided to the ORs and ICUs. We also performed a sensitivity analysis to validate the robustness of our assumptions and qualitative conclusions.

Results: We collected data for a total of 13,078 prepared drug syringes. Drug wastage varied from 7.8% (Urapidil, an alpha-1 antagonist antihypertensive) to 85.7% (epinephrine) of prepared syringes, with an overall mean wastage rate of 38%. The estimated yearly waste was 139,531 syringes, for a total estimated financial cost of €78,060 ($92,569), and an additional quantity of medical waste amounting to 4968 kg per year. The total provider time dedicated to the preparation of unused drugs was predicted to be 1512 working hours per year.

Conclusions: The overall extent of drug wastage in ORs and ICUs is concerning. Interventions aimed at minimizing waste-related costs and improving the environmental sustainability of our practice are paramount. Effort should be put into designing a more efficient workflow that reduces this waste while providing for the emergency availability of these medications in the OR and ICU.

Health care systems are responsible for an estimated 10% of total greenhouse gas (GHG) emissions and contribute to a variety of other environmental concerns, from particulate air pollution to being the second-largest producer of landfill waste in the United States. With the growing awareness of the impact health care has on the environment, the calls to acknowledge and mitigate these issues have increased. National and international organizations, including Practice Greenhealth and Health Care Without Harm, now provide tools, resources, and incentives to local and regional health care systems and facilities to analyze and reduce their environmen-tal footprints. Reductions in energy use and waste, moving away from reliance on heavy metals such as mercury, and more sustainable food systems in hospi-tals offer success stories for reenvisioning the role that health care can play in moving society toward a more sustainable future. Similarly, the use of inhalational anesthetics has received special attention because of the environmental externalities to the atmosphere and the impact on global climate change.

The Lancet Planetary Health is a gold open access journal that seeks to be the pre-eminent journal for enquiry into sustainable human civilisations in the Anthropocene. As such, it publishes peer reviewed Research and Reviews as well as Comment and Reportage broadly encompassing sustainable development (the SDG's) and global environmental change.