Topics in Companion An Med 44 (2021) 100550

Research Article

A Systematic Review of Environmental Sustainability in Veterinary Practice

Maria K. Koytchevaa, Leah K. Sauerweina, Tracy L. Webbb, Stacey A. Baumgarnc,
Sadie A. Skeelsd, Colleen G. Duncane,*

Keywords: A B S T R A C T
environment
sustainability A transition toward environmentally conscious business practices is underway in many sectors. For health-
green
care, the topic is both concerning and tragically ironic as hospitals have substantial environmental footprints,
eco-friendly
which are now known to contribute to significant health problems that the system itself was designed to
veterinary
clinic treat. The human medical field has been proactive in taking steps to reduce waste and carbon emissions by
identifying best practices to minimize such impacts. Characterization of needs and gaps has been addressed
a
through reviews of the literature regarding environmental sustainability in the context of human hospitals.
College of Veterinary Medicine and Biomedical
Our objective was to replicate methods used in a recent review of environmental sustainability in human
Sciences, Colorado State University, Fort Collins,
CO, USA
hospitals to summarize information available to clinical veterinarians. Two search algorithms were used
b
across 8 databases, however only 3 peer-reviewed opinion articles specific to veterinary medicine were iden-
Department of Clinical Sciences, College of
tified. These papers included 1 on anesthesia and 2 on production animals. Interestingly, all articles were
Veterinary Medicine and Biomedical Sciences,
Colorado State University, Fort Collins, CO, USA written by United Kingdom-based authors and none were specific to companion animal practice, the largest
c
sector in the veterinary industry in the United States. Results of this review highlight need for research and
Facilities Management, Colorado State
communication that supports veterinary clinics in adopting more environmentally sustainable practices. Pro-
University, Fort Collins, CO, USA
d
posed starting points informed from research in other sectors, including 5 physical themes of energy effi-
Veterinary Teaching Hospital Library, Colorado
ciency, water, waste, sustainable procurement, and transportation, and human behavior changes on the
State University, Fort Collins, CO, USA
individual, group, and organizational levels, are discussed. Additional work is needed to support veterinar-
e
Department of Microbiology, Immunology and ians and other animal health professionals to practice medicine in a way that upholds the veterinary profes-
Pathology, College of Veterinary Medicine and
sion’s oath to promote the health of animals, the public, and the environment we all share.
Biomedical Sciences, Colorado State University,
© 2021 The Authors. Published by Elsevier Inc. This is an open access article under the CC BY-NC-ND license
Fort Collins, Colorado, USA
(http://creativecommons.org/licenses/by-nc-nd/4.0/)

Introduction human healthcare are estimated to be between 1%-5% of the total

There is increasing discussion on the role of veterinarians in miti-
gating the animal health impacts of climate change.1-5 Broadly recog-
nized as the greatest global public health threat of the 21st century,
health professionals need to be able to respond to climate change
both by addressing the health concerns of their patients as well as
reducing the ecological footprint of that care.6,7 Recent studies illus-
trate the strong interest from clients, clinical staff, and both current
and future veterinarians to be engaged in the topic of climate change.
In a recent survey of pet owners, the majority of clients wanted to be
informed about how their veterinary clinic reduces its environmental
impact and were willing to pay more for sustainable veterinary serv-
ices.4 Concordantly, veterinary students, clinic staff, and graduate
veterinarians have stated a strong belief in the negative animal and
human health impacts of climate change and a need for additional
education on the topic.1,2,5 Veterinary students and practicing veteri-
narians have expressed great interest in learning ways to reduce their
own environmental footprint, particularly how to promote environ-
mental sustainability in offices, clinics, and hospitals.1,2 In order to
meet this need, evidence-based and affordable sustainability practi-
ces relevant to veterinary medicine should be accessible to all veteri-
nary students and professionals.
The human health industry has a substantial environmental foot-
print, and there is strong support for finding ways to deliver human
health care in a more sustainable way. Environmental impacts, quan-
tified using indicators including greenhouse gas emissions, from
*Corresponding author.
E-mail address: colleen.duncan@colostate.edu (C.G. Duncan).
global impact.8 In the United States (U.S.), this figure approaches 7%,8
and the indirect health impacts of these emissions have been esti-
mated to be equivalent to the tens of thousands of patients who die
annually in U.S. hospitals due to preventable medical errors.9 Efforts
to address the environmental and subsequent patient impacts of cur-
rent healthcare practices include professional societies, curriculum
reform, calls to action, and the emergence of solitary sustainability-
oriented private practices.
Work on best practices for sustainability in human healthcare sys-
tems has been informed by a growing body of literature and reviewed
to identify gaps, evidence-based practical shortcomings, and research
needs pertaining to climate change mitigation techniques in the health-
care sector.10 Similar information synthesis and gap analysis efforts
within the animal care sector are needed to support veterinary person-
nel in their efforts to minimize their environmental footprint. The objec-
tive of our work was to systematically characterize the currently
available research on veterinary hospital environmental sustainability
as compared to the human health sector in order to identify any signifi-
cant gaps. The results of this project can be used as a baseline upon
which to develop a targeted, impactful research agenda that informs
sustainability guidelines for veterinary clinics.
Materials and Methods
A systematic literature review was performed in accordance with
methods used in a recent review by McGain and Naylor10 on sustain-
ability in the context of human hospitals in order to facilitate the
comparison between human and animal hospitals. The search algo-
rithm used in the human hospital paper was adapted to the original

http://dx.doi.org/10.1016/j.tcam.2021.100550
1938-9736/© 2021 The Authors. Published by Elsevier Inc. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/)
2 M.K. Koytcheva et al. / Topics in Companion An Med 44 (2021) 100550
search algorithm by keeping identical search terms, except that “hos-
pitals” was changed to “veterinary hospitals” and expanded to be
more inclusive of veterinary equivalents to “hospital.” The final
search algorithm used the terms “veterinary hospital” OR “veterinary
clinic” OR “veterinary practice” OR “veterinary center” OR “veterinary
hospitals” OR “veterinary clinics” OR “veterinary practices” OR “vet-
erinary centers” AND “sustainability” AND at least 1 term from “green
OR environment OR architecture OR energy OR water OR travel OR
life cycle assessment OR waste OR recycling OR reusing OR reprocess-
ing OR psychology and behaviour.” Databases used were consistent
with those in McGain and Naylor (2014) including PubMed, Engi-
neering Village, Cochrane Library, and King’s Fund Library. The date
range of the search was January 1, 1990, the same starting date as the
human hospital review, to June 19, 2020. Inclusion and exclusion cri-
teria for the initial search were kept identical to those presented by
McGain and Naylor (2014) to provide a direct comparison. Included
studies needed to pertain to environmental sustainability in the con-
text of veterinary hospitals and had to either state new findings or
present the most current review regarding a topic. Any methodology
or study design was accepted. Studies were excluded if they were
commentary or advocacy writing, studies with outdated sustainabil-
ity practices, or studies that were encompassed in broader or more
recent literature reviews.
Out of concern that the search criteria used in McGain and Naylor
(2014) may not include other terms relevant to the veterinary litera-
ture, a second search algorithm was created to retrieve a broader
range of literature relevant to veterinary medicine and sustainability
topics. The new search algorithm kept the initial search string as a
foundation and expanded upon the search terms and databases used
to encompass a wider range of potentially pertinent literature. Addi-
tionally, the inclusion and exclusion criteria for the second search
were updated to be more inclusive of work in this area. The algorithm
required that variations of the words “veterinary” AND “environmen-
tal OR sustainability” were included in the title or abstract of the
search results and that at least 1 of the terms “LEED OR green* OR
architecture OR energy OR eco-friendly OR water OR travel OR life
cycle assessment OR waste OR recycling OR reusing OR reprocessing
OR psychology and behavior” were included anywhere in the studies.
The databases from the McGain and Naylor (2014) comparative
search, consisting of PubMed, Engineering Village, Cochrane Library,
and King’s Fund Library, were included to provide a reference point
for assessing the ability of the refined search to locate more applica-
ble articles to the veterinary field. In addition, CAB Abstracts (EBSCO),
Environmental Science Database (ProQuest), Web of Science (Clari-
vate Analytics), and Academic Search Premier (EBSCO) were included
to search a broader body of literature relevant to veterinary medicine
and environmental science. No date restriction was set for the search
start date, and all articles published up to June 19, 2020 were
included. The inclusion criteria required that studies needed to per-
tain to environmental sustainability and climate change in the con-
text of veterinary hospitals, practices, or clinics. The included studies
were peer-reviewed journal articles that provide scientifically backed
suggestions to making clinical veterinary establishments more sus-
tainable in routine clinical practice. Any peer-reviewed methodology
or study design was included. Articles and studies that were not rele-
vant to environmental sustainability and climate change in the con-
text of veterinary practice or that did not provide suggestions of
sustainability practices were excluded. Articles that were not peer-
reviewed journal articles were also excluded. Results from the
McGain and Naylor (2014) comparative search and the subsequent
refined search were compared and thematically assessed.
Results
The McGain and Naylor (2014) comparative search identified a total
of 32 results (Fig. 1) from PubMed, Engineering Village, Cochrane
Library, and King’s Fund Library. None of the 32 results were specific to
veterinary medicine, and, after reviewing the 32 abstracts, 31 were
excluded because they did not fit the inclusion criteria of being relevant
to environmental sustainability in veterinary hospitals. The full text of
the remaining study was thoroughly evaluated. This article was a labo-
ratory study on the chemistry and adsorption of chloramphenicol,11
which was excluded for being beyond the scope of clinical veterinary
practice. Consequently, the McGain and Naylor (2014) comparative
study, modeled after a review presented in human hospitals, generated
0 results relevant to veterinary hospitals.
The refined search (Fig. 2) yielded a total of 443 results from the 8
searched databases. Following the removal of duplicates, the
abstracts of 243 articles were reviewed. Of these articles, 199 did not
meet the inclusion criteria of being relevant to environmental sus-
tainability in the context of veterinary practices. Common themes
noted in the excluded articles were climate change impacts on infec-
tious and vector-borne diseases, livestock management contributing
to climate change, antimicrobial and drug resistance, policy and
advocacy, global conservation and ecology, and recommendations for
pet travel. Of the remaining 44 articles, 15 were excluded based on
publication type including books, conference proceedings, disserta-
tions or theses, interviews and opinion pieces, magazine articles, and
newspaper articles.
The remaining 29 peer-reviewed journal articles underwent full text
review and thematic classification. General topics included anesthesia
recommendations, pharmaceutical management, practice recommen-
dations, and sustainability in food animal production. Of these, 26
articles were excluded as they were not clinically relevant, focused on
pharmacovigilance (as seen in the McGain and Naylor (2014) compara-
tive literature search), used a non-environmental definition of “sustain-
ability” (e.g., economic or human resource sustainability), or pertained
to calls for action in relation to policy and education reforms. The final 3
peer-reviewed journal articles that matched the inclusion criteria fell in
2 categories: anesthesia and practice recommendations12 and livestock/
food animal production.13,14
Jones and West (2018) published a peer-reviewed scoping review
about environmental sustainability in veterinary anesthesia. They
discussed the contribution of agents used in veterinary anesthesia,
such as nitrous oxide and isoflurane, to emissions and ozone destruc-
tion.12 Methods proposed to mitigate the negative effects of anesthe-
sia on the environment included the need for carbon sequestration to
capture the anesthetic gases by means of filters on endotracheal
tubes or by gas reservoirs on anesthesia machines, replacing general
anesthesia with complete intravenous anesthesia, and reducing flow
rates to offset these climate impacts. The authors highlighted several
additional ways veterinary clinics can minimize their environmental
impact, including waste segregation, using reusable equipment and
surgical textiles, reducing pharmaceutical waste, refining the sterili-
zation process to decrease water consumption, and implementing
rechargeable batteries in mobile anesthetic units. A final recommen-
dation from this article was to integrate telemedicine into practice to
decrease emissions related to travel.12 This article was published in
the journal 'Veterinary Anaesthesia and Analgesia' by veterinary
anesthesia experts based in the United Kingdom who took an empiri-
cal, well-referenced approach to supporting their opinions.
Statham et al (2017), and Green et al (2011), published peer-reviewed
opinion pieces discussing the role of food animal veterinarians as advo-
cates for sustainability through promotion of herd health.13,14 Two meth-
ods were proposed for a veterinarian to promote proactive herd health:
assigning nutritional recommendations that reduce methane emissions
and the downstream effects of potentially toxic pharmaceutical and die-
tary supplements and using genetic techniques to ensure sustainability in
reproduction and fertility efforts within the herd, thereby creating a
more productive population and reducing forced culling.13,14 Both articles
were published in a British journal, 'In Practice,' and used a well-refer-
enced approach to support their opinions.
 M.K. Koytcheva et al. / Topics in Companion An Med 44 (2021) 100550 3

Fig. 1. Schematic diagram of the McGain and Naylor (2014) comparative literature review. This diagram demonstrates the number of initial search results and the screening process
used to finalize relevant articles to be included.

Discussion hospitals, and further expanded to include veterinary terminology,

The results of our study highlight the paucity of published work
guiding the development of objective environmental sustainability
guidelines specific for veterinary practitioners. Using methods
consistent with those applied in a recent review of human
only 3 veterinary opinion articles were identified as compared to
49 empirically referenced articles on environmentally-friendly
hospital design, energy, water, travel, procurement, waste, and
staff behavior implementations in the human hospital literature
from a search conducted 7 years prior.10 The final 3 articles focused
4 M.K. Koytcheva et al. / Topics in Companion An Med 44 (2021) 100550

Fig. 2. Schematic diagram of refined literature review. This diagram includes the number of initial search results compared to the number of final articles that met the inclusion cri-
teria for the literature review. The screening and selection process used to narrow results to the final included articles is indicated. Studies are broken down by article type and the-
matic category.

on anesthesia and the veterinarian’s role in food animal opera-
tions. The lack of resources pertaining to small animal general
practice is particularly relevant given that 75% of U.S. private prac-
tice veterinarians practice either companion animal exclusive or
companion animal predominant medicine.15 Interestingly, all 3 of
the identified articles were written by authors from the United
Kingdom. The discordance of opinions by country, notably the U.S.,
on the role of veterinarians addressing climate change has been
previously reported.1 The present study reaffirms the need to miti-
gate this disparity. Efforts are needed by veterinarians around the
world to further support the health of the animals, people, and
planet that we seek to protect.
 M.K. Koytcheva et al. / Topics in Companion An Med 44 (2021) 100550
Despite the identified gap in available literature on sustainability
in veterinary practice, resources from other related sectors can help
guide veterinary clinics to make meaningful changes until more sec-
tor specific information is available. Literature from human hospitals,
environmental engineering, building design, and human behavior
change research that did not meet the inclusion criteria for our veter-
inary-focused review can still be used to develop recommendations
relevant to the veterinary medical field. From these and additional
scoping reviews10 we have identified 5 physical themes and three
levels of behavioral changes that can be used as a starting point for
veterinary clinics interested in implementing change.
Physical Changes
Energy Efficiency: Given its massive contribution to greenhouse gas
emissions, energy is a critical theme for veterinary clinics to address.
Healthcare-derived energy consumption in developed countries is esti-
mated to account for nearly one-fifth of all public-sector consumption.10
Building design and the often more expensive first costs of high-perfor-
mance, energy-efficient equipment may present obstacles for veterinary
clinics, but electing renewable energy, such as solar electricity, shows
promising long-term cost effectiveness and is beneficial to the reduction
of harmful greenhouse gas emissions.16-19 Other lower emissions tech-
nologies may include ground source heat pumps or combined heat and
power and cogeneration technology to capture thermal energy.10,17,19
While combined heat and power and cogeneration systems are often
deployed in large buildings, corresponding in size to the hospital level,
they are not necessarily applicable to the majority of smaller veterinary
clinics. Thermal regulation in buildings can be managed to aid in reduc-
ing energy consumption by seasonally adjusting thermostats, installing
automated or timed thermostats, routinely monitoring for leaks in air
conditioning, allowing for night ventilation, regularly replacing filters in
ventilation systems, and using ceiling fans instead of air conditioning
when possible.10,16-21 To further increase efficiency of indoor tempera-
tures, window technology can be modernized by providing adequate
insulation, installing double-paned windows, reducing thermal bridg-
ing, and installing blinds to allow for natural light and shade as
needed.17-20 Though natural light in clinics should be optimized as a
substitute for artificial light whenever possible, other sources of artificial
light such as light emitting diodes can significantly reduce energy costs
and related emissions.16-20,22 Furthermore, installing motion sensing,
day-light sensing, or lighting controls in common areas will reduce elec-
tricity use and cost. Equipment affecting building plug loads, such as
radiology machinery, computers, and other electronic devices, should
be powered down at night to reduce stand-by electricity consump-
tion.21 Meters can be installed to monitor electricity use, and environ-
mental sustainability audits can be conducted to identify and evaluate
emission sources.18,19
Water: Recommendations for water efficiency and conservation
as a theme were generally very limited across the scientific literature
due to the simplicity of existing strategies for reducing water use,
which may have decreased the perceived need for technological
innovations.10,19 Furthermore, water is often a smaller utility expense
compared to energy, which lessens the robustness of its return on
investment.23 The most common water use reduction suggestions
were installing flow restriction devices on faucets, using low-flow
toilets, maintaining proper plumbing and pipes to prevent water loss
through leaks, and harvesting and recycling rainwater for sustainable
re-purposing.10,16,17,19,22,24 Installing water saving retrofit kits on
older autoclaves or purchasing new eco-friendly autoclaves,
decreases tempering water sterilizer consumption by 90% and has
the potential to save over 60,000 gallons of water per year.25-27 Sig-
nificant water savings can also be made by streamlining the surgical
scrubbing process. Switching from an ‘elbow-on’ tap operating sys-
tem to a leg-operated tap was found to save 5.7 liters of water per
scrub.24,28 Other innovations that were found to be effective included
5
planting drought-resistant plants to limit exterior landscaping water
needs and minimizing laundry water use needs with efficient, eco-
friendly machines.17,18 In addition to current green washing machine
options, recent technological advances of ozone laundry have dem-
onstrated its environmental and economic benefits through success-
ful decreases in water usage, energy consumption, and chemical use
relative to traditional detergent-based laundry.29
Waste: Veterinary waste management strategies have significant
overlap across multiple sectors, including agriculture, laboratories,
and pharmaceutical companies that handle various types of waste. As
a result, the most effective waste management strategies for veteri-
nary practices revolve around safe, appropriate waste reduction and
ensuring proper waste disposal. The first step is reducing the poten-
tial for waste creation by purchasing products that contain less pack-
aging, purchasing reusable alternatives instead of single-use
disposable products when available and appropriate, and purchasing
recycled-content products.16,17,19,21,30-32 Waste generation can also
be decreased in necessary daily clinical activities, such as cleaning,
treatments, and surgery. Environmental Protection Agency and other
third-party certified green cleaning products and reusable spray bot-
tles create a smaller amount of hazardous waste byproducts.19,33
Implementing proper waste-disposal training and green cleaning
protocols for staff helps reduce the negative effects of unavoidable
waste byproducts contaminating air quality and water
sources.18,19,21,22 Pictograms at waste stations can be an effective
approach to keep staff cognizant and updated on proper waste dis-
posal practices.19 Reusable sharps containers can reduce transporta-
tion emissions, manufacturing costs, and single-use plastic waste.21
Additionally, green printing practices, such as double-sided printing
and decreasing toner use, in conjunction with digitization of medical
records and invoices, minimize paper waste.18,19,21,24 Surgical practi-
ces can be made less wasteful by creating custom eco-friendly surgi-
cal packs that use less materials, focus on reusable components, and
reduce the use of environmentally-detrimental components, such as
cotton.30,32 The global accumulation of hazardous anesthetic byprod-
ucts in the atmosphere can be decreased by using more environmen-
tally-friendly anesthetic gas alternatives, using total intravenous
anesthesia and regional anesthesia instead of general anesthesia
when permissible, and avoiding pre-emptive drawing up of medica-
tions to minimize sedative agent waste.12,21,34,35,36 Although beyond
the scope of this review, references are available to help practitioners
make informed choices surrounding use of anesthetic gases, which
undergo minimal metabolic change during their clinical use and have
varying degrees of greenhouse gas potency.36 In terms of medical
equipment, reusable devices have been found to be more environ-
mentally-sustainable than their disposable alternatives.21,30 When
single use items are unavoidable, recycling, re-processing, and dona-
tion programs can be considered as an alternative when
appropriate.10,16,17,21,24 Finally, employee-generated food waste can
be decreased by implementing composting. Recycling programs and
promoting reusable meal containers, water bottles, and utensils are
also effective landfill diversion strategies.10,16,17,19,22,24
Procurement: Procurement strategies have a direct impact on a
clinic’s sustainability performance. Reviewing monthly expenditures
allows a practice to identify opportunities where they can directly
influence the life cycle impacts of a purchased good or service
through an environmental, social, and economic approach.37 In order
to make environmentally conscious product purchases, veterinarians
should evaluate product supply chains from sourcing and
manufacturing to product packing and transportation. Prior to order-
ing products, one should comparatively assess an item’s life-cycle
assessment (LCA) data, which traces the environmental impact of
energy use and pollution beginning with resource extraction and
ending at product disposal.10,21,30,32 Holding companies accountable
in creating more environmentally-sustainable products and encour-
aging sales representatives to be transparent with LCA data will
6 M.K. Koytcheva et al. / Topics in Companion An Med 44 (2021) 100550
provide the veterinarian with insight into how much waste is gener-
ated when purchasing any specific item.17,19,32 The Accountability,
Consistency, and Transparency (ACT) Environmental Impact Factor
Label is at the forefront of this movement.38 ACT-certified lab prod-
ucts provide transparent environmental impact data based on energy
and water use, manufacturing and packaging, and end-of-life dispos-
ability that is viewable to the consumer and allows for sustainable
purchasing.38 As it is difficult for individual veterinarians to obtain
and compare relevant product data, the veterinary profession should
encourage common product suppliers to provide LCA data and incen-
tivize these suppliers to move toward increasingly sustainable practi-
ces.
Transportation: Another area where veterinarians can actively
reduce carbon emissions is through transportation. If a veterinary
practice has control over building construction or location, a major
consideration should be accessibility to public transportation and
bicycle routes for clinic staff.16,22 Businesses that provide employee
incentives for workplace travel, such as free or discounted public
transportation passes, have the greatest increase in public transport
use.10,16-19,22,39 If public transportation is inaccessible, car share or
carpooling systems among employees can serve as an effective
alternative.10,16,17,19,22,24,39 Similarly, if a veterinary practice is
mobile, ambulatory, or requires client home visits, it is recommended
to have a company-sponsored electric or low emissions vehicle for
fleet travel.17,22 Veterinary practices should consider promoting
alternative forms of transport by providing maps of accessible bike
trails and considering financial incentives such as zero-interest loan
repayment programs for bicycle purchase.10,17,19,22,39 Offering bicycle
racks and increasing electric charging stations can further encourage
alternative or low emissions transportation.17,19 Lastly, utilizing tele-
medicine or teleconferencing services can be an efficient alternative
for client consultations and professional association conferences that
eliminates the need for travel.10,16,17,19,21,24,40-42 Living car-free and
reducing airplane travel have been shown to be 2 widespread, high-
impact actions that can substantially decrease annual personal emis-
sions and enact systemic sustainable change, making these critical
areas to target.42 When air travel is unavoidable, purchasing carbon
offsets can counterbalance the negative environmental impacts as
they help finance projects that reduce emissions of carbon dioxide in
other sectors.43
Behavior Change
When implementing sustainability in veterinary practice, one must
consider pro-environmental attitudes and behaviors of the participating
staff and the encompassing organization. Opportunities for behavior
change transcend all physical domains described above and can occur
at many levels. In a review by Young et al from 2015, an ‘employee pro-
environmental behavior’ framework was created to assess several, vari-
able qualities by their ability to influence workplace sustainability per-
formance.39 Behavior change metrics can be performed by assessing
increases in goal-oriented, pro-environmental outcomes. For example,
measuring the amount and frequency of recycling behaviors within a
clinic. From this research, there are 3 main categories within a veteri-
nary practice where behavior can be modified: the individual level, the
group level, and the organizational level.
Individual: At the individual level, employees can increase envi-
ronmental attitudes and awareness through training modules, sus-
tainability education, establishing individualized environmental
goals relative to an initial assessment of personal values, and discov-
ering how specific sources of environmental impacts within a clinic
can be individually mitigated.10,17,21,39,44 Though providing feedback,
reminders, and performance assessments improve employee behav-
ior at the individual level, it is most effective to provide feedback
through active and engaging visuals, simple and meaningful lan-
guage, personally-relevant material, deliberate discussion, and
financial incentives.17-19,39 More specifically, financial incentives
prove to be helpful on the individual level by rewarding staff who
use alternative transportation methods or carpool.39,44
Group: At the group level of teams within clinics, it is most effec-
tive to provide collective and comparative group feedback. Providing
comparative performance assessments regarding minimizing energy
use between groups of employees results in overall increased
resource conservation and an inclination towards staff being more
knowledgeable regarding this topic.39 Group problem-solving,
environmentally-oriented values, and teamwork are successfully
encouraged by incentivizing a team as a whole when they meet their
goals, rather than solely emphasizing individual responsibility.39,44
Financial incentives are also effective at the group level by retroac-
tively rewarding staff when shared clinic resources are deliberately
conserved.39,44 Building community around shared values, such as
environmental sustainability, in the veterinary profession may also
be beneficial in generating overall staff wellbeing.1
Organization: At the organizational level, consisting of upper
management and corporate support, considerations for evaluating
environmental sustainability include the overall infrastructure of the
practice, management support, and organizational culture.17,39 The
infrastructure of veterinary practices may vary drastically, from aca-
demic teaching hospitals, to leased spaces within shopping centers,
to mobile practices. In order to successfully implement impactful
change, the organization should determine the largest, controllable
aspects of their environmental footprint that are feasible to alter.
Individual clinic considerations include clinic size, number of
employees, geographic location, utility consumption, and accessibil-
ity to alternative forms of transportation or waste management pro-
grams balanced with realistic financial and time restrictions.39,44
Moreover, support from management and overall organizational cul-
ture allows staff members to have clear communication regarding
collective values in relation to positive environmental
performance.39,44 With these categories in mind, veterinarians or
practice managers should conduct an all staff meeting regarding
environmental sustainability goals within the practice and map out
how they will effectively improve their pro-environmental behaviors
as individuals, as a team, and as an organization.
Conclusions
Collectively our review highlights the opportunity to support veteri-
nary clinics’ ability to function in a way that minimizes their environ-
mental footprint. Given that this study contains an extensive literature
review and extrapolates information using outside research from
related fields, the study had several limitations. First, the literature
review on sustainability in veterinary practices only focused on peer-
reviewed papers, thereby excluding any available non-academic litera-
ture on the topic. Since evidence-based practices were extrapolated
from fields outside of veterinary medicine, sustainability recommenda-
tions from human hospitals may not be applicable to all forms of veteri-
nary practice. The veterinary profession is very diverse in practice type;
therefore, in-hospital recommendations may not be applicable to large
animal or mobile veterinarians. Furthermore, some recommendations
may be difficult to implement in buildings where electricity and water
use data are not metered per leased space or where the veterinary ten-
ants do not have operational control over certain energy or water using
equipment. Practical considerations surrounding the economic feasibil-
ity of environmental sustainability changes may pose challenges for
clinics to adopt some of the recommended practices, especially when
presented with large first costs, such as with renewable electricity,
although these are generally cost saving in the long term. While a cash-
purchased solar array may be cost-prohibitive in certain electricity mar-
kets, an abundance of options exist that allow for installation with zero
out-of-pocket costs. However, time constraints, a common problem in
veterinary clinical practice, may also impact veterinarians’ ability to
 M.K. Koytcheva et al. / Topics in Companion An Med 44 (2021) 100550
research and implement change. The hope in presenting this informa-
tion is to provide a resource to help veterinary practices implement all
feasible changes by considering both their personal situations and the
long-term environmental and economic co-benefits of these recom-
mendations. While these refinements in veterinary clinical practice are
important, in order for veterinarians' efforts at sustainability to have
their maximum benefit they also need to be made against the back-
ground of an appropriate overarching policy framework.
Implementation of sustainability best practices are needed to
attract and retain veterinary staff and clients who desire changes
within the profession that help mitigate the impacts of climate
change.1,2,4,5 The impact of supporting the well-being of veterinarians
and their clients by investing in personal values is additive to the
long-term beneficial economic and environmental outcomes. While
recommendations can be extrapolated from other sectors, as
described above, there is a need for the establishment of routine vet-
erinary clinic sustainability audits and assessments to measure prog-
ress and identify evidence-based recommendations and
opportunities for improvement that take into account the unique
challenges in veterinary medicine. In order to make accessible shared
resources that expedite sustainability progress in the field, veterinary
professionals need to prioritize and encourage the development of
continuing education programs and sustainability certifications. It is
important to acknowledge that veterinary medicine is very diverse
and that not every sustainability recommendation may be feasible in
each practice setting type. The power in this flexibility is that there is
a variety of eco-friendly options and that each clinic can make a dif-
ference that is uniquely tailored to their own circumstances. The
potential impact of developing resources to support and improve vet-
erinary clinic environmental sustainability is worthwhile and war-
rants increased attention moving forward.
Acknowledgment
The authors would like to acknowledge support from the One
Health Institute at Colorado State University (CSU) and our student
colleagues in the Veterinary Summer Scholars Program hosted by the
CSU College of Veterinary Medicine and Biomedical Sciences.
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