ChangeXUnzipped Global
Health Conference 2023
October 7th 2023
Dr Sonia Chanchlani
•
Board Director and Chair of the Medical Education
Committee, Doctors for the Environment
Senior Fellow, Climate Health and Sustainability
Melbourne Medical School, University of Melbourne
sonia.chanchlani@unimelb.edu.au
Dr Ben Dunne
Surgeon RMH/PMCC, Clinical Sustainability Lead Chair
Sustainable Healthcare SIG, Doctors for the Environment
Environmentally Sustainable Surgery Network
University of Melbourne
Ben.dunne@unimelb.edu.au
Workshop Outline Sat 7th October 2023
Sustainable healthcare QI methodology overview
10 mins RMH Case Studies: Reducing blood tests in clinic

Break out groups - draft a SH QI project proposal

20 mins
Present one newly populated project idea to the group
10 mins

2
 Healthcare Greenhouse Gas Emissions

Most healthcare emissions come from

providing clinical care.
It is estimated that 60% of care is high-
value care, but as much as 30% of care
is low-value (high cost for little patient
benefit) or harmful care (10%).
Reducing low-value and harmful care is
an opportunity to reduce the
environmental impact of healthcare.

Barratt AL, Bell KJ, Charlesworth K, McGain F. High value health care is low carbon health care. The Medical Journal of Australia. 2022 Feb;216(2):67.

Barratt et al. 2022

Promoting practical action at a micro level

How do I integrate
How do I improve planetary health into my
recycling in my education presentations?
workplace?

How can I reduce the waste

we generate in the operating
theatres?

How do I advocate for

better energy efficiency in
How can reduce the
my unit?
environmental impact of
anesthetic gases?
4
6
 Environmentally Sustainable is Financially
Sustainable
Clinical Practice Change: Choosing Wisely Theatre Audit: Nitrous Oxide Procurement
Reducing unnecessary blood tests order in the Audit and investigation for hospital NO
ED such as blood gases and coagulation pipelines to reduce unnecessary waste
studies
CO2 900Kg CO2 e/year CO2 240K Tonnes of CO2 e/year

$240, 000/year $8,000/year

Driving 3,712 km Driving 109,451,815 km

Telehealth: mask cost and waste reduction Facilities: Switching to Zero Emission Vehicles
Offering telehealth options to clinical suitable Replacing fossil fuel vehicles with electric
patients to reduce mask vehicles for services like hospital in the home

CO2 2.4 million Kg CO2 e/year CO2 305 Tonnes of CO2 e/year

$150, 000/year $60,000/year

Driving 9,901,516 km Driving 1, 141, 527 km

Environmentally Sustainable is Financially Sustainable
Clinical Practice Change: Choosing Wisely Nitrous Oxide Procurement & Consumption
Reducing unnecessary blood test in the ED Audit and investigation for leaks in hospital NO pipelines

CO2 900Kg CO2 e/year CO2 240K Tonnes of CO2 e/year

$240, 000/year $8,000/year

Driving 3,712km Driving 109,451,815 km

Telehealth: non-admitted outpatients Green Procurement

Reduction in use of N95 masks for F2F appointments Replacement of disposable products with greener options

CO2 2.4 million Kg CO2 e/year CO2 Likely large reductions

$150, 000/year Neutral

Driving 9,901,516 km - 8
 RMH Sustainability Competition 2022

Financial Savings
$500,000

CO2 savings
2.5 million kg eCO2

Waste savings
250,000 items kept from landfill

9
Case Study: Reducing
Unnecessary Pathology
Testing in the
Cardiothoracic
Preadmission Clinic
•
11
 Case Study: What is the problem,
what are your goals?
Problem:
Almost all patients undergoing cardiac and thoracic surgery had an extended
panel of pre-op blood tests requested
Many had these tests repeated even if they had been performed very recently

Goal:
Align practice with best practice guidelines to reduce unnecessary and
duplicate pathology testing

Measure of success:
Align practice with guidelines, reduce number of pathology tests
Financial and carbon savings 12
 Case Study: What are the contributing
factors?

No consultant led input

Out of date handbook

No oversight

Abundance of caution

13
 Case Study:
Intervention/Improvement ideas
Surgeons & anesthetists agreed on a consensus set of blood tests for CTS
patients preop

Updated resident orientation manual

Updated resident education

Ensured pre admission clinic nursing staff were aware of changes

Changed posters on wall in pre admission clinic

14
 Case Study: Measure
McAlister et al provides carbon footprint of a range of pathology tests in Australia

Measured Before After

Intervention Intervention
Calculated the number of each blood test 290 blood tests 140 blood tests
over a month
Calculated the carbon footprint of all 28.07 kg eCO2 20.73 kg eCO2
blood tests done that month
Calculated the cost $6176 $2920

Savings: 150 blood tests

7.34 kg eCO2 / month ; 88 kg eCO2/year
$3256/monthly; $39071/annual
15
Top tips to help you populate the Sustainable QI Project Planner

16
 SMART Goal Setting

Specific, Measurable, Achievable, Relevant, and Time-Bound

For example: Reduce the unnecessary blood tests ordered in the cardiothoracic preadmission
clinic over the course of 1 month
 Consider all relevant stakeholders

● Medical staff
● Nursing staff
● Allied health
● Patient care assistants
● Environmental services (cleaners)
● Infection prevention & control
● Facilities staff
● Procurement
● Relevant leadership/management
● Sustainability team

Just to name a few...

18
 Environmental impacts can be measured in many ways. Common ways include:

● Carbon Footprint/GHG emissions reductions – usually expressed in terms of carbon dioxide

equivalent emissions, or CO2e. See the next slide for an explanation on how to calculate.

● It may not be possible or appropriate to calculate the carbon savings for every project. Other
forms of environmental impact measures include:

● Waste reductions – usually expressed in mass/weight or number of items saved from

landfill/diverted to other waste streams

● Hospital admission avoidance / reduction in length of stay – this would inherently reduce
emissions and waste, due to a reduction in resource use

● Water reductions – expressed in litres of water reduced

19
 What is a carbon footprint?

A carbon footprint, also known as Greenhouse Gas (GHG) emissions, is the total impact an activity or process has on
our planet’s atmosphere. It’s how we measure our impact on climate change.

An activity / process can be anything that results in GHG emissions. For example, services, consultations, hospital admissions,
travel, etc.
To calculate the carbon footprint of your activity/process, follow the below steps:
1. Obtain your activity data:
○ A measure of a level of activity – e.g. reduction in usage of: litres of fuel, number of supplies, cubic metres of waste,
kilometres travelled.
2. Find an appropriate emissions factor:
○ This number is a set quantity that represents the amount of GHG emissions that are typically released
for that type of activity. An emissions factor is represented as: GHG emissions per unit of activity for a
given emissions source.
○ For example, a tonne of municipal waste emits 1.6 tonnes of GHG emissions. This is represented as: 1.6
t CO2-e/t waste
○ See slides for a list of potential locations for emissions factors. There is no one-stop-shop for emission
factors, they can be very tricky to find!
3. Use the below equation to calculate total GHG emissions/carbon footprint: 20
○ Carbon footprint (unit-CO2e) = Activity data X emissions factor
 The Healthcare LCA Database

Includes the carbon footprint of individual items and procedures used in healthcare as
well as the carbon footprint of entire healthcare pathways

https://healthcarelca.com/

HOWEVER... the quality of the studies included in the database has not been rigorously
assessed so they may not all be reliable sources 21
22
 Example ideas
• Avoid
- Avoiding higher carbon footprint products where a lower carbon footprint alternative exists. For example,
oral medications in place of IV (paracetamol is a good example) where there is no indication for IV
medications, or powdered inhalers in place of metered-dose inhalers for asthma
- Avoiding use of single use plastic items where avoiding them has a low risk of influencing patient care. For
example, bluey absorbent pads are frequently used for non-patient uses.
• Reduce
- Reduce use of higher cost and emissions waste streams by undertaking photographic waste audits. Clinical Patient
waste is expensive and gets incinerated, therefore having a higher carbon footprint than other waste
streams.
- Auditing routine testing in accordance with evidence-based guidelines – all tests come with a carbon
footprint. Examples include coagulation tests when they are not indicated, or expired pre-operative blood
grouping tests.
- Reducing staff travel and promoting alternative travel.
Planet Purse
• Reuse
- Measure staff plastic usage and explore reusable alternatives for staff to use in break areas
- (Of note, single-use medical equipment cannot be reused for patient use). The “triple bottom line”
• Recycle
- Introducing a new recycling stream into a new area.
- Recycling streams include: co-mingled, cardboard, confidential paper, metals (aluminium), clear soft plastics,
e-waste).
 Become a Member – Join DEA

Your support will help to…

• Raise awareness about the importance of a healthy environment to
human well being;
• Combat climate change;
• Influence public policy;
• Educate and assist the medical profession to become advocates for a
stable climate and healthy environment.

The more members we have, the bigger our voice and the better we’ll
be able to promote health through care of the environment.

With your help we can make a difference.

https://dea.org.au/member-join/
Sustainable Quality Improvemen
Thank you

Dr Sonia Chanchlani
•

Dr Ben Dunne

Senior Fellow, Climate Health and Sustainability
Dept of Critical Care, Melbourne Medical School
sonia.chanchlani@unimelb.edu.au
Surgeon RMH/PMCC, Clinical Sustainability Lead Chair
Sustainable Healthcare SIG, Doctors for the Environment
Environmentally Sustainable Surgery Network
University of Melbourne
Ben.dunne@unimelb.edu.au