Critical Care - Research Publications
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ItemHealth, financial and environmental impacts of unnecessary vitamin D testing: a triple bottom line assessment adapted for healthcare(BMJ PUBLISHING GROUP, 2022-08)OBJECTIVE: To undertake an assessment of the health, financial and environmental impacts of a well-recognised example of low-value care; inappropriate vitamin D testing. DESIGN: Combination of systematic literature search, analysis of routinely collected healthcare data and environmental analysis. SETTING: Australian healthcare system. PARTICIPANTS: Population of Australia. OUTCOME MEASURES: We took a sustainability approach, measuring the health, financial and environmental impacts of a specific healthcare activity. Unnecessary vitamin D testing rates were estimated from best available published literature; by definition, these provide no gain in health outcomes (in contrast to appropriate/necessary tests). Australian population-based test numbers and healthcare costs were obtained from Medicare for vitamin D pathology services. Carbon emissions in kg CO2e were estimated using data from our previous study of the carbon footprint of common pathology tests. We distinguished between tests ordered as the primary test and those ordered as an add-on to other tests, as many may be done in conjunction with other tests. We conducted base case (8% being the primary reason for the blood test) and sensitivity (12% primary test) analyses. RESULTS: There were a total of 4 457 657 Medicare-funded vitamin D tests in 2020, on average one test for every six Australians, an 11.8% increase from the mean 2018-2019 total. From our literature review, 76.5% of Australia's vitamin D tests provide no net health benefit, equating to 3 410 108 unnecessary tests in 2020. Total costs of unnecessary tests to Medicare amounted to >$A87 000 000. The 2020 carbon footprint of unnecessary vitamin D tests was 28 576 kg (base case) and 42 012 kg (sensitivity) CO2e, equivalent to driving ~160 000-230 000 km in a standard passenger car. CONCLUSIONS: Unnecessary vitamin D testing contributes to avoidable CO2e emissions and healthcare costs. While the footprint of this example is relatively small, the potential to realise environmental cobenefits by reducing low-value care more broadly is significant.
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ItemEveryone’s a winner if we test less: the CODA action plan.(CSIRO Publishing, 2022-08)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.
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ItemThe carbon footprint of hospital diagnostic imaging in Australia(ELSEVIER, 2022-07)BACKGROUND: Pathology testing and diagnostic imaging together contribute 9% of healthcare's carbon footprint. Whilst the carbon footprint of pathology testing has been undertaken, to date, the carbon footprint of the four most common imaging modalities is unclear. METHODS: We performed a prospective life cycle assessment at two Australian university-affiliated health services of five imaging modalities: chest X-ray (CXR), mobile chest X-ray (MCXR), computerised tomography (CT), magnetic resonance imaging (MRI) and ultrasound (US). We included scanner electricity use and all consumables and associated waste, including bedding, imaging contrast, and gloves. Analysis was performed using both attributional and consequential life cycle assessment methods. The primary outcome was the greenhouse gas footprint, measured in carbon dioxide equivalent (CO2e) emissions. FINDINGS: Mean CO2e emissions were 17·5 kg/scan for MRI; 9·2 kg/scan for CT; 0·8 kg/scan for CXR; 0·5 kg/scan for MCXR; and 0·5 kg/scan for US. Emissions from scanners from standby energy were substantial. When expressed as emissions per additional scan (results of consequential analysis) impacts were lower: 1·1 kg/scan for MRI; 1·1 kg/scan for CT; 0·6 kg/scan for CXR; 0·1 kg/scan for MCXR; and 0·1 kg/scan for US, due to emissions from standby power being excluded. INTERPRETATION: Clinicians and administrators can reduce carbon emissions from diagnostic imaging, firstly by reducing the ordering of unnecessary imaging, or by ordering low-impact imaging (X-ray and US) in place of high-impact MRI and CT when clinically appropriate to do so. Secondly, whenever possible, scanners should be turned off to reduce emissions from standby power. Thirdly, ensuring high utilisation rates for scanners both reduces the time they spend in standby, and apportions the impacts of the reduced standby power of a greater number of scans. This therefore reduces the impact on any individual scan, maximising resource efficiency. FUNDING: Healthy Urban Environments (HUE) Collaboratory of the Maridulu Budyari Gumal Sydney Partnership for Health, Education, Research and Enterprise MBG SPHERE. The National Health and Medical Research Council (NHMRC) PhD scholarship.
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ItemPlanetary health care: a framework for sustainable health systems.(Elsevier BV, 2021-02)
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ItemNet zero healthcare: a call for clinician action(BMJ PUBLISHING GROUP, 2021-09-20)Health professionals are well positioned to effect change by reshaping individual practice, influencing healthcare organisations, and setting clinical standards, argue Jodi Sherman and colleagues
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ItemNo Preview AvailableAerosol generation related to respiratory interventions and the effectiveness of a personal ventilation hood.(College of Intensive Care Medicine of Australia and New Zealand, 2020-09)OBJECTIVE: To quantify aerosol generation from respiratory interventions and the effectiveness of their removal by a personal ventilation hood. DESIGN AND SETTING: Determination of the aerosol particle generation (in a single, healthy volunteer in a clean room) associated with breathing, speaking, wet coughing, oxygen (O2) 15 L/min via face mask, O2 60 L/min via nasal prongs, bilevel non-invasive positive-pressure ventilation (BiPAP) and nebulisation with O2 10 L/min. INTERVENTIONS: Aerosol generation was measured with two particle sizer and counter devices, focusing on aerosols 0.5-5 μm (human-generated aerosols), with and without the hood. An increase from baseline of less than 0.3 particles per mL was considered a low level of generation. MAIN OUTCOME MEASURES: Comparisons of aerosol generation between different respiratory interventions. Effectiveness of aerosol reduction by a personal ventilation hood. RESULTS: Results for the 0.5-5 μm aerosol range. Quiet breathing and talking demonstrated very low increase in aerosols (< 0.1 particles/mL). Aerosol generation was low for wet coughing (0.1 particles/mL), O2 15 L/min via face mask (0.18 particles/mL), and high flow nasal O2 60 L/min (0.24 particles/mL). Non-invasive ventilation generated moderate aerosols (29.7 particles/mL) and nebulisation very high aerosols (1086 particles/mL); the personal ventilation hood reduced the aerosol counts by 98% to 0.5 particles/mL and 8.9 particles/mL respectively. CONCLUSIONS: In this human volunteer study, the administration of O2 15 L/min by face mask and 60 L/min nasal therapy did not increase aerosol generation beyond low levels. Non-invasive ventilation caused moderate aerosol generation and nebulisation therapy very high aerosol generation. The personal ventilation hood reduced the aerosol counts by at least 98%.
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ItemEffectiveness of portable air filtration on reducing indoor aerosol transmission: preclinical observational trials(W B SAUNDERS CO LTD, 2022-01)BACKGROUND: While the range of possible transmission pathways of severe acute respiratory syndrome coronavirus-2 in various settings has been investigated thoroughly, most authorities have recently acknowledged the role of aerosol spread in its transmission, especially in indoor environments where ventilation is poor. Engineering controls are needed to mitigate aerosol transmission in high-risk settings including hospital wards, classrooms and offices. AIM: To assess the effectiveness of aerosol filtration by portable air cleaning devices with high-efficiency particulate air filters used in addition to a standard building heating ventilation and air conditioning (HVAC) system. METHODS: Test rooms, including a single-bed hospital room, were filled with test aerosol to simulate aerosol movement. Aerosol counts were measured over time with various portable air cleaning devices and room ventilation systems to quantify the overall aerosol clearance rate. FINDINGS: Portable air cleaning devices were very effective for removal of aerosols. The aerosols were cleared five times faster in a small control room with portable air cleaning devices than in the room with HVAC alone. The single-bed hospital room had an excellent ventilation rate (∼14 air changes per hour) and cleared the aerosols in 20 min. However, with the addition of two air cleaning devices, the clearance time was three times faster. CONCLUSIONS: Inexpensive portable air cleaning devices should be considered for small and enclosed spaces in healthcare settings, such as inpatient rooms and personal protective equipment donning/doffing stations. Portable air cleaning devices are particularly important where there is limited ability to reduce aerosol transmission with building HVAC ventilation.
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ItemThe carbon footprint of pathology testing(WILEY, 2020-11)