The environmental impact of health care systems can no longer be denied. Ecodesign is an innovative approach to reduce the environmental impact of a product by using life cycle assessment (LCA).1 LCA aims to assess the environmental impacts from the extraction and processing of raw materials, through the manufacture, distribution, and use of the product, to the recycling or final disposal of the materials that make it up. The objective of ecodesign is to find compromises between environmental and other constraints involved in designing a product. Originally designed for products, it is now extended to services like health care under the name of “ecodesign of health care.” This consists of designing care to optimize the impact on the 3 pillars of Sustainable Development which are environmental, economic, and social.
Venous port insertion is a standard procedure. At Princess Grace Hospital, after organizational changes linked to coronavirus disease (COVID), some of the venous access procedures had to be performed by anesthetists (percutaneous procedure) rather than surgeons (surgical procedure). We seized the opportunity to eco-design this procedure and compare it with the previous organization in terms of the 3 pillars of Sustainable Development.
METHODS
Our usual procedure was surgical insertion under intravenous (IV) sedation using an electric syringe. Our ecodesigned care consisted of ultrasound-guided percutaneous insertion (as recommended by National Institute for Health and Care Excellence [NICE] guidelines2) by anesthetists under local anesthetic combined with conversational hypnosis. Conversational hypnosis with local anesthesia is fully in line with the sustainability approach by improving environmental and economic impacts (no need for anesthetic drugs for sedation,3,4 resulting in a reduction of drugs5 and therefore a reduction in waste and pollution) and social component of Sustainable Development (improved interactions between staff and patients).
First, we established the life cycle inventory of the single-use devices needed. We obtain their composition by the technical data sheet. Then we entered their weight and composition in the tool of simplified LCA Ecolizer 2.0 (based on the Eco indicator 99 method, currently used in the industrial sector) to obtain the environmental impact of each material, which we added together to obtain the total potential environmental impact (PEI).
Our protocol for sorting out medical waste, updated according to new guidelines, was applied. We chose to use the walking patient procedure which consists of asking the patients to walk to the operating room thus avoiding stretchers, fully in line with our sustainability approach.6
The environmental impact was assessed using a simplified LCA of the medical devices, waste quantification, and energy consumption. Costs of medical devices and their sterilization, costs of occupying operating theaters, and wage bills were used to quantify the economic impact. Percutaneous procedure ecodesigned organization was compared to surgical procedure. The social aspect of ecodesigned health care was also assessed, using questionnaires for staff.
In this nonrandomized single-center observational study, data for the percutaneous procedure were obtained prospectively from December 2020 to April 2021, and retrospectively for the surgical procedure. No patient data was collected, therefore patient consent was not required.
Fifty-nine consecutive percutaneous procedures were included in the percutaneous group and provided an adequate sample size. American Society of Anesthesiologists (ASA) scores were, respectively, 49% for ASA I and II and 51% for ASA III and IV. For surgical procedures, we studied all implantations performed the year preceding the study, ie 217 procedures: 62% ASA I and II and 38% ASA III and IV.
RESULTS
The ecodesigned percutaneous procedure is clearly more environmentally and economically beneficial compared to the usual surgical procedure.
According to the simplified LCA of medical devices, the potential total environmental impact was 5.4 times lower with the percutaneous procedure than with the surgical procedure (Table). Drug savings were also achieved as the IV sedation used for the surgical procedure was replaced by conversational hypnosis for the percutaneous procedure. The average total weight of waste was 2 times less with the percutaneous procedure, none of which was hazardous, and energy consumption was also 3.2 times less with the percutaneous procedure (no use of electric syringes).
Table. – Total Potential Environmental Impact of Each Material Category in Each Procedure and Total PEI for Each of Both Procedures and for Sedation
| PEI (mPt) | Percutaneous procedure | Surgical procedure |
|---|---|---|
| Plastics | 156,89 | 866,99 |
| Metals | 6,79 | 51,85 |
| Textiles | 114,05 | 603,48 |
| Papers/cardboards | 57,48 | 191,12 |
| Total PEI | 335,21 | 1713,44 |
| Sedation | 0 | 92,9 |
| Total PEI with sedation | 335,21 | 1806,34 |
In terms of economic impact, the price of medical devices was 25% lower with the percutaneous procedure, operating room costs divided by 2, payroll costs divided by 3.5, and sterilization costs divided by 3.5 (Figure).
The social impact of the percutaneous procedure showed a very high level of satisfaction among 83% of caregivers through improved patient interaction. Fifty percent of the staff felt an improved quality of life at work and 69% felt it was more meaningful.
DISCUSSION
Health care procedures consume resources, particularly medical devices (most of them single-use) and energy.1 Here, 2 different approaches to a very common care were examined from a sustainable perspective. A work reorganization was the opportunity to ecodesign this care according to the 3 sustainable development pillars.
Simplified LCA was a default choice because a complete LCA was very difficult to implement, expensive, and required specialized companies. Nevertheless, simplified LCA is recognized and used in other studies, particularly in the industrial sector.7 It enables identification of a trend, which corresponds to our initial objective ie comparison with the reference procedure in our hospital.
From an economic standpoint, the surgical procedure total cost was higher, due to medical devices cost, a greater number of staff, and operating room occupancy time (1.9 times longer).
From an environmental standpoint, the LCA reveals a considerable PEI for both procedures, but 5.4 times higher with the surgical procedure.
Insertion of a venous port is usually performed under local anesthesia, which was not the case at our hospital where IV sedation was used instead. Our study reveals the negative impact of sedation: increased environmental impact (PEI, waste, consumption of resources, energy, and water pollution), increased economic impact, and social impact (use of already scarce staff which could be allocated to other useful tasks).
Finally, this approach also conveys very positive values about the staff’s feelings. The resulting strengthening of human interaction fosters the social aspect of sustainability.
Eco-design of health care allows improved environmental, economic, and social impacts while maintaining quality. This study highlights the need to evaluate and question our practices to identify areas for improvement.
REFERENCES