Centre for Healthcare Resilience and Implementation Science, Australian Institute of Health Innovation, Macquarie University, Sydney, 2109, Australia
NHMRC Partnership Centre for Health System Sustainability, Australian Institute of Health Innovation, Macquarie University, Sydney, 2109, Australia.
BMJ. 2024 Oct 8;387:e081284. doi: 10.1136/bmj-2024-081284.
To review the international literature and assess the ways healthcare systems are mitigating and can mitigate their carbon footprint, which is currently estimated to be more than 4.4% of global emissions.
Systematic review of empirical studies and grey literature to examine how healthcare services and institutions are limiting their greenhouse gas (GHG) emissions.
Eight databases and authoritative reports were searched from inception dates to November 2023.
Teams of investigators screened relevant publications against the inclusion criteria (eg, in English; discussed impact of healthcare systems on climate change), applying four quality appraisal tools, and results are reported in accordance with PRISMA (preferred reporting items for systematic reviews and meta-analyses).
Of 33 737 publications identified, 32 998 (97.8%) were excluded after title and abstract screening; 536 (72.5%) of the remaining publications were excluded after full text review. Two additional papers were identified, screened, and included through backward citation tracking. The 205 included studies applied empirical (n=88, 42.9%), review (n=60, 29.3%), narrative descriptive (n=53, 25.9%), and multiple (n=4, 2.0%) methods. More than half of the publications (51.5%) addressed the macro level of the healthcare system. Nine themes were identified using inductive analysis: changing clinical and surgical practices (n=107); enacting policies and governance (n=97); managing physical waste (n=83); changing organisational behaviour (n=76); actions of individuals and groups (eg, advocacy, community involvement; n=74); minimising travel and transportation (n=70); using tools for measuring GHG emissions (n=70); reducing emissions related to infrastructure (n=63); and decarbonising the supply chain (n=48).
Publications presented various strategies and tactics to reduce GHG emissions. These included changing clinical and surgical practices; using policies such as benchmarking and reporting at a facility level, and financial levers to reduce emissions from procurement; reducing physical waste; changing organisational culture through workforce training; supporting education on the benefits of decarbonisation; and involving patients in care planning. Numerous tools and frameworks were presented for measuring GHG emissions, but implementation and evaluation of the sustainability of initiatives were largely missing. At the macro level, decarbonisation approaches focused on energy grid emissions, infrastructure efficiency, and reducing supply chain emissions, including those from agriculture and supply of food products. Decarbonisation mechanisms at the micro and meso system levels ranged from reducing low value care, to choosing lower GHG options (eg, anaesthetic gases, rescue inhalers), to reducing travel. Based on these strategies and tactics, this study provides a framework to support the decarbonisation of healthcare systems.
PROSPERO: CRD42022383719.
综述国际文献，评估医疗体系减轻和可以减轻碳足迹的方法，目前医疗体系的碳足迹估计超过全球排放量的 4.4%。
系统综述实证研究和灰色文献，以研究医疗服务和机构如何限制其温室气体（GHG）排放。
从各数据库和权威报告的起始日期搜索到 2023 年 11 月。
研究小组根据纳入标准筛选相关出版物（例如，英文；讨论医疗体系对气候变化的影响），应用四项质量评估工具，并按照 PRISMA（系统评价和荟萃分析的首选报告项目）报告结果。
在确定的 33737 篇文献中，经过标题和摘要筛选后，有 32998 篇（97.8%）被排除；在全文审查后，又有 536 篇（72.5%）被排除。通过回溯引文追踪，又确定并纳入了另外 2 篇论文。纳入的 205 项研究应用了实证（n=88，42.9%）、综述（n=60，29.3%）、叙述性描述（n=53，25.9%）和多方法（n=4，2.0%）。超过一半的出版物（51.5%）涉及医疗体系的宏观层面。使用归纳分析确定了 9 个主题：改变临床和手术实践（n=107）；制定政策和治理（n=97）；管理物理废物（n=83）；改变组织行为（n=76）；个人和团体的行动（例如，倡导、社区参与；n=74）；减少旅行和交通（n=70）；使用测量温室气体排放的工具（n=70）；减少与基础设施相关的排放（n=63）；以及供应链脱碳（n=48）。
出版物提出了各种减少温室气体排放的策略和战术。这些策略包括改变临床和手术实践；利用基准测试和设施级报告等政策，以及采购减排的财务杠杆，减少排放；减少物理废物；通过员工培训改变组织文化；支持关于脱碳益处的教育；并让患者参与护理计划。提出了许多工具和框架来测量温室气体排放，但对倡议的可持续性的实施和评估在很大程度上被忽视了。在宏观层面，脱碳方法侧重于能源网排放、基础设施效率和减少供应链排放，包括农业和食品供应的排放。微观和中观系统层面的脱碳机制从减少低价值护理到选择低 GHG 选项（例如，麻醉气体、抢救吸入器），再到减少旅行。基于这些策略和战术，本研究提供了一个支持医疗体系脱碳的框架。
PROSPERO：CRD42022383719。
