This research project, part of the Green Intensive Care Unit (ICU) initiative at the Erasmus University Medical Center (EMC), is focused on reducing the environmental impact of syringes at the ICU by designing solutions based on circular economy principles. Based on a Material Flow Analysis of the EMC ICU, syringes and their packaging have been identified as one of the main environmental impact hotspots. Therefore, this project aimed to redesign the syringes, their packaging, and their use, according to circular design strategies suitable for medical products to decrease their environmental impact, while remaining convenient and safe in use for the healthcare staff and patients. Research was executed to understand the context from multiple perspectives. The outcomes demonstrated that decreasing the impact of syringes is not only related to the design of the syringe itself. Manufacturing, preparation, use and disposal, all contribute to the environmental impact of the syringe. Various possible interventions were derived to reduce its impact:

1.
Adapting the infection prevention protocol and behaviour of the staff;

2.
Separating infectious waste from general hospital waste;

3.
Redesigning the syringe itself;

4.
Optimising the filling process of syringes.

The final design is an optimised filling process for prefilled sterilised syringes (PFSs), based on circular strategies such as reduce, reuse, rethink and repurpose. Interventions include: eliminating a redundant sterilisation phase, reducing residual medication and changing from steam to gamma sterilisation. This resulted in decreasing the amount of waste, material, energy and water consumption, while offering similar convenience and safety for the staff and patients of the ICU.@en

This project aims to reduce the environmental impact of the Intensive Care Unit (ICU) of the Erasmus Medical Center (EMC). Systemic design research was executed to map the current waste flow created by the ICU. Literature review, interviews and observations were performed to gather information about the healthcare protocols, hospital procurement process, intubation practices and used devices and consumables. This resulted in a set of challenges which were used to ideate from different perspectives to improve the sustainability of the ICU. A set of opportunities to introduce circularity within the ICU were defined. These opportunities ranged from waste separation to the reduction of the disposal of unused products. The selected circular opportunity was intubation, needed when patients cannot breathe by themselves. For this, a video laryngoscope, which is composed of various plastics, a video camera, and a led light, is used for only a few minutes and disposed of (and incinerated) directly afterwards. The aim of the second part of this research project was: Can we design a circular intubation procedure as a catalyzer for systemic change towards circular ICUs? One of the proposed circular strategies for the video laryngoscope is the reprocessing of intubation devices used at the ICU itself. A transition model toward reprocessing using UV-C radiation technique was further developed. Compared to current reprocessing procedures, UV-C disinfection consumes no water and less electricity and offers the possibility of decentralized reprocessing within the ICU department itself. This project aims to provoke conversations between the hospital, manufacturers and other stakeholders about how the healthcare sector could start reprocessing valuable medical devices towards a circular ICU.@en

Background
The health care sector is among the most carbon-intensive sectors, contributing to societal problems like climate change. Previous research demonstrated that especially the use of personal protective equipment (e.g., aprons) in critical care contributes to this problem. To reduce personal protective equipment waste, new sustainable policies are needed.

Aims
Policies are only effective if people comply. Our aim is to examine whether compliance with sustainable policies in critical care can be increased through behavioural influencing. Specifically, we examined the effectiveness of two sets of nudges (i.e., a Prime + Visual prompt nudge and a Social norm nudge) on decreasing apron usage in an intensive care unit (ICU).

Study Design
We conducted a field experiment with a pre- and post-intervention measurement. Upon the introduction of the new sustainable policy, apron usage data were collected for 9 days before (132 observations) and 9 days after (114 observations) the nudge interventions were implemented.

Results
Neither the Prime + Visual prompt nudge, nor the Social norm nudge decreased apron usage.

Conclusions
While previous studies have found that primes, visual nudges and social norm nudges can increase sustainable behaviour, we did not find evidence for this in our ICU field experiment. Future research is needed to determine whether this null finding reflects reality, or whether it was due to methodological decisions and limitations of the presented experiment.

Relevance to Clinical Practice
The presented study highlights the importance of studying behavioural interventions that were previously proven successful in the lab and in other field contexts, in the complex setting of critical care. Results previously found in other contexts may not generalize directly to a critical care context. The unique characteristics of the critical care context also pose methodological challenges that may have affected the outcomes of this experiment.@en

This research and design project is part of the Green ICU initiative and focused on reducing the environmental impact of gloves at the Intensive Care Unit (ICU) of the Erasmus Medical Center (EMC). At the ICU of the EMC around 108 gloves are used per patient per day; to protect the user (healthcare staff) from infections. The high frequency of use and the resource-intensive production define disposable nitrile gloves as one of the ‘hotspots’ contributing to the environmental impact created by the ICU. This research and design project addressed the problem from three different perspectives: user-centred, product-centred and supply-centred. The extensive research resulted in three design directions on how to reduce the environmental impact of gloves. Subsequently, all insights from the research were brought together into five design building blocks. These design building blocks provided guidance for the design phase of the project. The project resulted in a redesign of the current glove dispensers. The final design is named ‘GloVe’, a vertical dispense system. By incorporating the five building blocks, the design can provide benefits for multiple stakeholders within the healthcare system. It reduces the environmental impact of gloves in the ICU by dispensing one glove at a time. Furthermore, the gloves are dispensed at the cuff, which comes in little contact with the patient. The vertical movement is pleasant to the user. The use of colour for different sizes makes it clear to the care assistant which box should go in which holder. Also, nurses will see at a glance, which size gloves they are dispensing. The small V-shaped opening makes the undesirable behaviour, of placing gloves back, almost impossible.@en

Together we must reduce the impact of the healthcare sector and shift towards a circular economy. This paper describes the shift of three ICU environmental hotspots: gloves, gowns, and CRRT bags.@en

Purpose: The healthcare sector is responsible for 6–7% of CO₂ emissions. The intensive care unit (ICU) contributes to these CO₂ emissions and a shift from a linear system to a circular system is needed. The aim of our research was to perform a material flow analysis (MFA) in an academic ICU. Secondary aims were to obtain information and numbers on mass, carbon footprint, agricultural land occupation and water usage and to determine so-called “environmental hotspots” in the ICU. Methods: A material flow analysis was performed over the year 2019, followed by an environmental footprint analysis of materials and environmental hotspot identification. Results: 2839 patients were admitted to our ICU in 2019. The average length of stay was 4.6 days. Our MFA showed a material mass inflow of 247,000 kg in 2019 for intensive care, of which 50,000 kg is incinerated as (hazardous) hospital waste. The environmental impact per patient resulted in 17 kg of mass, 12 kg CO₂ eq, 300 L of water usage and 4 m² of agricultural land occupation per day. Five hotspots were identified: non-sterile gloves, isolation gowns, bed liners, surgical masks and syringes (including packaging). Conclusion: This is the first material flow analysis that identified environmental risks and its magnitude in the intensive care unit.

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