How to Preserve the Planet While Enhancing Our Healthcare

Healthcare services have improved globally over the last few centuries. Of course, this improvement has occurred at varying paces and levels across different regions, but generally, we are all moving in the same direction: toward longer and healthier lives than ever before.

While this is beneficial for us, unfortunately, the planet is paying the price, and it feels like we are running out of credit. McKee et al. wrote a compelling review in Radiology in April 2024 about the connection between our planet's health and advancements in radiology (find the link at the bottom of this article).

The Environmental Impact of the Healthcare System and Radiology

Diagnostic imaging is responsible for approximately 1% of global greenhouse gas (GHG) emissions. It also demands a significant amount of scarce resources like iodine and helium and generates considerable waste. The GHG emissions are from direct and indirect sources and can be divided into three different scopes according to the Greenhouse Gas Protocol Scope:

• Scope 1: Direct emissions caused by the hospital or outpatient clinic, e.g., heating or AC by the use of fossil fuels or Desflurane for anesthesia (17% of healthcare emissions).
• Scope 2: Indirect emissions caused by purchased electricity to run MRIs and CTs (12% of healthcare emissions).
• Scope 3: Other indirect emissions, from the production of medical imaging equipment to staff commuting (71% of healthcare emissions).

Looking for solutions: Mitigate and Adapt

It's clear that we cannot solve this immense problem by simply switching off all the machines. Diagnostic imaging is an invaluable part of modern medicine, and we need to find ways to maintain its benefits while mitigating its downsides. McKee et al. made some insightful suggestions on how to improve the situation and deal with its consequences.

1. How to improve the situation
2. How to deal with its consequences

Part 1: Reducing GHG Emissions - The Obvious Solutions

A critical step to reduce the high energy demand of MRIs and CTs could be to implement power-down modes when they are not in use or to activate automated low-power modes. Similarly, computers and lights should be switched off automatically when not in use. Optimizing scanner scheduling could also save a significant amount of energy: while a utilization of 90% caused an average energy use of 48 kWh per patient, this value increased to 136 kWh per patient at 30% utilization.

(AI-powered) clinical decision tools could significantly reduce energy consumption by minimizing low-value imaging and helping to choose lower-energy imaging tests (e.g., CT instead of MRI, radiograph instead of CT). Shortening examination protocols and using low field MRI in combination with AI de-noising tools is another direct way to reduce energy consumption in your radiology department.

Part 2: Reducing GHG Emissions - The Less Obvious Solutions

Constant air conditioning in your angio suite consumes a lot of energy, and it's actually no big deal to widen the temperature range during off times. Radiology departments produce a lot of waste energy. A smart solution here is to collaborate with building specialists and vendors to recover it.

Commuting to work causes a lot of GHG emissions, so why not promote remote work on some days of the week? Optimizing patient scheduling and coordinating imaging tests with other appointments on the same day is another way to reduce commuting-related damage to our planetary health.

The majority of imaging-related GHG emissions are due to the production of MRIs and CTs. Refurbishing this equipment and extending its lifespan from 5 to 10 years can make a massive difference.

Part 3: Footprints Beyond Energy Demand

Pollution and the demand for limited resources are another aspect to consider when evaluating the impact of radiology on planetary health. Recycling of contrast medium, smart and sustainable waste management, and even cryogen-free MRIs (though it remains unclear today if the high energy demand of those does outbalance the reduction of global helium demand) could be potential solutions. Moreover, sustainable procurement should be established including the reduction of packaging waste by cooperating with vendors and by purchasing multipatient contrast agent delivery systems and re-usable medical supplies like surgical towels and interventional procedure trays.

Of course, the suitability of these solutions depends greatly on the structure and workflow of your radiology department. However, the sum of many small actions can help create a sustainable radiology practice.

To promote screening programs can prevent late stage diseases. These are a tragedy for the patient and the planet because the corresponding treatment has a high demand of resources and energy.

Embrace Climate Change: How to Prepare and Adapt for What is Coming in 5 Actionable Steps

1. Set Up Disaster Management Protocols: Prepare for adverse weather events and other catastrophes, and address the potential for a higher demand in imaging diagnostics and a possible workforce shortage during these times.
2. Improve Building and IT Infrastructure: Strengthen your facilities and IT systems to resist natural catastrophes and ensure there are reliable backup systems for data storage and electricity.
3. Focus Your Medical Education on Climate Change-Related Conditions: Enhance training on conditions related to air pollution and cardiovascular diseases, which are increasingly relevant in a changing climate.
4. Develop Departmental Dashboards to Monitor and Measure Progress: Create dashboards to track advancements towards achieving a planet-friendly radiology department. This visualization aids in determining if adjustments are necessary and helps maintain momentum towards sustainability goals.
5. Form Sustainability Teams and Connect Stakeholders: Establish teams dedicated to sustainability efforts and ensure communication between all stakeholders is optimized. This includes forming connections not just within the department, but also with industry partners, referring clinicians, and patients.

Promote and monitor the progress: Form teams and set up a sustainability dashboard

The figure mentioned above showcases an example of a sustainability dashboard. These dashboards are excellent tools for visualizing and monitoring the progress of your sustainability transformation. The visualization simplifies the process of determining whether further adjustments are necessary to meet your goals. Depending on your department's specific objectives, you can define various key performance indicators (KPIs). The responsibility for measuring these KPIs can be assigned to the appropriate teams; for example, energy use metrics could be managed by the medical physics team.

The mission to cultivate a planet-friendly radiology department is fundamentally a collaborative team effort. It is essential for all stakeholders to work together efficiently. Success in this initiative relies heavily on forming the right teams and optimizing communication among them. By ensuring that all parties are aligned and engaged, the pathway to sustainable radiology becomes clearer and more attainable.

Why Sustainability Matters for Different Groups

• Patients: They are the central stakeholders in this process, and while their direct impact on sustainability may be limited, their perception of its importance is high—92% of patients consider sustainability in healthcare to be crucial.
• Radiologists: They play a critical role in establishing a planet-friendly radiology department. Their decisions influence capital purchases, the implementation of imaging protocols, and the management of relationships with various partners.
• Referring Physicians: These professionals are key in reducing low-value imaging. Enhancing communication between radiologists and referring physicians, possibly through standardized reporting and decision support tools that include data on GHG emissions associated with each imaging scan, is essential. A survey showed that 93% of referring physicians would consider CO2 production in their imaging-related decision-making process.

My Take on This

Sustainability in radiology was once a foreign concept, but the global diagnostic imaging community is now acutely aware of the significant impact that imaging has on energy consumption and GHG emissions. While radiology is energy-intensive, it's crucial to remember the immense benefits of medical progress driven by advancements in diagnostic imaging. Viewing the potential to transform current practices positively, radiology can significantly contribute to a more sustainable and effective healthcare system. The push for sustainability should be seen as a roadmap to refine and enhance workflows and foster new collaborative efforts among various stakeholders.

Sources:

McKee H, Brown MJ, Kim HHR, et al. Planetary Health and Radiology: Why We Should Care and What We Can Do. Radiology. 2024;311(1):e240219. doi:10.1148/radiol.240219