key: cord-0928562-ez6gyoey authors: McGain, Forbes; Muret, Jane; Lawson, Cathy; Sherman, Jodi D. title: Effects of the COVID-19 pandemic on environmental sustainability in anaesthesia. Response to Br J Anaesth 2021;126:e118–e119 date: 2020-12-03 journal: Br J Anaesth DOI: 10.1016/j.bja.2020.11.031 sha: be4649bba60c0ab2aa93388a98f6f11a1ee65660 doc_id: 928562 cord_uid: ez6gyoey nan with better evidence, education, and advocacy. Furthermore, although surgical activity has declined during the pandemic, there is likely to be a rebound increase in resource use and waste as the backlog of elective surgical cases is addressed. Conversely, other trends could well improve environmental sustainability in anaesthesia. Several authors have advocated the clinical, financial, and environmental benefits of regional anaesthesia over general anaesthesia during the pandemic and into the future, 3, 4 and there is evidence that practice is already changing in this direction (e.g. in hip fracture repair). 3e6 Similarly, greater familiarity with use of i.v. infusions of sedatives and opioids during secondment to critical care could yield environmental benefits if clinicians go on to administer total i.v. anaesthesia more commonly. Innovating more widely, the pandemic might stimulate, for example, multidisciplinary reconsideration around the use of finite healthcare resources (e.g. by rationalising preoperative investigations) 7 ; wider use of telemedicine (e.g. in assessment and follow-up clinics); closer engagement with colleagues in infection control when designing single-use equipment, packaging, and infection protocols; development of online education resources; and partnership with industry. 8 All of these aim to minimise travel and optimise resource management, whilst maintaining or improving the quality of patient care and experience. COVID-19 is an ongoing global disaster, but tragedy can lead to innovation and opportunity. Internationally, anaesthetists need to engage urgently and comprehensively in a consensus environmental research and implementation agendum. With this in mind, is the current 'anthropopause' likely to have a positive or a negative effect on environmental processes and behaviours in anaesthesia? And what are the most important opportunities for advancing environmentally sustainable healthcare arising from the COVID-19 pandemic? These are not only questions for the authors, but priorities for the profession to address as we emerge from COVID-19. The authors declare that they have no conflicts of interest. The Anthropocene epoch is used to describe the most recent period of Earth's history, when human activity first began to have significant impact on the planet's biosphere, hydrosphere, lithosphere, and atmosphere. 3 The Rockefeller Commission recently noted in Safeguarding Human Health in the Anthropocene Epoch that 'we have been mortgaging the health of future generations to realise economic and development gains in the present by unsustainably exploiting nature's resources'. 3 Humanity is exceeding Earth's resource capacity, and the wealthiest nations are disproportionately consuming more resources than poorer ones. The COVID-19 pandemic has markedly constrained society's travel, production, and resource consumption. This COVID-19 anthropopause has led to a worldwide reduction in greenhouse gas emissions by almost 9% for the first half of 2020 compared with 2019. 4 Is this a silver lining to an otherwise worldwide tragedy? Consider though that worldwide greenhouse gas emissions need to fall by 7.5% each and every year for this decade if we are to have any hope of meeting the stark warning of the Intergovernmental Panel on Climate Change to limit average surface temperature rise by no more than 1.5 C above pre-industrial levels by 2050 5, 6 to avoid the collapse of civilisation as we know it by the end of this century. Table 1 summarises actual and potential positive and negative effects upon the environment that the COVID-19 pandemic has had that are relevant to anaesthetists and critical care physicians, our professions, and healthcare delivery. There are many unknowns, but most importantly (i) positive and negative effects will occur across several domains, (ii) changing our behaviour is vital to achieving environmentally sustainable workplaces, and (iii) COVID-19 has shown us that rapid global transformation of society is possible if people work together and will it so. We can face the existential challenges of climate change and environmental degradation with as much verve as many nations have faced the COVID-19 pandemic. Beyond the human tragedy, the COVID-19 pandemic has been an alarming environmental disaster, most noticeable through both surges in demand and service interruptions, leading to shortages of the single-use disposable personal protective equipment (PPE) that we depend on and mountains of their physical waste. Whilst PPE is essential for protecting clinicians, many of us go through cognitive dissonance, remarking that one can easily use dozens of single-use plastic gowns, surgical and respirator face masks, and hundreds of gloves for one patient with COVID-19 (suspected or actual) per shift whilst experiencing shortages and facing ecosystem collapse. 9 It is surprising how often each of us has heard our clinical colleagues note that the COVID-19 pandemic has made us realise how wasteful we are now that we have experienced our own vulnerability to medical supply shortages. The fallacy of unlimited resources for rich healthcare settings has been lifted. We realise our need to prepare for shortages of oxygen, i. v. fluids, drugs, and medical devices. We need to review and revise regulations and protocols that drive wasteful practices to preserve resources and meet basic anaesthetic requirements for the most people possible. It is necessary to focus on restoring the foundational elements that support minimal needs. Locally made, robust, reusable medical equipment shifts healthcare away from a linear 'takeemakeewaste' high-carbon economy towards the circular economy that keeps materials in use as long as possible and eliminates waste. 10 An environmentally sustainable healthcare system is resilient, financially responsible, and ethical. We believe we have a moral obligation to conserve resources, always. Further discussion by national and world medical bodies (e.g. WHO and the World Federation of Societies of Anaesthesiologists) to harmonise and provide basic criteria worldwide, defining what resource conservation is best practice, is challenging but plausible and necessary to ensure equitable, universal access to basic healthcare in accordance with the United Nations Sustainable Development Goals. COVID-19 has revealed the necessity of engaging with our infection prevention and control colleagues to consider best infection prevention practice, whilst considering environmental repercussions and supply chain resilience. The default for infection prevention is routinely 'single use is better'; yet, we must address protection of both the patient and public health, including preservation of resources and pollution prevention. 11, 12 Antimicrobial stewardship, now a mainstream part of infectious diseases, exists to protect the patient and the people. Why is overconsumption of single-use disposable medical supplies any different? Could we research ways to protect the patient and healthcare workers without sacrificing our environmental health, or unfairly competing for limited resources? Such a pathway opens many opportunities to collaborate in fields as disparate as anaesthesia, infectious diseases, materials science, supply chain management, medical anthropology, and behavioural sciences. Post-COVID-19: an opportunity to accelerate to carbon net zero Advocating for more environmentally sustainable anaesthesiology and critical care, both as individuals and as members of professional societies, is vital to a resilient, sustainable healthcare system post-COVID-19. We would like to commend the very recently announced National Health Service (NHS) commitment to achieving 'net zero' greenhouse gas emissions by 2040. 13 The NHS net zero 2040 plan is grand in its stated aims, requires substantial upfront investment, is likely fraught with potential setbacks and halfway achievements, and will be challenging to maintain with required enthusiasm and dedication. Yet, if humanity is to reach a safe(r) climate, a Recognition of the value of reusable medical devices from both a supply chain resiliency and environmental sustainability perspective Innovation to conserve resources, including policies to reduce waste and safely reclaim and reuse materials net zero plan is necessary for every nation's healthcare system, particularly the wealthier nations that contribute disproportionately more to global environmental emissions. COVID-19 has taught us that in the face of imminent disaster, we can abruptly mobilise vast sums of money, alter behaviours of the majority of the populace, and prepare healthcare systems for the worst. Compared with this pandemic, a decade is a very long time to transition to a sustainable economy and avert the worst anticipated impacts from climate change. 14 Anaesthetists and critical care physicians can continue to serve as leaders in the path to a healthier, environmentally sound pandemic recovery. To paraphrase Rabbi Hillel, 'If not us, who? If not now, when?' Effects of the COVID-19 pandemic on environmental sustainability in anaesthesia Environmental sustainability within anaesthesia and critical care Safeguarding human health in the Anthropocene epoch: report of the Rockefeller FoundationeLancet Commission on planetary health Near-real-time monitoring of global CO 2 emissions reveals the effects of the COVID-19 pandemic Global Warming of 1.5 C. An IPCC special report on the impacts of global warming of 1.5 C above pre-industrial levels and related global greenhouse gas emission pathways United Nations Environment Programme Virtual health care in the era of COVID-19 Hydrogen peroxide vapor sterilization of N95 respirators for reuse Environmentally sustainable health care: now is the time for action A call for medical device industry transformation: toward a circular economy Balancing infection control and environmental protection as a matter of patient safety: the case of laryngoscope handles The green print: advancement of environmental sustainability in healthcare Delivering a 'net zero' national health service 2020 COVID and climate change The authors declare that they have no conflicts of interest.