Environmental sustainability is becoming an operational concern within intensive care units, where energy use, medications and single-use medical devices account for a substantial share of resource consumption. Previous benchmarking work has identified specific “hotspots” associated with high material mass and environmental impact, particularly non-sterile gloves, personal protective equipment, injectable medicines and devices used for intravenous administration. Targeted initiatives focusing on individual practices, such as favouring oral medication routes or optimising intravenous delivery, have already shown reductions in greenhouse gas emissions and material use. Building on this context, an intensive care unit implemented a broader, unit-wide approach aimed at reducing resource consumption by addressing several hotspots simultaneously. An eco-audit comparing practice before and after these changes provides insight into how coordinated interventions can influence material use and costs in critical care settings.
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Implementing A Bundle of Sustainable ICU Practices
The initiative was conducted in a single intensive care unit using a pre- and post-intervention design. Resource consumption during a reference period was compared with a follow-up period after the introduction of a bundle of sustainable care practices. Between September 2023 and June 2024, multiple interventions were rolled out as part of this bundle. Education formed a central component, with formal lectures delivered by the unit’s green team to attending physicians, junior doctors and other caregivers. These sessions aimed to raise awareness of environmental impacts linked to routine clinical activities.
Clinical protocols were then revised by a multidisciplinary group that included pharmacologists, caregivers, managers and physicians. Changes were aligned with available literature and recommendations and focused on reducing unnecessary material use while maintaining standard care. In parallel, recurring information materials were introduced, including updated posters displayed every six months to reinforce messages around hand hygiene and the use of oral medication routes when appropriate. Together, these actions were designed to embed sustainability considerations into daily ICU practice rather than relying on isolated measures.
Measuring Material Flow and Resource Consumption
To assess the impact of the intervention, a material flow analysis examined inflows and outflows of materials during each period. The functional unit was defined as the mass of products used per patient-day, encompassing both medications and medical devices, including personal protective equipment. Each product and its packaging were disassembled into components with a single material composition, such as plastic, glass, paper and cardboard, metals, fluids, active pharmaceutical ingredients and dry excipients. Each component was weighed individually to allow detailed comparison between periods.
Overall resource consumption from medications and medical devices declined from 5808 g per patient-day in the reference period to 4984 g per patient-day in the follow-up period, a statistically significant reduction. Plastic consumption decreased by 23%, corresponding to 1590 kg per year, while paper and cardboard use fell by 31%, equivalent to 249 kg per year. In contrast, consumption of metal and glass showed no significant change between periods.
Fluids represented the largest share of total material weight, accounting for 70%, largely due to injectable medications. Plastic contributed 22%, mainly from medical devices, and glass accounted for 4%, particularly from medications such as propofol, antibiotics, potassium syrup and neuromuscular blockade agents. Fluid consumption declined significantly in the follow-up period, while consumption of active pharmaceutical ingredients and dry excipients remained stable.
Effects On Costs and Clinical Activity
Alongside reductions in material use, the cost of medications and medical devices decreased by 14%, representing an annual saving of 46,283 euros. Analysis of commonly used medications showed no differences in overall consumption of propofol, noradrenaline or third-generation cephalosporins between periods. However, consumption of thiamine and pyridoxine decreased significantly, as did the use of intravenous paracetamol. Total paracetamol use remained unchanged, indicating a shift away from the intravenous route rather than a reduction in analgesic use overall.
Use of several disposable medical devices also declined. Consumption of gloves, perfusion tubing and syringes fell significantly during the follow-up period, while use of surgical masks did not differ between periods. Key indicators of clinical activity remained comparable. Median length of stay was three days in both periods, and the proportion of days involving mechanical ventilation was similar. Mortality rates differed between periods, but no causal link to the intervention was established within the scope of the analysis.
The eco-audit demonstrates that implementing a coordinated bundle of sustainable care practices in an intensive care unit was associated with lower material consumption and reduced costs without evident changes in length of stay or ventilation use. By targeting identified hotspots and combining education, protocol revision and ongoing information, the initiative achieved measurable reductions in plastic, paper and fluid use. While the single-centre design and focus on medications and single-use devices limit broader applicability, the findings highlight the potential for structured, unit-level interventions to address environmental impact alongside economic considerations in critical care.
Source: Intensive Care Medicine
Image Credit: iStock
