Training design now carries environmental significance for intensive care education, where clinicians need continued skills development without unnecessary travel-related emissions. A 2026 analysis published in Intensive Care Medicine and conducted by the European Society of Intensive Care Medicine compares the carbon footprints of three intensive care training formats: virtual reality, online training and a hypothetical in-person alternative in Brussels. It uses data from 116 participants across 18 European countries in ESICM training programmes, estimating CO₂ emissions from travel distances, transport modes and standardised emission factors. The comparison places sustainability alongside the practical design of training delivery, with in-person attendance assessed against two digital models using the same intensive care curriculum. The results indicate markedly lower median emissions for both online and VR training than for physical attendance.
Three Training Models Compared
The training comparison draws on the VICTORIA programme, which assesses intensive care education through two implemented formats and one hypothetical physical attendance model. The online and VR formats cover identical content across five modules: Antimicrobial Stewardship, Haemodynamic Monitoring, Mechanical Ventilation in ARDS Patients, Renal Replacement Therapy and Veno-Venous Extracorporeal Membrane Oxygenation. The same subject-matter experts contributed to VR module development and facilitated online sessions, creating alignment across educational objectives while preserving different delivery formats. Participants came from European countries selected according to the structure of their intensive care training programmes, supporting diverse representation across the cohort.
The online format consists of a single eight-hour expert-led live session delivered on Zoom on 15 April 2024. The VR format supports asynchronous learning over a two-week period from 8 to 22 April 2024, with participants working independently and using a moderated online forum for questions and discussion. The hypothetical in-person format places all participants at the ESICM office in Brussels and includes return travel from each country of origin. Of 141 randomised participants, 67 were allocated to online conventional training and 74 to web-based self-paced VR training. The completed cohort comprises 57 participants in online training and 59 in VR training.
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How Emissions Were Calculated
Emissions modelling uses each participant’s residential and hospital locations to estimate the carbon footprint of training delivery. Distances to Brussels are calculated from geospatial coordinates and adjusted to better reflect real travel. Car journeys receive a correction for road routing, with higher adjustment for shorter trips and lower adjustment for journeys over 100 km. Flights and high-speed rail receive an adjustment for indirect routes. The calculations then apply standardised emission factors to each mode of transport and sum total CO₂-equivalent emissions per participant.
For VR training, emissions include six car travel legs between home and the local hospital across three days, covering the pre-test, use of VR resources and post-test. VR content production also adds emissions because 21 intensivists travelled to filming sites in Leuven, Ghent and Paris. Online training follows the same local hospital commuting model but does not add emissions for VR production, as it uses the same clinical cases and instructional material without VR. The Brussels in-person model includes home-to-airport travel, air travel, local ground transport to the training venue, return travel along the same route and two hotel nights. Belgian participants are assigned no air travel or hotel accommodation. Internet use is excluded because modelling server energy, data transmission and online booking activity would require uncertain allocation to the training activity.
Emission Reductions and Remaining Limits
Median predicted CO₂ emissions reach 429 kg per participant for hypothetical in-person training, with an interquartile range of 345–490 kg. By comparison, VR training reaches a median of 43 kg, with an interquartile range of 28–56 kg, while online training also reaches a median of 43 kg, with an interquartile range of 32–64 kg. Both digital formats produce significantly lower emissions than in-person training, while VR and online training show no significant difference between each other. The digital reductions remain consistent across countries, irrespective of geographic distance.
Geography shapes the size of the physical-attendance footprint. The overall median travel distance to Brussels is 1168 km, with an interquartile range of 781–1498 km. Belgium records the shortest median distance at 84 km, followed by France at 320 km and the United Kingdom at 400 km. Malta, Finland and Portugal have the longest travel distances. In the in-person model, Finland and Malta produce the highest median emissions, while Belgium and France produce the lowest. Online and VR education can reduce travel and accommodation burdens while preserving access and flexibility if educational effectiveness and feasibility remain intact. The Brussels attendance model remains hypothetical, emission factors use averages and the assessment does not cover all life cycle stages, including digital infrastructure, VR hardware production and disposal or the full energy demand of online resources.
For intensive care education, training design has a measurable environmental dimension. Online and VR delivery both show markedly lower predicted CO₂ emissions than a Brussels-based in-person format, with no meaningful emissions difference between the two digital options. Travel distance and accommodation largely explain the gap, while remaining methodological limits concern assumed routes, average emission factors and incomplete life cycle coverage. Digital education offers a practical route for reducing the carbon footprint of professional training, provided that access, feasibility and learning quality remain central to decisions about training delive
Source: Intensive Care Medicine
Image Credit: iStock
References:
Istrate GM, Van Gelder F, Szőllősi GJ et al. (2026) The environmental cost of learning: CO2 emission comparisons of virtual reality, online, and alternative distance education. Intensive Care Med. https://doi.org/10.1007/s00134-026-08460-z
