Mapping Greener HealthcareMapping Greener Healthcare

Team members: 

• Jemma Alison Hardy – Satellite Dialysis Unit Sister
• Peter Jones – Renal Technical Services Manager
• Terence Simpson – Renal Technologist
• Dr V R Latha Gullapudi - Consultant Nephrologist
• Dr Mark Wright- Consultant Nephrologist and Haemodialysis Lead 

Aims:

1. Reducing the number of disinfections of the dialysis machines to once in 24 hrs in staggered manner and replacing the others with rinsing process
2. Once the initial priming process of the dialysis machines is complete, placing them standby mode whilst waiting to connect patients to the machine
3. Reducing the number of pharmacy deliveries from weekly to biweekly to the satellite dialysis unit

Background:

Haemodialysis is lifesaving therapy for patients with kidney failure. However, it comes with huge environmental costs as it involves usage of vast amount of medical consumables, water, and electricity. It is estimated that 3.8 tonnes of carbon-dioxide equivalent emissions are produced by one patient’s dialysis treatment per year (1). In the unit under review, we provide services to our patients in two different shifts per day. This means that a single dialysis machine is routinely used for provision of two dialysis treatments in a 24 hour period. Dialysis machines are primed and turned on at the beginning of the day, meaning dialysis fluid runs continuously whilst waiting for the patients to be connected. Each dialysis machine gets three heat disinfections per day.

Methods:

We started by creating a process map of the steps from the production of dialysis fluid to use of dialysis machine to identify our aims as above. We discussed aims 1 and 2 with the other staff members on the unit during the daily handovers. The majority of staff were enthusiastic to try the suggested changes which supported embedding these changes into everyday routines. A similar approach was adopted for Aim 3 by seeking staff opinions, exploring the availability of storage space, rearranging storage cupboards to improve utilisation of the available space, and relabelling of the cupboards as per the new agreed storage arrangements.

Measurement:

Baseline data was collected on

• Aim 1: electricity and water usage with each episode of disinfection and rinse during 24 hour periods for one dialysis machine. We then projected the electricity and water use over one year.
• Aim 2: the average waiting times between the dialysis machined being primed and turned on, to when a patient was connected. We then measured the consumption of electricity, water and central acid usage during this waiting time per minute and projected it over a: one-year period. There is a scope for further savings from this change by reduced number of central acid deliveries, however it is not possible to precisely calculate at this stage.
• Aim 3: Reducing pharmacy deliveries from weekly to biweekly will lead to an average saving of 104 miles in transportation per year. We are liaising with the teams at the other satellite units within the Trust to investigate if the same change is feasible in their setting. This would yield higher milage savings. 

Results:

In total, changes implemented will save 1,914.4 kgCO2e and £2,837.05.

• electricity: 1,672.3kgCO2e and £1,285.90
• water: 41.8kgCO2e and £264.90
• travel (miles): 9.8kgCO2e and £58.24 
• acid savings: 190.3kgCO2e and £1,228.00

This satellite unit is a part of Leeds Haemodialysis services which currently provides care provision for 550 incentre dialysis patients in 8 different dialysis units. After taking into consideration of the shift patterns in each unit, if we implement aims 1 and 2  across our haemodialysis services, the estimated savings will be much higher, with 15,828kgCO2e and £33,435.33 saved per year. 

If the same small changes were possible for all 24,365 people receiving dialysis in the UK2 and energy consumption of all dialysis equipment was similar across the 70 renal centres in the UK, the national reduction in CO2 emissions could be in the region of 4,495kg per treatment session. If everyone was having dialysis thrice per week, that would reduce CO2 emissions by approximately 700 tonnes per year. Social sustainability and clinical outcomes: The proposed changes may not directly impact individual patient experience but may contribute to an improvement in the turnaround of the patients in the dialysis unit, for example from saving time by replacement of disinfection (40 minutes) with rinse (9 minutes) of the machine in between patients. The unit is planning to move from a 2 shift to 3 shift cycle. Our new system will support in reduce staff workload.

Steps taken to ensure lasting change and conclusion:

We were pleasantly surprised by how much we could reduce our central acid water and electricity consumptions with relatively simple changes. Meeting with colleagues regularly and tackling a different sort of problem to usual was really uplifting and motivating, especially when we realised how much potential benefit there would be when we roll out across the service. Our next steps are to spread this enthusiasm by sharing our project aims and finding at an upcoming departmental meeting, and to explore if the other satellite units would consider a reduction in their pharmacy deliveries.

We are continuing to explore options for additional projects

• Aim 4: Water wastage from the purification process and system was measured as 1,337,000 litres/ year. Across the service equates to approximately 16,848,000 L of water wasted per year (equivalent to 6 Olympic sized swimming pools). We are liaising with appropriate teams to enable redirection of this water to grey water systems of our healthcare setting. Significant progress has been made in one of our other satellite dialysis units and we are looking forward to continuing this work to maximise the benefit of water preservation.
• Aim 5: We use acid supplied in 6 litre plastic canisters and our standard practice is to use one canister for each patient/ treatment. The leftover acid goes down the drain systems. On measurement of the wastage of the acid, the cumulative wastage of acid comes down to 18.75 Litres over 10 dialysis treatments. We are currently exploring the feasibility of avoiding this wastage, by liaising with the infection control team regarding potential safety issues if we were to use a cannister for multiple patients.
• Aim 6: Currently we do not recycle the plastic acid canisters. We are in discussion with the hospital wastage management team regarding recycling potential of these canisters by using existing steri-melt facilities.

References:

1. Connor A, Lillywhite R, Cooke MW. The carbon footprints of home and in-center maintenance hemodialysis in the United Kingdom. Hemodial Int. 2011 Jan;15(1):39-51. doi: 10.1111/j.1542-4758.2010.00523.x. Epub 2011 Jan 14. PMID: 21231998.
2. UK Renal Registry (2021) 23rd Annual Report- data to 31/12/2019, Bristol, UK. Available from renal.org/audit-research/annual-report