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Green nephrology

Improved waste management in the Dialysis Unit Queen Margaret Hospital, Dunfermline

By: NHS Fife

£35,718 (Estimated)

56.3 tonnes CO2e (Estimated)

This case study builds on the Reducing Waste in the Dialysis Unit Queen Margaret Hospital, Dunfermline case study from April 2010 (http://map.sustainablehealthcare.org.uk/nhs-fife/reducing-waste-dialysis...).

A Green Nurse role was established to promote awareness and education on environmental issues in the workplace and minimize landfill waste and inappropriate clinical waste. A waste management hierarchy was developed using the following in order of preference:

REDUCE – reduce the amount of waste produced in the first place (most favoured)

REUSE – using materials repeatedly where possible

RECYCLE – send used materials to make new material for use

RECOVERY – recover energy for waste

LANDFILL – safe disposal into landfill sites (least favoured)


STEP 1: Waste segregation

A major finding from Waste Watch Weeks in 2009-10 was a lack of formalised waste management procedures pre and post dialysis treatments. 2.9kg of waste was generated per dialysis treatment (40.3 tonnes / year). At the start of 2010, 100% of this was sent as clinical waste for incineration. This has a particularly detrimental impact on the environment because of the very high temperatures at which clinical waste must be incinerated. By April 2010 we had reduced this incinerated waste from 100% to 31%, with 69% now being directed into the domestic waste stream because it was not contaminated eg packaging, bicarbonate bags etc.

STEP 2. Recycling

Next, a Domestic Waste Audit was carried out, which identified most of the waste was paper and plastic. We collaborated with Fife Council to divert as much of this as possible from landfill. Domestic waste bins ie black bags were removed from the clinical area and replaced with recycling bins and 83% of domestic waste is now recycled. Grade 7 plastic (saline bags and bicarbonate bags) still remain a challenge but we hope Fife Council will be able to take these soon. Education on environmental good practice is now included in our nurse education programme.


Financial Considerations

The creation of a ‘Green Nurse’ with protected time has been central to the success fo this project. Initial funding for this came via NHS Education for Scotland and the Scottish Renal Association. Fife Council provided recycling bins for free. Diverting clinical waste which is expensive to dispose of into the cheaper, domestic stream saved us £11,273 annually. Removing unnecessary consumables saved a further £24,900 annually. The cost for domestic waste disposal after recycling was £454.74 annually. Overall £35,718 annual saving.


Carbon Savings

Initially 72.5 tonnes CO2e was generated form the incineration of our clinical waste. Which was reduced to 22.5 tonnes CO2e a saving of 50 tonnes CO2e annually. After recycling, 4.7 tonnes of domestic waste was put into landfill. Assuming this was mostly grade 7 plastic, 14.8 tonnes CO2e would be generated by this (this is an over estimate as a proportion was kitchen waste). 23 tonnes of paper and plastic was recycled saving 21.1 tonnes CO2e giving an overall annual saving of 56.3 tonnes CO2e


Queen Margaret Hospital, Whitefield Road, Dunfermline, Fife, KY12 0SU

The aim of the project was to promote awareness of environmental good practice by staff and reduce cost and carbon emissions with minimal impact on patient care.


(staff time: approx 4 hours per week from a dialysis nurse is spent on environmental awareness and practice.)

Staff engagement

Anyone wishing to change established staff working patterns can meet resistance. By getting support from senior staff early on and engaging with staff carrying out these changes or affected by them early we found this was easily overcome. In general staff were much more enthusiastic to change practice based on environmental concerns compared to economic arguments alone.

Patient safety

There was no impact on patient safety since contaminated waste continues to be treated as clinical waste. 

Mary Thomson, Haemodialysis nurse, maryathome@aol.com

Bolus Administration of Intravenous Antibiotics

By: NHS Fife

In addition to the cost and carbon savings, benefits were gained by reducing the volume of fluid administered in the context of renal failure, more efficient use of nursing time and increased nurse-patient contact and IV cannula observation. Also time was not wasted locating infusion pump devices and the ward was quieter without bleeping pumps.

£17,060 (Estimated)

6.73 tonnes CO2e (Estimated)

Queen Margaret Hospital (QMH)  has 24 in-patient beds, 20 dialysis stations and serves a population of 350,000. Prior to the end of 2010 all intravenous (IV) antibiotics were given by infusion even where bolus could be safely used. This used a great deal of plastic. Additionally semi-prepared ‘mini-bags’ (designed for use in the community) were being used for convenience which was unnecessary.

To determine if savings were possible a retrospective analysis of antibiotic use, cost and carbon emissions was performed based on pharmacy records over a one-year period (October 2009–September 2010). Savings were then calculated assuming a similar pattern of antibiotic use, price and nursing staff time, but assuming infusion is replaced by bolus administration. 13 antibiotics were identified as suitable for bolus administration after pharmacy review. Antibiotics requiring infusion were excluded from the analysis leaving a total of 6,175 doses infused. The financial and carbon saving (below) were large and steps were taken to change practice. Staff were educated to deliver drugs safely by bolus and a suitable preparation area was identified. Practice was changed from the beginning of 2011 with audit planned. This has been easily adopted by staff and there have been no safety concerns to date but maintining practice has been challenging.


The NHS has an increasing chronic care burden and must conform to the NHS carbon reduction strategy in a time of relative funding reduction. Procurement forms a significant component of the NHS budget and 60% of the NHS carbon footprint. This rises to 72% for renal services where equipment and pharmaceutical use is high. Reducing procurement emissions is a ‘quick win’ and systematic analysis of clinical processes can identify non-essential consumables and provide opportunities to lean treatment pathways that will deliver both cost and carbon savings.

Financial Considerations

This project incurred no additional cost to the NHS being funded entirely by staff enthusiasm where extra work was required. All training could be provided ‘in-house’.

Excluding drug costs, infusion via an infusion pump cost £1.96 per administration (pump administration set, £1.38; 50-100mls sodium chloride or dextrose bag, £0.35; 20ml syringe, £0.09; 21G needle x2, £0.04; Alcowipes x2, £0.01) verses £0.22 for bolus administration (10ml syringe, £0.12; 10ml sodium chloride, £0.045; 21G needle x2, £0.04; Alcowipes x2, £0.01). The total cost, including ‘mini-bags’ was £11,158. Assuming identical antibiotic use the predicted annual cost saving was £9,830 (88.1%). Savings from reduced disposal (0.41 tonnes equipment waste saved) by incineration are estimated at £165 annually (assuming a cost of £400 per tonne) bringing the total saving to £9,995 per year. In addition to consumables, further annual drug cost savings of £7065.33 were made by purchasing vials for bolus administration rather than pre-prepared mini-bags for infusion bringing the overall total saving to £17,060 annually.

Carbon Savings

Supply chain emissions saved (manufacture, transport etc):

  • Equipment: £9830 x 0.30 kg CO2e / £ * = 2949 kg CO2e
  • Drug: £7065 x 0.43 kg CO2e / £ * = 3038 kg CO2e

Emissions saved from avoided incineration of plastic waste:

  • 0.406 tonnes plastic x 1833 kg CO2e / tonne ** = 744 kg CO2e

Total emissions saved, per year: 

  • 2949 + 3038 + 744 = 10,020 kg CO2e, or 6.73 tonnes CO2e

* Greenhouse gas (GHG) conversion factors for supply chain were obtained from the 2012 Guidelines to Defra / DECC's GHG Conversion Factors for Company Reporting (Annex 13).

** Greenhouse gas (GHG) conversion factors for waste incineration were obtained from the 2011 Guidelines to Defra / DECC's GHG Conversion Factors for Company Reporting (Table 9d).



  1. Ascertain current practice by auditing antibiotic use and administration methods on the ward – are you missing opportunities to reduce infusions?
  2. Involve senior nursing, medical and pharmacy staff early on.
  3. Patient safety is the first priority – confirm drugs which can safely be given by bolus and how this is done. Set out clear procudures that can be easily accessed in the preperation area.
  4. Identify an areas for bolus preparation if not already in existence.
  5. Listen to staff concerns and address these through education and training as needed.
  6. Ensure adequate numbers of trained staff are on the ward so that drugs can be administered as boluses on every shift.
  7. Set a start date which everyone is aware of.
  8. Measure the outcome by audit and staff feedback.


Further tips

Savings could be amplified if IV bolus administration was adopted as standard practice across NHS specialties and for all IV drugs suitable for this route of administration.

Queen Margaret Hospital, Whitefield Road, Dunfermline, Fife, KY12 0SU


A suitable area on the ward is required to prepare drugs. If not already in existence most wards have an area that can be adapted. Staff attitudes are important especially when asked to do something new. Reassurance that adequate education and support will be provided is vital.

Staff had concerns over safety and time. It was found to take a similar amount of time to prepare and administer a bolus as compaered to locate, line, start and then dismantle the pump and giving set. Comprehensive staff training allayed safety fears.

Patient Safety

The main concern is from incorrect drug administration and this risk is reduced by appropriate training, support and review.

Mary Thomson, Dialysis Nurse, maryathome@aol.com

Central Delivery of Acid for Haemodialysis

By: Bradford Teaching Hospitals NHS Foundation Trust

Reduced acid wastage: only the actual acid required for any given treatment is ever used. Reduced solid waste: in 2008, 29,540 used canisters were disposed of as clinical waste. Saving on storage space and manual handling by nurses and porters: it is no longer necessary to transport 90 full canisters from ground- to first floor every day. Resilience to disruption of supply: the unit now has 3 weeks’ supply of solution at any one time.

£22,900 (Actual)

16.03 tonnes CO2e per year (Estimated)

The dialysis unit was previously supplied with 6 litre plastic cans of dialysate acid solution through weekly orders. These were delivered on pallets and could not be stacked to save on storage space. 

The Problem:

1. Acid Wastage

As dialysis patients are prescribed different flow rates (either 800ml/min or 500ml/min) there is generally always an element of acid wastage. More so is this seen with patients on a 500ml/min dialysate flow with approximately 2.14 litres not used out of the 6 litre can per treatment. Throughout one year this equated to a total wastage to drain of 50,142 litres. When considering the total order for St Lukes was 147,700 litres for 2008, this amounted to a high percentage of waste. 

2. Waste Disposal:

Empty canisters weighed approx. 143 grams and were disposed of via the clinical waste stream at a cost of £500 per ton. This amounted to an annual cost of approximately £2,363 per year.


The Solution:

In 2009, the renal technicians proposed a move to central acid delivery. This is acid delivered to a dialysis unit in bulk load through fortnightly/monthly deliveries and pumped into holding tanks (delivery frequency depends on the size of holding tanks installed). This acid is then distributed to all dialysis machines via a piped loop system with outlets at each dialysis station. They noted that all the dialysis machines in use had the capability to be retrofitted with central delivery acid systems at minimal expense. 

The new two-acid, two-loop system was installed in 2011, at a cost of £40,000.  This comprises a 7000 litre storage tank for the main acid solution, a 4000 litre tank for the low calcium solution, and a pressurised loop to deliver the acid to the dialysis machines. The Trust also paid an additional £3,900 for enabling works – a bund system connected to an outside drain, in case of leakage.


Benefits to the environmental sustainability of kidney care (section updated November 2012)

1. Reduced Acid Wastage

Using 6 litre cannisters, the average acid wastage per dialysis session for a patient on a 500ml/min flow rate was 2.14 litres. Throughout one year this equated to a total wastage to drain of 50,142 litres.

At £0.38/ litre, the predicted savings were £19,054 exc. VAT per year.  Actual savings achieved were £19,372 per year.

Multiplying this cost saving by the emissions factor for pharmaceuticals (2012 Guidelines to Defra / DECC's GHG Conversion Factors for Company Reporting, Annex 13) produces an estimate of carbon savings from avoided supply chain activities: 0.43 x 19,372 = 8,330 kg CO2e per year

2. Reduction in packaging waste

29540 empty canisters were previously disposed of per year (in 2008), each weighing 142.6 grams, amounting to 4.2 tonnes of plastic waste per year. The carbon savings from avoiding disposal of this waste via the clinical waste stream can be estimated at

4.2 x 1,833 (life-cycle GHG emissions factor for incineration)* = 7,699 kg CO2e

* DEFRA emissions factors for incineration do not specifically account for clinical waste, which is commonly undertaken at higher temperatures. To reflect the increased emissions that are likely to result from the incineration of clinical waste, the highest available emissions factor for incineration was applied (Table 9d, 2011 Guidelines to Defra / DECC's GHG Conversion Factors for Company Reporting)

[Combined savings = 16.03 tonnes CO2e per year]


Financial appraisal

Investment: £40,000 for storage tanks and piping; £3,900 for enabling works. Total: £43,900.

Actual savings: £19,372 per year from reduced acid wastage; £3,700 from reduced waste disposal.  Total: £23,072 per year.

Return on investment at 5 years: 

((Total saving to date - total cost to date) / (total cost to date)) * 100

((£23,072 * 5 - £43,900)/£43,900) * 100 = 163%

Renal Dialysis Unit, St Luke's Hospital, Bradford

To reduce acid wastage, packaging and money

Support from the Bradford Green Nephrology Local Representative, Dr John Stoves (consultant nephrologist)


Report published in the Trust newsletter ("Trust Today" March 2011, p8).  Green Nephrology Awards 2012 - award entry poster available to download from http://sustainablehealthcare.org.uk/green-nephrology/resources/2012/09/green-nephrology-award-entries-2012-posters-d


Storage space: the tanks are large and heavy.  We were fortunate to find suitable storage space by relocating the stores of peritoneal dialysis fluid.  There were no concerns about the capacity of the floor to withstand the load since it was a basement floor made from reinforced concrete.  A bund was created to contain any potential leakage, connected to an outside drain. 

Maintenance: there is no need to clean the tanks since the acid is sterile and is not open to the air (therefore no risk of crystallisation). The loop is also sterile, but is purged once per year as a precaution.  An initial low pressure leak (dribble) from the loop was fixed in-house with no need to disconnect the patients from dialysis machines.

Investment costs: these were covered from the capital replacement budget, with 20% of savings returning to the renal department under the Trust's Cost Improvement Programme.  The involvement of the procurement team was important to obtaining the best price for the acid system, since quoted prices varied from £40,000 to over £100,000.

Andrew Owen, Chief Renal Technologist, Andrew.Owen@bthft.nhs.uk

Waste Management in the Renal Dialysis Unit - Case Study & How-to Guide

By: NHS Greater Glasgow and Clyde

£15,567 (Estimated)

85 tonnes CO2e (Estimated)

Within NHS Greater Glasgow and Clyde (GGC) 505 people attend our chronic hospital haemodialysis programme equating to 78,780 resource intensive treatments per year in six renal dialysis units (RDUs).  We targetted clinical waste and unnecessary consumable equipment use as a simple and efficient method of reducing green house gas emissions (GHG) without impacting on the number or quality of dialysis treatments. Our health board already has off-site recycling of nearly 100% it’s domestic waste, so unlike many units we do not need to recycle at source. We focused on diverting wasteaway from expensive incineration and into the domestic waste stream for recycling. Environmental representatives for each of the units were asked to audit current equipment use per dialysis session for both fistula and line users and indentify possible areas of environmental saving in their unit. We then met as a group including senior nursing and medical representatives to agree which changes to make.

Areas of change identified included: Disposal of bicarbonate cartridges into domestic waste, segregation of domestic waste into black bags versus all waste into clinical waste bags as was prior practice, potential for reduction of Griff Bins® and online priming to reduce Saline bags.


The NHS generates 25% of the UK’s public sector GHGs. Legislation now requires drastic cuts in NHS emissions of 80% by 2050. While GHG emissions from procurement including waste, account for 52% of the NHS Scotland total, in renal services, where consumable equipment use is high, this rises to 72% with waste comprising 9.6% and medical equipment 25% of overall emissions. For frequent treatments such as haemodialysis, small environmental and cost savings per treatment can translate into much larger savings overall.


Intended benefits

Benefits to patients:

Dialysis patients are not only more susceptible to climate change (CC) effects such as heat waves and transport disruption, but they rely on the continued supply of drugs and disposable equipment. Reducing GHG emissions now will mitigate the effects of CC and reduce the financial burden associated with renal dialysis allowing redirection of funds into other areas of patient care including the predicted expansion of renal dialysis within our region.

Benefits to staff:

The use of a network of ground level representatives promotes good environmental practice at work and also engages staff in implementing change through quantifying savings directly attributable to their actions.

Benefits to the organisation:

In addition to cost and environmental savings for renal services, this project will contribute to institutional change by promoting lower carbon care on six acute hospital sites. Translating corporate environmental policies into operational practice remains a challenge for the NHS. The approach of using operational level networks of representatives to maintain and promote good environmental practice will generate lasting change and can be adapted to other high resource areas within NHS GGC such as theatres, ITUs and day case procedure areas with large potential savings.


Possible disadvantages 

Any potential effects on health and safety, infection control and porter services should be considered and discussed with the relevant departments as needed. No significant problems identified to date, although there is some resistance to getting rid of Griff Bins. Currently this is getting taken up at higher management levels to try and resolve. 


What barriers might be encountered when introducing a waste management programme?

All staff contacted were enthusiastic and keen to be able to contribute to reducing GHG emissions. No doubt the challenge will be maintaining good environmental practice in the longer term. The presence of local represenatives in each unit will help to sustain this change together with an ongoing audit process.


Financial Considerations

These changes have been free to implement and have been funded entirely by the good nature and enthusiasm of NHS staff.


Cost and Carbon Savings

Approximately 85 tonnes CO2e and £15,567 annually can be saved across all six RDUs (NOT includine reduced expenditure on unnecessary equipment, such as saline bags). Additionally, five sites use 1.7kg polyethylene Griff Bins® rather than orange clinical waste bags. By reverting to standard clinical waste bags (approximately 14,000 bins saved), 43 tonnes CO2e and £92,832 could be saved annually (£84,000 from purchasing and £8,592 from incineration costs). These estimates do not include supply chain emissions, i.e. those generated from the manufacture and transport of the product to the RDU.

Method of CO2e calculation:

  1. The CO2e emission conversion factor for the incineration of clinical waste has been taken as 1.8 tonnes CO2e per tonne clinical waste * however higher conversion factors exist. These can double CO2e estimates.
  2. The CO2e does not include domestic waste figures, which does increase in weight, due to uncertainty surrounding an appropriate conversion factor in our case. NHS GGC has an exemplary domestic waste policy with the majority of waste recycled. So it may represent a net CO2e saving, however further information is required before this calculation can be included.

* Reference: The Carbon Footprint of a Renal Service in the United Kingdom. Connor A, Lillywhite R, Cooke MW. Quarterly Journal of Medicine Advance Access published online on August 18, 2010 


Major Risks

Patient Safety

Only non-contaminated waste was diverted into the domestic waste stream so there was no adverse impact on patient safety.


Financial Risks

None identified.




  1. Set up the working group:
    1. Identify waste management representatives from each RDU to promote, sustain and develop an efficient waste management system as part of a coordinated waste management project within NHSGGC renal services.
    2. Engage senior stakeholders to support the project including senior nursing and medical staff, Renal Services management team, the Education and Practice Development Nurse for Renal Services, the Estates department and the Sustainability Officer for NHS GGC.
    3. Adapt for your area eg Glasgow already recycles all domestic waste off site, so no need to waste time and money doing this again.
  2. Focus on “quick wins” to reduce clinical waste by diverting it into the domestic waste stream:
    1. Use the Green Nephrology Programme as a model of good environmental practice and existing models of a successful waste management eg Queen Margaret Renal Unit, Fife, £36k annually and received 3rd place in the Innovation in Renal Medicine Awards 2011.
    2. Audit current patterns of consumable equipment use and disposal.
    3. Identify safe opportunities for reducing clinical waste (uncontaminated material does not need to be incinerated via the clinical waste stream).
    4. Identify equipment that could be safely removed from the dialysis process.
    5. Estimate potential financial and GHG emission savings, expressed as carbon dioxide equivalents (CO2e), by weighing clinical and domestic waste from two dialysis sessions (using AV fistula and catheter methods) before and after planned waste reduction and estimating the change in weight overall and emission factor. (Additionally, where unnecessary use of equipment has been discontinued, savings in supply chain emissions may be roughly estimated by multiplying avoided expenditure by the DECC GHG conversion factor* for the medical equipment industry.) *see “The 2009 Guidelines to Defra / DECC's GHG Conversion Factors for Company Reporting, Annex 13
  3. Consider potential health and safety or infection control issues identified and raise these with these departments as appropriate.
  4. Implement change and determine the actual cost and environmental savings by auditing total daily waste produced over a period of time before and after waste reduction.
  5. Repeat the audit after six months to ensure change is maintained.
  6. Consider extending to inpatient dialysis treatments.
  7. Look for additional opportunities such as reducing clinical waste for inpatient biopsy or central line procedures.

Further tips

Think of everyone who may be affected by your changes outside your unit eg Hospital Porters if you are changing the type or amount of waste for removal. Talk to these groups first to avoid problems later.



Pamela Sinclair pamela.sinclair@ggc.scot.nhs.uk

Tara Collidge tara.collidge@nhs.net


Project located across all six renal units in NHS Greater Glasgow and Clyde

Support received via the Green Nephrology Network:  http://sustainablehealthcare.org.uk/green-nephrology

Tara Collidge, Consultant Renal Physician, tara.collidge@nhs.net

Upgrade of Water Treatment Systems in the Dialysis Unit

By: Bradford Teaching Hospitals NHS Foundation Trust

Additional capacity for water treatment in case of unit expansion or plant failure; nursing time no longer required for heat disinfection; reduced maintenance costs

£18,000 (Actual)

8.42 tonnes CO2e (Estimated)

The St Lukes dialysis unit has gone through many expansions since its opening in 1994. Following the 2007 expansion, technicians noted that although there were now four water treatment systems, only the two installed from post 2002 had a ‘water saving’ feature, while the original water plants wasted approximately 70% more reject water to drain. 

In November 2009, with support from their Green Nephrology Local Representative, Dr John Stoves, the renal technicians submitted a proposal to the Trust Board, recommending upgrade of the two older water treatment plants. For a capital outlay of £60,000, they estimated that the upgrade could deliver a yearly saving of £20,000 on water supply and sewerage.

The project brought together the renal team with the Trust Patient Service Manager, the Deputy Director and Director of Estates, the Director of Finance, and the Procurement Department. A business case was developed and a budget of £60,000 was agreed from the capital replacement fund.  Following a five-month procurement process, the new plants were installed in January/February 2011. A straight replacement with Gambro systems was chosen to maintain standardisation and simplify maintenance.

Environmental & Financial Benefits (section updated November 2012) 

The new systems are saving 8 million litres of water per year, a carbon saving of 8.42 tonnes CO2e* and cost saving £18,000 from avoided water supply and sewerage.  Under the Trust’s Cost Improvement Programme, 20% of the savings are returned to the renal department budget.

* Calculated using conversion factors for water supply and water treatment, taken from the 2012 Guidelines to Defra / DECC's GHG Conversion Factors for Company Reporting (Annex 9, Table 9a): 344 kg CO2e / million litres (water supply) and 709 kg CO2e / million litres (water treatment)

Additional Benefits

Future proofing: The updated systems allow greater water flow to the dialysis unit, therefore allowing for future expansions of the unit, and providing further ‘redundancy’ in case of water treatment system breakdowns.

Heat disinfections: as the newer systems are able to automatically heat disinfect, it is no longer necessary for two nurses have to stay behind after everyone else has finished to switch the water system in to heat disinfection.

Maintenance: costs have been further reduced as the renal technicians can now carry out maintenance in-house.

Renal Dialysis Unit, St Luke's Hospital, Bradford

To reduce water wastage and save money

Support from the Bradford Green Nephrology Local Representative, Dr John Stoves (consultant nephrologist)


Report published in the Trust newsletter ("Trust Today" March 2011, p8)


To avoid the risk of interrupting water supply to the dialysis unit, a phased introduction was arranged for the two replacement plants, over a two-week period.  Water for dialysis was supplied via a temporary loop for a week while the new system was calibrated.  It was helpful that the supplier was the same as that used for the existing plants, facilitating seamless installation.

Close involvement of the renal technicians throughout (from development of the original proposal, to procurement and installation of the system) has been important to the project’s success.  Without their expertise, it can be easy for technical specifications to slip, for example in tendering documents.  Support from a consultant nephrologist was also crucial to gaining support from the Trust Board and from the other departments.

Andrew Owen, Chief Renal Technologist, Andrew.Owen@bthft.nhs.uk

Recycling reject water from the dialysis unit

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By: East and North Hertfordshire NHS Trust

Water saving: 3,145,000 litres / year

£6,300 (Actual)

3.3 tonnes CO2e (Actual)

Waste (concentrate) water from the reverse osmosis (RO) unit at the Renal department is now recycled into the main soft water storage break tanks - these are very large tanks and serve our hot water requirements for the main hospital site. The calculated water saving is 3,145 M3/Year or 3,145,000 L/Year - cash saving of £6,300 p.a. - this consumption has been closely monitored since the installation and it can be verified as achieving this reduction on the subsequent water bills.

The installation costs to recycle the RO water (break tank, pumps & pipe-work etc) was in the region of £6k so that the pay back for this scheme was less than 12 months.

Carbon calculations

3.145 million litres diverted from sewerage annually and, through re-use, avoiding the need for supply of the same volume of mains water.

3.145 x 709 kg CO2e / million litres (water treatment)* + 3.145 x 344 kg CO2e / million litres (water supply)* = 3311 kg CO2e per year

Conversion factors taken from2012 Guidelines to Defra / DECC's GHG Conversion Factors for Company Reporting (Annex 9, Table 9a)

Renal Unit, Lister Hospital

Cost savings, reduce water wastage

A meeting with Veolia water (now Affinity Water) in the summer of 2010 agreed to share the cost to get in consultants to look at a water efficiency review at Lister hospital.  The Water Efficiency Review Report picked up on the opportunities for RO water recycling and identified the water savings/pay back and budget cost of installation which was carried out by the Trust shortly afterwards.


Infection risk

The water is recovered from the RO water purification system, upstream of the supply to dialysis machines.  The system is supplied with mains water (drinking water quality), which it further purifies (softens) to produce ultra-pure water for haemodialysis.  Although the waste water is uncontaminated, we considered any possible infection risk from diverting/storing it.  We spoke in detail to our legionella water consultants - and we looked at the dilution rates and took a pragmatic view that it was safe to divert the water to the main hot water supply after considering the facts that: 

  • Our mains cold water supplying our site is disinfected using CL02 (carried out by the Trust) 
  • Our soft water is disinfected with CL02 (the Trusts secondary CL02 plant) 
  • The hot water is distributed @ >65 deg C (thermal disinfection)
Robert Jones, Property Services Manager, robert.jones@nhs.net

Implementing an Automatic Switch-off Policy for the Renal Unit Computers

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By: NHS Lanarkshire

The primary benefit of this initiative is that we save needless waste of money but also allow more timely installation of software installs that require system reboot such as antivirus software.

£724 (Estimated)

5486 kg CO2e (Estimated)

Problem – several members of staff routinely left their PCs switched on continuously. This is clearly a waste of electricity but also prevents regular IT updates e.g. anti-viral software.

Although automatic switch off software is available e.g. “nightwatchman” this has a financial cost and as yet there are no definite plans by the Trust IM&T department to introduce these types of software solution.

We decided to get our renal unit IT administrator to write a script that would be pushed out onto all the PCs within the renal unit.  The script is only a few lines of code, which was then installed onto each PC remotely, together with a scheduled job for each PC. The whole process took under 60 minutes to set up.  In the process, two new plans were created.  The first plan was that all Renal PCs/laptops, with the exception of the nurse's station PC and Duty Room PC were shutdown at 10PM each night, if left on.

The second plan was the creation of a new power option scheme called Renal, which operates throughout the working day and affects all Renal PCs and laptops. 

This new scheme conserves power by switching off the monitor after 30 minutes of inactivity.  After an additional 15 minutes (ie 45 mins) of inactivity the disk(s) will turn off.  Finally, after a further 15 mins (ie 60 mins) of inactivity, the machine will go into standby mode.  To restore power in the first two instances, the user simply taps any key on the keyboard to restore the desktop to it previous state.  If and when the machine is in standby mode (blinking power button), the user presses the power button as if you were switching the machine on.  The desktop is then restored to its previous state.

If the new power scheme activates at any time, none of the logged on user’s work is lost.

The response by our staff has been positive although many members seem to be/are unaware.

At the moment this has only been implemented within the renal unit. The Trust IM&T department are aware of our project however but at present are pursuing proprietary software solutions.


Financial Appraisal

Our hospital currently pays a favourable rate for electricity of 7.8p per KWh. For the purposes of our calculation we have assumed that ALL PCs get switched off at 10PM and get switched back on by staff at 8AM. We have also compared this to having ALL the PCs switched on constantly. The reality will be slightly different as not all PCs were being left switched on overnight. However, not all PCs are being switched back on at 8AM and in the absence of accurate usage data for each PC the calculations below should provide a reasonable estimate of savings.

Using Dell's energy savings calculator (http://www.dell.com/content/topics/topic.aspx/global/products/landing/en/client-energy-calculator?c=us&l=en&s=gen/) the energy costs are as follows:

32 desktop PCs running 24 x 7 consume 22038 KWh annually with annual costs of £1719

32 desktop PCs running 14 x 7 consume 14090 KWh annually with annual costs of £1100

Savings 7948 kWh, £619 annually


16 x laptops running 24 x 7 consume 3916 KWh annually with annual costs of £305

16 x laptops running 14 x 7 consume 2563 KWh annually with annual costs of £200

Savings 1353 kWh, £105 annually


In summary, the above small changes are saving 9301 kWh and £724 annually for no outlay.


Carbon savings

9301 kWh x  0.58982* = 5486 kg CO2e savings per year

(*conversion factor for UK Grid Electricity, taken from Table 6, 2011 Guidelines to Defra / DECC‘s GHG Conversion Factors for Company Reporting:  Methodology Paper for Emission Factors)

Monklands Renal Unit, Airdrie, Lanarkshire

Cost and carbon savings

"Script" developed in-house by the renal IT administrators.

There are no real disadvantages of this system. No-one has complained or noticed with the exception of one person who acknowledged that fact that the PC switched itself off at 10pm was a useful reminder that she was working far too late. Feedback from people in other renal units is that they leave their PCs switched on overnight on purpose as it takes too long to boot up in the morning. We have had no such feedback from within our unit but this might be relevant to other units wishing to implement a similar solution.

We have been fortunate that our renal unit is fairly small and mostly contained on a single site. The other crucial factor for us is that we have our own dedicated IT administrator (paid from renal unit) who has administrator level of control over all PCs within the department.  Although the ‘script’ he has written is very simple it takes someone who knows what they are doing to execute it. However, there is no reason why this solution could not be extended to the rest of the Trust by IM&T.

Most people have not noticed and as we warned people in advance no-one has complained. Only one person has commented that her work laptop switched itself off at home at 10pm and it took her a while to realise why.

Dr Jamie Traynor, Consultant Renal Physician, Jamie.Traynor@lanarkshire.scot.nhs.uk

Electronic Consultation as an Alternative to Hospital Referral for Patients with Chronic Kidney Disease

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By: Bradford Teaching Hospitals NHS Foundation Trust

convenience, avoidance of unnecessary referrals, increased GP confidence in managing chronic kidney disease in the community, facilitating prompt and informative decisionmaking by the nephrologist, releasing resources in the specialist unit, saving transport and resource costs

40kg CO2e per outpatient visit avoided (Estimated)

Over 90% of the primary care practices in the Bradford and Airedale PCT use a centralised IT system (SystmOne®), allowing detailed electronic health records to be shared by groups of healthcare professionals in various care settings.

The rising prevalence of recognised CKD prompted a multidisciplinary review of local renal service provision and a programme of work to strengthen communication at the interface between primary and secondary care.

Strategy for Change

  • Development of a CKD e-consultation service in SystmOne®, allowing GPs to send electronic referrals and share patient electronic health records with a renal specialist after first obtaining verbal patient consent.
  • Participating GPs attended education events and received paper and electronic guidance about the new service. It was explained that the service should be used to obtain advice for specific queries and to request virtual review of patients with an indication for hospital clinic referral that was ‘borderline’ according to local criteria.
  • GPs use criteria agreed in local guidelines to ‘request advice’ or ‘question the need for hospital clinic review.
  • The renal specialist is able to open the electronic health record and view important clinical details such as patient comorbidities, medication history, lifestyle factors, previous communications from other specialists, reports of previous imaging and a chronological display of selected numerical data (BP, estimated glomerular filtration rate, blood biochemistry and urinalysis).
  • A decision is then made as to whether a patient should be referred to clinic, undergo tests or interventions in the primary care setting, or continue to be monitored and treated by the primary care team.
  • Responses are saved in the patient’s electronic health record and also sent as tasks to alert the referring primary care team.

A single practice pilot of e-consultation indicated potential benefits, with better coordination of patient management and avoidance of clinic referrals. We therefore introduced e-consultation to 17 volunteer implementation practices in July 2007,supported by two nephrologists.

Effects of Change

  • E-consultation was regarded by GPs and patients alike as a convenient service that provided timely and helpful advice and avoided unnecessary referral to the hospital clinic. GPs recognised that e-consultation presented an educational opportunity that increased their confidence in managing CKD in the community. Patients were generally willing to consent to the viewing of their electronic health record by a renal specialist.
  • For the nephrologist, e-consultation permitted a detailed and efficient review of a patient’s primary care electronic health record, facilitating prompt and informed decision-making. Patients in need of renal outpatient clinic assessment were readily identified, and others benefited from the provision of timely advice. Avoidance of unnecessary hospital clinic visits was seen as an effective way of releasing resources in the specialist unit for those patients who need them most, as well as saving on transport and other environmental costs. The NHS Sustainable Development Unit estimates that an outpatient visit generates a carbon footprint of approximately 40 kgCO2e (Carbon Dioxide Equivalent).
  • Between September 2007 and September 2008 11 out of 68 (16%) econsultations were finally referred to clinic, comparedto 376 out of the 398 (94%) paper referrals.


Primary Care Teams have greater responsibility for the management of chronic kidney disease

Bradford and Airedale Teaching Primary Care Trustand the Bradford Institute for Health Research

John Stoves, john.stoves@bradfordhospitals.nhs.uk

Improving Waste Disposal in a Nephrology Procedures Room

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By: University Hospitals of Leicester NHS Trust

Reduction in clinical waste send to incineration

Nephrology uses a large number of consumables and is likely to be responsible for a significant amount of the total NHS carbon footprint. We reviewed the waste disposal in our designated nephrology procedures room, using a 4 week audit, to illustrate how improvements can be made locally and hopefully kick-start more widespread change within the department and hospital as a whole.

  • For each week, the number of sharps bins, orange sacks and black sacks produced was recorded. As the amount of waste is directly proportional to the number of procedures performed, the number and type of each procedure performed per week was also documented.
  • During the first two weeks we recorded the amount of waste produced using the waste disposal mechanisms which have been in place for years as a control.
  • During the second two weeks, we added an extra bin into the procedures room to allow black sacks and orange sacks to be used simultaneously.


  • In the first two weeks, waste was only disposed of in either sharps bins or orange sacks.In weeks three and four, waste was divided separately into clinical and non-hazardous bags resulting in a much smaller number of sacks for incineration.
  • During the third and fourth weeks, 66% and 59% respectively, of the waste produced during the procedures, did not require incineration. Furthermore, the majority of the waste in the black sacks wasplastic packaging and could potentially be recycled.
  • The amount of incinerated waste fell dramatically to 33% and 41% (in the third and fourth weeks respectively) of the total waste produced.
  • The number of sharps containers used remained constant, at a rate of one large container per week.

There is also a correlation between the type of procedure performed and the amount of waste produced. Some procedures such as PD catheter insertion produce a greater amount of waste as more disposable sterile equipment is used. In Week 1, a total of 29 procedures were performed, one of which was a PD catheter insertion but the total number of sacks used was 6.5. In Week 3, a total of 10 procedures, including 3 PD catheter insertions, were performed, and 6 sacks in total were used. Therefore, although the overall number of procedures performed in weeks 3 and 4 were fewer than in the initial two weeks, the overall number of waste sacks produced was not significantly different.

The majority of waste in the black sacks was recycleable (although not precisely measured in this study) and therefore the next step locally must be to engage with the estates department and establish recycling for paper, card and plastics. This may also require collaborative pressure from other hospital departments to create the impetus for change within the Trust. At the same time there is a need for widespread acceptance and involvement with appropriate waste disposal to effect a real change in waste collection throughout all clinical areas within the nephrology department.

This small inexpensive intervention has dramatically reduced the amount of waste sent for incineration. In financial terms this is also resulting in savings as the average cost of disposing of incinerated waste is in the region of £400 per tonne comparedwith £80 per tonne to disposal of waste to landfill sites. We are now trying to get recycling facilities within the hospital to reduce thenumber of black sacks produced.

To become less wastefull to reduce the impact on the environment

Rachel Westacott, rachel.westacott@uhl-tr.nhs.uk

Reduce, Reuse, Recycle Paper

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By: Countess of Chester Hospital NHS Foundation Trust

A reduction in paper use by 75%

£139.36 (Estimated)

109 kg CO2e (Estimated)

Countess of Chester Hospital Dialysis Unit has tried to reduce the amount of paper used through a 'Reduce, Reuse and Recycle' Programme.


Results of Local Changes

  • Since paper copies of blood results have been stopped from Pathology it has been calculated we will save a minimum of 3344 sheets of paper per annum (projected).
  • All printers within the unit have been defaulted to print double sided by our IT team.
  • Patient paper care plans have been reduced from 14 pages to 6, a reduction of 51%.
  • Staff and patient education and encouragement to recycle successfully measured by the recycling pick up needing to increase from once every 2 weeks to twice per week.
  • Overall paper consumption reduced from approximately 10,000 sheets to 2,500 sheets every 8 weeks, a reduction of 75%. With forecasted financial benefits of paper costs from £187.20 to £47.84 per annum giving a saving of £139.36.

Carbon savings (section updated November 2012)

£139.36 x 0.78 kg CO2e * / £ = 109 kg CO2e

* emissions factor for supply of paper products, 2012 Guidelines to DEFRA/DECC Greenhouse Gas Conversion Factors for Company Reporting, Annex 13

How To Guide:


  • Stop all paper copies of blood results as located within the IT system.
  • Double side all printed documents.
  • Reduce paper care plan to essential information only.


  • Implement a scrap paper A5 file to be used , for example telephone call messages, to do lists food orders.
  • Any non confidential paper waste to be used for scrap paper.


  • Ensure recycling bins are located within the renal unit.
  • Patient education to encourage recycling of newspapers read on the unit.
  • Ensure all paper waste is deposited in the recycle bins provided within the unit.

The Countess of Chester Hospital, Liverpool Road, Chester, Cheshire, CH21UL

To reduce paper waste

Libby Critchley, elizabeth.critchley@coch.nhs.uk, 01244 365000 ext. 5705/4