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Green nephrology

Carbon Reduction at a Renal Unit through Sustainable Action Planning

By: Royal Cornwall Hospitals NHS Trust

Clear improvement in patient experience with 50% less waiting, fewer aborted journeys and more self-care, an improved workplace for staff with more time to look after patients and better attendance, a reduction in healthcare acquired infections.

£57,528 (Actual)

36.545 kg CO2e (Estimated)

Using a classic resource efficiency method the team at the Renal Unit during three two hour workshops quickly identified carbon reduction opportunities, prioritised them, and moved into action. Led by Renal Unit Manager Simeon Edwards the team took the action plan developed in these sessions and integrated it into the normal management of their unit for continues improvement. The carbon reduction actions are now regularly reviewed and updated as part of normal unit management.  Resource efficiency tools are used as needed to get to the root of issues, identify possible actions, and to manage change positively.

Actions

Simple actions were attempted first: 

  • Waste sandwiches were reduced from 35% to <5% by involving patients in establishing a new sandwich menu, improving choice and avoiding costs of £4,000.
  • After full consultation with patients, linen use was reduced by 70%.  Some patients preferred to bring their own blankets, and the unit stopped using white sheets for patient’s chairs.  Avoided costs £4,800 and quite a good carbon saving too.
  • Encouraged by this success the unit team decided to tackle aborted ambulance bookings, aiming for zero %.  The team worked with the ambulance service to synchronise treatment times.  Within a few months the cost of aborted journeys reduced from £1,500 a month to £400, giving annual savings running at £13,200. After two years it is ‘zero’.
  • To reduce stress in the workplace the team undertook an analysis of the balance between staff availability and the peaks and troughs of patient activity. This led to some rescheduling which released more time to care, leading on to best practice in infection control, and improved staff attendance.
  • A renal unit uses a considerable amount of disposable kit and pharmaceuticals.  Bicarbonate cartridges were changed leading to a reduction in both packaging and chemical.  Cost avoidance now running at £11,000 p.a.  Work is ongoing with manufacturers to reduce wastage of haemodialysis fluids. Dressing packs have been slimmed by a ‘lean’ analysis saving £800 p.a.  Renal disposables wastage of 5 dialysis sets per week has been reduced to zero by not setting up machines in advance.  This amounts to a saving of £13,000 p.a.  By changing direct delivery of renal lines to ‘Blue Diamond’ supplies, topped up from NHS stores Bridgewater, costs of £5,900 are being avoided.
  • Cardboard for recycling was reduced by 65% when Fresenius 5L containers were switched to pallet delivery, instead of 4 to a box – avoiding the waste in the first place.

Carbon Savings (section updated November 2012)

Cost avoidances have been used in conjunction with the 2012 Guidelines to Defra / DECC's GHG Conversion Factors for Company Reporting, Annex 13. This enables a CO2 equivalent figure to be readily derived from cost figures to give staff an approximate idea of what they are achieving in carbon terms.

Our action

Sic code

Category

Cost avoided p.a.

GHG

Total kg CO2eq per £

Kg CO2eq

Sandwiches

15

Food & drink products

£4,000

0.97

3,880

Bicarb cartridges

Dressing packs

Dialysis sets

Supply of renal lines

24.4

24.4

24.4

24.4

Pharmaceuticals

Pharmaceuticals

Pharmaceuticals

Pharmaceuticals

 

£11,000

£800

£13,000

£5,928

0.43

13,213

70% linen reduction

 

55

Hotels, catering, pubs etc

£4,800

0.59

2,352

Aborted ambulance journeys

602

Road transport

£18,000

0.95


17,100

 

TOTAL

 

 

 

£57,528

 

 

36,545

Royal Cornwall Hospital, Treliske, Truro, Cornwall, TR1 3LJ

To save resources

Workshops were facilitated by Eco-nomic Ltd

ongoing
Sustainable Action Planning (SAP), a resource efficiency toolkit - http://sap.sustainablehealthcare.org.uk

At the moment the costs which have been avoided cannot be reinvested into more carbon reductions in the Renal Unit.

Simeon Edwards, Renal Unit Manager, simeon.edwards@rcht.nhs.uk

Conserving Water in Haemodialysis - Case Study and How To Guide

By: Ashford & St Peter’s Hospital NHS Trust

4.492 million litres water saved per year, giving considerable savings on mains water and sewerage costs, environmental benefits as water is a finite resource, compliance with carbon targets

£10,558 (Actual)

750kg CO2 (Estimated)

Haemodialysis consumes vast quantities of water. Producing the 120 litres of dialysate required for a typical four hour session requires approximately 400 litres of mains water. Reverse osmosis is an important step in the purification process that this water undergoes. Reverse osmosis systems vary in efficiency, but commonly reject up to two thirds of the water presented to them. Termed ‘reject water’, this high grade grey water does not come into contact with the patient at any stage and poses no infection risk, yet it is needlessly ‘lost to drain’ in almost all dialysis facilities.

The satellite dialysis unit in Ashford incorporated a simple water recycling system into its new design. The salvaged reject water is directed to a recovery tank.. From there it is pumped to a grey water tank. which feeds the laundry room. Float switches divert reject water to the drain if the grey water tank becomes full, and diverter valves direct the reject water directly to the drain from the reverse osmosis system during monthly chemical disinfections.

The installation of the water recycling system was only £2,500, £1,300 for tank and control panel and £1,200 for piping. The piping was laid alongside other services required by the new build, so no cost was incurred for the groundwork.

Investment Appraisal

The return on investment will depend upon:

1.    The investment: the cost of installation & maintenance.

2.    The return: the savings on mains water and waste water.  This can be calculated by multiplying the regional mains water and waste water rates by the volume of reject water which the system is able to provide in place of mains water for an alternative use (e.g. laundry). It is useful to factor in projected price rises and changes in demand to gain a view of future potential savings.

In general, the return on investment is likely to be greater for a new-build unit, where the installation costs may be lower, and there is greater flexibility in arranging an appropriate alternative use for the salvaged water.

Environmental savings

The finite volume of water on the earth is constantly being recycled and purified. So we must use water wisely. A ‘carbon footprint’ does not therefore do full justice to the environmental benefits of water conservation. However, energy is also required to treat and move the water that we use, and conserving water therefore also saves energy and reduces the carbon footprint of the renal unit.

Accounting for the energy used to power the pump, the carbon savings at the Ashford unit are approximately 750 kg CO2 equivalents per year. This figure is reached by a two step calculation. Firstly, calculate the carbon savings made by recycling the reject water in place of mains water. To do this, apply a mains water life-cycle conversion factor (available from, for example, the DEFRA website) to the volume of water saved per year. Secondly, subtract from this the carbon cost of any electricity required to pump the water to its place of use over the course of a year (this second step requires you to know the power of the pump, the duration of its use during the year, and a conversion factor for electricity to carbon consumption).

Carbon savings (kg CO2e/year)

=

[Volume water saved in one year (L)  x  mains water carbon conversion factor (kgCO2e/L)], e.g. DEFRA

-

[electricity used for pumping per year (kWh)  x carbon conversion factor (kgCO2e/KWh)]

 

How to Guide - Getting Started

1. Discuss the idea with your Renal Technician. They will play a vital role in any water conservation project, understanding the local set-up better than anyone else.

2. Involve your local Estates department.  The support and advice of the hospital Estates department is also vital. Their engagement may require the presentation of a sound business case. In most cases, it will be the Estates department that benefit financially from the methodology.

3. Clarify the scenario.  Will the methodology be implemented into the design of a ‘new build’ dialysis unit, at the time of replacing the RO system in an existing dialysis unit, or perhaps alongside an existing and satisfactory RO system already in place in a dialysis unit? These different scenarios will influence the total costs involved, but the return on investment may still make the project worthwhile.

4. Clarify the potential volume of reject water that will be salvaged each year.

In order to maximise the financial and environmental benefits of the project, it is important to match the volume of reject water available to an alternative use that requires a similar volume. Many reverse osmosis systems record the volume of reject water produced, but this can be ascertained with a simple flow meter if necessary. It should be remembered that, where reverse osmosis systems are being replaced, the newer system is likely to be more efficient and produce less reject water.

5. Assess the quality of the reject water to be salvaged.  The precise quality of the reject water produced will vary from region to region. Whilst it will almost always meet the requirements for its intended use, it is vital that this is assured prior to proceeding further. Your renal technician will be well versed in checking the water quality.

6. Given the volume and quality of the reject water available, now identify the intended use for this water.  Possibilities include: sanitation, laundry, boiler feed, sterilisation units and irrigation – on site or supplied to a neighbouring facility. Practical considerations are important. For example, salvaged reject water can only be used in laundry services if the plumbing required is feasible and affordable.

7. Calculate the financial cost per year of the current practice of supplying mains water for this intended use.  This will require knowledge of the mains water rates for your hospital, information which the Estates department can provide.

8. Calculate the financial savings resulting from the reduction in waste water from the haemodialysis unit. This will require knowledge of the waste-water rates for your hospital. Remember that some reject water may still be lost to drain if it exceeds the demand/capacity of the salvage system, and during disinfection cycles.

9. Calculate the initial total financial expenditure incurred in implementing the methodology (including the infrastructure required to transport the reject water to the place of use). Costs may include: storage tanks, pipework, pumps and installation costs.  Maintenance costs are likely to be small.

10. From these figures, develop a repayment projection and calculate the breakeven point (the point in time by which the savings - due to reduced mains water and reduced losses-to-drain - might be anticipated to have recouped the investment costs of the methodology, and from whence the use of reject water for the new purpose realises potential savings).

11. Convince your Trust to fund the work. Whilst this will certainly require the support of your Estates department, it may also require the approval of the Director of Finance. It is also worth applying for funding from Salix Finance, an organisation set up by the Carbon Trust to deliver interest free funding to accelerate investment in energy efficiency technologies within the UK public sector. Their website is http://www.salixfinance.co.uk/home.html

12. System maintenance should become part of routine estates plant room inspections - a simple check function tick list is sufficient. Water storage tanks will require cleaning in line with Trust protocols for other tanks in the hospital.

Ashford Hospital, London Road, Ashford, Middlesex, TW15 3AA

Conserving water

01/01/2007
completed
£2,500
Steve Milne, Renal Technical Manager, steve.milne@ekht.nhs.uk

Retro-fit of Heat Exchangers to Haemodialysis Machines - Case Study and How to Guide

By: East Kent Hospitals University NHS Foundation Trust

£2498.60 (Estimated)

16.46 tonnes CO2e (Estimated)

During haemodialysis, blood is removed from the patient and pumped through a dialyser, before being returned to the patient. Inside the dialyser, waste products in the blood diffuse across a membrane into the ‘dialysate’ fluid, a blend of treated water and chemicals. However, if the dialysate is too cool, the patient may become uncomfortably cold. Cool dialysate also reduces the rate of diffusion, making the treatment less efficient. For these reasons, the dialysate is usually warmed to just below body temperature. The way this warming is done varies. Most machines use a heater controlled by a thermostat to warm the dialysate. However, some machines will also have a heat exchanger incorporated into the system before this heater. In these machines, heat is recaptured from the dialysis effluent (‘used’ dialysate) and transferred to the incoming dialysate, warming it up before it enters the heater and thereby saving energy and reducing the environmental impact of a haemodialysis treatment.

The Kent and Canterbury renal service has predominantly purchased Braun Dialog+ haemodialysis machines, and these have been supplied without heat exchangers. However, the purchase of newer haemodiafiltration machines with built-in heat exchangers highlighted the potential financial and environmental savings that heat exchangers can offer. The renal technicians at the Maidstone dialysis unit decided to investigate the possibility of retro-fitting heat exchangers to their existing machines.

Retro-fit heat exchanger kits for Braun Dialog+ machines can be fitted by most renal technicians in less than half an hour. The technical team selected five machines at random and ran simulated dialysis treatments before and after fitting the machines with heat-exchangers. When they measured the electrical energy used by the machines on each run using a power monitor fitted between the wall socket and the machine plug, they found that the average reduction in power required for each treatment session was 0.86kWh, representing an 18% increase in efficiency (the full results are listed at the end of this case study).

In 2011, funding was obtained for retrofit of 52 machines across the East Kent renal service.  The retrofits have now taken place, and energy and cost savings are being monitored.

Environmental Savings (calculations updated October 2012)

Assuming each machine is used twice daily, six days a week for 52 weeks of the year, an annual power saving of 536.64 kWh per machine (2 * 6 * 52 * 0.86) is predicted. Applying a conversion factor of 0.58982 kg CO2 equivalents per kWh*, this in turn equates to an annual saving of 316.5 kg (0.3165 Tonnes) of CO2 equivalents per machine per year. For the 52 machines retrofitted across the Kent and Canterbury renal service, this equates to an annual power saving of 27,905 kWh and an annual carbon saving of 16.46 tonnes of CO2 equivalents.

* GHG emission factor for electricity consumed (2010 grid rolling average) taken from the 2012 Guidelines to Defra / DECC's GHG Conversion Factors for Company Reporting (Table 3c)

Environmental Saving                  Total                             Number                     Conversion

[in tonnes of CO2            =      power saving            *           of                *              Factor

equivalents] per yr                  per treatment                   treatments                   (0.58982)  

                                                   (0.86 kWh for                    run per yr

                                                  BBraun Dialog+)

Although the manufacture of heat exchangers incurs a carbon cost in itself, this is estimated to amount to less than one percent of the carbon savings derived from the improved energy efficiency in the first year of use alone.

Investment Appraisal

Given the local electricity rate of £0.089 per kWh, the lower energy usage translates to financial savings of £0.077 per treatment (0.089 * 0.86), and an annual financial saving of £48.05 per machine (if used twice daily, six days a week, for 52 weeks of the year).

 

Financial saving per treatment  =  local electricity rate  *  energy saving per treatment

                                                                (£/kWh)               (0.86 kWh for Braun Dialog+)

 

The unit cost of the device (£189) could be recouped within four years (£189/£48.05) and a profit made thereafter. In the case of Kent and Canterbury, following the retrofit of 52 machines with heat exchangers, an annual saving of £2498.60 (£48.05 * 52) is anticipated. 

 

HOW-TO GUIDE: GETTING STARTED

The case study and discussion outlined above includes most of the information required to develop a sound business case for a programme to retro-fit heat exchangers to existing dialysis machines. The following guidance will help you explore the practicalities and assess the financial benefits further.

  1. Firstly identify whether the machines in your unit are fitted with heat exchangers.
  2. If not, identify the make of the machine, whether a retro-fit kit exists and what it costs.
  3. Also, clarify any plans to replace or update the machines.
  4. Remember that the figure quoted here for the energy saving per treatment (of 0.86 kWh) has been derived from tests using Braun Dialog+ machines. If your unit uses different machines, for which retro-fit heat exchangers are available, you will need to clarify the potential energy saving per treatment (either using the method outlined in this case study, or through correspondence with the manufacturer).
  5. Ascertain the number of machines to which you plan to fit heat exchangers, and how frequently they are used.  
  6. Find out the local rate for electricity.
  7. You should now be in a position to follow through the calculations outlined above. This will enable you to determine the potential financial and environmental savings for your unit.
  8. Funding for projects of this nature is most commonly sought through the budget of the renal service. However, interest free loans for energy efficiency measures may also be available from Salix Finance - http://www.salixfinance.co.uk/home.html

Kent and Canterbury Hospital, Ethelbert Road, Canterbury, Kent, CT1 3NG

Newer haemodiafiltration machines with built in heat exchangers highlighted the potential financial and environmental savings heat exchangers can offer.

£11,600

Of course, not every unit uses Braun Dialog+ machines, and it may be that heat exchangers are already incorporated into the machines at your unit. Gambro and Fresenius machines, for example, are generally equipped with heat exchangers as standard.

It is also important to consider the longevity of the existing machines and whether there are any plans to upgrade or replace them. The machines must of course be expected to remain in service for longer than the anticipated period over which the investment outlay will be recouped.

Steve Milne, Renal Technician Manager, steve.milne@ekht.nhs.uk

Diversion of Waste to the Recycling Stream through the Use of Baling Machines

By: Heart of England NHS Foundation Trust

environmental benefits resulting from the diversion of waste to the recycling stream, 4.2tonnes of less plastic going to clinical waste, reduction of domestic waste by 50% , freeing up the physical space and reducing a potential fire risk

£4,150 (Actual)

8.665 tonnes CO2e per year (Estimated)

In 2005, an assessment by the waste management team responsible for the Birmingham Heartlands Hospital satellite dialysis unit at Runcorn Road identified two separate, but not uncommon, issues. The first issue was the disposal of the plastic acid and bicarbonate cartridges which were needlessly entering the clinical waste stream and therefore being incinerated, an expensive and environmentally damaging route of disposal.  The second issue was the disposal of the very large amounts of cardboard packaging associated with the clinical supplies purchased by the unit. Despite its recyclable nature, this was entering the domestic waste stream. Moreover, collections were infrequent and the cardboard was frequently accumulating in piles. As well as taking up valuable space within the unit, the identification of the fire risk that this posed had prompted the facility’s leaseholder to cover the resulting increases in insurance costs by requesting a higher rental fee. The solution to all of these problems was the purchase of a baling machine to compact the waste.

The machine is housed in the storage room adjacent to the main dialysis unit and measures approximately 6ft by 3ft by 3ft. An electronic machine was chosen ahead of piston-driven alternatives as it makes very little noise, an important consideration given the close proximity to a clinical area.

At the end of a patient’s dialysis session the acid cartridge is emptied and rinsed with tap water by the nurse. The cartridges are collected in plastic bags holding eight cartridges each . These bags are then baled together, along with bags containing other plastic waste collected within the unit . Ten bags are baled at a time, with cardboard layers at the top and bottom, to produce packages that weigh approximately 19 kg and are held together with binding tape. Packages of this size can be easily moved with the aid of a roller fork. Excess cardboard is baled together in separate packages weighing around 10kg. These plastic and cardboard packages are collected from the unit on a weekly basis, free of charge, by a local company which recycles them.  A similar set up is also in place at a second satellite dialysis unit in Castle Vale. 

Other plastic items that are collected and baled include shrink wrap, containers for alcohol-based hand gels, bicarbonate cartridges (although this is increasingly sourced in bags), and the containers for bleach and Citrosteril. Particular care must be taken with the containers of substances subject to COSHH regulations (the control of substances that are hazardous to health, such as disinfectants like bleach and Citrosteril), and dialysis units should ensure that they have the necessary sewer discharge consent if these substances are to enter the water course undiluted.

Investment Appraisal

The return on investment will depend on the investment and running costs (resulting from the purchase, installation and maintenance) and the savings resulting from the diversion of waste into cheaper disposal pathways.

A typical dialysis unit will use one acid cartridge per patient. Although the Runcorn Road Satellite Dialysis Unit is a 26 station unit, it is currently run at such a capacity that it generates 270 empty acid cartridges per week, each weighing 300 grams. This equates to 14040 cartridges per year, or 4.2 tonnes of plastic. The cost of disposing of clinical waste is determined by an economy of scale; larger units will produce greater amounts of clinical waste, and will be in a position to negotiate lower disposal costs per tonne. For the purposes of this case study, we have used a cost of £750 per tonne, which is considered representative of the current cost for most satellite units. The cost of sending 4.2 tonnes of plastic to clinical waste is therefore around £3150 per year.

The Runcorn Road unit also produces approximately 1 tonne of cardboard per year. These cardboard boxes were previously being put into domestic waste bins, usually uncrushed, along with other waste. The cost to the unit of their disposal was determined by the number of bins collected per year, which in turn would be influenced by how well crushed the boxes were. It is therefore difficult to provide a method to calculate the savings made, but the waste management team at the Runcorn Road Unit estimate that the introduction of the baler, which removed the cardboard from this waste stream, has reduced the number of bin collections by 50% and has saved the unit approximately £1000 per year.

Using these figures, the annual saving (equivalent to the overall cost of the original waste disposal methods) is approximately £4000 at the Runcorn Road Satellite Dialysis Unit.

The purchase of a baler requires an initial one-off investment. This is likely to be in the region of £3500 and will include installation. The ongoing costs might be anticipated to include an annual service (for which the Runcorn Road Satellite Dialysis Unit pays £195), the cost of the binding tape (£342 for the 12 reels required by the Runcorn Road Satellite Unit per year), and the cost of the plastic bags (which is likely to be very small and has been assigned a nominal figure of £50 for this case study). Therefore the total cost incurred during the year of implementation is £4087, with an annual cost of £587 thereafter.

The Runcorn Road unit therefore recouped the outlay cost at one year, and has been saving around £4000 thereafter. A comparable saving is also being made at the Castle Vale satellite unit. The savings might be even greater in units using plastic bicarbonate containers.

Carbon Savings (section added October 2012)

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

The GHG for incineration of clinical waste was taken as 1,833 kg CO2e emitted per tonne of waste (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).

The GHG for recycling of waste was taken as -230 kg CO2e per tonne.

Using these factors we estimated the GHG savings per year:

  • Previous GHG emissions from disposing as clinical waste, per year = 4.2 tonnes x 1833 kg CO2e per tonne = 7699 kg CO2e
  • Current GHG (as recycled waste), per year = 4.2 x -230 kg CO2e per tonne = -966 kg CO2e

Saving = 8,665 kg CO2e per year

Risk Management

There are no major risks associated with the implementation of a baler to compact dialysis waste. Minor risks can be minimised through appropriate staff education, and clear Health & Safety, Infection Control and Manual Handling guidance. Financial risks can be minimised through the careful development of a business case.

How-to Guide: Introducing a baling machine to compact waste from your dialysis unit

1. Clarify current practice regarding the disposal of cardboard and plastic waste within your unit. Consider how the use of a baler might improve it.

2. Identify the person(s) in charge of the waste budget for the renal unit. This is most commonly a member of the Renal Directorate or the Estates (or Hotel Management) Departments. They will be able to provide accurate information regarding the local disposal costs for the relevant waste streams.

3. Determine the cost of the baler. The person in charge of the waste budget may be able to help you identify suitable vendors. Explore maintenance contracts.

4. Liaise with the current waste contractor (almost all Trusts employ the services of private firms to remove and dispose of waste) at an early stage. Identify whether they could process the waste in the form you plan to provide it, and determine any cost that it might entail. Also, explore the possibility of alternative contractors who may remove the waste at a lower cost. In particular, the Environmental Department in your Local Council may know of companies willing to take recyclable material away at no cost.

5. Consider the future. In particular, is a move to central acid delivery planned (thereby dramatically reducing the number of cartridges produced)? Or is expansion of the unit planned, in which case the number of cartridges might be expected to increase?

6. Using the methodology outlined in the case study, calculate the potential savings for your unit.

7. Identify a suitable location for the baling machine and any alterations that might be required to house it.

8. Explore the idea with the dialysis staff to ensure that there is sufficient enthusiasm.

9. Use this document to develop and submit a Business Case.

                        

 

Birmingham Heartlands Hospital, Bordesley Green East, Birmingham, West Midlands, B9 5SS

Reducing clinical and domestic waste

01/01/2005
ongoing

"Reduce, Reuse, Recycle in the Renal Unit" case study and how-to guide published online on the Green Nephrology website.

£4,087

A suitable space must be found to house the baling machine. This need not necessarily be indoors as a simple shelter could be built in order to keep the electric parts dry. However, if the machine is outdoors or not close by, staff may be less inclined to bale the waste regularly during wet or cold weather, leading to problems with accumulation.

The attitudes of the staff members are crucial to the success of this initiative. Education around the environmental and financial benefits is likely to improve willingness to bale the waste regularly. Consideration should also be given to the amount of staff time required to operate the machine. At the Runcorn Road Unit the baling machine is typically in use for 20-30 minutes per day, during which time it is operated by a single staff member.

For some waste companies offering recycling, the collection of what are (for them) relatively small and frequent collections may prove financially unviable. Baling the waste at source may solve this problem, as it allows more plastic to be removed with each visit (and also reduces emissions associated with travel). Furthermore, not all waste companies will be able to recycle the containers, and some may wish to run checks to establish that the residual contents of the containers will not damage their machinery. Liaise with your Estates Department – if the waste company with whom they currently have a contract cannot recycle the containers, then investigate other local options. You may find companies who will be willing to collect the plastic for free, and whilst others may charge for the service it is usually cheaper than sending it to landfill (and definitely cheaper than treating it as clinical waste). The Environmental Department at your Local Council may also help you with this; in Dunfermline, the Local Council has leased four large bins to the renal unit, into which the dialysate containers are placed, and then collects the contents for recycling (as well as other plastic collected in the unit).

Paul Williams, Facilities Health and Safety Officer, paul.williams@heartofengland.nhs.uk

Reducing Waste in the Dialysis Unit Queen Margaret Hospital, Dunfermline

By: NHS Fife

Reduced clinical waste, 21.5 tonnes per year

£14907.10 (Actual)

26.847 tonnes CO2e / year (Estimated)

The dialysis unit at the Queen Margaret Hospital, Dunfermline, has 20 stations and provides over 13,000 treatments per year. Mary Thompson, a dialysis nurse in unit, ran a series of Waste Watch Weeks there in 2009, and identified opportunities to improve practice.

The unit has recently moved towards providing online haemodiafiltration (HDF) using 15 Fresenius 5008 machines. Mary noted that, for every dialysis session, a one litre bag of normal saline was used to re-infuse the patient’s blood at the end of the treatment. This bag would be opened and attached to a giving set at the start of the treatment (ready for use should the patient suffer a hypotensive episode during their dialysis treatment), despite the fact that the newer haemodiafiltration machines were able to prepare ultrapure sterile substitution fluid directly from the dialysate by directing it through an ultrafilter.

When it came to re-infusing the patients blood at the end of the treatment, only 200 mls of this fluid would typically be required. The remaining 800mls of normal saline, the plastic bag containing it, and the plastic giving set were then all placed in an orange bag – along with the extracorporeal circuit and bicarbonate bag - and disposed of through the clinical waste stream. Mary realised that there were a number of opportunities to reduce

REDUCTION 1

The use of saline and giving sets was reduced by stopping the unnecessary practice of hanging a bag for emergencies in favour of using the online facilities for emergencies and re-infusion. This saved not only the carbon embodied in their manufacture, but also the emissions associated with their disposal.

A bag of normal saline was costing the dialysis unit £0.52, whilst a single giving set was costing £0.35. During the course of the 10,764 treatments provided per year, the use of online substitution fluid saves £9,364 (minus the small but less quantifiable cost of producing the exact fluid volumes online) in procurement costs alone (waste disposal savings are outlined below).

REDUCTION 2

The amount of clinical waste was further reduced by improving segregation at source. The first measure had already removed a partially filled bag of normal saline and giving set from the waste stream, but the bicarbonate bag could also be diverted away from the clinical waste stream to domestic waste.

Bicarbonate is added to the dialysate throughout the treatment. Although it is sometimes supplied in plastic containers (see the Recycling Case Study), in Mary’s unit the bicarbonate is provided in bags (often referred to as B-Bags). Mary realised that these bags could be placed in the domestic waste stream after each treatment (as ongoing efforts to find a facility willing to recycle them have proven unsuccessful).

These two initiatives had reduced the clinical waste from a single treatment by 2 kg through the removal of one bag of reperfusion saline (usually with 800 mls remaining in it), one giving set and the bicarbonate bag. Over the annual 10,764 treatments provided by the unit using Fresenius 5008 machines, this would result in a reduction in clinical waste of 21,528 kg – or 21.5 tonnes. As a relatively large producer of clinical waste, the Queen Mary Hospital was charged at £300 per tonne of clinical waste, leading to an annual saving of £6458.40. This saving was offset by the increased cost of the domestic waste (£85 per tonne) attributable to the addition of the bicarbonate bag to this waste stream. The annual 10,764 treatments produce 10,764 bicarbonate bags, with a total weight of 10.764 tonnes and a disposal cost of £914.90, resulting in an overall annual saving of £5543.10.

Quantifying carbon savings (section added October 2012)

Greenhouse gas (GHG) conversion factors for procurement of pharmaceuticals and medical equipment were obtained from the 2012 Guidelines to Defra / DECC's GHG Conversion Factors for Company Reporting (Table 13). Using these factors we estimated the GHG savings per year from avoided procurement of saline bags and giving sets:

  • Reduction in pharmaceutical procurement (saline bags): £0.52 x 10764 treatments = £5597.28 / year. £5597.28 x 0.43 kg CO2e/£ = 2.407 tonnes CO2e
  • Reduction in medical equipment procurement (giving sets): £0.35 x 10764 treatments = £3767.40 / year. £3767.40 x 0.30 kg CO2e/£ = 1.130 tonnes CO2e

Greenhouse gas (GHG) conversion factors for waste disposal were obtained from the 2011 Guidelines to Defra / DECC's GHG Conversion Factors for Company Reporting (Table 9d). The GHG for incineration of clinical waste was taken as 1,833 kg CO2e emitted per tonne of waste (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). The GHG for landfill of plastic waste was taken as 34 kg CO2e per tonne.

  • Previous GHG emissions from disposing saline bags + giving sets + bibags as clinical waste, per year:Saline bag + giving set + bibag - 800ml residual saline = 1.2kg1.2kg x 10764 treatments = 12.917 tonnes. 12.917 tonnes x 1833 kg CO2e/tonne = 23.676 tonnes CO2e / year
  • Current GHG from disposing bibags (1kg) as domestic waste, per year:1kg x 10764 treatments = 10.764 tonnes / year. 10.764 tonnes x 34 kg CO2e/tonne = 0.366 tonnes CO2e / year
  • Net savings from waste disposal = 23.676 - 0.366 = 23.310 tonnes CO2e / year

Combined GHG savings (procurement and waste) = 1.130 + 2.407 + 23.310 = 26.847 tonnes CO2e / year

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

To reduce waste and its associated disposal costs

Mary Thomson, Renal Nurse, maryathome@aol.com

Telephone Clinics in Follow-Up of Renal Transplant Recipients - Case Study and How to Guide

By: University Hospitals Coventry and Warwickshire NHS Trust

heightened sense of empowerment in the management of the patients' medical problems, more convenient access to healthcare and considerable time savings for patients

2000kg CO2 The carbon savings of telephone clinics will of course vary between different renal units catering for different geographical areas and patient numbers. A ball-park figure for the carbon savings attributable to replacing a single face-to-face clinic with telephone consultations can be made by undertaking a simple transport survey on patients attending clinic. (Estimated)

The renal unit at the University Hospital of Coventry and Warwickshire has been successfully running a twice-monthly telephone clinic to provide follow up to transplant patients since 2006 to reduce the inconvenience to patients of frequent trips to hospital. Telephone clinics are offered to patients at the discretion of the clinical team. Patients must have a stable transplant function, and factors such as the patient's hearing and co-morbidities are also considered. Patients who are suitable for telephone follow-ups are offered the choice to remain in the traditional follow up system or switch to quarterly telephone clinic follow up, with just one annual traditional (‘face-to-face’) outpatient appointment at their local renal clinic. 

The UCHW service now provides follow up to approximately 125 of the 360 patients with stable transplants of more than one year's standing.

In preparation for a telephone consultation, patients undertake their blood tests in the normal way (at UHCW this entails visiting either their GP, one of four local hospitals, or the city centre phlebotomist service). Patients are also asked to provide up-to-date blood pressure and weight readings (which can either be taken at home or at the Family Practice). Telephone appointments are scheduled to last 10-15 minutes, and the patients ring in at designated times. Letters are sent to GP’s in the normal manner. Blood test forms are sent out to patients along with their next appointment time.

Patient Safety Risk Management

 Patients in whom follow-up is predominantly telephone-based may be examined by clinicians less frequently and this may introduce a risk to patient safety. Although further research is undoubtedly required, the medical literature does not appear to indicate that telephone consultations increase the risk to patient safety when used to provide routine follow up of patients with chronic diseases. Indeed, some studies show the opposite effect. However, efforts should be made to reduce the risk to patient safety in all aspects of clinical care, and two clear measures exist in relation to telephone consultations. Firstly, the exclusion of patients for whom telephone consultations might be inappropriate is vital. Secondly, should a clinician undertaking a telephone consultation identify a need to examine a patient, the system must allow the organisation of a face-to-face review in a timely and convenient fashion. The possibility of missing skin cancers may be a particular concern to clinicians providing telephone-based care for renal transplant recipients taking immunosuppressants. All patients, irrespective of their follow up modality, should be educated to look for and report new or changing skin lesions. In reality, those patients with a prior history of skin cancer will have open access to the local dermatology service. Those reporting their first skin lesion will usually be seen faster if referred by their General Practitioner (under the ‘2 week wait’ referral system for suspected skin cancers). The practice of the clinicians in the University Hospital of Coventry and Warwickshire telephone unit is therefore to ask these patients to seek a review (and possible referral) by their General Practitioner.

 

GETTING STARTED – ‘HOW TO’ GUIDE

Ascertain the size and frequency of the telephone clinic you wish to run.

1. Determine the catchment population for the telephone clinic. You may wish, eventually, to offer the service to all renal transplant patients under the care of the renal service. However, it may be simpler to begin by running a telephone clinic to cater for those patients under the care of a particular consultant.

2. Within this catchment population, estimate the potential number of patients that might be suitable for follow up by telephone clinic. Start by identifying the number of patients with stable renal transplants of more than one year’s standing. You might choose to ask these patients, at this early stage, whether they would be likely to opt for telephone consultations. This would provide you with a good understanding of the capacity to which to develop the transplant clinic. It would also allow you to return to these patients directly once the opportunity to book patients into the clinic arises, hopefully reducing the period for which the clinic is ‘underfilled’.

3. Clarify how many patients you envisage enrolling in the transplant clinic. Perhaps begin slowly, by developing a clinic with capacity to follow up around 10-20% of the patients with stable renal transplants (as, of course, not every one of the patients you have identified so far will meet the necessary criteria, or indeed wish to switch to follow up by telephone) or around 50% of those patients who have indicated that they would prefer to be followed up in this way.

4. Given the number of patients you intend to follow up by telephone consultation, the approximate frequency with which you plan to review them, and the duration of time you anticipate allocating to each consultation (usually 10-15 minutes), ascertain how frequently you will need to hold telephone clinics.

Consider the resources you will require.

5. Ensure that your department will have the necessary resources and administrative support to run the clinic. Once the telephone clinic is running near to its intended full capacity, the reduction in the number of consultations in other clinics should ‘free up’ the staff and resources required for the telephone clinic, but this might not happen immediately.

6. Identify where you will run the clinic. For example, by moving the clinic to your office you will free up a room in the outpatient department (but you would need to re-organise the delivery of patient notes).

7. Identify how patient blood tests will be undertaken. Any departure from current practice may have costing implications. Also, where necessary also consider how results will be retrieved, and whose responsibility this will be.

Determine how your unit will be funded for the telephone clinic.

8. Involve the Contracting Department in your hospital in order to commence negotiations with the Primary Care Trust commissioning body.

9. Ensure that any agreed tariff fully covers the activities entailed in the running of the telephone clinic.

Further tips

1. Ensure that patients appreciate that they can return to face-to-face appointments at a later date if they choose to do so.

2. It is important that the Trust and commissioning body define the unit of care covered by any agreed tariff. For example, it might be important to state whether or not impromptu phone calls between patients and clinicians that occur between designated telephone clinic appointments will also count as consultations.

University Hospital of Coventry and Warwickshire

To reduce the inconvenience to patients of frequent trips to hospitals

01/01/2006
ongoing

Financial Security The likely discrepancy between the suggested PbR tariff for non-face-to-face activity (£23) and the re-imbursement that a Trust currently receives for providing its existing outpatient clinic service means that there is a potential financial risk to the Trust whereby the tariff does not cover the full cost of running a telephone clinic. This risk is avoidable as the tariff for non-face-to-face activity is negotiable and must be agreed in advance with the commissioning body, allowing Trusts the opportunity not to introduce the service where tariffs might be insufficient. As, in most cases, the telephone clinic will simply replace the existing face-to-face activity, we would suggest that Trusts are well placed to argue that it should be financially supported.

In some units, blood tests are undertaken at the renal clinic itself on the day of the appointment, with the results reviewed after the consultation. Implementing a telephone clinic service in these units would require alternative arrangements to be made to allow patients to have their blood tests undertaken as locally as possible. This change in practice may have implications for the cost of the service.

Staff may also prove to be a barrier, as not all clinicians in a unit may wish to participate in a telephone consultation clinic. One solution is to have the clinics run by the enthusiasts, and to allow ‘referrals’ from their colleagues.

Although sometimes perceived as a barrier to virtual medicine, the Payment by Results (PbR) system in fact makes provision for it. Clauses 174-177 of the Payment by Results Guidance for 2009 (available at http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/documents/ digitalasset/dh_097469.pdf) state that the tariff commanded by non-face-to-face activity of any nature is £23. However, this figure is designated as ‘non-mandatory’, meaning that it is negotiable with the Primary Care Trust commissioning body.

A renal service cannot introduce a telephone consultation service without the consent of the commissioning body, and the hospital’s Contracting Department should be involved. A suggested approach to the necessary series of negotiations is to request that the commissioning body pay the existing tariff for a face-to-face consultation, less a percentage (eg 10-20%) to reflect the need for blood tests to be undertaken in primary care – rather than to undertake a bottom up costing of the telephone consultation service. A renal service will also need to provide reliable activity baselines during these contract negotiations (often with a risk tolerance), and it is likely that most commissioning bodies will require at least six months notice prior to the intended first clinic date. The renal service will need to record the clinic activity at a patient level in order to charge the commissioners.

Rob Higgins, Consultant Nephrologist, robert.higgins@uhcw.nhs.uk

Conserving Water in Haemodialysis - Case Study and How To Guide

By: East Kent Hospitals University NHS Foundation Trust

Considerable savings on mains water and sewerage costs, good for the environment as water is a finite natural resource, compliance with carbon targets

£7,500 (Actual)

Haemodialysis consumes vast quantities of water. Producing the 120 litres of dialysate required for a typical four hour session requires approximately 400 litres of mains water. Reverse osmosis is an important step in the purification process for water used in haemodialysis. Reverse osmosis systems reject up to two thirds of the water presented to them. This 'reject water' does not come into contact with the patient at any stage and poses no infection risk, yet it is 'lost to drain' in almost all dialysis facilities.

In 1999, two years after the Canterbury dialysis unit installed a new reverse osmosis plant, a simple system capable of recycling 800 litres of reject water per hour was installed at a cost of £15,000 with the help of the  hospitals estate department. The system has now been running for over 10 years, saving the Trust £7,500 per year on mains water and sewerage costs.

The salvaged reject water is directed to a recovery tank in the basement. From there it is pumped up to the grey water tank on the roof, which then supplies the water to the hospital toilets. Float switches divert reject water to the drain if the grey water tank is full, and diverter valves direct the reject water directly to the drain from the reverse osmosis system during monthly chemical desinfections.

Investment Appraisal

The return on investment will depend upon:

1.    The investment: the cost of installation & maintenance.

2.    The return: the savings on mains water and waste water.  This can be calculated by multiplying the regional mains water and waste water rates by the volume of reject water which the system is able to provide in place of mains water for an alternative use (e.g. laundry). It is useful to factor in projected price rises and changes in demand to gain a view of future potential savings.

Risk Management

Careful planning and calculations will prevent the implementation of a project which is financially inviable due to physical barriers or miscalculations regarding the amount of reject water produced.

The new use supplied by the recycled water needs a back-up mains supply.

Calculation of Carbon Savings

Carbon savings (kg CO2e/year)

=

[Volume water saved in one year (L)  x  mains water carbon conversion factor (kgCO2e/L)], e.g. DEFRA

-

[electricity used for pumping per year (kWh)  x  carbon conversion factor (kgCO2e/KWh)]

 

How To Guide - Getting started:

1. Discuss the idea with your Renal Technician. They will play a vital role in any water conservation project, understanding the local set-up better than anyone else.

2. Involve your local Estates department.  The support and advice of the hospital Estates department is also vital. Their engagement may require the presentation of a sound business case. In most cases, it will be the Estates department that benefit financially from the methodology.

3. Clarify the scenario.  Will the methodology be implemented into the design of a ‘new build’ dialysis unit, at the time of replacing the RO system in an existing dialysis unit, or perhaps alongside an existing and satisfactory RO system already in place in a dialysis unit? These different scenarios will influence the total costs involved, but the return on investment may still make the project worthwhile.

4. Clarify the potential volume of reject water that will be salvaged each year.

In order to maximise the financial and environmental benefits of the project, it is important to match the volume of reject water available to an alternative use that requires a similar volume. Many reverse osmosis systems record the volume of reject water produced, but this can be ascertained with a simple flow meter if necessary. It should be remembered that, where reverse osmosis systems are being replaced, the newer system is likely to be more efficient and produce less reject water.

5. Assess the quality of the reject water to be salvaged.  The precise quality of the reject water produced will vary from region to region. Whilst it will almost always meet the requirements for its intended use, it is vital that this is assured prior to proceeding further. Your renal technician will be well versed in checking the water quality.

6. Given the volume and quality of the reject water available, now identify the intended use for this water.  Possibilities include: sanitation, laundry, boiler feed, sterilisation units and irrigation – on site or supplied to a neighbouring facility. Practical considerations are important. For example, salvaged reject water can only be used in laundry services if the plumbing required is feasible and affordable.

7. Calculate the financial cost per year of the current practice of supplying mains water for this intended use.  This will require knowledge of the mains water rates for your hospital, information which the Estates department can provide.

8. Calculate the financial savings resulting from the reduction in waste water from the haemodialysis unit. This will require knowledge of the waste-water rates for your hospital. Remember that some reject water may still be lost to drain if it exceeds the demand/capacity of the salvage system, and during disinfection cycles.

9. Calculate the initial total financial expenditure incurred in implementing the methodology (including the infrastructure required to transport the reject water to the place of use). Costs may include: storage tanks, pipework, pumps and installation costs.  Maintenance costs are likely to be small.

10. From these figures, develop a repayment projection and calculate the breakeven point (the point in time by which the savings - due to reduced mains water and reduced losses-to-drain - might be anticipated to have recouped the investment costs of the methodology, and from whence the use of reject water for the new purpose realises potential savings).

11. Convince your Trust to fund the work. Whilst this will certainly require the support of your Estates department, it may also require the approval of the Director of Finance. It is also worth applying for funding from Salix Finance, an organisation set up by the Carbon Trust to deliver interest free funding to accelerate investment in energy efficiency technologies within the UK public sector. Their website is http://www.salixfinance.co.uk/home.html

12. System maintenance should become part of routine estates plant room inspections - a simple check function tick list is sufficient. Water storage tanks will require cleaning in line with Trust protocols for other tanks in the hospital.

Canterbury dialysis unit and satellite dialysis unit in Ashford

Large volumes of 'reject' water were lost to the drains

Hospital's estate department

01/06/1999
completed
£15,000

A potential barrier to a financially viable water conservation system might be the physical constraints imposed by the existing layout of the renal unit and the available space.

The necessary pipework might be impractical or too expensibe too install.

Steve Milne, Renal technician, steve.milne@ekht.nhs.uk