Laboratory Sustainability: The Need for Green

Climate change has become the “greatest global health threat facing the world in the 21st century” (1). Climate change brings with it a decline of planetary and public health – and the effects we are already seeing on these systems are escalating on a global scale.

In 2015, nearly 200 countries recognized this threat and committed to a global collaboration in the form of the Paris Agreement. The aim? To limit the harm caused by climate change by setting a target to decrease global warming to below 2 °C. The Lancet Countdown came soon after, and was established to follow the 2015 Lancet Commission on Health and Climate Change. The annual Lancet report tracks the global progress of the commission across five key areas (see Figure 1).

The report also highlights the health impacts of climate change and potential health benefits that could result from our accelerated climate action. At the time of writing in 2023, the most recent version of the report (2022) presents a worrying view – the impacts of climate change are worsening. The number of extreme weather events is not just rising but accelerating, heat related deaths among our elderly population have risen by 68 percent over the last 20 years (1), infectious diseases are on the rise, and food security is declining.

As we continue through 2023 and reflect on the status of the economy and cost of living, we may find it difficult to focus on the wider picture of our climate and our planet. As a species, we have an addiction to the use of fossil fuels, which accelerates climate change. Unfortunately (or fortunately, depending on your view), if we are to have any hope of mitigating the worst scenarios of climate change, we need to curb our addiction. You need only look in the 2022 Lancet report to see the view that moving away from fossil fuels can save 1.2 million lives.

The healthcare sector is responsible for 4–5 percent of global greenhouse gas emissions (2); therefore, it has a role of responsibility in the mitigation of climate change, ultimately by substantially reducing its greenhouse gas emissions.

Here, I present an overview of my own healthcare sustainability advocacy and explore what we, as healthcare science professionals, can do to reduce the carbon footprint of clinical laboratory practice. By sharing these insights, I hope to add just one voice to the bigger conversation to help healthcare reach its targets for carbon-zero.

Developing a passion to promote change
 

As a healthcare scientist currently working in academia, I have developed a passion for environmental sustainability. I have always had an interest in the environment and ecology preservation, recycling where possible, following a vegetarian diet, and ensuring minimal personal impact on my surroundings. However, it was only when I became an academic in a sustainability-conscious university that my passion evolved into action as a sustainability ambassador. 

As I developed skills of leadership and teaching, my knowledge for curriculum development grew to encompass the concepts of education for sustainable development (ESD). Sustainability became a consideration for student employability skills, student research projects, and for healthcare scientist continual professional development.

I found that, although the research and academic laboratory environments were actively looking to practice more sustainably, clinical laboratories were behind – despite national efforts to reduce the carbon footprint of healthcare.

I adapted my own laboratory practice and became a sustainability ambassador for the Institute of Biomedical Science and Nottingham Trent University. From there, I went on to facilitate change across UK clinical laboratories. Using expertise gained through 21 years of clinical laboratory practice as a biomedical scientist – and knowledge collected from published research and case examples – I promote positive quality improvements in practice to lessen the carbon footprint of healthcare laboratory science. 

Current work includes collaboration with organizations, such as Laboratory Efficiency Assessment Framework (LEAF), to develop a clinical laboratory tool, acting as a core member of the European Federation of Laboratory Medicine’s Green and Sustainable Laboratory Taskforce, and launching the Centre for Sustainable Healthcare’s international network for clinical laboratory professionals – Clinical Labs Susnet. I bring these activities up not as a list of achievements but as an example of how an initial curiosity can blossom into a lifelong vocation. If you find yourself passionate about sustainability, know that the first steps are often the most important.

From fundamentals of laboratory sustainability to case examples of good practice, there are some practical steps that a laboratory (and you!) can take.

A circular economy – reducing the need for Earth’s resources
 

As healthcare facilities increase to match global demand, so does global healthcare waste generation – at an accelerated rate of 2–3 percent (3). Global healthcare waste is fast becoming an environmental concern, and so targeted management and suitable treatment strategies before waste becomes waste are needed to limit the harmful impact. There is a need for healthcare environments to adopt safe mechanisms that segregate, collect, transport, and treat waste before disposal.

In truth, there are many challenges to implementing a healthcare waste management policy. A World Health Organization (WHO) assessment in 2015 highlighted that only 58 percent of the sampled facilities from 24 worldwide countries had proper systems for waste disposal. This deficit results from a lack of budget allocation, lack of workforce skill, and outdated technologies.

If we can adopt changes that reduce resources at the source, the need for treatment naturally decreases – as does the associated carbon footprint and environmental impact of waste accumulation and disposal.

The circular economy – unlike our current “take, make, waste” economy – is a viable solution. The concept is simple: promote the reuse, the repair, and the reconditioning of products. But for a circular model to be adopted, we need management of the sustainable healthcare supply chain. To get there, we will need information collection, supply analysis, discussion and collaboration with suppliers, consideration of service providers, investment by internal and external customers – and, of course, the involvement of end users (4).

For reuse, repair, and reconditioning to work, a clinical laboratory needs to work and share with every other link in the supply chain – including other departments, organizations, suppliers, and local education providers. Sharing resources reduces the need for new production, reselling resources offers possible financial benefits, and reusing equipment in new settings, such as education, not only supports the circular economy model, but provides realistic training opportunities for the future workforce.

Adapting practice: the carbon footprint of travel
 

Adopting the principles of a circular economy is one of – if not the best – practices to halt the demand on new resources. But the requirement for change goes far beyond the scope of “recycle and reuse.” A laboratory needs to look at the practices that directly produce carbon and other greenhouse gases.

According to the NHS England’s 2018 report, Reducing the use of natural resources in health and social care, health and care-related travel constitutes approximately 5 percent of all road travel in England each year (5), while transportation accounts for 27 percent of total national emissions across the US (6).

Since 2010, the NHS has reduced its emissions by 30 percent, falling under the Climate Change Act requirements (5); however, when we consider the healthcare-related travel associated with pathology, we need to encompass travel by the patient, the sample, the suppliers, and the staff. Laboratory leaders need to consider promoting a reduction in carbon intensive modes of transport and consider changes in practice that can reduce the carbon footprint of sample and resource delivery. 

Healthcare organizations already have numerous initiatives to promote sustainable staff commuting – therefore, we need to consider current processes and their impact. Regular fluctuations in test demand can often lead to urgent “kit” orders, with suppliers receiving multiple requests for single delivery of items, often transported by carbon intensive methods. Looking at the comparison of carbon emissions by differing transportation options (see Figure 2), we can better understand the impact of urgent deliveries.

By encouraging organizations to share kits and consumables when an urgent need arises, we save carbon by eliminating the need for single item, long-distance deliveries.

Sample collection and processing
 

The widely-understood concept of carbon footprint from travel can also be applied to sample transportation. Collection frequency, transport type, delivery route, and number of samples collected will all contribute to the carbon footprint of the laboratory. To promote evidence-based changes in practice, this data needs to be collated and analyzed to permit evaluation of sample delivery routes.

Furthermore, how we transport the sample to the laboratory is also an area for sustainability consideration. If you consider the production, use, and disposal of sample transport bags, it is easy to see how the laboratory feeds into the plastic waste of healthcare. Globally, 8,300 million tonnes of plastic were produced from 1950 to 2015, with only 7 percent recycled and more than half discarded into landfill or leaked into the environment (7). Although My Green Lab provides us with statistics on laboratory production of plastic (5 million tonnes per year from laboratories), the contribution for healthcare laboratories is unquantified. The move to single-use plastics is fundamental in this plastic waste production, but we can take steps to reverse this practice. 

One initiative is the use of sample transport boxes, replacing the single-use sample bag. Samples can be transported in boxes securely and safely, but the switch away from bags also improves confidentiality and reduces the risk of sample loss. A simple change like a reusable transport box can reduce single-use plastics, save time in sample unbagging, and reduce turnaround times – all from a small amount of initial effort.

Using POCT
 

Point-of-care also has an impact on sustainability. It’s believed that the impact of point-of-care testing (POCT) is considerably less than laboratory analysis. This is not only because of the equipment manufacturing process and running emissions, but often as a direct result of the reduced need for patient, sample, and staff transportation requirements. Moreover, one case study explored the use of POCT CRP test in nursing homes (8), finding that application of the test for suspected lower respiratory tract infection safely reduced antibiotic prescribing compared with usual care in nursing home residents. This suggests that implementing POCT CRP in nursing homes might contribute to reduced antibiotic use. And because the POCT test would relieve the need for laboratory analysis, the approach also brought additional environmental gains.

That said, more robust research is needed in this area to truly quantify the carbon intensity of POCT versus laboratory analysis. When considering POCT implementation, we must also consider the fundamental clinical patient requirements and quality assurance practices. Though we may look for clever ways to reduce our impact, we must always meet safety and quality related regulatory requirements. 

Further studies and quality improvement approaches, such as Sustainability in Quality Improvement (SusQI), in healthcare professional development aim to promote evaluations of the patient pathways and the need for laboratory samples (9). In recent years, quality improvement (QI) and sustainable healthcare have become integral to healthcare professional curricula. QI is a fundamental requirement of good laboratory practice and accreditation, and by employing principles of SusQI, a laboratory can achieve sustainability and QI objectives in tandem.

Sustainability in clinical laboratories – getting it right first time
 

My final thoughts on laboratory sustainability center on the frequency of pre-analytical errors seen in laboratories. Data from numerous studies puts the pre-analytical error rate at around 12.1 percent. A paper by Alcantara and colleagues gathered information on error rates from numerous countries and found preanalytical error rates ranging from 0.15 percent in India to 43.7 percent in Egypt (10). Regardless of these exact figures, conclusions can be drawn that pre-analytical errors contribute to an unnecessary carbon footprint. Some Initiatives, such as the UKs Getting It Right First Time and implementation of the international standard, ISO 15189, reduce the error rate, but there is an urgent need for further education. Mislabeling, sample rejection, and retests are just a few of the pitfalls that phlebotomy practitioners can fall into. But let’s not forget the need to educate clinicians on lowering their number of inappropriate testing requests. In all, by reducing the number of samples being transported, processed, and disposed of, true carbon savings and environmental benefits can be realized.

Doing no harm
 

As responsible healthcare professionals, we need to connect, educate, and share sustainability practices to combat the climate and public health crisis. Leaders need to embed the sustainability agenda into current and future practice, and ensure that sustainability practice education becomes embedded into every single thread of what they do – inductions, professional development resources, and professional qualifications. 

Climate change affects every single aspect of our lives, and so sustainability should be considered at every single stage of our work.