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J Intensive Care Soc
J Intensive Care Soc
INC
spinc
Journal of the Intensive Care Society
1751-1437
2057-360X
SAGE Publications Sage UK: London, England

10.1177/17511437231212072
10.1177_17511437231212072
Special Articles
The 2023 intensive care society cauldron: Five ways to tackle sustainability
Kirkdale Richard 1
Knudsen Rasmus 2
Yeung Emily 3
https://orcid.org/0009-0007-5251-9532
Anderson Catherine 4
Hjelde Nina 5
https://orcid.org/0000-0001-7585-3591
Brindley Peter George 6
1 Royal Derby Hospital, Derby, UK
2 Mid Yorkshire Hospitals, Wakefield, UK
3 Glasgow Royal Infirmary, Glasgow, UK
4 South Yorkshire Hospitals, South Yorkshire, UK
5 Manchester Hospitals, Manchester, UK
6 University of Alberta, Alberta, Canada
Peter George Brindley, University of Alberta, 2nd Floor, Clinical Sciences Building, Edmonton, AB Alberta T6G 2B7, Canada. Email: peter.brindley@albertahealthservices.ca
16 11 2023
2 2024
25 1 102104
© The Intensive Care Society 2023
2023
The Intensive Care Society
https://creativecommons.org/licenses/by-nc/4.0/ This article is distributed under the terms of the Creative Commons Attribution-NonCommercial 4.0 License (https://creativecommons.org/licenses/by-nc/4.0/) which permits non-commercial use, reproduction and distribution of the work without further permission provided the original work is attributed as specified on the SAGE and Open Access pages (https://us.sagepub.com/en-us/nam/open-access-at-sage).
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pmcIntroduction

‘The Cauldron’ is a tradition unique to the Intensive Care Society, and occurs at their annual State of the Art Conference. It is an opportunity for trainees to get on the big stage, and highlight their worthy ideas, perspicacity, wit and verbal dexterity. This is further facilitated by an exuberant audience, and a panel of ‘curmudgeon’ judges. Theses presentations are always insightful, popular and worth sharing. The 2023 debates took place in Birmingham on June 28th. The topic was ‘sustainability’, namely the ability to maintain the work we do and to avoid depleting natural resources.

The 2023 Cauldron was ably chaired by Dr Segun Olusanya. The judges were Professor Shondipon Laha, Dr Catherine Chalifour, Rosie Cervera-Jackson RN and Professor Peter Brindley. We are grateful to the Journal of the Intensive Care Society for the opportunity to share the work of such talented young healthcare professionals. The following abstracts were written by the presenters, and compiled and edited by Peter Brindley.

Presentation 1: Richard Kirkdale

The cost of being environmentally friendly: A new metric, the POCK – ‘Price of a CO2 Kilo’

We want to make environmentally sound choices. For example, we favour low flow vapours and avoid ‘polar bear killers’, such as desflurane or nitrous oxide. Similarly, Sevoflurane is likely better for the environment than desflurane, because it has a lower global warming potential over 100 years (GWP100). However, it gets confusing with intravenous anaesthesia. For example, how much does it ‘cost’ the environment to make Propofol, or 50 ml syringes? Perhaps a 250 ml bag of fluid and 5 ampules of Noradrenaline is less environmentally damaging than single ampules in multiple 50 ml syringes, but what if large amounts are thrown away?

Home dishwashers and washing machines include energy efficiency labelling. This facilitates environmental decision-making, but what about a Drager Evita versus a Maquet Servo-I? Regardless, our goal should be to balance clinical risk against environmental impact. To date, we have had few resources to assess the environmental impact of our clinical choices. Accordingly, I propose a novel metric, the ‘Price of a CO2 Kilo’ (POCK).

The GWP100 of a ton of CO2 is an accepted benchmark for environmental impact. The energy required and CO2 generated while processing raw materials (e.g. metals, paper and plastics) is available, 2 as is the impact of manufacturing (i.e. wire drawing for needles, injection moulding of syringes), 2 as are the estimated transport costs. With these data we can assign an estimate of GWP100 to many treatments. From this we can approximate how much it will cost your department to be more environmentally friendly. The provocative unanswered question remains, namely, how much we are willing to pay?

Presentation 2: Rasmus Knudsen

Prioritise doing good, deprioritise the environment?

To mitigate our environmental impact, we should focus on good outcomes rather than good intentions. This is because only a realistic, economically-sound, approach will work. We should stop seeking ‘popular’ interventions if they have a poor scientific or economic basis. Instead, we should focus on how we can objectively improve more lives and decrease our environmental impact.

We should embrace three things that Intensivists are good at: reflection, critical appraisal of evidence and pragmatic action. Moreover, we actually want to do more than just reduce greenhouse gases or global temperatures; namely we wish to reduce human suffering, and particularly for those with the greatest need. While biodiversity matters, we should also accept that environmental change disproportionally impacts the poor. Moreover, lower income countries have less capacity to adapt, and aggressive reductions in emissions may even further increase their poverty. 1

The United Nations has surveyed large numbers of people regarding their priorities. Notably, tackling climate change is repeatedly near the bottom, whilst the economy is near the top. Accordingly, we need to focus on measures that are evidence-based AND cost effective. For example, if we invested £24,095 (an amount that equates with 75% of ICS subscribers donating 5% of their dues), this could offset 4077 tons of carbon dioxide, thereby yielding a benefit of £6,564.2 –4 Alternatively, thousands of mosquito nets could be provided, which would yield £867,420. 5

In conclusion, if we reprioritized, we could improve lives, reduce poverty and increase environmental resilience. The ICS should encourage its members to use their skills in reflection, critical appraisal and communication to promote priorities that not only sound good, but do good.

J Intensive Care Soc
J Intensive Care Soc
INC
spinc
Journal of the Intensive Care Society
1751-1437
2057-360X
SAGE Publications

16 11 2023
2 2024
25 1 Presentation 3: Emily Yeung

Keep calm and just stay in the hospital

This abstract argues that it is time- both from a patient safety and sustainability point-of-view- to institute round-the-clock in-house (aka resident) consultant coverage.

In a 2018 UK-wide survey performed by the Faculty of Intensive Care Medicine (FICM), only 1% of respondents reported providing in-house coverage out-of-hours. 1 This is despite non-resident on call consultants receiving up to six phone calls per night after 9 pm. 2 Increasing the specialist’s physical presence could improve patient outcome but also increase environmental sustainability. 3

In the NHS, transport and travel are responsible for approximately 10% of total carbon dioxide emission. 4 Moreover, rotating trainees may commute in excess of 30 minutes to work, with an average one-way distance of 18 miles. 5 Consultants are expected to reside within 10 miles of the hospital (or 30 min) by road. Although this is a shorter travel distance, non-resident on call (NROC) consultants are likely to makes multiple journeys.

If, for example, the NROC consultant returns to the hospital every night of the week, then they will have driven an additional 140 miles per week, or 560 miles per month. Multiply 560 miles by 283 UK intensive care units 3 and you have 158,480 miles travelled per month; or 1,901,760 miles per year by NROC consultants in England, Northern Ireland and Wales. This constitutes, approximately, 467 metric tons of avoidable carbon dioxide. Telemedicine also offers great potential, but is less applicable to critical care medicine.

By making in-house consultant coverage the norm, we can offset significant carbon, as well as providing better triage, resuscitation and education. There will need organisational engagement to ensure that hospitals can accommodate in-house consultants. In return, however, the environmental reward could exceed initiatives the current focus on equipment or chemical waste.

J Intensive Care Soc
J Intensive Care Soc
INC
spinc
Journal of the Intensive Care Society
1751-1437
2057-360X
SAGE Publications

16 11 2023
2 2024
25 1 Presentation 4: Cat Anderson

Enteral nutrition in Critical Care – There must be another ‘whey’

Food production is responsible for one quarter of global greenhouse emissions. Accordingly, one of the biggest modifiable parts of any individual’s carbon footprint is their diet. This includes practitioners and patients. Changing from a diet reliant on animal-protein to plant-protein could reduce our diet related carbon footprint by over 50%.

In terms of enteral feeding for Intensive Care Unit patients, the traditional protein source for nasogastric (NG) feeds is whey. The protein content of milk is small, meaning we need large volumes of milk to produce that whey. The carbon footprint of milk is a CO2 equivalent (CO2eq) of 5.4 kg/100 g protein. There are also a variety of other animal products used in NG feeds and supplements, such as beef collagen and fish oils.

Pea protein is a better alternative, because it contains all the essential amino acids but only CO2eq of 0.36 kg/100 g protein. It can also be grown in the UK, thereby reducing transportation-related carbon. Pea plants also have symbiotic bacteria in their roots that fix nitrogen, reducing the need for fertilizer. Reducing nitrogen is important given that we have exceeded the high-risk line for nitrogen in the environment.

In the UK we treat approximately 200,000 patients in Critical Care each year, of whom approximately 50% receive NG feed during their stay. The average length of admission is 5 days (according to NHS digital data). European guidelines suggest 1.3–1.5 g/kg/day of protein, and 100 g of protein per day.

A plant-based NG feed has potential to benefit three bottom lines: financial, social and environmental. Switching from whey to pea protein could save 4350 tonnes of CO2eq nationally per year, the equivalent of driving a petrol-car around the world 224 times. An alternative could be insect protein. After all, insects have a complete amino acid profile, a smaller CO2eq (just 0.11 kg/100 g protein), and low land and water usage.

Switching to plant-based NG feeds could significantly reduce the environmental impact of Critical Care Medicine. Furthermore, encouraging a low carbon diet to those that work in Critical Care – namely reducing beef, dairy and lamb in favour of chicken, eggs and plant-based options – would greatly reduce our specialty’s carbon footprint.

Presentation 5: Nina Hjelde

Climate conscious medicine starts with the basics

The sound of the tea trolley rattling through the corridor helps to unify and reenergize staff. My hope is for this noise comes courtesy of china cups, and without any plastic. Similarly, this abstract argues against individual tea packets, and for one enormous teapot. In short, our goal should be to bring staff together while promoting minimal waste and maximal health.

Pollution breeds ill health. This, in turn, generates higher waste. The NHS is already responsible for 4% of the UK’s carbon footprint, yet many feel overwhelmed when asked to address this. Things are worse still in intensive care where we rely so heavily on single use plastic tubes, lines and personal protective equipment.

What we need is a simple place where we can start reducing waste. Sustaining good practice is half the battle when tackling climate change, and a department with good morale is likely to go on and tackle larger sustainable projects.

A staff survey performed after plastic cups were removed showed 100% satisfaction, and that no-one missed the old way. While this is a small endeavour, it is a way to show that changes are achievable and iterative. In fact, the tea trolley can be a platform for advertising further climate initiatives. Regardless, tomorrow’s consultants cannot hope to start influencing climate change when surrounded by the hypocrisy of plastic waste (or luke-warm tea).

ORCID iDs: Catherine Anderson https://orcid.org/0009-0007-5251-9532

Peter George Brindley https://orcid.org/0000-0001-7585-3591
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References

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2 Intensive Care Society. Trustees annual report 2021 [Internet], https://ics.ac.uk/about-us/how-we-re-governed/trustees-annual-reports.html (2021, accessed 12 February 2023).
3 My Carbon Plan. Carbon offset [Internet], https://www.mycarbonplan.org/offset (2022, accessed 12 February 2023).
4 Tol RS. The marginal damage costs of carbon dioxide emissions: an assessment of the uncertainties. Energy Policy 2005; 33 : 2064–2074.
5 Malaria No More. Malaria: bad for business [Internet]. Malaria No More. https://malarianomore.org.uk/file/2286/download?token=DuJHxTdR (2022, accessed 12 February 2023).
