A new Green Paper published by the European Society of Intensive Care Medicine highlights the importance of addressing environmental sustainability in intensive care. Katherine Price speaks to Professor Jan De Waele, who led the work, to find out the context, conclusions and key takeaways of the Green Paper and how frontline intensivists can help to drive the sustainability agenda forwards while maintaining high quality patient care.
Intensive care units (ICUs) are among the most resource-intensive hospital departments, with high levels of energy consumption, waste, reliance on single-use devices, medicines and resource-intensive therapies.
One study found the greenhouse gas emissions per ICU bed per day were more than double that of an acute care bed. This creates a vicious cycle in which ICU emissions are contributing to climate change, which itself is producing more patients, increasingly complex conditions and even new diseases.
Against this backdrop, the European Society of Intensive Care Medicine (ESICM) sought to produce a white paper demonstrating how it is possible to maintain and even enhance patient care at a high standard while limiting the environmental impact of ICU activities.
Objectives included evaluating the impact of climate change on ICUs, the environmental impact of ICU activities, identifying key opportunities to reduce this impact, and developing a framework for initiatives including actionable strategies. The resulting Green Paper entitled ‘Environmental sustainability in intensive care: the path forward‘ was published in October 2024.
Developing the sustainability Green Paper
The ESICM Executive Committee appointed a task force of experts and committee representatives to develop the Green Paper. They worked to identify key areas and actions informed by personal experience, relevant literature and member feedback.
Lead author and task force chair, Professor Jan De Waele, is an intensivist in the surgical ICU at Ghent University Hospital in Belgium. President of the ESICM since October 2024, he was drawn to intensive care medicine by the dynamics of acute disease and multifaceted, fast-changing environment.
‘Intensive care medicine is becoming a speciality in its own right,’ he says. ‘It has become much more complex over the last 20-30 years compared to when I started my training.’
Interested in environmental sustainability, he noticed that while many intensive care professionals were taking steps to be more sustainable in their private lives, this wasn’t necessarily being applied to their practice in the hospital.
‘This Green Paper is not only a practical guide, it’s also a call to action. The fact that we prioritised this hopefully helps people understand that this is an important thing for them, and that it’s not just something that you can switch off when you enter the hospital,’ he explains.
‘It’s an overview of the little information we have right now and trying to give some direction and guidance for our members.’
While he says the intensive care community mirrors society at large in that there is a growing awareness of the importance of environmental sustainability, equally, there are those who turn a blind eye to the problem or resist change, presenting a challenge to the task force and the aims of the Green Paper.
‘There is, of course, always some resistance. Climate change is still something that is contested around the world and, based on recent trends in international politics, one may expect that we still have some work to do,’ Professor De Waele says.
Categorising sustainable actions
As well as highlighting four main areas for strategies and solutions – clinical care; research and innovation; awareness and education; and ESICM leadership – the Green Paper categorises actions into three tiers.
Tier 1 actions require minimal resources and can quickly contribute to environmental sustainability, such as energy-saving measures, training and promoting reusables. Tier 2 actions require more investment and coordination but can result in significant benefits, for example digitising communications and recordkeeping, or investing in more energy-efficient equipment. Tier 3 includes highly impactful actions that may require considerable investment, long-term planning, like sourcing renewable energy and retrofitting buildings, and cultural change within an organisation.
Intensivists and other intensive care professionals are encouraged to contribute to a multidisciplinary ‘green team’ and evaluate systems and processes to identify low-value clinical practices that could be changed or removed to reduce costs and environmental burden but also improve patient care. Professor De Waele explains that this includes ‘unnecessary lab tests, examinations, having patients in the hospital for too long’, among others.
The paper also lists recommendations for the ESICM itself, such as developing sustainability educational pathways, embedding the topic into courses and organising an annual sustainability conference.
Embracing sustainable clinical and research practices
Professor De Waele hopes the main takeaway for intensivists is ‘that what we do in the ICU does significantly impact the environment’ and that to mitigate this goes beyond switching the lights off.
‘Part of the resistance to environmental sustainability is often rooted in the fact that people think, “people are taking things away from me”. But it’s more than that, it’s added value,’ he explains, noting that there’s much more to do. For example, integrating sustainability into research, such as including the environmental impact of a new drug or intervention in the outcome measures.
The Green Paper also stresses the ‘critical’ need to develop flexible sustainability strategies that can be adapted to local needs, resources and conditions. Initiatives that have been seen across Europe include the UK Intensive Care Society’s Gloves Off in Critical Care campaign or efforts in the Netherlands to reduce the amount of paracetamol delivered intravenously in ICUs.
‘There is no uniform solution for every unit and country. You need to look at the low-hanging fruit, and the best to see that are those working at the bedside – the nurses and clinicians,’ explains Professor De Waele.
Green teams, he says, need to be multidisciplinary to ensure initiatives are rooted in clinical practice, are context specific and work for all members of the team – and the best place for teams to start is by focusing on actions that reduce environmental impact but also save time, money and maintain quality of care.
Evolving throughout 2025
Priorities for the ESICM for 2025 include updating the Surviving Sepsis Campaign guidelines, which are expected to be published within the next 12 months, as well as addressing the Green Paper’s recommendations – towards which the environmental sustainability task force will evolve into a formal multidisciplinary environmental sustainability committee.
The ESICM plans to provide research grants and set up infrastructure to support knowledge exchange on sustainable ICU practice, such as hosting an annual online sustainability conference. There is also work to be done on making ESICM operations more sustainable and engaging with patient and community groups to ensure people understand why changes are being made and that they will not compromise patient care.
‘Now we need to bring this to the bedside, to our members,’ says Professor De Waele. ‘We’ve laid out a number of ideas and solutions, but now it’s up to us – and all of us, not only the ESICM – to solve it and take it seriously and take action.’
