Environmental and financial impacts of perioperative paracetamol use: a multicentre international life-cycle analysis.

BACKGROUND: Pharmaceuticals account for 19-32% of healthcare greenhouse gas (GHG) emissions. Paracetamol is a common perioperative analgesic agent. We estimated GHG emissions associated with i.v. and oral formulations of paracetamol used in the perioperative period. METHODS: Life-cycle assessment of GHG emissions (expressed as carbon dioxide equivalents CO2e) of i.v. and oral paracetamol preparations was performed. Perioperative paracetamol prescribing practices and costs for 26 hospitals in USA, UK, and Australia were retrospectively audited. For those surgical patients for whom oral formulations were indicated, CO2e and costs of actual prescribing practices for i.v. or oral doses were compared with optimal oral prescribing. RESULTS: The carbon footprint for a 1 g dose was 38 g CO2e (oral tablet), 151 g CO2e (oral liquid), and 310-628 g CO2e (i.v. dependent on type of packaging and administration supplies). Of the eligible USA patients, 37% received paracetamol (67% was i.v.). Of the eligible UK patients, 85% received paracetamol (80% was i.v.). Of the eligible Australian patients, 66% received paracetamol (70% was i.v.). If the emissions mitigation opportunity from substituting oral tablets for i.v. paracetamol is extrapolated to USA, UK, and Australia elective surgical encounters in 2019, ∼5.7 kt CO2e could have been avoided and would save 98.3% of financial costs. CONCLUSIONS: Intravenous paracetamol has 12-fold greater life-cycle carbon emissions than the oral tablet form. Glass vials have higher greenhouse gas emissions than plastic vials. Intravenous administration should be reserved for cases in which oral formulations are not feasible.

Advance care planning for patients with COVID-19: a communication guide.

In view of the high morbidity and mortality associated with COVID-19, early and honest conversations with patients about goals of care are vital. Advance care planning in its traditional manner may be difficult to achieve given the unpredictability of the disease trajectory. Despite this, it is crucial that patients' care wishes are explored as this will help prevent inappropriate admissions to hospital and to critical care, improve symptom control and advocate for patient choice. This article provides practical tips on how to translate decisions around treatment escalation plans into conversations, both face-to-face and over the phone, in a sensitive and compassionate manner. Care planning conversations for patients with COVID-19 should be individualised and actively involve the patient. Focusing on goals of care rather than ceilings of treatment can help to alleviate anxiety around these conversations and will remind patients that their care will never cease. Using a framework such as the 'SPIKES' mnemonic can help to structure this conversation. Verbally conveying empathy will be key, particularly when wearing personal protective equipment or speaking to relatives over the phone. It is also important to make time to recognise your own emotions during and/or after these conversations.

Education for sustainable health care: From learning to professional practice.

A number of planetary boundaries, including climate change as a result of greenhouse gas emissions, has already been exceeded. This situation has deleterious consequences for public health. Paradoxically, 4.4% of these emissions are attributable to the healthcare sector. These problems have not been sufficiently acknowledged in health professions curricula. This paper addresses two main issues, humanistic learning and the application of knowledge acquisition to clinical practice. Humanistic learning principles can be used to emphasize learner-centered approaches, including knowledge acquisition and reflection to increase self-awareness. Applying humanistic principles in everyday life and clinical practice can encourage stewardship, assisting students to become agents for change. In terms of knowledge and skills application to clinical practice, an overview of varied and novel approaches of how sustainable education can be integrated at different stages of training across several health care professions is provided. The Health and Environment Adaptive Response Taskforce (HEART) platform as an example of creating empowered learners, the NurSusTOOLKIT, a multi-disciplinary collaboration offering free adaptable educational resources for educators and the Greener Anaesthesia and Sustainability Project (GASP), an example of bridging the transition to clinical practice, are described.