Green respiratory health care: Time for us all to act

Respiratory physicians are well aware of the risk to their patients from pollution, both outdoor and indoor. As well as having an adverse effect upon the heart and lungs, there is increasing evidence of the involvement of pollution in the causation of diseases such as obesity and dementia and an effect on foetal growth and on semen quality. However, are we as aware as we should be of the contribution of health care, and the way in which we work, to the increasing burden of pollution? The opening of a new hospital is a time for a reappraisal of the way in which we work and the University of Hong Kong-Shenzhen Hospital (HKUSZH) is a hospital committed to delivering and evaluating new ways of working. A regional symposium on 29 October 2017 celebrated the Fifth Anniversary of the hospital opening of was devoted to these issues. The ‘2017 International Green Healthcare Reform Forum’ brought together domestic and foreign government officials, hospital chief executives and prominent medical leaders from a broad range of disciplines to discuss the core issues of medical reform, institutional reform, lean-management constructs, best practice in medical training, cultural innovation and quality and safety, all within the context of global green health (http://mp. weixin.qq.com/s/00nrywElqSLc2f6obTeeUQ or http:// www.szdaily.com/content/2017-10/30/content _17611381.htm). At the forum, Professor Cliff Hughes, immediate past president of the International Society for Quality in Health Care (https://isqua.org/) stated ‘The core of green health care is that people should be responsible in the way they use medical resources. We all need to look at health care and ensure that health care is sustainable’. In Europe, sustainable healthcare initiatives have been initiated and proposed by a European Steering group on Sustainable Healthcare (https://www.abbvie.com/content/dam/abbviecorp/us/ desktop/sustainablehealthcare/images/EU-SustainableHealthcare-White-paper.pdf/, Accessed 13 December 2017), by the British Thoracic Society (https://www. brit-thoracic.org.uk/document-library/audit-and-quality -improvement/environment-and-lung-health/the-envir onment-and-lung-health/, Accessed 13 December 2017) and the Royal College of Physicians of London and National Health Service (https://www.rcplondon. ac.uk/projects/outputs/breaking-fever-sustainability-an d-climate-change-nhs, Accessed 13 December 2017). Medical specialities such as oncology and nephrology have also published papers outlining their approach to greener health care, and there are several published hospital-centred approaches to this issue. But, are respiratory physicians sufficiently engaged in these processes and where might more emphasis be needed? Delivering health care is a complex logistics process involving use of buildings, use of transport, use of personnel, use of materials and disposal of waste. All parts of this process can contribute to pollution and others have described admirable efforts to reduce the contribution of health care by greater attention to the design of hospitals and their heating and lighting and water usage, but many other aspects also require attention. For example, cleaning materials have a prominent role in delivering safe health care and care in their selection and disposal may be of greater importance than in some other environments. Obsession with single-use devices may have a logical safety basis, but they require disposal and are often hard to destroy safely. A universal plastics and single-use products reduction policy would apply to all specialities but there may be possible interventions in respiratory medicine that could be changed overnight. One example is the overuse of the nebulized route of administering bronchodilators despite systematic reviews and international guidelines on both asthma and COPD making it clear that there is no evidence that this route is superior. The speciality did acknowledge the contribution of chlorofluorocarbon propellants in metered-dose inhalers to damage to the ozone layer and the speciality played a significant role in ensuring their safe phasing out under the Montreal protocol. However, the replacement hydrofluoroalkanes themselves are polluting with an adverse effect on global warming and continued vigilance regarding how best to deliver medicines to the airways is needed. Waste due to inefficient processes can similarly contribute to pollution, whether by unnecessary repetition of investigations, unnecessary need for transport because of poor location or co-location of services or multiple clinical records containing duplicate materials because of lack of electronic records or more universal access. A respiratory green task force might address methods by which we might reduce unnecessary travel to hospitals and more clinical follow-up could and should be done by telephone, e-mail, use of the internet or video calls. For example, taking the history from new patients before first face-to-face consultation in a respiratory medicine department has been shown to permit better requesting of investigations with a reduction in overall number of patient attendances at hospital. A new emphasis on motivating our patients, on shared decision-making and supporting them better as they self-manage their own condition would also reduce unnecessary travel and attendance at hospitals. Attention could also be focused on risk stratification strategies. Examples could be the correct use of d-dimer estimation to reduce unnecessary computed tomographic pulmonary angiograms or the use of scoring systems to ensure the correct focusing of resources in