By Jennifer Collins, PhD student in Nursing & Infection, prevention and control with the Safeguarding Health Through Infection Prevention research group at Glasgow Caledonian University. Jennifer has a background in IPC, public health and nursing, with an interest in antimicrobial resistance prevention, planetary health and environmental sustainability.
The movement towards environmental sustainability is growing. As someone with an avid interest in furthering sustainable infection prevention and control (IPC), I spoke to healthcare sustainability leaders to understand their views on ‘Net Zero Healthcare’ and what it means for the IPC community. Graham Pike, lead of the Infection Prevention Society Sustainability Group, and Dr Mahmood Bhutta, specialist in environmental sustainability in healthcare systems, discussed how to move IPC towards an environmentally sustainable healthcare system.
The climate crisis is reshaping industries and healthcare is no exception. The NHS is committing to deliver Net Zero emissions (an equilibrium between the amount of greenhouse gas that’s produced and the amount that’s removed from the atmosphere). However, the challenge is to deliver quality care while reducing healthcare’s environmental impact. Surprisingly, healthcare’s carbon emissions exceed those of aviation and shipping sectors combined—a stark contrast to a system designed to heal, not harm. One growing focus in the sustainability movement is IPC. From single-use items to disinfectants, the practices aimed to prevent infections are now under scrutiny. How is this drive for sustainability reshaping infection prevention and control?
Speaking with Dr Mahmood Bhutta, it’s clear that he sees circularity, facilitated by IPC, as the way forward – a system that focuses on reuse instead of waste generation. “People often see infection control as a barrier to allowing reuse. And of course, let’s be nuanced with that. There are circumstances where you cannot reuse a product because it is unsafe to do so. Things like needles and cannulas, I can’t see those in the foreseeable future becoming reusable. But there are many other circumstances where there is a perception that we cannot reuse, and sometimes that is actually a misconception”.
To Graham Pike, addressing the misconceptions in IPC towards single-use items is the most important first step for IPC professionals when engaging in sustainability. “It’s easy in IPC to want to avoid risks and throw away everything a patient has come into contact with. But that’s the easy option, it’s not using good IPC expertise. The approach we’ve got [in] IPC over the last few years [is to make] everything disposable, [to] use PPE for everything. There’s a real opportunity for people with real IPC expertise to avoid this and say ‘no’”. “It kind of almost takes away the need for that real IPC expertise”. Dr Bhutta’s experience is similar when it comes to overuse and failure to reuse: “I know some doctors who say, ‘oh, well, infection control tells us […]to always use gloves’, and that’s [their] misconception. But equally, it’s also fair to say that we do have some misconceptions from infection control experts who will say things cannot be reused, and that’s perhaps because they don’t have the time or the understanding”.
In order to address this, he believes there is a need for more investigation into the root cause of the issue. “There is a bit of research needed into what people’s understandings of infection control are, both within the infection control community but also outside of that. People are often and quite rightly concerned first and foremost with patient safety, and that’s what we’re all here for, but perhaps there are times where people are not willing to think through things and to take appropriate risks. I find it bizarre as a surgeon. If I was worried only about risk, I wouldn’t operate on anybody ever!”. I have to agree with Dr Bhutta on this, we as IPC professionals really need to weigh the risks appropriately, especially considering that there are serious consequences from planetary damage and warming, including increased respiratory infections, zoonotic diseases and environmental antimicrobial resistance. Our current practices are promoting, on a global scale, the very infections we are trying to overcome.
Additionally, variation in practice is something he suggests we need to address to increase circularity in IPC. “Some hospitals will say, for example, you can use reusable theatre scrub caps, others say absolutely not. That is bizarre because the theatre scrub cap is not in the surgical field., it is just to stop your hair falling into the patient”. “Those who say you can’t do that do so because of a lack of understanding. What has led to a failure to apply infection control principles?” This is a prime example of missing evidence-based practices. In my work I have witnessed hospitals across different countries varying their practice between both reusable and single-use, with those using single-use often quoting ‘infection risk’ as the rationale (It was an example also shared by Graham Pike).
This idea that a fear of infection is driving the use of disposable products is something that has informed a novel concept, so-called ‘yellow washing’, developed by Dr Bhutta. “I’ve come up with this new idea of yellow washing, which is where you use infection control as an excuse for not moving to reduce or reuse of materials that we have in healthcare. The surgical caps [and single-use endoscopes], these are examples of yellow washing: using infection control as an excuse and we just need to stop this”. This idea really struck a chord with me as it is the most common issue I have encountered when advocating for IPC to become more sustainable.
When listening to Graham Pike and Dr Bhutta, I can’t help but think of my own journey towards sustainable IPC and how this was driven by working in humanitarian settings where limitations on supplies really challenge one’s IPC knowledge. When you have to make the safest decisions possible with the equipment available and to return to the traditional basics of IPC, to ask questions such as: What is safe to sterilize? What truly needs to be single-use? This is something Graham Pike highlighted when considering the research needed to implement IPC in a ‘Net Zero’ healthcare system. “We’re trying to go back to the [conventional] ways – the move to single use wasn’t driven by research, but by fear”. Graham Pike sees a need for more evidence showing the effectiveness of older methods, however, he worries that the waiting for a ‘gold standard’ research may slow urgent action on sustainability. “I worry that there are now people who will say, ‘Oh, we better wait for the results of that study before we make our change’. There is evidence out there. Not randomised control trials but [NHS] trusts have been using the methods for years, there’s so many different levels of evidence”.
Although there is a need for IPC professionals to get on board with sustainability at the hospital level and accept their role in protecting the planet, it’s clear both specialists feel there is also a need for work at the policy level. “Having national guidance that talks about it would be really helpful” Graham Pike feels. “At the moment, to do some of the things that you’d like to do, you have to move away from national guidance. It [takes] not just bravery from the IPC team, you know, [but] also from your board”. This need for national support is something Dr Bhutta also agrees with. “We need national policy on these things to say this is the best standards and how we drive that policy forward. More than that, we need to be more ambitious in the way that we look at things”. Having worked on sustainability and IPC internationally, this is something I feel is important not only nationally in the UK, but globally, where variation in IPC practices is even wider.
Addressing policy and behaviour change can seem overwhelming for the average IPC specialist. I questioned our specialists on where individual IPC professionals could start their journey towards sustainability. Dr Bhutta feels that talking is the way forward. “It’s not as pessimistic. What I found is, if you actually go to people and speak to them and talk about this idea of, ‘hey, we don’t want to throw things away’, most people are on board. We’re all busy, but actually go and speak to people […] in areas where you can see a lot of your equipment is being used. I always quote the glove use example and what we found is glove use is very difficult to change. But in my trust, we’ve seen over 90% reduction in my department in ENT simply because someone [Dr Bhutta himself!] was championing it”. It is common knowledge that overuse of gloves inhibits correct handwashing so really this point is win-win for IPC and sustainability.
To Graham Pike, he suggests a practical approach that starts in an unlikely place “I normally suggest people start by looking in their bins and thinking ‘what’s taking up most of the space, what could we use less of, what could we find reusable alternatives for?’”. This is one point I couldn’t agree more with, some great sustainability projects have started from this approach (like Graham’s example of sustainable continence wear). It’s also important to Graham that we echo our sustainability message in our daily lives. “We can’t expect people to make changes unless they see that we are living, breathing it ourselves: moving our bank accounts to banks that don’t fund the fossil fuel industry, changing our electricity supplier to renewable ones, eating less meat and dairy”. His call to action on this is one of being an exemplar. “If we truly believe this is the emergency that the World Health Organization and NHS England and me and others are saying it is, then why wouldn’t we be doing that?”.
The key message from both these experts is that there is a need for action by IPC professionals, and the wider healthcare community, at all levels. If we expect real change toward ‘net zero’ healthcare, we need to act as individuals, healthcare systems, and governments. For IPC professionals, that means questioning ‘the norm’, challenging our beliefs, and weighing up the risks and benefits correctly. As Graham Pike aptly quoted Professor Jennie Wilson “We’ve got to include the planet in our risk assessments”. Whichever method we choose to engage, the overarching message promoted by both sustainability specialists is to take action! Whether this action is to use the exemplar site project report recommended by Graham Pike for examples of an individual NHS trust’s actions or Dr Bhutta’s recommended policy brief ‘Reducing the environmental impact of medical devices adopted for use in the NHS’. There is always a first step to be taken as an IPC professional, even if it’s simply in your personal life. What will yours be?
Has this article inspired you to start your own sustainability journey in your IPC practice? Here are some resources to help:
- Join the Centre for Sustainable Healthcare’s Infection, Prevention & Control Sustainability Network: https://production.networks.sustainablehealthcare.org.uk/infection-prevention-control-sustainability-network/about
- Read these publications:
- Watch this video on the ‘Gloves off’ campaign from IPS
- Complete these free courses from the World Health Organisation:
- AMR in the environment https://openwho.org/courses/amr-environment
- Environment & climate change: https://openwho.org/courses/health-environment-climate-change
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