Purpose The healthcare sector is responsible for 6–7% of CO₂ emissions. The intensive care unit (ICU) contributes to these CO₂ emissions and a shift from a linear system to a circular system is needed. The aim of our research was to perform a material flow analysis (MFA) in an academic ICU. Secondary aims were to obtain information and numbers on mass, carbon footprint, agricultural land occupation and water usage and to determine so-called “environmental hotspots” in the ICU. Methods A material flow analysis was performed over the year 2019, followed by an environmental footprint analysis of materials and environmental hotspot identification. Results 2839 patients were admitted to our ICU in 2019. The average length of stay was 4.6 days. Our MFA showed a material mass inflow of 247,000 kg in 2019 for intensive care, of which 50,000 kg is incinerated as (hazardous) hospital waste. The environmental impact per patient resulted in 17 kg of mass, 12 kg CO₂ eq, 300 L of water usage and 4 m² of agricultural land occupation per day. Five hotspots were identified: non-sterile gloves, isolation gowns, bed liners, surgical masks and syringes (including packaging). Conclusion This is the first material flow analysis that identified environmental risks and its magnitude in the intensive care unit.

Purpose The European Society of Intensive Care Medicine (ESICM) Green Paper aims to address the challenge of environmental sustainability in intensive care and proposes actionable strategies for integrating sustainability into intensive care unit (ICU) stakeholder actions. Methods The ESICM Executive Committee appointed a task force of topic experts and ESICM committee representatives to develop the ESICM Green Paper. The task force convened biweekly from January to June 2024, identifying key domains for environmental sustainability and prioritizing actions. Drafts were iteratively refined and approved by the ESICM Executive Committee. Results Climate change will impact activities in intensive care in many ways, but also the impact of ICU activities on the environment is considerable; drivers for this include extensive resource use and waste generation in ICUs from energy consumption, use of disposable items, and advanced therapies for critically ill patients. The ESICM Green Paper outlines a structured approach for ICUs to reduce their environmental impact, emphasizing energy efficiency, waste reduction, and sustainable procurement. Furthermore, it endorses the need for awareness and education among healthcare professionals, integration of sustainability into research, and sustainable policies within scientific societies. Conclusions The ESICM Green Paper reviewed the relevance of climate change to intensive care and provided suggestions for clinical practice, research, education, and ESICM organizational domains. It underscores that reducing intensive care's ecological footprint can coexist with high-quality patient care. Promoting a resilient, responsible healthcare system is a joint responsibility of all ICU stakeholders.

Medication errors occur frequently in the intensive care unit (ICU) and during care transitions. Chronic medication is often temporarily stopped at the ICU. Unfortunately, when the patient improves, the restart of this medication is easily forgotten. Moreover, temporal ICU medication is often unintentionally continued after ICU discharge. Medication reconciliation could be useful to prevent such errors. Therefore, the aim of this study was to determine the effect of medication reconciliation at the ICU. This prospective 8-month study with a pre- and post-design was carried out in two ICU settings in the Netherlands. Patients were included when they used ≥ 1 chronic medicine and when the ICU stay exceeded 24 h. The intervention consisted of medication reconciliation by pharmacists at the moment of ICU admission and prior to ICU discharge. Medication transfer errors (MTEs) were collected and the severity of potential harm of these MTEs was measured, based on a potential adverse drug event score (pADE = 0; 0.01; 0.1; 0.4; 0.6). Primary outcome measures were the proportions of patients with ≥ 1 MTE at ICU admission and after discharge. Secondary outcome measures were the proportions of patients with a pADE score ≥ 0.01 due to these MTEs, the severity of the pADEs and the associated costs. Odds ratio and 95% confidence intervals were calculated, by using a multivariate logistic regression analysis. In the pre-intervention phase, 266 patients were included and 212 in the post-intervention phase. The proportion of patients with ≥ 1 MTE at ICU admission was reduced from 45.1 to 14.6% (ORadj 0.18 [95% CI 0.11–0.30]) and after discharge from 73.9 to 41.2% (ORadj 0.24 [95% CI 0.15–0.37]). The proportion of patients with a pADE ≥ 0.01 at ICU admission was reduced from 34.8 to 8.0% (ORadj 0.13 [95% CI 0.07–0.24]) and after discharge from 69.5 to 36.2% (ORadj 0.26 [95% CI 0.17–0.40]). The pADE reduction resulted in a potential net cost–benefit of € 103 per patient. Medication reconciliation by pharmacists at ICU transfers is an effective safety intervention, leading to a significant decrease in the number of MTE and a cost-effective reduction in potential harm. Trial registration Dutch trial register: NTR4159, 5 September 2013, retrospectively registered

Aims and objectives: To identify the prevalence and determinants of medication administration errors (MAEs).Background: Insight into determinants of MAEs is necessary to identify interventions to prevent MAEs.Design: A prospective observational study in two Dutch hospitals, a university and teaching hospital.Methods: Data were collected by observation. The primary outcome was the proportion of administrations with one or more MAEs. Secondary outcomes were the type, severity and determinants of MAEs. Multivariable mixed‐effects logistic regression analyses were used for determinant analysis. Reporting adheres to the STROBE guideline.Results: MAEs occurred in 352 of 2576 medication administrations (13.7%). Of all MAEs (n = 380), the most prevalent types were omission (n = 87) and wrong medication handling (n = 75). Forty‐five MAEs (11.8%) were potentially harmful. The pharmaceutical forms oral liquid (odds ratio [OR] 3.22, 95% confidence interval [CI] 1.43–7.25), infusion (OR 1.73, CI 1.02–2.94), injection (OR 3.52, CI 2.00–6.21), ointment (OR 10.78, CI 2.10–55.26), suppository/enema (OR 6.39, CI 1.13–36.03) and miscellaneous (OR 6.17, CI 1.90–20.04) were more prone to MAEs compared to oral solid. MAEs were more likely to occur when medication was administered between 10 a.m.–2 p.m. (OR 1.91, CI 1.06–3.46) and 6 p.m.–7 a.m. (OR 1.88, CI 1.00–3.52) compared to 7 a.m.–10 a.m. and when administered by staff with higher professional education compared to staff with secondary vocational education (OR 1.68, CI 1.03–2.74). MAEs were less likely to occur in the teaching hospital (OR 0.17, CI 0.08–0.33). Day of the week, patient‐to‐nurse ratio, interruptions and other nurse characteristics (degree, experience, employment type) were not associated with MAEs.Conclusions: This study identified a high MAE prevalence. Identified determinants suggest that focusing interventions on complex pharmaceutical forms and error‐prone administration times may contribute to MAE reduction.Relevance to clinical practice: The findings of this study can be used to develop targeted interventions to improve patient safety.

Background: Voriconazole is one of the first-line therapies for invasive pulmonary aspergillosis. Drug concentrations might be significantly influenced by the use of extracorporeal membrane oxygenation (ECMO). We aimed to assess the effect of ECMO on voriconazole exposure in a large patient population. Methods: Critically ill patients from eight centers in four countries treated with voriconazole during ECMO support were included in this retrospective study. Voriconazole concentrations were collected in a period on ECMO and before/after ECMO treatment. Multivariate analyses were performed to evaluate the effect of ECMO on voriconazole exposure and to assess the impact of possible saturation of the circuit’s binding sites over time. Results: Sixty-nine patients and 337 samples (190 during and 147 before/after ECMO) were analyzed. Subtherapeutic concentrations (<2 mg/L) were observed in 56% of the samples during ECMO and 39% without ECMO (p = 0.80). The median trough concentration, for a similar daily dose, was 2.4 (1.2–4.7) mg/L under ECMO and 2.5 (1.4–3.9) mg/L without ECMO (p = 0.58). Extensive inter-and intrasubject variability were observed. Neither ECMO nor squared day of ECMO (saturation) were retained as significant covariates on voriconazole exposure. Conclusions: No significant ECMO-effect was observed on voriconazole exposure. A large proportion of patients had voriconazole subtherapeutic concentrations.

Background: The healthcare sector is responsible for 7% of greenhouse gas (GHG) emissions in the Netherlands. However, this is not well understood on an organizational level. This research aimed to assess the carbon footprint of the Erasmus University Medical Center to identify the driving activities and sources.Methods: A hybrid approach was used, combining a life cycle impact assessment and expenditure-based method, to quantify the hospital’s carbon footprint for 2021, according to scope 1 (direct emissions), 2 (indirect emissions from purchased energy), and 3 (rest of indirect emissions) of the GHG Protocol. Results were disaggregated by categories of purchased goods and services, medicines, specific product groups, and hospital departments.Results: The hospital emitted 209.5 kilotons of CO2-equivalent, with scope 3 (72.1%) as largest contributor, followed by scope 2 (23.1%) and scope 1 (4.8%). Scope 1 was primarily determined by stationary combustion and scope 2 by purchased electricity. Scope 3 was driven by purchased goods and services, of which medicines accounted for 41.6%. Other important categories were medical products, lab materials, prostheses and implants, and construction investment. Primary contributing departments were Pediatrics, Real Estate, Neurology, Hematology, and Information & Technology.Conclusion: This is the first hybrid analysis of the environmental impact of an academic hospital across all its activities and departments. It became evident that the footprint is mainly determined by the upstream effects in external supply chains. This research underlines the importance of carbon footprinting on an organizational level, to guide future sustainability strategies.