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1. Australian and Canadian clinicians’ views and application of ‘carbon health literacy’: a qualitative study

Author: Michelle Lynch, Kirsten McCaffery, Alexandra Barratt, Katy Bell, Fiona A. Miller, Forbes McGain, Philomena Colagiuri, and Kristen Pickles
Subjects: Carbon, Greenhouse gases, Environmental sustainability, Clinician, Health professional, Knowledge, Public aspects of medicine, RA1-1270
Abstract: Abstract Background Clinical care contributes to at least 50% of the greenhouse gas (GHG) emissions of healthcare. This includes the 40% of healthcare that is harmful or low value, adding avoidable emissions without improving health or quality of care. Clinicians are well-placed to mitigate emissions associated with the provision of clinical care. This study aimed to explore clinicians’ views on a new construct we have termed ‘carbon health literacy’ to understand how knowledge, skills and capacities related to the emissions of clinical care has application in clinical practice. Methods Qualitative interviews were conducted between August 2022 and February 2023 with clinicians from Australia (n = 15) and Canada (n = 13). Clinicians with an interest in climate change and healthcare sustainability were sampled from a variety of clinical specialty areas, such as primary care, nursing, anaesthetics, and emergency. Clinicians were recruited through advertising on social media and via professional networks. A pre-piloted interview schedule was used to guide the interviews. Interviews were audio recorded, transcribed verbatim and analysed using framework analysis. Results Participants viewed carbon health literacy as an increasingly important skill for clinicians to have or acquire, though they reported that the level of carbon health literacy and knowledge needed varies by job roles, clinical specialty areas, and individual capacity to generate healthcare system change. Many clinicians reported implementing strategies to mitigate their work-related GHG emissions, such as reducing waste or choosing lower carbon commuting options. There was limited awareness of reducing low-value care as a strategy to decrease emissions. All participants had encountered barriers to providing low-carbon care, including managing patient expectations, inadequate training and information, and limited capacity to generate system change in their organisational roles. Conclusions To support the delivery of high value low carbon healthcare, work is needed to build the carbon health literacy of clinicians and remove other barriers currently impeding their capacity to practice and promote sustainable clinical care.
Published: 2024
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2. Behavioural change interventions encouraging clinicians to reduce carbon emissions in clinical activity: a systematic review

Author: Carys Batcup, Matilde Breth-Petersen, Thomas Dakin, Alexandra Barratt, Forbes McGain, Ben R. Newell, and Kristen Pickles
Subjects: Behaviour change, Carbon emissions, Intervention, Healthcare delivery, Clinical activity, Clinicians, Public aspects of medicine, RA1-1270
Abstract: Abstract Background Clinical activity accounts for 70–80% of the carbon footprint of healthcare. A critical component of reducing emissions is shifting clinical behaviour towards reducing, avoiding, or replacing carbon-intensive healthcare. The objective of this systematic review was to find, map and assess behaviour change interventions that have been implemented in healthcare settings to encourage clinicians to reduce greenhouse gas emissions from their clinical activity. Methods Studies eligible for inclusion were those reporting on a behaviour change intervention to reduce carbon emissions via changes in healthcare workplace behaviour. Six databases were searched in November 2021 (updated February 2022). A pre-determined template was used to extract data from the studies, and risk of bias was assessed. The behaviour change techniques (BCTs) used in the interventions were coded using the BCT Taxonomy. Results Six full-text studies were included in this review, and 14 conference abstracts. All studies used a before-after intervention design. The majority were UK studies (n = 15), followed by US (n = 3) and Australia (n = 2). Of the full-text studies, four focused on reducing the emissions associated with anaesthesia, and two aimed at reducing unnecessary test ordering. Of the conference abstracts, 13 focused on anaesthetic gas usage, and one on respiratory inhalers. The most common BCTs used were social support, salience of consequences, restructuring the physical environment, prompts and cues, feedback on outcome of behaviour, and information about environmental consequences. All studies reported success of their interventions in reducing carbon emissions, prescribing, ordering, and financial costs; however, only two studies reported the magnitude and significance of their intervention’s success. All studies scored at least one item as unclear or at risk of bias. Conclusion Most interventions to date have targeted anaesthesia or pathology test ordering in hospital settings. Due to the diverse study outcomes and consequent inability to pool the results, this review is descriptive only, limiting our ability to conclude the effectiveness of interventions. Multiple BCTs were used in each study but these were not compared, evaluated, or used systematically. All studies lacked rigour in study design and measurement of outcomes. Review registration The study was registered on Prospero (ID number CRD42021272526) (Breth-Petersen et al., Prospero 2021: CRD42021272526).
Published: 2023
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3. Health, financial and environmental impacts of unnecessary vitamin D testing: a triple bottom line assessment adapted for healthcare

Author: Alexandra Barratt, Katy Bell, Kristen Pickles, Scott McAlister, Forbes McGain, and Matilde Breth-Petersen
Subjects: Medicine
Abstract: Objective To undertake an assessment of the health, financial and environmental impacts of a well-recognised example of low-value care; inappropriate vitamin D testing.Design Combination of systematic literature search, analysis of routinely collected healthcare data and environmental analysis.Setting Australian healthcare system.Participants Population of Australia.Outcome measures We took a sustainability approach, measuring the health, financial and environmental impacts of a specific healthcare activity. Unnecessary vitamin D testing rates were estimated from best available published literature; by definition, these provide no gain in health outcomes (in contrast to appropriate/necessary tests). Australian population-based test numbers and healthcare costs were obtained from Medicare for vitamin D pathology services. Carbon emissions in kg CO2e were estimated using data from our previous study of the carbon footprint of common pathology tests. We distinguished between tests ordered as the primary test and those ordered as an add-on to other tests, as many may be done in conjunction with other tests. We conducted base case (8% being the primary reason for the blood test) and sensitivity (12% primary test) analyses.Results There were a total of 4 457 657 Medicare-funded vitamin D tests in 2020, on average one test for every six Australians, an 11.8% increase from the mean 2018–2019 total. From our literature review, 76.5% of Australia’s vitamin D tests provide no net health benefit, equating to 3 410 108 unnecessary tests in 2020. Total costs of unnecessary tests to Medicare amounted to >$A87 000 000. The 2020 carbon footprint of unnecessary vitamin D tests was 28 576 kg (base case) and 42 012 kg (sensitivity) CO2e, equivalent to driving ~160 000–230 000 km in a standard passenger car.Conclusions Unnecessary vitamin D testing contributes to avoidable CO2e emissions and healthcare costs. While the footprint of this example is relatively small, the potential to realise environmental cobenefits by reducing low-value care more broadly is significant.
Published: 2022
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4. The carbon footprint of hospital diagnostic imaging in Australia

Author: Scott McAlister, Forbes McGain, Matilde Petersen, David Story, Kate Charlesworth, Glenn Ison, and Alexandra Barratt
Subjects: Diagnostic imaging, Carbon footprint, Life cycle assessment, Net-zero carbon, Aging, Comorbidities, Public aspects of medicine, RA1-1270
Abstract: Summary: Background: Pathology testing and diagnostic imaging together contribute 9% of healthcare's carbon footprint. Whilst the carbon footprint of pathology testing has been undertaken, to date, the carbon footprint of the four most common imaging modalities is unclear. Methods: We performed a prospective life cycle assessment at two Australian university-affiliated health services of five imaging modalities: chest X-ray (CXR), mobile chest X-ray (MCXR), computerised tomography (CT), magnetic resonance imaging (MRI) and ultrasound (US). We included scanner electricity use and all consumables and associated waste, including bedding, imaging contrast, and gloves. Analysis was performed using both attributional and consequential life cycle assessment methods. The primary outcome was the greenhouse gas footprint, measured in carbon dioxide equivalent (CO2e) emissions. Findings: Mean CO2e emissions were 17·5 kg/scan for MRI; 9·2 kg/scan for CT; 0·8 kg/scan for CXR; 0·5 kg/scan for MCXR; and 0·5 kg/scan for US. Emissions from scanners from standby energy were substantial. When expressed as emissions per additional scan (results of consequential analysis) impacts were lower: 1·1 kg/scan for MRI; 1·1 kg/scan for CT; 0·6 kg/scan for CXR; 0·1 kg/scan for MCXR; and 0·1 kg/scan for US, due to emissions from standby power being excluded. Interpretation: Clinicians and administrators can reduce carbon emissions from diagnostic imaging, firstly by reducing the ordering of unnecessary imaging, or by ordering low-impact imaging (X-ray and US) in place of high-impact MRI and CT when clinically appropriate to do so. Secondly, whenever possible, scanners should be turned off to reduce emissions from standby power. Thirdly, ensuring high utilisation rates for scanners both reduces the time they spend in standby, and apportions the impacts of the reduced standby power of a greater number of scans. This therefore reduces the impact on any individual scan, maximising resource efficiency. Funding: Healthy Urban Environments (HUE) Collaboratory of the Maridulu Budyari Gumal Sydney Partnership for Health, Education, Research and Enterprise MBG SPHERE. The National Health and Medical Research Council (NHMRC) PhD scholarship
Published: 2022
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5. Air exchanges, climate change, and severe acute respiratory coronavirus virus 2 (SARS-CoV-2): Results from a survey of the Society of Healthcare Epidemiology of America Research Network (SRN)

Author: Jason P. Burnham, Fred Betz, Roger Lautz, Ehsan Mousavi, Richard A. Martinello, Forbes McGain, and Jodi D. Sherman
Subjects: air exchanges, climate change, COVID-19, HVAC, operating rooms, Infectious and parasitic diseases, RC109-216, Public aspects of medicine, RA1-1270
Abstract: In this cross-sectional survey, we assessed knowledge, attitudes and behaviors regarding operating room air-change rates, climate change, and coronavirus disease 2019 (COVID-19) pandemic implications. Climate change and healthcare pollution were considered problematic. Respondents checked air exchange rates for COVID-19 and ∼25% increased them. Respondents had difficulty completing questions concerning hospital heating, ventilation and air conditioning (HVAC) systems.
Published: 2022
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6. Planetary health care: a framework for sustainable health systems

Author: Andrea J MacNeill, Forbes McGain, and Jodi D Sherman
Subjects: Environmental sciences, GE1-350
Published: 2021
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7. The Melbourne epidemic thunderstorm asthma event 2016: an investigation of environmental triggers, effect on health services, and patient risk factors

Author: Prof Francis Thien, MD, Paul J Beggs, PhD, Danny Csutoros, MPH, Jai Darvall, MBBS, Mark Hew, PhD, Janet M Davies, PhD, Prof Philip G Bardin, PhD, Tony Bannister, BSc, Sara Barnes, MBBS, Prof Rinaldo Bellomo, MD, Timothy Byrne, MBBS, Andrew Casamento, MBBS, Matthew Conron, MD, Anthony Cross, MBBS, Ashley Crosswell, MBBS, Prof Jo A Douglass, MD, Matthew Durie, MBBS, John Dyett, MBBS, Elizabeth Ebert, PhD, Bircan Erbas, PhD, Craig French, MBBS, Ben Gelbart, MBBS, Andrew Gillman, MBBS, Nur-Shirin Harun, MBBS, Alfredo Huete, PhD, Louis Irving, MBBS, Dharshi Karalapillai, MBBS, David Ku, MBBS, Philippe Lachapelle, MD, David Langton, MPH, Joy Lee, MBChB, Clare Looker, MBBS, Christopher MacIsaac, PhD, Joseph McCaffrey, MBBS, Prof Christine F McDonald, PhD, Forbes McGain, PhD, Edward Newbigin, PhD, Prof Robyn O'Hehir, PhD, David Pilcher, MBBS, Shivonne Prasad, MBChB, Kanishka Rangamuwa, MBBS, Laurence Ruane, BSc, Vineet Sarode, MD, Jeremy D Silver, PhD, Anne Marie Southcott, MBBS, Ashwin Subramaniam, MMed, Cenk Suphioglu, PhD, Nugroho Harry Susanto, MD, Michael F Sutherland, PhD, Gopal Taori, MBBS, Philip Taylor, PhD, Paul Torre, PhD, Joseph Vetro, MBBS, Geoffrey Wigmore, MBBS, Alan C Young, PhD, and Prof Charles Guest, PhD
Subjects: Environmental sciences, GE1-350
Abstract: Background: A multidisciplinary collaboration investigated the world's largest, most catastrophic epidemic thunderstorm asthma event that took place in Melbourne, Australia, on Nov 21, 2016, to inform mechanisms and preventive strategies. Methods: Meteorological and airborne pollen data, satellite-derived vegetation index, ambulance callouts, emergency department presentations, and data on hospital admissions for Nov 21, 2016, as well as leading up to and following the event were collected between Nov 21, 2016, and March 31, 2017, and analysed. We contacted patients who presented during the epidemic thunderstorm asthma event at eight metropolitan health services (each including up to three hospitals) via telephone questionnaire to determine patient characteristics, and investigated outcomes of intensive care unit (ICU) admissions. Findings: Grass pollen concentrations on Nov 21, 2016, were extremely high (>100 grains/m3). At 1800 AEDT, a gust front crossed Melbourne, plunging temperatures 10°C, raising humidity above 70%, and concentrating particulate matter. Within 30 h, there were 3365 (672%) excess respiratory-related presentations to emergency departments, and 476 (992%) excess asthma-related admissions to hospital, especially individuals of Indian or Sri Lankan birth (10% vs 1%, p
Published: 2018
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8. The carbon footprint of Australian health care

Author: Arunima Malik, PhD, Prof Manfred Lenzen, PhD, Scott McAlister, MEngSci, and Forbes McGain, PhD
Subjects: Environmental sciences, GE1-350
Abstract: Background: Carbon footprints stemming from health care have been found to be variable, from 3% of the total national CO2 equivalent (CO2e) emissions in England to 10% of the national CO2e emissions in the USA. We aimed to measure the carbon footprint of Australia's health-care system. Methods: We did an observational economic input–output lifecycle assessment of Australia's health-care system. All expenditure data were obtained from the 15 sectors of the Australian Institute of Health and Welfare for the financial year 2014–15. The Australian Industrial Ecology Virtual Laboratory (IELab) data were used to obtain CO2e emissions per AUS$ spent on health care. Findings: In 2014–15 Australia spent $161·6 billion on health care that led to CO2e emissions of about 35 772 (68% CI 25 398–46 146) kilotonnes. Australia's total CO2e emissions in 2014–15 were 494 930 kilotonnes, thus health care represented 35 772 (7%) of 494 930 kilotonnes total CO2e emissions in Australia. The five most important sectors within health care in decreasing order of total CO2e emissions were: public hospitals (12 295 [34%] of 35 772 kilotonnes CO2e), private hospitals (3635 kilotonnes [10%]), other medications (3347 kilotonnes [9%]), benefit-paid drugs (3257 kilotonnes [9%]), and capital expenditure for buildings (2776 kilotonnes [8%]). Interpretation: The carbon footprint attributed to health care was 7% of Australia's total; with hospitals and pharmaceuticals the major contributors. We quantified Australian carbon footprint attributed to health care and identified health-care sectors that could be ameliorated. Our results suggest the need for carbon-efficient procedures, including greater public health measures, to lower the impact of health-care services on the environment. Funding: None.
Published: 2018
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9. The Green Print: Advancement of Environmental Sustainability in Healthcare

Author: Sherman, Jodi D., Thiel, Cassandra, MacNeill, Andrea, Eckelman, Matthew J., Dubrow, Robert, Hopf, Harriet, Lagasse, Robert, Bialowitz, Joseph, Costello, Anthony, Forbes, McGain, Stancliffe, Rachel, Anastas, Paul, Anderko, Laura, Baratz, Mark, Barna, Stefi, Bhatnagar, Urvashi, Burnham, Jason, Cai, Yizhen, Cassels-Brown, Andy, Cimprich, Alexander F.P., Cole, Heidi, Coronado-Garcia, Lorea, Duane, Brett, Grisotti, Gabriella, Hartwell, Arthy, Kumar, Varshini, Kurth, Ann, Leapman, Michael, Morris, Daniel S., Overcash, Michael, Parvatker, Abhijeet G., Pencheon, David, Pollard, Adam, Robaire, Bernard, Rockne, Karl, Sadler, Blair L., Schenk, Beth, Sethi, Tushar, Sussman, L. Scott, Thompson, Jeff, Twomey, Janet M., Vermund, Sten H., Vukelich, Daniel, Wasim, Natasha, Wilson, Debbie, Young, Steven B., Zimmerman, Julie, and Bilec, Melissa M.
Published: 2020
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10. Learning to treat the climate emergency together: social tipping interventions by the health community

Author: Courtney Howard, Andrea J MacNeill, Fintan Hughes, Lujain Alqodmani, Kate Charlesworth, Roberto de Almeida, Roger Harris, Bruno Jochum, Edward Maibach, Lwando Maki, Forbes McGain, Jeni Miller, Monica Nirmala, David Pencheon, Scott Robertson, Jodi D Sherman, Joe Vipond, Hao Yin, and Hugh Montgomery
Subjects: Health (social science), Health Policy, Public Health, Environmental and Occupational Health, Medicine (miscellaneous)
Published: 2023
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11. Aerosol Generation During High Intensity Exercise—Implications for COVID-19 Transmission

Author: Brian Cowie, Imogen Wadlow, Andrew Yule, Kristel Janssens, Jason Ward, Steve Foulkes, Ruhi Humphries, Forbes McGain, Rana Dhillon, and André La Gerche
Subjects: Pulmonary and Respiratory Medicine, Cardiology and Cardiovascular Medicine
Abstract: COVID-19 can be transmitted through aerosolised respiratory particles. The degree to which exercise enhances aerosol production has not been previously assessed. We aimed to quantify the size and concentration of aerosol particles and evaluate the impact of physical distance and surgical mask wearing during high intensity exercise (HIE).Using a prospective observational crossover study, three healthy volunteers performed high intensity cardiopulmonary exercise testing at 80% of peak capacity in repeated 5-minute bouts on a cycle ergometer. Aerosol size and concentration was measured at 35, 150 and 300 cm from the participants in an anterior and lateral direction, with and without a surgical face mask, using an Aerodynamic Particle Sizer (APS) and a Mini Wide Range Aerosol Spectrometer (MiniWRAS), with over 10,000 sample points.High intensity exercise generates aerosol in the 0.2-1 micrometre range. Increasing distance from the rider reduces aerosol concentrations measured by both MiniWRAS (p=0.003 for interaction) and APS (p=0.041). However, aerosol concentrations remained significantly increased above baseline measures at 300 cm from the rider. A surgical face mask reduced submicron aerosol concentrations measured anteriorly to the rider (p=0.031 for interaction) but not when measured laterally (p=0.64 for interaction).High intensity exercise is an aerosol generating activity. Significant concentrations of aerosol particles are measurable well beyond the commonly recommended 150 cm of physical distancing. A surgical face mask reduces aerosol concentration anteriorly but not laterally to an exercising individual. Measures for safer exercise should emphasise distance and airflow and not rely solely on mask wearing.
Published: 2023
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12. The Effect of an Accelerated Renal Replacement Therapy Initiation Is Not Modified by Baseline Risk

Author: Federico Angriman, Bruno L. Ferreyro, Natalia Angeloni, Bruno R. da Costa, Ron Wald, Sean M. Bagshaw, Neill K.J. Adhikari, Rinaldo Bellomo, Didier Dreyfuss, Bin Du, Martin P. Gallagher, Stéphane Gaudry, François Lamontagne, Michael Joannidis, Kathleen D. Liu, Daniel F. McAuley, Shay P. McGuinness, Alistair D. Nichol, Marlies Ostermann, Paul M. Palevsky, Haibo Qiu, Ville Pettilä, Antoine G. Schneider, Orla M. Smith, Suvi T. Vaara, Matthew Weir, Glenn M. Eastwood, Leah Peck, Helen Young, Peter Kruger, Gordon Laurie, Emma Saylor, Jason Meyer, Ellen Venz, Krista Wetzig, Craig French, Forbes McGain, John Mulder, Gerard Fennessy, Sathyajith Koottayi, Samantha Bates, Miriam Towns, Rebecca Morgan, Anna Tippett, Andrew Udy, Chris Mason, Elisa Licari, Dashiell Gantner, Jason McClure, Alistair Nichol, Phoebe McCracken, Jasmin Board, Emma Martin, Shirley Vallance, Meredith Young, Chelsey Vladic, Steve McGloughlin, David Gattas, Heidi Buhr, Jennifer Coles, Debra Hutch, James Wun, Louise Cole, Christina Whitehead, Julie Lowrey, Kristy Masters, Rebecca Gresham, Victoria Campbell, David Gutierrez, Jane Brailsford, Loretta Forbes, Lauren Murray, Teena Maguire, Martina NiChonghaile, Neil Orford, Allison Bone, Tania Elderkin, Tania Salerno, Tim Chimunda, Jason Fletcher, Emma Broadfield, Sanjay Porwal, Cameron Knott, Catherine Boschert, Julie Smith, Angus Richardson, Dianne Hill, Graeme Duke, Peter Oziemski, Santiago Cegarra, Peter Chan, Deborah Welsh, Stephanie Hunter, Owen Roodenburg, John Dyett, Nicos Kokotsis, Max Moser, Yang Yang, Laven Padayachee, Joseph Vetro, Himangsu Gangopadhyay, Melissa Kaufman, Angaj Ghosh, Simone Said, Alpesh Patel, Shailesh Bihari, Elisha Matheson, Xia Jin, Tapaswi Shrestha, Kate Schwartz, Rosalba Cross, Winston Cheung, Helen Wong, Mark Kol, Asim Shah, Amanda Y. Wang, Zoltan Endre, Celia Bradford, Pierre Janin, Simon Finfer, Naomi Diel, Jonathan Gatward, Naomi Hammond, Anthony Delaney, Frances Bass, Elizabeth Yarad, Hergen Buscher, Claire Reynolds, Nerilee Baker, Romuald Bellmann, Andreas Peer, Julia Hasslacher, Paul Koglberger, Sebastian Klein, Klemens Zotter, Anna Brandtner, Armin Finkenstedt, Adelheid Ditlbacher, Frank Hartig, Dietmar Fries, Mirjam Bachler, Bettina Schenk, Martin Wagner, Philipp Eller, Thomas Staudinger, Esther Tiller, Peter Schellongowski, Andja Bojic, Eric A. Hoste, Stephanie Bracke, Luc De Crop, Daisy Vermeiren, Fernando Thome, Bianca Chiella, Lucia Fendt, Veronica Antunes, Frédérick D'Aragon, Charles St-Arnaud, Michael Mayette, Élaine Carbonnaeu, Joannie Marchand, Marie-Hélène Masse, Marilène Ladouceur, Alexis F. Turgeon, François Lauzier, David Bellemare, Charles Langis Francoeur, Guillaume LeBlanc, Gabrielle Guilbault, Stéphanie Grenier, Eve Cloutier, Annick Boivin, Charles Delisle-Thibault, Panagiota Giannakouros, Olivier Costerousse, Jean-François Cailhier, François-Martin Carrier, Ali Ghamraoui, Martine Lebrasseur, Fatna Benettaib, Maya Salamé, Dounia Boumahni, Ying Tung Sia, Jean-François Naud, Isabelle Roy, Henry T. Stelfox, Stacey Ruddell, Braden J. Manns, Shelley Duggan, Dominic Carney, Jennifer Barchard, Richard P. Whitlock, Emilie Belley-Cote, Nevena Savija, Alexandra Sabev, Troy Campbell, Thais Creary, Kelson Devereaux, Shira Brodutch, Claudio Rigatto, Bojan Paunovic, Owen Mooney, Anna Glybina, Oksana Harasemiw, Michelle Di Nella, John Harmon, Navdeep Mehta, Louis Lakatos, Nicole Haslam, Francois Lellouche, Mathieu Simon, Ying Tung, Patricia Lizotte, Pierre-Alexandre Bourchard, Bram Rochwerg, Tim Karachi, Tina Millen, John Muscedere, David Maslove, J. Gordon Boyd, Stephanie Sibley, John Drover, Miranda Hunt, Ilinca Georgescu, Randy Wax, Ilan Lenga, Kavita Sridhar, Andrew Steele, Kelly Fusco, Taneera Ghate, Michael Tolibas, Holly Robinson, Matthew A. Weir, Ravi Taneja, Ian M. Ball, Amit Garg, Eileen Campbell, Athena Ovsenek, Sean van Diepen, Nadia Baig, Sheldon Magder, Han Yao, Ahsan Alam, Josie Campisi, Erika MacIntyre, Ella Rokosh, Kimberly Scherr, Stephen Lapinsky, Sangeeta Mehta, Sumesh Shah, Daniel J. Niven, Michael Russell, Kym Jim, Gillian Brown, Kerry Oxtoby, Adam Hall, Luc Benoit, Colleen Sokolowski, Bhanu Prasad, Jag Rao, Shelley Giebel, Demetrios J. Kutsogiannis, Patricia Thompson, Tayne Thompson, Robert Cirone, Kanthi Kavikondala, Mark Soth, France Clarke, Alyson Takaoka, David Mazer, Karen Burns, Jan Friedrich, David Klein, Gyan Sandhu, Marlene Santos, Imrana Khalid, Jennifer Hodder, Peter Dodek, Najib Ayas, Victoria Alcuaz, Gabriel Suen, Oleksa Rewa, Gurmeet Singh, Sean Norris, Neil Gibson, Castro Arias, Aysha Shami, Celine Pelletier, Alireza Zahirieh, Andre Amaral, Nicole Marinoff, Navjot Kaur, Adic Perez, Jane Wang, Gregory Haljan, Christopher Condin, Lauralyn McIntyre, Brigette Gomes, Rebecca Porteous, Irene Watpool, Swapnil Hiremath, Edward Clark, Margaret S. Herridge, Felicity Backhouse, M. Elizabeth Wilcox, Karolina Walczak, Vincent Ki, Asheer Sharman, Martin Romano, R.T. Noel Gibney, Adam S. Romanovsky, Lorena McCoshen, Gordon Wood, Daniel Ovakim, Fiona Auld, Gayle Carney, Meili Duan, Xiaojun Ji, Dongchen Guo, Zhili Qi, Jin Lin, Meng Zhang, Lei Dong, Jingfeng Liu, Pei Liu, Deyuan Zhi, Guoqiang Bai, Yu Qiu, Ziqi Yang, Jing Bai, Zhuang Liu, Haizhou Zhuang, Haiman Wang, Jian Li, Mengya Zhao, Xiao Zhou, Xianqing Shi, Baning Ye, Manli Liu, Jing Wu, Yongjian Fu, Dali Long, Yu Pan, Jinlong Wang, Huaxian Mei, Songsong Zhang, Mingxiang Wen, Enyu Yang, Sijie Mu, Jianquan Li, Tingting Hu, Bingyu Qin, Min Li, Cunzhen Wang, Xin Dong, Kaiwu Wang, Haibo Wang, Jianxu Yang, Chuanyao Wang, Dongxin Wang, Nan Li, Zhui Yu, Song Xu, Lan Yao, Guo Hou, Zhou Liu, Liping Lu, Yingtao Lian, Chunting Wang, Jichen Zhang, Ruiqi Ding, Guoqing Qi, Qizhi Wang, Peng Wang, Zhaoli Meng, Man Chen, Xiaobo Hu, Xiandi He, Shibing Zhao, Lele Hang, Rui Li, Suhui Qin, Kun Lu, Shijuan Dun, Cheng Liu, Qi Zhou, Zhenzhen Chen, Jing Mei, Minwei Zhang, Hao Xu, Jincan Lin, Qindong Shi, Lijuan Fu, Qinjing Zeng, Hongye Ma, Jinqi Yan, Lan Gao, Hongjuan Liu, Lei Zhang, Hao Li, Xiaona He, Jingqun Fan, Litao Guo, Yu Liu, Xue Wang, Jingjing Sun, Zhongmin Liu, Juan Yang, Lili Ding, Lulu Sheng, Xingang Liu, Jie Yan, Quihui Wang, Yifeng Wang, Dan Zhao, Shuangping Zhao, Chenghuan Hu, Jing Li, Fuxing Deng, Haibo Qui, Yi Yang, Min Mo, Chun Pan, Changde Wu, Yingzi Huang, Lili Huang, Airan Liu, Anna-Maija Korhonen, Sanna Törnblom, Sari Sutinen, Leena Pettilä, Jonna Heinonen, Eliria Lappi, Taria Suhonen, Sari Karlsson, Sanna Hoppu, Ville Jalkanen, Anne Kuitunen, Markus Levoranta, Jaakko Långsjö, Sanna Ristimäki, Kaisa Malila, Anna Wootten, Simo Varila, Mikko J Järvisalo, Outi Inkinen, Satu Kentala, Keijo Leivo, Paivi Haltia, Jean-Damien Ricard, Jonathan Messika, Abirami Tiagarajah, Malo Emery, Aline Dechanet, Coralie Gernez, Damien Roux, Laurent Martin-Lefevre, Maud Fiancette, Isabelle Vinatier, Jean Claude Lacherade, Gwenhaël Colin, Christine Lebert, Marie-Ange Azais, Aihem Yehia, Caroline Pouplet, Matthieu Henry- Lagarrigue, Amélie Seguin, Laura Crosby, Julien Maizel, Dimitri Titeca-Beauport, Alain Combes, Ania Nieszkowska, Paul Masi, Alexandre Demoule, Julien Mayaux, Martin Dres, Elise Morawiec, Maxens Decalvele, Suela Demiri, Morgane Faure, Clémence Marios, Maxime Mallet, Marie Amélie Ordon, Laura Morizot, Marie Cantien, François Pousset, Florent Poirson, Yves Cohen, Laurent Argaud, Martin Cour, Laurent Bitker, Marie Simon, Romain Hernu, Thomas Baudry, Sylvie De La Salle, Adrien Robine, Nicholas Sedillot, Xavier Tchenio, Camille Bouisse, Sylvie Roux, Fabienne Tamion, Steven Grangé, Dorothée Carpentier, Guillaume Chevrel, Luis Ensenyat-Martin, Sophie Marque, Jean-Pierre Quenot, Pascal Andreu, Auguste Dargent, Audrey Large, Nicolas Chudeau, Mickael Landais, Benoit Derrien, Jean Christophe Callahan, Christophe Guitton, Charlène Le Moal, Alain Robert, Karim Asehnoune, Raphaël Cinotti, Nicolas Grillot, Dominique Demeure, Christophe Vinsonneau, Imen Rahmani, Mehdi Marzouk, Thibault Dekeyser, Caroline Sejourne, Mélanie Verlay, Fabienne Thevenin, Lucie Delecolle, Didier Thevenin, Bertrand Souweine, Elisabeth Coupez, Mireille Adda, Jean-Pierre Eraldi, Antoine Marchalot, Nicolas De Prost, Armand Mekontso Dessap, Keyvan Razazi, Ferhat Meziani, Julie Boisrame-Helms, Raphael Clere-Jehl, Xavier Delabranche, Christine Kummerlen, Hamid Merdji, Alexandra Monnier, Yannick Rabouel, Hassene Rahmani, Hayat Allam, Samir Chenaf, Vincenta Franja, Bertrand Pons, Michel Carles, Frédéric Martino, Régine Richard, Benjamin Zuber, Guillaume Lacave, Karim Lakhal, Bertrand Rozec, Hoa Dang Van, Éric Boulet, Fouad Fadel, Cedric Cleophax, Nicolas Dufour, Caroline Grant, Marie Thuong, Jean Reignier, Emmanuel Canet, Laurent Nicolet, Thierry Boulain, Mai-Anh Nay, Dalila Benzekri, François Barbier, Anne Bretagnol, Toufik Kamel, Armelle Mathonnet, Grégoire Muller, Marie Skarzynski, Julie Rossi, Amandine Pradet, Sandra Dos Santos, Aurore Guery, Lucie Muller, Luis Felix, Julien Bohé, Guillaume Thiéry, Nadia Aissaoui, Damien Vimpere, Morgane Commeureuc, Jean-Luc Diehl, Emmanuel Guerot, Orfeas Liangos, Monika Wittig, Alexander Zarbock, Mira Küllmar, Thomas van Waegeningh, Nadine Rosenow, Kathy Brickell, Peter Doran, Patrick T. Murray, Giovanni Landoni, Rosalba Lembo, Alberto Zangrillo, Giacomo Monti, Margherita Tozzi, Matteo Marzaroli, Gaetano Lombardi, Gianluca Paternoster, Michelangelo Vitiello, Shay McGuinness, Rachael Parke, Magdalena Butler, Eileen Gilder, Keri-Anne Cowdrey, Samantha Wallace, Jane Hallion, Melissa Woolett, Philippa Neal, Karina Duffy, Stephanie Long, Colin McArthur, Catherine Simmonds, Yan Chen, Rachael McConnochie, Lynette Newby, David Knight, Seton Henderson, Jan Mehrtens, Stacey Morgan, Anna Morris, Kymbalee Vander Hayden, Tara Burke, Matthew Bailey, Ross Freebairn, Lesley Chadwick, Penelope Park, Christine Rolls, Liz Thomas, Ulrike Buehner, Erin Williams, Jonathan Albrett, Simon Kirkham, Carolyn Jackson, Troy Browne, Jennifer Goodson, David Jackson, James Houghton, Owen Callender, Vicki Higson, Owen Keet, Clive Dominy, Paul Young, Anna Hunt, Harriet Judd, Cassie Lawrence, Shaanti Olatunji, Yvonne Robertson, Charlotte Latimer-Bell, Deborah Hendry, Agnes Mckay-Vucago, Nina Beehre, Eden Lesona, Leanlove Navarra, Chelsea Robinson, Ryan Jang, Andrea Junge, Bridget Lambert, Michel Thibault, Philippe Eckert, Sébastien Kissling, Erietta Polychronopoulos, Elettra Poli, Marco Altarelli, Madeleine Schnorf, Samia Abed Mallaird, Claudia Heidegger, Aurelie Perret, Philippe Montillier, Frederic Sangla, Seigenthaller Neils, Aude De Watteville, Mandeep-Kaur Phull, Aparna George, Nauman Hussain, Tatiana Pogreban, Steve Lobaz, Alison Daniels, Mishell Cunningham, Deborah Kerr, Alice Nicholson, Pradeep Shanmugasundaram, Judith Abrams, Katarina Manso, Geraldine Hambrook, Elizabeth McKerrow, Juvy Salva, Stephen Foulkes, Matthew Wise, Matt Morgan, Jenny Brooks, Jade Cole, Tracy Michelle Davies, Helen Hill, Emma Thomas, Marcela Vizcaychipi, Behrad Baharlo, Jaime Carungcong, Patricia Costa, Laura Martins, Ritoo Kapoor, Tracy Hazelton, Angela Moon, Janine Musselwhite, Ben Shelley, Philip McCall, Gill Arbane, Aneta Bociek, Martina Marotti, Rosario Lim, Sara Campos, Neus Grau Novellas, Armando Cennamo, Andrew Slack, Duncan Wyncoll, Luigi Camporota, Simon Sparkes, Rosalinde Tilley, Austin Rattray, Gayle Moreland, Jane Duffy, Elizabeth McGonigal, Philip Hopkins, Clare Finney, John Smith, Harriet Noble, Hayley Watson, Claire-Louise Harris, Emma Clarey, Eleanor Corcoran, James Beck, Clare Howcroft, Nora Youngs, Elizabeth Wilby, Bethan Ogg, Adam Wolverson, Sandra Lee, Susie Butler, Maryanne Okubanjo, Julia Hindle, Ingeborg Welters, Karen Williams, Emily Johnson, Julie Patrick-Heselton, David Shaw, Victoria Waugh, Richard Stewart, Esther Mwaura, Lynn Wren, Louise Mew, Sara-Beth Sutherland, Jane Adderley, Jim Ruddy, Margaret Harkins, Callum Kaye, Teresa Scott, Wendy Mitchell, Felicity Anderson, Fiona Willox, Vijay Jagannathan, Michele Clark, Sarah Purv, Andrew Sharman, Megan Meredith, Lucy Ryan, Louise Conner, Cecilia Peters, Dan Harvey, Ashraf Roshdy, Amy Collins, Malcolm Sim, Steven Henderson, Nigel Chee, Sally Pitts, Katie Bowman, Maria Dilawershah, Luke Vamplew, Elizabeth Howe, Paula Rogers, Clara Hernandez, Clara Prendergast, Jane Benton, Alex Rosenberg, Lui G. Forni, Alice Grant, Paula Carvelli, Ajay Raithatha, Sarah Bird, Max Richardson, Matthew Needham, Claire Hirst, Jonathan Ball, Susannah Leaver, Luisa Howlett, Carlos Castro Delgado, Sarah Farnell-Ward, Helen Farrah, Geraldine Gray, Gipsy Joseph, Francesca Robinson, Ascanio Tridente, Clare Harrop, Karen Shuker, Derek McLaughlan, Judith Ramsey, Sharon Meehan, Bernd Oliver Rose, Rosie Reece-Anthony, Babita Gurung, Tony Whitehouse, Catherine Snelson, Tonny Veenith, Andy Johnston, Lauren Cooper, Ron Carrera, Karen Ellis, Emma Fellows, Samanth Harkett, Colin Bergin, Elaine Spruce, Liesl Despy, Stephanie Goundry, Natalie Dooley, Tracy Mason, Amy Clark, Gemma Dignam, Geraldine Ward, Ben Attwood, Penny Parsons, Sophie Mason, Michael Margarson, Jenny Lord, Philip McGlone, Luke E. Hodgson, Indra Chadbourn, Raquel Gomez, Jordi Margalef, Rinus Pretorius, Alexandra Hamshere, Joseph Carter, Hazel Cahill, Lia Grainger, Kate Howard, Greg Forshaw, Zoe Guy, Kianoush B. Kashani, Robert C. Albright, Amy Amsbaugh, Anita Stoltenberg, Alexander S. Niven, Matthew Lynch, AnnMarie O'Mara, Syed Naeem, Sairah Sharif, Joyce McKenney Goulart, Ashita Tolwani, Claretha Lyas, Laura Latta, Azra Bihorac, Haleh Hashemighouchani, Philip Efron, Matthew Ruppert, Julie Cupka, Sean Kiley, Joshua Carson, Peggy White, George Omalay, Sherry Brown, Laura Velez, Alina Marceron, Javier A. Neyra, Juan Carlos Aycinena, Madona Elias, Victor M. Ortiz-Soriano, Caroline Hauschild, and Robert Dorfman
Subjects: Renal Replacement Therapy, Pulmonary and Respiratory Medicine, Critical Illness, Medicine and Health Sciences, Humans, Acute Kidney Injury
Published: 2022
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13. Carbon emissions and hospital pathology stewardship: a retrospective cohort analysis

Author: Mark Brown, Ivan Koprivic, Gian Luca Di Tanna, Brendan Smyth, Kate E. Charlesworth, Forbes McGain, Scott McAlister, and Pamela Konecny
Subjects: Pathology, medicine.medical_specialty, Healthcare associated, business.industry, Public health, Greenhouse gas, Internal Medicine, medicine, Retrospective cohort study, Logistic regression, business, Rate ratio, Cost savings
Abstract: BACKGROUND As healthcare is responsible for 7% of Australia's carbon emissions, it was recognised that a policy implemented at St George Hospital, Sydney to reduce non-urgent pathology testing to two days per week and on other days only if essential, would also result in a reduction in carbon emissions. The aim of the study was to measure the impact of this intervention on pathology collections and associated carbon emissions and pathology costs. METHODS The difference in the number of pathology collections, carbon dioxide equivalents (CO2 e) for five common blood tests, and pathology cost per admission were compared between a 6-month reference period and 6-month intervention period. CO2 e were estimated from published pathology CO2 e impacts. Cost was derived from pathology billing records. Outcomes were modelled using multivariable negative binomial, generalised linear, and logistic regression. RESULTS In total, 24,585 pathology collections in 5,695 patients were identified. In adjusted analysis, the rate of collections was lower during the intervention period (rate ratio 0.90, 95% CI, 0.86 to 0.95; P
Published: 2022
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14. Survey of intensive care unit staff views on a newly introduced reusable isolation gown

Author: Nikolaos, Angelopoulos, Samantha, Angiolella, Paula, Lyons, Bryan, Ross, and Forbes, McGain
Subjects: Health Policy
Published: 2022
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15. Evaluation of propofol wastage and disposal in routine anesthesia care

Author: Matilda Swee Sun Tang, Forbes McGain, David EP Bramley, Nicole M Sheridan, and Richard Seglenieks
Subjects: Anesthesiology and Pain Medicine, Critical Care and Intensive Care Medicine
Published: 2022

16. Climate change and child health

Author: Forbes McGain
Subjects: Climate Change, Pediatrics, Perinatology and Child Health, Child Health, Humans, Child
Published: 2022

17. Everyone’s a winner if we test less: the

Author: Oliver Walsh, Roger Harris, Oliver Flower, Matthew Anstey, and Forbes McGain
Subjects: Health Policy
Abstract: In this era of ‘Choosing Wisely,’ we present a four-step action plan to reduce unnecessary pathology testing and the associated patient harm (blood loss through repeated phlebotomy), economic cost and environmental impact. The authors are experts from the CODA group; a medical education and health-promotion charity that aims to build on the Choosing Wisely initiative to provide meaningful and sustainable actions to reduce the carbon footprint of healthcare, globally. Pathology testing is expensive and carbon-intensive, with as many as half of all tests being not clinically indicated. Reducing unnecessary testing is the only effective way to decrease the carbon footprint and other associated costs, as opportunities to reuse and recycle pathology specimens are limited. The four key steps for action are (i) auditing local practice; (ii) defining unnecessary testing including developing a clinical guideline for rational ordering; (iii) educating stakeholders; and (iv) measuring the impact of the intervention through re-audit. This proven method is designed to be used in any healthcare setting around the world; having a small group of passionate ‘champions’ is thought to be as important as strong clinical governance and more important than access to sophisticated equipment. Electronic medical record systems and other technological solutions offer new ways to help establish a sustainability mindset and reduce unnecessary testing. The Codachange.org/coda-earth/ website provides a dynamic crowdsourcing platform through which we can collectively learn to meet the diverse needs of our international medical community. Self-reported outcomes are gamified through collaborative feedback, amplification via social media and the ability to earn rewards, be uploaded to the CODA website, or added to the template as a success story. By combining our existing local networks with the emerging international CODA community, we can initiate meaningful change now and enter the era of environmental stewardship.
Published: 2022
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18. Carbon Footprint of Anesthesia: Reply

Author: Forbes McGain, Kasun Wickramarachchi, Nicole Sheridan, and Scott McAlister
Subjects: Anesthesiology and Pain Medicine
Published: 2022
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19. Carbon Footprint of General, Regional, and Combined Anesthesia for Total Knee Replacements

Author: Kasun Wickramarachchi, Nicole Sheridan, Simon Yates, Scott McAlister, Forbes McGain, and Brandon Chan
Subjects: Victoria, Nitrous Oxide, chemistry.chemical_element, Carbon dioxide equivalent, Anesthesia, General, Sevoflurane, Desflurane, chemistry.chemical_compound, Anesthesia, Conduction, medicine, Humans, Prospective Studies, Arthroplasty, Replacement, Knee, Life-cycle assessment, Carbon Footprint, business.industry, Nitrous oxide, Carbon Dioxide, Combined Modality Therapy, Anesthesiology and Pain Medicine, chemistry, Anesthesia, Anesthetics, Inhalation, Anesthetic, Carbon footprint, business, Carbon, medicine.drug
Abstract: Background Health care itself contributes to climate change. Anesthesia is a “carbon hotspot,” yet few data exist to compare anesthetic choices. The authors examined the carbon dioxide equivalent emissions associated with general anesthesia, spinal anesthesia, and combined (general and spinal anesthesia) during a total knee replacement. Methods A prospective life cycle assessment of 10 patients in each of three groups undergoing knee replacements was conducted in Melbourne, Australia. The authors collected input data for anesthetic items, gases, and drugs, and electricity for patient warming and anesthetic machine. Sevoflurane or propofol was used for general anesthesia. Life cycle assessment software was used to convert inputs to their carbon footprint (in kilogram carbon dioxide equivalent emissions), with modeled international comparisons. Results Twenty-nine patients were studied. The carbon dioxide equivalent emissions for general anesthesia were an average 14.9 (95% CI, 9.7 to 22.5) kg carbon dioxide equivalent emissions; spinal anesthesia, 16.9 (95% CI, 13.2 to 20.5) kg carbon dioxide equivalent; and for combined anesthesia, 18.5 (95% CI, 12.5 to 27.3) kg carbon dioxide equivalent. Major sources of carbon dioxide equivalent emissions across all approaches were as follows: electricity for the patient air warmer (average at least 2.5 kg carbon dioxide equivalent [20% total]), single-use items, 3.6 (general anesthesia), 3.4 (spinal), and 4.3 (combined) kg carbon dioxide equivalent emissions, respectively (approximately 25% total). For the general anesthesia and combined groups, sevoflurane contributed an average 4.7 kg carbon dioxide equivalent (35% total) and 3.1 kg carbon dioxide equivalent (19%), respectively. For spinal and combined, washing and sterilizing reusable items contributed 4.5 kg carbon dioxide equivalent (29% total) and 4.1 kg carbon dioxide equivalent (24%) emissions, respectively. Oxygen use was important to the spinal anesthetic carbon footprint (2.8 kg carbon dioxide equivalent, 18%). Modeling showed that intercountry carbon dioxide equivalent emission variability was less than intragroup variability (minimum/maximum). Conclusions All anesthetic approaches had similar carbon footprints (desflurane and nitrous oxide were not used for general anesthesia). Rather than spinal being a default low carbon approach, several choices determine the final carbon footprint: using low-flow anesthesia/total intravenous anesthesia, reducing single-use plastics, reducing oxygen flows, and collaborating with engineers to augment energy efficiency/renewable electricity. Editor’s Perspective What We Already Know about This Topic What This Article Tells Us That Is New
Published: 2021
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20. An LCA of hospital pathology testing

Author: Scott McAlister, Tim Grant, and Forbes McGain
Subjects: Pathology, medicine.medical_specialty, Urinalysis, medicine.diagnostic_test, Impact assessment, business.industry, Incubator, Test (assessment), Health care, medicine, Blood test, Environmental science, Environmental impact assessment, Economic impact analysis, business, General Environmental Science
Abstract: There is increasing interest within the healthcare sector about the environmental impacts associated with the provision of health services, with the sector being responsible for approximately 4.4% of global greenhouse gas emissions. The aim of this study is to develop an LCA of six commonly used pathology tests in hospitals in Australia, as testing is ubiquitous within healthcare. The study is a cradle-to-grave assessment of pathology testing, from raw material acquisition for collection equipment and reagents, the collection of the sample from the patient, sample transport to the pathology lab and its subsequent analysis, and the disposal of clinical waste. The study has been performed in accordance with ISO 14,040 and ISO 14,044. The data were modelled using SimaPro® software, version 9.0.0.27, using the Australian National Life Cycle Inventory Database (AusLCI) for Australian specific data, and from Ecoinvent 3.5® for all other data. Impact assessment was performed using the ReCiPe 2016 V1.02 (H). We focused on midpoint indicators that damage human health, as well as reporting in disability adjusted life years (DALYs). Focussing on climate change, the impact of a single blood test given in a hospital ranges from 74 g CO2e through to 274 g CO2e, whilst for a urinalysis in a hospital the impact is greater at 538 g CO2e. Expressed in DALYs, blood tests ranged from impacts range from 0.146 µDALYs through to 0.383 µDALYs, whilst urinalysis was 0.701 µDALYs. For the majority of the tests, the major source of impacts was the collection tubes and jars, and the electricity use of the analysers. Test reagents had only a minimal impact. Urinalysis had additional impacts due to test consumables (agar plate), and compressed air required for the automated analyser and incubator. Globally, tens of billions of pathology tests are performed annually, with each individual test having a low environmental impact. Not all testing, however, is necessary, and reducing this unnecessary testing will reduce environmental and economic impacts and potential adverse health outcomes. Increasing laboratory utilisation (efficiency) will additionally reduce environmental impacts per test.
Published: 2021
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21. Climate responsibilities in intensive care medicine-let's go green! An introduction to a new series in Intensive Care Medicine

Author: Thomas, Bein and Forbes, McGain
Published: 2022

22. Towards zero carbon healthcare: anaesthesia

Author: Clifford L Shelton, Rebecca Knagg, Rakesh V Sondekoppam, and Forbes McGain
Subjects: Anesthesia, Conduction, Anesthesiology, Humans, General Medicine, Carbon Dioxide, Delivery of Health Care, Carbon
Published: 2022

23. Climate emergencies and health system resilience collaborative research action (CHESS): challenges and best practice from the UK and Australia

Author: Ioannis Bakolis, Alexandra Barratt, Thomas Canning, Rebecca Haddock, Seeromanie Harding, Arnagretta Hunter, Daniela Espinoza Oyarce, Nina Lazarevic, Forbes McGain, Christopher Nolan, Lisa Page, Mark Pelling, Christine Phillips, Roslyn Prinsley, Nick Sevdalis, Richard Sullivan, Peter W Tait, Apostolis Voulgarakis, Shuo Zang, Kate Charlesworth, and Sotiris Vardoulakis
Subjects: General Earth and Planetary Sciences, General Environmental Science
Published: 2022
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24. Use of portable air cleaners to reduce aerosol transmission on a hospital coronavirus disease 2019 (COVID-19) ward

Author: Nick Keogh, Amanda J. Wheeler, Forbes McGain, Melita Keywood, Jason Monty, Kevin Kevin, Ruhi S Humphries, Imogen Wadlow, Grant Skidmore, Marion A. Kainer, Behzad Rismanchi, Robyn Schofield, Caroline Marshall, Louis Irving, Kristy L Buising, and Ashley Stevens
Subjects: Microbiology (medical), Coronavirus disease 2019 (COVID-19), Epidemiology, Airflow, 010501 environmental sciences, complex mixtures, 01 natural sciences, Air cleaner, law.invention, 03 medical and health sciences, 0302 clinical medicine, law, HEPA, medicine, Humans, Air Conditioning, 030212 general & internal medicine, Hospital ward, 0105 earth and related environmental sciences, business.industry, COVID-19, Respiratory Aerosols and Droplets, respiratory system, medicine.disease, Hospitals, Aerosol, Infectious Diseases, Transmission (mechanics), Air Filters, Healthcare settings, Original Article, Medical emergency, business
Abstract: Objective:To study the airflow, transmission, and clearance of aerosols in the clinical spaces of a hospital ward that had been used to care for patients with coronavirus disease 2019 (COVID-19) and to examine the impact of portable air cleaners on aerosol clearance.Design:Observational study.Setting:A single ward of a tertiary-care public hospital in Melbourne, Australia.Intervention:Glycerin-based aerosol was used as a surrogate for respiratory aerosols. The transmission of aerosols from a single patient room into corridors and a nurses’ station in the ward was measured. The rate of clearance of aerosols was measured over time from the patient room, nurses’ station and ward corridors with and without air cleaners [ie, portable high-efficiency particulate air (HEPA) filters].Results:Aerosols rapidly travelled from the patient room into other parts of the ward. Air cleaners were effective in increasing the clearance of aerosols from the air in clinical spaces and reducing their spread to other areas. With 2 small domestic air cleaners in a single patient room of a hospital ward, 99% of aerosols could be cleared within 5.5 minutes.Conclusions:Air cleaners may be useful in clinical spaces to help reduce the risk of acquisition of respiratory viruses that are transmitted via aerosols. They are easy to deploy and are likely to be cost-effective in a variety of healthcare settings.
Published: 2021
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25. Characteristics, presentation and outcomes of music festival patrons with stimulant drug‐induced serotonin toxicity

Author: David Anderson, Martin Dutch, Kristy Austin, Shaun L Greene, Andis Graudins, Joe-Anthony Rotella, Lachlan F Miles, Alan Eade, Jacqueline Maplesden, and Forbes McGain
Subjects: Adult, Serotonin, medicine.medical_specialty, medicine.medical_treatment, Ecstasy, law.invention, Young Adult, 03 medical and health sciences, Patient safety, 0302 clinical medicine, Interquartile range, law, Humans, Medicine, 030212 general & internal medicine, Holidays, Retrospective Studies, business.industry, Incidence (epidemiology), 030208 emergency & critical care medicine, Retrospective cohort study, Intensive care unit, Stimulant, Pharmaceutical Preparations, Emergency medicine, Cohort, Emergency Medicine, business, Music
Abstract: OBJECTIVE: A large number of stimulant drug-associated deaths at music festivals in Australia were reported during the southern hemisphere summer of 2018-2019. This led to the prehospital deployment of healthcare professional-led critical care response teams. We aimed to describe the characteristics, clinical presentation, management and outcomes of music festival patrons with stimulant drug-induced serotonin toxicity managed using this model during the study period. METHODS: We performed a retrospective observational study of patients presenting with stimulant drug-induced serotonin toxicity and/or drug-induced hyperthermia who presented between December 2017 and December 2019. Comprehensive follow-up data were collected for those patients who required hospital admission. Data included demographics, clinical features, management and disposition, hospital outcomes and laboratory data, stratified by severity of presentation. RESULTS: Forty-seven patients were included. Median age was 21.9 years (interquartile range 19.6-22.2). 3,4-Methylenedioxymetamphetamine was the most frequently reported agent ingested (32/47). After stratification, 13 of 47 patients were classified as mild, 20 of 47 as moderate and 14 of 47 as severe. Median presenting temperature in this latter cohort was 41.1°C (40.5-42.0°C). All severely ill patients required intensive care unit admission, with a median hospital stay of 4.63 days (interquartile range 2.08-8.36). End-organ complications were reported in 11 of 14 patients. No mortalities were reported. All patients (13/13) from the mild cohort and 15 of 20 patients from the moderate cohort were treated and discharged on-site. CONCLUSIONS: Severe illness was associated with a high incidence of end-organ impairment. A high proportion of patients without severe disease were able to be successfully managed at the event without transport to hospital. No deaths are reported in this series.
Published: 2021
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26. Efficacy of a patient isolation hood in reducing exposure to airborne infectious virus in a simulated healthcare setting

Author: Leo Yi Yang Lee, Shane A Landry, Milan Jamriska, Dinesh Subedi, Simon A Joosten, Jeremy J Barr, Reece Brown, Kevin Kevin, Robyn Schofield, Jason Monty, Kanta Subbarao, and Forbes McGain
Abstract: BackgroundHealthcare workers treating patients with SARS-CoV-2 are at risk of infection from patient-emitted virus-laden aerosols. We quantified the reduction of airborne infectious virus in a simulated hospital room when a ventilated patient isolation (McMonty) hood was in use.MethodsWe nebulised 109 plaque forming units (PFU) of bacteriophage PhiX174 virus into a 35.1m3 room with a hood active or inactive. The airborne concentration of infectious virus was measured by BioSpot-VIVAS and settle plates using plaque assay quantification on the bacterial host Escherichia coli C. The particle number concentration (PNC) was monitored continuously using an optical particle sizer.ResultsMedian airborne viral concentration in the room reached 1.41 × 105 PFU.m-3 with the hood inactive. Using the active hood as source containment reduced infectious virus concentration by 374-fold in air samples. This was associated with a 109-fold reduction in total airborne particle number escape rate. The deposition of infectious virus on the surface of settle plates was reduced by 87-fold.ConclusionsThe isolation hood significantly reduced airborne infectious virus exposure in a simulated hospital room. Our findings support the use of the hood to limit exposure of healthcare workers to airborne virus in clinical environments.Lay summaryCOVID-19 patients exhale aerosol particles which can potentially carry infectious viruses into the hospital environment, putting healthcare workers at risk of infection. This risk can be reduced by proper use of personal protective equipment (PPE) to protect workers from virus exposure. More effective strategies, however, aim to provide source control, reducing the amount of virus-contaminated air that is exhaled into the hospital room.The McMonty isolation hood has been developed to trap and decontaminate the air around an infected patient. We tested the efficacy of the hood using a live virus model to mimic a COVID-19 patient in a hospital room. Using the McMonty hood reduced the amount of exhaled air particles in the room by over 109-times. In our tests, people working in the room were exposed to 374-times less infectious virus in the air, and room surfaces were 87-times less contaminated. Our study supports using devices like the McMonty hood in combination with PPE to keep healthcare workers safe from virus exposure at work.
Published: 2022
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27. Diabetes mellitus, glycaemic control, and severe COVID-19 in the Australian critical care setting: A nested cohort study

Author: Mark P. Plummer, Louise Rait, Mark E. Finnis, Craig J. French, Samantha Bates, James Douglas, Mansi Bhurani, Tessa Broadley, Tony Trapani, Adam M. Deane, Andrew A. Udy, Aidan J.C. Burrell, Adam Visser, Adrian Mattke, Adrian Regli, Alan Rashid, Alexis Tabah, Alison Walker, Allen Cheng, Amanda Corley, Andrew Udy, Anil Ramnani, Anthony Eidan, Bart DeKeulenaer, Benjamin Reddi, Brent Richards, Cameron Knott, Cara Moore, Carmel Delzoppo, Catherine Boschert, Catherine Tacon, Craig French, Danielle Austin, David Brewster, David Cooper, David Crosbie, David Hawkins, Edda Jessen, Eduardo Martinez, Edward Fysh, Edward Litton, Felix Oberender, Forbes McGain, Gavin Salt, Glenn Eastwood, Gopal Taori, Hayden White, Hergen Buscher, Ian Seppelt, Isabel Anne Leditschke, Janelle Young, Jayshree Lavana, Jeremy Cohen, Jessica Lugsdin, John Botha, John Santamaria, Jonathan Barrett, Kasha Singh, Kevin Laupland, Khaled El-Khawas, Kristine Estensen, Kush Deshpande, Kyle White, Leigh Fitzpatrick, Lewis Campbell, Mahesh Ramanan, Manoj Saxena, Marion Kainer, Mark Kol, Mark Page, Mark Plummer, Martin Sterba, Matthew Anstey, Matthew Brain, Matthew Maiden, Myrene Kilminster, Naomi Hammond, Neeraj Bhadange, Nicole Humphreys, Paras Jain, Paul Azzi, Paul Secombe, Paula Lister, Peter Chan, Peter McCanny, Phillip Britton, Pierre Janin, Ravi Krishnamurthy, Ravikiran Sonawane, Ravindranath Tiruvoipati, Richard Totaro, Rinaldo Bellomo, Ritesh Sanghavi, Sandra Peake, Shailesh Bihari, Shane George, Simon Erickson, Steve Webb, Subhash Arora, Subodh Ganu, Thomas Rozen, Toni McKenna, Umesh Kadam, Vineet Nayyar, Wei Han Choy, and Wisam Albassam
Subjects: Emergency Nursing, Critical Care Nursing
Abstract: Internationally, diabetes mellitus is recognised as a risk factor for severe COVID-19. The relationship between diabetes mellitus and severe COVID-19 has not been reported in the Australian population.The objective of this study was to determine the prevalence of and outcomes for patients with diabetes admitted to Australian intensive care units (ICUs) with COVID-19.This is a nested cohort study of four ICUs in Melbourne participating in the Short Period Incidence Study of Severe Acute Respiratory Infection (SPRINT-SARI) Australia project. All adult patients admitted to the ICU with COVID-19 from 20 February 2020 to 27 February 2021 were included. Blood glucose and glycated haemoglobin (HbA1c) data were retrospectively collected. Diabetes was diagnosed from medical history or an HbA1c ≥6.5% (48 mmol/mol). Hospital mortality was assessed using logistic regression.There were 136 patients with median age 58 years [48-68] and median Acute Physiology and Chronic Health Evaluation II (APACHE II) score of 14 [11-19]. Fifty-eight patients had diabetes (43%), 46 patients had stress-induced hyperglycaemia (34%), and 32 patients had normoglycaemia (23%). Patients with diabetes were older, were with higher APACHE II scores, had greater glycaemic variability than patients with normoglycaemia, and had longer hospital length of stay. Overall hospital mortality was 16% (22/136), including nine patients with diabetes, nine patients with stress-induced hyperglycaemia, and two patients with normoglycaemia.Diabetes is prevalent in patients admitted to Australian ICUs with severe COVID-19, highlighting the need for prevention strategies in this vulnerable population.
Published: 2022
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28. Health Care Sustainability Metrics: Building A Safer, Low-Carbon Health System

Author: Martin Hensher and Forbes McGain
Subjects: medicine.medical_specialty, business.industry, 030503 health policy & services, Health Policy, Public health, Climate risk, Benchmarking, Public relations, Environmental stewardship, 03 medical and health sciences, 0302 clinical medicine, Sustainability, Health care, medicine, Corporate social responsibility, Sustainability measurement, 030212 general & internal medicine, 0305 other medical science, business
Abstract: As understanding grows of the scale of health care's environmental impacts, so too does interest in measuring and reporting on sustainability as a facet of health care system performance. This article examines important lessons from health care's long experience with performance and quality measurement and reporting that can be applied to the creation of health care sustainability metrics. Although some large health systems such as Kaiser Permanente have invested heavily in environmental stewardship, in the US the focus of health care sustainability measurement and reporting has typically been on corporate social responsibility and climate risk disclosure. The ability of health care organizations to generate data on and control environmental impacts can be limited by legacy infrastructure and complex supply chains. However, just as in other domains of performance, health care sustainability measurement and reporting must proceed from a clear conceptual framework and statement of purpose. Measurement must reflect strategic goals, instead of letting goals become dictated by ease of measurement. Health system leaders now need to set clear and compelling sustainability goals, invest in internationally comparable metrics by which to measure their success, and embed them in their core business.
Published: 2020
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29. Transforming The Medical Device Industry: Road Map To A Circular Economy

Author: Steven B. Young, Matthew J. Eckelman, Aman Khanuja, Robert S. Lagasse, Forbes McGain, Lyndon V. Hernandez, Jodi D. Sherman, Andrea J MacNeill, Kari A. Simonsen, Melissa M. Bilec, Saed Alizamir, Harriet W. Hopf, and Cassandra L. Thiel
Subjects: medicine.medical_specialty, Medical device, business.industry, 030503 health policy & services, Health Policy, Supply chain, Public health, Circular economy, 03 medical and health sciences, 0302 clinical medicine, Resource (project management), Health care, medicine, Circulation (currency), 030212 general & internal medicine, Road map, 0305 other medical science, business, Industrial organization
Abstract: A circular economy involves maintaining manufactured products in circulation, distributing resource and environmental costs over time and with repeated use. In a linear supply chain, manufactured products are used once and discarded. In high-income nations, health care systems increasingly rely on linear supply chains composed of single-use disposable medical devices. This has resulted in increased health care expenditures and health care-generated waste and pollution, with associated public health damage. It has also caused the supply chain to be vulnerable to disruption and demand fluctuations. Transformation of the medical device industry to a more circular economy would advance the goal of providing increasingly complex care in a low-emissions future. Barriers to circularity include perceptions regarding infection prevention, behaviors of device consumers and manufacturers, and regulatory structures that encourage the proliferation of disposable medical devices. Complementary policy- and market-driven solutions are needed to encourage systemic transformation.
Published: 2020
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30. The Effect of Sterically Active Ligand Substituents on Gas Adsorption within a Family of 3D Zn-Based Coordination Polymers

Author: Forbes McGain, Helen E. Maynard-Casely, Timothy A. Hudson, Richard Robson, Jessica L. Holmes, A. David Dharma, Keith F. White, Ravichandar Babarao, and Brendan F. Abrahams
Subjects: Inorganic Chemistry, chemistry.chemical_classification, Steric effects, Molecular dynamics, Crystallography, Adsorption, chemistry, Ligand, Molecule, Metal-organic framework, Sorption, Polymer, Physical and Theoretical Chemistry
Abstract: An investigation of the adsorption properties of two structurally related, 3D coordination polymers of composition Zn(2-Mehba) and Zn(2,6-Me2hba) (2-Mehba = the dianion of 2-methyl-4-hydroxybenzoic acid and 2,6-Me2hba = the dianion of 2,6-dimethyl-4-hydroxybenzoic acid) is presented. A common feature of these structures are parallel channels that are able to accommodate appropriately sized guest molecules. The structures differ with respect to the steric congestion within the channels arising from methyl groups appended to the bridging ligands of the network. The host network, Zn(2-Mehba), is able to take up appreciable quantities of H2 (77 K) and CO2 and CH4 (298 K) in a reversible manner. In regard to the adsorption of N2 by Zn(2-Mehba), there appears to be an unusual temperature dependence for the uptake of the gas such that when the temperature is increased from 77 to 298 K the uptake of N2 increases. The relatively narrow channels of Zn(2,6-Me2hba) are too small to allow the uptake of N2 and CH4, but H2 molecules can be adsorbed. A pronounced step at elevated pressures in CO2 and N2O isotherms for Zn(2,6-Me2hba) is noted. Calculations indicate that rotation of phenolate rings leads to a change in the available intraframework space during CO2 dosing.
Published: 2020
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31. The carbon footprint of pathology testing

Author: Scott McAlister, Katy J.L. Bell, Alexandra Barratt, and Forbes McGain
Subjects: carbon footprint, Pathology, medicine.medical_specialty, Venipuncture, business.industry, emissions, carbon dioxide, General Medicine, 1117 Public Health and Health Services, Test (assessment), 03 medical and health sciences, climate change, 0302 clinical medicine, greenhouse gas, environmental policy, Greenhouse gas, Carbon footprint, Medicine, Arterial blood, pathology, 030212 general & internal medicine, Sample collection, business, Life-cycle assessment, Water use
Abstract: OBJECTIVES To estimate the carbon footprint of five common hospital pathology tests: full blood examination; urea and electrolyte levels; coagulation profile; C-reactive protein concentration; and arterial blood gases. DESIGN, SETTING Prospective life cycle assessment of five pathology tests in two university-affiliated health services in Melbourne. We included all consumables and associated waste for venepuncture and laboratory analyses, and electricity and water use for laboratory analyses. MAIN OUTCOME MEASURE Greenhouse gas footprint, measured in carbon dioxide equivalent (CO2 e) emissions. RESULTS CO2 e emissions for haematology tests were 82 g/test (95% CI, 73-91 g/test) for coagulation profile and 116 g/test (95% CI, 101-135 g/test) for full blood examination. CO2 e emissions for biochemical tests were 0.5 g/test CO2 e (95% CI, 0.4-0.6 g/test) for C-reactive protein (low because typically ordered with urea and electrolyte assessment), 49 g/test (95% CI, 45-53 g/test) for arterial blood gas assessment, and 99 g/test (95% CI, 84-113 g/test) for urea and electrolyte assessment. Most CO2 e emissions were associated with sample collection (range, 60% for full blood examination to 95% for coagulation profile); emissions attributable to laboratory reagents and power use were much smaller. CONCLUSION The carbon footprint of common pathology tests was dominated by those of sample collection and phlebotomy. Although the carbon footprints were small, millions of tests are performed each year in Australia, and reducing unnecessary testing will be the most effective approach to reducing the carbon footprint of pathology. Together with the detrimental health and economic effects of unnecessary testing, our environmental findings should further motivate clinicians to test wisely.
Published: 2020
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32. Consensus on Prioritisation of Actions for Reducing the Environmental Impact of a Large Tertiary Hospital: Application of the Nominal Group Technique

Author: Jessica F. Davies, Forbes McGain, and Jillian J. Francis
Subjects: climate change, consensus, Health, Toxicology and Mutagenesis, Public Health, Environmental and Occupational Health, healthcare, environmental sustainability
Abstract: Hospitals are the largest greenhouse gas producers within the Australian healthcare sector due to the large amounts of energy, resource utilization, equipment and pharmaceuticals required to deliver care. In order to reduce healthcare emissions, healthcare services must take multiple actions to address the broad range of emissions produced when delivering patient care. The goal of this study was to seek consensus on the priority actions needed to reduce the environmental impact of a tertiary Australian hospital. A nominal group technique was utilized within a multidisciplinary, executive-led environmental sustainability committee to find consensus on the 62 proposed actions to reduce the environmental impact of a tertiary Australian hospital. Thirteen participants joined an online workshop during which an educational presentation was delivered, 62 potential actions were privately ranked according to two domains of ‘amenability to change’ and ‘scale of climate impact’ and a moderated group discussion ensued. The group achieved verbal consensus on 16 actions that span staff education, procurement, pharmaceuticals, waste, transport and advocacy on all-electric capital works upgrades. In addition, the individual ratings of potential actions according to each domain were ranked and shared with the group. Despite a large number of actions and varied perspectives within the group, the nominal group technique can be used to focus a hospital leadership group on priority actions to improve environmental sustainability.
Published: 2023
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33. Quantitative nitrous oxide usage by different specialties and current patterns of use in a single hospital

Author: Angela Wong, Alice Gynther, Christine Li, Max Rounds, Jung H. Lee, David Krieser, Elske Posma, and Forbes McGain
Subjects: Anesthesiology and Pain Medicine, Nitrous Oxide, Humans, Carbon Dioxide, Hospitals
Published: 2022
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34. Environmental sustainability in anaesthesia and critical care. Response to Br J Anaesth 2021; 126: e195–e197

Author: Mads P. Sulbaek Andersen, Forbes McGain, James A. Renwick, and Jodi D. Sherman
Subjects: Anesthesiology and Pain Medicine, Coronavirus disease 2019 (COVID-19), business.industry, Sustainability, MEDLINE, Medicine, business, Environmental planning
Published: 2021
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35. Evolution Over Time of Ventilatory Management and Outcome of Patients With Neurologic Disease

Author: Tejerina E. E., Pelosi P., Robba C., Penuelas O., Muriel A., Barrios D., Frutos-Vivar F., Raymondos K., Du B., Thille A. W., Rios F., Gonzalez M., Del-Sorbo L., Marin M. D. C., Valle Pinheiro B., Soares M. A., Nin N., Maggiore S. M., Bersten A., Amin P., Cakar N., Young Suh G., Abroug F., Jibaja M., Matamis D., Ali Zeggwagh A., Sutherasan Y., Anzueto A., Esteban A, Fernando Ríos, Damian Violi, Marisol Rodríguez-Goñi, Roger Lamoglie, Fernando Villarejo, Norberto Tiribelli, Santiago Ilutovich, Matías Brizuela, Mariana Monllau, Fernando Saldarini, Silvina Borello, Alberto Marino, Mauricio Vinzio, Karina Bonasegla, Julián Hernández, María Belén Yapur, María Eugenia González, Sebastián E Mare, Judith Sagardía, Marco Bezzi, Cecilia Pereyra, Julian Strati, Daniel Vargas, Claudia Diaz, Pablo Gómez, Marcelo Palavecino, Graciela Elizabeth, Aguilera García, M Eugenia, Luis Pablo Cardonnet, Lisandro Betttini, Hernán Nuñez, Lucas Vallejo, Fernando Fernández, Jorge Arroyo, Daniel Duarte, Gerardo Filippa, Cayetano Galetti, Hernan Nunia, Fernando Lambert, Elisa Estenssoro, Marina Busico, Javier Horacio Álvarez, Alejandro Raimondi, Gustavo Badariotti, Martín Lugaro, Fernando Lipovestky, Alan Javier Zazu, Hugo Capponcelli, Patricia Vogl, Cristina Orlandi, Alejandro Gómez, Gustavo Jannello, Alejandro Risso, Leticia Rapetti, Guillermo Chiappero, Juan Domingo Fernández, Rodrigo E Gómez-Paz, Marcos Juan Zec, Pascual Valdez, Jorgelina Guyon, Ariel Chena, Sergio Lasdica, Martin Deheza, Schimdt Alejandra, Francisco Criado, Norma Beatriz Márquez, Pablo Desmery, José Luis Scapellato, Gonzalo Javier Ríos, Cristian Casabella, Jasmin Board, Andrew Davies, Andrew Bersten, Elisha Matheson, Amy Waters, John Santamaria, Jennifer Holmes, Cartan Costello, Manoj K Saxena, John Myburgh, Ellen Kinkel, Forbes McGain, Claire Cattigan, Allison Bone, Ian Seppelt, Leonie Weisbrodt, Cheryl Cuzner, Christopher MacIsaac, Deborah Barge, Tania Caf, Cameron Knott, Graeme Duke, Imogen Mitchell, Helen Rodgers, Rachel Whyte, Elisha Fulton, Alistair Nichol, Hergen Buscher, Priya Nair, Claire Reynolds, Simon J G Hockley, Ian Moore, Katherine Davidson, David Milliss, Raju Pusapati, Helen Wong, Jason Fletcher, Julie Smith, Paul Goldrick, Dianne Stephens, Jane Thomas, Anders Aneman, Sutrisno Gunawan, Tom Cowlam, George Lukas, Rick McAllister, Minka Springham, Joanne Sutton, Jeff Presneill, Tony Sutherland, Dianne Hill, Howard Connor, Jenny Dennett, Tim Coles, Freddy Sandy, Sando Chavarria, Marcelo Choque, Ronald Pairumani, Juan Guerra, Marco Antônio Soares Reis, José Carlos Versiani, Eduardo Fonseca Sad, Maria Aparecida Braga, Dinalva Aparecida Gomes, Fernando Antônio Botoni, Maurício Meireles Góes, Frederico Costa Val Barros, Rogério de Castro Pereira, Hugo Urbano, Valéria de Carvalho Magela, Aline Camile Yehia, Bruno Bonaccorsi Fernandino, Marco Antônio Ribeiro Leão, Rovílson Lara, Rubens Altair Amaral de Pádua, Janine Dias Alves, Aloísio Marques do Nascimento, Bruno do Valle Pinheiro, Carlos Alberto Studart Gomes, Marcelo Alcântara Holanda, Frederico Rodrigues Anselmo, Niall Ferguson, Neill Adhikari, Robert Fowler, Cheromi Sittambalam, Mehar-Un-Nisa Raja, Nicole Marinoff, Lauralyn McIntryre, Shawna Reddie, Laura Jones, Irene Watpool, Jeffrey Singh, Madison Dennis, Andrea Matte, Marc Lipkus, Ryan Albert, Andrew Steel, Emily Stern, Michael Miletin, Antonio Raso, Robyn Klages, Jan Friedrich, Orla Smith, Laura Wilson, Deborah Cook, Mark Bailey, Sangeeta Mehta, Stephen Lapinsky, Hannah Mathers, Cheryl Ethier, Stephanie Lubchansky, Samer Haj-Bakri, Dietrich Henzler, Lisa Julien, Luis Soto-Román, Juan Carlos Maurelia, César Antonio Maquilon, Luis Soto-Germani, Bin Du, Yan Kang, Bo Wang, Fachun Zhou, Fang Xu, Haibo Qiu, Yi Yang, Qingyuan Zhan, Bing Sun, Zhenjie Hu, Bin Yu, Xi Zhu, Yu Bai, Gang Li, Yi Li, Geng Zhang, Jianbiao Meng, Xiaobo Huang, Hong Pu, Daxing Yu, Chuanyun Qian, Wei Zhang, Yongjie Yin, Debiao Song, Yunxuan Yue, Zhengxuan Lv, Chengmin Yu, Qunmei Yao, Xue Wang, Yuan Xu, Wei He, Mian Chen, Zhihua Hu, Dongpo Jiang, Jian Huang, Wei Yu, Juanxian Gu, Yangong Chao, Zhixiang Li, Zhicheng Zhang, Wanxia Li, Zhenyang He, Jianguo Li, Chang Liu, Tiehe Qin, Shouhong Wang, Feng Li, Jun Jin, Jianhong Fu, Hongyang Xu, Hongyuan Lin, Jianying Guo, Yalin Liu, Jinghua Wang, Maoqin Li, Jiaqiong Li, Lei Chen, Qing Song, Liang Pan, Xianyao Wan, Jiuzhi Zhang, Weihai Yao, Yuhong Guo, Pang Wing Yan, Kelly Choy, Kwan Ming Chit, Patricia Leung, Chau Chin Man, Marco González, Ricardo Buitrago, Marcela Granados, Guillermo Ortiz, Cesar Enciso, Mario Gómez, Bladimir Alejandro Gil, Juan Pablo Sedano, Luis Fernando Castro Castro, Carlo Alberto Acosta, Marco Gonzalez, Francisco Molina, Camilo Pizarro, Mario Villabon, Carmelo Dueñas, Carlos Andrés Díaz, Nelson Fonseca, Rubén Camargo, Juan David Uribe, Hans-Henrik Bülow, Simona Beniczky, Jens Brushoj, Mikkel Præst, Birgitte Viebaek, Sine Wichman, Anette Mortensen, Susanne Andi Iversen, Bo Broberg, Edgard Luna, Manuel Jibaja, Leonardo Pazmiño, Katty Trelles, Fabricio Picoita, Gustavo Paredes, Vanesa Ramírez, Guillermo Falconí, Cristian Cevallos, Boris Villamagua, Marco Escobar, Freddy Sánchez, Miguel Llano, Miguel Lazcano, Ramiro Puetate, José Miguel Guerrero, Mijail Játiva, Myriam Montalvo, Franklin Villegas, Luis González Zambrano, Ronnie Mantilla, Gina Quinde, Andrea Gimenez, Luis Gonzalez Mosquera, Henry Caballero, María Fernanda García, Marcelo Ochoa, Soraya Puertas, Jackeline Coello, Mario Acosta, Medhat Soliman, Arnaud W Thille, Achille Kouatchet, Alain Mercat, Laurent Brochard, François Collet, Guillaume Marcotte, Pascal Beuret, Jean-Christophe M Richard, Gaëtan Bedunaeu, Pierre-Gildas Guitard, Fabien Soulis, Frédéric Bellec, Philippe Berger, Dorothée Carpentier, Benoit Veber, Salem Ould Zein, Géraldine Dessertaine, C Canevet, Fabien Grelon, Konstantinos Raymondos, Rolf Dembinski, Rolf Rossaint, Steffen Weber-Carstens, Christian Putensen, Maximillian Ragaller, Michael Quintel, Winfried Schubert, Thomas Bein, Heinrich Paulus, Walter Brandt, Lutz Pfeiffer, Silke Frenzel, Thoralf Kerner, P Kruska, Leila Eckholt, Joachim Hartung, Harald Fritz, Monika Holler, Johannes Busch, Andreas Viehöfer, Jens Buettner, Jörn Schlechtweg, Achim Lunkeit, Roland Schneider, Maria Wussow, Nils Marquardt, Christian Frenkel, Falk Hildebrandt, Tumbass Volker, Thomas Lipp, Cezar Mihailescu, Thomas Moellhoff, Thomas Steinke, Oliver Franke, Marcus Ruecker, Markus Schappacher, Steffen Appel, Heinz Kerger, Andreas Schwartz, Jan Dittmann, Jörg Haberkorn, Wolfgang Baier, Walter Seyde, Dimitros Matamis, Eleni Antoniadou, Pertsas Evangelos, Maria Giannakou, Zoltan Szentkereszty, Zsolt Molnar, Pravin Amin, Farhad N Kapadia, Nagarajan Ramakrishnan, Deepak Govil, Anitha Shenoy, Umesh G, Samir Sahu, Sheila Nainan Myatra, Subhash Kumar Todi, Sanjay Dhanuka, Mayur Patel, P Samaddar, Dhruva Chaudhry, Vivek Joshi, Srinivas Samavedam, Ankur Devendra Bhavsar, Prachee Sathe, Sujoy Mukherjee, Salvatore Maurizio Maggiore, Francesco Idone, Federica Antonicelli, Paolo Navalesi, Rosanna Vaschetto, Arianna Boggero, Rosalba Tufano, Michele Iannuzzi, Edoardo De Robertis, Romano Tetamo, Andrea Neville Cracchiolo, Antonio Braschi, Francesco Mojoli, Ilaria Curro', Mirko Belliato, Chiara Verga, Marta Ferrari, Erika Mannelli, Valerio Mangani, Giorgio Tulli, Francesca Frigieri, Armando Pedulla', Monica Rocco, Giorgia Citterio, Di Russo, Gaetano Perchiazzi, Loredana Pitagora, Antonio Pesenti, Michela Bombino, Davide Chiumello, Federica Tallarini, Serena Azzari, Antonina Pigna, Ivano Aprile, Marco Adversi, Antonio Corcione, Marianna Esposito, Annunziata Mattei, Vito Marco Ranieri, Rosario Urbino, Ilaria Maria Mastromauro, Antonino Giarratano, Maurizio Raineri Santi, Ambrogio Sansone, Younsuck Koh, Moo Suk Park, Je Hyeong Kim, Kyung Chan Kim, Hye Sook Choi, Yun Seong Kim, Jin Hwa Lee, Myung-Goo Lee, Won-Yeon Lee, Jin Young An, Gee Young Suh, Ki-Suck Jung, Asisclo J Villagómez Ortiz, César Cruz Lozano, Zalatiel Maycotte Luna, José Francisco López Baca, José Elizalde, Guillermo Cueto Robledo, Mario Alonso Treviño Salinas, Ricardo Martinez Zubieta, Claudia Olvera-Guzman, Marco Montes De Oca, Silvio A Ñamendys-Silva, José Salvador Martínez Cano, Jose Angel Baltazar Torres, Gustavo Morales Muñoz, Antonio Villa Delgado, Javier Ladape Martinez, Amine Ali Zeggwagh, Tarek Dendane, Abderrahim Azzouzi, Ahmed Sbihi, Wajdi Maazouzi, Mourad Amor, Charki Haimeur, Michael A Kuiper, Matty Koopmans, Uli Strauch, Dennis Bergmans, Serge Heines, Sylvia den Boer, Bas M Kors, Peter van der Voort, Paul J Dennesen, Bert Beishuizen, Ingrid van den Hul, Erna Alberts, Harry P P M Gelissen, Eduard Bootsma, Auke Reidinga, Kim Heus, Diane Mackle, Paul Young, Rachael Parke, Eileen Gilder, Jodi Brown, Lynette Newby, Catherine Simmonds, Jan Mehrtens, Seton Henderson, Tony Williams, Judi Tai, Chantal Hogan, Mary La Pine, John Durning, Sheree Gare, Troy Browne, Shirley Nelson, Jennifer Goodson, Julio Osorio, Chabu Coronado, Rollin Roldán Mori, Rosa Luz López Martínez, Adam Mikstacki, Barbara Tamowicz, Rui Moreno, Eduardo Almeida, Joana Silvestre, Heloisa Castro, Irene Aragão, Susana Alves Ferreira, Nelson Barros, Filomena Faria, Carlos André Correia Casado, Fausto Fialho Moura, Paulo Marcal, Ricardo Matos, Edward Nicolayenko, Mikhail Kirov, Andrey Yaroshetskiy, Andrei Piontek, Valery Subbotin, Yaseen Arabi, Olivia Dulfo, Chafrina Marie Olay, Edgardo E Tabhan, Nicolas Nin, Alfonso Muñoz, César Aragón, Ana Villagrá, Ainhoa Rosselló, Joan Maria Raurich, María Garitacelaya, Miguel Ángel González-Gallego, Francisco Ortuño, Miguel Fernández-Vivas, David Freire, Francisco Guerrero, Francisco Manzano, Juan Carlos, Alfredo Padrón, Pedro Rosa, Rafael Morales, Liliana Caipe, Maurizio Bottiroli, José María Nicolás, Marta Ugalde, Javier Ruiz, Lucia Capilla, Guillermo Muñiz, Jesús Sánchez-Ruiz, Javier Cebrián, Begoña Balerdi, Elena Parreño, Alvaro van Bommel, César Pérez-Calvo, Irene Dot, Javier Blanco, Raquel Manzanedo, José J Blanco, Daniel Fontaneda, Raúl González, Javier Díaz Domínguez, Alfonso Moreno, Antonio Reyes, Ian Carrasco, Itziar Mintegui, Rosa Sebastián, Javier García-Alonso, Carolina Lorencio, Josep Maria Sirvent, Patricia Jimeno, Miguel León, Pedro Galdos, Nuria Alonso, Julia López-Díaz, María Victoria de la Torre, Jorge Vidal Hernández, Nicolás Zamboschi, Francisco Lucena, Gemma Rialp, Raquel Montoiro, Victoria Goñi, María Ángeles Pena, Antonio Maestre, Marc Fabra, Jacinto Baena, Eva Benveniste, Susana Temprano, Jesús Sánchez, Carmen Campos, Sara Cabañes, María Elena Pérez-Losada, José Claudio Leo, Enrique Piacentini, María Del Carmen de la Torre, Laura Álvarez-Montero, Fernando Sánchez, Antonio Viñuales, Bernabé Álvarez, Javier Castañeda, Ángela Alonso, María Isabel Ruiz, Pedro Jesús Domínguez, Marcos Delgado, Eugenio Palazón, Antonio García-Jiménez, Rosa Álvaro, Clara Laplaza Eva Regidor, Enrique Maraví, José María Quiroga, Amalia Martínez de la Gandara, Cecilia Carbayo, María Luisa Navarrete, Manuel Valledor, Raquel Yano, José María Gutiérrez, Javier González-Robledo, Amparo Ferrandiz, Alberto Belenguer, Lidón Mateu, Laura Sayagues, María José Tolón, Nieves Franco, Elena Gallego, Félix Lacoma, Patricia Albert, Vicente Arraez, Mar Gobernado, Susana Moradillo, Carolina Gímenez-Esparza, Teresa Sánchez de Dios, Carlos Marian Crespo, Cecilia Hermosa, Federico Gordo, Genis Carrasco, María Ángeles Alonso, Alejandro Algora, Raúl de Pablo, Sofía García, Ana Carolina Caballero, José María Montón, Teresa Mut, Eva Manteiga, Alejandro de la Serna, Ana Esther Trujillo, Rafael Blancas, Inmaculada Vallverdú, José Manuel Serrano, Miquel Ferrer, Juan Diego Jiménez, Carlos Gallego, Dolores Vila, Luis Marina, Valentín Parra, Juan Ramón Cortés, Chen Chin-Ming, Ai-Chin Cheng, Fekri Abroug, Besbes Mohamed, Imed Chouchene, Mounir Bouaziz, Stambouli Neji, Islem Ouanes, Ayed Samia, Nahit Cakar, Ismail Kati, Ali Aydım Altunkan, Remzi Iscimen, Zafer Dogan, Bilge Çetin, Tayfun Adanir, Sabriye Guvenc, Unase Büyükkoçak, Antonio Anzueto, Ashley Ellis, Gary Kinasewitz, Allan Walkey, Phil Alkana, Gregory A Schmidt, Susan Gillen, Kathleen Lilli, Jennifer Twombley, Denice Wells, Larry Welder, Alejandro Arroliga, Alfredo Vasquez-Sandoval, Vincent John Scott, Craig Cernosek, Christopher Spradley, Dimple Tejwani, Sindhaghatta Venkatram, Gilda Diaz-Fuentes, Amber Monson, Anthony Saleh, Madhav Gudi, George Liziamma, Mohamed A Saad, Crissie De Spirito, Bryan Beatty, Samir Vermani, Crissie Despirito, Zaza Cohen, Amee Patrawalla, Samir Abdelhadi, Rupesh Vakil, Steven Y Chang, Brian Sherman, Rosanna Del Giudice, John Oropell, Timothy D Girard, Cayce Strength, Joyce Okahashi, Leanne Boehm, Matthew Kirchner, Erwin J Oei, Sebastian Circo, Nelson Medina, Mohammed Al-Jagbeer, V J Cardenas Jr, Smyth Smith, Shelby Sutton, Marcela Canola-Mazo, Tim Houlihan, Yogeet Kaur, Travis Parry, Craig A Piquette, Kerry Canady, Rahul Nanchal, Dana K Soetaert, Maria Del Mar Torres-Perez, Carlos Robles-Arias, William Rodriguez-Cintron, Mark Tidswell, Jennifer Germain, Lori-Ann Kozikowski, Erin Braden, Geneva Tatem, Javier Hurtado, Alberto Deicas, Daniel Weiss, Marta Beron, Román Garrido, Cristina Santos, Mario Cancela, Raúl Lombardi, Pedro Alzugaray, Jorge Gerez, Silvia Mareque, Graciela Franca, Oscar Cluzet, Edgardo Nuñez, Julio Pontet, Sergio Cáceres, Elias Caragna, Alberto Soler, Frank Torres, Gastón Pittini, Gabriel D Empaire, Stevens Salva, Fernando Pérez, Clara Pacheco, Zoraida Parra, Ingrid Von der Osten, Luis Williams, José Salinas, Do Danh Quynh, Pham Thi Van Anh, Nguyen Huu Hoang, Nghuyen Ba Tuan, RS: NUTRIM - R2 - Liver and digestive health, MUMC+: MA Arts Assistenten IC (9), Intensive Care, MUMC+: MA Medische Staf IC (9), Tejerina E.E., Pelosi P., Robba C., Penuelas O., Muriel A., Barrios D., Frutos-Vivar F., Raymondos K., Du B., Thille A.W., Rios F., Gonzalez M., Del-Sorbo L., Marin M.D.C., Valle Pinheiro B., Soares M.A., Nin N., Maggiore S.M., Bersten A., Amin P., Cakar N., Young Suh G., Abroug F., Jibaja M., Matamis D., Ali Zeggwagh A., Sutherasan Y., Anzueto A., Esteban A, and Fernando Ríos, Damian Violi, Marisol Rodríguez-Goñi, Roger Lamoglie, Fernando Villarejo, Norberto Tiribelli, Santiago Ilutovich, Matías Brizuela, Mariana Monllau, Fernando Saldarini, Silvina Borello, Alberto Marino, Norberto Tiribelli, Mauricio Vinzio, Karina Bonasegla, Julián Hernández, María Belén Yapur, María Eugenia González, Sebastián E Mare, Judith Sagardía, Marco Bezzi, Cecilia Pereyra, Julian Strati, Daniel Vargas, Claudia Diaz, Pablo Gómez, Marcelo Palavecino, Graciela Elizabeth, Aguilera García, M Eugenia, Luis Pablo Cardonnet, Lisandro Betttini, Hernán Nuñez, Lucas Vallejo, Fernando Fernández, Jorge Arroyo, Daniel Duarte, Gerardo Filippa, Cayetano Galetti, Hernan Nunia, Fernando Lambert, Elisa Estenssoro, Marina Busico, Fernando Villarejo, Javier Horacio Álvarez, Alejandro Raimondi, Gustavo Badariotti, Martín Lugaro, Fernando Lipovestky, Alan Javier Zazu, Hugo Capponcelli, Patricia Vogl, Cristina Orlandi, Alejandro Gómez, Gustavo Jannello, Alejandro Risso, Leticia Rapetti, Guillermo Chiappero, Juan Domingo Fernández, Rodrigo E Gómez-Paz, Marcos Juan Zec, Pascual Valdez, Jorgelina Guyon, Ariel Chena, Sergio Lasdica, Martin Deheza, Schimdt Alejandra, Francisco Criado, Norma Beatriz Márquez, Pablo Desmery, José Luis Scapellato, Gonzalo Javier Ríos, Cristian Casabella, Jasmin Board, Andrew Davies, Andrew Bersten, Elisha Matheson, Amy Waters, John Santamaria, Jennifer Holmes, Cartan Costello, Manoj K Saxena, John Myburgh, Ellen Kinkel, Forbes McGain, Claire Cattigan, Allison Bone, Ian Seppelt, Leonie Weisbrodt, Cheryl Cuzner, Christopher MacIsaac, Deborah Barge, Tania Caf, Cameron Knott, Graeme Duke, Imogen Mitchell, Helen Rodgers, Rachel Whyte, Elisha Fulton, Jasmin Board, Andrew Davies, Alistair Nichol, Hergen Buscher, Priya Nair, Claire Reynolds, Simon J G Hockley, Ian Moore, Katherine Davidson, David Milliss, Raju Pusapati, Helen Wong, Jason Fletcher, Julie Smith, Paul Goldrick, Dianne Stephens, Jane Thomas, Anders Aneman, Sutrisno Gunawan, Tom Cowlam, George Lukas, Rick McAllister, Minka Springham, Joanne Sutton, Jeff Presneill, Tony Sutherland, Dianne Hill, Howard Connor, Jenny Dennett, Tim Coles, Freddy Sandy, Sando Chavarria, Marcelo Choque, Ronald Pairumani, Juan Guerra, Marco Antônio Soares Reis, José Carlos Versiani, Eduardo Fonseca Sad, Maria Aparecida Braga, Dinalva Aparecida Gomes, Fernando Antônio Botoni, Maurício Meireles Góes, Frederico Costa Val Barros, Rogério de Castro Pereira, Hugo Urbano, Valéria de Carvalho Magela, Aline Camile Yehia, Bruno Bonaccorsi Fernandino, Marco Antônio Ribeiro Leão, Rovílson Lara, Rovílson Lara, Rubens Altair Amaral de Pádua, Janine Dias Alves, Aloísio Marques do Nascimento, Bruno do Valle Pinheiro, Carlos Alberto Studart Gomes, Marcelo Alcântara Holanda, Frederico Rodrigues Anselmo, Niall Ferguson, Neill Adhikari, Robert Fowler, Cheromi Sittambalam, Mehar-Un-Nisa Raja, Nicole Marinoff, Lauralyn McIntryre, Shawna Reddie, Laura Jones, Irene Watpool, Jeffrey Singh, Madison Dennis, Andrea Matte, Marc Lipkus, Ryan Albert, Andrew Steel, Emily Stern, Michael Miletin, Antonio Raso, Robyn Klages, Jan Friedrich, Orla Smith, Laura Wilson, Deborah Cook, Mark Bailey, Sangeeta Mehta, Stephen Lapinsky, Hannah Mathers, Cheryl Ethier, Stephanie Lubchansky, Samer Haj-Bakri, Dietrich Henzler, Lisa Julien, Luis Soto-Román, Juan Carlos Maurelia, César Antonio Maquilon, Luis Soto-Germani, Bin Du, Yan Kang, Bo Wang, Fachun Zhou, Fang Xu, Haibo Qiu, Yi Yang, Qingyuan Zhan, Bing Sun, Zhenjie Hu, Bin Yu, Xi Zhu, Yu Bai, Gang Li, Yi Li, Geng Zhang, Jianbiao Meng, Xiaobo Huang, Hong Pu, Bin Du, Daxing Yu, Chuanyun Qian, Wei Zhang, Yongjie Yin, Debiao Song, Yunxuan Yue, Zhengxuan Lv, Chengmin Yu, Qunmei Yao, Xue Wang, Yuan Xu, Wei He, Mian Chen, Zhihua Hu, Dongpo Jiang, Jian Huang, Wei Yu, Juanxian Gu, Yangong Chao, Zhixiang Li, Zhicheng Zhang, Wanxia Li, Zhenyang He, Jianguo Li, Chang Liu, Tiehe Qin, Shouhong Wang, Feng Li, Jun Jin, Jianhong Fu, Hongyang Xu, Hongyuan Lin, Jianying Guo, Yalin Liu, Jinghua Wang, Maoqin Li, Jiaqiong Li, Lei Chen, Qing Song, Liang Pan, Xianyao Wan, Jiuzhi Zhang, Weihai Yao, Yuhong Guo, Pang Wing Yan, Kelly Choy, Kwan Ming Chit, Patricia Leung, Chau Chin Man, Marco González, Ricardo Buitrago, Marcela Granados, Guillermo Ortiz, Cesar Enciso, Mario Gómez, Bladimir Alejandro Gil, Juan Pablo Sedano, Luis Fernando Castro Castro, Carlo Alberto Acosta, Marco Gonzalez, Francisco Molina, Camilo Pizarro, Mario Villabon, Carmelo Dueñas, Carlos Andrés Díaz, Nelson Fonseca, Rubén Camargo, Juan David Uribe, Hans-Henrik Bülow, Simona Beniczky, Jens Brushoj, Mikkel Præst, Birgitte Viebaek, Sine Wichman, Anette Mortensen, Susanne Andi Iversen, Bo Broberg, Edgard Luna, Manuel Jibaja, Leonardo Pazmiño, Katty Trelles, Fabricio Picoita, Gustavo Paredes, Vanesa Ramírez, Guillermo Falconí, Cristian Cevallos, Boris Villamagua, Marco Escobar, Freddy Sánchez, Miguel Llano, Miguel Lazcano, Ramiro Puetate, José Miguel Guerrero, Mijail Játiva, Myriam Montalvo, Franklin Villegas, Luis González Zambrano, Ronnie Mantilla, Gina Quinde, Andrea Gimenez, Luis Gonzalez Mosquera, Henry Caballero, María Fernanda García, Marcelo Ochoa, Soraya Puertas, Jackeline Coello, Mario Acosta, Medhat Soliman, Arnaud W Thille, Achille Kouatchet, Alain Mercat, Laurent Brochard, François Collet, Guillaume Marcotte, Pascal Beuret, Jean-Christophe M Richard, Gaëtan Bedunaeu, Pierre-Gildas Guitard, Fabien Soulis, Frédéric Bellec, Philippe Berger, Dorothée Carpentier, Benoit Veber, Salem Ould Zein, Géraldine Dessertaine, C Canevet, Fabien Grelon, Konstantinos Raymondos, Rolf Dembinski, Rolf Rossaint, Steffen Weber-Carstens, Christian Putensen, Maximillian Ragaller, Michael Quintel, Winfried Schubert, Thomas Bein, Heinrich Paulus, Walter Brandt, Lutz Pfeiffer, Silke Frenzel, Thoralf Kerner, P Kruska, Leila Eckholt, Joachim Hartung, Harald Fritz, Monika Holler, Johannes Busch, Andreas Viehöfer, Jens Buettner, Jörn Schlechtweg, Achim Lunkeit, Roland Schneider, Maria Wussow, Nils Marquardt, Christian Frenkel, Falk Hildebrandt, Tumbass Volker, Thomas Lipp, Cezar Mihailescu, Thomas Moellhoff, Thomas Steinke, Oliver Franke, Marcus Ruecker, Markus Schappacher, Steffen Appel, Heinz Kerger, Andreas Schwartz, Jan Dittmann, Jörg Haberkorn, Wolfgang Baier, Walter Seyde, Dimitros Matamis, Eleni Antoniadou, Pertsas Evangelos, Maria Giannakou, Zoltan Szentkereszty, Zsolt Molnar, Pravin Amin, Farhad N Kapadia, Nagarajan Ramakrishnan, Deepak Govil, Anitha Shenoy, Umesh G, Samir Sahu, Sheila Nainan Myatra, Subhash Kumar Todi, Sanjay Dhanuka, Mayur Patel, P Samaddar, Dhruva Chaudhry, Vivek Joshi, Srinivas Samavedam, Ankur Devendra Bhavsar, Prachee Sathe, Sujoy Mukherjee, Salvatore Maurizio Maggiore, Francesco Idone, Federica Antonicelli, Paolo Navalesi, Rosanna Vaschetto, Arianna Boggero, Rosalba Tufano, Michele Iannuzzi, Edoardo De Robertis, Romano Tetamo, Andrea Neville Cracchiolo, Antonio Braschi, Francesco Mojoli, Ilaria Curro', Mirko Belliato, Chiara Verga, Marta Ferrari, Erika Mannelli, Valerio Mangani, Giorgio Tulli, Francesca Frigieri, Armando Pedulla', Monica Rocco, Giorgia Citterio, Di Russo, Gaetano Perchiazzi, Loredana Pitagora, Antonio Pesenti, Michela Bombino, Davide Chiumello, Federica Tallarini, Serena Azzari, Antonina Pigna, Ivano Aprile, Marco Adversi, Antonio Corcione, Marianna Esposito, Annunziata Mattei, Vito Marco Ranieri, Rosario Urbino, Ilaria Maria Mastromauro, Antonino Giarratano, Maurizio Raineri Santi, Ambrogio Sansone, Younsuck Koh, Moo Suk Park, Je Hyeong Kim, Kyung Chan Kim, Hye Sook Choi, Yun Seong Kim, Jin Hwa Lee, Myung-Goo Lee, Won-Yeon Lee, Jin Young An, Gee Young Suh, Ki-Suck Jung, Asisclo J Villagómez Ortiz, César Cruz Lozano, Zalatiel Maycotte Luna, José Francisco López Baca, José Elizalde, Guillermo Cueto Robledo, Mario Alonso Treviño Salinas, Ricardo Martinez Zubieta, Claudia Olvera-Guzman, Marco Montes De Oca, Silvio A Ñamendys-Silva, José Salvador Martínez Cano, Jose Angel Baltazar Torres, Gustavo Morales Muñoz, Antonio Villa Delgado, Javier Ladape Martinez, Amine Ali Zeggwagh, Tarek Dendane, Abderrahim Azzouzi, Ahmed Sbihi, Wajdi Maazouzi, Mourad Amor, Charki Haimeur, Michael A Kuiper, Matty Koopmans, Uli Strauch, Dennis Bergmans, Serge Heines, Sylvia den Boer, Bas M Kors, Peter van der Voort, Paul J Dennesen, Bert Beishuizen, Ingrid van den Hul, Erna Alberts, Harry P P M Gelissen, Eduard Bootsma, Auke Reidinga, Jasmin Board, Andrew Davies, Kim Heus, Diane Mackle, Paul Young, Rachael Parke, Eileen Gilder, Jodi Brown, Lynette Newby, Catherine Simmonds, Jan Mehrtens, Seton Henderson, Tony Williams, Judi Tai, Chantal Hogan, Mary La Pine, John Durning, Sheree Gare, Troy Browne, Shirley Nelson, Jennifer Goodson, Julio Osorio, Chabu Coronado, Rollin Roldán Mori, Rosa Luz López Martínez, Adam Mikstacki, Barbara Tamowicz, Rui Moreno, Eduardo Almeida, Joana Silvestre, Heloisa Castro, Irene Aragão, Susana Alves Ferreira, Nelson Barros, Filomena Faria, Carlos André Correia Casado, Fausto Fialho Moura, Paulo Marcal, Ricardo Matos, Edward Nicolayenko, Mikhail Kirov, Andrey Yaroshetskiy, Andrei Piontek, Valery Subbotin, Yaseen Arabi, Olivia Dulfo, Chafrina Marie Olay, Edgardo E Tabhan, Nicolas Nin, Alfonso Muñoz, César Aragón, Ana Villagrá, Ainhoa Rosselló, Joan Maria Raurich, María Garitacelaya, Miguel Ángel González-Gallego, Francisco Ortuño, Miguel Fernández-Vivas, David Freire, Francisco Guerrero, Francisco Manzano, Juan Carlos, Alfredo Padrón, Pedro Rosa, Rafael Morales, Liliana Caipe, Maurizio Bottiroli, José María Nicolás, Marta Ugalde, Javier Ruiz, Lucia Capilla, Guillermo Muñiz, Jesús Sánchez-Ruiz, Javier Cebrián, Begoña Balerdi, Elena Parreño, Alvaro van Bommel, César Pérez-Calvo, Irene Dot, Javier Blanco, Raquel Manzanedo, José J Blanco, Daniel Fontaneda, Raúl González, Javier Díaz Domínguez, Alfonso Moreno, Antonio Reyes, Ian Carrasco, Itziar Mintegui, Rosa Sebastián, Javier García-Alonso, Carolina Lorencio, Josep Maria Sirvent, Patricia Jimeno, Miguel León, Pedro Galdos, Nuria Alonso, Julia López-Díaz, María Victoria de la Torre, Jorge Vidal Hernández, Nicolás Zamboschi, Francisco Lucena, Gemma Rialp, Raquel Montoiro, Victoria Goñi, María Ángeles Pena, Antonio Maestre, Marc Fabra, Jacinto Baena, Eva Benveniste, Susana Temprano, Jesús Sánchez, Carmen Campos, Sara Cabañes, María Elena Pérez-Losada, José Claudio Leo, Enrique Piacentini, María Del Carmen de la Torre, Laura Álvarez-Montero, Fernando Sánchez, Antonio Viñuales, Bernabé Álvarez, Javier Castañeda, Ángela Alonso, María Isabel Ruiz, Pedro Jesús Domínguez, Marcos Delgado, Eugenio Palazón, Antonio García-Jiménez, Rosa Álvaro, Clara Laplaza Eva Regidor, Enrique Maraví, José María Quiroga, Amalia Martínez de la Gandara, Cecilia Carbayo, María Luisa Navarrete, Manuel Valledor, Raquel Yano, José María Gutiérrez, Javier González-Robledo, Amparo Ferrandiz, Alberto Belenguer, Lidón Mateu, Laura Sayagues, María José Tolón, Nieves Franco, Elena Gallego, Félix Lacoma, Patricia Albert, Vicente Arraez, Mar Gobernado, Susana Moradillo, Carolina Gímenez-Esparza, Teresa Sánchez de Dios, Carlos Marian Crespo, Cecilia Hermosa, Federico Gordo, Genis Carrasco, María Ángeles Alonso, Alejandro Algora, Raúl de Pablo, Sofía García, Ana Carolina Caballero, José María Montón, Teresa Mut, Eva Manteiga, Alejandro de la Serna, Ana Esther Trujillo, Rafael Blancas, Inmaculada Vallverdú, José Manuel Serrano, Miquel Ferrer, Juan Diego Jiménez, Carlos Gallego, Dolores Vila, Luis Marina, Valentín Parra, Juan Ramón Cortés, Chen Chin-Ming, Ai-Chin Cheng, Fekri Abroug, Besbes Mohamed, Imed Chouchene, Mounir Bouaziz, Stambouli Neji, Islem Ouanes, Ayed Samia, Nahit Cakar, Ismail Kati, Ali Aydım Altunkan, Remzi Iscimen, Zafer Dogan, Bilge Çetin, Tayfun Adanir, Sabriye Guvenc, Unase Büyükkoçak, Antonio Anzueto, Ashley Ellis, Gary Kinasewitz, Allan Walkey, Phil Alkana, Gregory A Schmidt, Susan Gillen, Kathleen Lilli, Jennifer Twombley, Denice Wells, Larry Welder, Alejandro Arroliga, Alfredo Vasquez-Sandoval, Vincent John Scott, Craig Cernosek, Christopher Spradley, Dimple Tejwani, Sindhaghatta Venkatram, Gilda Diaz-Fuentes, Amber Monson, Anthony Saleh, Madhav Gudi, George Liziamma, Mohamed A Saad, Crissie De Spirito, Bryan Beatty, Samir Vermani, Crissie Despirito, Zaza Cohen, Amee Patrawalla, Samir Abdelhadi, Rupesh Vakil, Steven Y Chang, Brian Sherman, Rosanna Del Giudice, John Oropell, Timothy D Girard, Cayce Strength, Joyce Okahashi, Leanne Boehm, Matthew Kirchner, Ashley Ellis, Gary Kinasewitz, Erwin J Oei, Sebastian Circo, Nelson Medina, Mohammed Al-Jagbeer, V J Cardenas Jr, Smyth Smith, Shelby Sutton, Marcela Canola-Mazo, Tim Houlihan, Yogeet Kaur, Travis Parry, Craig A Piquette, Kerry Canady, Rahul Nanchal, Dana K Soetaert, Maria Del Mar Torres-Perez, Carlos Robles-Arias, William Rodriguez-Cintron, Mark Tidswell, Jennifer Germain, Lori-Ann Kozikowski, Erin Braden, Geneva Tatem, Javier Hurtado, Alberto Deicas, Daniel Weiss, Marta Beron, Román Garrido, Cristina Santos, Mario Cancela, Raúl Lombardi, Pedro Alzugaray, Jorge Gerez, Silvia Mareque, Graciela Franca, Oscar Cluzet, Edgardo Nuñez, Julio Pontet, Sergio Cáceres, Elias Caragna, Alberto Soler, Frank Torres, Gastón Pittini, Gabriel D Empaire, Stevens Salva, Fernando Pérez, Clara Pacheco, Zoraida Parra, Ingrid Von der Osten, Luis Williams, José Salinas, Do Danh Quynh, Pham Thi Van Anh, Nguyen Huu Hoang, Nghuyen Ba Tuan
Subjects: Male, medicine.medical_treatment, pulmonary complications, RESPIRATORY-DISTRESS-SYNDROME, Critical Care and Intensive Care Medicine, CASE-FATALITY, 0302 clinical medicine, Risk Factors, Brain Injuries, Traumatic, Multicenter Studies as Topic, Hospital Mortality, Prospective Studies, Simplified Acute Physiology Score, Stroke, POPULATION, Age Factors, ANEURYSMAL SUBARACHNOID HEMORRHAGE, Middle Aged, Hemorrhagic Stroke, Intensive Care Units, Observational Studies as Topic, Anesthesia, Breathing, Female, medicine.symptom, Ventilator Weaning, Cohort study, Adult, TRAUMATIC BRAIN-INJURY, Pressure support ventilation, mechanical ventilation, prognosis factors, ACUTE LUNG INJURY, 03 medical and health sciences, medicine, Humans, Aged, Ischemic Stroke, Mechanical ventilation, Noninvasive Ventilation, business.industry, MORTALITY, neurologic patients, Organ dysfunction, 030208 emergency & critical care medicine, Length of Stay, medicine.disease, TRENDS, Respiration, Artificial, 030228 respiratory system, Etiology, NEUROCRITICAL CARE, Nervous System Diseases, Tracheotomy, business
Abstract: OBJECTIVES: To describe the changes in ventilator management over time in patients with neurologic disease at ICU admission and to estimate factors associated with 28-day hospital mortality. DESIGN: Secondary analysis of three prospective, observational, multicenter studies. SETTING: Cohort studies conducted in 2004, 2010, and 2016. PATIENTS: Adult patients who received mechanical ventilation for more than 12 hours. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Among the 20,929 patients enrolled, we included 4,152 (20%) mechanically ventilated patients due to different neurologic diseases. Hemorrhagic stroke and brain trauma were the most common pathologies associated with the need for mechanical ventilation. Although volume-cycled ventilation remained the preferred ventilation mode, there was a significant (p < 0.001) increment in the use of pressure support ventilation. The proportion of patients receiving a protective lung ventilation strategy was increased over time: 47% in 2004, 63% in 2010, and 65% in 2016 (p < 0.001), as well as the duration of protective ventilation strategies: 406 days per 1,000 mechanical ventilation days in 2004, 523 days per 1,000 mechanical ventilation days in 2010, and 585 days per 1,000 mechanical ventilation days in 2016 (p < 0.001). There were no differences in the length of stay in the ICU, mortality in the ICU, and mortality in hospital from 2004 to 2016. Independent risk factors for 28-day mortality were age greater than 75 years, Simplified Acute Physiology Score II greater than 50, the occurrence of organ dysfunction within first 48 hours after brain injury, and specific neurologic diseases such as hemorrhagic stroke, ischemic stroke, and brain trauma. CONCLUSIONS: More lung-protective ventilatory strategies have been implemented over years in neurologic patients with no effect on pulmonary complications or on survival. We found several prognostic factors on mortality such as advanced age, the severity of the disease, organ dysfunctions, and the etiology of neurologic disease.
Published: 2021
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36. High value health care is low carbon health care

Author: Katy J.L. Bell, Alexandra Barratt, Forbes McGain, and Kate Charlesworth
Subjects: business.industry, Climate Change, media_common.quotation_subject, carbon, Australia, MEDLINE, Climate change, healthcare, footprint, General Medicine, Sustainable Development, Mental health, 1117 Public Health and Health Services, Economic data, climate change, Greenhouse gas, Environmental health, Health care, Carbon footprint, Humans, Business, Delivery of Health Care, Welfare, Carbon Footprint, media_common
Abstract: We are in a health emergency precipitated by climate change.1 As well as physical health threats, climate change and its effects are adversely affecting Australians' mental health,2 and worsening the health inequities suffered by vulnerable populations. In response, the Australian health care community must both adapt to increased demand and to deteriorating environmental conditions, and mitigate the carbon footprint of health care, currently 7% of our national carbon emissions.3 Using economic data from 360 sectors, Malik and colleagues3 estimated carbon emissions by Australian Institute of Health and Welfare categories of health care expenditure, finding that the hospital and pharmaceutical sectors had the largest footprints, together accounting for 63% of health care emissions.
Published: 2022

37. Climate Change and Human Health

Author: Colin D. Butler, Ben Ewald, Forbes McGain, Karen Kiang, and Ann Sanson
Published: 2021
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38. Overdiagnosis is increasing the carbon footprint of healthcare

Author: Alexandra Barratt and Forbes McGain
Subjects: Male, business.industry, Natural resource economics, General Medicine, Medical Overuse, State Medicine, Health care, Carbon footprint, Medicine, Humans, Female, Overdiagnosis, business, Delivery of Health Care, Carbon Footprint
Published: 2021

39. Economic evaluations for intensive care unit randomised clinical trials in Australia and New Zealand: Practical recommendations for researchers

Author: Colman B. Taylor, Kelly J. Thompson, Carol Hodgson, Cheelim Liew, Edward Litton, Forbes McGain, Alistair Nichol, Rashmi Rauniyar, Emma Ridley, and Alisa Higgins
Subjects: Emergency Nursing, Critical Care Nursing
Abstract: Economic evaluations of intensive care unit (ICU) interventions have specific considerations, including how to cost ICU stays and accurately measure quality of life in survivors. The aim of this article was to develop best practice recommendations for economic evaluations alongside future ICU randomised controlled trials (RCTs).We collated our experience based on expert consensus across several recent economic evaluations to provide best-practice, practical recommendations for researchers conducting economic evaluations alongside RCTs in the ICU. Recommendations were structured according to the International Society for Pharmacoeconomics and Outcomes Research (ISPOR) Consolidated Health Economic Evaluation Reporting Standards (CHEERS) Task Force Report.We discuss recommendations across the components of economic evaluations, including: types of economic evaluation, the population and sample size, study perspective, comparators, time horizon, choice of health outcomes, measurement of effectiveness, measurement and valuation of quality of life, estimating resources and costs, analytical methods, and the increment cost-effectiveness ratio. We also provide future directions for research with regard to developing more robust economic evaluations for the ICU.Economic evaluations should be built alongside ICU RCTs and should be designed a priori using appropriate follow-up and data collection to capture patient-relevant outcomes. Further work is needed to improve the quality of data available for linkage in Australia as well as developing costing methods for the ICU and appropriate quality of life measurements.
Published: 2021

40. Effectiveness of portable air filtration on reducing indoor aerosol transmission: preclinical observational trials

Author: Caroline Marshall, Max Rounds, Kirsty Buising, L. Irving, Imogen Wadlow, Jason Monty, Ashley Stevens, Kevin Kevin, Marion A. Kainer, Grant Skidmore, Forbes McGain, J. H. Lee, and Robyn Schofield
Subjects: Microbiology (medical), Air changes per hour, complex mixtures, Article, law.invention, law, air clearance rate, HVAC, Medicine, Humans, Air Conditioning, Personal protective equipment, Air filter, Aerosols, Waste management, Aerosol transmission, business.industry, SARS-CoV-2, portable air filtration, indoor ventilation, COVID-19, General Medicine, Particulates, respiratory system, Control room, Ventilation, Aerosol, Infectious Diseases, Air Pollution, Indoor, Ventilation (architecture), business, Filtration
Abstract: Summary Background While the range of possible transmission pathways of severe acute respiratory syndrome coronavirus-2 in various settings has been investigated thoroughly, most authorities have recently acknowledged the role of aerosol spread in its transmission, especially in indoor environments where ventilation is poor. Engineering controls are needed to mitigate aerosol transmission in high-risk settings including hospital wards, classrooms and offices. Aim To assess the effectiveness of aerosol filtration by portable air cleaning devices with high-efficiency particulate air filters used in addition to a standard building heating ventilation and air conditioning (HVAC) system. Methods Test rooms, including a single-bed hospital room, were filled with test aerosol to simulate aerosol movement. Aerosol counts were measured over time with various portable air cleaning devices and room ventilation systems to quantify the overall aerosol clearance rate. Findings Portable air cleaning devices were very effective for removal of aerosols. The aerosols were cleared five times faster in a small control room with portable air cleaning devices than in the room with HVAC alone. The single-bed hospital room had an excellent ventilation rate (∼14 air changes per hour) and cleared the aerosols in 20 min. However, with the addition of two air cleaning devices, the clearance time was three times faster. Conclusions Inexpensive portable air cleaning devices should be considered for small and enclosed spaces in healthcare settings, such as inpatient rooms and personal protective equipment donning/doffing stations. Portable air cleaning devices are particularly important where there is limited ability to reduce aerosol transmission with building HVAC ventilation.
Published: 2021

41. Net zero healthcare: a call for clinician action

Author: Forbes McGain, Frances Mortimer, Andrea J MacNeill, Jodi D. Sherman, Melissa Lem, and Wayne B. Jonas
Subjects: Conservation of Natural Resources, Health Services Needs and Demand, Health professionals, business.industry, SARS-CoV-2, Climate, Climate Change, COVID-19, General Medicine, Public relations, Planetary health, Zero (linguistics), Action (philosophy), Health care, Humans, sense organs, business, Delivery of Health Care, Analysis
Abstract: Health professionals are well positioned to effect change by reshaping individual practice, influencing healthcare organisations, and setting clinical standards, argue Jodi Sherman and colleagues
Published: 2021

42. Discrepancy between procurement and clinical use of nitrous oxide: waste not, want not

Author: Richard Seglenieks, Forbes McGain, Angela Wong, and Fiona Pearson
Subjects: Greenhouse Effect, business.industry, Natural resource economics, Nitrous Oxide, Nitrous oxide, United Kingdom, chemistry.chemical_compound, Greenhouse Gases, Anesthesiology and Pain Medicine, Procurement, chemistry, Sustainability, Anesthetics, Inhalation, Medicine, Humans, Environmental impact assessment, business
Published: 2021

43. Pourquoi les anesthésistes-réanimateurs doivent-ils se soucier du changement climatique ?

Author: Laure Bonnet, Florence Lallemant, Clément Dubost, Matthieu Belin, Jean-Claude Pauchard, Juliette Marcantoni, El Mahdi Hafiani, Caroline Couchepin, Jane Muret, Paer Selim Abback, Charlotte Kelway, Stéphanie Chandler-Jeanville, Karine Pujol, and Forbes McGain
Subjects: Anesthesiology and Pain Medicine
Published: 2020
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44. Why be sustainable? The Australian and New Zealand College of Anaesthetists Professional Document PS64: Statement on Environmental Sustainability in Anaesthesia and Pain Medicine Practice and its accompanying background paper

Author: Scott C.Y. Ma, Forbes McGain, Peter Roessler, Vanessa G Percival, Ingo A Weber, Rob Burrell, Eugenie Kayak, and Andrew D Weatherall
Subjects: Medical education, business.industry, Statement (logic), Pain medicine, Critical Care and Intensive Care Medicine, 03 medical and health sciences, 0302 clinical medicine, Anesthesiology and Pain Medicine, 030202 anesthesiology, Intensive care, Sustainability, Health care, Medicine, 030212 general & internal medicine, business
Abstract: Healthcare’s environmental sustainability is increasingly an area of research and advocacy focus. The Australian and New Zealand College of Anaesthetists (ANZCA) has produced a professional document, PS64, Statement on Environmental Sustainability in Anaesthesia and Pain Medicine Practice, and a background paper, PS64 BP. The purpose of the statement is to affirm ANZCA’s commitment to environmental sustainability and support anaesthetists in promoting environmentally sustainable work practices. This article presents the main features of PS64 and its background paper, and the associated supporting evidence. The healthcare sector is highly interconnected with activities that emit pollution to air, water and soils, considerably adding to humanity’s collective ecological footprint. As anaesthetists, we are uniquely high-carbon doctors due to our work anaesthetising with greenhouse gases (particularly desflurane and nitrous oxide) and our exposure and contribution to large amounts of resource and energy use and waste generation in operating theatres. Discussion is made of the improving research base of anaesthetic life-cycle assessments—that is, cradle-to-grave studies of how much energy, water and so on a product or process requires throughout its entire life. Thereafter, reducing, reusing and recycling as well as water use are examined. Ongoing research efforts within environmentally sustainable anaesthesia are highlighted. Environmentally sustainable anaesthesia requires scholarship, health advocacy, leadership, communication and collaboration. The focus is placed on practical initiatives within PS64 and the background paper that can be achieved by all anaesthetists striving towards more sustainable healthcare practices that reduce waste, reap financial benefits and improve health.
Published: 2019
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45. Effectiveness of portable air filtration on reducing indoor aerosol counts: preclinical observational trials

Author: Forbes McGain, J. H. Lee, Max Rounds, Imogen Wadlow, Caroline Marshall, Kevin Kevin, Kirsty Buising, L. Irving, Grant Skidmore, Jason Monty, Robyn Schofield, Marion A. Kainer, and Ashley Stevens
Subjects: Air filtration, Waste management, Air changes per hour, business.industry, Particulates, law.invention, Aerosol, HEPA, law, Ventilation (architecture), HVAC, Environmental science, business, Filtration
Abstract: ObjectiveTo assess the effectiveness of aerosol filtration by portable air cleaning devices with high efficiency particulate air (HEPA) filters used in addition to standard building heating ventilation and air-conditioning (HVAC).MethodsTest rooms, including a hospital single-patient room, were filled with test aerosol to simulate aerosol movement. Aerosol counts were measured over time with various portable air cleaning devices and room ventilation systems to quantify the aerosol concentration reduction rate and overall clearance rate.ResultsPortable air cleaners were very effective in removing aerosols, especially for the devices with high flow rate. In a small control room, the aerosols were cleared 4 to 5 times faster with portable air cleaners than the room with HVAC alone. A single bed hospital room equipped with an excellent ventilation rate (∼ 14 air changes per hour) can clear the aerosols in 20 minutes. However, with the addition of two air cleaners, the clearance time became 3 times faster (in 6 minutes and 30 seconds).ConclusionsPortable air cleaning devices with HEPA filtration were highly effective at removing aerosols. To clear aerosols (above 90% clearance) in under 10 minutes requires around 25 air changes per hour; readily feasible with air cleaners. Inexpensive portable air cleaning devices should be considered for small and enclosed spaces in health care settings such as inpatient rooms, personal protective equipment donning/doffing stations, and staff tea rooms. Portable air cleaners are particularly important where there is limited ability to reduce aerosol transmission with building HVAC ventilation.
Published: 2021
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46. Renewable energy use in Australian public hospitals

Author: Matthew Anstey, Forbes McGain, and Hayden Burch
Subjects: business.industry, Hospitals, Public, Climate Change, Fossil fuel, Australia, Environmental pollution, General Medicine, Liquefied petroleum gas, Agricultural economics, Renewable energy, Natural gas, Greenhouse gas, Air Pollution, Public hospital, Carbon footprint, Humans, Electricity, Renewable Energy, business
Abstract: Objective Are Australian hospitals moving towards renewable energy sources for their electricity, and aligning energy choices with core business, i.e. protecting and promoting health? Design Cross-sectional analysis of Australian state/territory amalgamated energy data Setting Healthcare’s carbon footprint is approximately 7% of Australia’s total carbon footprint. It is unknown if Australian public hospitals are decoupling energy needs from carbon emissions over and above state/territory based renewable energy targets. Participants 693 Australian public hospitals direct energy usage (renewable & non-renewable electricity [produced/purchased], natural gas, liquefied petroleum gas, for the three consecutive years from 2016/17 to 2018/19. Main outcome measures All direct energy produced/purchased and consumed (converted to kilowatt-hours). Results Australian public hospitals consumed 4,122 gigawatt-hours of energy in 2018/19. Electricity use was 2,504 (61%) GWh, natural gas 1,436 (35%) GWh and renewable energy 94 GWh (2.3%). Victoria and New South Wales combined consumed 2,494/ 4,122 GWh (60%) of total Australian public healthcare energy but each produced/purchased less than 1% renewable electricity. For Queensland, a Health GreenPower purchase comprised the majority (71/94 GWh; 76%) of renewable energy production/purchase by all Australian public hospitals. By comparison, individual tertiary education institutions produced/purchased more renewable energy than all Australian public hospitals combined (University of NSW 124 GWh/yr, Swinburne University 90 GWh/yr, 2018/19). Conclusions Australian public hospitals obtain approximately 2.3% of total energy from renewable electricity. One third of hospital energy use stems from fossil gas use. The Australian public hospital system has no documented plans to transition to renewable energy, contrasting with the University sector. The known Australian healthcare contributes approximately 7% of Australia’s total carbon footprint with public hospital energy use a major source of healthcare associated carbon emissions. The new Australian public hospitals consumed 4122 gigawatt-hours in 2018/2019. Approximately 2.3% (94/4,122 gigawatt-hours) of hospital energy was sourced from renewables, beyond state-wide renewable electricity penetration. The implications Australian public hospitals are large emitters of greenhouse gases. Hospital fossil fuel energy use and subsequent pollution continues unabated. Such increasing pollution is at odds with the ethos ‘first do no harm’.
Published: 2021

47. Use of portable air cleaners to reduce aerosol transmission on a hospital COVID-19 ward

Author: Amanda J. Wheeler, Imogen Wadlow, Jason Monty, Kevin Kevin, Behzad Rizmanchi, Melita Keywood, Nick Keogh, Kirsty Buising, Ruhi S Humphries, Ashley Stevens, Robyn Schofield, Marion A. Kainer, Forbes McGain, Caroline Marshall, Louis Irving, and Grant Skidmore
Subjects: Waste management, Coronavirus disease 2019 (COVID-19), business.industry, Public Health, Environmental and Occupational Health, medicine.disease, Air cleaner, Article, law.invention, Aerosol, Patient room, Infectious Diseases, Transmission (mechanics), law, HEPA, Healthcare settings, Environmental science, Medicine, Medical emergency, business, Hospital ward, General Nursing, Clearance
Abstract: ObjectiveTo study the airflow, transmission and clearance of aerosols in the clinical spaces of a hospital ward that had been used to care for patients with COVID-19, and to examine the impact of portable air cleaners on aerosol clearance.DesignObservational studySettingA single ward of a tertiary public hospital in Melbourne AustraliaInterventionGlycerine-based aerosol was used as a surrogate for respiratory aerosols. The transmission of aerosols from a single patient room into corridors and a nurses’ station in the ward was measured. The rate of clearance of aerosols was measured over time from the patient room, nurses’ station and ward corridors with and without air cleaners (also called portable HEPA filters).ResultsAerosols rapidly travelled from the patient room into other parts of the ward. Air cleaners were effective in increasing the clearance of aerosols from the air in clinical spaces and reducing their spread to other areas. With two small domestic air cleaners in a single patient room of a hospital ward, 99% of aerosols could be cleared within 5.5 minutes.ConclusionAir cleaners may be useful in clinical spaces to help reduce the risk of healthcare acquired acquisition of respiratory viruses that are transmitted via aerosols. They are easy to deploy and are likely to be cost effective in a variety of healthcare settings
Published: 2021
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48. Recovery of Sevoflurane Anesthetic Gas Using an Organosilica Membrane in Conjunction with a Scavenging System

Author: Sandra E. Kentish, Forbes McGain, and Liang Liu
Subjects: Methyl Ethers, General Chemistry, Permeance, Microporous material, 010501 environmental sciences, 01 natural sciences, Global Warming, Sevoflurane, Greenhouse Gases, Ceramic membrane, Membrane, Chemical engineering, Anesthetic, Anesthetics, Inhalation, medicine, Environmental Chemistry, Humans, Relative humidity, Selectivity, 0105 earth and related environmental sciences, medicine.drug
Abstract: Approximately 95% of the anesthetic gas administered to a patient is exhaled and ultimately released into the atmosphere. Most anesthetic gases have high global warming potential and so this approach adds significantly to the global greenhouse gas footprint. In this work, we develop a feasible means to capture such an anesthetic gas (sevoflurane) before it is released to the hospital scavenging system so that it is retained within the anesthetic circuit. Sevoflurane is retained using a microporous 1,2-bis(triethoxysilyl)ethane (BTESE) membrane prepared by a sol-gel method. The use of a ceramic membrane facilitates sanitization at high temperatures. A rapid thermal processing (RTP) technique is employed to reduce production time and to create a looser organosilica network, resulting in higher gas permeances, compared with the membrane synthesized from conventional thermal processing. The RTP membrane shows a slight decline in gas permeance when used with a dry mixture of CO2/N2/sevoflurane. This permeance falls again under 20% relative humidity feed conditions but the CO2/sevoflurane selectivity increases. The membrane performance shows little variation when the relative humidity is further increased. These promising results demonstrate that this microporous BTESE membrane has great potential for the recovery of sevoflurane in an anesthetic application.
Published: 2021

49. Environmental impact of medical oxygen production in Australia. Comment on Br J Anaesth 2020; 125: 773–8

Author: Scott McAlister, Forbes McGain, and Richard Seglenieks
Subjects: business.industry, Oxygen evolution, chemistry.chemical_element, Oxygen, Fresh gas flow, Anesthesiology and Pain Medicine, chemistry, Environmental protection, Sustainability, Medicine, Healthcare cost, Environmental impact assessment, Total intravenous anaesthesia, business
Published: 2021
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50. Planetary health care: a framework for sustainable health systems

Author: Forbes McGain, Jodi D. Sherman, and Andrea J MacNeill
Subjects: lcsh:GE1-350, 2019-20 coronavirus outbreak, Health (social science), Coronavirus disease 2019 (COVID-19), Health Policy, Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), Climate Change, Public Health, Environmental and Occupational Health, MEDLINE, Medicine (miscellaneous), Climate change, Planetary health, State Medicine, England, Carbon footprint, Business, Environmental planning, Delivery of Health Care, lcsh:Environmental sciences, Healthcare system, Carbon Footprint
Published: 2021

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