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Featured Articles
Investments in healthcare: a quest for seeking improvements
Dr. Gianfranco Scaperrotta, the head of SS Senology Radiology at Fondazione IRCCS Istituto Nazionale dei Tumori (INT) in Milan, offers his perspective on what advisable investments healthcare executives should consider, pointing to inefficiencies in workflow and patient satisfaction in the stereotactic breast biopsy procedure to help illustrate his position.
by Dr. Gianfranco Scaperrotta
Healthcare executives – who are responsible for investment decisions – are constantly working to justify how a particular asset or purchase is beneficial to their facility. With multiple priorities to consider, from doctors’ and patients’ needs, to a facility’s financial goals and beyond – combined with budget limitations – the need to find and rationalize the right investment options can be particularly complex. This is largely caused by the demands being placed on facilities and doctors to work more quickly and efficiently. In an era marked by the concept of constantly doing more, faster and better, the search for the right investment essentially comes back to the same basic, and yet truly powerful idea: in the healthcare field, we are always on a quest for improvement.
One of the best ways to warrant an investment is to become immersed in the field’s overall functionality from a clinical, financial and patient perspective to unearth any weaknesses. There are certainly processes and procedures in each part of the healthcare industry that can and should be improved, and that, if effectively handled, could have a positive, widespread ripple effect across facilities.
Breast biopsy procedure
The radiology sector, for example, is one of many in healthcare that has room for improvement. As the head of SS Senology Radiology at Fondazione IRCCS Istituto Nazionale dei Tumori (INT) in Milan, I feel this is particularly apparent when it comes to the current state of the stereotactic breast biopsy procedure. Throughout my 25-year career, I have performed many breast biopsy procedures, and although none of my experiences are exactly the same as one another, there are a few consistent aspects that are worth noting that help showcase a need for change. This is made evident when considering the overall procedural experience, from start to finish.
More often than not, when patients come in for a breast biopsy, they’re already feeling anxious and uncertain about the procedure before they even enter the room. In addition to fearing a needle in the breast, they are likely contemplating the unsettling idea that they may be diagnosed with breast cancer. Their level of discomfort may grow while waiting for the clinicians to enter the room and begin to prepare for the procedure. To begin, the technologist will help the patient get into the appropriate position to ensure the biopsy needle is targeting the proper area of the breast, where the suspicious tissue was noted on the mammography exam. Depending on where the calcification is in the breast, in some cases, the patient must be placed in a particularly awkward position in order for the needle to reach the correct target area, and she must hold her body in that same position until the procedure is complete.
At this point, the radiologist collects the tissue samples, which then require verification. This process varies depending on the facility. Whereas I have the resources to verify my patients’ samples in the same room where the biopsy is taking place, there are many cases in which the clinician must prepare the samples for transport, and then leave the procedure room to image and verify the samples on another piece of imaging equipment, which may already be in use for another patient and therefore cause scheduling delays. During this time the patient must remain in compression, which may increase her anxiety. In some cases, the clinician will determine the need to take more samples from the patient, making the procedure time lengthier than anticipated. After the tissues are verified, the breast biopsy procedure can conclude, yet the patient must first await her results, which will come later, after the samples have been sent to and evaluated by pathology.
This one scenario in the radiology field demonstrates a few issues that must be tackled. First and foremost, patients are extremely anxious, and radiologists need to help ease their concerns. Perhaps they could be helped by enhancing the ambiance of the procedure room with more calming visuals or music to reduce tension. Additionally, positioning patients when their calcifications are in unusual areas can add to their discomfort. Similarly, lengthier procedure times only add to patient apprehension, while also slowing radiologists down, which can affect their subsequent appointments. Lastly, patients must still wait for the samples to go through the pathology process before receiving a diagnosis.
Patients satisfaction
It’s clear that today’s stereotactic breast biopsy could benefit from better workflow efficiency, yet this deep dive into the procedure also reveals a need for improved patient comfort. Together, time-savings and comfort contribute to overall patient satisfaction, and the fact that the stereotactic breast biopsy falls short in this area presents an opportunity for improvements to be made. For any doctor and facility, providing a positive patient experience and increasing satisfaction is crucial for success. Not only is it important to deliver high quality, swift care for patients for their health and happiness, but it’s also worth recognizing the business logistics associated with patient satisfaction – positive experiences can result in future referrals. Additionally, fast and efficient procedures mean that radiologists can get more work done in a day, furthering the overall productivity and financial success of a facility.
In my opinion, when healthcare executives are thinking about their next investments, they should not only remember to consider a sector’s inefficiencies, but they should also take special note of those shortcomings that have the widest impact across the facility, like workflow and patient experience. Even beyond investments, it is human nature to constantly seek improvements. For example, I envision one day that radiologists will take an entirely new approach to the biopsy procedure, perhaps removing calcifications as a whole at once to start potential cancer treatment early, instead of taking smaller samples to first test the tissue. I encourage clinicians to similarly identify inefficiencies in their respective industries and search their minds for new, better ways. Let us challenge what we know and never tire from our quest to keep improving.
Encouraging family visiting for hospital patients
Visiting hours for hospitalized patients have traditionally been restricted to set periods during the day and limited in duration. However, the situation is slowly changing towards a more open approach to family visits, even in wards where visits are often most restricted, such as intensive care units (ICUs). As just a few examples of this general change in attitudes towards visiting, many American hospitals have now completely removed restricted visiting hours; a campaign of extended visiting hours was launched in France a few months ago; and a bill is currently being discussed in Italy to expand hospital visits.
by Prof Jean-Louis Vincent
Why restrict hospital visiting?
The reasons behind restrictive visiting are not very clear or, in today’s context, very credible. The fear of transmission of infection was perhaps the earliest reason for restricting visits, but with improved infection control measures, this concern is generally unfounded. Other suggested reasons include the need for patient to have adequate rest periods and the belief that visitors interfere negatively with medical and nursing care.
Because sick patients need rest?
It was widely believed that having periods of the day without visiting would ensure that patients had sufficient periods of rest, without disturbance from visitors. However, the need for sick patients to rest is often exaggerated. Indeed, this idea is now rather out-of-date, even for the sickest of patients. Although patients must clearly not be exhausted by their visitors, too much rest can encourage muscle weakness and prolong convalescence. When a family member says “doesn’t he/she need to rest Doctor?”, I often reply “certainly not; in fact you should wake him/her up!”. The current trend is to encourage physical and intellectual stimulation for all patients.
Of course patients need some time to sleep and rest, as we all do, but this can be determined on an individual basis, preferably after discussion with the patient, rather than being enforced at fixed times by restricted visiting hours. Moreover, the presence of a loved one in the room does not necessarily prevent restorative sleep. Rest is also important for family members and it is sometimes necessary to remind them to take a break, particularly at night. In any case, access to hospitals is generally limited during the night, for security reasons.
Because visitors interfere with patient care?
The presence of visitors was often believed to interfere negatively with medical care. Visiting hours were therefore concentrated on periods of the day during which patients were least likely to be undergoing medical consults or examinations. However, hospitals of today function almost continuously or at least with considerably more extensive hours than in the past, notably for laboratory and radiological investigations, making it difficult to predict when examinations and rounds are most likely to take place.
The presence of visitors was also often believed to hinder good nursing care, and perhaps much restricted visiting was devised for the benefit of nurses, rather than the patient. Nurses often complained that they were unable to perform the necessary care in the best possible way, because they were bothered by the presence of relatives, sometimes numerous and noisy, who asked a lot of questions, and were even critical of the care being provided!
However, it is now widely believed that extended visiting hours can be beneficial not only for the patient and visitors, but also for the staff. Staff members, especially nurses, are often initially reluctant to the proposed change to more extensive or unlimited visiting, concerned that it will increase their workload. But this is not necessarily true, and is in fact often the reverse. Allowing visitors to be present at different times during the day enables them to understand better the work of the nurses, doctors and other healthcare personnel. When visiting hours are restricted, nurses often make use of the visiting periods to have a small break, to catch up or even have a joke with their colleagues. This can sometimes give visitors the impression that nurses have nothing to do, or are not really concerned about looking after the patients under their care. By arriving at different times of the day and staying for longer periods, family members can better appreciate hospital life and realize that nurses also need some time for relaxation and distraction, thus reducing the risk of conflicts between family members and staff. Extending visiting hours also reduces the number of telephone calls from relatives asking after their loved one, thus freeing up nursing time.
Let’s welcome visitors
Importantly, fixed visiting hours can discourage relatives from visiting a patient. For example, it can be difficult for family members who are working to request time off during the day to be able to observe the fixed visiting hours; sometimes family members simply forget (or are unaware of) the specified times, especially when units have different hours on different days of the week, and have to go home having missed the allocated slot; similarly, visitors who have to travel some distance to visit their loved one may be put off by the risk of being late and missing the fixed visiting period. Finally it is sometimes just easier to say, “I’ll visit when they’re better and out of hospital…”
Rather than being made to feel that they are the enemy and not welcome, relatives should be encouraged to visit and be involved. We must not talk about “them” and “us”. The patient must be at the centre of our preoccupations at all times and we must all work together to ensure he/she has the best possible chances of a good recovery without complications. Family members and loved ones form part of the patient’s immediate supportive environment and can form a useful bridge between the patient and hospital staff. They can also play an active role in patient surveillance, for example by indicating to staff if there is a problem that has not been noticed or that the patient may not want to report. In certain American hospitals, pamphlets are now available to explain how relatives can identify and report important signs of deterioration, for example, confusion that wasn’t there before or a small change in respiration that has gone unnoticed.
Family members can even sometimes contribute directly to some aspects of patient care, for example helping with feeding, washing or dressing. Indeed, these practices are commonplace in countries with limited resources, where family members never leave the bedside. In western society, however, patient care has been completely transferred from the family to professional carers, which can sometimes lead to the patient feeling patronized or being treated like a child.
The hospital structure is also changing to be more welcoming for visitors. Instead of a few folding seats at the end of the corridor for relatives waiting while the patient is examined or comes back from an examination, many hospitals have now introduced reception rooms where relatives can stay as long as they wish, in comfortable conditions. In the United States in particular, hospitals have set up small kitchen-lounges where families can rest, prepare a meal in the microwave or watch television… and why not socialize, chat, share experiences with relatives of other patients.
Indeed, the hospital is no longer a detached world, which we are somewhat hesitant or even scared to enter. Hospitals are increasingly user friendly and should be seen as somewhere positive and welcoming. After all, many hospitals now have a cafeteria (if not a restaurant), small shops, a bank, a post-office, pleasant gardens… creating the idea that hospitals can be part of everyday life, and indeed are for the many patients and visitors that pass through the doors daily. Visitors can make use of these areas when their relative is undergoing an examination or receiving nursing care.
Family presence during interventions?
As families spend more time visiting their loved ones in hospital, the chances that they will be present when an intervention is needed are increasing, perhaps particularly on high acuity wards. But should they be allowed to stay in the room? Perhaps yes for a simple blood test or changing of a dressing, but what about during cardiopulmonary resuscitation (CPR)? This issue continues to raise considerable debate, not least because the patient needing CPR cannot be asked if they mind. Although some staff members find having family members present adds stress to an already complex situation, studies have suggested that the presence of a relative can help a surviving patient understand what has happened and, if the patient dies, having been present can reassure the family member that everything possible was done. This is an area where attitudes are changing and, if a family member wishes to be present during CPR, this request should not be refused.
The rights and responsibilities of visitors ….
Clearly, although visitors have the right to see their loved ones in hospital, they must also abide by certain rules. They must leave the room when asked to do so by the hospital staff and should not interfere with patient care. They should not slow the work of the nursing or medical staff by asking repetitive, unnecessary questions or by engaging in prolonged conversation. Importantly, too, visitors are there to visit only their relative/loved one and must not look, even surreptitiously, into the rooms of other patients!
… and the rights of the patient
On reflection, rather than asking whether visiting the sick patient is allowed, the question should rather be the reverse, whether the patient is allowed to see his/her relatives? Limiting hospital visits is generally harmful for the patient and opening up visiting is reported to improve patient satisfaction. By bringing news from the outside world, family, friends, pets, … visitors can stimulate a patient’s intellect and interest, helping promote a quick recovery. There is nothing worse than lying in bed all day just looking at the ceiling… But, it is important to consider the patient’s viewpoint when considering visitor access. For example, some patients may prefer to have only close family members visit, feeling embarrassed about less well-known friends and relatives seeing them unwell, and others may prefer not to discuss their condition when family members are present for fear of upsetting them. Patients have the right to see visitors whenever they wish, but should not have visiting forced upon them.
Conclusion
It is not so long ago that, when visiting a patient in hospital, an often rather officious nurse would announce the end of visiting hours and insist you leave your loved one. Such strict practices have become less common and there is much more flexibility, particularly on general hospital wards. We need to go further and extend open visiting to all areas of the hospital, including ICUs, where visiting still remains, in general, more restricted. In many cases, we should be actively inviting relatives to visit more and to stay longer, especially when the patient has few visitors and feels isolated. Visiting is humane and good for the patient.
If you still have restricted visiting hours at your hospital, I am sure this will change in the near future. I am not convinced that there should be a law on this subject, whether in Belgium, Italy or elsewhere, but rather a collective effort needs to be made to change our mentality related to visiting hours and thus improve the quality of care for our patients.
Suggested reading
Giannini A, et al. What’s new in ICU visiting policies: can we continue to keep the doors closed? Intensive Care Med 2014; 40: 730-33
Jabre P, et al. Family presence during cardiopulmonary resuscitation. N Engl J Med 2013; 368: 1008–18.
McAdam JL & Puntillo KA. Open visitation policies and practices in US ICUs: can we ever get there? Crit Care 2013; 17: 171
Shulkin D, et al. Eliminating visiting hour restrictions in hospitals. J Healthc Qual 2014; 36: 54-7
The author
Jean-Louis Vincent, MD, PhD
Dept of Intensive Care, Erasme University Hospital, Université libre de Bruxelles,
Route de Lennik 808, 1070 Brussels,
Belgium
jlvincent@intensive.org
Automation and integration of LC-MS/MS services into the clinical laboratory workflow
Despite significant inherent advantages of liquid chromatography-tandem mass spectrometry (LC-MS/MS) over immunoassay techniques in clinical laboratory applications, its adoption into routine practice has been slower than might have been expected. The barriers to more widespread uptake are a function of issues in the laboratory workflow. This article analyses those issues and discusses how they can be overcome by improved automation and integration with the laboratory information management system, drawing on examples from the North West London Pathology (NWLP) clinical laboratories at Imperial College Healthcare NHS Trust.
by Dr Emma L. Williams
Introduction
Liquid chromatography-tandem mass spectrometry (LC-MS/MS) has seen over two decades of use in specialist clinical laboratories in the UK, offering a number of significant advantages over immunoassay techniques. These advantages include increased specificity, sensitivity and accuracy, as well as the detection of multiple analytes within a single assay. There is no need for an antibody for analyte detection and the method is not susceptible to the antibody-based interferences that plague immunoassays [1]. LC-MS/MS is suitable for multiple sample matrices and avoids the need for radioactive tracers. LC-MS/MS assays also have a wider dynamic measurement range and have improved between-method bias when compared to immunoassays.
LC-MS/MS initially played a role in specialist clinical laboratories in areas such as newborn screening, inborn errors of metabolism, toxicology and in immunosuppressant and therapeutic drug monitoring. More recently LC-MS/MS has established a role in diagnostic endocrinology, with the first appearance of LC/MS-MS for the measurement of vitamin D in the international vitamin D external quality assurance scheme (DEQAS) in 2005. There are now over 150 labs registered in this scheme using LC/MS-MS for the measurement of vitamin D. However, automated immunoassay still dominates and represents 69% of participants registered in the DEQAS scheme. Why has there not been more widespread adoption?
A number of issues have inhibited wider adoption and routine use of LC/MS-MS in the clinical laboratory. First among these is the use of labour-intensive manual workflows, which result in lower throughput, decreased productivity and longer turnaround time. Furthermore, a high level of technical expertise is needed, not only for method development, but also for troubleshooting assay and equipment failures. In addition to the high initial capital costs of purchasing the equipment, ongoing personnel costs are higher because of the need for more technically competent staff. With a clear understanding of where the bottlenecks in the process arise, these barriers can be overcome.
Figure 1 depicts the six main steps of a typical LC/MS-MS workflow, from sample receipt and extraction, separation in the LC, MS/MS analysis, data review and reporting of the results [2]. Of these steps it is the pre- and post-analytical stages that are the most time consuming and therefore if there is a focus on streamlining these, maximum benefit can be achieved. A number of steps can be taken to streamline the workflow, and these come under three broad headings of reduced manual processes, increased throughput and improved integration. Dependence on manual processes can be reduced by the automation of liquid handling and extraction, use of barcode reading for worklist generation and implementation of automated data analysis. Throughput can be increased with strategic column and sample management and by analyte multiplexing. Integration can be improved by bi-directional interfacing of the LC/MS-MS system to the laboratory information management system (LIMS) allowing automatic worklist upload and results download. These three strategic areas will be discussed in more detail below.
Reduced manual processes
Unlike the case with immunoassay, samples for LC-MS/MS usually require extraction prior to analysis. Historically this extraction step utilized liquid–liquid extraction or protein precipitation, these being carried out after the addition of internal standard to the calibrators, quality controls and patient samples. All of these steps involved manual pipetting and were very slow and time consuming. Use of an automated liquid-handling platform for the pipetting of samples and addition of internal standard allows some of the steps of liquid–liquid extraction and protein-precipitation methods to be automated. These liquid-handling platforms are available from a number of suppliers including Hamilton and Tecan.
With the advent of 96-well plate technology it became possible to carry out fully automated off-line solid phase extraction (SPE) using platforms such as the Freedom Evo (Tecan) and the Biomek NX (Beckman Coulter). More recently, supported liquid extraction (SLE), which allows solvent extraction to occur on a diatomaceous earth inert support, has also become available in a 96-well plate format. The Extrahera system (Biotage) enables automation of SLE by carrying out all of the pipetting and extraction steps required. In the NWLP laboratory, this system is used for the extraction of patient samples for vitamin D measurement by LC-MS/MS. A sample throughput of up to 50,000 samples per annum is achieved with capacity remaining for additional extractions for use in other LC-MS/MS applications. The system is robust and reliable with good pipetting precision and uses disposable pipette tips, thus avoiding sample carry over. Figure 2 depicts the Tecan Freedom Evo 200 and Biotage Extrahera liquid handlers in use in the NWLP laboratory.
In some manufacturers’ LC-MS/MS systems, on-line sample preparation and extraction is enabled by use of turbo flow or 2D chromatography. On-line protein precipitation and SPE is also now available using the Clinical Laboratory Automated sample preparation Module (CLAM)-2000 (Shimadzu Corporation) [3] and the Rapidfire 365 MS system (Agilent) [4] respectively. These latter examples most closely resemble the immunoassay workflow, whereby samples are introduced into the analytical system without any sample preparation or pre-treatment.
Increased throughput
Increased throughput can be achieved through the use of column and sample managers, allowing multiple assay batches to be queued up for overnight analysis of different LC-MS/MS assays. LC multiplexing enables multiple columns to be coupled to one tandem mass spectrometry system, maximizing the MS detection capability. In this approach, the use of quaternary solvent pumps in the LC enables column switching between different columns using different mobile phases. Finally there is analyte multiplexing, which can use manufacturers’ kits or in-house laboratory developed tests (LDTs). This approach enables multiple analytes to be detected in a single chromatographic separation by the use of multiple reaction monitoring for MS/MS detection. Perkin Elmer and Chromsystems both provide kits enabling the simultaneous measurement of multiple steroid hormones within a single assay panel. In the NWLP laboratory an in-house LDT steroid panel for the simultaneous measurement of androstenedione, 17-hydroxyprogesterone and testosterone has been implemented. This multiplexed assay has replaced the previous stand-alone assays for these analytes, thus increasing throughput and offering faster turnaround time. The assay utilizes off-line SPE using Waters Oasis PRiME HLB 96-well plates and the Tecan Freedom Evo 200 automated liquid handler [5].
Improved integration
Improved integration can be achieved by the use of bi-directional interfacing between the LIMS and the LC-MS/MS instrument software. Nowadays, manufacturers of LC-MS/MS systems offer customer support to allow their systems to be interfaced to the LIMS. One example is the MassLynx LIMS interface (Waters), which enables both worklist download and results upload. The MassLynx LIMS interface is accessed via the LC-MS/MS system software allowing sample worklists, created by barcode scanning of the patient samples, to be imported directly. Following peak integration and analyte quantitation the results are directly transmitted from the LC-MS/MS to the LIMS via an HL7 interface. This avoids the need for manual transcription thus saving a great deal of staff time and eliminating transcription errors.
The ultimate aim of LC-MS/MS integration is to achieve complete integration of LC-MS/MS instruments into the automated workflow of high-throughput routine clinical laboratories. With the recent launch of the Cascadion LC-MS/MS analyser (Thermo Fisher Scientific) this ultimate aim has now been achieved [6]. This analyser offers a complete LC-MS/MS solution including primary blood tube sampling, on-board sample extraction, LIMS connectivity and a random access workflow enabling the provision of a 24/7 service. Traceable manufacturer’s kits are offered for the measurement of a panel of immunosuppressant drugs, testosterone and vitamin D with further assay kits in the development pipeline. The Cascadion analyser is shown in Figure 3.
Summary
LC/MS-MS automation and integration is now a reality, allowing faster sample processing and improved turnaround time, as well as offering increased staff productivity, improved quality and reduced error rate. Staff time is liberated for further service development, allowing the more rapid introduction of validated in-house LDTs into the assay repertoire. Finally there is the possibility of complete analyser integration allowing routine, high-throughput analysis, as is already the standard approach for the common immunoassay platforms. This exciting development will support the more widespread adoption of LC-MS/MS in the routine clinical laboratory by offering complete automation and integration, overcoming the barriers discussed in this article and enabling the inherent advantages of LC/MS-MS in clinical laboratory practice to be more fully realized.
References
1. Jones AM, Honour JW. Unusual results from immunoassays and the role of the clinical endocrinologist. Clin Endocrinol Oxf 2006; 64: 234–244.
2. Zhang YV, Rockwood A. Impact of automation on mass spectrometry. Clin Chim Acta 2015; 450: 298–303.
3. Shimadzu. CLAM-2000. Fully automated sample preparation module for LCMS. (https://www.shimadzu.com/an/lcms/clam/index.html).
4. Jannetto PJ, Langman LJ. High-throughput online solid-phase extraction tandem mass spectrometry: Is it right for your clinical laboratory? Clin Biochem 2016; 49: 1032–1034.
5. Williams EL. LC-MS/MS measurement of serum steroids in the clinical laboratory. Clinical Laboratory International 2017; Sept: 18–20.
6. ThermoFisher Scientific. Cascadion SM Clinical Analyzer (www.thermofisher.com/cascadion).
The author
Emma L. Williams PhD, FRCPath
North West London Pathology, Imperial College Healthcare NHS Trust, London, UK
E-mail: emma.walker15@nhs.net
Greening hospitals: Yes we can!
Earlier this year the American Medical Association (AMA) published an article entitled ‘Lower costs by going green!’ aimed at the healthcare sector. They note that, in the USA, 9 – 10 percent of the nation’s total carbon dioxide emissions are generated by the health care industry – and the USA is not alone in this high carbon footprint. In Europe the average emissions is estimated to be about 5 percent. Cleary there is a margin for improvement. The AMA article makes practical, money and energy saving proposals aimed at the small medical practices. The question arises as to how this could be achieved in the larger hospital environment. There is a trove of excellent suggestions for building new energy efficient and environmentally friendly hospitals – but what of existing hospitals?
A very useful source of information is the Global Green and Healthy Hospitals (GGHH) community. The community of almost 1000 members have the aim to transform the health sector and foster a healthy future for people and the planet. To achieve this aim GGHH brings together hospitals, health systems, and health organizations from around the world under the shared goal of reducing the environmental footprint of the health sector.
To achieve their aims, they suggest a 10 goal strategy: Leadership -making environmental health, safety and sustainability key organizational priorities; substituting harmful chemicals with safer alternatives; to reduce, treat and safely dispose of healthcare waste; to reduce water consumption, as well as to source, purchase and serve sustainably locally grown, healthy food. Other goals include implementing energy saving strategies; safely manage and dispose of pharmaceuticals; transportation planning, building efficiency design; and purchasing safe and sustainable products.
GGHH points out that there is not one model of green and healthy hospital but indicate that many health systems around the world are already taking steps to reduce their environmental footprint contributing to public health while at the same time saving money. Initiatives such as the ‘Health Promoting Hospital Network’ originating in Europe and with the support of the World Health Organisation, is developing a set of sustainability criteria. Such initiatives and conferences of greening the health sector are emerging in countries as diverse as Argentina, China, India, South Africa and Sweden – to name a few.
The Global Green and Healthy Hospitals agenda sets out to support these existing efforts around the world to promote greater sustainability and environmental health. European hospitals would do well to align themselves with this community, reducing the European healthcare contribution to the carbon footprint, as well as, in many cases, saving money –immediately and in the future.
