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Abstract
Background With a global annual carbon footprint of the healthcare sector of 2 gigatons of CO2e, healthcare systems must contribute to the fight against climate change. Hospital pharmacists could be key players in ecological transition due to their role in managing healthcare products. The aim of this study was to summarise the evidence on interventions implemented in healthcare facilities involving pharmacists to improve the environmental footprint of healthcare.
Methods This systematic review was conducted following PRISMA 2020 guidelines. The Medline, Web of Science and ScienceDirect databases were searched for studies published between 2013 and 2023. To be eligible for inclusion, studies had to include hospital pharmacists and present contributions aimed at reducing the environmental footprint of healthcare in healthcare facilities. Outcomes were the description of the contribution, the methods used and the stages of healthcare product lifecycle analysed. A Mixed Methods Appraisal Tool was used to assess the risk of bias for each study.
Results Seventeen studies were included. Pharmacists played a leading role in 15 (88%) and had a supporting role in the others. The healthcare products targeted were medicines (59%), medical devices (12%) or both (29%). The stages of the healthcare product cycle addressed by the contributions were elimination (71%), dispensing (35%), procurement and supply (35%), production (29%), and prescription (24%). Only two studies used life cycle assessment and only one assessed all three pillars of sustainability. Two studies had good methodological quality while the rest had at least one element of uncertainty.
Conclusion This review confirms the central role of the pharmacist and the importance of a multidisciplinary approach in implementing eco-responsible actions. It could be useful to hospitals and other teams wanting to improve sustainable actions and it emphasises the importance of collaborating with pharmacists when planning sustainable initiatives. Future eco-responsible initiatives must use robust reproducible methods.
Trial registration PROSPERO #CRD42023406835
- PHARMACY SERVICE, HOSPITAL
- PHARMACEUTICAL PREPARATIONS
- Drug Compounding
- MEDICATION SYSTEMS, HOSPITAL
- STERILIZATION
- PUBLIC HEALTH
Data availability statement
All data relevant to the study are included in the article or uploaded as supplementary information.
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- PHARMACY SERVICE, HOSPITAL
- PHARMACEUTICAL PREPARATIONS
- Drug Compounding
- MEDICATION SYSTEMS, HOSPITAL
- STERILIZATION
- PUBLIC HEALTH
WHAT IS ALREADY KNOWN ON THIS TOPIC
The healthcare system contributes to climate change and paradoxically contributes to the deterioration in the health of the population.
It is now possible to incorporate sustainable development into healthcare and to decarbonise healthcare systems.
No review has assessed pharmacist contributions to greener healthcare.
WHAT THIS STUDY ADDS
The methods used to measure the environmental impacts of an action are still heterogeneous, and the reference method (life cycle assessment) is insufficiently implemented.
HOW THIS STUDY MIGHT AFFECT RESEARCH, PRACTICE OR POLICY
This literature review provides an overview of eco-responsible hospital contributions conducted by hospital pharmacists.
Background
The temperature of the Earth’s atmosphere has risen by approximately 1°C since the late 19th century.1 The impacts of climate change on our society and human health have been extensively studied for many years. In 2019 the New England Journal of Medicine described the major health risks, demonstrating, for example, that air quality can potentially affect cardiovascular diseases, asthma exacerbations and respiratory illnesses.2 Paradoxically, although they care for people, healthcare systems contribute to global warming.3 To achieve the goal of limiting the temperature increase to 1.5°C above the pre-industrial levels set by the 2015 Paris Agreement, all stakeholders have a role to play.4 Healthcare systems must participate in the global fight against climate change and engage in sustainable development (SD) initiatives. SD was described as a “development that meets the needs of the present without compromising the ability of future generations to meet their own needs” by Gro Harlem Brundtland, the Norwegian Prime Minister in 1987.5 Healthcare professionals are gradually taking initiatives to reduce the environmental footprint of healthcare. In France, hospital pharmacists are responsible for healthcare products (HP) (medication and sterile medical devices) from supply to distribution in healthcare units. This cross-functional role positions them as potential key players in SD within healthcare facilities. Despite the emergence of studies evaluating the environmental impact of various actions within healthcare facilities, no reviews have specifically explored the contributions of pharmacists to assess their environmental footprint or the knowledge of healthcare professionals and patients on the subject. To address this gap, our systematic review sought to explore the involvement of hospital pharmacists in SD strategies by answering the following questions: (1) What is the role of hospital pharmacists in SD? (2) Who do they interact with, and how? (3) What methods do they use? and (4) Which stages of the lifecycle of HP are analysed? We thus identified and summarised articles on hospital pharmacists’ contribution to assess the environmental impacts of healthcare.
Methods
Sustainable development (SD)
SD is defined as economically efficient, socially equitable, and ecologically SD. These three foundational pillars of SD are conventionally represented by three spheres (social, economic and environmental) that intersect, with sustainability positioned at the intersection of the three. The simultaneous consideration of these three components is an essential prerequisite for the concept of sustainability.
Life cycle assessment (LCA)
Life cycle assessment is the most advanced tool for assessing environmental impact of products or services. This standardised approach (ISO 14040 standard) allows for the measurement of quantifiable effects of products or services on the environment. It analyses and quantifies the physical flows of material and energy associated with human activities throughout the life cycle of products. LCA is a multi-criteria approach as it provides results on various environmental impacts (up to 18 impacts including climate change, water resource depletion, etc). However, by evaluating only the environmental footprint of a product or service, LCA does not take into account the remaining two pillars of SD (economic and social).
Protocol and registration
This systematic review was conducted in accordance with the 2020 PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines6 (see online supplemental file 1) and the protocol was registered on PROSPERO (ID number CRD42023406835).7
Supplemental material
Eligibility criteria
Eligible studies included research published between 1 January 2013 and 1 January 2023. The inclusion and non-inclusion criteria are summarised in table 1.
Inclusion and non-inclusion criteria
Search strategy
Three databases were searched (Medline, Web of Science and ScienceDirect). The complete list of search terms is shown in table 2 and the search strategy is detailed in online supplemental file 2. Apart from the terms “hospital pharmacy” and “hospital pharmacist(s)”, which were sought in the full text, all other terms were only sought in the article title. Studies deemed relevant from manual searches of the reference lists of selected articles were also retained.
Supplemental material
Search terms used
Study selection
Using inclusion and exclusion criteria, two authors (MP, VC) independently selected relevant articles based on title and abstract readings and subsequently analysed them. In case of disagreement, the opinion of a third author (GL) was considered.
Risk of bias assessment
The same methodology was used for assessing the methodological quality of the included studies. The methodological quality of the included studies was evaluated using the 2018 version of the Mixed Methods Appraisal Tool (MMAT) due to the different study methodologies.8 Each study was assessed according to seven items depending on the study design (non-randomised quantitative, descriptive quantitative, or mixed method), classed as ‘yes’, ‘no’, or ‘can’t tell’. The algorithm employed to assist in selecting the category of criteria is shown in online supplemental file 3. No quality score was calculated because the MMAT developers advise against calculating an overall score from the ratings of each criterion. Additionally, it is not recommended to exclude studies solely based on low methodological quality.
Supplemental material
Data collection and data items
Two authors (MP, VC) independently extracted data including the year, country, research question/objective, targeted HP (medication, sterile medical devices), description of the contributions, the pharmacist’s role (lead or support), type of participant, outcomes measured and the stage of the pharmaceutical process targeted (purchasing/procurement, prescription, preparation/pharmaceutical compounding, dispensing/distribution of care services, elimination). The results of all selected articles were summarised in two Excel spreadsheets. These different tables are available in the results section. Missing data were specified in the tables.
Results
Study selection
A total of 829 articles were found from the initial database search, of which 121 were duplicates. After removal of 618 articles that were not relevant and a further 11 which could not be retrieved, 79 articles were assessed, with 69 deemed ineligible mostly due to the absence of a pharmacist (n=48). With the seven studies found by the manual search of reference lists, 17 articles were included in this review. The search process is shown in figure 1.
Summary of the the search process.
Study characteristics
Study characteristics are summarised in online supplemental table 1. All 17 included studies described contributions taking place in a healthcare facility. Only one study was carried out in the central sterilisation unit,9 while the other studies assessed the hospital pharmacy, the operating room, and/or other care departments. The studies were primarily based in Europe and North America: France (n=4), USA (n=4), Ethiopia (n=2), Saudi Arabia (n=2), and one each from England, Italy, Netherlands, Brazil, and Spain. For 10 studies (59%) the contribution involved a team composed exclusively of pharmacy personnel (pharmaceutical team).10–19 The remaining studies (41%) involved medical (healthcare professionals)18 20–25 or mixed multidisciplinary teams (healthcare professionals and professionals from other fields such as a sustainability engineer). The study by Rouvière et al 9 was the only one involving a mixed multidisciplinary team.
Supplemental material
Description of contributions
The description of contributions is summarised in online supplemental table 2.
Supplemental material
Studies highlighted the contribution of hospital pharmacists to the SD across various stages of the HP cycle. Some studies were interventional,9 11 18 20–22 24 25 where pharmacists directly or indirectly implemented actions aimed at reducing the environmental impact of care. Others were observational studies10 12 13 19 led by pharmaceutical research teams, reflecting the practices of healthcare professionals or patients. Some studies used several methods concurrently. Most studies (53%) included a survey in their contributions.9 10 12 13 15–17 19 20 This could involve a questionnaire asking healthcare professionals or patients about waste management15 16 19 or assessing the social pillar of SD through staff satisfaction.20 The description of the questionnaires used in the articles is shown in online supplemental file 5.
Supplemental material
The second most commonly targeted contribution was waste collection. Seven studies (41%) documented the waste generated18 21 23 24 and/or weighed it.9 20 22
Four studies (24%) used quality management techniques to help develop and implement their contribution.11 18 21 25 Lin et al 18 and Abbasi et al 25 employed the ‘lean management’ technique and Furukawa et al 21 used the ‘Lean Six Sigma’ technique. Toerper et al 11 employed a computer simulation technique to develop the optimal production schedule. Four studies (24%) used theoretical and practical training in addition to other methods to improve their study outcomes.9 11 21 24 Only two studies (12%) used LCA, which is currently the most advanced tool for assessing the environmental impact of a contribution. Rouvière et al 9 conducted their own LCA to quantify the environmental impacts of their actions whereas Leraut et al 14 used LCA results published in the literature.
The role of the pharmacist was identified in each study. In 15 studies (88%) pharmacists were defined as the pilot, directly implementing or executing the action.9–21 24 25 In the remaining studies,22 23 pharmacists played a supporting role in the contribution and the implementation did not directly depend on them.
Regarding the HP distribution circuit, the majority of contributions focused on the disposal phase of HP (71%).9 10 13 15–17 19–24 Six studies (35%) evaluated the purchasing and procurement stages of HP9 10 12 13 17 20 and six studies (35%) addressed the dispensing and distribution stages of HP to healthcare units.10 13 14 17 21 24 Five studies (29%) involved the preparation of medications (pharmaceutical compounding) within the production units of the hospital pharmacy,10 11 17 18 25 or the operating room.23 Finally, four studies (24%) focused on medical prescription.10 13 17 21
Risk of bias in the studies
The bias risk analysis for each study is shown in online supplemental file 4. Two of the non-randomised quantitative studies were judged as being of good quality.9 20 The remaining studies received at least one ‘Can’t tell’ response and were therefore considered of lower quality. The maximum number of ‘Can't tell’ responses obtained per article was two (n=4).10 21 22
Supplemental material
Only one study received a ‘no’ response,11 which was the response to the question ‘Are the confounders accounted for in the design and analysis?’ in the quantitative non-randomised studies category.
The questions that received the most ‘Can't tell’ responses were: ‘Are there complete outcome data?’ and ‘Are the confounders accounted for in the design and analysis?’ for quantitative non-randomised studies; ‘Is the risk of non-response bias low?’ for quantitative descriptive studies; and ‘Are divergences and inconsistencies between quantitative and qualitative results adequately addressed?’ for mixed methods studies.
Results of interventions
Online supplemental table 1 summarises the outcomes measured in the studies. These criteria included environmental impact measurements (expressed in kgCO2e, weight of waste), economic impacts, and any other relevant qualitative results.
Regarding the primary outcome of environmental impact, only one study calculated the impact of its interventions on the environment.9
Among the studies that evaluated the number or weight of waste through their research, 100% showed a reduction in waste generated after the interventions.9 11 18 20–22 24 25 Six studies conducted different assessments to highlight the extent of HP waste and its economic impact or sought to identify pharmaceutical waste management practices. By assessing the disposal practices of healthcare professionals and/or patients, Mohammed et al, 15 Gidey et al 16 and Al-Shareef et al 19 showed that methods of healthcare product disposal were varied, including open-air incineration,15 household waste,19 with a small portion being returned to the pharmacy (1.7%).19 Gidey et al found that 60.7% of surveyed patients had received no information about HP disposal methods,16 while Al-Shareef et al reported that preferred methods for teaching good disposal practices included social networks (16.72%), mobile applications (14.17%) and hospital pharmacists (13.91%).19 The engagement of healthcare professionals in SD was assessed by Giraud et al 12 and Singleton et al. 13 Giraud et al focused on HP procurement procedures by pharmacists and reported that 90% of HP suppliers considered themselves to be significantly or very significantly engaged, with 40% of sustainable purchasing criteria being integrated into the overall rating by at least one buyer. Singleton et al explored the engagement of hospital pharmacists in the NHS carbon reduction policy and highlighted the main barriers to incorporating SD into their practice, such as a lack of professional training and the absence of environmental guidelines.13
Two studies described SD actions that could be initiated by pharmacists. Bekker et al identified 14 actions in ‘developed countries’10 and Alhomoud identified 21 actions in the Gulf countries.17
Only one study simultaneously evaluated the three pillars of SD.20 In this study the social pillar was assessed by three different means: calculation of the difference in equipment preparation time; analysis of musculoskeletal disorder factors; and surgeon satisfaction survey regarding the implementation of the custom pack.
Nine studies (53%) measured the economic effects of their intervention.9 11 15 18 20 22–25 For eight studies it was an economic gain11 15 18 20 22–25 and for one study it was an additional economic cost.20
The economic impact analysis of interventions has most often been conducted based on the price of HP saved through the implementation of the intervention, notably using the bottom-up micro-costing methodology based on unitary costs from a hospital perspective (89%).9 11 15 18 20 23–25
The economic impact was also analysed by calculating the average monthly savings in the segregation of healthcare waste, considering prices from the contract with the company responsible for hospital waste removal (11%).22
Discussion
The main findings of this systematic review have been summarised in a graphical abstract shown in online supplemental file 6. Seventeen studies describing contributions to reduce the environmental footprint of healthcare involving hospital pharmacists were included in this review. In the majority, the pharmacist had a leading role (88%) and they were integrated into a pharmaceutical team (59%), a multidisciplinary medical team (35%) or a mixed multidisciplinary team (6%). These results demonstrate the central and cross-disciplinary role of hospital pharmacists in the field of SD. The only study that implemented a mixed multidisciplinary team was also the only study to have used LCA, the reference method for calculating the environmental impacts of actions.9 The other methodologies used to reduce the environmental footprint of healthcare included surveys, waste collection and/or weighing, quality management methods and theoretical and practical training. Waste collection was the most commonly used method (41%) but, in most studies, no environmental impact results were extracted from these data beyond reduction in the mass of waste generated. Some studies presented methodological uncertainties (eg, non-response bias, incomplete effect data) leading to studies that were less reproducible and less robust. Furthermore, since most of the included studies were qualitative, it is difficult to draw conclusions about the actual impact of the contributions. Finally, the study by Rouvière et al 9 demonstrated significant environmental impacts by involving both medical and non-medical personnel (sustainability engineer) using the reference methodology and presenting good methodological quality. Although LCA is the reference methodology, this literature review shows that LCA is rarely applied in healthcare. It is a rigorous methodology that requires human resources, theoretical and practical training, and specific software. This demanding methodology would benefit from a designated team member, such as a pharmacist, with the knowledge and skills in this field to carry out these studies.
Supplemental material
Furthermore, only one study investigated all three pillars of SD.20 The social pillar is often neglected in favour of the ecological and economic pillars, but to meet the definition of SD, this third aspect must be assessed and taken into account. The aim of the social aspect is to ensure a quality of work life for practitioners and caregivers throughout the care process, while also satisfying all users. This pillar can be assessed through satisfaction surveys; Mouarbes et al evaluated the social pillar by analysing musculoskeletal disorder factors and conducting satisfaction surveys in staff.20
Regarding the economic pillar, only nine studies examined the economic impact of interventions.9 11 15 18 20 23–25 These studies focused on the prices of HP, demonstrating the savings achieved through the reduction of pharmaceutical waste or changes in care practices. Indeed, the ‘micro-costing’ approach is the most precise method for estimating the actual cost of a healthcare intervention in a healthcare facility. However, in this approach, the estimated costs reflect the state of practice at a particular healthcare facility. On the other hand, the additional costs related to personnel generated by data collection or the implementation of actions were not assessed and can vary the economic impact of an action. Conversely, potential time saving-related economic gains were not reported in the studies. It would be interesting to integrate the costs of healthcare personnel into economic studies of interventions.
Despite the heterogeneous results of the contributions, this literature review shows that the actions already cover all the key stages of the HP circuit. The disposal of HP was addressed in almost all studies, indicating that the amount of waste generated by healthcare facilities is a significant concern and waste-related actions were generally the first initiatives taken. However, some studies took place in developing countries, making it challenging to compare the results with those of developed countries with different regulations, for example, regarding HP disposal. Few contributions have been described concerning the purchase, procurement and stock management of HP. As shown by Giraud et al, implementing sustainable actions at this stage of the HP circuit requires commitment from suppliers, healthcare facilities and governments to update regulations.12 Although suppliers claim to be committed to sustainable policies (with 90% of criteria being considered important or very important by the suppliers), the practical implementation of these results needs further evaluation. Thus, mandatory questionnaires for suppliers, specifically targeting HP, to incorporate environmental rating in procurement contracts seem necessary to initiate a sustainable approach. Regarding the dispensing and distribution of HP in healthcare units, the studies were mainly descriptive and applied to specific services, making the reproducibility of these contributions more challenging.24 Contributions targeting the pharmaceutical prescription stage highlighted the importance of consolidating prescriptions for patients requiring specific preparations or medications to minimise waste. However, no study has explored the potential role of the pharmacist in the concept of eco-directed prescribing. It is conceivable that, in the coming years, pharmacists could raise awareness among prescribers about the environmental impact of prescribed medications and medical devices in their role as clinical pharmacists. However, this role would require transparency from suppliers regarding the environmental impact of their pharmaceutical products, as well as the mobilisation of governments to update regulations, especially in terms of marketing authorisations or CE marking access.
Regarding the pharmaceutical compounding stage, the included studies focused on optimising pharmaceutical compounding to limit dose wastage. These studies applied quality management methods initially designed for the automotive industry. These methods, aimed at improving the quality and efficiency of work processes, seem relevant for optimising production processes.
In parallel, several studies showed a lack of environmental knowledge, indicating a deficiency in practitioner training.13 16 19 Pharmacists could contribute to the theoretical and practical environmental training of future healthcare professionals by integrating directly into health studies curricula. They could also participate in the theoretical and practical training of their colleagues, encouraging good practices in pharmaceutical waste disposal, for example.
The locations targeted by the contributions were mostly the hospital pharmacy or the operating room (94% of included studies). Only one study included the sterile processing department by implementing the recycling of defective metallic medical devices ineligible for repair.9 The sterilisation unit is a significant consumer of water (washers, autoclaves, air conditioning circuit in the controlled atmosphere area), electricity (washers, autoclaves) and plastics (sterile packaging), concentrating numerous environmental challenges. As this service is not always under the responsibility of the pharmacist, particularly in France, it may explain the low number of studies included in our research. Nonetheless, the study by McGain et al, who calculated the environmental impact of extinguishing inactive autoclaves, optimising loads or implementing automatic standby mode in this unit, reported a reduction of 79 tons of CO2 per year.26
This study has several limitations to be considered. The low number of articles identified in this review may be due to the lack of explicit mention of the pharmacist’s role in the studies, despite their participation, or to differences in pharmaceutical responsibilities between countries. To overcome this limitation, the reference lists of included publications were manually searched, which is why some articles were only found through manual searches. However, numerous studies can be found in the grey literature but we did not search the grey literature sources because of the sometimes lower methodological quality and difficult access to these studies. Studies focusing on medications (88%) were more numerous than those on medical devices (41%). This imbalance may be related to the fact that the management of medical devices is not necessarily the responsibility of the pharmacist in all countries. Finally, some reports may have been missed despite our broad search strategy and new studies may have been published since our last search and will continue to emerge.
The topic of SD is not currently mentioned in the French Public Health Code regarding the missions of the hospital pharmacy and hospital pharmacists. However, the 2010 version of the hospital pharmacy reference framework already stated that hospital pharmacists should take SD into account and integrate its challenges.27 This role involves economic management concepts (eg, procurement policy), social responsibility and environmental responsibility.
This systematic literature review is the first to specifically address the role of hospital pharmacists in SD contributions within healthcare institutions. It serves as a starting point to enable hospital pharmacists to engage in the development, implementation and monitoring of SD actions. It demonstrates that, through their cross-functional role and expertise, hospital pharmacists are major players in the ecological transition of healthcare institutions and can actively contribute to the shift towards low carbon healthcare systems. This review could also signal to hospital managers that pharmacists ought to be involved in SD. Based on this review, the first step for a hospital pharmacist wishing to implement SD actions would be creating or participating in a sustainable multidisciplinary working group including various professional profiles. The actions implemented should be monitored using before-and-after indicators and LCAs should be undertaken to obtain robust results. Social and economic pillars should be integrated into the methodology as early as possible to assess all three pillars of SD. Any action initiated could begin with theoretical training for healthcare professionals to provide them with the necessary knowledge. Moreover, further studies are still required to evaluate the feasibility and environmental impact of interventions in sterilisation or chemotherapy production units. Other studies are also required to assess the role and environmental impact of the clinical pharmacist—for example, e-prescribing, raising awareness during pharmaceutical interviews and the impact of pharmaceutical interventions on healthcare facility effluents.
Conclusion
This systematic review shows that there is limited research published on the role of pharmacists in interventions to reduce the environmental impact of healthcare, and that most of the existing studies do not use the standard method (LCA) to quantify their impacts. The results of the studies were heterogeneous but cover all stages of the healthcare product cycle, which nonetheless confirms the central role of the pharmacist and the importance of a multidisciplinary approach in implementing eco-responsible actions. Future studies should systematically quantify the environmental impacts of their interventions and describe the role of each participant to improve the robustness of results and enhance replicability.
Data availability statement
All data relevant to the study are included in the article or uploaded as supplementary information.
Ethics statements
Patient consent for publication
Ethics approval
Not applicable.
Supplementary materials
Supplementary Data
This web only file has been produced by the BMJ Publishing Group from an electronic file supplied by the author(s) and has not been edited for content.
Footnotes
EAHP Statement 2: Selection, Procurement and Distribution. EAHP Statement 3: Production and Compounding. EAHP Statement 4: Clinical Pharmacy Services. EAHP Statement 6: Education and Research.
Contributors MP wrote the main manuscript and prepared figure 1, tables 1 and 2 and supplementary tables 1 and 2. GL resolved disagreements in the article selection. VC and NR reviewed the manuscript. All authors read and approved the final manuscript.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests None declared.
Provenance and peer review Not commissioned; externally peer reviewed.
Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.