Frederik: Hello and welcome to the Sustainable Healthcare Podcast. I’m your host, Frederik van Deurs, a medical anthropologist by training. I’m really excited to have Nicole and Jasper with me today to talk about the ESCH-R project. The reason I think you’ll find this interesting is that in the ESCH-R project, they’ve done a material flow analysis and figured out all of the stuff that goes into an intensive care unit, broken it down by different fractions, and found out just how much is being consumed in an ICU. This has all turned into a paper that is publicly accessible with lots of very beautiful graphics that I warmly recommend you look at yourself. But before I get ahead of myself, welcome Nicole and Jasper. Jasper, you’re a PhD student on the ESCH-R project, a PhD student on sustainability in healthcare at Erasmus MC.

Jasper: Yeah, that’s right.

Frederik: And Nicole, Nicole Hunfeld, you’re an Associate Professor in Sustainable Healthcare at Erasmus University Medical Center and Principal Investigator of the ESCH-R Project. I had to write all this down to make sure I didn’t stumble. I think I did okay. I’m really excited to have you here. So first off, could you please give our listeners the elevator pitch for the ESCH-R project? What is the ESCH-R project?

Nicole: The ESCH-R project is a project in which we tend to make hospitals more circular, and we figured out that we cannot do this from a hospital perspective on our own. So we need the whole system in the room. I think the unique feature of the ESCH-R project is that we have all the stakeholders on board, from the company that makes the polymers in the Netherlands for medical products, all the way to the waste processor helping us sort out the waste and create insights. And the other thing we’re doing is we’re looking at it from multiple perspectives. So we look at procurement, that’s one work package. We look at how systems work, that’s another work package. We also look at behavior and how protocols are being used by healthcare professionals within hospitals. And we’re also very keen on how products are being used and tend to make them more circular. So at the end of the project, which will be 2028, we’ll come up with 12 products that are being reprocessed or redesigned together with students from Technical University, and Jasper is the PhD student on this part, to show people that we can do better and work in a circular manner. So that’s the ESCH-R project in a few sentences.

Frederik: Super cool. Thanks a lot Nicole. And if you want to look it up, it’s ESCH-R. It’s a project that runs for a couple of years. Can you say a little bit more about how it’s funded and how it’s structured and where it takes place?

Nicole: Yeah, it’s funded by the Dutch research agenda, called NWO. And this funding requires you to do co-creation, or work at least together with companies. So Philips, Medtronic, and Dork, an eye surgery company from the Netherlands, are involved. And many institutions like the Technical Universities and School of Applied Sciences. The key thing is to get as many people on board with their own expertise so we can mix and match our knowledge to get better insights. We started this one year ago, and in the meantime, all the PhDs, these students and the postdocs started. We had our first papers published so far, and everybody’s busy now trying to reach their goals.

Frederik: Super cool. Thanks a lot. And looking at this in context, I think it’s super inspirational to see something like this and to see the scientific approach in action, trying to systematically understand what’s happening in sustainability in healthcare. But what inspired you to start working with the ESCH-R project?

Nicole: Well, I think what inspired me was during the COVID pandemic a couple of years ago, during the first wave. We switched in the ICU, and all the rooms were isolation rooms at that time. That was needed and necessary to keep COVID within patient rooms, but that also meant that all the waste was put outside the rooms. Normally waste is inside the rooms, but with COVID, that wasn’t possible. So we literally saw all the waste. With 108 COVID patients at that time, we were one of the biggest ICUs in the Netherlands filled with COVID patients. We noticed the waste. At that time I said, whoa, this is not normal anymore. Okay, it’s needed for patient care, but we are wasting scarce resources at the moment. At that time, we didn’t have gowns, we needed to wait for the next airplane to fly in. The gloves ran down, we didn’t have alcohol, for instance. So at that moment you saw everything being used for a short time, but there was scarcity on the other hand. And then I talked to the head of department. I said, we need to change this. We cannot continue like this. There’s only one planet and what we’re doing at the moment is not okay. And then he said, yeah, to be honest, I feel the same. Well, let’s start a project. And then we started with a large material flow analysis of the whole ICU. That became a big success. And from there, I started working together with Technical University of Delft and other institutions to get all the knowledge within the hospital. And that ended up with a large project being funded by the national research agenda in the Netherlands. So that’s basically the story. And I think as a pharmacist in the ICU, I always try to go for less medication, stop when I can help the intensivist in changing the dosage. So that’s also part of who I am, I think it’s in my DNA.

Frederik: Yes, it’s actually interesting that in the paper you’re also mentioning the 10-R strategy. So in circular economy you have these 10 Rs, where you have refuse, reduce, recycle, reuse, all of these words that start with R, right? Everything basically is “Re” something. And when we’re considering rational pharmacology, looking at limiting the amount of medicine we give to a patient unless we know rationally that it has a purpose and serves a purpose, we try not to give it. Right? And I think it’s really interesting to link that to the circular economy strategies. But do you find that this has been explicitly linked before, or was that something that emerged as part of this project where you could say, hey, this is actually something we’re already doing?

Nicole: I think we started this years ago when I started in the ICU, but then it wasn’t, it had nothing to do with sustainability or with circular strategies. And I think this whole 10-R model really helps us in speaking the same language, and we can give it a name. If I can tell them, hey, let’s reduce on this or let’s refuse that, now people understand. So it’s a very good way of describing something and also making sure you’re on the same page. I think it’s a very nice model that everybody understands. So we use it a lot.

Frederik: Cool. Thanks. And yes, but for you, Jasper, what was your personal motivation for engaging with the ESCH-R project?

Jasper: So when I finished up med school, I knew that I wanted to pursue a PhD to further develop myself. And I wanted to do that in a field where you could create a positive societal impact, and that was on the verge of being partly in the medical world but more of a multidisciplinary approach. And before, during my time in med school, I also worked at the pediatric intensive care unit where we threw out a lot of material. And also throughout the COVID pandemic, it’s sort of eye-opening. So I knew that this was an area I was very much interested in. But before I did a PhD, I also did some policy work and worked on sustainability and healthcare policy. So all those pieces together, I was really motivated to work on this. And then I read an article that the ESCH-R Project got its funding. So I got really excited and got in contact, and the rest is history.

Frederik: That is thanks a lot, Jasper. And what does a typical Tuesday in life as a PhD student on the ESCH-R project look like?

Jasper: So one of the things I really like most about the ESCH-R project is because we’re such a multidisciplinary project, I get to work with people from a whole lot of many different disciplines. So my typical day is that I have some students who are making reports or doing internships at the ESCH-R project with assignments for us, and they are design students, health technology students, pharmacy students. So my typical Tuesday would be to start reading new papers and getting up to speed about the research that’s been published in the past days, working on my own research and getting to collaborate with all these great diverse partners. And currently, how my Tuesday looks is that I’m already working on the next paper in which we’re looking at medical waste from different interventions at the cardiology departments. So my days is sipping through hospital trash. We actually go out to the physical hospital trash and go through it.

Frederik: Yes, we actually sift through it. That’s amazing. You’re performing like a massive waste audit. So I think the whole terminology of “bin diving” gets a new perspective within this project.

Jasper: Yeah, and our lab also is insane. It’s an empty ward, actually the place where the old interventional radiology department used to be. And now it’s an OR lab and it’s, I think, 50 square meters or something. It’s huge.

Frederik: Super cool. And I think something that we have encountered many times in working with different sustainability departments and various organizations, both public and private, is that right now we have a very low degree of clarity and line of sight when we’re talking about the emissions from the healthcare sector. We’re typically saying it’s around 6% of global emissions, but we don’t really know what’s what. And when we start doing this material flow analysis that you’re doing right now, where we get a bit firmer understanding of, at least at a hospital level or an ICU level, we can get quite specific. Right? So do you think that building off the work that you’re doing, do you think it’ll be possible to have more precise estimates of the carbon emissions intensity of ICU care and different therapeutic areas? Or is that out of scope of what you’re trying to do?

Nicole: So maybe to answer this, it’s interesting to explain a little bit on why we’re doing this new study, for instance. And that had to do with the green team of the interventional cardiology department who actually came to us with, oh, we want to make our department greener, but we don’t know where to start because we do not know which areas of opportunities we have. So in order to facilitate that, we’re now doing the material flow analysis for the department. And with that research we can identify certain hotspots that they can then, as a green team, work on. So I think that step one is always to map out what we’re doing, because then you know what your potential actions could include. If you just start by taking random stuff and making it more sustainable, sure you have an impact, but you don’t know if you have the biggest impact that you could achieve. If you have the data to back it up, then you know actually how you can make the biggest impact possible.

Frederik: I think that’s a very good point, and it’s also leading to one of the bigger trends that I see in healthcare sustainability right now, which is that it seems there’s a little bit of an awakening going on. Rather than looking at drug versus drug, device versus device, level of carbon emissions, we’re starting to look at it from a more systemic point of view and figuring out what are the emissions associated with the entire care pathway for a treatment or for a patient. And also looking at it at a patient level, not as much at a disease level, so that you get the actual patient journey and figure out what are the levers that we can pull to reduce the carbon emissions associated with delivering healthcare. But a logical conclusion from that is also to focus on prevention, and to say we have a lot to gain if we can prevent disease onset in the first place. But that’s very much out of scope of the mandate of an intensive care unit. Right? So the ICU cannot do a lot of things to prevent patients from developing. Right? So are you familiar with that sort of awakening that I’m talking about around care pathways? And if yes, how do you relate the ESCH-R project to that?

Nicole: Well, I think we have somehow a bit of a different approach. We also did some work on patient care pathways, but what we do within ESCH-R is that we do a product pathway or product journey. And we often also do a healthcare professional journey because what happens with products is often different in clinical practice. So you need to map both to understand behavior of healthcare professionals. It gives a lot of information. It’s also nice to tell them what they’re doing because often they just do this and have no idea until you show them. And from the product perspective, it’s also quite eye-opening that products are put in a storage room, but it’s far down the hall, so people need to walk a lot. Then it travels from department to department. It gets lost. So okay, go for a single use one that’s easier, then it won’t get lost. Or we don’t care. So we also, I think, altogether did a lot of things to make it easiest for ourselves, but not for the planet. So creating this insight, following a product, following a healthcare professional, really helps us in changing the system.

Frederik: That’s super cool. What, I mean, as an anthropologist, I’m just really excited to hear that you’re following the humans and seeing what these humans actually end up doing. Is there an anthropological arm in the project or do you use another branch of behavioral science?

Nicole: We have a whole work package on behavioral science. It’s both psychological background, but also anthropological, like you mentioning, and I did some anthropological classes myself. So I’m really interested in that topic. What moves people, what happens there? What’s the culture?

Frederik: Yeah, super cool. Um, well, one thing that sat with me was that the study finds, I think it’s 2.3% of medication mass, that that is the actual API. Um, please correct me if I got the number wrong, but in essence, can you walk us through what you found around the quantities of waste and how they’re distributed across different categories? So you found that one patient in an ICU receives around five kilos of medication on average, and to me that just sounded like a whole lot. I’m imagining sort of five cartons filled with drugs going inside one patient per day. And I’m just thinking that that’s gotta be a lot of drugs, you know, to sort of the human mind. It just seems like an extraordinary amount. Can you walk us through some of those sorts of distributions of how much of what was going where?

Nicole: Yeah, sure. So what we did is we calculated the amount of medication that the average patient receives daily on the ICU. And that’s in total 89.5 pieces of medication. And that is sort of evenly distributed amongst blister packaging, so those are tablets that you push out, vials that contain either a powder or a fluid, syringes and ampules, and then also some quite a large sum of infusion bags. And all that mass combined is five kilos of medication per day. And 1.7 kilograms of packaging material related to the medication. And if you look at what is then the medication mass, 80% of that comes from the infusion bags, which, you know, makes sense because they are large containers. But that really contributes to what a patient receives daily.

Frederik: Yeah. And I suppose that that’s also an element where you need to kind of water down the medicine so it’s easier to distribute and measure how much of a drug a patient needs. Yeah, rather than if…

Nicole: And also sometimes you need to keep an infusion line open. That also takes a little bit of medicine. Or you have some waste because you need to switch materials, or if the medication changes for the patient, you need to create a new IV bag. So there’s all these different reasons on why maybe not the entirety of that five kilograms ends up in the patient, but it is at least used for the patient.

Frederik: Did you look at how much of these five kilos is wasted but never used? If you see what I’m meaning, do you know how much of the five kilos never goes into a patient? You know, we hear a lot that in different surgical theaters, for instance, they have these vials that they used to pull out a drug, and then at the end of the day, a lot of them go unused because they just need to be ready in case they’re needed. But then if it’s not needed, then they have to throw it out at the end of the day. So did you also map out drugs and medications that were made available but couldn’t be used and then were wasted without ever being used?

Nicole: So we use delivery data for the study. So we don’t know exactly if all the medication that’s delivered for a patient also ends up in the patient. However, we did correct for medication that’s passed its due date, so that got taken out in the system. So those medications are not part of this 89.5, but maybe Nicole can answer a little bit more about this.

Jasper: Yeah, I think we changed the system in the ICU already years ago. We use a lot of prefilled, sterilized syringes. Those can be kept for years at room temperature, especially compounded by a Dutch pharmacy, because I saw all these syringes being wasted at the end of the day or not being used. So we changed this. So those syrings are ready. Nurses can take them out of just a normal cupboard in the medication room. And they can use them and we’re very keen on stopping medication on time during the rounds in the morning, trying not to waste medication. So the system is prepared like that. And the pharmacy prepares most of the medication. That also saves a lot. It also saves a lot of money.

Frederik: Yeah, so that’s degree optimization that has happened here as well. But you said that it’s prefilled. Does that mean that it’s always a full dose going in? Or will you sometimes distribute 80% of the drug and leave the 20% remaining for waste?

Nicole: Well, it can be that a doctor decides to stop an order. Then you have some spill. But I think that that’s part of medicine anyway. I mean, if a patient gets better and doesn’t need a drug anymore, then you need to stop it. Then I think it makes no sense to finish this syringe because that could create side effects or unwanted effects. So then we will stop. But we also, let’s say we try to look at it and it has a tension between the nurses and the intensivist. It sounds like you, once again, sort of the economic gains have been mobilized in the service of sustainability and achieving economic gains and saving. Having these cost savings is also an environmental gain.

Frederik: Yes, but I think also the time that it saves, we also look at the workload for the nurses. I think one of the reasons that we have these prefilled syringes is because the nurses don’t need to prepare them anymore. It saves them time. I think we always try to look at it from a multi-perspective approach. So it’s of course safety and quality, that’s no discussion there. We will never compromise on that. But if a nurse doesn’t have to prepare the syringe, then that’s also an important factor. Buying it from a local compounding pharmacy, it’s better for the environment. It might be a little bit more expensive, but okay, we have, again, environmental part and the workload. So that’s how we approach it.

Frederik: Cool. And it also means that the nurse won’t have to prepare it in the operating theater. There’s no risk of dropping it in the process of preparing it, and there’s a speed of delivery that can be increased as well.

Nicole: That’s a nice point. Um, you identified CRRT as a major hotspot. Can you walk us through what is CRRT and what kind of innovation could help CRRT be more sustainable?

Frederik: Maybe I could do the first part and then Nicole can take the second part of the question. So CRRT, what we mean by that is continuous renal replacement therapy, or kidney replacement therapy. So when you have your kidneys, the kidneys filter out the waste of your body, and then you urinate that out. But for some patients in the ICU, their kidneys stop functioning because of their illness. So what we need to do is we need to replace that function. We do that by using a machine that sort of is an artificial kidney, and that ma�[�H\��[�ܙ\���X[�]�ܝو�\�H�ZY�]H�و�]\�[�H�وX[\�\��ZY�[��HH�HYX[�^H�]H[��] ��M[�H[��Y��وU��ZY�]\�H\�Y\�^H\�]Y[��[���H�Y��\�H\�X[H�]�H]\��Y��܈��]\��Y�ˈ��\�H\�H�وX\��]�X�]Y�HX[\�\��X�]\�HHXX�[�\�\�H��\�Y��X�Y[�\��\��Y�^\�[���K�������ۙϒ�\�\�����ۙψ[KZ���] ���H\�H\�H�وX\��]�X�]Y�]]XZ�\��[��K�[��X��KY��IܙH���[��]Ԕ�[�[��[��X��]���H��[��]\��]\�H\�H[�H��Z\�[����][ۜ�[�H[���\O�������ۙϓ�X��N����ۙψYXZH[���H[�XYHYH�Y��؈ۈ�X�X�[��H�Y�ˈ�H]�HH��\[�H]YH�X\�[��YX\��Y�ˈ^H��]�Y�H\�X�]����Z�H�\��[[�H�܈Z\��Y�ˈ[�]YX[��]�H��X���H�Y�ˈHۛH[��\�]�H]�H��]ٙ�H�ۛ�X�[��\��وH�Y�] ��HY��\�[�\Hو\�Xˈ��ۙHوHXZ�܈[�����[�H��[��H]X]\�X[[��Hۉ�]�H��\�[�[[ܙK��]�܈^HP�K\�YX[��]�H�[��]�HL�[�ܘ[\�و\�X����H\�HX[\�\��Y��\�YX\��] ��MIHو�[�\�K�������ۙϑ��Y\�ZΏ���ۙψ��ˈ[��X�X�[��\�H���و��\��K[�HLT�[�[��H�]�[��L�[�ܘ[\�و\�X�]YX[���Hۉ�[��[�\�]H]�Hۉ�^H�܈]�]��\��H�\�H���\��܈[�H�]\�[��[��H�]��YH[ۙ^H�X���܈][�] ����H�[�[��[���] ��[��X�ۛ�ZXˏ������ۙϓ�X��N����ۙψYXZ�]�܈���] ��H�Y��Z[�[��\��\��[\�]K�������ۙϑ��Y\�ZΏ���ۙψ����]\��\�H����[���H��܈[X�ܘ][��ۈ]�[K[�IܙH[���[�[����Y�\�H[���X�[ۜ��܈\�K��H\\�[\]�]��YH�][�H�Y�[�]�X�H] ��\��X�]Y[�HX[�\�H�X�܋[�H[��\�\�ۙHوH�]�ܚ]HX�X�[�[ZY\�و[�[ۙH��[�\���\�Z[�X�[]H[�X[�\�K�] ��Z�K�H��H]�H\�H����]�]��ۙI���XY[���[��[�^H�XY]^H�]�X[H��\�YوH�YHY��X��܈وYYX�[\]Z\Y[��]�[��H�\�H\��H�Y\�]\�H�]�\��XY�HHۙ\�]\�H�\�][��H]�X�\ˈ^H�\��YY��H\�K��]�HZY�\��[]�H]\�T���H][�H��[��[�[�[�H��[]�HHQ�H]�Z[X�H[�[�^\�\�]H\��[���\�H��[�HH�و�[�Y�]��]��]H�\�X�X[H�\��\�Y�X�]\�HIݙH[�^\��Y�]\�\��ܝوۙHو\�H][�[ۈܘX��] ��X\�H��YH[�X\�H�[�\��[�[�[�[�H\��X�]��]]�\�X�X[H�\�ۜ�X�H�܈H�Y��\�ܝ[ۈ[�H]�H�Y�]��[�K����[�[�H�[�\���Y�H�\�HوHQ�O���HX��Y�H[��\��^H�\�\�[�KL�[��وX\��[��X[H�܈[�\�P�K�[���H\�H[����]�]�H�]�\��[�[��[\H����]وHX��Y�[�ˈHYX[�[[���]�\��[��X�]\�H�H]�H[H[��ܛX][ۈ[�]�\�K�������ۙϓ�X��N����ۙψ[�\�H[�H\�H�\�H�X�X[^�Y��ܚ��]\�HYYX�[�\���^Hۛ���]^IܙH�]�[���]Y[�ˈ��] ��[�[��[�H[[�[�وX��Y�[��X]\�X[�[��܈��YH��X���HۛH�]Z�H�\�H�X[����]�][�H[���]Y�[�H�^HH��وYYX�[�H]H��[\�XX�K��]�܈��YH�\���X���H[���]�\�H\��H����]��][��وY�\�ۈM�^�K[�M�Y��\�[�[��XY�\ˈ[�] ��[�[��[�H[[�[���؛�H[�\��[���H�H�[]�H\ˈ]�\ۉ�XZ�H[�H�[��H]\��[��] ��[YH��]�Yو]�������ۙϑ��Y\�ZΏ���ۙψ[��]�\�]�HوH�[�\�O�������ۙϓ�X��N����ۙψ�[H^X��[X�\��] ��KN
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