Part IV - Sustainability in Ambulance Services

SUS

ABIL LITY TAIN

Part IV: Emergency Healthcare and Sustainability

Emergency healthcare and sustainability share a complex, two-way

relationship.

While the primary purpose of emergency healthcare is to provide immediate medical care to those in urgent need, environmental sustainability seeks to ensure the long-term wellbeing of our planet, its resources, and its inhabitants. Despite their seemingly divergent paths, these two trajectories intersect at crucial points, where demand meets supply.

Ambulances constitute pivotal elements within emergency healthcare systems, facilitating the delivery of urgent medical care and transportation services to individuals in distress.

Assessment of ambient air pollution exposure

While their role in preserving lives and ensuring prompt medical intervention is indispensable, it is essential to acknowledge the environmental implications associated with their operations. The sustained provision of emergency healthcare services necessitates a consistent allocation of resources, notably energy and water. Any compromise to this ecological equilibrium directly impacts the effective management of essential resources, marking an initial consideration within a broader context.

Source: Mumtaz A, Rehman E, Rehman S, Hussain I. Impact of environmental degradation on human health: an assessment using multicriteria decision making. Frontiers in Public Health. 2022 Jan 20;9:812743.

An impaired environmental condition not only amplifies the need for emergency medical care but also exerts direct and indirect influences on the quality of healthcare provided.

Environmental degradation significantly contributes to the deterioration of existing health conditions and the emergence of new health risks. For instance, industrial emissions and vehicle exhausts culminating in air pollution can instigate respiratory complications, heightening the necessity for emergency care among susceptible populations.(105) Concurrently, water pollution, compromised food sources, and exposure to hazardous substances further compound health emergencies, encompassing instances of poisoning and acute gastrointestinal illnesses.(106)

Deteriorating air quality, attributed to pollutants like particulate matter and ozone, heightens the susceptibility to respiratory infections, aggravates asthma, and elevates the occurrence of cardiovascular events.(107) Factors linked to climate change, such as heatwaves and extreme weather events, contribute to an escalation in the frequency and severity of cardiovascular events, heat-related ailments, and dehydration.(108)

The aggravation of these health conditions stemming from environmental degradation results in an augmented demand for emergency healthcare services.

Environmental degradation not only amplifies the need for emergency care but also compromises the quality of care delivered. For instance, during natural calamities such as floods, hurricanes, or heatwaves, emergency healthcare systems may become inundated, struggling to provide timely and efficient care to affected populations. Constraints on access to healthcare facilities, disrupted supply chains for medical resources, and compromised infrastructure present substantial impediments to emergency responders.(109) Furthermore, these environmental disasters can lead to the displacement of communities, further complicating the delivery of emergency healthcare services.

The growing demand for emergency healthcare in the face of environmental degradation underscores the critical need for comprehensive and sustainable strategies.

Addressing the fundamental causes of environmental decline requires concerted efforts on multiple fronts. One aspect involves reducing greenhouse gas emissions, a pivotal contributor to air pollution and climate change. Implementing stringent policies to curtail emissions from industrial processes, transportation, and energy production becomes paramount.

Simultaneously, advocating for the adoption of clean energy sources, such as renewable energy technologies, contributes to mitigating the adverse impacts on air quality and climate. Furthermore, the enforcement of effective pollution control measures, including stringent regulations on waste disposal and emissions, plays a crucial role in safeguarding environmental health.

On the other front, proactive investments in climate resilience and disaster preparedness are pivotal to fortifying societies against the escalating challenges posed by environmental crises. Developing robust infrastructure capable of withstanding extreme weather events, such as hurricanes or floods, becomes essential to ensure the continued functionality of emergency healthcare systems.

Moreover, fostering community education and engagement in climate resilience practices can empower individuals to respond effectively to environmental emergencies, reducing the strain on healthcare resources. Incorporating these dual approaches, addressing the root causes of environmental degradation, and fortifying societal resilience, communities can effectively alleviate the burden on emergency healthcare systems, as emphasised by Campbell-Lendrum et al.(110)

Chapter Eight: Carbon Emission and Ambulance

Ambulances are an integral part of healthcare systems, providing emergency medical care and transport to those in need.

Chapter Eight: Carbon Emission and Ambulance

Ambulances are typically used to respond to medical emergencies from basic first aid to advanced life support, transport patients between healthcare facilities, and provide on-site medical care.

However, the operations of ambulances dramatically enhance carbon emissions, gases released into the atmosphere because of burning fossil fuels, such as gasoline and diesel, commonly used to power ambulances. Additionally, ambulances often need to travel at high speeds and use sirens and lights to navigate through traffic, further increasing their carbon footprint.

While ambulance operation is an absolute need for human communities, the impact of it on carbon emissions can be significant. In the United Kingdom, a similar exploration of ambulance emissions reveals that the annual carbon output amounts to a significant figure.

NHS Ambulance activity-based greenhouse gas emissions by emissions category, 2019

The Lancet Planetary

2021 Feb 1;5(2):e84-92.

Adapted from: Tennison I, Roschnik S, Ashby B, Boyd R, Hamilton I, Oreszczyn T, Owen A, Romanello M, Ruyssevelt P, Sherman JD, Smith AZ. Health care’s response to climate change: a carbon footprint assessment of the NHS in England

Health.

Implementing measures to decarbonise the ambulance fleet in the UK has the potential to yield a substantial reduction in emissions, estimated at 87 kt CO2e annually.

To put this into perspective, this reduction is parallel to mitigating the environmental impact of approximately 730,000 car journeys of eight hours each, per year.

According to a study published in the journal Prehospital Emergency Care, ambulance operations in the United States were estimated to produce over 5 million metric tonnes of CO2 equivalent emissions, in one year.

This is equivalent to the emissions from over 1 million passenger vehicles driven for a year. The study also found that ambulance operations accounted for 0.04% of the total US healthcare sector emissions.(111) In Australia, the total emissions from ambulance operations equal to 110,000 to 120,000 metric tonnes of CO2 equivalent each year.(112, 113)

Primary sources of Australian ambulance services’ greenhouse gas emissions, and comparison with reported North American data

Adapted from: Brown LH, Canyon DV, Buettner PG, Crawford JM, Judd J, Australian Ambulance Services Emissions Study Group. The carbon footprint of A ustralian ambulance operations. Emergency Medicine Australasia. 2012 Dec;24(6):657-62.

The quantification of the carbon footprint of ambulance operations extends beyond a mere consideration of fuel consumption, to the term of life cycle assessment (LCA).

LCA is defined by UNE-EN ISO 14,040 as a technique for assessing environmental aspects and potential impacts associated with a product or service.(114) For ambulance vehicles, it is used to holistically evaluate the environmental impact at every stage of ambulance activity, encompassing production, maintenance, fuel consumption, and disposal.

This approach involves assessing the embodied carbon associated with the manufacturing process, which includes the extraction and processing of raw materials, assembly, and transportation.It also entails evaluating the maintenance practices, fuel efficiency, and the operational phase, where emissions are derived not only from fuel combustion but also from auxiliary activities such as idling.

Life Cycle

The disposal phase also considers the environmental impact of decommissioning and recycling or disposing of retired ambulance units, where the emissions at each stage were converted into CO2 equivalent units, incorporating the global warming potential of additional greenhouse gases, such as methane and nitrous oxide, using established emission factors specific to the Australian context.(64)

The incorporation of a broader range of emissions, as outlined in the life cycle assessment, provides a more accurate representation of the environmental impact associated with emergency medical services.(115)

Vehicle

Chapter Nine: Sustainability Approaches

Ambulances can significantly reduce their carbon emissions and environmental impact through various strategies.

Alternative Fuel Resources

One approach is encouraging the use of alternative fuel sources, such as biofuels, electric, or hybrid vehicles.

This aligns with global efforts to reduce carbon footprints and introduces the possibility of charging these vehicles using renewable energy sources, reducing dependence on traditional fossil fuels. However, transitioning to alternative fuel sources involves more than a shift in vehicle technology; it may require substantial investments in infrastructure, including charging stations and grid enhancements, to support the unique energy requirements of electric or hybrid vehicles.

Operational changes, training programs, and maintenance protocols must also adapt to accommodate the distinctive features of these alternative fuel systems. Despite challenges, the potential benefits in terms of reduced emissions and long-term sustainability make the pursuit of alternative fuel sources a meaningful avenue for advancing eco-conscious ambulance operations.

Sources and Solutions of Transportation Air Pollution

Source: Chen Q, Khattak SI. The future of green transportation: evaluating the impact of innovation in hybrid electric vehicles relating technologies on carbon dioxide emissions in Asia’s top knowledge-based economies. Environmental Science and Pollution Research. 2023 Oct;30(48):105398-414.

Using Electric Powered Vehicles in Ambulance Services

One effective strategy to mitigate the environmental impact of ambulances is the adoption of electric vehicles powered by batteries.

Electric ambulances have gained attention due to their potential to reduce greenhouse gas emissions and dependence on fossil fuels.

While the upfront investment for electric ambulances may be higher, the potential for long-term savings is considerable.

Total CO2-Equivalent Life-Cycle Emissions from Commercially Available Passenger Cars

Source: Buberger J. et al. Renewable and Sustainable Energy Reviews, 2022, 159, J. Buberger, A. Kersten, M. Kuder, R. Eckerie, T. Weyh, T. Thiringer (2022) Chapter Nine: Sustainability Approaches

Electric ambulances typically incur lower operating costs, primarily attributed to reduced maintenance and fuel expenses.

This cost-efficiency is particularly advantageous for ambulance services operating within constrained budgets, offering the prospect of substantial savings over the vehicle’s lifespan. The financial benefits extend beyond the initial purchase, as electric ambulances require less frequent maintenance and have fewer components prone to wear and tear.

Additionally, the ongoing operational costs are mitigated by the lower cost of electricity compared to traditional fuel. These factors contribute to a compelling economic case for the adoption of electric ambulances, making them an increasingly attractive option for emergency medical services globally.

Zero-Emission Electric Ambulance, Netherlands

Several regions worldwide have already begun adopting electric ambulances, indicating a growing acknowledgment of the manifold benefits they bring, not only in terms of environmental sustainability but also in addressing fiscal constraints faced by ambulance services. This global shift toward electric ambulances can be seen as a pragmatic response to financial challenges.

Despite the initial higher acquisition costs, the long-term economic advantages, driven by reduced maintenance and operational expenses, position electric ambulances as a financially astute investment. The decreasing reliance on traditional fuels contributes not only to cost savings but also to a diminished carbon footprint, demonstrating a harmonious integration of economic prudence and environmental responsibility within emergency medical services.

The Hart van Brabant Ambulance Service in the Netherlands has introduced electric ambulances as part of their fleet. These electric ambulances are equipped with state-of-the-art medical equipment and have a range up to 250 kilometres (155 miles) on a single charge.

Moreover, as technology advances and charging infrastructure becomes more prevalent, the economic viability of electric ambulances is poised to strengthen.

Ongoing research and development in battery technologies promise continuous improvements in energy storage capacity, charging speed, and overall performance. The integration of cutting-edge battery innovations into electric ambulances not only enhances their operational capabilities but also positions them as dynamic contributors to the evolution of sustainable and technologically sophisticated emergency medical services.

Electric ambulances typically utilise lithium-ion batteries, known for their high energy density, long cycle life, and fast charging capabilities. These batteries seamlessly power essential functions, ranging from critical medical equipment to auxiliary systems that ensure the comfort and wellbeing of patients and medical staff.

The high energy density enables the support of diverse ambulance functions, underscoring the versatility and reliability of electric ambulances in delivering comprehensive emergency medical services.

Furthermore, the long cycle life of lithiumion batteries contributes to the durability and longevity of electric ambulances. These batteries can withstand numerous charge and discharge cycles, ensuring a sustained and dependable power supply over an extended operational lifespan. Fast charging capabilities further enhance the operational efficiency of electric ambulances, allowing for quick turnaround times between emergency missions and minimising downtime. As technology continues to advance, ongoing research and development in battery technologies promise continuous improvements in energy storage capacity, charging speed, and overall performance.

Electric Power Train

Chapter Nine: Sustainability Approaches

In addition to their environmental benefits, electric ambulances operate silently, without the noise and vibrations associated with internal combustion engines.

This creates a more comfortable environment for patients during transportation, reducing stress and anxiety and allowing for better communication between healthcare professionals and patients. The silent operation can also benefit the ambulance crew by reducing noise-related fatigue during long shifts.

of the working mechanism of a lithium-ion battery

Source: Liang S, Yan W, Wu X, Zhang Y, Zhu Y, Wang H, Wu Y. Gel polymer electrolytes for lithium ion batteries: Fabrication, characterization and performance. Solid State Ionics. 2018 May 1;318:2-18.

Schematic

Electric ambulances are also known for their instant torque and smooth acceleration, resulting in improved performance compared to traditional ambulances.

This can be particularly useful in emergency situations where quick response times are critical. With fewer mechanical components compared to traditional ambulances, electric ambulances demonstrate improved reliability, operational efficiency, reduced downtime, and lower maintenance requirements. The streamlined design of electric ambulances potentially offers smoother acceleration and deceleration, providing paramedics better control during emergency responses.

However, electric ambulances face challenges such as limited range due to battery capacity and the energy required to power medical equipment. This can be particularly challenging in rural or remote areas where charging infrastructure may be limited.

To overcome this challenge, electric ambulances may require larger battery capacity or advanced battery management systems to optimise energy usage and extend the range. Introducing a sufficient number of charging infrastructures is crucial to ensure that electric ambulances have access to a reliable and widespread charging network.

The weight of medical equipment carried by ambulances is another challenge for electric ambulances. Medical equipment, such as defibrillators, ventilators, and monitors, requires power to operate, which can drain the battery quickly.

Managing the power needs of medical equipment while maintaining overall efficiency and range is a complex task that requires careful planning and coordination.

All-electric, zero-emissions Ambulance, USA

Unites States, DocGo unveiled the first all-electric, zero-emissions Ambulance in 2023. Before that in California, the Los Angeles County Fire Department has tested an electric ambulance built by Zero Emissions Systems (ZES) and has plans to add electric ambulances to their fleet. The ZES ambulance is equipped with advanced medical equipment and has a range of up to 250 miles on a single charge.

Zero Emissions Ambulance

Zero-Emission EV Ambulance, Tokyo

Nissan Motor and Tokyo Fire Department rolled out the NV400 Zero-Emission EV Ambulance, the first electric vehicle ambulance in Japan. This collaboration is a part of the eco-friendly initiative of the Tokyo Metropolitan Government.

Electric Ambulance Conversion, UK

In the United Kingdom, the West Midlands Ambulance Service has introduced a pilot program that includes electric ambulance. These ambulances are converted from existing diesel-powered ambulances and feature electric drivetrains, reducing emissions and noise pollution.

Auto Eject

Alternator

Solar Panels

Lithium Ion Battery

Using Solar Powered Vehicles in Ambulance Services

A

solar powered ambulance is the other eco-friendly vehicle that relies on solar energy to power its operations.

These vehicles harness solar energy to redefine how ambulances operate, reducing reliance on conventional fuels and minimising environmental impact. At the heart of this innovation are photovoltaic solar panels positioned on the ambulance’s roof and other suitable surfaces. These panels are designed for optimal sunlight absorption, ensuring a continuous conversion of sunlight into electrical energy.

Solar energy also serves as the primary power source for a range of critical onboard systems. LED lights, both inside and outside the vehicle and medical equipment, including defibrillators and ventilators, and communication devices crucial for real-time coordination are all powered by the energy stored in batteries charged by the solar panels. The solar-powered ambulances are equipped with advanced battery storage systems that store excess solar energy generated during the day. This stored energy becomes indispensable during periods of low sunlight, such as nighttime or overcast days.

Using solar-powered ambulances reduces reliance on traditional fuel sources, letting ambulances contribute to lowering greenhouse gas emissions and shrinking the overall carbon footprint associated with emergency medical services.

The ambulance may be powered by an electric motor that is charged by the solar panels and/or the battery storage system. Electric propulsion can reduce emissions and noise pollution, making the ambulance more environmentally friendly and suitable for urban areas. In case of prolonged periods of low sunlight, the ambulance may also have alternative charging options such as a backup generator or a plug-in charging system to ensure uninterrupted power supply for critical medical operations.

Ongoing improvements in solar panel efficiency and energy storage systems hold promise for even greater reliability and performance. The integration of artificial intelligence for optimised energy management and predictive analytics is on the horizon, offering potential enhancements to the sustainability and efficiency of ambulance vehicles.

Chapter Nine: Sustainability Approaches

Solar energy supplements the electrical needs of ambulances, USA

Solar-powered Rapid Response Vehicle (RRV) fleet, UK

Richmond Ambulance introduced an innovative approach to using solar energy to supplement the electrical needs of ambulances.

South Central Ambulance Service NHS Foundation Trust’s (SCAS) Rapid Response Vehicle (RRV) fleet is now solar powered.

Solar Water Ambulances

A solar water ambulance is a watercraft equipped with medical facilities powered by renewable solar energy. Typically, it features solar panels, or photovoltaic (PV) cells installed on its surface to harness sunlight for generating electricity. This power is used to charge batteries, operate electric motors, and run medical equipment on board.(116) By eliminating the need for fossil fuels, solar water ambulances become an eco-friendly mode of transportation that significantly reduces carbon emissions, minimising environmental impact.

These ambulances offer various environmental benefits. Solar energy, being a clean and renewable source, produces no greenhouse gas emissions or air pollutants during operation.(117) Consequently, this contributes to a reduced carbon footprint and improved air quality in waterway areas. Moreover, solar water ambulances operate silently compared to traditional combustion engine-powered vessels, reducing noise pollution. This is particularly crucial for emergency medical care, where quiet and calm conditions are essential for patient comfort and treatment.(118)

Energy Efficiency and Autonomy

In terms of energy efficiency and autonomy, solar water ambulances, equipped with efficient solar panels and energy storage systems, can operate autonomously for extended periods. The solar panels capture sunlight and convert it into electricity, stored in batteries for use during low-light conditions or at night. This ensures a continuous power supply for medical equipment and propulsion, minimising reliance on external power sources.(119)

Adaptability and Versatility

Solar water ambulances have proven effective in disaster-prone areas, where floods or cyclones can disrupt transportation infrastructure, ensuring timely medical assistance during critical situations. Additionally, they can reach isolated communities, riverine islands, or coastal villages with limited access to healthcare services. Deployable in areas with ample water resources, such as rivers, lakes, or coastal regions, solar water ambulances navigate waterways swiftly and efficiently, overcoming challenges associated with traffic congestion or lack of road access during emergencies.(120)

Water ambulance design

Solar-powered ambulance navigating waterway, UK

Adapted from: Tawheed H. et al. Ann Med Surg (Lond), 2022, 80: 104141.

Front LEDs - top Front LEDs

LEDs Rear LEDs - top

Solar Panel Medical Equipment

Case Studies and Proof-of-Concept Projects

While solar water ambulances are a relatively new concept, there have been notable case studies and proof-of-concept projects demonstrating their feasibility:

a. The “Solar Water Ambulance” project in Bangladesh was designed to deliver healthcare services to remote riverine communities through solar-powered boats equipped with medical facilities. The project sought to evaluate the efficiency of solar energy in powering medical equipment and reaching underserved areas, yielding impressive results.(121)

b. The “Solar Ambulance Boat” initiative in Kerala, India, involved the deployment of solar-powered boats equipped with medical facilities to deliver healthcare services in the backwaters of the state. The project demonstrated the practicality and advantages of solar-powered water transport for emergency medical care.(122)

Overall, the concept of a solar water ambulance presents a sustainable and innovative approach to emergency medical services, particularly in areas with abundant water resources. By harnessing solar energy for propulsion and power generation, solar water ambulances offer environmental benefits, energy efficiency, and adaptability. Continued research, development, and investment in solar water ambulance technology can pave the way for sustainable and efficient emergency medical care delivery in waterway-rich regions.

Solar-powered boat ambulance, India

Hydrogen-Powered Ambulance

In recent years, there has been a noticeable surge in the exploration of hydrogen-powered vehicles as a compelling and environmentally friendly alternative to conventional fuel-based counterparts.

This growing interest extends into the realm of Emergency Medical Services (EMS), where the idea of utilising hydrogen-powered ambulances has evolved from speculation to tangible reality.

As the world increasingly seeks cleaner and more sustainable modes of transportation, hydrogen-powered ambulances stand at the forefront of this evolution, promising not only a reduced environmental impact but also enhanced efficiency in critical medical situations.

A hydrogen-powered ambulance (Project Zerro) by ULEMCo

Environmental Impact

The advent of hydrogen-powered ambulances presents substantial advantages over their conventional gasoline or diesel-powered counterparts in terms of environmental impact. The key lies in the operational mechanism of hydrogen fuel cells, where electricity is generated through a clean chemical reaction between hydrogen and oxygen, yielding only water vapor as a benign byproduct. This inherent zero-emission characteristic aligns with stringent environmental standards and has the potential to significantly mitigate the adverse effects of traditional ambulances on air quality.

The reduction in greenhouse gas emissions, particularly carbon dioxide, marks an essential contribution to broader global efforts aimed at combating climate change. Moreover, the absence of harmful pollutants typically associated with internal combustion engines underscores the potential of hydrogenpowered ambulances to create healthier and more sustainable environments in the communities they serve. This paradigm shift toward cleaner energy sources in emergency medical services exemplifies a conscientious commitment to both patient wellbeing and planetary health.

Energy Efficiency

The adoption of hydrogen fuel cells in ambulances brings forth a notable advancement in energy efficiency, positioning them as a highly viable option for EMS. Hydrogen fuel cells excel in energy conversion efficiency, potentially achieving levels between 45% and 60%, surpassing the efficiency of traditional internal combustion engines and marking a substantial leap forward in the utilisation of clean energy for critical services.

This enhanced energy efficiency extends beyond environmental considerations to practical benefits for EMS operations. The superior efficiency of fuel cell-based powertrains equates to prolonged driving ranges and extended operational durations. This prolonged endurance becomes a crucial asset in emergency situations, ensuring that ambulances equipped with hydrogen fuel cells can sustain constant power for medical equipment and onboard systems.

When it comes to patient care during critical situations, the longer driving ranges and extended operation times offered by hydrogen-powered ambulances play a fundamental role in facilitating uninterrupted and continuous emergency medical services. This technological advancement not only underscores the environmental responsibility of the healthcare sector but also emphasises the pragmatic advantages that cleaner energy sources bring to the forefront of emergency response capabilities.

Refueling Infrastructure

A prominent challenge linked to the integration of hydrogen-powered vehicles, including ambulances, is the availability of refueling infrastructure. Recent progress has been made on a global scale to address this challenge and pave the way for the wider adoption of fuel cell vehicles. This includes expanding the network of hydrogen refueling stations, a pivotal development that augurs well for the future.

Countries at the forefront of this initiative, such as Germany, Japan, and the United States, have demonstrated significant commitment and investment in establishing comprehensive hydrogen infrastructure networks. This strategic approach not only mitigates concerns about the accessibility of refueling stations but also creates a conducive environment for the deployment and operation of hydrogen-powered ambulances.(123)

Globally, countries have announced plans to build 2800 hydrogen refuelling stations by 2025

Operational Flexibility

Hydrogen-powered ambulances offer operational advantages due totheir quick refueling time compared to electric vehicles.

Unlike battery-electric ambulances, which require hours to recharge, hydrogen refueling can be completed in a matter of minutes, ensuring rapid turnaround times for emergency responders.

This enables ambulance fleets to remain active for extended periods without significant downtime, enhancing overall operational efficiency.(124)

Comparison of Hydrogen fuelling and electric charging of cars

Source: Renner S, Wellmer FW. Volatility drivers on the metal market and exposure of producing countries Mineral Economics. 2020 Oct;33(3):311-40.

Case Studies and Pilot Programs

To assess the viability and potential benefits of hydrogen-powered ambulances, various case studies and pilot programs have been conducted globally

These initiatives have provided valuable insights into the performance, practicality, and sustainability aspects of deploying hydrogen fuel cell technology in emergency medical services (EMS).

London’s “Zeus” Project

London’s “Zeus” Project, spearheaded by London South Bank University (LSBU) in collaboration with the London Ambulance Service, represents a pioneering initiative in the realm of Emergency Medical Services (EMS) vehicles.

The primary objective of the Zeus project was to assess the practicality and advantages of incorporating hydrogen fuel cell technology into the day-to-day operations of ambulances within the dynamic urban landscape of London. London provided an ideal setting for the project, serving as the backdrop for exploring the potential of hydrogen fuel cells as a departure from traditional combustion engines.

The Zeus project aimed to evaluate the feasibility and potential benefits of integrating hydrogen fuel cell systems into the EMS fleet, aligning with broader efforts to reduce carbon emissions and promote sustainability in the transportation sector.

Throughout the project, the fuel cell system not only powered the ambulance’s movement but also supplied electricity to crucial medical equipment on board, ensuring the vehicle’s full functionality during emergency situations. This holistic approach addressed both the transportation and medical aspects of emergency response vehicles.

The Zeus project transcended mere experimentation, as the hydrogenpowered ambulance underwent realworld operations, interacting with the demanding conditions and challenges inherent in the city’s emergency response scenarios.

The data and insights gathered from these operational experiences played a crucial role in evaluating the effectiveness and reliability of hydrogen fuel cell technology in a practical and high-pressure environment. The outcomes of the Zeus project have the potential to significantly influence future decisions regarding the adoption of hydrogen fuel cell technology in EMS fleets:(125)

Environmental Benefits

The hydrogen fuel cell ambulance produced zero tailpipe emissions, contributing to improved air quality and reduced greenhouse gas emissions in urban areas.

Performance and Range

The vehicle demonstrated comparable performance to conventional ambulances, including similar acceleration and top speed. It achieved a driving range of approximately 200 miles, ensuring sufficient operational capability for emergency responses.

Refueling Infrastructure

The project underscored the need for an expanding hydrogen refueling infrastructure network to support the widespread adoption of hydrogenpowered ambulances. This critical insight emphasises the importance of developing a robust refueling infrastructure to facilitate the seamless integration of clean and sustainable technologies in emergency medical services.

HyMed-Health Project in Germany

The HyMed-Health project, conducted in Germany, represents a significant exploration into integrating hydrogen fuel cell technology within ambulance operations.

The project’s primary focus was to assess the performance of retrofitted ambulances in real-world conditions, scrutinising technical feasibility, economic viability, and environmental impact.

At the core of the HyMed-Health project was the strategic retrofitting of conventional ambulances with hydrogen fuel cell power systems.

This involved integrating advanced fuel cell technology into the existing ambulance infrastructure, emphasising a pragmatic approach to upgrading the emergency medical service (EMS) fleet. By choosing retrofitting over manufacturing entirely new vehicles, the project aimed to assess the adaptability and scalability of hydrogen fuel cell technology within the current EMS infrastructure.

Germany Aims at H2Med to Cover Part of its Demand for Green Hydrogen in 2030.

The HyMed-Health project’s overarching objectives were threefold.

Firstly, it rigorously examined the technical feasibility of hydrogen-powered ambulances, evaluating the performance of fuel cell power systems in terms of reliability, efficiency, and adaptability to diverse ambulance operational conditions, from urban to rural settings.

Secondly, economic viability was a critical aspect of the HyMed-Health project. It involved analysing the cost implications of retrofitting existing ambulances compared to potential benefits, such as reduced operational expenses and long-term sustainability. Economic considerations played a pivotal role in determining the feasibility of large-scale adoption of hydrogen-powered ambulances within the healthcare and emergency response sectors.

Lastly, the project aimed to quantify the environmental impact of hydrogenpowered ambulances. These vehicles, relying on a clean and sustainable energy source, have the potential to significantly reduce carbon emissions and contribute to environmental conservation.

Assessing the ecological footprint of hydrogen fuel cell ambulances provided valuable insights into the project’s overall impact on mitigating the environmental consequences associated with traditional combustion engine vehicles.

Through evaluating technical, economic, and environmental aspects, the HyMedHealth project positioned itself as a comprehensive endeavor. The outcomes of this project could influence future decisions and policies regarding the adoption of sustainable technologies in emergency medical services, paving the way for a more eco-friendly and efficient approach to ambulance operations in Germany and beyond:(110)

Environmental Impact

Hydrogen fuel cell ambulances demonstrated zero emissions during operation, contributing to local air quality improvement and reduced noise pollution.

Operational Efficiency

The quick refueling time of hydrogen fuel cells enabled rapid turnaround times for ambulances, minimising downtime and ensuring efficient emergency response.

Economic Viability

The project highlighted the importance of government support and incentives to promote the adoption of hydrogen fuel cell technology in EMS vehicles.

Japan’s H2-Mobility Project

Japan’s H2-Mobility Project stands as a significant initiative aimed at advancing the exploration and integration of hydrogen fuel cell technology, particularly in the context of ambulance operations.

The overarching objective was to assess and validate the performance, reliability, and feasibility of hydrogen-powered ambulances within the unique and dynamic context of Japan.

One distinctive feature of the H2-Mobility project was its collaborative nature, bringing together a diverse array of stakeholders. Government agencies, automotive manufacturers, and research institutions joined forces to comprehensively evaluate the potential of hydrogen fuel cell technology in the field of emergency medical services.

A zero-emission hydrogen ambulance launched by Kumamoto hospital

The focal point of the project was the practical demonstration of hydrogen fuel cell vehicles, including ambulances, under real-world conditions.

This involved deploying these vehicles in diverse scenarios that mirrored the actual operational environments encountered by emergency medical services in Japan. Such scenarios could include urban and rural settings, varying traffic conditions, and a spectrum of emergency response situations to thoroughly evaluate the adaptability and effectiveness of hydrogenpowered ambulances.

The evaluation process encompassed several key aspects. Firstly, the performance of the hydrogen fuel cell vehicles, particularly the ambulances, was rigorously scrutinised. This assessment included considerations of speed, range, and overall operational efficiency under different conditions. Reliability, a crucial factor in emergency response, was a key metric in determining the suitability of hydrogen fuel cell technology for this critical application.

Furthermore, the project aimed to clarify the feasibility of hydrogen-powered ambulances in the Japanese context. This assessment encompassed not only the technical aspects but also economic considerations, exploring the potential cost-effectiveness and sustainability of integrating such vehicles into the existing emergency medical services infrastructure.

The outcomes of the H2-Mobility Project have the potential to guide the broader conversation on eco-friendly and innovative transportation solutions not only in Japan but also globally:

Technological Advancements

The project facilitated the development of advanced hydrogen fuel cell systems for ambulances, including improved power density, efficiency, and durability.

Public Acceptance

The project aimed to raise public awareness and acceptance of hydrogen fuel cell technology through public demonstrations and educational initiatives.

Infrastructure Development

The H2-Mobility project contributed to the expansion of hydrogen refueling infrastructure across Japan, enabling greater deployment of hydrogen-powered ambulances and other vehicles.

Battery Fuel Cell Vehicles vs Hydrogen Fuel Cell Vehicles

Battery fuel cell vehicles (BEVs) and hydrogen fuel cell vehicles (FCVs) stand out as prominent alternatives to conventional internal combustion engine vehicles, offering clean and sustainable transportation solutions. Despite their environmental benefits, both technologies have distinct advantages and disadvantages.

Battery Fuel Cell Vehicles (BEVs)

Advantages

Zero Emissions

Operating solely on electricity stored in rechargeable batteries, BEVs produce no tailpipe emissions, contributing to improved air quality and reduced greenhouse gas emissions.(126)

Resource Efficiency

Benefiting from the increasing availability of renewable energy sources like solar and wind power, BEVs charging with clean energy further reduces their carbon footprint and dependence on fossil fuels.(127)

Established Infrastructure

The charging infrastructure for BEVs is more developed compared to hydrogen refueling stations, with an extensive network of charging points in many regions, facilitating widespread adoption.(128)

Disadvantages

Limited Range and Charging Time:

BEVs typically have a restricted driving range and longer charging times, potentially causing range anxiety, and limiting practicality for long-distance travel or emergency services.(129)

Battery Production and Recycling:

Battery production involves the extraction and processing of materials like lithium, cobalt, and nickel, posing environmental and social impacts. Battery recycling poses challenges due to complex processes and potential waste management concerns.(130)

Hydrogen Fuel Cell Vehicles (FCVs)

Advantages

Zero Emissions

Similar to BEVs, FCVs produce no tailpipe emissions, using hydrogen and oxygen to generate electricity, with water vapor as the only byproduct, addressing climate change concerns.(131)

Fast Refueling

FCVs can be refueled quickly, typically in a few minutes, providing a similar refueling experience to conventional gasoline-powered vehicles, making them suitable for applications requiring frequent and rapid refueling, such as emergency services.(132)

Extended Range

FCVs offer longer driving ranges compared to most BEVs, as hydrogen has a higher energy density, making them a viable option for long-distance travel and applications demanding extensive mobility capabilities.(133)

Disadvantages

Limited Infrastructure

Hydrogen refueling stations are currently limited compared to the widespread charging infrastructure for BEVs, necessitating the development of an extensive hydrogen refueling network for widespread FCV adoption.(134)

Hydrogen Production and Storage

Hydrogen production often relies on energy-intensive processes, potentially reliant on fossil fuels. Additionally, storing hydrogen requires special infrastructure and technologies, adding complexity to the overall system.(135)

Distribution Challenges

Hydrogen distribution faces logistical challenges due to its low energy density per unit volume, requiring specialised transportation methods and infrastructure, which can be costly and may limit availability in certain regions.(136)

Source: U.S. Department of Energy. Visualised: Battery Vs. Hydrogen Fuel Cell visualcapitalist.com

Overall, both BEVs and FCVs offer important clean and sustainable alternatives to traditional combustion engines.

BEVs, powered solely by electricity stored in rechargeable batteries, benefit from a well-established charging infrastructure, providing convenience and peace of mind to electric vehicle owners. However, challenges such as limited range and charging times hinder broader adoption, necessitating continuous innovation and investment.

On one hand, FCVs, utilising fuel cells, offer longer driving ranges and faster refueling times, resembling the familiar experience of conventional vehicles. Overcoming challenges and accelerating the shift towards a greener future requires ongoing collaboration and investment among stakeholders.

However, a couple of challenges hinder the broader adoption of BEVs. The limited driving range of many electric vehicles remains a concern for potential buyers, as it requires careful planning and consideration for longer trips. Additionally, the time required to recharge the batteries, especially when using standard charging methods, can be a significant inconvenience for some individuals.

The development of faster charging technologies and the expansion of charging infrastructure are crucial to alleviate these concerns and enhance the appeal of BEVs for consumers.

On the other hand, FCVs utilise fuel cells to generate electricity, which is then used to power an electric motor. These vehicles have the advantage of longer driving ranges and faster refueling times compared to BEVs. The use of hydrogen as a fuel source offers a high energy density and quick refueling capabilities, resembling the familiar experience of filling up a conventional gasoline-powered vehicle. Furthermore, FCVs emit only water vapor as a byproduct, making them an attractive zero-emission option.

Continuing innovation, investment, and collaboration among stakeholders are vital to overcoming these challenges and accelerating the shift towards a greener future of mobility.

Clean vehicles as percent of total new vehicle sales

Projected EV adoption is accelerating

Adapted form: About | California Air Resources Board

Market share of light vehicles sold

Adopted from: EV Adoption, Trends & Statistics: US Electric Cars in 2023 (recurrentauto.com)

Adopted from: EV Adoption, Trends & Statistics: US Electric Cars in 2023 (recurrentauto.com)

Note: FCEV = Fuel Cell Electric; BEV = Battery Electric; PHEV = Plug-in Hybrid Electric; MHEV = Mild Hybrid Electric. Because of rounding, the percentage for a particular year may not equal 100%. 1 Forecast includes cars, SUVs, and all other light vehicles except heavy vans.

Case Studies

Stockholm, a pioneer in sustainable development, has unveiled the world’s first eco-friendly ambulance, marking a significant leap toward greener emergency medical services.

This groundbreaking initiative combines cutting-edge technology, renewable energy sources, and a strong commitment to reducing carbon emissions, transforming the landscape of emergency healthcare.

Stockholm’s Revolutionary Eco-Friendly Ambulance

Carefully designed with sustainability in mind, the ambulance features a lightweight body made from recycled materials, ensuring a reduced carbon footprint during manufacturing. Its structure incorporates eco-friendly composite materials, improving fuel efficiency and minimising overall energy consumption.

Chapter Nine: Sustainability Approaches

At the heart of this innovative ambulance is an advanced electric power train, replacing the conventional internal combustion engine.

Powered by a state-of-the-art battery system, the electric ambulance produces zero tailpipe emissions, significantly reducing its carbon footprint. This not only decreases air pollution in the city but also provides a healthier environment for both patients and healthcare professionals.

AISAB, Ambulanssjukvården i Storstockholm AB, is Stockholm’s leading ambulance company and carries out almost half the county’s assignments – that’s over 56,000 assignments every year.

The green ambulance in figures, May 2009 to the end of Feb 2010:

Assignments 1,367

Distance 34,180 kilometres

Petrol 615 litres

Biogas 3,887 Nm3 (equates to 4,276 litres of petrol)

To ensure a sustainable energy supply, the ambulance is equipped with solar panels on the roof, capturing and converting sunlight into electricity to supplement the battery’s charge and extend the vehicle’s range. Additionally, regenerative braking technology recovers kinetic energy during braking, optimising efficiency and further reducing energy consumption.

• Tyres without harmful HA oils. HA oils get into lakes and oceans via surface water. The oils are toxic to aquatic organisms.

Stud-free tyres. Studded tyres contribute to high particle levels in the air during the winter.

Chapter Nine: Sustainability Approaches

The ambulance is outfitted with state-of-the-art medical equipment designed for maximum energy efficiency.

LED lighting fixtures minimise power consumption, while energy-saving monitors and diagnostic devices ensure high-quality care while minimising energy usage. The city’s robust charging infrastructure ensures the smooth operation and uninterrupted availability of electric ambulances across Stockholm.

• Halogen and PVC-free electricity cable. Halogens break down ozone.

Insulation without environmentally hazardous substances. Only natural materials in the insulation.

This eco-friendly ambulance not only serves as a shining example of sustainable innovation but also highlights the commitment of Stockholm’s healthcare sector to environmental stewardship. The success of this project paves the way for further advancements in sustainable healthcare practices, inspiring other cities worldwide to embrace similar initiatives.

• PVC-free floor mat. The production of PVC includes the use of many substances that are hazardous to health and the environment – such as halogens, mercury, dioxins and phthalates.

Adhesive free of solvents and isocyanates. These substances are primarily a work environment problem, as they can cause asthma.

In Amsterdam, the Netherlands, an innovative initiative has been undertaken to introduce electric ambulances into the city’s EMS fleet.

Working in collaboration with ambulance service providers, electric vehicle manufacturers, and sustainable energy providers, the Amsterdam Ambulance Service implemented a fleet of fully electric ambulances.

These vehicles significantly reduce carbon emissions and noise pollution, contributing to a healthier and more sustainable urban environment.

Electric Ambulance Fleet in Amsterdam, Netherlands

In rural areas with limited access to reliable electricity, a solar-powered ambulance project has been implemented in the state of Rajasthan, India.

The non-profit organisation, Smile Foundation, introduced solar-powered ambulances that rely on solar energy to power essential medical equipment, lighting, and communication systems.

Solar-Powered Ambulance in rural Rajasthan, India

These ambulances are equipped with solar panels on the roof, ensuring uninterrupted operations even in areas with erratic power supply.

In California, a pioneering approach to eco-friendly emergency medical services has led to the development of hydrogen fuel cell ambulances.

The California Fuel Cell Partnership, in collaboration with various stakeholders, has been instrumental in promoting the use of fuel cell technology in transportation, including emergency vehicles.

Hydrogen Fuel Cell Ambulance in California, United States

Recognising the emissions produced by idling ambulances, the London Ambulance Service undertook a retrofitting project to equip their fleet with idle reduction technology.

This initiative was implemented in collaboration with technology providers such as Air Products and Loughborough University. The retrofit includes automatic engine shutdown when the vehicle is stationary for a certain period, reducing unnecessary fuel consumption and exhaust emissions.

Auxiliary power units were also installed to provide electricity for medical equipment, minimising reliance on the engine during patient care.

The auxiliary power unit (APU) that powers the ambulance’s vital equipment when the engine is turned off.

Ambulance Fleet Retrofit with Idle Reduction Technology, London, UK

Overall, the case studies mentioned exemplify the ongoing efforts to integrate eco-friendly practices into emergency medical services.

Through the adoption of electric vehicles, solar power, hydrogen fuel cells, and idle reduction technologies, ambulance services are successfully reducing their carbon footprint, mitigating environmental impacts, and promoting sustainable healthcare delivery.

These initiatives not only contribute to environmental conservation but also demonstrate a commitment to public health and wellbeing. Continued research, innovation, and collaboration within the EMS sector are crucial to further advance these sustainable practices and ensure a greener future for emergency medical services.

Effects of greenhouse gases on surgery, obstetrics, and anaesthesia care

Source: Roa L, Velin L, Tudravu J, McClain CD, Bernstein A, Meara JG. Climate change: challenges and opportunities to scale up surgical, obstetric, and anaesthesia care globally. Lancet Planet Health. 2020 Nov;4(11):e538-e543. doi: 10.1016/S2542-5196(20)30247-3. PMID: 33159881.

Optimising Dispatch

Efficient ambulance dispatch is vital for sustainability, employing advanced technologies like geographic information systems (GIS), computer-aided dispatch systems (CAD), and global positioning systems (GPS) to minimise travel distances, reduce fuel consumption, and improve response times.

Collaborative efforts with other emergency services, strategic resource allocation based on data analysis, and predictive analytics further enhance optimisation, especially in urban areas.

The implementation of CAD involves network analysis, recommending the shortest paths for ambulance routes, minimising fuel consumption, and emissions. In addition, considering factors like traffic congestion, road conditions, and time of day, ambulance drivers can further optimise routes to reduce environmental impact.

Navigation data processing for assisted driving method in an ambulance transportation scenario.

Source: Anjum M, Shahab S. Emergency Vehicle Driving Assistance System Using Recurrent Neural Network with Navigational Data Processing Method. Sustainability. 2023; 15(4):3069. https://doi.org/10.3390/su15043069

Dispatch optimisation can be complemented by collaborative efforts with other emergency services and healthcare facilities.

This optimisation can be particularly beneficial in urban areas where traffic congestion is common. Another important factor in dispatch optimisation is esource allocation. Analysing historical data, demand patterns, and population densities, assist ambulance services to strategically position their vehicles in areas with high call volumes or potential emergency hotspots.

Emergency vehicle data processing model

This proactive approach enables them to be more prepared and responsive, reducing the need for unnecessary and inefficient travel. Additionally, using predictive analytics and machine learning algorithms can further enhance resource allocation by forecasting demand and adjusting ambulance deployment accordingly.

Source: Anjum M, Shahab S. Emergency Vehicle Driving Assistance System Using Recurrent Neural Network with Navigational Data Processing Method. Sustainability. 2023; 15(4):3069. https://doi.org/10.3390/su15043069

Computer-Aided Dispatch Systems (CAD):

To calculate the closest ambulance service vehicles, the CAD system does a network analysis of the road system based on these routable street centrelines.

It assesses the path from the service call to the available vehicle location. The system recommends the service vehicles with the shortest path. Dispatching ambulances more efficiently and using the most direct routes, reduce unnecessary fuel consumption and emissions.

CAD System Algorithm

Ambulance drivers should identify the most direct and efficient routes to the destination, considering factors such as traffic congestion, road conditions, and time of day. This way ambulance drivers can save fuel and reduce emissions, by avoiding detours and unnecessary backtracking, while also ensuring timely arrival at the patient’s location.

Optimising dispatch can also involve integrating alternative transportation methods into ambulance services.

For non-life-threatening cases or routine transfers, utilising bicycles, electric scooters, or hybrid vehicles can significantly reduce emissions and alleviate traffic congestion.

In Australia, Tasmania’s Emergency Service CAD system was launched in 2020. A new CAD system was also launched in New South Wales (NSW) Ambulance on May 2022, in partnership with eHealth. In South Australia CAD is managed by the South Australia Attorney-General’s Department, receiving more than a million calls for service in a year.

Electric ambulance scooter to join the fleet of the Egyptian Ambulance Authority

Riders with two types of motorcycle ambulances in Norway.

Paramedics of Queensland Ambulance Service Bicycle Response Team

Computer-aided dispatch systems in NSW,

Source: Advanced Mobile Location technology helps save lives | eHealth NSW

Australia

Automatic Lane Clearance System (ALCS)

The development and implementation of an Automatic Lane Clearance System (ALCS) for emergency vehicles have proven to be a significant technological advancement with crucial implications for sustainability, environmental impact, carbon footprint reduction, and climate change mitigation. This innovative system effectively addresses the challenges emergency vehicles face while navigating congested roads, enabling them to reach their destinations swiftly and safely. From a climate change perspective, the ALCS helps combat one of the key contributors to global warming, which is reducing the excessive emergency vehicles’ emissions.

In densely populated urban areas, traffic congestion poses a major hurdle for emergency vehicles trying to respond promptly to life-threatening situations.

The traditional approach of relying on sirens and flashing lights to alert other drivers has limitations, as it heavily depends on the awareness and reaction time of surrounding motorists. Furthermore, emergency vehicles often encounter obstacles or difficulties due to vehicles blocking their path or insufficient space for manoeuvring through traffic.

The ALCS serves as a breakthrough solution to tackle these challenges. Using advanced technologies such as sensors, cameras, and intelligent algorithms helps the system automatically detect and clear a designated path for emergency vehicles, ensuring their unimpeded movement through traffic. This intelligent system communicates with traffic signals, infrastructure, and vehicles in real-time, orchestrating a synchronised flow of traffic to create a clear passage for emergency vehicles.

Source: Ramaprasad, Shruti and K. N. Sunil Kumar. Intelligent traffic control system using GSM technology. 2017 IEEE International Conference on Power, Control, Signals and Instrumentation Engineering (ICPCSI) (2017): 830-834.

Automatic lane clearance system for emergency vehicles

The impact of the ALCS on sustainability and the environment is significant.

Firstly, by facilitating the smooth and uninterrupted flow of emergency vehicles, the system contributes to the reduction of response times, which is critical for saving lives. Swift emergency response can prevent further damage, minimise casualties, and improve overall public safety.

In addition, the ALCS plays a pivotal role in reducing traffic congestion caused by emergency situations. Through swiftly clearing a path for emergency vehicles, the system prevents the formation of traffic bottlenecks, which often result in prolonged idling and increased emissions. The reduction in congestion translates into decreased fuel consumption and emissions, leading to a substantial reduction in the carbon footprint of both emergency vehicles and other vehicles on the road.

Intelligence approach of traffic control of emergency vehicles

Source: Bollapragada, Manikanta. (2018). An Approach of Traffic Management System for Control of Emergency Vehicles Using IOT (Internet of Things). International Journal of Pure and Applied Mathematics. 118.

Intelligent Traffic with Emergency Control

Source: Singh AP, Sharma SK. A Review on Intelligent Traffic with Emergency Control and Stolen Vehicle Tracking System International Journal of Computer Applications. 2016 Jan 1;136(13)

Emergency Control System

Source: Singh AP, Sharma SK. A Review on Intelligent Traffic with Emergency Control and Stolen Vehicle Tracking System. International Journal of Computer Applications. 2016 Jan 1;136(13).

Environmentally Friendly Driving Practice

Environmentally friendly driving practices in ambulance services play a crucial role in promoting sustainability and reducing the environmental impact of emergency medical transportation, while ensuring efficient and effective patient care.

Ambulance services have the responsibility to respond quickly and effectively to emergency situations while also considering the impact their operations have on the environment.

Adopting environmentally friendly driving practices, can significantly contribute to sustainability efforts in ambulance services and minimise their carbon footprint.

Shares of energy consumption and CO2 emissions in the transportation industry

Shares of energy consumption and CO2 emissions in the transportation industry in the United States, China, and the European Union* shares of energy consumption, ** shares of CO2 emissions. Source: Xu, Nan, Xiaohan Li, Qiao Liu, and Di Zhao. 2021. An Overview of Eco-Driving Theory, Capability Evaluation, and Training Applications Sensors 21, no. 19: 6547. https://doi.org/10.3390/s21196547

One of the key aspects of environmentally friendly driving in ambulance services is the adoption of fuel-efficient vehicles.

Ambulance providers can choose vehicles that are designed to be fuel-efficient, have low emissions, and incorporate hybrid or electric technologies. These vehicles not only reduce greenhouse gas emissions but also lower fuel consumption, thereby minimising the overall environmental impact of ambulance operations.

Environmentally friendly driving practices for ambulance drivers are essential for minimising the environmental impact of ambulance operations.

Ambulance drivers vplay a critical role in reducing emissions, conserving energy, and promoting sustainable transportation. A crucial practice is maintaining the vehicles in optimal condition. Regular maintenance, including proper tire inflation, alignment, and engine tune-ups, ensures that the ambulance fleet operates at its highest level of efficiency. Well maintained vehicles consume less fuel and produce fewer emissions, contributing to a cleaner and greener environment.

The primary factors affecting vehicle energy consumption

Source: Xu, Nan, Xiaohan Li, Qiao Liu, and Di Zhao. 2021. An Overview of Eco-Driving Theory, Capability Evaluation, and Training Applications Sensors 21, no. 19: 6547. https://doi.org/10.3390/s21196547

Driver Training and Education in Ambulance Services

Driver training and education are vital components of promoting environmentally friendly driving practices in ambulance services.

Equipping ambulance drivers with the necessary knowledge and skills, can contribute to sustainability efforts by adopting eco-driving techniques and behaviours.

Ambulance drivers can be trained in eco-driving techniques, such as smooth acceleration and deceleration, maintaining a consistent speed, and avoiding unnecessary idling. These practices not only conserve fuel but also reduce wear and tear on the vehicle, extending its lifespan and minimising the need for replacements.

Rule- based eco-driving theory in the main driving modes

An Overview of Eco-Driving Theory, Capability Evaluation, and Training Applications

Source: Xu, Nan, Xiaohan Li, Qiao Liu, and Di Zhao. 2021. An Overview of Eco-Driving Theory, Capability Evaluation, and Training Applications Sensors 21, no. 19: 6547. https://doi.org/10.3390/s21196547

Eco-Driving Techniques

With the increasing emphasis on sustainability and reducing carbon footprints, ambulance drivers can benefit from eco-driving techniques that prioritise smooth acceleration and deceleration, ultimately leading to improved fuel efficiency and reduced emissions.

Rapid and aggressive acceleration not only consumes more fuel but also increases emissions. Gentle and gradual acceleration can improve fuel efficiency significantly. On the contrary, adopting gentle and gradual acceleration can significantly enhance fuel efficiency, resulting in reduced operational costs and environmental impact.

Moreover, the adoption of smooth deceleration techniques becomes crucial in eco-driving. Through anticipating traffic conditions and utilising engine braking methods ambulance drivers can conserve fuel and simultaneously alleviate wear on the braking system.

efficient driving techniques

This approach not only contributes to a more sustainable operation but also enhances overall vehicle maintenance and longevity.

Training ambulance drivers in ecodriving techniques is essential to instil the necessary skills and knowledge required to drive efficiently and responsibly. Such training programs can cover topics such as proper acceleration and deceleration techniques, anticipatory driving, and efficient route planning, ensuring that drivers are equipped with the tools to make environmentally conscious choices while maintaining their commitment to swift emergency response.

Source: B V, Prajwal. (2017). Prediction of Drive Cycle along a route for Eco Routing. 10.13140/RG.2.2.14103.88489/1.

Fuel

1. Maintaining a Consistent Speed

Ambulance drivers can be trained to maintain a consistent speed whenever possible. Frequent speed changes and erratic driving patterns not only consume more fuel but also contribute to increased emissions.

By driving at a steady pace within the legal speed limits, drivers can optimise fuel efficiency and reduce the environmental impact of their operations.

It has been shown that at low speed a vehicle emits the highest CO while higher speed emits minimum pollutant. The greener speed range is 60–100 km/h in terms of emission. At green speed, it emits the lowest level of CO.(137, 138)

Basic relationship of the vehicle speeds with the fuel consumption from which exhaust pollutant by the driving pattern can be assumed

Source: Nasir MK et al.Source: Nasir MK et al. Reduction of Fuel Consumption and Exhaust Pollutant Using Intelligent Transport System Scientific World Journal. 2014; 836375.

2. Avoiding Unnecessary Idling:

The term idling refers to the continuous operation of a vehicle’s main propulsion engine while the vehicle is stopped.

Idling is a significant source of fuel wastage and unnecessary emissions. Ambulance drivers can be educated on the importance of avoiding unnecessary idling by turning off the engine when waiting for extended periods.

Modern ambulances often have auxiliary power units (APUs) that can provide power for onboard systems without the need for idling the main engine. Combining these APUs and avoiding idling minimises fuel consumption and emissions.

Average estimated daily emissions and fuel consumption for laden highway truck

Adapted from Idling Emissions (dieselnet.com)

A Low-Cost Ambulance Idle Reduction System

Source:  Kung, Kaplan, Kotowick, & Montgomery. 2018; https://doi.org/10.30542/JCEMS.2018.01.S1.10

Vehicle Maintenance

Vehicle maintenance is a crucial aspect of ensuring the sustainability and efficiency of ambulance operations.

In addition to providing emergency medical care, ambulance drivers play a significant role in maintaining the vehicles they operate. Integrating education on the importance of regular vehicle maintenance into driver training programs, can promote sustainable practices and maximise the lifespan of ambulance fleets.

Well-maintained vehicles offer numerous benefits, both environmentally and operationally. Firstly, they operate more efficiently, which translates into lower fuel consumption. That requires conducting routine vehicle inspections, which enables ambulance drivers to identify and address any issues that may affect the vehicle’s performance.

This proactive approach helps optimise fuel efficiency and minimises unnecessary fuel consumption, resulting in cost avings for the ambulance service. Moreover, properly maintained vehicles emit fewer pollutants into the atmosphere. Through regularly monitoring and maintaining exhaust systems, filters, and other vehicle components, ambulance drivers can help minimise harmful emissions. This contributes to cleaner air quality and reduces the environmental impact of ambulance operations.

The training must include information on the importance of complying with emission standards and guidelines to ensure that the ambulances are operating within legal limits. Driver training should also emphasise the significance of tire maintenance.

Proper tire pressure is essential for vehicle safety and efficiency. Ambulance drivers can be educated on how to check and maintain tire pressure regularly, as underinflated tires can reduce fuel efficiency and increase the risk of accidents.

Additionally, monitoring tire wear and promptly replacing worn-out tires can improve overall vehicle performance and ensure the safety of patients and staff during emergency responses.

Timely reporting of any maintenance issues is another crucial aspect of driver training.

Ambulance drivers should be encouraged to promptly report any problems they notice during their inspections, whether it’s a malfunctioning engine component, a worn-out brake pad, or an electrical issue. This enables the maintenance team to address the problems promptly, preventing further damage and ensuring the vehicle is in optimal working condition. Through emphasising the importance of vehicle maintenance in driver training, ambulance services can extend the lifespan of their vehicles.

Regular maintenance helps identify and resolve small issues before they become major problems, reducing the likelihood of unexpected breakdowns and costly repairs. As a result, ambulance fleets can remain operational for longer periods, reducing the need for premature vehicle replacements. This not only saves costs but also minimises the environmental impact associated with manufacturing and disposing of new vehicles.

An environmentally friendly approach is an investment into the future

✓ Servicing

✓ Maintenance

✓ Investment into the future

Telematics and Feedback Systems

Ambulance services can integrate telematics systems into their vehicles to provide real-time feedback to drivers.

These systems monitor driving behaviour, fuel consumption, and other performance metrics. Through receiving feedback on their driving habits, drivers can make adjustments to improve fuel efficiency and reduce emissions.

This feedback mechanism can be used as a training tool to reinforce environmentally friendly driving behaviours. Incorporating these training and education strategies, can create a culture of environmentally friendly driving practices in ambulance services. It empowers ambulance drivers to be proactive in minimising fuel consumption, reducing emissions, and extending the lifespan of the vehicles. The cumulative impact of these ecodriving techniques contributes to the overall sustainability of ambulance services, promoting a cleaner and greener environment while efficiently fulfilling their life-saving responsibilities.

Video Telematics with ambulance integration

Chapter 10: Energy

Energy management is a critical component of sustainability in the ambulance sector.

As the operations of emergency medical response teams are heavily relied on energy-intensive equipment and facilities, effective energy management practices can significantly reduce the environmental impact, operational costs, and carbon footprint of ambulance services.

Regular energy audits and monitoring of energy consumption is the first step to provide valuable insights into the energy performance of ambulance stations and help identify areas for improvement.

Energy audits can also assess the energy efficiency of building systems, equipment, and operations, and provide recommendations for optimising energy usage. Monitoring energy consumption in real-time and analysing data can help identify trends, patterns, and anomalies in energy usage, allowing for prompt actions to rectify issues and improve energy management practices.

State and territory public hospital total energy consumption (2018-2019)

Renewable electricity use by state/territory public hospitals

Gas use by state/territory public hospitals

Electricity use by state/territory public hospitals

Source:  Burch H, Anstey MH, McGain F. Renewable energy use in Australian public hospitals. Med J Aust. 2021 Aug 16;215(4):160-3.

Alternative Energy Sources in Ambulance Stations

Ambulance stations are essential facilities that require a constant supply of energy to power their operations, including lighting, heating, cooling, and medical equipment.

One of the key aspects of energy sustainability in ambulances is the adoption of alternative energy sources that are renewable, clean, and efficient.

Traditionally, the ambulance stations rely heavily on fossil fuels, such as electricity from the grid and natural gas for heating and cooling. However, the use of fossil fuels contributes to greenhouse gas emissions, air pollution, and climate change. One of the key steps in making an ambulance station more energy sustainable is to invest in renewable energy sources, such as solar and wind power.

Percentage of state/ territory public hospital direct energy use from renewable sources over and above statebaseline renewable penetration (2016/17 to 2018/19)**

Solar panels can be installed on the rooftop of the ambulance station building to harness the power of the sun to store excess energy and generate electricity. These energy storage systems can be used to power the ambulance station during periods when renewable energy production is low, such as during the night or when there is little wind or sun. Energy storage systems can also provide backup power during emergencies or power outages, ensuring uninterrupted operations of the ambulance station.

*Large increase in Qld due to whole-of-government purchase of GreenPower. ACT = Australian Capital Territory; NSW = New South Wales; NT = Northern Territory; QLD = Queensland; SA = South Australia; TAS = Tasmania; VIC = Victoria; WA = Western Australia. Source: Burch H. et al. MJA. 2021 Source:  Burch H, Anstey MH, McGain F. Renewable energy use in Australian public hospitals. Med J Aust. 2021 Aug 16;215(4):160-3.

Wind turbines can also be installed on the premises if the location is suitable for wind energy generation.

These renewable energy sources can provide a consistent and clean source of electricity, reducing the reliance on fossil fuels and lowering greenhouse gas emissions.

Energy Sustainability- Case Study:

An example in this area includes Ambulance Victoria (AV), a distributed service provider with 260 locations, providing emergency response services across the state, who have entered into a power purchase agreement with a renewable energy farmer.

This arrangement is enabling AV to reduce its greenhouse impact and providing the wind farmer assurance to invest and develop the project. This will reduce AV’s emissions by 7% and is part of its commitment to source 100% of its electricity from renewable sources by 2025.

Photovoltaic solar array at Yarrawonga Health

Chapter Ten: Energy

Alexandra District Health

Alfred Health Alfred Health

Alfred Health Bright Hospital

Alfred Health Doug Lloyd Cottage Myrtleford

Alfred Health Hawthorn Village Hospital

Alfred Health Mt. Beauty Hospital

Alfred Health Myrtleford Hospital

Ambulance Victoria Caroline Springs Branch

Ambulance Victoria Cowes

Ambulance Victoria Geelong Branch

Ambulance Victoria Horsham Branch

Ambulance Victoria Melton Branch

Ambulance Victoria Mildura Branch

Ambulance Victoria Sunshine Branch

Ambulance Victoria Swan Hill Branch

Ambulance Victoria Wangaratta Branch/ Hume Regional

Barwon Health Renal Home Training Facility

Barwon Health University Hospital, Geelong

Beaufort and Skipton Health Service Beaufort Hospital

Benalla Health Service Benalla Health Service

Bendigo Health New Bendigo Hospital

Gippsland Health Service Heyfield

Gippsland Health Service Wilson Lodge

Echuca Regional Health Echuca Regional Health

Gippsland Southern Health Service Korumburra District Hospital

Gippsland Southern Health Service Leongatha Hospital

Heathcote Health Heathcote Health

Maidon Hospital Maidon Hospital

Mansfield District Hospital Mansfield District Hospital

Mayborough District Health Service Avoca Campus

Mayborough District Health Service Dunnoly Campus

Mayborough District Health Service Mayborough Campus

Melbourne Health Royal Melbourne Hospital

10

on information reported to the department as of 5 July 2018 and therefore may not include all

Integration of Energy-Efficient Technologies

Another important aspect of energy sustainability in ambulance stations is energy conservation.

The integration of energy-efficient technologies in buildings has become increasingly important for reducing energy consumption, improving indoor air quality, and optimising operational costs.

Two notable examples of such technologies are programmable thermostats and high-efficiency lighting, heating, ventilation, and air conditioning (HVAC) systems.

Managing the energy and other needs in buildings efficiently and intelligently can have considerable benefits.

A building energy management system (BEMS) is a sophisticated method to monitor and control the building’s energy needs. Next to energy management, the system can control and monitor a large variety of other aspects of the building regardless of whether it is residential or commercial. Examples of these functions are heating, ventilation, and air conditioning (HVAC), lighting or security measures. BEMS technology can be applied in both residential and commercial buildings. The teaser image illustrates several of the different functions a BEMS can monitor and control.

1. Light Emitting Diode (LED) lighting

In the pursuit of sustainability and energy efficiency, the adoption of LED lighting has gained significant attention and acclaim.

LED lighting technology presents numerous advantages over traditional incandescent bulbs, including reduced energy consumption, extended lifespan, and enhanced sustainability.

LED lighting is renowned for its superior energy efficiency compared to traditional incandescent bulbs. Incandescent bulbs generate light by heating a filament, resulting in substantial energy waste through heat dissipation.

In contrast, LED bulbs operate by passing an electric current through a semiconductor, producing light with minimal energy loss. According to the U.S. Department of Energy (DOE), LED bulbs use 75-80% less energy than traditional incandescent bulbs.(139) This significant reduction in energy consumption translates into substantial energy savings and a notable decrease in greenhouse gas emissions.

LED lighting also boasts an impressive lifespan compared to traditional bulbs. Incandescent bulbs typically last for around 1,000 hours, while LED bulbs can endure up to 25,000 hours or more.(132)

This extended lifespan not only reduces the frequency of bulb replacements but also minimises waste generated from discarded bulbs. The environmental benefits of LED lighting extend beyond energy efficiency and lifespan. LED bulbs do not contain hazardous materials like mercury, which is present in some traditional bulbs, such as compact fluorescent lamps (CFLs).(140)

This absence of toxic substances reduces the environmental impact of LED lighting, particularly during the disposal phase. LED lighting also offers enhanced controllability and flexibility, further optimising energy usage. LED bulbs can be easily dimmed or adjusted to different light levels, allowing users to customise lighting according to specific needs and preferences.

This way the energy waste is minimised as it is dynamically adapted to lighting requirements.(140)

The adoption of LED lighting has been significant in various sectors, including residential, commercial, and industrial settings.

A study conducted by Energy Efficiency Alberta(141) evaluated the energy savings potential of LED lighting in the commercial sector. The results demonstrated that by replacing traditional lighting with LEDs, energy consumption for lighting purposes could be reduced by up to 60%. Additionally, the study highlighted the positive financial impact of LED lighting upgrades, with a potential payback period of fewer than three years.

Based upon 3hrs/day and rate of $0.11 per kilowatt hour

Comparrison between Incandescent, Flouresent and LED light bulbs

2. Programmable thermostats

Programmable thermostats offer a practical and efficient solution for managing heating and cooling systems in Ambulance stations.

These thermostats allow users to program temperature settings based on occupancy patterns, optimising energy usage throughout the day. Automatically adjusting temperature settings during unoccupied periods or at night helps reduce energy consumption without compromising comfort. The use of programmable thermostats can lead to significant energy savings. As it was shown by many studies.

A study conducted by the National Institute of Standards and Technology (NIST) in commercial buildings found that proper use of programmable thermostats resulted in average energy savings of around 10%.(142) Additionally, a review of residential studies conducted by the Lawrence Berkeley National Laboratory (LBNL) revealed that programmable thermostats can save up to 10% on heating and cooling energy costs.(143)

Managing the energy and other needs in buildings efficiently and intelligently can have considerable benefits.

Source:Mandlem, Koushik, Energy efficiency effectiveness of smart thermostat based BEMS (2018). Graduate Theses, Dissertations, and Problem Reports. 4009.

Programmable thermostats contribute to improved indoor air quality (IAQ). They maintain consistent temperature settings, avoid temperature fluctuations, and help prevent conditions that can promote mold and mildew growth.

Some programmable thermostats also offer advanced features, such as air filtration scheduling, which can enhance IAQ by ensuring regular air filtering and purification.(144) The combination of energy savings and IAQ improvements makes programmable thermostats an asset for sustainable building operations in Ambulance stations.

High-efficiency HVAC systems are another vital component of energy-efficient buildings. These systems utilise advanced technologies and design strategies to optimise energy consumption while providing superior comfort and indoor air quality. Incorporating features such as variable speed motors, advanced controls, and heat recovery systems, allow high-efficiency HVAC systems to deliver substantial energy savings compared to conventional systems.

According to the U.S. Department of Energy (DOE), high-efficiency HVAC systems can reduce energy consumption by up to 30% compared to standard systems. The utilisation of advanced controls enables precise temperature and humidity management, ensuring optimal comfort conditions while minimising energy waste.

Heat recovery systems, on the other hand, capture waste heat from various sources, such as exhaust air or cooling processes, and repurpose it for heating or other energy demands. This approach significantly improves energy efficiency by maximising the utilisation of available energy resources.(145)

High-efficiency HVAC systems also contribute to improved indoor air quality through enhanced filtration and ventilation capabilities. These systems utilise advanced filters, such as high-efficiency particulate air (HEPA) filters, to capture and remove airborne pollutants, allergens, and contaminants. Additionally, high-efficiency HVAC systems employ demand-controlled ventilation strategies, which adjust ventilation rates based on occupancy levels, ensuring adequate fresh air supply while minimising energy waste.(144) The combination of energy efficiency and enhanced indoor air quality makes highefficiency HVAC systems a compelling choice for sustainable building operations.

The Environmentally Friendly HVAC Solution that Allows High-Performance Buildings to Breathe

Sustainable Design of Ambulance Stations

In recent years, sustainability has become a critical consideration in the design and construction of buildings across various industries, including healthcare.

Ambulance services stations, where emergency medical response teams are based and operations are managed, are no exception. Sustainable building structures in ambulance services stations can offer a range of environmental, operational, and economic benefits, including reduced energy consumption, lower carbon emissions, improved indoor air quality, and enhanced operational efficiency.

Ambulance service stations represent a distinct category of facilities that necessitate meticulous planning and design considerations to effectively support the needs of emergency medical response teams. These stations serve as operational hubs for emergency medical services and are essential for facilitating rapid and efficient emergency response efforts. The design of ambulance service stations is tailored to meet the specific requirements of these critical healthcare providers.

The brief was for a building with a low carbon footprint, which makes use of renewable materials to complement its natural context.

One of the fundamental components of ambulance service stations is the inclusion of offices.

These administrative spaces provide a dedicated area for staff members to carry out essential tasks such as documentation, coordination of resources, and communication with other emergency response teams and medical facilities.

Offices within the station serve as the central command and control hub, enabling effective coordination of emergency medical services.

Ambulance Station Built from Renewable Materials has a Nearly Energy-Neutral Footprint

Rest areas are another essential feature of ambulance service stations.

Given the demanding and high-stress nature of emergency medical work, providing a comfortable and rejuvenating space for personnel to rest and recharge is crucial. These rest areas typically include restrooms, break rooms, and sleeping quarters to accommodate the needs of on-duty staff during extended shifts.

Creating a conducive environment that promotes relaxation and wellbeing is vital for ensuring the physical and mental wellbeing of emergency medical response teams.

Source: Baciu, Ioana-Roxana & Isopescu, Dorina & Taranu, Nicolae & Maxineasa, Sebastian. (2019). Green roof influence over the characteristics of the linear thermal bridges. IOP Conference Series: Materials Science and Engineering. 586. 012007. 10.1088/1757-899X/586/1/012007.

The connection between the exterior wall and the roof slab

The connection between the interior wall and the roof slab (without reinforced concrete beam)

The connection between the interior wall and the roof slab (with reinforced concrete beam)

Training rooms form an integral part of ambulance service stations as well. These dedicated spaces are designed to facilitate ongoing training and skill development for emergency medical personnel. Equipped with audiovisual systems, simulation equipment, and interactive learning tools, these rooms allow for hands-on training sessions, educational workshops, and team exercises. Training rooms play a vital role in enhancing the knowledge and capabilities of medical response teams, ensuring that they remain up to date with the latest practices and technologies.

Garages within ambulance service stations serve as housing for ambulance vehicles. These garages are specifically designed to accommodate the unique dimensions and requirements of emergency medical vehicles. They provide secure and easily accessible parking spaces, often equipped with maintenance facilities and cleaning areas to ensure that the ambulances are properly serviced, stocked, and maintained. The layout and organisation of the garage area are optimised for quick deployment and seamless movement of ambulance vehicles during emergency responses.

A garage space that occupies the front portion of the building incorporates transparent roller doors and circular skylights that ensure plenty of natural daylight reaches the interior.

Storage areas are crucial components of ambulance service stations, designed to house medical supplies and equipment necessary for emergency medical response. These storage spaces are carefully organised and equipped with shelving, cabinets, and specialised storage units to ensure efficient inventory management and easy access to critical resources. The storage areas are designed to accommodate various medical supplies, including medications, medical equipment, personal protective gear, and specialised tools needed for emergency medical interventions.

Sustainable building structures in ambulance services stations can be designed to integrate various environmentally friendly features and practices that minimise the environmental impact of the facility and enhance the overall sustainability of operations. One example is incorporating water-efficient landscaping, such as native plants that require less water for irrigation into the site design.

Indoor air quality is crucial for the health and wellbeing of ambulance personnel who spend considerable time indoors in the station. Poor indoor air quality can result in various health issues, such as respiratory problems and allergies. Sustainable building structures in ambulance services stations can prioritise indoor air quality by using low-emission building materials, such as paints, adhesives, and sealants, that do not release harmful pollutants into the air.

Proper ventilation systems with highefficiency filters can also be installed to ensure a constant supply of fresh air and to remove indoor air pollutants. This can create a healthy and comfortable indoor environment for ambulance personnel, leading to increased productivity and reduced sick leave.

The newest Austin-Travis County Fire and EMS station includes a well-ventilated ambulance bay with visibility enhancements and a vehicle exhaust removal system.

Source: https://www.pulsara.com

Incorporating green spaces and landscaping is another sustainable feature that can be integrated into ambulance services station design.

Green spaces, such as courtyards, rooftop gardens, and vegetative roofs, not only enhance the aesthetics of the building but also provide a range of environmental and health benefits.

Green spaces can help reduce the urban heat island effect, improve air quality by absorbing pollutants, provide natural insulation to the building, and promote mental wellbeing and stress reduction for ambulance personnel.

Ambulance Stations: Sectional perspective.

Green spaces can also be used for recreational purposes, providing opportunities for relaxation and physical activity for the personnel.

Sustainable Building Structures

Utilisation of sustainable materials and construction practices plays a pivotal role in minimising the environmental impact of the ambulance sector. Through embracing sustainable materials and construction practices, ambulance service stations can demonstrate their commitment to environmental responsibility and contribute to a more sustainable future.

One essential aspect of sustainable materials is their low carbon footprint. These materials are selected based on their ability to reduce greenhouse gas emissions throughout their lifecycle, from extraction or manufacturing to disposal.

Opting for materials with a low carbon footprint can significantly decrease the contribution of ambulance service stations to climate change. Examples of such materials include recycled materials, which are repurposed from waste streams, reducing the need for extraction and processing of virgin resources. Additionally, sustainable materials may encompass natural or renewable materials that have a lower environmental impact compared to their non-renewable counterparts.

Another consideration in sustainable building practices is the responsible sourcing of materials. This entails prioritising materials that are ethically and sustainably obtained. Locally sourced materials, for instance, are favored to reduce transportation-related emissions and support the local economy.

Switching to procure materials from nearby suppliers assists ambulance service stations to minimise the energy and resources required for transportation while fostering local business relationships.

Embodied energy is a crucial factor when evaluating the sustainability of materials. It refers to the total energy consumed in the extraction, manufacturing, and transportation of materials. Sustainable building structures in ambulance service stations aim to incorporate materials with low embodied energy. These materials are chosen for their minimal environmental impact during the production phase. Examples include materials that require less energy-intensive manufacturing processes or those that can be sourced from renewable or recycled sources.

Improving a Building’s Ecological Performance

In addition to material selection, sustainable construction practices also encompass efficient use of resources. This includes minimising waste generation during the construction process through careful planning, effective project management, and the adoption of waste reduction strategies. Construction techniques that prioritise energy efficiency, such as proper insulation, the use of renewable energy sources, and efficient lighting systems, contribute to the overall sustainability of ambulance service stations.

The laminated shell is wrapped in a highly insulated envelope, with photovoltaic panels incorporated on the sedum roof contributing to a solar water-heating system. An all-electric system with a heat pump and underfloor heating also aids the building’s ecological performance.

Minimising Waste Generation:

Sustainable construction practices aim to minimise waste generation right from the design stage to the construction process.

Careful planning involves evaluating the quantity of materials required and implementing measures to reduce waste. This can include accurate material estimation, pre-cutting materials to minimise offcuts, and utilising prefabricated components to reduce on-site waste.

Effective project management ensures that construction activities are streamlined, avoiding unnecessary rework or overuse of materials. Through adopting waste reduction strategies such as recycling, reusing materials, and implementing construction waste management plans, construction sites can significantly minimise waste generation.

Source: adapted from Gavilan & Bernold J. Constr. Eng. Manag. 1994, 120, 536–552.

Generic Flow Pattern of Construction Material on Site

Energy Efficiency and Insulation:

Energy-efficient design plays a crucial role in sustainable ambulance service stations. Proper insulation of the building envelope, including walls, roofs, and windows, helps reduce heat transfer and maintain comfortable indoor temperatures. This reduces the reliance on heating and cooling systems, resulting in lower energy consumption and reduced greenhouse gas emissions. Insulation materials with high thermal resistance, such as cellulose insulation or spray foam insulation, are commonly used to enhance energy efficiency in construction.

Use of Renewable Energy Sources as a Part of Construction:

Integrating renewable energy sources into ambulance service station design and construction further enhances sustainability. Photovoltaic (PV) systems can be installed on the roofs of service stations to harness solar energy and generate electricity. This renewable energy source can power the building’s lighting, heating, and cooling systems, reducing reliance on non-renewable energy sources, and lowering carbon emissions. In some cases, surplus electricity generated by PV systems can be fed back into the grid, contributing to the local renewable energy supply.

Efficient Lighting Systems as a Part of Stations’ Design:

Lighting constitutes a significant portion of energy consumption in buildings. Employing energy-efficient lighting systems, such as LEDs or compact fluorescent lamps (CFLs), can significantly reduce electricity usage and increase the lifespan of lighting fixtures. Implementing lighting controls, such as occupancy sensors and daylight harvesting systems, ensures that lights are only used when needed, further optimising energy efficiency. Properly designed lighting systems can create a safe and comfortable environment within ambulance service stations while minimising energy consumption.(139)

Including these sustainable construction practices into the design and construction of ambulance service stations not only reduces the environmental impact but also promotes operational efficiency. Energy-efficient buildings require less energy for heating, cooling, and lighting, resulting in reduced operating costs for the ambulance service. Moreover, the adoption of sustainable construction practices sets an example for other sectors and promotes a culture of environmental responsibility and stewardship.

Chapter 11: Water

Water is a precious resource that plays a vital role in sustaining life and supporting various human activities.

Almost 70% of the Earth’s is occupied by water, however, only 3% of it can be used as drinkable water.

In recent years, increasing awareness of environmental sustainability has led to the adoption of water management and recycling practices in various industries, including healthcare facilities. Ambulance stations are among critical healthcare facilities that require water for various purposes, including cleaning and disinfection, patient care, and staff hygiene.

The high demand for water in ambulance stations, coupled with the need to maintain strict hygiene and infection control standards, can result in significant water usage and wastage. Therefore, effective water management and recycling practices in ambulance stations is essential to minimise the environmental footprint of these facilities and promote sustainability.

Adapted from: Mittermeier RA, Farrel TA, Harrison IJ, Upgren AJ, Brooks TM. Fresh water. The essence of life. CEMEX and ILCP. 2010.

Strategies for Saving and Recycling Water in Ambulance Services

One key aspect of water management in ambulance stations is water conservation. Implementing measures to reduce water consumption can help minimise the strain on local water resources and reduce the environmental impact of ambulance sector. There are several strategies that can be employed to achieve water conservation in ambulance stations.

1. Incorporating Smart Water Management Technologies

Water- efficient appliances, such as lowflow faucets, showerheads, and toilets, can significantly reduce water consumption. These fixtures are designed to use less water without compromising performance, and they can result in substantial water savings over time.

Water Consumption and Saving Using Different Types of Fixtures

One of the key water-efficient fixtures that can be installed in ambulance services is low-flow faucets. These faucets are designed to limit the flow rate of water while maintaining adequate pressure for effective handwashing and other cleaning activities.

Low-flow faucets typically have flow rates of 1.9 to 5.6 litres per minute (LPM), compared to standard faucets that may have flow rates of 9.5 LPM or higher. Similarly, low-flow showerheads can also be installed in ambulance stations to conserve water. Standard showerheads may have flow rates of 9.5 LPM or higher, while low-flow showerheads typically have flow rates ranging from 5.5 to 7.5 LPM.

Adapted from: Kurle P. et al., JASRAE, 2018, 15 (2), 100-104.

Toilets are another significant source of water usage in ambulance stations, and installing water-efficient toilets can contribute to water conservation efforts.

Traditional toilets may use 6 to 13.2 litres of water per flush (LPF), while waterefficient toilets, such as dual-flush toilets or pressure-assisted toilets, use significantly less water per flush, typically ranging from 3 to 6 LPF. Dual-flush toilets allow users to choose between a lower flush volume for liquid waste and a higher flush volume for solid waste, thereby reducing water usage.

Pressure-assisted toilets use pressurised air to aid flushing, providing a powerful and efficient flush, while reducing the amount of water needed for each flush.

Traditional gravity-fed toilets rely solely on the force of gravity to move waste from the bowl to the drain, requiring a larger volume of water to create enough force for effective flushing. In contrast, pressureassisted toilets use compressed air to create additional pressure in the toilet tank, which propels the water and waste out of the bowl with greater force.

The water savings associated with pressure-assisted toilets can be substantial. While standard toilets typically use 6 to 13.2 litre of water per flush (LPF), pressureassisted toilets typically use between 3 to 6 LPF, depending on the model and design. This can result in water savings of up to 50% or more per flush, which can add up to significant water conservation over time, especially in high-traffic areas such as ambulance stations.

Adapted from Mittermeier RA, Farrel TA, Harrison IJ, Upgren AJ, Brooks TM. Fresh water. The essence of life. CEMEX and ILCP. 2010.

In Addition to Water Savings, Pressure-Assisted Toilets also Have Other Benefits.

The improved flushing performance of pressure-assisted toilets can help reduce clogs and blockages, which can be particularly important in ambulance stations where toilets may experience heavy use. This can help minimise maintenance and repair costs associated with toilet issues, ensuring that the toilets are in optimal working condition for staff and users.

Furthermore, pressure-assisted toilets are also known for their hygienic advantages. The forceful flush created by the compressed air helps to thoroughly clean the bowl with each flush, reducing the likelihood of stains and odours. This can contribute to a cleaner and more sanitary restroom environment in ambulance stations, which is crucial for maintaining the health and safety of staff and patients.

Source:   What is EcoFlush? – WDI Technology Co Ltd (wdiecoflush.com)

When installing pressure-assisted toilets, it is important to ensure that the appropriate water pressure is available in the building to support their operation.

Pressure-assisted toilets require a minimum water pressure of 25 psi (pounds per square inch) and a maximum pressure of 80 psi for proper functioning. Therefore, it may be necessary to assess the water pressure in the ambulance station and make any necessary adjustments or upgrades to the plumbing system to meet the requirements of pressure-assisted toilets. It is also important to choose dualflush or pressure-assisted toilets that are certified by relevant industry standards by the Green Building Council Australia. These certifications ensure that the toilets meet specific water efficiency and performance criteria, providing assurance that they are environmentally responsible and sustainable choices.

In addition to low-flow faucets, showerheads, and toilets, sensor-based faucets and toilets are from other options to install in ambulance stations for saving water. Sensor-based faucets use infrared sensors to detect the presence of hands, and they dispense water only when hands are detected, helping to prevent unnecessary water wastage. Sensorbased toilets also use sensors to detect when a user has left the toilet, and they automatically flush, ensuring that water is not wasted due to forgetting to flush. These fixtures can be particularly useful in high-traffic areas of ambulance stations, where water usage can be significant, and manual control of faucets and toilets may result in water wastage.

Proper maintenance, regular inspections and repair of these fixtures are critical for ensuring their optimal performance and maximising water savings. Leaks and drips from faucets, showerheads, and toilets can result in significant water wastage. Implementing a proactive maintenance program that includes regular inspections and prompt repairs can help identify and address any issues promptly.

2. Grey Water Recycling

Another water recycling practice is greywater recycling. Greywater refers to wastewater generated from activities such as handwashing, showering, and laundry, which can be treated and reused for non-potable purposes. Implementing greywater recycling systems in ambulance stations help reduce the discharge of wastewater into the sewer system and minimise the use of freshwater for non-potable purposes.

Greywater recycling systems typically involve collection, treatment, and storage of greywater, followed by distribution for approved non-potable uses.

Moreover, wastewater generated in ambulance stations can also be treated and recycled for potable purposes through advanced treatment processes such as reverse osmosis and ultraviolet (UV) disinfection. Recycling wastewater for potable use can significantly reduce the demand for freshwater.

With greywater recycling systems, the greywater generated in the ambulance can be treated and reused, reducing the need for fresh water, and conserving this valuable resource. The system should also comply with relevant regulations and standards for greywater recycling, ensuring that the treated greywater is safe for non-potable uses.

Another important consideration is the maintenance and operation of the greywater recycling system.

Regular monitoring and maintenance are necessary to ensure the proper functioning of the system and to prevent any potential issues. This may include monitoring water quality, inspecting and cleaning filters, and conducting routine system checks. Proper training of ambulance staff on the operation and maintenance of the greywater recycling system is also essential to ensure its effective use.

A Typical ultra-GTS Grey-Water Recycling System

3. Promoting Water-Conscious Behaviour

Studies suggested that creating awareness can decrease people’s water consumption.(146)

In a study performed by Fan et al. in 2014, showed that people who estimate their water consumption accurately have more water awareness and behave more water sustainable than people who underestimate their water consumption.(147) It proves the importance of awareness, not just about the reality of climate change, but about the impact that every person can have on creating it. That also includes providing practical tips on how to conserve water in daily activities.(148)

Model of Responsible Environmental Behaviour

Internal factors

Attitudes

Locus of control

Personal responsibility

Action Skills

Knowledge of action strategies

Knowledge of issue

Personality factors

Simple practices such as turning off taps when not in use, reporting leaks or drips promptly, and using water-efficient fixtures appropriately can collectively make a significant difference in reducing water consumption in ambulance stations. Encouraging responsible water use through educating and raising awareness in the ambulance environments, helps create a sustainable water management mindset in ambulance services and promotes water-conscious behaviours.

Situational factors

Intention to act

Responsible environmental behaviour

Adapted from: Chao YL. Predicting people’s environmental behaviour: Theory of planned behaviour and model of responsible environmental behaviour. Environmental Education Research. 2012 Aug 1;18(4):437-61.

Infographic source: Oponeo.co.uk

Chapter 12: Waste

Like any other sector, ambulance services generate waste as a part of their operations.

Ambulance services produce various types of waste, including medical waste, hazardous waste, general waste, and electronic waste.

Medical waste, such as used needles, syringes, dressings, and blood-soaked materials, can pose a significant risk to public health and the environment if not managed properly. Hazardous waste, including chemicals, medications, and disinfectants, can be toxic and harmful to human health and the environment.

Non-hazardous wastes including general waste (food containers, plastic bottles, and paper waste), can contribute to pollution and waste accumulation in landfills.

Medical Waste Production

Electronic waste, such as old medical equipment and devices on the other hand, can contain hazardous materials and contribute to electronic waste pollution.(149, 150)

Proper waste management in ambulance services is an essential aspect of achieving sustainability in healthcare operations. It significantly reduces the negative impacts of waste on the environment and minimises pollution of air, water, and soil, while it conserves resources. On the other hand, it helps prevent the spread of infections, reduces the risk of accidents and injuries, and promotes sustainability in healthcare operations.(151)

Source: Gao J. et al. Scientific Programming, 2021

Strategies to Achieve Sustainability in Waste Management.

There are several strategies that ambulance services can implement to achieve sustainability in waste management and promote responsible environmental practices. Ambulance services should have standard operating procedures (SOPs) in place and personnel should be trained in these procedures to ensure compliance.

Develop Comprehensive Plans

Ambulance services can develop comprehensive waste management plans that outline the procedures, protocols, and responsibilities for waste management, while it ensures compliance with waste management regulations and promotes sustainability. A waste management plan can include the following elements:

The waste hierarchy

Source: Araújo N, Cardoso L, Fraiz Brea JA, De Araújo AF. Green jobs: The present and future of the building industry. Evolution analysis. Social Sciences. 2018 Dec 12;7(12):266.

1. Waste Reduction

Waste reduction is the first and foremost strategy for waste management sustainability.

Waste reduction strategies can include measures such as purchasing only what is necessary, avoiding unnecessary packaging, and promoting the use of reusable items. One key aspect of waste reduction in the ambulance sector is the careful procurement of supplies and equipment.

Ambulance services should prioritise purchasing only the necessary supplies and equipment, avoiding excessive packaging, and choosing products that are durable and long-lasting. This can help minimise the amount of waste generated and reduce the need for frequent replacements.

Average Values, Upper Limits, and Lower Limits of the Main Medical Waste Fractions

Source: Giakoumakis, G. et al., Energies, 2021, 14.

2. Waste Classification and Segregation

One of the first steps in waste management in ambulance services is waste segregation and classification, which is the process of separating different types of waste at the point of generation to prevent cross-contamination and facilitate proper disposal.

2.1 Medical Waste

Medical waste includes any waste that is generated during patient care activities, such as discarded medications, dressings, bandages, syringes, needles, and other materials contaminated with blood, body fluids, or potentially infectious materials. Proper handling and disposal of medical waste are crucial to prevent the spread of infections and protect public health.

A Schematic Diagram on Medical Waste Categories/Types

Ambulance services should have a clear system in place for segregating and disposing of medical waste. This may include using color-coded bins or bags to differentiate between different types of medical waste, such as red for infectious waste, yellow for sharps, and black for pharmaceutical waste. These kinds of waste should be properly disposed of in accordance with local, state, and federal regulations. Additionally, proper training should be provided to ambulance personnel on how to handle, segregate, and dispose of medical waste safely.

Adapted from: Giakoumakis, G. et al., Energies, 2021, 14.

2.2 Hazardous Waste

The healthcare sector including ambulance services generate a significant amount of hazardous waste, including medical supplies, pharmaceuticals, and contaminated materials. It is crucial to manage this waste in an environmentally sustainable manner to minimise the negative impact on both public health and the environment.

Hazardous waste refers to waste that poses a risk to human health or the environment due to its physical, chemical, or biological properties.

In ambulance services, hazardous waste may include chemicals, batteries, broken or damaged equipment, and other materials that contain hazardous substances, such as mercury or radioactive materials.

Proper handling and disposal of hazardous waste are essential to prevent potential harm to the environment and ensure compliance with environmental regulations. Ambulance services should have a designated area or container for hazardous waste storage, which should be clearly labelled and secured to prevent unauthorised access.

Hazardous waste should be properly segregated from other waste streams and handled by trained personnel wearing appropriate personal protective equipment (PPE). Ambulance services should also have procedures in place for identifying, segregating, and disposing of hazardous waste in accordance with local, state, and federal regulations.

2.3 Segregation and Identification

The first step in managing hazardous waste in ambulance services is proper segregation and identification.

Waste should be categorised into different types, such as sharps, pharmaceuticals, chemicals, and infectious materials. Clear labeling and color-coding systems should be implemented to ensure proper handling and disposal.

2.4 Proper Segregation and Identification:

The first step in managing hazardous waste in ambulance services is proper segregation and identification. Waste should be categorised into different types, such as sharps, pharmaceuticals, chemicals, and infectious materials. This segregation is crucial to ensure appropriate handling and disposal procedures are followed for each waste type.(152)

2.5 Clear Labeling and Colour-Coding Systems

Clear labeling and colour-coding systems are essential components of effective hazardous waste management in ambulance services. Labels should be prominently displayed on waste containers, providing information about the waste type, potential hazards, and any necessary handling precautions. This facilitates proper identification and minimises the risk of accidental exposure or mishandling.(153)

In addition to labeling, colour-coding systems can be implemented to further enhance waste identification and segregation. For instance, using specificcoloured containers or bags for different waste categories helps personnel easily recognise and differentiate between them. For example, red containers can be designated for sharps, yellow for pharmaceuticals, blue for chemicals, and so on. This standardised system assists in preventing cross-contamination and promotes safe disposal practices.(154)

2.6 Benefits of Proper Segregation and Identification

Implementing proper segregation and identification measures in ambulance services brings numerous benefits.

Firstly, it reduces the risk of occupational hazards for healthcare workers, minimising the chances of accidental injuries or exposure to hazardous substances. This, in turn, protects the wellbeing of healthcare personnel and ensures the continuity of emergency medical services.(152)

Secondly, proper segregation and identification contribute to environmental protection. Categorising waste accurately facilitates applying appropriate disposal methods and prevents the release of harmful substances into the environment. It also aids in waste management planning, ensuring compliance with local, state, and federal regulations related to hazardous waste.(153)

Moreover, the implementation of clear labeling and color-coding systems promotes efficiency and productivity within ambulance services. Easy identification of waste types saves time and effort during waste handling, transportation, and disposal processes. It enhances overall workflow and reduces the likelihood of errors or mix-ups that could lead to adverse consequences.(152)

3. Training and Awarenes

Comprehensive training programs play a pivotal role in equipping ambulance personnel with the necessary knowledge and skills for effective hazardous waste management.

These programs should cover various aspects, including proper handling, storage, and disposal techniques in accordance with local, state, and federal regulations.(152)

Training should focus on educating personnel about the different categories of hazardous waste, their associated risks, and appropriate handling procedures.

This includes providing guidance on the use of PPE, such as gloves, masks, and goggles, to minimise the risk of exposure to hazardous substances.(153) Training programs should emphasise the importance of waste segregation and the use of proper containers for different waste types. Staff members should be educated on the significance of separating sharps, pharmaceuticals, chemicals, and infectious materials to prevent crosscontamination and ensure safe disposal.(152)

Creating awareness among ambulance personnel about the potential risks of improper hazardous waste management is crucial.

Informing staff member about the adverse consequences of mishandling or incorrect disposal, such as injuries, infections, and environmental pollution helps them understand the significance of adhering to waste management protocols and encourages responsible behaviour.(153)

Raising awareness about the benefits of environmentally sustainable practices among ambulance personnel improves the positive impact of proper waste management on public health and the environment.

Emphasising concepts such as pollution prevention, recycling, and resource conservation fosters a sense of environmental responsibility and motivates staff members to adopt sustainable practices.(152)

Comprehensive training programs and creating awareness among ambulance personnel yield numerous benefits.

Firstly, such initiatives reduce the risk of occupational hazards for healthcare workers. Proper knowledge and training enable personnel to handle hazardous waste safely, minimising the likelihood of injuries or exposure to harmful substances. This promotes the wellbeing of healthcare professionals and ensures their ability to provide uninterrupted emergency medical services.(152) Secondly, training and awareness contribute to regulatory compliance.

This way, ambulance services can ensure adherence to applicable local, state, and federal guidelines, leading to reducing the risk of legal penalties and fostering a culture of compliance within the organisation.(153) Comprehensive training programs and awareness initiatives also improve overall operational efficiency.

Properly trained personnel can handle hazardous waste more effectively, reducing the likelihood of errors or accidents. This enhances workflow and saves time and resources associated with waste management processes. Furthermore, responsible waste management practices contribute to cost savings through reduced waste generation and optimised resource utilisation.(152)

Mapping Healthcare Waste Management

Source: Ranjbari M. et al., J Hazard Mater. 2022, 15; 422: 126724.

4. Safe Storage and Transportation

Proper storage of hazardous waste is crucial to prevent leaks, spills, or contamination.

Having proper storage areas equipped with appropriate containers and secure lids prevents any release of hazardous substances. These storage areas should be well-ventilated and located away from public access, minimising the risk of unauthorised handling or accidental exposure. Additionally, the areas should be equipped with appropriate storage containers that meet regulatory requirements for the storage of hazardous waste.(152, 154)

Containers used for hazardous waste storage should be sturdy, resistant to corrosion, and compatible with the waste being stored.(153) They should have secure lids or closures to prevent any leaks or spills. The lids should be tightly sealed to ensure containment and minimise the risk of release during storage.(152) Proper labeling is also crucial for safe storage. Containers should be clearly labeled with the waste type, potential hazards, and any required handling precautions. This ensures that staff members can easily identify and handle the waste appropriately.(153)

During transportation, hazardous waste must be securely sealed and stored to prevent leaks, spills, or exposure.

Specially designed containers that meet transportation regulations an are suitable for the waste being transported, with secure closures, such as screw caps or tight-fitting lids, prevent any potential leakage during transportation. It is important to ensure that the containers are in good condition and free from any defects that could compromise their integrity.(153)

In addition to secure closures, the containers used for transportation should be sturdy and resistant to physical damage.

This helps to protect the waste from accidental spills or exposure due to mishandling or accidents during transit.(152) Proper loading and securing of containers within the transport vehicle is also essential. Containers should be arranged in a manner that prevents shifting or movement during transportation. This can be achieved by straps, braces, or other appropriate securing mechanisms(153) it is also crucial to comply with any specific transportation requirements or regulations set forth by local, state, and federal authorities. This includes obtaining any necessary permits or licenses and adhering to proper documentation and recordkeeping procedures.(152)

5. Recycling and Reuse

Whenever possible, ambulance services should explore opportunities for recycling and reusing certain materials.

For instance, recyclable plastics, paper, and cardboard can be separated and sent to recycling facilities. Reusable medical equipment and supplies, such as tourniquets, immobilisation devices, or non-contaminated items, should be properly cleaned and sterilised for future use.

6. Proper Disposal

When waste cannot be recycled or reused, proper disposal methods must be followed.

Ambulance services should partner with licensed waste management companies that specialise in handling hazardous waste. These companies have the necessary expertise and facilities to safely treat and dispose of the waste in accordance with local regulations and environmental standards.

7. Collaboration and Partnerships

To further enhance environmentally sustainable waste management, ambulance services can collaborate with other healthcare facilities, waste management agencies, and regulatory bodies.

Sharing best practices, exchanging knowledge, and participating in collective initiatives can lead to more efficient waste management systems and the development of innovative solutions.

8. Monitoring and Evaluation

Regular monitoring and evaluation are essential to ensure compliance with waste management protocols and to identify areas for improvement.

Ambulance services should track and record the volume and types of waste generated, monitor disposal practices, and assess the effectiveness of recycling and reuse initiatives. This data can inform future decision-making and help refine waste management strategies.

8.1 General Waste

General waste refers to non-hazardous waste that does not pose any immediate risk to human health or the environment. In ambulance services, general waste may include food waste, paper, cardboard, plastics, and other non-hazardous materials. While general waste does not require the same level of handling and disposal precautions as medical or hazardous waste, proper waste management practices should still be followed to minimise environmental impact and promote sustainability.

Ambulance services should have clearly marked bins or bags for general waste disposal and educate personnel on proper waste segregation practices. General waste should be disposed of in designated waste receptacles, and recycling practices should be encouraged whenever possible.

Ambulance services should also explore opportunities to reduce waste generation through waste reduction strategies, such as reducing the use of disposable items, implementing recycling programs, and promoting sustainable procurement practices.

Adapted from: Zikhathile, Thobile, Harrison Atagana, Joseph Bwapwa, and David Sawtell. 2022. A Review of the Impact That Healthcare Risk Waste Treatment Technologies Have on the Environment International Journal of Environmental Research and Public Health 19, no. 19: 11967. doi.org/10.3390/ijerph191911967

Healthcare Waste Generation (HRC) Categories

The Three Big Rs (Reduce, Reuse, Recycle)

The three Rs of Reduce, Reuse, and Recycle in sustainability are a set of principles that guide individuals, organisations, and governments towards more sustainable practices.

These principles encourage the conservation of resources, reduction of waste, and the promotion of sustainable development.

One of the most widely recognised approaches to the three Rs is the waste hierarchy, which places the highest priority on reduction and reuse, followed by recycling and disposal.

The goal of the waste hierarchy is to minimise the amount of waste that is sent to landfill and promote a circular economy, where waste is viewed as a resource and is repurposed instead of discarded.

In a study published in the Journal of Cleaner Production(155) evaluated the impact of the three Rs on the reduction of greenhouse gas emissions.

The study found that prioritising the three Rs can reduce greenhouse gas emissions by up to 30%. Studying the role of the three Rs in the circular economy showed that it contributed to the transition towards a circular economy by promoting the reduction of waste and encouraging the reuse and recycling of resources.(156)

In addition to academic research, there are numerous initiatives and programs focused on the three Rs of sustainability. The Zero Waste initiative encourages individuals and organisations to adopt a zero-waste lifestyle by reducing waste, reusing materials, and recycling.

Impacts Area of focus Resource impacts

Use of resources Medical instruments / equipment

This is the largest area of carbon emissions and the fourth largest water impact area. Many medical items have significant impacts from their manufacture and through their lifecycle, using natural resources like energy, water and disposable items. The natural resource impacts of equipment such as sterilisation and medical devices should be evaluated including the costs of disposal. Many single use items are made of plastic or high value materials such as metal which has a value beyond their “useable” life either as a material or as an entire product.

Reduce

Reducing the use of items in healthcare is a critical aspect of achieving sustainability goals. Healthcare facilities generate significant amounts of waste, and many of the items used in patient care and treatment are single-use and made of materials that are not biodegradable. Reducing the use of these items can not only reduce the amount of waste generated but can also save money and resources.

Re-use

Description and examples of actions

Lean processes should be developed to avoid the use of unnecessary products and resources, through approaches such as Getting It Right First Time (GIRFT) especially in high value areas such as pharmaceuticals and medical devices. The system must also work in partnership with the supply chain to explore and accelerate the use of circular economy approaches to minimise the creation of waste. And further embedding resource efficiency in HSC by maximising the value of the proposed government waste and resources strategy.

The British Red Cross in Nottinghamshire saved the NHS over £1.7m through re-use of community equipment. Equipment reuse networks such as WarpIt saved 34 NHS trusts over £1.64m combined in 2017. A reusable sharps containers project at University Hospitals Coventry & Warwickshire NHS Trust over 10 year duration will have saved over 2,000 tCO2e

Adapted from: Reducing-the-use-of-natural-resources-in-health-and-social-care.pdf (lancsteachinghospitals.nhs.uk)

Reduce single-use plastic items

Reducing single-use plastic items in healthcare facilities is an important step towards achieving sustainability goals.

Single-use plastic items, such as bags, straws, utensils, and packaging materials, contribute significantly to plastic pollution and pose a threat to the environment and human health. Several studies have explored the issue of single-use plastic waste in healthcare facilities and have proposed measures to reduce their use.

In a study published in the Journal of Cleaner Production, Al-Salem et al.(157) assessed the feasibility of implementing a zero-waste program in a healthcare facility and found that reducing single-use plastic was a key component of the program. One way to reduce single-use plastic in healthcare is to switch to reusable alternatives.

For instance, reusable water bottles and coffee cups can be provided to staff instead of single-use plastic bottles and cups. Investigating the effectiveness of replacing single-use plastic water bottles with reusable ones in hospital showed a significant reduction in plastic waste.(158) Another strategy to reduce single-use plastic in healthcare is to implement a circular economy strategy, such as using recycled plastics in the production of new products. For example, the NHS in the UK has launched a project to recycle single-use plastics from hospitals and turn them into items such as plastic tubing, car parts, and garden furniture.(159)

In ambulance services, reducing single-use plastic items is an important step towards achieving sustainability goals.

A study in 2021 assessed the level of plastic waste generated by ambulance services in Nigeria and found that reducing single-use plastic was a key component of waste management.(160) One way to reduce single-use plastic in ambulance services is to switch to reusable alternatives.

For instance, reusable bags and gloves can be provided to staff instead of single-use plastic ones. Using reusable bags in ambulance services is significantly feasibility and can result in a reduction of plastic waste.(161)

Source: Living Sustainably on a Budget — The Considerate Consumer (considerate-consumer.com)

Reduce Using Disposal Coffee Cups

Reducing the use of disposable coffee cups is an important step towards achieving sustainability.

These cups are a significant contributor to the amount of waste and their production and disposal have a negative impact on the environment.

It is estimated that more than 2.7 million single-use coffee cups are throw out every day only in Australia, adding up to 1 billion coffee cups thrown out every year. The number has been raised to 3 billion in the UK.

It was shown that the production and disposal of these cups had a significant environmental impact, including greenhouse gas emissions and water consumption. Reducing the use of disposable cups and promoting the use of reusable cups (personal cups, compostable cups, biodegradable cups) can significantly reduce waste generation.(162, 163)

Source: Poortinga, W. and Whitaker, L. (2018), MDPI.

Reuse

In response to growing concerns about sustainability and environmental impact, reusing strategies for waste in ambulance services have gained attention as a practical and effective approach to minimise waste, improve efficiency, and promote sustainability.

Although many items in ambulance services are designed for single-use and are discarded after each patient encounter, not all of these items are necessarily contaminated or rendered unusable after a single use. Implementing reusing strategies for waste in ambulance services requires careful planning and coordination and involves identifying and collecting items that can be safely cleaned, sanitised, and repurposed for reuse, instead of being disposed of as waste.

For example, ambulance services can encourage the use of reusable medical supplies, such as washable blankets, reusable masks, and reusable medical instruments, instead of single use disposable items. It can also lead to cost savings by reducing the demand for new supplies and lowering procurement costs, which can contribute to more efficient resource utilisation and cost-effective healthcare delivery.

Rethink

The Sustainable Hierarchy

The 7R’s of sustainability

Another reusing strategy for waste in ambulance services is the repurposing of packaging materials.

Even when the packaging is recyclable, using it for another purpose avoids the long process. Packaging materials, such as cardboard boxes, plastic containers, and bubble wrap, are commonly used in ambulance services for the transportation and storage of medical supplies, medications, and equipment. Instead of being discarded as waste, these packaging materials can be collected, sanitised, and repurposed for other uses within the ambulance service or donated to other healthcare facilities or charitable organisations. For example, cardboard boxes can be reused for storage or as makeshift splints, and plastic containers can be repurposed for organising and storing smaller items.

Repurposing of packaging materials can offer multiple benefits. Firstly, it can reduce the demand for new packaging materials, which can help conserve resources and reduce energy consumption associated with the production and disposal of packaging materials. Additionally, repurposing can also lead to cost savings by eliminating the need to purchase new packaging materials. Furthermore, repurposing can also promote sustainability and environmental awareness among ambulance personnel and patients, creating a culture of waste reduction and resource conservation.

Items such as stretchers, wheelchairs, and other medical equipment can often be refurbished or repaired instead of being discarded as waste. Ambulance services can also explore partnerships with local organisations or charities to donate or sell reusable items that are no longer needed but are still in good condition. This can significantly reduce the amount of waste generated and promote sustainability in the ambulance sector.

Reusing and Donating Medical Devices to Remote Health Facilities

Reusing and donation of medical devices and equipment plays a pivotal role in addressing the disparities in access to quality healthcare, particularly in remote areas.

This approach not only promotes environmental sustainability by reducing electronic waste but also contributes to the improvement of healthcare infrastructure in underserved regions.

The reuse of medical devices and equipment involves extending their lifespan through thorough inspection, cleaning, and sterilisation processes. This practice is gaining momentum as a cost-effective and environmentally friendly solution for healthcare providers. It allows institutions to maximise the utility of their resources while minimising the ecological footprint associated with the disposal of electronic medical equipment.

Several studies have highlighted the safety and efficacy of reusing medical devices when appropriate protocols are followed. The FDA, in its guidance on reprocessing medical devices, emphasises the importance of stringent quality control measures to ensure the safety of reused devices. Implementing standardised procedures for device reprocessing not only guarantees patient safety but also ensures compliance with regulatory standards.(164)

Furthermore, the reusing of medical devices can significantly reduce healthcare costs, making quality healthcare more accessible to remote and economically disadvantaged areas. This cost-effectiveness can be attributed to the reduced need for frequent equipment replacements, ultimately leading to financial savings for healthcare institutions.

Donating Medical Devices and Equipment to Remote Health Facilities

Donating medical devices and equipment to remote health facilities is a compassionate and impactful way to address the healthcare disparities prevalent in underserved areas.

Numerous organisations and initiatives facilitate the donation process, channeling surplus medical equipment from developed regions to healthcare facilities in need.

The WHO has recognised the importance of medical equipment donations in strengthening healthcare systems, particularly in resource-limited settings. WHO emphasises the necessity of aligning donated equipment with the recipient facility’s needs and ensuring that the donated items are in good working condition.(165)

Donated equipment, when integrated into ambulance services, can bridge the gap between remote areas and more centralised healthcare facilities, facilitating early intervention and stabilisation of patients during transit.(166) Collaborative efforts between governmental bodies, non-governmental organisations, and private enterprises are essential to streamline the donation process.

Source: (24) Rivkin Private Wealth: Posts | LinkedIn

Case Study 1: Sustainable Reuse of Medical Devices

A notable case study comes from the University of Washington Medical Center, where a comprehensive program for the reuse of medical devices was implemented.(167) The program involved the meticulous inspection, cleaning, and sterilisation of single-use medical devices such as catheters and surgical instruments. The results of this initiative demonstrated substantial cost savings for the medical center, reducing the need for frequent purchases of new equipment.

Case Study 2: Donating Medical Equipment for Remote Health Facilities

MedShare, a nonprofit organisation dedicated to redistributing surplus medical supplies, presents an exemplary case of donating medical equipment to remote health facilities.(168) The organisation collects unused and surplus medical equipment from hospitals, manufacturers, and other donors, thoroughly inspects and refurbishes the items, and then redistributes them to healthcare facilities in underserved regions. Through partnerships with healthcare institutions and donors, MedShare has facilitated the donation of medical equipment to over 100 countries, positively impacting millions of lives.

Case Study 3: Enhancing Ambulance Services Through Equipment Donation

The case study of the London Ambulance Service (LAS) provides insights into the positive outcomes of incorporating donated medical devices into emergency response vehicles.(169) LAS collaborated with medical equipment manufacturers and donors to equip their ambulances with advanced diagnostic tools, defibrillators, and ventilators. The integration of donated equipment significantly improved the prehospital care provided by LAS, allowing paramedics to administer life-saving interventions more effectively during emergencies. This case study highlights the potential of targeted equipment donations to enhance the capabilities of ambulance services, particularly in remote areas where access to advanced medical technologies may be limited.

Recycling

Recycling is another important strategy for waste management sustainability in the ambulance sector.

Recycling can help reduce the environmental impact of waste disposal and promote the circular economy, where waste is considered as a valuable resource.

Ambulance services should implement effective recycling programs to ensure that recyclable waste materials, such as paper, cardboard, plastics, and glass, are properly collected, segregated, and recycled.

This can be achieved by providing clearly marked recycling bins in appropriate areas and educating personnel on the importance of recycling and proper waste segregation practices. Additionally, ambulance services should partner with local recycling facilities or waste management companies to ensure that the recycled materials are processed and utilised in an environmentally responsible manner.

Medical gloves

Medical gloves are an essential part of medical procedures, protecting both healthcare personnel and patients from infections and diseases. However, the widespread use of gloves in healthcare sector has led to a significant amount of waste generation, and improper disposal of these gloves can have severe environmental consequences.

In recent years, there has been a growing demand for sustainable and eco-friendly medical products and recycled surgical gloves have emerged as a promising solution to address the issue of waste management in healthcare.

The recycling process involves collecting used gloves from healthcare facilities, cleaning and sterilising them, and then shredding or melting them to create new products. Recycled gloves can be used in various industries, such as healthcare, construction, gardening, and automotive.(170)

Adapted from: Mousavi SS. et al. Sustainability. 2022;14(16):9908.

An example for Reusing Latex and Vinyl Gloves in Construction

Types of Medical Gloves:

1. Latex Gloves

Latex gloves are the most common type of surgical gloves used in healthcare facilities worldwide.

These gloves are made from natural rubber latex and provide excellent tactile sensitivity, flexibility, and durability. In recent years, manufacturers have introduced recycled latex gloves as a sustainable alternative. These gloves are produced from post-consumer waste, specifically used gloves collected from healthcare facilities.

Through a rigorous recycling process involving cleaning, shredding, and sterilisation, recycled latex gloves are created, meeting the necessary quality standards. This article examines the sustainability aspects of latex gloves, focusing on their recycling initiatives and the benefits they bring to healthcare facilities.

Source: Akhtar S, Pranay K, Kumari K. Personal protective equipment and micro-nano plastics: A review of an unavoidable interrelation for a global wellbeing hazard. Hygiene and Environmental Health Advances. 2023 Apr 11:100055.

1.a. Recycled Latex Gloves: A Sustainable Alternative

Recycled latex gloves are an innovative solution to address the environmental impact associated with traditional latex gloves. Because of utilising post-consumer waste, these gloves contribute to waste reduction and resource conservation. Recycled latex gloves are made from post-consumer waste, which includes used gloves collected from healthcare facilities. The recycling process involves cleaning, shredding, and sterilising the gloves to ensure they meet the required quality standards.

First, the collected used gloves undergo a thorough cleaning process to remove any contaminants or residual substances. This step is crucial to eliminate potential pathogens and ensure the gloves are safe for reuse. Following the cleaning process, the gloves are shredded into smaller pieces. This facilitates the subsequent steps of the recycling process and ensures uniformity in the resulting material.(171)

To guarantee the safety and hygiene of the recycled gloves, sterilisation is performed. This process effectively eliminates any remaining pathogens or microorganisms, ensuring that the gloves meet the required medical standards.(171)

INCINERATION

RAWMATERIALS

1.b. Benefits of Recycled Latex Gloves

Recycled latex gloves offer several benefits, both in terms of environmental sustainability and economic considerations. These gloves divert a significant amount of glove waste from landfills, reducing the environmental impact associated with glove disposal. Such a waste reduction aligns with the principles of the circular economy, promoting resource conservation and minimising the need for virgin materials.(171)

In addition to waste reduction, recycled latex gloves contribute to cost savings for healthcare facilities. By opting for recycled gloves, facilities can potentially reduce procurement costs, as recycled materials are often more cost-effective compared to their virgin counterparts. This cost advantage allows healthcare facilities to prioritise sustainability without compromising on quality or patient safety.(172)

Recycled latex gloves maintain the key characteristics that make latex gloves popular in healthcare settings. They offer excellent tactile sensitivity, flexibility, and durability, ensuring healthcare professionals can perform procedures with precision and confidence.(171)

Biodegradable Gloves

Biodegradable gloves offer an environmentally conscious alternative to traditional disposable gloves.

As the global emphasis on sustainability in healthcare practices continues to grow, these gloves have found relevance in emergency services, particularly among paramedics and first responders. Designed to break down naturally over time, biodegradable gloves contribute to a reduced environmental impact compared to their non-biodegradable counterparts.

Typically crafted from materials like natural rubber, cornstarch, or other plantbased sources, these gloves align with the broader goal of minimising single-use plastic waste in the healthcare sector.

Suited for short-term use, biodegradable gloves are particularly advantageous in emergency situations where quick and efficient protection is essential. Their disposal process involves specific conditions depending on the materials used, often requiring microbial action, heat, and moisture to facilitate the biodegradation process.

Considering supply chain implications, emergency service organisations can adjust procurement strategies to prioritise suppliers offering biodegradable glove options. Engaging with suppliers committed to sustainability aligns with the broader environmental goals of these organisations.

Sustainability Considerations and Best Practices

While recycled latex gloves offer significant sustainability benefits, it is important for healthcare facilities to implement best practices to maximise their environmental impact. Facilities should prioritise the collection and proper segregation of used gloves to ensure a reliable supply of post-consumer waste.

Collaborating with waste management companies or implementing internal collection systems can help streamline the collection process.(172)

It is essential for healthcare facilities to maintain stringent quality control measures when incorporating recycled latex gloves into their operations. Working closely with manufacturers who follow rigorous recycling processes and adhere to regulatory standards ensures that the recycled gloves meet the necessary quality and safety requirements.(171)

Source: Mousavi SS. et al. Sustainability. 2022;14(16):9908.

Latex and Vinyl Recycled Gloves are Turned into Fibers During the Recycling Process

2. Nitrile Gloves

Nitrile gloves are a popular alternative to latex gloves, especially for individuals with latex allergies.

These gloves are made from synthetic materials and provide excellent chemical resistance and puncture resistance. In addition to their protective properties, nitrile gloves possess the advantage of recyclability. The recycling process involves shredding and melting the gloves to create new products. As a result, recycled nitrile gloves find applications in diverse industries, including healthcare, automotive, and construction. Nitrile gloves, composed of synthetic materials, possess inherent recyclability. After use, these gloves can be diverted from conventional waste streams and subjected to recycling processes.

The recycling of nitrile gloves typically involves shredding and melting to transform the used gloves into new products. Recycling nitrile gloves offers several sustainability benefits. First, it diverts glove waste from landfills, reducing the environmental burden associated with traditional disposal methods. Additionally, recycling nitrile gloves helps reduce the carbon footprint associated with the production of new gloves. The recycling process consumes less energy compared to the production of virgin nitrile gloves, contributing to overall energy conservation and environmental preservation.(173)

3. Vinyl Gloves

Vinyl medical gloves, made from polyvinyl chloride (PVC), are frequently used in non-surgical procedures due to their affordability.

While vinyl gloves offer cost advantages compared to latex and nitrile gloves, they provide less protection and durability. They also pose environmental challenges as they are not biodegradable and can release harmful chemicals during incineration. However, in recent years, manufacturers have started producing recycled vinyl gloves using post-consumer waste, offering a potential solution to reduce the environmental impact of these gloves.

3.a. Environmental Impact of Vinyl Gloves

Vinyl gloves have a significant environmental impact due to their composition and disposal methods. PVC, the primary material used in vinyl gloves, is derived from fossil fuels, and requires energy-intensive processes for production.(172) The extraction and manufacturing of PVC contributes to greenhouse gas emissions and resource depletion, making vinyl gloves less environmentally friendly compared to alternative glove materials.(173) Additionally, vinyl gloves pose challenges in terms of disposal. As non-biodegradable products, vinyl gloves persist in landfills, contributing to the accumulation of waste.

Incineration, a common disposal method, can release toxic chemicals such as dioxins and hydrochloric acid, further exacerbating environmental concerns.(174)

3.b. Recycled Vinyl Gloves as a Sustainable Alternative

Recognising the environmental impact of vinyl gloves, some manufacturers have introduced recycled vinyl gloves as a sustainable alternative. These gloves are produced using post-consumer waste, typically from discarded vinyl gloves or other PVC-based products. The recycling process involves cleaning, shredding, and reprocessing the waste material to create new gloves.(171)

Recycled vinyl gloves offer several environmental benefits. They reduce the reliance on virgin PVC, mitigating the need for new resource extraction, minimising associated environmental impacts and promote a circular economy approach.(171) In terms of performance, recycled vinyl gloves are comparable to traditional vinyl gloves, offering adequate barrier protection for non-surgical procedures.(172) They provide an opportunity for healthcare facilities to prioritise sustainability without compromising safety or cost-efficiency.

3.c. Moving Towards Sustainable Glove Practices

To enhance sustainability in glove usage, healthcare facilities can adopt several practices.

First, reducing glove usage overall through proper risk assessment and training can help minimise waste generation. This involves evaluating the necessity of glove use for specific tasks and encouraging proper hand hygiene practices as an alternative when gloves are not essential.(174)

The universal image of a healthcare worker often includes the presence of gloves, a symbol of infection prevention and personal protective equipment. However, the visual portrayal of glove use in the media sometimes diverges from the actual necessity in real-life healthcare scenarios.

This discrepancy is a matter of concern, as it raises questions about the appropriateness of glove use in various healthcare activities. Observing healthcare professionals in media representations, it is not uncommon to witness them donning gloves while offering comfort by holding someone’s hand, or simply maneuvering a trolley. While gloves are undeniably a crucial component of personal protective equipment, their pervasive use has grown disproportionately to the risks they are designed to mitigate. The abundance of gloves, while necessary for availability, has led to challenges in confining their use to situations that genuinely warrant protection.

Reducing waste associated with unnecessary personal protective equipment (PPE)

SICPs Gloves Apron Gown (ambulance staff use Coveralls)

No anticipate exposure to blood or body fluid, mucous membranes, or non-intact skin.

Exposure to blood or body fluids, mucous membranes, or non-intact skin is anticipated but no risk of splashing or spraying.

Exposure to blood , mucous membranes, or non-intact skin is anticipated and risk of spraying or splashing.

Unless in place of an apron if extensive spraying or splashing is anticipated.

TBPs Gloves Apron Gown (ambulance staff use Coveralls)

Contact precautions

Unless exposure to blood or body fluid, mucous membranes, or non-intact skin is anticipated.

Droplet precautions

Unless in place of an apron if extensive spraying or splashing is anticipated.

Unless in place of an apron if extensive spraying or splashing is anticipated.

Fluid resistant surgical mask (FRSM)

Unless risk of splashing or splashing of blood or body fluids is anticipated.

Fluid resistant surgical mask (FRSM)

Respiratory Protective Equipment (PPE)

Eye/face protection

Airborne precautions

Adapted from Personal-Protective-Equipment-for-Use-in-Healthcare-Policy-exp-June-26.pdf (leicspart.nhs.uk)

Eye/face protection

Unless risk of splashing or splashing of blood or body fluids is anticipated.

It is crucial to recognise that gloves are indispensable when handling situations involving contact with blood or body fluids, non-intact skin, mucous membranes, or exposure to harmful drugs and chemicals.

However, the routine use of gloves in activities such as entering data onto tablets or computers is a practice that requires reconsideration. Hand hygiene stands as a preferable alternative during administrative tasks, highlighting the need for a discerning approach to glove use based on the specific risks involved.

Furthermore, healthcare facilities should explore alternatives to vinyl gloves. Latex and nitrile gloves are more durable and offer better protection, although they may have higher costs. Assessing the risk levels of different procedures and selecting appropriate glove materials can optimise both safety and sustainability.(172, 173, 175)

Toilet Paper Tubes

While these tubes may seem small and insignificant, they add up quickly and can have a significant impact on the environment.

Toilet paper tubes are typically made from cardboard, which is a recyclable material. However, many people do not recycle these tubes and instead toss them in the trash, where they end up in landfills.

In landfills, they can take years to break down, contributing to the buildup of waste and pollution. In addition to reducing waste, recycling these tubes also conserves natural resources, reduces greenhouse gas emissions, and saves energy.

When toilet paper tubes are recycled, they are typically broken down and turned into new cardboard products. This process requires less energy and resources than producing new cardboard from scratch, which makes recycling a more sustainable option. However, it’s important to note that not all toilet paper tubes are recyclable.

Assuming one roll of tiolet paper weighs 140g. Source: Statista, 2018 @Statistics_Data_Facts

Rolls of Toilet Paper Used per Person per Year

Some tubes may be coated with a plastic or wax material that makes them difficult or impossible to recycle.

It’s always best to check when shopping for toilet paper products made from recycled materials. This supports the recycling industry and helps reduce the amount of waste that ends up in landfills. Some companies have implemented their own recycling programs for toilet paper tubes.

Environmental Impact of a Toilet Paper Roll

For example, Kimberly-Clark, the manufacturer of the popular toilet paper brand Cottonelle, offers a tube recycling program in partnership with TerraCycle. Through this program, consumers can send their used tubes to be recycled, and Kimberly-Clark will donate $1 to the World Wildlife Fund for every 2,000 tubes collected.

Recycling in Ambulance: Case Study

Australia, Victoria Ambulance Service

Recycling is an important aspect of sustainability in healthcare industry. One case study that highlights the benefits of ambulance recycling is the Ambulance Victoria Sustainability Program.

The program was launched in 2010, with the aim of reducing the environmental impact of Ambulance Victoria’s operations. One of the key initiatives of the program was the recycling of decommissioned ambulance vehicles.

Ambulance Victoria partnered with a local company, which disassembled the vehicles and recycled over 95% of the materials. The program has since recycled over 150 decommissioned ambulance vehicles, resulting in significant environmental benefits.

According to Ambulance Victoria, the program has helped reduce the organisation’s carbon footprint by over 1,500 tonnes of CO2e (carbon dioxide equivalent) per year. It has also saved over 70,000 litres of water and reduced waste going to landfill by over 200 tonnes per year. In addition, the program has generated revenue from the sale of recycled materials, which has been reinvested back into Ambulance Victoria’s sustainability initiatives.(176)

Premier’s Sustainability Award Winner Jo Algie on Uniform Recycling

2. Australia, St John Northern Territory (NT) Ambulance Service

The “St John NT Ambulance Sustainability Program” is another example of implementing sustainability in ambulance services. Launched in 2015, the program aimed to reduce the environmental impact of St John Ambulance NT’s operations and improve resource efficiency. As part of the program, St John Ambulance NT partnered with a local recycling company to recycle decommissioned ambulance vehicles.

The program has since recycled over 20 decommissioned ambulance vehicles, with over 90% of the materials being recycled. This has resulted in significant environmental benefits, including a reduction in carbon emissions and waste going to landfill. According to St John Ambulance NT, the program has helped reduce the organisation’s carbon footprint by over 40 tonnes of CO2e (carbon dioxide equivalent) per year.

In addition, the program has generated revenue from the sale of recycled materials, which has been reinvested back into St John Ambulance NT’s sustainability initiatives.(177) St John NT Ambulance has also implemented other various sustainability initiatives, including reducing paper usage, energy-efficient lighting, and rainwater harvesting. It has saved over 25,000 litres of water and reduced waste going to landfill by over 20 tonnes per year.

In 2019, St John NT Ambulance was awarded the “Bronze Sustainable Certification” from EarthCheck, a leading scientific benchmarking, certification, and advisory group. This certification recognises the organisation’s commitment to sustainable practices and reducing its environmental impact.(178)

Source: St John - Newsroom - Northern Territory (stjohnnt.org.au)

Recycling of Old St John NT Uniforms Helps Fight Against Textile Waste

3. Australia, New South Wales (NSW) Ambulance Service

In the sense of the importance of uniform recycling and sustainability in Australia, the NSW Ambulance Service Uniform Recycling Program was launched in 2012. Through recycling and repurposing old uniforms, the program recycled over 4,000 kilograms of used uniforms, resulting in significant environmental benefits.

According to NSW Ambulance Service, the program has helped reduce the organisation’s carbon footprint by over 12 tonnes of CO2e (carbon dioxide equivalent) per year. It has also reduced the amount of waste going to landfill by over 2 tonnes per year and has also generated economic benefits, including cost savings from not having to purchase new uniforms and revenue from the sale of recycled materials.(179)

Emergency Services Uniforms are Transformed into Clothing For Children

Source: Repurposing Uniforms for Children in Need - NAUMD, Network Association of Uniform Manufacturers & Distributors, a global network

4. Australia, Queensland (QLD) Emergency Services

In an inspiring initiative taking place in Queensland, Australia, old uniforms from police officers, paramedics, and firefighters are being given a new lease of life. Rather than allowing these uniforms to go to waste or be discarded, they are being recycled and repurposed into vibrant and playful clothing for underprivileged children. This innovative project not only tackles the issue of uniform waste but also brings joy and opportunities to children who may be facing challenging circumstances.

The recycled uniforms are carefully deconstructed, and the fabric is skilfully repurposed to create new garments, ensuring that each piece retains its distinct identity and the memories associated with the original uniform. The resulting clothing is both functional and visually appealing.

5. Australia, Tasmania, Hobart Clinic

The Hobart Clinic is a private mental health hospital that has implemented several sustainable practices to reduce its environmental impact. The hospital uses solar panels to generate renewable energy, recycles paper and cardboard, and has implemented a range of watersaving measures. The Hobart Clinic’s sustainability initiatives demonstrate how healthcare providers can reduce their environmental impact by implementing eco-friendly practices and promoting sustainability.

6. United Kingdom, Yorkshire Ambulance Service

Yorkshire Ambulance Service

Sustainability Program was launched in 2010 for the first time. One of the key initiatives of the program was the recycling of decommissioned ambulance vehicles. Yorkshire Ambulance Service partnered with a local recycling company, which dismantled the vehicles and recycled over 90% of the materials. Since the program’s inception, over 350 decommissioned ambulance vehicles have been recycled, resulting in significant environmental benefits.

According to Yorkshire Ambulance Service, the program has helped reduce the organisation’s carbon footprint by over 1,100 tonnes of CO2e (carbon dioxide equivalent) per year. It has also saved over 170,000 litres of water and reduced waste going to landfill by over 200 tonnes per year. The program has also been economically beneficial. It has generated revenue from the sale of recycled materials, which has been reinvested back into Yorkshire Ambulance Service’s sustainability initiatives.(180)

7. United States, San Francisco Fire Department

In San Francisco, the fire department initiated a sustainability program in 2003, with the aim of reducing the environmental impact of San Francisco Fire Department’s operations. The department partnered with a local company, which dismantled the decommissioned vehicles and recycled over 90% of the materials. Since the program’s inception, over 70 decommissioned vehicles have been recycled, resulting in significant environmental benefits. According to the San Francisco Fire Department, the program has helped reduce the organisation’s carbon footprint by over 20 tonnes of CO2e (carbon dioxide equivalent) per year. It has also saved over 2 million litres of water and reduced waste going to landfill by over 60 tonnes per year, while it also generated revenue from the sale of recycled materials.(181)

8. United States, New York City Fire Department (FDNY)

New York City Fire Department (FDNY)

Uniform Recycling Program is an example of a successful program to reduce the environmental impact of FDNY’s operations and improve resource efficiency by recycling and repurposing old uniforms. The program started in 2012. It involves collecting used uniforms from FDNY employees, cleaning and repairing them, and then redistributing them to new employees.

Since the program’s inception, over 50,000 pounds of used uniforms have been recycled, resulting in significant environmental benefits. According to FDNY, the program has helped reduce the organisation’s carbon footprint by over 200 tonnes of CO2e (carbon dioxide equivalent) per year. It has also reduced the amount of waste going to landfill by over 20 tonnes per year. The program has also generated economic benefits, including cost savings from not having to purchase new uniforms and revenue from the sale of recycled materials. The revenue generated from the sale of recycled materials has been reinvested back into FDNY’s sustainability initiatives.(182)

9. Germany, German Red Cross

In Germany, the Uniform Recycling Program of the German Red Cross was launched in 2012. The program collected used uniforms from German Red Cross employees and redistributed them to new employees after cleaning and repairing them.

Since the program’s inception, over 50,000 pieces of used clothing have been collected and recycled, resulting in reducing the organisation’s carbon footprint by over 270 tonnes of CO2e (carbon dioxide equivalent) per year. It has also reduced the amount of waste going to landfill by over 20 tonnes per year. The program’s economic benefits included cost savings from not having to purchase new uniforms and revenue from the sale of recycled materials.(183)

Challenges in Waste Management in Ambulance Services

Waste management within ambulance services presents numerous challenges that stem from a variety of factors.

One of the primary hurdles encountered is the diverse range of waste generated, encompassing different types of waste with varying degrees of hazardousness. Ambulance services produce medical waste from patient care, hazardous waste from chemicals and medications, general waste from consumables, and electronic waste from medical equipment. Effectively managing these distinct waste streams necessitates proper segregation, handling, storage, transportation, and disposal methods, which can be intricate and time-consuming.

Another significant challenge arises from the limited space and resources available within ambulances. These vehicles are purposefully designed to be compact and efficient for emergency medical care, often resulting in restricted storage capacity for waste management purposes. Such constraints can lead to issues like overcrowding, contamination risks, and inefficient waste handling practices. Moreover, ambulances operate in dynamic environments where time is of the essence, and waste management may not always be the top priority for emergency medical personnel amidst their critical life-saving tasks.

Lack of awareness and training among ambulance staff regarding proper waste management practices poses another challenge. Emergency medical personnel may not possess comprehensive knowledge about the potential hazards associated with waste or the correct handling and disposal methods, which can result in improper waste management practices. Insufficient training and awareness can contribute to mishandling of waste, thereby posing risks to public health, safety, and the environment.

Additionally, limited infrastructure and facilities for waste management can present challenges in certain regions. Ambulance services operating in remote or underserved areas may encounter difficulties in accessing appropriate waste management facilities, such as waste treatment plants or recycling centers. This can lead to improper waste disposal practices, such as landfill dumping or incineration, which can have adverse environmental impacts and contribute to pollution.

To address these challenges a multifaceted approach involving several key aspects must be designed.

First and foremost, comprehensive waste management plans tailored specifically for ambulance services need to be developed and implemented. These plans should include guidelines for waste segregation, storage, and transportation, considering the diverse waste streams encountered in these settings. Training programs should be provided to ambulance staff to enhance their awareness and understanding of proper waste management practices, emphasising the importance of public health, safety, and environmental protection.

Collaboration and partnerships with waste management authorities and organisations are essential for ensuring the availability of appropriate infrastructure and facilities. This may involve establishing collection points, collaborating with local waste management services, or exploring innovative waste management technologies suitable for the unique needs and constraints of ambulance services.

Regular monitoring and evaluation of waste management practices should be conducted to identify areas for improvement and ensure compliance with regulations and best practices.

Addressing the challenges of waste management within ambulance services, assist in promoting safer, more efficient, and environmentally conscious practices. Proper waste management not only protects public health and the environment but also contributes to the overall professionalism and sustainability of ambulance services, aligning with broader efforts to minimise the environmental footprint of the healthcare sector.

Chapter 13: Responsible Procurement and Logistics

Responsible procurement is an important component of sustainability in the healthcare sector.

As a major purchaser of goods and services, the healthcare industry has significant potential to drive sustainable practices throughout the supply chain.

Prioritising responsible procurement practices reduces healthcare organisations’ environmental impact, improves social and labor conditions, and promotes sustainable economic development.

The healthcare industry is a major contributor to global greenhouse gas emissions, with hospitals alone accounting for 5% of total emissions in the United States.

In addition to contributing to climate change, healthcare waste can also have significant negative impacts on human health and the environment.

Through promoting the use of environmentally friendly products and services, responsible procurement practices can help reduce the environmental impact of healthcare operations. While the potential cost of implementing sustainable procurement practices and initiatives may be more expensive than traditional options, the long-term benefits of responsible procurement, including reduced environmental impact and improved social and labor conditions, can outweigh the short-term costs.

Prioritising Wellness:

Mitigate pollution and prioritise the use of safer products to safeguard the health and wellbeing of patients, healthcare workers, and communities, aligning procurement practices with public health priorities.

Resilience:

Bolster operational continuity by designing systems and supply chains resilient enough to withstand health crises and environmental emergencies, ensuring uninterrupted delivery of essential healthcare services.

Efficient Resource Management:

Optimise financial resources through efficient processes and judicious management of resources and labour, maximising budgets without compllomising on sustainability goals.

Partnerships:

Utilise the collective purchasing influence of the healthcare sector to stimulate demand for innovative and sustainable products, fostering a culture of collaboration and progress within the industry.

Small Footprint:

Prioritise the adoption of products and services with minimal environmental impacts, including reduced carbon footprints, to minimise the ecological footprint of healthcare delivery.

Empowering Communities:

Drive investment towards diverse and local suppliers as part of sustainable procurement strategies, aiming to mitigate inequities across the supply chain and romote community prosperity

Leadership:

Empower healthcare organisations to assume leadership roles, actively responsive to the health and wellbeing needs of their communities, setting high standards for ethical and sustainable procurement practices.

In recent years, the Australian Government has undergone a transformative shift in its procurement practices, recognising the need to integrate sustainability considerations.

This shift is evident in the Australian Government Procurement Guidelines (AGPG), which serve as the guiding framework for public procurement. This comprehensive analysis explores the nuanced aspects of the government’s sustainability criteria, with a particular focus on different sectors, including the critical healthcare sector. The government’s sustainability criteria span environmental, social, and economic dimensions, presenting a comprehensive framework for evaluating the impact of procurement decisions. These criteria encompass considerations such as the environmental footprint of goods and services, adherence to fair labor practices, and the economic viability of procurement choices.

Within the larger context of sustainability, sector-specific considerations become imperative. The healthcare sector, as a vital component of public services, demands a tailored approach. The Australian Government recognises this and has outlined specific criteria for sustainability in healthcare procurement. For medical devices and equipment, criteria include the evaluation of environmental impact and considerations for end-of-life disposal. Similarly, pharmaceuticals and supplies are scrutinised for their environmental impact and ethical sourcing practices. When it comes to infrastructure and facility management, the focus shifts to sustainable design, energy solutions, and green building certifications.

Legislative Framework

Underpinning these sustainability initiatives are key legislations that provide the necessary legal foundation.

The Commonwealth Procurement Rules (CPR) establish fundamental principles for procurement entities, emphasising value for money, non-discrimination, and ethical conduct. The Environment Protection and Biodiversity Conservation Act 1999 (EPBC Act) ensures that environmental impact assessments are considered in procurement decisions.

Additionally, the Workplace Gender Equality Act 2012 promotes diversity and inclusion, indirectly influencing the supply chain. The Public Governance, Performance and Accountability Act 2013 establishes a framework for responsible resource management, aligning with the broader sustainability goals.

Sustainability Supply Chain

The healthcare sector supply chain has a high potential for sustainable improvement. From construction of buildings to purchasing medical equipment, any purchase by a healthcare service can impact the environment and the community who live in it (174).

Healthcare organisations can promote responsible procurement by selecting environmentally friendly products and services from suppliers who prioritise sustainability and have environmentally friendly practices themselves. Supporting suppliers who meet these standards by healthcare organisations can help promote fair and safe working conditions throughout the supply chain.

In addition to promoting sustainable practices and fair labor standards, responsible procurement can also contribute to sustainable economic development. Choosing local suppliers is another way that healthcare organisations can support the development of local economies, reduce transportation emissions, and build stronger relationships with suppliers.

Source: Duque-Uribe et al., Sustainability 2019, 11(21), 5949.

Chapter 13: Responsible Procurement and Logistics

Conceptual Framework for Hospital Sustainable Supply Chain Management

To effectively implement responsible procurement practices, healthcare organisations must prioritise sustainability throughout their procurement processes.

This can include establishing sustainability criteria for suppliers, including environmental, social, and economic factors in procurement decisions, and conducting regular sustainability assessments of suppliers. Additionally, healthcare organisations can promote sustainable practices by working with suppliers to develop and implement sustainability plans and initiatives.

Selecting suppliers who prioritise sustainability and have environmentally friendly practices themselves is an important aspect of responsible procurement. Healthcare organisations can establish criteria for suppliers that focus on reducing their environmental impact, such as minimising waste generation, implementing energy-efficient processes, and using renewable resources. Through partnering with such suppliers, healthcare organisations ensure that the products and services they procure have a lower carbon footprint and contribute less to environmental degradation.

Promoting sustainable practices throughout the supply chain is also essential for responsible procurement. Healthcare organisations can support ethical working conditions and human rights. This means partnering with suppliers that provide safe working environments, pay fair wages, and prohibit exploitative practices such as child labor or forced labor, via choosing suppliers that uphold fair labor standards. Through demanding these standards, healthcare organisations help create a ripple effect that encourages suppliers to improve their labor practices and contribute to better global working conditions. In addition to promoting sustainability and fair labor standards, responsible procurement can contribute to sustainable economic development. Healthcare organisations can choose to source products and services from local suppliers whenever possible. This choice supports the development of local economies by creating job opportunities and fostering economic growth.

Investing in local suppliers also assists healthcare organisations in reducing transportation emissions associated with long-distance supply chains and supports the creation of a more resilient and self-sufficient healthcare system.

Furthermore, selecting local suppliers helps build stronger relationships within the community. Collaboration and partnership with local suppliers can lead to better communication, faster response times, and increased trust. These relationships can facilitate innovation, customisation, and the sharing of best practices, ultimately benefiting both the healthcare organisation and the supplier.

Source: https://www.unicef.org UNICEF Supply Chain Maturity Model.

Working closely with local suppliers is an effective approach for healthcare organisations to contribute to a more sustainable and interconnected ecosystem. To effectively promote responsible procurement, healthcare organisations should establish clear guidelines and evaluation processes for supplier selection. They can require suppliers to provide evidence of their sustainable practices, certifications, and adherence to fair labor standards. Collaboration with industry associations and third-party organisations that provide sustainability certifications can also support the verification of supplier practices.

Responsible Procurement in Ambulance Services

Responsible procurement is an important aspect of sustainability in the ambulance sector. Ambulance services are a critical component of healthcare delivery, and as such, they have significant potential to drive sustainable practices throughout the supply chain. Like the other sectors of healthcare system, sustainable procurement in ambulance services aims to reduce the environmental impacts and maximising the lifecycle of the products that they use, while providing the same high quality emergency care to the people in need.

Sustainable Procurement Plan

Establishing a comprehensive and effective responsible procurement strategy is imperative for organisations seeking to minimise their environmental footprint and contribute to sustainable practices. The initial phase involves the development of a robust sustainable procurement plan, encompassing the formulation of procurement metrics, benchmarking expenditures, and a meticulous examination of methods to mitigate the environmental repercussions associated with purchases.

Ambulance services, in particular, confront substantial environmental implications, primarily stemming from the greenhouse gas emissions generated by their fleet of vehicles. To address this challenge, implementing responsible procurement practices becomes crucial. This entails advocating for the adoption of environmentally friendly vehicles, with a specific focus on acquiring lowemission options such as hybrid or electric vehicles. Additionally, promoting the use of alternative fuels, such as biodiesel or compressed natural gas, and selecting vehicles that consume fewer resources are essential components of a sustainable procurement approach in this context.

To ensure the seamless integration of responsible procurement practices, ambulance services can further underscore their commitment to sustainability. This involves establishing explicit sustainability criteria for suppliers, incorporating environmental, social, and economic considerations into procurement decisions. Regular sustainability assessments of suppliers become integral to maintaining accountability and adherence to set standards. Furthermore, fostering collaboration with suppliers to develop and implement sustainability plans and initiatives can significantly contribute to the promotion of sustainable practices throughout the procurement process.

Adopting these measures helps ambulance services not only reduce their environmental impact but also cultivate a more responsible and sustainable supply chain.

Responsible procurement can also contribute to sustainable economic development by prioritising local suppliers. While many healthcare products in ambulance sector are made overseas, ambulance services can choose to work with local suppliers to reduce transportation emissions, support the development of local economies, and build stronger relationships with suppliers.

Additionally, ambulance services can prioritise the use of products and services from social enterprises and other businesses that prioritise sustainability and social impact. To overcome the complexity of supply chains in the ambulance sector, due to working with numerous suppliers, ambulance services can prioritise the use of supplier sustainability assessments, which can help identify areas where suppliers may need to improve their sustainability practices.

Sustainability and Logistics

The key principle in sustainability is the ability to meet the present needs without compromising future generations’ ability to meet their own needs.(184)

Since ambulance services have a direct impact on the environment through their carbon footprint, planning, implementation, and control of the flow of goods, services, and information through from the point of origin to the point of consumption can define this sector’s impact on environment.(185)

The Triple Bottom Line of Sustainable Logistics

Logistics in Ambulance Services

In ambulance services, logistics refers to the management of resources required to respond to emergency calls, transport patients, and dispose of medical waste. The logistics of ambulance services involve the coordination of various resources, including ambulances, equipment, personnel, and medical supplies.

Logistics and sustainability intersect in ambulance services because ambulance services need to ensure that they deliver emergency medical services in a sustainable manner. Achieving this requires a comprehensive approach that addresses all aspects of ambulance services, including the procurement of medical supplies, the maintenance of ambulances, and the disposal of medical waste.

Greenhouse Gas Protocol Scopes 1, 2, and 3

Source: Health Care Without Harm, Climate-smart health care series Green Paper Number One, Produced in collaboration with Arup September 2019:1-48