-What-
Medicines are used for all types of surgeries in the operating room (OR). They are needed to provide safe and effective care. However, the use of medicines also results in waste. Research conducted by Barbariol et al. (2021) highlighted that a substantial proportion, ranging from 20% to 50%, of medications prepared in the OR ultimately remain unused and are consequently discarded. The Leiden University Medical Centre (LUMC) and ‘Nationaal Netwerk de Groene OK’ aim to minimize the waste of medicines at the OR.

-Why -
The environmental impact of medicines

Research conducted last year by RIVM presented that the contribution of chemical products, including medicines in particular, is responsible for 41.2% of healthcare CO2

Medicine scarcity
The ‘Koninklijke Nederlandse Maatschappij ter bevordering der Pharmacie’ (KNMP), presened that last year in 2022 the highest number of medicine shortage ever occurred. They predict that these kind of issues will only grow more in the further, so it is important to stay mindful about medication prescription, use and disposal.

Ethical obligation
Medication waste raises ethical concerns within the healthcare context. The waste of medications contradicts the principles of equity and justice, as resources that could have been allocated to patients in need are wasted.

-How?-
DrugWise

Consequently, a final concept called ‘DrugWise’ was devised. This sustainable approach targets medicine waste prevention in the OR through a holistic approach. DrugWise consists of five critical steps:
1. Measure the waste to gain an understanding of the current situation.
2. Prioritize areas for action based on the measurements.
3. Raise awareness amongst OR staff regarding the extent and implications of medicine waste.
4. Initiate action in four key areas: medicine use, prescribing practices, stock management, and disposal.
5. Evaluate the effectiveness of the interventions implemented.

The target audience of the approach is the Anaesthesia Green Team. The DrugWise approach was developed in collaboration with the primary stakeholders involved in medication use - anesthesiologists and anaesthetic nurses. This collaboration ensured that the solution was rooted in their practical experience and professional knowledge.

-Future steps-

Looking ahead, LUMC will serve as the pilot hospital for the DrugWise approach. Upon successful implementation and review, the intention is to broaden the reach to other hospitals, advocating for a nationwide effort in reducing medicine wastage in the OR.

This thesis explores the relatively large contribution of the product category ‘chemicals n.e.c.’ (chemicals not elsewhere classified) to the Dutch healthcare sector’s carbon and material footprint observed in previous studies. For this, an input-output study using SNAC-EXIOBASE data was performed. SNAC-EXIOBASE uses national statistics for the Dutch part of the multi-regional input-output table. It also distinguishes a separate chemical and pharmaceutical industry in the Dutch part. This can help identify possible aggregation problems in the EXIOBASE category ‘chemicals n.e.c.’ which is an aggregate of the chemical and pharmaceutical industry sectors. Comparing the carbon and material footprint of pharmaceuticals used in the Dutch health care sector as calculated with (default) EXIOBASE and SNAC-EXIOBASE shows that there is an aggregation problem in the ‘chemicals n.e.c.’ category. This means that grouping the pharmaceutical industry with the chemical industry greatly influences the carbon and material footprint of pharmaceuticals. The carbon footprint decreases by 11% and the material footprint by 61% when using SNAC-EXIOBASE compared to EXIOBASE data. The multiplier analysis showed that in all cases the Dutch pharmaceutical industry has a lower carbon, mineral and metal intensity (footprint per euro) compared to the Dutch chemical industry or ‘chemicals n.e.c.’ confirming the aggregation problem. The LCA literature review showed that the range of carbon intensities of individual pharmaceuticals matches the carbon intensity of the ‘pharmaceutical industry’ in SNAC-EXIOBASE. This study also showed that the material footprint of the Dutch healthcare sector is uncertain and should be used with care. Future research should focus on using MRIOs that better depict the pharmaceutical industry like the ICIO which is based on the ISIC Rev. 4 classification and, therefore, includes a separate pharmaceutical industry. Before performing analyses with the ICIO is possible, higher sectoral resolution and environmental extensions are needed.