A collection of top research from the journal
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Contents Being a patient in a crowded emergency department: a qualitative service evaluation Environmental impact of low-dose methoxyflurane versus nitrous oxide for analgesia: how green is the ‘green whistle’? Diagnosis of Acute Aortic Syndrome in the Emergency Department (DAShED) study: an observational cohort study of people attending the emergency department with symptoms consistent with acute aortic syndrome Cessation of Smoking Trial in the Emergency Department (COSTED): a multicentre randomised controlled trial Perceived barriers and opportunities to improve working conditions and staff retention in emergency departments: a qualitative study
Trip-killers: a concerning practice associated with psychedelic drug use
Original research Being a patient in a crowded emergency department: a qualitative service evaluation Alex I P Craston, 1 Harriet Scott-Murfitt, 1 Mariam T Omar, 1 Ruw Abeyratne, 2 Kate Kirk, 3 Nicola Mackintosh, 3 Damian Roland , 2,3 James David van Oppen 3,4
ABSTRACT Background Emergency department (ED) crowding causes increased mortality. Professionals working in crowded departments feel unable to provide high-quality care and are predisposed to burnout. Awareness of the impact on patients, however, is limited to metrics and surveys rather than understanding perspectives. This project investigated patients’ experiences and identified mitigating interventions. Methods A qualitative service evaluation was undertaken in a large UK ED. Adults were recruited during periods of high occupancy or delayed transfers. Semi-structured interviews explored experience during these attendances. Participants shared potential mitigating interventions. Analysis was based on the interpretative phenomenological approach. Verbatim transcripts were read, checked for accuracy, re-read and discussed during interviewer debriefing. Reflections about positionality informed the interpretative process. Results Seven patients and three accompanying partners participated. They were aged 24–87 with characteristics representing the catchment population. Participants’ experiences were characterised by ’loss of autonomy’, ’unmet expectations’ and ’vulnerability’. Potential mitigating interventions centred around information provision and better identification of existing ED facilities for personal needs. Conclusion Participants attending a crowded ED experienced uncertainty, helplessness and discomfort. Recommendations included process and environmental orientation. INTRODUCTION Crowding affects emergency departments (ED) worldwide and is a current pressing UK concern. 1 It is caused by increased attendances and delayed transfers. 2 Reduced throughput is associated with increased mortality. 3 Crowding impacts on patient safety and outcomes, including delayed time to treatment and increased patients departing unseen. 4 5 Qualitative work has explored the impact of working in crowded EDs, citing moral stress, dissat- isfaction with working conditions and deviation from care protocols. 6–8 While there is a growing body of evidence for professionals’ poor experi- ences working in crowded environments, aware- ness of the impact on patients is limited to analyses of service outcomes rather than a more detailed understanding of perspectives. 2 Qualitative work with patients has tended to explore their reasons for attending departments (aiming to reduce or divert
Handling editor Liza Keating ► Additional supplemental material is published online only. To view, please visit the journal online (https://doi. org/1 0.1136/e mermed-2023- 213751). 1 Medical School, University of Medicine, University Hospitals of Leicester NHS Trust, Leicester, UK 3 Department of Population Health Sciences, University of Leicester, Leicester, UK 2 Emergency & Specialist Leicester, Leicester, UK 4 Centre for Urgent and Emergency Care Research (CURE), The University of Sheffield, Sheffield, UK Correspondence to Dr James David van Oppen; james.vanoppen@d octors. org.u k
healthcare resource use) rather than appreciating their experience once there. 9 Experience, though, is a key measure of emergency care and contributes to any outcomes attained to subsequent satisfaction. 10 ED crowding is an issue with complex causes; there is no single solution for its prevention that departments can implement, and instead, a whole- system response will be required. 11 This study aimed to improve understanding of ED crowding and its emotional, psychological and experiential impacts from the patient perspective and thereby identify potential local interventions for alleviation. A qualitative service evaluation was undertaken. The methodology used semi-structured interviews with interpretative phenomenological analysis to elicit in detail and make sense of participants’ perspectives. This method extends beyond the narration of participants’ experiences and insights to double hermeneutic interpretation of their perspectives. 12 13 This uses a relatively small number of in-depth interviews and focuses on appreciating the essence of experience rather than necessarily deriving generalisable theory. METHODS Study design experiences of receiving healthcare in a crowded emergency department and identified potential mitigating interventions for improvement. Crowding contributed to uncertainty, helplessness and discomfort for these participants, who suggested process and environmental adjustments for amelioration. HOW THIS STUDY MIGHT AFFECT RESEARCH, POLICY OR PRACTICE ⇒ Evaluating crowding impacts from the patient perspective can identify interventions for experience improvement. Reinforcement of information and orientation may help to relieve negative healthcare experience when our emergency department is crowded. WHAT IS ALREADY KNOWN ON THIS TOPIC ⇒ Crowding in emergency departments is associated with poorer outcomes for patients and poorer working conditions for professionals. WHAT THIS STUDY ADDS ⇒ This qualitative evaluation studied patients’
AIPC, HS-M and MTO contributed equally.
Received 9 November 2023 Accepted 13 July 2024
© Author(s) (or their employer(s)) 2024. No
To cite: Craston AIP, Scott- Murfitt H, Omar MT, et al . Emerg Med J Epub ahead of print: [ please include Day Month Year]. doi:10.1136/ emermed-2023-213751 commercial re-use. See rights and permissions. Published by BMJ.
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Interviews took place in private areas of the ED, including examination rooms and assessment cubicles. These were under- taken at points of participants’ healthcare journeys that were convenient to them and staff—typically while waiting for assessments, investigations or transfers. Conversations were semi-structured using a topic guide based on recent emer- gency care experience literature, developed iteratively through discussion among the study team and informally with ED patients (online supplemental material 1). 13 15 This was loosely organised around establishing rapport and context, exploring participants’ experiences of their ED attendance and encour- aging enablement through the elicitation of potential interven- tions. ‘Crowding’ frequently appeared in media coverage at the time of recruitment and the word was therefore avoided in the topic guide and interviewer questions, to reduce influence on participants. Interviews were audio-recorded, and observer notes were made. Following each interview, the study team debriefed on reflex- ivity and elicited topics, discussing emerging themes and plan- ning future interviews. Data quality was judged by the depth of discussion and expression of negative healthcare experiences. We expected that all participants would have some negative experiences but would express these less frequently in interviews affected by power dynamics or lack of trust. Analysis Interpretative phenomenological analysis was undertaken, proceeding through data immersion and note-making, formula- tion of emergent themes and connecting the synthesis. Analysis aimed first to understand and describe the meaningful context of ED crowding through interpretation of the participants’ experi- ences, and second to formulate recommendations for mitigating interventions both from participants’ experiences and their own suggestions. Recordings were transcribed verbatim and anonymised by an approved and contracted professional service. The last author listened to each recording twice and checked transcripts for accuracy. The first and last authors then read each transcript at least twice and appended observer notes. To organise the data set and facilitate review, transcripts and observer notes were annotated in Microsoft Word with open codes for instances discussing experience and potential interventions. The codes and corresponding quotes were tabulated using a macro script. The interviewers then met together twice to discuss interviews and reflections in depth. Common themes between experiences and interpretations were then explored through a review of quoted instances for similarity and connection.
Setting and population The study was conducted at a busy UK ED with a catchment population of 1.4 million. During the study period (March to April 2023) there were approximately 900 daily attendances. The department has separate entrances and environments for adults and children. The adult area is divided into physical zones with a 12-bed resuscitation room, two bedded adult majors with 32 and 16 cubicles, an adult ambulance assessment/initial triage area (10 beds indoors plus, at the time of this study, 10 beds in a temporary tented overflow structure) and separate seated areas totalling approximately 200 chairs for adult ambulatory majors, adult injuries and adult triage. Adult patients attending the ED during periods of crowding and not requiring immediate healthcare interventions were eligible. Prisoners were excluded. We sought to understand the experience of crowding rather than waiting, and so did not select based on minimum stay times or departmental disposi- tion. Current heterogeneous measures of crowding are gener- ally based on service metrics. 2 14 We acknowledged that local physical design may allow for crowding to be perceived in one or more zones within an overall non-crowded department. Therefore, we pragmatically identified crowding by: >75% waiting room seats occupied; >75% bed spaces occupied; ambu- lance handover times exceeding 30 min; or ward transfer times exceeding 60 min. During the recruitment period, however, bed space occupancy routinely exceeded 100% and ward transfer times often exceeded 12 hours. Transfer times were used as a proxy for hospital capacity and waiting time was not considered an inclusion criterion. Potential participants were approached purposively, seeking to represent the department’s typical demography in times of sample age, ethnicity, frailty, healthcare acuity and waiting time. Participant recruitment Our recruitment included evenings and weekends. Patient participants were recruited using opportunistic sampling across most ED areas. We did not recruit in resuscitation or the 32-bed majors area. Here, care is in doored cubicles away from waiting areas to reduce noise and distraction; we therefore felt people here would have less awareness of crowding. We did include the other bedded majors area as well as ambulatory majors, triage, injuries and the temporary outdoor overflow area. In keeping with the interpretative phenomenological approach there was no predetermined recruitment target, and rather the goal was richness of data and description over sample size or saturation. Potential participants were approached following identifica- tion with the zone’s nurse co-ordinator so that care would not be disrupted. The aims were explained, and individuals were given time to reflect on their involvement and to ask questions. We only included people who had the capacity to consent, as assessed by a clinician. People who were accompanied by another person were privately offered a joint interview. Verbal consent was obtained from participants and any accompanying person. Data collection Interviews in English were each conducted by two people: the last author (male middle-grade emergency physician with PhD training in qualitative and psychometric methodologies—all interviews) and by the first authors (two female and one male senior medical students—two to three interviews each). Inter- viewers introduced themselves explaining their interest as healthcare workers in improving quality by understanding both positive and negative experiences.
RESULTS Participant characteristics
Seven participants were recruited in the department’s adult triage area (two), adult ambulatory majors (three) and adult ambulance assessment temporary overflow structure (two). Four patient participants were accompanied during their interview. This was their partner in all cases. The sample broadly represented the characteristics of people using this ED (table 1). Experience of ED crowding Accounts of negative healthcare experiences predominated. Interpretations of perspectives were summarised by themes of ‘loss of autonomy’, ‘unmet expectations’ and ‘vulnerability’.
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Table 1 Participant characteristics ID Age
Gender
Ethnicity
Accompanied
ED area
Wait
A B C D
60–69 20–29 20–29 50–59 40–49 80–89 40–49
Female Female Female Female Female
White White Indian White Black White
Partner
Triage waiting room Triage waiting room Ambulatory majors Ambulatory majors Ambulatory majors Ambulance overflow Ambulance overflow
2.5 hours
No
3 hours
Partner
0.5 hours
No No
1 hour
E F
13 hours
Male Male
Partner Partner
2 hours
G
British Asian
1.5 hours
Wait: emergency department length of stay at the time of recruitment. Ambulance overflow: a 10-bed temporary structure extending the adult ambulance assessment zone. ED, emergency department .
Loss of autonomy Participants felt that they resigned themselves to the ED process and that there were no available alternatives to acquiescing and tolerating their situation. Three people who were queuing to see a clinician felt they had no choice other than to wait: I feel upset but there’s nothing else I can do. I need to be seen. Person C We’re hoping it’s going to be fixed, but like I said until we get the results through, we don’t know where we’ll be going … we’ve just got to hang on and wait haven’t we. Person F You can’t regulate what’s going on, yourself as a patient. It feels very restrictive than what you would in a ward. Person G People waiting in the adult ambulatory and ambulance over- flow areas could see department thoroughfares. Participants here felt unable to approach healthcare professionals for assistance, considering them to be too busy: I don’t want to take the trouble to ask them [for medication] … I think that would just take longer so I’d rather just wait here. Person C They are just too busy. You see them all the time on the go and there’s too much to fit in. I sometimes think don’t even go and ask them because they’re too busy to ask anything. Person G Uncertainty around processes and timing made participants feel unable to understand the setting or update important contacts. This affected not only people queuing for clinicians, but also those who had been seen and were receiving treatments. People B and C wanted to be able to plan how they would travel and needed to anticipate their discharge time, while Person E was concerned about her baby at home: I don’t drive so I have to rely on taxis or people to come and pick me up so it would be nice to be able to give them a bit of an indica- tion about when they could come. Person B I don’t know how long it’s going to take me today. I asked one of the nurses. He’s like he’s not sure either so I have no expectation of the time. Person C The first nurse said about eight hours, nine hours. So you are catch- ing on that you’re going to be here for a considerable amount of
time, but it’s a very long time. And I have a baby that I’m breast- feeding at home. Person E Person G’s long-term condition had caused them to require care in several hospitals. While they were familiar with health- care processes, uncertainty around temporary reconfigurations disrupted understanding of their current situation, causing dissatisfaction: Nobody explains to you why you’re in the tent. If you’re told that we’re sorry this is the situation and that’s why we’re putting you here, it’s the assessment thing. Person G Unmet expectations The UK was no longer under pandemic restrictions at the time of these interviews. Still, participants felt that the crowded envi- ronment posed danger. Person E, who had spent the full night waiting, was conscious of risk: Obviously because of Covid, you kind of want to spread out a bit … It’s such a small space and there’s so many people coming, I don’t know what more they could do. Person E People C and E felt uncomfortable in the waiting room due to the lack of facilities for nutrition and personal hygiene: I haven’t seen a water supply anywhere … I think they provide food but I’m not sure. Person C It’s very grubby. There was tissue on the floor, there was urine on
the floor. Person E
Despite the crowd, participants attending alone could still feel lonely. Person B had become unwell at university, far from family. They sought distraction by contacting relatives: I’ve been texting family to give them updates … just so I don’t feel so alone because I’m here by myself. Person B Other people were also distracting themselves by conversing or making calls. This inevitably led to feeling disturbed or even frightened by the level of noise: I found it quite difficult, people having telephone calls when they’re obviously very frustrated. I think it can be quite hard on
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other people when, you know, there’s someone beside them raising their voice. Person B Due to their health problems, People F and G could not wait on chairs and required trolleys. They were being accommodated in a temporary structure. This caused surprise and disappointment: We were hoping it was in the main hospital with the sliding doors where it’s quieter and they can shut it off a bit. Person F When you’re coming into hospital and you’ve been put in a tent, you’re thinking what’s going on. You’re already not well and going through anxiety and stress, and then you’re put somewhere which is unfamiliar. Person G These expectations being unmet led to participants being reluctant to attend in the future: Person C I don’t want to come back to A&E. I’d rather wait for the GP, unless I feel like it’s life and death. Person E We were at the point where we looked at treatment even if we have to pay … because it saves the time and effort of everybody coming
Table 2 Potential interventions to mitigate unpleasant crowding experiences
Loss of autonomy
Unmet expectations
Intervention
Vulnerability
Screens detailing ED processes Screens identifying staff professions and roles Signs directing to toilets, water and food Process updates from staff during interactions
•
•
•
•
•
•
•
•
•
Distractions (eg, television)
•
ED, emergency department .
Hopefully there’s support for the staff as well so that everybody feels that they can make the best of a bad situation. I think they must be under a lot of pressure. Person B I’m sure it’s stressful, a lot, because there’s so many people that they have to tend to and help. Person E Participants in the waiting area felt that they were invisible or even forgotten. This led to missed treatments, as Person E had been prescribed analgesia that was not given: People who came in after us were being seen and that makes me feel that I’m not a priority when I know jolly well I am. Person A They are busy and you do get forgotten … So when the four hour mark came when I was in pain I did go up to them and ask. I just wish it was something that they were doing it more often rather than just leaving you. Person E Person G likened their experience in ambulance overflow to being on a conveyer belt, perhaps referencing depersonalisation while proceeding through processes: Basically it’s a conveyer belt, that’s what you’re running right now, the NHS is running a conveyer belt, a sandwich factory. Person G Potential alleviating interventions Participants suggested interventions to mitigate their situation in the crowded setting. Summarised by themes (table 2), these focused on the provision of accessible information and orienta- tion to available facilities for personal needs. Loss of autonomy Lessening uncertainty was a priority. Participants suggested improved information provision, both from staff and with signage: They could say a rough estimate of how long you’ll be waiting. Instead of just saying ‘the doctor will come’, maybe they could say ‘we can’t guarantee but it could be up to an hour wait’. Person B
to A&E. Person G
Vulnerability Participants worried for their safety. Person A explained that security personnel were not visible in the waiting area, while for Person F this was caused by feelings of powerlessness due to uncertain processes and timing. Person F feared their condition deteriorating, unnoticed by staff: I didn’t feel safe at all. There were too many people, there were alcoholics, drug addicts and people just literally shouting. Person A How do you feel about calling for help? Respondent: They’ve not been rude, but they don’t seem to have
the time. Person F
Participants in the waiting area worried about other patients, as well as family members who were alone at home. Here, people were exposed to higher numbers of other patients and staff members. There was a girl there who didn’t look well at all, but she went up to the counter a few times and they were putting things on her finger, checking pressure and everything. Person A If someone’s on their own, it will be so hard for them. Person C I’m breastfeeding. My husband does not cope very well when it comes to – he can’t offer – you know, so there’s a lot of stress hap- pening. So I do want to go home as soon as possible. Person E They were also concerned for the well-being of staff and reflected on working in a crowded department:
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Relationships with existing literature Our patient-level enquiry echoed literature reporting deleterious consequences of crowding on patient satisfaction, where boarding was associated with poorer survey responses. 16 These considered professional communication and responsiveness, and responses may have reflected the uncertainty over processes and reluctance to interrupt professionals which we observed. Crowding has been associated with missed or delayed treatments. 17 18 Similarly, participants in this current work were aware of such risks, even if they were unharmed. Such delays perhaps occurred due to the effects of crowding on efficiency; while this has been studied at the service level, here we identified the frustration and deperson- alisation experienced by individuals. 19 Identifying mitigating interventions is a research priority. 20 The imminent impact of crowding on patient care is widely acknowledged and represented in National Health Service-wide strategy. 21 Those system-level interventions aim to reduce occu- pancy to avoid crowding-related harms. Here, we identified interventions that may help to alleviate poor experiences once crowding has occurred, with particular focus on information. Information improves patient satisfaction. 22 While these focused on summary information at discharge, our findings highlight a need for updates and direction throughout attendances during times of crowding. This need not create an additional profes- sional workload as participants suggested maximising existing departmental signage space and passing updates within existing care interactions. While these recommendations appear simple, further evalu- ation of effects will be required. Simple, generic interventions may present new issues with understanding: as examples, people with atypical presentations requiring complex care flows (as is often the case for those living with frailty) may be even more confused by signage designed for a standardised pathway, and diagrams detailing professionals’ uniforms cannot account for agency workers. It is notable that information screens were already installed but had been switched off due to issues about the accuracy of previous information regarding waiting times. Issues and compliments capture only the extremes of health- care experiences, and so implementation of quality improve- ment interventions might better be appraised using validated measures on a routine or targeted basis. The identified themes are represented in existing emergency care patient-reported measures. 15 23 24 Limitations These findings may be relevant to other settings; however, the methodology sought internal validity for local interventions rather than necessarily transferability. 25 We aimed to describe and interpret experiences, and a richer understanding of under- lying social constructs and theories was beyond the scope. The setting had certain qualities that may limit external validity: the floorplan prevented the use of corridors for boarding and cubicles had soundproofing. Here, crowding disproportionately affected people early in attendances or with lower acuity presen- tations, as they queued in waiting rooms or overflow areas. In alternative operating models, people move rapidly into assess- ment areas but subsequently experience crowding in corridors. The proposed mitigating interventions require evaluation for feasibility and efficacy. Opportunistic sampling recruited participants around researchers’ availability and crowded periods. This risked intro- ducing selection bias. People who were more comfortable sharing opinions or less unwell may have been more likely to participate.
It was confusing where to sit. Some chairs had stickers on saying different things but it wasn’t obvious where you should sit. I think some better instructions so you know you’re in the right place to hear your name. Person B There is always going to be a change, but it would be nice to know there’s seven people ahead of you. Person E These could be enacted using a rolling presentation. This would display realistic waiting times, a medical priority system overview and aid for recognising professional roles from their uniforms. The department was already fitted with suitable screens. However, these had been switched off following issues that information was imprecise. Unmet expectations Participants felt that access to food and drink would improve comfort, and that distractions such as television made the setting more tolerable: A nice old cup of tea would help. Person F I don’t know if you’re able to get a sandwich if you’re really hungry. Person D Last time I came there wasn’t a TV on so that’s a bit of distraction. I’d say that’s an improvement. Person D Signage could aid in accessing the existing toilets and water station. The procedure to access refreshments should also be displayed. All current signage was in English, often with small text and required improvement for maximal accessibility. Vulnerability Suggestions to improve efficiency and clarity were often borne of concerns for other patients: People with broken legs, they’re struggling to get up there. It should all be done in one go. Person A If I couldn’t see the sign, I’m sure it will be confusing for older people. Person C Feelings of frustration and abandonment might be overcome with information overviewing processes, including interventions such as triage which might already have taken place. The pres- ence of security staff should be displayed. Crowding negatively impacted on patient’s emergency care experiences, encapsulated in three overarching themes of ‘loss of autonomy’, ‘unmet expectations’ and ‘vulnerability’. Partic- ipants described their uncertainty and discomfort. Negative events were often compounded by both the lonely invisibility and the constant disturbance of being in a crowd. We identified local recommendations from participants’ suggestions. These centred around information provision and clear signage for care and waiting areas within the department. DISCUSSION Summary of findings
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Original research We recruited only people who spoke conversational English with the capacity to consent. While we identified interventions that may help ED users locally, we cannot claim generalisability. We recruited, interviewed and analysed data from positions as healthcare professionals. This may have limited the extent and detail of discussions. Our experiences and perspectives inevitably influenced interpretations of data and the themes generated. However, participants’ expressions of negative perspectives and suggestions for mitigating improvements add confidence to the quality and openness of the interviews. Our structured debriefing and collaborative analysis strengthen findings. CONCLUSION Crowding negatively impacted on the patient experience of emergency care, summarised by themes of ‘loss of autonomy’, ‘unmet expectations’ and ‘vulnerability’. Mitigating recommen- dations centred on information provision to identify existing facilities for basic needs within the department and alleviate uncertainty around personnel and processes. X Damian Roland @damian_roland and James David van Oppen @J_vanOppen Acknowledgements The authors gratefully acknowledge Dr Mandar Marathe for advice and support with project methods and regulatory approvals. Contributors JDvO conceptualised the project. AIPC, HS-M, MTO and JDvO collected and analysed the data and wrote the first draft. RA, KK, NM and DR gave academic supervision and reviewed the first draft. All authors revised the draft manuscripts. JDvO accepts full responsibility as guarantor for the work and conduct of the study. Funding This project was not specifically funded. JDvO was funded by the National Institute for Health and Care Research (NIHR): Doctoral Research Fellowship 300901 and Clinical Lectureship. Competing interests None declared. Patient and public involvement Patients and/or the public were not involved in the design, conduct, reporting, or dissemination of this service evaluation. Patient consent for publication Not applicable. Ethics approval The study was registered with the hospital trust as a service evaluation (ref 12348). The NHS Health Research Authority confirmed that additional regulatory approvals were not required (ref 81/81). Participants gave informed consent to participate in the study before taking part. Provenance and peer review Not commissioned; externally peer reviewed. Data availability statement No data are available. Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise. ORCID iDs Damian Roland http://orcid.org/0000-0001-9334-5144 James David van Oppen http://orcid.org/0000-0002-2570-7112 REFERENCES 1 Higginson I, Boyle A. What should we do about crowding in emergency departments? Br J Hosp Med 2018;79:500–3.
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Original research Environmental impact of low-dose methoxyflurane versus nitrous oxide for analgesia: how green is the ‘green whistle’? Aleksis EV Martindale , 1 Daniel S Morris, 2,3 Thomas Cromarty, 4 Amarantha Fennell-Wells , 5 Brett Duane 6,6
ABSTRACT Background The NHS has the target of reducing its carbon emission by 80% by 2032. Part of its strategy is using pharmaceuticals with a less harmful impact on the environment. Nitrous oxide is currently used widely within the NHS. Nitrous oxide, if released into the atmosphere, has a significant environmental impact. Methoxyflurane, delivered through the Penthrox ’green whistle’ device, is a short-acting analgesic and is thought to have a smaller environmental impact compared with nitrous oxide. Methods Life cycle impact assessment (LCIA) of all products and processes involved in the manufacture and use of Penthrox, using data from the manufacturer, online sources and LCIA inventory Ecoinvent. These data were analysed in OpenLCA. Impact data were compared with existing data on nitrous oxide and morphine sulfate. Results This LCIA found that Penthrox has a climate change effect of 0.84 kg carbon dioxide equivalent (CO 2 e). Raw materials and the production process contributed to majority of the impact of Penthrox across all categories with raw materials accounting for 34.40% of the total climate change impact. Penthrox has a climate change impact of 117.7 times less CO 2 e compared with Entonox. 7 mg of 100 mg/100 mL of intravenous morphine sulfate had a climate change effect of 0.01 kg CO 2 e. Conclusions This LCIA has shown that the overall ’cradle-to-grave’ environmental impact of Penthrox device is better than nitrous oxide when looking specifically at climate change impact. The climate change impact for an equivalent dose of intravenous morphine was even lower. Switching to the use of inhaled methoxyflurane instead of using nitrous oxide in certain clinical situations could help the NHS to reach its carbon emission reduction target. BACKGROUND The climate crisis is a health crisis. A recent report by Lancet Countdown, which tracks progress on health and climate change, discusses the unequiv- ocal contribution that ill-health and healthcare makes to rising global temperatures and vice versa. 1 In line with UK Government ambitions described in the Climate Change Act 2008, the Paris Agreement 2016 and the most recent Health and Social Care Act 2022 NHS England has set ambitious targets for carbon reduction. 2–4 The first goal is reducing NHS England’s prepandemic carbon emissions of 25 megatonnes of carbon dioxide equivalents
Handling editor Caroline Leech ► Additional supplemental material is published online only. To view, please visit the journal online (http://dx.doi. org/1 0.1136/e mermed-2022- 213042). 1 General Duties Medical Officer, 3 Medical Regiment, Catterick, UK 2 Ophthalmology, University Hospital of Wales, Cardiff, UK 3 Wilderness Medical Training, Wilderness Medical Training, Kendal, UK 4 Emergency Medicine, Southampton Children’s Hospital, Southampton, UK 5 Centre for Sustainable Healthcare, Centre for Sustainable Healthcare, Oxford, UK 6 Dental Science, Trinity College Dublin, Dublin, Ireland Correspondence to Capt Aleksis EV Martindale, Royal Army Medical Corps, Camberley GU15 4NP, UK; m artindalealeksis@gmail.c om Received 18 December 2022 Accepted 12 September 2023
(MtCO 2 e)—around 5% of England’s carbon foot- print—by 80% by 2032. 5 Of these 25 MtCO 2 e, 2% is attributable to anaesthetic gases. 6 Two recom- mendations are to be implemented to reduce these significant emissions: (1) altering clinical practice pertaining to prescribing and (2) administering and disposing of anaesthetic gases. Nitrous oxide (N 2 O), is a commonly used anaes- thetic gas in EDs in the UK and elsewhere. 7 Inhaled methoxyflurane can also be used in acute emergency care for analgesia during painful procedures and is superior in managing pain from trauma compared with standard analgesic treatments. 8 9 It is also thought to have a smaller overall environmental impact compared with N 2 O. We know that N 2 O has a 100-year global warming potential 66.25 times greater than methoxyflurane (N 2 O: 265, methoxy- flurane: 4) and is one of the six major greenhouse gases targeted by the Kyoto Protocol, however, the overall environmental impact of methoxyflurane is unknown. 10 ⇒ This type of analysis allows healthcare professionals and managers to make more informed decisions regarding procurement and delivering care, taking environmental impact into account. ⇒ The findings suggest a shift in the type of short- term analgesia used by clinicians to agents that are less harmful to the environment. WHAT IS ALREADY KNOWN ON THIS TOPIC ⇒ Nitrous oxide is frequently used for analgesia but has significant environmental impacts. ⇒ Inhaled methoxyflurane can be used as an analgesic agent in certain clinical settings. WHAT THIS STUDY ADDS ⇒ This life cycle impact analysis calculates the overall environmental impact of the currently available form of methoxyflurane, Penthrox. ⇒ Penthrox was found to have lower climate change impact by a factor of 117.7 for equivalent use of Entonox (nitrous oxide:oxygen, 50%:50%). ⇒ Morphine has the lowest climate change impact of the three analgesic agents. HOW THIS STUDY MIGHT AFFECT RESEARCH, PRACTICE OR POLICY
Published Online First 28 September 2023
► http://d x.d oi.o rg/1 0.1 136/ emermed-2 023-213432
© Author(s) (or their employer(s)) 2024. No
To cite: Martindale AEV, Morris DS, Cromarty T, et al . Emerg Med J 2024; 41 :69–75. commercial re-use. See rights and permissions. Published by BMJ.
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Figure 1 Steps for conducting the life cycle impact assessment (LCIA). Step 1: dismantling Penthrox into its component parts and weighing these. The figure shows the Penthrox device along with a 3 mL vial of methoxyflurane in the top box. The methoxyflurane drug is represented by the tablet. Step 2: arrangement of each component part into flows with LCIA software. In the figure an example flow is shown. Step 3: data analysis.
hazardous waste bins and incinerated. All inputs and outputs for this flow are 19.4 g as that is the weight of this component. A full list of all flows with inputs and outputs are listed in online supplemental appendix 1. Step 3: results and data analysis as provided by the LCIA software. Functional unit The unit measure in this study was one unit of Penthrox with 3 mL of methoxyflurane 99.7%, equivalent to 30 min use. The UK product version assessed in this study includes a charcoal filter and alert card. Southampton General Hospital was used as The ‘system boundary’ considered in this project is summarised in figure 2. This includes the manufacture of all physical compo- nents and drugs through to assembly, transport, use and disposal of the product. All components were searched for on Ecoinvent V.3.8, an LCIA inventory database. 11 This is important for any LCIA project as the software running the analysis, in this proj- ect’s case, OpenLCA, draws on an LCIA inventory database for its data on previously logged LCIAs on various materials, prod- ucts and processes, which have used a standardised framework for their calculation. 12 Where a product or process is missing from Ecoinvent, an appropriate substitute can be used, or, as occurred in this project with the drug methoxyflurane, more analysis is required to fill this gap. Mechanism of drug synthesis the end destination. System boundaries Methoxyflurane had no matching record in Ecoinvent, therefore, potential reaction processes were searched for online. Three
The overall environmental impact can be calculated by carrying out a life cycle impact assessment (LCIA). The cradle- to-grave methodology of LCIAs calculates much more than the commonly measured ‘carbon footprint’, which only considers the carbon dioxide equivalent (CO 2 e). LCIA is a scientific method used to measure the entire environmental impact of a product or process, from raw material acquisition—the ‘cradle’—through its manufacture, transport and use, to product disposal—the ‘grave’. The primary aim of this project is to carry out an LCIA of the currently available formulation of methoxyflurane, Penthrox, also known as the green whistle. The secondary aim is to compare the climate change impact of Penthrox with that of N 2 O. METHODS We carried out an LCIA on Penthrox in July 2022. We have summarised the LCIA process into three steps (figure 1). Step 1: dismantling the Penthrox device into component parts and weighing each part. Each part was made of one material, and this was cross-referenced with data sent by the manufacturer. Step 2: entering data into LCIA software using ‘flows’. A flow consists of all inputs (raw materials, processes, transport and energy requirements) and outputs (waste disposal and excretion of drug) corresponding to each part of Penthrox. In figure 1 an example flow is shown. The flow is for the char- coal filter case which has the inputs of ‘polycarbonate’ as the raw material required for making the charcoal filter case and ‘injection moulding’ as the process required to make the char- coal filter case from the polycarbonate. The output of this flow is ‘hazardous waste incineration’ as at the end of the life cycle of Penthrox, it is assumed that the device will be thrown in the
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Figure 2 System boundaries for Penthrox. The system boundary shows the ‘cradle-to-grave’ analysis of the life cycle impact assessment. This is a simplified representation of all ‘flows’ shown in online supplemental appendix 3. *The manufacture of methoxyflurane from its raw materials has been considered as a separate process from other raw materials in the results to allow for contribution analysis.
charcoal. Perfect technique, as guided by the manufacturer, was assumed in our analysis. Around 35% of the inhaled methoxy- flurane is exhaled unchanged with the rest absorbed by the body. The exhaled methoxyflurane is captured by the charcoal, reducing the exhaled concentration of methoxyflurane to the environment to zero, as described by the manufacturer. 16 This project assumed complete patient compliance with the instruc- tions of exhalation into the device and 100% effectiveness of the charcoal. The literature is less clear about the exact outcome of the 65% of 3 mL methoxyflurane that is absorbed by the human body. Studies have shown the metabolised products to be organic fluorine, fluoride and oxalic acid (29%, 7.7% and 7.1%, respec- tively). 20 For the purposes of this study, the remaining 21.2% of methoxyflurane is assumed to be excreted unchanged. Disposal Although many component parts of Penthrox are easily recy- clable, experience shows that the practicalities of recycling in clinical environments makes this unlikely to happen. For the purposes of this project, and the likely real-life disposal after use, all components were assumed as being discarded into hazardous waste bins and incinerated. Data analysis Data from Ecoinvent were modelled and analysed in OpenLCA. Table 1 includes both the impact category results and the LCIA methods used within this study alongside a description of each category. Contribution analysis of different parts of the LCIA was also assessed using five distinct areas: raw materials, methoxyflu- rane manufacture, production processes, transport and disposal. OpenLCA also calculated the normalised impact and disability- adjusted life years (DALYs). Comparative analysis of Penthrox No complete LCIA was currently available online for N 2 O. Climate change impact was available online for Entonox. 21 Data from the study by Pearson et al were extrapolated to represent 30 min continuous use of Entonox at a minute volume rate of 14 L/min.
reactions are required to manufacture methoxyflurane (online supplemental appendix 2) and were considered in the LCIA. 13–15 Bond energies were used to determine the energy change within each reaction. If energy was required, it was input into the LCIA as electricity demand and if energy was released it was listed in the LCIA as steam output. The by-products from reaction 2 were unclear from source material, therefore, assumed products were 1,1-dichloro-2,2-difluoroethylene, dichloromethane and water. Methoxyflurane is distributed/manufactured by Medical Developments International Limited (MDI) based in Victoria, Australia. It was assumed that the drug was manufactured on site at Scoresby Manufacturing facility in Melbourne, Australia, as this information was not available. An MDI representative provided information on the energy source at the Scoresby Manufacturing facility, explaining that the company has installed a solar array providing 750 MW of electricity, which was consid- ered in the LCIA. 16 Product manufacture Component part and weight information was gathered from the manufacturer in June 2022. 16 Manufacturing processes involved within the production of Penthrox were assumed and energy requirements of the machines involved within these processes were correlated with online literature. 17 Transportation MDI provided information on transport logistics of Penthrox. 16 The end location used in this project was University Hospital Southampton, UK. Road distances were calculated using Google Maps and shipping distances were calculated using www.ports. com. 18 19 Modes of transport include by truck and ship and appropriate fuel types were assumed. Summary of transport data is shown in online supplemental appendix 3. Use Penthrox requires no additional components for its use. The 3 mL vial of methoxyflurane is emptied into the chamber containing the wick. The user then forms an oral seal around the mouthpiece and inhales. They then exhale back into the device, where the valve causes the exhaled gases to pass through
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