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Bevan Exemplar Cohort 7 Projects

The sustainable value of analgesics within the NHS: Could adoption of oral pre-operative analgesia reduce the need for IV analgesics?

Sienna Hayes

Cardiff and Vale University Health Board

Climate change has been defined by the World Health Organisation as the most substantial threat to human health in the 21st century.

Currently the NHS accounts for 25% of public sector carbon dioxide emissions in the UK and is coming under increasing pressure to reduce its environmental impact.. The current NHS carbon footprint is 24.9 million tones CO2e per year. The main contributors being medical equipment and pharmaceuticals  and thus scrutinisation of these areas to help deliver a net-zero NHS by 2050 has been of particular interest

Anesthetics specialty has the highest overall Greenhouse Gas (GHG) emissions in  secondary care. The use of preoperative oral analgesia is being practiced more over recent years, however the traditional intraoperative IV analgesia is still the most popular method6.Paracetamol is widely accepted as an effective analgesic worldwide based on its well established efficacy and tolerability, with recommendations for its use as first line analgesia established globally .

As pharmaceuticals are the largest GHG emitter within the NHS, and with paracetamol being the most clinically used analgesic, it represents an ideal target to determine the magnitude of GHG emission attributable to its different delivery formats.

Project Aims/Objectives:

Calculate per 1g paracetamol:

  1. Carbon footprint- Published emission factors were applied to each of the specific data activity involved in the total LCA, with a single unit of measurement being calculated and compared, namely the carbon dioxide equivalent (kgCO2e) per 1 gram of paracetamol.
  2. Cost
  3. Clinical efficacy

 To enable the study to evaluate the’ sustainable value’ of each preparation. Once results attained, see if this clinical change can be discussed and integrated into clinical practice within NHS pre-operative wards across Cardiff and further Wales nationally.

Project Outcomes:

The IV preparation had the highest price per 1g of paracetamol at £1.20. Of significance was the substantial cost of suppositories at £11.04 per 1g, being the most expensive.

Overall this equated to 1g of IV paracetamol being x48 more expensive that oral.

IV preparation has a significantly higher total kgCo2 at 9.23, oral suspension at 2.79, suppositories 0.71, effervescence at 0.39 and oral at 0.084 kgCo2 per 1g of each preparation. This equated to IV having x110 fold increase in KgCo2 in comparison to the oral tablet preparation.

Extrapolation of these result for the use of oral over IV paracetamol peri-operatively for the current Wales/ England yearly surgical total could yield a reduction of 42.8 million kgCO2e per year. The government would have to plant 2.7 million trees to have the same effect (Kendall 2012), so over 4 years that’s the same number as all the tress in wales !

Clinical efficiency between all preparations were equivalent.

90% of anaesthetists were concerned about the impact of their clinical practice on the environment and already actively take measures to try and reduce this.  Further the vast majority (85%) administer paracetamol IV intraoperatively but most (86%) would also consider changing their practice to prescribing oral paracetamol preoperatively.

Project Impact:

To instigate a clinical change from IV to oral paracetamol preoperatively , through creating the ‘IMPROVE’ project at Noah’s ark –

Improving Paracetamol use with Routine Oral over Venous administration

Guidelines have been formatted for both doctors and nurses involved in pre-operative patients care (see below)

View the project poster and slides from the Cohort 7 Exemplar Showcase