Dear Editor,

Single-use items are frequently used for central venous catheter (CVC) insertions. In a previous study comparing a single-use kit to a kit containing reusable metal items, it was found that the carbon footprint was lower for the single-use kit, whereas the reusable kit was cheaper [1]. We wanted to re-examine these findings in a contemporary European setting and to extend the scope of the analysis to include textiles and assessment of additional environmental impact categories.

We used life cycle assessment (LCA) methodology to assess the effects on resource use, climate change, ecosystem quality and human health [2] of items commonly used during CVC insertions. We compared a kit consisting of a reusable bowl, scissors, haemostatic forceps, and needle holder (instruments) and a reusable gown and drape (textiles), a kit consisting of the reusable instruments and single-use textiles and a kit with only single-use items (Fig. 1, see supplementary Table S1-3). Our primary model was based on input data collected at a Swedish Hospital. Sensitivity analyses and Monte Carlo analyses were used to assess uncertainties and differences between the kits [3]. The results are presented as medians and 2.5th to 97.5th percentiles. We used life cycle costing to assess financial costs (see supplementary Table S4).

Fig. 1
figure 1

The instruments (scissors, needle holder, haemostatic forceps, bowl) and the textiles (gown and drape) in the kit containing reusable metal items and reusable textiles (RR), the kit containing reusable metal items and single-use textiles (RS), and the kit containing single-use metal and plastic items and single-use textiles (SS) are shown in panel a. Reusable items are in green and single-use items are in blue. Absolute impact on the resource use, climate change, ecosystem quality, and human health endpoints are presented in panels b1–e1. MJ Primary = total amount of extracted non-renewable energy. Kg Co2eq = the climate effect of carbon dioxide equivalents emitted in to the air over 100 years. PDF*m2*years = potentially disappeared fraction of species per square meter during a year. DALY/person/years = disability adjusted life years per person and year. The median difference between the kits, as estimated by paired Monte Carlo simulations on the respective endpoint is presented in panels b2e. The two alternatives were considered to have different effects on an endpoint if the 2.5th–5th percentile range did not cross 0. Data are presented as median and 2.5th–97.5th percentiles in all panels

Full size image

The kit with reusable instruments and reusable textiles had a 65% lower impact on resource use compared to the single-use kit [∆: 27 MJ primary (19–33)], a 90% lower impact on climate change [∆: 2.1 kg-CO2eq (1.9–2.5)], an 85% lower impact on ecosystem quality [∆: 3 PDF*m2*yr (1.6–4.5)], and a 95% lower impact on human health [∆: 5.8 × 10–6 DALY/person/yr (4.8 × 10–6-7.1 × 10–6)] (Fig. 1). The results were largely robust in sensitivity analyses (supplementary Fig. S1). The kit with reusable instruments and single-use textiles had about 20% lower impact on resource use and climate change compared to the single-use kit and about 70% lower impact on ecosystem quality and human health (Fig. 1). The results were largely robust in sensitivity analyses (supplementary Fig. S2). The cost of the kit with reusable instruments and reusable textiles was €5.7 compared to €9.1 and €9.2 of the two other kits (supplementary Table S5). Additional results and detailed description of the methodology are found in the electronic supplementary material (ESM).

In contrast to the study by McGain et al. [1], we found that the reusable kit was associated with a lower climate impact than the single-use kit. This is mainly explained by the inclusion of sterile textiles in our analysis, but the low carbon electricity mix and lower energy use in our primary model also contribute (supplementary Fig. S4). The fact that we used consumption data for the washer-disinfector and autoclave provided by the manufacturer and excluded standby time and test runs from our analysis, instead of the site-specific data used by McGain et al., also contributed to the lower climate impact. Furthermore, different loading capacities of the autoclaves and washer–disinfectors led to different allocations. While we allocated 1.7% and 6.7% of the autoclave and washer–disinfector’s energy consumption to the reusable CVC kit, respectively, McGain et al. allocated 2.3 and 3.1%, respectively. We note that in our sensitivity analysis using an average European electricity mix, the climate impact of the reusable kit approaches that of the reusable kit in the McGain et al. study. Taken together, the above emphasize the need to consider both scope and local context when interpreting LCA results [4, 5].

A major finding in our study was that the change from single-use to reusable textiles during CVC insertions dramatically reduced the environmental impact on resource use and climate change. The production of sterile single-use textiles represents 65–85% of the total impact on resource use and climate change for the kits using single-use textiles (supplementary Fig. S4). This result highlights an area which could be targeted to reduce the environmental impact of not only CVC insertions, but also of other procedures requiring sterile textiles.

We conclude that the use of CVC-insertion kits containing reusable metal instruments and reusable textiles offer a robust opportunity to reduce the environmental impacts and financial costs of CVC insertions in a European setting, compared to the use of kits containing solely single-use items.