GreenED Initiative: A Briefing for Emergency Department Professionals

Executive Summary

Climate change presents an existential threat to public health and a direct challenge to the delivery of healthcare services in the UK. The NHS, which contributes 4% of the UK's carbon footprint (1), is responding with a world-leading commitment to become the first net-zero national health service, an ambition enshrined in the Health and Care Act (2022). For Emergency Departments (EDs), this national mandate coincides with the compounding crisis of rising demand, creating both a significant challenge and a unique opportunity.

The Royal College of Emergency Medicine (RCEM) has established the GreenED initiative to guide departments in this transition. This briefing synthesises the core principles and practical guidance for implementing environmentally sustainable practices within the emergency care setting.

Key Takeaways:

Sustainability as Quality Improvement: The core principle is that sustainable healthcare is high-quality healthcare. By improving efficiency, optimising patient pathways, and reducing waste, EDs can enhance patient care, improve staff well-being, generate cost savings, and reduce their environmental impact simultaneously.
Leadership is Crucial: A key finding from the GreenED pilot project is that lasting change is exceptionally difficult without senior buy-in. Engaging clinical leads, senior nurses, and managers by aligning green initiatives with trust-level strategic goals (e.g., cost savings, patient experience) is essential for success.
A Whole-Team Approach: Effective change requires the engagement of all staff, from consultants and nurses to porters, administrative staff, and managers. Establishing a multidisciplinary "Green ED" group is a foundational first step.
The "Reduce, Reuse, Recycle" Hierarchy: The greatest environmental and financial benefits come from reducing consumption in the first place (e.g., rationalising blood tests, avoiding unnecessary cannulation). This is a more impactful strategy than reuse, which in turn is more effective than recycling.
Actionable Framework: This document provides a practical framework covering strategic context, RCEM's official recommendations, and a detailed guide to implementation, including forming a green group, identifying carbon hotspots, and motivating an already exhausted workforce with tangible, data-driven benefits.

1. The Strategic Context: Climate Change and the NHS

Emergency Medicine is at the forefront of two compounding crises: the immediate pressures on the emergency care system and the escalating health consequences of climate change. Extreme weather events, such as the 2022 UK heatwaves, are already increasing demand on EDs (2). The Lancet has described the climate emergency as "the greatest threat to human health of the 21st Century" (2).

In response, the NHS has embarked on a transformative journey.

National Mandate: In October 2020, the NHS became the world's first health service to commit to reaching carbon net-zero. The "Delivering a Net Zero Health Service" report outlines the evidence-based targets for this ambition (3).
Legislative Backing: In England, these net-zero targets are enshrined in the Health and Care Act (2022), with the responsibility for implementation delegated to Integrated Care Boards (ICBs) (2).
Demonstrable Progress: As of 2025, five years into the initiative, the NHS has reduced direct emissions by 68% since 1990 and by 14% since 2020 (3).

The RCEM's position is that embracing environmental sustainability is not an additional burden but an opportunity to innovate and improve care. By creating more efficient patient pathways and minimising unnecessary interventions, EDs can improve patient flow, reduce harm, and maximise resources, thereby tackling both the emergency care crisis and the climate crisis (2).

2. RCEM Recommendations for a Sustainable ED

The RCEM has issued a formal position statement outlining five core recommendations for improving the environmental sustainability of emergency medicine (2).

Understand and Reduce Impact: ED staff should actively work to comprehend and minimise their environmental impact. This includes developing tools to measure carbon emissions of services and care pathways, in partnership with suppliers, and using 'green' or sustainable Quality Improvement (QI) methodologies to implement change.
Leadership Engagement and Structure: ED leadership teams must engage with the environmental agenda as part of their core business. The ideal structure includes a dedicated 'Green ED' group and a nominated environmental sustainability lead to drive cultural and systemic change.
Promote Efficient, Low-Carbon Care: EDs can contribute significantly by optimising resource use to ensure the right patient receives the right care at the right time. Initiatives like the Getting It Right First Time (GIRFT) programme, which saw a 30% reduction in surgical admissions in one example, not only improve patient flow but also cut the significant carbon footprint of inpatient stays (estimated at 37-85 KgCO2e per 24 hours) (2, 4).
Champion Public Health and Prevention: The most sustainable healthcare is healthcare that is no longer needed. Emergency care professionals can play a vital role in public health by promoting active transport, physical activity, and social prescribing initiatives. They can also use their trusted voices to advocate for wider societal decarbonisation to protect health systems (2, 5).
Develop the Evidence Base: There is not yet a consensus on what a net-zero health service looks like in practice (6). Dedicated research funding is required to evaluate best practices and ensure that net-zero goals are achieved while maintaining excellent standards of patient care.

3. Implementing GreenED: A Practical Framework

Translating strategic goals into departmental action requires a structured approach focused on engagement, prioritisation, and communication.

3.1 Building the Foundation: Engagement and Senior Support

Lasting change is built on the engagement of the entire departmental team, critically underpinned by senior support.

Forming a Green Group:

Start the Conversation: Talk to a wide range of colleagues—clinical and non-clinical—to identify interest. A 2017-2019 survey found 98% of NHS staff believe it is important to be environmentally responsible (7).
Identify Champions: Form a multidisciplinary group of "green champions," ensuring representation from junior and senior staff across medical, nursing, domestic, and administrative roles.
Ensure Longevity: Involve permanent, long-term staff members to maintain momentum beyond junior doctor rotations.
Define a Purpose: Once formed, the group should agree on a clear set of aims and objectives to keep activities focused.

Securing Senior Buy-in: The 2022 GreenED pilot identified a lack of senior buy-in as a primary barrier to success (8). To secure support from clinical leads and managers, it is crucial to align sustainability projects with their priorities. The FRAME mnemonic can guide this approach:

Letter	Driver	Description
F	Financials	Demonstrate clear cost savings from reducing waste and consumption. This is a powerful motivator for management.
R	Reputation	Frame initiatives as an opportunity for positive publicity and to position the Trust as a regional leader in sustainability.
A	Alignment	Show how GreenED projects directly support the strategic objectives of the Trust, the ICB, and NHS England.
M	Mandates	Highlight that sustainability targets may become mandatory, and some trusts are already including them in consultant appraisals.
E	Efficiency	Emphasise improvements to patient care, quality, and staff workload. Frame sustainability as a core pillar of quality.

3.2 Prioritising Action: The Sustainability Hierarchy

Efforts should be prioritised according to the "reduce, reuse, recycle" hierarchy, as reduction has the greatest carbon impact.

1. REDUCE (Highest Impact): This involves systematically eliminating wasteful practices.

Clinical Interventions: Rationalise blood tests on admission and reduce unnecessary cannulation. Switch to lower-carbon alternatives, such as providing paracetamol in tablet form instead of intravenously.
Procurement: Challenge historical ordering practices. One Trust stopped an annual order of 87,000 water bottles with just two emails.
Energy and Travel: Reduce the carbon impact of staff presence by promoting virtual meetings and teaching sessions where appropriate.

2. REUSE (Medium Impact): This focuses on challenging the disposability culture prevalent in healthcare.

Staff Amenities: Incentivise staff to bring reusable cups for drinks. This can be supported with funds from a hospital staff charity.
Equipment: Investigate and establish mechanisms for cleaning and testing returned equipment, such as crutches, that are often needlessly thrown away.

3. RECYCLE (Lowest Impact of the Three): While important, recycling should be seen as the final step after reduction and reuse have been maximised.

Start with Easy Wins: Focus first on recycling and single-use plastics in catering.
Conduct a "Waste Walk": Physically trace the waste process to understand segregation and identify opportunities. Ensure bins are plentiful and signage is clear (e.g., "no masks or gloves").
Collaborate: Speak to the Trust waste team to discover what can be recycled. In some Trusts, this includes plastic wrappers from syringes and IV fluid bags.

3.3 Identifying and Tackling Carbon Hotspots

A carbon hotspot is a specific activity or resource with a disproportionately high carbon footprint. Identifying and targeting these can yield significant results.

Common ED Hotspots:
- Nitrous Oxide: This can be reduced by switching off manifolds that supply the ED.
- Metered-Dose Inhalers (MDIs): Switching to Dry-Powder Inhalers (DPIs) where clinically appropriate offers a dramatic carbon saving.
- Waste Streams: Diverting clean packaging from clinical waste into recycling streams.
Measuring Impact: Learning to "carbon count" allows a team to measure the impact of changes. The Centre for Sustainable Healthcare runs courses on this topic. Converting savings into relatable formats is a powerful communication tool.

Item Comparison	Carbon Footprint Equivalent
Ventolin MDI	175 miles in an average petrol car
Salbutamol DPI	4 miles in an average petrol car
One Trust's Annual IV Paracetamol Use	Seven return flights to Perth, Australia

4. Overcoming Challenges and Maintaining Momentum

Implementing change in a high-pressure environment requires persistence and savvy communication.

Motivating an Exhausted Workforce: Acknowledge that saving the planet may not be front-of-mind during a busy shift.
- Highlight Hidden Benefits: Frame projects as workload reducers (e.g., less cannulation, oral meds).
- Make it Easy: Recycling must be convenient, and staff should be incentivised (e.g., free reusable mugs).
- Communicate Effectively: Use direct "shop floor" engagement, handovers, and WhatsApp groups, which are more effective than emails. Regularly explain the reasons for change to embed new habits.
Expect a Drop-off: Initial enthusiasm may wane due to departmental pressures or staff rotations. Plan for this by integrating GreenED updates as a standing item on governance agendas and in staff inductions.
Self-Promote: Use the Trust communications team to publicise successes. Share regular updates with the entire ED and key managers. As one consultant noted, framing initiatives as a way to save money and gain good publicity almost always gets a quick, positive response.

Ultimately, turning an ED green is a rewarding journey that offers insights into hospital-wide operations and the satisfaction of seeing positive, tangible change take root.

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References

Source for 4% UK healthcare carbon footprint not fully cited in context material (cited as [1] in RCEM position statement).
Royal College of Emergency Medicine. RCEM position statement on environmentally sustainable emergency healthcare. May 2023.
NHS England. Greener NHS. [Website]. Accessed from source context.
Sustainable Healthcare Coalition. Sustainable Care Pathways Guidance: Inpatient Bed Day Module. Oct 2015. Available from: https://shcoalition.org/wp-content/uploads/2019/10/Sustainable-Care-Pathways-Guidance-Inpatient-Bed-Day-Module-Oct-2015.pdf
Source cited as: BMJ 2023;380:p378.
Source cited as: EMJ 2022;38(4):315. Available from: https://emj.bmj.com/content/38/4/315
NHS Sustainable Development Unit. Staff and sustainability survey 2017-2019. (As described in source context).
GreenED Pilot Report March 2023. Available from: https://rcem.ac.uk/wp-content/uploads/2023/04/GreenED-Pilot-Report-March_2023.pdf

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