Forward steps in green medical laboratory practices for a sustainable future

: This paper provides information on the signi ﬁ - cance of environmental sustainability and the potential bene ﬁ ts of implementing green laboratory processes. Sus-tainability is a broad concept that includes goals such as conservation of natural resources, energy e ﬃ ciency, waste management, and reducing environmental footprints. Green laboratories strive to minimise environmental foot-prints by embedding sustainability principles into their everyday practices. This involves improvements in energy consumption, water usage, chemical waste reduction, and recycling, ultimately, as well as lower waste disposal costs. Implementing green laboratory approaches provides many bene ﬁ ts, such as a smaller environmental footprint, increased energy e ﬃ ciency, water conservation, and cost savings. Moreover, a rational test ordering process can e ﬀ ectively contribute to reducing environmental impacts in medical laboratories. Rational test ordering provides cost-e ﬀ ectiveness and reduces the carbon footprint. Establishing a green and sustainable laboratory culture in medical laboratories requires a permanent organisation in where all personnel participate. Training of the hospital management teams, clinicians, and laboratory professionals is a vital point. Methodology and quality indicators should be de ﬁ ned by international and national laboratory associations within the framework of a green and sustainable laboratory plan, and data should be collected. In conclusion, adopting green laboratory practices reduces environmental impacts, saves costs, and accelerates innovation processes. Setting quality targets and rational test ordering practices are also essential for sustainability. Applying sustainability principles in laboratory workplaces is an important step towards protecting the environment and leaving a more liveable world for future generations.


Background
The climate crisis is a product of global inaction, costing the world dearly.In recent years, environmental sustainability has become a global concern.There has been a significant social awareness of the need for a sustainable future, leading to changes in many sectors.Science, technology, and health systems are among the sectors affected by this change.Especially in laboratory medicine, adopting sustainability principles minimises environmental footprints and more efficient use of resources [1][2][3].In this paper, the significance, and potential benefits of green laboratory practices, together with the concept of sustainability, have been discussed.
Sustainability is a broad concept encompassing specific goals such as conservation of natural resources, energy efficiency, waste management and reducing environmental impacts.This concept also plays a significant role in science and technology.A green laboratory can be defined as a laboratory that integrates sustainability principles into laboratory work and focuses on reducing its environmental footprint.Green laboratory practices aim to improve in various areas, such as reducing energy consumption, optimising water use, reducing chemical waste, and promoting recycling.Medical laboratories contribute to a sustainable healthcare system by efficiently using economic and ecological resources while providing crucial services to patients and clinicians [3].
The International Organization for Standardization (ISO) 14001:2015 document promotes effective environmental management systems in organisations [4].Most recently, the European Federation of Clinical Chemistry and Laboratory Medicine (EFLM) published the "Guidelines for Green and Sustainable Medical Laboratories" in August 2022 [3].This guide and checklist are a handbook and are accompanied by a self-assessment checklist for any medical laboratory to start its green journey.Adopting green laboratory practices provides significant benefits.The first of these is the reduction of environmental footprints.Medical laboratories significantly impact energy consumption, water use and waste production.Energy efficiency can reduce carbon footprint, water conservation can conserve water resources, and waste management strategies can minimise pollution risks.Green and sustainable laboratory practices can minimise energy and water use and the impact of hazardous chemicals without compromising health quality [3,4].However, there is a need for information on the total environmental impact of the consumption and production of medical laboratories.

Determining implementation goals for a green and sustainable medical laboratory
Laboratories in the healthcare sector need to strategize ways to minimize environmental impact while maintaining operational efficiency and high clinical standards.Professionals in laboratory medicine can achieve this through careful planning in four major areas: energy consumption, water consumption, waste generation and hazardous chemicals.Diminishing energy and water consumption lead to cost savings operating.Effective waste management, including reduction and recycling of chemical waste, helps to mitigate waste-related expenses.Medical laboratories should develop their goals based on the four fundamental areas and develop practices according to their laboratory infrastructure and financial capabilities.Professionals in this field have crucial tasks in the planning, organisation, and realization of all these issues.
For example, an important goal could be to reduce the use of blood tubes, which constitute a significant amount of solid waste in medical laboratories.In this regard, singletube implementation is required for tests [(biochemistry tube=immunochemistry, serology) or (cell blood count tube=sedimentation, HbA 1c , and haemoglobin electrophoresis)] that are performed on similar samples.Andreeva et al. reduced the number of tubes per test from 2.25 to 1.9 % after five years of single-tube implementation despite the increasing number of tests (10-12 %).Based on the cost analysis in the study, approximately 900,000 tubes and 150,000 euros were saved.The authors also detected a reduction of approximately 29 tons of carbon footprint during this period, indicating this implementation's environmental benefit [5].In 2019, Ross et al. reported that an Australian laboratory saved over $500,000 by implementing ISO 14001:2015, which included switching to double-sided printing of patient results, introducing digital reports, using LED (light-emitting diode) and motion-sensor lights, turning off unused equipment, and running air conditioning only for rooms in use after hours [6].
Wastewater from medical laboratories generally comprises chemicals, organic and inorganic compounds, heavy metals, acids, and bases, causing significant environmental damage.Medical laboratories generate an average of 500-1,000 L of wastewater daily.In many countries, including ours, this wastewater is discharged into city sewage systems, treated alongside domestic wastewater, if any, and then released into the environment [7].According to a guide published by the Turkish Biochemistry Association regarding laboratory and dialysis wastes, if the wastewater from laboratory devices is reported as non-hazardous, it can be discharged into the sewer by pH control and balancing.However, liquids containing cytotoxic and cytostatic flammability, reactivity, and corrosion substance(s) state that wastes cannot be discharged into the sewer system.The guide recommends determining whether liquid wastes have hazardous waste status due to their complex matrix [8].
Although many studies have been conducted on the management and treatment of hospital wastewater in the world in recent years, the number of studies on the characterisation and management of laboratory wastewater is limited.In the study conducted by Akın et al., it was demonstrated that the average concentrations of cadmium, chromium and lead concentrations in laboratory wastewater analysis were slightly above set by the standard values of the World Health Organization, Turkish Standards Institute, and the US Environmental Protection Agency [9].
The hazardous chemical content of laboratory wastewater varies depending on the characteristics of each laboratory.Determining whether these chemicals can be safely discharged into sewers is essential.Avoiding toxic chemicals, such as cyanide (commonly used in haematology analysers), and opting for reagents with less concentrated chemicals are crucial.Additionally, separately analyzing the resulting concentrated wastewater, employing appropriate disposal techniques, and recycling some environmentally toxic chemicals when possible are essential practices.Each laboratory should manage these aspects appropriately, creating a waste management plan tailored to their laboratory's wastewater matrix, providing training, and regularly reviewing practices.Effective management of these aspects will contribute to environmental sustainability and natural conservation.

Rational test ordering and sustainable green medical laboratory
EFLM encourages the transition to Green and Sustainable Medical Labs and has published a guide on this issue [3].According to this guideline, medical laboratories should define implementation goals for green and sustainable laboratories.The primary action towards those goals should be rational test ordering, as overusing laboratory tests is a widespread problem.Rational test ordering is both cost-effective and reduces the environmental impact of laboratories.For example, McAlister et al. calculated the carbon footprint per test to determine the environmental impact of clinical laboratory testing; carbon dioxide equivalent (CO 2 e) emissions for haematology tests were 82 g/test (95 % confidence interval (CI), 73-91 g/test) for the coagulation profile and 116 g/test (95 % CI, 101-135 g/test) for the complete blood examination.CO 2 e emissions for biochemical tests were 0.5 g/test CO 2 e emissions (95 % CI, 0.4-0.6 g/test) for C-reactive protein (low because typically ordered with urea and electrolyte assessment), 49 g/test (95 % CI, 45-53 g/test) for arterial blood gas assessment, and 99 g/test (95 % CI, 84-113 g/test) for urea and electrolyte assessment [10].The item that caused the most significant carbon footprint per test was the high amount of waste generated by the materials and tubes used for sample collection.Billions of tests performed in our country and worldwide create a significant carbon footprint.Efficient and rational test ordering practices can positively impact both the healthcare economy and the environment by effectively reducing the carbon footprint.
Turkey produced 449.724.90 kilotons of CO 2 e emissions in 2021 [11].However, to our knowledge, there needs to be data on CO 2 e emissions generated because of healthcare services and laboratory in Turkey.Research conducted in Australia determined that the total CO 2 e emissions in 2014-2015 were 494.930 kilotons, and CO 2 e emissions due to health services were 7 % of the total emissions in Australia [12].Although these rates will vary depending on countries and years, if we assume a rate of roughly 10 % for our country, approximately 40.300 kilotons of CO 2 e will be produced in health services.Let us take 116 g/test CO 2 e as a basis for whole blood analysis, as stated in the study of McAlister et al.The carbon footprint in our country is 14.000 kilotons of CO 2 e (3.8 % of the total amount of CO 2 e in our country), according to the total annual number of clinical biochemistry laboratory tests (approximately 1.2 billion tests).The carbon footprint will be reduced by reducing test requests by 2-20 %, depending on rational laboratory practices [10].This reduction will not only reduce environmental impacts but also reduce energy consumption and water consumption.At the same time, it will also lead to significant cost savings in health expenditures.

The way ahead
As laboratory professionals, we should do everything to create a sustainable, healthier environment.To create a green and sustainable culture in medical laboratories, current problems, and the point we want to reach in the future should be determined, and what can be done for this process without compromising the quality of healthcare should be planned.In this way, the first task of laboratory medicine professionals is to create and guide a permanent culture of the organisation in which all laboratory personnel participate.The most crucial action without cost in this regard is the training of the laboratory's hospital management team, clinicians, professionals, and staff.Continuous education and training programs should be created according to the procedures, instructions, and action plans established for the green and sustainable laboratory policy, and the impact of the training should be evaluated.This situation should be shared regularly with the relevant personnel.In the training given to clinicians, it is necessary to raise awareness that each laboratory test has a carbon footprint and encourage rational test ordering to contribute to the environment.
International and national laboratory associations have recently defined quality indicators for total testing processes in laboratory medicine [13].Over the years, the quality of the total testing process has improved and is now closely monitored.EFLM Task Force -Green and Sustainable Labs (TF-GLS) aims to establish guidelines, criteria, and critical recommendations for the performance of sustainable practices in clinical laboratories.In this process, they published a guide for transforming Green and Sustainable Medical Laboratories, a key document, and a checklist including chemical, energy, waste, and water topics [4].The EFLM -TF-GLS established a webpage for the application and assessment of the laboratory certification, from May 2023.With these advances, international and national laboratory associations should identify quality indicators for green and sustainable laboratories.Given the breadth of the concept of a green and sustainable laboratory, determining these indicators will indeed pose a challenge.These indicators should be grounded in scientific data, easy to comprehend, applicable over time, and adaptable to various types of laboratories (reproducible and cost-effective).This stepby-step process will eventually lead to laboratories becoming more sustainable and environmentally friendly organisations in the long term.In addition, by identifying and implementing green laboratory indicators, it will be a measurable and improvable issue.The data collected can be used to accelerate solutions to environmental problems.Thus, this will contribute to a sustainable future.