Objective To review the international literature and assess the ways healthcare systems are mitigating and can mitigate their carbon footprint, which is currently estimated to be more than 4.4% of global emissions. Design Systematic review of empirical studies and grey literature to examine how healthcare services and institutions are limiting their greenhouse gas (GHG) emissions. Data sources Eight databases and authoritative reports were searched from inception dates to November 2023. Eligibility criteria for selecting studies Teams of investigators screened relevant publications against the inclusion criteria (eg, in English; discussed impact of healthcare systems on climate change), applying four quality appraisal tools, and results are reported in accordance with PRISMA (preferred reporting items for systematic reviews and meta-analyses). Results Of 33 737 publications identified, 32 998 (97.8%) were excluded after title and abstract screening; 536 (72.5%) of the remaining publications were excluded after full text review. Two additional papers were identified, screened, and included through backward citation tracking. The 205 included studies applied empirical (n=88, 42.9%), review (n=60, 29.3%), narrative descriptive (n=53, 25.9%), and multiple (n=4, 2.0%) methods. More than half of the publications (51.5%) addressed the macro level of the healthcare system. Nine themes were identified using inductive analysis: changing clinical and surgical practices (n=107); enacting policies and governance (n=97); managing physical waste (n=83); changing organisational behaviour (n=76); actions of individuals and groups (eg, advocacy, community involvement; n=74); minimising travel and transportation (n=70); using tools for measuring GHG emissions (n=70); reducing emissions related to infrastructure (n=63); and decarbonising the supply chain (n=48). Conclusions Publications presented various strategies and tactics to reduce GHG emissions. These included changing clinical and surgical practices; using policies such as benchmarking and reporting at a facility level, and financial levers to reduce emissions from procurement; reducing physical waste; changing organisational culture through workforce training; supporting education on the benefits of decarbonisation; and involving patients in care planning. Numerous tools and frameworks were presented for measuring GHG emissions, but implementation and evaluation of the sustainability of initiatives were largely missing. At the macro level, decarbonisation approaches focused on energy grid emissions, infrastructure efficiency, and reducing supply chain emissions, including those from agriculture and supply of food products. Decarbonisation mechanisms at the micro and meso system levels ranged from reducing low value care, to choosing lower GHG options (eg, anaesthetic gases, rescue inhalers), to reducing travel. Based on these strategies and tactics, this study provides a framework to support the decarbonisation of healthcare systems. Systematic review registration PROSPERO: CRD42022383719. All datasets generated and analysed for this study, including the search strategy, list of the included and excluded studies, data extracted, analysis plans, and quality assessment are available in the article or supplementary material and upon request from the corresponding author. No individual participant data were used for this study.

中文翻译：

---

减少医疗保健对气候变化影响的战略和战术：系统评价


目的 回顾国际文献并评估医疗保健系统减轻和减轻碳足迹的方式，目前估计碳足迹占全球排放量的 4.4% 以上。设计 对实证研究和灰色文献进行系统评价，以研究医疗保健服务和机构如何限制其温室气体 （GHG） 排放。数据来源 检索了从建库日期到 2023 年 11 月的 8 个数据库和权威报告。选择研究的资格标准 研究小组根据纳入标准（例如，用英语;讨论了医疗保健系统对气候变化的影响）筛选了相关出版物，应用了四种质量评估工具，并根据 PRISMA（系统评价和荟萃分析的首选报告项目）报告了结果。结果 在确定的 33 737 篇出版物中，32 998 篇 （97.8%） 经标题和摘要筛选后被排除;其余出版物中有 536 篇 （72.5%） 在全文审查后被排除。通过反向引文跟踪确定、筛选和纳入另外两篇论文。纳入的 205 项研究应用了实证 （n=88， 42.9%） 、综述 （n=60， 29.3%） 、叙述性 （n=53， 25.9%） 和多种 （n=4， 2.0%） 方法。超过一半的出版物 （51.5%） 涉及医疗保健系统的宏层面。 使用归纳分析确定了九个主题：改变临床和外科实践 （n=107）;制定政策和治理 （n=97）;管理物理废物 （n=83）;改变组织行为 （n=76）;个人和团体的行动（例如，倡导、社区参与;n=74）;尽量减少旅行和运输 （n=70）;使用测量温室气体排放的工具 （n=70）;减少与基础设施相关的排放 （n=63）;以及供应链脱碳 （n=48）。结论 出版物提出了减少温室气体排放的各种战略和战术。这些措施包括改变临床和手术实践;使用设施层面的基准和报告等政策，以及财务杠杆来减少采购产生的排放;减少物理浪费;通过员工培训改变组织文化;支持有关脱碳益处的教育;以及让患者参与护理计划。提出了许多用于测量温室气体排放的工具和框架，但在很大程度上缺乏对倡议可持续性的实施和评估。在宏层面上，脱碳方法侧重于能源网排放、基础设施效率和减少供应链排放，包括来自农业和食品供应的排放。微观和中观系统层面的脱碳机制范围从减少低价值护理，到选择较低的 GHG 选项（例如，麻醉气体、救援吸入器），再到减少旅行。基于这些战略和战术，本研究提供了一个支持医疗保健系统脱碳的框架。系统评价注册 PROSPERO： CRD42022383719。 为本研究生成和分析的所有数据集，包括检索策略、纳入和排除的研究列表、提取的数据、分析计划和质量评估，均可在文章或补充材料中获得，并应通讯作者的要求获得。本研究未使用个体受试者数据。