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Sustainability in Radiology: How Can Imaging Services Go Green Without Compromising Care?

Sofia Franklin

shmf1g21@soton.ac.uk

University of Southampton

Introduction 

As our planet and population continue to face increasing threat from climate change, sustainable living must be everyone’s responsibility. Sustainability was defined by the 1987 United Nations Brundtland Commission as “meeting the needs of the present without compromising the ability of future generations to meet their own needs”¹. It is commonly divided into three pillars – environment, economy and society² – meaning that sustainable development should be environmentally responsible, economically valuable, and socially equitable.

Globally, health care produces 4.4% of annual greenhouse gas (GHG) emissions², with approximately 10% of the carbon footprint due to clinical radiology and radiotherapy waste³. The environmental impact from radiology services arises mainly from energy usage by energy-intensive equipment such as Magnetic Resonance Imaging (MRI) and Computed Tomography (CT) machines, generation and storage of huge amounts of data, and clinical waste from single-use products and radiopharmaceuticals³. As the demand for imaging services increases, so does the necessity for sustainable radiology that meets the needs of patient care in the present without jeopardising health care in the future.

Energy Consumption

The equipment within radiology departments uses large quantities of energy, with MRI using the most, followed by CT. Although highest energy requirements are during examination, Heye et al. found that 1/3 of MRI energy consumption occurred during the system-off state due to cooling operations, and 2/3 of CT energy consumption occurred during the non-productive idle system-on state⁴. This provides an opportunity for greener radiology through powering down imaging equipment when idle, particularly outside of core working hours. However, there is a risk that turning off the scanners could lead to patients facing delays in accessing urgent imaging which could impact their care. Therefore, some scanners should be left on to accommodate for emergency situations.

Other sources of energy wastage in radiology departments include workstations and lights being left on when not in use. An observational study by McCarthy et al. found that 67.4% of desktops and 92.6% of PACS reporting stations in a radiology department were left on overnight and at weekends⁵. These figures suggest a need for increased awareness amongst radiology staff around things they can do to reduce their environmental impact at work. As well as reminders to staff to shut down workstations when finished, automated shutdown/restart of workstations and motion-sensor lights are potential solutions to this energy wastage⁶. Cutting down on energy usage will be environmentally friendly and also economically beneficial to hospitals by reducing energy costs.

Value-based radiology – a concept that means considering the added value of providing a radiology service to the patient, healthcare system and society as a whole⁷ – is a key strategy to more sustainable radiology practice. Conducting only the necessary scans, those that would change management, is better for the environment and the economy of the healthcare system due to less energy consumption and single-use product waste. Social benefits include reduced workload for the staff and, for the patient, less time in hospital and less exposure to radiation and contrast agents. Doctors can use guidance such as the ‘Choosing Wisely’ initiative⁸ to help guide them in deciding which imaging investigations will provide value and which ones to avoid without compromising patient care.

Data Storage

Imaging services generate massive amounts of data each year. The problem with this is that all the data generated require transfer and storage. Data centres are large buildings with servers that require significant amounts of energy to power their operations and water to cool their servers. A 2021 study reported that data centre water consumption in the USA alone was 1.7 billion litres of water a day⁹. This figure is expected only to grow with the increase in use of artificial intelligence (AI). 

Actions such as removing duplicate and redundant data, then compressing the remaining data could be taken to reduce storage needs and therefore the associated energy and water requirements¹⁰. However, one could argue that restricting storage could compromise patient care as deleting older images means loss of images for comparison to new imaging which is vital in radiology. Since data centres will continue to require large amounts of energy, a shift to renewable energy sources should be encouraged.

Artificial Intelligence

The boom in the use of AI in radiology provides many opportunities as well as detrimental effects on the environment and healthcare services which will continue to become apparent as technology progresses. 

Firstly, developing new AI models uses huge amounts of energy and water, with many tools using deep learning techniques with high computational requirements. Once the AI model is put into use, energy consumption and GHG emissions often exceed those from training by an estimated magnitude of hundreds to thousands of times higher¹¹. With rapidly progressing technologies and introduction of new AI systems, the hardware components required for these will often be discarded before reaching the end of their lifespan, replaced by newer, more capable systems. The resulting electronic waste can be an environmental hazard due to contamination of soil and water from toxic substances contained in these components¹¹.

When considering the social sustainability of AI, it is important to understand that AI models are trained using existing datasets in which minority populations can be underrepresented, leading to biased algorithms which potentiate existing healthcare disparities. Therefore, the datasets used to train these models must be monitored to ensure they are representative of the population.

Whilst taking into account the risks associated with AI, it can also be used in helping radiology services go green. As discussed previously in this essay, CT and MRI scanners use significant amounts of energy when not in active use. By monitoring and analysing patterns of active and idle states during radiology examinations, AI could potentially be used to automatically switch between these using predicted patterns of use. This would be both environmentally and economically beneficial by reducing energy consumption and GHG emissions¹⁰. 

Another opportunity AI could offer is supporting clinicians in making value-based imaging decisions. Considering factors individual to the patient, a personalised recommendation could be made using an AI tool which can then be used in conjunction with clinical judgement to reduce low-value imaging¹⁰. However, these tools must be rigorously tested and monitored to ensure patient safety. 

Single-Use Products and Contrast Waste

Hospitals generate huge amounts of clinical waste daily and radiology services, particularly Interventional Radiology (IR), play a big role in this due to conducting many procedures. Despite being relatively short, these procedures generate high volumes of waste from single-use products such as syringes, catheters, wires, sterile drapes, gowns and gloves as well as the packaging these come in. One study investigating the burden of waste in manufactured IR products found that 54.8% of the overall weight of IR products tested consisted of waste. The study also reported that 76% of the overall waste was recyclable, highlighting the importance of recycling where possible¹². 

Actions radiology departments could take to be more sustainable include reducing contents of procedure packs to exclude commonly unused items and working with manufacturers to minimise excessive packaging and make packaging easier to recycle. Also moving away from single-use products in favour of safely re-usable items such as instruments and gowns⁶, processed at the highest standards to avoid increasing infection risk.

Attention must also be paid to the potential environmental effects of radiopharmaceuticals. Increasing contamination of water sources by both iodinated and gadolinium contrast media have been reported^13,14. Around 300 million CTs happen globally each year, meaning an estimated 10 million litres of iodinated contrast media agents enter the ecosystem³, including surface water and drinking water. With emerging evidence of negative environmental effects of contrast breakdown products¹⁵, steps to reduce the amount of contrast media being used and safer processing of excreted contrast media should be taken.

Firstly, radiologists can be more careful with decisions to use contrast. Patient’s urine could then be collected after examinations using contrast for special processing¹³. However, this may create extra burdens for patients and staff with extra time spent in the department.

Conclusion

Imaging services have a responsibility to make the changes to go green for the good of our planet, our patients and our population. Key areas such as energy consumption, data storage and waste management should be targeted and changes most likely to be adopted should be prioritised. Radiologists in training should be taught about sustainability in their curriculum, from medical students through to consultants, to create a culture of sustainability within radiology. To protect patient care in the future changes must be made, but safely, along with audits and continuous quality improvement, so the care of patients in the present is the best it can be.

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