How to make medical transport more sustainable

As part of the Galician Health Service (SERGAS), the Ourense Health Area serves 92 municipalities with a population of 300,000, comprising one university hospital and two regional hospitals with more than 1,105 beds, 103 primary care centers, and 14 primary care emergency centers. The Ourense hospitals employ 3,600 people. The Ourense province is impacted by an aging, shrinking population. It faces many extreme weather events and often experiences the highest temperatures in Europe.

At SERGAS, Scope 1 emissions account for 14% of the hospitals’ total emissions. Medical transport and mobile combustion fall under this category of emissions, meaning they are under the direct control of the medical sector (Health Care Without Harm Europe, 2022). SERGAS is currently working to reduce the emissions from its fleet vehicles, which produce approximately 55.57 tons of carbon dioxide equivalent (tCO2e) annually. To achieve this, the Ourense hospitals launched a project to introduce electric ambulances.

• To reduce the use of fossil fuel vehicles
• To decarbonize medical transport activities
• To improve air quality
• To adopt eco-efficiency strategies that reduce energy consumption
• To improve medical transportation
• To promote sustainable health care 

The Ourense hospitals’ involvement in sustainability projects started in the early 2010s with their participation in the project Hospital 2050, which aimed to create a more green, sustainable, and energy-efficient hospital through a health innovation plan. The Ourense hospitals, together with SERGAS, have participated in a number of sustainability projects and initiatives, including acting as a pilot hospital in the Life Resystal project, joining the European Network of Living Labs, developing a circular economy strategy, and carrying out an organic waste project in collaboration with the University of Vigo.

Within the SERGAS mitigation framework, since 2018 Ourense hospitals have developed a strategy to decarbonize the transport of patients and professionals. It started in 2019 with the use of the first electric vehicles for the transport of home care medical personnel, also used during the COVID-19 pandemic. After converting in 2021 to hybrid technology for the entire fleet of vehicles used by professionals, it became necessary to continue transporting patients since it had a high environmental impact with more than 175,000 trips per year.

This project promotes the decarbonization of medical transport activities by reducing GHG emissions and the adoption of eco-efficiency strategies to reduce energy consumption.

In January 2021, the Ourense Health Area had the option to select a new provider for their medical transport. The new contract signed in July 2021 has a duration of three years with the possibility of a two-year extension. The company specialized in medical transport but not electric vehicles, so it was given time to renew and adapt its fleet, as well as adjust routes to the shorter range of the ambulances. The annual cost of the service is almost 5 million euros.

Complementary medical transport includes all scheduled rides from patient homes to the hospital for various medical procedures, such as radiotherapy, rehabilitation, or hemodialysis, and transfers between the three hospitals of the Ourense Health Area and beyond. 

A new contract was tendered in January 2021 from the Ourense Health Area for all patients covered, or 300,000 people. The initial duration of this contract was established at three years with an extension of two additional years. The annual cost of this service is almost 5 million euros, and the maximum tender amount was established at 14.9 million euros for the three-year contract.

Sustainable awarding criteria were used: 15 points out of 100 were established for the provision of vehicles that use clean energy, awarding one point to each hybrid vehicle and two points to each vehicle free of fossil fuels.

After the contract was awarded, the successful bidder had a period to renew its fleet according to its offer.

Within this fleet, there are three types of ambulances:

1. Life support for individual transport of critical patients.
2. Basic support for transfer on a stretcher.
3. Collective ambulances for small groups of patients. 

These three types of ambulances were selected based on the characteristics and limitations of this kind of transport rather than the specific needs of the hospitals. Electric ambulances meet the requirements for basic support and are typically used for journeys between Ourense hospitals. They are also typically used for non-urgent patients, as being loaded with more patients and equipment lowers their range. Charging stations were installed in all three Ourense hospitals, but few charging stations are available in the Ourense province. Consequently, the transport company preferred to use electric ambulances to only cover routes between the three hospitals.

The contract does not ask for a specific number of vehicles but establishes their presence in the three hospitals at certain times. Given the uncertainty surrounding the COVID-19 pandemic, needs in 2021 were established at 175,000 trips per year, of which 80% would correspond to regular transport and 20% would be on demand. Fifteen electric vehicle charging stations were installed for the provision of clean energy vehicles, with one station for each hybrid vehicle and two stations for each fully electric vehicle.

To measure the project’s success, the hospitals compared their electric ambulances with existing ambulances in their fleet in terms of fuel and financial savings. When using a private charging point, electric ambulances used 97% less fuel, leading to an 80% reduction in CO2 emissions. Additionally, more than €22 was saved per 102km (the length of a standard ambulance route), which means that there is an excellent economic incentive in addition to the tremendous environmental impact. Between May 31 and Sept. 27, 2022, the two electric ambulances covered 2% of the total distance traveled by the fleet, LPG ambulances covered 6%, and diesel ambulances 92%.

• 97% financial savings due to reduced fuel consumption
• 80% reduction of CO2 emissions

Electric ambulances represent an environmental improvement and help Ourense hospitals reduce their carbon footprint. These vehicles are extremely beneficial as a complementary service and for the individual transport of patients. They also represent significant economic savings and a rapid return on investment.

Despite their excellent performance, electric ambulances pose a series of challenges: 

• They require specific infrastructure with fast charging stations at health care facilities and along the routes. It is necessary to improve this network of charging stations in the Ourense region. 
• Although the nominal range of these vehicles is 400 km, once they are equipped and loaded, their range is reduced to approximately 280 km.
• These vehicles require specialized maintenance and qualified workshops that are not widespread in the Ourense region.
• Since May 2022, the fully electric ambulances have worked in a complementary manner. They are being used for individual patient transfers, but not for collective transport or critical patients.

To improve the efficiency and reliability of electric ambulances, vehicles can be equipped with a complementary energy source such as hydrogen. New innovative energy sources such as green hydrogen will also enable greater autonomy. As a next step, Ourense hospitals aim to ensure their complementary medical transport becomes 100% electric.

Designing a net-zero roadmap for health care (Health Care Without Harm Europe, 2022)