The Pediatric Hospitalist’s Guide to Climate Action

Climate change is the “single biggest health threat facing humanity,” per the World Health Organization. It is a uniquely dangerous public health crisis because it affects human health and well-being across a person’s lifespan, regardless of race, ethnicity, or household income.1 From heat-induced dehydration and rhabdomyolysis, to asthma exacerbations triggered by wildfire smoke, to the health and mental health impacts of extreme weather events such as hurricanes and floods, pediatric hospital medicine (PHM) providers are battling the global climate crisis on the front lines. In addition to its direct health impacts, climate change is often dubbed a “threat multiplier” because of its downstream influences on environmental and social drivers of health.2 To complicate matters further, extreme weather events and environmental degradation threaten supply chains, health care facilities, and our ability to provide care to those who need it most. The synergistically negative impacts of climate change on pediatric health will worsen without prompt, substantive action.In the United States, health care generates 8% to 10% of all greenhouse gas (GHG) emissions, accelerating and exacerbating the climate crisis.3,4 Fortunately, PHM providers are uniquely well-positioned to drive meaningful climate action through their work. As leaders in high-value care (HVC) and quality improvement (QI), PHM providers are advancing the field of environmentally sustainable health care by avoiding low-value practices, optimizing resource use, and reducing waste in clinical processes. Environmentally sustainable health care aligns with goals to improve the quality, equity, and value of health care, all of which are threatened by climate change.5 Here, we describe how climate change impacts pediatric health and health care, and we propose a multifaceted framework through which PHM providers can conduct meaningful climate action (Table 1).Children’s unique susceptibility to climate-related impacts will significantly influence how care is used and delivered in the hospital setting. Children can be at high risk for heat-related illness due to increased surface area-to-mass ratios of their growing bodies, underdeveloped thermoregulatory capacities, time spent playing outside, and dependence on adult caregivers.8 Additionally, in utero exposures to extreme heat and air pollution have both been strongly associated with preterm birth and low birth weight.9,10 Much of our harmful air pollution is attributable to the combustion of fossil fuels; this pollution not only accelerates the human-driven climate crisis, but it also worsens asthma and other respiratory diseases.11,12 Vector-borne diseases—especially Lyme and dengue—are spreading to new areas as changing weather patterns make parts of the United States more hospitable to ticks and mosquitoes.8 Above-average temperatures, extreme heat events, deteriorations in air quality, and extreme weather events have all been shown to increase hospital use by pediatric patients.13,14Unpredictable variability in acute care use is one of many ways that PHM providers will experience impacts on their clinical practice. For children with homecare needs or technology dependence, extreme weather events and unexpected power outages can result in hospital admissions that would likely be otherwise avoidable. Caregivers of children with medical complexity have reported transportation difficulties, equipment failures, mental health impacts, and social isolation in the setting of extreme weather events.15 Additionally, climate-related disruptions to homecare services and supply chains can delay discharge and prolong length of stay. Following the unexpected shortage of intravenous fluids in the wake of Hurricane Helene, many families and PHM providers experienced difficulty—or the complete inability—to acquire the parenteral nutrition or fluids that their child needed. Even for hospitals and facilities that currently consider themselves to be geographically protected from extreme weather events, catastrophic supply chain disruptions have proven the ability to wreak havoc in all corners of the country. Unfortunately, we expect severe storms like Hurricane Helene to become more frequent in the coming decades because of climate change. By exacerbating social health factors, climate change disproportionately impacts rural, underserved, under-resourced, and minoritized communities.8 Maintaining adequate levels of staffing during unpredictable climate and weather events will prove challenging, especially in rural settings.The hospital setting presents an opportunity to deliver climate-informed care and guidance for patients and their families. Studies from outpatient settings have shown that patients are accepting of counseling that focuses on the connection between climate change and health.16 In the hospital setting, context-appropriate preventive counseling may help reduce readmissions for conditions that are climate-sensitive. For example, counseling on the air quality index can help mitigate risk exposure for patients admitted for asthma exacerbations, whereas guidance on hydration and the heat index can be provided to patients experiencing rhabdomyolysis, frequent outdoor exposures, or a lack of air conditioning. For children with special health care needs, discussions should ensure that families have disaster kits and emergency preparedness plans.17,18 Some aspects of primary care frameworks on climate change communication—such as easy-to-read discharge instructions and counseling for specific pediatric populations—can be used by PHM providers during direct inpatient care.19,20 Finally, PHM providers can help track the public health impacts of climate change by using International Classification of Diseases, Tenth Revision, Clinical Modification codes that capture climate-related causes of the primary admission diagnosis (Table 1).21While the health care sector scrambles to adapt to the reality of global warming, it must also confront itself as a disproportionately large producer of GHG emissions. If global health care was a country, it would be the fifth-largest emitter of GHGs in the world. The United States contributes far more than its fair share; per capita, the GHG emissions of American health care exceed those of any other nation’s health care sector by a wide margin, reflecting our long-standing difficulties in providing HVC.4 State-level health care GHG emissions are significantly associated with increased per capita health care spending, but they are not associated with improved quality of care.22 In 2019, Shrank et al estimated that low-value care (LVC)—the clinical decisions and practices that increase cost of care without improving outcomes—likely costs the US health care system between $75.5 billion and $101.2 billion annually.23In PHM practice, providers see financially and environmentally costly LVC manifest as prolonged use of intravenous antibiotics in lieu of enteral equivalents, the ordering of imaging studies that are not clinically indicated or evidence-based, and unnecessary use of single-use devices (SUDs) like stethoscopes and blood pressure cuffs. Our duty as providers to “first do no harm” includes minimizing LVC and the resultant GHG emissions that directly and indirectly worsen health outcomes for the patients and communities we serve.PHM providers—many of whom are leaders in HVC and QI—are uniquely well-positioned to improve the environmental sustainability of hospital-based care. Often, without realizing, providers are championing sustainable health care by choosing and following HVC practices. For example, timely transition from intravenous to oral medications—like in the case of acute osteomyelitis or community acquired pneumonia—can save a large amount of GHG emissions and improve family satisfaction, decrease length of stay, and decrease financial costs.24,25 PHM leaders can partner with infection prevention and control teams to optimize institutional policies on isolation precautions, which can decrease waste of personal protective equipment and facilitate more frequent interaction between patients and health care staff. PHM providers can also partner with hospital procurement and supply chain leadership to identify SUDs and products—like stethoscopes, pulse oximeters, and blood pressure cuffs—that could be recycled, refurbished, or replaced with reusable alternatives.26 Leveraging high-value clinical practices, processes, and resources can reduce wasteful resource use, driving both financial cost savings and GHG emission reductions.27PHM providers can advocate on behalf of children’s health to promote policies that encourage environmental sustainability. For example, dry-powdered inhalers (DPIs) represent an opportunity to advance sustainable health care because they generate far less GHG emissions than metered-dose inhalers. For this reason, DPIs are becoming more popular in many other countries.28 Currently, however, DPI availability and insurance coverage in the United States are suboptimal. By advocating at the policy level for expanded DPI access and coverage, PHM providers could help bolster the feasibility of lower-carbon asthma management in older children and adolescents, many of whom could use DPIs appropriately. Many regional and national organizations can assist providers with climate- and sustainability-focused advocacy efforts (Table 1). Similarly, there are a variety of educational resources and professional development opportunities that can empower PHM providers. By educating trainees and colleagues on sustainable health care and climate action, we will ensure that practice improvements are maintained and that policy advances are adopted broadly.In addition to practicing HVC, PHM providers routinely champion value-based care principles by reducing avoidable readmissions, optimizing care coordination, and standardizing evidence-based care.29 However, the widespread impacts of climate change threaten our success in improving key value-based population metrics, such as quality goals associated with prevention and chronic disease control.30–32 Thus, it is critical for both individual providers and health care systems to catalyze climate action and sustainable health care initiatives.33 At the institutional level, this work requires expertise in cross-disciplinary communication, team-building, and problem-solving—skills that PHM providers almost invariably possess. Importantly, PHM providers can demonstrate to hospital leadership that high-value, sustainable health care tangibly improves GHG emissions, community health and equity, and the financial costs of care. This work—which can be catalyzed by PHM providers—aligns closely with health institutions’ guiding missions and core values.Urgent action is needed to mitigate the negative impacts of climate change on children’s health, well-being, and access to care. We have a responsibility to our patients and communities to practice high-value, climate-smart health care. PHM providers are well-equipped and well-positioned to advance climate action through sustainable QI, advocacy, patient care, medical education, and institutional leadership.