Environmental Benefits of Reducing Patient Mobility and Hospitalization

Abstract

New healthcare management strategies aim to reduce in-person visits and patient hospitalization while ensuring patient safety. These strategies optimize resources, alleviate pressure on healthcare services, and decrease travel and mobility within healthcare environments. This research analyzes the environmental impact and sustainability associated with transportation and mobility in traditional hospital-based healthcare services, which have been relocated to bring healthcare closer to patients. This retrospective study utilizes data from two hospital centers spanning the years 2021 to 2023. The objective is to highlight the environmental benefits and sustainability of providing healthcare in the patient’s environment. The methodology employs life cycle analysis to compare three scenarios: traditional healthcare in hospitals, healthcare provided at the patient’s location through home hospitalization and medical consultations at nearby health centers, and healthcare professionals’ travel using electric vehicles. The results demonstrate that healthcare professionals traveling to the patient’s home or nearby health centers reduce environmental impact across all analyzed impact categories. Promoting home hospitalization, specialized consultations at local health centers, and primary care can effectively reduce unnecessary patient travel and minimize environmental impact, enhancing sustainability. Health policies should prioritize actions to reduce hospital visits, emphasizing prevention over disease treatment. Such practices would not only benefit patients but further promote sustainability and environmental protection.

1. Introduction

In the last decades, vehicle-generated polluting emissions have decreased due to the development and application of new automotive technologies. Nonetheless, transportation remains one of the main sources of environmental pollution to date. Data from the European Environment Agency (EEA) reveal that transport is the only major economic sector in the EU with increased greenhouse gas emissions over the past 30 years. In 2021, transportation was responsible for nearly a quarter of the greenhouse gas emissions (GHG) in the European Union (see

Table 1. Sectoral shares in EU in 2021–2022 (Kt CO₂ eq) [2].

Sectors	Kt CO2 eq
	2021	%	2022	%
Energy Supply	901,625	26%	926,100	27%
Domestic Transport	782,101	23%	803,284	24%
Industry	757,474	22%	684,431	20%
Residential and Commercial	454,640	13%	400,290	12%
Agriculture	378,430	11%	365,719	11%
International Shipping	129,086	4%	130,645	4%
Waste	109,284	3%	109,723	3%
Other Types of Combustion	88,147	3%	109,707	3%
International Aviation	69,754	2%	85,212	3%
Land Use, Land Use Change and Forestry	−229,985	−7%	−236,402	−7%

), of which 71.7% came from road transport [1].

Health systems worldwide produce 2 gigatons (GT) of CO₂ equivalents, which represents 4.4% of global greenhouse gas emissions, or the emissions not reduced by 514 coal-fired power plants [3].

The healthcare system in Spain is primarily structured around hospitals and health centers. Hospitals serve as major hubs of mobility, with patients, users, and workers accessing these facilities through a multitude of transportation modes, including ambulances, private motor vehicles, public transport, as well as freight delivery activities related to services and material resources.

An earlier study [4], which calculated environmental efficiency indices in a hospital in La Rioja, Spain, concluded that the environmental impact caused by the transport of workers, patients, and goods is the most significant contribution to the studied environmental efficiency indices. The results of this research indicate that transportation and material consumption have the greatest impact on hospital environmental efficiency among the global environmental indexes. Hospital centers are in continuous operation throughout the year. These facilities are analogous to small cities, not only in terms of the number of patients who utilize their services but also in regard to the multitude of individuals, employees, and goods transported to and from the facility, which, in many instances, surpasses the population of a typical small town. The high mobility that occurs within healthcare facilities contributes significantly to overall CO₂ emissions. Consequently, hospitals are increasingly considering the calculation of their carbon footprint as an indicator of their environmental impact. For example, Andrews et al. [5] conducted an analysis of the carbon footprint of patient transport in the United Kingdom. The carbon footprint of the National Health System is distributed as follows: 17% is due to transport (including patient transport, which accounts for approximately 8%), 24% is due to energy consumption, and 59% is due to the procurement of materials. These findings underscore the importance of directing efforts towards reducing emissions in these areas, implementing effective measures to mitigate their environmental impact, and promoting more sustainable practices in the healthcare sector.

At present, Spain is under the parliamentary process of approving the Sustainable Mobility Law, thus fulfilling its commitment to the European Commission in compliance with the milestones and objectives of the PRTR, as this law is one of the reforms committed by Spain under the Recovery, Transformation, and Resilience Plan (PRTR in Spanish) [6]. Within the first section, the State Strategic Mobility Planning Instrument (IPEEM in Spanish) and its equivalent for the Autonomous Communities are established. This includes obligations for the development of sustainable mobility plans for local entities, major activity centers, and sustainable commuting mobility plans.

In Spain, hospitals are increasingly aware of the high mobility associated with their activities, and some have developed Mobility Plans (e.g., La Paz University Hospital in Madrid, Virgen de Las Nieves University Hospital in Granada) with the aim of improving access for patients, families, and employees, thus reducing emissions, and promoting environmental sustainability.

The use of digital health techniques, the establishment of home hospitalization units, and the implementation of all measures that facilitate the proximity of healthcare professionals to the patient’s environment are key strategies in this regard. The same applies to streamlining management and contributing to a reduction in the number of trips and an enhancement of mobility within the hospital environment.

The use of telemedicine has expanded across all Spanish regions over the past three years, primarily in its telephone modality, to address specialties such as pediatrics, gynecology, psychiatry, or dermatology, a high percentage of which do not require in-person visits (see

Table 2. Appointments conducted in Spain in 2020/2021/2022 [10].

Year	Number of Appointments		% Telemedicine
	Hospital	Telemedicine
2020	134,980,670	105,675,718	44%
2021	122,165,633	137,237,298	53%
2022	153,381,709	100,329,423	40%

). It is also used for conditions where imaging is crucial, such as neurology, tele-stroke, or radiology [7,8,9].

According to the latest available data, in 2021, just over half of all consultations in Spain (52%) were conducted remotely.

Driven by the emergence of the pandemic and its impact on hospitals and healthcare centers, telemedicine was widely adopted across all autonomous communities in Spain starting in 2020, increasingly solidifying its presence in the National Health System. Its potential is exceptional as it helps alleviate waiting lists and consultation overload, simplifies bureaucracy, and optimizes resources by avoiding unnecessary travel for both patients and healthcare professionals.

The use of digital health techniques such as telemedicine, artificial intelligence, and patient telemonitoring not only facilitates management and more efficient diagnosis but also promotes environmental benefits by reducing the number of trips and improving mobility within hospital environments.

Until recently, the only way to receive a diagnosis or administer intravenous treatment was through hospitalization. However, today there are other alternatives, and the patient’s home is even becoming ‘part of the hospital’.

There are alternatives to conventional hospitalization to avoid admitting patients who require clinical monitoring and hospital treatments, such as home hospitalization (HH) or telemonitoring. These alternatives involve ‘bringing the hospital’ to the patient’s home, where they are attended to by healthcare personnel and using hospital resources. Bringing the hospital to the patient’s environment allows for a new care model in a familiar environment that promotes recovery, involving their usual surroundings.

Home hospitalization is defined as an alternative care option capable of conducting diagnostic and therapeutic procedures at home, providing care analogous to that offered in hospitals [11]. It is delivered by specialized healthcare professionals for a limited period to patients who would otherwise require hospital care in any of its areas [12].

To receive care through the home hospitalization unit (HHU) first requires the patient’s voluntary acceptance after complete information about this type of assistance. Secondly, the patient’s clinical stability of the condition is crucial, defining clinical stability as not foreseeing acute worsening requiring intensive care in the short term.

New healthcare management strategies aimed at reducing in-person visits and patient hospitalization while always ensuring patient safety, which enables resource optimization, contributes to alleviating pressure on healthcare services, and reduces travel and mobility within healthcare environments. Analyzing the environmental impact of healthcare strategies that bring care closer to the patient’s home can provide necessary information to facilitate decision-making and the adoption of measures in healthcare, thus promoting environmental sustainability.

This research aims to analyze the environmental impact caused by transportation and mobility generated by healthcare services traditionally provided in hospitals, which have recently been relocated to bring healthcare closer to the patient’s environment.

2. Literature Review

A review of the literature has revealed a growing trend in recent years of studies analyzing the digital transformation of the healthcare sector [13,14,15,16]. For example, Bevere et al. [17] examine the current digital and ecological transition in the healthcare sector. They emphasize the increasing relevance of sustainability given its high energy consumption. Alajlan et al. [18] also highlight the significance of considering the sustainability of digital solutions being implemented in the healthcare sector. They propose a sustainability model and evaluation of digital solutions to allow for a more detailed and systematic assessment of proposals. With the same perspective, Sepetis et al. [19] suggest combining factors of digital transition and social, environmental, and corporate governance to enhance sustainability and resilience in the healthcare sector.

The application of new technologies and the digitalization of healthcare systems has resulted in a shift in traditional medical practice and patient care [20]. Initially driven by technological development, which led to the emergence of platforms offering virtual and home-based services to individuals [21,22,23,24,25], public administration, and private entities, this trend was notably accelerated by the coronavirus pandemic crisis [26]. Tebeje and Klein [27] conducted a systematic literature review identifying 60 articles showcasing the utilization of digital technologies in the healthcare system. They emphasize the potential of these technologies to enhance the quality and personalization of the healthcare system during the pandemic. For instance, Gajarawala and Pelkowski [28] concluded that patients utilizing telemedicine underscore efficiency, convenience, comfort, and privacy as key elements of this technology. Despite existing barriers such as the usage of technology by older individuals, lack of broadband connectivity in rural areas, potential security breaches, or regulatory limitations, the acceptance and implementation of telemedicine are on the rise as technologies advance. It is also crucial to note that from the healthcare system perspective, evaluating interventions employing digital technologies is imperative. Murray et al. [29] analyzed the challenges posed by such evaluations and presented an evaluation strategy to facilitate the assessment of such interventions, providing pertinent information for administrative and policy decision-making.

The environmental benefits of telemedicine have been the subject of numerous studies [30,31,32] analyzing the balance between clinical use and its economic and environmental impact. Authors like Purohit and Tsagkaris [33,34] conclude that telemedicine does reduce the carbon footprint of healthcare, primarily by reducing emissions associated with transportation. Blenkinsop and Foley [35] analyze the reduction in environmental impact associated with the utilization of telemedicine in specialized services for epilepsy. The authors observed that the use of these technologies with 1200 patients led to a reduction of 224,000 km in transportation and a decrease in associated environmental impact by approximately 35,000 kg CO₂ eq. They concluded that in the case of specialized services for epilepsy, telemedicine usage can contribute to minimal environmental impact on clinical outcomes.

Several analyzed studies [36,37] indicate that home healthcare for certain disease groups can safely substitute hospital care for the patient, while other studies [38,39] highlight that home care for acute patients is a cost-effective alternative, both for shortening hospital stays and preventing admissions, thus alleviating hospital congestion. Home hospitalization is a care model delivering medical and nursing care, typically provided in a hospital setting, at the patients’ homes. This has evolved to a point where they no longer require hospital infrastructure, although they still need active medical monitoring and complex assistance. Numerous pathologies can be managed through home hospitalization, ranging from post-surgical care to oncological diseases or acute conditions monitoring. The rise in chronic illnesses and multiple pathologies due to increased life expectancy makes home hospitalization an increasingly prevalent option. Data used for the study indicate that home hospitalization admissions account for between 6 and 7% of hospital admissions. To assess the environmental impact, the notion was considered that these same patients, if not hospitalized at home, would have been admitted to the reference hospital.

3. Methodology

3.1. Research Context

This research focuses on a case study of the public hospital healthcare network in La Rioja, located in northern Spain, serving the healthcare needs of a population of 319,914 citizens (data from 2020) spread across 174 municipalities. Hospital healthcare services are mainly provided by two hospitals: Hospital 1, located in the capital of the autonomous community of La Rioja, serving a total of 312,996 users with health cards, and Hospital 2, located in the lower Rioja region with a reference population of 72,717 inhabitants (Figure 1).

Both institutions offer a wide range of healthcare services, documenting their annual activities categorized by medical specialties in their annual reports.

Twenty years ago, two decentralized healthcare services emerged to avoid patient travel and bring hospital care closer to patients’ homes, nursing homes, or the nearest health centers. These services are home hospitalization units (HHU) and consultations conducted at health centers closest to the patient.

3.1.1. Home Hospitalization Unit (HHU)

The home hospitalization unit (HHU) began operations in Hospital 1 in 2004 and completed its development in the La Rioja Autonomous Community with the opening of the unit in Hospital 2 in 2007. Thus, home hospitalization units are available in all public hospitals, covering 99% of the population of La Rioja.

The healthcare activity performed by HHUs is measured using the same activity indicators as conventional hospitalization. The data collected for the activity conducted during 2021, 2022, and 2023 are shown in

Table 3. Hospital admissions/home hospitalization admissions.

Year	Discharges			Admissions			Census Stays			Average Stays (Days)
	Hospital	HH	% HH/h	Hospital	HH	% HH/h	Hospital	HH	% HH/h	Hospital	HH
2021	25,292	1860	7.4%	25,803	1843	7.1%	162,543	26,945	16.6%	5.48	14.64
2022	26,118	1732	6.6%	26,381	1762	6.7%	166,047	26,787	16.1%	5.36	15
2023	25,061	1886	7.5%	28,313	1894	6.7%	180,646	28,542	15.8%	5.29	14.17

.

Home hospitalization unit (HHU) travels are conducted from each of the hospitals using vehicles driven by healthcare professionals to the patient’s home or the socio-healthcare center where the patient is located.

Since the creation of these HHUs in the hospitals of La Rioja, the necessary vehicles have been provided for the professionals under a rental scheme to enable their movements. Since 2017, the 16 vehicles used by the HHUs of the two hospitals are hybrid vehicles that are periodically renewed every 4 years through a public tender process.

In planning HHU activities, routes across the region are optimized to reach patient locations, considering daily routes, distances, and patient visits.

3.1.2. Consultations at Primary Healthcare Centers

Another activity used to provide healthcare, which also helps avoid patient and family travel to hospital centers, involves moving healthcare personnel (doctors and nurses) from the hospital to the nearest health center when possible. Normally, these consultations are conducted within hospital premises.

In the two hospitals under study, several healthcare specialties converge, allowing medical consultations to be conducted at health centers and bringing care closer to the patient’s location instead of at the hospital (See

Table 4. Consultations at hospital/consultations with specialists traveling to health centers.

Item	Year
	2021	2022	2023
Number Hospital consultations	496,643	508,848	555,650
Number of consultations outside the hospital	43,730	35,867	36,761
% consultations outside the hospital	8.8%	7.0%	6.6%

).

From Hospital 1, there are 11 health centers distributed across the La Rioja Alta area where healthcare personnel travel. From Hospital 2, healthcare personnel travel to 2 health centers that serve the largest population in the lower La Rioja area.

In this case, the activity of the traveling healthcare personnel is optimized by scheduling appointments to attend to the maximum number of patients in the area on a single day. Initial consultations are scheduled for 15 or 20 min, depending on the healthcare specialty, and follow-up appointments are allocated 10 min in the schedule. Thus, during a morning session, traveling doctors attend to an average of 22 patients.

These decentralized healthcare activities require, in addition to having a fleet of vehicles, efficient route and travel management.

The study focuses on environmental analysis utilizing available healthcare-level data, considering patients’ residential locations, their relationship to reference hospitals, and the fulfillment of requirements for home hospitalization. Admission to a home hospitalization unit involves patient selection based on a review of their status and adherence to specific criteria: confirmed diagnosis, clinical stability, presence of a primary caregiver, and telephone communication availability. Additionally, patients must voluntarily agree to their home admission. The admission is of limited duration and must occur in a residence meeting the specific distance criteria from the corresponding hospital. One determinant of patient safety at home is their socioeconomic status, as it determines their available resources and living environment [40]. However, despite the home’s significance in home hospitalization safety, home characteristics and conditions are not exclusion criteria during admission assessment, as they are discovered post-patient transfer.

The research conducted is a retrospective study using information obtained from the two hospital centers for the years 2021, 2022, and 2023, aiming to highlight the environmental benefits of healthcare provided in the patient’s environment. This includes reducing mobility within hospital environments and promoting the movement of healthcare professionals (doctors and nurses) to provide healthcare in patients’ homes, health centers, or nursing homes. For admission to a home hospitalization unit, a patient must have a primary caregiver. This caregiver may reside in the same household or commute to the patient’s residence. The study did not include potential commutes of the primary caregiver due to the lack of caregiver-related data, with only patient data available. The data employed for the study suggest that home hospitalization admissions account for approximately 6 to 7% of total hospital admissions. To allow for an environmental impact comparison, it has been considered that these same patients, if not treated at home, would have been hospitalized at the reference facility.

3.2. Data Collection

The methodology used for this study employed life cycle analysis to compare the environmental impact arising from three scenarios: traditional healthcare (hospital admissions and consultations conducted at the hospital), the environmental impact of healthcare provided at the patient’s location through home hospitalization and medical consultations at health centers near the patient, and finally, the scenario where healthcare professionals travel using electric vehicles (see Figure 2). The study contrasts the distances between patients’ residential locations and the two hospitals under study. Data analysis revealed minimal feasibility of walking to the hospital, primarily due to the remote suburban location of the study hospitals. Public transport, walking, scooters, or bicycles were not considered in this study. Due to patients’ health status and the distance to the studied hospitals, personalized transportation, typically via private vehicles, is required. Scenarios 1 and 2 analyze situations where healthcare is provided near the patient’s home, including environmental analysis for healthcare personnel commuting to patients’ homes or primary care centers. Primary care centers are geographically spread across the autonomous community, catering to patients within a close radius to provide basic and initial healthcare. This study examines hospital healthcare professionals’ commutes to primary care centers to provide services typically offered in hospitals, potentially reducing hospital congestion by expanding primary care center usage.

In Scenario 1, professionals commute using combustion vehicles, while Scenario 2 involves electric vehicles for transportation.

The study includes the activities conducted by the two hospitals under study, where a life cycle analysis was performed to assess the potential reduction in transport-related impacts from activities of 16 healthcare specialties conducted at health centers (cardiology, general and digestive surgery, etc.).

Depending on the patient’s condition and clinical practice, these specialties are sometimes suitable for use in locations outside the hospital premises. Some consultations do not require specialized equipment and can be conducted in a primary care center.

To obtain inventory data related to the transport of these activities, the distances traveled for the movements in three scenarios were calculated. The study has mapped the commutes and routes taken by healthcare professionals to reach patients. The two analyzed home hospitalization units are divided into 10 zones within their geographic area. Daily visits, typically ranging from 6 to 10 visits/day, are manually planned by healthcare professionals considering factors such as patient pathology complexity, treatment, zone, and travel times. This route planning aims to maximize patient care efficiency within the workday. Analysis of route data highlights the need for improved route planning methods, models supporting zoning decisions, and automation to enhance service efficiency, potentially reducing time and costs while improving environmental impact.

After collecting and structuring the data related to analyzed healthcare transport, the environmental impacts were calculated. The software chosen for the study is SimaPro v.9.1^®, a professional tool for calculating environmental, social, and economic impacts associated with a product throughout its life cycle. Using the CML-IA baseline V3.05/EU25 calculation methodology, environmental impacts were evaluated, classified, and assessed in 11 impact categories. The impact categories analyzed were as follows:

Abiotic Depletion (AD): This impact category concerns the safeguarding of human well-being, human health, and ecosystem health and is associated with the extraction of minerals and fossil fuels resulting from inputs into the system. The Abiotic Depletion Factor is calculated for each extraction of minerals and fossil fuels (kg antimony equivalents/kg extraction) based on the reserve concentration and rate of deaccumulation [41].

Fossil Depletion (ADF): This category maintains the same foundation as the Abiotic Depletion category but focuses on fossil fuels, utilizing their reserves expressed in Megajoules (MJ) as a reference point [42].

Global warming potential (GWP): Climate change can lead to detrimental impacts on ecosystem health, human health, and material prosperity and is linked to the release of greenhouse gases into the atmosphere. The climate change factor is quantified as the global warming potential for a 100-year timeframe in kg carbon dioxide/kg emission [41]

Ozone layer depletion (ODP): This impact category is associated with the proportion of UV-B radiation penetrating the Earth’s surface. The characterization model is devised by the World Meteorological Organization (WMO) and delineates the ozone depletion potential of various gases (kg CFC-11 equivalent/kg emission) [41].

Human toxicity potential (HTP): This category is associated with the exposure and repercussions of toxic substances over an infinite timeframe. The human toxicity potential for each toxic substance is expressed as 1,4-dichlorobenzene equivalents/kg emission [41].

Freshwater Aquatic Ecotoxicity Potential (FAETP): This impact category is concerned with the consequences on freshwater ecosystems resulting from the release of toxic substances into the air, water, and soil over an infinite timeframe. The ecotoxicity potential for each toxic substance is quantified as 1,4-dichlorobenzene equivalents/kg emission [41].

Marine Aquatic Ecotoxicity Potential (MAETP): This category focuses on the repercussions on marine ecosystems. Similarly to the human toxicity potential, the eco-oxicity potential is expressed as 1,4-dichlorobenzene equivalents/kg emission [41].

Terrestrial Ecotoxicity Potential (TETP): This impact category is linked to the impacts on terrestrial ecosystems. Analogous to the human toxicity potential, the ecotoxicity potential is expressed as 1,4-dichlorobenzene equivalents/kg emission [41].

Photochemical Oxidant Creation Potential (POCP): This category is associated with the generation of reactive substances (primarily ozone) that are harmful to human health and ecosystems and can also harm crops. The impact potentials are expressed as an emission equivalent of the reference substance ethylene, C₂H₄ [43].

Acidification potential (AP): This impact category is related to the acidifying substances that induce a variety of effects on soil, groundwater, surface water, organisms, ecosystems, and materials. The primary acidifying substances include SO₂, NO_X, HCl, and NH₃. For emissions into the atmosphere, the acidification potential is defined as the number of H⁺ ions produced per kg substance in relation to SO₂ [44].

Eutrophication potential (EP): This category is connected to all effects arising from excessive levels of macro-nutrients in the environment caused by the release of nutrients into the air, water, and soil. Nitrogen (N) and phosphorus (P) are the two nutrients most closely associated with eutrophication. Eutrophication potentials are expressed as PO₄₋ equivalents [44].

3.2.1. Base Case: Traditional Healthcare

In the base case, the environmental impact caused by the transport of patients treated within the hospital itself, whether for hospitalization or medical consultations, was calculated. Data related to treated patients were analyzed to obtain the distance, in kilometers, they would have traveled from their residence to the hospital and back.

For hospitalized patients, a round-trip was estimated for each hospital admission from their place of residence. In this case, patients only travel once to the hospital and once back. The number of days spent in the hospital does not affect this calculation. The study does not consider information regarding accompanying individuals as those data are not available.

In contrast, home hospitalization requires healthcare professionals to travel for a greater number of days, depending on the patient’s condition and the length of their stay at home.

The data set includes information on the distance traveled by patient’s vehicles to reach the hospital for the years 2021, 2022, and 2023 (see

Table 5. Kilometers traveled by patients.

Item	Unit	Year
		2021	2022	2023
Home hospitalization unit (HHU)	km	211,440	227,280	240,720
Consultations outside the hospital	km	2,623,800	2,152,020	2,205,660
Total	km	2,835,240	2,379,300	2,446,380

).

To calculate the environmental impacts in the base case, the fleet of patient vehicles was considered according to the following distribution by fuel type [45]:

• Gasoline: 39.5%;
• Diesel: 55.7%;
• Electric: 4.8%.

The distribution regarding the types of vehicles used by patients was extracted from statistical data from Spain concerning the percentage and types of vehicles in use in the year 2022.

The selected references from the Ecoinvent database for each type of transport can be seen in

Table 6. Ecoinvent process selected per transport.

Transport	Ecoinvent Process Selected
Electric vehicle	Transport, passenger car, electric {GLO}
Gasoline vehicle	Transport, passenger car, medium size, petrol, EURO 5 {GLO}
Diesel vehicle	Transport, passenger car, medium size, diesel, EURO 5 {GLO}

.

3.2.2. Scenario 1: Healthcare Provided in the Patient’s Area

In this first scenario, the environmental impact of transportation is assessed for patients who have been hospitalized at home or attended specialized consultations at the nearest health center to the patient. In this case, healthcare professionals travel using vehicles from the healthcare system to provide healthcare closer to the patient’s location. Routes are optimized for daily travel to minimize distances.

The data set comprises the fleet vehicles’ distances traveled by healthcare personnel for these movements, obtained for the years 2021, 2022, and 2023 (see

Table 7. Kilometers traveled by healthcare personnel (Scenario 1).

Item	Unit	Year
		2021	2022	2023
Home hospitalization unit (HHU)	km	225,511	232,545	237,714
Consultations outside the hospital	km	119,264	97,819	100,257
Total	km	344,775	330,364	337,971

).

3.2.3. Scenario 2: Healthcare Provided in the Patient’s Area Using Electric Vehicles

The second scenario compares the impact of traditional transportation with electric mobility. Therefore, environmental impacts were calculated using the data from Scenario 1 and applying the use of battery-operated electric vehicles for healthcare personnel transportation.

The same distances traveled in Scenario 1 were used to calculate the resulting environmental impacts when using battery-electric vehicles for these movements.

4. Results

This research calculates the environmental impact derived from transportation for two hospital activities: home hospitalization and specialized consultations conducted away from the hospital, focusing on two hospitals serving patients from an autonomous community in Spain. The analysis covers their healthcare activities in the years 2021, 2022, and 2023. The obtained results are detailed across each of the eleven impact categories studied (see

Table 8. Overall results for the base case and analyzed scenarios.

Impact Category	Base Case			Scenario 1			Scenario 2
	2021	2022	2023	2021	2022	2023	2021	2022	2023
AD	1.05 × 101	8.84 × 100	9.09 × 100	9.14 × 10−1	8.76 × 10−1	8.96 × 10−1	4.38 × 100	4.20 × 100	4.30 × 100
ADF	1.46 × 106	1.40 × 106	1.43 × 106	1.12 × 106	1.07 × 106	1.10 × 106	8.97 × 105	8.60 × 105	8.80 × 105
GWP	1.06 × 105	1.02 × 105	1.04 × 105	8.21 × 104	7.86 × 104	8.04 × 104	7.79 × 104	7.47 × 104	7.64 × 104
ODP	1.61 × 10−2	1.54 × 10−2	1.58 × 10−2	1.23 × 10−2	1.18 × 10−2	1.20 × 10−2	4.64 × 10−3	4.45 × 10−3	4.55 × 10−3
HTP	9.76 × 104	9.35 × 104	9.57 × 104	6.77 × 104	6.49 × 104	6.64 × 104	2.53 × 105	2.42 × 105	2.48 × 105
FWAE	6.25 × 104	5.99 × 104	6.13 × 104	4.41 × 104	4.22 × 104	4.32 × 104	1.85 × 105	1.77 × 105	1.81 × 105
MAETP	9.45 × 107	9.05 × 107	9.26 × 107	6.75 × 107	6.47 × 107	6.61 × 107	2.79 × 108	2.68 × 108	2.74 × 108
TE	1.69 × 102	1.62 × 102	1.66 × 102	1.22 × 102	1.17 × 102	1.20 × 102	4.44 × 102	4.25 × 102	4.35 × 102
POCP	2.47 × 101	2.37 × 101	2.42 × 101	2.27 × 101	2.17 × 101	2.22 × 101	1.09 × 102	1.05 × 102	1.07 × 102
AP	3.69 × 102	3.54 × 102	3.62 × 102	2.37 × 102	2.27 × 102	2.32 × 102	4.58 × 102	4.39 × 102	4.49 × 102
EP	1.14 × 102	1.09 × 102	1.11 × 102	7.21 × 101	6.91 × 101	7.07 × 101	2.14 × 102	2.05 × 102	2.10 × 102

).

As a base case, environmental impacts are calculated assuming patients travel to hospitals for hospitalization or specialized consultations.

In the first scenario, results were considered after healthcare personnel (doctors and nurses) traveled to provide healthcare at the patient’s home or to the nearest primary care health center for specialized consultations.

In the second scenario, results are analyzed assuming healthcare personnel (doctors and nurses) use electric vehicles for transportation.

4.1. Base Case: Traditional Healthcare

In this scenario, results were obtained for each environmental impact category regarding healthcare provided in the patient’s area.

These results indicate that healthcare professionals traveling to the patient’s home or nearby health centers reduce environmental impact in all analyzed impact categories.

This brings healthcare closer to the patient and averts trips to hospitals whenever possible, reducing the environmental impact associated with healthcare transportation. This outcome hints at the significance of analyzing the location of hospitals and primary care centers, considering factors such as distances from patients’ residences to reduce emissions and environmental pollution.

Promoting home hospitalization, specialized consultations at local health centers, and primary care can positively contribute to reducing unnecessary patient travel and, thereby, reducing environmental impact.

4.2. Scenario 1: Healthcare Provided in the Patient’s Area

In Scenario 1, environmental impacts were calculated for the 11 impact categories (see Table 8 and

Table 9. Variation in environmental impacts by scenario and impact category.

Impact Category	Scenario 1			Scenario 2
	2021	2022	2023	2021	2022	2023
AD	−91.30%	−90.09%	−90.14%	−58.29%	−52.49%	−52.70%
ADF	−23.29%	−23.57%	−23.08%	−38.56%	−38.57%	−38.46%
GWP	−22.55%	−22.94%	−22.69%	−26.51%	−26.76%	−26.54%
ODP	−23.60%	−23.38%	−24.05%	−71.18%	−71.10%	−71.20%
HTP	−30.64%	−30.59%	−30.62%	159.22%	158.82%	159.14%
FWAE	−29.44%	−29.55%	−29.53%	196.00%	195.49%	195.27%
MAETP	−28.57%	−28.51%	−28.62%	195.24%	196.13%	195.90%
TE	−27.81%	−27.78%	−27.71%	162.72%	162.35%	162.05%
POCP	−8.10%	−8.44%	−8.26%	341.30%	343.04%	342.15%
AP	−35.77%	−35.88%	−35.91%	24.12%	24.01%	24.03%
EP	−36.75%	−36.61%	−36.31%	87.72%	88.07%	89.19%

for percentage variations), considering that hybrid gasoline vehicles were used for healthcare personnel transportation.

Upon analysis of the contribution to the LCA of Scenario 1, it was found that transportation had a significant impact on all the studied impact categories. The greatest impact was observed in Marine Aquatic Ecotoxicity (MAETP) and Abiotic Depletion (fossil fuels) (ADF).

The result associated with global warming potential (GWP100a) shows a reduction of −22.55% in 2021, −22.94% in 2022, and −22.69% in 2023.

In 2021, the environmental impacts caused by transportation were higher compared to those in 2022 and 2023. This is because there was a higher level of decentralized healthcare activity, requiring more travel by healthcare personnel. The effects of the COVID-19 pandemic and its consequences in 2021 maintained reduced hospital activity, with greater use of teleconsultation, telemonitoring, or patient home care compared to 2022 and 2023.

4.3. Scenario 2: Healthcare Provided in the Patient’s Area Using Electric Vehicles

As evidenced in Table 8 and Table 9, the results demonstrate a significant reduction in certain impact categories and a notable increase in others. These findings are examined in greater detail below. The Abiotic Depletion (AD) impact category (measuring the extraction of non-renewable resources) decreases significantly from the base case to Scenario 1 (between −90.09% and 91.30%) due to reduced patient travel, implying less consumption of fossil fuels. In Scenario 2, although it decreases compared to the base case (between −52.49% and −58.29%), the use of electric vehicles still involves notable consumption of non-renewable resources due to battery production, maintenance, and recycling.

The ADF impact category significantly decreases in both alternative scenarios. Scenario 2 shows a notable improvement (−38.46% to −38.57%), indicating that electric vehicles are more efficient in using fossil fuels, reducing dependence on these resources.

Greenhouse gas emissions (GWP) decrease significantly in both alternative scenarios, with Scenario 2 being the most efficient (−26.51% to −26.76%) due to reduced direct CO₂ emissions when using electric vehicles.

Scenario 2 shows significantly higher reductions in ozone layer depletion compared to the base case (−71.18%, −71.10%, and −71.20%). This is because electric vehicles do not emit exhaust gases like internal combustion engines, which release nitrogen oxides (NO_x) and other pollutants. Electric vehicles also emit fewer fine particles (PM_2.5).

Reducing environmental impacts by bringing healthcare closer to the patient is primarily achieved through decreased associated transportation (whether by combustion or electric vehicles). This reduction in transportation leads to decreased fossil fuel consumption, as fewer private vehicles and ambulances result in lower gasoline and diesel usage. Consequently, CO₂ emissions and other pollutants are reduced [46,47]. Furthermore, fewer commutes decrease nitrogen oxide (NO_x) and fine particulate matter (PM_2.5) emissions [48], thus enhancing air quality. Reduced traffic entails decreased release of toxic substances like heavy metals [49] and polycyclic aromatic hydrocarbons, which can contaminate soil and water sources. Ultimately, the usage of refrigerants and ozone-depleting substances is diminished, as fewer vehicles in circulation mean reduced cooling systems and subsequently lower emissions of gases like HFCs [50].

The human toxicity potential (HTP) category shows a significant increase in Scenario 2 (around +159%). Human toxicity potential increases considerably, possibly due to the production and recycling processes of electric vehicle batteries, which may release toxic substances. Similarly, Freshwater Aquatic Ecotoxicity (FAETP) increases in Scenario 2 (around +195.5%), and Marine Aquatic Ecotoxicity (MAETP) increases by approximately 196%. The rest of the impact categories are similarly affected negatively, with the Photochemical Oxidant Creation Potential (POCP) impact category showing values exceeding +341%.

These negative results are due to several factors. The production of Li-ion batteries used in electric cars generates environmental impacts compared to combustion vehicles due to the extraction and processing of metals like lithium, cobalt, and nickel [51,52]. Mining these metals consumes large amounts of water, causes soil and water pollution, and emits greenhouse gases and other atmospheric pollutants. Additionally, LIB manufacturing is highly energy-intensive, releasing toxic compounds into the environment [53]. Materials used in batteries [54], such as electrolytes and polyvinylidene fluoride (PVDF), can release hazardous gases during production, further contributing to pollution. During the use phase of electric vehicles, emissions depend on the electricity mix used to charge batteries, adding high GHG emissions if renewable sources are not used. At the end of their life cycle, batteries can release heavy metals and toxic substances into the environment if not properly managed [55]. Finally, commonly used recycling processes (pyrometallurgy and hydrometallurgy) can generate additional pollutant emissions [56].

5. Conclusions

This research employs a retrospective approach, analyzing data from two hospital centers over the years 2021, 2022, and 2023. The objective is to demonstrate the environmental advantages of delivering healthcare in the patients’ environments. This includes minimizing intrahospital mobility and encouraging healthcare professionals to deliver care in patients’ homes, local health centers, or nursing facilities. The methodology employed entails a life cycle analysis to ascertain the environmental impact of three scenarios: conventional hospital-based care (encompassing admissions and consultations), healthcare provided at patients’ locations via home hospitalization and medical appointments at nearby health centers (Scenario 1), and healthcare professionals traveling using electric vehicles (Scenario 2).

The results suggest that healthcare professionals visiting patients’ homes or local health centers reduce environmental impact across all analyzed categories. In relation to greenhouse gas emissions (GWP), both alternative scenarios yield substantial reductions. Scenario 2 demonstrates the highest efficiency (−26.51% to −26.76%) owing to diminished direct CO₂ emissions from electric vehicles. Furthermore, Scenario 2 exhibits markedly superior reductions in stratospheric ozone depletion (−71.18%, −71.10%, and −71.20%) due to the absence of exhaust gases, which internal combustion engines emit, thereby releasing nitrogen oxides (NOx) and other pollutants.

Additionally, electric vehicles produce fewer fine particles (PM_2.5). However, Scenario 2 displays a substantial increase in the human toxicity potential (HTP) category (+159% approximately). This escalation can be attributed to the production and recycling processes of electric vehicle batteries, which may discharge toxic substances. Analogously, Freshwater Aquatic Ecotoxicity (FAETP) rises in Scenario 2 (+195.5%), and Marine Aquatic Ecotoxicity (MAETP) rises by approximately 196%. The remaining impact categories similarly experience negative effects. In this case, the Photochemical Oxidant Creation Potential (POCP) category exhibits values exceeding +341%.

Providing care closer to patients and eliminating hospital visits, where feasible, can decrease the environmental impact associated with healthcare transportation. This outcome underscores the significance of considering hospital and primary care center locations and contemplating factors such as distance from patients’ residences to minimize emissions and environmental pollution.