Life cycle assessment of pharmaceutical and clinical packaging required for medication administration practices
Authors: Baehr Julian , Göllner-Völker Laura , Baehr Michael , Muthukumar Hariharan , Lapa Nuno , Schebek Liselotte 
Published: December 2023

Abstract
Purpose
Digital closed-loop medication administration (CLMA) is a prime example of how digitalization in healthcare can reduce time and costs while simultaneously increasing patient safety. However, in contrast to its social and economic benefits, associated environmental impacts have never been investigated. Since the required amount of packaging material is seen as a major subject of criticism, we assess associated environmental burdens using life cycle assessment (LCA) methodology to identify hotspots and provide adaptation recommendations.

Methods
Digital, as well as conventional paper-based medication management (PBMM), involve two types of packaging: pharmaceutical packaging (blisters or bottles), containing purchased medication, and clinical packaging (unit doses or medical dispensers) for medication dispensation. Therefore, a cradle-to-grave life cycle model was established comparing impacts at pharmaceutical packaging level, clinical packaging level, and a combined level. While PBMM requires small, blistered boxes, CLMA requires large, bottled packages. Therefore, the functional unit allows to compare different box sizes but inhibits comparing medication from different manufacturers. Primary data is obtained from University Medical Centre Hamburg-Eppendorf which practices state-of-the-art CLMA. PBMM data is obtained in three dispenser scenarios, varying the reusability of medical dispensers. The life cycle impact assessment was performed for five impact categories using CML 2001(2016) method.

Results and discussion
All compared blistered pharmaceutical packaging options yield higher impacts than their bottled counterparts. Cardboard and package inserts result in up to 40 times higher impacts for blisters than for bottles, which, however, is attributed to the methodology of comparing different box sizes. Yet, this does not influence the required amount of blister laminate. All blister materials were found to result in higher environmental burdens, peaking in nearly 240 times higher ozone depletion impacts for polyvinylchloride/polychlorotrifluoroethylene blisters. In terms of clinical packaging, two of three dispenser scenarios result in higher environmental burdens than the respective unit dose scenario. Only if reused, 7.2 times this trend is reversed. When combining selected impacts from both pharmaceutical and clinical impacts, all three dispenser scenarios perform worse than the unit dose scenario.

Conclusions
Packaging impacts are lowest if unit dose dispensation is combined with bottled pharmaceutical packaging. Given a specific pharmaceutical packaging, dispensation via medical dispensers may perform better, if they are comprehensively reused. With this study, the authors disproved that packaging impacts are generally higher for CLMA than for PBMM. However, both systems certainly comprise other processes and materials like consumed paper or energy to run required digital infrastructure, which should be subject to future studies.