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or &#8220;ecodialysis&#8221;&#44; is becoming a major goal in various settings&#46; Notable initiatives include &#8220;Green Nephrology&#8221; &#40;<a href="http://sustainablehealthcare.org.uk/green-nephrology">http&#58;&#47;&#47;sustainablehealthcare&#46;org&#46;uk&#47;green-nephrology</a>&#41; and &#8220;Green Dialysis&#8221; &#40;<a href="http://www.greendialysis.org/">www&#46;greendialysis&#46;org</a>&#41;&#44; and those of societies such as the European Dialysis and Transplant Nurses Association&#47;European Renal Care Association &#40;EDTNA&#47;ERCA&#41;&#44; with their recent Environmental Guidelines for Dialysis&#46;<a class="elsevierStyleCrossRef" href="#bib0265"><span class="elsevierStyleSup">16</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">In Europe&#44; and indeed in Spain&#44; there are outstanding instruments available for environmental protection&#46; In addition to taxes and tax benefits&#44; and current legislation and regulations on health care waste &#40;bearing in mind that there is no national standard&#44; but some autonomic communities of Spain have specific legislation on health care waste<a class="elsevierStyleCrossRef" href="#bib0270"><span class="elsevierStyleSup">17</span></a>&#41;&#44; comes the emergence of voluntary environmental management systems &#40;EMS&#41;&#46; The Environmental Management and Auditing System<a class="elsevierStyleCrossRefs" href="#bib0275"><span class="elsevierStyleSup">18&#44;19</span></a> &#40;EMAS III&#41; and the International Organization for Standardization &#40;ISO 14001&#58;2004&#41;<a class="elsevierStyleCrossRef" href="#bib0285"><span class="elsevierStyleSup">20</span></a> are 2 international standards for EMSs&#44; which allow institutions and businesses to be classified as &#8220;environmentally friendly&#8221;&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">Classically&#44; an EMS is defined<a class="elsevierStyleCrossRef" href="#bib0290"><span class="elsevierStyleSup">21</span></a> as the framework used to guide an organisation to achieve and maintain an operation in accordance with established environmental goals&#44; responding efficiently to changes in regulatory&#44; social&#44; financial&#44; and competitive pressures&#44; and to potential environmental risks&#46; We will not debate here whether EMSs are positive or represent little more than a nostrum&#59; however we consider that presenting a summary of their pros and cons is relevant&#46; As a part of the general everyday management system of an organisation&#44; EMSs offer a technological and informative solution for monitoring compliance with legislation and regulations&#44; from a local level to an international level&#46; They involve the use of a policy&#58; a plan with procedures and environmental risks that are clearly defined and disclosed to the whole organisation&#46; This should work to ensure that operations are consistent with environmental policy&#44; and that the institution has an organisational structure for physical resources and the appropriate personnel to address and implement the environmental tasks&#46; An EMS can help encourage the generalised development of better environmental practices and generate the &#8220;change&#8221; involved in converting health care centres into socially dependable organisations&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">Likewise&#44; EMSs help to manage and assess internal environmental concerns and provide the opportunity to make public the institution&#39;s environmental efficiency&#44; improving its image of corporate citizenship to both an external community and an internal public&#44; namely the professionals in the organisation&#46; Other key elements characteristic of an EMS include the training and awareness-raising among the professionals for better environmental conduct&#44; and an established frequency for audits and reviews&#46; Such reviews verify the adequacy&#44; efficacy&#44; and performance of the system and it serves the purpose maintaining a constant improvement in performance and&#44; in the case of failures or non-conformity with the agreed targets&#44; correcting it&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">Difficulties include the resistance that occurs in any organisation when management changes are introduced&#44; and the increased time spent on implementation&#44; including any specific training that may be required&#46; Initial funding is required to introduce the changes in everyday practice and to make the reforms needed to meet the regulations and targets involved in the certification&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">It must be noted that EMS certification is not accreditation of the environmental performance&#44; but of the management system implemented&#46; For example&#44; it does not ensure that emissions are lower than a determined level&#44; but that the organisation has the necessary components of an active management system that works adequately&#46; An EMS dose not in itself mean an immediate decrease in environmental impact&#59; it is an instrument that allows the organisation to meet the desired or required environmental standard&#58; the EMS is the instrument&#44; and the improvement of environmental damage is the goal&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">The main aim of this article was to establish which haemodialysis units &#40;public or private&#44; inpatient or outpatient&#41; of our National Health System &#40;NHS&#41; have implemented a certified EMS&#44; and the type of EMS they use&#44; to ascertain their involvement in the high environmental impact that haemodialysis clearly has&#44; and to obtain references from which we could explore actions for environmental improvement&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Methods</span><p id="par0050" class="elsevierStylePara elsevierViewall">To determine which inpatient and outpatient dialysis units in Spain worked with a certified EMS&#44; the general approach focused on developing a database that showed these centres separated by autonomous community &#40;regions&#41;&#46; The EMS &#40;EMAS III or ISO 14001-2004&#41; had to be certified by a competent authority or company in 2012 and 2013&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">Before developing the database&#44; we look for&#44; official databases either European&#44; national&#44; or regional&#46; We used a general search system &#40;Google&#169;&#41;&#44; examining the first 10 pages of results with the key words &#8220;dialysis centre&#44; hospital&#44; environmental management system&#44; EMAS&#44; and ISO 14001&#8221;&#46; At this point&#44; we search for an updated registry containing the institutions with an EMS in Spain&#46; To do so we contacted by e-mail and telephone the Spanish National Accreditation Body &#40;<span class="elsevierStyleItalic">Entidad Nacional de Acreditaci&#243;n</span> &#91;ENAC&#93;&#46;<a class="elsevierStyleCrossRef" href="#bib0295"><span class="elsevierStyleSup">22</span></a> The ENAC is the only organisation in Spain that certifies accreditations to institutions on technical competency by conducting &#8220;conformity assessments&#8221;&#44; which determine the degree of compliance of an institution with the regulations it voluntarily deals with in its everyday running&#44; independently of the sector in which it operates&#46; The ENAC is a part of the Ministry of Industry&#44; Energy&#44; and Tourism&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">We found no available official register at a ministerial &#40;Health&#44; Environment&#44; Industry&#41;&#44; regional&#44; or company level&#46; The ENAC reported that it did not keep an up-to-date database of organisations with an EMS&#46; Therefore&#44; we moved on and planned the creation of a list of hospitals and outpatient dialysis units certified with an EMS&#46; Available data for assessment on health care centres and environmental certification in Spain came from the following public health and environmental management databases&#44; in March 2013&#58;<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">&#8211;</span><p id="par0065" class="elsevierStylePara elsevierViewall">The National Catalogue of Hospitals 2013 &#40;<span class="elsevierStyleItalic">El Cat&#225;logo Nacional de Hospitales</span> &#91;CNH&#93;&#41;&#44; a section of the Ministry of Health&#44; Consumer Affairs&#44; and Social Policy<a class="elsevierStyleCrossRef" href="#bib0300"><span class="elsevierStyleSup">23</span></a> and official register of hospitals in Spain&#46; Hospitals with haemodialysis equipment declared in &#8220;high-technology equipment&#8221; were selected by autonomous community&#46;</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">&#8211;</span><p id="par0070" class="elsevierStylePara elsevierViewall">The Spanish Register of Health Care Certification and Accreditation &#40;<span class="elsevierStyleItalic">El Registro Espa&#241;ol de Certificaci&#243;n y Acreditaci&#243;n Sanitaria</span> &#91;RECAS&#93;&#41;<a class="elsevierStyleCrossRef" href="#bib0305"><span class="elsevierStyleSup">24</span></a> of the Spanish Society of Health Care Quality&#46; This register includes the centres and health care services that have obtained certification or accreditation&#46; Its main purpose it to make the public aware of the work organisations do to improve the Spanish health system&#46; Currently&#44; the register is public access&#44; free&#44; and voluntary&#46; Registration requires an application and evidence of certification&#46;</p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">&#8211;</span><p id="par0075" class="elsevierStylePara elsevierViewall">The responses of each of the Spanish bodies accredited by the ENAC to provide environmental certification&#46;</p></li><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">&#8211;</span><p id="par0080" class="elsevierStylePara elsevierViewall">The EMAS registers for each autonomous community&#46; At a national level&#44; The Ministry of Agriculture&#44; Food&#44; and Environment is responsible for this&#46; The European Union also provides an updated list of EMAS-registered organisations&#44; called the EU EMAS Register&#44; which has its own website&#46;<a class="elsevierStyleCrossRef" href="#bib0310"><span class="elsevierStyleSup">25</span></a></p></li></ul></p><p id="par0085" class="elsevierStylePara elsevierViewall">The group of outpatient dialysis centres was assessed by consulting the public databases of dialysis centres of the leading Spanish scientific societies and patient associations&#58;<ul class="elsevierStyleList" id="lis0010"><li class="elsevierStyleListItem" id="lsti0025"><span class="elsevierStyleLabel">&#8211;</span><p id="par0090" class="elsevierStylePara elsevierViewall">Spanish Society of Nephrology &#40;<span class="elsevierStyleItalic">Sociedad Espa&#241;ola de Nefrolog&#237;a</span> &#91;SENEFRO&#93;&#41;&#58; <a href="http://www.senefro.org/modules.php?name=dialisis">www&#46;senefro&#46;org&#47;modules&#46;php&#63;name&#61;dialisis</a></p></li><li class="elsevierStyleListItem" id="lsti0030"><span class="elsevierStyleLabel">&#8211;</span><p id="par0095" class="elsevierStylePara elsevierViewall">Spanish Society of Dialysis and Transplantation &#40;<span class="elsevierStyleItalic">Sociedad Espa&#241;ola de Di&#225;lisis y Trasplante</span> &#91;SEDYT&#93;&#41;&#58; <a href="http://www.sedyt.org/centros-de-dialisis">www&#46;sedyt&#46;org&#47;centros-de-dialisis</a></p></li><li class="elsevierStyleListItem" id="lsti0035"><span class="elsevierStyleLabel">&#8211;</span><p id="par0100" class="elsevierStylePara elsevierViewall">National Federation of Associations for the Fight Against Kidney Disease &#40;<span class="elsevierStyleItalic">Federaci&#243;n Nacional de Asociaciones para la Lucha Contra las Enfermedades del Ri&#241;&#243;n</span> &#91;ALCER&#93;&#41;&#58; <a href="http://alcer.org/servicios/centros-de-dialisis">http&#58;&#47;&#47;alcer&#46;org&#47;servicios&#47;centros-de-dialisis</a>&#46;</p></li></ul></p><p id="par0105" class="elsevierStylePara elsevierViewall">Analysis is provided of the environmental information available on the corporate or institutional web portal of each health centre identified as having an EMS&#46; This information was searched and assessed by 2 of the authors&#44; at different timing &#40;observer 1&#44; 10&#8211;13 January 2013&#59; observer 2&#44; 10&#8211;13 April 2013&#41;&#46; The percentage agreement between the 2 observers was assessed&#46; Each hospital and outpatient clinic website was searched individually&#44; using the first 5 pages of results from the general search system Google&#169;&#46;</p><p id="par0110" class="elsevierStylePara elsevierViewall">Finally&#44; to obtain a global reference of environmental certifications in the health care sector&#44; and to compare these figures with the national figures&#44; the official registers of ISO 14001<a class="elsevierStyleCrossRef" href="#bib0315"><span class="elsevierStyleSup">26</span></a> and EMAS were assessed&#44; via website&#44; in March 2013&#46;</p><p id="par0115" class="elsevierStylePara elsevierViewall">All the information collected was entered in a data matrix in Excel&#174; 2010 version&#46; The unit of analysis was each inpatient and outpatient dialysis centre&#44; separated by regions within Spain territory&#59; absolute and relative frequencies were used&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Results</span><p id="par0120" class="elsevierStylePara elsevierViewall">The 2013 CNH provided a register of 789 centres &#40;432 of them are private&#41;&#46; Of these&#44; 210 centres had haemodialysis facilities&#46;</p><p id="par0125" class="elsevierStylePara elsevierViewall">RECAS provided a total of 305 registered centres&#59; only 4 of them had ISO 14001&#44; and only 1 of those offered haemodialysis in its service portfolio&#46;</p><p id="par0130" class="elsevierStylePara elsevierViewall">There were 19 certifying companies accredited by ENAC&#46; We contacted all of them via e-mail and telephone during January to February 2013&#46; Only 9 of these companies had certified environmental management systems in hospitals&#58; 7 offered them selves to send their list of certified hospitals by email&#44; and 2 of them referred their web portal or asked us to send a request to their offices&#46; Of the 9 companies&#44; only 6 had accredited hospitals and outpatient clinics with haemodialysis facilities&#46; The individual results from each of these companies are not given to avoid commercial bias&#46;</p><p id="par0135" class="elsevierStylePara elsevierViewall">Evaluation of the regional EMAS register showed that only 8 of the 17 autonomous communities in Spain contained accredited hospitals&#46; None of the outpatient clinics had EMAS&#46;</p><p id="par0140" class="elsevierStylePara elsevierViewall">In the group of hospitals specially formed from the data available from the certifying companies &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#44; we can see that an EMS was implemented in 53 hospitals with haemodialysis units&#58; this represents 6&#46;7&#37; of all national hospitals &#40;789&#41; and 25&#37; of hospitals with haemodialysis units &#40;210&#41;&#46; Of these 53 hospitals&#44; 14 were private&#46; All 53 worked with ISO 14001&#59; only 15 also had EMAS&#46; Of the 4&#44;298 haemodialysis stations registered on the CNH&#44; from 210 centres&#44; 1&#44;291 stations were classified as having an EMS&#58; 30&#37; of all stations&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0145" class="elsevierStylePara elsevierViewall">Of note were the autonomous communities of Madrid&#44; Andalusia&#44; and Valencia&#44; that had 12&#44; 10&#44; and 7 hospitals&#44; respectively functioning with an EMS&#46; Catalonia was also notable with 4 hospitals with EMAS&#46;</p><p id="par0150" class="elsevierStylePara elsevierViewall">Regarding outpatient centres&#44; the records from the different societies and patient associations&#44; that included all the autonomous communities &#40;regions&#41; but were not up-to-date&#44; were found to have discrepancies&#58; &#40;SENEFRO had&#44; 191 registered outpatient centres&#59; by contrast SEDYT and Alcer had 64 and 152 respectively&#41;&#46; Therefore&#44; only information from the lists obtained from the certifying bodies was assessed &#40;6 companies&#41;&#46; From this data&#44; there were only 11 centres with certification&#44; all with ISO 14001 alone&#58; 2 centres in Andalusia &#40;with no data available on treatment post&#41;&#44; 4 in the Canary Islands &#40;also with no data&#41; and 5 in the Valencian Community &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0155" class="elsevierStylePara elsevierViewall">Regarding website information&#44; 20 of the 53 hospitals with an EMS in the final sample group did not include information on environmental certification on their institutional web portals&#46; In 2 of these 53 hospitals&#44; no reference web site was found&#46; For outpatient clinics&#44; 10 of the 11 certified clinics had a web site and provided information about their environmental certification&#46; The percentage agreement between the 2 observers on the information assessed and provided was 100&#37;&#46;</p><p id="par0160" class="elsevierStylePara elsevierViewall">The review of the ISO and EMAS studies showed that Spain had a high level of awareness of environmental certification&#44; despite the socioeconomic context&#44; being the fifth country worldwide in ISO-14001 certifications &#40;16&#44;051 of the 301&#44;647 certifications worldwide&#58; 5&#46;32&#37; of the total&#41;&#46; However&#44; there was a distinct lack of these certifications in social and healthcare activities&#44; representing just 0&#46;33&#37; globally &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>&#41;&#44; with a similar figure in Spain&#46; The EMAS register contained 1&#44;014 organisations&#58; 49 of them were hospitals &#40;4&#46;8&#37;&#41;&#44; and 15 of those were in Spain &#40;1&#46;5&#37; of the total&#41;&#44; a significant number from the total hospitals with EMAS&#46;</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Discussion</span><p id="par0165" class="elsevierStylePara elsevierViewall">The number of patients on dialysis continues to grow&#44; as does the quantity of natural resources consumed and the waste generated&#46; The lack of environmental awareness in health care professionals and organisations is a significant problem that needs assessment and improvement&#46; Likewise&#44; we must assess and improve the high environmental impact of dialysis&#46; The need for long-term sustainability in this service and in the health system as a whole is pushing some professional groups to develop environmental initiatives&#44; to avoid compromising future generations&#8217; capacity to adequately meet their health care needs&#44; as well as and global environmental health&#46;</p><p id="par0170" class="elsevierStylePara elsevierViewall">The question of whether a dialysis unit should be a healthy place ought to be beyond all doubt&#46; The environmental sustainability of health care&#44; and of dialysis in particular&#44; working in a way that does not damage the planet&#44;<a class="elsevierStyleCrossRef" href="#bib0320"><span class="elsevierStyleSup">27</span></a> must be an ethical issue rather than a fashion or a one-off event&#46; Reflecting on our current routine practice and re-thinking the processes involved could reap rewards&#44; not just clinically and in terms of health care&#44; but also socially&#44; economically&#44; and environementally&#46;<a class="elsevierStyleCrossRef" href="#bib0325"><span class="elsevierStyleSup">28</span></a> There are many areas for improvement and innovation&#58; consumption of water and electricity&#44; generation of hazardous waste&#44; use of solar energy&#44; recycling of plastics&#44; and use of alternative materials&#46; We could even consider the use of other therapeutic techniques &#40;see&#44; for example&#44; the decision involving the patient on the possibility of peritoneal dialysis&#44; which offers a lower environmental impact&#44;<a class="elsevierStyleCrossRef" href="#bib0330"><span class="elsevierStyleSup">29</span></a> an aspect that is not mentioned in recent literature<a class="elsevierStyleCrossRefs" href="#bib0335"><span class="elsevierStyleSup">30&#44;31</span></a>&#41;&#46; The use of other&#44; less harmful materials in the equipment&#44;<a class="elsevierStyleCrossRef" href="#bib0345"><span class="elsevierStyleSup">32</span></a> the impact of the carbon footprint&#44;<a class="elsevierStyleCrossRefs" href="#bib0350"><span class="elsevierStyleSup">33&#44;34</span></a> and the need for a real transformation in health care&#44; including haemodialysis&#44; to meet global and national objectives and to plan strategies for reducing CO<span class="elsevierStyleInf">2</span> emissions&#44; all bear consideration&#46; There are initiatives in our country&#44; such as the carbon footprint register&#44; managed by the Spanish Office for Climate Change &#40;<a href="http://www.magrama.gob.es/es/cambio-climatico">www&#46;magrama&#46;gob&#46;es&#47;es&#47;cambio-climatico</a>&#41;&#44; that show whether an organisation has calculated&#44; reduced&#44; or offset its carbon footprint&#46;<a class="elsevierStyleCrossRef" href="#bib0360"><span class="elsevierStyleSup">35</span></a> If we launch a project locally and we value its benefits&#44; the improvements obtained at an individual level have an extraordinary potential on a macroeconomic scale<a class="elsevierStyleCrossRef" href="#bib0365"><span class="elsevierStyleSup">36</span></a> &#40;regionally and nationally&#41;&#44; due to the multiplier effect&#46;</p><p id="par0175" class="elsevierStylePara elsevierViewall">Regarding ISO 14001 certification&#44; there was no official updated reference showing its implementation&#46; This is basic information&#44; and it is surprising that it is not supplied by a competent public body&#46; In contrast&#44; the EMAS register is available and updated officially at a European level&#46; Certain autonomous communities have been seen to implement the environmental certification with great impetus&#44; particularly in hospitals&#46;</p><p id="par0180" class="elsevierStylePara elsevierViewall">Compiling this list of hospitals and outpatient haemodialysis clinics that work every day with a certified EMS could be relevant in developing an official up-to-date register that provides information and helps make public the environmental practices of health care organisations&#46; Regarding hospitals and the volume of certified dialysis stations&#44; the level of participation may be considered acceptable&#58; 25&#37; of hospitals with dialysis facilities in our country&#59; this was not the case for outpatient units&#44; based on the information obtained&#46;</p><p id="par0185" class="elsevierStylePara elsevierViewall">It is worth noting that the registers were openly available on the web portals of the various scientific societies&#46; By working together with these societies&#44; it would be possible to create an initiative to provide an exhaustive&#44; reliable&#44; up-to-date source of information that was more well-known&#44; at both a professional level and a public level&#46; This could include other quality management systems certifications<a class="elsevierStyleCrossRef" href="#bib0370"><span class="elsevierStyleSup">37</span></a> and tried and tested management practices and systems&#44; particularly in clinical&#44; healthcare&#44; social&#44; economic&#44; innovative&#44; and environmental areas&#46;</p><p id="par0190" class="elsevierStylePara elsevierViewall">This study is the starting point of a wider investigation to ascertain if the everyday use of environmental management systems in haemodialysis improves the environmental impact&#44; starting with the management of hazardous waste and the consumption of natural resources&#46;</p><p id="par0200" class="elsevierStylePara elsevierViewall">We must recognise&#44; at least&#44; that &#8220;ecodialysis&#8221; is here to stay&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Conflicts of interest</span><p id="par0195" class="elsevierStylePara elsevierViewall">The authors declare no conflicts of interest&#46;</p></span></span>"
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        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Introduction</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">The environmental impact of haemodialysis is very high&#46; Institutional activity in this sense is important&#44; even in the production of references&#46; Voluntary environmental management systems &#40;EMS&#41;&#44; environmental management and auditing systems &#40;EMAS&#41; and the International Organization for Standardization standards &#40;ISO 14001&#41; are important tools for environmental protection&#44; together with legislation&#44; taxation and tax benefits&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Objectives</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">To determine the degree of implementation of EMS in hospital units and outpatient haemodialysis in the Spanish National Health System to provide a group of reference centres in environmental management in this healthcare activity&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Methods</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Development of a list by autonomous communities showing hospital and outpatient dialysis units using an EMAS and&#47;or ISO 14001 in 2012&#8211;2013&#46; The sources of information were the Spanish National Catalogue of Hospitals&#44; Spanish Registry of Healthcare Certification and Accreditation&#44; European and regional EMAS records&#44; world ISO registrations&#44; dialysis centre lists from scientific societies and patients&#44; responses from accredited entities in Spain for environmental certification and the institutional website of each haemodialysis centre identified&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Results</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Of the 210 hospitals with a dialysis unit&#44; 53 &#40;25&#37;&#41; have the ISO 14001 and 15 of these also have an EMAS&#46; This constitutes 30&#37; of all hospital dialysis chairs in Spain&#58; 1&#44;291 &#40;of 4&#44;298&#41;&#46; Only 11 outpatient clinics are recorded&#44; all with the ISO 14001&#46;</p></span> <span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Discussion</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">There is no official documentation of the implementation of EMS in dialysis units&#46; Making this list provides an approach to the situation&#44; with special reference to haemodialysis because of its significant environmental impact&#46;</p></span>"
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          1 => array:2 [
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        "titulo" => "Resumen"
        "resumen" => "<span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Antecedentes</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">El impacto ambiental de la hemodi&#225;lisis es destacado&#46; Est&#225; destacando la actividad en este sentido incluso a nivel bibliogr&#225;fico&#46; Los sistemas de gesti&#243;n medioambiental &#40;SGMA&#41; voluntarios&#44; Environmental Management and Auditing System &#40;EMAS&#41; e International Organization for Standardization &#40;ISO 14001&#41;&#44; son instrumentos destacados para la protecci&#243;n medioambiental junto a legislaci&#243;n&#44; impuestos y beneficios fiscales&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Objetivos</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Conocer el grado de implantaci&#243;n de los SGMA en las unidades de hemodi&#225;lisis hospitalarias y ambulatorias del Sistema Nacional de Salud espa&#241;ol&#44; para disponer de un grupo de centros de referencia en gesti&#243;n medioambiental en esta actividad sanitaria&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">M&#233;todos</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Elaboraci&#243;n de un listado por comunidades aut&#243;nomas que muestre las unidades hospitalarias y ambulatorias de di&#225;lisis que disponen en 2012&#8211;2013 de EMAS o ISO 14001&#46; Fuentes de informaci&#243;n&#58; Cat&#225;logo Nacional de Hospitales&#44; Registro Espa&#241;ol de Certificaci&#243;n y Acreditaci&#243;n Sanitaria&#44; registros europeo y auton&#243;micos de EMAS&#44; registro mundial de ISO&#44; listados de centros de di&#225;lisis de sociedades cient&#237;ficas y de pacientes y&#44; respuesta de entidades acreditadas para certificaci&#243;n medioambiental en Espa&#241;a e informaci&#243;n de web institucional de cada centro sanitario identificado&#46;</p></span> <span id="abst0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Resultados</span><p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Un total de 210 hospitales cuentan con hemodi&#225;lisis&#44; 53 &#40;25&#37; de centros hospitalarios con di&#225;lisis&#41; disponen de ISO 14001 &#40;y 15 de ellos&#44; tambi&#233;n EMAS&#41;&#44; el 30&#37; del total de puestos hospitalarios en Espa&#241;a&#58; 1&#46;291 &#40;de 4&#46;298&#41;&#46; Solo se registran 11 cl&#237;nicas ambulatorias&#44; todas con ISO 14001&#46;</p></span> <span id="abst0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Discusi&#243;n</span><p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">No existe referente oficial que muestre la implantaci&#243;n de los SGMA en hospitales&#46; Confeccionar este listado ofrece una aproximaci&#243;n a su situaci&#243;n&#44; con especial referencia a la hemodi&#225;lisis por su destacada implicaci&#243;n ambiental&#46;</p></span>"
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        "etiqueta" => "&#9734;"
        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Garc&#237;a Vicente S&#44; Morales Su&#225;rez-Varela M&#44; Mart&#237; Monr&#243;s A&#44; Llopis Gonz&#225;lez A&#46; Desarrollo de la gesti&#243;n medioambiental certificada en unidades hospitalarias y ambulatorias de hemodi&#225;lisis&#46; Nefrologia&#46; 2015&#59;35&#58;539&#8211;546&#46;</p>"
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          "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Extent of EMSs in NHS hospitals with haemodialysis facilities&#46; List of hospitals by autonomous community with haemodialysis and EMS certification&#58; ISO 14001 and EMAS&#59; those with both are highlighted&#46;</p>"
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          "en" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">Changes 2009&#8211;2013 in the global number of ISO 14001certifications&#44; with particular reference to Spain&#46;</p>"
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Original article
Development of certified environmental management in hospital and outpatient haemodialysis units
Desarrollo de la gestión medioambiental certificada en unidades hospitalarias y ambulatorias de hemodiálisis
Sergio García Vicentea, María Morales Suárez-Varelab,
Corresponding author
sergarvi@alumni.uv.es

Corresponding author.
, Anna Martí Monrósc, Agustín Llopis Gonzálezb
a Departamento de Gerencia, Hospital Lluís Alcanyís, Conselleria de Sanitat, Generalitat Valenciana, Xàtiva (Valencia), Spain
b Unidad Docente de Medicina Preventiva y Salud Pública, Facultad de Farmacia, Universidad de Valencia, Burjassot (Valencia), Spain
c Servicio de Nefrología, Consorcio Hospital General Universitario de Valencia, Valencia, Spain
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with the WHO<a class="elsevierStyleCrossRefs" href="#bib0195"><span class="elsevierStyleSup">2&#8211;4</span></a> as a reference &#40;&#8220;WHO&#39;s Health in the Green Economy Sector&#8221; <a href="http://www.who.int/hia/green_economy/en/">www&#46;who&#46;int&#47;hia&#47;green&#95;economy&#47;en&#47;</a>&#41;&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">Nephrology&#44; and specifically haemodialysis&#44; are not exempt from this&#58; there are significant environmental consequences due the high use of natural resources<a class="elsevierStyleCrossRefs" href="#bib0230"><span class="elsevierStyleSup">9&#44;10</span></a> and generation of waste&#44;<a class="elsevierStyleCrossRefs" href="#bib0210"><span class="elsevierStyleSup">5&#8211;8</span></a> which can also be hazardous&#44; such as sharps&#44; dialysis lines&#44; and arteriovenous fistula needles&#46; Per dialysis session&#44; it is estimated that up to 2&#46;5<span class="elsevierStyleHsp" style=""></span>kg of solid waste is produced and 500<span class="elsevierStyleHsp" style=""></span>L of water are consumed&#46; To this we must add the contamination of soil and underground and surface water&#44; and the generation of allergic reactions&#44; caused by contamination from dialysers&#44; bicarbonate cartridges&#44; bottled disinfectants&#44; and by the release of polyvinylchloride &#40;PVC&#41;&#44; polychlorinated dibenzo-p-dioxins &#40;PCDD&#41; and di-&#40;2-ethylexyl&#41;-phthalate &#40;DEHP&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0240"><span class="elsevierStyleSup">11&#8211;14</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">The scientific literature in the area of dialysis is beginning to advance&#44; in an attempt to improve the environmental impact&#44; with prominent authors writing on the subject&#44; and one &#40;JW Agar&#41; even being referred to as the &#8220;spokesman of ecological dialysis&#8221;&#46;<a class="elsevierStyleCrossRef" href="#bib0260"><span class="elsevierStyleSup">15</span></a> This direction towards &#8220;green&#8221; management of haemodialysis&#44; or &#8220;ecodialysis&#8221;&#44; is becoming a major goal in various settings&#46; Notable initiatives include &#8220;Green Nephrology&#8221; &#40;<a href="http://sustainablehealthcare.org.uk/green-nephrology">http&#58;&#47;&#47;sustainablehealthcare&#46;org&#46;uk&#47;green-nephrology</a>&#41; and &#8220;Green Dialysis&#8221; &#40;<a href="http://www.greendialysis.org/">www&#46;greendialysis&#46;org</a>&#41;&#44; and those of societies such as the European Dialysis and Transplant Nurses Association&#47;European Renal Care Association &#40;EDTNA&#47;ERCA&#41;&#44; with their recent Environmental Guidelines for Dialysis&#46;<a class="elsevierStyleCrossRef" href="#bib0265"><span class="elsevierStyleSup">16</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">In Europe&#44; and indeed in Spain&#44; there are outstanding instruments available for environmental protection&#46; In addition to taxes and tax benefits&#44; and current legislation and regulations on health care waste &#40;bearing in mind that there is no national standard&#44; but some autonomic communities of Spain have specific legislation on health care waste<a class="elsevierStyleCrossRef" href="#bib0270"><span class="elsevierStyleSup">17</span></a>&#41;&#44; comes the emergence of voluntary environmental management systems &#40;EMS&#41;&#46; The Environmental Management and Auditing System<a class="elsevierStyleCrossRefs" href="#bib0275"><span class="elsevierStyleSup">18&#44;19</span></a> &#40;EMAS III&#41; and the International Organization for Standardization &#40;ISO 14001&#58;2004&#41;<a class="elsevierStyleCrossRef" href="#bib0285"><span class="elsevierStyleSup">20</span></a> are 2 international standards for EMSs&#44; which allow institutions and businesses to be classified as &#8220;environmentally friendly&#8221;&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">Classically&#44; an EMS is defined<a class="elsevierStyleCrossRef" href="#bib0290"><span class="elsevierStyleSup">21</span></a> as the framework used to guide an organisation to achieve and maintain an operation in accordance with established environmental goals&#44; responding efficiently to changes in regulatory&#44; social&#44; financial&#44; and competitive pressures&#44; and to potential environmental risks&#46; We will not debate here whether EMSs are positive or represent little more than a nostrum&#59; however we consider that presenting a summary of their pros and cons is relevant&#46; As a part of the general everyday management system of an organisation&#44; EMSs offer a technological and informative solution for monitoring compliance with legislation and regulations&#44; from a local level to an international level&#46; They involve the use of a policy&#58; a plan with procedures and environmental risks that are clearly defined and disclosed to the whole organisation&#46; This should work to ensure that operations are consistent with environmental policy&#44; and that the institution has an organisational structure for physical resources and the appropriate personnel to address and implement the environmental tasks&#46; An EMS can help encourage the generalised development of better environmental practices and generate the &#8220;change&#8221; involved in converting health care centres into socially dependable organisations&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">Likewise&#44; EMSs help to manage and assess internal environmental concerns and provide the opportunity to make public the institution&#39;s environmental efficiency&#44; improving its image of corporate citizenship to both an external community and an internal public&#44; namely the professionals in the organisation&#46; Other key elements characteristic of an EMS include the training and awareness-raising among the professionals for better environmental conduct&#44; and an established frequency for audits and reviews&#46; Such reviews verify the adequacy&#44; efficacy&#44; and performance of the system and it serves the purpose maintaining a constant improvement in performance and&#44; in the case of failures or non-conformity with the agreed targets&#44; correcting it&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">Difficulties include the resistance that occurs in any organisation when management changes are introduced&#44; and the increased time spent on implementation&#44; including any specific training that may be required&#46; Initial funding is required to introduce the changes in everyday practice and to make the reforms needed to meet the regulations and targets involved in the certification&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">It must be noted that EMS certification is not accreditation of the environmental performance&#44; but of the management system implemented&#46; For example&#44; it does not ensure that emissions are lower than a determined level&#44; but that the organisation has the necessary components of an active management system that works adequately&#46; An EMS dose not in itself mean an immediate decrease in environmental impact&#59; it is an instrument that allows the organisation to meet the desired or required environmental standard&#58; the EMS is the instrument&#44; and the improvement of environmental damage is the goal&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">The main aim of this article was to establish which haemodialysis units &#40;public or private&#44; inpatient or outpatient&#41; of our National Health System &#40;NHS&#41; have implemented a certified EMS&#44; and the type of EMS they use&#44; to ascertain their involvement in the high environmental impact that haemodialysis clearly has&#44; and to obtain references from which we could explore actions for environmental improvement&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Methods</span><p id="par0050" class="elsevierStylePara elsevierViewall">To determine which inpatient and outpatient dialysis units in Spain worked with a certified EMS&#44; the general approach focused on developing a database that showed these centres separated by autonomous community &#40;regions&#41;&#46; The EMS &#40;EMAS III or ISO 14001-2004&#41; had to be certified by a competent authority or company in 2012 and 2013&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">Before developing the database&#44; we look for&#44; official databases either European&#44; national&#44; or regional&#46; We used a general search system &#40;Google&#169;&#41;&#44; examining the first 10 pages of results with the key words &#8220;dialysis centre&#44; hospital&#44; environmental management system&#44; EMAS&#44; and ISO 14001&#8221;&#46; At this point&#44; we search for an updated registry containing the institutions with an EMS in Spain&#46; To do so we contacted by e-mail and telephone the Spanish National Accreditation Body &#40;<span class="elsevierStyleItalic">Entidad Nacional de Acreditaci&#243;n</span> &#91;ENAC&#93;&#46;<a class="elsevierStyleCrossRef" href="#bib0295"><span class="elsevierStyleSup">22</span></a> The ENAC is the only organisation in Spain that certifies accreditations to institutions on technical competency by conducting &#8220;conformity assessments&#8221;&#44; which determine the degree of compliance of an institution with the regulations it voluntarily deals with in its everyday running&#44; independently of the sector in which it operates&#46; The ENAC is a part of the Ministry of Industry&#44; Energy&#44; and Tourism&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">We found no available official register at a ministerial &#40;Health&#44; Environment&#44; Industry&#41;&#44; regional&#44; or company level&#46; The ENAC reported that it did not keep an up-to-date database of organisations with an EMS&#46; Therefore&#44; we moved on and planned the creation of a list of hospitals and outpatient dialysis units certified with an EMS&#46; Available data for assessment on health care centres and environmental certification in Spain came from the following public health and environmental management databases&#44; in March 2013&#58;<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">&#8211;</span><p id="par0065" class="elsevierStylePara elsevierViewall">The National Catalogue of Hospitals 2013 &#40;<span class="elsevierStyleItalic">El Cat&#225;logo Nacional de Hospitales</span> &#91;CNH&#93;&#41;&#44; a section of the Ministry of Health&#44; Consumer Affairs&#44; and Social Policy<a class="elsevierStyleCrossRef" href="#bib0300"><span class="elsevierStyleSup">23</span></a> and official register of hospitals in Spain&#46; Hospitals with haemodialysis equipment declared in &#8220;high-technology equipment&#8221; were selected by autonomous community&#46;</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">&#8211;</span><p id="par0070" class="elsevierStylePara elsevierViewall">The Spanish Register of Health Care Certification and Accreditation &#40;<span class="elsevierStyleItalic">El Registro Espa&#241;ol de Certificaci&#243;n y Acreditaci&#243;n Sanitaria</span> &#91;RECAS&#93;&#41;<a class="elsevierStyleCrossRef" href="#bib0305"><span class="elsevierStyleSup">24</span></a> of the Spanish Society of Health Care Quality&#46; This register includes the centres and health care services that have obtained certification or accreditation&#46; Its main purpose it to make the public aware of the work organisations do to improve the Spanish health system&#46; Currently&#44; the register is public access&#44; free&#44; and voluntary&#46; Registration requires an application and evidence of certification&#46;</p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">&#8211;</span><p id="par0075" class="elsevierStylePara elsevierViewall">The responses of each of the Spanish bodies accredited by the ENAC to provide environmental certification&#46;</p></li><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">&#8211;</span><p id="par0080" class="elsevierStylePara elsevierViewall">The EMAS registers for each autonomous community&#46; At a national level&#44; The Ministry of Agriculture&#44; Food&#44; and Environment is responsible for this&#46; The European Union also provides an updated list of EMAS-registered organisations&#44; called the EU EMAS Register&#44; which has its own website&#46;<a class="elsevierStyleCrossRef" href="#bib0310"><span class="elsevierStyleSup">25</span></a></p></li></ul></p><p id="par0085" class="elsevierStylePara elsevierViewall">The group of outpatient dialysis centres was assessed by consulting the public databases of dialysis centres of the leading Spanish scientific societies and patient associations&#58;<ul class="elsevierStyleList" id="lis0010"><li class="elsevierStyleListItem" id="lsti0025"><span class="elsevierStyleLabel">&#8211;</span><p id="par0090" class="elsevierStylePara elsevierViewall">Spanish Society of Nephrology &#40;<span class="elsevierStyleItalic">Sociedad Espa&#241;ola de Nefrolog&#237;a</span> &#91;SENEFRO&#93;&#41;&#58; <a href="http://www.senefro.org/modules.php?name=dialisis">www&#46;senefro&#46;org&#47;modules&#46;php&#63;name&#61;dialisis</a></p></li><li class="elsevierStyleListItem" id="lsti0030"><span class="elsevierStyleLabel">&#8211;</span><p id="par0095" class="elsevierStylePara elsevierViewall">Spanish Society of Dialysis and Transplantation &#40;<span class="elsevierStyleItalic">Sociedad Espa&#241;ola de Di&#225;lisis y Trasplante</span> &#91;SEDYT&#93;&#41;&#58; <a href="http://www.sedyt.org/centros-de-dialisis">www&#46;sedyt&#46;org&#47;centros-de-dialisis</a></p></li><li class="elsevierStyleListItem" id="lsti0035"><span class="elsevierStyleLabel">&#8211;</span><p id="par0100" class="elsevierStylePara elsevierViewall">National Federation of Associations for the Fight Against Kidney Disease &#40;<span class="elsevierStyleItalic">Federaci&#243;n Nacional de Asociaciones para la Lucha Contra las Enfermedades del Ri&#241;&#243;n</span> &#91;ALCER&#93;&#41;&#58; <a href="http://alcer.org/servicios/centros-de-dialisis">http&#58;&#47;&#47;alcer&#46;org&#47;servicios&#47;centros-de-dialisis</a>&#46;</p></li></ul></p><p id="par0105" class="elsevierStylePara elsevierViewall">Analysis is provided of the environmental information available on the corporate or institutional web portal of each health centre identified as having an EMS&#46; This information was searched and assessed by 2 of the authors&#44; at different timing &#40;observer 1&#44; 10&#8211;13 January 2013&#59; observer 2&#44; 10&#8211;13 April 2013&#41;&#46; The percentage agreement between the 2 observers was assessed&#46; Each hospital and outpatient clinic website was searched individually&#44; using the first 5 pages of results from the general search system Google&#169;&#46;</p><p id="par0110" class="elsevierStylePara elsevierViewall">Finally&#44; to obtain a global reference of environmental certifications in the health care sector&#44; and to compare these figures with the national figures&#44; the official registers of ISO 14001<a class="elsevierStyleCrossRef" href="#bib0315"><span class="elsevierStyleSup">26</span></a> and EMAS were assessed&#44; via website&#44; in March 2013&#46;</p><p id="par0115" class="elsevierStylePara elsevierViewall">All the information collected was entered in a data matrix in Excel&#174; 2010 version&#46; The unit of analysis was each inpatient and outpatient dialysis centre&#44; separated by regions within Spain territory&#59; absolute and relative frequencies were used&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Results</span><p id="par0120" class="elsevierStylePara elsevierViewall">The 2013 CNH provided a register of 789 centres &#40;432 of them are private&#41;&#46; Of these&#44; 210 centres had haemodialysis facilities&#46;</p><p id="par0125" class="elsevierStylePara elsevierViewall">RECAS provided a total of 305 registered centres&#59; only 4 of them had ISO 14001&#44; and only 1 of those offered haemodialysis in its service portfolio&#46;</p><p id="par0130" class="elsevierStylePara elsevierViewall">There were 19 certifying companies accredited by ENAC&#46; We contacted all of them via e-mail and telephone during January to February 2013&#46; Only 9 of these companies had certified environmental management systems in hospitals&#58; 7 offered them selves to send their list of certified hospitals by email&#44; and 2 of them referred their web portal or asked us to send a request to their offices&#46; Of the 9 companies&#44; only 6 had accredited hospitals and outpatient clinics with haemodialysis facilities&#46; The individual results from each of these companies are not given to avoid commercial bias&#46;</p><p id="par0135" class="elsevierStylePara elsevierViewall">Evaluation of the regional EMAS register showed that only 8 of the 17 autonomous communities in Spain contained accredited hospitals&#46; None of the outpatient clinics had EMAS&#46;</p><p id="par0140" class="elsevierStylePara elsevierViewall">In the group of hospitals specially formed from the data available from the certifying companies &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#44; we can see that an EMS was implemented in 53 hospitals with haemodialysis units&#58; this represents 6&#46;7&#37; of all national hospitals &#40;789&#41; and 25&#37; of hospitals with haemodialysis units &#40;210&#41;&#46; Of these 53 hospitals&#44; 14 were private&#46; All 53 worked with ISO 14001&#59; only 15 also had EMAS&#46; Of the 4&#44;298 haemodialysis stations registered on the CNH&#44; from 210 centres&#44; 1&#44;291 stations were classified as having an EMS&#58; 30&#37; of all stations&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0145" class="elsevierStylePara elsevierViewall">Of note were the autonomous communities of Madrid&#44; Andalusia&#44; and Valencia&#44; that had 12&#44; 10&#44; and 7 hospitals&#44; respectively functioning with an EMS&#46; Catalonia was also notable with 4 hospitals with EMAS&#46;</p><p id="par0150" class="elsevierStylePara elsevierViewall">Regarding outpatient centres&#44; the records from the different societies and patient associations&#44; that included all the autonomous communities &#40;regions&#41; but were not up-to-date&#44; were found to have discrepancies&#58; &#40;SENEFRO had&#44; 191 registered outpatient centres&#59; by contrast SEDYT and Alcer had 64 and 152 respectively&#41;&#46; Therefore&#44; only information from the lists obtained from the certifying bodies was assessed &#40;6 companies&#41;&#46; From this data&#44; there were only 11 centres with certification&#44; all with ISO 14001 alone&#58; 2 centres in Andalusia &#40;with no data available on treatment post&#41;&#44; 4 in the Canary Islands &#40;also with no data&#41; and 5 in the Valencian Community &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0155" class="elsevierStylePara elsevierViewall">Regarding website information&#44; 20 of the 53 hospitals with an EMS in the final sample group did not include information on environmental certification on their institutional web portals&#46; In 2 of these 53 hospitals&#44; no reference web site was found&#46; For outpatient clinics&#44; 10 of the 11 certified clinics had a web site and provided information about their environmental certification&#46; The percentage agreement between the 2 observers on the information assessed and provided was 100&#37;&#46;</p><p id="par0160" class="elsevierStylePara elsevierViewall">The review of the ISO and EMAS studies showed that Spain had a high level of awareness of environmental certification&#44; despite the socioeconomic context&#44; being the fifth country worldwide in ISO-14001 certifications &#40;16&#44;051 of the 301&#44;647 certifications worldwide&#58; 5&#46;32&#37; of the total&#41;&#46; However&#44; there was a distinct lack of these certifications in social and healthcare activities&#44; representing just 0&#46;33&#37; globally &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>&#41;&#44; with a similar figure in Spain&#46; The EMAS register contained 1&#44;014 organisations&#58; 49 of them were hospitals &#40;4&#46;8&#37;&#41;&#44; and 15 of those were in Spain &#40;1&#46;5&#37; of the total&#41;&#44; a significant number from the total hospitals with EMAS&#46;</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Discussion</span><p id="par0165" class="elsevierStylePara elsevierViewall">The number of patients on dialysis continues to grow&#44; as does the quantity of natural resources consumed and the waste generated&#46; The lack of environmental awareness in health care professionals and organisations is a significant problem that needs assessment and improvement&#46; Likewise&#44; we must assess and improve the high environmental impact of dialysis&#46; The need for long-term sustainability in this service and in the health system as a whole is pushing some professional groups to develop environmental initiatives&#44; to avoid compromising future generations&#8217; capacity to adequately meet their health care needs&#44; as well as and global environmental health&#46;</p><p id="par0170" class="elsevierStylePara elsevierViewall">The question of whether a dialysis unit should be a healthy place ought to be beyond all doubt&#46; The environmental sustainability of health care&#44; and of dialysis in particular&#44; working in a way that does not damage the planet&#44;<a class="elsevierStyleCrossRef" href="#bib0320"><span class="elsevierStyleSup">27</span></a> must be an ethical issue rather than a fashion or a one-off event&#46; Reflecting on our current routine practice and re-thinking the processes involved could reap rewards&#44; not just clinically and in terms of health care&#44; but also socially&#44; economically&#44; and environementally&#46;<a class="elsevierStyleCrossRef" href="#bib0325"><span class="elsevierStyleSup">28</span></a> There are many areas for improvement and innovation&#58; consumption of water and electricity&#44; generation of hazardous waste&#44; use of solar energy&#44; recycling of plastics&#44; and use of alternative materials&#46; We could even consider the use of other therapeutic techniques &#40;see&#44; for example&#44; the decision involving the patient on the possibility of peritoneal dialysis&#44; which offers a lower environmental impact&#44;<a class="elsevierStyleCrossRef" href="#bib0330"><span class="elsevierStyleSup">29</span></a> an aspect that is not mentioned in recent literature<a class="elsevierStyleCrossRefs" href="#bib0335"><span class="elsevierStyleSup">30&#44;31</span></a>&#41;&#46; The use of other&#44; less harmful materials in the equipment&#44;<a class="elsevierStyleCrossRef" href="#bib0345"><span class="elsevierStyleSup">32</span></a> the impact of the carbon footprint&#44;<a class="elsevierStyleCrossRefs" href="#bib0350"><span class="elsevierStyleSup">33&#44;34</span></a> and the need for a real transformation in health care&#44; including haemodialysis&#44; to meet global and national objectives and to plan strategies for reducing CO<span class="elsevierStyleInf">2</span> emissions&#44; all bear consideration&#46; There are initiatives in our country&#44; such as the carbon footprint register&#44; managed by the Spanish Office for Climate Change &#40;<a href="http://www.magrama.gob.es/es/cambio-climatico">www&#46;magrama&#46;gob&#46;es&#47;es&#47;cambio-climatico</a>&#41;&#44; that show whether an organisation has calculated&#44; reduced&#44; or offset its carbon footprint&#46;<a class="elsevierStyleCrossRef" href="#bib0360"><span class="elsevierStyleSup">35</span></a> If we launch a project locally and we value its benefits&#44; the improvements obtained at an individual level have an extraordinary potential on a macroeconomic scale<a class="elsevierStyleCrossRef" href="#bib0365"><span class="elsevierStyleSup">36</span></a> &#40;regionally and nationally&#41;&#44; due to the multiplier effect&#46;</p><p id="par0175" class="elsevierStylePara elsevierViewall">Regarding ISO 14001 certification&#44; there was no official updated reference showing its implementation&#46; This is basic information&#44; and it is surprising that it is not supplied by a competent public body&#46; In contrast&#44; the EMAS register is available and updated officially at a European level&#46; Certain autonomous communities have been seen to implement the environmental certification with great impetus&#44; particularly in hospitals&#46;</p><p id="par0180" class="elsevierStylePara elsevierViewall">Compiling this list of hospitals and outpatient haemodialysis clinics that work every day with a certified EMS could be relevant in developing an official up-to-date register that provides information and helps make public the environmental practices of health care organisations&#46; Regarding hospitals and the volume of certified dialysis stations&#44; the level of participation may be considered acceptable&#58; 25&#37; of hospitals with dialysis facilities in our country&#59; this was not the case for outpatient units&#44; based on the information obtained&#46;</p><p id="par0185" class="elsevierStylePara elsevierViewall">It is worth noting that the registers were openly available on the web portals of the various scientific societies&#46; By working together with these societies&#44; it would be possible to create an initiative to provide an exhaustive&#44; reliable&#44; up-to-date source of information that was more well-known&#44; at both a professional level and a public level&#46; This could include other quality management systems certifications<a class="elsevierStyleCrossRef" href="#bib0370"><span class="elsevierStyleSup">37</span></a> and tried and tested management practices and systems&#44; particularly in clinical&#44; healthcare&#44; social&#44; economic&#44; innovative&#44; and environmental areas&#46;</p><p id="par0190" class="elsevierStylePara elsevierViewall">This study is the starting point of a wider investigation to ascertain if the everyday use of environmental management systems in haemodialysis improves the environmental impact&#44; starting with the management of hazardous waste and the consumption of natural resources&#46;</p><p id="par0200" class="elsevierStylePara elsevierViewall">We must recognise&#44; at least&#44; that &#8220;ecodialysis&#8221; is here to stay&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Conflicts of interest</span><p id="par0195" class="elsevierStylePara elsevierViewall">The authors declare no conflicts of interest&#46;</p></span></span>"
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            0 => "Haemodialysis"
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            0 => "Di&#225;lisis"
            1 => "Nefrolog&#237;a"
            2 => "Hospital"
            3 => "Cl&#237;nica ambulatoria"
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        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Introduction</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">The environmental impact of haemodialysis is very high&#46; Institutional activity in this sense is important&#44; even in the production of references&#46; Voluntary environmental management systems &#40;EMS&#41;&#44; environmental management and auditing systems &#40;EMAS&#41; and the International Organization for Standardization standards &#40;ISO 14001&#41; are important tools for environmental protection&#44; together with legislation&#44; taxation and tax benefits&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Objectives</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">To determine the degree of implementation of EMS in hospital units and outpatient haemodialysis in the Spanish National Health System to provide a group of reference centres in environmental management in this healthcare activity&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Methods</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Development of a list by autonomous communities showing hospital and outpatient dialysis units using an EMAS and&#47;or ISO 14001 in 2012&#8211;2013&#46; The sources of information were the Spanish National Catalogue of Hospitals&#44; Spanish Registry of Healthcare Certification and Accreditation&#44; European and regional EMAS records&#44; world ISO registrations&#44; dialysis centre lists from scientific societies and patients&#44; responses from accredited entities in Spain for environmental certification and the institutional website of each haemodialysis centre identified&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Results</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Of the 210 hospitals with a dialysis unit&#44; 53 &#40;25&#37;&#41; have the ISO 14001 and 15 of these also have an EMAS&#46; This constitutes 30&#37; of all hospital dialysis chairs in Spain&#58; 1&#44;291 &#40;of 4&#44;298&#41;&#46; Only 11 outpatient clinics are recorded&#44; all with the ISO 14001&#46;</p></span> <span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Discussion</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">There is no official documentation of the implementation of EMS in dialysis units&#46; Making this list provides an approach to the situation&#44; with special reference to haemodialysis because of its significant environmental impact&#46;</p></span>"
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        "titulo" => "Resumen"
        "resumen" => "<span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Antecedentes</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">El impacto ambiental de la hemodi&#225;lisis es destacado&#46; Est&#225; destacando la actividad en este sentido incluso a nivel bibliogr&#225;fico&#46; Los sistemas de gesti&#243;n medioambiental &#40;SGMA&#41; voluntarios&#44; Environmental Management and Auditing System &#40;EMAS&#41; e International Organization for Standardization &#40;ISO 14001&#41;&#44; son instrumentos destacados para la protecci&#243;n medioambiental junto a legislaci&#243;n&#44; impuestos y beneficios fiscales&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Objetivos</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Conocer el grado de implantaci&#243;n de los SGMA en las unidades de hemodi&#225;lisis hospitalarias y ambulatorias del Sistema Nacional de Salud espa&#241;ol&#44; para disponer de un grupo de centros de referencia en gesti&#243;n medioambiental en esta actividad sanitaria&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">M&#233;todos</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Elaboraci&#243;n de un listado por comunidades aut&#243;nomas que muestre las unidades hospitalarias y ambulatorias de di&#225;lisis que disponen en 2012&#8211;2013 de EMAS o ISO 14001&#46; Fuentes de informaci&#243;n&#58; Cat&#225;logo Nacional de Hospitales&#44; Registro Espa&#241;ol de Certificaci&#243;n y Acreditaci&#243;n Sanitaria&#44; registros europeo y auton&#243;micos de EMAS&#44; registro mundial de ISO&#44; listados de centros de di&#225;lisis de sociedades cient&#237;ficas y de pacientes y&#44; respuesta de entidades acreditadas para certificaci&#243;n medioambiental en Espa&#241;a e informaci&#243;n de web institucional de cada centro sanitario identificado&#46;</p></span> <span id="abst0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Resultados</span><p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Un total de 210 hospitales cuentan con hemodi&#225;lisis&#44; 53 &#40;25&#37; de centros hospitalarios con di&#225;lisis&#41; disponen de ISO 14001 &#40;y 15 de ellos&#44; tambi&#233;n EMAS&#41;&#44; el 30&#37; del total de puestos hospitalarios en Espa&#241;a&#58; 1&#46;291 &#40;de 4&#46;298&#41;&#46; Solo se registran 11 cl&#237;nicas ambulatorias&#44; todas con ISO 14001&#46;</p></span> <span id="abst0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Discusi&#243;n</span><p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">No existe referente oficial que muestre la implantaci&#243;n de los SGMA en hospitales&#46; Confeccionar este listado ofrece una aproximaci&#243;n a su situaci&#243;n&#44; con especial referencia a la hemodi&#225;lisis por su destacada implicaci&#243;n ambiental&#46;</p></span>"
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        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Garc&#237;a Vicente S&#44; Morales Su&#225;rez-Varela M&#44; Mart&#237; Monr&#243;s A&#44; Llopis Gonz&#225;lez A&#46; Desarrollo de la gesti&#243;n medioambiental certificada en unidades hospitalarias y ambulatorias de hemodi&#225;lisis&#46; Nefrologia&#46; 2015&#59;35&#58;539&#8211;546&#46;</p>"
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          "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Extent of EMSs in NHS hospitals with haemodialysis facilities&#46; List of hospitals by autonomous community with haemodialysis and EMS certification&#58; ISO 14001 and EMAS&#59; those with both are highlighted&#46;</p>"
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                          "etal" => false
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Article information
ISSN: 20132514
Original language: English
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Idiomas
Nefrología (English Edition)
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