The energy and environmental burden of Australian ambulance services

Brown, Lawrence H. III (2012) The energy and environmental burden of Australian ambulance services. PhD thesis, James Cook University.

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Ambulance services are a vehicle-intense sector of healthcare and, as such, are particularly vulnerable to the threats posed by energy scarcity, rising energy costs, and tightening constraints on greenhouse gas emissions. The objective of this thesis is to establish the energy- and environmental-burden of Australian ambulance services.


This thesis encompasses four specific aims: (1) Review the literature on the energy consumption and environmental impact of health services; (2) Identify the primary sources, and measure the amount, of greenhouse gas emissions arising from the direct and purchased energy consumption of Australian ambulance systems; (3) Estimate the complete life cycle greenhouse gas emissions of Australian ambulance systems, including emissions arising upstream in the supply chain; and (4) Evaluate the historic relationships between energy costs and the resource, operational and safety performance measures of Australian ambulance systems.


The PubMed, CINAHL and ScienceDirect databases were searched—along with the tables of contents of 12 energy and economics journals—to identify publications reporting energy consumption, greenhouse gas emissions, and/or environmental impacts of health-related activities. Data were extracted and tabulated to enable cross-comparisons among different activities and services; where possible, per-patient or per-event emissions were calculated. Next, a two-phase study, including a test-retest pilot trial to establish consistency in the data collection process, used operational and financial data from a convenience sample of Australian ambulance operations to inventory their energy consumption and greenhouse gas emissions for one year. Inventoried energy sources included petrol, diesel, aviation fuels, electricity, natural gas, compressed natural gas, liquefied petroleum, fuel oil, and employee travel. Ambulance systems serving 58% of Australia's population and performing 59% of Australian ambulance responses provided data for the study.

To estimate complete life cycle emissions from Australian ambulance agencies, data from the inventory of direct and purchased energy consumption were combined with input-output based emissions estimates generated using aggregate ambulance system financial data and published emissions multipliers for the 'health services', 'other services', and 'government services' sectors of the Australian economy.

Lastly, Generalised Estimating Equations (GEE) were used to explore the contemporaneous and one-year lagged relationships between energy prices and ambulance service performance measures. Data included 2001-2010 resource, operational and safety performance measures for all Australian ambulance services, as well as state average diesel prices, world crude oil prices, and electricity prices.


Thirty-two relevant publications were identified by the literature search. On a per-patient or per-event basis, health-related energy consumption and greenhouse gas emissions are quite modest; in the aggregate, however, they are substantial. In England and the United States, health-related emissions account for 3% and 8% of total national emissions, respectively. The inventoried emissions of the participating Australian ambulance agencies totalled 67,390 t of CO2e, or 35 kg CO2e per ambulance response, 48 kg CO2e per patient transport, and 5 kg CO2e per capita. Vehicle fuels accounted for 58% of emissions from ground ambulance operations, with the remainder primarily attributable to electricity consumption. Emissions from air ambulance transport were nearly 200 times those for ground ambulance transport. Emissions from the direct and purchased energy consumption of all Australian ambulance operations are estimated at between 110,000 and 120,000 t of CO2e annually.

The complete life cycle emissions of Australian ambulance services are estimated at between 216,000 and 547,000 t CO2e annually, with approximately 20% arising from direct consumption of vehicle and aircraft fuels, 22% arising from electricity consumption, and 58% arising from upstream processes. The estimates vary substantially depending on the extent to which inventory-based versus input-output-based data are incorporated into the estimates, and whether ambulance services’ economic structures are presumed to resemble those of the health, other services, or government services sector. Emissions from ambulance services represent between 1.8% and 4.4% of total Australian health sector emissions. As ambulance service expenditures represent 1.7% of total health expenditures, all except the most conservative estimates suggest ambulance services disproportionately contribute to Australian health sector emissions.

Energy conservation is also an economic issue for Australian ambulance systems. There is an association between energy prices and Australian ambulance service resource, operational and safety performance characteristics. Diesel prices and oil prices have an inverse relationship with expenditures per response and employees per 10,000 responses; that is, higher energy costs are associated with diminished resource allocation. There is a one-year lagged association between increasing diesel and oil prices and increasing median ambulance response times, and a contemporaneous association between higher electricity costs and increasing injury compensation claims.


These data demonstrate that Australian ambulance services produce meaningful amounts of greenhouse gas emissions. In terms of the emissions from the direct and purchased energy consumption that are most easily influenced by EMS systems, consumption of vehicle fuels is the primary contributor to the carbon footprint of Australian ambulance systems, but electricity consumption is responsible for a substantial portion of their emissions. Efforts to minimise the carbon footprint of Australian ambulance services and ensure their environmental sustainability should target both of these energy sources.

The complete life cycle emissions of Australian ambulance services account for between 1.8% and 4.4% of total Australian health sector emissions. Ambulance services could make a meaningful contribution in efforts to reduce health sector emissions—which could be both an opportunity and a threat. As nearly 60% of ambulance service complete life cycle emissions arise from upstream supply chain processes, implementing environmentally friendly purchasing practices would be required to achieve substantial reductions in the complete life cycle emissions of ambulance services. The upstream products and services that contribute most to the complete life cycle emissions of ambulance services include some products and services that are not intuitively linked to ambulance services.

Finally, there are both environmental and economic aspects to the 'sustainability' of Australian ambulance operations. Energy costs have measurable impacts on ambulance service resource, operational, and safety performance measures that could affect both patient care and employee well-being. Managing ambulance system greenhouse gas emissions is managing energy consumption, and vice-versa. It is a 'win-win' situation.

Item ID: 24343
Item Type: Thesis (PhD)
Keywords: ambulances, Australia, carbon emissions, carbon footprint, compressed natural gas, diesel, electricity consumption, emergency medical services, energy consumption, energy costs, energy use, environmental costs, environmental effects, fuel oil, greenhouse emissions, greenhouse gases, health services, life cycle emissions, liquefied petroleum, operational costs, petrol, transport costs, transportation of patients
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Additional Information:

For this thesis, Lawrence Brown received the Dean's Award for Excellence 2013.

Publications arising from this thesis are available from the Related URLs field. The publications are:

Brown, Lawrence H., and Blanchard, Ian E. (2012) Energy, emissions and emergency medical services: policy matters. Energy Policy, 46 . pp. 585-593.

Blanchard, Ian, and Brown, Lawrence H. (2009) Carbon footprinting of emergency medical services systems: a proof-of-concept study. Prehospital Emergency Care, 13 (4). pp. 546-549.

Blanchard, Ian E., Brown, Lawrence H., and North American EMS Emissions Study Group, (2011) Carbon footprinting of North American emergency medical services systems. Prehospital Emergency Care, 15 (1). pp. 23-29.

Date Deposited: 21 Dec 2012 06:07
FoR Codes: 11 MEDICAL AND HEALTH SCIENCES > 1117 Public Health and Health Services > 111799 Public Health and Health Services not elsewhere classified @ 50%
11 MEDICAL AND HEALTH SCIENCES > 1103 Clinical Sciences > 110305 Emergency Medicine @ 50%
SEO Codes: 92 HEALTH > 9204 Public Health (excl. Specific Population Health) > 920499 Public Health (excl. Specific Population Health) not elsewhere classified @ 50%
85 ENERGY > 8507 Energy Conservation and Efficiency > 850702 Energy Conservation and Efficiency in Transport @ 50%
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