Anesthesia providers lead in health care GHG reduction

How 1 hospital is saving $20k a month and reducing GHGs

By Kaeleigh Sheehan, Practice Greenhealth Greening the OR and member engagement manager

With mounting threats posed to human health from climate change, more health care facilities are focusing on opportunities to reduce their greenhouse gas (GHG) emissions. And anesthesia practice has come under an increasing level of scrutiny and interest since anesthetic gases (most commonly desflurane, sevoflurane, isoflurane, and nitrous oxide) used for patient care are greenhouse gases.

During a procedure, only about 5 percent of administered anesthesia gas is metabolized by the patient. The remaining 95 percent is exhaled as waste anesthetic gas (WAG) by the patient during respiration. A scavenging system draws the WAG out of the surgical field, up through the medical vacuum pipeline to the hospital roof, where it’s vented to the outside air.

Since waste anesthetic gases are vented from the hospital, they are considered a scope I or direct greenhouse gas emission. Studies in the United Kingdom suggest anesthesia makes up 5 percent of a hospital’s GHG emissions. This footprint may actually be greater in the United States, since the U.K. study only represented acute care, inpatient hospitals, where provider practice may vary in the amount and type of gases used.

The three most common anesthetic gases used are sevoflurane, isoflurane and desflurane, with 20-year global warming potentials of 349, 1401, and 3714 respectively. Desflurane, which has the largest impact on the environment, also happens to be the most expensive.

In a Gallup poll, health professionals – nurses, pharmacists and medical doctors – were ranked as the top three most trusted professions for honesty and ethical practice. The public places a great amount of trust in its clinicians, and as they say, with great power, comes great responsibility. Most clinicians have the ability to be leaders within their organizations and professional associations, helping educate their peers and patients on healthy ways to be environmental stewards. Anesthesia providers also have the ability to directly contribute to the reduction of their facility’s carbon footprint.

After reading peer-reviewed research, anesthesia providers can consider their current practice and ask key questions such as:

1. Which anesthetic agents are commonly being used – anesthetic gases, intravenous, local or other?

2. Is there a specific clinical indication for the method being used, or could they use an alternative, less environmentally impactful method without impacting patients?

3. Do they lower the fresh gas flow rates after patient induction, or is this a technique they could begin to practice?

Low-flow technique has both environmental and financial benefits. After induction and with careful patient monitoring, an anesthesia provider can lower the flows of anesthetic gases to the amount needed to maintain sedation. This practice helps reduce excessive, unnecessary gas flow that would otherwise not be metabolized by the patient and vented into the environment.

In a survey of over 780 anesthesia providers from the U.K., Australia, and New Zealand, 95 percent supported increasing recycling and sustainability efforts in their clinical environments. A similar survey was conducted in the U.S. with over 2,000 responses indicating 91 percent of anesthesia providers surveyed were interested in recycling and sustainability programs. The common takeaway from both surveys was despite interest, clinicians believed they lacked adequate education around these practices. Thirty-four percent of Practice Greenhealth award winners reported providing staff education on environmental impacts of inhaled anesthetics and reduction strategies for clinicians in 2015.

The delivery of this education is vital. Because of its complex, clinical, and direct patient impact, it is imperative that anesthesia providers and experts are leaders and advisors in this space.  Anesthesia providers educating their peers will go much further than non-clinician led efforts.  Educating support staff and ensuring ready access to tools and resources is also a key to advancing this work.

Karin Zuegge, MD, associate chair for education in the Department of Anesthesiology and health medical director for sustainability, championed this initiative at the University of Wisconsin-Madison School of Medicine and Public Health. She conducted education, developed a website with additional resources and information, and created vaporizer label stickers as a quick visual reminder for providers to consider the environmental impact of their practice. The stickers include the global warming potential of each of the anesthetic gases, links to FDA-recommended flow rates for each, and a QRC code so providers could use their smartphones to scan the code and be directed to the website for more information.

Simply by conducting education and making the information available to providers, their facility saved more than $20,000 a month by reducing desflurane use. They also calculated their emissions per case, going from 91.67 kg/CO2 per case pre-education to 56.32 kg CO2 per case after education. This reduction adds up to over 4 million kg of CO2 annually, or the equivalent of taking 875 cars off the road for one year.

In addition to the peer-reviewed literature and resources from the American Society of Anesthesiologists Environmental Sustainability for Anesthesia Practice, the Department of Anesthesiology at Yale School of Medicine developed an interactive app, Yale Gassing Greener, to help anesthesia providers examine the footprint on a case-specific level, as well as view the usage and impact on a facility level.

Gaining a better understanding of best practices in tracking anesthesia usage to establish a more definitive greenhouse gas footprint for current practice is necessary to benchmark, develop a goal, and track reduction efforts and impact. Only 49 percent of Practice Greenhealth award winners attempted to enter anesthetic gas purchasing data on the award application in 2016. This is an increase from several years ago, and as more facilities begin to look for low-hanging greenhouse gas reduction strategies, we expect this number to grow.
Momentum toward environmental stewardship in anesthesia care has been building and is reaching a critical tipping point. And anesthesia providers have an exciting opportunity ahead of them to lead and directly influence not only their organization’s carbon footprint, but the health of their communities, patients, and future generations.

Physicians interested in this work and connecting with peers should contact Amy Collins, MD, senior clinical advisor for Health Care Without Harm and Practice Greenhealth.

Visit the anesthetic gas resource list for additional information.