Less Gas More Green
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Share PrintTo decrease a facility’s CO2 footprint, anesthesia providers can lower their fresh gas flow during an anesthetic that is completely safe for patients. This lowering results in a decrease in anesthetic pollution of the environment and a decrease in expenditure on anesthesia gases. This solution can be easily taught, but healthcare providers are sometimes resistant to change, especially when the behavior change seems complicated. Through an educational approach, providers will be asked explicitly to stop using desflurane, nitrous oxide, and to decrease their fresh gas flows to under 2 liters.
Origin:
April 2022, Hunter Holmes McGuire Hospital (Richmond, Virginia)
Adoptions:
3 successful, 1 in-progress
Awards and Recognition:
iNET Seed Investee, iNET Spread Investee, Quality on Parade People's Choice Winner 2023, VA Strong Practice Forum: February 2024, VA Lean Yellow Belt awardee: January 2024, Challen ... iNET Seed Investee, iNET Spread Investee, Quality on Parade People's Choice Winner 2023, VA Strong Practice Forum: February 2024, VA Lean Yellow Belt awardee: January 2024, Challenge Innovation Competition: collaboration between Office of Climate Change and Health Equity and the VHA Innovation Ecosytem, Featured Innovation on Diffusion Marketplace Newsletter: February 2024
Partners:
Anesthesiology
Recent Updates
Overview
The problem
When an anesthetic is performed, all the excess gas is that isn't used is pushed into the atmosphere via a waste system where it contributes to GHG formation. One of the agents used equates t ... Healthcare is a giant amongst greenhouse house gas (GHG) contributors. Hospitals produce enormous amounts of waste, and operating rooms account for 30% of this waste.
When an anesthetic is performed, all the excess gas is that isn't used is pushed into the atmosphere via a waste system where it contributes to GHG formation. One of the agents used equates to driving 420 mph in CO2 production and this very same gas was recently banned in Scotland. Additionally, another one of the agents used lasts in the atmosphere for 114 years.
Over the course of the investment cycle, a prototype educational series was delivered to various anesthesia provider groups, feedback was sought from these groups, and the iterative process completed. Through this process of iteration, a program was developed that met most the users needs without complicating the material excessively.
Prototyping allowed me to pivot quickly and refine the program to really help to distill the message. Healthcare providers are typically inundated with new information, research, and procedures. It was super important to me to make sure my messaging accounted for this, thus achieving a true human-centered design approach. See more
Videos
Above:
Climate action is speeding up -- and we each have the power to push that transformation forward. As the head of the UNFCCC, the UN's entity supporting the global response to climate change, Simon Stiell points to clear social and technological signals that show we're at the tipping points of a green revolution -- and invites us all to apply our unique skills to defending the planet against the catastrophic impacts of the climate crisis
The solution
Videos
Above:
Respiratory gas conditioning is important to protect the lungs and is a universal standard of care. Cold and dry respiratory gases reduce ciliary activity in the respiratory epithelium. The reduction of mucociliary clearance can lead to atelectasis and infections, conditions referred to as postoperative pulmonary complications. Various studies demonstrated, that protective ventilation approaches allow the reduction in incidence of postoperative pulmonary complications (PPC). Warming and humidifying the respiratory gases using low-flow anaesthesia can reduce these negative effects on the respiratory epithelium
Above:
This video explains why set oxygen and agent values may not match measured values when the patient is rebreathing recycled gas, which is the result of mixing fresh gas with recycled gases when using low fresh gas flows.
Above:
Anesthesia providers can set targets for end-tidal oxygen (EtO2) and end-tidal anesthetic agent (EtAA), and the Et Control software2 will automatically and efficiently adjust fresh gas concentrations to quickly achieve and maintain these targets, even with changes in the patient’s hemodynamic and metabolic status. Providers can switch to manual fresh gas control at any time. Safety mechanisms help maintain targets, so providers can practice low-flow anesthesia with confidence.
Above:
The ecoFLOW feature shows how much anesthetic agent is being consumed and shows the anesthetic agent costs associated with each case. This features allows providers to track agent costs, helps support low-flow anesthesia practices and may help hospitals achieve their sustainability goals in reducing greenhouse gas emissions
Files
- Printable methodology Low flow with Isoflurane
- Printable methodology Low flow with Sevoflurance
Links
- Gas Man® is the answer for teaching, experimenting and planning anesthesia administration on the computer before trying it in the operating room. Gas Man® is used by hundreds of practicing anesthesia providers and dozens of medical and veterinary teaching programs around the world. Computer Teaching Tool for Uptake and Distribution
- An official podcast of the American Society of Anesthesiologists, this episode of Central Line offers an in-depth exploration on Low Flow Anesthesia. Dr. Adam Striker discusses low-flow anesthesia with Drs. Jeffrey M. Feldman and David Hovord. Podcast on low flow anesthesia
The results
In addition to the cost avoidance, Richmond VAMC reduced it's CO2 footprint.
Images
Above:
Pharmacy purchase data showing a decreasing expenditure pre- and post-implementation of the two main agents used at our facility; Sevoflurane and Isoflurane. Before this innovation was implemented, Desflurane was 3% of our usage and 26% of our total cost and after implementation, our usage has dropped to zero.
Diffusion tracker
Does not include Clinical Resource Hubs (CRH)
Implementation
Timeline
-
1-2 months
Process Buildout-Identify champions/early adopters-Train personnel to administer low flow anesthesia-Engage with local leadership and stakeholders to gain buy-in-Provide ongoing support -
3-6 months
Program evaluation and measurement outcomes:-measure impact on system performance from pharmacy purchasing data pre- and post-implementation-measure the extent of spread via staff surveys pre- and post-implementation
Departments
- Pharmacy
- Outpatient surgery
- Neurosurgery
- Dental/oral surgery
- Colon and rectal surgery
- Bariatric surgery
- Cardiovascular surgery
- Anesthesia
Core Resources
| Resource type | Resource description |
|---|---|
PEOPLE |
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PROCESSES |
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TOOLS |
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Files
- Comprehensive review of low flow techniques Theory of low flow
- Concentration of NaOH in modern CO2 absorbers CO2 Absorption
- Observational cohort of heat-related illness Heat-Related Illness
- Primer on health sector decarbonization AHRQ
Links
- Draeger white paper on Clinical Techniques of Low-flow and Minimal-flow anesthesia
- 2023 Committee on Equipment and Facilities Statement on the use of low-flow anesthesia for Sevoflurane ASA statement of proven safety of low-flow
- This course consists of 8 topics designed to empower the anesthesia professional with the knowledge required to safely and effectively reduce anesthetic waste and pollution through the practice of low-flow anesthesia. Using guided, simulation-based learning, basic concepts of low-flow anesthesia are explored along with strategies for reducing fresh gas flow during the induction, maintenance and emergence phases of inhalation anesthesia. APSF Course on low-flow
- Health Sector commitments to lowering GHG emissions Health Sector Climate Pledge
Optional Resources
Links
- The U.S. health care industry is one of the world’s worst polluters, causing many of the deaths it seeks to prevent. Opinion: Hospitals and Public Health
Risks and mitigations
| Risk | Mitigation |
|---|---|
| Anesthesia providers not adopting new practice | Consistent messaging from early adopters and leadership in support of practice change |
Contact
Comment
Comments and replies are disabled for retired innovations and non-VA users.
Email samuel.smith2@va.gov with questions about this innovation.
About
Origin story
Original team
Samuel Smith, CRNA
Nurse Anesthetist
I am sorry but frankly this is ridiculous. Yes these are GHGs, yes they can be reduced with low flow anesthesia and yes we can restrict (or eliminate in the case of Soctland) anesthetic gases. However, to brag about the fact that you saved 10 or 15K over one year when the cost of one errant implant or in some cases, the additoinal special screws etc easily wipe this out is patently absurd.
Thank you for your comment, despite it's rude nature. As the project innovator, I would like to say that the intent of this project is not to "brag" about the cost savings, as I fully aware that medical waste exists in many forms, but the cost savings is only a minor part of this project, as you so eloquently stated. The true power exists in the universal adoption of low flow in 170 -plus VA medical centers. Please reach out to me directly if you have any further concerns.
To me the cost savings are more of a tertiary benefit (cherry on top!), although it could add up if adopted across VA. What I like about Sam's work is the emphasis on reducing emissions needlessly and environmental/resource stewardship. This seems like a no-brainer.