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Smartflow: Anesthesia Modernization (S.A.M.)
Share PrintTo decrease a facility’s expenditure on anesthesia gases, providers can lower their fresh gas flow during an anesthetic. This approach is completely safe for patients and reduces risks of surgical site infections caused by hypothermia. This solution can be easily taught through methodical, clear, and consistent education. However, health care providers are understandably resistant to change, especially when the necessary behavior change seems complicated. Through an educational approach, providers will be asked explicitly to stop using desflurane and nitrous oxide, and to decrease their fresh gas flows to under 2 liters.
Origin:
April 2022, Richmond VA Medical Center (Richmond, Virginia)
Adoptions:
12 successful, 6 in-progress
Awards and Recognition:
iNET Seed Investee, iNET Spread Investee, Quality on Parade People's Choice Winner 2023, VA Lean Yellow Belt awardee: January 2024, VA Strong Practice Forum: February 202, Featured ... iNET Seed Investee, iNET Spread Investee, Quality on Parade People's Choice Winner 2023, VA Lean Yellow Belt awardee: January 2024, VA Strong Practice Forum: February 202, Featured Innovation on Diffusion Marketplace Newsletter: February 2024, Entrepreneur in Residence: Innovation Ecosystem Fellowship FY2025, OHIL Sponsored BETS awardee, VA Innovation Unit: Phase 1 awardee, AVANA CRNA of the Year: 2025
Partners:
Anesthesiology, Diffusion of Excellence, Healthcare Innovation and Learning, iNet Seed-Spark-Spread Innovation Investment Program, Innovation Ecosystem, Nursing, Office of Healthcare Innovation and Learning (OHIL), Surgery, VHA Innovators Network
Recent Updates
Overview
Problem
Hospital operating rooms often have great difficulty cutting costs because of the urgency and fragility of patient health in the setting. Volatile anesthetic agents, a necessary tool for surgery, are frequently overused or wasted due to leakage in old facilities. Desflurane costs ten times other agents despite little clinical difference. Additionally, curren
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Hospital operating rooms often have great difficulty cutting costs because of the urgency and fragility of patient health in the setting. Volatile anesthetic agents, a necessary tool for surgery, are frequently overused or wasted due to leakage in old facilities. Desflurane costs ten times other agents despite little clinical difference. Additionally, current systems of piping nitrous oxide into the operating room mean that 80-90 percent of nitrous oxide is leaked and unable to reach the patient. Current anesthesia practices increase costs and miss out on the clinical benefits of low flow.
One challenge slowing widespread low flow adoption is the FDA insert guidance for the use of sevoflurane, which recommends keeping flows above 2 liters due to risks associated with carbon absorbers from 20 years ago. While this warning is no longer relevant due to innovation in carbon absorbers, many anesthesia practitioners still follow its guidance. Low flow anesthesia is a proven method that is safe, efficient, effective, and endorsed by the American Society of Anesthesiologists, American Association of Nurse Anesthesiologists, and the Anesthesia Patient Safety Foundation. Because practitioners may not have training in low flow practices, know the context of the FDA insert, or understand low flow’s benefits, SAM takes an educational and human-centered design approach to teach about and encourage adoption of low flow practices.
Healthcare providers are often inundated with new information, research, and procedures. Therefore, clear, understandable messaging is critical to any education-centered program such as SAM. A prototype educational series was delivered to various anesthesia provider groups throughout the investment cycle. A program was iteratively developed that met users' needs without complicating the material. See more
One challenge slowing widespread low flow adoption is the FDA insert guidance for the use of sevoflurane, which recommends keeping flows above 2 liters due to risks associated with carbon absorbers from 20 years ago. While this warning is no longer relevant due to innovation in carbon absorbers, many anesthesia practitioners still follow its guidance. Low flow anesthesia is a proven method that is safe, efficient, effective, and endorsed by the American Society of Anesthesiologists, American Association of Nurse Anesthesiologists, and the Anesthesia Patient Safety Foundation. Because practitioners may not have training in low flow practices, know the context of the FDA insert, or understand low flow’s benefits, SAM takes an educational and human-centered design approach to teach about and encourage adoption of low flow practices.
Healthcare providers are often inundated with new information, research, and procedures. Therefore, clear, understandable messaging is critical to any education-centered program such as SAM. A prototype educational series was delivered to various anesthesia provider groups throughout the investment cycle. A program was iteratively developed that met users' needs without complicating the material. See more
Links
- Ted Talk: In the US, the very same blood test can cost $19 at one clinic and $522 at another clinic just blocks away -- and nobody knows the difference until they get a bill weeks later. Journalist Jeanne Pinder says it doesn't have to be this way. She's built a platform that crowdsources the true costs of medical procedures and makes the data public, revealing the secrets of health care pricing. Learn how knowing what stuff costs in advance could make us healthier, save us money -- and help fix a broken system. What if all US health care costs were transparent? | Jeanne Pinder
- IT'S SAFE TO GO LOW FLOW WITH SEVO! Extensive research has found no evidence of harm in humans due to sevoflurane use with low FGF. Notably, countries of the European Union never introduced minimal FGF restrictions and routinely use low FGF in practice. Furthermore, purposeful selection of CO2 absorbent can eliminate any remaining safety concerns surrounding low flow sevoflurane. ASA Statement on the Use of Low Gas Flows for Sevoflurane
Solution
Providers can lower their fresh gas flow during general anesthesia to decrease a facility's anesthesia expenditure and promote value-based care. This approach is completely safe for patients and reduces risks of surgical site infections caused by hypothermia. This solution can be easily taught through methodical, clear, and consistent education. Through an e
...
Providers can lower their fresh gas flow during general anesthesia to decrease a facility's anesthesia expenditure and promote value-based care. This approach is completely safe for patients and reduces risks of surgical site infections caused by hypothermia. This solution can be easily taught through methodical, clear, and consistent education. Through an educational approach, providers will be asked explicitly to stop using desflurane and nitrous oxide and to decrease their fresh gas flows to under 2 liters. Literature and methodology will be QR-linked in the OR to aid the provider in safely lowering fresh gas flows. This initiative will be led by frontline providers, with site champions leading the way to adoption.
See
more
Images
QR-linkage to externally-facing VA-hosted website accessible with personal devices. Sticker file that is placed in operating room on anesthesia machine. This sticker serves 2 functions: memory jog to lower flows, and QR-link to learn more about low flow anesthesia.
- Printable methodology for performing low flow anesthesia with Sevoflurane How to with Sevo
- Printable methodology for performing low flow anesthesia with Isoflurane How to with Iso
- Addresses desflurane national formulary elimination, eliminating use of pipeline Nitrous Oxide, and transitioning practice to low flow. Memo from Assistant Under Secretary for Health for Clinical Services
- Low-flow, Minimal-flow, and Metabolic-flow anesthesia: Clinical Techniques The Low Flow Book
- Comprehensive Reference List
- 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. GasMan: Uptake and Distribution
- 16-minute podcast on how to perform low flow safely from Dr. Jeff Feldman, the creator of the APSF low flow course. How Low Can You Go? Keeping Patients Safe During Low-Flow Anesthesia Care
- Warming and humidifying the breathing gas by using low-flow anaesthesia can reduce the negative effects on the respiratory tract and hence the risk for PPC. This video explains how Atlan family design and functionalities can support the anaesthesiologist to apply minimal- and low- flow anaethesia during general anaesthesia. Low-flow anaesthesia for lung protective ventilation with Atlan anaesthesia workstations
- Watch this video to learn how End-tidal (Et) Control software on the Aisys™ CS2 Anesthesia Delivery System helps clinicians practice safe, low-flow anaesthesia1, so they can focus more time on patients and not on adjusting machine settings. 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. 1. Refer to GE HealthCare Et Control Pivotal Study Report DOC2163005. When used as indicated, Et Control is as clinically safe as manual fresh gas control. 2. Et Control in the United States is indicated for patients 18 years of age and older. GE Low-flow Anesthesia Series: End-tidal Control (US)
- Lecture on LFA given at ISAP meeting Low Flow Anesthesia - 100 Years Later_Jeffrey Feldman, MD, MSE
- In this educational video you will learn how the dilution effect of rebreathing affects the measured oxygen and anesthetics agent values displayed on an anesthesia machine that uses a circle breathing system. 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. GE Low-flow Anesthesia Series: Dilution Effect of Rebreathing
Files
Links
Results
Richmond VA Medical Center saved approximately $10,000 from FY2023-2024 by lowering fresh gas flows. Additionally, avoidance of desflurane use saved $5,000. SAM is now being implemented at multiple VAMCs across many VISNs
Diffusion tracker
Does not include Clinical Resource Hubs (CRH)
Implementation
Timeline
-
1-3 months
Process buildout-identify champions/early adopters at local facilities-engage section and executive leadership for support-provide implementation guide-train anesthesia providers on low flow-provide local marketing materials-ongoing support -
3-6 months
-monitor for adoption process locally-engage site champion, support as needed -
6-12 months
Metrics-monitor local purchasing data-monitor national purchasing data-highlight trends and celebrate wins
Departments
- Quality Management
- Anesthesia
- Pharmacy
- Biomed
- Purchasing and supplies
Core Resources
| Resource type | Resource description |
|---|---|
PEOPLE |
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PROCESSES |
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TOOLS |
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Files
- In this review article, comprehensive information is given about the theory and basics of low flow anesthetic techniques. Mainly, however, practical aspects of low flow anesthesia are discussed to enable the reader to perform this technique safely in clinical practice, Low Flow Theory
- CO2 absorbents were introduced into anesthesia practice in 1924 and are essential when using a circle system to minimize waste by reducing fresh gas flow to allow exhaled anesthetic agents to be rebreathed. For many years, absorbent formulations consisted of calcium hydroxide combined with strong bases like sodium and potassium hydroxide. When Sevoflurane and Desflurane were introduced, the potential for toxicity (compound A and CO, respectively) due to the interaction of these agents with absorbents became apparent. Studies demonstrated that strong bases added to calcium hydroxide were the cause of the toxicity, but that by eliminating potassium hydroxide and reducing the concentration of sodium hydroxide to <2%, compound A and CO production is no longer a concern. Carbon Dioxide Absorption During Inhalation Anesthesia: A Modern Practice
- Clinical techniques for use with rebreathing systems. Low-flow, minimal-flow and metabolic-flow anaesthesia
- Guide dedicated to step-wise implementation of a low-flow program SAM Implementation Guide
- Business case data SmartFlow Business Case
Links
- IT'S SAFE TO GO LOW FLOW WITH SEVO! Extensive research has found no evidence of harm in humans due to sevoflurane use with low FGF. Notably, countries of the European Union never introduced minimal FGF restrictions and routinely use low FGF in practice. Furthermore, purposeful selection of CO2 absorbent can eliminate any remaining safety concerns surrounding low flow sevoflurane. ASA Statement on the Use of Low Gas Flows for Sevoflurane
- For internal users SmartFlow SharePoint
Risks and mitigations
| Risk | Mitigation |
|---|---|
| Low adoption rate | Leadership can mitigate this risk with support of practice change. The reason behind low adoption should be explored and mitigated. Often, motivation and awareness are quite frequently the underlying reason. |
About
Origin story
Sam Smith developed this innovation initiative after watching an unsuccessful deployment of this methodology in private practice anesthesia. I saw an opportunity for meaningful engagement with the most critical stakeholder in this conversation: the anesthesia provider. The practitioners on the front line are those who truly “do” anesthesia and can make the
...
Sam Smith developed this innovation initiative after watching an unsuccessful deployment of this methodology in private practice anesthesia. I saw an opportunity for meaningful engagement with the most critical stakeholder in this conversation: the anesthesia provider. The practitioners on the front line are those who truly “do” anesthesia and can make the greatest impact. Understanding the anesthesia provider's concerns, needs, and wants is critical to making a sustainable practice change. S.A.M. is a way for this stakeholder to make a small change in their practice that makes a big difference for VA and their patients.
Comment
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