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Smartflow: Anesthesia Modernization (S.A.M.)

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To 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.

This innovation is scaling widely with the support of national stakeholders. See more scaling innovations.

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

Contact Team

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 ... See more

Links

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 ... 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.

    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)

Statuses

There are no unsuccessful adoptions for this innovation.

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
  • CRNA or Anesthesiologist Champion 1-2 hours per week for 3-4 months to establish program and support implementation
PROCESSES
  • Facility would receive training on low flow anesthesia
TOOLS
  • QR-linked sticker for anesthesia machine
  • Marketing materials to support practice implementation in local facility

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.

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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.