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NYSSA • The New York State Society of Anesthesiologists, Inc.
NYSSA • The New York State Society of Anesthesiologists, Inc.
Volume 76 Number 3
Anesthetic gases are responsible for up to 50% of perioperative emissions, contributing substantially to hospital scope 1 greenhouse gas (GHG) emissions (direct emissions).1 To decrease the environmental impact of anesthesia practice, the World Federation of Societies of Anesthesiologists (WFSA) encourages all anesthesiologists to minimize waste and choose environmentally preferable medications.2 The American Society of Anesthesiologists (ASA) recommends transitioning from centralized nitrous oxide (N2O) pipes to portable point-of-care delivery (“e-cylinders” on anesthesia machines or contained systems for mixed oxygen and N2O delivery).1 Without altering patient care practices, this step substantially reduces N2O waste, as up to 99% of purchased N2O may leak out of a pipe system without ever reaching a patient, whereas contained cylinder systems have a less than 3% leak rate.3 This has obvious financial and environmental implications that should be addressed at every institution.
How can you facilitate your hospital’s transition to portable N2O? Three members of the NYSSA’s Ad Hoc Committee on Sustainability in Anesthesia report on how they achieved this critical step in environmental stewardship.
With no formal environmental committee at my hospital, I took advantage of a departmental meeting to present the idea of decommissioning the central N2O pipes. After receiving support from my department, I began learning about the exact delivery system at my hospital, touring the gas room with a facility representative and photographing the large K-type tanks and manifold system. I spoke with the regional manager from our N2O vendor, who was well-versed in the decommissioning process and able to summarize our past purchases and outline the decommissioning costs (about $7,500). I discovered we purchase approximately $5,000 worth of N2O annually and pay around $500 annually to rent equipment. Assuming a 95% loss rate from the pipes,4 only about $250 worth of N2O is used for clinical care per year.
I presented this information to all departments involved with N2O procurement and use, including engineering, materials management, operations, value analysis, surgical services, biomed, perioperative business, and patient care services. While I met some initial resistance from those unfamiliar with the project, the cost analysis spoke for itself. Materials management agreed to pay the decommissioning fees, which would be recouped within two years through the reduced N2O purchasing costs (approximately $4,500 annually).
After receiving the go-ahead to proceed, we quickly transitioned to the e-cylinder delivery system. Subsequently, I presented to the Medical Executive Committee and received accolades from the hospital president. We are preparing to expand the project to all hospitals in our network.
Key takeaways:
Several years ago, our institution identified sustainability as a strategic goal. A multidisciplinary team of facility management, procurement, nursing, anesthesia, and surgery representatives was formed and led by the institution’s associate director for sustainability. With all the key players represented, our group quickly identifies achievable goals to create meaningful change, resulting in wins for the environment and national awards for the institution.
One goal set by the sustainability group was to reduce scope 1 emissions from anesthetic gases. To do this, the anesthesia department began monitoring fresh gas use and other metrics through an opt-in reporting system (e.g., Multicenter Perioperative Outcomes Group [MPOG]). With active monitoring and monthly sustainability reports sent to all anesthesiologists and nurse anesthetists, by 2023 we achieved a 79% reduction in anesthetic gas GHG emissions (2019 baseline). This was further impacted by the removal of desflurane vaporizers at all sites by 2023.
To target N2O emissions, we educated our team on N2O’s environmental impact and encouraged total intravenous anesthesia. Reductions in overall N2O use (68.6% reduction from 2022 to 2023) increased the feasibility of using portable cylinders rather than central pipes with their inherent delivery leaks. With these reductions in use, N2O bulk tanks were decommissioned in 2023. With a hospital sustainability team in place, the process was streamlined and efficiently carried out.
Key Takeaways:
At our institution, encompassing eight separate campuses, decommissioning piped N2O began with problem recognition and a desire to intervene. Upon learning of the consistent discrepancies between N2O purchasing and use across the globe,3-4 anesthesiologists from two major campuses joined together to investigate our institution’s data. We quickly realized the breadth of work at hand, as our complex network had several N2O vendors and delivery systems.
Working within an institution of such scale, our first hurdle was gathering the relevant individuals into the same (virtual) room. Assembling an interdisciplinary team was key, ensuring facilities, engineering, supply procurement, and regulatory considerations were all accounted for. Bringing everyone together early helped minimize the natural silos that occur at a large academic institution. Having anesthesiologists head the initiative, as leaders in the perioperative space and subject matter experts, was also of paramount importance. At every step of the process, our expertise and inherent knowledge of the clinical importance of N2O was called upon and became the critical guiding force in this interdisciplinary decommissioning process.
Finally, our efforts required approval from several administrators. Persistent follow-up was essential to ensuring continued progress. With our team assembled and key hospital leaders in support of the project, we have been able to move toward achieving our decommissioning goal. We are currently trialing the process at one facility while putting the necessary steps in motion to continue the process enterprise-wide.
Key Takeaway:
Have more questions about N2O pipe decommissioning? Step-by-step advice is available on the Practice Greenhealth website, including an open access webinar detailing everything from the purchase versus use assessment process to the estimation of how many portable tanks to purchase.3 The Ad Hoc Committee on Sustainability in Anesthesia is also available to answer questions and provide 1:1 coaching. Contact Deirdre Kelleher at dck7002@med.cornell.edu for more information and/or to join the committee.
Nicholas Gadsden, M.D., completed his anesthesiology residency at NewYork-Presbyterian/Columbia University and is now pursuing his fellowship at Hospital for Special Surgery. Ellen Brand, M.D., is medical director of obstetric anesthesia at Danbury Hospital/Nuvance Health in Danbury, Connecticut, and an assistant professor of clinical anesthesia at New York Medical College. Vittoria Arslan-Carlon, M.D., is the chief of the anesthesiology service at Memorial Sloan Kettering Center. Deirdre C. Kelleher, M.D., is the chair of the NYSSA Ad Hoc Committee on Sustainability in Anesthesia and an assistant professor of clinical anesthesia at Weill Cornell Medicine.
References
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