Project SPRUCE: Saving Our Planet by Reducing Carbon Emissions, a Pediatric Anesthesia Sustainability Quality Improvement Initiative

Abstract

BACKGROUND: Children are particularly vulnerable to adverse health outcomes related to climate change. Inhalational anesthetics are potent greenhouse gasses (GHGs) and contribute significantly to health care–generated emissions. Desflurane and nitrous oxide have very high global warming potentials. Eliminating their use, as well as lowering fresh gas flows (FGFs), will lead to reduced emissions. METHODS: Using published calculations for converting volatile anesthetic concentrations to carbon dioxide equivalents (CO2e), we derived the average kilograms (kg) CO2e/min for every anesthetic administered in the operating rooms at our pediatric hospital and ambulatory surgical center between October 2017 and October 2022. We leveraged real-world data captured from our electronic medical record systems and used AdaptX to extract and present those data as statistical process control (SPC) charts. We implemented recommended strategies aimed at reducing emissions from inhalational anesthetics, including removing desflurane vaporizers, unplugging nitrous oxide hoses, decreasing the default anesthesia machine FGF, clinical decision support tools, and educational initiatives. Our primary outcome measure was average kg CO2e/min. RESULTS: A combination of educational initiatives, practice constraints, protocol changes, and access to real-world data were associated with an 87% reduction in measured GHG emissions from inhaled anesthesia agents used in the operating rooms over a 5-year period. Shorter cases (<30 minutes duration) had 3 times higher average CO2e, likely due to higher FGF and nitrous oxide use associated with inhalational inductions, and higher proportion of mask-only anesthetics. Removing desflurane vaporizers corresponded with a >50% reduction of CO2e. A subsequent decrease in anesthesia machine default FGF was associated with a similarly robust emissions reduction. Another significant decrease in emissions was noted with educational efforts, clinical decision support alerts, and feedback from real-time data. CONCLUSIONS: Providing environmentally responsible anesthesia in a pediatric setting is a challenging but achievable goal, and it is imperative to help mitigate the impact of climate change. Large systems changes, such as eliminating desflurane, limiting access to nitrous oxide, and changing default anesthesia machine FGF rates, were associated with rapid and lasting emissions reduction. Measuring and reporting GHG emissions from volatile anesthetics allows practitioners to explore and implement methods of decreasing the environmental impact of their individual anesthesia delivery practices.

Reducing the carbon footprint of general anaesthesia: a comparison of total intravenous anaesthesia vs. a mixed anaesthetic strategy in 47,157 adult patients

“…practice restrictions; and data analysis to develop protocols and feedback mechanisms [26]. Our findings align with these proposals, as they include educational programs implemented by the operating theatre sustainability task force within the TIVA strategy hospital, such as removing desflurane vaporisers and the continuous monitoring of carbon emissions related to anaesthesia [18].…”

Transforming into a Learning Health System: A Quality Improvement Initiative

“…Modified from the original article. 25 opioid-sparing anesthetic techniques 13,[26][27][28] and easily focus on a center-wide versus procedure-specific ERP approach due to the universal opioid-sparing anesthetic practice and ease of access to the center-wide outcome, process, and balancing measures. The ability to successfully launch a center-wide ERP likely represents the culmination of our progressive efforts to use all aspects of the LHS in our ambulatory practice.…”

“…Finally, another SCV was seen after the start of Project Saving our Planet by Reducing Carbon Emissions (December 2021), followed by phase 3 interventions, including monthly email updates and unplugging the nitrous oxide hoses (January 2022), resulting in a new stable level of emissions at 0.05 kg CO 2 e/min (Fig. 5 , modified figure 25 ).…”

Strategies for Achieving Sustainable Anesthesia: Insights from Austrian Experts—A Qualitative Interview Study

“…At Seattle Children's Hospital, a multidisciplinary green team was formed including members of anesthesiology, surgery, and nursing. Based on their knowledge, they started with their first interventions in 2017 and, in the following 4 years, the CO 2 emission in operating theatres decreased from 570 tons CO 2 e to 166 tons CO 2 e in 2021, representing a reduction of 71%, which indicates how important a multidisciplinary green team is [43].…”