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In this article:
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Chemicals like inhaled anesthetics are a major contributor to greenhouse gas emissions in health care, contributing up to 40% of direct emissions for hospitals.
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As a crucial part of the WE ACT framework and to combat the climate crisis, Providence is working to curb emissions from chemicals like these through data-driven initiatives.
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To date, this work has led to a 78% reduction in emissions from anesthetic gases and millions of dollars in cost savings.
Caregivers in health care organizations use a lot of chemicals when caring for patients, from medicine to cleaning materials to refrigerants. However, one area of chemical use has proven to be a major source of greenhouse gas (GHG) emissions: Anesthetic gases are significant contributors to these emissions and climate change, accounting for up to 40% of hospitals’ scope 1 (direct) GHG emissions.
Chemical use is the “C” of the WE ACT framework, which helps the Providence team organize its sustainability work around reducing carbon emissions and pollution across its facilities, supply chain and care delivery. This framework also tracks waste, energy and water, agriculture and food, chemicals and transportation. As a result of these mitigation efforts, Providence has massively reduced its emissions from anesthetic gases like desflurane and nitrous oxide by 78%, saving more than $2.4 million annually.
“It’s critical to address chemical and pharmaceutical use across health care,” says Brian Chesebro, M.D., medical director, environmental stewardship for Providence. “Given our overarching goals around reducing our carbon footprint, we wanted to focus early on inhaled anesthetics as these gases account for such a substantial portion of our healthcare-specific greenhouse gas emissions.”
The invisible threat of anesthetic gases
Volatile anesthetic gases are a type of chemical known as “fluorinated hydrocarbons.” These gases have powerful anesthetic properties but also have 100-2500 times the potency of carbon dioxide in terms of greenhouse gas emissions.
“All these anesthetics circulate through our patients, but they are not metabolized,” says Dr. Chesebro. “Eventually, patients breathe them all back out, unchanged, into the environment. As clinicians, it is our responsibility to use the lowest carbon intensity anesthetic and dose as efficiently as possible, because anything extra generates unnecessary GHG emissions.”
Dr. Chesebro and his team analyzed volatile anesthetic and nitrous oxide use for all anesthesia clinicians across Providence and encouraged them to rethink how they practice in these areas. In addition to their focus on decarbonization, the team applied a broad quality perspective to consider measures of safety, efficiency, efficacy, equity, patient-centeredness, resilience and compliance. This approach encouraged clinicians to reassess their practice, identify opportunities to curb emissions and implement practice changes – all while ensuring the continuation of high-quality patient care.
Raising awareness of the costs of volatile anesthetics
Volatile anesthetic agents like desflurane are considered chemicals of concern in health care given their environmental impact as a potent source of greenhouse gas emissions. Many of these chemicals are used across Providence facilities, and while all inhaled anesthetics generate GHG emissions, some of these gases are far less environmentally damaging than others. The environmental stewardship team took a data-driven approach to evaluate anesthetic use across Providence facilities to better understand how different gases were being used in clinical settings.
“We reached out to colleagues in information services to gather our clinical data,” says Dr. Chesebro. “We built an anesthesia reporting structure from scratch and applied it throughout the health system so all clinicians could better understand the impacts of their underlying clinical practices.”
The team found there was a perception that desflurane, the highest carbon-intensity anesthetic, led to improved efficiency in the operating room. However, through an analysis of 20,000 cases in Providence hospitals, the team found no difference in clinical efficacy between anesthetics.
“It was important that we looked at all aspects of quality and cost,” says Dr. Chesebro. “We needed to make sure the change we were advocating didn’t undermine the overarching value of care we provide. Expanding the definition of value to include environmental cost helped clarify the impacts of practice habits and encouraged clinicians to develop confidence with using lower carbon-intensity anesthetics.”
As a result of these changes, Providence saw a 95% reduction in its volatile emissions burden in its Oregon facilities, but there is still work to do.
“As the next step, we’re working to redesign our system to make sure we don’t backslide, limiting access to desflurane and empowering physicians to be advocates for environmental stewardship and climate action,” says Dr. Chesebro.
The reporting strategies used by the Providence team have since been incorporated into the electronic medical record system, Epic, so health systems across the country can similarly evaluate their own anesthetic use.
Innovating ways to cut nitrous oxide emissions
One particularly challenging chemical to get a handle on was nitrous oxide. That’s because nitrous oxide emissions often account for nearly double those of all other volatile anesthetics combined.
“People have known for a long time that nitrous oxide, with its high carbon intensity, is a significant source of GHG emissions in health care,” says Dr. Chesebro. “Initially, we tried to apply the same mitigation strategies we did for volatile anesthetics but found that those clinical and behavioral changes didn’t work as well as we expected. We saw a 61% reduction in clinical use of nitrous oxide, but there was really no impact on overall nitrous oxide-related emissions, which meant that clinical use was not the primary driver of nitrous oxide emissions. Something else was going on.”
The environmental stewardship team reached out to the engineering and information services teams to learn more. Again, developing unique clinical reports within Epic, the group found that the standard system of delivering nitrous oxide through wall pipes meant upwards of 90% of the gas volume was lost due to leakage.
“We followed the flow of nitrous gas through the whole system and realized there was leak potential everywhere,” says Dr. Chesebro. “The ‘aha!’ moment came when we compared the amount of nitrous we supplied to the central “piped” system to what was being used during patient care. The percentage of gas lost to the inherent inefficiency of the central system was hard to fathom – we kept repeating the math because we couldn’t believe it – but in the end we confirmed that the overwhelming majority of nitrous oxide was being lost before we could use it clinically.”
The group has since repeated this analysis for more than 30 health care systems outside of Providence and found the problem is nearly universal. Fortunately, the team also validated a simple solution to move away from leaky wall pipes.
“We’re transitioning to a system using small, portable cylinders attached to anesthesia machines,” says Dr. Chesebro. “That means we’re able to confine the supply and delivery of nitrous oxide within the operating room.”
After significant testing at Providence facilities across Portland, the team found the portable system reduced nitrous oxide emissions by more than 95%. Anesthesia teams now lose less than 1% of their nitrous oxide to the environment. More than 25 Providence hospitals in California, Oregon, Washington, Montana, Alaska and Texas have completed the shift away from central supply “piped” nitrous oxide to portable cylinders.
“This is not a particularly difficult or expensive project,” says Dr. Chesebro. “It is an easy, effective way to curb emissions and there is really no reason not to do it. Importantly, from a clinical perspective, we are not eliminating nitrous or restricting access to it. Instead, we’re taking a very inefficient supply system and replacing it with a very efficient one.”
Spreading the word on curbing chemical emissions
Addressing chemical usage across health care can have major positive impacts for both the environment and public health. By working closely with caregivers across Providence, the environmental stewardship team has been able to change how clinicians manage inhaled anesthetics and generate insights that other health systems can use to reduce their own emissions.
These efforts are not isolated to Providence. The work Dr. Chesebro and his team completed is extending throughout Portland, the Pacific Northwest and the rest of the country. Efforts like the Cascadia Collaborative, focusing on nitrous oxide emissions, help to bring learnings from Providence ministries to other health systems across the country. Providence also published a toolkit, available to any health system, with information on how to measure nitrous oxide emissions and make the switch to an efficient portable cylinder system.
As a next step, the environmental stewardship team is evaluating the impact of refrigerants, or chemicals used in cooling systems, across its facilities. While these chemicals help to keep hospitals, medication and equipment cool, they are also potent sources of greenhouse gas emissions. Future projects may include finding new refrigerants with lower emissions and modernizing equipment to reduce leakage.
“These chemicals are health care sector-specific sources of emissions,” says Dr. Chesebro. “No one is going to address these except for us. That means we need to rely on nontraditional collaborations between clinicians and non-clinicians to better understand what to do and how to do it, and then help others follow us as fast as we possibly can.”
Contributing caregiver
Brian Chesebro, M.D., is an anesthesiologist and the medical director of environmental stewardship for Providence.
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This information is not intended as a substitute for professional medical care. Always follow your health care professional’s instructions.
