Welcome to the Anesthesia Services, P.A. Environmental Initiatives Page!
ASPA's Environmental Initiatives and Fresh Gas Flow Research
Each year, general anesthesia is provided to more than 200 million individuals worldwide1. Although the chemical properties and physiological effects of these gases are well understood, what happens to them after they are scavenged out of anesthesia circuits and vented into the atmosphere has yet to be sufficiently determined. Over the past few decades, research has been conducted to examine and understand the atmospheric impact of anesthetic gases. Some assert that anesthetic agents accumulate in the atmosphere where they have the potential to act as greenhouse gases2,3. Others have discovered that inhalational anesthetics possess distinct properties, such as infrared heat production and absorption, which can contribute to both atmospheric and climate changes1.
Anesthesia Services, P.A. (ASPA) is a professional corporation located in New Castle, Delaware. It is the largest anesthesia group in Delaware and one of the largest anesthesia practices in the country. The Anesthesia team consists of over 130 anesthesia providers consisting of anesthesiologists, CRNAs and student nurse anesthetists. ASPA is proud to be the exclusive anesthesia provider for Christiana Care Health System (CCHS), and provides services at two hospitals and 2 ambulatory surgical centers that they comprise.
ASPA has been looking at ways to reduce our environmental footprint. As a department, we have taken steps to be more eco-friendly by purchasing reusable ceramic cups instead of Styrofoam or plastic cups, purchasing a water filtration system to reduce the need for preprocessed bottled drinking water, and placing recycling receptacles for glass, plastic and paper products in several places throughout our offices.
One area of environmental impact that we had overlooked was the anesthetic vapors that we use to maintain the depth of anesthetic for most of our general anesthetics.
Anesthetic Vapors: Did You Know?
The three main anesthetic vapors that are currently being used in anesthesia range from 440 to 6810 times more harmful to the environment than Carbon Dioxide (Andersen, Anesthesia & Analgesia 2012). In comparison, the volume of pollutants that anesthesia produces is relatively small as compared to the amount of Carbon Dioxide that the automobile industry produces. Worldwide it has been estimated that anesthetic gases produce about as much environmental damage as the exhaust of one million cars driven for one year (Andersen 2010). In an effort put a little perspective on this issue, it was estimated that the anesthetics administered in 2010 in the Christiana Care Health System alone contributed the equivalent of 569 tons of Carbon Dioxide (or driving 113 cars for year).
Lowering the Fresh Gas Flow rate (FGF) is the single most effective means for reducing the amount of anesthetic vapor that is being used per hour of anesthetic.
Over a four-week period from May-June 2011 we looked at the FGF rates for the maintenance phase of our general anesthetics and found that nearly half of our anesthetics were being done with excessive FGF rates. A review of the past anesthesia records and inventory sheets showed that about half of the anesthetics were done using Desflurane in 2010. A three-stage performance improvement project was conducted by ASPA at Christiana Care Health System (CCHS) in 2011. Educational interventions were presented to our anesthesia providers that emphasized lowering the FGF through their anesthesia machines to reduce the amount of anesthetic agent released into the atmosphere. Additionally, it was suggested that, when possible, providers should switch to the more environmentally friendly Sevoflurane. Pre- and post-interventional data was collected throughout the nine month period. A comparison between the total number of bottles of anesthetic vapor purchased in 2011 to 2009 was used to determine the effectiveness of previous interventions.
Follow up data was then collected over the last six months of 2011. The results were remarkable! There was nearly a 30% reduction in the amount of anesthetic vapor that was purchased by the anesthesia department for the entire health care system as compared to 2010. At Christiana Hospital alone there was a 21.13% reduction in our use of Desflurane, 22.58% reduction in Isoflurane, and a 1.75 % increase in Sevoflurane. This increase in the Sevoflurance purchasing could be explained by an over 10% increase of use of Sevoflurane by the anesthesia staff. This was done while the department had a 3.1% increase in the number of general anesthetics in 2011. That equates to reducing the environmental impact of the anesthesia department by the equivalent of 45 cars driven for an entire year. Reducing the FGF has also had a significant increase in the average number of anesthetics that could be performed per bottle of anesthetic agent (4.04 general anesthetics per bottle of anesthetic in 2010 vs. 7.92 in 2011).
The operating rooms at Christiana Hospital are part of the Christian Care Health System which are part of large community based tertiary care referral and teaching hospital that is also a level-one trauma center located in Newark, Delaware. There are 39 anesthetizing areas on the main campus at Christiana Care Hospital; with a majority of the cases performed are general anesthetics with inhalational anesthetic vapors. The ASPA team provides all of the anesthesia requirements for all of the surgical subspecialties at Christiana Hosptial.
One of the concerns brought up by some of our staff was that by reducing our FGF, there would be an increase in the amount of CO2 absorbers that we were using. There was, in fact, a 21% reduction in the amount of Soda Sorb canisters that were used at Christiana Hospital.
Wilmington Hospital is a full service institution that is part of the Christiana Care Health System and is located near downtown Wilmington, Delaware. The operating rooms at Wilmington Hospital provide an additional 9 anesthetizing areas for the ASPA anesthesia team. Wilmington Hospital is the home of the Total Joint Replacement Center and the majority of cases are orthopedic. General, gynecological, plastic and ear, nose, and throat surgeries make up the bulk of the other specialty surgical procedures.
Christiana Surgicenter (CSC)
The Christiana Surgicenter has 8 operating rooms and provides anesthesia care for a vast array of surgical specialties including gynecologic, orthopedics, general surgery, plastic surgery, and urology.
Roxana Cannon Arsht Surgicenter (RCA)
The 7 operating rooms that are part of the Roxana Cannon Arsht Surgicenter in Wilmington Delaware allow ASPA to provide anesthesia for number of different surgical specialties which include ophthalmology, podiatry, orthopedic, plastic, gynecologic, otolaryngology, minor vascular, and general surgery. This surgicenter has consistently scored as one of the top two surgicenters of its size for outstanding patient satisfaction in the Press Ganey survey. The anesthesia services provided were also cited to be exceptional and were an integral part of the overall evaluation.
This project started off as a simple review of the current literature on the environmental impact of inhaled anesthetic gases. As is often the case, when seeking answers to questions, new questions arise as well. While ASPA has made great strides in our environmental stewardship, there are still considerable steps that we can make.
For example, we are currently compiling data to determine the average emergence times for all three anesthetic vapors that we use. An interesting trend has started to emerge: by increasing our awareness of our anesthetic vapors we have seen a 12% reduction in emergence time for Sevoflurane and a 16% reduction with Desflurane cases.
In striving to make improvements, we are reviewing our practice to ensure that we are providing the best possible care for our patients while leaving the smallest environmental footprint.
ASPA has challenged itself to improve its effect on the environment. We now challenge you to join us by striving to improve your practice and reduce your carbon footprint.