A Data Driven Approach to Reduction

of Greenhouse Gas Emissions

MassGeneral Brigham

Lucy Everett, MD, MHCM

Disclosures

• No financial disclosures

• I chair Epic’s Anesthesia Specialty Steering Board

• I am the MPOG Technical Champion for my health system

A Story

Part 2: MPOG 2019, Orlando

MPOG 2022

Outline

• Climate and health

• Measuring inhaled anesthetic usage

• Quality measures

• Case study: MGH sustainability efforts

Multiple organizations have recognized the link between

climate change and health

Climate and Health

• Climate change affects the social and environmental determinants of

health – clean air, safe drinking water, sufficient food and secure shelter

(WHO)

• Climate change affects people’s health: (EPA)

• By changing the seriousness or frequency of health problems that people

already face.

• By creating new or unanticipated health problems in people or places where

they have not been before.

• The U.S. health care sector contributes 8.5% of overall greenhouse gas

(GHG) emissions nationally, directly from health care facilities and

indirectly through supply chain of goods and services. [

Commonwealth Fund]

Environmental Impact of Anesthesia Practice

• Waste (disposable equipment, syringes, etc)

• Electricity (equipment, sterilization, suction)

• Water

• IV medication waste (potential toxins)

• Inhaled anesthetics

‒ Scavenged waste gas is vented into the atmosphere

‒ All anesthetic gases absorb and retain infrared thermal energy

‒ Desflurane and nitrous have the highest environmental impact

Determinants of environmental impact of inhaled

anesthetics:

• Fresh gas flow

• Use of nitrous oxide (duration and flow)

• Choice of volatile agent

• Roll-up “currency” = KgCO2e (“global warming footprint”)

• Calculated as: mass of agent x GWP

Inhaled Anesthetics

• Global warming potential (GWP) is a measure of how much the gas

contributes to global warming compared to CO2 (over a specified time)

• Desflurane’s impact is primarily due to a very high GWP, while nitrous

oxide’s deleterious effects come primarily from its long lifespan

Anesthetic gas environmental and financial costs

MPOG Sustainability Dashboard

MPOG Sustainability Measures

• Fresh Gas Flow

o SUS-01: FGF < 3 LPM

o SUS-04: FGF < 2 LPM

o SUS-06 (Peds): Low FGF, pediatric induction

• Avoiding Nitrous Oxide

o SUS-05 (Peds): Nitrous Avoided, Induction

o SUS-07: Nitrous Oxide Avoided, Maintenance

• Global Warming Footprint (KgCO2e)

o SUS-02: Global Warming Footprint, Maintenance

o SUS-03: Global Warming Footprint, Induction

Denominator Considerations (maintenance)

• Includes only cases with an airway AND 30+ min volatile and/or

nitrous

• Results will improve from using lower flows or preferable

agents

• Switching to TIVA or regional will cause cases to “drop off”

Pediatric Induction

• Fresh gas flow > minute ventilation does not speed induction, it

only produces waste

• Induction can be successfully done without nitrous oxide in

many children

Graphics courtesy Ari Weintraub MD, CHOP

EHR and MPOG - complementary data?

• MPOG advantages

• Standard/consensus-driven definitions

• Detailed inclusion/exclusion criteria

• Ability to benchmark nationally

• EHR data

• Once set up locally, may be easier to drill down, identify patterns, etc.

EHR Reporting - time, gas flows, volume

Drill down examples - service and provider

MGH Anesthesia

MGH Anesthesia - Sustainability

• Annualized KgCO2e now 25% of baseline from 2021

• Sevoflurane consumption down by 40% (from lower FGF)

• Estimated cost savings $115,000/year

• KgCO2 decrease from all gases, using EPA calculator:

QI Initiative: Sustainability

EDUCATION

DATA

FEEDBACK

MGH Sustainability Interventions

11/21:Added FGF<3L metric to MPOG provider emails

• 2/22: 2 hour Grand Rounds- Sustainability Conference

3/22: Began developing EHR reports to assess total

impact and service/provider variation

• 5/22: Changed MPOG FGF metric to 2L threshold

6/22: Turned on EHR BPA for high FGF

• 10/22: Posted FGF for pediatric inductions

11/22 Added SUS-02 (Global Warming, maintenance)

• 3/23: Grand Rounds on Low Flow, Educational Modules

• 5/23: Published EHR sustainability dashboard

QI/Change Management - Lessons Learned

• Trust but verify

• Build your case for change

• Listen to concerns

• Stress that safety & optimal care are always most important

• Look for quick wins, celebrate progress

• Incentives work

• Beware unintended consequences

Questions/Discussion