Case study: choosing wisely

Module: SUSTAINABLE HEALTHCARE
Chapter: Climate Solutions

The Problem

Choosing which tests to order and which drugs to prescribe can be a daunting task on its own. Often, physicians find themselves over-ordering and over-prescribing for fear of missing a diagnosis or undertreating a patient’s complaints.

However stewardship of tests and medications can go a long way in terms of climate change mitigation by decreasing the use of resources and limiting the amount of waste produced. This usually results in more appropriate patient care as procedures and tests can cause direct harm to patients, through unwarranted stress, time constraints and physical injury. In fact, up to 30% of tests and treatments in Canada are potentially unnecessary indicating there is a lot of room for improvement. [2]

With the gradual onset of climate health research into the impacts of the healthcare system on the planet, some findings have emerged that indicate that it is not only beneficial to reduce ordering, but to critically evaluate which options are less environmentally impactful when therapies are essential.

The Study

Anesthetic Gas Use Across Health Authorities: Island Health, Interior Health, Northern Health

Within the field of anesthesia, volatile anesthetic gases are greenhouse gases. After being used in a surgical operation, they collect in the atmosphere and contribute directly to the warming of the planet. However, not all gases are equal. From the list of commonly used volatile anesthetics, desflurane has a global warming potential 2540 times that of CO2 over 100 years, which is 5 times higher than its counterpart isoflurane at 510, and almost 20 times higher than sevoflurane at 130. [6]

DEFINITIONS: [5] Global Warming Potential: A greenhouse gas’ ability to trap heat in the atmosphere in comparison to carbon dioxide. Carbon dioxide equivalent over 20 years: A greenhouse gas’ emissions in terms of how much CO2 is needed to produce a similar global warming effect over 20 years.

A study was completed that identified the trends in volatile anesthetics across three health authorities in BC: Vancouver Island Health Authority, Interior Health Authority, and Northern Health Authority. Data for the volumes of volatile anesthetic gases were collected from 2013 to 2019 and the researchers used the annual carbon dioxide equivalent over 20 years to compare each anesthetic agent. [4]

Results

Overall, the cumulative carbon footprint due to anesthetic gases has decreased across all 3 health authorities from 2013 to 2019 by an average of 58%. This equated to a net decrease of 8, 807, 573 kg of CO2 produced between 2013 and 2019, which corresponds to 208 kg of CO2 per operation! [4]

 

MEthods

In IHA and VIHA a switch from desflurane to sevoflurane contributed considerably to the reduced carbon footprint of operations.

In NHA, sevoflurane was already used quite significantly, however, overall use of volatile gases decreased.

In VIHA, the installation of low-flow anesthetic machines in 2015 was a major driver for lower emissions.

STUDY CONCLUSIONS

These results are quite uplifting as it is comforting to see trends in carbon footprints decreasing. However, even in the world of anesthetic gases there is much more room for improvement. One idea is that environmentally inert gases, although currently too expensive, could be used as effective general anesthetics and do not contribute to a warmer atmosphere at all. Also, there are many inefficiencies when considering the administration of volatile anesthetics. For example, the fit of patient masks could be improved to prevent escaped gases from being wasted. Even more inefficiencies exist during the management of gases after use. Currently, gases are collected and discarded instead of using feasible technology to recycle and reuse these agents. [4]

THE INITIATIVE

The example above is only one small part of the healthcare system.

Each specialty has its own unique decisions and tools at its disposal in terms of choosing when tests and treatments are necessary and which ones to use.

Choosing Wisely Canada is an initiative that advocates for reducing unnecessary tests and prescriptions in healthcare. Their goal is to limit healthcare spending and improve patient care.

Visit the Choosing Wisely Canada website to learn more about specific recommendations and toolkits to reduce needless ordering.

[1] Alexander, R., Poznikoff, A., & Malherbe, S. (2018). Greenhouse gases: the choice of volatile anesthetic does matter. Canadian Journal of Anesthesia, 65(2), 221–222. https://doi.org/10.1007/s12630-017-1006-x 

[2] Canadian Institute for Health Information. (2017). Unnecessary Care in Canada. https://www.cihi.ca/sites/default/files/document/choosing-wisely-baseline-report-en-web.pdf 

[3] Choosing Wisely Canada. (n.d.). Imaging Tests for Lower Back Pain: When you need them and when you don’t - Choosing Wisely Canada. Retrieved May 4, 2021, from https://choosingwiselycanada.org/imaging-tests-low-back-pain/ 

[4] de Vos, M., & Alexander, R. (2021). BC anesthesiologists reduce carbon footprint by choosing wisely | British Columbia Medical Journal. BC Medical Journal, 63(1), 301–333. https://bcmj.org/articles/bc-anesthesiologists-reduce-carbon-footprint-choosing-wisely?fbclid=IwAR0m1ty_JOIP5g3-EE_mNMHe0Dq_b_8Gj9K-X0fNupoVWUtRkFQ8zZJ92QE 

[5] Government of Canada. (2019, February 18). Global warming potentials. https://www.canada.ca/en/environment-climate-change/services/climate-change/greenhouse-gas-emissions/quantification-guidance/global-warming-potentials.html 

[6] MacNeill, A. J., Lillywhite, R., & Brown, C. J. (2017). The impact of surgery on global climate: a carbon footprinting study of operating theatres in three health systems. The Lancet Planetary Health, 1(9), e381–e388. https://doi.org/10.1016/S2542-5196(17)30162-6 

[7] Schoen, J., McGinty, G., & Quirk, C. (2021). Radiology in Our Changing Climate: A Call to Action. Journal of the American College of Radiology. https://doi.org/10.1016/j.jacr.2021.02.009