To begin investigating N₂O emissions, purchase data (volume and cost) were collected and compared to total use data (clinical delivery) using the Epic SlicerDicer tool, part of the Epic electronic health record (EHR) [8]. Epic yearly clinical use data for N₂O are available per clinical service in the SHC’s operating rooms. Gas losses in the system can be estimated by comparing documented gas delivery at the point of care with the volume of N₂O purchased. Initial data analysis revealed a drastic amount of lost N₂O, leading us to perform a pilot study (phase 2, E-cylinder implementation) to enable remediation aimed at reducing N₂O emissions.

Using the Institute for Healthcare Improvement framework of “Plan, Do, Study, Act” for performance improvement [9], a pilot study was conducted in the 8 operating rooms of the SHC campus in Redwood City, California (campus A). E-cylinder canisters were deployed in each operating room and all central N₂O pipelines were disconnected. EHR documentation of gas delivered in liters (volume) was compared to measured E-cylinder mass. To verify use and track N₂O leaving each tank, the E-cylinders were weighed before and after use on a weekly basis with the difference in mass converted to volume (liters). Since the measured pressure remains the same as long as liquid remains in the cylinders, pressure differences cannot be used for measuring N₂O flow until only gas is left (at which point the pressure drop correlates with the amount of gas being removed) [10]. By using the conversion of 1 lb (0.45 kg) of N₂O being equal to 247.5 L [6], the volume of N₂O dispensed could be calculated. Total calculated volume leaving the E-cylinders based on measured mass was compared to total volume delivered according to Epic data.

Following the results of phase 2, a secondary study was conducted in 16 operating rooms at Blake Wilbur Drive Palo Alto, California (campus B). Phase 3 used the same methodology as phase 2 over a 3-week period.

Due to the nature of the research and institutional approval, no IRB approval was necessary. No identifying patient data was used as we only measured nitrous oxide gas delivery and utilization.

According to the Stanford Medicine Sustainability Program Office [2], the annual Palo Alto SHC 2022 Scope 1 emissions were 19,374 MTCO₂e (metric ton of CO₂ equivalent, the standard unit for comparing different GHGs to quantify their environmental impact and GWP) of which medical gases (including N₂O, CO₂, sevoflurane, and isoflurane) represented 4862 MTCO₂e. N₂O contributed 4590 MTCO₂e of the medical gases. Thus, medical gases account for 25.1% of all SHC scope 1 emissions, and N₂O alone accounts for 94.4% of those emissions (or 23.7% of the total).

Annual clinical usage of N₂O in 2022 per Epic data (Table 1) was 780,882.2 L (3155.1 lbs or 1431.1 kg), with the greatest use being for orthopedic surgery, general surgery, and neurosurgery cases. However, the total amount of N₂O purchased was 8,217,449 L (33,201.8 lbs or 15,060.1 kg), at a total cost of US $63,298. Thus, only 9.5% of the total purchased N₂O was actually delivered to patients, and 90.5% (or US $57,285 worth) was wasted.

With these data indicating a loss of greater than 90% between storage tanks and clinical use, a highly inefficient storage and pipeline system was recognized. The proposed solution (for phase 2 of the study) was to decommission the storage tanks and pipelines and switch to portable E-cylinders that stored and delivered N₂O at the point of care.

The change in mass of the E-cylinders indicated that N₂O use at campus A totaled 7.4 lbs (3.4 kg), or a volume of 1831.5 L, over the 5-week study period. Epic data showed total N₂O volume delivered to be 1839.3 L calculated to 7.4 lbs (3.4 kg; consistent with the measured 7.4 lbs). Using the standard of 1 E-cylinder=1590 L or 6.4 lbs (2.9 kg) [11], total use equaled 1.16 E-cylinders.

The E-cylinder change in mass indicated that N₂O use at campus B totaled 10.4 lbs (4.7 kg), or 2574 L, over the 3-week data collection period. Epic data showed total N₂O volume delivered to be 2840.3 L calculated to 11.5 lbs (5.2 kg; compared to the measured 10.4 lbs, which would be equivalent to 1.63 E-cylinders) [11].

Results from phase 1 corroborate findings from previous studies in the United Kingdom and Portland, Oregon [12,13], which reveal excessive waste from centralized storage of N₂O and pipe systems for delivery. Phases 2 and 3 of this study, from 2 different SHC campuses, demonstrate the efficient, cost-effective elimination of waste through substitution of E-cylinders with storage and delivery at the point of care. In phases 2 and 3, avoidable N₂O emissions were almost completely eliminated (Multimedia Appendix 1). The discrepancy between actual weighed N₂O and Epic-reported use for campus A was 7.8 L, or <0.1 lb (<0.1 kg). Campus B had a greater discrepancy with the difference in actual weighed N₂O and Epic-reported use being 266.3 L, or 1.1 lbs (0.45 kg). The amount of gas delivered according to the EHR was greater than the amount actually measured at the source, potentially accounted for by limited precision of the scales used to weigh the E-cylinders (only to 0.1-lb increments), or accidental reconnection of N₂O pipelines in one operating room during phase 3. This issue was detected after 1 week and immediately rectified.

E-cylinders provide an efficient and effective solution, but they hold limitations. E-cylinders must be stored properly to ensure that they do not present a catalyst in the event of a fire [14]. However, no policy implementation is required as E-cylinders are already in use in operating rooms and costs associated with storage can be offset by the N₂O saved. Ready accessibility, lower cost, reduced supply chain issues, and efficiency of E-cylinders far outweigh the abovementioned disadvantages.

The limitations of this study include the fact that real-world use and waste may vary from our experimental conditions, likely incurring greater losses. If e-cylinder valves are accidentally left open, losses may simulate those from centralized pipelines until the valve is closed [6] or the E-cylinder is emptied. The amount of N₂O to be purchased would need to be greater than the amount used in our example (Table 1), to provide surplus in the E-cylinders as well as spare E-cylinders. Prospective estimates of volume when making a purchase order would likely exceed actual use. Both recording and documentation of N₂O readings and the scale measurements are susceptible to error.

Converting the delivery of N₂O from centralized storage to point-of-care E-cylinders has dramatically reduced waste and expense with no detriment to patient care. Stanford’s pledge to reduce scope 1 and 2 emissions by 50% can be achieved and even surpassed if this practice is changed in all SHC locations. The introduction of E-cylinders will provide a nondisruptive means for immediately decreasing emissions while continuing to provide optimal anesthetic care. Pilot studies throughout Stanford’s campuses continue, with the goal of removing the centralized N₂O system and switching to E-cylinders at other sites, thereby significantly reducing anesthetic GHG emissions. Efforts to reduce GHG emissions may begin locally but have applications globally. Reducing the anesthetic carbon footprint of health care organizations is necessary for our planet and can begin with the reduction of wasteful emissions.