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Abstract

A shift in practice by anaesthetists away from anaesthetic gases with high global warming potential towards lower emission techniques (e.g. total intravenous anaesthesia) could result in significant carbon savings for the health system. The purpose of this qualitative interview study was to understand anaesthetists’ perspectives on the carbon footprint of anaesthesia, and views on shifting practice towards more environmentally sustainable options. Anaesthetists were recruited from four hospitals in Western Sydney, Australia. Data were organised according to the capability–opportunity–motivation model of behaviour change. Twenty-eight anaesthetists were interviewed (July−September 2021). Participants’ age ranged from 29 to 62 years (mean 43 years), 39% were female, and half had completed their anaesthesia training between 2010 and 2019. Challenges to the wider use of greener anaesthetic agents were identified across all components of the capability–opportunity–motivation model: capability (gaps in clinician skills and experience, uncertainty regarding research evidence); opportunity (norms, time, and resource pressures); and motivation (beliefs, habits, responsibility and guilt). Suggestions for encouraging a shift to more environmentally friendly anaesthesia included access to education and training, implementing guidelines and audit/feedback models, environmental restructuring, improving resource availability, reducing low value care, and building the research evidence base on the safety of alternative agents and their impacts on patient outcomes. We identified opportunities and challenges to reducing the carbon footprint of anaesthesia in Australian hospitals by way of system-level and individual behavioural change. Our findings will be used to inform the development of communication and behavioural interventions aiming to mitigate carbon emissions of healthcare.

Keywords

Anaesthesia climate change sustainability carbon footprint behaviour change environment

Introduction

Volatile and gaseous anaesthesia represent 5% of total national United Kingdom healthcare greenhouse gas (GHG) emissions,^1,2 and within hospitals can account for one-third of the total carbon footprint of surgical operating rooms.^3,4 An anaesthetist’s daily anaesthetic practice can, therefore, greatly impact the magnitude of their individual GHG emissions, with some anaesthetic agents (particularly desflurane and nitrous oxide (N₂O)) contributing significantly more than others.^5
–8

Some health systems internationally have pledged to, or have already achieved, reduced use of desflurane and/or N₂O in clinical care.^9,10 In Australia, these are still frequently used,¹¹ although a growing number of hospitals have made considerable financial and environmental savings by eliminating desflurane.^12,13 A shift in practice by anaesthetists away from high global warming potential anaesthetic gas use could result in significant carbon and cost savings. Propofol-based total intravenous anaesthesia (TIVA) is a well-established anaesthetic technique internationally that has a substantially lower carbon impact than inhalational anaesthesia.¹⁴ Yet it is used less frequently than volatile and gaseous anaesthesia¹¹ despite demonstrating clinical equivalence for many procedures.¹⁵

Anaesthetists can play a critical role in reducing the environmental impact of their clinical practice and profession. Importantly, any changes in practice must not adversely affect patient outcomes, so changes must be based on evidence about safety and effectiveness in addition to environmental and cost impacts. Recent guidance has been published providing safe and effective measures that anaesthetists can individually take to reduce their carbon footprint.^16,17 These include avoiding desflurane and N₂O, practising ‘low-flow’ anaesthesia, and utilising non-inhalational methods, such as regional anaesthesia or TIVA. However, little is known about the psychological, social, behavioural and clinical factors that motivate or prevent choosing sustainable anaesthesia.¹⁸ Identifying key determinants of behaviour may inform more effective design and implementation of interventions that encourage lower emissions clinical care. This study aimed first to understand anaesthetists’ perspectives on the carbon footprint of anaesthesia and views on shifting towards more environmentally sustainable options. We then aimed to use the capability–opportunity–motivation (COM-B) model of behaviour¹⁹ to identify potential mechanisms for change.

Materials and methods

Ethics

Ethical approval was obtained from the Sydney Children’s Hospitals Network (SCHN) Human Research Ethics Committee (2021/ETH00551).

Study design

This qualitative study involved in-depth interviews with anaesthetists in Sydney, Australia.

Participants and setting

Anaesthetists were recruited from four public hospitals in Sydney, Australia. Participants were eligible to participate if they were currently employed anaesthetic doctors at any level (including registrars and fellows), working at a children’s hospital in Sydney or one of three hospitals in the Western Sydney Local Health District (WSLHD). WSLHD is one of 15 local health districts in New South Wales (NSW), Australia and provides health services to approximately 1.1 million residents.²⁰ It is important to mention that at three of the four hospitals, desflurane canisters had been removed from anaesthesia machines but could still be accessed on provider request.

Three anaesthetists on the investigator team circulated an email advertising the study to their anaesthesia departments. Recruitment occurred in two rounds. In the first round, any anaesthetist who expressed interest and met the eligibility criteria was included. Preliminary analysis of the first 15 interviews showed that several topics warranted further investigation for better understanding. We also recognised that several first-round participants were highly conscious of the environmental impacts of anaesthesia. To capture a more diverse sample, we altered the study advertisement to make the focus on environmental impacts less explicit (i.e. we removed mention of ‘environmentally friendly anaesthesia’ in the study description but stated ‘reducing carbon emissions’ as a focus of exploration). Following the second round of recruitment, yielding a further 13 participants, it was decided that no further recruitment was required, given that similar ideas and patterns were repeatedly discussed with no new themes identified (i.e. saturation was achieved).

Data collection

Basic demographic information was collected by a short online survey. Interviews were conducted virtually by phone or videoconference. The interview guide (see Supplementary online information) covered a range of topics about determinants of current practice, understanding of environmental impacts of anaesthesia, and views on choosing lower emission options.

Data analysis

Interviews were audio-recorded and transcribed verbatim. Data analysis was completed using NVivo software (QSR International Ltd., Burlington, MA, USA; 2020), following a framework approach, a matrix-based analysis method used to order and synthesise textual data.²¹ The framework was informed by a combination of a priori topics relevant to addressing the aims (e.g. ‘clinician barriers to practice shift’; ‘reasons for choice of anaesthetics’) and themes that were derived from initial data analysis (e.g. TIVA as a more visible form of physical waste than gases). Several subcategories were included (e.g. ‘clinical care vs. environmental care’ under ‘perspectives of environmental impacts’).

We systematically applied the framework to each interview transcript by extracting text from the transcripts into the relevant category of the framework. Charting was facilitated by NVivo and involved organising the indexed data into a more manageable format. Mapping and interpretation involved pulling together key patterns and characteristics of the data, clarifying concepts, and interpreting and making sense of the entire dataset considering our aims.

Finally, we used the COM-B model¹⁹ to map perceived challenges and facilitators to behaviour change identified in the interviews. It was important to understand these to identify potential mechanisms for change.

Results

Twenty-eight anaesthetists were interviewed between July and September 2021. The average interview length was 37 minutes (range 15 − 70 minutes). Characteristics of the participants are summarised in Table 1. The average age was 43 years, 11/28 (39%) were female and most participants (23/28, 82%) worked predominantly in a tertiary hospital (n = 3 worked predominantly in a metropolitan non-tertiary setting). Thirty-two percent (8/28) had completed their anaesthesia training before 2010. At the time of interviewing, two participants were registrars, and one was a research fellow.

Table 1.

Characteristics of participating anaesthetists employed at four hospital sites in Western Sydney, Australia (N = 28).

Demographic variable	Category	n	%
Age, years	<30	1	3.6%
	31–40	12	42.9%
	41–50	10	35.7%
	51–60	4	14.3%
	>60	1	3.6%
Gender	Female	11	39.3%
	Male	17	60.7%
Clinical area/subspecialisation	General adult anaesthesia	18	64.3%
	Paediatric anaesthesia	4	14.3%
	Obstetric anaesthesia	1	3.6%
	Cardiac anaesthesia	4	14.3%
	Other	1	3.6%
Year of anaesthesia training	1990–1999	2	7.1%
	2000–2009	6	21.4%
	2010–2019	14	50.0%
	2020+	5	17.9%
	Still in training	1	3.6%
Location of practice^a	Adult hospital 1	16	57.1%
	Adult hospital 2	7	25.0%
	Children’s hospital	6	21.4%
	Adult hospital 3	5	17.9%
Nature of primary practice	Metropolitan tertiary	23	82.1%
	Metropolitan	5	17.9%
Percentage of work in private practice	0%	9	32.1%
	1–10%	5	17.9%
	11–20%	4	14.3%
	21–30%	2	7.1%
	31–40%	4	14.3%
	41–50%	3	10.7%
	>50%	1	3.6%
Predominant anaesthetic agent/gas used	Sevoflurane	18	64.3%
	Total intravenous anaesthesia (TIVA)	6	21.4%
	Nitrous oxide (N₂O)	1	3.6%
	Desflurane	1	3.6%
	Hard to tell	2	7.1%

Several participants worked at more than one of the four hospital sites.

Sevoflurane was the most commonly reported anaesthetic agent used by the anaesthetists in this study (64%; n = 18), followed by propofol-based TIVA (21%; n = 6) (Table 1). The reported use of desflurane and N₂O was rare among the sample, with only one participant reporting desflurane, and only one participant reporting N₂O as their predominantly used anaesthetic agent.

Across the interviews, we identified capability−opportunity−motivational challenges to moving towards lower emissions anaesthesia options which we describe in Table 2 and the sections below, as well as suggestions that participants made for overcoming some challenges to change (Table 3). Text in italics below refers to direct quotations by participants, along with the respective participant ID number (‘[PX]’).

Table 2.

The challenges and barriers to shifting towards more environmentally sustainable anaesthesia: quotes by anaesthetists working across four metropolitan Sydney hospitals (N=28).

Barrier/challenge	Description	Quote
Individual level			COM-B
Beliefs and attitudes	Personal beliefs that the environmental impact of anaesthesia is minimal, so changing practice is ineffective	We are part of a much bigger ecosystem, and we are actually only a very small cost. […] We can do the best we can, but don't beat ourselves up about it because there are much greater costs involved. [P12]	Motivation
Knowledge and experience	Gaps in anaesthetists’ knowledge, confidence, experience and vigilance in relation to using lower carbon-emitting techniques	TIVA as a go-to-technique is for most anaesthetists relatively new… familiarity with a sevoflurane-based anaesthetic makes them feel that they can get the safest anaesthetic with sevoflurane [P7]There's no question that it [TIVA] requires the anaesthetist to be more vigilant. […] And that may be a challenge to some. [P9]	Capability
Habitual and standard practice	Anaesthetists’ habits, standard practice	I think a lot of people work on habit, that’s just normally what you do. You’re comfortable with it, you get good at a program. [P24]	Motivation
Department/hospital/system level
Culture of anaesthesia	Social norms and professional culture of anaesthesia create barriers for practice shift, for example, isolated practice, judgement from colleagues, freedom of choice, and difficulties influencing colleagues’ choices.	It's quite hard to actually see what other colleagues do, like once you finish your training. I mean, I wouldn't even know what they do unless a trainee told me what they did. [P14]The variety of anaesthetics is all over the shop in terms of what people are doing, even for the same cases. And in the end, it all works out about the same, but it’s just your preference… you do what anaesthetic works for you not because of a particular drug. [P19]I don't think I would go and approach another consultant and say hey you should run TIVA. […] I guess for harmony [laughs] [P14]	Opportunity
Time and resources	Time pressures and availability of resources can make prioritising lower carbon emission options challenging, for example, lack of TIVA equipment, lack of time or personnel to set up the equipment, and lack of time to self-educate about sustainability options. In addition, resources are lacking in paediatrics to allow routine use of TIVA, which requires a system level change.	Using a volatile is, for me, a more obvious choice ’cause it saves me time in setting up things like organising pumps, drawing of medication, making sure everything’s well-connected. [P18]My hospital isn't set up to routinely give paediatric intravenous induction because that would involve having all the kids be given, like, EMLA cream on their hands at least half an hour before coming to theatres. And then for the anaesthetic staff, and the nurses to tell the patients in advance that the patients are going to get a drip. And that's not routine in the hospital, and that would actually require like a big change in the system and having to take extra efforts to try something different. [P6]	Opportunity
Research/evidence limitations
Lack of research and conclusive evidence	Anaesthetists feel uncertain about making changes to their practice due to gaps in current evidence about alternatives (e.g. patient outcomes and safety, plastic waste, propofol in waterways)	I think that we need, I think at this point, more research into this area. And I think especially propofol. So propofol's impact, we need more information about its whole environmental impact. [P9]	Capability

TIVA: total intravenous anaesthesia; EMLA: eutectic mixture of local anaesthetics.

Table 3.

Suggestions for overcoming some of the challenges and barriers to shifting towards more environmentally sustainable anaesthesia: quotes by anaesthetists working across four metropolitan Sydney hospitals (N = 28).

Recommendation	Examples	Quote
Department/hospital level
Implement departmental standards	Implementing performance indicators to ensure consistency across practitioners	I do all of those things [e.g. using low flows] automatically and I just assume that that’s what everyone does, but I guess that would all be part of making sure that everyone in your department is following those kinds of strategies. [P28]You know, when the department wanted to change to desflurane, I was like, ‘Oh, yeah, that makes sense,’ because that’s the departmental level that’s more likely to have an impact. [P28]
Education	Departmental meetings about environmental impacts, reminders and reinforcements, audit and feedback based on practice, and translating carbon emissions using analogies to aid understanding of environmental impacts	I'd struggle a lot with doing it [influencing colleagues] on a personal basis. Just going up and going, 'ah, do you, do you realise that you're using a lot of desflurane?' I think I would prefer to do it in the format of a, you know, like a departmental meeting to sort of look at education and change from that point of view. [P11]I think reinforcement is good, like reminders and reinforcements are good, and updates are good…. I do want to be further educated, but maybe not on a very, very, very frequent basis. [P3]… one of the hospitals in my local health district does actually have a quantification of the amount of volatile anaesthetic they’re using, but—and we’re just in the process of building up some sort of analytics information streams to help comprehend our usage of these things, and you can’t really do much until you comprehend the usage numbers. [P5]I think they [environmental impacts of different technique/agents] could definitely be made more accessible particularly when it comes to what's the impact of my anaesthetic on the environment which I think is an important thing to feed back to anaesthetists because you can use all these hypotheticals and things but it’s not until you see what you are doing that it brings it home and the potential for change as well. [P13]That classic story about if you use desflurane for so many hours, it's like driving across New South Wales in your car versus driving 50 kilometres with sevoflurane. And that's quite a powerful example […] it stuck with me. [P12]
Environmental restructuring	Removing desflurane canisters from the machine, and adding posters and tags to vaporisers about environmental impacts of agents	We have actually moved away from desflurane already in the theatre, as in we've removed the cannister altogether from our practice. It's not physically available to us. So it's locked up somewhere in the room, unless we're super, super desperate with clear indications and we cannot use any other agents, then we can ask for permission to use desflurane, but otherwise it's locked up in a room somewhere. It's not being used. [P1]They've taken desflurane off the machines so that you have to actually ask for it. And so I think that having that extra step makes people think about it, […] the data has shown it's meant that people use less desflurane. [P11]We've got posters about recycling plastics and paper around but not the actual anaesthetics. [P1] … tags on the vaporizers saying you might like to consider using something else. [P5]
Resource availability	Improving the protocols and resource availability in the paediatric operating theatre to allow for TIVA to be used	I’ve worked in places where the nurses were also just keeping the kids distracted and we just did everybody as an IV induction no matter what their age, and so we just run them all in propofol […]. In that place, what we had is we had excellent anaesthetic nurses who would really do a great job at distracting the kids and they have these big wide books and they’d put the book in front of the kids so they couldn’t see anything, and into the arm it went, so it was just a really nice protocol of people used to doing there. Whereas the kid’s hospitals I work in now, they're just not used to that protocol, they haven’t got things in the room. [P24]
Clear messages and solutions	Providing concrete and simple messages and solutions to anaesthetists about what they can do to reduce their environmental impact	It's always good to have those numbers [comparing carbon emissions per agent] to tell people. [P8][Environmental impact information] … is not necessarily presented in a very accessible way, particularly when it comes to comparing techniques [P13][When asked about willingness to learn more about the environmental impacts of anaesthesia] It could be a bit depressing, so if there's a solution, then yeah [laughs]. But if it's just something to be depressed about, then no! [P27]All of us are so busy in our various ways that having a localised pre-digested sort of effective literature review or summary is extremely high impact because it makes it—it gives you concrete things that you can do. Saying like the choice of agent and intravenous anaesthesia and just concrete things that you can do in every day. [P5]We can’t sort of hold a thesis in our head all the time [about the carbon footprint of anaesthesia]. We just have to have the top three items for trying to reduce the environmental impact. [P5]
Encouraging discussions among colleagues	Encouraging discussions among colleagues to question and influence more environmentally friendly practice	I think we should all try to influence each other to do the best that we can, and I would hope that my colleagues would, respectfully, try to influence me if they saw me doing something that was not good for the public or the environment or the patient. [P7]People need to start being a little bit more vocal and asking their colleagues why they're making particular choices when there's alternatives available. [P2][at work] …we have the chance to influence other people and their choices much more than we do at home. So it’s one of the ways for very little effort, I feel, I might be able to make some positive impact. [P7]
System-level
Curriculum changes	Incorporating environmental impacts of anaesthesia into the anaesthesia curriculum and examinations	My understanding is that it [environmental impacts of anaesthesia] even came up as an exam question for… in the primary exam for the trainees, maybe not in this sitting, but the sitting before. And quite a lot of them are thrown by it. And it was answered quite badly as a question. So I suspect given that happened, more and more of them are actually going to be forced to read about cause it's more likely to be asked again. [P22]
Anaesthesia training	Educating all anaesthetists on low-flow practice; Train anaesthetists out of automatic behaviour/habits; be more critical/aware	For future pushes from environmental impact side of things, I think that's where we need to concentrate our efforts on, to educate anaesthetists to move to low-flow anaesthesia. [P9]The aim for us going forward really needs to be that we need to train anaesthetists to use low-flow anaesthesia. Not to make a blanket statement that we need to not use desflurane, not use nitrous oxide. I think the shift has to be, every anaesthetist in Australia needs to practice low-flow anaesthesia […] the real problem here, is anaesthetists who use high-flow anaesthesia. Whenever I go to a private hospital, I'll always look on the machine and see what the previous anaesthetist, for the previous three cases have used from a gas point of view. And I am horrified, most of the time, at the volume of gas that people use, and it's simply because they use high-flow anaesthesia. [P9]It’s just that apprenticeship model that just gets out forward over and over and you just have to try and train people out of doing that [P13]
Institutional leadership	Supporting departments	I can change as much as I want with my practice but unless I can influence the practice of the department, the LHD and larger networks, there’s not gonna be any real change [P13]We should be working out what’s the ideal model for supporting departments to make that change (from volatile to TIVA). What education resource do you need… there’s a lot of equipment and infrastructure change that needs to be made such as medication ordering practices, availability of pumps, and they’re expensive… there’s just so many barriers in place that will prevent them from making that change. [P13]
Peak bodies (e.g. ANZCA) to set standards	Clinical practice guidelines/college recommendations	I think what the emphasis should be is they [ANZCA] should insist that every anaesthetist needs to know how to do low-flow anaesthesia. Use the best drugs you think, for the patient. But whatever you do, do it efficiently, use low-flow anaesthesia. [P9]
Research priorities
Technology advancements	Capture and recycle technology	The other thing that's on the horizon is technology that can absorb volatile anaesthetic at the end of a case…. So they are using it clinically in Canada […] I'm pretty sure they're working on it, to bring it to Australia […] And so what then that means is that at the end of a case, rather than washing out your volatile anesthetic gas into the environment, it will be absorbed onto this special charcoal type filters and then that can then be returned to the company and they can extract it again and recycle it. So I think that's something that is an important advancement from an environmental point of view. [P9]
Addressing TIVA-specific research gaps to building evidence base	Research the whole environmental impact of propofol, including the impact on waterways. Also, more research is needed to be brought to anaesthetists’ attention to understand patient outcomes and confirm patient safety using TIVA in specific contexts, e.g. emergency caesarean sections	We don’t know the unintended consequences of change (to TIVA) … if we’re reducing what we’re putting in the air… we don’t know what’s happening with what we’re disposing into the ground… on patient outcomes…. [P13]
Environmental co-benefits of reducing low value care	Studies to measure the environmental co-benefits of reducing low value care	I think the biggest environmental impact that we can do is not to do pointless cases and I think that’s an area that is not getting enough discussion. [P20]

TIVA: total intravenous anaesthesia; ANZCA: Australian and New Zealand College of Anaesthetists; LHD: local health district; IV: intravenous.

Capability factors

Anaesthetists’ skills and experience with lower emissions anaesthetic options can influence confidence and ease in choosing greener anaesthesia techniques

Some participants perceived TIVA as ‘a little bit fiddlier’ [P20], risky (e.g. potential awareness), and requiring more vigilance from the anaesthetist: ‘TIVA requires a higher baseline level of attention and monitoring and care. There are more things that can go wrong at random times with TIVA than volatile [anaesthesia].’ [P20].

Some anaesthetists felt less skilled in using TIVA, for example, because ‘…for a lot of anaesthetists, TIVA is still a relatively new concept … and they are reluctant to use it’ [P10]. One participant explained that when they first completed training, the predominant way of anaesthetising was volatile-based, and ‘TIVA was seen as exceptional anaesthetic … non-mainstream and only reserved for special circumstances’ [P3], so their ‘comfort zone’ acquired from training was to give a volatile-based anaesthetic. On the other hand, anaesthetists who had trained more recently were less inclined to use more environmentally harmful agents, because they ‘didn’t really grow up using desflurane, so … got very comfortable with not using it’ [P11], ‘I just don’t even think of it as now something up my sleeve’ [P14].

A few participants held the opinion that registrars training with environmentally conscious consultants (who refused to use particular agents) could be disadvantaged. They explained that this could limit the opportunity to learn all anaesthetic techniques and diversify their skills through exposure and could even become an issue for patient safety, for example:

There should be a bit less concern about the environmental impact on some of these techniques, which I think strongly discourages trainees from using certain techniques for a fear of—'Oh, you don’t care about the environment, hey—' questions from your consultants … it mentally impacts the ability of trainees to learn about using other techniques in a safe and skilled environment, whereas they might have to do it solo when their consultant isn’t around. [P20]

Their view was that volatile anaesthesia remains the predominant technique, so trainees should be exposed to all types of anaesthetics during their training, ‘even the non-environmentally friendly ones’ [P15], so that they understand each one and ‘are comfortable with that’ [P11].

Anaesthetists can feel uncertain about making changes to their practice due to perceived gaps in current evidence

Several participants highlighted the complexity of choice between modes of anaesthesia when considering their environmental impact, stating that ‘it’s not just black and white that volatile [anaesthesia] is bad and TIVA is good’ [P21]. Many felt uncertain about changing practice due to a perceived lack of conclusive research evidence regarding a) the clinical and environmental impacts of alternative agents and techniques, and b) in support of removing or banning agents such as desflurane and N₂O. There was also a strong sense of uncertainty regarding the broader ecological impacts of newer techniques such as TIVA, specifically the plastic waste involved and concern about the persistence, bioaccumulation and toxicity of propofol in waterways, which some felt were currently unresolved issues, for example:

I think we need something to balance the scientific argument and really understand what propofol’s complete environmental impact will be. [P9]

I haven’t necessarily got to the stage where I feel that I should be doing all my cases with TIVA, if in order to reduce the plastic footprint, I still haven’t quite reconciled the idea of the propofol waste and where that goes in terms of polluting our water supplies. [P26]

Opportunity factors

Social norms and the professional culture of anaesthesia can make it difficult to make greener choices or influence colleagues

Many participants described anaesthesia as an isolated practice, wherein anaesthetists tend to work alone, ‘not really exposed to other people’s practice’ [P21], particularly in private practice. As a result, some anaesthetists become isolated from newer techniques and workplace norms that encourage self-reflection, accountability and discussion around the environmental impacts of anaesthesia. Freedom of choice also meant that there was large variety in preferred techniques.

A small number of participants had experienced judgement and anger from colleagues who perceived making shifts for environmental reasons as ‘a tree-hugging thing’ [P13], for ‘a crazy greenie’ [P2]. Being judged as going against the norm was portrayed as a barrier to behaviour change because, ‘people like to follow the common practice in the department, no one wants to be someone on the extreme’ [P13].

Most participants said they would not feel comfortable attempting to influence their colleagues to use more environmentally friendly options due to ‘professional courtesy’ [P15], to maintain ‘harmony’ [P3] and avoid potential safety risks, for example:

The last thing you want is to convert somebody into another type of anaesthetic or another version of the anaesthetic that they’re not used to and then have them provide unsafe anaesthesia. [P3]

Time pressures and the availability of resources can make prioritising lower carbon emission options challenging

Participants explained that delivering TIVA requires extra equipment and takes longer to set up than a volatile anaesthetic. When rapid patient turnover is a priority, volatiles are the ‘most obvious choice’ [P18] pragmatically, due to faster setup and perceived wake-up time, ‘the surgeon will get annoyed if you are slowing down the list’ [P13]. This was particularly an issue in private practice, in which patient lists are expected to move quickly. A few participants also mentioned that without having adequate personnel available (e.g. anaesthetic nurses), using TIVA is difficult and ‘too labour intensive’ [P10].

Most participants raised some concerns around the availability of equipment for TIVA (e.g. syringes, infusion pumps, ‘timely access to propofol bottles’) limiting their capacity to use it. Private hospitals were specifically noted as being ill-equipped for running TIVA: ‘the private hospitals didn’t buy the algorithms in their hardware’, and their impression was that private hospitals ‘didn’t see it as worthwhile because it’s an additional cost’ [P3].

A few participants discussed issues in hospitals where anaesthetists practise across multiple hospitals and therefore do not have the time to work out sustainability solutions, related to what one participant described as a ‘lack of institutionalised energy to decrease our environmental impact’ [P11].

Motivational factors

Personal belief that the environmental impact of anaesthetic gases is minimal, so reducing use may be ineffective

Some participants believed that the environmental impact of anaesthesia is minimal, comprising only a ‘small subsection’ of total hospital or healthcare emissions and compared with the environmental damage caused by other sectors, ‘our anaesthetic gases contribute to a very, very small proportion of GHG emissions’ [P9]. They reasoned that limiting the use of volatiles for environmental reasons may be an unnecessary or ineffective way to reduce GHG emissions, for example:

Mining companies are doing a lot more environmental damage than I am by sometimes using sevo [sevoflurane]…. So, I’m not sure how important my choices are… [P28]

One participant believed that their use of both desflurane and N₂O had a minimal environmental impact and that their clinical advantages (e.g. ‘waking up more quickly, brighter … protecting the airway reflexes’) ‘far outweigh the very small disadvantages’ [P9]. This participant defended their belief by explaining that they use ‘efficient, low flow anaesthesia’, and so ‘at the amounts that I use, I think the impact is minimal enough that it is well worthwhile using’. [P19]

Interestingly, the proportion of GHGs attributed to anaesthesia was viewed differently between participants. For example, one participant interpreted the approximate percentage of emissions attributable to anaesthesia as small, ‘only about one percent of GHGs in the whole world’ [P25], while another participant perceived this same percentage as representing a significant impact:

If you realise that you are one percent as healthcare workers, then you might actually go, ‘Oh, we’re not as insignificant as I first thought’. [P4]

Some participants spoke of other aspects of healthcare being more important to target than anaesthetic gases to reduce emissions. Packaging and production of anaesthesia, for example, was described as adding significantly to the GHG impact ‘rather than the agent itself’ [P23].

Many participants explained that because volatile/gaseous anaesthesia is not visible, ‘sevoflurane is like an invisible waste’ [P12], it is easier to be unaware of the impact or to believe it is negligible. On the other hand, we were told that TIVA produces visible waste, ‘you can see a bag full of syringes and plastic rubbish’ [P12], so it can seem worse for the environment than the invisible impact of volatiles/gases. ‘Psychologically it just feels like you throw a lot more visible waste away’ [P12]. One participant voiced their perspective that anaesthetics can never be net zero, no matter what steps they take to minimise their personal contribution: ‘I can’t provide what I’m doing without using carbon. Anaesthetics will never be net zero without having an offset’ [P23].

Environmental care is perceived as secondary to patient care

While most anaesthetists indicated concern regarding the environmental impacts of anaesthesia, almost all reported that patient safety and comfort is their number one priority and the biggest factor affecting their choice of anaesthetic agent: ‘clinical care will always trump environmental impacts’ [P12]; ‘I don’t wanna give a worse anaesthetic just so that I can save a few tons of CO₂’ [P13].

One participant explained that their overall impression was that anaesthetists would choose their anaesthetics based on ‘anaesthetic reasons first, and then cost reasons are secondary, and environmental reasons are on the radar of a very small subsection’ [P23]. However, there appeared to be a diversity of opinion on whether anaesthetists were motivated by environmental care. One argued that it does not have to be one or the other: ‘we can safely anaesthetise patients whilst being environmentally aware’ [P2]. Many described avoiding desflurane because of its ‘huge environmental cost’ [P3], despite perceiving it as having some advantages for particular patient groups.

Using particular anaesthetics habitually is comfortable and predictable

Many participants stated that they, or their colleagues, have developed a standard way of practising, in which they are ‘just going to work and doing what they were taught or what they’re comfortable with day-in-day-out’ [P28]. This way of practising brought comfort, certainty, predictability, and less effort, whereas seeking out or understanding alternative ways of practising was perceived as uncomfortable and unpredictable, for example:

Most people wanna give the same anaesthetic everyday cause there’s a certainty a comfort in that, … whereas if you change over to something else, it’s highly unpredictable. You have to expend more effort. [P13]

Some anaesthetists with more established practice were described as ‘…stuck in their ways of this is how I’ve done it for the last 30 years, so I’m going to continue to do it’ [P10]. One participant mentioned that, as a registrar, they would know which consultants regularly use which type of agents so could anticipate what agents they would be using that day:

There are certain consultants you know will want TIVA and you know, before you start, it’s going to be a TIVA day…. And then there are other anaesthetists that, when you see their name, it’s going to be a sevoflurane day. [P10]

A sense of personal responsibility or guilt in relation to anaesthesia’s carbon footprint can motivate practice shift

It became evident from the interviews that, for some participants, awareness of the environmental impact of anaesthesia had translated emotionally and manifested in their practice. Some participants perceived themselves as personally having a key role to play in improving the sustainability of anaesthesia, while others mentioned that anaesthetists more broadly have a collective responsibility in reducing the environmental harms of their profession. Some reported a responsibility to protect future generations, which influenced their choices, for example:

There was a year or so with lots of awareness and constantly feeling guilty … and so, I’m doing a little bit … because I have children and I’m really worried about the future, not just theirs but generally, that helps. [P16]

One participant indicated taking onboard other anaesthetists’ lack of environmental responsibility as their own burden, specifically colleagues who use high flows of volatile agents: ‘I’d just walk into some rooms and I’m just seeing some numbers on the screen, that makes me cry on the inside when I see how much… [high flow anaesthesia is used]’ [P13].

Several participants felt guilty about the harm they as anaesthetists are causing the environment, and tried to counter this by supporting sustainability initiatives at their hospital for example, or making environmentally friendly choices in their personal lives, such as recycling or installing solar panels. One participant described the contrast in their work versus home identity:

At home, I’m very green, trying to recycle everything, limit the use of water and electricity…. Sometimes at work, I feel like I’m a different person cause there’s so much rubbish I produce. [P18]

A few participants attempted to ‘balance out’ the environmental harms of their clinical practice by using greener options or different techniques when appropriate to lessen guilt about the overall footprint, for example:

Sometimes I feel like, even more like guilt, as in like yesterday, I used a lot of volatiles. Maybe I should use some more TIVA today, to try to balance it out a little bit. [P1]

Feelings of personal guilt appeared lessened in situations where volatiles were clinically indicated and considered an essential component of patient care, such as for induction in paediatric populations.

Opportunities and recommendations for practice shift

Various recommendations were made by participants to enable a shift towards more environmentally friendly anaesthesia (Table 3). These include education and training, implementing guidelines and audit/feedback models, environmental restructuring (i.e. modifying the physical environment to encourage more sustainable choices), improving availability of TIVA equipment, and building the research evidence base on TIVA safety and impact on patient outcomes.

Some participants mentioned department and hospital-level changes that have already been implemented in several hospitals, specifically targeting a reduction in desflurane use, including complete removal from anaesthesia machines. Other existing strategies included adding visual tactile reminders such as posters or labels on volatile bottles, prompting anaesthetists to consider the environment when making anaesthetic agent choices.

There was a consensus among participants that anaesthetists should not be forced to change their practice or told what to do. For this reason, many participants strongly felt that increasing awareness around the carbon impacts of anaesthesia was the best way forward. Several participants noted that education efforts should particularly target private practice for ‘big gains’ [P9].

One participant indicated reducing low value care in anaesthesia as an important strategy for reducing emissions: ‘I think the biggest environmental impact that we can do is not to do pointless cases and I think that’s an area that is not getting enough discussion.’ [P20].

Discussion

This study provides valuable insights into the perceived challenges of delivering more environmentally sustainable anaesthesia. We identified and mapped factors that motivate or prevent the transition to greener anaesthesia, in addition to suggested ways to overcome these from the perspective of clinicians on the frontline. Barriers to the wider use of greener anaesthetic agents were identified across all components of the COM-B model: capability (clinician skills and experience, uncertainty around state of the evidence); opportunity (social and professional norms, time and resource pressures); and motivational factors (personal beliefs, habitual clinical behaviour). A sense of responsibility and guilt was reported by several participants as a key motivation for selecting lower emission alternatives. Recommendations for shifting towards more environmentally friendly anaesthesia practice included access to education and training to address the knowledge and skill barriers, implementing guidelines and audit/feedback models, environmental restructuring, improving the availability of TIVA equipment to address resource barriers, reducing low value care, and building the research evidence base on TIVA safety and impact on patient outcomes.

Previous studies have identified similar challenges to providing greener clinical care to those identified in this study, including psychological and social barriers to action, conflict of priorities in care delivery, organisational constraints, and lack of leadership.^22
–24 This study adds further understanding of individual and system-level factors preventing sustainable behaviour change, including the difficulties weighing up the consequences of visible (plastic) versus invisible (gaseous) wastes and clinician uncertainty regarding the available evidence on alternative options for anaesthesia, particularly concern about TIVA’s ecological contamination and unknown impacts on biodiversity. Previously underexplored social factors were also identified in this study, including how professional culture and lack of accountability may be hindering behaviour change. These social factors suggest that efforts to encourage a cultural shift in the profession may be warranted. Importantly, our results highlight the value of prioritising better system-level support for clinicians to practise greener healthcare through improved access to training and educational resources and encouraging institutional leadership and involvement.

Implications

Global calls for clinician action have already been made in this area,²⁵ and system-level initiatives such as the Greener NHS plan aim to reduce the use of desflurane and N₂O.²⁶ Reducing the use of these agents should be prioritised to reduce global environmental impacts immediately without compromising patient care.²⁷ In Australia, our findings suggest that some anaesthetists feel a sense of collective responsibility to reduce the environmental impacts of their profession, with some reporting that their responsibility to protect future generations influences their choices. Shifts in personal choices are already proving impactful in lowering emissions by anaesthetists worldwide,^28,29 including some hospitals and individual anaesthetists who have begun implementing change (e.g. removing desflurane canisters). Further action is needed to implement the clinician-focused strategies for practising more sustainably¹³ (i.e. avoiding desflurane and N₂O, practising low-flow anaesthesia, and using non-inhalational methods). Our study has identified several barriers that may be preventing the uptake of some of these strategies, as well as settings where volatile anaesthesia may be in higher use. We recommend that these be addressed as a priority as we cannot expect behavioural change without intervening on key barriers across all components of the COM-B model.

Mapping our results to the COM-B model highlights opportunities to move forward with intervening on clinical behaviours using evidence-based behaviour change techniques (BCTs) to promote sustainable practice.¹⁹ For example, to overcome the identified capability challenges, effective interventions may include workshops or courses educating clinicians on the social and environmental consequences of high carbon-emitting agents and training clinicians in using lower carbon-emitting anaesthetic techniques. Carbon literacy should be addressed among anaesthetists to improve their ability to make decisions appropriately with an awareness of environmental consequences. Further research is needed to clarify and inform anaesthetists of the ecological impacts of TIVA (e.g. polluting waterways). Interventions targeting the opportunity factors could include restructuring the physical environment (e.g. increasing the availability of TIVA equipment) and supporting hospitals and anaesthetic departments to shift social norms by creating cultures that value environmental care.^16,25 Furthermore, employing ‘clinical champions’ to encourage and advocate for sustainable practice and avoid low value care³⁰ could address the lack of institutionalised energy and capacity to prioritise sustainable behaviour change.³¹ Finally, BCTs to target motivational barriers might include outcome-focused goal setting and, given that our data indicate responsibility as a motivation for change, emphasising the consequences of using high carbon-emitting agents. We recommend that future interventions should only implement and assess a few BCTs simultaneously, with a comparison group, to most accurately assess which are effective.³²

Strengths and limitations

The project was a collaborative partnership between researchers and clinicians to support change towards the delivery of more environmentally friendly anaesthesia. It demonstrates the challenges of practising more sustainably from the perspectives of a sample of Australian anaesthetists representing common practice settings. A noteworthy strength is mapping behavioural barriers and facilitators using the COM-B model to allow the relevant BCTs to be applied in future behaviour change interventions.

A limitation of this study is the recruitment of self-selecting participants from public metropolitan hospitals from one state in Australia, many of whom were already interested in and aware of the environmental impacts of anaesthesia. Desflurane canisters had been removed from anaesthetic machines in three of the four hospitals, and as such, we were unable to explore barriers to practice shift among anaesthetists primarily using higher carbon-emitting agents. We acknowledge that this study focused on general anaesthetic agents and note that many additional environmental impacts of anaesthesia contribute to its overall carbon footprint, including single-use equipment. This study also did not explore regional anaesthesia as a low carbon option as well as the relative benefits, harms and costs when comparing minimal flow volatile anaesthesia with TIVA. These topics warrant further research.

Conclusions

This qualitative study highlights opportunities and challenges to reducing the carbon footprint of anaesthesia in Australian hospitals by individual and system-level behavioural changes. As part of a larger programme of research aiming to mitigate carbon emissions and support long-term sustainability of healthcare, these findings are informing the development of communication and behavioural interventions to support change towards more environmentally friendly anaesthetic practice.

Supplemental Material

sj-pdf-1-aic-10.1177_0310057X231212211 - Supplemental material for Exploring anaesthetists’ views on the carbon footprint of anaesthesia and identifying opportunities and challenges for reducing its impact on the environment

Supplemental material, sj-pdf-1-aic-10.1177_0310057X231212211 for Exploring anaesthetists’ views on the carbon footprint of anaesthesia and identifying opportunities and challenges for reducing its impact on the environment by Matilde Breth-Petersen, Alexandra L Barratt, Forbes McGain, Justin J Skowno, George Zhong, Andrew D Weatherall, Katy JL Bell and Kristen M Pickles in Anaesthesia and Intensive Care

Footnotes

Author Contribution(s)

Matilde Breth-Petersen: Data curation; Formal analysis; Investigation; Methodology; Project administration; Software; Visualization; Writing – original draft; Writing – review & editing.

Alexandra L Barratt: Conceptualization; Funding acquisition; Methodology; Resources; Supervision; Validation; Writing – review & editing.

Forbes McGain: Conceptualization; Supervision; Validation; Writing – review & editing.

Justin J Skowno: Conceptualization; Methodology; Project administration; Supervision; Validation; Writing – review & editing.

George Zhong: Conceptualization; Investigation; Methodology; Project administration; Validation; Writing – review & editing.

Andrew D Weatherall: Conceptualization; Methodology; Project administration; Validation; Writing – review & editing.

Katy JL Bell: Conceptualization; Methodology; Writing – review & editing.

Kristen M Pickles: Conceptualization; Data curation; Formal analysis; Methodology; Project administration; Resources; Software; Supervision; Validation; Visualization; Writing – review & editing.

Acknowledgements

Katy Bell is supported by a National Health and Medical Research Council (NHMRC) investigator grant (no. 1174523). She is an Investigator for the Wiser Healthcare Collaboration, funded by a NHMRC Centre for Research Excellence grant (no. 2006545).

Forbes McGain has received grant funding from the NHMRC and Medical Research Future Fund, along with Australian and New Zealand College of Anaesthetists and College of Intensive Care Medicine of Australia and New Zealand grants. He receives royalties for a co-patented medical device (the McMonty hood).

Matilde Breth-Petersen and Kristen Pickles were supported by Wiser Healthcare Australia. Wiser Healthcare is a research collaboration to reduce overdiagnosis and overtreatment, funded by the NHMRC ().

Declaration of conflicting interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

ORCID iDs

Matilde Breth-Petersen

Forbes McGain

George Zhong

Andrew D Weatherall

Kristen M Pickles

References

Tennison

Roschnik

Ashby

, et al. Health care's response to climate change: a carbon footprint assessment of the NHS in England. Lancet Planet Health 2021; 5: e84–e92. doi:10.1016/S2542-5196(20)30271-0

Campbell

Pierce

JT.

Atmospheric science, anaesthesia, and the environment. Br J Anaesth Educ 2015; 15: 173–179. doi:10.1093/bjaceaccp/mku033

MacNeill

Lillywhite

Brown

CJ.

The impact of surgery on global climate: a carbon footprinting study of operating theatres in three health systems. Lancet Planet Health 2017; 1: e381–e383. doi:10.1016/S2542-5196(17)30162-6

Sherman

Chesebro

BB.

Inhaled anaesthesia and analgesia contribute to climate change. BMJ 2022; 377. doi:10.1136/bmj.o1301

White

Shelton

Gelb

, et al. Principles of environmentally sustainable anaesthesia: a global consensus statement from the World Federation of Societies of Anaesthesiologists. Anaesthesia 2022; 77: 201–212. doi:10.1111/anae.15598

Seglenieks

Wong

Pearson

, et al. Discrepancy between procurement and clinical use of nitrous oxide: waste not, want not. Br J Anaesth 2022; 128: e32–e34. doi:10.1016/j.bja.2021.10.021

Shelton

Knagg

Sondekoppam

, et al. Towards zero carbon healthcare: anaesthesia. BMJ 2022; 379: doi:10.1136/bmj-2021-069030

Chakera

Driving down embedded emissions from medical nitrous oxide. BMJ 2021; 375: n2922. doi:10.1136/bmj.n2922

Association of Anaesthetists. Joint statement on NHSE’s plan to decommission desflurane by early 2024. 2023. https://anaesthetists.org/Home/News-opinion/News/Joint-statement-on-NHSEs-plan-to-decommission-desflurane-by-early-2024 (accessed 21 February 2023).

10.

Assocation of Anaesthetists. Nitrous Oxide Project. 2023. https://anaesthetists.org/Home/Resources-publications/Environment/Nitrous-oxide-project (accessed 21 February 2023).

11.

McGain

Bishop

Elliot-Jones

, et al. A survey of the choice of general anaesthetic agents in Australia and New Zealand. Anaesth Intensive Care 2019; 47: 235–241. doi:10.1177/0310057x19836104

12.

Tay

Weinberg

Peyton

, et al. Financial and environmental costs of manual versus automated control of end-tidal gas concentrations. Anaesth Intensive Care 2013; 41: 95–101. doi:10.1177/0310057x1304100116

13.

McGain

Five ways hospitals can reduce their environmental footprint. ANZCA Institutional Research Repository. 2018. https://airr.anzca.edu.au/anzcacrisjspui/handle/11055/567 (accessed February 2023).

14.

Sherman

Lamers

, et al. Life cycle greenhouse gas emissions of anesthetic drugs. Anesth Analg 2012; 114: 1086–1090. doi:10.1213/ane.0b013e31824f6940

15.

Lim

Braat

Hiller

, et al. Inhalational versus propofol-based total intravenous anaesthesia: practice patterns and perspectives among Australasian anaesthetists. Anaesth intensive Care 2018; 46: 480–487. doi:10.1177/0310057x1804600509

16.

McGain

Muret

Lawson

, et al. Environmental sustainability in anaesthesia and critical care. Br J Anaesth. 2020; 125: 680–692. doi: 10.1016/j.bja.2020.06.055

17.

Devlin‐Hegedus

McGain

Harris

, et al. Action guidance for addressing pollution from inhalational anaesthetics. Anaesthesia 2022; 77: 1023–1029. doi.org/10.1111/anae.15785

18.

McGain

Naylor

Environmental sustainability in hospitals—a systematic review and research agenda. J Health Serv Res Policy 2014; 19: 245–252. doi:10.1177/1355819614534836

19.

Michie

Van Stralen

West

The behaviour change wheel: a new method for characterising and designing behaviour change interventions. Implement Sci 2011; 6: 1–12. doi:10.1186/1748-5908-6-42

20.

New South Wales Health. Western Sydney Local Health District – About Us. 2023. https://www.wslhd.health.nsw.gov.au/About-Us (accessed 21 February 2023).

21.

Ritchie

Spencer

Bryman

, et al. Chapter 9. In: Bryman

Burgess

(eds). Analysing Qualitative Data. London: Routledge, 1994. doi.org/10.4324/9780203413081_chapter_9

22.

Charlesworth

Ray

Head

, et al. Developing an environmentally sustainable NHS: outcomes of implementing an educational intervention on sustainable health care with UK public health registrars. New South Wales Public Health Bull 2012; 23: 27–30. doi:10.1071/nb11018

23.

Dunphy

JL.

Healthcare professionals’ perspectives on environmental sustainability. Nurs Ethics 2014; 21: 414–425. doi:10.1177/0969733013502802

24.

Griggs

Fernandez

Callanan

Nursing and the barriers to sustainable health care: a literature review. Br J Nursing 2017; 26: 1230–1237. doi:10.12968/bjon.2017.26.22.1230

25.

Sherman

McGain

Lem

, et al. Net zero healthcare: a call for clinician action. BMJ 2021; 374. doi:10.1136/bmj.n1323

26.

NHS England, NHS Improvement. Delivering a ‘net zero’national health service. London: NHS England and NHS Improvement. 2020. https://www.england.nhs.uk/greenernhs/wp-content/uploads/sites/51/2020/10/delivering-a-net-zero-national-health-service.pdf (accessed February 2023).

27.

Shelton

Sutton

White

SM.

Desflurane in modern anaesthetic practice: walking on thin ice (caps)?

Br J Anaesth 2020; 125: 852–856. doi:10.1016/j.bja.2020.09.013

28.

Glenski

Levine

The implementation of low‐flow anesthesia at a tertiary pediatric center: a quality improvement initiative. Paediatr Anaesth 2020; 30: 1139–1145. doi:10.1111/pan.13994

29.

Carter

Oyewole

Bates

, et al. Promoting low-flow anaesthesia and volatile anaesthetic agent choice. BMJ Open Quality 2019; 8: e000479. doi:10.1136/bmjoq-2018-000479

30.

Choosing Wisely Australia. RECOMMENDATIONS: Australian and New Zealand College of Anaesthetists 2017. 2023. https://www.choosingwisely.org.au/recommendations/anzca (accessed February 2023).

31.

Cavicchi

Healthcare sustainability and the role of intellectual capital: evidence from an Italian regional health service. J Intellect Capital 2017; 18: 544–563. doi:10.1108/JIC-12-2016-0128

32.

Batcup

Breth-Petersen

Dakin

, et al. Behavioural change interventions encouraging clinicians to reduce carbon emissions in clinical activity: a systematic review. BMC Health Serv Res 2023; 23: 384. doi:10.1186/s12913-023-09370-2

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