Harmful anaesthetic gas decommissioned at Cardiff and Vale UHB

Studies had shown that nitrous oxide has more than 265 times the global warming potential than CO2.  Fiona knew this. She knew that it was far more environmentally harmful as a greenhouse gas than two others which are most commonly used.

At the same time, Fiona noticed a project being promoted by the American Society of Anaesthesiologists called ‘Project Drawdown’ which aimed to reduce the environmental impact of anesthetic gases. 

In 2018, Fiona began to ignite this work with the pharmacy team by gathering data on how much of these volatile agents were purchased each year at the Health Board. After working hard to analyse the data and calculate the carbon footprint, she could see that the CAV UHB were buying millions of litres of these gases even though they weren’t being used. Modern anaesthetic practice had almost eliminated the use of nitrous oxide in adult anesthesia, though it is still used in paediatric anesthesia and for short procedures in the dental hospital, and Entonox is still widely used in hospitals, maternity unit being the biggest consumer by far.

Recognising the scale of this project Fiona gathered a team that would be able to dedicate time to investigate, implement change work and source funding.

The multi-disciplinary team was made up of Elaine Lewis (Pharmacy), Charlotte Oliver (Anesthetics), Steve Frome (Paediatric Anesthetics), the medical gas committee, estates and clinical engineering. 

One of the key members of the team was Dr Amarantha Fennell-Wells, a dental trainee. Amarantha, being a dentist, was licensed to use nitrous oxide and the project caught her interest. She led the way by delving into the data and investigating the manifolds in place at Cardiff and Vale UHB. She also connected with those leading the same work in Lothian, Scotland which was a considerable help for implementing this work.

It was clear from the investigation that there were significant leaks in the nitrous oxide pipelines at CAV UHB. So, what could be done? The team established a project group to understand the steps they could take to reach the goal of decommissioning the manifolds. There were quite a number of steps to undertake in order to do this and this is what unfolded over the next period:

1. The team introduced a pilot of the new cylinder system in one anesthetic room in the children’s hospital and tested efficiency and practicality.
2. Based on the successful pilot, the team assessed the requirement for nitrous oxide across all the Health Board and then upscaled the pilot and implemented a small cylinder supply to the whole of University Hospital Llandough (UHL).
3. Once the small cylinder supply at UHL had been tested for a month and was proven to be effective, the UHL manifold was removed (March 2022). However, before all this could happen the wall outlets were capped off, initially temporary, then permanent caps, and the pressure alarm system deactivated. Following this, the large cylinders could then be removed from the manifold.
4. Next was the much larger challenge of University Hospital Wales’ (UHW) manifold. Small cylinders were rolled out across the children’s hospital and UHW. The team allowed a month to prove this system worked.
5. In December 2022, the main UHW manifold was decommissioned.

It might seem like a simple five-point process but it certainly challenges. Leak testing was very hard to do without causing disruption to services and the results were also difficult to interpret. Equally, current standards meant that any new theatres are automatically fitted with nitrous oxide so uncovering this information and new data points was a constant struggle.

Alongside these challenges, time was a key constraint for those working within this dedicated team as they had their own jobs to focus on but their determination led to significant gains.

The Healthcare Without Harm Report says 5.6% of UK emissions are from healthcare settings and the NHS Wales Decarbonisation plan highlights anaesthetic gases reduction. The Health Board has projected savings of 1.15 million litres of nitrous oxide or 679 tonnes of CO2e each year which will play a huge part in making healthcare more sustainable in Cardiff and the Vale of Glamorgan and beyond. 

Following the success of this project, the team were successful in securing Welsh Government SBRI (Small Business Research Initiative) funding and are now working across Wales with other Health Board’s and industry to develop technology to break down the gas ensuring it is not released into the atmosphere. Health Boards and Trusts across NHS Wales could potentially adopt this solution.