Percentage of cases with mean fresh gas flow (FGF) equal to, or less than 3L/min, during administration of halogenated hydrocarbons and/or nitrous oxide.

Halogenated agents and nitrous oxide leaking or vented into the atmosphere are environmental pollutants.  Reducing fresh gas flows can reduce cost of anesthesia without compromising patient care. This measure considers Fresh Gas Flow (FGF) during administration of halogenated hydrocarbons and/or nitrous oxide, as an indirect measure of anesthetic gas waste.

Intubation to Extubation time

Patients with an ETT or LMA (determined by Anesthesia Technique: General value codes: 1,2,3,6)

• Cases without an ETT or LMA placed (determined by Anesthesia Technique: General value codes: 0,4,5)
• Cases without halogenated hydrocarbons or nitrous oxide administration
• Case with < 30 minutes of halogenated hydrocarbons and/or nitrous oxide administered between intubation & extubation
• Cases with documentation of Nitric Oxide use
• Cases with only manually entered fresh gas flow values (fresh gas flow values must be automated to be considered for this measure)

Mean FGF equal to, or less than 3L/minute when inspired halogenated hydrocarbons is >0.2%, or nitrous oxide FGF >0.2L/min, during the maintenance period of anesthesia.

Measure Start:

1. Intubation. If not available, then
2. Induction End

Measure End:

1. Latest Extubation Time. If not available, then
2. Latest LMA Removal Time. If not available, then
3. Surgery End. If not available
4. Patient Out of Room. If not available, then
5. Anesthesia End.

• If Fresh Gas Flow Total (MPOG Concept ID: 3214) is documented for the case, this concept will be used to determine success in the setting of halogenated agents or nitrous oxide use.
• If Fresh Gas Flow Total (MPOG Concept ID: 3214) is not documented for the case, MPOG will calculate Fresh Gas Flow: Flows Oxygen (ID: 3215) + Flows Air (ID: 3220) + Flows Nitrous Oxide (ID: 3225)
• If there are no fresh gas flows documented on the case or the variables are mapped to the incorrect MPOG concept, the case will be excluded. 
• There must be at least 30 minutes of non-artifact Nitrous Oxide or inspired halogenated hydrocarbons during the maintenance period. Maintenance period is defined as measure start to measure end. See Appendix for how minutes are included before calculating mean fresh gas flow. When calculating the mean Fresh Gas Flow, the sum of all flows will be added and divided by the total number of minutes that have a documented gas flow. If there are 30 cumulative minutes of halogenated gas documented, but only 24 minutes of fresh gas flow, the mean will be calculated using the 24 minutes of fresh gas flow.  
• Of the total number of minutes of gas flows documented, at least 80% of the Fresh Gas Flow values must be machine data captured for the case to be included. Any manually entered fresh gas flow or agent values will be included in the calculation of mean FGF if this threshold is met and the case is included.
• If there is a gap in documentation for fresh gas flow values, each value is valid for up to one minute.
• If multiple flow values for oxygen (3215), air (3220), and Nitrous Oxide (3225) occur at different second intervals in the same minute, all values will be aligned to the beginning of the minute and the one documented first will be used. For example, if 1 L/min of oxygen flow was documented at 13:02:30 and 2 L/min of air flow was documented at 13:02:32, both would be assigned 13:02 as the documented time and the total FGF would equal 3 L/min for that minute.
• Values for flows and gases will be assessed and considered artifact if inside the following ranges:
  • Nitrous Oxide Flows: <0.2 L/min
  • Isoflurane Insp %: <0.3%
  • Sevoflurane Insp %: <0.4%
  • Desflurane Insp %: <1.2%
  • Nitrous Oxide Insp % <20%

** Calculating CO₂ eq For Nitrous Oxide:

For cases with only Nitrous Oxide reported as inspired (%), convert Nitrous Oxide (N₂O) reported as inspired (%) to L/min: (If reported as L/min, skip to CO₂ equivalent calulation below).

1. If not available. MPOG will determine percentage inspired for Oxygen by subtracting Nitrous Oxide percent inspired value from 100.
2. Calculate the total Fresh Gas Flow by dividing Oxygen flows (L/min) by Oxygen percent.
3. Calculate Nitrous flow by subtracting Oxygen flows (L/min) form total Fresh Gas Flow.

Please note: In rare cases where both nitrous oxide and air are delivered, MPOG adjusts these steps to include both air and oxygen in these steps (instead of just oxygen alone).

CO₂ Equivalent Calcuation (N₂O):

1. Convert Nitrous Oxide (l/min) → mols/min: Nitrous Oxide  / 24.4 = Nmol
2. Convert Nmol → N20 mass (kg/min): (Nmol *44) / 1,000 
3. Convert Nmass → CO₂ equivalents: Nmass * GWP 

*For cases with both valid Nitrous Oxide % and Nitrous Oxide flows reported, only Nitrous Oxide flow values will be considered (N₂O values reported as % will be ignored).

*This measure will include valid MPOG cases defined by the Is Valid Case phenotype.

Not applicable.

Provider(s) signed in while patients are administered halogenated hydrocarbons, and/or nitrous oxide > 30 minutes from placement of the airway device to removal of the airway device. See ‘Other Measure Build Details’ section for algorithm for determining measure start and end times.

1. Sherman J, McGain F. Environmental sustainability in anesthesia: pollution prevention and patient safety. Adv Anesth. 2016;34:47-61.
2. Feldman JM. Managing fresh gas flow to reduce environmental contamination. Anesth Analg. 2012;114:1093-1101.
3. Eisenkraft JB, McGregor DG. Waste anesthetic gases and scavenging systems. In: Ehrenwerth J, Eisenkraft JB, Berry JM, eds. Anesthesia Equipment: Principles and Applications. 2nd ed. Philadelphia, PA: Saunders; 2013:139-145.
4. Ek M, Tjus K. Destruction of Medical N O in Sweden, Greenhouse Gases - Capturing, Utilization and Reduction. Liu G, ed. InTech. 2012. www.intechopen.com/?books/?greenhouse-gases-capturing-utilization-and-reduction/?destruction-ofmedical-n2o-in-sweden. Accessed March 1, 2017.
5. Barwise JA, Lancaster LJ, Michaels D, et al. Technical communication: an initial evaluation of a novel anesthetic scavenging interface. Anesth Analg. 2011;113:1064-1067.
6. American Society of Anesthesiologists’ Task Force on Environmental Sustainability Committee on Equipment and Facilities. Greening the operating room. http://www.asahq.org/resources/resources-from-asacommittees/environmental-sustainability. Accessed March 1, 2017.