Climate Checkup for Health Care

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By Rita Colorito

At Seattle Children’s Hospital, during procedures, pediatric anesthesiologist Elizabeth Hansen, MD, can tell if kids have been exposed to wildfire smoke damage. Some 15 miles north in Kirkland, cardiologist Mark Vossler, MD, recalls one heart patient who was stable when they left a checkup, broke down driving home, and had a heart attack waiting for a tow in 100-plus-degree heat. Like these physicians, at some point nearly every health care professional will treat someone impacted by climate change. Yet health care’s role in the climate crisis goes beyond patient health. The U.S. health care sector produces approximately 8.5% of all domestic greenhouse gas emissions-the highest health sector percentage of any country, according to the most recent analysis.

These and other unintended climate consequences challenge medicine’s long-held credo of “first, do no harm.” Increasingly, however, concerned members of the medical community, including the WSMA, are taking an active role in the climate equivalent of “physician, heal thyself,” asking what health care can and should do to reduce its carbon footprint.

WSMA House of Delegates leads the charge

Since 2016, the WSMA House of Delegates has adopted varied policies calling for solutions that both reduce pollution and promote healthier, sustainable communities, including those aimed at mitigating the health effects of climate change through sustainable practices statewide. Adding to the roster of climate-forward policy, last year, delegates passed new policies focused on specific actions for health care professionals and organizations. They include policies directing the WSMA to:

• Encourage hospitals and surgical centers in Washington to adopt programs to reduce the climate impacts from anesthesia.
• Encourage hospitals and clinics to reduce their use of plastics, particularly single-use plastics.
• Urge members, health care organizations, and affiliated stakeholders to decarbonize the U.S. health sector by following the National Academy of Medicine’s Sustainability Journey Map (see sidebar on pg. 11).

“There’s motivation for most people in health care to do what they can to reduce emissions. The challenge is picking what things to focus on and the costs,” says Dr. Vossler, who co-authored the new policies. Dr. Vossler, now retired, serves as the president of Physicians for Social Responsibility and on the climate and health task force of the national advocacy group’s Washington chapter.

The priority? Reducing the use of anesthetic gases. “If we had to pick one thing to do first, that’s the area to focus on for every hospital and every surgical center,” says Dr. Vossler.

Desflurane and nitrous oxide gas are the worst offenders based on clinical equivalency, according to the American Society of Anesthesiologists. Desflurane is the inhaled anesthetic that is the most potent greenhouse gas, with a global warming potential 2,540 times that of carbon dioxide. N2O has a global warming potential 273 times that of carbon dioxide and an atmospheric lifetime of over 100 years. Currently, N2O is also the single greatest contributor to the destruction of the ozone layer. In the U.S., it’s estimated to contribute some 3% to ozone destruction.

Reducing single-use plastics matters on two levels, says Dr. Vossler. One, the manufacturing of these materials is carbon intensive. Moving to reusables means less is produced and less carbon dioxide emitted.

The other issue is the proliferation of microplastics and nanoplastics in the human body. Dr. Vossler cites a study published in the New England Journal of Medicine that found microplastics in atheromatous plaque removed from carotid arteries.

“Patients who had microplastic in their carotid arteries at the time of surgery had higher subsequent cardiac event rates than patients who did not have it,” he says. “The thing about plastics is that for a lot of things, we have alternatives. We just have fallen into this complacency.”

Partnering for progress

Following NAM’s Sustainability Journey Map to decarbonize the health sector is the goal, says Dr. Vossler, but one that will take firm, continuous commitment and resources to achieve. To get health care there, the WSMA, at the direction of its House of Delegates, is working with the Washington State Hospital Association to explore ways to promote and implement these climate change policies.

“When we seek to mitigate health care’s impact on climate change, we only want to do so in a manner that maintains patient safety and clinical excellence, doesn’t increase the administrative burden or workload for physicians, and does not significantly increase the cost of delivering care,” says WSMA President John Bramhall, MD, PhD. “Addressing the climate impacts of health care should not supersede the clinical judgment of a physician acting in a patient’s best interest.”

At its Quality Leaders Collaborative this spring, hospital leaders throughout the state and the Washington State Health Care Authority shared what they are doing to mitigate climate change and improve resilience and adaptation. “Hearing from hospitals similar to theirs that are successfully implementing innovative approaches inspires meaningful change,” says Tracy Wellington, RN, WSHA senior director of clinical excellence and rural programs, who oversees the Medicaid Quality Incentive Program, a partnership between the two organizations.

The increased use of telemedicine and wearable patient-monitoring devices, such as for blood glucose, are some ways hospitals identified to reduce their carbon footprint while maintaining high- quality care, says Wellington. “Reducing patient travel presents an opportunity not only to enhance accessibility and convenience for patients but also to significantly cut emissions, improving environmental sustainability.”

WSHA is collaborating with the HCA to focus on measures in the Medicaid Quality Initiative Program to address climate change and highlight its impact on health, and with the American Hospital Association to plan a regional workshop on environmental impact on community health to take place in September.

Paving the way

Hospitals and medical centers throughout Washington state are already making climate change a priority. In a 2024 WSHA survey, 53 hospitals reported actively monitoring their greenhouse gas emissions.

Some, like Providence, have created executive roles to tackle climate change. In 2023, Providence appointed Brian Chesebro, MD, as its first medical director for environmental stewardship, a role he had served at Providence Oregon since 2019.

“The position isn’t just standing upon a soapbox talking about environmental impacts. It provides perspective in a broader conversation and analysis of driving health care toward higher value,” says Dr. Chesebro, defining value as quality divided by cost. Quality factors include safety, efficacy, efficiency, equity, patient centeredness, resilience, and compliance. Cost includes financial, social, and environmental costs.

Under Dr. Chesebro’s leadership, Providence undertook two large anesthesia-related emissions mitigation projects, including one addressing nitrous oxide consumption-reducing these greenhouse gases by the equivalent of 10,000 metric tons of CO2 a year. N2O is relatively inexpensive, so an environmental impact analysis revealed something a scan of financial ledgers alone would have missed, says Dr. Chesebro: The hospitals’ central pipe systems were leaking and wasting over 90% of N2O.

Leaks can happen throughout the system, making it challenging and unfeasible to avoid N2O losses through maintenance and repair. The environmental health impact to patients, caregivers, and staff is more difficult to measure but was also a serious concern, says Dr. Chesebro.

“It wasn’t an issue with clinical overuse,” he says. “Financially, it’s not a huge expense for the hospital … But when we looked at it on our environmental ledger, we said ‘whoa, this is an opportunity for us to start thinking about the other facets of value.’ ”

In October, following similar recommendations from the Royal College of Anaesthetists in the U.K. and referencing Dr. Chesebro’s analysis, the American Society of Anesthesiologists recommended deactivating central piped N2O and transitioning to a portable source for N2O delivery for all clinical use-building on its 2022 guidelines to reduce the carbon footprint from inhaled anesthesia, which included:

• Avoiding inhaled anesthetics with disproportionately high climate impacts, such as desflurane and nitrous oxide.
• Selecting the lowest possible fresh gas flow when using inhaled anesthetics.
• Prioritizing regional anesthesia and intravenous anesthesia when appropriate, since they have less of a negative environmental impact.
• Avoiding centrally piped N2O, substituting with portable canisters that should be closed between uses to avoid continuous leaks.

Providence had already implemented these changes. Dr. Chesebro’s current project is focusing on value-based solutions to reduce the use of metered- dose inhalers for people with asthma and chronic obstructive pulmonary disease. The propellant used has 1,000 times the global warming effects of carbon dioxide, and at 75% of the market, according to The Commonwealth Fund, has an equivalent emissions impact of driving half a million cars for a year.

“You have to go through that whole value analysis again. Is it going to improve [patient] resilience? Is it going to improve their disease control? Is it going to cost them 10 times more? How do you balance all of that? It’s really complicated, but it is another opportunity,” says Dr. Chesebro.

A data-driven approach to mitigation

Anyone hoping to undertake a climate- change initiative should start with data- driven analysis, looking at all aspects of operations, including clinical delivery of care, says Dr. Chesebro. “It has to be this holistic assessment of the way our health system operates.”

A data-driven approach is at the heart of Senate Bill 5236, legislation the WSMA supported during the 2025 legislative session to require the Washington State Department of Ecology to address greenhouse gas emissions from anesthetic gases by establishing a multistep process to study, understand, and reduce these emissions in Washington. WSMA’s support was driven by House of Delegates policy asking the WSMA to assist hospitals, surgical centers, and anesthesiology practices in their efforts to reduce greenhouse gas emissions.

The Washington State Society of Anesthesiologists also supported the bill. “We were happy to support it as a generally environmentally responsible piece of legislation, perhaps not primary to our mission, but the board felt like we could support it, given that it preserved the autonomy of the physicians to make good patient decisions and that it was not unduly burdensome,” says Erik Condon, MD, president of the society.

The bill did not pass the Senate Ways and Means Committee but will automatically be reintroduced during next year’s session. Dr. Vossler remains hopeful that some version will pass.

Dr. Condon, an anesthesiologist affiliated with Providence Sacred Heart Medical Center and Children’s Hospital in Spokane, remains encouraged by organizations like his own that have already taken action to reduce anesthesia-related greenhouse gases. “The more we do things of our own volition, the less likely we’re going to have clumsy rules made that reduce our flexibility and ability to exercise our judgment at the point of care,” he says.

He advocates for physicians to review data and practices at the patient care level to mitigate the climate impact; for example, grouping medical procedures under a single anesthetic when possible. “From a patient standpoint and from a more environmental and just efficiency standpoint, it’s better for us to be proactive,” says Dr. Condon.

When Dr. Hansen joined Seattle Children’s eight years ago, data is what propelled her to become a climate change crusader. The hospital’s then- manager of sustainability programs, Colleen Groll, produced yearly greenhouse gas emissions reports. Anesthesia gases represented 7% of the hospital’s total emissions. Shocked by the data, Dr. Hansen resolved to learn and share all she could about mitigation.

To build collaboration among different groups, Dr. Hansen took software Seattle Children’s uses for clinical quality improvement metrics and used it to track climate change educational initiatives and emission mitigation strategies. Each month she sends out a performance report, highlighting high performers and sharing their strategies for reducing emissions. After each report, physicians often ask how they can improve and get recognized in the newsletter. That friendly competition helps motivate everyone to do better, says Dr. Hansen. “Now we’re more than 90% lower in terms of our average emissions for every anesthetic that we do at Seattle Children’s compared to where we started.”

Sustainability work by Dr. Hansen and others are part of Seattle Children’s commitment to become carbon neutral by the end of 2025. Since Groll retired, the hospital has hired a sustainability director with a higher level of authority to implement sustainability programs.

Building bridges

Building consensus is a critical part of implementing any sustainability initiative, says Dr. Hansen. Before moving desflurane vaporizers out of the OR to a separate room-the idea being the effort to get it would cause someone to rethink its need-her group went through several rounds of use analysis and conversation. After one year, the group reanalyzed their decision and removed desflurane from Seattle Children’s formulary altogether.

“It took a little bit of time to have those discussions and really make sure that we were listening to everybody’s viewpoints, taking into account patient safety and those concerns, and reviewing the literature … And once we were able to all feel comfortable with that, then we moved forward,” says Dr. Hansen.

Sharing Seattle Children’s emissions- reduction success during meetings of the Society of Pediatric Anesthesia led to the expansion of Project SPRUCE into a pediatric anesthesia quality improvement consortium. Dr. Hansen serves as its principal investigator. The group applies the same data tracking to their own hospital systems.

Since it began a little over a year ago, the consortium has grown to include 12 hospitals. Emissions from inhaled anesthetics have already decreased by 50% among the consortium’s nine initial hospitals. This also results in cost savings. Yearly spending on inhaled anesthetics, minus nitrous oxide, has gone from a total of $250,000 a year down to about $75,000 a year, says Dr. Hansen.

“Sustainable care isn’t just using the lower-carbon-intense widget,” says Dr. Chesebro. In his own work, he often uses the Sustainability in Quality Improvement Programme from the U.K.-based Centre for Sustainable Healthcare. In this model, patient empowerment and disease prevention are the two most upstream principles of sustainability.

“The greenest health care is the health care that we don’t need to do,” says Dr. Chesebro. “It includes partnering with our patients to make sure that they stay healthy … so they don’t have to enter into care delivery in these high resource- intense hospital environments. That is climate action that does reduce the climate impact of health care.”

As we head into summer, Dr. Chesebro worries about the larger implications of dangerously high temperatures. At the top of his mind: heat domes-high pressure systems that create and trap extreme high temperatures over a region like the one over the Pacific Northwest in the summer of 2021. “One thing that’s often overlooked is the impact on the day-to-day operations of health care facilities under a sustained heat dome,” he says. “We’re also having to think about how our facilities continue to operate safely in the face of these environmental challenges.”

One thing is clear as climate change continues to wreak havoc in Washington state and across the globe: Health care is an inextricable part of the problem and the solution.

“There are so many opportunities for every single one of us in Washington state to be taking on some aspect of this work-whether that’s advocacy, working with our patients on education, or doing the kind of mitigation work that we’re trying to do,” says Dr. Hansen. “We are trusted voices. We do understand and know this information. And we can make a big difference.”

Rita Colorito is a freelance writer specializing in health care.

This article was featured in the May/June 2025 issue of WSMA Reports, WSMA’s print magazine.