Exploring barriers to discontinuing desflurane use.

Abstract

Background: Desflurane has a high environmental impact compared to alternative agents. ANZCA encourages the use of 'agents that have a lower impact on the environment' 1 and many anaesthetic departments have removed desflurane from their operating theatres. These approaches have been 'top down' rather than following a traditional change management approach. We undertook a mixed method study using a survey and focus groups to determine how desflurane is used and barriers to removal of the agent. Specifically: (1) How often and why desflurane is used (2) If it would be missed if no longer supplied (3) Why users are resistant to change Methods: Following local ethics committee approval (QA/80514/PH-2021/285952(v1)), an online survey was sent to consultants and trainees. Questions related to use of desflurane including frequency and indication, knowledge of the environmental impact of desflurane, compared other agents and asked for opinions on how desflurane should be used within the department. Following completion, the survey was discussed at a departmental meeting, followed by a further discussion with just trainees. Independent thematic analysis by the two researchers established topics raised and discussed by group members relating to ceasing desflurane use. Result(s): Response rate was 46/66 (70%) and reflected the composition of the department. Over half the respondents (25/46, 54%) used desflurane with 7 (15%) using daily or weekly. Most trainees (72%) were non-users. Users chose the agent for rapid awakening. Commonly for patient obesity, carotid endarterectomy, and long surgical duration. Non-users cited environmental concerns as their reason for avoiding the agent (20/21, 95%). Only 7 respondents (15%) were unaware that propofol total intravenous anaesthesia (TIVA) had a lower environmental impact than desflurane, of whom 86% (6/7) were daily or weekly desflurane users. Most people (36/46, 78%) stated that desflurane removal would not affect their practice. Only 8 respondents (17%) believed that desflurane should be available on every anaesthetic machine. Themes identified in discussions supporting desflurane availability were anaesthetist independence, patient safety and registrar teaching. Opposing themes were environmental concerns and availability of TIVA as an alternative. Discussion(s): Many hospitals have removed or restricted desflurane availability by edict, but there is limited literature for a consensus-based approach. This mixed-method study is limited by examination of a single site, but has a high response rate that allows the identification of several enablers and barriers to change. Despite a majority of anaesthetists using desflurane in our department, there is a willingness to change. Both survey and focus group results indicate the main barrier to change is a small, older group who believe it is superior in some circumstances and cannot be replaced. Reducing agent availability to small number of vaporisers with availability on request was supported by most respondents and doesn't restrict autonomy. Frequent users of desflurane indicated a relatively poor understanding of its environmental impact. Improved awareness may result in reduced usage in this group, even in their private practice. Education on TIVA use may also increase confidence in this technique as an alternative.