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Facility Inhaled Anesthetic CO2 Survey
Direct link (for ease of use, we recommend filling out this form on a computer) :
https://goo.gl/Vt6K6B

Inhaled anesthetics are potent greenhouse gases, and waste is routinely vented off facility rooftops to the outdoor environment where emissions are currently not controlled. Project Drawdown aims to POOL ANONYMOUS DATA to benchmark facility-level inhaled anesthetic carbon footprints, as well as per-case averages, to compare and inspire performance improvement efforts. Project Drawdown is a quality improvement project and does not require IRB approval. The email address provided will be used solely for returning the facility report and will not be sold, transferred or used for any other purpose.

Please read through the survey before completing it (there is no ability to save your data mid-stream.) UPON ACCURATE COMPLETION OF THIS SURVEY, PARTICIPANTS MAY OPT TO RECEIVE A REPORT OF THEIR RESULTS.

User Agreement
USERS MUST NOT SUBMIT PARTIAL, INACCURATE, OR DUPLICATE INFORMATION, AS THIS WOULD JEOPARDIZE THE STUDY.
Year of Data Entry
In order to generate a report for different years, please repeat the survey. IF YOUR HEALTH SYSTEM HAS MORE THAN ONE FACILITY, YOU ARE ENCOURAGED TO ENTER ONE SURVEY FOR EACH FACILITY.
*
Volatile Anesthetics
Annual usage data can be easily obtained through purchasing records, typically overseen by OR Pharmacy staff. CAUTION: It is essential to report the size of the bottle, and number of bottles purchased (NOT cases.) NOTE: if your institution purchases MORE than one size bottle for the same drug, please comment on details in the space provided at the bottom.
Sevoflurane: SIZE of Bottle (mL) *
NUMBER of Sevoflurane Bottles in Size Above *
Your answer
Isoflurane: SIZE of Bottle (mL) *
NUMBER of Isoflurane Bottles in Size Above *
Your answer
Desflurane: SIZE of Bottle (mL) *
NUMBER of Desflurane Bottles in Size Above *
Your answer
Halothane: SIZE of Bottle (mL) *
NUMBER of Halothane Bottles in Size Above *
Your answer
Volatile Anesthetics: How sure are you about these numbers? *
Not Sure
Very Sure
Nitrous Oxide and Entonox
Annual usage data can be obtained through purchasing records, typically overseen by Medical Gases staff (a SEPARATE department from OR Pharmacy.) Nitrous Oxide is typically supplied in at least two different sized tanks: the main tank that supplies the OR pipeline, and the standard E-cylinder on the anesthesia machine. Some institutions also have a third, portable type tank. Eccept for the E-cylinder, there is NO STANDARD TANK SIZE OR NAME. It is therefore critical for you to specify the tank size AND number of annual refills. NITROUS OXIDE ROUTINELY ACCOUNTS FOR 50% OF AN INSTITUTION'S INHALED ANESTHETIC CARBON FOOTPRINT. IT IS ESSENTIAL THAT YOU NOT EXCLUDE THIS (or any) DATA.
UNITS of Nitrous Oxide Main Tank to OR Pipeline *
SIZE of Nitrous Oxide Main Tank to OR Pipeline (in units above) *
Your answer
NUMBER of Nitrous Oxide Main Tank to OR Pipeline REFILLS *
Your answer
NUMBER of Nitrous Oxide E-cylinder Refills (NOTE: may appear as 6 lb or 3kg) *
Your answer
UNITS of Nitrous Oxide ALTERNATIVE Tank *
SIZE of Nitrous Oxide ALTERNATIVE Tank (in units above): *
Your answer
NUMBER of Nitrous Oxide ALTERNATIVE Tank Refills *
Your answer
Nitrous Oxide: How sure are you about these numbers? *
Not Sure
Very Sure
In addition to the ORs, Nitrous Oxide analgesia is also used in your: (Select ALL that apply) *
Required
UNITS of Entonox Main Tank to OR Pipeline *
SIZE of Entonox Main Tank to OR Pipeline (in units above) *
Your answer
NUMBER of Entonox Main Tank to OR Pipeline REFILLS *
Your answer
NUMBER of Entonox E-cylinder Refills (NOTE: may appear as 6 lb or 3kg) *
Your answer
UNITS of Entonox ALTERNATIVE Tank *
SIZE of Entonox ALTERNATIVE Tank (in units above): *
Your answer
NUMBER of Entonox ALTERNATIVE Tank Refills *
Your answer
Entonox: How sure are you about these numbers? *
Not Sure
Very Sure
In addition to the ORs, Entonox analgesia is also used in your: (Select ALL that apply) *
Required
Total Number of Anesthetic Cases
TOTAL NUMBER OF ANESTHETIC CASES is routinely tracked and can be easily obtained from Anesthesia OR Managers. This total is required to benchmark your case average and enable comparisons with other facilities. THE TOTAL NUMBER OF ANESTHETICS INCLUDE: adult + pediatric + OB-surgery + non-OR anesthesia (NORA, e.g. Gastroenterology, Interventional Cardiology, etc.) Total anesthetics is NOT the same as TOTAL NUMBER OF SURGERIES, since many surgeries do not require anesthesia and many anesthetics are for non-surgical purposes (e.g. radiology imaging tests.) Numbers of surgeries and deliveries can often be located through the hospital website, wiki page, OR manager, etc.
TOTAL NUMBER of ANESTHETIC CASES: Adult + Pediatric + OB-surgery + Non-Operating Room Anesthesia (NORA) *
Your answer
TOTAL NUMBER of DELIVERIES (Births) *
Your answer
TOTAL NUMBER of SURGERIES *
Your answer
Case Totals: How sure are you about these numbers? *
Not Sure
Very Sure
Please explain all fields labeled "Not Sure" below.
Your answer
Demographics
Please enter information about your facility, below. INFORMATION WILL REMAIN CONFIDENTIAL, AND IS FOR RESEARCH VERIFICATION PURPOSES ONLY.
Name of FACILITY and name of HEALTH SYSTEM *
Your answer
Country *
State or Province *
Your answer
Type of Institution *
Size of FACILITY *
Title of Person Completing Survey *
Do you wish to receive a copy of your facility results? *
Email Address to Receive OPTIONAL Report
Your answer
Please Provide Any Additional Feedback or Suggestions for this Project:
Your answer
By clicking "Submit," I agree that:
I WILL NOT SUBMIT PARTIAL, INACCURATE, OR DUPLICATE INFORMATION, AS THIS WOULD JEOPARDIZE THE STUDY.

I have accept the Terms of Use and consent to having my responses included the Yale Gassing Greener research study. Full consent available at: https://goo.gl/TPmbJT

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