DP53: BUILDING A LOW EMISSIONS FUTURE IN PEDIATRIC ANESTHESIA: EARLY LESSONS FROM PROJECT SPRUCE AT NICKLAUS CHILDREN'S HOSPITAL
Hannah Tuckwell, MD, Pediatric Anesthesiology1; Raul J Fernandez Torrealba, MD, Chief of Pediatric Anesthesiology1; Julie Katz2; Christina Gonzalez2; Kaylee Medoza, BS, Medical Student3; Imelda K Moise, PhD, Associate Professor3; Chad Perlyn, MD, PhD, MBA, FACS3; Katy Flanagan, RN, BSN, Clinical Impact Manager4
1Nicklaus Children's Hospital Miami - NCPS; 2Nicklaus Children's Hospital Miami; 3NOVA Southeastern University Dr. Kiran Patel College of Allopathic Medicine; 4AdaptX
Background: Nitrous oxide (N2O) central pipeline has long supported anesthesia delivery in hospitals, yet they contribute to avoidable greenhouse gas emissions, workflow inefficiencies, and safety concerns. Growing attention to environmental impact of inhaled anesthetics and longstanding concerns about central pipeline leak rates >90%, has increased interest in system-level approaches to N2O reduction. As health systems prioritize sustainability and modernization, practical guidance on retiring this legacy infrastructure remains limited. Nicklaus Children’s Hospital (NCH) in Miami, Florida, is part of Project SPRUCE and launched this initiative as its institutional effort to eliminate N2O pipeline within pediatric anesthesia. This early-phase evaluation examined whether a phased, system-based approach could feasibly support initial N2O elimination by strengthening workflow, cultural operational change and coordination, cost economic data through dashboards and decision-support tools, and environmental performance. We hypothesized that a multidisciplinary implementation strategy would enable early progress by aligning clinical and facility teams and identifying barriers to guide subsequent phases.
Methods: Project SPRUCE began at NCH in April 2022 and is led by a multidisciplinary team representing anesthesia, perioperative services, community health, IT, sustainability, and facilities. The team uses a phased, system-based approach that includes mapping existing N2O infrastructure, reviewing clinical workflows, and identifying operational barriers to pipeline decommissioning. Early activities were guided by quality-improvement principles, including iterative workflow assessment, phased implementation planning, and use of AdaptX dashboard, initially adopted for Project SPRUCE. Engagement efforts included meetings with clinical and operational leaders through Game Changers financial optimization initiative to evaluate cost savings, targeted education through anesthesia department meetings, and communication to support adoption through Quality Improvement and Patient Safety (QuIPS) Committee. Data were documented through workflow observations via AdaptX and implementation phases. Information was gathered from anesthesia practice in Minor Procedures (MPS), the Operating Room (OR), and other perioperative units (excluding MRI).
Results: Early-phase implementation initially encouraged avoidance of N2O use and low-flow anesthesia. The hospital achieved at least 50% reduction in N2O use within six months. The secondary phase implementation was an E-Cylinder trial of N2O in MPS and the Main OR from October and November 2025, respectively. Due to the low N2O use during this period, central pipeline was disconnected in these clinical areas in January 2026. AdaptX supported monitoring of N2O use, low-flow anesthetics and Total Intra-Venous Anesthesia (TIVA) adoption. Barriers included engineering costs and adopting evidenced-based anesthesia practice as opposed to traditional clinician preferences. While facilitators in the process included leadership support, multidisciplinary collaboration, and early measurable success. Practical considerations included communication needs, equipment logistics, and ongoing staff training.
Conclusion: The Project SPRUCE offers a practical early-phase model for hospitals seeking to eliminate central pipelined N2O and promote sustainability within pediatric anesthesia practice. Ongoing work will provide further insight into long-term sustainability, operational impact, opportunities for broader adoption, and the permanent decommissioning of pipelined N2O. Further sustainability elements of Project SPRUCE include reducing anesthetic gas use and increasing use of TIVA in the long term.