With one of the largest healthcare engineering teams in the country, working with the International Federation of Healthcare Engineers (IFHE) to volunteer engineering and design services to the World Health Organization (WHO) is a natural fit for HH Angus. We first answered IFHE’s call for volunteers in 2020 during the early days of the COVID pandemic, and our involvement has grown from there. The Infectious Disease Treatment Module (IDTM) project is our fifth under the auspices of the IFHE. Supporting the vital work of the WHO by donating time and resources for healthcare facilities in low-resource countries fits well with both our commitment to give back to the global community and the desire of HH Angus employees to contribute to these worthwhile initiatives. We also have deep experience in implementing systems design to support infection and control procedures in healthcare settings, so our most recent involvement was well suited to our strengths.

Rapid Response

The World Food Programme (WFP) INITIATE2 IDTM is the first project in a five-year initiative to develop innovative and standardized solutions to support readiness and response capabilities for health emergencies worldwide.

The focus of the IDTM is to allow stakeholders to rapidly deploy and operate treatment modules in emergency situations to treat the first patients with infectious diseases and to protect the healthcare workers who are treating them. As part of the design team, HH Angus employees volunteered their expertise and time over the course of 12 months to design, tender and prototype an IDTM, which was delivered and tested in Brindisi, Italy. The design team is subsequently supporting refinement of the design by addressing opportunities for improvement that were identified during medical and technical testing.

The inflatable IDTM structure was compartmentalized to separate staff and patient areas while maintaining necessary sightlines and quick response to patients through a transparent screen without staff needing to don full personal protective equipment. In addition to the physical barrier, the separation is also supported by directional airflow. The structure of each module and inserts allow for flexibility and the ability to accommodate more patients if needed.

Complex Challenges Inspire Innovation

Developing a treatment module that is rapidly deployable with no specialized tools, is easily transportable, adaptable to different climates, accepted by the local community, safe for staff, and suitable to respond to an unknown infectious disease outbreak is an extraordinary challenge.

The testing stage of the IDTM was a unique aspect of this project, and it provided the design team with the opportunity to meet and work alongside emergency response team members who would be using this product in the field. Their feedback during medical and technical testing was critical to fully evaluating the performance of the prototype during a series of logistical and medical drills.

As the needs and anticipated use of the IDTM vary by partner organization, designing a flexible and adaptable solution was an important element of the criteria. The intent of the IDTM is that it is re-deployable to other communities and emergencies which will reduce its overall environmental impact.

We are always grateful for the opportunity to be able to contribute to the important work of the IFHE, WHO and WFP, building on previous design support for projects in Burkina Faso, Chad, Mozambique, and Ukraine.

To view a video about the IDTM from the United Nations Humanitarian Response Depot, click on the link below:

INITIATE - Delivered and tested the prototype of an infectious disease treatment module (youtube.com)

Want to learn more about this initiative? Contact Meagan Webb who was the HH Angus lead for the project. 

Background

Historically, N2O has been used in healthcare facilities (“HCF”) for anesthetic and/or analgesic purposes:
(1) Anesthetic use has often been as the “carriergas” for delivery of vaporized anesthetic agents (Sevoflurane, Isoflurane and Desflurane as examples) to a patient using a breathing circuit and undergoing general anesthesia, (2) Analgesic use has traditionally been for pain management and can be clinician- or patient administered (for example, by expectant mothers breathing N2O to reduce pain associated with contractions). Typically, it does not require the use of a breathing circuit (anesthetic machine) as the patient will be conscious while directly expelling the N2O into the room instead of into a breathing circuit. While N2O continues to have clinical application, there has been a significant shift to reduce its use, particularly in surgical settings, in favour of more environmentally-friendly anesthesia techniques.

N2O Consumption and Leakage Concerns

As HCF’s continue to grapple with reducing emissions, N2O has again come under the spotlight. In the US, the healthcare sector is responsible for an estimated 8.5% of US greenhouse gas emissions(1). Further, medical gases contribute up to 40% of hospitals’ direct emissions(2), with N2O pipeline leakage alone contributing upwards of 90% of the N2O consumption when measured against actual clinical consumption use. It has been known for some time that most centrally piped N2O pipeline leakage occurs through the plastic hoses used in ceiling arms (aka booms, articulating arms, ceiling pendants) that can move vertically and horizontally, as well as the plastic hoses supplied with equipment that connect to a terminal unit (outlet). N2O is known to permeate these plastic hoses. The leakage of N2O through the plastic hose is typically across its entire length. Teflon pigtails used to connect nitrous oxide cylinders to a cylinder manifold have also been found to leak, but the CSA Z7396.1 standard banned the use of polymer-lined flexible metallic pigtails for pressure gases in favor of copper pigtails.

Health Effects of Exposure to N2O

Studies have reported adverse health effects for workers exposed to N2O. These include reduced fertility, spontaneous abortion, and neurological, renal and liver disease(1). Patient and clinical staff health effects can also include nausea and vomiting(1). There have been studies on acute and chronic exposure to individuals or groups inside a HCF(4). The results indicate a significant difference in health effects for groups exposed to N2O which include headaches, dizziness, nausea, vomiting, euphoria and tachycardia (heart rate > 100 bpm).

Recent Opinion from the Canadian
Anesthetists Society on N2O Usage

In 2024, the Canadian Anesthesiologists’ Society (CAS) issued their revised edition of Guidelines to the Practice of Anesthesia.(5) In this guideline, Section 10 (page 31 Guidelines for Environmental Sustainability), indicates the following points with regard to N2O:

“The use of desflurane and N2O should be eliminated or minimized to the extent possible given local resources, locations, and the clinical context.”

“Environmentally-friendlier anesthesia techniques such as neuraxial/regional anesthesia and total intravenous anesthesia may be considered as alternatives to volatile inhalational anesthesia to minimize greenhouse gas burden when clinically appropriate, feasible, and available.”

Recent Opinion from the Association des anesthésiologistes du Québec (AAQ)

On April 25, 2024, the AAQ(3) issued the following statement: AAQ aposition statement on N2O pipelines The Association des anesthésiologistes du Québec Board of Directors, representing the largest traditional users of medical N2O, has unanimously taken a position on N2O pipelines in hospitals on April 25:

“The AAQ supports decommissioning central N2O pipelines in existing hospitals, no longer installing them in new hospitals, and, if necessary, working with N2O cylinders.”

Furthermore, the elimination or minimization of N2O from anesthetic practice has been a recommendation of the Canadian Anesthesiologists’ Society’s Guidelines to the practice of anesthesia since 2023.

Recommendations

Given the opinions from the CAS and AAQ to pivot away from using N2O in favour of other friendlier anesthesia techniques, and coupled with the known leakage concerns from centrally piped N2O pipeline systems, an opportunity exists for HCF’s to reevaluate with their anesthesiology department stakeholders the clinical use of N2O and the delivery method. Reevaluating N2O usage and delivery methods also aligns with Annex P recommendations in CSA Z7396.1 medical gas standard.

Disclaimer

HH Angus cannot provide any opinion on the clinical use of N2O as this is a medical issue. This client advisory serves only to highlight recent opinions and studies on known problems associated with the leakage of N2O from centrally piped medical gas pipeline systems, as well as the recommendations from the CAS and AAQ. The HCF must make its own determination on the suitability of continued clinical use of N2O and the associated delivery methods.

Reference Sources

1. Decommissioning N20 Playbook - WORKING VERSION.docx (practicegreenhealth.org).
2. Collaborating to prevent nitrous oxide waste in medical gas systems_FINAL 5-2-2023.pdf (practicegreenhealth.org)
3. https://mcusercontent.com/195cedfbb43cfc829ac342437/files/d239380c-8484-d56a-92b4-c50f920bd63a/Prise_de_position_AAQ_N2O.03.pdf
4. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5661723/
5. https://www.cas.ca/CASAssets/Documents/Practice-Resources/Guidelines/CAS_Final_Guidelines_2024.pdf

For More Information

Edward Hood, P.Eng.
Principal | Engineering Director, Health
Edward.Hood@hhangus.com