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Instagram as an engagement tool for awareness of the environmental impacts of anesthesia

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Instagram as an engagement tool for awareness of the environmental impacts of anesthesia

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Content SUSTAINABLE ANAESTHESIA EDUCATION WITH INSTAGRAM

INSTAGRAM AS AN ENGAGEMENT TOOL FOR AWARENESS OF THE
ENVIRONMENTAL IMPACTS OF ANESTHESIA
By
Mindy Chin

A Doctoral Capstone Presented to the
FACULTY OF THE USC KECK SCHOOL OF MEDICINE
UNIVERSITY OF SOUTHERN CALIFORNIA
In Partial Fulfillment of the Requirements for Degree
DOCTOR OF NURSE ANESTHESIA PRACTICE

May 2024

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The following manuscript was contributed to in equal parts by Mindy Chin, Amanda Farris, and
Utha Lumbantobing.

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Dedication
Mindy Chin, SRNA, Amanda Farris, SRNA, and Utha Lumbantobing, SRNA dedicate
this capstone to the continued efforts and advancements in green anesthesia. As technology
continues to shape the modern world, we hope that education adapts with it.

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Acknowledgments
The authors would like to thank Dr. Elizabeth Bamgbose, Dr. Elisha Bilsborough, Dr.
Jason Bolt, and the librarians at the University of Southern California. Their continued support,
guidance, and expertise throughout the research process of this capstone were essential in
identifying current issues in anesthesia practice, building a robust literature review, and
developing the methodology of our study.
The authors would also like to thank GASP Anaesthesia’s co-founder, Jonny Groome,
who shares the same passion for protecting Earth and has allowed us to use the non-profit’s
Instagram account to disseminate education regarding green anesthesia.

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Table of Contents
Dedication ..................................................................................................................................... iii
Acknowledgments ........................................................................................................................ iv
Abstract ......................................................................................................................................... vi
Chapter One .................................................................................................................................. 1
Introduction ................................................................................................................................. 1
Research Question and Specific Aims ........................................................................................ 2
Background and Significance...................................................................................................... 2
Harmful Effects of Healthcare on the Environment .............................................................................................. 2
Accountability and Sustainability ......................................................................................................................... 4
Greener Anaesthesia & Sustainability Project ...................................................................................................... 5
Social Media in Healthcare: Instagram ................................................................................................................. 5
Instagram Algorithm for Posting ........................................................................................................................... 7
Chapter Two ................................................................................................................................ 12
Literature Review ...................................................................................................................... 12
Impact of Anesthesia on the Environment .......................................................................................................... 12
Green Anesthesia ................................................................................................................................................. 16
Instagram as an Educational Tool ....................................................................................................................... 19
Chapter Three ............................................................................................................................. 24
Methodology ............................................................................................................................. 24
Literature Search ................................................................................................................................................. 24
Intervention ......................................................................................................................................................... 24
Content Creation and Dissemination ................................................................................................................... 25
Engagement Analytics ......................................................................................................................................... 26
Chapter Four ............................................................................................................................... 27
Results ....................................................................................................................................... 27
Chapter Five ................................................................................................................................ 29
Discussion ................................................................................................................................. 29
Limitations .......................................................................................................................................................... 30
Conclusion ................................................................................................................................. 31
References .................................................................................................................................... 33
Tables ........................................................................................................................................... 43
Table 1 – Working Definitions.................................................................................................. 43
Table 2 – Instagram Intervention Results ................................................................................. 44

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Abstract
Background: The healthcare industry’s climate footprint accounts for 4.4% of global net
emissions (Karlinger et al., 2019). Operating rooms generate significant waste; the lack of
education and accountability in green practices leads to improper waste disposal. This capstone
examines social media as an educational tool to disseminate sustainable anesthesia practices.
Specific Aims: 1) Perform an exhaustive literature review investigating the utilization of social
media as an educational tool to distribute information. 2) Investigate and summarize the impact
of anesthetic agents on the environment. 3) Develop and implement a protocol for disseminating
information regarding anesthesia’s impact on the environment, utilizing GASP’s Instagram
account. 4) Analyze impact of social media engagement methods for dissemination of healthcare
data and develop a series of recommendations for future Instagram initiatives.
Methods: Three student registered nurse anesthetists utilized GASP Anaesthesia’s Instagram
page (@gasp_anaesthesia) to disseminate sustainable anesthesia content. User engagement was
calculated with Instagram Insights pre- and post-intervention over three months. Engagement
data was gathered via Instagram Insights using raw data and calculated with an engagement
equation.
Results: Engagement increased significantly with Instagram reels and polls in stories. Between
January 30, 2022, and April 23, 2022, the @GASPanaesthesia follower count increased
146.27%. Most of the engagement was initially from the United Kingdom (79.7%) but
transitioned to the United States (52.8%) as the content creators pushed recognition locally.
Conclusion: Engagement increased from 0% to 7.096%--proving Instagram to be an effective
method to engage and educate healthcare communities on sustainable practices in anesthesia.
Keywords: Instagram, engagement, green anesthesia, education
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Chapter One
Introduction
Since inception in the 1990s, social media has become a source of information,
entertainment, and income. The platform allows for innovative photo and video-sharing via
social media. In December of 2018, Instagram reached a milestone of one billion active users for
the month, with 500 million users accessing the app daily (Wong et al., 2019). It is forecasted
there will be 1.2 billion Instagram users worldwide by 2023 (Statista, 2021). Utilizing the appeal
of images to attract audiences across the lifespan, Instagram can capture a breadth of individual
interests and backgrounds. The role of social media platforms such as Instagram are becoming
increasingly diverse in modern society as they infiltrate people’s daily lives across the globe
(Wong et al., 2019).
Social media has recently developed in healthcare as a means for professional
communication and educational initiatives (Wong et al., 2021). In a 2020 study survey, 43% of
healthcare professionals reported utilizing social media for educational endeavors, and 85%
reported social media as an effective educational tool (Pizzuti et al., 2020). Physicians and
healthcare organizations utilize social media to promote health movements to millions of users
every day (Wong et al., 2019). The innovative ways of utilizing social media in the healthcare
sector are endless--providing supportive communities for patients suffering from the same
diseases, helpful tools for learners of every medical specialty, and live virtual healthcare
conferences and events (Wong et al., 2019).

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Research Question and Specific Aims
The research question guiding this paper is: What is the trend of engagement for users on
GASP’s Instagram account when a variety of social media techniques are employed? The
specific aims of this investigation include the following:
1. Perform an exhaustive literature review investigating the utilization of social media as an
educational tool to distribute information, inclusive of its utility in the health care setting.
2. Investigate and summarize the impact of anesthetic agents on the environment.
3. Develop and implement a protocol for disseminating information regarding anesthesia’s
impact on the environment, utilizing Greener Anaesthesia and Sustainability Project
(GASP)’s Instagram page.
4. Analyze impact of social media engagement methods for dissemination of healthcare data
and develop a series of recommendations for future Instagram initiatives in this sector.
See Table 1 for working definitions of important concepts.
Background and Significance
Harmful Effects of Healthcare on the Environment
The environmental effects of the healthcare industry have resulted in the United States
accounting for approximately 10% of the national greenhouse gas emissions (Cummings, 2020;
Chung & Meltzer, 2009). Operating rooms generate 20-30% of total hospital waste, and with
inhaled anesthetics being potent greenhouse gases, the field of anesthesia has a significant
environmental impact (Wyssusek et al., 2018). Green anesthesia is a concentrated initiative in
healthcare referring to conscious, evidence-based anesthetic practices focused on reducing this
negative environmental impact.
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The Intergovernmental Panel on Climate Change (IPCC) declared climate change as an
issue undisputedly caused by human actions, affecting every world region (United Nations, n.d.).
In a systematic review of 11,944 peer-reviewed scientific articles from 1991-2011, Cook et al.
(2013) reported a 97.1% consensus among scientists that humans are the cause of global
warming. The Center for Medicare & Medicaid Services (2020) reported the United States spent
approximately $3.8 trillion on its health care system in 2019--more than any other nation
worldwide--yet climate change remains the greatest threat to global health in the 21st century.
Eckelman and Sherman (2016) reported hospitals as the second leading energy-intensive created
buildings in the United States, with most hospitals’ ventilation systems, medical and laboratory
equipment, electrical and lighting, sterilization, environmental services, and food services
operating twenty-four hours a day, seven days a week. The United States healthcare system is the
second largest contributor to trash, generating an average of over four billion pounds of waste
every year--with one-third originating from operating rooms (Wormer et al., 2013).
Greenhouse gas emissions (GHGs) trap heat in the atmosphere, leading to global
warming and climate change. Speaking directly to anesthesia’s impact, volatile anesthetic gases
(sevoflurane, desflurane, and nitrous oxide) released into the atmosphere, where they deplete the
ozone for a few years to thousands of years, depending on the type of gas (United States
Environmental Protection Agency, 2021). A single hour of sevoflurane or desflurane usage is
equivalent to greenhouse gas emissions of 30 miles of travel by gas vehicle (Ryan & Nielsen,
2010). Air, water, and land temperatures continue to rise exponentially due to the billions of tons
of greenhouse gas emissions released into the atmosphere (National Aeronautics Space
Administration, 2021). According to the National Aeronautics Space Administration (2021),
nineteen of the hottest years on record have occurred since 2000, and recent global temperatures
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have been the hottest in the past 2,000-plus years. Sherman et al. (2012) indicated healthcare
industries accounted for over 8% of total carbon dioxide emissions, the most by any other sector.
The healthcare industry’s climate footprint accounts for 4.4% of global net emissions, with the
United States, China, and the European Union responsible for 56% of this impact (Karlinger et
al., 2019).
Pharmaceutical waste is another aspect of how healthcare contributes to harmful effects
on the environment, defined as regulated medical waste, solid waste, or hazardous waste--all of
which require special disposal. Medications are frequently “flushed and dumped” in hospitals--a
phrase used to describe unused or expired pharmaceutical waste improperly discarded into toilets
and sinks. This material then travels through sewer water, seeping septic tanks, and wastewater
treatment plants which cannot filter pharmaceutical compounds from water. The waste
terminates in crop fields, livestock farms, and waterbeds (i.e. lakes and rivers) (Shaaban et al.,
2018). Studies have determined antibiotics, hormones, nonsteroidal anti-inflammatory drugs,
lipid regulators, beta-blockers, and antidepressants are the primary medications detected in the
environment (Shaaban et al., 2018). One example of pharmaceutical waste in the environment is
propofol, a prevalent anesthetic. This drug is a lipid regulator resistant to the natural progression
of chemical decomposition; its effect on the environment primarily impacts aquatic life when not
appropriately wasted (Mankes, 2012).
Accountability and Sustainability
The World Health Organization (WHO) (2021) estimates between 2030 and 2050,
climate change will result in about 250,000 deaths per year, with an estimated two billion USD
per year dedicated towards health treatments. As healthcare providers, physicians and nurse
anesthesiologists carry the responsibility of protecting and promoting health. The American
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Association of Nurse Anesthesiology (AANA) (1986) Code of Ethics for practices in
anesthesiology holding certified nurse anesthesiologists accountable for supporting activities to
reduce the environmental impact of disposable items and waste anesthetic gases. The American
Society of Anesthesiologists (ASA) (2020) holds similar guidelines stating an anesthesiologist
should consider the environmental impact of their clinical management and decision making.
Despite the recognition to garner an environmentally friendly anesthesia practice, the profession
continues to be a major contributing factor to the greatest health threat of the 21st century: the
climate crisis (Karlinger et al., 2019).
Greener Anaesthesia & Sustainability Project
Greener Anaesthesia & Sustainability Project (GASP) is a non-profit, collaborative
community of anesthesia professionals and allies who state their mission is to understand the
impact of anesthesia on the environment, research ways to improve our anesthesia practices, and
disseminate education on these practices to anesthesia providers worldwide. The mission of
GASP is to take immediate, collective action to reduce the environmental impact of healthcare in
the UK and beyond (GASP Anaesthesia, 2020). GASP is headquartered in the United Kingdom,
and partners with medical associations across the globe to educate on the impact of anesthesia
practices on the environment. The four ways GASP strives to decrease the negative
environmental impacts of the anesthesia profession are through education, advocacy initiatives,
research, and consulting. Their educational and research initiatives include reducing the carbon
footprint of anesthesia, decreasing drug waste, and using an operating room shutdown checklist
for energy use reduction. GASP currently operates a website, Twitter, and Instagram to aid in
dissemination of their sustainability initiatives.
Social Media in Healthcare: Instagram
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Social media in medicine is defined as any digital media that enables widespread
connectivity between users using a defined methodology of approach (i.e., blog, podcast) (Keir
et al., 2018). Free open access medical education (FOAM) -- a global movement encompassing
open education resources usually published initially via media (blogs, podcasts, and
infographics) and then disseminated on open platforms like Instagram. FOAM allows for
instantaneous interactions in healthcare, considerably decreasing translation time, and allows for
quick detection and correction of errors (Chan et al., 2020). This type of platform has made it
easier for healthcare professionals to develop and share evidence-based medicine research and
collaborate with colleagues (Keir et al., 2018). With its own best practices and scholarship,
FOAM is rapidly evolving and becoming a mainstream academic approach for education
dissemination (Chan et al., 2020).
Instagram is a photo and video-sharing social media platform with approximately one
billion active users a month (Statista, 2021). MarketingCharts, a United States marketing
database and publication website, showed an analysis of more than 22 million posts from 56,296
business pages between January 2019 and the end of October 2020, Instagram remains the social
media platform with the highest engagement rate, ahead of Facebook and Twitter, growing
0.07% since the 2020 annual data. Statista (2021), a German company specializing in
quantitative data and the number one globally ranked data platform, reports over half of global
Instagram users are aged 34 years or younger as of July 2021. They also report 51.4% of global
users are females, and 48.6% are males. It is estimated there will be approximately 1.2 billion
Instagram users worldwide by 2023 (Statista, 2021). Perrin (2015) reported 76% of American
adults with college or graduate degrees to utilize social media networks. In a survey of 355
healthcare workers in southeast Texas, 97% indicated owning electronic devices, and 87.9%
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noted the utilization of social media. Additionally, subjects reported using social media for
approximately one hour daily (Surani et al., 2017). Instagram has been utilized to collaborate
ideas, chat discussions, and healthcare-related alerts (Pizzuti et al., 2020).
Instagram Algorithm for Posting
Instagram Insights is a native analytics tool accessible through the individual login of any
business Instagram account’s mobile application. Instagram Insights provides an overview of
basic metrics from the last 7, 14, 30 and 90 days, or previous month on three tabs: accounts
reached, content interactions, and total followers. Opening these tabs will provide more detailed
data. In the first tab, Reach, the number of impressions, profile visits, website taps, and call-to-
action button taps data are presented numerically and as a percentage increase or decrease from
the chosen timeframe (Pokrop, 2021). Metrics also offered in the Reach tab include Top Posts
based on reach, with specific likes, comments, saves, and shares numerically shown for each
piece of content. Discovery is the final subcategory of Reach and provides quantitative data on
follows, reach, and impressions--with the impressions data divided into sections of how each
user arrived at the profile (via hashtag, home feed, explore feed, or another avenue. The second
metrics tab is Interactions, which displays the total number of post interactions, likes, comments,
saves, shares, story interactions, and IGTV video interactions for the specified time frame. The
final metrics tab is Followers, which provides the total number of followers and the percentage
of change over time, a visual growth chart over time, the time of day the followers are most
active, and the breakdown of the age ranges and top five geographical locations of users
interacting with the page and content (Pokrop, 2021).
Likes alone are considered passive engagement because pressing the like button requires
little effort; on the other hand, shares, comments, and saves are considered active forms of
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engagement as these functions require more effort (Foxwell, 2020). Comments are particularly
valuable because they require conscious effort and allow for instantaneous discussion. Saves
indicate which posts are valuable enough that users want to store and reference later. Shares are
essential because when a post is shared, it increases the chances other users are viewing the post.
Reach refers to the number of total unique Instagram accounts looking at each post or piece of
content. Impressions are the total number of times a profile’s content was displayed; one user can
account for multiple impression counts depending on the frequency the user views that particular
content (Pokrop, 2021).
Roach (2020) describes likes, comments, followers, saves, and shares as beneficial but
refers to them as vanity data. He argues, engagement rate is a more comprehensive metric to
measure since it emphasizes the frequency of follower interactions on a page’s content.
However, the most significant measure of social media success requires a big audience and an
engaged audience (McLachlan, 2020). Engagement rate is defined as a metric used to see how
many people interact with your social media content -- the percentage of people who were
exposed to a post chose to engage with it in some way (Worthy & Newberry, 2020). The world’s
leading businesses, social media analytics platforms, and social media educators -- Forbes,
Hootsuite, Iconosquare, Oberlo, and Corporate Finance Institute -- use the following classic
formula for calculating Instagram engagement: adding the average likes and comments a page
receives (per post, per specified time frame), divide that by the number of followers a page has,
and multiplying by 100 to get a percentage (CFI Education Inc, 2021; Rabo, 2019; Roach, 2020;
Sauthier, 2020; Sehl & Tien, 2021):
(( Σ (Likes + Comments) / # of posts) / # of followers ) x 100 = Engagement Rate
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Forbes considers this classic formula to be the one used for most industry benchmarks,
influencer campaigns, and social media analysis tools (Sauthier, 2020). However, there is no
universally accepted “good” engagement rate, average engagement rates on Instagram range
from 1% to 5% -- with a rate of 0.85% considered “doing well” (Roach, 2020). On an analysis of
30,226 Instagram business profiles, the average engagement rate was 4.7% (Rabo, 2019).
However, this average percentage differs greatly depending on the industry each page is
considered part of, including Shopping & Retail, Media, Food & Beverage, Consumer Brands,
Travel, Education, and Public Figures. Rabo (2019) considers less than 1% a low engagement
rate, a good engagement rate being 1%-3.5%, a high engagement rate being 3.5%-6%, and a very
high engagement rate being above 6%.
Ryan Mosseri, the Head of Instagram, created the platform to utilize a variety of
algorithms, classifiers, and processes to determine which posts display on unique individual
Instagram accounts. On Instagram’s blog, Mosseri reports (2021), Feed (each user’s home feed),
Explore (the searchable feed with suggested posts listed), and Reels (feed for videos) each use
unique algorithms to decide if a page’s post appears for a user in each of these types of feed. The
algorithm for deciding if a an account will show up in a user’s home feed includes the following,
ranked in order of importance: information about the page’s post (popularity, how long ago it
was posted, if there is a location attached), information about the page posted (how interesting
the page might be to the user and how many times people have interacted with that page in the
last few weeks), the user’s activity (to help understand what they might be interested in), and the
history of the user interacting with that page (shows how interested a user could be in seeing
posts from that page). Similar multi-variable algorithms exist for Explore and Reels as well.
From the information gathered about the user and posting page, a set of approximately a dozen
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predictions are made and, over time, with Instagram’s algorithms for each user adjusting over
time with signals and predictions being added and removed as Instagram gets to know the user
better.
Building a consistent cadence around the frequency of posting on a page is recommended
to increase engagement. Hootsuite, a social media scheduling platform, has reported success
with two-to-three posts and stories each week (McLachlan, 2020). Wahid and Wadud’s (2020)
study shows posting time determines likes and comments and is best served on weekdays instead
of weekends for higher engagement rates. According to a study from Sprout Social, the world’s
leading social media management platform, the best time to post to Instagram is when most user
engagement occurs - Monday through Friday around 11 am, with Tuesdays being the best day to
post and weekends and mornings seeing more scattered engagement by users (Arens, 2021;
Martin Ferreira, 2021). Research by the American Marketing Association shows the best times to
post on Instagram are Wednesday and Friday from 10-11 am, with Wednesday being the overall
best day to post (Powers, 2019). Oberlo, a top e-commerce application notes, because of the
changes in lifestyle since COVID-19, Mondays, Tuesdays, and Fridays are the current best days
to post, an hour before lunch at 11 am – with a new peak engagement on Tuesdays at 2 pm
(Martins Ferreira, 2021). Instagram Insights allows the account owner to see times of day where
most users are active, along with the days of the week where the account followers are most
engaged.
Similar to consistency in posting frequency, it is recommended to have a consistent style
with all post content and visual appeal to create an expectation for the account page that
followers can count on and trust (Martins Ferreira, 2021). According to Oberlo (2021), content
strategy is another component of successful posts, with the appropriate use of hashtags beneficial
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for increasing foot traffic on an Instagram page as posts without hashtags will likely only reach a
page’s existing audience (Gaid, 2021). To help grow followers, hashtags are recommended to be
niche-specific and relevant to the specific post to increase the likelihood of being found by the
relevant audience, as opposed to generic words or phrases that already have heavy traffic or are
not related to the post or page’s content (Martins Ferreira, 2021). Instagram has a limit of 30
hashtags per post, with successful recommendations to use between five and fifteen hashtags per
post to increase reach, but relevant hashtags are more important than quantity. In addition to
unique hashtags, moving or strong captions convey a story around the video or image being
posted and attract an audience instead of a short or mundanely captioned post (Gaid, 2021).
Although only 15 seconds long and lasting only 24 hours, Instagram stories have become a better
way to gain foot traffic on a page, with more than 500 million people using Instagram stories
since January 2019. Gaid (2021) conducted a study analyzing over 48 million Instagram posts
from more than 300,000 popular users shows video content had twice the engagement of a still
picture, he reported videos have gained traction as they can be used on both posts and stories.

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Chapter Two
Literature Review
Impact of Anesthesia on the Environment
Kostrubiak et al. (2020) examined the relationship between aquatic life toxicity and the
most commonly used anesthesia medications. The study took place at a mid-size regional Level
1 trauma center in Burlington, Vermont. The authors reported the top five most commonly used
intravenous medications by anesthesia providers to be cefazolin, propofol, acetaminophen,
sugammadex, and lidocaine. These medications were tracked using Picis Clinical Solutions, Inc.
(PICIS) through a wastewater treatment plant, before being released into a lake supplying the
town’s public drinking water. Kostrubiak et al. found propofol, a common sedative and second-
most administered drug by mass, had the potential for significant bioaccumulation in organisms--
including growth inhibition and death of algae as well as acute toxicity in crustaceans and
freshwater fish. Once propofol reaches the aquatic ecosystem, it takes over one year to degrade.
Additionally, the authors reported that lidocaine and acetaminophen degrade much quicker, but
their constant use and existence in the aquatic environment result in pseudo-persistence.
Cefazolin, a surgical prophylactic antibiotic, not only represents the greatest drug by mass
administered by anesthesia providers, but it also is the most wasted and discarded antibiotic. In
the study, cefazolin was administered 20 kg more than the next highest mass drug. It is also
considered one of the most discarded antibiotics in the operating room, indicating the amount of
drug entering the waste stream could be more significant than what is administered to the patient.
The current conventional wastewater system cannot eradicate cefazolin completely. Researchers
indicated cefazolin had measurements as high as 4.8 ug/mL even after undergoing wastewater
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treatment. This highlighted the incomplete removal of cefazolin by current wastewater treatment,
thus, indicating the potential impacts it may have on the aquatic environment.
Wluka et al. (2017) conducted a study in Germany, looking to identify two anesthetics
propofol and lidocaine in wastewater using gas chromatography, a mass spectrometry-based
screening analysis. Propofol was identified in sewage water and surface water samples in one of
the three wastewater treatment plants under investigation, proving inefficient drug removal
during wastewater treatment and highlighting their potential impact on the aquatic environment.
Lidocaine was also found sporadically in wastewater and surface water from all three wastewater
treatment plants in the study. Lidocaine has also been determined as a harmful substance to
aquatic organisms with an EC-50 (concentration of a drug that gives half-maximal response)
value for acute toxicity of daphnia of 61 mg L
-1
(GholipourKanani & Ahadizeh, 2013). The acute
toxicity for goldfish LC50 (lethal concentration in 50% of test animals) is 6.34 mg L
-1

(GholipourKanani & Ahadizeh, 2013).
Mankes (2012) examined the pharmaceutical waste bins in eight operating rooms over
ten months and discovered 45% of all drug waste was attributed to propofol. About one month
into the study, the standard 50mL and 100mmL bottles of propofol were eliminated from the
hospital and replaced with 20mL bottles. As a result, the facility’s propofol waste decreased from
an average of 29.2 mL/day/bin to 2.8 mL/day/bin. Mankes (2012) found reducing the size of
propofol vials reduced the amount of drug waste and its negative environmental effects.
Özelsel et al. (2019) conducted a descriptive study identifying sevoflurane and isoflurane
as anesthetic agents with short-term impacts and desflurane as an anesthetic agent with long-term
impact on the atmosphere. The study’s operational definition of greenhouse gas is the product of
absorption and reflection of infrared radiation from the earth. The authors established the three
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properties determining atmospheric gas potency as (1) the atmospheric lifetime of the gas, (2) the
amount of infrared radiation absorbed during the atmospheric lifetime, and (3) presence of
natural atmospheric chemical compounds. Fluorocarbons make up all volatile anesthetics and
satisfy all three properties as evidenced by their potent greenhouse effects. The most common
way to measure environmental impact of anesthetic agents is the Global Warming Potential
(GWP). GWP is calculated by comparing reference gas carbon dioxide with the amount of heat
inhalation agents trapped over a specific time. Two standard time metrics are 100 years (GWP100)
and 20 years (GWP20). In order to effectively convey the data to anesthesia providers, the authors
converted the metrics GWP100 and GWP20 to driving equivalences. In the study, one day of surgery
is classified as seven hours of inhaled anesthetics usage, and results are based on the global
warming potential at one year. Using desflurane at a fresh gas flow of two liters per minute for
one full calendar year is the equivalent of the carbon dioxide emissions of driving a car for
15,698 km; thereby, concluding desflurane as the highest greenhouse gas emitter. Sevoflurane
accounted for 3,132 kilometers and isoflurane for 2,668 kilometers of carbon dioxide emission
when converted into driving equivalences. This quantitative data makes the data more relatable
for providers–increasing awareness and promoting conscious decision-making in anesthetic
selection.
Sherman et al. (2012) investigated the life cycles assessment of five anesthetic
medications: sevoflurane, desflurane, isoflurane, nitrous oxide, and propofol. The researchers
adopted the cradle-to-grave approach to account for the impact of each step from manufacturing
to use and waste of medications. Specifically, the authors focused on resource gathering and
production, transportation, clinical use, disposal, and emission to the atmosphere. In conclusion,
the uncontrolled atmospheric waste accounted for the most significant greenhouse gas emissions
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within the inhalation anesthetics; specifically, desflurane emitted greenhouse gases into the
atmosphere at a rate 15 times that of isoflurane and 20 times that of sevoflurane. Factors
contributing to the findings include the higher MAC percentage, higher radiative forcing effect
based on a GWP100, and lower rates of vivo metabolism. Nitrous oxide was reported to have
GWP100 310 times higher than carbon dioxide, making nitrous oxide a harmful agent to the
atmosphere when used as carrier gas. Lastly, propofol had the least impact on greenhouse gas
emissions even after assuming other characteristics within the life cycle. Propofol impacts the
environment in other forms, mainly through the improper disposal of the agent.
Vollmer et al. (2015) evaluated the effects of volatile anesthetics on the atmosphere over
13 years; the study utilized a “top-down” approach in which the atmospheric abundances of the
various volatile anesthetics to assess global and regional emission patterns were measured. The
authors noted no existing policy requiring hospitals to integrate a waste capture system for
anesthetic gases; as a result, all volatile anesthetic gases are directly released into the atmosphere
and contribute to global warming. The study monitored volatile anesthetics halothane, isoflurane,
sevoflurane, and desflurane for the duration of the study. Gases were collected from various
remote locations, including the Northern Hemisphere, North Pacific, and South Korea Antarctic
station King Sejongs, to establish baseline conditions free of direct exposure to anesthetic gases.
Researchers then collected air samples from an observatory at Jungfraujoch, Switzerland, about
3580m above sea level, with known exposure of anesthetic compounds due to the urban
neighborhood sitting below. Ongoing measurements from Dubendorf Zurich were also taken
with immense traces of anesthetic compounds within the atmosphere. The atmospheric levels of
halothane concentrations declined year after year because of its relevance in anesthesia practice
and the short half-life. Halothane was heavily utilized in the 1960s and 1970s and is no longer an
SUSTAINABLE ANESTHESIA EDUCATION WITH INSTAGRAM

16
anesthetic utilized in modern-day anesthesia. Isoflurane, sevoflurane, and desflurane recorded
increasing concentrations within all tested sites. In addition, more concentrations of the flurane
anesthetics were located within the Northern Hemisphere, thus signifying a more significant
emission of volatile anesthetics from northern hemispheric countries. To quantify the results,
researchers noted between 2001 to 2014; halothane declined in global emission from 490 t yr
−1
to
250 t yr
−1
. In contrast, the global emissions of isoflurane and desflurane increase from 440 t
yr
−1
to 880 t yr
−1
and 150 t yr
−1
to 960 t yr
−1
respectively within the same time frame. The earliest
quantified data for sevoflurane was identified in 2004; thus, the time frame differs from the other
anesthetic agents. Nonetheless, from 2004 to 2014, global emission for sevoflurane rose from
1100 t yr
-1
to 1200 t yr
-1
. Vollmer et al. further indicated desflurane has the highest carbon dioxide
equivalent emissions accounting for the largest GWP among all volatile anesthetics utilized. Out
of the total carbon dioxide emissions calculated within volatile anesthetics in 2014, nearly 80%
of carbon dioxide emissions derive from desflurane.
Green Anesthesia
Seven consensus guidelines on environmentally sustainable anesthesia have been created
and studied by White et al. (2021) and led by the World Federation of Societies of
Anaesthesiologists (2021) after recognizing the crucial negative contribution many anesthetic
practices have on the environment. The World Federation of Societies of Anaesthesiologists
(WFSA) has been a global alliance of anesthesiologists since 1955. With 135 member societies,
their vision is to provide universal access to safe anesthesia with their specific mission to unite
anaesthesiologists around the world to improve patients care and access to safe anesthesia and
perioperative medicine (World Federation of Societies of Anaesthesiologists, 2021). Although
the WFSA focuses on patient safety, there is recognition of the anesthesia practice on global
SUSTAINABLE ANESTHESIA EDUCATION WITH INSTAGRAM

17
warming, and environmentally conscious anesthesia practices are possible without sacrificing
patient safety. The authors use a three-stage Delphi process conducted in English to recruit 45
anesthesia practitioners from 29 countries across all continents (excluding Antarctica) to create a
WFSA Global Working Group. This working group was tasked to submit broad principles of
sustainable anesthesia that any anesthetic group globally should aim to practice. These principles
were reviewed by the Steering Committee, condensed by consensus, merged into 58 statements,
and then released as a binary survey to the 45 practitioners to find seven principles of consensus
and then finally reviewed by the WFSA Global Working Group. The seven principles of
environmentally sustainable anesthesia state anesthesia providers should:
1. Minimize the environmental impact of their clinical practice.
2. Use environmentally preferable medications and equipment when clinically safe
to do so.
3. Minimize the overuse/waste of medications, equipment, energy, and water.
4. Incorporate environmental sustainability principles within formal anesthesia
education.
5. Embed environmental sustainability principles within anesthesia research and
quality improvement programs.
6. Be able to lead environmental sustainability activity within their healthcare
organizations.
7. Collaborate with industry to improve environmental sustainability.
A literature review by Wyssusek et al. (2018) explored operating room greening
initiatives from the past 25 years, including anesthesia scope of practice and its impact. The most
distinguished practices have been successfully trialed and recommend using what the authors
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18
deem the Five R’s: reducing, recycling, reusing, rethinking, and researching. The Association of
Anaesthetists (2021) is an association of anesthesia providers in England, Wales, Ireland, and
Scotland with a mission to promote and support education, relevant science, and research in
anesthesia while encouraging supportive cooperation between anesthesia providers throughout
the world. The research and practice recommendations of the Association of Anaesthetists mirror
the Five R’s approach recommended by Wyssusek et al. Reducing was defined as efforts to
mitigate the amount of waste generated in the first place. Staff was more inclined to reduce waste
when physical documentation and display of unnecessary overages. Other successful reduction
efforts include: using electronic recording to reduce paper use, eliminating large medication
bottles (use 20mL propofol bottles instead of 50ml and 100ml bottles), ensuring sharps bins are
full before disposal, avoiding the use of nitrous oxide, using low flow anesthesia (usually less
than one liter per min), considering regional or total intravenous anesthesia (TIVA) over general
anesthesia (especially desflurane and nitrous oxide) were safe, and only opening non-emergent
instrumentation and medications as needed -- not ahead of time. Reusing includes washing and
reusing plastic or metal ‘drawing-up trays, safely reusing sterilized equipment (particularly
metalware) when possible instead of single-use items, or utilizing medical device reprocessing
for items including blood pressure cuffs and pressure bags. Recycling starts with waste
segregation and is imperative for recycling cardboard from packing, stainless steel from
disposable laryngoscope blades, aluminum from volatile anesthetic cans, glass from certain
medications, and plastics including bins and endotracheal tubes. Rethinking involves educating
and training staff concerning evidence-based, sustainable anesthesia practices and engagement
with hospital leadership to implement greener waste policies, both through the anesthesia scope
SUSTAINABLE ANESTHESIA EDUCATION WITH INSTAGRAM

19
and hospital-wide. Finally, research encompasses encouraging studies to expand the knowledge
base of research in sustainable anesthesia practices.
Instagram as an Educational Tool
Arceneaux & Dinu (2018) conducted a study with 405 American college students testing
the difference between recall of digital information using textually based messages and visually
based messages. The study also tested which sources participants were more likely to find
trustworthy. The students were randomly assigned into one of the four tested groups: Twitter
users, Instagram users, casual information sources, and professional information sources. First,
each participant was given six news stories, each with five items of a quantitative measure which
recorded the participants’ preference for that information source’s credibility. All participants
were given a distracting task involving matching photos of countries to their corresponding
names and were then administered a cued memory test regarding the six news stories introduced
at the start of the intervention. The results identified visually dominated platforms like
Instagram as more effective than textually dominated platforms like Twitter. These findings
support utilizing images to disseminate education to help college students recall information with
strong mental associations. The study also found participants were more likely to believe
credible sources, such as professional news outlets, over casual Instagram users, contradicting
past research findings from other studies. These findings guide educators to use social media
effectively to improve global competence in issues such as climate change.
Hortigüela-Alcalá (2019), conducted a study on 197 university students to analyze the
impact of different social media platforms. In this study, participants were divided into
experimental and control groups; both groups received a pre-and post-test 18 items validated
questionnaire called Student Motivation and Involvement in the Learning Process in Higher
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20
Education. The experimental group utilized Twitter and Instagram to review information covered
in the classroom--utilizing hashtags, uploading pictures and videos, and sharing links to provoke
constructive debate. The control group did not use Twitter and Instagram; instead, they used the
traditional in-class assignments and homework with all resources provided. The study results
found Twitter and Instagram statistically significantly increased body of knowledge acquired (p-
value = 0.013) and in-class involvement (p-value < 0.05).
Nguyen et al. (2021) conducted a study in which 170 students from the University of
Texas School of Dentistry (UTSD) and University of Nebraska Medical Center (UNMC) College
of Dentistry were evaluated to determine the effectiveness of Instagram when utilized as a
resource for enhancing anatomy education in dental school. Faculty created and facilitated two
Instagram accounts at two dental schools. The @YoachimAnatomy account was created in
February 2020 exclusively for UNMC dental students, and @TheAnatomyDoctor was
established in January 2019 exclusively for UTSD dental students. The content of the Instagram
pages was created by professors and disseminated in images, videos, practice questions, and
interactive quizzes. A Qualtrics survey followed the completion of the programs’ anatomy
courses to measure the effectiveness of utilizing Instagram as an educational tool. The survey
had a total of 50 questions based on a five-point Likert scale (1=strongly agree, 2=agree,
3=neutral, 4=disagree, and 5=strongly disagree) along with a narrative response section. Results
indicated the top three most utilized platforms by the students were Facebook (96.3%),
Instagram (94.4%), and GroupMe (91.9%). Regarding student intentions with social media use
from both dental schools, 96.9% reported using social media as a source of information, while
92.5% reported using social media for educational endeavors. Students unanimously agreed the
Instagram page was a helpful tool in learning anatomical content and facilitated comprehension
SUSTAINABLE ANESTHESIA EDUCATION WITH INSTAGRAM

21
in a convenient, engaging, and professional/appropriate manner. In the narrative response
section, both cohorts praised the accessibility of information and reported plans to use the
Instagram page for board exam preparation. Both cohorts also recommended other professors use
Instagram as an educational tool to enhance students’ learning. Students further noted utilizing
the app did not induce further stress as 85.1% have had seven years or more experience in social
media, nor did it cause concerns for the invasion of privacy. While students unanimously
reported social media led to distractions during study sessions, they also reported social media
was a resourceful supplement to their education.
Prudencio et al. (2021) conducted a pre-and post-test quasi-experimental design in 2018
of 69 third-year doctor of pharmacy candidates enrolled in an Introductory Pharmacy Practice
Experience course (IPPE). At the beginning of the fall semester, all pharmacy students were
required to take a pretest consisting of 30 multiple choice and select-all-that-apply questions
regarding various pharmaceutical therapies pertinent within the ambulatory care field. The
pretest awarded one point for every correct response, with a maximum of 30 points. The study's
principal investigator created an Instagram account @AmbCareRx tailored to posting
ambulatory clinical pearls during the fall semester, posted relevant content, and monitored
engagement levels daily. Microsoft PowerPoint was utilized to format educational content
related to common diseases in the ambulatory care setting along with appropriate corresponding
pharmaceutical management. Posts were paced at three-a-day, with a total of 48 infographic
posts in 16 consecutive weeks. Following the creation of the Instagram page, all pharmacy
students enrolled in IPPE were informed of accessibility to the account availability and purpose.
Students were not required or given incentives to engage with the Instagram page. Those who
voluntarily followed @AmbCareRx constituted the intervention group (37), while those who
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22
abstained were the control group (32). Students self-reported their engagement on the Instagram
page but were also cross-checked with the @AmbCareRx follower's list. The study evaluated the
change between pre-test and post-test scores – results indicated the pre-test mean score of
37.47% in the control group, compared to 40.93% in the intervention group. Post-test mean
scores increased to 40.53% in the control group and 55.93% in the intervention group. There was
an increase in mean score from pre- to post-test within the interventional group (15%) compared
to the control group (3.07%) (p=0.004). Individual participants in the interventional group scored
3.58 points higher from pre- to post-test than the control group.
A pilot study at the University of North Carolina (UNC) School of Medicine
hypothesized Instagram would be an effective social media platform for disseminating histology
study materials to first-year medical students (MS1) (Essig et al., 2020). The researchers created
a public, professional Instagram account @UNCSOPMHisto2023 and required MS1 students to
“direct message” the account to verify their MS1 status. Engagement with the Instagram page
was voluntary and available to access if students chose to do so during any time of the study. The
public professional account status allowed access to Instagram Insights, a data analytic tool
which shows account engagement statistics. Posts were spread at least four to six hours apart
during the high usage times indicated by Instagram Insights. Researchers utilized first and
second-order questions to promote quick, straightforward responses. A total of 79 histology posts
were created; of the 190 MS1s enrolled, 92 followed the account on day one and 141 MS1s at
the conclusion. A total of 64 students responded to the survey; 98% of users considered the
platform beneficial to prepare for tests and quizzes. When the page was utilized as a
supplemental educational tool, 95% of students surveyed had increased confidence regarding
SUSTAINABLE ANESTHESIA EDUCATION WITH INSTAGRAM

23
histology materials. The profile analytics indicated an average of 125.9 users with an average of
441.7 impressions per post.
Voorveld et al. (2018) found one method of evaluating the effectiveness of social media
platforms is to measure digital engagement via quantitative metrics on comments, views,
followers, shares, or likes. Using eight social media platforms (five of the most used and three of
the fastest growing), the authors surveyed 1,919 respondents ages 13 and above who indicated
regular social media use on 42 experience items to measure engagement with each social media
platform. Instagram scored the highest of the eight platforms on topicality dimensions and
pastime: it was often used to fill gaps in time and seen as a platform guaranteeing users to feel
quickly informed on current, helpful information. The study found that conceptualizing digital
engagement is difficult due to the newness of these quality metrics and lack of academic
evidence. Through combining both theory and a review of available evidence-based literature,
social media engagement was defined as the emotional, intuitive experiences or perceptions
people undergo when using a particular platform at a particular moment. The authors defined
social media engagement as multidimensional experiences satisfying the requirements of either
doing or sharing something with others, discovering useful information, or filling empty gaps of
time. Along with the complexity of social media engagement of consumers, there are differences
in engagement dimensions when comparing multiple platforms.

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Chapter Three
Methodology
Literature Search
The literature search was conducted on Google Scholar, PubMed, Embase, CINAHL, and
EBSCOhost. Keywords entered into the databases included: “green anesthesia,” “global
warming,” “Instagram as an educational tool,” “environment sustainability in anesthesia,”
“Instagram in healthcare,” and “anesthesia waste,” “greenhouse gases,” “carbon footprint,”
“medication waste,” “Instagram engagement algorithm,” and “Instagram marketing.” Inclusion
and exclusion criteria varied based on the topics of the literature review. For example, Instagram
was created in 2010 and has only recently developed as an educational tool; as a result, there is
limited evidence-based published literature surrounding effective Instagram algorithms for
measuring engagement and posting content. Instagram engagement information was gathered
primarily from grey literature such as social media marketing blogs and press release distributors
like Newswire. The inclusion criteria for topics unrelated to Instagram algorithms included: peer-
reviewed, published within the last ten years, and published in any country but translated into
English. Exclusion criteria included research articles published prior to 2012 and those not peer
reviewed.
Intervention
This study measured engagement on @gasp_anaesthesia, an Instagram account aiming to
educate anesthesia providers on the environmental impact of anesthesia. With an aim to complete
a quality improvement project, the methodology did not require Institutional Review Board
(IRB) approval. Pre-intervention data was collected between November 1, 2021-January 29,
2022; the intervention phase was implemented between January 30, 2022-April 23, 2022.
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25
Three student nurse anesthetists from the USC Program of Nurse Anesthesia assumed
control of GASP Anaesthesia’s current Instagram page (@gasp_anaesthesia) and employed a
series of posts and stories to create an impact on its activity daily. The Instagram account was
promoted via social circles of USC Program of Anesthesia faculty members and students, online
forums of professional anesthesia organizations, social circles of student nurse anesthesia and
physician anesthesiologist schools around the United States, professional organizations affiliated
with GASP Anaesthesia, and the current followers of GASP Anaesthesia. The Instagram page
@gasp_anaesthesia is set as a public Business account, which allows anyone in the world to
view the page’s content.
Content Creation and Dissemination
Suitable content was extracted from best practice recommendations created by the
second-year student registered nurse anesthetists’ capstone by Chikwere et al. (2023) and Gaddy
et al. (2022). Evidence-based green anesthesia education was also utilized to create content. The
education was designed to be simple and encourage active participation. Complex environmental
and medical verbiage was avoided to ensure understanding for those providers with limited prior
knowledge. The content was posted at a rate of two to three times per week during high traffic
times identified under Instagram Insights.
Instagram content was disseminated through Instagram's stories, lasting for 24 hours, and
posts, which remain on the GASP page indefinitely. Permanent posts consisted of images or
videos with educational points specifically catered towards anesthesia providers regarding the
environmental impact of their practice, practical ways to reduce their carbon footprint, and open
discussion topics. Followers of @gasp_anaesthesia were able to view stories and posts
automatically displayed on their daily feed without searching for the account. Anyone with an
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26
Instagram account was able to answer polls directly on the stories and have the option to like,
share, or comment directly on any of the posts. Followers were able to review previously posted
content via the @gasp_anaesthesia home account page. Instagram stories included polls
containing trivia content, multiple choice quizzes, questions with open-answer responses for the
audience, hashtags, and an “add yours” function where users could attach their photos to a chain
using a prompt provided by the account. Platforms used to create content included Adobe
Express and Canva. Hashtags used include: #greenmedicine #greenanesthesia
#reusereducerecycle #zerowaste #sustainablehealth #climatechange #globalwarming
#climateaction #savetheearth #environment #anesthesia #gogreen #noharm.
Engagement Analytics
User engagement was calculated using Instagram Insights at the conclusion of the
intervention using the following equation:
(( Σ (Likes + Comments) / # of posts) / # of followers ) x 100 = Engagement Rate.
This engagement rate was then compared to the page’s pre-intervention engagement rate and
assessed for an increase or decrease, with a low engagement rate considered less than one
percent, a good engagement rate of one to three and a half percent, a high engagement rate being
three and a half to six percent, and a very high engagement rate being above six percent by
industry standards (CFI Education Inc, 2021; Rabo, 2019; Roach, 2020; Sauthier, 2020; Sehl &
Tien, 2021).

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Chapter Four
Results
From the initial post on Instagram page @gasp_anaesthesia on February 24, 2020, until
the start of our intervention on January 29, 2022, there were 11 posts, 172 followers, and an
average of eight and a half likes per post. Furthermore, no posts or stories were posted between
November 1, 2021, and January 29, 2022 – the three-month period immediately prior to our
intervention – thus, the engagement rate was 0%. Fewer than 100 accounts viewed the content,
and there were zero profile visits. The posts were infrequent and inconsistent; there were four
posts in August and September, and the post prior to that was eight months ago. Instagram
stories and interactive tools, such as polls and quizzes, had not been used. Hashtags are used in
six out of the eleven posts; posts that contained hashtags included an average of six hashtags.
During the 12-week intervention, 7,215 accounts were reached overall, of which 293
were followers, and 6,922 were non-followers. This is a +86,425% reach in accounts that did not
follow @gasp_anaesthesia compared to the previous three months. Reels generated the highest
content reach at 5,930 profiles. Posts generated the second highest reach at 2,184 profiles,
followed by videos at 1,193 profiles and stories at 441. Each week reels alone had an average of
593 reach compared to posts, stories, and videos which had a combined weekly average of 318.
Although stories reached the fewest profiles, they generated the most conversation via direct
messages and individual group chats. There were 262 accounts engaged, which is a 13,000%
increase from the pre-data. Content interactions increased by 23,733% for a total of 1,430
interactions. Of the 1,081 post interactions, there were 998 likes, 58 comments, 95 saves, and 72
shares. Stories received 12 interactions, reels received 162 interactions, and videos received 175
interactions (Table 2).
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After the intervention, there were 496 followers, for an overall growth of 324 followers.
Using the classic formula for calculating Instagram engagement, engagement increased from 0%
pre-study to 7.096% post-study. The top locations included the United States (52.8%) and the
United Kingdom (38.8%). The majority of followers were women between the ages of 25 and
34. Instagram insights also indicated that the most highly trafficked times were between 12 pm
and 2 pm Pacific Central Time, roughly the same every day of the week for the duration of
intervention. While we cannot determine the background of every follower, Instagram reached a
broad audience.

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Chapter Five
Discussion
Two critical components to creating a healthier environment include accountability of
good resource stewardship and robust environmental education to those in the field of anesthesia.
As the field of green medicine evolves, anesthesia providers have increasing opportunities to
reduce their carbon footprint and impact the health of all living things. The solution to climate
change is multi-faceted and would not be possible without sustainable initiatives and teamwork -
from the local level to global efforts.
Using Instagram to disseminate information and educate on sustainability in anesthesia
can be beneficial moving forward. With a very high engagement rate being considered above 6%
per Rabo (2019), and an engagement increase from 0% to 7.096% from the start to finish of the
3-month long intervention as well as an increase in followers from increased from 172 pre-
intervention to 496 post-intervention, this study confirms the success of using Instagram as a
platform to increase engagement in the realm of education on sustainable anesthesia practices.
The 172 pre-intervention followers of the @gasp_anaesthesia page were primarily
located in the United Kingdom, however the three anesthesia students running the Instagram
page were located in the United States. The time zone differences could affect visibility and
engagement in either location, as well as locations across the globe, given the time of each post.
In addition, Instagram’s algorithm which chooses what content appears on each individual’s
home feed consists of many variables, both from each individual’s clicks and interactions as well
as the clicks and interactions of the three students using the @gasp_anesthesia page. The global
nature of social media limited the assurance of the content from @gasp_anesthesia reaching as
many users as possible at the right time. There is also no way to assess the affiliation of each
SUSTAINABLE ANESTHESIA EDUCATION WITH INSTAGRAM

30
participant seeing or interacting with @gasp_anaesthesia content, whether that be an anesthesia
provider, another type of healthcare professional, or someone unaffiliated with healthcare.
This study’s intervention was only completed on Instagram and did not branch into other
popular social media platforms including Facebook, Snapchat, and TikTok. Popularity and use of
these various social media platforms changes over time, so the rise of new platforms could be
studied in the future. Much of the recommendations for posting and ways to increase Instagram
engagement came from gray literature, often social media blogs, due to lack of published studies
specifically covering validated ways to increase engagement on Instagram for educational
purposes. Much of this gray literature also focused on recommendations for increasing Instagram
engagement for business accounts trying to generate sales and may not encompass appropriate
ways to generate engagement for a healthcare or educational Instagram account. This study’s
intervention thus is a compilation of recommendations as there is also no published protocol
specifically outlining verifiable ways to increase engagement.
Limitations
Being a preliminary investigation on engagement using social media in the realm of
sustainable anesthesia, this study had many limitations resulting in the need for more expansive
studies in the future. This was a pilot study, only running over the course of 3-months with no
substantial previous follower base of the @gasp_anaesthesia page. Izood, a popular blog
covering tips on social media marketing, reports it can take up to 3 months to gain follower
traction, even with consistent and frequent posts, commenting on and liking public posts, and
appropriate use of hashtags (Harrison, 2021). Given this, future studies should have a longer
timeframe. The content creation and dissemination were completed by three anesthesia students
without any previous marketing or social media training and the engagement still increased
SUSTAINABLE ANESTHESIA EDUCATION WITH INSTAGRAM

31
significantly. Social media is time consuming, and most marketing has entire teams working full
time on social media to ensure success. Due to lack of funding, no posts were able to be
promoted, which is a common way business accounts can generate profile and post views.
Conclusion
There is a growing push to become more environmentally conscious in the healthcare
industry, especially with the rise of climate change. The operating room is a top generator of
waste in healthcare, with anesthesia playing a major role through the use of intravenous
medications, inhaled gases, and equipment. Education on sustainable practices in anesthesia are
necessary to provide understanding on the impact of anesthesia on the planet. Social media has
recently developed in healthcare as a means for professional communication and educational
initiatives, with Instagram showing particular promise as a beneficial platform for education on
healthcare practices. The aim of this pilot study was to explore how taking over a sustainable
anesthesia Instagram page in a regimented way could affect engagement when used as an
educational platform aimed at teaching about and recommending best practices in sustainable
anesthesia to users across the world. We hypothesized engagement would increase from the pre-
intervention rate of 0% to a post-intervention rate of at least 6%. A significant increase was made
in the engagement rate to 7.096% after the completion of the 3-month long intervention using
recommendations for consistent frequency of posts, hashtag use, interaction with other users, and
multimodal combination approach of posts, reels, and stories. Followers count also increased
from 172 pre-intervention to 496 post-intervention. Further research and publications on using
Instagram as an educational platform for increasing engagement on sustainable anesthesia are
needed to fully understand how social media can be of benefit for educating healthcare
professionals, however, this study’s protocol for posting on Instagram can be used as a model for
SUSTAINABLE ANESTHESIA EDUCATION WITH INSTAGRAM

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further investigation. With the current pressures of climate change in addition to the advances of
technology and accessibility of social media, Instagram is a viable option for enhancing
dissemination and education on ways anesthesia providers can be as environmentally conscious
in their practice as possible.

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Tables
Table 1 – Working Definitions

Data Definition
1 Green
anesthesia
conscious, evidence-based practices in the anesthesia profession focused
on reducing negative environmental impact
2 Engagement Cumulative Instagram likes, followers, and comments
3 Increased
engagement
an engagement rate greater than at the start of the study, with a low
engagement rate considered less than 1%, a good engagement rate of 1%-
3.5%, a high engagement rate being 3.5%-6%, and a very high
engagement rate being above 6%

SUSTAINABLE ANESTHESIA EDUCATION WITH INSTAGRAM

44
Table 2 – Instagram Intervention Results

Followers Content Interactions Engagement Reach

Followers Likes /
comments/
saves
Content
inter-
actions
Post
inter-
actions
Accounts
engaged
Followers/
non-
followers
Profile
visits
Impressions Content
reach
(posts /
stories /
videos /
reels)
Pre-
data

201 4 / 0 / 0 6 6 2 13 / 8 59 106 29 / 0 / 0
/0
Week
1

224

66 / 5 / 4 86 77 43 187 / 23

90 1,464 193 / 172
/ 87 / 0
Week
2

263 42 / 0 / 2 102 102

34 179 / 852 217 2,588 165 / 137
/ 988 / 0
Week
3

273 56 / 3 / 4 90 90 43 186 /
2768
73 4,776 133 / 150
/ 339 /
2,884
Week
4

341 78/ 12 / 18 127 127 74 231 / 389 166 2,234 754 / 183
/ 71 / 34
Week
5

342

47 / 2 / 2 51 51

32 232 /
1036
50 2,084 187 / 131
/ 131 /
931
Week
6

366 122 / 1 / 3

155 155

34 230 / 709 89 2,905 265 / 173
/ 22 /
825
Week
7

405

53 / 4 / 6 92 69 60 255 /
1,746
100 3,906 398 / 183
/ 16 /
1,747
Week
8

423 222 / 10 /
4

245 197 44 247 / 393 81 2,002 628 / 169
/ 16 / 23
Week
9

424 52 / 2 / 6

81 62 44 274 / 736 67 3,438 379 / 196
/ 8 / 768
Week
10

435 39 / 2/ 1 55 29 29 270 / 32 59 2,105 276 / 234
/ 3 / 21
Week
11

463 163/3/41

221 187 46 227 / 120 95 2,038 381 / 168
/ 8 / 27
Week
12

495 58 / 14 / 3 97 96 52 277 / 85 67 2,145 325 / 205
/ 4 / 10

Abstract (if available)

Abstract Background: The healthcare industry’s climate footprint accounts for 4.4% of global net emissions (Karlinger et al., 2019). Operating rooms generate significant waste; the lack of education and accountability in green practices leads to improper waste disposal. This capstone examines social media as an educational tool to disseminate sustainable anesthesia practices.

Specific Aims: 1) Perform an exhaustive literature review investigating the utilization of social media as an educational tool to distribute information. 2) Investigate and summarize the impact of anesthetic agents on the environment. 3) Develop and implement a protocol for disseminating information regarding anesthesia’s impact on the environment, utilizing GASP’s Instagram account. 4) Analyze impact of social media engagement methods for dissemination of healthcare data and develop a series of recommendations for future Instagram initiatives.

Methods: Three student registered nurse anesthetists utilized GASP Anaesthesia’s Instagram page (@gasp_anaesthesia) to disseminate sustainable anesthesia content. User engagement was calculated with Instagram Insights pre- and post-intervention over three months. Engagement data was gathered via Instagram Insights using raw data and calculated with an engagement equation.

Results: Engagement increased significantly with Instagram reels and polls in stories. Between January 30, 2022, and April 23, 2022, the @GASPanaesthesia follower count increased 146.27%. Most of the engagement was initially from the United Kingdom (79.7%) but transitioned to the United States (52.8%) as the content creators pushed recognition locally.

Conclusion: Engagement increased from 0% to 7.096%--proving Instagram to be an effective method to engage and educate healthcare communities on sustainable practices in anesthesia.

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Asset Metadata

Creator Chin, Mindy (author)

Core Title Instagram as an engagement tool for awareness of the environmental impacts of anesthesia

School Keck School of Medicine

Degree Doctor of Nurse Anesthesia Practice

Degree Program Nurse Anesthesiology

Degree Conferral Date 2024-05

Publication Date 09/01/2023

Defense Date 08/31/2023

Publisher Los Angeles, California (original), University of Southern California (original), University of Southern California. Libraries (digital)

Tag anesthesia,anesthetic gases,carbon footprint,drug waste,education,educational tool,engagement,green anesthesia,green health,Instagram,medicine education,OAI-PMH Harvest,propofol,social media,sustainable healthcare

Format theses (aat)

Language English

Contributor Electronically uploaded by the author (provenance)

Advisor Bamgbose, Elizabeth (committee chair), Bilsborough, Elisha (committee member), Bolt, Jason (committee member)

Creator Email mindychi@usc.edu,mindychin.rn@gmail.com

Permanent Link (DOI) https://doi.org/10.25549/usctheses-oUC113302655

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