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I haven't Welcome to the prota sustainability in orthopedic surgery conference. I want to thank all of you for joining us today. Um, it's ah, been a bit of a journey, but probably reason why we're here today. Is that last year in April 2021 The RCs England knots there. Sustainability in surgery strategy which outlines how they want to, or the have a plant in bed, financial, environmental and social to stay in ability with ethical part. Sink into everything that we do. And this is being in keeping with the NHS England greener and they just goal, which is to become a net zero carbon organization by 2045. As as many of you who attuned in today may already know, climate change is the defining issue of this decade, with the recent cottony six Conference with the Glasgow climate and packed helping to align the goal of reducing 90% of the global emissions. The Net. Zero in the next few years, person, Like many of you, I've often being scrubbed for a case and thought about the amount of waste that we produce, particularly with you guys start operating and single use plastic for example, and thought that we could be doing this better. Onda As a result, one of the one the main goals as both president this year has been have bean to champion sustainability. As one of our organization goes to everything that we do, I would therefore like to welcome, uh, you to today's conference which was an idea born out of discussions with my partner organization, the Southwest London Elective Orthopedic Center on Mr Mr Ripping s Open your own force. You can't be here with us today. I would like to introduce you to our boat of sustainability lead for this year. Juliet Cotton, who's also our world rep. Who would be our host for today? Um achieved you. Thank you very much. All over. Um, as a liver says I am the boat of Wales rep. But I'm also the boat sustainability lead for this year. Um, stability, something that I'm very passionate about on when the idea of this conference first came up, there were two main emotions, the first of which Waas. This is a brilliant idea on a second, which waas Oh, gold. Um I don't know who's doing what about staying ability at the moment. I don't know where to start with this. I don't know how sustainability projects get off the ground. I just know it's all really important on hopefully throughout the course of this afternoon, we're gonna be able to show you through the help of some really, really fantastic, because that were incredibly lucky to have that sustainability is attainable for the neck chest on. There's already some great work on going, and hopefully we're going to inspire you to start your own sustainable projects. With that in mind, the first person I like to introduce the seed is Professor Mahmoud Butter. He is the founder off the B M, a medical fair Unethical trade group in a consultant ENT certain at Brighton and Substitute oversee hospitals. In 2000 and six, he founded the Medical Fair Unethical Trade Group in response to labor rights abuses in the manufacture medical products, including surgical instruments, gloves and textiles. He works with the NHS and international procurement organizations and NGOs to foster better working conditions in healthcare healthcare supply chains. Thank you very much for joining us. Press about it. Please go ahead. Thank you, Juliet, for the kind introduction and thank you, everybody for joining today. So you've already had a long intro to tell what I'm doing. But I've been interested. Sustainability for some time on bleeding a national important. What's sustainable surgery might look like. So I'm just gonna give you some sort of tips. And point is as to where we need to take our strategy, just give me a moment. I'm just going to share now. Can you just confirm with May that you can see that with some games? So, yes. Can you see my sides? But not quite yet. Uh huh. Okay, So we were just having a tech test just before this. Just to check. Everything was okay in the environment. I'll try again. College. I see. Oh, I think I think people are able to see you are able to. Yeah, yet. Great. Okay. All right. Thank you. So, just to give you some background to where we can align our strategy and I'm gonna talk about, start with healthcare generally and are carbon footprint carbon being the most common metric we use to measure our environmental impact on then talking about what we can do in surgery, and then hopefully a little bit of nuance. A zit comes to orthopedics. So as I mentioned, this is not something new for me. A. I actually, my background is in labor rights concerns related to the product that we buy. And in 2006, I wrote an article on the Brush Medical Journal actually talking about labor, I subleases and Social Instruments manufacture, which I'm gonna talk to you about it later. But also that time I was well aware that healthcare also has an environmental impact on the run this letter in 2000 and eight as an essay show together with the family of the Center for Sustainable Healthcare. So this is nothing new, but hopefully with finally on on the idea of this is something important and that we should be trying to work on this. So just to give you some background to the problem and apologies of many of you already aware of this, but I'm rehearsing what you already know. So in the NHS in England is responsible for around 25 million tons of carbon dioxide. That's around 4 to 5% off total greenhouse gas emissions, about one in 20 or all greenhouse gas emissions in this country are due to the NHS on that's equivalent in England alone to the entire complicated operation. So it's huge and all four U K nations have declared Teo on ambition to inform Let's hero for healthcare by 2045 which is a fantastic ambition, and I hope that we achieve it. 50 additional countries have signed a pledge to develop more carbon health systems, and I'll be honest, they look into the UK because we are trying to lead the field. I'm not suggesting that we know what we're doing, but we are trying. And then I think really, it's in, um, enthused by how much enthusiasm there is amongst both trainees and senior people. Onda, uh, to get this on the agenda. So what are the principles we might follow in sustainable healthcare? And I think it is, perhaps not that, uh, not rocket science really reduced should be the first principle. So that is about making sure that the care we deliver is required. Or maybe it's something that we don't need to provide. And in terms of equipment, which I'm gonna particularly focus on later on, it's Do you need that equipment in the first place. That is, of course, the best way to reduce the come footprint of anything is not to use it in the first place. Not to deliver that care in the first place, where clinically appropriate with equipment in particular, it's reused. So we need to stop this, throw a culture. We need to re use equipment wherever possible, because we know that that's better for the planet or shaves and date on that. And then people comes to write a lot on recycling and look recycling. It's part of the solution, but let's not kid ourselves that we're going to save the planet by recycling everything. Under optimal conditions, recycling comes around four or 5% of the carbon footprint of a product, and actually in healthcare is very difficult to recycle things because often some of things that we use may have multiple components in them. They may be infected. So to just disassemble this, in fact, all of that, you're really going to recover hardly any carbon from such a thing. And so carbon footprint ing study showed. Like I say at best, you recover 4% is much better if you don't use it in the first place. So in terms of reducing, what does that mean in terms of patient care? We do need to engage in public health agendas to prevent disease, So that includes road safety to prevent traumatic injuries. And I'm glad to see that many zones. Now. We're down to 20 miles from our to reduce injuries. And actually, can we imagine a future where most city centers don't have cars? And then it behooves us, Of course, to stop using the cars as our main form of transport were possible. Do you cycling in public transport where reasonable and possible, we need to consider where know so she's actually required. I have my own views about cosmetic procedures and low priority procedures. Controversial topic. The past. This is something that we need to consider that we can consider these in silence, and we also need to have some honest discussions about political surgery. What is low chance of cure where we don't necessarily benefit the patient either, as well as not benefiting the planet? No point in my suggesting that we compromise clinical care, but I do any think we need to Monistat about this and we also anything about the Cialis? Easy. And I think actually, in orthopedics there's been a huge shift that this is nothing new for things like like a femur fractures where you do it under a spinal surgery. Ah, lot of the time on, uh, carpal tunnel which were longing done under local anesthetic That needs to be the norm. And I think we need to expand that to wherever possible, because where you do need to deliver surgery, we know that local regional anesthesia is much better for the planet. So we're gonna look at the carbon footprint of healthcare. We've got this very useful pie chart ready that's produced by the NHS in England to tell us where are calm for print is on. We know that Ah, lot of it traditional was focused on the state's things like green electricity insulation and led Gneiting. That's all important to cause, but it's only part of the solution. We do need way, segregation and recycling because that's a part of this picture. We need to also eliminate toxic compounds, particularly desflurane and anesthetic gas, which I think hopefully all your nieces are trying to eliminate. Certainly we eliminated in in parts of our trust in Sussex On. That's because that's Lauren has 3000 times the global warming potential come by oxide. It's a horrendous gas, and none of it really should be released in the atmosphere. And the best way to do that, not to use it in the first place. We also need to reduce nitrous oxide and because nitrous oxide has 300 times a global warming potential, off guard dioxide and people are trying to work on that or to potentially capture it after use and or crack it international oxygen. And then there's this whole thing about transports. A remote consultation were clinically appropriate. I appreciate that many of us are a little bit tired of remote consultation with, rather than rejecting the concept altogether. What I think we need to do is have to find where it is appropriate her to use. We need green transport both for ourselves and our patients, and we need remote working wherever possible because that green strategy has to include these transport emissions. Why, for remote consultation, We know the carbon footprint of a consultation is almost entirely determined by the transport of the patient to get to you so most patients will drive. Some will take public transport regardless, and majority of the common put print of it to their travel. So, for example, any anti where I work, we've looked up, follow up of patients where we found the anti. A lot of follow patients could be adequately have the consultation remotely on also new patients for tonsillectomy when we don't necessarily need to examine the patient. But we need do need to take a history again. We found actually high patient satisfaction about using it in that context. But I'm gonna come straight, really a bit more on the what's called scope three missions. So that's something I should have mentioned. School scope one and two missions Scope one and two Emissions directly related. What activity we're providing in healthcare. That's a scope one. A mission to scope two missions the carbon dioxide produce from the energy we're using to create to provide that. But I'm gonna construct down scope three admissions, which is a big part. That part on then, is everything that we're buying to bring in toe healthcare, and that's quite a large and and this work going on with the medical side with inhalers, for example, but asthma, which are also toxic greenhouse gases and D prescribing, sort of not providing medicines where they're not clinically indicated. You know exercise is just a a new story this morning that the NHS has suggested we should be promoting exercise instead of using statins for a cholesterol reduction. Well, that was always true. We need to enable that we can look at digitization, repair of furniture and things on that. We can look at offering low carbon food because our addiction to meet is is completely destroying our environment both in terms of land uses. One is production of gas is such a me thing. But I'm going to really concentrate now here on reducing reuse off medical equipment because that's a particular focus of mind on within that focus, The operating theater is particularly bad because the operating theater usual eyes, is a huge amount. It's the most resource intensive care of the hospital. I think we all know that from my own experience after a third of our total waste of the hospital, and it has normally 3 to 6 times higher energy consumption, the typical operation generates between 100 50 and 170 kg of carbon dioxide that's equal of driving a bridge federal car from London to Edinburgh for just one single operation. Some operations will be much higher than that on hot spots from a systematic of you undertook related energy use. Anesthetic gases. Well, the anesthetic gases are actually bean. Improved energy use is also becoming more efficient. And we're moving towards hopefully green sources of energy wherever possible, 100% green electricity and then consumable equipment. And it's a consumer about a quite well in particular that I'm gonna focus on as we move forward. So we've just this's data from a PhD student. Shanta Reason. She's a carbon footprint. It the five most common operations, actually just doing the data for four of them. Here, you can see there's some orthopedic procedures in there, and when we broke down what's actually contributing to come down also off the products used within an operation, you can see the biggest part is that red part job. So around two thirds overall off all the total carbs footprint of products relates to single use equipment, particularly production, but also it's waste. So if we really want to focus on reducing the carbon footprint off our operations with the operating theater. It's that single use culture wherever possible, we need to remove. And that is true regardless of the approach that you. So. For example, these is some data from study that was done in the US, which compared different approaches to a hysterectomy with you do Evangeline approach and abdominal approach and laparoscopic approach or robotic approach. Actually, the constituents of the off the operation are pretty stable in terms of the anesthesia. That's the bar on the writing. In fact, since the study was done, that would have gone down because in the states are, as I say, eliminating some of the gas is they were using. And then there's a bit around energy consumption, and and so and that's the stuff on the left. But if you see that red circle that is around single use equipment, so the biggest difference between different approach is actually related. Single use equipment on sure. If you want to do your robotic approach to a hysterectomy, that's fine. But why do you have to use so much single use equipment to do that? Why can that quick mint not being made reusable. And that's a question. We have to ask on the idea that we can achieve this and that. Maybe there's problems. If we look at, we can look elsewhere. So cataract operation in the UK is estimated have the same sort of carbon footprint as we find for most operations. About 100 80 kg of calmed outside but a cataract operation performed with the Arab and I center in India. Whether he's highly efficient systems patients of well through and operated really in a factory, almost, they reused almost all of their equipment and they have a carbon footprint of that operation around 30 fold lower 30 fold lower than what we do in the UK and they've ordered it two million of their operations. They've gotten lower rates off, infant infected and off for my age is after the operation. Then we report in the UK So this is better on every single metric, you can measure financial carbon on infection, right? So what is the market? Don't know. It's a medical goods, at least this single use economy. We have this slight disconnect in healthcare in that the consumer is not the purchaser. You know, if I buy a mobile phone, I will be. The person uses that, probably the purchaser. I'll be the user we could consumer. But in healthcare, we have the user that is different to the consumer on is providing that care. And the payer is often someone different to that as well. Of course, So there's this disconnect as well that we need to recognize on the supplier is trying to sort of, if you like, and negotiate this complex marketplace so usually consumer. What we are interested in is products of deliver the high standards of clinical care, and sometimes those are particularly high cost products where you might be saying, this is the best time that this is the best implant. This is the best electrosurgical quarterly forceps that you can buy between the using the pear is tends to be low cost pronounce that they're targeting with high volume things such as gloves and gowned. When we're using so much of them, we want them. A cheap is possible, and this is a $300 billion industry provisional healthcare products. It's not small by any means, so for high cost parents, what we find is they are complex after quite a lot of them. Very well, of course. And that means, of course, that they have high embedded carbon and that they also so In some cases, many instances have restricted or limited number of uses. And this is from the Association of Medical Device Reprocesses, who say that medical device three processing emerged about two decades ago when a lot of manufacturing gas change certain device from reasonable to single patient use. In their view, after motivated by economic objectives. Rather, patient safety concerns on this is a complex area low cost for us. What we're looking for, what manufactures of looking for is actually cheapest possible, because that's what where are people and it's subject a free market you can often. So here is the example of some bandages being produced in Mexico, where I was a few years ago, and they're all coming off this production line, and they're all going into six different boxes. The box on the right is a well known brand name in the US On the box on the left is a product sold only Mexico, a brand name you would never heard of. It's exactly the same product. So if you want to produce this, you are producing it in wherever you can, and selling it as cheap as possible, or possibly with a PSA high profit margin is possible that you could get away with the problem with outsourcing production. Sounds okay, but it can be two issues and I'm going to talk to you about some of that labor rights issues that we've found through the outsourcing production of these simple products, if you like. So here's a mask being produced in a factory in the Jiang Province off northwest China. These master coming into the US but also coming into the UK on what was found there was of these products were actually made using force weaker labor. Don't if you're aware of the week of situation, but this is clearly cultural genocide State sponsored forced labor off these off this particular group in China and also some of our gowns coming into the injection. The pandemic well, Matt were also manufactured in China, but using forced labor from North Korea in North Korea, around 10% of your workers working before slaver, that is that they're forced to work in factories and between. In this instance, between 70 to 100% of their salary was forfeited to the North Korean state and loves. Around 70% of all the world's cramps are produced in Malaysia, and they will come in to talk to you about the issues with force immigrant labor in the production off gloves that you are using every day in the chest and for surgical instruments. I'll come in to talk about based because for social instruments, a lot of them are outsourced for manufacture in Pakistan and a chemical sample and produce around 70% of the world. So it against mint, including the low cost throw away ones that you might want to use in any on the high quality reusable ones that you use in theater. So the production of surgical instruments in Pakistan is not to the sort of conditions that you would hope for. Here is, it's a multistage process from war material down to final polishing, and you can see that this gentleman here is working on the effectively sweatshop labor conditions even more so. Standing here, these burning metal fell onto his foots of health and safety is an issue. Long working hours are on issues of these workers, definitely worth 13 hours a day, seven days a week. They get paid a piece, right? So if they don't work, they don't get paid on. Get working on grinding machines. I can tell you the stories I heard off people getting minor injuries. Sometimes a a graze on the finger, sometimes a thumb that is crushed, sometimes in tire arm, that is torn out of its socket. And these people have no compensation. So this is outsourcing production to the cheapest possible source. And so it comes with concerns for human well being abroad. And this includes a ring, a scope blades that includes dietary me forceps. It also includes, when last evaluated several 1000 Children. So there are 50,000 laborers working in this industry in Pakistan. On that, the last count several 1000 which will run. I've seen seven year old Children working on grinding regimes, making the very instruments that we are using in the NHS. So these Children normally start around the age of 12. Very few of them go to school. This is their job, and they hate this work. They do know, enjoy this. They want to go to school. They want to go and play. Cricket is no just surgical instruments. You want the lowest possible price for your blood. So I'm going to take you to Malaysia. This is a factories of a company called Top Club, which actually is the largest love manufacture in the world. You may not be aware of that brand because they make products for hundreds and hundreds of other different brand names that you may well recognize. So these gloves are producing these factories, and actually, everything looks okay when you look at it. But when you go behind the scenes, actually all of these workers work in the shop floor immigrant workers on. But they paid a legal recruitment fees for this privilege to come and work here. So most of them have come from the pole in Bangladesh to come and work in this factory. And they're told it's going to be okay to get a huge amounts of money. So some of them will sell sell land for this opportunity to come here when they arrive. Many of them were worth three months without a single day are they were worth 12 to 13 hour days, and they will live in this accommodation. All of the accommodation I've seen is a renders. This is possibly the worst. Where these workers were living in shipping containers. They're life is between this shipping container and the factory. They have their passports confiscated so they're not allowed to leave the compound. There are allegations off work is being beaten at some of these factories, and I've seen some photos that I'm not allowed to share with you. That would be certainly upsetting. Should we say this is not the life that based on and up to. And when we serve a 1500 workers last year, that's two of the largest manufacturers. What we found is that 40% of them said that they had paid a large recruitment. He's averaging $2000 which is someone coming from the fall of Bangladesh is a horrendous amount of money. A third of them have been told him not to report that group if it's because they are a legal. They're working typically 12 hours a day, one in 10 and not had a day off in the last three months on one and three and only a single day off in the last month. Half of them felt unable to leave their employment because of concerns about contractual obligations outside and huge recruitment fees they paid. This is forced labor by any measure. There's not much I like to talk up in bright way, but actually a wheeze. Other manufacturers producing Malaysia all have been found to have the same issues with forced labor in the supply chain. Using immigrant labor work is going on. That's an entire separate talk I could give you about this T remedy. Things and things have certainly move forward, but they're still huge problems in this industry on the endemic issues with in relation culture. To use such forced labor we don't have. Her biggest problem is. But when we surveyed and try to get data, which is very, very difficult, we've got some data from Norway from my partners in Norway, and when we were able to ascertain where products were made, what half of the companies wouldn't tell you where their products of May because of presumably commercial sensitivity or perhaps some of them don't even know because they just buy it and they bring it in and re brand it, but off those that we were able to get data for at least 40% and others we've got some other data suggest is higher than there were producing countries with very high risk off labor rights abuses. So what perpetuates is linear economy for medical products? First of all, there's a There's a myth that goes around that is better for finance or better for carbon if you throw it away. Absolutely no. True. So we've done some of the analyses. Actually, this paper is very, very soon be published, and we looked at pair of scissors as an example of single use. Less is reusable and, um, supplies me. If you use the reusable and you take a full assessment on this life cycle bleeding sterilization repair, bring it back. It's got less than 1/10 of the carb foot print off a single use. Throw away scissor on. It's per use. Cost is much lower because obviously you do pay more because you want a better quality border, but you use it so much that it pays for itself. In fact, there's been a systematic review that was published last year by Jonathan drew on. He found, quite rightly, that just about every single circumstance reusable was better than disposable. So don't believe the hype. If anybody tells you ever that the reused that the disposable is better, it may be very specified circumstances. But any company that tells you that would have to prove it from independent, robust academic analysis. And I mentioned the robust because there's a lot of people I'm afraid tinkering in this field and getting the wrong conclusions. So the other is the idea of the myth of sterility and this. I think this is really important for people to understand that were historic problems of sterilization standard. So in the 19 nineties we had inconsistent or inadequate sterilization. There are also play machines in the back of your surgery that you could use in a GP on. That was fine in principle. What people are not cleaning instruments. They were not checking that the steroids, a shin machine was up to scratch and so we had really inadequate or inconsistent sterilization, and together with that, we've got this thing called C A. D, which is a prime disease which is incurable, can be transmitted on, can lead to death. So these two things just lead to this idea that we have to have single use products for a lot of things. But we don't live in that world anymore. And now we have robust decontamination sterilization of bean to these percentages. This is for laundry. This on the left is the largest washing machine I've ever seen is bigger than my entire house on every single stages automated. There are computers that check everything that the standards have been met. So you don't need to worry about it. Here on the right is it is a light light box of tap for microscopic perforations in the material that you might be using, for example, a drape and checked again robust. Everything has to me a c m 0104 for laundry, which is the highest standard in the world. And then, for instruments, we have hedged am of one on one and again automated, fully auditable systems. It is sterile. You really just don't need to worry about it. So that world in the 19 nineties is gone, and nobody has got CJD from any social procedures. Since the 19 seventies, when the standards were not bad when some neuro surgeons and she took some brain electrodes, work them with electro. What sort of white thing with alcohol and stuff, um, in someone else's brain. We don't do that anymore. And single use, which is the culture in many places, may not meet those standards. So last year there was an alert. Because if you buy a single use for it's not necessarily sterilize in the UK to our standards, it could be sterilized over. Season off it is. And there's a company in northern Italy which have been falsify records for years on sterilization on We know off instances where probably lead to patient infections on this. 88 major brands are affected by this. So if you want to know sterile, get steroids are going to you can standards using? Are you gay processes? So what else? Perpetuating any economy? This economic off person, where there's a disconnect between the post in the use of always really alluded to that models of procurement based on product quantity, rather modern such a servicing. So we should actually be telling cos, for example, for complex parents. Actually, I'm going to buy you to provide diet for me. Forceps for five years. I'm not gonna buy certain number. You just have to provide enough for us to move our service. It is then in the purchases, interest of natural. Those products last because they're gonna make more profit rather than keep on replacing them. And there's nothing special about the manufacturer of medical products. Have already shown you some data on that, for example, and so doing a pandemic was making lots of class for us. But when they couldn't meet capacity, we know that they ask all these other companies all these other manufacturers to make gloves on rebrand them is on cell to cell to us. So it's interesting that infirmary rather than tax we don't have equipment danger for every 1 lb spend on research. 19 lb is spent on advertising information. We also the medical devices can be designed to be reused a complex ones in the USA There over 31 million device reprocess. These supposedly single use of items can actually take it apart. Reprocess and reuse. There are Elektronik chips and some of these devices programmed to allow them to even be used once, And it seems I'm not sure entirely why that's going on. There's also in fines in the US for legal activity. For example, some of your hip and spinal surgery implants have bean claim to be made in us, but actually they have manufactured in Malaysia and China, and there's no problem with that as long as the quality standards is there. Ondas long as you're protecting workers in the industry. So when we have these lack of information and misconceptions, we get knowledge voice filling, this the's idea. So one of my butt bases around gloves, gloves in, none in in non sterile environment. So it is white foam misconceptions, gloves of synonymous with her analogy and data we have published or my colleagues. A published suggested more than 60% of glove use in healthcare is unnecessary. You only need to wear gloves, non sterile gloves, a virus situation. We're in contact with potential infected body fluids to reduce your burden on your hands. So that's mucosal services. It might be sort of, you know, feces and things like that, but I see people wearing gloves to transfer patients across on the table. It's utter nonsense, and it's against national guidance. So we're trying to really embed this. You do need to wash your hands and washing hands is far, far better than wearing gloves. So it's a hell of a lot of class. In fact, I worked out even before the pandemic I worked out yesterday in before the pandemic, the NHS for 1.7 billion gloves. That's enough that if you put them into end, they were stretched from the earth to the moon in one year on. 60% of that at least, was not necessary in terms of orthopedics, for this is controversial, So probably gonna go off. So with this but laminar flow versus conventional float laminar flow for your arthroplasty use a hell of a lot of energy on drippy tid systematic reviews of felt a show, any real benefit from them in terms of joint infections there. There are some basic science data that may say, actually, it improves the amount of bacteria within the within the environment. So I'm not going to go into it. But suffice to say, in the real world environment, where actually those lamina flows are not actually really, because there are people moving through where some of the contaminants you might find in the air are irrelevant. Joint infections, which is you come from skin. Such a staph aureus and staph aureus is not really found in the year. I'm going to leave that for now. But what I am going to construct, um, is your orthopedic textiles. I I'm still under trying to understand why there's so much single use orthopedic textiles, particularly. But arthroplasty is so we can convert printed cover tunnel knee arthroplasty on. You can see that almost half of the carbon footprint off a carpal tunnel when it was performed in my stool using single you straits half of the products it was due to the single you strips. I just don't understand why. And even with the knee arthroplasty, it was huge. That's equipment to driving 72 miles an average car from using single use textiles, reusable textiles. Exactly one third the carbon of disposable. When you take a count of all the laundry, sterilization, transport, all of that still one third the carbon of disposable, and perhaps this is historic again. The bristles possession quite rightly say drapes and gums must be made of in Paris materials. I understand that completely agree. Thin cotton drugs and guns have no place in orthopedic surgeon. We don't use cotton anymore. This is parking back to the 19 nineties or 19 eighties. So what are textiles of the moment? Single. Use it if you want. Single use. Typically none. Movement made from petrochemicals manufactured overseas. Still dominant in this country that cheap, your reusable, far better quality product, typically woven high density. My fiber, still made from petrochemicals called cotton, is not appropriate a compound for this, But actually, if you reason many, many times it's it's absolutely it will. The carbon is obviously much, much better typically relieves 75 times. Do you need to worry about whether it's got penetration? Of course you don't because we have a standing year 13795, which ensures that liquid penetration of microbial penetration is maintained throughout the entire life cycle on this product, and that's why we get to 75 because after 75 there is some uncertainty there something actually 100 times it could be reused. You don't need to worry about that. Your provider is taking care of all of that and has to order it. Actually, what's happening to these product if you want performance. Actually, your reusable is much, much better. Got four times higher that tensile strength 10 times higher than tens on strength of wet. So if you're worried about tearing urine operation, why are you using single use in terms of birth? That's a puncture again. 10 times better with a reasonable next out. And you worry about limiting little particles coming up, causing infections eight times over with reusable so reusable. If you're worried about clinical care, reusable textiles and the only option should be using because the cheap single you stop is far lower quality and final right lead to problems. Do we see this? We see parallels elsewhere so you can fool. A lot of people are back. Part of water is another about bear mind water that you got available. Tap packaging, petrochemicals and transported to you costs more. No shortness of contents. Fiji water That's supposed brand need er has our sink levels are higher than will be allowed in tap water. It things plasticizers such a d H B, which are bad for your health. But yet it's a $1.5 billion industry in the UK. So to finish looking forward, we don't need to come footprint everything before we add we can move to a reusable economy because we know that that's what we don't need to recycle as, ah, main strategy. It's important, but it will recover a small amount of the carpet. And it's to be where we focus on. We need to be wary of Tokyo. Mr. Greenwashing, I can tell you that our company is approaching me trying to say that we're making We're broke some solar panels on our on our roof. But we still make a disposable plastic problems, I can tell you that a major supply to the NHS off textiles asked me to speak on there. Webinar but they were using single use. And they asked me specifically not to talk about single use textiles. And I refuse on. There are executive board with Drew my invitation because I know that I'm speaking the truth. So going forward, we have a natural part sustainable in surgery coming up next year on great in the academic. A nice. It's creating a circle economy for medical products. Have you been able to support that? Thank you for your time, Professor Butter. Thank you so much for that really interesting and thought provoking talk. I don't know if we've got time to to take any questions live unless we've got anything in the chat which I don't think we have. Thank you very much of You know, your time, cause I know I know you've got a lot on this afternoon on. I think you probably got a head off, but I will try and get If anyone's got questions, I'll try and get in touch with the team from the Southwest London Elective Orthopedic center On. With that in mind, I'd like to introduce a remarks. I'll routine PS Perrilloux and calm a food. Who? We're going to give her the cereal of talks from what's been going on at sweaty Oxo. Welcome. And thank you very much for joining us guys just bad with me. I'm just gonna show my screen. Hey, you gonna we'll see the screen so I'd like to welcome. It's really alters. Well, it will be talking to be talking about sustainability as well. Not so my colleagues and I go through a series of different talks. So just like to welcome buddy in May, Perry and myself. So the introduction and walking stick recycling will be done by my colleague. Bodies are professional lead US Southwest and elected with Pedic Center on Social system, able to be discussed by May, who are genius, a little research fellow improving interrupt to police management. Its will be done by our our funny peri is that, you know, clinical research, whether it's well, I got. And we're also talking about Ritchie reducing discharge people work. That's why we put patients on that. I'll just give us some really off the what would be doing at the Southwest and elected of Music Center. On with that, I'm gonna have straight over to booty. Thank you. Very hurt you and thank you very much for having me. My name's Bodine and I'll be talking about the recycling project that we have within the center within the therapy team. So swimming is a high volume joint replacement center, and we working really hard to make sure that patients are receiving their elective orthopedic surgery as soon as possible, not only within our sector but actually offering mutual aid to other areas nationally. With exception, any long waiting lists and we want to also make sure that patients are able to go home as soon as possible after their surgery and that they're able to safely do so with the appropriate equipment and walking aids. What we found is that there are national shortage is off assistive equipment and walking aids. But not only that. There is a really strong focus now in terms of financial and environmental sustainability and looking at how we might be able to reuse and recycle our equipment. This required a multi pronged approach. So first it was about identifying the appropriate equipment that can be reused and recycled. We labeled that equipment so that stuff and patients were able to easily identify which equipment is able to be recycled safely. We also updated all of our patient information to ensure that patients are very well aware about the fact that we strongly encourage them to bring back particular equipment to the center when they're coming. For there are patient appointments or indeed at any point along their journey. We also placed posters up across the center, especially in our patients when campaign coming back for there are patient appointment, but also for staff to make sure that we are consistently providing that message that we really hoping Teo. I'm recycle and reuse appropriate equipment. We did community engagement, which included social media as, well, a Z, a meeting up with charities and local recycling centers. So this is very preliminary results because we've only started with some of our recycling project. But in terms of the public engagement, it really is at its infancy. But one of the exciting breakthroughs is working with and collaborating with one of the local recycling centers that's got 15 centers across the sector, and they really delighted to collaborate with us as part of their commitment to reducing waste and also supporting the NHS. Patients have been brilliant in terms of engaging in this initiative and not only patients that have had surgery with us, but patients in the public that has seen our our social media campaigns. So we developed standard operating procedures for receiving, cleaning and being able to reuse this equipment. So, as I said, this is really preliminary result in prior to a full public launch. But we've managed together data over five months of ingrowing and outgoing walking AIDS. This doesn't include the occupational therapy equipment and based on that, it's very encouraging to see that based on those returned thus far, we do have the opportunity to save up to 40% and that's prior to an official launch. So, in collaboration with patients and recycling centers, we can put unused equipment to good use rather than and ending up in in in your local recycling center to be able to help other patients. But it also goes towards our sustainability efforts to reduce it expenditure, and that's significant impact on the planet at the same time as this. There is a strategy in the NHS now that's recent recently being publicized. That device, re use and refurbishment is one of those interventions contributing to reaching that. Nets here is zero NHS supply chain by 2045 on that walking, it's contribute to 60% of the NHS carbon footprint. So they say that if we where to drive just 40% increase in returns and refurbishment of walking aids in five years, we will help save the NHS 2.4 tons of carbon. And what's really encouraging is are very preliminary results before unofficial launch in the public We've already managed to achieve that. So I'm hoping that it can just continue to grow from here. Thank you. I'm spreading. I'll have her over to my colleagues. May and Perry now, thank you. It often and everyone. Welcome to our My name is Pair Mining's May have Ms. It's therapy on where With clinical fellows, that's well, you look so just really rightly. Sustainability covers three main pillars. Essentially, we're talking about planet profits and people. So my presentation, very briefly is going to talk about social stability and how this feets into the environment. Um, social Systane ability is defined very broadly is the ability to meet these human needs on an ongoing basis. Next light, please. On back on text of healthcare. It is about being able to meet these needs for our patients, but also making sure that our stuff are not forgotten about. Walls were doing so Next light, please. And so ego helping is a relatively new term that we come across, and it basically describes how our relationship with each other in the workplace can contribute to our actions for improving the environment. There is evidence to suggest that actually good working relationships among stuff are positive values in contributing to sustainable changes within the workplace. Um, next I please. Last year we carried out a small pilot survey, so we focused on a very small aspect of socialist inability across. Well, you look looking at these five different domains. Perceive support is essentially how we perceive the support available to us from other leaks. Commitment is how much we feel a part of our teams helping is the actions that we take voluntarily when um, other colleagues need help. Job satisfaction is fairly self explanatory, and ICO helping, as I mentioned, is our collective actions in supporting each other to implement changes within the workplace. Next time, please eso the results from our last year survey in multiple war. Largely positive, actually. Most stuff reports that feeling very supported at work next time, please. Even more Encouragingly, they were very eager to help and felt very much a part of the team that they were in Ah, lot of them worlds very satisfied with the job that they were doing next time, please. Um And in doing so, this has showed that this was a very positive predictor of some of the success is that we have had in making environmentally sustainable changes within the within our senator. Following this initial survey, we have carried on with a lot of sustainability work within our department are sensors. Well, y'all coast fortnightly regular sustainability meetings where all the different teams within swelling all come together, which aims to essentially foster sustainable changes across the department. So during these meetings will be discussing and implementing changes all across the center, which can range from small team based projects done by the ward's with the other stuff, which parables. So we'll talk about in second or up to, you know, large center white changes. Um, so in March this year, we carried out very similar survey using an update a questionnaire, and we sent it out to a much bigger cohort of stuff within swell up. We collected a total of 57 responses. Across. All are different teams who were working in various roles in various parts of the center. Next time, please, the responses so echo our previous survey, and they were very positive. A majority of stuff felt very supportive at work. The take boxes that you see along the way are essentially improvements that we've had since doing the loss survey in October, which is very encouraging to see. Um, a large majority of stuff felt very much a pair of the team. Next side, please. Um, and then side After that, we can see that most stuff are actually very keen to help each other out, especially involuntarily taking time to help someone else or making sure that a lot of the decisions that we make as a team are not made without thinking about someone else. Next light, please. Yep. Next. Um, so majority of stuff were generally very satisfied with the work that they did. Um, next light next one yet so in a week. Oh, initiatives is a new domain that we've looked at only in the cycle which looks at our own individual behaviors towards environmentally sustainable changes in the workplace, which has also been very positive. Um, and then the next side and then lastly, stuff have been, you know, very supportive towards each other in trying to maintain all the sustainable behaviors that we've started to adopt in our work. Please. Next light. So, based on these results, if we can have the next slides. I very much believe our stuff are very inclined to support each other in the workplace, Having set that there are a few limitations to this survey. You know, we've not collected that much information in regards to confounding factors that may influence the results. Next sides onda. Also, when we're talking about the bigger picture of social sustainability in the workplace, um, you know, ego helping and ICO initiatives is only a very, very small portion of this. I know, Professor, um, what has already talked a lot about this? Um, in his talk, there are plenty of other areas where social sustainability needs to be considered, especially in things which is ethical purchasing of goods. Um, you know, maintaining well being off our stuff and also looking in regards to sustainable workforce training. Um, I guess the baseline is, you know, are in conclusion, Our survey has very much shown that, um, the working relationship since, well, your has had a very positive impact on the changes that we've made on and will make in the future. Um, and also, this survey has has probably open up many doors for discussions for other ways that are censored can improve improve on social Systane ability within our workplace. 100 over two Peri. No. Okay. Thank you for that. May. Good afternoon, everyone. I'm Peri, one of the other fellows as well. I'm moving on from social Systane ability. I just wanted to talk about the work we have done that improved intraoperative waste management here. It's well, yeah. So next line, please. On dissent. Campuses. The environmental aspect of the three pills that may alluded to in the orthopedic literature waste management has been the main target improving sustainability. And this is particularly important as one third of hospital waist comes from the operating theaters in the NHS. On these offers identified that within orthopedics arthroplasty procedures are particularly baseball. They generate a high proportion of recycable waste. We're not always correctly segregated. Next light, please. Um Andi. So what we wanted to do was evaluate our practice here, on down in fluent ways, improve the portion of waste that could be correctly segregated in theaters on reduced avoidable waste. Where possible? Next line, please. The's are the bins President now theaters so white for recycling black for normal waste and yellow for clinical waste. Onda uh, we devised service evaluation, which was complete by six fellows who attended theater observing that the disposal of items in the packaging also identifying whether items being open on also been used in the procedure. We form two cycles, the first in October, a very brief cycle and follow up on in March in April. We've been performing intervention since October as of last year. Thanks like please. So our first cycle as a mention was a very brief snapshot cycle where we were just wanted to assess baseline practice next life easier. Six cases were observed 166 consumables accounted martinated was that there was variability across the dispose of items next slide. So from this checklist of items that we gathered seven out of the 26 we're being disposed of in different types of bins. Next, like please. So he wants different improve on this and we commence. Um, interventions, improved way segregation also to reduce waste disposal as well. So we created a poster amongst those fellows to classify recyclable waste on display them in all operating theaters here. As may mention, we started sustainability meetings on a fortnightly basis where we were educating members of stuff and raising awareness as a whole to regarding waste disposal. We were switching to reusable items where possible on this financial benefits as well. For example, of tonic aids as professor booster already alluded to in previous talk, we also wanted to reduce preemptive open of consumables with for a handovers in the morning as well. Next line, please. So this is the post that we created and displayed in or features next. Like please in our second cycle, it was much more for assessment of our practice. Um, use a much more for a performer following the patient up from when they were being positioned or the way to them leaving the operating theater. Um, once the results showed next lefties are, um we observed 10 cases, four total hips and six days with these. Around 3000 consumables were opened off, which 98% were being used in the procedure, which was really good off. The items used but also disposed of in a been around three quarters were being correctly segregated. However, with recyclable items, only about 50% were being correctly recycled. What can we conclude in this very simple service evaluation that we did well. Education of staff is a simple, invaluable tool. It's promote sustainable change. We were able to quantify this by performing a quiz assessing staff members knowledge, off way segregation before our interventions, but also after, and what it showed was that there was an increase to 85% knowledge of correct sister and correct way segregation knowledge. However, stuff knowledge does not necessarily translate Teo clinical practice. However, we've regressed, recycling and up quiz. There was an increase in 26% of correct recycling knowledge amongst our staff. However, only 50% as I mentioned, we're being recycled, so ongoing work is required. Improve recycling here. That's what we aim to do. And there there were limitations. Admittedly, with the evaluation that we performed, the main one being that further cycle would be needed much more. For one, I'm a larger scale to see if our sustainable approach continues to be continues to proceed and the way that we hope it would thank you for that on down here today to also talk about this quality improvement project that our ward team has done in reducing discharge paperwork for our patients. Next, like please. So this encompasses the environmental but also financial aspects of the three pillars. As with any elective institution, patients are discharged with a significant amount. Paperwork out discharge Summary consistently has about four sheets. So what's he wants to identify a way to reduce the waist. And they treated on a five size a discharge card next line, which can be a seen here. Essentially, this summarizes all the key information for the patient, but also has QR codes for the patient's access. The full discharge summary. Also, physiotherapy exercise is a zoo well on, but we gain positive feedback from the patients following its inception. Next line, please. Um so what we wanted to do was actually calculate the benefit that this would have. So we calculated the theoretical carbon foot and prayed, footprint saving that could be achieved a one year period by switching to this discharge card next lab. Eso What we did was unlike all the patients that underwent knee arthroplasty in the last year to see how many we did, instructed by carbon footprint and cost saving that could be achieved from using our conventional methods versus our new method. Next slide, please, over Last year, we operated on about 1500 patients with the other plus D. And so what if we were to operate on another 1500 this year? What this shows is that we could achieve a carbon footprint saving of over a half from 26.9 kg to 12.6 your ethically by switching accordingly. Next slide, please On. This can also have a carbon cost saving of around 38 lbs a year, which doesn't seem that much, but every little helps when it comes to sustainability. Next, slide forward, please. So in conclusion, this was just a very simple quality improvement project that was an example of how other members of the multi disciplinary team could help with the collective effort to promote sustainability in an institution like hours. Thank you for your time. Today. I'll 100 to Erin for the conclusions and thanks very much, baby. In May and Perry, I'm just given overall summary off the work that we've been doing the Southwest and, um, electively like center. So, as my colleague said, that Southwest uncollectable beats and to be implemented having bi bi weekly me of meetings for sustainability and the only real aim of the purpose of this was to improve sustainability, to provide strategic direction and leadership to ensure that we were meeting the environmental financial institution. Sustainability factors on dejected is we're to uphold the principles of reducing we're using on recycling. But what can we do? So what we can do? So we initiated all these different ours within this Well, not with the green initiatives. So this was to rethink, reduce reuse, repair revamp, restore refused recycle on we start on. We embedded sustainability into our government structure. So now it's part of us Could governance was disgusting. Like a government meetings. We have our Wednesday meetings in which multidisciplinary teams come together to discuss the different activities off sustainability that they're doing with in that department. So we have X ray department coming together. We have the ward's coming together prepared from Parents Day. He's given a quality improvement project in the wards of doing our physio teams have been working on, you know, every recycling equipment. So all the different departments of coming together we also discussed this in governance, were adhering to the green initiatives. On our aim is to become advocates for the green bean purchasing by switching to energy efficient, safer, clean, recyclable reusable products in order to reduce. I are footprint. I were doing this by every processing, such a poor supplies and moving away from that throw a culture so previously heard and and to talk today about the throat culture on our aim is to guide education and power. All start members within within, swelling up to about sustainability on then to advocate research into sustainability. So you'll see in the bone and Joint Journal open Doctor Food has had a paper published on sustainability. So pleased you have a rule of that one that does come out on. I just, like, say that well, a lot do what? Collaboratively together we can meet the energies goals of becoming that zero by 2020 25 I think very much. And thank you. Behalf of swelling. Thank you. Thank you very much. Scrutiny in at May Perry. And here, um, for those fantastic talks cover in a while, free of the pillows of sustainability and really highlighting what a difference we can make with simple changes and in getting kind of colleagues partner organizations to thank you very much. Hello and welcome back. Everybody hope you all have a nice 10 minute break. Next up, we've got a presentation from Mister Prostate, the Dayton who's a consult in orthopedic surgeon in That's the sequence of Bangor in North Wales. He's a consultant, hand surgeon and orthopedic surgeon on he on his team were one of the winners last year off the Send for Stable Healthcare's Green Surgery Challenge through massively reducing the carbon footprint off Couple Tunnel syndrome, which is one of the procedures that Professor Butter related to earlier eso. Without further ado, I'm going to introduce this's presentation from Mr Edison about how to turn your sustainability ideas into reality. Good afternoon, everyone. My name is Edwin Pressure Jason Nelson, known as pressure to my friends and colleagues. It's a great privilege and honor to be speaking to you at this vote of sustainability virtual conference. I'm so pleased that sustainability has crept up the surgical agenda. I had the privilege off organizing the Wealth Orthopedic Society meeting last year, which had a sustainability symposium in it. For the very first time last week, I was at the International Federation for Surgical Societies of the Hand our biggest international hand meeting with 4000 delegates on there too sustainable surgery. Symposia on the society will be releasing a sustainable sustainability statement later this year. So what I wanted to talk to you today about is just to share with you my experience on to give you some tips and tricks on how to facilitate change on to turn your sustainability ideas into reality. So my conversion event was the green Surgery Challenge. So this was a collaboration between the Royal College is on the center of sustainable healthcare on Do we in Bangor. Andan Wrexham in North Wales looked at a couple tunnel operation on in 20 21/10 weeks. By making some relatively small changes, we were able to demonstrate quite significant changes. 65% reduction in plastic waste, 80% reduction in carbon footprint, reduced consumables, reduced instrument processing, increased productivity, increased staff and patient satisfactions on, of course, financial savings. So two contextualized this we estimated that our green pathway could save the organization at least 12,000 lbs a year on would save the equivalent carbon as driving 33,000 miles in a petrol vehicle. However, how do you demonstrate this is a good idea. Now it's a no brainer to all of us. Now the picture on the left is how most of you will set up for a couple tunnel decompression. It's the way I've done the operation for 20 years to sponges or smoking a steak prep to the elbow, two sheets under the hand board on enormous extremity trip from the fingers to the feet frequently thrown over the patient's face to freak him out even more. And I used to talk okay for the 10 year 1st 10 years of my career never gave it a thought. That's the way it's always been done. What creatures of habit on me. So now this is my set up. On the right hand side, I used to small 90 by 90 or 75 by 75 ft, no tourniquet. Wide awake, local anesthesia without tourniquet, know light handles. I prepped with chlorhexidine through a spray bottle and let it dry. It's a fairly radical rethink, but when you see it like this, it just seems like common sense. However, you must demonstrate the change, like this is in everybody's interest. Let's look at the left. This is a north of Peter cancer, which many your department's will use and have, and these are frequently open because we don't have enough minor handsets. It includes a plethora of instruments that I will never use. On the right is my carpal tunnel decompression set, which is used for most local anesthetic hand cases. Now I think our hospital has about six of these sets, but they're so popular they get open for many other procedures, Um, onto the default is to open an orthopedic cancer if we don't have enough of these sets in circulation on the day of the surgery. But it's not easy, but you haven't uphill battle because you're fighting against habit fighting. It's dogma. Dogmatic assertions around patients safety, the evidence based Eltham safely sterility concerns on what I've learned also is that there are procurement arrangements in place for drapes on extremity packs. Now the large extremity drapes in most hospitals will come prepackaged in an extremity pack, which usually has two or three large drapes to three small drapes and extremity drape with a hole in the middle on D, often some single use plastic. So, um, suction tubing on a few other bits and pieces on the hospital procured the's by the 1000 sometimes by the tens of thousands on. They're cheap. They're convenient. They're easy. Onda the's extremity packs are open for any extremity operation of the upper or lower limb. So changing this may create work for other people in the short term. Um, and you need to consider this. So the way to do this is to demonstrate viable alternative, show your colleagues and theaters a different way on. The best way to do this is to collaborate to bring them with you, make them part of the team. My the top tip would be to formalize any sustainability ideas you have. Contact your audit department, your quality improvement. Um, on register. It's a quality improvement project. Um, bring with you your consultant colleagues, um, on your planet, Have it in your diary is part of your weekly plant trainings, and students could be helpful a symbiotic relationship to great for them. They get some project experience on we get an extra pair of hands to help us with, um, with the actual nitty gritty of data collection on the work itself on, Look for national on local innovation projects. So I joined the Green Surgery Challenge, which I suspect what we run again. Uh, this year or next on this was undertaken by the center of Sustainable Healthcare. I also joined the Bevin Commission as an exemplar. Now the Bevin Commission is based in Wales. They're a government. They not the government body. But they're a think tank that advises the Welsh assembly on and the chest whales on health care innovation projects. And they were enormously helpful in getting this project off the ground. So these bodies will help you on give you that those of the resource is on leadership experience required to get off the ground. So how do you do it? So the way to do it is to make time, make time in your job. We all live busy lives on the's projects require some focus. So make time and you're working when you're working week to actually sit down, plan, coordinate and deliver this cetaphil working party in a group, which is what I did make friends identify all the green champions. Now, with regards my project, um, corridor conversations the operating theater lead to be identifying two or three people in terms of the theater nurses on D o d P's who were particularly interested in particularly passionate about, um, improving, um, productivity and decreasing waste generation. And I brought these into my team on. We also brought on board the manager off the, uh, sterile services unit. He was hugely helpful with the procurement arrangements and the instrument processing a vengeance. And also, I would suggest identify all the green champions within your hospital. Yeah, most hospitals. Now, we'll have a green group. Certainly in Wales, this is extremely popular on we have a whole green network green groups across North Wales on South Wales as well on this be very helpful. Other colleagues from other disciplines and backgrounds can give you guidance, support and also identify but the places to showcase your work. So make friends make time, make friends. The next thing I would say is make it financially attractive. Now, when you go to your managers with sustainability ideas, they'll be extremely interested. However, you must remember they're not performance managed against a carbon footprint or west generation, their performance managed against financial savings. Now we know that most sustainable solutions are almost always cheaper. However, you need to articulate this, properly quantify it, put a price tag against it or, you know less resource is required. It's etcetera, and then you will find that there will be very much on your side away really go out of their way to help you make it happen. On the other thing is to make noise eatin a cious. But since here, so make noise in local meetings, department meetings, surgical meetings, grand round quality improvement in order to meetings, make everyone in your hospital where off this fantastic work you doing. The next step is to go to national and international meetings and, of course, generate a manuscript for publication. Social media and your hospital website can be very helpful. And I strongly recommend contacting your local press officer within your organization who could be very helpful and helping you with this work. So my next steps well, my project is just in its infancy, really. My the next state release to move all mine hon surgery out of Maine theaters into a procedure room. We walk patients down, discharged, um, directed from the procedure room. They're all in their own clothes to be no gowns or no hats, etcetera. We're gonna move too small, reusable trips we're going to give people operate appointment times for their operation, just like a clinic. Streamline wanted Ward on admission Theater paperwork So rewarded mission on theater paperwork. We're also doing some work around reducing water consumption in the theater by the use of alcohol rub rather than the standard surgical scrubbing between cases 100. Already doing some work on rolling out Arlene Grain set up across other commonly performed operations in hand surgery. Neck femur surgery on after plastic. So that's all to do that lien set up. I'm taking a step backwards. We're looking at the whole patient pathway for carpal tunnel syndrome and for trigger finger and other procedures to try and reduce the number of times pay for. People need to come to see us in the hospital. So to summarize, open your eyes to environmental and efficiency. You will see it everywhere, So when you see an efficiency, embrace it challenge it changes, make friends make noise. Make time. Thank you very much. I'd like to also thank my wingman from wrecks and hospital pre thing codeine. Murray consultant had an orthopedic surgeon Also, he was my collaborator on the green surgery Challenge on is also a passionate leader in sustainable surgery. I'm hopefully be available to answer any questions for you. Um, here is my twitter handle and email. If you have any specific issues, do get in contact. Thank you again for the opportunity. Great. Pleasure speaking you today. Thank you. Good bye. Thank you ever so much. Mr is us in for that. That really inspired presentation about really how to get things off the ground. Because I know from personal experience and for a lot of other people where to get started. Who to talk to you, How to go about this is, you know, one of the big stumbling blocks in starting sustainability projects. Um, we're very lucky to have been joined by Mr Dawson. Just a moment. So if anyone's got any questions, can't see anything in the chart. Just presently, if anyone's got any questions. Oh, there we are. One from add Stone Canyon finally published evidence that doesn't increase infection rates or that you're a mute. Hi. Good afternoon, everyone. Yes, there is plenty published evidence about low for no changes in infection doing procedures procedure in versus an operating theater. I will try and put something in the link if I can. In the chat, Um, before the end of the session, I'll upload that there was some new guidance from the British Society of Surgery. The hand that came out, uh, just a couple of weeks ago. So they're very, very up to date on these show that probably about two thirds of hand operations can be done safely outside of theater. So this is a game changing document. There's plenty of evidence from around the world that mine hand operations don't need to be done in a theater environment, So I will. I will upload that in a moment. Brilliant. Thank you. On another question in the tract from Alan Hilly, did you get much pushback your colleagues? And how did you overcome this? Well, interesting. No, I didn't get much pushback. Some of my older colleagues were a bit reticent to take this on board and the still a bit of a battle there. But most of my colleagues are really infused and interested in this and, um, their interest in it for two reasons. Obviously, everybody is interested in reducing their carbon footprint on sustainability in healthcare is getting much more traction, and they want to be part of it. So that's one issue on a second issue. From a practical, pragmatic point of view. It's it's improving. Anything that improves your productivity is a surgeon. There's got to be a good thing. So it's a win win for everybody. So no, I didn't get much pushback. I have some colleagues are a little bit apprehensive. Um, on my plan with that is to invite some of those colleagues to do some green green l A list with me. So, like I said in the talk, bring people on with you. Bring them on the journey. Absolutely. Thank you so much. Um, really. We got any more questions in the chat, But thank you very much for providing your toe handle on contact details in case it does have any more questions later on. I know you're having an incredibly busy day, so thank you very much for taking the time to join us on. Give us your insights on your thoughts about sustainability. Thank you very much. I will. It's an absolute absolute pleasure. Thanks for too late for the opportunity to speak to your new governmental. Thank you for coming. Good luck to everyone with their own projects. Like I say, I said in a talk, Just look for those inefficiencies. Find them test thumb. I caught with a different way. And then, you know, together we'll make such a massive difference. Good luck. Thank you. Yes. Trainee in Yorkshire and the Humber on has come to us aspartic her role in gas, which is the green around us. Easier answer stain ability project on her. Aims within gas to try to help, to try to help to reduce waste, increased recycling and make the NHS a green operation, which I think is something we can, uh, we'll appreciate. So thank you very much, Doctor Lever. But joining us today and I will get you to share your screen to start presenting high. I'll just get my slides up. Can everybody see that? Yes. Become perfect. And so hi, everyone. And thank you very much to Julia and Oliver from biting me to speak at your brilliant sustainability conference. Um, it's been really great hearing about how three days is going green. Um, as judios mentioned, I am part of gas which is green around, it's easier and sustainability projects. We are multi disciplinary organization that working towards greeting anesthetics but also the wider theater environment. I have been touched with speaking to you today about the impact of anesthetic gases, but first I think it is important that we start with just reminding ourselves why this is important. What is a steak leaching of cold reefs is one key example of the destructive impact of climate change with increasing global see temperatures. The algae that make the home is either coral are expelled on. If temperatures remain high, there no able to return to the coral and it will die this least a loss of habitat and biodiversity and generally disrupts the balance of this ecosystem but also impacts on humans as coral reefs are natural title barriers and they absorb the force of waves. Carbon dioxide levels in the atmosphere in the lifetime have followed this natural ebb and flow. And in the 19 fifties, my parents' generation that we're being told that there will be a nice age and you could forgive them for thinking this because scientists would have been expecting a downturn and I was very excited to as it waas industrialization. Going back to the 18 hundreds clearly was beginning to bite. What that CEO to rise equates to. It's an increase in global temperatures. It's hard to appreciate the magnitude of energy required to raise global temperatures, but one example is that to raise the Earth's temperature by one degrees Celsius, this requires the equivalent energy consumption of the USA for four million years. Carbon dioxide levels in the atmosphere just this week are at 420.58 parts per million, which is up by 1.1 parts per million since last year. The results of rising so two and rising temperatures is what we're seeing in the news on a daily weekly monthly basis. Extreme weather, floods, famine, wildfires, drought record, high temperatures and Antarctica. I could go on, but we can't go on like this. On the Earth is victory on fire. Healthcare Without Home is a global organization that's working to tackle the impact of healthcare on the environment. And they calculated that if healthcare was a country, it would be the fifth largest admit of 02 in the world. In the UK, the attic chest contribute to 5% of our national oh two emissions, so we've really got work to do. So how are we going to change? Professor Booster has already showed me this pie chart, but I think it's worth briefly revisiting if you'll give me the time any chest is broken down. It's carbon footprint by contributors, so this spits them up into those outside. The NHS is direct control, which you're on blue on those that those within our direct control, which would agree so factors outside our direct control of things like pharmaceuticals, medical equipment, supplies, chain on factors within our control are things like water and waste staff commuting, building energy. But also included on the left is anesthetic gases. A metered dose inhalers on This is where is an East it's We can make a significant contribution to reducing or carbon footprint. Okay, this is another graph produced by the NHS, which shows the 02 emissions the historic emissions of seeing at the top left, and you can see that they were coming down. However, a few years ago, we hit a crossroads and you can see projections of emissions if we were to take no action, which is the dash line at the top and projections of emissions if we tackled all the areas listed in the dash line, going down toward zero. The blue section in particular, holds relevance for any cysts, GPS and anybody who's using nitrous or intern ox on the blue, which could be wiped out if we make the change is required to green. If I anesthetics and stop prescribing me to dose inhalers in particular, I couldn't do this talk. I do apologize. I couldn't start without plugging my own trust, who have been incredibly engaged with doing their bit to tackle the climate crisis. What's the NHS is a whole has pledged to be next year by 2045. My trust has been a lot more ambitious and is only to be next year, about 2030 on they are well on their way. They've built their own solar form, which the other week was featured on the BBC as one of our main hospitals was entirely powered by the solar form. For a whole day. They were making so much energy they actually sold it back to the grid. In addition, we've already reduced anesthetic gases emissions by over 50% through reduction of desflurane and nitrous oxide. There is still work to do, but it is great seeing trust that is so motivated. So the science bit basic science. I'm not a viral mental scientist, but anesthetic gases are greenhouse gases. Once released into the atmosphere, they essentially add to This carpet of gas is in the stratosphere and drops for it usually so no energy troubles from the sun reaches the earth, and it's reflected back out into space. But greenhouse gases trump the energy and prevent it from escaping backing space, which warms up on it. So our three main Allison volatile agents are in this yellow box desflurane, isoflurane and CVA for it. But you could also see nitrous in blue see or, to me thrown a water vapor sitting in the same part of the atmosphere, all of which are acting as greenhouse gases. So how do we decide the badness of the greenhouse gas? We use a measurement called global Warming Potential. Good Woman potential is made up of two factors, firstly, the atmospheric lifetime of gas, and secondly, it's ability to absorb infrared radiation. It's a measure of how many times more powerful a gas is that heat trapping compared to the same mass for reference gas, which is usually calm dioxide when we measure this over 100 years. This enables a direct comparison of greenhouse gases, so you can see here that CO2 has a global warming potential of one because it's the reference gas, and it hangs around in the atmosphere for up to 1000 years. Me thing has a great warming potential. Up to 36 times higher than 02 on nitrous oxide is 265 times out of the 02, which means whatever nitrous we're releasing into the atmosphere today is still going to be on the Earth when our grandchildren and great grandchildren are born. The bottom category includes anesthetic gases. So let's look at the numbers You can see here that the obvious outlier is does for reading, which is the blue canister that you can see on the left. It has a global warming potential of 2540 times that too. It is a gas. We are moving away from an anesthetic. Thankfully, is it doesn't really have any clinical advantage of receiver flu rain on it's anesthetic Impact, as professor but it's mentioned, is absolutely horrendous. And it is important, though, to talk about nitrous while small. It'll anesthetic. So receiver for a rain. I suffer in a desperation. Do you have very high global warming potentials? And they are definitely a problem. They actually contribute less than a quarter of the anesthetic gas Cop of Different, where it's nitrous contributes over three quarters of the anesthetic gas carbon footprint, really situs. There's an easy way to assess the environmental impact of of a little anesthetics. The anesthetic impact calculator App was produced by Dr Tom Pierce. Here is the colleges environmental Advisor. It allows you to improve your anesthetic figures into a sort of mini anesthetic machine. On. It will tell you both how expensive your anesthetic is, which is relevant. Particular does lowering because it's very expensive and also the environmental impact in equivalent distance driving for patients. There is an excellent resource on the colleges website called Your Anesthetic and the Environment. On this our patients to see clearly what the impact of our gas is is it's clear that obviously patient safety and comfort is of paramount importance, and sometimes clinical care will have to override any environmental concerns. But wherever possible, we should be considering both the patient on the environmental impact as one. So I've talked a lot about the problem. But what are the solutions? So, firstly, don't give a general anesthetic use regional instead. That could be a spinal or a nerve block, and this is something I'm sure you're familiar with. The North Pedic. Send something that we should be promoting as much as possible. Regional anesthesia has a much more environmentally friendly profile, and it's also beneficial for the patient as they don't have the risks of a general anesthetic. Sometimes, of course, it's not appropriate option, but is what we should be trying to lean towards wherever possible. Secondly, if you're going to give a general anesthetic than do differently, so one option here is to use total intravenous on this easier or TBA. This involves running a syringe of propofol on an opiate throughout the operation to keep the patient anesthetized. We turn it off about five minutes before the end of the operation, and the patients generally wake up really, really nicely. It also acts as an antiemetics, so it's doubly good. In my book. I actually really like using TV just because the wake up is really good. But people do get concerned understandably about the plastic pump to the electricity and the propofol. And this is a reasonable concern, especially as propofol is made from soybean oil on. We have quite limited information available regarding the sources of the soybean oil for practical production, however, in life cycle analysis when compared with a volatile anesthetic. So your standard gas anesthetic, the greenhouse gas impacts of TV of four orders of magnitude lower. So the moment it's the more environmentally friendly option. If, after a while that you still want to use a gas for your anesthetic, then captured technology is starting to be adopted. So it's a check is a British company on Baxter's, a German company, and they both make canisters, which absorb the volatile gas through the stabbing system that comes out of the anesthetic machine and connects to the wall. This is the canisters of transported to the companies home facility. On that gas is a kind of distilled out of the canister and could be separated, ideally in the future that be able to recycle scavenge gas is creating sort of closed economy. On that would stop was releasing these gases into the atmosphere. I am sure this is a familiar sight, too many of you. A classic emergency department phone call to ask you to come and help reduce the desiccated shoulder on your patient is uncomfortable, and you need to get in some decent pain relief. And I've already told you about the problems with nitrous. So what are you gonna use instead? So first choice conscious sedation you could use either propofol, catamenia or bit of both, and this is a really good option that should get your potion nice and relaxed of floppy enough to give you the better chance of success of getting that shoulder back in. However, this option has that caveat of needing either an E D Register or consultants who is confident in sedation to give you a hand in the current time of e. D. I don't know how realistic it is to be able to pull someone away from the shop floor for this, but if they're able to, then it's a really good option again, it's important to remember that no all emergency departments will have doctors who are competent in this technique, especially at night time. And it's important that we the sedatives, are only used by those who are competent to do so. On booking is one team with our emergency department colleagues as well. So if you can't do that, this is another option. So pen frocks, which is known in the prehospital world, particularly down under as the green whistle on this is an anesthetic volatile agent as well, Just like CVA. Oh hi! So it does. But it's methoxyflurane, which has been made into a powder. It's tipped into this plastic whistle on the patient, inhales and exhale through the whistle. On they become particular, but they get really decent relief on. It's a good option for patients, particularly when there's no be able to deliver contrast a shin or if the patient maybe has difficult IV access. I have given this to a number of patients in E. D. To eight with fracture with inflation on dislocations, and it generally goes down really well. If, however, the patient doesn't exhale, probably back through the inhaler, you will probably get a with of it, so they were because it might make you a little bit giddy. Also, um, pen trucks has a global warming potential of four, so it is significantly better than the 265 that you get with nitrous. But like all of these things, it does have a disposal problem in that it's single use plastic, and I'm not convinced it's recyclable. So what next? If you really want to use the Internet, there is new technology coming through to help reduce his environmental impact. So Medicare is a standard aiding company that's created a scavenging and cracking system for and knocks essentially instead of just having one and spiritually homes from the cylinder or the wall to the mouthpiece. It also has an exploratory hose, which plugs into this machine that you can see on the left. The patient needs to keep the mouthpiece in their mouth. For expiration is, well, much like the pen frocks on. This means that the expired gases will go into the experience, the hose and into the machine. The machine is quite a basic but of technology in the sense that it just heats up the gas to 400 degrees Celsius on that splits the nitrous into nitrogen on oxygen, which could be released harmlessly into the atmosphere. These machines, all relatively new to the UK and they're expensive. The picture here shows you a mobile unit. But Medicare also make a system that can kind of be plumbed into the nitrous manifold system as well. It's going to take time for the UK to adopt this kind of technology, and realistically, it's gonna be maternity units. You get it first because they have the host use event knocks. However, I would expect and hope that the emergency department will be next. So essentially. But watch this space. So thanks very much for listening. That's all I have to say. Really. I hope it's been helpful if anyone has questions, I think that's a Q and A session, so I can try and help on. If anybody would like to join Gasp, let me know, because it's not just for any statistics. We've got lots of other specialties, including pediatricians GP psychiatrists often gynie emergency medicine. It's just 1 may help your family, so if anyone would like to join, please get in touch theorem assist is here. But if you want things, I can send them to Julia and chicken for them on to you, as that's everything for me. Thanks very much for this thing. Meantime, I'm going to introduce another speaker who's been brought to us through gasped to whom we are really, really grateful. Alex Fun over. And who is coming from a little bit of a different perspective today, as he spent the last six years is a vendor in the space of orthopedic was sharing. It's, um, product related ticks. The greening up the operating theater on were really very grateful to Alex for joining us all the way from the US. Thank you ever so much for that were really grateful. Yeah. Let me just share my screen really quick. Here one second. Sorry about that. Cool. Um, can you see the screen? Yes, become. Thank you. Great. Um well, thank you, Julia. And, um And again, thank you to the gas organization as well to four. Um invited me to come speak to you. All is well today to it is a huge honor for me. And, um and as you said, I'm coming from just a slightly different perspective today, but I hope that some of the things that I've seen from the other side of the fence can help impact your practices as surgeons and conditions in the field. Um, before we get going, though, uh, just a quick outline of what I would like to talk about today is just give you a brief background of my background, um, kind of industry trends on where where things have been going, Um, some opportunity for you to get involved with some Maybe just more tangible, um, things to do. And then also some future things that I've seen that that I think you're promising for the future of surgery. Um, so starting with my background, you'll see, uh, I'll start. I'll start with the end and work my way back. Um, why does it say vegetarian on there? And what does this have to do with anything? Eso Quick story. Four years ago, as a carnivore traveling around the country and driving 25,000 miles per year for work, I decided to make one small change to reduce my personal carbon footprint. The change was actually easier than I thought, but the impact was much greater than I imagined it would be. What I noticed as I moved away from meat was people would engage me first with ridicule, then with curiosity and in many cases, finally action on their part to make Let's change themselves. Um, why don't I start telling you about vegetarianism? Know it's not to convert you all. It's It's to say that sometimes even the little list of actions, despite how small they may feel to you, have a lasting impact on those around you and can actually shake more change than drastic measures. Um, now to my clinical background, a little different than those on this call, I am not a trained clinician, but I have spent the past six years working for orthopedic company called Arthrex. My job entail supporting surgeries on a daily basis and constantly working with operating theaters in the U. S. In my six years with arthritis, I saw growing trend by many industry leaders, including my own towards single use plastic products, um, with MAWR and more moving away from reusable goods, whether these were in common T notices, screws used almost daily or a new Nana scope cameras all we're moving away from re use and into one time use. This growing trend drove me mad and let me to dig into this a bit further to see if there could be any solutions available. Um, so over the past, over the last 30 years, the medical industry and largely the surgical feeder has moved some of it's most commonly used goods to plastic for form for related safety and cost savings. From the safety side, research does support this trend as it is reduced the risk of transitions of things like HIV have a, B and C and most importantly, CJD. Our cruise felt Jacobs disease. While the use of plastics for certain items can get back to justify, for one time use, do the risk of infection. Other common good. Such a zombie wraps for trays, caps and gowns, one time use anchor systems and even kidney bulls, which are used almost every surgery. I have no real basis for their transition of plastic form. Most of this development in one time use can be attributed to history. Influence as capitalization has led the drive for less reusable and move through continual replacement. Are you so when when you look at it from the cost perspective, you could argue as well that money has been saved in one time. Use items that do cost sometimes 1/10 or 1/20 overall cost of reusable goods, but one must look at the full cycle and not just the initial transaction costs. Yes, one time plastics can be cheaper initially, but full cycle they can produce more than a save, both economically and environmentally. Currently, when you look at the NHS, then it's just produces or 600,000 tons of medical waste each year. And of that, 130,000 tons of that is plastic waste. But yet only 5% is said to be recycled. Right now. The cost of disposal for this waist is upwards of 73 million lbs each year, which then goes on to landfills that are now becoming more full and forcing many in the industry to start burning. These items, which nearly brings more health risks, risks back to society in the form of poor air quality. So you see, the cost is not not a good next trick for moving to more plastic. It is a metric for movie, more products when the benefits few in the form of industry in harm's way more in the form of economics and lasting environmental impact. So what we actually do about it? We have heard this our whole lives reduce, reuse, recycle. But today I'm going to argue some of the ways to, um, more so reduce and reuse. And when necessary, I would say recycle. And I know we've heard some great talks on recycling, which is fantastic. Well, but I think on the, um, next point, So I'll show you that, um, maybe reducing reuse is also ah, great way to to, um, reduce. This is well and And you do this, I think, most importantly through the voice that you have a surgeon's and as clinicians in this room to really speak and use that voice that's powerful in the operating theater. So I mentioned earlier blue wraps this year, a study came out from I'm gonna miss pronounce her name. But Frida see and eggman, um produced the fruits the study of the US, where they found that each year 115 million kg up the wrap is wasted in the US alone. Blue wrap is a multi layer nonwoven packaging material made a polypropylene, a plastic that is actually quite stable, to be recycled into other forms such a Z dishware containers and clothing fibers. Um, the issue with the wrap is twofold. One. The recycling of this material is really being done. Or it's being done in properly, um, leading to blue wrap, making up nearly 11.5% of all medical waste in surgical care. More importantly, the ICO cost associated with the rap comes mostly from its production, contributing 88% of its total. Ekoko just before it ever reaches the facility it serves, meaning even when recycled after the major cost, the environment have already been established, making recycling less impactful than one might think. Um, there there is a solution, though. In this same study, the authors brought to light the use of reusable, rigid sterilization containers, or RSC's, which are a fancy way of saying metal containers. Um, these RSC's have a net 85% less equal cost than that of blue wrap. They congenitally be used up to 10,000 cycles, as opposed to a single of cycle with the wrap and have a net ICO benefit After just 68 of the 5th 5000 cycles to use by surgeons and, um, conditions like yourselves grazing, your voice is to your surgical coordinator and procurement specialists, Um could lead to major transitions in the front of blue wrap with huge upsides, both economically and environmentally. The 2nd 2nd, practical area of focus comes in a commonly used items for O. R. Set up the surgeon preference cards, and we've heard a couple of talks on this is well, too. But in 2016, a group of researchers at UCSF in California followed their neurology surgical department and found that on average, eat surgery had a wasted product costs of $960. This limited scope study estimated that the recurring cost accounted for $2.9 million a year and wasted products, and this was just one department. Now, um, this study, of course, has some gaps in its scope, but in reality, there many estimations as high as 30% that have been made about the amount of products opened but never used in surgery. This is something I know. I have personally witnessed multiple times as a rep supporting these cases. The solution may be simpler, though. Then, I thought, While not all products will go on to be used in surgery, paying close attention to the common procedure cards can make a huge impact on the overall wasted goods and surgery. Staff, as you know, uses these as the recipe card to make sure all items are ready and available for surgery when the first incision is made. If the court says it often the opening first thing to avoid any delays, I know time is limited and the solution I am suggesting next will require some more time invested. But setting up a common cadence to review procedure cards on a quarterly or bi annually basis can lead to significant savings in products not used a good good for step. For this could be simply. Just inform your daily staff of your own desire to track and manage these cards with the preference. That preference is that correct? You can ask them to mark items with a highlighter that are not used that are not used but opened, and then give that back to back to you. At the end of the case, likely your office manager can collate these items for a better visual. And really, tracking of your items can be made with the combo of both oversight and review. These unused products can be drastically reduced. So uh, um, finally, I just want to touch on a couple of cool things. I My research also found kind of exciting for the future ahead. I mentioned it before, but digital preference cards are on the horizon and could bring significant impact. I mentioned that also that time is often the killer of many. Preference is not being updated, but the advance of options are becoming available where all parties, including vendors, have access to change and update these cards so the right things are available and open every time for surgery. Another really cool trend that I found was in medical remanufacturing and, um, working with different systems to to bring down the total amount of goods that have to be produced at one time. Some companies, like Vanguard and Intra Test UK, are rethinking the way we manufacture, read and reprocess are goods. While they have not bridged yet to orthopedics, the future is bright for when they do make you sleep and then lastly, Um, and more probably most importantly, more surgeon input will ultimately be the driver of many changes induced industries. Missing mission is to gain more surgeon access and more surgeon attention. If the voices collectively changed to demand more sustainable products, Industry will respond even if it takes some time, as most waist is produced before the product is even in the hands of the surgeon surgeons becoming more active, forming discussion groups, leaving and leading the charge toward industry players to find more creative ways to reduce overall ICO impact will ultimately play the largest role in the market as a whole. Um, again, I just want think the gas organization, um, and yourselves for allowing me to the short opportunity speak a bit more from the vendor perspective and lend some, hopefully practical tips of where to start. I hope you found this helpful, and I've left this last screen with Q r. Take to my information. If you have any desires to continue a conversation about driving down waist from a product perspective. Thank you. Thank you all in. Um, yeah, we'll take any question you have. That was brilliant. You so much. Alex, Um, I'd like to invite a jillion back as well on the stage to take any questions from the floor. If I would be happy to do that. Alex, can I have a quick question? Just about the kind of last point you were mentioning about industry responding to kind of pressure coming from us because obviously not something we can do. You know, as with pedic surgeons and hopefully will be the consultants of the future. Have you seen many kind of groups of orthopedic surgeon or surgeons general Kind of funding together to push for a change either in the UK or over in the US And you know how they got about that? Yeah, that's a great question. As far as from the state of really aspect. Um, sadly, it's, um, not something that I've seen a ton of just yet in the US. Um, but I have seen it from just the product perspective. Um, I like I said I worked for arthritis. They're very responsive company. And, um, they did have ah, really good year to listen to what the surgeons were actually saying and giving them in the field. And so I do really believe that? Um, as we kind of moved to these I mentioned intratesticular. Okay, I didn't really dive into them much. But their whole model in the whole vision for the future is is building systems where you can actually, um, create smaller units of product meaning instead of having to produce a million at a time, they can produce 5000 to 10,000 at a time, which is a huge change. And I think as industry continues to move that way, and I think his conditions put that pressure on them to move that way, um, ultimately, they're gonna have to get creative and find ways to work with them. Um, and not against them, because, ah, it is the truth. I mean, industry is truly trying to gain more access. So a slow is the voices are collecting and moving them. They will move with them. So is what I've seen multiple times. Great. Thank you very much. That Gillian, we had a question in the chapped from Donna. More asking. Have you look to any other gas? I think it's got a volatile capture technology. And you told me well, is year so well There are two companies that I'm aware of, which the ones I mentioned. So this stage tech, which is a British company, they're based down in Devon, um, and then Baxter, based in Germany. On that, both adds, a Baxter is more established at the moment. It's being used more widely because they've already got a system in place where a stage tack is. I mean, essentially, it was a startup company, and it's just done really well. They've been piloting their product in various hospitals, in different parts of the UK, particularly down indefinite, calmer, but also up in Newcastle on I think they are looking to start actually selling their technology to hospital. So I think they are the only ones I'm aware off on. But I could be broke about out. Thank you. And another question kind of really assumes for either or both of you. Alex, we we've spoken a little bit about a push from a cyst. Surgeons, you know, to more kind of sustainable technology. Gillian, do you foresee or do you know anything about anything similar kind of going on from within our set? It's I know you guys have formed gas, which is incredible, but all the pushes from within anesthetics to sort of fun together and say No, we don't want We don't want to use your stuff if you're not gonna make it green. Yeah, absolutely, I think from the gas perspective. Absolutely. So I'd say there's a There's a massive push to get rid of desflurane entirely, so that's that's the first thing on. I think there's been some decent evidence to say that there isn't really a good clinical indication to keep using it on the indications that were cited previously. So things like neurosurgery, bariatric surgery. Actually, the evidence isn't good enough to say that they're worth using. So I was at our Syria conference a few weeks ago on there was loads of discussion about it, and it was just a sort of clear message that were ditching it and it's going to go, so that's really good, because that's coming from a sort of a college level on. I think everybody is aware of the issues with Nightdress that's a little more complex because it is outside of our remit. I mean, it's within a remember if it's within other people's remain as well. So emergency medicine on maternity, but again that there has been really big pushes on. There was some really good work presented actually from from Cardiff. I believe, um, find any stress there who has done a really good sort of nitrous reduction project. So that's really good. And in terms of, like, single news items, that sort of thing, yes, I would say it's less off. Push it the moment cause I think grasses of the low hanging fruit At the moment, they're the other thing that we we have more control over whether we use or no on. But my own trust had a talk from somebody who was selling single use bronchoscopes. Andre was a lot of angry chatter in the sort of chap box saying, Why? Why are we having somebody selling single use bronchus like what we're doing? So I think I think it's the message is getting through. But it does take a bit of time for people to get on board. Yeah, absolutely. I think there's a there's a big push from, as you say, the people who are making single you stuff to perpetuate this myth. That single use is is the cleanest and the best we're going to get. Um I think some of the stuff you mentioned, Alex about different ways of getting rid of, for example, the blue rock, you know, and ways around, because obviously, that's something we use, you know, hundreds and hundreds of tons over a year, you know, wrapping all of our stuff, and then half the time we find holes in it and, you know, send a K off. Anyway, um, we've had a comment in chapped from Cyrus. A Thank you, sire. Are amazing. On a said excema, Oxford is sure we can see the, um, it group and save testing an emergency appendicectomy. And they're pushing for our surgical teams to review on. I think that's something really important that we can all look up. Isn't it across? You know, there are, You know, from our point of view, lots of procedures that we you know, we need groups and save across much is for but reducing unnecessary testing. I know that was, um was it the Green Ward challenge? I think in emergency department 11 of the green. More challenges. By reducing the number of unnecessary blood test they were doing I think that's that's gonna be really important going forward. And I wonder coming back to your previous point, Gillian. Whether it kind of with regards to stuff like nitrous, which is obviously actually under the remainder of so many different specialists, we in orthopedics use it quite a lot, as you're saying, you know, reduce enjoying, you know, doing the NEBs all of that sort, obviously. Maternity, big users, emotion department, big users. You know, maybe we'll need to bands together, you know, and take out like that idea on and just, you know, kind of work, you know, just in silos with their own specialties. But across specialties to kind of make that different assay know we knew, You know, we we want better way to this away. If you want us to buy it, we want you to do it better. Yeah, it's It's definitely got to be a multi disciplinary kind of team approach. You've got to get from maternity in particular. You've got to get the sort of lead midwives on board. It's got to be clear that it's know about taking away analgesia. Cop shins For women in labor, it is about disposing of the gas responsibly. I think that's quite a lot of understandable concerns about. I think sometimes it's interpreted with reducing Nitrous is interpreted as no pain relief for women who are in labor on it's really not that at all. And I quite like to dispel that because it frustrates me a little bit because actually, the capture technology means that we could keep using it. It just means it's not going to be doing the home that it was doing before on. But it's not taking away and anagesic option. But that's sometimes how it's been interpreted. It can be a bit of a challenge with communication, particularly to the media, on to the wider public why this is important and why it's not going to impact on patient care, making these environmental changes that such gonna make it better. I'm going what back to what you said about packaging. There is some really good sort of. I love the term low hanging fruit, but there are some really good options on, but recently in our region, we have been auditing the contents of our central line packs on arterial line packs on. Basically, people are saying what they're not using from the pack because it's just a generic Paxil. It's been they've been told what to put in the pack by a certain group of people 10 years ago. But actually, some of it's not relevant anymore. So even just really small changes, even taking out the drawing up needle or that sort of thing, it reduces the Sharps waste. So there's there's loads of little projects that could be there could be done. And you can make quite a big impact with just small things as well. Yeah, absolutely. And I think that's that's something I thought about several times kind of an orthopedics, You know, the amount of stuff we open, you know, And how much of it do we actually need? A news? And actually, if there were ways to you're sterilized and wrap stuff as Alex was suggesting that don't you know we don't necessarily need you to put everything into 57 different individually wrapped bits if we're not going to use? And but actually, if there's ways to minimize the kit we use as a process, that decision was saying, you know we can then, you know, probably reduce the carbon footprint of what we're doing, you know, by a significant amount by just just like, as you said, just taking out what we do use it when I think I think two never, like just one last point on that, too. On the voice to you, I think Just never underestimate how powerful your voice really is. This as a physician and a clinician and and how how responsive these companies will become as more and more people kind of collect. And I think it does kind of start with those little minor changes changes making yourself kind of the advocate within your certain trust. Um, and in those little kind of first initial steps, then kind of labels you in the industry of such. And you have a different platform within the industry itself, too. I think it really Yeah. Don't underestimate how powerful your voice really is, is all I would say to that because industry will respond, even though they seem like giants. And they won't. They will. So brilliant. Thank you so much. Have we got any more questions from the floor? Um, at the moment doesn't look like it. So we're going to go to another quick coffee break. Just until about court past four, if that's okay with people. Alex. Gillian, thank you. So so much for coming to our conference and given as your opinions and I think really starting a lot of ideas about you know what we can do. As you say, Alex, you know how we can use our voices for good and kind of. I think sometimes we feel like, you know, we just do it were told, but actually, you know, I think you're right. We can We can push the change from within within the NHS, always within the private sector or whatever. People are working, you know, we can bump together and really, really push. We're good. So thank you ever so much. Guys. Remember the on the sessions tab? There is a room in a Congrats on and have a chart and discuss ideas if you like. Um, if anyone's to use that during the break, you are more than welcome on. We'll see you back again at court past, so Hi, guys. Welcome back to our third and final session of this afternoon. It's my great pleasure now to introduce on Hilly who I think I'm writing is a glass go negative. Now in orthopedic registrar in the Northeast on he's currently out of program doing a fellowship in sustainability and is here to share with us some of his knowledge unexperienced off sustainability faculties on champion networks. So thank you so much for joining us, Alan, if you want to share whenever you're ready. Yes, No problem. Thanks very much to it. Just so. First of all, just a warning. I'm actually up in the highlands off Scotland. So on, hopefully my Internet holds out, So I've been assured I'll be a left of it pox in Syria. First of all, um, I would just say that a couple of my slight have already bean showing by Dr Lever. But I think the message is important and I think he can bear repeating. So, um, first of all, my name's on hurry. As Julie said, I am a classical negative, and it's a absolute privilege to have been asked to come and present to day at the inaugural Ah bought er sustainability conference. So a little bit, though myself. So that is a picture off King Edward B, which is a beautiful beach in the tone of tame most, which is where I'm from and I spend a lot more time out walking along the beach or out in the hills and elite district running, claiming swimming. And it really was my experience on love for nature was my gait way into having quite grave concerns about the climate crisis and is what sparked me into action to try and contribute to solution. So as July mentioned, I am an orthopedic training in the Northeast on I'm sure, as we've talked about today, we really are quite big contributors to the any chest is carbon footprint, and I really wanted to use my Year of program as a leadership fellow, too. Focus on sustainability to try on, uh, make a difference. So today I'm just going to talk a little bit briefly about the climate crisis and a few, this lady said, I've seen showing already on and then we'll talk a little bit about sustainable quality improvement, and I think we'll talk more on broad brush strokes on concepts and principals. And I think quality improvement and sustainability really underpins everything that we are going to do. Um, in sustainable healthcare and then I'm going to talk about, um, My year is a sustainability fellow working with the faculty of Sustainable Healthcare under Green Champions Networks. So this graph has been showing already, but I've done a few presentations known sustainable healthcare. And I always start with this late because it really does, uh, you know, concerned me, and I think it's a very worrying slight. As we can see from the Industrial Revolution, carbon dioxide in the atmosphere has risen exponentially year on year, and we really are critical. Tipping point on. There's a consensus amongst claim that scientists it's a of less. We drive the carbon dioxide to lessen 400 parts per million. We are on course for climate catastrophe. And what do these numbers matter? Why do these numbers matter? So this is a graph that shows the projected global temperature predictions based on our current policies. And if we do nothing on every current, we continue on a current predictor e that it's predicted that the global temperatures will rise by between in 4.1 of 0.8 by four 2100. And what does that mean? It doesn't mean that we're going to have Ah, better sometime and there's summers are going to be warm and glorious. The consequences really are catastrophic as being US has been mentioned before. It would result in fatal heat waves, droves, flash floods, conflict, uh, some. And on that, ironically, is the populations that have contributed least to the problem that will be impacted most by its consequences. So really, it is time to act and we need to like to know again. This has been touched on already. But the healthcare globally is major contributor to carbon emissions. If it was a country, ah produces much carbon dioxide carbon emissions as Canada. The NHS is the biggest public and mr off carbon dioxide in the public sector for about 45% on your case, total carbon emissions on on a daily basis. We produce more carbon non Heathrow airport, and it really is quite a vicious positive feedback loop. We know that about 44,000 deaths pair year can be directly associated with poor air quality and the more morbidity and mortality that there is, the more stress and utilization there is off the healthcare system, resulting in more carbon emissions on more mobility from for AARP. Will it e So it's a vicious cycle? No, we need to work out how we can great on one of the ways we can do this by engaging in sustainable quality improvement. So stable quality improvement isn't designed to try and replace ah traditional quality improvement projects, but rather it needs to be integrated into any quality improvement intervention that we make. And this was recognized by the Royal College Off Physicians, which have no integrated sustainability, is a key demean off their quality improvement framework and what is sustainable. Quality improvement was all about maximizing sustainable value and sustainable value. Recognizes that we live in a world with finite resources and we have to make sure that we maximize our patient outcomes. Well. Minimizing are utilization off these final resources, and these resources can be classified as environmental social on financial, and this is broadly termed on the triple bottom line. So, in summary, sustainable value is all about maximizing patient outcomes. Woest minimizing or impact on triple bottom line whenever we're doing are sustainable quality improvement project. We should really keep in mind the Center for Sustainable Healthcare's Principles Off Sustainable Clinical Practice. So the top. We have got prevention, and it's at the top for Ah for a reason, because prevention really is the most powerful thing that we conducive to reduce the carbon impact off any any service that we're providing. That is often something that is neglected because it is. There's quite difficult to impart things that strategies for prevention off all health, our public health strategy. So put campaigns to improve healthy eating, exercise, smoking cessation also campaigns to improve hosting and here quality. And then we have got self care. So that's all about educating and imposing our patients to have more autonomy over their own healthcare on health. And then we've got Lynparza three. So we've talked to touch the ice on the previous presentations. It's all about making are pathways mortification on less carbon intensive, and then we've got low carbon alternatives. And so this could be. For example, switching to lower carbon intensive medications are switching from single use, uh, items. And as we move down those principles the impact it has on the carbon footprint. Often intervention decreases. But often it is the law carbonyl 10 10 in terms that we focus on as clinicians cause its laws that we can have the most direct impact on So, um, and my years as a fellow. So actually, I'm not a sustainability fellow leadership fellow working for health education. England Northeast on the North from Breo Trust. But from the outset off my fellowship year, I was very adamant that I wanted to make sustainability the focus off that year. And I've been working very closely with the faculty off Sustainable Healthcare in health education. Northeastern. This is the first faculty off. It's kind in the UK, and this chair, by Elaine Weekly is a consultant. And if you test in the Northeasterners, Elaine's of really driving force behind lot of the good work has been done in the region. As a faculty, we are responsible to our post graduate dean on the meter Coomer and profit. Chemo has been really supportive off all the interventions and all the projects that we've tried to get off the ground. So in terms of our aim, our aims, broadly speaking, are all about awareness. So there's a recognition that amongst trainees and amongst the wider MDT, the really is quite your awareness off the impact that healthcare system, heart on the claim it contribution. That has to the claim that emergency and we really wanted to try and do something about that. We also really wanted to educate Ah, the trainees in the region of boat healthcare and sustainability, but also about the principles off sustainable quality improvement and Holick and implement, not in their own clinical practice. We then, once we recognize the importance off networking collaboration is a very powerful tool, and it's far more powerful to implement change on the regional level or a national level rather and then everybody working in silos, doing their own thing. And then importantly, we wanted to celebrate. So we really wanted to celebrate all the great work that's being done by, uh, the region, um, and also to share good practice. It can be used as an example for all of people to follow for achievement sissies. Ah, this is just a selection off are cheap, but so far we've been up and running for a year over a year now and and not really the time. We really have managed to achieve quite quails. So in terms of raising awareness, so we know produce a quarterly newsletter which um has got all the, uh, sustainability. Relevant news is happening in the region and beyond, as well as updates on sustainability projects on a ways that people can get involved. And we also education is being a real focused off our first year and we teamed up with the Center for Sustainable Healthcare. And we've designed the number of workshops that we've ruled out across the region, focusing on sustainability in healthcare, but also the principals off a sustainable quality improvement. And we're also training up a team off facilitators in the region so that we can provide these workshops independently. Onda Also, we've designed and ruled out you learning platform, uh, learning module unseasonable healthcare on the even eat for health platform. In terms of networks, we've come on to talk about that a little second and then in terms of celebrating, I'm really happy to see that we are about to have our first annual faculty of Sustainable Healthcare Conference, which is going to be in the Catalyst and Newcastle. We've got really fantastic program off speakers and exhibitors and we're also going to have a port of presentations to try and, uh, celebrate all the good work that's been going on in the region. So in terms off the Green Champions Network, this is a piece of work that I've been working on over the last few months, and it was born from, Ah, a survey that was carried out during our launch event, and the themes that were really repeated over and over again was that people wanted our mechanism to collaborate to, um, network they wanted read on a central hub for resources and two kids, really, it was born on the recognition as trainees. Specifically, Is that the rotational nature off the training program? It's very difficult to embed yourself within. Each trusts sustainability work because it's soon as you get your kind of fingers and you know you get you get your teeth into a project. It's no longer four, you're moving on and all that momentum congeal lost. We really want you to have something that could perpetuate it through a training training program so that they could start projects, completely projects and then share their experiences with, um uh, the the next generation of trainees. So they're all up. The The role that we invested for agreeing champions was free see, So we wanted him to be to communicate, so we wanted them to be the conjurer. It between the training is that the represent on the faculty of sustainable healthcare we wanted them to contribute content to do the, uh, case reports and for the platform on Also, in terms of collaborations who locally originally on nationally. And we also appreciate that when you get started on your green champions and when you when you get started on your sustainability journey, it could be really quite daunting and really difficult to know where to start. So we have been working to produce a green champions, huh? Which is Ah, one stop shop for everything that you will need to get started on your sustainability journey. It will have resources to kiss. It also has a bank off. Case reports from previous work has been done as well. This current projects that, uh, the champions Consejo for it to get involved with eso that is just in the phone of stages of production and it's going to be ready to get ruled out very shortly. Oops. So that is just ah whistle stop at Bruv. My years on similar important concepts. My one bit of advice for anybody that's kind of just starting out on their sustainability. Johnny would be too faint. And I'll I think having something do who is just maybe a little bit more experienced in kind of sustainable healthcare that may have, um, faced some of the challenges that you are up against Converium really helpful and really pouring and give you the confidence to try and on make the changes that you want to achieve. So thanks very much. There's a couple of acknowledgements down there on on your I'm happy to take any questions. Alan, thank you so much for that. That with the absolutely brilliant talk on kind of really shoulders, you know, kind of what's going on, you know, to try and develop stable health care that there is hope that, as you say, you know, the important thing is to have an ally someone to kind of show you the way. And hopefully, you know, the work that you guys are doing well help a lot of people make those connections to people. You could help thumb going forwards. Incredibly honored, very pleased to have Mr David Jones with us. David is working part time as a medical examiner with ensure or throw in Manchester. He retired. Is a consultant generally, CORRECTS Inserted in 2020 on has extensive experience and surgical education on professional affairs and healthcare. He was the TPD in general surgery on develop cataracts, simulation course surgical trainees in the Manchester Surgical Skills and Simulation Center. He's been drink course, a rectal for the fire fighting Manchester Me to Trauma Skills course, which he helped develop following the Manchester Arena attacks for the local major trauma network. He developed an interest in sustainable healthcare towards the end of it's surgical career, and that was the theme for his years. President of the Month Just a medical society in 2021. David is jointly for the Green or operations James Lind Alliance NIH. Our medical priority setting partnership, which aims has that research funding priorities through public and professional engagement to deliver green or operations eso to give his talk on changing green operations. Thank you very much for joining us, Mr David Jones. Thank you and confirm you can hear me and see my screen. We can definitely hear you. I can't see your screen in the moment. My? Yep. There we go. We can see your screen. Now you see the presentation now? Yeah, well, thanks very much for that very kind introduction, Onda. So now go to talk about changing to green or operations. And I just like to set the scene a little bit on. But I'm going to assume that everybody is on board with the concept of climate change in the need to do something about it on, I'm going to set the scene and then move on to the greener operations research, priority setting partnership that I've been involved with that came to a conclusion just the day before yesterday. So the data at the end is very hot off the press on, you've spoken quite a lot already about the need to make change and and changes quite difficult. Isn't it? On. I don't know how many of you sat outside of pubs, which is this one on the left, next to a patio heater in April or May on with were addicted to travel. And yeah, we we've got to start making changes to the way we live, the way we work in the way we deliver surgery and perhaps challenging mates that you shouldn't actually go and sit it outside the pub with the patio heater. But go somewhere else. Where? A coat. Oh, our sit inside. But these are discussions you need to start having with your friends, family and contact. So heard the NHS is responsible for something like 4% of the UK Is carbon dioxide equivalent emissions on? There's a commitment to get to Net zero in the NHS. Now that's going to mean a big change in clinical practice on that changing clinical practice needs to be evidence based. It needs to deliver the health care, in your instance orthopedic surgery with a lower carbon footprint, but with the outcomes that all our patients want and deserve. Now my own journey on sustainability is there started with something very simple. And this is an example of what I called normalized deviance. And you might want to put or think about your own example in your own operating theaters, your own orthopedic practice of something that's become normalized part of your practice but perhaps shouldn't be so. My practice had a lot of inguinal hernia surgery on I noticed that there was two diet firm ease on the instrument tray. There was the conventional forceps dive off their meet with the red lead, which came with the instrument pack. But for every case, they were opening a single used finger switch diet same which everybody liked. So I started looking into that and I was told, you know, don't be silly. It only costs 1 lb 64 for the version with the 3 m cable. Um, but But I started to pursue this in generator on interest in sustainability. And it's just some simple little trigger like this that you need to think about your own practice that you can then used to start to make a difference on whilst the only cost 1 lbs 64. The procurement of this finger switch diet. Same. It would be responsible and have a significant carbon footprint on, I would say for a *** little hernia operation. There's nothing you can't do with the conventional reusable diet. Same the indeed the finger switch for I did a lot of laparoscopic. Cholecystectomy is a side was finishing my training. Laparoscopic surgery was just coming in, and I must have done probably possibly even 1/4 finger number of laparoscopic cholecystectomy is using reusable instruments only. I never saw a plastic court probably toe the last 10 to 15 years by operating practice on these started to creep in on Teo the fear to trace, um, because I was getting towards the end of my career. I I wanted to be seen to be down there with the kids. So I just normalized the use of plastic reusable laproscopic ports and got rid of the reusable drapes and started to use the single use drapes and the single use plastic kidney dishes. As we've heard on, I'm sure there's something that you can all think off in your environment. Where you working? That's approval into my diet firm in my laparoscopic ports that you've adopted but could be focused for change and perhaps put it in the chat box if you know any. So I don't know whether you know your trust. Green plan yesterday was actually clean Air day on Green or an HS and out yesterday that every NHS trust in the country now has a green plan on. If you haven't seen the Green plan for the organization where you're working, I would go and look it out and perhaps go and talk to the sustainability team because you will have one on baby something in your particular trust that you can get involved with straight away. And this is the, uh, clean the big the The Green Plan. For my trust. It's Manchester University MHS Foundation Trust. We've got several hospitals and we're actually the biggest trust in the country on this is how our carbon footprint breaks down. So three quarters of our carbon footprint relates to the supply chain on procurements. And I know you have heard from a mood butter earlier on this afternoon on certainly in surgery, procurement of the equipment that we use, Have you heard today is a highly significant component of our carbon footprint. Travel for patients and visitors and staff is down at about 6%. Then is the in eight carbon footprint off your particular trust? Your particular hospital, at about 20% on waist, is in their waist. Itself isn't responsible for a large part of the carbon footprint. It is responsible for pollution. But the best management of waste is not to produce any waste if you can. In the first instance, with responsible procurement. So let's just have a look at a couple of operations, one that I know very well. I did lots of England or hernia repairs, and you can do in England hernia repair As an open technique, you can use a local anesthesia, spinal anesthesia, general anesthesia. You can do keyhole surgery, which is usually under general anesthesia, And for any of these options, you could use single use well, reusable equipment. When I was a training became a consultant. I did about a third of my hernias under local anesthesia. But then, perhaps another example of normalized deviance. It was easier to do them under general anesthesia if I did them under local anesthesia. Everybody else left the operating theater and left me there on my own on. Do you start to adopt practices that perhaps there not best to the patient on for the environment? So just a simple operation, like an inguinal hernia repair as many variables that you're associating with different clinical outcomes on different carbon footprints on, I know in orthopedics and this is a bit technical. This, like a very keen on measuring patient, reported outcomes on these air. The outcomes for inguinal hernia surgery. For some reason, we've stopped publishing these. We haven't done them since 2017 work. The shocking thing about England or hernia surgery is that something like a half, depending on which lot of quality of life assessment you used either resulted in no change in the quality of the quality of health or worsened quality of health. And the worsened quality of health was probably because the hernia wasn't associated with that much in the way of symptoms, perhaps didn't the mending on the purpose and had chronic pain or growing pain after the operation. So this avoidable surgery, which is very contentious, is potentially a part of our carbon footprint that we could address. Now I know you're old orthopedic surgeons and coming from Manchester, we're very proud of professors to John Charlie, who did the first total hip replacement back in 1960 on day worked in various places but most noticeably, a writing the hospital near Wigan. Now you've seen ah graph of temperature change and climate change, and on this graph, you can see I put this set of bilateral hip replacements. They're in 1960 if you look above, you can see the global warming that's happened since the first hip replacement. So all the hip replacements that have ever been done in the world have been done in this last part off the rise in global temperatures. I'm not saying it's all due to hip replacements, but it just Redflex a change in the way we live, the way we work on the advances in medical care, surgical care, which company? Increasing carbon footprint on associative emissions. Now I know in orthopedics you're very good monitoring your outcomes on. As a general surgeon, I have to pay homage to you because most people who have a hip replacement on it and the latest data that was published earlier this year, I think 97.2% of patients having a hip replacement reported in improvement in health. So it's a fantastic operation. So is one we want to you to carry on delivering. But can we do that within a lower carbon budget? Now I know. Get it right? First time is a bit of ah Marmite topic, but get it right. First time I started in orthopedics on I think the first report forget it right. First time related to orthopedics was back in 2015, and this showed a very significant variation in practice and outcomes, uh, across the country, on dingy different hospitals. Onda I'm no expert, and I know there are various ways that you could do. A hip replacement, I don't know, really should cement it in or don't cement it in which one's easier to do. Which one's more likely to need revision. Need revision. Which one's going to be easier on give the better outcome to the patient. But there is a significant variation in the clinical environmental impact from the operations that you're doing. Gets it right. First time in orthopedics They they've gone back on had another look at it on This was from the first study in Manchester on the blue part of the grafts of those having a cemented hip replacement on. You may know some of these centers that if you see there's such a huge variation between the sort of hip replacement you get in stop oars Compared to bolt, Um, which is probably at the most 20 miles apart on my trust is somewhere in the middle between those two organizations, so if you look at the get it right First time, follow up study. They did actually, in a very small part, look at the environmental impact and there was something like nearly 50,000 procedures avoided by adopting the principles of guess it, right. First time on reducing the variables. It's a very contentious topic, but the word used in the get it right first time report is undesirable activity. And getting rid of what was perceived is undesirable. Activity was associated in something like 18 million lbs of procurement savings on a significant reduction and the CEO to be equivalent emissions, associate it with orthopedic practice so well, don't. So I'm gonna move on now to the initiative that I've been involved with, which is the James Linda Lions Greener operations Priority setting partnership. James Lend, if you've never heard of him, was the Scottish naval physician who is credited with doing one of the first clinical trials back in the 18th century who showed in a trial giving all sorts of strange substances that you could reduce scurvy on there by mortality and sailors by giving Citrus fruits on James Linda's name is attached to something called the James Linda Lines, which is allied to the National Institute for Health Research on the James Lind Alliance, does priority setting partnerships to raise awareness of research. Questions on one of the keys is this. The involved patients? Carers, A. Z well, as clinicians, all working together on the James Lynn priority setting partnership, agrees which uncertainties about treatments matter most on deserve the priority on attention for research funding on The unique thing about this is that it gives a voice to patients, and care is not just the clinician's. So the outcome isn't just that of, ah, researcher. You may be biased towards a particular technique, a particular implant or whatever, but it's a it's an open process on, hopefully delivers the research that is important for patients. Uh, we started a project I I'll tell you a couple of years ago. But the NIH are actually announced quite large streams of funding at the time of Cop 26 in Glasgow last year on they still have many funding streams open, uh, which would be applicable for people, wants him to do research, wants him to make operations greener. So it's food for thought, and I think This is an area for research funding. This is only likely to get bigger. So the Green or Operations James Lind Alliance Priority setting partnership. The aim was to set a top 10 research priorities to deliver more sustainable operations on every PSP comes up with a top 10. This actually concluded only two days ago in London on Wednesday, so the results are hot off the press. So we started on this journey back at the end of 2019 when we got approval for it. A cove it came along on inevitably delayed everything. So it's hosted in my trust. Manchester University Foundation Trust and it's funded from monies are how, within the charity that came from a philanthropic patient, what we hosted in Manchester. It's very much a national partnership on We've got many, many major national partners in medical and allied health care professionals, including the Road College of Surgeons of England, the Role College of Surgeons of Edinburgh, the role college of any statistic association of any statistics, many professional body's associating with Hal I happy with with allied health professionals that help us deliver operations on. It's also supported by Center for Stable Healthcare UK Health Alliance for Climate Change. This week was actually the first time I've ever met because we did everything on the zoom up until this Wednesday. So the process involves two keys, surveys and initial survey on an interim survey. The initial survey ran last year on it asked a very open questions about what your thoughts were around delivering more sustainable operations. Um, we have almost 300 responses. Almost 80% of those were healthcare professionals on about 20% from the patient care on public, and we got 1600 suggestions. We then had to distill that into something called the interim survey, which was open until this spring on. I know some of you completed that survey and thank you very much for helping us with this project. We had to include every suggestion that had been raised to be seen, to be given an equal voice to everything. Convince resulted in 60 questions in the interim survey, all the questions in the interim survey hoping subject to a verification of evidence. So we've done on up to date state of the art literature search around the topic of green earth operations on that will be published shortly along with the rest of the project. And we got more responses in the interim survey on a similar split between health care workers on the patient in public. So 25 of those 60 questions were taken to the final beating on Wednesday. So if you completed the survey you out to identify your own 10 priorities, I'm pleased to say that it was actually very good concordant. So despite having a much farm or healthcare workers in patient in public, there was a lot of concordant between the two groups of healthcare and patient and public groups. We identified 25 questions to be considered at the meeting on Wednesday on the concordant spend, there were 15 of each group stopped, 20 included in the top 25. So we had the meeting, which was hosted by the Association of Any Statistics Can do, made their facility in London available, and again it was mix of participants with laypeople, professional people, people from allied health care. They were recruited openly. The nature of the procedure to get to a top 10 out of these 25 is by independent small group working using facilitators from the James and Alliance to make sure that everybody got an equal voice and nobody dominated. So this is just a sample of some of the workings, and you might see mood butter in the picture on the left who was involved on the small groups changed throughout the day. Eso that we get a consensus and there's no strong voice in any particular group, so that you come out with a top 10 that we think is valid. So this was the end of the day. On Wednesday, we was all gathered together, having agreed a top 10 on our going to show you a short video which just announced the top 10. We're here today to send the top 10 priorities for research funding to deliver greener operations to help the NHS achy zero. Today we were joined by diverse group of people. Patients carries conditions members of the public on they've worked really hard to help us to robustly develop these top 10 research priorities. What's the most sustainable forms of effective infection prevention and control used around the time of a non operation? For example, ppd drapes cleaner in ventilation. How can environmental sustainability be incorporated into the organizational management of operating victors. How should the environmental impact in operation we weighed against its clinical outcomes? FINANCIAL. What is the environmental impact? Different anesthetic techniques, for example, different types of general regional local anesthesia used for the same operation? How do we measure and compare the short, long term environmental impacts of surgical and non surgical treatments that the same condition? How come the amounts of waste generated during it around the time of the operation be minimized? Can more efficient use of operating theaters associative practices reduce the environmental impact off for a shins? How can healthcare professionals who deliver care, joining and around this type of operation encouraged to adult sustainable actions in practice? How can help care organizations will sustainably prop your medicines, equipment and I Tums used during and around the time of operation. How come more sustainable reusable equipment safely be used during and around the time of a non operation so that that's the top 10? It's probably difficult to take on board just looking at it like that, but I'll show the top 10, and there's probably something for everybody in there. It's always possible to debate the questions But as I say, there's a very detail literature review to check that all of these questions that were included, uh, not been answered by research or if they're partially answered. There's an identified need for more research in this area. And if you're going to get involved in doing some research in this area, or just making some changes in the environment in which you work the priorities which were a James Lindle, I install 10, um, or likely to be received favorably and more likely to attract funding. Whilst we published the top 10, we're going to publish all of the project, so none off the questions that were raised will will be lost. But you can see there are questions around, uh, the the use of reusable equipment, and the cow cannot be safely use. Uh, there's a lot about procurement, and you've heard already today about procurement. On. That's still a very difficult area is how we procure with an appropriate Calvin budget. They're behavioral questions. How do we actually get ourselves? T change on deliver more sustainable operations? It's difficult enough not to be enticed and sit outside that hope with the patio heater so There's a huge area of research relations about behavior, and I'm sure they're. You'll recognize there are ways that we can use the operating theaters more efficiently, and we need to do research to see how we can show that safe within a lower carbon budget. There's a lot of discussion about waist on down. It's really about minimizing or waste the questions around. Minimizing waste rather than what you do with it with the aim is really not to generate waste, because waste itself is a so were they fairly low proportion of a carbon budget but minimizing that wasting the procurement is important. Measuring our outcomes, which you've been very good at an orthopedic surgery on a short term, the long term basis is important to do. We need to operate how the outcomes for operative and non operative treatments comparing You've heard about anesthesia earlier on, and there's still a lot of questions. There are some assumptions around inhaled and intravenous forms of anesthesia, but it's still a area that's right for research. And there's this big factor about how do we weigh up the environmental impact of an operation with that against its clinical and financial costs on day. Perhaps we should be talking about carbon budgets rather than financial budgets. Or perhaps we should be talking about both. How do we get you get in behavioral term sustainability embedded in our daily practice on what are the most suitable forms off infection prevention? Which compass is many of the things that we've discussed today? So what I would encourage you to to do, we've This's we We've just published the results on the James Lind Alliance website. So if you go and visit the James Lind Alliance website, your see there's links to the green or operations sustainable peri Operative Practice Top 10. Ah, we only got to the conclusion on Wednesday, so we're going to publish the results in full, including the priorities that we're not in. The top 10 will be publishing the literature review but really want to encourage research around these themes on Teo. Get engaged around these things as you discussed on disseminating this, and we're the team that I'm involved with, a very happy to come and talk to two groups that may be interested in doing research in that area. So I'll conclude there. I'm very happy. Teo take any questions or look to see what your evidence of normalized deviance in your operating theaters. A Z being do. What's this space? Is Mork coming out very quickly. Visit James Lind. Alliance Website. Thank you, David. Thanks so much. That was absolutely brilliant. Talk on Thank you very much. Well, for a lot of hard work you're doing with the James Lind Alliance program setting partnership because I think without that kind of engage in our national level, you know, we wouldn't, you know, make a much progress is we would like. So thank you ever so much for that. Um, thank you very much for joining us. And I'm now gonna hand over to all over for some closing remarks from our conference today. Thank you very much. You know, And I just wanted to pass the thank you for your work on today's conference and bringing together a fantastic array of speakers. Thank you, Mr Jones for you. The Aquino speak speech today on. I just want to thank all of you for attending today and making our first on my Naugle sustainability in orthopedic surgery. Conference of success. It truly has been the journey to get this far, but but by you being here today, we hope that we can continue to develop, develop and deliver this event in the years to come on. The hopefully become bigger and better. I want to thank all our speaker's who have shared fantastic initiatives, ideas and ways for us Ultram to aspire to and used to improve our sustainability quality improvement within the NHS. I'm really make a difference. What is clear is that the world is more where the challenge with regards to sustainability, climate change, inefficiency and I think it's vital the surgeons. We continue to contribute to sustainable healthcare and it's triple bottom line to give them it just the best possible chance to improve patient's lives on. I leave you wanting to highlight our Congress. The boat annual congress is in November 21st, the 25th on, so we will be offering a prior to the best test and a beauty projects admitted submitted for presentation. So a lot of you there today who keen on stent ability, we encourage you to Teo get your projects admitted on. We look forward to seeing you in November, which will also be on the metal platform, please. Do you feel that the feedback for me at the end of today on. But that's just know what you thought of the event on. Remember that this event will be available, undermined on the metal platform that anyone teo review to watch with the sessions on, even collect a certificate at the end of attendance. Please do that. Your friends know if you thought that this was a good event, let them there they can Still, it's union and still get a comfort. A course certificate for for it. So thank you all for coming on, but hopefully we'll see you. Our Congress. Oh, last week. Sorry. Before I go, I want to say a big thank you to meddle at Phil and sue for their amazing work and making this happen without it could be possible. So I just want to say thank you to them as well. Much appreciated on their support. So without further ado, enjoy, enjoy the sunshine. And like I said, see our congress