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And invite our next speaker to the stage. We've got MS you mcgee who's coming to us from ST George's in London and she's going to be talking to us about elective surgery in elective hand surgical hubs. Um So I'm going to, I know that your wifi is potentially a little bit dodgy, but we're gonna hopefully work from there and we're delighted to have you here today. The stage is yours. Thank you very much. Indeed. It's a real pleasure to be here. Thanks. Um I'm a shame, Yamaji, um a hand surgeon, orthopedic, hand surgeon at ST George's. Um And I'm also clinical director for surgery there. Um We, the, the opportunity to do is in a more sustainable and more efficient manner presented itself to us really post pandemic. We were suddenly presented with these modular theaters. Um There was central funding for those and um we were told, get on and make those, you know, there's a four new theaters off site, so not on our main site on our, one of our satellite hospitals called Mary's. Um And there's a and E there. So it's separated from uh you know, emergency pressures, the government gave us the opportunity to build those things. Of course, said, yes, this was to help us tackle the elective backlog. Um And then we, we also were able to access funding from the CDC project and the CDC stream, that's the community diagnostics worked. And they, they were going to give us some funding so that we could create some clinical pathways that involved some diagnostics. So we thought a bit naturally and we thought, how could we apply to some are muscular skeletal systems? And an obvious one is hands and we, we, that's how it all happened. And then these things just somehow, you know, eventually just sort of come together. And um so ball so much of the stuff I'm going to talk about, particularly regards to hand surgery is, is stuff we've always been doing actually, but this was an opportunity to impact really good bits of practice um and such and, and make them um you know, sort of policy and more widespread. So, um we, we know that we have quite a lot of um common hand conditions which, you know, are high volume and low complexity and they're often mixed in with some of our more complex treatments which we see in the same clinics and it makes clinics quite difficult actually. They're kind of quite difficult to manage and pay sh just getting booked into the wrong areas and stuff like that. And we thought, let's do this better with this opportunity post pandemic. So we decided that create new clinical pathway whereby some key common hand conditions, these are really high volume carpal tunnel syndrome, treated it. Basil thump arthritis and quervain's. We see lots and lots that we see hundreds of these each year and we thought we'd cohort them and do and treat them in a more lean and efficient manner. These are painful, debilitating conditions and these were arguably dip prioritized like lots of muscular scalito orthopedic problems during the pandemic. So we did indeed have a massive backlog. These are really important conditions like arthritis of the hip and arthritis of the knee because they really are painful and debilitating and have an extremely impactful for patient's yet very effective treatment is available. Carpal tunnel is a good example of such a thing. That's a 5 5% of the population are affected. So that's millions. And according to the Royal College of Surgeons, these are a priority to condition, which means you really ought to treat them within four weeks. Um And that's the same as some of the cancers that we treat. Um And the reason it's important because carpal tunnel syndrome can cause numbness, tingling, loss of dexterity, weakness and wasting. And yet you've got a really effective treatment available for them. Carpal tunnel decompression is a good operation like total hip replacement. It's a good operation. It's very effective. The quality value is really competitive. It's 0.78 this makes it a highly effective safe if procedure to do. And the success rate in the right patient is about 90% if not higher. And it has a big socio economic impact. If my hands, if I had severe carpal tunnel syndrome, I would struggle to work as a surgeon. And that would certainly be very, very impactful, not just for me, but for my family and my lifestyle and also for my patient's the and there are established um, evidence based guidelines endorsed by British Hand Society, Girth Bo A and Back Press, which is the Plastics Association. And there's really very little reason to deviate away from these pathways there, good pathways, they make sense, they're endorsed by all the right people and, and the same exists, um certainly from be ssh perspective, other pathways for trigger digit to court veins and basil from arthritis. And at the core of all these pathways is ensuring that patient's all always have the first line non operative treatments um delivered to them. In the first instance, it's really important that only patient's who meet the criteria for surgery, undergo, undergo surgery. And there still is variation. We see it within our own practices in our own hospitals and we certainly see it beyond that too. So only surgery for patient's who meet those cry criteria there established and agreed criteria. And it's important that we do that many of the symptoms that these patient's our experience and can be managed effectively nonoperatively with, for example, splints, hand therapy, steroid injections and so forth, and many of them are really effectively treated by those treatments that we've just talked about. So how does the hand hub work? The hand hub will set up um to look after those key conditions, the high volume, low complexity conditions off site. So we wanted to cohort them and we wanted to treat them away from our acute service. So that pressures of the things like the pandemic and more laterally, even emergency pressures would not be impactful on these um on these conditions that were already dip prioritized during the pandemic. So all patient's all referrals underwent a virtual triage by a clinician and this clinician was a nurse consultant for us. Um This nurse consultant happens to be extremely experienced in hand surgery and hand conditions and she was looking for a different way of working. She had previously been with us doing a lot of the hand trauma and wanted a change of scene. And if we hadn't come up with this new pathway in a different site, we would have lost her and that would have, we would have lost a really experience, a really valuable member of staff. And if anything we've learned during the pandemic, just how important staff are, how important it is to retain and recruit staff, it's no mean feat. Um And you know, I'm particularly proud of the fact that we were able to keep um and um you know, progress and develop our nurse consultant. So she had a new role, this excited her. Um it was good for her career and, you know, for her ambitions. And so she would virtually triage all the referrals and all those key conditions we talked about would be um booked to go to the hand hub offsite and leaving the complex referrals on the main site. Um And if any patient's required any tests locally like nerve conduction studies, they were preordered so that when patient's were seen in the hand hub, they had already had the nerve conduction study done and that was usually done locally. Um And we were able to empower GPS to order those for us and so forth and if not, we would help them. Um So the benefit of having an initial virtual consultation meant that about 10% of patient's who didn't need to be seen because their conditions were already improved whilst waiting, they didn't, they didn't get a face to face visit, it was unnecessary. So only those patient's who were symptom Matic were booked in for a face to face consultation with the nurse consultant. And so she would be the first person to see all the triggers, the ganglia, the decor veins and the carpal tunnels. And she was more than capable of seeing those patients' assessing them, treating them and discharging them. And if patient's met the surgical criteria, like some of the carpal tunnel syndrome patient's would then they were added directly onto the waiting list. Um The steroid injections could be done in the clinic as you can see in that image on the right or they were done under ultrasound guidance by a radiologist and we had a radiologist on site um doing a list side by side with us. So that conditions like the basil thumb arthritis, those most of us do those under image guidance, those were done by the radiologist on the same day. Now, all of these patient's once they had their treatments, we could discharge them, um they didn't require any further follow up. Um And we gave them some the ability to get back into the system if required, that's called patient initiated follow up or pitch fu and we're developing that further and rolling it across our various other specialties. We haven't got to where we really want to be with that, but that is a really good thing to do because lots of patient's often asked for follow up and often junior doctors are reluctant to fully discharge patient's because they're worried about what if this happens when they go etcetera. But by given them the confidence to get back into the system if required, if there was a reason to do so, that helps a lot. And it meant that our follow up rate was 15%. This is a huge reduction compared to our usual clinics where the follow up rate is you know, at least 50% is too high. Um But because the whole ethos of this clinic, the hand hub was to see treat discharge patient's. Um that was the expectation, the whole set up was geared towards that patient's were empowered. They had information that was available to them on the website. Um And, and they had the confidence of coming back to the service if required. We've had really positive feedback from patient's. Um it's had a really positive impact on our waiting list and I'll show you the numbers in a bit and we haven't had any serious complications. I just expect these are relatively low risk treatments. Um Steroid injections, it's very unlikely um that they would get any serious complications and empowering patient's informing them as to what they should expect helps a lot. So the common things like um deep pigmentation and skin atrophy, we'd inform them about that quite clearly and they would expect it and it doesn't usually trouble patient's. So the impact on our waiting list has been really positive February last year, we had about 530 patient's on our PTL. That's the patient cracking list. And with the next appointment available at 12 weeks and that's three months. And when we last looked at it in April, we had about 230 patient's on our PTL. So that's 60% reduction with the next available appointment at six weeks. So that's a massive reduction from 12 weeks to six weeks for a for conditions like hand, common, common hand conditions. That's a really good reduction in our waiting list. And that's thanks to the virtual triage, the reduction in follow up. Um and the, the one stop nature, the ability to offer same day definitive treatment and discharge resulting in a much leaner clinical pathway. And that's what the hand hub has allowed us to do. Coming on to sustainability. We all know about carbon net zero by 2045. The NHS is a big polluter and the operating theater is an even bigger polluter. Um And you know, sort of numbers wise, they're sort of 25 mega tons of carbon um carbon footprint. Thanks to the NHS. All surgeons like efficiency. There is, I don't know, a single surgeon who does not like efficiency. I love efficiency. Um and efficiency equals sustainability. If you do things efficiently, your practice will probably be very, very sustainable environmentally. Um And so we've talked about the non treatment options, patient education. It that's where the biggest gains, our insurance understand how to prevent actual disease and that's impossible with those conditions. I've talked about carpal tunnel syndrome, etcetera. And we've created patient friendly, user friendly digital emission sheets that they can access by going on to our hand website. And we even we pink sheets out to patient so that they are armed with all that information even before they come to see us um fewer trouble journeys we've already talked about by having fewer follow ups by having virtual consultations. Patient's come into the hospital for face to face, much less, which is great. Um um And going on to the surgical side itself, hands lends itself to wide awake surgery and while and stands for wide awake, local anesthetic take no tourniquet. Um A lot of hand surgery can be done that boy and by having these post pandemic, um you know, innovations like the hand hub and are modular theaters, we've really had to bed that well and approach and um you know, it was a bit patchy. Sometimes people would say it's a quicker to do a general anesthetic, let's just do that. Um But we've got to move away from that. We've got to do what's right for the patient and we've got to do um what's also right for the environment, you know, with the fullness of time, all these things make a big difference. We know that general anesthetic is quite a major polluter. And in hand surgery really does lend itself to local anesthetic as well as regional anesthetic. And um you know, we, we've had big discussions with our anesthetists, nearly all the newer trainees in anaesthetics are really good at doing regional techniques. Um And, you know, this is not just upper limits, also lower them. So very important that we promote that and, you know, and, and set that as an expectation for our patient. So my hand list, most of my patient's when they go on the list, there will be booked for a regional anesthetic or a local anesthetic and they will come in if the patient will come in expecting that, which helps enormously, then other measures like um Leena instrument sets. If you my surgical handset for a simple thing like carpal tunnel used to have sort of 50 items on it, completely unnecessary. Um This was a real historic Larry uh relic. It was the same handset that my predecessor 20 years ago used. And um nobody had ever bothered to rationalize that because it's hard work involves a lot of um re um sort of a badging and redistribution of, you know, and working quite hard with procurement to create new sets and all the rest of it. But that initial work is really worthwhile. It isn't easy but, and it does require, you know, good conversations in depth conversations with procurement between clinicians and procurement and scrub teams. And, and we had to put time aside to do that and it was the pandemic that forced those discussions. And the fact that we had these new theaters where we could start with a blank canvas meant that we could start off with sets that we wanted. Having massive sets with lots and lots of items particularly unnecessary is a real problem. A it takes ages to count them out for the nurse. It, they're heavy, they're not great ergonomically and storage wise. A big problem. We'll come onto that a bit later and the whole based handrub and I'll talk about that using that instead of running water. And we've talked about the sustainable modular theaters. So reducing travel journeys. We, we, by having the virtual consultations, we really have been able to um cut those right down. We've gone from for, for carpal tunnel syndrome, um including surgery and POSTOP visit. We've gone from five previous visits to a total of three and for trigger digit to basil thumb arthritis. We've gone from three previous visits to single one and that represents a footprint saving or six kg 6.6 kg um carbon footprint per one stop. That's and when you amplify that by hundreds and hundreds, um that's really, you know, massive, that's massive and you got to roll that out within this, outside, outside our own hospital, within the sector and beyond. And that's when you get the savings the same day nature of diagnostics. Having that available has obviously been incredibly helpful to. Um we talked earlier about alcohol based handrub, the Royal College of Surgeons recently approved this as well, I think not recently quite some while ago. And so the first um scrub of the day is a traditional two minute scrub with a brush water. Um And you know, the usual thing, you brush your hands, you brush your forearms, um use clot hex 2% and running water. That's the first scrub of the day. So we should still, we're doing that. And then all subsequent scrubs are involved using this alcohol based hand rub and that's proven to be really useful. We initially had lots of concerns that it's going to dry people's hands out and they're gonna get dermatitis and, um, it would be a problematic and it's just absolute nonsense. These have got built in moisturizer and I really like them, the hands feel really clean afterwards. Um You know, your hands are slathered in this high concentration, alcohol. And I certainly have not developed any, you know, problems with my skin, etcetera and all those concern, I have not really proven to materialize. It's really good and all my colleagues who have started using it and quite a lot of them have really like it, it's not new in North America. They arthroplasty surgeons have been using this for many years. There's a massive evidence base. There's no evidence that the infection rates are higher with alcohol based handrub compared to traditional techniques. Um So really people ought to look into that. That, that is excellent. I have to say I was cynical about this about a year ago when, when, when a colleague mentioned it and now we're totally embraced it and we're trying to roll it out into the rest of our operating theaters. And, and we found that if we, if we, if we start using this instead of um running water for every single case, then you will definitely see a reduction in electricity and water use. And um one of my colleagues calculated it would be eight kg carbon footprint per hand case. And of course, if you magnify this, if you, you know, magnify the sub scale it up for all these common hand conditions and beyond the saving would be massive in terms of running water and electricity bills. So, um coming too wide awake surgery, um, you know, it's a no brainer for limb surgery. We should absolutely be thinking about regional anesthesia. This is for trauma as well as for elective surgery. Um, the, the, you know, when you look at the impact of general anesthetic on the, on the on greenhouse gas emission, it's massive and we've, we've all seen what the weather has been. I'm not a sort of massive environmentalist, but I do like efficiency and, um, you know, and, and I, and we can all see what the climate has been doing latterly. So there's something in this. We've got to embrace it. Um, and we, the numbers from, um, I think these come from the Royal College of surgeons, actually 18 kg carbon footprint saved by using regional or local anesthetic instead of general anesthetic. Um, so it's a big saving, streamlining handsets. We talked, I touched on this earlier. If you look at the picture above, in the picture below, I previously had about 50 almost 50 items in my handset for a simple case like a trigger finger or a carpal tunnel. Um And that's been reduced right down to 19. And that, that represents quite a significant saving of, of about 66 to 77 grams per carbon footprint, per instruments. Saved less sterilization, less packaging, less plastic, much easier on storage. Storage is a massive problem in most hospitals. Um They're not as heavy the instruments as the sets as a result, which the nurses appreciate greatly. Um Previously, when we had 50 items, it used to take longer to count the instruments out by the nurse. You know, they have to say, um count them out at the start of a procedure. And at the end of the procedure and all that took much longer than the operation itself is absolutely absurd. And the longer all that time takes, the longer you're in the operating theater and that's, that's less efficient and that's more carbon footprint. So anything we can do to reduce the total turnaround time that helps a lot. Um And coming on to our modular theaters, these were again a product of the pandemic. We were given central funding to create these. These are, are Queen Mary site in Roehampton. They were built in a car park. Actually, they were created offsite, they were built elsewhere and then they once created, they were brought over to Queen Mary's and, you know, with cranes and all the rest of it and they were put together, they composed together energy management, better waste management. Um And it's good for the site not to have all this construction happening on site. So, um you know, and, and these are modern theaters when you look at the inside of these theaters are absolutely amazing. They're better than our old theaters on our ST George's site. They, they're bright, they've got the state of the art ventilation. Um They've got Laminar flow, their lead line and the doors open electronically. Um You know, everything about the modern building techniques are really excellent and their energy consumption is much lower. They all get turned, everything gets turned off after, you know, six pm when everybody when everything is finished. So they really are presenting us with significant energy savings there better insulated. For example, of course, they're day surgical and the knee nature of them means nearly everything we do there is under regional or local anesthetic. We do have some general anesthetic cases, but it's not just for hands, it's also for gynaecology, ophthalmology, max, facts, surgery, etcetera. Um When we, when we first created these theaters, which was about two years ago, people reluctant to go, the surgeons were reluctant to go there because surgeons are quite, it's quite hard to change habits. And I remem been a bit snooty about going there as well, but now that they're embedded and by having a surgical hand hub on site on the same site as the modular theaters has helped a lot. And it's attracted more surgeons and we're beginning, people are now asking to go there and we're working at full capacity only last week, we celebrated the two year anniversary of these theaters and they're, they're doing really well. The rate at which the utilization has improved has been exp financial is sluggish at first, but it really has improved day surgical procedures compared to inpatient procedures, even if it's the same case, have a huge carbon footprint saving. So if you do a case as day surgery, the same operation 26 kg, carbon footprint versus 92 kg, if it's done as a day, day impatient and that's excluding the uh anesthetic gases. So there's real benefit in doing day surgery. There are so many things here. We've touched on so many small steps that together can have a significant impact. And we've talked about patient education and empowerment. Those are the biggest gains who really need to work, only patient's who meet the criteria for surgery. That's good medical practice. And it's also means you're, you know, you're following evidence based guidance and and, and it's good in terms of sustainability. Also. Um we talked about the simple measures like um you know, reducing travel journeys using virtual consultations where you can have in the same day diagnostics and um same day treatments having pin fu or patient initiated follow up reducing for follow up unnecessary follow up using regional techniques as opposed to general aesthetic. We touched on the alcohol based handrub, all those small things make the clinical pathways and the surgical pathways more efficient and efficiency, equal sustainability. I think that's all I have to say for. Thank you very much. Indeed. That's fantastic. Thank you so much for your time today. That was, that was an absolutely brilliant uh presentation and actually, we've had lots of comments um in the chat saying thank you so much for how clear this was and actually just for bringing it home about what we can actually do and thinking about one of the subspecialties um within orthopedics. Um Mr Sopa. Did you have any questions or would you like me to go for the ones from the, from the chat to start with? Um I, I actually just wanted to say that was a brilliant presentation and it's an excellent transformation project. Um It's brought about a lot of benefits both from um environmental perspective, social perspective for staff, for patient's and from a cost perspective. So I think it's a really good example of a project and I guess if you're going to go through some of the questions, but I, I can understand why these are coming in. So thank you. Very kind. I think our first one was, it's, it's fantastic. You've got these hubs and that you're utilizing the members of the MDT. And one of our questions is where do you see trainees fitting in within the virtual clinic, triaging or nurse consultant model. Yeah, it's a good question and actually it's protected um teaching and training opportunities by having it off site or a site. The first of all, we had the pressures of the pandemic and everything got de prioritized. And once we got over that the emergency workload, people might bottom what it's been like in the last 6 to 89 months. But we've had the equivalent of winter pressures since last summer. With the urgency work. Most hospitals is absolute. Absolutely spiral. We've all heard about it with the pressures on ambulances, you know, ambulances holding papers not able to get into um the ed the emergency department and the impact of that on elective worse if because the beds have been occupied by acute emergency patient's. These are patient's from all specialties, particularly medicine. Um We've not been able to do some of our elective surgery even in the summer months. And so having an offsite modular theater, the ed pressure's just don't interfere even during industrial Axion laterally, we were able to keep those theatres going because carpal tunnel is a priority to condition. Um you know, same as some of the cancers that we look after. So we were able to keep those theatres running despite all the pressure's on the acute, I always have a trainee with me when I go to the hands hub, nurse consultants very experienced. And if, if we could certainly have a trainee with, to, um, the operating list. We always have a trainee even during the industrial. Actually, we're lucky to have, um, some of our juniors, non trainees as well. The trainees, um, some of not everybody was striking, they were able to be there if they wanted to be there. And I've seen nothing but positivity around the hand hub and the modular theaters in terms of training because just being offsite effectively ring site, ring fences. Um that activity that's really interesting and actually from a trainee's perspective, it's really reassuring to hear that there are people that are going to be advocating for us in this kind of a model. Um We've got another question from the chat here that refers more back to um reduce reuse, recycle and thinking about the alcohol based hand rubs for surgical preparation. And Alexandra has asked with the alcohol hand rub proposal, what's the impact of water use in manufacturing that alcohol gel compared with using running water directly? I wonder if that research has been has been done. Yeah. Well, I don't know the answer to that and you know, it's something we need to look into. Um But you know, one's gut feeling is using this stuff is definitely more energy friendly than having a running tap water for two minutes. I mean, cases like hand surge, you know, simple hand surgery, we would do eight carpal tunnel's on a single list, for example, So that's more session and it's, it having the alcohol, it speeds up the turnaround time because it takes about 30 seconds compared to two seconds, two minutes of, um, you know, wash time. Um It feels very much so like it's more efficient efficiency is sustainability. We get more cases done if the turnaround time is effective. Um, it feels, I don't know the exact answer you Mary and maybe the research has been done or needs to be looked into. Um, but, you know, you know, it feels like the right thing to do. Um, I just want to add. So we, we did work on water wastage at Swell EOC Southwest London Elective Orthopedic Center and we, we calculated that we were wasting 100,000 liters of water a year in the time between applying soap and washing hands. So that, um, that's just because the timers wouldn't switch off. So there's a lot of water that's wasted in scrubbing over a year, particularly high volume centers and alcohol rubs which are recommended by the who have a good role in this. Um, in our practice, I, I actually use alcohol rubs, um, for my subsequent cases. Um, I do one wash and then alcohol rub as opposed to four, you know, five or six washes at the start of the day. Yeah, that's good to know. Um, I don't think there's any other questions from the chat, but thank you very much for your time. Today, I think we've all really appreciated it. And actually, it's been a fantastic um discussion about what we can do and what we can achieve. And actually I'm seeing a lot of your work reflected in what I'm doing all the way up in, in North Wales, with, with my hand surgeon consultant at the moment. So I think that there is, this work is, is spreading and it is becoming more and more common. So it's, it is fantastic to see. So, thank you very much for your time. Yeah, thanks very much. Indeed. The best, all the best, what we're going to do now is we're actually going to move.