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And next speaker to the stage. Um It gives me great pleasure to be able to welcome Mr Oliver Donaldson from Yeovil District Hospital to talk to us about their project they've done over the last couple of years looking at surgical trade rationalization. So Mr Donaldson over to you. Uh Thanks Fran, it's pleasure to see you. Um It's been a little while but it seems that you're thriving, which is fantastic. So hopefully you can see my slides, okay. Um And I've been giving half an hour. If I go on for half an hour, you feel free to stop me. But please, because I think I'm just before lunch, but I don't think I'll go on for a full half an hour. So we did a study looking at rationalisation of orthopedic surgical instrument trades and, and working out whether we can produce this to improve on costs. Um So I won't bore you too much with this, but as you can all understand, orthopedics is a high um uh there's a significant proportion of surgical workload throughout the k with well over a million procedures done per year. And so what we want to do is look as to whether we could reduce the amount of instrument trades that we opened per case that we did. Um So why do we do this? Well, I've been a consultant for 10 years that I, when I realized that I was a bit disappointing cause I still feel like a new consultant. But when we all become consultants or go to a new hospital, we do observe different things. And so when I did a shoulder replacement, I'm a shoulder surgeon. When I did a shoulder replacement, I was asked by the nurses whether I wanted the Chandler tray and the smile but retractors and, and Mr Chandler was my predecessor. So maybe the Chandler tray had some things which were important and the smile Retractors was also a predecessor of mine. I thought, well, I don't need trays named after me. And, and, and I just suddenly thought, well, why are we using trades which have been used for for years and years? So that was one observation. Uh maybe, maybe my ego, I suppose. Um the second thing was when I looked at the DHS trays, um when we opened the DHS trades, we're opening four trays. And I could only really think about sort of 10 instruments ever used on those trades. I thought this ridiculousness and the same thing happened with arthroscopy. So a simple arthroscopy were open three trades. And I suppose the the thing when you go into a new, new place of work. You, you uh suddenly realized that what has just become completely ingrained in terms of what the hospital does. Sometimes having a new look on that might make a difference. And so, um I have to confess that the reasons we did this was not in any way looking at sustainability or anything like that, it was more because I just thought it was a bit crazy to open all these things. But thankfully, the secondary benefits have been to reduce costs and, and improve efficiency. So, so what do we do? So it took me a few years to get round to doing this, but we looked at uh specific uh specific and common surgeries that we did. And so, and tried to work out whether we could reduce the amount of social instruments uh that we're opening a specifically dynamic hip screw because that was fairly common operation. And then I, I um specifically looked at the shoulder ones because um as the as the main shoulder surgeon in the in the department that was relatively easy to uh influence. Uh So for reach surgical instruments trade, we tried to identify what we were opening and then tried to work out um what we were duplicating what wasn't required and what were the specific instruments that we had within their, which we did need. Um We looked at the numbers of trade, you're opening before we started the rationalization processing. And then, um and then afterwards to identify how many, how, how, how, how much of a reduction we could, uh, achieve and then worked out what our numbers were for those specific cases over an annual basis. So, in the end we did it over a three year basis. So, uh, I don't think anybody would know exactly how much it costs to, uh, sterilize one surgical tray. And there was not a clear answer. There's no clear answer within the literature either but through a numerous uh sort of sources which uh an investigations, a reasonable estimate in terms of what the cost is to just sterilize one surgical trades about 35 lbs. So it's not an insignificant amount. And you think about how many were opening on a daily basis to do our other surgeries were doing. So this is an example. So you won't be able to see this that clearly. But I uh what you can see here is, is part of what we used to open for the DHS. So these were two trades we opened. So one was called the general trades. That's the general surgery. And then that's the top, right? And then the other one was called the orthopedic Extras Tray. Um So, uh to me that beggared belief in its own right, that we're open a general surgical trade to do an orthopedic case. But, but there, there we are, um and so the variety of instruments we didn't need and we were duplicated hugely So that was two out of the four trades we opened, obviously, we have the power tools and then the DHS specific uh instruments that we would need as well. So myself and the scrub nurse when, and um looked into these trades and tried to work out what uh what we actually did need and what we didn't need a cautionary word. Now about your sterile services department is, is change is quite a challenge for them. And they're, they're quite process driven. They like to know that what, what's happening with all their trades. And so trying to change trades can be quite a challenging process to go through. It doesn't mean that you shouldn't do it, but you need to ensure that you um fill them with positive words of encouragement throughout this process because in theory, it should make their life easier in the long run. So what we had with those four trays, we managed to get down to a simple tray of orthopedic instruments, which we thought we would need including the DHS tray of specific instrument and then the power tools. So this was put on a sort of a two layered tray uh followed by the power tools. And so we went from have four trays here down to just two trays. Um So I think, I think what we forget is the amount of time it takes to open these trades to check all the instruments on the trays, the weight of the trade. So it's not just about the cost of sterilization, this had a huge number of benefits in terms of trying to reduce that. So when after we did the dynamic hip screw one, we thought, well, let's look at the other trades. And so for basic arthroscopies, we were opening three trades every time we did a knee scope of shoulder scope, anything basic, we would be opening three trays. But but by trying to um uh consolidate what we had, I managed to get that down to one for things such as rotator cuff repairs, and stabilizations. We're opening five trays just to do a, a simple rotator cuff repair. But I managed to get that down to two and then for a shoulder replacements and things, we went from three trays down to one. So we made a significant difference in terms of the number of trades we're using. And, and I think the reason this happened was mainly because it was somebody coming in and having a new look and saying, you know, these things which we open, why are we doing that? So, you know, for example, the amount of times you hear about needing one specific instrument during surgery and someone goes, oh, that's on that trail. Let's open a whole tray and it's like for one instrument, that's absolutely crazy. But that's, that's just the nature of what we do. So when we look at the number of procedures, it's a little bit of a busy slide. So I'll just take you through this. So these estimated number of procedures in terms of our hospital. So we do roughly um uh about 80 to 100 DHS is per year. We do a significant proportion of um arthroscopies. So we had a number of procedures here. Um And you could see the number of trees were opening. So this is over three year periods and we had 2500 operations over three year period. So, um and during that time, we opened 8000, 355 surgical instruments trades. That's ridiculous amounts of trades that we're opening. And then once we've rationalized how many trades we were going to open, we managed to get that down to 3000. So if you look at the simple maths, simple math is, is the two thirds reduction in the number of trades are opening. When you look at the costs, assuming a cost of 35 lbs per tray, you can see over the three years, we made a cost saving of 100 and 80,000. So that's 60,000 lbs per year. You can look probably at the improvement in terms of uh from a sustainable perspective. So I have to think about this. Now, France told me it's sustainability at all about, but from sustainable perspective, I don't know how much energy is used to um to uh to sterilize each trade, but that is a significant reduction if you think a two thirds reduction in terms of the cost and the energy to, to uh, sterilize these trays. So we all know that surgeons can be quite reticent to any change. And so how do we inform them? Well, for the DHS ones that was the main worry I had. And I thought, well, I'm not going to inform them because I knew that there were some surgeons within our department who would say that they always use this when they do A DHS. And uh and I realized those surgeons actually probably didn't do that many DHS is so, and it was normally the registrar who did it. So I decided not to tell them. And then I monitored what happened over the first sort of 10 to 20 to see if they noticed and guess what nobody noticed. So we managed to change it and no one noticed that we changed it. So I'm not suggesting necessarily that is a way to get through change, but sometimes it is a way to be able to proactively get things sorted. But we did follow that up in more detail. So we did do a survey to see what people, um people thought about the changes to looking at in terms of what variety of questions relating to whether they noticed a change where they thought it was a good idea to change. How often do they need to get other instruments? And so I'll briefly go through that as well for you. So, the survey results for, um, DHS trades. So if you look on the figures here, you can stay with the current DHS trade. You require any further instruments during the surgery. So, 50% thought that was rare. 30% thought it was occasional and then a quarter thought that it was never so in general, it was pretty well, um, uh well received and we accommodated most people's, um, needs a lot of the time when we do surgery as well. Um, we will, uh, ask for an instrument and someone goes and runs and gets that instrument for you in the trade. And by the time that instrument comes back, you kind of dealt with it. So you don't really need that instrument anymore. And inadvertently, a lot of the time they would have opened that instrument by that time. And so you have to almost pretend to use it to make sure that all that effort goes to good use. Uh, maybe that's just me, I don't know, but I'll just be mindful and, and, uh, about that. And so I, I probably worthwhile when you're asking for certain instruments just to change how you ask instead of saying I need this saying, have you got this? Because, um, if they haven't got that, I'm sure you'll be able to cope a lot of the times because a lot of times it will take about five or 10 minutes to find an instrument and you, you will have coped most of the time. Um Maybe that's just me. But give it a go again when we're looking at the arteries, uh the arthroscopy trays in a similar way, everybody seemed to be able to cope quite well. Um There weren't any particular issues uh in a similar way with the shoulder arthroplasty um trays uh and with the proximate humeral trays as well. So in general, reducing the trays was not a problem from a, from an octave perspective. So as I said to you, I wasn't intending to do this project from a sustainability perspective, but it did definitely have a good secondary um outcome by improving our efficiency, reducing our costs and reducing the amount energy that we're using to sterilize trays. The and it's a really easy thing to do. You just, you, you can engage with your sterilize uh with, with the Sterilization Services department, you can engage with your scrub nurses and you can make simple changes, try and improve things. Um There are some, there is some evidence out there already to um support this. Um But in January rationalization, as I said, is reduced in cost, it does reduce the effort because some of these trades can be quite weighty and remember they all have to be checked before and after the case. And so there is a lot more prep time associated with that. This is one paper which published back in 2019, which showed a significant reduction. Once they rationalize the trades, it was an American paper. And so the amount they were able to say was significantly better than us. But again, you know, you're looking at rationalisation, improving efficiency, improving costs. And so how do you judge what is a usable surgical instruments? So anecdotally that the on the shoulder arthroplasty trade that I've got, you have to remember, you can't, unless you're going to start buying certain instruments to make a new trade, you usually just have to amalgamate the trades that you have otherwise that starts becoming costly. And so sometimes there will be instruments which you won't have very commonly, I don't know, like a mcdonald's. So I, I use, um, so uh mcdonald's, I would use it very occasionally when I'm cementing a shoulder replacement in place and that's use your trauma, shoulder replacement. And I thought, well, I don't really use it that much. So we don't have many mcdonald's. So we're going to do without that. And then I pretty much forget every time I do a trauma, shoulder replacement and I asked for mcdonald's, but before they go off chasing for it, I remember, I said, don't worry, I'll cope and you do cope. So there are some little compromises you have to make, but those are little compromises. You will always get the surgeon who says I always use such and such. Um and uh and that's quite difficult to challenge. Uh But you, you can try and challenge that if you want or you just have to accommodate for that. But I think what we've done is we have demonstrated change and a lot of the time those um uh the instruments people always use, you find that they haven't noticed that they've gone and they will only occasionally use them. So those are ways around that. So we are just one center. Uh We didn't get a full feedback. But to be honest, I'm quite happy with the feedback we've had and we've established that since 2017. So we're now six years in, we've saved quite a lot of money for our trust. They seem to be quite happy from that. Um And uh and I am as yet, haven't gone on to other um operations. I, we would, we considered looking at hip replacements and the replacements was the next obvious place to go because that's obviously a high volume um surgery. But as I'm a shoulder surgeon, I will have a number of other interested parties in trying to make any changes there, which is uh is perhaps a battle I'm not willing to take on us yet. Um Thank you very much. So, we know that there's a huge huge amount we need to do regarding efficiency. Really, if you look at efficiency, um that makes a massive difference. If you reduce the number of surgical trays, it can make a huge difference in terms of, in terms of efficiency for your theater staff. Another little anecdote because I'm allowed to because I've got enough time before Fran tells me to stop. But we, we use the ETS hemiarthroplasty for our fraction X femur patient's here. But from a cost perspective, we're strike were giving us a better deal to use something called the unit tracks. Where would you put an extra stem in? Um But uh so we've, we've dabbled and trying to do that from a scrub nurse perspective. They are quite anti it because automatically it means they have to open another two or three trays. They just think that that is not uh efficient. Uh And it, it's made what was a simple um simple operation, a bit more complicated from their, from their side. So remember to bring your scrub nurses along with you and, and talk to them about what they feel are the efficiencies you can make and, and just go for some simple, simple solutions in the first instance. Uh Thank you very much. I think there's some references here and I want to thank Shoddy and Fran who both inputted quite a lot of work on the in this. I think Shoddy has. Uh Well, he's deleted a message just there. I can see. So he was obviously trying to take credit and remind me to thank him, but thank you very much. Thank you very much, Mr Donaldson. Um I will say that obviously, I've got a slight bias, invested interest having worked with you on this paper that we published last year. Um But it really is a fantastic project. And you're saying that this came from maybe more of a cost savings point of view. But I think it's important that everyone thinks that actually sustainability isn't just about green policies, it's actually about service provision as well. And we need to be thinking about financial sustainability given that the NHS is a publicly funded resource. So thank you very much, Mr A soapy. Did you have any questions? As I know, we've got some from the floor already, Mr Donaldson. That's great. Thank you very much for your presentation. Um I just wanted to know what can the trainees do who are with us today um in terms of taking back um the concepts that you've presented and helping to improve their place of work. Uh I think the first things is observation. So just so uh I'm a great believer in that. I'm disappointed in myself when a scrub nurse has to find me from a coffee room or uh to come in because the patient is ready. I'm in theater quite early. I want to be there. I help set up the table if necessary, help set up a lot of things. Um I even occasional mop the floor at the end of the case. So I'm quite happy to do that. A sort of problem. Uh But, but I think observation is quite important. So if you're there at the beginning and you see how many trades they're opening, that's a simple observation to make. You could say, well, it's common operation. It's a hemiarthroplasty. You're opening 55 trays, you know, uh these are the simple things to do. And then from that observation, you can make a judgment call as to whether you can change anything. That that's what I'd say it, it really was uh observation. So start with the observation and then probably a gentle challenge as in do we need to open all these things, you know? Thank you very much. Thanks Francesca. And I know that we've got a question here from Rory saying, um do you have a guide or a plan on or thought thinking about potentially developing a guide which could be used by other trusts to help introduce instrument rationalization? Or do you think it's a little bit too personalized from department to department? So, so one option. So, so I would tell you what not to do. So what we, so what you'll find is actually, um there are elements where when you do a knee replacement, hip replacement, shoulder replacement, you'll have the company specific trades. And actually, on the company's specific trades, there'll be lots of instruments on those trades that you don't use. And so I did think at one stage, well, actually, why don't I just take the ones that I do use and put them on a separate trade and then we can disregard the others. But, and that seemed to be, um, conceptually a good idea. But actually in practice was a bad idea because first of all, the company not happy with that because they say that if you have them rattling around in a cage, they're more prone to getting damaged and therefore they're less like to replace them. So that puts you in a difficult situation. And secondly, the way that the scrub nurse will check those trays is they will open the tray up and they just say no gaps because you can see everything that says no gaps and that's a really quick way of doing that. And so you have to, you have to balance what you can and can't achieve. So, so if you're going to do anything I would use, I would, I would concentrate on the general trades that you use, not, not the ones which are and company specific. Um And you want to ensure that you look at the common operations. So the common operations are clearly the common trauma operations. So what you would use for fracture, neck fema, patient's what you'd use for ankle fractures, things like that. Um And then try and accommodate, you know, try and accommodate as many operations you can within that one tray, my disappoint. So every, every pro problem you solve, you produce another problem that you say so with this, with the open shoulder tray, what that has happened with my open shoulder trays, it's now perceived that I can do all shoulder operations with an open shoulder tray, which I can't do because for clavicle fixation and things like that, there are a variety of different things I need. And sometimes I say, oh, you don't. Well, it's an elbow is an elbow is quite close to the shoulders, will open the open shoulder tray because that will give us everything you need. But it doesn't quite work that way. So you do have to change things. A bit specific guide. Sadly not, I'm afraid just, but start with the observation. That's the key because you may find that they've already done it. That's fantastic. Thank you so much for your time today, Mr Donaldson. Um, we didn't quite hit up the half an hour as you suspected. Um, but thank you very much for your time. We really appreciate it. Um, and I think what we will do now guys is we will have a short break for lunch unless we've got any other questions for any presentations that we've had this morning. Um, I think we've had a fantastic morning so far and I think certainly I've learned an awful lot and I think there's lots of scope for ideas going forwards. Thanks very much, Fran, nice to see you. We see you