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And hopefully everyone is feeling nice and rested and um we're able to get cracking um for our next section. We've got a couple more presentations before lunchtime. Um I know that we've had a jam packed morning um already and hopefully we've all managed to learn a lot. I know that it's been very thought provoking so far. I've really enjoyed the Dragon's Den with our three fantastic projects, lots to think about and so much scope for potential research and projects going forwards within the field of sustainability in orthopedics. Um I'm going to give everyone just a couple more moments and then we will crack on with um hearing from Mr Prakash, who is our NJ, our sustainability fellow. Thrilled to be able to welcome to the stage, Mr Rohan Prakash. He is one of our new NJ our sustainability fellows. It's the first year that this is um that this fellowship has started and I'm really thrilled to be able to hear from him. I want to say a massive thank you as well because he's actually all the way over the pond in Candida presenting some of his work over there. So Mr Prakash, if you'd like to join us on the stage. Sure. Just share ing my slides now. Perfect. So I'm assuming everyone can see and hear me. Okay. Um So just increase myself. I'm Rohan Prakash. I'm an ST five registrar in Birmingham. Um And I've had the privilege of being the NGR and Bo A sustainability fellow, one of, one of two this year. Uh And I've just got a few slides to present and just want to talk to you a bit about the work that I've done so far and more importantly, what we're planning to do in the next 12 months. Um uh and hopefully that will give you a flavor of things to come. So, uh the topic is the environmental impact and sustainability, particularly of hip and knee arthroplasty. Um So just move forward. So obviously, you guys are well aware of the issue and the NHS produces more than 500,000 tons of waste every year and this equates to 25 megatons of CO2 every year. And these numbers are always interesting but they need context. Um And so in context, that's more than one third of the Uk's public sector emissions. And the work in Brighton has shown that within the hospital, we know that surgery is 3 to 6 times more energy intense than any other department, which is why I really wanted to focus on this issue going forward. Uh And we also know that the energy s has pledged to be net zero by 2045 which is why there's a lot of focus on this area in particular. Um So within the orthopedic subspecialties, we know that arthroplasty produces the most surgical waste per case, which is why the Boe and the NGR in particular wanted to focus on lower limb arthroplasty. And the other aspect to remember is obviously there are environmental benefits of improving how much we're recycling and disposing of waste correctly. But for trusts at an individual level, there are significant financial implications as well, which I'll talk about in a little more detail as we go forward. So my initial study or our initial study at the Royal Orthopaedic Hospital aimed to quantify the amount of waste generated from a primary hip and knee replacement. We also wanted to work out how much we're recycling and also how much waste we're generating from all of the other waste streams. And overall, the aim was clearly to find strategies to reduce the carbon footprint in primary hip and knee arthroplasty. So we, we, we did this initial work last year in summer. Um it was a prospective study and we included primary hips and primary knees. Uh and we excluded any complex primary cases or revision cases because we wanted our findings to be applicable um to the wider population, looking at just primary hips and knees in the first instance. Now, how did we categorize the waist? So we divided them into five streams which will be common across different hospitals in the UK. Uh So the five streams with the dry non hazardous waste, this is typically what goes into the black bins or is known as general waste. The next category is hazardous waste which goes into the orange bins. And then we have recycling sharps and linens. Now, what we did was as the patient was brought into theater from the start of the case to the end of the case, we weighed the bags at the end. Um And the second part of the study was we looked at the general waste specifically and individually itemized what was being thrown into that stream and assessed whether it is recyclable or not to see whether actually we could have been recycling a lot of this waste instead of throwing it away in the general waste. And this is just an image which will illustrate what many of you are already familiar with. So we've got the different waste streams there. So on the right hand side, you've got your contaminated orange bags, then you have your linens, then you have your general waste, then your recycling and then your sharps on the left. So looking at our results, this is a bit busy slide. But if I just attention to the bottom right hand corner, so we had 15 hips uh in our study, the majority were unscented. Uh And now we're producing just under 15 kg of waste per case. Disappointingly. However, if you look at the left hand side of the screen, we're recycling less than half a kilogram of this. The other point to note is that about 70% of this waste is being disposed of as hazardous waste, which seemed quite large to me when we were collecting this data. So looking at our knee replacements, we had 16 knees and we're producing a significantly greater amount of waste per knee replacement. So that was over 17 kg per case. Again. However, we're recycling less than one kg out of this and again, approximately 70% is hazardous waste. So just summarizing that really, we're recycling less than 3% of our waste in our hips and just over 5% in our knees, which certainly is an area that we need to improve on going forward. The other point we noted was a large percentage, as I mentioned is hazardous waste. Um And the nonhazardous or general waste only made up 11% in our hips and 15% in our knees. So looking at the itemized breakdown, I mentioned that we looked at the general waste and then actually itemized what we were throwing away in there. So we looked at 10 hips and 10 knees. And here's an example of one of our hips. So I've broken down the different things that were thrown into the general waste here. The vast majority of the items in terms of number of love packaging and the surgical tray wrapping. And I've highlighted here the disappointing figure that only two items of all of the items thrown were actually labeled as recyclable and that is a big issue and something that we need to address going forward looking our knee replacements. Only one of the items in the entire general waste stream was actually labeled as recycle. And that's the scrub brush packaging. Otherwise everything else was ambiguous. Now, to put these results into context, if you have a normal four joint list, let's say you're doing four total hips all under spinals, just from the waste that we generate alone from the surgical side of things. That's the equivalent in terms of carbon dioxide of flying from London to Edinburgh. And that's excluding all of the anesthetic gases which we know have a significant contributory effect. So we know that we're doing more than 100 and 80,000 hip and knee replacements annually in the UK. So, extrapolating our figures, we estimate that we're generating more than 2.7 million kg of waste every year of this. It seems based on our results locally, we're only recycling less than 3% of the waste in our hips and just over 5% in our knees. Now, the reason that's an issue is because we know that recycled waste has the lowest carbon footprint of all the different waste streams. The other aspect, our initial pilot study identified was incorrect waste segregation. For example, in half the cases in our study, the non contaminated blue sterile wrapping that lines, the instrument trays was being disposed of in the hazardous waste purely because those bins were closest. But in fact, they could have been disposed of in the general waste. Now, why is that an issue? So the work in Brighton has shown that hazardous waste can generate up to 10 times more carbon dioxide than recyclable waste. And this is because the hazardous waste goes off a high temperature incineration which is clearly more energy intensive. And I mentioned cost at the start of the talk. So in our trust, I've I've got the figures and disposing of one bag of hazardous waste is three times more expensive than general waste. And there has been work which has shown that about 60% reduction of operating room waste disposal costs is genuinely achievable purely with diligent waste segregation alone, which is why I think this is a topic worth looking into further. So what can we do? So we can be diligent with our waste segregation and in particular, we can reduce our hazardous waste. I highlighted that only two items in our hip replacements were actually labeled as recyclable, but anything that can be recycled must be recycled. But I think the big challenge going forward is to liaise with medical suppliers and encourage them to improve their labeling. They need to improve their labeling so that we can recycle whatever is recyclable, but they also need to use more recycled materials in making their packaging and that I think can have a big impact and make a big difference. There's awareness amongst the surgical team which is going to be improved with events such as this and, and our impetus going forward. And our next step, which I will be talking about is to form a further study looking at the effect of real time waste segregation in theater. Now, we did this locally. So um I invited our waste management lead to theater so that she could guide me uh and guide us on to what's the optimal strategy of disposing things correctly. So she was able to point out to me what was and was not recyclable uh and what streams things needed to go into. So we, we, we did this for 10 hips and 10 knees and we had an unscripted team member, which was myself in this case, actively segregating the waist during real time during the procedure. And we have some promising early results. So we managed to reduce the hazardous waste by about 20%. So just 17% in our hips and 21% in our knees, the overall waste was reduced slightly. So we reduced it to 94% of the original for hips and 87% of the original for knees. But the focus more was on what we managed to achieve in terms of reducing hazardous waste. Now, initially, 20% reduction, hazardous waste may not seem like a huge deal. But actually, if you extrapolate that to the general population, that can lead to over 300,000 kg of CO2 per year being reduced. So the next step is a multi center study and this is what we'll be doing over the next 12 months. Um both locally in the West Midlands. But also, I've been put in touch with the group cornet, which is a research collaborative group in the northeast who are very kindly assisting with this uh and helping me lead on this. So we'll be performing a prospective waste audit um looking at multiple centers across the UK. And this is important because as you know, each trust has different practices. So some trust will use disposable drapes, disposable gowns, uh some surgeons will pre prep some won't. Um And there's, there's differences um in, in disposal um management strategies in different trust as well depending on local contracts. So what we aim to really do is define the waste generation across trusts with varying practices to give us an overall picture of what we're doing in the UK. So we'll be performing this prospective waste audit and then we'll introduce an intervention which will be local strategies because obviously every trust has their own issues that need to be resolved in terms of waste segregation. But we'll be also be producing an educational talk. It which involves educational videos and um paper work that can be used in theater to try and improve segregation, then we'll reorder it and see if we've managed to make a difference, which I hope we will. Now, as I mentioned, even if we can achieve what seems like a modest reduction of 20% of hazardous waste to general waste. That's the equivalent of someone flying from London to New York every single day of the year. So that's why I think it's worth pursuing because this is something that we can achieve purely with our own diligence and doesn't require anything else. Um So that's, that's the end of my talk. Um Hopefully we have some time to take questions. Um More than happy to answer anything. Uh If you have any questions for me, Rohan, thank you very much for this excellent presentation. Um So I've got a couple of questions. Well, couple of points. The first is um do you know what happens to the waste once it's been put into the separate bins in your trust? Where, where do the bags go practically? And then what, what, how are they processed individually? Yeah. So um our trust recently has, has changed um it's practice in this regard. So actually the general waste. So whatever goes into the black bags is now being sent to um an energy renewal facility. So it's, it's, it's being used again to, to generate further energy. In essence, it's, it's almost being recycled. Um The, the orange waste goes to a high temperature incinerator, um which is, which is the main issue. Um So actually what we've been encouraged to locally is yes, they want us to recycle more. But actually what they want us to do is just make sure things don't go unnecessarily into the orange hazardous waste because that's the real culprit here. Whereas actually the difference between the general waste and recycling streams in in our hospital is not that different, but obviously that this will vary because not every trust we use energy renewal facilities for their, for their black bags. So the sac that leads me on to my second point and that is in our trust. Um The cost of processing a bag of recycled material is actually cheaper than the general waste bag. I'm not sure if you made that point when you were talking about costs, but I just thought I'd just reiterate that that should be one of the motivations for us to recycle items as well as trying to help the environment and potentially make our lives easier. Yeah. No, absolutely. I agree. So the figures that I managed to get from our trust reflect that. Um So recycled waste was, was the cheapest followed, you know, closely by the general waste. Um And, and, and our trust, one bag of hazardous waste is three times more expensive than both of those. So I completely agree that the, the incentive for the trust is, is definitely going to be cost as well. Excellent. Thank you, Francesca. Thank you very much. That was absolutely fantastic, Rohan, we really appreciate you coming and joining us all the way from over in Candida. And I think we said it's incredibly early in the morning there for you. So thank you so much for taking the time and I hope that your presentation later today goes well, thanks brand. I really appreciate it. Thanks for having me. Thank you very much. We look forward to hearing more about your work in the future. Um And it, I'd like to uh introduce our next speak.