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speakers here in person with us. And this is Doctor Katie Bag. She is an academic clinical fellow in general surgery in Yorkshire who aspires to specialize in colorectal surgery. She holds a particular interest in the impact of surgery and healthcare on the environment and is keen to progress with sustainable surgical practices. The team that leads teaching hospitals recently won the National Green Surgery Challenge for entry, demonstrating a sustainable appendicectomy. Since then, they've pioneered the pathway, um, and continue to make changes to ensure that they minimize the impact of the profession as a whole on the environment. They welcome Katie. Thank you. Move this down to my height. Uh, so thanks very much for inviting me to be here today. It's a real pleasure to be here and to be in person and see so many faces in the crowd. Um, So what I'm going to talk today about is an environmental change in theater. I'm going to first discuss green surgery challenge. Um, and then I'm going to discuss what we've done in leads teaching hospitals since then. And I'm going to attempt to small how to guide, um, to see if that can spark an interest in in yourself and whether you might want to get involved in something. Uh, spoiler alert. It's not very easy. So a little bit about myself. I'm proud to have called Yorkshire my home for the last 11 years. I'm a trainee in Yorkshire. Um, and these are some pictures of my last dog walk. Uh, so if anybody needs any reason more to come and train in Yorkshire, that's that's it. Um, I couldn't do a presentation and not get a picture of my dog in. So there. There he is. So the green surgery challenge was in 2021. Um, it was essentially a national competition, which involved six teams from around the country, uh, and was run by the National Institute for Sustainable Healthcare. Um, it was a collaborative competition, and they gave us advice and guidance on how to complete our projects. Leads entry was a holistic approach to a sustainable appendicectomy. Uh, appendicectomy. These were an obvious choice for us. It's an extremely common, uh, emergency operation. And 522 took place in leads in 2019. So we're quite a high volume center for this as well. Um, what we did was we picked four key areas that we wanted to change. And we then performed this on a simulator. Simulated. We simulated this on a cadaver. So we did a normal standard procedure, and then our procedure changes so that we could measure the difference. So what did we do? First of all, we decided to eliminate eliminate catheterization. What? What we did was we ask patients to pass urine straight, right before they came to theater in the in the toilet, literally, just outside theater. Um, what this does is this eliminates the plastic use for catheters. And in a short procedure, when, uh, if you ask the patient to pass urine, then the battle is going to be empty for the duration of the procedure. Um, we on the on the screen, you can see some carbon savings. So first per procedure. And then we we assumed about 80% 80% applicability. Uh, for this. So, um, per year we assumed about 418 operations, you could avoid a catheter. What? This saves in real money is about 1200 miles in a in a petrol car. Um, so not huge savings, but they are. They're the financial impact as well. Demonstrated by not using the equipment is a little bit better. It's about 1000 lbs per year. Our next change was a green laproscopic tray. So in leads we open a large tray for all appendicectomy, which has two trays and 119 items on each tray. Most of these items aren't touched for the entire operation. They're there in case you need to convert to an open operation, and the tray is also suitable for use in laparoscopic cholecystectomy. He's what we did was we identified the most used instruments, the instruments that are touched day in, day out with every operation. And we reduced the tray down to just the 41 most used items, with the option that you could open separate items if you needed to. What this did was, uh, when you send your trays to be sterilized, the company charges you both on the size of the train and the number of trays. So we reduce this to just one tray from to, and we reduced the size, which only not only saves financially because they charge us less, but it also means that they can fit more into the autoclave when they sterilize equipment. So it's, uh, more sustainable as well. Rather than sterilizing equipment that wasn't touched for an entire operation, this is about 2500 miles in a car per year. Next is an obvious choice. Reusable gowns and drapes. These were commonplace years ago, but due to concerns about CJD, an infection control, they were taken away and everybody started to use disposable. The trend is going back to reusable gowns and grapes, and the reasons are obvious. The W. H O says there's no difference. And numerous studies have said that there's that they have considerable financial and environmental, uh, implications. So this is quite a staggering. Just in Appendicectomy is alone. We can save about 6000 miles in a petrol card just by converting to reasonable grounds and grapes. And this is fairly easy in our trust because we already had reasonable in certain areas. So it was just about increasing that supply. Finally, um, what? Our biggest change was using a retractor for abdominal, uh, retractor for abdominal insufflation. This surgery. This was in partnership with Lead Global Health Research Group and essentially, it's a retractor that enables you to, uh, winch up the abdomen without using, um, CO2 for inflation. I'm not going to dwell on this too much because it doesn't have much applicability at the moment in the n. H s, but it is being used in India and has regulatory approval there. Um, this dwarfed all other changes because you eliminate CO2, you eliminate the plastic tubing that goes along with it, and the devices is reusable. So this was a staggering difference. Here's an action in a cadaver. Um, we were in All are reusable gear. You can actually see the views. You get a pretty good um and, uh and this was us in our simulation. What we found most staggering is the amount of physical waste that you produced in an operation. Um, I think I hadn't really thought about it. You see the bags tied up at the end, but you don't actually see the waist laid out in front of you. And this was a standard appendicectomy. We did nothing fancy, nothing different. That's the waist from just a standard procedure. Um, and that equates to about 2 kg of waste that goes to incineration. This was our waste after our changes, which equates to about 500 g of waste, and I think late in front of us was pretty staggering. So the bottom line of our changes, um, I won't discuss too much about the raised device When you just look at our other changes, um, you can save about 10,000 lbs a year and over 10,000 miles in a in a petrol card. Just from those changes in one procedure in one hospital, it seems fairly modest. But when you think of the scalability of that and able to, if you're starting able to do that in all procedures and all hospitals, the savings could be could be staggering. So what have we done since it's all great, we've done it on a cadaver. We've shown our change, but we haven't done anything in the real world. So since May 2020 to what we did was we implemented the green appendicectomy pathway and leads. What that means is that all patients will undergo a green appendicectomy unless the surgeon chooses to opt out. That means they reduced tray reasonable gowns and drapes and pre op, uh, situation. We've introduced a green dependency checklist that's done it brief. And if the surgeon chooses to opt out for certain reasons, then they're able to a brief. We've included the entire theater team in this, and they're really involved. Um, they also have a small audit sheet that they fill in afterwards. Just detailing if there are any deviations from the pathway and if any extra equipment was used. This is our team on our first day, uh, lovely tray there and And our surgeons performing the procedure, I'm just going to go back quickly. So this is our tray here. We procured eight, uh, reduced trays. And these trays actually have metal lids as well. So you don't need the disposable wrapping. Um, that comes standard with most trays. We even went as far as a metal galley, pots and kidney dishes, which is actually my favorite. They're quite tactile. Um, they're very shiny still. So, um, So evaluation Since May. So far, we've done 100 and 20 appendicectomy is in on on the green pathway, which is pretty good, and we've less than 10% of, uh, the pen diskectomies. Did they open any extra equipment, so I think that I don't That's a really good figure. So either single use or reusable single equipment there is less than less than 12 operations opened anything. I think this stems from good identification from the surgeon and brief of whether they think this is going to be a difficult operation where they might need other equipment or they might need to open, and that leads to. That means that they might choose to deviate from the pathway. All surgeons and staff that we've asked have been really satisfied with the changes. We've not had anything negative. I think this stems from including the entire theater team in this decision and introducing this pathway. There have been some challenges along way, that's for sure. Um, one would include we only have eight trays. So when it's been a busy week, we need to fast track these trays two so that we have them, and that is a financial implication to the trust. I'm not sure about the environmental impact of that. We also have been having issues of getting different equipment back in our trays, so you might get some places that are useless You know, we've all been there. You can't cut cut through anything with them. Um, when we've bought new equipment specifically for these trays, we have finally ironed out with, uh, supplier. Um, so hopefully that shouldn't happen any longer. Um, further work that we've done. I'm pleased to announce that we've just been awarded a grant from the healthier future Features Action Fund to extend this towards laparoscopic cholecystectomy knees both in acute and elective. So, um, what's the space for that? So I'm going to attempt to how to guide now so that I can maybe spark an idea in your head. There's by know, by no means that one size fits all for everybody. But if I can, you know, see if I can kind of help you to to think where to start, then I'm happy with that. So first of all, identify your procedure process that you want to change. This is really key. You want to make sure this is a high volume procedure, something that's happening day in, day out, because there's no point using an operation that happens once a year that produces 100 tons of rubbish. You're not really going to make a difference there. What you're gonna make a difference is something that just happens all the time that you want to change. Process, map, process, process, map. That's the most important thing you need to choose your start and your endpoint. Um, so we chose when the patient enters theater, too, when they leave, and you need to make a detailed process map of that procedure, including everything that goes on and an inventory of every equipment that's used. This will help you to see really clearly where to make those changes and where to make a difference. For example, catheterization wasn't something we thought about until we saw a process map. And we thought, Why are we doing that? Still, calculate the difference Sounds easy. Anybody that's done it before, this is the most difficult thing that you'll ever do. I'm not a mathematician. I hate maths, and this is impossible. Um, so it's really different. Difficult to calculate carbon footprint ing. Um, and there's lots of resources out there, particularly from the Institute of Sustainable Healthcare that might help you. What everyone says is that don't try to carbon footprint the entire procedure you can fall into a black hole of thinking about the van that takes things from the supplier to here and how the person got theater and all of this. Think a bit smaller and just calculate the difference in your project. So if you have, in terms of physical waste 500 g rather than 2 kg, that's easy to calculate the difference rather than to calculate the waist from the start. Find your procurement team. Make them your best friend. If you're changing anything about the supply or anything about equipment, these guys are your friend. They'll know more about supply chains than you do. I know nothing about supply chains before I started, and, um, they are usually really knowledgeable, and sometimes they even have life cycle analysis. You come across a lot of red tape, and these guys are usually your best friend at trying to avoid that. And so and lastly is two. Pilot The change. Don't try and make a change really quickly and make and have every operation doing what you want to change, try and pilot it in one operation, or even like we did on a cadaver, thanks to lead university and show that you've made a difference, and then you'll have more people on board in order to actually make a make a change. So lesson I learned. So hopefully you don't have to do is, uh, first of all, collaborate with everyone. Don't do this on your own. It won't work. Like I said, I had knew nothing about supply chains. I knew nothing about procurement with involving the entire theater team, like our senior sister, Arlene, who knew everything about who our suppliers were. Everything about where she got all the equipment from meant that she was amazing at procuring the trays. Sounds really easy to get eight new trace, but the red tape and the hoops you have to jump through is incredible. So these people are your friends, and you won't be able to do anything on your own. Trying to have senior buying is really important as well. Choose your changes wisely. Don't fight with infection control for six months about paper towels. When you can make a three fold difference somewhere else, choose a small change. Don't try to reinvent the wheel. Don't expect change overnight. Anybody has worked in the NHS knows that this is impossible. You can't have change overnight. You might not even have changed in a year, but it's really important to try and, you know, continue. Even when you face these challenges, just keep plugging along. Keep putting in that next meeting with procurement and keep, and you will get there eventually. Finally, entice your trust to take up your project by showing a financial implication. If you can prove that what you want to do is also cheaper, then you're making a business case to your trust as to why you should make that change. All trusts are bound by by net zero by 2040 but cash is still king. So if you can say this is cheaper and I can show you why, then they'll probably be on board with your idea. That's it from me. I hope that you guys have learned something. I hope I've sparked an idea, and I'm more than happy to have a conversation and help you any way, the way that I can feel free to get in touch with me. Um, that's my email. That's my Twitter. Thanks very much.