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I hope everyone is gonna woken up from their post lunch slumbers with those two incredible little sessions. There s 01 of the things that we've been introduced from last year's conference is actually submissions from medics on beyond from all over the country and beyond as well. We invited people to submit abstracts of which we received over 30 submissions from such a wide variety of areas in sustainable healthcare. Hopefully, you've had a chance to view some of the posters in the main hall in Sorry in the in the map room. And if you go online, checked out the posters online as well. What we've got now is three out of the five or a presentations. Now we selected what we thought were the best abstracts on. We've got three here in this stage here today. Eso We've got Rebecca, who will be talking about inhalers in primary care on. We've got Chloe. I'm Natasha who are both both gonna be looking at different aspects of recycling and disposal in hospitals. So if we can first start with Rebecca, I think Thank you. Reckon brilliant. Thank you very much for having me today. I'm Becky Davis. a GP registrar, and I'm here today to talk on behalf of five colleagues of myself about our project, which is could have on hand me Okay, yeah, some here today to talk on behalf of five colleagues and myself about quality improvement project that we've done a mean to reduce the inhaler related emissions. A primary care in Cambridge. So just outline the problem. I'm I'm sure many of you will be familiar with some of these aspects already, but three. There a haters count for about 3 to 4% of an inch. Chest is carbon footprint. However, this is substantially Maurine primary care, given our and our system chronic disease management and aspirin, COPD management especially so on this diagram. Here you can see the carbon hot spots with Indiana Jess on the every points to just inhalers from primary care alone's. He can see it's a substantial problem. Why is this a problem so historically an inhaler, specifically meter dose inhalers, which your typical puffer ones contain chlorofluorocarbons. But they were problematic for the ozone layer, so they were replaced with hydrofluorocarbons but unfortunately have created a greenhouse problem. Now is there 1000 times more potent in Oh two, and this diagram here illustrates the problem visually is well, so you can see the one called Ventolin Meat dose inhaler is equipment drying 175 miles, whereas dry powder equivalents, which is equally efficacious. The kind of the carbon footprint is about the same with driving four miles in an average car. So it's a really, really significant issue. So what did we permit in terms of quality improvement project? We picked kind of three main key learning points that hope you're able to take home today as well. So first off that good symptom control is green, so we know that in the UK, we've got heavy reliance on me to dose inhalers, and we tend to over use our butts, which is short acting. Be two agonist, also beautiful. The average patient uses about six a year of those, whereas good control is about 2 to 3 a year, or even less so. If we can improve asthma and COPD control with better preventer inhalers, we can reduce our reliance and supper, which is good for patients on also the environment. Secondly, we promoted the use of dry powder inhalers on. These are suitable for most people. They're not suitable for patients in most part under 12, those with potentially severe exacerbations of asthma and those who are very, very frail because they rely on kind of taking a deep breath quickly or obviously, patient preference is fine or population are not suitable for and finally we promoted another teaching point. So if you must use a meter dose inhaler, try and minimize the number of puffs by using it. Inhaler MDI inhaler with a higher concentration of medication, or switch to an alternative with the lower admission. So this form part of a substantial part of our projects over enter than MG Eyes, for example, are over double the carbon footprint of a Salamone, which is also an MDI. So in terms off what we did to explore the problem, so we carbon footprint it on within our for practices, which covered just over 80,000 patients that I'm carbon footprint of me to dose inhalers in in those four practices over a year, and we worked out to be 903 tons of carbon dioxide equivalent, or over 33,000 London Sheffield car trips so We're just fought practices in a relatively small city. In you case, you get a gauge of there a gauge of the problem similar to what next said earlier. We surveyed healthcare professionals and found about 94% Encouragingly believe the environmentally sustainable health care is important, and they're motivated to learn more in terms of interventions. So one aspect was education's. We talked about 60 G peas locally on this issue, and we also talked in our respective practices, and we promoted the new asked me guidelines that were released locally for us suggesting that dry powder inhalers a first line and in green, you can see are dry powder equivalence in our region. They might be different in yours, but those are all ones crucially, and we identified inhaler switches that could be made without the need for consultation there by saving precious GP and nurse time. Because, you know, that's that's a pressure on the chest of the moment. And then we sent text messages to those patients explaining the switch and made the switch is sometimes results. So we got environmental results, social results or financial results so environmentally, and we changed just over 1000 prescription to generic salbutamol to Salam. Also Teo explain generic salbutamol war Specifically, you can prescribe generically, but on average, about 80% of pharmacies will dispense Ventolin rather than San Immel. That's how we worked out that carbon footprints. We made those switches. I'm saving about 57 tons of carbon dioxide a year. We also switched just about nearly 100 patients and Bensel into Sanimor, saving 8.6 tons. We also identified a subset of 17 patients in one practice who are already on dry powder preventers. But they weren't on dry powder relievers. They're one MG I relievers and we switched those over, saving 2.2 tons. Here it's accumulatively. We've saved about 2500 London Sheffield Car trip is also a cultural shift to DP eyes or in our practice conditions. Now initiate DP eyes far more than MG eyes. We haven't measured that in our project is yet, but we've noticed that cultural shift and we also promoted return of inhalers. Two pharmacies in our text, a patient. So if you return mg eyes to pharmacy pharmacy there could be incinerated, the hydrofluorocarbons burnt off, which seems counterintuitive. Actually, it's far better than letting them any concern asleep by just throwing it in the BIN way. Also, in terms of social benefits to improve local education on the topic, I'm dry powder inhalers, also more likely to have a dose counter is on them, and patients are less likely to use empty inhalers. And you also don't need to carry a space around with them. Possibly there's a long time improve kind of crap comes. That's difficult to quantify currently in terms of finances. So there's arguably less waste with dry powder inhalers because they have those days counters on the patients. Don't choke him away early earlier. You don't need to pay for a spacer, and also there's a plastic saving with that in terms of insulin to Salamone switches. So there's a it's cost neutral or slight saving um, in terms of switching salbutamol mg eyes Teo Dry powder equivalent is slightly more expensive, but that costs my arguably be mitigated by some of the financial incentives that you're coming in with. The Investment and Impact Fund. Aimed prime recurrent minimum on this graph just illustrates some kind of tentative possible benefits from our educational interventions. It's on the left. I got control practice, which is just down the road from where I work in a similar demographic on on the right hand side of my practice. So the green arrow reflects where we did the educational interventions, but crucially, and these grafts end before we did. Actually, any of the inhalers is and you can see it kind of the carbon footprint off ourselves. Beautiful prescribing in general, his starting down trend, Um, at the bottom. We've also got our future plans. They're planning more sanimor switches. Another practice has recently being recruited on this kind of continued shifter dp eyes. And it was also normal going she So finally a quarter action for anyone who might be interested in trying to replicate this, I think first off, remember three key learning points. They good control his green try and choose dry powders inhalers where possible. But if you're going to choose and meter dose inhalers for any reason, try and minimize the number of puffs and switch bland. So a good kid only point is Ventolin to Sanibel, especially for generics, are beautiful animal especially. We think it's ideal for GP train is working individually or collaboratively, but we weigh know to the real benefit working collaborative in terms of supporting each other or so good for GPS and post CCT Fellowship time, which is sometimes funded good for any GP practice in general. Or pharmacists working with primary care networks, which there are a handful of GPS that work together. But it can also, you cannot extract ideas for use with an emergency medicine, pediatrics, respiratory or, if your hospital pharmacist take these ideas in terms of the good news. So guidelines are increased in the changing to dry powder inhalers. First line nationally and locally, there's an aspirin talk. It's, um, one of our colleagues to work on this project with us. Worked with two people from green or practice, And is that this fantastic resource, which is accessible via agree? Agree in a practice dot co dot UK, which basically shows you how to replicate this quality improvement project. All those resources out there, including texts already premade up investment impact funds, rice financial incentives to GPS for these switches. And finally there's a service which is funded by AstraZeneca, and they fund the's farm. Independent pharmacists will interface clinical services. You kind of come into your practice and switch it off. Patients from typically need to dose inhalers, too. Dry powder, inhalers on bats, a free service that GP school access and preciously save that consultation time. Thanks very much. I'm happy to answer any questions. Thanks. I'll just wondering how have patients found the switch? Have they been quite open to it? And they liked it. Or has it been about the struggle? Yeah, so I mean, so my practice, for example, we switched 500 patients from generic salve you tomorrow to San Immel on by. I sent a text. Um, they could reply directly to it. Onda. Only five out of that 500 said no. There was a slightly higher and kind of decline. Rates with the Ventolin to salam or switch is directly. So roughly about 8% of our of our patients said no to that, But the generic Sanibel is under 1% overall. Thank you. Sorry. I remember from economics. I just, um, as a GP. I find this really amazing and I want to be similar. My in practice, a bit of a similar question, but I just wonder if you had any tips on sort of how to encourage patients who aren't sure and sort of what the main barriers were in. Because I I imagine that to be something that I might face in my particular demographic of patients. Yeah, I mean, I think I mean, what we promoted was obviously so in terms of texting patients, you can't do it and me to go see the d. P. I switch by text. It needs a consultation. That's kind of another Keelan point, I guess on. But I mean, I guess just from are statistics now are are low decline, right? Hopefully there are minimal barest from switching MDI MDI in terms of DPA eyes, I mean, it's it's a bit dependent, I think are independent. Pharmacists have quite good success. She's had 20 minutes to do each appointment, so I think a lot of it is explanation. Education. Where I've done it opportunistically in practice is the same. Anecdotally, 60% have kind of said yes. Some have just said no, but then I haven't quite necessarily given it a lot, you know, it's been a tack on things. End of the consultation I'm having necessary, given it'll the time I mean barriers. I think it's just cultural. About 60 to 70% of our our use in our region is MG eyes currently. And it's just what people are starting on. It's what they're used to. Sweden, they're 10% MDI use, and they have better outcomes in us. So it's just a cultural shift that needs to happen. And it and it will start Very sorry, you know, be around later in the day. Yeah, so I'll just ask anymore questions to be directed to Rebecca at the coffee break, if that's all right. Thank you so much dot Sorry about that. Just ended interest of time because we're coordinating two rooms, but well done. A backup. So just to let you guys know this whole presentation is going on in the other room is Well, I'll just let you know what's happening in the other room as well. So if you feel that you're interested more suited to there, please do drop and change because we want to try and get people into the other room as well. So, in the other room, in the next 20 minutes, we've got Doctor Moreau goody one talking about switching to reasonable theater caps. And we've got, um, around the federal Wells, talking about delivering the nitrous oxide project. So if anyone wants to move over to the other room, please do next we have Tasha ask her off talking about improving clinical recycling in the delivery. Sweet. So welcome. Okay, so you could often in Canada on hand Me. Okay, It's, um my name's and Sasha. I'm a junior doctor. Bristol role in family. My project today is on improving recycling in the delivery. Sweet. And this is actually a project I did while start real common hospital with heavy walker on jury Crocker. So as a background to the projectors, everyone in this room is aware we're in the midst of acclimate emergency, which is a health emergency on this is due to the divers impacts on human health of climate, on environmental changes impacting our patients under healthcare service. Yeah, we in healthcare crunch beating significantly to problem with our substantial carbon footprint. A Z heard from neck area. The chest has accelerated. It's action to become carbon neutral, not zero by 2030 which requires not just system level change for action from a 1.4 million. Any chest staff ti on from a more local perspective to the project income on the eyes of silly, they declared acclimate emergency in 2020 on have actually pledged to become next year by 2030. From a personal perspective, I'm very passionate about environment and always looking to the environmental projects. When I started on ARBs and dining, I realized we using a lot of plastic which I thought would be recyclable, but we didn't have anywhere to recycle it on. So just chatting two stuff about it. People are engaged with recycling at home and in the staff room, and they wanted to be able to do in clinical areas too. So I speak to Joke, who is the team leader for midwifery, and we decided, or make a good project onset out. Three. Broad Ames first was to increase the number of recycling facilities in the department. The second was so identify waste that we thought could be recycable plastic waste on by the trust way stream until third, raise awareness amongst after clinic or cycling was a possibility on we brought the follow the plan to study at to methodology for quality improvement on the planning stage involved two main areas first looking at what was already available. So there was a paper and carbo been in the anesthetic room, but only the need to just be using it on. There was a domestic recycling point, which was being used by stuff for the normal kind of meal items. Yet those know motorcycle clinical waste. So we thought the treatment room would be a great place to start on. Decided to put a pin in there. We then need it to work out actually, good plastic clinical plastic be recycled by the trust way stream. They recently being a project on the acute medical unit where stuff we're collecting clinical plastic, I'm psyching it. But when I speak to them, they were actually having to take the plastic home on recycling externally. Themselves on this just seemed to much of a barrier, and I'm very much dependent on really dedicated individuals. And actually, we're going to make change. We need to embedded in the system. So I had a meeting with the sustainability lead heaven on the way steam, we decided, but actually flank or plastic could be recycled, but there were certain caveats. It had to be HDP type two or pet type one plastic, and it had to be objects over two centimeters. The other main issue was that the waste team weren't happy to recycle things that were very clinical on. I didn't know what that men and they weren't too short but men, either, because they weren't familiar with what we were using on the ward's. So that was another clear action point. I needed to work out what was to clinical safe. Start with. We introduced a mixed clean course I can been in the delivery sweet treatment, um, initially for paper and cardboard whilst we worked on the plastic issue. Help us with this. We refashion to no Sharps, then on our staff members to put in any items. A four could be potentially recyclable from the clinical plastic they were using. Know so please of how quickly that's been filled up. And there's all sorts of items I wouldn't have thought of. When I went, I emptied it and took pictures, went back to the waist team on. We worked out where they're line was with what was to clinical on cleated a list of items that were being companies. Um, we're recycable. That was kind of the first stage of the project with identified that stuff were engaged with recycling, would introduce. Then you been on wood worked out what plastic could be recycled. So then we need to teo this information out of that. A measure of it was making any impact on I made a paste which hard to the main rules from the waist team on its own on terms of more types of plastic and also pictures of the objects which were most commonly used on were appropriate for recycling. We also ask people to send in any items that they weren't sure about, and we would get them verified on, As you can see, that the line that the wasting weren't happy with where need a chiefs you syringes on giving sets and also things contaminated medication. They were happy with normal saline on pills and bottles, as you can see in the top left, Then we needed to see if this was having any difference. So we put the pacer up in the treatment room above the new clinical way. Spin on the old outside. Then you were strikingly in the old clunker waste been on. I put up this very sophisticated Charlie system, just asking people to mark one whenever they changed. The mix was liking bag. Obviously, this is not an ideal way to measure waste, but without me camping out 24 7 in every three treatment room, I wasn't sure what else would work, and I think, if anything, it was under estimating the amount of waste were collecting, which is acceptable on the tens of results. Just over the first five week initial period, we're getting T 23 bags of mixed clinical recycling per week from that one treatment room been. This might not sound like much, but it was 12 bags that we were diverting from incineration on over the course of a year would be 100 25 from one treatment room, which is equivalent of 150 years of carbon on roughly 400 miles. Driven in a patrol car on the sustainability team thought this was worthwhile enough to make the poster Trustwave publication and start rolling out clinical plastic recycling across the tress. So after a lot of lives and with myself on the communication team to balance. The face of that was usable but also looked good, and we came out of this is the final version on This is now used in all the treatment areas across the trust and to help guide people on what they can and can't recycle in the mix clinical recycling bags, which the trust is now firmly collecting on in terms of next steps. We really just want to make sure about their enough recycling facilities available in a clinical areas to go with the poster, educating cell from what I can and can't be recycled on measuring, reciting output. Both our department tool interest levels and I think recycling champions on each ward is a good way to go with, um, in terms of sustainability at Rahkamo. Still, as NEC mentioned earlier, they're doing load of great things about Twitter Handle if you want to check them out. I think the main lessons learned from this project was actually it's really a simple project is something you could do yourself. You just need to find someone locally in the department here, is willing to get involved with this and speak to this subject sustainability team together. It was very simple, but it's resulted in sustained improvement for the trust, which is great and just really quick on. And did you model the cost savings because certainly am in London, recycling bugs are considerably cheaper for trusts like they're 60 lbs a bag or something like that. On them, incineration is 150 if it's not a clinical waste in, like, 250 otherwise, is that massively different? I wondered if you don't cost modeling as well, just to try and, like, push things further. Yeah, I think that that is something I definitely wanted to get on voiding. I'm working breast. Oh, now I've been involved very remotely from the project. I'm hoping to get back to normal on, I think Either way, this product kind of started. It is now being embedded, which is great, but you're right. There's so many course savings for natural savings as well as carbon savings. And we could go so much further with the modeling to kind of prove that I think, to write up a kind of case study for people directly, we get to have the financial savings on there, too, for trust that are less and less on board. Think or more you might not know because you're not in Cornwall at the moment. I'm just interested. Know whether the label team have gone on to do other stain ability projects. Cause it. It seems to me that this is it really nice project to get people interested in sustainability. So I presented the project at the order meeting remotely back in November. People working to kind of carry on as a project, but I think it's really difficult. I think people struggle to find time alongside that. Busy as we all know yourself, Good pressures were really busy, and I think they're planning to get someone with dedicated kind of time a few hours a week to kind of work on this as a consultant as, well. Tumbleweed. And I think that's another kind of tip from stuff I've done calm always. We had a consultant. He was very, very prove this and someone having someone clinical, he could kind of push for people to have dedicated time, included women. They're working weeks. It's it's hard to get this in side clinical GTC You know any more questions, guys, let me just check the chat online. Did you find sources from Jessica Pinto? Did you find there were many non recyclable materials being put in the plastic recycling bin? Did this change over time? So, yeah, initially, we didn't kind of dove for kind of safety reasons. We didn't do too much delving in because that gets kind of don't buy the the wasting that we did find initially, there was, um, clearly non recyclable items. But more just, for example, on the picture that I got like a cannula, Uh, can you pocket So sometimes people, It was more more of a contamination issue rather than completely normal cycle writing. Because it was it was pretty broad. So maybe things are okay. Most things are patent A GP. The things we were getting off, which is why we had to put in the picture where the little medication toppers from popping the medications. They're just too small for the trust to recycle, but they're looking to work on that. We were finding a lot of the small plastic discs in there. Which knee just got removed and stays a contamination issue. And yeah, that's just kind of another education project. Really. Thank you. so much, Natasha Toby says. Amazing work, Well done, which I can only echo's Well, so one of the questions for that particular dog was about the financial cost of recycling. So the next talk is by Chloe Gilda, who's gonna be talking about the cost of not sourcing waste, the NHS and the environment s. So let's just welcome Chloe. And you just need to use this. Thank you. So I'm clearly I'm a neurosurgery training in leads. But I undertook this order and right at the end of my F two in Glasgow. And so they plans I've used or actually the Scottish any chest plans for this. So how it all started? Well, I was continually infuriated by seeing people constantly wash their hands, put the paper towels in the orange been just because it was the been right next to the sink. I was sick and tired of seeing people do a cannula. So if you look at like, the stuff like, it's just been pointed out, a lot of the stuff is packaging, and it's really nice to find out that these ampules can be recycled. People will often I saw my colleagues I would do a cannula and I go when I feel like right where that could go in the black domestic waste that could go in the orange. One of my colleagues were just opening the orange been and dumping it all in on a lot of it just comes from one lack of education and two. Sometimes I think it's just a bit of laziness, and so I decided to take it for myself to do a little project on it. So I went and looked at in the literature and things to do with it and found that, actually, the quantities of waste that generated by the health care sector in the UK are noted to be some of the highest in Europe. Unsurprisingly, to me it was noted that been disposal habits of staff report with non biohazard waist constantly going into a biohazard waistbands. I think somebody's just pointed out. The cost to the NHS is really significant difference between disposing off a black been black domestic, been and pertuan on an orange clinical waste bin is 298 lbs per ton. I'm reason it's not showing, but this screen did say methods and essentially what I did was I then went on to find my trusts waste disposal guidelines. There's an any chest Scotland waste disposal guideline. I took that and I ordered it with in my department, which consisted of four wards on games. Um, see Attar's so I went to theater as well, and the order is very simple to do. It just involves walking around the ward's taking some photographs, and I actually did a focus group with some of the staff. So this is the NHS Scotland Waste Order policy plan. So basically, you determine what activities are happening on your ward. Are the been suitable, and that's not suitable for what's going on. It's suitable. For if the waist is correctly segregated are the types of bins and the size of them. The location appropriate is the sign it around the bends appropriate? Interestingly, none of the sign ejactulate depicts a cost on there, and I do wonder if that would help people to realize the impact of their actions. I'm observe what materials have been put in the bed. Obviously, for the nature of our work, we can't go delving into the business to see exactly what's in there, but taking photographs of the pens and then I'll show you later. What we did. We just quantified from the photographs what was in there. I'm And then we questioned the staff about their been disposal habits. Except so what we found was that and we went to theater one morning. What happened in the theater was that and just before the case was being set up, the there were black domestic bins and orange domestic being being used. As soon as the case started, it went to solely orange clinical waste bones. I am. And the reason for that was because the case had started. It was a clinical environment. However, what we noticed was that nearly everything that went into the orange clinical bags was packaging. I'm from things being opened and handed to the theater nous. Now none of the packaging goes near a patient, so it could easily have gone into a domestic bag on. But then, you know, people just need to know which bags to use. I'm so we had 18 clinical waistbands between 44 wards and one theater on, but had 100 87 items that we identified from them 75% of those were non clinical, um, waste. And actually, 59% of it was hand towels. Paper hand tells which it's interesting that we're currently not. We don't use a recyclable hand towel. Okay, If we did, that's 59% of this waste that could one not have been incinerated and to could have gone into a recycling bin. Been placement. Didn't meet demands of certain areas on, but there were no recycling bins available anywhere. I'm just a quick show of hands who has recycling bins and mattress. Okay, A lot more than I encouraging. I'm so these are some of the pictures. So this was the medical preparation room. So we just start the objects. Anything that could have gone in a domestic waste bag was a white star. Anything that needed to be clinical, the paper towels we classified as going into a domestic waste bag if unless they had body fluids on them, I'm honest. And when we did it, none of them had any sign of any body fluids on them. These two pictures this this one is from staff toilet. And I don't know why we needed been that was the only been in the stuff toilets. And this one's from a patient toilet as well. I'm aside from the gloves, plastic bottles, normal waste. I'm putting them. So been size was an issue. So in every single staff toilet between four wards, these were the only bins in there. There was no sanitary, been just these bins. And in the focus group we had later we asked and one of the senior nurses said, Well, actually, there was this one incident where we were fined from some blue gloves being in the orange pen. So in the black been so we just switched them all to orange. Clinical way spins to avoid being find because we cannot trust the doctors to know which one to put things in was the response we got. I'm on. Obviously, this size have been is wholeheartedly inappropriate for a toilet that's being used all day. One thing I forgot to mention in methods is you need Teo. Actually, if you're gonna conduct disorder, you need to check what time of day they empty the didn't because the first time you want to do it, they just empty depends on it was useless I'm but we one of the things we did part of the order, it was looked at. We just do a map of each of our wards. And actually, there are a lot of rooms. Sometimes it was the medical preparation room. Sometimes it was the dirty utility is a switch between them as to which one did not have a domestic been as well as a I'm clinical waste bin. The size of it was generally acceptable on the sign it was usually there. It was just the stuff toilets and the patient toilets that were be, um, main problems with not having any domestic way spends it. So this was the general results, as you can see. And paper towels was the main problem at 59% and packaging was the other of the one there. So, and as I've alluded to lack of compliance, we found three quarters of the waist could have been disposed off them in a different been. Now the cost saving for that is that could have been 223 lbs per ton saved in the waist order guidelines that I used. It stated that between 2012 and 2013. 17,147 tons of clinical waist was produced by any chest. Scotland, if three quarters of that could have been disposed of in a different bed, that's a saving. If it only went into a domestic waste bin that's isn't saving nearly 4 million lbs to NHS. Scotland US without England whales, Northern Ireland These are the prices per ton, and you can see. Actually, if we can recycle some of that, then we would have uneven, great to cost saving. And that's without the environmental impact off all of that waist being incinerated. Three quarters of it's about 13 tons of waste being incinerated and the carbon footprint of that I didn't look into. But you can imagine that's 13 tons of material that we don't need to incinerate. So what can you do? You could be an advocate. You conduct your own audits, intervene, reorder it, it ensure that waste disposal. So the Lord it's been done. Nobody had heard of a waste disposal, Lord, it one. When we asked about in the focus group, then staff said that they were really concerned about the environment they really wanted to recycle things, but actually the education was significantly lacking. And I've seen in my just now this tendency to towards helping the environment helping and rolls like this come about. And there are such things as grasp champions, which are green recycle, be aware on be sustainable for our patient representatives. So introducing rolls like that. But I think one of the biggest things that needs to be introduced is actually, if your department save that money, you can spend that money on resources in your department. And I think that would be one of the biggest incentives to people I'm sorting waste properly. I'm so does anybody have any questions? Shouldn't the waist team be ordering that? As a question on wondered to the rest of the floor a swell, um, bit shocking that a doctor has to? Yeah, when I did the order, the team on the wards and when we're on the focus group had never seen a waste team, they never Then you didn't know that existed. They didn't know the order guidelines existed. I'm I did it cause I was continually second tired of seeing things going. But yes, definitely they should be. There's anybody seen anybody do anyway stored? It's hands up. Yes. 33 people have seen people do waste orders. Yeah, well, take one question from online. So Thomas Adam says this was really great. Have you tried to make changes in your hospital and found any barriers we try to in Middlesbrough? Ever come up against a lot of hurdles from Circo? Who? The contractors, I'm Unfortunately, I did that and my two And then I moved Trusts eso I we didn't have time. We did some education sessions, but I didn't have time to reorder it to see if it made any difference. I am. It'll be interesting to run it again. But again, unless you say, I would hope that the waste teams I'm be involved in this. I haven't run in my current trust. I'm Interestingly, we have no recycling bins anywhere in my trust. And I see the same problem and actually, I did a shift in any of the of the day and I couldn't find a domestic waste bin every patient day in and he had an orange clinical been on. I suspect this is as a result of cove it and I couldn't work out Why? Because we were telling the general population. If you're really worried about covert on your post to put it to one side for 72 hours, it would have died off. So why can't put a been to one side for 72 hours? Um and then deal with it. I evidence behind some people's actions. Sometimes it leads me. I am. Yeah. So everyone. My street from where? The medical student days and officers, A spot of ICO medics. A couple of things we tried to do this year is trying incorporates an 87 the healthcare societies in your medical schools across the UK and we've been quite successful so far. You know, website, you can have a look at what we have a link because the a map of the UK is showing where all the medical schools have sizes. So if you look at that and you see that you have been going, uh, healthcare society, this relates sensibility your university have a chat with those, send a message on instagram or email on. We could try help you make your anxiety as well. Where things have been doing is we made a competition called a half a form on what this was kind of looking at is the Senate Healthcare isn't really well done in medical education so far. On recently in medical school, counselors just actually released a sustainable healthcare curriculum earlier this month. And so we create a half, um, how would be the best way to incorporate Senate healthcare in the medical curriculum in the UK on our winner was a sonic on regards. Video shows everyone now. So just first play on that and there might be a couple of couple minutes or so questions. My name is out of a funny question. 10 drugs invested during cell phone. We'll begin by, say, the climate crisis is here and action has to be taken now traverse the disastrous consequences of climate. Imagine that we already see particular short, probably professional. Some slides present my Boesel to integrate it. GT Sustainable Healthcare Guidance into the curriculum at ST Georges to every story has the beginning and then of climate change began with widespread industrialization more than 100 years ago. Now what's become under the damage has already been done to the environment. On the assistance around the world, we can begin to feel better, more sustainable system. Don't allow nature to grow back in you for us is conditions. We have a responsibility to control the health of the not only our future patients, but then it's you on the way the world. So the actions that we demand by actually recognized by the government on by the ability to check parties on climate change the X plus the the general public around 40 seismic shift to more sustainable working with the Imitrex and stuff you to you. So we've identified the urgency problem. I'm just now I just rated in the political will to make a change exists from the top down on from the bottom. So what I'm seeing here is how it all fits together, how we're going to solve this problem. And luckily, there's actually a wonderful conceptual framework here to guide our problem solving. So this kingdom three three's approach and using this approach treating to the women for change only opens up when problems the political will to tackle these problems on the right solution arrives together. So this happens and we knew of opportunity to change. So let me talk to you about concept called one Health. The One Health Perspective on medicine places value on environmental, health and animal health. In balance with human. It respect the complex into play beat. Three elements have to make all health better to address the duty 2018 outcomes. I have those a three problem time to improve medical treated vacation. Pay someone else. One other changes to public health and TKs lectures are introducing. Reintroduce My Health at TJ put in the early years of medical school to train the trainer. One. Healthy learning package conditions have any involved in the teaching of medical students and three petition building student lead pressure to do the one health concept. It's the gene season you came away on. The board enjoys you have a spiral, an incorrect in stable students to revisit ocean topics as a little knowledge. The Progress Medical School initial sustained release the topics You just tell me what you can see it on in the form of kimchi expectorate. So now that's the patient populations and society. Electricity on these topics could be revisited as part of the public health electricity in term. For, of course, it's important to tackle with feasibility the slope of Christian Church, so the parent running and gallant feedback on a pilot workshops through to enjoy his environment of society. Example would be excellent. We're collecting signatures and, more importantly, demonstrating improvement. Since you've been understanding of the topic with pre post works appreciate for inclusion of one health in the local character at this point could be feet. Have you done by taking a result in spite of work and engaging direct unification? Electra's such a professor Peter wake up all through the student TV in the medication. Of course. Push that from Lexiscan. Be expecting, and there is always the risk of any either a long time to make changes or require more work better. But this which is highly tight. It metal my pilot workshop questionnaires that she will buy a school with motivated students. And can you run on line to get, um, I see you two emissions from transport. So you one time one video term for our exit opportunities to introduce and revisit concept of one house respect, provide future conditions foundational understand the concept. But what about the clinical practice is 700 of this rash tree between the trainer one Health United package shaking come early clinical scientists Clinical practice years. She's engaged in self guided on didactic teaching from senior questions. This office another opportunity to interact with students. And if you did, the importance of systems ability in healthcare no. The most important way of communicating a sensitive collect is to we've one house into education, not as a stand alone block teaching brachy as a fan of clinical practice truthfulness. To further explore it in detail, I spoke to Doctor here in San by the National Medical Directors Clinical fellow on your greener NHS daughter Karen spoke with his area of expertise how we can teach conditions to reflect on and share sustainability topics in the road specialist area. It gives off over spiritually specialists talking to medical students about discussing with pictures of the environmental impact of switching to dry powder about the cysts. Students for the transition from gas is just more involved in a message about a seizure. No, I'll pause. Act like imagine the wider and the impact conditions on the medical students you have. It's sustainable. Thinking was a teachable opportunity. Nothing proposed. Train the train in your back. Now students that's in Georgia's who previously collaborating is Factive to create a highly successful, you know, massive open online course on transgender healthcare through the future, I propose we learn from successful fellow students and put together, of course, the questions on how to think about and teach medicine in one health, um, as a medium term aspect, but my overall for both stretching the creation of the learning resourceful to consider a little time. And in order to make a real bus resource, we're quite seriously ablation. Ablations and then Jordan's, however, is propose is extremely label on account of your ability. Cocker. This resource could be used by many other schools. National. I'm doing special. Find me a third of my surgery. Integrate the one health contact with the GYN, sees you K and content this so that aspect of the solution, because there's a long term changes to the quicker With the incoming, you came in a colossus in assessment successful. This is a surefire way to draw attention to the concept of sustainability medication as a valuable addition to the particular of all set for you can open now. I appreciate this is a heavily bureaucratic protest But after some, contact them away officials. It's actually clearly review mechanisms that alter the Emily content now open to commit from individuals. Still puts on especially for the B M. A medical students committee. Where are suggestive polyps? Proposal that one health is proposed as a crucial part of sustainable health education at their upcoming years on meeting to find a solution to talk in the long term. And I recognize that the one with the timeframe for any intervention, the higher the risk of failure. But the solution is for lasting and for a pattern change must be a powerful individual on bleakly has to be recognized for the average extremely busy medical student already slowed under my work. The hydro changing focus of atopic where you have to get that topic is formally assessed on exams. So as a fluke or paralysis sanity we'd accountability on what is measured is after what gets done. Well, the proposal presented to you as outlined the problems we face and how window of opportunity as a reason as a result of the rising political will fracture. I think that you've enjoyed my tripartite sushi on you see value and feasibility but working hard to prevent a plan that continues a short media and long term. Thank you. Okay, Questions is yet I sounds a great topic, but what happens if I go? The lectures are in a lot of things. Sustainable healthcare. Yeah. Teo the's. They're talking about taking me PKS actress. Like a special, uh, good sight. Is that a patient s. So I was told that they have a prominent on standing off. This is the thing that was changed. Some of the examples of looking to get your work intentions were before make small adjustments off using what helps is uncles instead of So this also is uncles were talking about that. Is that controlled? Yeah, it's all right, right? I need a questions. Property. Mom, Thanks for going so much with That was really very good. Receiver. I'm good. Okay. Okay. Who and then, if you can. And great. Well, thank you so much for having me today. Um, my name's Amaranth. Final Wells. I think first was the first well, she clinical leadership fellow in sustainable healthcare. And that was for 2020 2021 on Duren that year. I was introduced to a phenomenal pharmacist based in Scotland named a leaf. Yeah, KERA. And it was her pioneering investigation into the seemingly innocuous medicines nitrous oxide that I instantly recognized is having incredible potential to reduce co point emissions. So this is what she had started doing back in 2019. And those already know this work. Tell me your investigative results, she says, with a week for those that don't I've got your back. You're gonna learn about it now. It's a quick summary of what I did to deliver the nitrous oxide project in Wales. Okay, so I'm hopefully preaching to the choir hit. But for those that aren't aware, nitrogen oxide is a powerful climate pollutant in a major greenhouse gas 300 times more damaging than two. And it remains in the atmosphere up to 150 years on is known in some circles as a tangible successor to the CFCs that destroy the ozone layer. Towards the end of the month century and our signatures to the Kyoto Protocol, you take eight must report on nitrous activity to prove you're meeting reduction targets currently set at a whopping achievable 100% by 2050 on in our clinical careers. Nitrous is probably part of the furniture, literally. I'm figure it figure to be speaking. Uh, it's been used for so long in healthcare, but right now I challenge anyone a watching this presentation to recall the number of wall outlets with the little blue ring around your present in your clinical environment. I am talking about the two different forms of medical nitrous oxide that we get patients. There's obviously pure nitrous oxide and enter knocks about 50 50 ratio with oxygen on the soon as you start counting, you know, system everywhere behind yeah, spot boxes of tissues. We bins cupboards. Honestly, they were everywhere, like multiple ones and resource based and knocks out. Let's that every cubicle and mine injuries on an inhalation sedation unit, every dental bay on a clinic it it was crazy, and I started to actually counted them. But the actual nuts and bolts of the data so under a leaf, US guidance and mental shit, I discovered that my health board kind of the Vale months, a trauma center, tertiary referral center, you name it. It probably does it for whales was consuming nitrous oxide products at an alarming rate through decades of mismanagement on neglect. And just highlight this. You can see the three lovely volatile colors of the volatile gas is from, or any statistics on. The remaining 94% of this wheel is quote unquote anesthetic gas actually attributable to nitrous oxide products. And obviously it's exhales without being metabolized. So the fact that it's molecular structure amazed unchanged remains. That means that every molecule purchased counts towards go on emissions missions diary produced by the hospital for which health boards are responsible on. Just be facetious. You need to plant a holding 26 trees every year just to attempt to offset this single health boards. Nitrile different. I'm sure everyone here listening knows that misleading nature of saying it's a simple as offsetting emissions by planting trees. So it's a flatter nitrous oxide emissions. By 2050 strong, collaborative leadership must be developed. Multi disciplinary relationships must be nurtured on responsibility must be assumed, even though it's labeled as an anesthetic gas. I'm going to show you how many people were involved in my project, so because it's a site visible and complex than I did have to start. But the most immediate ble, I guess the lowest hanging fruit part of this huge, complex tree. And it was obviously anesthetics supplied by a pipe delivery system by a collection of large cylinders known as the manifold to these horrendously dirty images are where are esteemed estates? Colleagues spend a lot of their time around these medical gases, so the one on the left is pure nitrous to use my niece tests, and the one on the right is supplying the Internet's mixture literally used for anyone else across the hospital site. And is the efficacy of this permanent medical gas supply that we are assessing, not the smaller portable cylinders yet, she says. So the project involve cultivating relationships with many different state. Coldest. I'm a dentist, but I didn't introduce myself such until the clinical query started coming through. I felt I was able to make much more impact by using the gravitas. If my fellowships out subtitle in Sustainable Healthcare on my clinical Experience and knowledge was recognized on discussion with stakeholders, including supplies, any statist obstetricians, pharmacists, engineers, porters, emergency staff were very productive, and collectively our research and engagement built the network that enabled state called us to take responsibility for their part of this huge puzzle on the methodology is accessible. Fire this QR code, so I'll give you two seconds if you want to do it. But it comes up later on in a sec. So the results of this project demonstrated the sheer absurdity of how much nitrous oxide the health board purchased compared to how much it used clinically so purchased 1.2 million liters, but only used 50,000 clinically based on investigations by any service, there is a waste factor of 96% and this is not isolated. It's been steadily maintained for the past three financial years. No change during Cove it and this is happening at acute sites all over the UK. So if we have a brief overview of the situation in Wales for the financial year 1920 pretty cope it. The manifold supply for the carbon footprint shown by the sliver of green is my fold nitrous oxide. And if 96% of these tiny green slivers is literally venting from every crevice, you can think off how much of these light blue enter knocks manifolds columns is being wasted like it, but boggles my mind. So leave his method was to build the multi disciplinary team, a task force comprising representatives from the state, cause I mentioned as a day to driven individual. I was very perturbed at my damning report demonstrating the system waist was not immediately validated and address. I came up against a lot of stigma and belligerence, So it was a really exercise in networking, influencing and orchestrating to get people something to believe me. Um, but once I did, I was with all friendships. It was with a sad heart that I left, but I did so with the promise that the task force we're going to do something about it, and I've kept in touch your toes. See where? Nearly 89 months later on the latest update shows Thie lean Alternative supply Trial of nitrous fire Port was seven distant, peaceful still has been very successful, proving that the manifolds can be just decommissioned on This is now happening, she says in the pipeline. It's case upon. I'm also pleased to report that the concurrent research we did it to enter knocks numbers are also being addressed on this is more focused on technology and funding and patient views. Locally missing a ting nitrous reduce his waist, reduces occupational exposure and saves money. And nationally, this project has improved understanding of managing nitrous oxide, and this work targets up to 350,000 tons of CO2 emissions that come from nitrous oxide, your nitrous oxide across the way. So it's been 16 months since we launched this back in January of last year with a tiny little webinar attended by 60 people. And I am really proud of how far this project has reached. Just two days ago, I received an email out of the blue from in any statistic you attend that webinar showing the success of their own projects on a leaf. A subsequent policy reports has been adapted into green on HS Tool kit, which is available online on the feature platform on her methodology, is being scaled up across the globe, and I just want to do it. You shout out the knowledgeable and supported leaders who my respect greatly having dedicated, tenacious female mentals believe in me has been immensely most baiting. I dedicate this presentation to them. You can fire them on Twitter. We need to pass technics the nitrous on. As I said, check out The free resource is by the QR code. Do no harm. There is no time to waste. So thank you for listening on any questions. Please fire them at me. Thanks. Amazing a project. It Does anyone have any questions from the audience in this interest of time? I think No, I think I think that speaks the character of your of your work. I really, really well presented. And thanks for thanks for putting all of that effort and presenting it so clearly to us today. Thank you dot Thanks. Oh, just just enjoy the rest of it.