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Hi there, everyone. Um my name's Andy Stevenson. I um um welcoming you all to this Royal College of Surgeons Sustainability webinar. Um This is the first session we're doing of 2024. Um and though it says that it's Royal College of Surgeons of England, this has been done in, in collaboration with the Royal College of Surgeons of Edinburgh also. Um and they have inputted significantly to this work. Um I will just uh wait to hear back that we've got um everyone that we think is online and then we will progress with the er evening. Uh We've got three talks, so I've got an introductory talk, er, from myself. Uh really framing sustainability, why it's important? Um why um acting as healthcare professionals in a sustainable manner um is important. Um And then there are two surgical registrars, Mary Clarkson, who is a general surgical registrar working down um in Taunton Somerset with myself, although I'm an orthopedic surgeon, Mary um has er, initiated the rab scrub as part of the general surgical group here. And Alice Robinson who is a plastics trainee um and who's done her own er Q IP and um service improvement, er, project uh with regards to rub scrub. And so there's slightly slightly different ways of doing um, the Q IP and, and, and, er, instigating, er, RBB scrub. So, next slide, please. Yep. So my, what, what I'm saying is factually based, um, my views and all of that. Um, I'm, I'm the rep of the R CS England and I've given versions of this talk many times. So, um, I hope you find it interesting next slide. So, as I say, we are here, this is the um this is the webinar um on Rob Don't scrub. And this is one element of the uh green theater checklist, which is an intercollegiate checklist um as to how to conduct your surgery more sustainable, sustainably. Um And this ii love this image of uh an oak tree because trees, er, fundamentally are the only reason that we're here. Um They've been around for many 100s of millions of years and they're the reason we have soil, they're the reason that we have oxygen. Um And they are for me, the epitome of the natural sustainable system. Um and we could learn a lot through the way that they go through a variety of cycles. Um And I think refocusing on nature and how nature works um will give us the ability to maintain ourselves as a prosperous species going forward next slide, please. So, um the climate crisis can be quite be bewildering and um there's a lot of talks about it and often people er, talker about and across purposes. And so it's really a triple planetary crisis. So the one that gets all the um the attention or the most of the attention is climate change. Um This is as a result of greenhouse gasses, greenhouse gasses, principally carbon dioxide and other greenhouse gasses such as methane, uh nitrous dioxane, the halothane anesthetic agents and some others er cause the earth to heat up. Um and is measured, the meas unit of measurement is CO2 E that E stands for equivalence. Um The greenhouse gas effect is causing our world to get hotter and it's causing climate instability. That's the first element of the planetary crisis. The second one is E coside essentially, it's the destruction of habitat, you know, mankind has always impacted on its environment and on the natural environment, but we are really doing it in an unprecedented and industrial way. And so we need to take that into account when we're thinking about how to progress sustainably. And thirdly, the third part of this is pollution, you can see and smell pollution in the air on the land and in the sea. Plastic is everywhere from the top of Mount Everest to the Marriott's Trench. Um It's in newborn babies. It's, we eat a credit card of plastic every week. Um And it's, and, and it's, it's the, the weird way the world is now that we kind of accept all of the these three things as, as the modern way of things and it doesn't have to be like this next like please. Now these are two figures that the, the one on the left as you were looking at it. Greta Thunberg is a divisive figure. The one on the right is the grandfather of the nation and the conscious of the nation. They hold exactly the same message. So beware um people that attack the messenger, it's called messenger shaming and you should be aware of it. If you are going to be an advocate for sustainability, you will e either overtly or, or covertly uh lay yourself open to messenger shaming. So just be just beware, they say exactly the same thing, they are allies and yet they're treated very, very differently uh because of how people perceive them next. Likely if you wanna get to know things the BBC have done loads of good programs on it. I'm gonna show you another one. Extinction, the facts and climate change. The facts are two hour long documentaries done by Sir David Attenborough, really outlining exactly what's going on with regards to those two elements of the planetary crisis next like this. Um And this is kind of where we are now. So this is a graph of last year. So this is from the Copernicus Institute which is er the European er cli climate er science um lab. Um and it's based in Italy. Um and as you can see last year, 2023 hottest year ever recorded and by a magnitude that really upset lots of climate scientists because that is outside of their normal models. Next slide, please. And you can see the um Arctic sea ice as well is um in rapid decline. Um But again, you'll be ch you I was challenged by someone just recently saying, oh no, the Arctic makes loads of like ice every year. It does make loads of ice every year. That's the seasonal change. But overall the, the duration of ice and the thickness is decreasing quite substantially. Next slide, please. Um And this is, this is why we're here with regards to the climate change. Modern humans came in at 300,000 years BC. If you look at the X axis, that big red arrow is just a little past 300,000 BC at the er, the origin of the X axis is 800,000 years ago. This is from, this is ice core data. Um And you can see that we haven't been over 300 parts per million CO2 um, until we hit 1950 we've racked it up since then. We are now up to nearly 420. Next slide, please. And the reason for it is fossil fuels. Ok. Fossil fuels are responsible for the vast majority of that CO2, a little bits to do with other burning, but it's, it's largely fossil fuels. Um, so let's let, let's not beat around the bush. This fossil fuels are what are causing climate change and they're also responsible for practically all the plastic pollution as well. Ok. It's all from fossil fuels. Next. Likely if you wanna get, um, some detailed information on this. This is a TED talk, um, hosted by Al Gore. Um, and this is 25 minutes long. It really tells you exactly the extent to which the fossil fuel industry are going to try and slow this down. Next slide, please. Um And this is another, er, BBC. Er, this is a sort of triple header of big oil versus the world. Again, it's a pretty sobering watch these three as you can see on the bottom, the three Ds. So there's climate denial, there's climate doubt and now climate delay and we're still seeing denial, doubt and delay playing out the amount of money going into um trying to keep things as they are ie very profitable for fossil fuels is extraordinary. Next slide, please. Um And aside the destruction of nature is largely down to us, clearing forest for cattle and if it's not for cattle to graze directly, it's for cattle, um fodder, it's for the er moocs that are particularly soy that are used to feed cattle, uh both in the home countries, but more more largely for support uh for um exports to other beef pro production and other meat production. Next slide, please. So I mentioned air pollution as part of the, um, the triple planetary crisis, air pollution now is the number one exogenous killer in the world. It overtook uh, smoking, um, three or four years ago. Most of this is fossil fuel related though a proportion of that, um, is due to, er, burning indoor solid fuels, uh, in, in poor ventilation, in resource poor countries. Um, again, this is a, it, it highlights the need for, for moving away from um, that sort of, er, that sort of um uh heat and energy production. Next slide, please. Um And if you wanna have a look at it, look at this is the sixth iteration of the IPCC report. Um Over 20,000 scientists um have put their names to this. Um It's the biggest scientific collaboration ever. Um And it, and it, and it encapsulates everything that I've said just previously. Next slide, please. Um And again, just ii always like to think of this man. He um he himself, when you watch those documentaries that I've mentioned earlier, really, uh really kind of puts an emotional edge on all of this um because he's seen first hand, you know, he over over the last 60 years, um what we have done to the planet and if you will not listen to me, listen to him and if other people won't listen to you, then ask them to listen to him because he's a very powerful, powerful messenger. Next slide please. So this is why um we us as doctors and healthcare professionals really need to get in involved with this um climate change, air pollution, habitat loss is gonna play out um with regards to health outcomes and that's why we're here. We're not only good advocates for, for, for, for stopping um nonsustainable ways of living, but um we are the ones that are gonna have to um help people with the problems that it causes. Next slide, please. So, and this is where the Royal College of Surgeons of England and of Edinburgh and of Glasgow um came up with this. This is um a wonderful document er from which the rub do scrub um has come next slide, please. So this is searchable on uh the internet um on the R CS and Edinburgh home pages and this is a graphic from it. If you're not aware of the hierarchy with regards to sustainability, it's reduce, reuse, recycle rethink and then research so reduce, if you don't have to do something, don't do it, that's the most effective way of cutting resource use. Um and energy. If you can't uh not do it, then do it in a reusable way using reusable materials. If you can't reuse the materials, recycle them and if you can't recycle them, you've gotta rethink and research what you do next slide, please. So this is what the green theater checklist looks like. Next slide, please. And we're gonna be looking at um the preparation for surgery. Um nu- number eight, which is a rub. Don't scrub. So next slide, please. So just to highlight that. So rub, don't scrub. I'm gonna hand you over uh very shortly to um firstly to Mary to talk you through this but essentially rub. Don't scrub is the way in which the wh o nice and all the Royal colleges advocate that you scrub up. So after the first scrub of the day, so when you have visibly clean hands, you do not need to use subsequent water based scrubs. Alcohol based handrub is the way to go. Next slide, please. Um This is a uh poster from NHS Scotland that was shared with me uh by Vivian Gough. Um and just goes to show the sorts of things that could be put above a sink. Um, just to nudge people to rub don't scrub. Um And as I say, Alice or first Mary, then Alice are going to tell us about their Q I pro projects that have, um that have instituted this and how far along the journey they have gone. Um And, er, I'll hand you over to them. So, next up, it's Mary. Thanks so much. Hi, everyone. I'm Mary, I'm actually a surgical sho from Musgrove Park Hospital, er, down in Taunton and I've just been asked today to talk about our Green theater team and the work we've been doing. So, um I'm part of a multispecialty group of surgical juniors, all collaborating to improve sustainability across our theaters trying to exact effective change in practice. So Mr Stevenson's already run you through the green theater checklist. Um And our hospital has already made really good strides within reducing CO2 emissions in the anesthetic aspect of this list to the top part. So as a group, we decided to focus first on rub, don't scrub, which uh like you've seen as a part of the second aspect of the checklist. So preparation for surgery. Uh this was a good option for us to make quick but effective change as our hospital was already set up with the alcohol based hand rub dispensers in all of its theaters and a good proportion of our staff weren't using it yet. So I'll just briefly introduce the concept for anyone that's not sure. Say next side, please. So Rob doing scrub is a Royal college nice and who backed evidence based initiative aiming to reduce our water consumption and heat energy within theaters. Xi please. Xi please. Um So this is the, this is from the Royal College website that what's on the screen. But the advice is to use a traditional water based scrub for the first scrub of the day or if your hands are visibly soiled for all other cases of the day, you can use an alcohol based hand rub. And the current evidence supports this finding that the alcohol based hand rubs are at least as effective as traditional water based scrubs. And if you wanted to review this evidence for yourself, it's at the bottom of the Green Theater checklist or as part of the reason Royal College Green Report. Uh So what are the benefits next slide, please? So current evidence shows that the use of our coal based hand rubs is as at least as effective as using the water based scrub. And remember that the water that we use isn't actually sterile. It saves on water with the average scrub using up to 20 L, which is a huge amount of water, it saves on heat energy, not having to heat the water. And since the average operation generates as much CO2 as driving up to 450 miles in the average petrol, petrol car reductions here are gonna make a big difference. So our hand of alcohol rubs certainly contains a moisturizer. And er the evidence suggests this lowers rates of skin irritation and dryness. It reduces the time taken to scrub down to just 90 seconds and it saves the trust money. So there are many benefits to using this approach, not just for, and I say just for improving sustainability, the big one here is saving water since we use up to 20 L per scrub with our hands only under the stream for about 5 L of this. I think we can all agree that there's significant room for improvement without compromising our stability as we've grown fond of saying in our departments, you wouldn't keep the water running whilst you're brushing your teeth, at least, hopefully you wouldn't. So why are we still doing it within theaters when there's a good alternative option with all of these benefits? Next slide piece? So what we've done locally, so we started with a snapshot questionnaire to gauge the current practice, awareness and opinions around the techniques used for hand sterilization. And this was across all of the theaters in the hospital, across all specialties and staff of all grades who squab were encouraged to fill it out during just one day of data collection. And we were thrilled to get 94 responses with the majority coming from scrub, nurses, surgical consultants and surgical registrars. So the people doing this day in day out next slide, please. Uh Sorry for the slightly busy slide here. Um But this is just a few highlights from the data that we collected. So firstly, er the pie chart on the left as you see it, um 68% of people hadn't heard of the Green Theater checklist at all. 18% of people had heard of it. Uh but didn't really know what it involved for the central er pie charts, which is sort of looking at the current practice within our hospital. 42% of the blue segment um of people who are still using a traditional water based scrub for every case of the day happily 39%. So the green segment were already following the Royal College advice and this included nine out of the 14 consultant surgeons that responded interestingly 3%. So the red segment um answered that they just use whichever method the consultant surgeons using which just shows the importance of sort of top down learning and change, setting positive and evidence based examples for your colleagues. Then finally, the pie chart on the right. So 38% of people, the blue segment thought that using the alcohol based rub would be less effective than a water based scrub, which highlights the opportunity here to instigate change by education. 59% the orange and gray segments thought that the alcohol rub would be as or more effective than water based scrubs, which is what we found in the literature. Interestingly, those numbers don't match up with the actual practice in that 59% think it's gonna be as or more effective, but only 42% which is the green and orange se segments of the middle pie chart are actually consistently using the alcohol rub. So there must be other factors in play as well, which leads me on nicely to the qualitative data. Uh Next slide, please. So at the end of our questionnaire, we asked people whether they'd be happy to use the web. Don't scrub method having just explained it, an 18 out of 94 responded. No, it's a thematic analysis of the reasons given provided those that are displayed on the screen. These points have been covered individually during our subsequent educational interventions. And the majority stem from a lack of understanding education or awareness of the current evidence. Taking them point by point, we've already discussed the effectiveness of the alcohol based hand rubs. We were already planning widespread local educational interventions and then in regard to skin irritation, we've explained to that our brand of alcohol based hand rub actually contains a moisturizer and that often people find it gentler to their skin. We highlighted that it's not the same as alcohol based hand gels that people struggled with through COVID as this was a common misconception. Medicare legal defensibility was an interesting concern raised. And in response to this, we've emphasized the emphasized the evidence base and the backing from professional bodies such as the Royal College, the World Health Organization and nice. The more difficult aspect is the cultural norm, habits and not wanting to use an alcohol based hand rub if the consultant surgeon is scrubbing and these are more beh behavioral based and often there's no quick fix we hope for and are beginning to see a shift in the cultural norm with more people discussing and using the RBB don't scrub technique, which will hopefully help change these behaviors for for everyone over time. Next slide, please. So what have we done? We've deployed educational posters like the one on the screen um above every scrubbing sink in the hospital with QR codes to the evidence base to Royal College advice and the checklist and also to our um our brand of alcohol rub for kind of instructions on how to use it. Um And you may recognize those bullet points from earlier on a we've also attended the theater audit meetings for almost all of the specialties now, um and presented our data and provided some education on this technique along with the current evidence base. This was really well received um which we, we were really grateful for. Um And it sparked a lot of really valuable discussion around what else we can be doing to improve our sustainability within theaters. Our hospital is currently in the process of building new theaters and we've approached the trust regarding pedal or sensor driven taps and are just waiting a response. If we, if we know that we're wasting 50 L every time we scrub because the tap continues to run this, even this intervention on its own is gonna make a huge impact. Uh The project is still ongoing and there are various steps that we're still undertaking. Uh And that includes persistent mentions at the theater team briefings bringing in the alcohol based hand rub reps, um educating our foundation, doctors and medical students to preemptively improve future practice. Uh We're also in the process of producing some tiktok style educational videos for dissemination across the trust and maybe beyond to continue to raise awareness, keep people talking, educate and hopefully instigate change. We're then gonna be re auditing in due course. Next slide please. And then to just touch upon our future aims, we're hoping to produce a replicable package with all of our resources to provide to other interested hospitals or trusts, which actually, I think Alice may already be doing separately. And we plan to introduce screen theme of the week where we highlight highlight more sustainable practice likely on rotation um to keep the repetition to invoke lasting change. For example, things like not using gloves to transfer patients, not using inca pads to wrap arms and so on. Uh And then we'll look to address other aspects of the green theater checklist such as theater kit rationalization, which I suspect will be our next project, next slide. Um Yeah, thanks for listening. I hope that by the end of this talk, we uh convince you to use the alcohol hand rub er rather than the scrubbing technique if you aren't already doing so. Yeah, thanks again. Brilliant Mary. Thank you very much. That's a really, really great talk. Um And a good example of um Q IP in action and, and the um the questionnaires at the beginning, really interesting to see um the barriers to change. Um Alice um is now going to er tell us about her uh Q IP with regards to Rob Don't grab. So Alice, please take it away unmute it would help find me to myself, wouldn't it? Um Good evening everyone. My name is Alice and I'm gonna talk you through, I suppose, quite a similar project that I did at Queen Victoria Hospital. Um, but hopefully I'm, I'm gonna just explain it in a way that will encourage some of you or inspire some of you to, to do this yourselves. Um And, and to do that, I just need to kind of explain a bit of a basis behind um how to go about doing a green project. So we've spoken already a lot about the, the Green theater checklist. And the reason why it's so useful is because whenever you're doing an audit or a quality improvement project, you need the standard or the guideline to base it on. And now you've got this enormous list of different things that you can delve into and some of them are more difficult than others. Some of them are going to require quite big institutional changes in order to implement. Um But others are easy, quick wins like Rub Don't scrub and as a trainee, um you know, you always want to, you tend to be the ones doing all these quality improvement projects and audits. And it's just really important that you make sure you pick something that you're going to be able to achieve. Um Which is why Rub Don't Scrub is, is quite a good place to start if you're just at the beginning of your journey into, into green quality improvement. Um So just make sure that whatever project you embark upon, whether it's, you know, to do with hand washing or anything else on the checklist, just make sure it's something that you can achieve. Um And, and if not, then at least hand over to someone else if you do move on from wherever you're working. So I just wanted to mention um sustainable quality and um you might have heard of it before. Uh But if you haven't, I would really encourage you having a look at the qi website um effectively the Center for Sustainable Health Care, which again, um they have their own website as well, have have created this kind of um equation as you can see on the screen, which describes like quite a nice methodology for carrying out quality improvement projects. Um So essentially you want to improve sustainable value by improving or at least maintaining outcomes for patients and populations, but minimizing the environmental, social and financial impacts of any intervention you make. And that's the triple bottom line um which you'll hear me speak about later. And I just think it's a really nice model because it, it's straightforward. Um It doesn't get too wordy and you, it just, it's a really good way of approaching any quality improvement project. So if you haven't already looked at these resources, um SQ i.org is the website, they've got great examples, loads of good. Um sort of methodology, resources that you can use and then the Center for Sustainable Health Care um have their own website as well, which is in the bottom left. Um And they have a whole kind of um project based um database essentially. So you can have a look at what other departments have done. So things like gloves off rub, don't scrub um all the way up to much more involved projects and it's all on their website. So I'd highly recommend you have a look if this is something that interests you. So, the background we've already heard about, um, anyone that, you know, that's dialed in, we've got a nice mix of different people, but there are some kind of more junior team members. Um, so I'll just explain that that generally speaking, people either use the pink Chlorhexidine wash or a Betadine based wash. Um, and these are both effectively soaps that you need water for. Um, and that's how most people tend to scrub up the theater and this, this can use a huge amount of water because the, the sinks have different flow rates and people do have a tendency of leaving the tap running while they wash their hands. Um, and it has been quoted up to 29 L, uh, depending on, you know what taps you're using and how long you're leaving them on for and that's per person per case. So it's a huge amount and we've heard about the issues regarding sort of carbon dioxide and, and habitat destruction, climate change. Um But we also just need to think about water itself as a resource we use it. Um You know, and I don, I don't think we always think about the bigger consequences, but it is actually a finite resource. And there are lots of people who live in water stress situations and with our current patterns, uh this could increase and actually about two thirds of the world's population could be living in, in more water stress situations by 2025. Um And as mentioned, there is a carbon and cost impact of heated water as well. And water scarcity is a huge problem as you can. Um It leads to poor sanitation, poor health outcomes and waterborne diseases like cholera typhoid. And often with these, with these issues that come about from, from climate change and, and environmental issues. Um It's not places like the UK that get impacted first, it's people that are already in quite stress situations. Um And the impacts that we have in this country are far reaching. Um wetlands are disappearing and as a result, ecosystems and natural resource will suffer including agriculture and as healthcare professionals, we need to try and minimize the environmental impact of what we do to promote health and welfare, not just here in the UK, but globally. So we've already spoken about the alternative and that's alcohol based hand rub and um nice guidelines. Have, uh, and as you can see, the World Health Organization as well have endorsed this as a very reasonable way of decontaminating your hands for theater, um, for a long time now. But it seems that all over the country, people are using it in very different ways. Um, and I think generally speaking, it's not that well known and people aren't using it so often as we've mentioned, it has the same, if not better antiseptic capabilities than water based scrubs and it can be better tolerated by users as well. I certainly find it's much better for my skin. Um, and so getting started and how I got started is you need to see what's happening where you're working. Um, we've spoken about different types of sinks. You can have pedal operated and sensor operated taps and also, um, uh, yeah, so taps or you can have sort of, um, ft taps like there were in my hospital. Um, and it's not reasonable for you to go to your theater managers and ask for all the sinks to be replaced. It, it's not going to be a quick process. Um, and you know, think of the cost involved in that as well. Um, but something that you can do that I've had mentioned to you before, if you've got sensor operated taps, sometimes they run for just far too long than what's necessary. So you can, there are ways of reprogramming how long the taps run for Um And so that's actually quite a good way of saving water as well. Other little things on the side just to think about is people often use nail picks and scrubbing brushes. Um, sometimes for every case, which again isn't really necessary. And these are single use, sterilized plastic pieces of equipment that will go in the bin. So I think considering when you need to use those is also quite an important part of it. Um So as with most hospitals, um my sins had tabs. Um So to from a baseline audit, I looked at 44 cases which included 100 and 41 members of staff and not one single person used alcohol based hand RB and everyone turned the tap on and left that tap running. Um And I actually measured how much water that was at our hospital. So I basically bought a universal silicone plug. I put it in the bottom of all the sinks. Um I allowed everyone to scrub up and then I measured the volume of water. Um, that was used over that time, over scrub, everyone's scrubbing and then made an average and it worked out at about 11.6 L per scrub. So a bit less than what's previously been quoted. And that's probably to do with flow rates on the sinks. And so using some data from the Environment Agency, it might be around 98 g of CO2 equivalent just in the heated water alone. So that's not taking into account the carbon footprint um associated with treating the water and processing wastewater at the end, which means that a year of scrubbing at the hospital I was working at would work out as about the same carbon dioxide as driving halfway around the earth. So taking all this information, I again made some posters um and uh put them above all the sinks and something I also tried to push was the concept of just turning the tap off while scrubbing. So I measured the water um used in that and it was still about 2.5 L per scrub if the the tap was turned off. Um And so, you know, if people really don't like hand RB, that is also a very, very good option in terms of raising awareness. Um I presented the findings locally um in the plastics department. We actually with our, we also have a sort of green theater team. Um I don't think it's quite as comprehensive as Mary's, but there's a few of us in the department that were interested and we decided to launch a Green Theater week. Um So we actually modified the green theater checklist. We picked out things that we thought were achievable day to day on a on a regular theater list. And within that we integrated another hand washing audit. Um and that helps spread the word lots of posters. Um And obviously just telling people to try turning the tap off. Um, even if they didn't want to use alcohol based handrub and re auditing this. Um, so we got data from 23 lists with 236 grabbing episodes. And it was quite a nice thing to, to look at because obviously you go from a baseline of absolutely everyone using water, um, and not turning the tap off. So any slight change was going to be a good one. But as you can see, about 50% still stuck with that traditional method. Um But we managed to convince around 30% to turn the tap off while scrubbing and just over 20% started using hand gel, which in just one week, um over these lists would have saved 1230 L of water, which is pretty good actually, just for a week, um which works out about 10 kg of CO2 equivalent and a very modest financial saving, but every little helps. So, coming back to that equation at the beginning, just to show how this kind of fits into that methodology. Um in terms of outcomes for patients and populations, we know that it's, it's at least as effective as normal soap and soap and water, um perhaps even better, which would obviously improve outcomes for patients, it saves time. Um But I think overall the the main uh benefits come from the from underneath. So obviously, the environmental aspect, the carbon dioxide, the conservation of water. Um people tolerating the hand rub better and just general satisfaction that you're doing even just a small bit to help your environmental impact at work. And in terms of financial impact, um this is the reference at the bottom is actually quite a good paper to look at because they've, they've actually published their own um essentially quality improvement project in the same area. Um And while Chlorhexidine an iodine per Scrub is, is really not that different. Once you add the water on um alcohol based handrub is technically the cheapest. So, um but you know, it's really very equivocal, hence the only 7 lbs saving. Nevertheless, um at least it's not horrendously more expensive. So people can't complain about that. So I hope that's kind of given you a bit of an overview, maybe it has inspired you to try this in your own hospitals. Um in terms of top tips, uh I think it's really good that everyone's attending the webinar tonight. Um because that's how you sort of learn about what other people have done and, and start getting inspired to implement it, I think, find your trust screen plan. And if you're particularly if you're a rotational member of staff, like I am, um you can look ahead. So these things are usually publicly available. Every hospital now has to have or every trust has to have a green plan and you can look them up and you can often find people that are already doing things so you can get some contact details. So when you're about to rotate into a new hospital, um you can just fit straight into what they're doing and get going join your local green team if you have one and if not think about starting one, keep up to date with the green theater checklist. There should be a second version coming out at some point this year and it's updated all the time. It's a really good body of evidence and it just gives you something to base your audits and quality improvement projects around. Um the Green surgery Report, which is what's pictured on this slide is it was released at the end of last year and again, just loads of really good recommendations completely evidenced. Um And it, it just acts as, as more guidance for you. Um and staying in, in touch about the webinars, always think about any project you do, just be smart about it, make sure it's something that you can feasibly achieve. And um this project uh helped um essentially, we've been trying to recognize that people want to get involved in these sorts of projects, but, uh you know, within time frames and, and not really knowing how, how to start. Um We've taken some aspects of the Green Theater checklist and we've started making quality improvement recipes. So I've, I've turned this project into a quality improvement recipe which basically includes lots of background information. It includes, it's a data collection sheet. So proforma where it will calculate the carbon footprint and water savings and cost savings as well. So you're looking at the triple bottom line and also powerpoint slides. So once these sort of packages are together, they'll be available on the Royal College of Surgeons website for you to download and just start using locally. So you don't have to reinvent the wheel. You can literally just use what we've already done and, and crack on and, and do it. So keep an eye out. Hopefully they should be coming soon and um check out social media posts. Um So the Royal College of Surgeons um posted a video today. It was my Instagram influencer debut. Um So if you are keen on, you know, social media, uh you know, tiktok videos, um and you're doing really good stuff at your own hospital or trust the Royal College would want to know about it. And so do get in touch um and, and send in anything that you have um because they may well turn you into a celebrity. Um So that's me. Um And I'll be very glad to welcome any questions a bit later, but I think we're gonna watch the video first. Um It's, I think it might be a bit jumpy depending on what your internet connection is like. Um But the, the video itself you can find on the Instagram page, we all know we need to take care of the environment, conserve water energy and to practice in a more sustainable way. Did you know that operating theaters are the most resource intensive area of the hospital? My name is Alice and I'm a sustainability champion at the Royal College of Surgeons and I'm calling on you to take part in operation green. How can you scrub up faster? Greener and cleaner? When I first arrive in theater, I wash my hands to make sure they're visibly clean. I only use a nail brush and pick if I need to and I turn the water off while I'm doing this. If you don't still leave the t on while brushing your teeth, why would you are scrubbing up for four whole minutes? That's up to 30 L of water in one of these sinks. This is the only water based rug needed at the day. If your hands are visibly clean, you can go straight to alcohol based hand rub after getting your gown and gloves out, use alcohol based hand rub for approximately two minutes. It saves time water detergent money and it's the least effective if not more so than the traditional method. Find out what else you can do. Check the green theater checklist. Look after your and your patients. Fantastic. Alice. Thank you very much for all that, all that you did there. That's a, that's a really great project um, that you've told us all about and really very specific and um quite detailed with regards to the environmental impact. Um and what a great video at the end. I mean, those are, that's, that's the way so many of us um consume information now, isn't it? And it's, it's so, it's so much easier to forward on something like that to, to push the message. Um And I know down in um down in Somerset we're doing a similar thing and if any of you are out there, if you want to have a look at that video again, or search the Royal College, uh Instagram and social media pages to see if there's, there's further content there. Um Now we've got almost 20 minutes left for discussion. Um And so, uh before we kick off with the discussion, there is a poll. Um and I think Alice, if you could launch that second question, please, so we probably should have asked this a bit earlier. But basically, um can you, can you say whether or not um you currently use alcohol based hand rub or not? Uh What you currently do prior to having seen the talks that have been given today? And then after the questions, um we'll, we're gonna ask that, that poll. Um We're gonna ask you that again. Um And just to recap on what Mary and Alice have done, they've taken slightly different approaches for Q IP, both of them equally valid and Al Al Alice really, er, pointed out. Well, um using the green, the checklist as the gold standard against which to audit. And you can do it. You can do it as a kind of an old fashioned audit, you know, audit, audit against the gold standard and then institute a change and then reaudit or you can do more of the more Q IP one which is the P DSA Cycles or you can do a hybrid version. It's, you know, it's, you don't, it's not one size fits all, but we are going to be providing a recipe book that will be coming up um on the resource page of the Royal College of Surgeons. So, um I would just like to say now, um that if anyone has any questions, please uh post them in the messages and we will answer them for you. But I'm gonna kick the, the, the questions off. I'm gonna ask um both Alice and Mary um Alice first. Um The same question um the nature of surgical medical training is that you rotate out Alice, how do you think you're gonna be able to make this a sustainable change in the sense of a, a time, time wise, sustainability um in terms of making sure that this doesn't disappear when you disappear and everyone go back to the old ways of, of scrubbing up. So when I did this project, it was in a very small hospital um with basically absolutely nothing going on in terms of, of the green, um, green surgery and finding the relevant people. Um, it turns out that in terms of the anesthetic side, which is often the way the anesthetists are much, much better at getting through the green theater checklist and being a lot more conscious about green surgery. But there, there were a couple of anesthetists there that kind of after COVID hadn't really picked up on things and I think just having someone, uh, push for, for something else has really got things going. So, um although I've rotated out of that hospital now, um I hope I'll go back at some point and pick it up again. But actually, since leaving, um I know that they've carried on with the Green Group. Um and they've now got reusable textiles. So I think sometimes um it just, you just need someone just to give a little nudge to get things going and, and people will carry on doing things after you. Um But it, you do need kind of representation from everyone in theaters. Otherwise it, it just gets really difficult. So you kind of want someone from management. You want some anesthetists, you do want some consultants because they are permanent. Um And, but, but ultimately, it's trainees that are good at just getting the audits done. So, um yeah, it's not easy. But if you can do a closed loop audit, get the posters out there, start the conversation. Um even if things drop off when you leave at least you've, you've made some progress and you've hopefully inspired the team to get to get going brilliant. Um Thank you very much. Yeah, that's, I think that's a really key point you've made there just to kind of summarize it's finding allies, isn't it? And this is something that I've really found in this hospital. Um, you've gotta find allies, um, and particularly permanent staff members, Mary, I've probably given it, we, you've probably had the answer there. But have you come up with a any other strategies? So when you rotate out of your current um placement, how do you think you might be able to make this a AAA permanent change? Not just something that passes when you move on? Oh, yeah, I think it's a really important, really important question. I think for me, it's a lot easier because I always have people like yourself and other consultant, colleagues who are involved with the Green Theater side of things. I think it's making sure that you kind of have people, you kind of highlight it as something that other people can get involved in and kind of help with that tran transition period. Certainly, I know that where I am, the Sh Os and registrars are on a different rotation pattern. So if we could get some registrars involved, then they can kind of keep it going and introduce the next group of Sh Os and then the same with the Sh Os when the registrars change over so that there's a constant flow. Brilliant. Thank you. Um, I'm just having a quick look, Phoebe or Antonia. Do we have any other questions or? I'm gonna ask a few other questions? I've got some system changes. Obviously, I bought P taps is the RT S trying to address this at a national level. Um, it's the R CS, um, and the intercollegiate group that is, uh, trying to promote sustainable career does have a national focus. Um, and I suppose the analogy that we're trying to, um, hang on, I'll re re, I'll go back one bit from that. So, yes, trying to change things at a national level. But already in the NHS, there's the NHS net zero document. So we're already committed to carbon neutrality in the NHS overall. What, 12 and three emissions by, by, um, 2045. Um, but this is, you know, we're on a journey and we've only had the green theater check this out for 18 months now and we're gonna have a slightly more usable version. So, um, absolutely, we will try and we will try and push this nationally and it's, uh, it's culture changes, er, takes a bit of time and, um, specifically if you want it to, to be embedded, um going forward. Um, I'd just like to, I hope, um, I hope that answers your question. Manu, I've, there's another question here. Has anyone found an easy way of recycling reusing the drapes that aren't needed that come in the set anyway. Um, Alice or Mary. Do you have any, any, uh, answers for that before? I just keep talking and, um, I know that, uh, I know that they, people take them away. Um, the single use shapes do take them away for home decorating. I know they don't get completely thrown away and they can also be used for lining of shelves in, in, um, hospitals. Um, just to keep things a bit easier to clean. But, um, Alice or Mary do you have? Unfortunately, I mean, the, the materials in, in these are, they're not recyclable. Um, you know, you can be creative in your own way and a lot of them are fluid resistant. So, instead of getting a new inco every time, if you have a stack of them that you haven't used and kept to one side, I suppose you could use them in that sense. But really they are pretty terrible things. And, um, going back to reusable textiles is something we should all hope for. I think it's a really good point. And I think the other thing that, um, we've certainly talked about locally is, um, with using the rub don't scrub technique in your, um, gown kit. There's often the, um, you know, the drying towels, um, and that's certainly something that could be used for other, for other things within theaters as well. Um, so making sure that you kind of have a, a pot or a tub or something to put those in so that they're not just going in the bin as well. So, um, if we could, Antonia, could you rewind to the picture of the green theater checklist on my talk, the full, the full side of one? Um, and just to touch on that and o on that, er, reusable drapes. So, um, one of the things that we're gonna need to plan for that, some of you may or may not have plopped with regards to sustainability is there's been huge disruption to supply chains recently, obviously COVID dis disrupted supply chains. So is the Ukrainian war. Um so is the conflict in Gaza with regards to the Red Sea traffic? Um and er so you, you know, so many other events, not just climate change. And so talking about um single use drapes um is, is um important in the sense that if we all switched over to reusable drapes and reusable gowns, not only is that better environmentally, but we also make ourselves um more robust with regards to the shocks that will continue to come um in modern life. I mean, these, these events are not going to become less frequent. I'd say I'd say we're on, we're on an accelerating path. So um we haven't quite got those back but um certainly that mantra of reduce reuse, recycle rethink. So when it comes to, when it comes to the drapes um, if you get them in your sets, talk to your scrub team and ask for them to be, ask them to ask for them to be changed so you can take it out. Um, so, and there we are in the preparing for surgery, switch to reusable check styles including theater hats. Uh, on that question, just while we're waiting for some another question. Alice, where did you get your hat? Because you're in your video, you're wearing a reusable hat. Is there any way you could sign post people to that hat? Um, well, I've, I've got quite a few hats now. Um, uh, I think I bought some off, um, one of the scrub nurses mum because she was making them, but a good place is always Etsy. Etsy has lots of really good hats. They're not cheap but if you know, they're really nice and I look, I take good care of them. So, um, I think it's well worth it. It's kind of like a little fashion piece as well when you have to wear the same thing as everyone else all day. Having a different hat is quite a nice thing really. Um, so I'd recommend Etsy Brilliant Mary. Have you got, have you got, um, any, any movement on hats? Uh, yeah, so, I mean, II also have bought some hats on Etsy. It's always a good site. Um, but I think our, our, er, hospital, our trust is um, very kindly getting er, all of the juniors hats, reusable hats with their name and their, their role on it, um, which is, which is great strides really good to have support from them as well. I think it's great as well because it's, it's a communication thing, particularly if you're a trainee and no one, no one knows you and, and actually communicating in theater when you have a who at the beginning and everyone says their name, you don't remember half of them unless you work with them regularly. So I think actually from a safety perspective and probably for patients, it's just better just to have your name visible um on your hat. So that's great. I think that's something that I'd like to look into as well. Great. And I'm just gonna pick up on a question from Shaji Mahmood are single use dr superior than recyclable, reusable ones in maintaining a sterile ot environment. Uh There is no evidence of this. Ok. So in the Green Surgery report, um which is also available. Um And also in the compendium of evidence from the theater checklist, there is no evidence that there is superiority of single use over um uh over reusable. Um And it's something we just kind of drifted into. Um And so you shouldn't feel worried by that. I'm an, I'm an arthroplasty surgeon. Um And, you know, we are absolutely paranoid with regards to infection prevention. I rub that scrub. Um And though at the moment, I don't have a full hood but when I have a full washable hood, I'll be wearing that and I'm very happy to use reusable, er, er, reasonable gowns. With regards to the drapes. We do need to, we, we need to figure out how we're gonna do that because we've been doing single use, um, extremity drapes for a very long time. Um, let's just see, reasonable ones. Um, so one of the things that has also been mentioned in the comments here, so I'm trying to talk and read Alice if and Mary, if you want to pick up any of the comments, um is trade rationalization. And I know that uh Jasmine Winter Bei who is one of the coauthors of the Green, the checklist, he's not with us today, um has recently published in the B MJ about trade rationalization. And that's something I I'd really look at closely all of you. Um We've recently, well, we're doing a project here at Musgrove looking at er rationalization of our total hip trays. There's so much equipment that is not required on the trays. So that's a, again, that's a reduction that's reduced, which is right at the top. Um Is there anything in there that you can, I can't, people have mentioned um just trying not to over drape and in certain cases, you don't need a full sterile gown and I think that's a really, really great, great thing to do because uh yeah, like some, some procedures are dirty. Sometimes you're literally going into someone's mouth or, yeah, bum abscesses. Um, and in, in plastics there's lots of very, very minor skin procedures that actually in, in certain parts of the country would be done in a GP clinic room. So, yeah, I think you can like coming back to how, how you go about doing a surgery reduce is always the best. So if you don't need a huge patient drape and if you don't need a full sterile gown for what you're doing, um just don't use it in the first place. And uh the concept of field sterility is definitely growing on. Um hand surgery is also quite a nice uh example of that and there, there is some literature out there as well by someone called particularly in Canada. Um If you were interested in having a look at that and in the second iteration of the green theater checklist, there will be a section on field sterility as well. Great. Thanks Alice. I'm just gonna pick up on a question from Manu er Shrivastava, um who said the er theater staff ordered drapes and equipment. I tried to pursue this in my hospital about reusable drapes and told they're more expensive, same with reusable equipment. So it would be nice nationally if we could coordinate, have a standardized way where hospitals can get reusable equipment. So we're to the, that's a really, really well put and that kind of frames one of the problems. So in terms of uh changing from a linear economy, which is what a re um single use economy is, which is basically you, you make stuff, use it and throw it away to a circular economy. Whereas you make stuff, you use it, you clean it, reuse it and then do it again, you need to have um that um workflow as it were set up. And so that will require a business case, it will require going and talking to um all of the stakeholders involved in that from procurement to laundry to transport. Um And all the people that are going to be part of that circular economy because essentially this is what we're trying to do, isn't it? We're trying to build a circular economy, not a linear one. In the long run, it's cheaper to use reusable. That's a full stop, that's easy. Um But in the short run, it's more difficult specifically because of storage um and space available for it. Um But also because of um the fact that we don't have the laundry capacity to deal with it just presently. So that that kind of encapsulates AAA A, a real problem with regards to um changing to sustainable workflows, it does um take a fair bit of work. And that's one of the reasons that we started with the rub. Don't scrub is the first webinar is because this takes very, very little change. Most hospitals have a B hr alcohol based hand rub available and this is just a, this is a, this is AAA um, an evidence based change. Um I've got 11 new message while just while I'm reading that. Um, thank you, man. That's very kind. Um I'd just like to put up. Could we put up, um, Alice's final slide, please? Um, and so I'm just gonna make a big note of this. So this is the green surgery report. Um So the compendium that goes with the green theater checklist, which is what we're taking. The r don't scrub off today has over 90 references in the back about sustainable practice and how to do sustainable to, to do sustainable surgery. It's all evidence based, most of it's very uncontroversial. Um And so I'll, I'll just take one of those things and just make one of those changes today. We've done rub don't scrub this, this green surgery report that came out over Christmas has got over 600 references in the back. Um It's headed up by uh Professor Mood Beer from er Bryson and Chantal Rosan, uh from Surrey, who have been, who are the principal author, authors and this is um, has been, can't quite see it at the bottom, but it's been um a publication funded by the UK, a Health Alliance against Climate Change, uh which is an organization with over a million representatives. You're probably a member of it without you knowing um, and, uh, and I would urge you to have a look at this specifically. Don't read, well, do read the whole thing if you have time but there are, uh, quick takeaway messages. Um, now I'm conscious that we're coming up to, um, the end of this. Um, I'd like to thank you all for coming. Alice and Mary. Are there any things, any questions you'd like to ask each other or myself or, um, or post to the group? Oh, I suppose while we're doing that, while you think of that, um, can we do the final poll? So, Alice, if you could link the final poll, if you could fill out the final poll, that would be really good. Um And uh, they're on screen, you can see um, the um QR code that links to the Royal College Sustainability and Sur Surgery web page. Um Please do go and have a look at that. Um, that has got lots of good linkages. It's grown a lot recently and that's gonna be the place where we host the recipes for, um, the rub oat scrub. There is also on there, my email sustainability at R csn.ac.uk. Uh Please feel free to send me any emails or queries that you may have and I will try and help you, um, in any way or more often than not, it's about sign posted. Uh We've got one final question that maybe Antonia um or Isabel could answer is the webinar recorded. Will this be available? Um So I don't know about that, but I think we'll try and we'll certainly try and put a link to that. We might cut out the question and answer a bit at the end. But we'll have a, we'll have a look, let's see what that is, uh will be put in metal. OK. Will it be put in metal? We will find out about that. Um So I'm, I'm happy to keep talking for another five minutes or so, if people have questions to ask, um, if you'd like to do that, otherwise, I thank you very much for coming along and, um, taking the time out to listen to our talks. I'd like to say a massive thank you to A and Mary um, for coming and giving up their time and for presenting the work that they've done. And I think it's, uh, it's, it's really fantastic to see um, how things can change and how things can change quite quickly. And, er, for me it's, you know, it's, it's a very hopeful thing that, um, that we're all gathered today talking about this. So, um, and I've just seen from Phoebe there, uh that yes, indeed. Er, the video will be available on that. Um, so if there are any other questions, please feel free to post them and I'll answer them. Um, and just thank you very much for uh Mary Alice, um, Phoebe and Antonia in the back room for er, supporting today's event. Uh We'll leave out the screen there if you want to take a picture of the QR code and, and take any of the contact details. Thanks so much.