Computer generated transcript

Warning!
The following transcript was generated automatically from the content and has not been checked or corrected manually.

Hi there. Good afternoon, Pay Thieve who had a chance to have um have a cup of tea or a bite to eat. Um Thank you for joining us here in the session on, on waste. Um I think when, when we think about sustainable healthcare people often, do you think about the, the waste streams? Um And really when, when we think about the waste that we generate the issues that are often upstream, say it's, it's reflective of that embodied carbon upstream in the manufacturer and the, and the distribution of these items that, that are often single use. Say it's, it's a real problem in terms of the volumes of waste that we're producing. But perhaps some of these strategies that we speak through earlier in terms of uh switching two reasons might, might help in this. Uh um We're delighted, we've got four excellent uh speakers that are joining us today. We're just waiting on one to join the session. Um But essentially we're gonna be going three uh a similar vein to the breakout sessions this morning. We'll go through the four different sections SRE the four different presentations first off. So seven minutes per presenter. Um and we'll then have an open discussion with all of the presenters and, and hopefully have a debate about some of these issues relating to healthcare waste and what we can do about it. Um I'd like to invite you if you, if you've got questions as we go along, if you're able to paste them in the chat. Um And we'll try to address them um at the, at the end of this session. Um And uh for the, for those of you who are then uh asking questions or presenting, please do put your camera on uh and, and um meet yourselves, but whilst you're not presenting uh or asking questions, if you're able to make sure that you are uh on meat, that would be great. Um So we're going to be starting off today with Zen, you one from Nottingham University, uh sorry, Nottingham City Hospital. Um He will be talking to us about his recycling um quality improvement project in the theater setting. Um So then if you're able to start sharing your slides, sure. Can, can everyone hear me? Yeah, that's great. Thank you. All right. So I'll be starting now. So, hi, I'm then you guys can also call me Oscar. So I'm from North in Communion City Hospital NHS Trust. And I'm really pleased to have the opportunity today to present my quality improvement project on recycling theater waste. Okay. So, before we dive into that, this project, just a bit of background information. As we all know, uh climate change has been recognized as one of the biggest global health track and the NHS has pledged to meet the net zero carbon target by 2045. Um And why is this important NHS itself accounting for 4.6% of U K's total carbon footprint. An operation theatre itself tend to produce approximately 15 70% of the total hospital waste. So this bring this brings me and my team to start thinking about how we can contribute this uh issue. So uh just a bit of sharing of this information, besides what, what we can do, we also refer to a few resources. So from the Royal College of Surgeons England, we can see there is a guidelines, sustainability in the uh operation Theater, there's a champion group which is working on this issue. And latest, I I think came out a few months ago, there's the Inter Collegial green theater checklist which helped promote reducing the carbon footprint in operation theater. So basically what this project is about. So we all know that the stuff in the operation theatre are usually really busy. And for the past few decades, uh there has been an increase in volume of theater race and there has been a shifting from reusable to one time use uh instrument or any material. Actually, the original goal was to reduce any blood blood diseases. But over the over the years, actually they have noticed there has been increased in the ways and stuff are usually quite under pressure, time, pressure to empty and clean the theater and sometimes, you know, non recyclable waste can go into non recyclable been. So this quality improvement project aims to assess and reduce waits related costs and carbon footprint by improving the proportion of race recycle. So I'm going to move into a method. So how do we actually do it? So, uh actually came from uh one of my general surgery with traditional, we were having a chat about it about this idea. We talked to the Department of Ways of our local hospital and we look at data from 2022 January until December. So that was our first cycle. We tried to capture what the data was there and we try to brainstorm if there's any, uh there's anything that we do can, can improve it. And actually before pre COVID, there was actually a lot of activities trying to promote recycling in operation theater, unfortunately, doing COVID everything as we stop and nothing has been uh resume. So uh we sat down, we talked to a lot of other theater stuff trying to brainstorm of project. And we actually put uh we, we actually put all ideas together on the poster and this poster serve as a guide for theater stuff to recycle their ways. So they know what exactly can be recycled and what exactly can't be recycled. And what we did is uh we did it in two ways, we printed the physical poster and then we post and then replace it in almost every corner of the theater. We, we email to all the tater stuff and we opened an emailed threat for everyone to discuss. So we did this in January 2023 we clarify any questions. And we realize with the waste department to make sure our answers are always accurate and correct. And we did a second cycle in uh second cycle of data collection in February and March 2023. So this is just the poster that we have uh eventually designed, we focus on making it less worthy. So it's a picture center so that it is very clear and easy to follow. And you can find this in the operation theatre in Nottingham City Hospital. So moving on to result. So this graph is just a proportion of recyclable of recycled waste in Nottingham City Hospital theater, main theater. So the first cycle indicates uh January to December 2022. As we can see, it ranges, it's actually quite uh it fluctuates a lot. It ranges from 9.5% to all the way close to 35%. So uh we, we actually capture the second cycle which is, which is shown in blue. And what we, what we observe is actually the. So we were trying to compare month by month because of the large, large fluctuance in the data and we can actually see a huge improvement in February. But however, in much, it seems to be, you know, the same and we'll talk and I'll talk more about it in, in our, in my discussion. So our secondary outcome was the proportion of the disposable cost for recyclable for recycle waste. So I think similar trend can be seen there was a huge improvement in February comparing both years. But in much is it doesn't even seem to be improving, but it seems to be even lower than the year before, even after we did the project. Nevertheless, we try to compare the proportion of weight and the proportion of course. So recycle way actually uh is actually close to almost 20% of the total waste. It uh in terms of weight, but it only costs uh for 8% of total cost. So it indicates that is an economical benefit for NHS if more ways of being is being recycled because it's cheaper uh to process recyclable ways compared to the ones which can be. So this uh moving on to discussion, I know this is a very simple project, is a local project. But why? But I believe everyone can agree. This topic is really important. Uh just for your inside recyclable waste and non recyclable ways, they have a 15 times difference in terms of carbon footprint. So that's why every, even every 1% of increase can mean can mean a lot to the environment and what we are trying to prove on this project, local effort is useful. If every, every local hospital has a team that starts doing this, eventually, we will be able to see a drastic huge improvement in a national level. So team work makes the dream work. And I really need to thank all the people that are liars with including theaters, including nurses, uh you know, other surgeons and, and the waste department who was really passionate in supporting this project that offer a lot of advice is on how we can look at this issue. And correct waste segregation can actually avoid recyclable ways go into incineration, which is actually really expensive and harmful to the environment. But however, from the result I have presented, we can, we can we also a huge improvement right after uh we did a project but however quick, quickly things went back to square one. So protecting our environment is really difficult and sustainable effort is uh it's necessary if we really want to solve this issue. So uh we are we are planning for third cycle and fourth cycle to see how we can get this issue solved and try to get things improved. But long story short, uh it requires uh it requires constant effort and I really hope that more people who will be aware of this issue and try to contribute it. Thank you so much then. Thank you. Um it's really interesting to see some of these trends over time and perhaps we can talk a little bit more about that at the end. And, you know, I think it's really interesting phenomenon that they do out there. Um I'd like to uh E B and uh Sam will be joining her today also in this presentation um to, to present their abstract based on enteral feeding muscles and recycling and really drug on in traditional uh teams to bring about change in the I C A. Thank you. Thanks John Cell. That's great. Can you hear me? Great. So yeah, I said that's are types of our project there. My name's Sam and let's feed. Hello, halfway through with both junior doctors working in the North Bristol Trust at the moment. So as we've heard today, the climate emergency represents an ever increasing threat to global health and well being and healthcare systems account for more than 4% of global carbon emissions and NHS weight is estimated to cause 3% of the total carbon footprint from healthcare. So it's well documented that providing care for patient's in the intensive care setting produces more waste and carbon emissions than the general ward environment. And whilst working in the ICU, we definitely felt this was the case and noticed behavior changes in terms of waste production uh since the COVID pandemic. So therefore, we set out to try and improve the environmental sustainability of our ICU and our overall aim for the project was to initiate collaborative Axion amongst members of the MDT uh working towards this goal of improving sustainability. And I hope to talk through our objectives here and methods of achieving the same throughout the presentation. So North Bristol Trust ICU is a 48 bedded unit and one of the largest in the UK. And to start our team conducted a blinded baseline waste audit, so always produced by the department for a continuous 72 hours was weighed and sorted into different waste streams. We weighed a total of 963 kg in 72 hours equating to over 100 and 17 tons of waste annually. And this graph here shows a breakdown of the streams of waste was disposed into. And as you can see, by far, the greatest proportion was disposed of as infectious waste and less than 4% of total waste was recycled. We also considered these estimated annual figures of weight and financial cost of the trust of waste produced per waste stream as you can see the stats here. So infectious waste was definitely the most costly. And because that we, we then calculated the carbon cost of processing these different waste streams into annual carbon dioxide equivalent. And this showed that in total are ICU produces 54,900 kg of carbon dioxide equivalent from waist alone each year. And this equates to providing electricity for 10 homes for over a year or over 100 and 40,000 miles about an average petrol passenger car. So based on these findings, we formed the ICU sustainability champions a group of professionals from across the multidisciplinary team together focusing on how we can improve our unit's recycling rate. With the literature search and produced this driver diagram to consider different factors, influencing recycling behaviors. And with these drivers in mind, we developed and distributed a survey to all staff including nursing teams, domestics, allied health professionals and doctors. And our survey showed that only 22% of surveyed staff strongly agreed that they recycled at work on a day to day basis. However, 100% of these same staff recycled at home and 88% of staff were willing to recycle at work. So this showed a clear appetite for improving our recycling rates and we found this mismatch between Axion and enthusiasm hugely encouraging. Can everyone hear me? Yeah, carry on. So, guided by the driver's identified as important in our survey, we designed and carried out a nursing focused recycling quality improvement project focusing on our overarching aim of raising the profile of possible sustainability initiatives on the intensive care unit. We decided to focus on one element of possible recyclable waste enteral feed bottles. Now, MBT I T U is a trauma and they're a surgical center. So many of our patient's require enteral feeding during their stay and from our baseline waste audit we noted that none of these bottles were being recycled at present. This also aligned well with our aim of involving the MBT because feed prescribing, administering recycling, it involves the doctors, dieticians, bedside nurses, domestic teams. So here is a PDS a cycle for our central quip to summarize. We, we launched a month long feed bottle challenge. So during this month, we asked the war teams to briefly rinse out and recycle all their Nutricia enteral feed bottles and put them into the project recycling bins. The dieticians on our project team provided information about the total number of bottles prescribed weekly. Um So that way we could calculate the proportion of bottles recycled. Mhm. Our intensive care unit is up into four pods which meant we were able to launch this as a fun into pod competition. We had a whiteboard in the staff room displaying the running week totals and of course, with any good competition, there was a prize for the winning team. So um here's a slide showing our our whiteboard with the running totals from week number three. Um and some of our projects looking very happy by our whiteboard. Mhm. Here are our results from the month long challenge from this single small intervention. The teams managed to recycle 446 plastic feed bottles over and overall an increased from 0% to 53% of total bottles recycled. This represents 15.2 kg of plastic recycled rather than disposed of into other waste streams. A saving of 3.46 kg of carbon dioxide equivalent in the month alone. If we were able to continue recycling these bottles at the rate we did during the challenge month, this would equate to 100 and 77 kg of plastic recycled yearly or a potential saving of 42.9 kg carbon dioxide equivalent yearly. So we were able to use this central quip as a springboard to promote team working and kickstart sustainability initiatives on our intensive care. So what's next? So we celebrated the success of our nursing teams recycling effort in both local and national communications, hoping that this project would be something that the whole MDT was proud of. Since the end of the challenge. Our team has been contacted by other departments in the trust, but also by other trusts. And we hope we hope that we'll be able to help support them carry out similar local quips. We currently have a survey out to all staff on the unit gauging their thoughts on the recycling challenge. And following on from this will be planning our next step to promoting recycling and other sustainability initiatives on the intensive care. Mhm So I absolutely love this picture. Um At the end of March, we removed our project bins from the pods while we've been re surveying and planning our next steps. However, I recently spotted this on the unit, a member of staff, not from our project team has put a cardboard box in the project been place and the clinical teams have continued to recycle the feed bottles into it. Now, I know that this is an infection control or fire safety compliant, but this image really represents to me real enthusiasm for sustainability initiatives and most importantly, the start of culture and behavior change on our intensive care unit. Um Here are references both Sam and I will be looking forward to answering any questions and having a chat after presentations. Thank you both. And it's fantastic to see what can be achieved when you have these specific challenges and great to see that then over spilling and people really getting infused and, and wanting to continue the good work. Um I'd like to now invite uh abdomen. He will be joining us from Brighton Sussex Medical School. Um He has been undertaking a systematic review looking at inappropriate single use glove use within healthcare and looking at the reasons why we might be abusing um clinical gloves so ever to you abdomen. Hello. Can you hear me? Yeah. Can you see my slides as well? Perfect. Hello, I'm Abby Man. I'm 1/4 year medical student at the University of Liverpool. And today I'll be presenting the findings of the systematic review I carried out into inappropriate use of non sterile gloves in healthcare settings globally. Um And this, this system review was carried out as far as my, as part of my dissertation for my global health MSC A Brighton Sussex Medical School. And I'd like to thank my Super Fighters doctor got to go to and doctor Jones. So here's a quick overview of my presentation. I'll be going through key definitions justifying why this research was necessary. Going through the research aims and an overview of the methods and finally discussing the results. So we use the World Health Organization's glove use guidelines to formulate our definition for what inappropriate glove use is. Um inappropriate, non sterile glove use was defined as wearing gloves during a procedure for which it is not indicated inappropriate techniques when putting on the gloves or taking them off, putting gloves on too early or too late during a procedure, not wearing gloves when required to and lastly double gloving. So due to the limited time, I'll briefly go over the justification, um please feel free to email or ask at the end if you have further questions about this. Um So we identified four main areas from an environmental perspective. The manufacturing and disposable disposal process of gloves is very energy intensive and releases a lot of toxic gasses, some of which are some of which contribute to climate change. Secondly, inappropriate use can also lead to increase hospital acquired infections which results in longer stays for patient's and increase mortality. Antibiotics are often prescribed to deal with these infections and can contribute towards antibiotic resistance. And with regards to the ethics, we can think of it from the healthcare worker perspective, um as inappropriate use that causes harm to patient's. Um And we can also consider it from the perspective of the glove industry. Um as most of these gloves are produced in Southeast Asia um in factories where workers are poor working conditions. And finally, um the inappropriate use of gloves, gloves has severe implications um on the finance, on the on the finance of health systems and this money can be saved and utilizing on other parts. The three research aims of this review were to identify barriers to using non sterile gloves, inappropriately identify drivers, enabling appropriate use and finally identify the knowledge and attitudes of healthcare workers towards inappropriate and appropriate non sterile glove use. Um So this was a mixed methods systematic review which contained the total 15 studies ranging from quantitative qualitative and mixed methods studies. We only use studies published from the year 2009 as this is when the World Health Organization released the latest guidance on glove use. Um The data was grouped together based on the similar similarity of meaning. Um And this formed eight key categories which I'll now go over. So, knowledge and understanding. Um So this is one of the key themes that we identified um and it can be broken down into overuse. So this is when healthcare workers war gloves were not indicated, for example. And when giving oral medications, taking observations um or giving intramuscular or subcutaneous injections under use. So, not wearing gloves when it was indicated to do so, not washing hands before wearing gloves, um inappropriate actions whilst wearing gloves such as not changing them in between patient's and finally not washing hands. After the removal, removal of gloves risking cross contamination. The next category was influenced. Healthcare workers were influenced by the glove use of others, especially those of seniority, even when they questioned in their minds, the behavior of the glove use by others by other staff, they often confirmed to their actions. Moving on the next category um is organizational policy and training. Um There was a lack of organizational policy and training um and that influenced glove use behavior and healthcare workers. Um Some responses explained that they were not given formal training and they often have to use a an initiative. Um There was also a contradiction between the bold health organizations guidance and local policy. The next category identified healthcare workers perceiving patient's as dirty or disgusting. Um as a reason for wearing non sterile gloves in circumstances that they shouldn't be wearing them. Often. This perception was based of pre judgment on whether the patient could meet their own self care needs. They also felt that it helps them feel safer when doing the job. For example, one participant had described how wearing gloves makes them feel less obsessive compulsive about wearing, about washing their hands. Um without the gloves, she feels more conscious. The next category is regarding healthcare workers wearing gloves primarily for the reason of protecting themselves. Um I'm maintaining a professional image, they misperceived risk by wearing gloves for everything because they were not able to differentiate between patients for infections and those who weren't. Um In contrast, the next category identified healthcare workers who wore gloves for patient centred approach and respecting their dignity. This was interesting as on one hand, some healthcare workers reported wearing gloves to protect their patient's from infections. However, on the other hand, some actively avoided wearing gloves to stop the patient feeling stigmatized and maintain a good relationship with the patient. In addition, some and reported wearing gloves during intimate procedures which didn't require them. For example, one responded in a study that how we wore gloves to put on the C G leads on a patient with a very large breasts um as he wanted her to um as he wanted to maintain her dignity. The workload category focuses on how the working environment of healthcare workers affects their glove use. The main findings were that healthcare workers would wear gloves to avoid having to wash their hands and save their time. Some reported that washing their hands before putting the gloves and would make their hands more sicky. Um And as a result made putting gloves on more difficult and resulted resulted in waited time. And finally, the last category was availability and accessibility of gloves in hospital overuse was reported in some cases when gloves were easily accessible as it was easier than having to wash their hands. However, in some settings where the availability of gloves was restricted, um uses more conserved leading to reluctance on changing in between patient's um leading to an increase in infection risk, cross contamination risk. So the key findings whether there's a complex interconnection between multiple factors impacting glove use the decision to weigh non sterile gloves is commonly based on emotion and feelings of aversion rather than patient safety. There is a disparity between existing policy and guidance um and real life practice. The World Health Organization last revised their guidelines, um revised the guidelines on glove use in 2009. So these need to be revised to reflect the wide range of factors that influence non style glove use. There needs to be regular training on health of healthcare workers at all levels, particularly post COVID 19 pandemic. Um I'm sure you can all agree that we, we, we did a lot of things differently during the COVID 19 pandemic and we're still carrying on with those actions. Now. Um finally, it's important to create a working environment where healthcare workers regardless of their position can challenge non sterile glove use. Thank you for listening. Thank you very much. I mean, it really does help to unpick the sort of complexities and just how many different angles there are. When, when we think about this issue of uh maybe, maybe use of gloves and, uh, there's multiple factors that, uh, interesting that you've highlighted there and perhaps we can, um, discuss later on how some of those might be addressed. Um, uh, just moving on to the final presentation now. So we've got Callum Byrne joining us from guys in ST Thomas's Hospital. Um, just checking your able to share your slides. Callum. Um And Callum will be discussing uh study looking at which is looking at switching single use to reusable plastic trays um using a mixed method analysis. Callum, are you able to share your slides? I don't know if we need abdomen to stop sharing, perhaps. Sorry. Yeah, I think it's just says it's processing the slides now. So I think I can start wait. Let me, there we go. Brilliant. Thank you very much. So I can see everybody hear me yet. So thank you Santa. And as you said, just then this is looking at a mixed meth analysis is switching from single use poultry reusable plastic. Um and trying to combat the previous beliefs that plastic is sort of the most harmful thing to be using within NHS trusts. So just a brief summary of the contents and there'll be a few different calculations, the numbers in it, which I'm very happy to review again in the discussion afterwards, but just to cover the content you're moving through. And now this is a slide that we've seen a few times today. As it's been previously described, um really focusing on the NHS Net Zero initiative, medicines, medical equipment and other supply chain factors, which is a large source of uh carbon dioxide equivalent emissions with an H S and the plans to try and resolve that. So what we'd like to do, what we're talking about specifically here are these pulp trays which hopefully recognized from the trust and these blue reusable medical equipment trays. And the concept was looking at the amount of trades procured between um the years 2019 to 2022 throughout guys and symptoms is NHS trust and individually carbon costs and based on their base ingredients for carbon dioxide equivalent emissions. And then comparing that if we brought in enough plastic trays to phase these out within the trust. So first of all, just looking at, we got the shear numbers of trade procurement between 2019 to 22. And what we can see is first of all, there are, there has been a reduction. However, we think a large element of this is due to reduction in elective operations during the COVID pandemic. And even so at that point, we still have 520,000 trades procured in the year of 2020 21 2, 22. Now using the government greenhouse gas conversion factors, we were to convert that to equivalent tons of carbon dioxide per year, which showed that we have 5292 kg of CO2 production from the production use and disposal of these poll trees. Now, that kind of equates to quite a large amount of uh CO2 and this is just a couple of factors can put that into context. All right. So now um what we looked at was essentially the dimensions of these portrays what kind of plastic trades are used, for example, within theaters in certain elements. And they're starting to be used in the wards as well compared equivalent dimensions. And we lose our procurement team to get a quote for the amount of trades we would need to procure in order for them to stop purchasing the pulp trays and the quotas 6000 as their initial. So when we then uh carbon cost, this um material uh showed could take around 5852 kg of conduct and equivalent emissions. And this would cost around 10,000 lbs for a procurement rate. So this show the individual plastic tray compared to the pulp tray had a much higher carbon dioxide equivalent emission portray which we think is what's been feeding into the previous narrative that plastic is bad and pulp is almost a solution to this. However, it's really important remember that these are usable as opposed to the single use pulp trays. So now this brings on to our comparative analysis over a five year period, what we've shown within the first year is that procuring the plastic trays which are the highlights of green, purple and blue, which should have initially have a higher carbon dioxide emissions um compared to the pulp trays. However, moving on from that in a five year period, you can show that the poll tray emissions are consistent. However, because of these reusable trays, there is a marked decrease in C 02 equivalent emissions going forwards. The difference between the three different meters in the graphs are modeling for replacement rate. We were quoted a high rate of 20% and a more realistic rate of 10%. And we can show throughout that that um the carbon dioxide emissions are significantly lower after the first year. Now, it's just one thing demonstrating that we can do this and this is a useful thing for um and it's just an F zero project going forward. So I think as we've seen today that can be a lot of obstructive nous towards this just because the data that doesn't mean change necessarily happens. So the next thing we try to look at the secondary outcomes cost and as you can see from cost from the initial year because of the volume of trades needed to be acquired in terms of pulp versus plastic. The initial purchasing cost of the plastic trays is significantly lower than the pulp trays and then year on year, this only progresses further. So as you can see by the end over a five year period. If we continued with the previous modeling data would be expected to spend 70,000 lbs. This NHS trust on procuring portrays whereas even with a higher replacement rate of 20% of plastic trays, it would be less than 20,000. So there's a few different outcomes we got from this. But really, I think the main ones to focus on all that, the plastic trays are cost leaders initially from the very first year. And although they have a larger carbon impact from the very first year modeling on from five years from there, they shouldn't have significantly reduced carbon footprint compared to the poll trees twinkly compound with this, we wanted to address barriers to change. So we um reviewed both doctors and nurses work which commonly work with these trades reaching out across a series of different specialties to first of all get an understanding of their usage and also understanding of their disposal patterns. And as you can see from this this pie chart here that there's actually quite a wide mix of opinion of how the poultry should be disposed um with quite a large amount going recycling in the recycling, which if they've had any kind of clinical contact is an inappropriate thing to do in the first place in terms of disposal, child lights need for education. In this. Furthermore, some the quality of data shows that while people are generally in favor of the plastic tray, there is an ongoing feeling that the pulp tray actually has a perceived sustainability value and the plastic is actually a less beneficial thing or less environmentally friendly thing uh to be using uh within the NHS. So after that, we had, we want to quickly delve into the use and disposal of the plastic trays. And we have worked with a really fantastic procurement team which has shown us that non clinical waste is taken down to bywaters and disposed of in a in an effective way to help our local homes. Clinical waste is all shredded and heated 250 degrees. And there is a current owners are looking to recycling to help improve the non clinical exposed plastic trays. So this really just summarize that there's an ongoing issue with pulp in the sense that there is a uh it's been depicted as a really beneficial single use items. And these suppliers have the forest certified certificate in place on their websites to advertise that they're any environmentally friendly. None of these certificates are actually active. So it's about thinking about what the underlying things are in terms of single use versus reusable items. And that really brings me onto concludes that there is a openness and willingness to engage in this as well as financial and carbon um incentives in order to try and switch from individual single use trays to reusable in the future. That's everything. Thank you. Thank you, Kalle. Um um And I think this really highlights that when it comes to sustainability. Um There's no sort of hardened particles and it's not that all plastic is bad, for example. And typically the answer is that it, it depends. Um Can I, can I invite all of the speakers to join with your, with your cameras? Um And I'd like to introduce at this point, Eleanor who's co chairing the session um and uh introduce yourself and, and pick out some of the questions from, from the chest if that's okay. Yes. Pleasure. Hi, I'm Eleanor. I'm a dual 20 in I T and aesthetics in the West Midlands. And I also co share the environmental sustainability workgroup at the intensive care society. So really pleased that we've had sort of a theme which fits quite nicely in a lot of um the work we do as well. Um There was a maybe if we start with some questions from the audience and start with the first presentation, I don't think they actually was anything raced from the audience. It was regarding recycling theater waste. Um I did have a question. So if that um I might have escaped me while you were presenting. What guidelines did you draw on when you were um doing your local guidance? I know you worked with your local waste team. But did you, which, which guidelines were you able to find to relate to? Um So, so we, we decided to use the local guideline because we recognize the difference between trust different products and we want our person to be accurate, accurately describing the product we use. If, if you get what I mean? Because you know, if, if you put a product, for example, if we're using a different brand of a glove and stuff, we want it to be exactly the same with what is being used in our operation Tate. And so it's, it fully serves as a purpose of a guideline in a sense. I really, I hope, I hope to answer your questions. Yeah, I did, I really liked your posters. Um The G B I have actually brought out a waste segregation guideline for theaters a year or two ago. And I was just wondering whether you'd also looked at that kind of help you further along because I think you can probably break down your way streams even further than what you had done already. Um I really like the graph chantel which you picked out at the end as well where you sort of had the dips in you sort of change what you see in terms of um everyone contributing to recycling and then it became less and then you had another initiative of reminding, so to speak. And then your recycling came back in for me personally, I kind of think that actually probably needs to be integrated and your local trust induction, um induction for doctors, nurses, as well as probably part of a general hospital education, I guess. Have you had any thoughts about how, how to change, or how to make that change more sustainable over time? Yeah. I think, I think that's a really good idea at my team and, I mean, we are thinking about something similar, we were thinking of more of like an online because in, in, uh, in my trust, I'm not sure about other trust. We have, we have saw this mandatory e learning and we were thinking of making them into one of the models where people can watch about the information. But yeah, certainly I agree. If, if it was to be integrated into induction will be a lot more useful. So, so really, thanks for the suggestion. We got any other questions, child? For the first presentation, I think you picked up on an interesting point there in terms of that initial um dip, uh there's a baseline that was evaluated and then the and then the intervention initially um and then the recycling rates actually fell below the initial baseline that that was observed. I wonder if um perhaps can comment or suggest what might've been going on there. So I, I believe uh as soon as we introduced project, everyone was quite passionate about it and stuff. But I think the problem with this kind of project that is having a very short lasting effect, that's why I highlighted in the discussion. Constant, constant effort is necessary. And I believe the suggestion. Bye bye bye. Doctor them just now like putting into induction, making people aware and we really just have to come up with more solution to tackle this issue because everyone is, you know, is quite forgetful. Uh in terms when, when you are in operation theater, you focus on the operation, focus on your patient. And this is not always on the top of our mind in the mind of the manager of the surgeon. And all we can do is just, you know, pushing and pushing. Yes, I don't think my tia and may have come up with a definitive solution. Uh But we, we, we'll definitely try to see what we can do the further this uh conversation at this idea. Thank you. Great. Thank you, Zen. Um Moving on to the 2nd 2nd presentation from from Phoebe and Sam. Um There's a question in the chat from Jackie more uh to ask whether these central feeding bottles can be placed into a general recycling bin you might typically find on the wards. Um And they, they sort of thought about this in the low query, but they just weren't where, whether you, whether you were able to use those waste streams or not. Yes, I can answer that question. Um So it depends from brand brand. We use Nutricia in North Bristol Trust and also three Steuben. Um Both companies have recently in the, in the last sort of five years. Moved to recyclable materials. Um So it would be worth contacting the company who provide the feed bottle for your trust. So for example, with the three subin bags, we were told that yes, they're recyclable, but you just have to cut the top off. There is generally um someone within the company who will be able to provide information. Um but yeah, they recycled into the normal dry mixture cycling in our trust. And I suppose that would then depend also on the local systems in place. Um and just checking with the local trust and they're usually might be sort of adequate signage and so on. Um But I imagine that on a sort of trust trust basis, there will be a, there'll be variation in terms of what can be recycled in these, in these waste streams. Um I wonder, do you, do you know what happens to the bottles when they're recycled? You know what they get used and recycled into? So this was something we really struggled with. This project was the clarity from. So our waste is managed by an external company. All of the North Bristol Trust goes to the external company and getting clarity on exactly the processing streams that the dry mixed recycling goes to. Um in terms of what the guidelines were for how dry, what like there's a, there's guidelines on the materials that could be recycled, but kind of that is something we really struggled with was the clarity from the external company. Yeah. And I suppose what we typically do you see with these sorts of PVC type fighters that they end up being used for things like, um, in horticultural tree ties or in toolboxes and that sort of thing. Um, but ideally we would actually be using that PVC with, within a healthcare application. Um, so that we reduce the amount of raw materials that we're actually needing to use for the healthcare sector and really trying to keep as high as possible the the usage of those plastics. Um And I know I don't, I don't if you had any further questions or or other author, other contributors also feel free to ask questions of your case speakers. I guess I just wanted to know whether you saw a general change towards sustainability or change in behavior outside of your central feeling bottles, whether there was an appetite for a general change. Yeah, perhaps hard to that one. Yeah, we um we have, yeah, massively, I think Phoebe touching it at the end with some of the people external from the team trying to carry on the project after finishing. But we've also running a survey at the moment, a repeat survey to look at behavior change really and how people are feeling following the project to help guide the sustainability champions and initiative to making further further changes and continue the project on a more kind of broad, broad infection. I think we always saw this is more of a springboard to discussion rather than a big solution. And I think it's really, that's probably been the main outcome is that there's a lot more conversation about recycling but also wider sustainability initiatives within the ICU now. So we'd like to carry on in that light. That's brilliant. Thank you. Just add to that as well. Anecdotally following this project, my inbox pretty much on a daily basis is flooded by members of the MDT who are so keen to have this sort of thing started. Obviously, Sam and I are rotational junior doctors, but the main aim of this project was to start the conversation. Um And I really encourage everyone to do the similar in their own trusts. That's brilliant. Thank you, Phoebe. Um Yeah, I do think waste um and reduction of ways a really good springboard to kind of jump on to kind of do that with because it's such a visual impact you can achieve to start that conversation with. Um If there's no other questions regarding that and maybe we move on to the third presentation um about inappropriate of non sterile gloves. There were a couple of questions uh from and I know I think that your wife might have dropped out. I can't be used with the audience. So one of them was um I think I think your back, sorry, it cuts out for a movie. Yes, I did cut out, sorry, just moving on to the project. I'm not sure what people heard. Um There was a couple questions from the audience of how is pick up the first one, someone asked whether, um, you've noticed a difference in attitudes uh coming in different countries or within different words, glove use. Um Yeah. So, um, the systematic review included studies from eight different countries. Um, but most of these were in high income countries. Um The only one that was a low income country was, I think it was based in Malawi. Um And it was interesting to see in this, in this country they had days where the hospital didn't have any gloves. Um, they had days where they had limited gloves. So on these days, they were more reserved with their glove use, um, which lead to inappropriate glove use. Whereas in the high income countries, they reported having an abundance of gloves. So people would often use them without, you know, thinking should I, should I be using these gloves, um, using them, um, for procedures which don't wait for, for which gloves are not indicated. So that was one of the main attitude differences that was able to see between the, the, the two different like um between high income and low income countries. Um Yeah, uh answer your question better. Thank you. And then there was another question, whether you feel that may be moving over to biodegradable gloves or compostable gloves would be a solution to move away from PVC. Gloves to avoid obviously uh toxins releasing incineration. Um Whilst it, it can be argued that biodegradable gloves, you know, can help with this issue. We need to understand that, you know, these gloves are classes um clinical waste. So at the end of the day, they will be incinerated. So they will release like gas is back into the environment. But we also need to realize that these gloves are often produced abroad in my, I think majority of the gloves right now that we have in the UK are produced in Malaysia. So they carry a big carbon footprint. So even if they're biodegradable, they're, they're made somewhere else um in a different country. Um And the manufacturing process, even for biodegradable will release a lot of greenhouse gasses in the production and in the transport. So we should all that we should, we should focus more on reducing our usage and being more reserved in on what we should use our gloves for. Um biodegradable gloves can help towards this. Um But I think we'll have a bigger impact by being more conscious about when we use gloves and what we use it for. I think you touched on some really interesting points that abdomen and just to, to come in a few days. Um So I think one of the things that's, that's come up in some of these presentations relates to the different healthcare waste streams. Um and throughout the presentations, those quite a high usage of both infectious waste streams and also clinical waste streams. When in fact, often times it would be appropriate to use non infectious offensive waste streams of the tiger bags they will see on the wards. Um And really the the infectious way stream should be reserved for when um when there's a known or suspected actual uh infection with a specific patient. Um And for clinical waste, it's actually uh at the point that there's pharmaceuticals then also involved. So we, we see overuse of, of some of these other way streams that then um I have to undergo a high temperature incineration, for example. Um And I suppose on this biodegradable side of things, um it really depends on quite a lot of factors such as whether there's deforestation involved for the land that's then used for the crop. Um And it, it depends on, on this of practices, whether this is sort of food waste and so on, that's then um used as the feedstock. There's, there's all sorts of factors and it also depends if we're thinking about sort of biogenic greenhouse gas emissions from, from materials. Um distinguishing that from these sort of fossil fuel derived and when we're releasing carbon that's been locked up for many years. Um And I wonder also whether there might be a role more for, for reasonable gloves for some of our uh some, some processes such as um changing sheets and so on. Sorry, I I could probably go on a bit, but I don't know if you've got any comments there on, on some of those points. Um I agree with what you said about the deforestation if you know, for biodegradable gloves, um, like, you know, the term biodegrade will make it seem more greener. However, we need to understand that the manufacturing process, the transport process it entails does carry a big carbon footprint in itself. Um And with regards to, I think you, you mentioned using reusable gloves, I think even with that, it's, it's a matter of how people perceive what can be reused and what, what can't be reused. Um So what I may consider being able to be reused might not count for everyone like for another person. So that can, that it's very hard to distinguish between, it's very hard to come up with a guideline that says, you know, you should, you reuse gloves for this and reuse something for that. Um, because everyone, the way they perceive things is very difficult. Um So which is why I think it's more important to educate people on when it's appropriate to use gloves and when it's not, um, rather than the element of having to, you know, re using gloves if that makes sense. Yeah, I totally, I, I agree with that. I think the re education is a really big part. Um And as you pointed out the who guidelines from 2009 point out quite clearly you know, when you should, when you shouldn't use gloves and COVID obviously then changed the perspective of how we use gloves, especially in I T U. Um We've actually with the intensive Care society, together with the infection prevention Society have just launched a campaign last week called Gloves Off, which is hoping to kick start that re education process, which will be followed up with um some more formal guidelines. I do feel free to have a look on our website but your um your work fits of the beautifully with that. So thank you very much has been really interesting to listen to you. Um Any other questions or shall we move on to the last presentation um over to your column? Um Thank you very much. Um I wondered, I have a very specific question of that. Okay. Um The carbon cost you estimated, do you know whether that was based on life cycle analysis or was I more based on a pound equates to this amount of carbon equivalent? Uh Yes. So it was based on a uh a pound equivalent to thinks in terms of life cycle. We're looking at transportation costs as well if I'm not misunderstood. And that was the thing that we struggled in terms of within our procurement department, finding the actual trucks there. So in terms of we broke down to the pure elements um to the base materials and then pound per uh CO2 in terms of costing. And then from there, we by, by the amount of units that we had, we, then we were able to get our final figures. And I wonder just building on that in terms of the calculations, one of the challenges with these sorts of projects is to allocate the uh the carbon of the reasonable product across the likely number of uses. Um And I wonder how you found that process in terms of estimating the number of uses for the reasonable items. Yeah, it was, it was quite challenging process. Um in terms of that, that we had to bring in lots of different teams. I think the first thing that to start off with was an infection control. Um sign off which um was given to us for kind of a different amount of uses provided things are cleaned in an appropriate fashion. Um I think after that, what the data we then used was because there are some within our Lamba theaters department already, some plastic medical trades being used. Um So we looked at the amount that they are procuring um in terms of how frequently how into a cure and replaced per year. And from there, the trust were able to extrapolate the procurement department and tell us what their estimations for the entire trust would be. However, obviously, there is gonna be some variability between theaters versus wards and then what's damaged and what's not. We're hoping in terms of award environment if you can keep them sort of stacked up in a certain situation, clean at the end of the day, that that could give us a more beneficial way. But that's why we modeled across multiple different replacements. And actually, even if you go up to 50% which is high, which was a further point that we went to, you still demonstrating marked difference in C 02 emissions and also cost over a five year period. And on that point in terms of the re processing and the sort of cleaner wide or what have you did it, was that something that you take into account in terms of the analysis? So that's the next thing that we wanted to take into account go for as the specific Lynell um wipe as in the individual use of that and costing it within the analysis essentially had the sign off from infection control within that these are appropriate devices, views and that actually fits in with the integrated greenfield's checklist. Um But in terms of we were the next thing we want to do in terms of. So we've liaised with procurement in terms of securing the correct amount of trays, we've engaged in some user stakeholder analysis, but now want to cost for the canals and also pitched to higher management in terms of rolling out as a trust wide trial. That's great. And I think with all these projects, it's, it's highlighting the sheer number of uh stakeholders that you need to engage to bring about change in this space and be that clinical groups and procurement finance, heads of departments and uh you know, sometimes infection French and sterilization and so on. Um But it's great that, that you've already been able to gave you that process and bring about world, world change. Um Linda, did you have any um any final questions or comments to make before we wrap up? Uh No, thank you, Chantelle. Thank you everyone. Um And especially to our presenters today and to add in areas of co chair uh for your contribution. Um It's been really interesting to hear your projects from, from all sorts of different areas and we've got this sort of broad um title of the session relating to, to waste, but actually, the products have been uh come as it from all sorts of different angles and, and it's great to hear from uh what you're doing in all these different settings. Um We'll be going into a break, I think now. Um Sorry, I should have just, I should have checked this before. And um so we've got a break into 1 45 and then we'll be back into the, the main stage theater for our address from, from Rachel stuff, from the sense, sustainable healthcare. Uh But thank you every everyone for all of your contributions. Um And do you go and grab yourself a cup of tea? Uh Now I appreciate you would join David Lunch. Maybe you've been munching lunch in the background. But, um, we'll see you back in the main stage in a minute. Thank you. Thank you.