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Doctor Reason was appointed as clinical lecturer in sustainable healthcare, the Brighton and Sussex Medical School in 2022. Following her phd, evaluating ways to mitigate the carbon footprint of products used in operating theatre. She seeks to translate her research into practice and policy and as an academic advisor for a national report on greener surgery in collaboration with the UK Health and climate change Alliance. Key achievements include receiving the Hillary International Health and Care Leadership Award in 2022 the Adam Wyler Doctoral Impact Award in 2021 for outstanding academic Impact Dr Reasons. Research aims to provide an evidence based approach to improve the sustainability of healthcare. The particular focus on mitigating carbon footprint associated with products used for surgical products. She uses carbon footprint ing and life cycle assessment methods to identify carbon hotspots, to evaluate the environmental impact of alternative products and to optimize associated processes. So um I will now pass a restaurant to Chantelle who's going to present for roughly the next 20 minutes or so. And if you would like to use the chat function to ask any questions we can allow for. That's alright, Chantelle maybe 5, 10 minutes towards the end um to have any questions or comments and responses from the audience. Thank you very much, Chantelle. Thank you for so much Heather for the warm introduction. Um And good morning everyone. My name is Chantelle. I'm a clinical lecturer based at Brighton and Sussex Medical School and I attended my first share conference back in 2018, right at the very start of my phd journey and in the subsequent year during the committee, and it's been fantastic to see it grow. Um going really from strength to strength both in terms of numbers. And it's been uh fantastic to see an increase in terms of the, the both the volume and will say the quality of the objects that have been put forward. Um So thank you every so much from wherever you're joining us today. I know we've got a strong international audience. Um And really this is an opportunity for, for me to um to talk to you about so my own research, but actually drawing on that wider literature base and to really think about that evidence based approach to sustainable healthcare systems. And we're going to be thinking about that particularly in the context of surgery. Um And, and hopefully giving an idea of the sorts of things that we can do transition towards sustainable healthcare systems just to give you a bit of a sense of my backgrounds, I'm adopted by background. I started out as an academic trainee within management and leadership. And during that time, I was streamlining patient pathways using lean management techniques. And that formed the basis of my master's research. But I recognize that when we have these lean models of patient care that actually there are environmental savings as well. And I was increasingly concerned at the time about the amount of particularly single use plastic items that we used in my clinical area, which was E N T surgery at the time. Um And I realized that there was actually very little out there both in terms of our understanding of our environmental impact, but more importantly, what we could do to, to reduce it. So, back in 2018, I embarked on this phd journey to evaluate how we can actually mitigate our environmental impacts. I'm pleased to share that with you today. Um So I'm going to start off, I can't emphasize this first and foremost, that climate change is a healthcare issue and hopefully all of you who are attending today uh familiar with this. Um But, but really it is our duty as doctors to really transition to a sustainable healthcare systems. We know that climate change has been poses the greatest threat to human health of the 21st century. Um And they're a direct and indirect way, ways in which climate change impacts on, on our health through extreme weather events, droughts, flooding heatwaves, as well as indirectly impacting on things like our food and water security and those climate sensitive vector borne diseases. And we know that it's those who are already suffering from health inequalities who are most at risk. And so really, this is a matter of climate injustice. And so it's paradox school when we provide healthcare itself that we're actually contributing to this problem. Uh We were responsible for around 45% of our greenhouse gasses in in the UK and, and these figures are roughly reflected globally. Uh It's around a quarter of all of our public sector, green house gasses. And what's interesting when we break this down? Um is that actually a lot of our greenhouse gas emissions relate to the stuff that we're using to provide clinical care to go around 10% contribution from our medical equipment, 20% relating to, to our pharmaceuticals and other areas such as anesthetic gases that really we are in control of when we uh when we make decisions as clinicians uh in terms of what we used to provide patient care. So we have this bidirectional association between human and planetary health and we're very much interdependent. Um And it's been fantastic in the, in the last three or four years, we've seen a huge upsurge in terms of the, the global interest in this area. Um The, the UK became the first national health care system to commit to reach net zero. Um But for, for Scotland in 2019, and England in 2020 And in fact, in, in England, last year, we've integrated these principles into legislation. Um So back last year, we integrated the Climate Change Act and the Environment Act into our Health and Social Care Act. I was fortunate enough to attend COP 26 a couple of years ago and 22 other countries came on board at that point in terms of these uh similar comparable net zero targets. And there are many other countries around the world who have pledged to develop sustainable uh and low carbon healthcare systems. Um And we're going to be thinking uh during this talk specifically about the operating theater. And one of the reasons that it's, it's such a good case study for us to look at is because of the sheer volume of uh single use items that we typically see being used is particularly resource intensive error of the operating theater. Um And to just put it in context for a given operation. If we were to equate that equate that to me, driving in an average petrol car would be the equivalent of me driving somewhere between 456 150 miles in an average petrol car. Um And towards the start of my phd journey and I undertook a systematic review to look at the hotspots. So the carbon uh contributors within the operating theater um and they're I found that the principal areas were the consumables. So the things that we're using alongside the anesthetic gases and our energy consumption, particularly for the heating, ventilation and air condition, air conditioning's in the maintenance of the theater environment. But we have this particular issue relating to the products that we're using. Um on the right hand side, you can see they're a graphic that we took from an and no tonsillectomy, uh a straightforward operation, generating over 100 pieces of single use plastic. Um and to get a sense in terms of in a bit more detail, looking at these products and looking at what the underlying contributing processes. Um I undertook a carbon footprint to look at the five most common operations in England to look at all of the products that we were using to get a better sense of what were the hotspots within these products. And I found across the board that uh the majority of the emissions related to the single use items that were using so 55% in in red at the bottom with the production of the single use items. There's a further contribution from the packaging of those single use site items in red towards the top of the bar graphs. Um And the second key hotspot area was the decontamination of the reasonable items. And the third was then the waist in yellow. So it will come on to those um as we go free the talk, but these are the main hotspot areas when it comes to products uh And then another way of getting the pie and, and looking at this data was then to look at what are the biggest contributing, um what were the biggest contributing individual products? Um And what I found was that there were actually very few items that were responsible for the majority of the impact. And in fact, it was 23% of the products responsible for 80% of the, of the carbon footprint. And that corresponds quite closely with the Pareto principle. So the 80 20 principle that you might be familiar with, and these products were predominantly single use plastic, quite bulky items. And this analysis indicates that when we're looking to make a change, we need to be identifying and facing on those few items that have the biggest contribution. And actually, there were very many items that actually had a very small impact. Uh That was really the problem space that we're working in. And then it's more a question of, well, actually, what can, what can we do about this? Um And really, it's about applying circular economy principles to the healthcare system. And by that, I I contrast um sector economy principles with the linear economy where we extract resources, we use them once and we dispose of them. Um And instead, when we apply sector economy principles, it's really about capturing uh materials and energy throughout the system and to minimize waste where wherever possible. Uh And this uses the principles of reduce reuse, recycle and, and some others such as repair and remanufacturing, which will will come on to. Um But really, this is a useful framework to think about the sort of things that we can do at a product level. Um And the very first principle that we have to apply whenever we're looking to improve the sustainability of a system is to look for those opportunities for reduction. And we can apply that across whole patient pathways and looking for there's opportunities to, to, to streamline our patient pathways. Uh for example, setting up one stop clinics uh and seeing where actually, for example, it's appropriate to simply right to a patient with a negative result as opposed to calling them back into the clinic. But once that patient's actually reached the stage of needing an operation itself, there are opportunities when we look at particularly are pre prepared single use sets where there are items that routinely not used by any of the uh by any of the healthcare professionals within the trust. So the image on the right hand side there is a handset that's used for a couple tunnel decompress. Um and the white sponges weren't used by any of the surgeons in the trust. Uh And you'll also notice other items there that could easily be reusable. Um So there was a hand draped at the bottom there, a kidney dish, a galley pot, a purple light handle as well. All of these things to be reusable. But there were also uh these items that were simply thrown away. Um And the second key principle is then looking at these opportunities to switch from single yeast to reusable items. And in terms of our evidence for this, there, there are a couple of reviews, one of which I've contributed to you on the right hand side, this is the paper that we published in Lancet Pantry Health were being all the healthcare carbon footprints and lifecycle assessments to date. Um And we identified a whole range of products and as used in a whole array of different country settings. Um And we found that in the vast majority of cases, the reusable had a lower carbon footprint relative to the single use items. And you'll see the reusable in blue on the left hand side of, of this graphic and then the red with a higher impact uh for the single use items. Um And this is supported by another review by Qili Town. Um And here they found that actually across the board, the average reductions were 38 to 50% through that through that switch. Now, there are exceptions and it's important that we understand what the reasons for these exceptions. Um And many of those studies were undertaken in Australia. Um And here there's a higher proportion of coal based energy used for the re processing of the of the reusable items just bearing in mind that the life cycle approach is used for these studies where they will take into account the raw material extraction, the manufacture, the distribution for reusable is it will take into account the the sterilization, any laundering and then the final disposal as well. Um So where, where studies were undertaken in Australia because of that high burden from, from, from the re processing. Uh Then in that situation, the single use were preferable but where authors, we modeled their studies using European or us energy sources. Then again, we saw that we used had a lower environmental impact. We also have to be mindful that when we do these sorts of comparative studies that were actually comparing like with like um and that we have a comparable uh functional unit of assessment. Um And there was a study that indicated that the carbon footprint of reusable uh spinal fusion instruments was was actually greater than single use. But when we looked at what was compared, actually, there was a huge number of reusable instruments that were compared to just a small highly consolidated single use set. Um And the clinical comparability is is perhaps debatable. But actually, if we were able to use just a few instruments um as per the bigger on the right than actually, this is an engineering challenges. How could those items be made to be reasonable? And again, we would likely then see that the reasons would have a lower impact. Um There have been a few studies with some, some mythological concerns which, which we picked up more recently. Um And this includes a study that looked at single use versus reusable cyst escapes. Um And here they equated 10.5 kilowatts of energy that was used for the re processing in the washer disinfect er uh 10 to 10.5 kg of calmed outside equivalents. And for that to have been true, assuming a UK energy source, which we assume given the Irish uh group, um then actually the machine would have to have been on for 3.5 hours. But looking at the manufacturer information, um uh in fact, the the average duration of 35 minutes. And so, uh when we factored this in, we found that actually there's a significant reduction when we switched to the reusable. So you have to be mindful of, of some of these methods, logical assumptions. Um and say the vast majority of evidence is indicating that we should be switching from single use to reusable where possible, but sometimes it's not clinically feasible or appropriate to have a fully reasonable item. But in this instance, we need to be increasing the proportion of reasonable uh materials that are used. Um And for example, um in that initial study where I looked at the five common operations for a lap scopic cholecystectomy. So, removal of the gallbladder, I found that there were just three products that were responsible for 1/5 and 2020% of the carbon footprint and they were the uh single use clip applier, scissors and ports that we used for, for that keyhole surgery. And so, having identified these as hotspot items, I then undertook a life cycle assessment to um to compare those to hybrid items that were reasonable with a small single use component. And there I found that with that simple switch were able to reduce the carbon footprint by 75%. Um This is a full life cycle assessment looking at a whole array of environmental impact categories and that actually reduced 17 out of 18 impact areas. And if we were to adopt these three items, but uh laparoscopic cholecystectomy in England, um this would save the equivalent of uh over a million miles on the average petrol car in terms of the common oxide equivalents. Um And the financial savings looking at the life cycle costing was around 11 million per year. I think it's helpful when we do these sorts of studies to look at both the environmental impact and also look at the financial life cycle costing. Um And typically we see that the two go hand in hand. Um And so you may remember that the second key hotspot error with the sterilization process for the reasonable items. So once we switched to a reasonable item, the hotspot then becomes the the decontamination process. Uh So I undertook a study published in the British Journal surgery looking at the not only the carbon footprint of the sterilization process, but more importantly, how we can actually reduce this. Um And I found that this could be reduced by around a third through a combination of measures, um particularly through preparing our instruments as sets, as opposed to the individually wrapped single um items. And that's, that's for two reasons. Firstly, when we had these individually wrapped items that often uh double wrapped in a single use, um flexible peel pouches, but also when we load the decontamination machine, uh they're often inefficiently loaded when, when there are those individually wrapped items. The second key area was to use as many of the slots as possible within the determination machine. Um And then to use those, those general principles of uh increasing the proportion of renewable energy supplies as well as recycling of the sterile barrier system. Um And so, if we're using reusable items were optimizing sterilization, what more can we do to then reduce the environmental impact? Uh Well, there are certainly opportunities for repair to really maximize our resource use. So for example, if we have a blunt pair of scissors, rather than purchasing a new reusable item, we can actually, we can actually repair these. Um And I undertook a life cycle assessment to evaluate the impact of this and found that we would reduce the carbon footprint by 20% through use of repair. And with cost savings of around a third looking again at the life cycle cost Ing's and I compared on site versus offsite repair and found that really, it didn't make too much difference in terms of the, the environmental impact. But in fact, the main benefit here was in terms of the faster turnaround times. Um And, and, and finally, if we're using reasonable items, we're automating sterilization, we're repairing them. When they finally get the end of life, we need to be making sure that we, we recapture uh these, these materials um and recycle wherever possible. Um I undertook a carbon footprint study um in, in the journal cleaner Production where I compared different healthcare waste streams. And here I found there was actual 50 fold impact when comparing high temperature incineration with recycling. Uh And, and certainly we should be where we are sending things for, for incineration. We should be using energy from waste um technologies where we actually generate both electricity. Um And we collect the slag metal as well um which, which can again be recycled. Um But really, we're not gonna see much of a benefit from recycling in the healthcare context until we start to increase the recycled content of the actual materials that we're using within healthcare. So often times when we send things for recycling, um they're ending up in other industries. So, for example, in, in construction, um and so just piecing some of these things together and, and some of the strategies um as applied to that original studies. So where I looked at the carbon footprint of the five common operations, I found that if we use a combination of strategies, it was possible to reduce the carbon footprint by a third. Um And this is three rationalizing um products. So using the having looked at 10 of each of the operations modeling, the lowest number of gloves that we use, for example. Um and also looking at switching to the reasonable equivalent products that we're currently available in the market. Hopefully, that figure will be um see proceeded as we see further innovation towards more reasonable products. But I was looked at applying that optimized decontamination process and optimizing the waist as well. And I've also looked at combining strategies in the context of the PPE that we use. So during the first six months of the pandemic, um I undertook a life cycle assessment to evaluate the impact there. Um And I found that uh we, we generated over 100,000 terms of conduct said equivalents during that six month period. And that would be the equivalent of me flying from London to New York to 244 times every single day. So a really significant impact, it's around an additional 1% burden on the NHS carbon footprint from PPE alone. Um But it, it wasn't just a question of looking at the scale of the problem. What was more interesting was to actually model uh the mitigation strategies. And I found that we could reduce our conflict print by 75% through a combination of rationalizing glove, yeast and domestic manufacture, as well as using reasonable gowns and, and faye shows and uh and recycling. Uh so hatefully this illustrates there a real potential when we combine these strategies. Um So what, what do clinicians think? Well, we undertook a survey uh back in 2020 to evaluate surgeons from uh from the UK from across uh surgical subspecialties. And what we found was that the vast majority were in support of sustainability measures. Many were doing things in their home less so in the workplace. But what they really wanted was greater leadership as well as educational resources. Um And partially in response to that, I've been involved in the development of a green surgery checklist. Um And this is co badged by the Royal College of Surgeons of England, Edinburgh and I'll uh sorry and Glasgow. Um And here we've, we've come up with a one page checklist with really practical ways that on a day to day basis, a theater group can think through the ways that they can reduce their environmental impact. Um And I think the real strength of this is that it's then supported by a 20 page compendium of evidence where where clinicians when they're looking to develop a business case for change, for example, they can reverse that document and they can see the environmental impact as well as any relevant policy documents. Um And the and the second key thing in terms of trying to respond to that need for increased leadership uh in this area, I'm academic advisor and lead edit er of a national report on Green Surgery um in collaboration with the UK Health Alliance on climate change and with the Center for sustainable healthcare. Uh and we're fortunate fortunate enough to have engaged the various national organizations um from across the whole surgical ecosystem um including the Royal College of Nursing and um those with imperative care. Uh And um and with international colleagues from the Royal College of Surgeons of Australasia, Candida and, and US. Uh and these national groups, one part of our Oversight committee and they've been involved from the start in terms of the, the development of this project um is the first draft is currently undergoing review with the Oversight Committee, but we are putting this out for public consultation. Um This June uh following that feedback from the Oversight Committee. So, um if you want to use the cure code, if you're interested in, in reading that in future, then that will be that will become available. Um And the idea is that this will provide an evidence based approach to a complete review of the evidence to date in terms of green surgical care um exploring the barriers and enablers to change. Um And that will then be followed by a package of a second phase, which is really looking at how we implement some of these things. Um And, and the last thing I wanted to draw your attention to. So people are also within our survey data, they were really looking for greater education and where could they find more information um to, to look at the evidence to date in terms of sustainable healthcare. Um And I'm, I'm the co lead of a resource that might may be of interest too many of you here today called Healthcare L C A. And this is an open access uh single point repository of all healthcare lifecycle assessments and carbon footprints to date. We've got over 200 uh studies that that feature here and we try to keep it um as up to date as possible. Sometimes things take a few weeks from them being made available online ahead of print. But what urinated on the right hand side is that there's been this huge upsurge in terms of the volumes of studies in this, in this area. Um And some of these summary metrics are also helpful for us to identify those areas that are perhaps lagging behind. Um uh For example, in primary care and public health, there's a real need for greater data there. Uh So I'd encourage you to access this web page if you're wanting to search for calm footprints within your clinical space or for a specific clinical product. Um We haven't evaluated the quality here. So it is to be used with a bit of a pinch of salt. But if you, if you want to see the, the evidence that has been generated in a particular area, then this is hopefully a useful resource for you. Um So as a bit of a bit of a whistle stop stop touring, both in terms of that evidence based approach for mitigation of the carbon footprint of surgery, but then also some of that wider work that we're undertaking to actually translate this into, into practice. Um And I'd really like to invite you at this point just to take a moment to think about um what you might do in this. Uh Well, next, next week, whereas uh Friday, but what can you do tomorrow? What can you do next week um personally to actually uh improve things within your own setting? And what's that one thing that you would do uh to play your role in terms of that transition, sustainable healthcare systems? Um I've left on there, my, my email address, um and as well as that link to our Brighton Sussex Medical School Sustainable Healthcare Group, and you'll, you'll find further resources there. So I'll stop presenting there and I'm very happy to take questions. Thank you very much Heather. Um Thank you very much until really interesting. And um and it's great to see. I remember the systematic review talked about. I'm pretty sure that was a poster at one of the share conferences um number years about in it. So it's, it's really lovely to see your progression um throughout these conferences and now having finished the phd and coming back as a keynote speaker, so really great to have your contribution. I've been keeping an eye on a chat. I didn't see any specific questions for Chantelle. I don't know if anybody wants to either make a comment or um there's some comments around in credible work that was brilliant, well done. Um There's just a little bit of time and actually the questions just come in from Alison Watson. My biggest issue with developing sustainable research is finding, are finding our maybe about the funding before the opportunity passes. Is there a comprehensive database for sustainable funding? I'd love for one to exist and maybe that's something that we can uh let's take forward. But um I think we've seen increasing uh increasingly that that funding bodies are realizing the importance of this research field. Uh And I think previously it was, it was fairly challenging. I'm really trying to be a bit crazy in terms of getting, getting some of those grants in. But I think we are seeing this really features as more of a mainstream theme for those of you in the UK and hr have supported sustainability within a number of their themes and that's probably a good place to start but agree would be helpful if, if some of these opportunities could be collated in one place. And obviously, this is perhaps the UK England specific with the National Institute of Health Research. But I'll make sure I post that because there's been a real increase in the number of sustainability specific research opportunities from N H R or um the other thing that people can do is, you know, sustainability relates to everything we do. So it's using a sustainability lens on maybe not an obviously environmental sustainability research grant, but, you know, by putting that lens on it, um there's another way of going about it, there's been a few more questions come in and we'll sneak another one here. Um Kushnick has done some, some comments and things. Um and emojis, I'm loving all the emojis on this platform. But the question is, how do trust tend to respond when you present these findings to them? Do they generally seem keen proactive to take on recommendations? What barriers are being placed to implement the strategies you've recommended? So it's been really encouraging, having worked in this space for a while to see that transition. Um I think back when I started thinking about this, um you know, people look at you a little bit strangely, but actually this is becoming really quite mainstream. And uh and really, I think for those that uh you know, putting up challenges or barriers, then the question is why. Um And so, you know, I think on a, on a broad level we have seen increased support uh from both the trust level, but then departmental and individual clinicians, um we're very aware that, you know, it's, it's all well and good to have this growing body of evidence and to really have a clearer direction in terms of what needs to happen. But the key challenge now is actually translating this into um practice and policy and um part of this is to deal with, to do with leadership. Um But also it's about creating these educational resources and, and networks. Uh So I think as part of our wider plans for surgery specifically, then it will be about creating uh these green champions, both regionally but also within the various different surgical subspecialties. Um and hopefully creating um networks uh that we're able to then help to disseminate some of these uh that some of those key findings. And two, there's that need for the practical support um in terms of the logistics also, thank you very much. And there's one more question, but just because we've just gone slightly one minute past we're keeping to time. But if maybe you can respond in the chat room and if people want to keep asking questions throughout, I've also put all of the keynote speakers profiles onto the pad lit as well if people want to look at publications and further things. So, um thank you again. And that's our first keynote um finished. We