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Good morning. Good afternoon. Good evening, depending on where you're calling in from. So, um, I'm mood, I've already introduced myself in the main session but for those who weren't, er, there, um, I'm Professor of Stable Healthcare at Brighton Sussex Medical School and I'll be, er, sharing this session together with Rose Rose if you want to introduce yourself. Hi, everyone. My name is Rose. I'm a Neurosurg Registrar and I'm a National Sustainability Fellow this year. Thank you. So we've got, um, potentially, er, five speakers. I know that one of our speakers has unfortunately been called away to clinical work, which is, er, as many of us know what happens. Um, but I don't know, Rebecca, if you are joining us on a speaker link or if there's a problem, if you just, um, let us know through the chat or something, we can make sure that you can join us. Um, but, er, if it's ok, we're gonna start, this session is all about the circular economy. So we're going to hear about some interesting ideas related to largely reduce and reuse of, of things like medical equipment and materials that we use as well as some stuff about anesthetic use. So, our first speaker then, um, Rebecca, like I say, if you're here and you're able to message us, um, then do, um, otherwise it's Gemma Jones who's organizing things and we'll get you in, ah, Rebecca is joining us now on a speaker link, I think Rebecca. Are you there? Hi. Sorry about that. A couple of technical issues. But yes, I'm, I'm here. I'm here with no problem. My colleague, Lee Lindley, who's the clinical lead for the project as well. Fantastic. Thanks for joining us. So I don't know if you're ready to go or you, you just, you're flustered and want a minute, but you are scheduled to be first. If you're happy to go first, we would be delighted to host you. Yeah. Very happy. Bear with me. I hope I'm ok with the uh the technology. This is new for me, but it's exciting to be here. So, thank you very much. Let's see what we can do. Rebecca and your colleague. Sorry, I forgot your name. Um All right, welcome. So, from Sheffield, please, uh we're gonna hear about reasonable toner case. Thank you and thank you for inviting us today. So, like I say, I'm here with Lee Lindley. I'm Rebecca Palmer. Er We're both project leads for um the reusable toner case for sustainable phlebotomy. This is a project that was undertaken by Sheffield teaching hospitals with uh in collaboration with the center, the center of sustainable health care, er, which was a fabulous opportunity for six teams across our five hospital sites to get together to um explore um quality improvement using A A SQ I um improvement model. So, what we did at the start of this was um explore what options we may well have. And in actual fact, the decision was that working with Lee, it would be a collaboration with the Chestman Outpatients, which is cardiothoracic outpatients and the nursing teams there. Our aim was around looking at sustainability and we wanted to work with our nursing team to or er what mattered to them and, and what we could do to make a difference. Um overwhelmingly, it was felt that the single use phlebotomy, er torna cases that we were using were of poor quality um poor for the patients, poor for staff. And er we're really proud that the nurses were overwhelmingly passionate about getting involved to do something different. So the decision was made with, with our teams and, and that was really important for us. It wasn't being driven by the leadership structure. It was um involvement with the teams, we worked with cardio thoracic and we then formed a again another collaboration with our Renal department, huge users of of tourniquets um to start to explore what we could do. And this was using um so I methodology and the sustainable value equation that we were learning about from the center of sustainable healthcare. We had um long term visions and that was really to take our toner case trust wide if we could, er, roll the, er, er toner case out and, and we're hopeful that we could um spread, spread the word really much wider than that, er, which is why it's great to be here today. So the duration of the projects were 10 weeks. So we had 10 weeks to really pull all this together. So we were very much involved in stakeholder engagement. We were very creative about what that looked like. We involved our patients and staff right from the very start, they say we've got a captive audience, we've got a nurse taking blood and the patients there. So we were focused around patient conversation but were logical in how we, we documented feedback that we got, we got endorsement from our um directors, our triumvirate leadership and the matrons that are in, in um leaders for our departments if you like. And uh most importantly for us, we got endorsement from the trust infection prevention and control team. Um The hearts were in our mouths. Cos obviously, this is a new innovation and we were wholly supported by them, which was um a, you know, a, a real, a great moment for us. We took our er project through the governance teams for all of our, our directorates within our care group. Again. Um you know, discussing any questions and, and just having their approve approval procurement team involvement was hugely important and, and that was something that we're still working with now as this project is rolling out on a on a wider basis. So, um in terms of, of that, we move forward and then basically went to actually roll out and, and trial the, the tourniquets. So I'm just mindful of time. Um And obviously, there will be questions later. Um So using the Sustainable Value Equation that is, is promoted was hugely relevant in, in us understanding with balance what we were looking at with SQ I methodology. And these were the areas that we focused on clinical social, financial and environmental as per the equation. Fortunately, for us, we were getting the support and education from the Center for sustainable Health Care. So I feel we have confidence with the, the data that we have on the slide today and, and that, that feels helpful in in our own learning as well. This was very powerful in terms of us articulating um why we were making our improvements. Um And you know, one would argue if you want to discuss with the operational side. Financial data is important if you're dealing with the clinicians and the clinical social side um help support the work that we were doing environmentally, obviously, um is what's underpinning everything that we're trying to do from an NHS net zero perspective. So the key learnings that we had from from our project er was hugely important for both you and myself listening to what matters and that was giving the staff and, and our patients a voice and that made it meaningful and, and the engagement that we've had from, from both our patients and staff has been incredible, the quality and safety side, the importance of education and learning. It's a new product. Um And this is why it's been hugely important with, er, Leigh's involvement that we've had quality education around that we open to unexpected consequences of change. We identified some um unwelcome practice if you like using um other variations of non reusable tourniquets. So, with a superior product, we're standardizing our practice clinically as well. Consider the risks in a nutshell. The tourniquets were so good. Er, we were concerned about people, er, wandering off with them. So we piloted it in our Cath lab, cardiac Cath lab. And in actual fact, you know, we, we did lose five tourniquets because um people took a shine to them. So, um working with procurement and the education side with Leigh has helped have oversight and managed that risk. So, um at the point, we are now the next steps, we are rolling out, er, trust wide, at least um coordinating that in terms of the quality education and, and um sort of product information. And we've actually already extended out into 19 other departments across our sites with more, er, waiting to happen, I think as well. The bit um that brings this to completion is the fact that there is the potential to recycle the torn cases and these tourniquets can be used for two years or 10,000 usage. But if after that period of time and we will work through what that's going to look like. Um, we can work to um get those back to the company with some degree of recycling. That's AAA future goal for us. It's, we're not, we're not at that point yet. But um essentially that's, that's our story. And um you know, it started out with an, an idea to be part of a, a SAS Q I um competition and this is where we're at now. So thank you. Thanks very much um for your presentation and uh nicely kept to time, although I would say we've got a few minutes because we have one speaker that hasn't. Um It was, was called away clinically. So if you've got any questions, please do put them in the chat. Um But otherwise, if I might start with a question, if that's OK. Um So this is great, but I suppose the question is, how do we scale this? Have you got any ideas? I mean, scaled, not only within your organization, you probably started in one area scale for the whole organization, but actually, why isn't this the norm across the entire country? What do you think are the challenges there that we need to overcome? II, th I think there were lots of challenges in as much as that we've um been used to going down the pathway for a long time around single use. And, and I think that was a way that we felt we had a lot of confidence um around infection prevention and control. So I think there are a lot of learned behaviors around that, that we need to break away from er our experience in this project is that there are challenges around procurement as well that there are options within procurement where we order. I think at times in isolation. So we don't really know what's going on out within the wider organization or what's available nationally. So I think there's a conversation to be had there where we, we can link that and I know we are working with our procurement team to do it. Um I don't know if Leigh's got any thoughts around um the and Leigh's w working very practically on the effort to um roll out within the organization. But it's um the fact we have limited opportunity due to our substantive roles. These are elements of our passion if you like that, that take it forward. So, you know, it's maybe create more opportunity that people are focused on transformation and delivery. So I think that there's scope on that, but I will hand over to lou from a clinical point of view when we actually surveyed the staff, none of the staff liked any of the single use options that we've got and we've got four different options, but we all assumed that we couldn't go back to reusable equipment because for so long we've gone through everything is disposable. Then we've been through the pandemic and PPE just went crazy and nothing was reused. So we just all automatically assumed that infection control was going to be an issue and they would not let us go to a reusable project. And when we took this on and they were supportive, it really did make a difference because we thought we can change as we can get some better equipment, which was the main drive for most of the staff and all the areas that we've been to. We literally only have presented into two areas and one into the competition and then to the infection control trust meeting. And once people realize we can actually change the equipment and go to something that's a superior product rather than just disposable equipment. The staff that have been in touch wanting to change equipment in so many areas and across several sites as well as being nonstop as soon as the information is out there for staff that you can actually make a difference and change what you're using to a better product rather than something that's been picked by a procurement team that's never seen the equipment on and never used it. People are just b with it and there's so many people who want to change other equipment as well. So I think it really has started the ball rolling. I think the other as well we've been asked for from the ICB, we've been asked for the ambulance service. And so we have been involved in multiple presentations to, to lots of agencies, but to have the opportunity to present in a, in a forum like today, I think is where you can have mass cascade and, and I think that the these forums are going to be critical where people can get together and you can share. And I think once, once you have people in the room, you have a ripple effect, there's nothing better than a debate and a communication. And, and, and I think, you know, this is where we really need to go cos we're happy to present, you know, to, to lots of departments. But the more people in, in one forum like today means, you know, we have a stronger voice in, in terms of how we can take this forward. And it is those links for us in, in NHS England that we're driving and, and inclusive in, in, in those forums as well. So I think it's got to be targeted at that level that, you know, we, we are um operating with a high quality standard that we can roll out further. Great. Yeah, I mean, what I'd really like to see as well is all those thousands of pounds that you've saved, which we found the same is reinvested into someone who's given the time to actually take the product on because that's the difficulty we find rose. I think there's a question in the chat. I don't know if you wanted to voice that and, and lead that. We've probably got time for at least one more question before we move on. Thanks. Yeah. So there's a question from Catherine Anderson, which is what requirements did infection control have in you see, to a case. Um Originally for the 10 week trial, we agreed that we just use it for patients that weren't buried and non infectious patients. But since we've actually rolled out and because the actual Tonique is made by crystal wet that supplied cleaning products, we now use that on every patient, I think as well. The other element that we did have with this was that we had two processes. We had an initial process, but then we did a, a reevaluation and that went through our consultant, lead for microbiology for Sheffield teaching hospitals alongside um Janice Burn, who is our nurse consultant for IPC as well. So there was very much engagement and we actually went into the forum with the um the IPC team and um have communicate, presented to, to our champions across our organization as well. So there's a lot of scrutiny, you know, that continues to happen and, and that's part of the conversation. It has to be good and, and, and that's given um our infectious diseases um clinical area, the confidence to come through and use the product as well. So, you know, each step is very much underpinned with governance, but it is with the clinical experts um having an opinion. So, uh yeah, and that was important also for us to reassure the nurses using it because that was a question for them and it would have halted at that point if we hadn't have had that. So it, the asking the correct questions at the right time, I infiltrates at every point across the project. Great. Seems like it's just common sense really cos I think the skin is a pretty good immune barrier. Um But uh it gets bizarre because I know that in the US, uh many pulse oximeters are single use because of the apparent risk of infection, which is obviously unintelligent. I'm afraid is what I'm going to call it sometimes the mind. Yes. Um Yeah, we, we could never shake hands. Of course, cos we might kill each other if we did that. So we better move on. Thank you for that. Um I think you're, you're next. So you're from Hampshire Hospitals if you're able to introduce yourself and the stage is yours? Thank you. Hello. Can you hear me? So? Yep. Brilliant. Um I'll just put my slide up. We'll start on the side here. There we go. Um So my name is Riia. I'm a recovery nurse practitioner at the Hamshire County Hospital. Um along with my colleague, Laura, um we took on this project of reducing waste in the operating theaters. Um As you can imagine, theaters are a very highly resource intensive area. Um Surgical care was responsible for 5.7 million tons of CO2 in 2019. Um Laura and I are both very passionate about this project and we're both link practitioners um within the trust uh for sustainability. Um and seeing every day um in our everyday practice, the amount of waste that's thrown away in theaters um was our real motivation for trying to, to do something about this and seeing what, what it is that we could change in our everyday practice. So we think it's a really exciting time to be involved with sustainability and working towards the net zero in the NHS. So we looked at, we took part in the Green Team competition also. Um So we used a framework um and we originally wanted to look at greening a theater pathway, but we quickly realized that within those 10 weeks, that was a very ambitious idea. So we, we scaled it down to just looking at these two different things that we thought we could try and achieve within that time. Um So our first things uh looking at a harmonic scalpel, um which for, if anybody doesn't know is an ultrasonic instrument used to cauterize tissue and laparoscopic surgery. So it's mainly used in general surgery and Gyne surgery. Um and we were looking at moving from a single use device. So if you can see that little picture in there, that whole thing is thrown away after every operation. So it was moving from the single use to reprocessing or remanufacturing that device so that we could use it again. The second part of our project was to switch from disposable surgical gowns to reusable. Um I think this uh feels for some of our surgeons. They, they, they remember this from a long time ago. So it was almost going round in a circle and back to, to using the old reusable gowns. Um But a great, a great project. Um So those were our 22 things. So I was going to talk a bit about the remanufacturing process and how that worked for the harmonic scalpels. Um So this is the process. So you buy the original device. Um It's used in surgery. It's then sent away to a remanufacturing company. So they'll strip it down, um dis disassemble it, parts are replaced if they need to, it's re sterilized and packaged again. And this is all in line with eu um regulations. Um It's then we then buy it back from, from the remanufacturing company and we can use it again in surgery and this whole process can be done twice for every new device brought. Um So this is just closing that circular economy. We were already selling our devices, our used devices to the remanufacturing company before we took on this project. So the aim for us was to just close that circle and start buying the products back. This is such a easy and project to take on for anybody that wants to do it with such great outcomes. Um I think on the next slide is some of the results that we got from this project. Um Oh No. So I was gonna talk about um how we got to this point first. So um we had to engage the stakeholders so that a lot of that was a surgeon. So there was a little bit of reservation from them about the sort of the safety of the whole process. But um once we sort of reassured them that it, they needed to be in line with the eu regs. Um they easily came on on board, we then trialed the product and the feedback from the surgeons was really positive. Um e effectively, it's exactly the same product it works in exactly the same way. So there was no learning that needed to happen from the, from them and all the feedback was perfect. So that was great. And while that was happening, we forecasted all the savings um from the carbon savings to the financial savings. Um And we put all that together um during the, the Green Team competition and these were the the results or the predicted results from our um from the Harmon X was an amazing financial savings. So for this project to work, there has to be a certain amount of new products bought into the cycle because it can only happen twice. Um So the new product, uh sorry, the remanufactured products are sold back to us at half the price of buying them new. So that's where the, the huge financial saving comes. Um The carbon saving, not amazing but still a saving. Um So we were really pleased with that and I, we think that comes from um so the original devices uh from Mexico um and the reprocessing habits in Germany. So there's a lot of travel distance saved there. Um Yeah, so that was that and then, so the one, so I was gonna go onto the reasonable gowns. Um So again, we had to engage the stakeholders with this. So this was the surgeons and as I mentioned earlier, again, there was a little bit of discussion about um infection rates and um how we could um how we could ensure that that wasn't gonna happen. And actually, um this was a little bit tricky because there isn't a huge amount of research out there that says gown, reasonable gowns are better than disposable. But what what you can say is that they are just as good. They have to comply with exactly the same regulations as the disposable ones. I think there is a huge project. I think it's called the dragon trial happening at the moment um which will give us that evidence um to be able to say they're better or, or, or, you know, this is the piece of evidence that you need to see. So we obviously then have to engage with infection control and get those on board. Our biggest stumbling block with this has been procurement. So we've had to work really, really closely with procurement on contracts um and trying to get this over the line COVID um really highlighted the use of these uh disposable gowns and the increase um in, in what we needed to use. And actually, as a result of that, we were receiving a lot of um free PPE um which hasn't long finished. So that put a delay on the contract being able to be signed. Um So that, that's our biggest stumbling point. Um and then um infection control, sorry were really, really helpful. So they, they were great in engaging on this. Um But this has been, it has been quite a tricky er project actually. Um But it really rewarding, I think on the next slide. So a huge carbon saving, as you can imagine, um the logistics are a little bit tricky. So we've had to work with the States as well. Um trying to figure out how, how to store them, deliver them, order them all those kind of things. Um and also a huge financial saving. Um So yeah, we were really pleased with the outcome of this. Um So overall, the projects save AAA huge, huge financial saving and, and a great carbon saving. Um With we predict no, no clinical or social impact to the patient um through either of these. Um Yeah, I think, I think that's, that's it. So this is an overview of the project um that we do with the, with the center of sustainable healthcare. Um Yeah, I think that's everything if anybody has any questions. Thanks very much. Great work. I know that. Um Yeah, like your previous speaker trying to get change in a complex and multifaceted and multi opinionated system can be difficult. So to bring everybody on board and get them aligned is, is, is well done. Is the job well done. Um Just a comment really from me. If that's OK before rose, there's a question, you'll have to say that. So there is already good evidence that there is no difference for disposable versus reusable gowns and drapes. It's out in our green surgery report. For those who are interested, we highlight the evidence. It's actually supported by uh all the surgical colleges. So it's a misconception. The gowns and drapes must be exactly the same standards and it's the same with your harmonic scalpel. It is recertified, which means it has to be exactly the same standards as a brand new product. So nobody can say it's inferior because you'd have to say then, I mean, I've, I've unfortunately had to have these conversations with others as well because everybody thinks they know best. And I say, well, if you're saying that the standards are not good enough, please give me the evidence and I'll report it to the government because what you're saying is quite serious and then people know me go quiet because they don't have the evidence. It's just their opinion. So, actually what we need to do is just bring some common sense so well done for pushing it through as more uncommon for others. I'm sorry, I don't know how aggressive you want to be about these things. But I'm just saying there is no evidence for people saying that I don't think it's right. So Rose, can I pass over to you for a couple of questions? We've got so far, but please keep the questions coming in. So we've got two questions. So first one is about land and I think this is with respect to the harmonic scalpels. So Sarah Taylor has said um on your slide regarding your manufacturing of harmonic scalpels, do you know what they sent to landfill as we're working hard to be a no landfill trust? And are they able to work on this to ensure there's no landfill from the remanufacturing process? So if I can just come in for a moment, I think someone's got their microphone on. So if you're not speaking, please, can you turn your microphone off? So it doesn't interfere. Thank you. Do. II don't know the answer to that question, I'm afraid. Um I don't think we quite picked apart exactly what the remanufacturing company do with them once because they come to site themselves, the company and take away um, each one, each harmonic scalpel is bar coded. So whether it's been used twice, once, twice or it's the first time they take it away and then the barcode will tell them whether it can be reprocessed again or not. So then the company dispose of them. So I'm not sure uh what it is um that they actually do with them or how they dispose of them. So sorry, can't. And then the second one says, um with regards to the gowns, did you um did your orthopedic surgeons engage or change? Um So, yeah, I mean that this is, this is the, this was the push back was from some of the orthopedic surgeons. Um So it, it seems to be a general area with them where there, it's a little bit of a question mark over it. Um But, but as we mentioned, you know, on once we can say, you know, that the, the quality of these are exactly the same as what you're already using. We have some, some orthopedic surgeons that are happy. I think they're maybe they're using them in other trusts and they're happy to go over. So our idea to roll it out uh for all other surgeries and, and as, as it's rolled out, we'll push the orthopedics as well. Um, hopefully it will sort of catch on as some are using it and then, um, war will come along. We've got one more first time mood. Um, so sir Anson said, what their interest from those in charge of your theater budgets. Um, and can a similar question to what mood identified? Can the savings identified be recycled and used for other projects? Oh, we would love that so much. It's uh it's just one of those uh those things. So there's been a lot of interest obviously with um procurement and, and the figures that are um that are shown above. I mean, that's they're great savings and we would love to be able to reinvest them and the other projects. Um We've, we've got going at the moment, you know, with, with a lot of this is anybody to projects. It's great that we see huge financial savings, but some of them have will have an outlay and we would love to be able to reinvest this money to, to be able to cover that initial outlay to make the, the carbon savings in the long run. Um It's not something that is, is happening at the moment. Um But II have heard discussions about it. II just do one last one from DPA, which is what is the if any pollution footprint used in the sterilization of disposable gowns? Um Yeah, so I don't have those figures to, to hand. Um, but they were considered within our, um, carbon footprinting when we carbon foot printed this. Um, and it, I'm pretty sure very read valuable from the companies that you ask, uh, that are laundering these, um, and, and bringing them back cos they're laundered off site, um, and then delivered back to us. So, um, if you ask the companies, I'm sure they're, they're already available with that information. So, yeah, I think in general there's been a few studies that have shown that the reason we will have a third of the carbon footprint of the disposable version that's taking account of the full life cycle, including the sterilization. So, um yeah, it, it's kind of one of these things. It's a no brainer. In fact, I'm trying to push for our government to make reusable grapes and gowns complete normal in the UK because I cannot see any argument against it. Austria has 80 to 90% of their gowns reusable and they're moving to move to 100%. So are we saying that they are clinically negligent? I don't think so. So it's just cultures and behaviors. I'm afraid like all of these things, but well done. Thank you very much. So, we better move on. So our next speaker speakers are Poppy Rhodes and Rachel Cotton from Sheffield again. So if you're here, Poppy, I can see you're online, I don't know if you're presenting by yourself or Rachel who is joining you. But yeah, if you'd like to introduce yourself and please take the stage, right? So I'm Pope, I'm an ODP from S and G Theaters at Sheffield teaching Hospitals. Um So this presentation is part of a project that we did for the Green Team competition in collaboration um with Center for sustainable healthcare. I worked on this with Timor. He's a consultant, anesthetist and sustainable, but he's not able to be here today cos he's away. Um And we've also got Rachel Cotton. She's a core percenter as well. Um And she's our strategy and planning planning manager at Sheffield teaching hospitals. Um So what I wanted to do was look at ways of reducing single use plastic and saving money within our theaters. Um So consumables and equipment, the kit we use in the NHS makes up for 42% of the NHS carbon footprint. NHS England produces 2500 tons of plastic waste every single day. Um And one in 20 road journeys are NHS related. So the more single use items we use, the more road journeys and more congestion and air pollution which directly impacts our patients. 36 to 48,000 deaths a year are due to air pollution in the UK. So we looked at two different areas. Um We looked at anesthetic tubing and suction way. So the first one, anesthetic tubing is on every one of our anesthetic machines across the trust. Um And we currently change it every seven days. Um There's no real reason for this. It's just because this is how long the manufacturers say that it's validated for. And we forecast that we use up to 22 kilometers of this every year at Sheffield teaching hospitals, right? So the proposal, so what we did is we conducted a of the robustness of the circuit tubing um with a view to expanding the life to 31 days. We currently change it on a weekly basis. So we've produced a staff survey to evaluate the attitudes of staff if we were to expend the li expand the life of the circuits. Um And hopefully it would raise any concerns that they might have about us doing that. And then lastly to estimate potential financial and carbon savings if we were to increase the cycle to 31 days. So it, we tested the robustness of the circuit by doing 1240 connections and disconnections and then we ran it through a machine check to make sure that it's still passed. Um We got this number cos we estimate, estimated it on worst case scenario, which would be one of the busiest theaters, theaters, which is the emergency theaters. Um So we base it on 20 users per day for a month and then we doubled it for 100% safety factor. Um And after we'd run it through the test and done all the connections, it did, it did still pass. Um When we were working out savings, we got quite different numbers from supplier and procurement. Um on the number of circuits that we do actually use, they were both a lot lower than the numbers that we should be using. So we modeled our savings on the lowest figure which was from procurement. And this works out a saving of between 3302 and 7887 kg CO2 equivalent. Um 1245 and 3192 kg of plastic waste. And then a cost saving of between 72,000 surveys rev revealed widespread variation in the practice from our staff. Some didn't change it on a weekly basis. Anyway, some only changed half the circuit. So it was very varied. Um But majority of them support supported the proposed change, right? So suction waste. So currently, um so this is a second area that we looked at. We currently dispose suction waste in rigid plastic boxes. We put five suction liners per box and then they're disposed of um by a high temperature incineration which is a expensive and carbon intensive and it's not because of the need to, it's just the way that those boxes are disposed of. Um the boxes also get heavy, which is a moving in hand and risk for staff. Um And we do it this way because of an interpretation of the National Patient Safety addict. Um And it was said that we couldn't use a gel and agent because once somewhere on a ward, somebody ate some, some um and they died, but we're a secure unit where patients don't room freely. So it doesn't really make sense for us. So I'm got you. What we wanted to do was explore what governance thought about us using the gellin agent for our suction waste within the theater environment. Um and calculate the carbon savings of switching to using the gellin agent as opposed to the single use plastic boxes. Um And then this would mean that it could go down the offensive waste stream rather than for high high temperature incineration. We did sur we did a survey on the staff to gauge the impact of the change and see if they supported the idea. Um And then the results were that if we did convert to using a reline agent and sending it down the offensive waste disposer ro and we could save 8258 kg of CO2 equivalent 1379 kg polypropylene and then 10,408 7 lbs. So basically savings on average suction volume that we use per case and the number of suction liners that we use as well. Um And then the staff survey showed that staff were all supported of this. They thought it was a lot easier and less work for them. Thank you. Thanks very much, Poppy. Great, an interesting new area to work on and I'm sorry that Rachel, we were trying to get her in to join, but she's abandoned you. I don't think on purpose. So, thank you for taking the. Thank you. So, um great word there. I mean, er, some s so wasn't clear to me. Have you instigated a change in terms of the duration of um er an a set of tubing use or is that still working for you? So that's still a work in progress. It is going to governance now. Um But it has had the thumbs up from the infection control. So it's a work in progress. But hopefully, and, and you mentioned that there was variation in what O DPS were actually doing in terms of the presume that was the duration of um the EMT tubing being used. Ha Have you got more details of that? Have you got, so we used to change it on a, on a, on a Monday, we changed the circuit but it comes in lots of different parts. So some people were changing every part of this. Others were only changing half the circuit. Um uh But I mean, some fitters might, you might do two cases a day so they might use that, that tube in only two days, whereas others might use it 20 20 times a day. Um, and there's a filter on for each case. So I think people, some people get worried about their risk of the infection, er, of infection control that it's reusable and like I said, they do have those filters on as well. So, but we wanted to do 31 days so that it's a monthly thing that it gets changed and it's not confusing for anybody. Cos, I think a lot of people don't, don't see the point in changing it weekly, which is probably why they don't do it. Mm ok, great. Uh Again, Rose, I'm going to bow to you if you're happy to take the questions from the floor. Sure. So we've got a few questions about the anesthetic um tubing which also links into something I wanted to ask. So Richard Newton's asked about your workings and how we share this across the UK. Um And Janette Rogers asked, um, how did you test the integrity? Um And as a follow up, I kind of wondered if you'd engaged with the supplier who's saying that this is seven days where you're doing all this work and if, if you've engaged with them at all to try and change their advice, which might help with, with scaling elsewhere. Yeah, so we are working, we have spoken with the suppliers. Um The only reas there's no reason why they can't validate it for longer. The only reason is because that's what they've done their testing for. So we need to try and work with them to get that testing further. Um But obviously it is hard work because we're not gonna be buying as many anesthetic tubing from them. Um But in order of testing it, we um so we connected it to the mountain piece on the oxygen mask and we did that, like I say, 1240 times as of like, so you disconnected it from a patient onto the next well onto the filter. And I think there's a, a couple of um recommendations about how you test it after it's been exposed to um a volatile anesthetic for a month. Um And is that something you're looking at? Uh we will do further testing. Um But obviously you don't, it, it's got that filter. So generally nothing should go past that filter. Otherwise the whole anesthetic machine will need, you know, is not clean. And I think an interesting question from Richard Newton saying that if um we decide to go against what the manufacturer's recommended duration is and something does happen. Um Do you think the trust would be liable in that case? I'm that's all something that we'd have to look into. But I mean, it, you do have emergency backup if you, if you c there is a chance that you could run over your circuit with an anesthetic machine anyway. Um So you would have a back a bag and mask available or a new circuit so it wouldn't take, you know, it, it's the same as other, any other emergency if you, if you've got a leak with your circuit and I think there's lots of people in the chat who are potentially interested in, um, engaging with you or finding out a little bit more about, about your work. So, if you're happy, um, either yourself or to share your email, I think, um, I think there's a lot of people interested on t or anesthetic tubing work. Yeah, there is on the presentation as well. I IW I did a lot of work with, well, Tim did a lot of work. Um He's one of the consultant at the and he has put his email address on, on one of the sides. So I'm sure that they'd be more than happy to help everybody out if they had any questions. Thanks so much. So, yeah, you're welcome people. Um You can obviously contact you. Um So I just put something in the chat. The guidance is if you go against manufacturer guidance, the the person who is undertaking that um deviation is responsible, but people then get worried and scared. So I think we just need a body of evidence that says this is it is it, it is with governance at the moment. So what would be good is actually to get us on a national stage, of course, to say this is fine. Also, we should be pushing the manufacturers. I mean, I've also had a conversation with M hra saying, why is that? Ok. They should say actually this is the maximum time that you can use this and we say it is ok or what's the evidence for it. But people shouldn't be scared about reusing things as well. 5.9 million scissors are classified as single use. So you've cut a pair of sutures and then you're supposed to throw them away according to the regulations, there's only one reason for that which the companies are very happy about. So, you know, let's all be sensible in here. Not, not, er, er, not scared, too much. Er, obviously sensible includes being, er, um, appropriate for infection control. So, thank you, we better move on. Um, cos we've got, we are filling the time, which is great, um, because there's lots of interest but next is, er, James, er, James Dalton, who's actually, er, working with myself and the, and the team at, er, in, in Brighton, but he's gonna talk to us about some of the work he's been doing on, uh, doing his fellowship with us on anesthetic sustainability. So James, please go ahead and I'm gonna give you extra hard questions because you work with me. Thanks me but nothing less morning, everyone. Thanks very much for coming. Hm. My slides, are you gonna have a sneak preview? There we go back to the beginning. Um, so my name is James, I'm an anesthetic and intensive care registrar. Uh I'm taking a year away from training down with mood um, and, er, Richard Newton over at University Hospital of Sussex down on the south coast of UK. And I'm doing a new role with the trust um on anesthetic sustainability. Um, er, it's um 80% of my time is spent on sustainability projects and 20% of my time is spent on clinical work lest I forget how to put in a cannula. Um So the um the er my, my personal background is I've been an anesthetic R for a couple of years. Um And um I think that experience has been really important um uh to, to help me with um the, the, the job role really, which I'll go on to sort of describe in a moment. And so the whole purpose of the job was to help facilitate changes described in the trusts green plan. So in the UK, we've got every NHS Trust organization has a or should have a published green plan to achieve sustainability goals as per the national strategy for the NHS to become carbon neutral in the not too distant future. So that's my role within the trust. And this is where we, I sit along with a colleague of mine, Jasmine who's also attending this conference today. She's doing some excellent work on inhalers in the medical side of things. So, here we are in the green box reporting to the environmental sustainability steering group um and also reporting to our prospective clinical teams in our department. So, the goals specifically from this green plan for Anesthesia were to establish a medical gas working group eradicate Des Luane, develop um a tool or strategy to improve nitrous oxide management. And um also look at wider um objectives within the world of anesthesia, for example. So, new devices and para and et cetera. Um So we'll go through those um er step by step. The first one I've, as you can see, I've skipped the um um Desferan because er because there's don't know if everybody is aware of this, but there's a national ban um impending um on Desferan in, in England and Wales. Um And so the trust has actually very rapidly adapted to that already, which is fantastic. Nitrous oxide. Oh dear, these charts haven't perfectly translated, but maybe I can describe them to you if you can't see them. So nitrous oxide is a traditional co anesthetic gas. So you can't give an anesthetic alone with it, but it does um help and it does um provide some analgesia. It's got a significant global warming potential over 100 year time horizon. In UL six, we've got multiple sites and this, this gas is stored in cylinders at the back of a hospital attached to anesthetic machines via internal piping from a manifold. Now we a lot of this stuff 1.7 million L per year which is a significant environmental impact as you can see and a not insignificant cost including maintenance in this manifold system. Unfortunately, because of the aging NHS infrastructure and other issues, it is very, very common for manifolds and pipework to have small leaks, which if you take that as an entirety of across seven manifolds and seven sites, you can leak 100s of thousands of liters per year undetected. Now, I've done a baseline survey here before addressing this issue and figuring out how we're going to solve this big problem, this big footprint. And I've just tried to get a handle on exactly how many of our staff members, our anesthetic colleagues use this gas because as I said, traditional, it really is traditional and it is not actually a part of modern, most anesthetists, modern anesthetic practice. So it does seem a bit nonsensical again and established behavior established inert in the system of procurement, where maybe are we not actually using this enough or we're not actually matching the clinical use to how much we're buying. So I suspect looking at these charts that we are buying are quite a lot more than we're ending up using. And uh thus, I think we're, we're losing a lot through leaks. So as you can see, almost half of our anesthetists had 90 responses to the survey. Don't use this gas at all. And the vast majority of the remainder use it once a month or less as in as a, for a case. Um, again, induction of general anesthesia. That's fancy talk for making a patient go to sleep. Um, now, almost all of our nieces don't use this, um, or they use an alternative and, or, or they use it for less than half of their, of their gasses induction, which in itself is quite an unusual event. 61% say occasional use of this gas should be permitted. Right. So you still need it and we're just not gonna necessarily use it as much as we did before. This project was an interesting nut to crack because there was a medical gas working group prior to my arrival in the trust in the recent political history of, of Sussex, there's been a merge between East and West. So two organizations have become one and as a result, there's been a lot of change in management and organizational structure as a result of that. And from other working issues, the medical gas group was effectively disbanded several months before I arrived. This is, this is a sketch here of the, the pipework of the one of our site, having to assess all of these and find out exactly where our nitrous is piped to how it, how it's distributed throughout the hospital. So, what I've done is I've e engaged stakeholders. I've built relationships using this 80% of my time, I've discovered some things that have happened in the past. So we've assessed for leaks, no leaks reported. However, down to a sensitivity of 1 L per minute, definitely was not significant enough of a threshold to definitively say there were no leaks. I've built some working relationships really, really strong ones with both allies to are the green calls in estates and pharmacy and people who are highly cynical of the abolishment of or the reduction in use of nitrous oxide. And they've both been equally as valuable to helping us move forward with this limitations to this technology. Um And the available data to say how much we're actually using, I can tell, I can tell you how much we're procuring, but I can't tell you how much is actually coming out of the tap at the other end. And that's due to aging technology that has been very slow to be replaced. Um And we are limited by um the anesthetic machines themselves and how much data we can, we can draw from them to tell us how much this nitrous we're actually using at the point of care. Again, funding is a very big issue for all NHS trust at the moment and trying to institute change. So I made a comment to try and make this change within a cross neutral envelope. So what we've done is changed, the, we've assessed our baseline, we've assessed the need for education, but actually having done an educational intervention and survey on this, the, the knowledge is there, the practices changed and there's less than 10 consultant, at least who regularly use this stuff across the entire trust. So we're not going to remove it. We're gonna move from an on demand system to a planned use system with mobile cylinders decommission. Our manifolds all cost neutral within a year from our pharmacy budget. It's been fantastic to have some excellent um colleagues and executive physicians who are able to facilitate this and make it work. I'm happy to say we're replacing our manor folds across the shop with 8% of the volume of mobile cylinders which have a shelf life of three years. And we're going to move from an on demand model to a planned use model. Decommissioning work is starting later this week and hopefully we finish by the end of July across our trust. So I'm very pleased with that. Moving on to interox, this is nitrous oxide with oxygen. It's used for analgesia, mostly in labor units for maternity, but also in A&E we've got four sites that have um maternity units, three manifolds and one use bottled a very significant volume because this this stuff is inhaled in large volumes by patients in pain, a very significant carbon footprint and a very significant cost. As you can see, this is an issue because again, this nitrous oxide component if inhaled in significant quantities in an occupational manner will cause harm. So it will cause harm to our colleagues. It will cause harm in this. I'm not going to read this out, but for time, it will cause significant harm. And this is why the substance is legislated for and there are maximum permissible levels and there are minimum air changes in the room that need to be, that have this substance being used in it, not to shed too much light on the inner workings of a hospital. But there are places in the hospital that do have inadequate ventilation and this needs to be addressed and is being addressed. When I found out about this, I made a working group with our risk colleagues. Again, this is a massive benefit of having 80% of my time available to me to work on these things, making contacts and building relationships. I've we've suggested a central destruction unit which is this palladium reactor to destroy the nitrous oxide that women in labor are exhaling and therefore potentially reduce our carbon footprint by a very significant sum. This obviously requires some capital investment but in the face of in the face of the potential consequences in terms of health and safety at work legislation, I feel like this is the, this is the this is the only solution and it also happens to spectacularly agree with our green plan objectives. So I'm very pleased with this other things. I've been working on paracetamol. I'm not going to go into the science of this but effectively intravenous paracetamol is expensive and very carbon intense 5040 to 50 times more carbon intense than oral or four times more carbon intense than liquid suspension. Um And so there's a potential, very large amount of money we can save for the trust and also a very large amount of carbon. So in pediatrics, we've moved from preoperative um, no paracetamol and a system where we would give intravenous paracetamol in the operation to oral paracetamol. You can see in green here, the results 50% had them in December of our patients in the pediatric hospital in Bryson, they prescribed oral dose preoperatively. And now we've moved to three quarters instead of half after some interventions including education, post a campaign and we saved 3.5 1000 lbs over the year in just three theaters and almost 500 kg of CO2 across the year that's projected. Um And you can see the pie chart on the left. These are all the reasons why patients weren't given documented reasons why patients weren't given pol before our intervention. And afterwards, um we've got only four different reasons and the most pressing one is time. Um So there's still work to be done. The next step for this project is to introduce the same change in adults. Now, that's a bit more complicated because we have an electronic prescribing system there. So it's taking you a bit more time, but we're getting there. Um Moving on the next project of American single use culture. So this is this is more of a flavor of our work of our um breakout session today. Um We perform almost 50,000 operations in the year across the trust. When giving a general anesthetic, we use a laryngeal mask airway and we use 20 or an end to kill you and we use 22,000 of these laryngeal mask airways a year in Sussex and they're all single use, significant carbon footprint. There is, there are alternative um reusable devices available to market. Steam sterilize 40 uses and it's well documented elsewhere. Jody Sherman's paper from a few years ago, looking at life cycle footprint, reasonable versus use Lasco and the winner is obviously reusable. Um These things, there are barriers to introduce this. So there's culture. We all use our gels at the moment. They're easy and recognizable. There's also expenses, steam sterilization costs and also the equipment we require to put in a washer costs. So that's our next plan. Sorry, James just two minutes if that's ok. Thank you. In that case, thanks. I'll move on to the academic side of my work, which is much more exciting. So we're looking at, we're looking at with Brighton Sussex Medical School, we're looking at moving away from this single use airway culture where laryngoscopes are made of plastic or steel are single use and thrown away or plastic devices like those Ls I was talking to you about just now used once and then thrown away after a few minutes moving it from that to a reused. Economy of devices where the devices are used and used again and cleaned effectively or sterilized if required. Obviously, the current barrier to that is that we have a culture problem, single use based on myths where it was dangerous for infection. No, it's not. The evidence is against that. Oh, it's more expensive. No, it's cheaper to reuse. Oh, it's more carbon intense. No, it's definitely not. It's always less carbon intense to have a reusable version. So we're going to be, we've got those barriers over the count. We know that steam autoclave is the most carbon intense part of the process of maintaining a device. And so we're looking at alternative ways of decon and decontaminating and sterilizing these products and potentially working with partners are not fit for that process to redesign them. So they are fit for that process. And so we've got some grant funding to explore this with two technologies, ultraviolet radiation and low temperature peroxide, both environmentally friendly and lower carbon and steam. And we're gonna be working very closely with our microbiology. Colleagues to look at industry standards um for proving sterility and decontamination to an appropriate level and also clinically relevant organisms, for example, drug resistant organisms, yeasts, Staph and strep. Um as part of this project, we're going to do carbon footprinting and looking at health economics and to see the cost benefit to the NHS as a whole. I'm really hopeful that we'll be able to roll out what's been achieved with ent and those endoscopes with the ultraviolet light to laryngoscopes and a reusable sort of bedside culture where it becomes very easy to be confident that we've got these reasonable devices that are safer and going to last for a very long time. Quickness to partners. Thank you very much. Any question to you. Um So um we probably better move straight to the chat if that's OK. We've got time for maybe one or two questions. Um Rose. Are you happy to take those? Yeah. So there's been quite a lot of theme about the nitrous oxide and leakage. Um I think a lot of people asking how you've calculated it and whether you're measuring um what you're using versus what's delivered and then, and then kind of a follow up about, are you having issues um about how much you're sending back to um to bo with the knowledge that is going to be vented rather than that, that's being leased to your own pipes. So kind of a general nitrous question. General question. Yeah, fantastic. So I think this is a, this is a really big problem when approaching this project from any in any trust and you rely on the documentation you rely on um the the technology available to measure. Um And as I outlined the talk, the technology is inadequate to measure our use to the point of care. So the onset of machines are two roles. The software has not been updated to tell us exactly liter for liter, how much is being used. So all we have to go on is purchasing and procurement. Bo do invoice us, we do pay them, they do deliver, but it's very infrequent and it's on a very much an ad hoc basis. Auditing on our use at the manifold. There are, we should be doing it but we're not always doing it. So how have I calculated it? I've used my figure of less than 10 anit use this versus how many millions of liters we're ordering a year and it definitely does not add up there. So the only answer is we are either venting and it's not being recorded or we're leaking. Either of those two options leaves me one solution which is mobile cylinders and an elective planned use of nitrous, which will end up reducing our overall use regardless. Maybe one quick one. You mentioned how you've been able to change practice and use of paracetamol in pediatrics. But in adults, it was more difficult due to the electronic prescribing and just wondered if you could outline a little bit more what that specific challenge was. Yeah, of course. With a paper prescription chart, you just need your system scribble with an electronic system. You need your patient formally admitted onto EP in the process we have here in Sussex, similar to elsewhere in the UK on the day. Of surgery. Patient will come in in the morning and be assessed by a very, very busy preoperative nurse who has lots of other things to do as well. And one of those tasks is to admit the patient onto the electronic prescribing system. And there's the stumbling block of um, finding A N at the right time, you know, after the patient has been admitted electronically, um so that these can prescribe. So what we've been trying to do is a workaround because that's not going to work because they often get seen before electronically admitted if that makes sense. So what the workaround will be to give permission, electronic permission and training to our nursing cohort, so they can document a single dose under a what we call a patient group directive AAA waiver. That makes sense. Thanks very much. I think in the interest of time we better move on. So, thanks James DPA. If you're happy to come on also DPA is also from the University of Brighton just to make it clear. I had no role in selecting the presenter. So this is not an insider job. So, but I'm very happy that we have Brighton and Sussex represented DP A, please. Thank you. Thank you. Thank you morning. Just everyone. Um So the first slide is, is just a summary of the whole presentation. Um So my name is Depo Saka. I'm a materials scientist and uh I'm going to talk a little bit about materials in the healthcare sector and the notions of circular economy with an with a view to sort of reducing waste and management of that waste and getting a better picture of sustainability and how material science can help in that way. So this diagram is complicated. Originally, my powerpoint slides had revealed uh time by time, but in the PDF form, it doesn't show that. So the information moves from left to right. So the on the left hand side, it talks about what material science is. It's a composite of chemistry, physics and engineering. It also might involve little aspects of biology, obviously, geology for minerals and a lot of computational sciences and so on. In terms of trying to predict the behavior of materials and how they work. And its relevance in medicine is because we might be able to use that material science expertise to develop new and adapted products. So that means we can take existing materials. Somebody talked about that earlier on in the session and the complexity of materials and twist, twist and tweak them in order to improve them, have them as less emitting of waste and less polluting. Um It also means that we generate some waste too and what do we do with that waste? So in research which is indicated by the blue arrows, we can use that material science, we can possibly recycle some of the material or repurpose that material, ah we can make use of that waste for alternative sources. Sometimes. Now people are thinking of using that waste for not the same purpose but repurposing so embedded waste plastic in concrete, using waste plastic to create fuels, diesel and other kind of combustible fuels. Uh and also using that waste in some way inventively to create new products because of the properties of the plastic largely that we're dealing with. And the reason that we might be interested is because we can think about the certain types of materials that we use. So for example, recyclable and recycled specular, for example, what those are made out of in terms of metal or plastic and essentially the lifetime of those materials. We can also think about um using technology, for example, to create lots of implants and ceramic implants and many other sorts of things. Now we talk about something called four dimensional printing and that means you take something in three dimensions like a cube and when it's in a particular environment, it takes up moisture or takes up up some other kind of medium and reconfigures itself into a different form. So swellable material and this could be used in in certain instances within the medical field. Now, we can invent materials, we can generate waste materials and we can use materials within the medical sector. But also at some point, we have to rely on industry. So what's industry's roles indicated by the brown arrows? Well, they can have a role in development of new products, new coatings, new types of devices themselves. They could be involved with material science research, for example, in terms of development of new materials, new products. And also they have a key role now in managing the waste that we generate through that medical sector. So it isn't useless waste. At the moment, we're landfill and incinerating a lot of that waste material. And I would propose that we could do something with that material. In fact, I worked on a project relatively recently, which was about repurposing absorbent healthcare products. And so using the cotton and the plastic in absorbent healthcare products after being thoroughly sterilized for repurposing and using a whole manner of things. OK. So again, the left hand side of the image is the ones that we look at first of all. And I talk here about the lonesome material which are plastics. Most of the materials that we talk about in the medical context, glass paper, iron based materials, linen, aluminum are recycled and repurposed relatively well. They often involve high temperature processing which by itself is kind of sterilization and removes harm from that medium. You know, those sorts of objects might be single use items like the plastics that we talked about earlier. PPE packaging, textiles, food waste that we'll talk about in the next breakout session, drugs, dressing, anesthetic gasses and a range of different rather complex items such as electronic items and devices. These are made more complex because there are mixed media that contain many different types of materials which are difficult to disentangle. All of that processing involves greenhouse gasses that we talked a bit before. And that might be carbon oxide, methane, which is about 2030 times as powerful as carbon dioxide nitrous oxide, which is about 300 times as powerful as carbon dioxide and perfluorinated organic chemicals, which are between 1000 and 15,000 times more powerful than carbon dioxide. Ok. So those are all issues associated with that repurposing, reusing recycling. But those materials on the left hand side are recycled and have many, many possible lives. One of the issues that's raising itself, it's had recently is the use of electronic devices and the rare metals that are in those devices and the waste that's generated from the use of those waste metals if they go to landfill. So those are the metals that we now think about in terms of electric vehicles and all those controversial uh metals that are difficult to get hold of the plastics features there because plastics as we talked about in the first talk are wondrous materials, truly wondrous materials. They are persistent resistant, but that means they also can cause environmental harm. So when we make them, we generate greenhouse gasses. When we destroy them, we generate g greenhouse gas, greenhouse gasses. If we leave them alone, then they generate so called microplastics and nanoplast, which we heard earlier on can be very harmful. Ok. So plastics almost always feature in the waste mix mix. And as I said, they have a particular problem because when we try to recycle plastics, they undergo degradation. So they don't really handle recycling very, very well, particularly more than maybe once or twice. Why do we love them so much? Because they're cheap as chips, they're easily formed and molded. That means they can be used for many things. We talked about face masks and you can see some items there, an IV bag, uh a cannula, you can see a pharmaceutical blister pack full of chlorinated plastics, a face mask, uh they're easily formed, they are molded, they're abundant and they're resistant chemically and environmentally. But that's a double edged sword because they are resistant and that means they're persistent in the environment. So we have to think really carefully about the amount of plastic that we're using because of this difficulty with recycling. So I use as an example, a syringe that you're all familiar with and the complexity of that syringe on face value, it looks very simplistic, but you can see the syringe barrel is made out of polypropylene and cyclic olefin called polymer. That's two different types of plastics and silicone or lighting lining is a lubricant that's three materials. The plunger itself is made out of polyethylene, polythene. And so that's 1/4 material. The plunger tip is made out of rubber and elastomer er sbs er that's 1/5 material. The syringe again is made out of its container is made up of polyethylene. The blister pack is made out of polyethylene bonded onto paper. That's 1/6 material. The needle is made out of stainless steel and the needle hub is made out of PVC, that's 1/7 and eighth material. So a simple syringe and the waste generated by syringe use means there are eight materials to disentangle and sort if you want to have the possibility of recycling, it presents a problem with a lot of those mo mono er non mono material types materials that we're using. Ok. So the left hand side, we talked about the three Rs which are reduced, replace and recycle reduced would mean perhaps light weighting something that we're doing. Now instead of having having solid plastics, we're using them with a rated cavities and we're using lots of fins and struts. In order to use less overall plastic, we could think about replacing, which is some of the work that I do. I look for alternatives to plastic. So things like bioplastic have become popular. Uh There's a possibility for recycling or reworking. So you could use that waste for a second life repurposing it, as I said, not necessarily using it for the identical life that it had in the first instance, but repurposing it. But also there's the idea that we could think about six hours, so called six hours, which is in the first place thinking about would we refuse the use? Would we rethink if it's really necessary in the first place? Ah within there, there's the idea that you could perhaps as somebody mentioned earlier on in the session, actually re reengineer goods to be sterilized, repurposed and reused again. Or the sixth item is that we think about materials which are degradable and bio can be composted in some way. So in this case, they rot, they degrade. And if you have aerobic degradation, then you produce CO2 rather methane, a much more environmentally friendly waste gas. So overall, I think we have to really consider, consider the generation of waste in the first instance, is the material really needed or is it a matter of convention and habit and a culture that says, for example, we, we uh we use dressings and PP, for example, when it's not entirely necessary, we use, we use coverings and excessive packaging, something I'm very enthusiastic for trimming down. And this idea of the full cycle from its inception, all the way to its disposal so called cradle to grave concept alternatives that might be more easily made or offer better recycling characteristics. As I mentioned, metal and glass hugely polluting in the first instance to make much less polluting to recycle something like 55% reduction in CO2 by recycling aluminum than making it in the first instance. OK. And then the idea of cost reduced alternative materials. So if we are going to substitute. This is one of the problems we are facing biomaterials. Um Things like polycaprolactone and other bioplastic, they're expensive, they're about three or four times as expensive as the traditional petrochemically derived plastics. So if you're really gonna substitute, you've got to have materials which are economically viable, you know, which of course, will become cheaper, the more they're taken up. And then the fifth point really is that we really got to think very, very carefully about the environmental calamity that is awaiting us by the continued use of plastic. So the plastic that's in the environment is there as a sink, it's not degrading. Currently, we think that plastics in the environment are there between about 250 up to 1000 years, they've only really been made in significant numbers since the 19 fifties. Every bit of plastic that has been sent to landfill is still there. Ok. So we really gotta think very carefully about either hoovering up this material, which is really very tricky indeed on not generating it in the first place. Ok, thanks. Thanks very much deep that, that's a great overview of some of the difficulties we have in our material use. Um Just in the interest of time, I think we've probably got time for one question. So if I may um I just wonder whether I mean, from what I understand, material scientists are often trying to analyze things and find out what they're made of rather than manufacturers telling you what they're made of. And this is one of the difficulties, you know, that Janette's, you know, key not talked about is we're trying to find out what's going on when there is a risk to our planning and a risk to human health because some of these things are obviously coming in contact with, with inside our bodies. Do you think there is actually a mandate now that that device manufacturers, whether in the medical sector or broader should be absolutely transparent about everything that's in their products. Yeah, I mean, I think, I think that that James mentioned a little bit. He said the difficulties there and what I wanted to ask after his talk was, yes, how do you overcome those difficulties? You need government policy, you need government practice, you need legislation because you're not going to see a paradigm change without enforcement of some way, you know, the spontaneous change is not likely to happen. So I think there is a need for legislation and clamping down on those companies and kind of the dirty little secret. I think Janette mentioned there in her first talk about materials and the additives that are in there. But actually as I wrote to her, those additives largely give the properties to the plastics and you can maybe select ones that are less harmful. I mean, we know about ones like the phal that are xeno oestrogens and procarcinogenic and so on and so on and maybe, you know, it's time for those things to be trimmed away. I think we now have to be very serious about continuing use of certain materials, you know, continued use of widespread use of PVC, continued use of widespread additives that are on a mysterious list and so on. And I think that's enforcement is neededed. It's sorry, a long winded answer to a short question. Great. Thank you. No, I mean, I completely agree and I think people sometimes react more to the threat to human health than they do to the planetary health. I'm afraid to say, I think the planet is just as important, if not more important than us in our existence. But perhaps Janette as your work comes through as well, we can make a strong arguments with the precautionary principle that these products should not be used because of the harm rose. If it's ok, I'm going to ask you to close the session and thank you everybody for joining Rose. Go ahead. Oh, ok. Rose's left. Ok. Thanks everyone for joining and er, yeah, great presentations. I learned a lot. Thanks. And uh we'll see you next time or on the next session. Love. I'll just say it's a lunch break now and we'll see everybody uh take a break and then it's 1245. It's the next breakout session. Ok. Thanks Heather. Sorry. Ok, bye.