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Good afternoon, everyone and welcome to the thought-provoking session on sustainability and surgery. I did as, as uh associate honorary secretary and exact team member and plastic surgery trainee cour the session uh with my colleague Oscar, we've got plenty of really exciting presentations and Q and A and panel uh discussion at the very end. So do bring up your questions uh to the chat and we'll address them at the very end and uh I'll give a word to you Oscar. Uh the give the floor to Oscar, my colleague to introduce himself and our first speaker. So, hi, I'm I'm also Wong. I'm currently a surgical trainee at Wales and I'm really happy to have the opportunity to, to check for this talk and introduce some exciting talks to you guys. So as we face the growing challenge of climate change, the healthcare sector has a crucial role to play in reducing its environmental impact. So today's session brings together experts and researchers who are paving the way for greener surgical practices. So let's dive into the session with our first speaker, Doctor Napo Good who is an academic clinical lecturer in public health at the university of Birmingham and the Cole of the Green surgery initiated. Please join me in. Welcome Dr Ne. Good, brilliant. Well, well, thank you very much for the invitation and the opportunity to um share some thoughts with you all today. So I'm gonna give a bit of a broad overview of our program and then I think uh Virginia and Tianna and Anna will delve into some more specific elements of the program. So, um sorry, sorry and move my slope. Yeah, here we go. So where, where do we begin? Um In Birmingham, we've been doing surgical research studies, randomized trials for uh well over a decade now. Um And since 2017, we've had a global surgery unit that we've been fortunate to have funded. And this has been about bringing together collaborative teams from around the world to tackle common challenges um around surgical safety, access to surgery financing and and other topics in surgery. We have hubs in seven countries. India, South Africa, Rwanda, Benin, Ghana and Nigeria and Mexico, uh where we have surgical teams um that are that have the infrastructure to conduct really high quality studies. Around the time of the pandemic. We really pivoted to providing the best possible evidence to support safe care during the pandemic. So some of you might have heard of COVID surge. This was an initiative where we collaborated with over 2000 hospitals in 100 and 20 countries to collect prospective data to uh inform the global guidance around how we could maintain surgery as safely as possible during the pandemic. Um coming out of the pandemic, we, we were left sort of thinking well, that COVID surgery work had really evolved. Our thinking. We went from being people who mostly did general surgery, colorectal research to working across all specialties on a cross cutting issue that was important to everyone, which was COVID. Um And so we were now sort of thinking, well, what other topics were there where we could bring together surgeons, anesthetists, obstetricians, and gynecologists and others together to tackle common challenges. And one of them was sustainability and how we could uh mitigate and um reduce the impact of climate change. So, environmentally sustainable surgery, we, we've been successful and um fortunate to be funded by the National Institute for Health Research to develop research programs both in the UK and with our global network. So we have two separately funded but closely aligned research programs. Um And, and they have substantial funding behind them from the IR. Um So why is this important? So climate change, we know this is a global emergency, it's already happening. Um And recently the lancet countdown on climate change was published. If you haven't read that I would really recommend you go away and have a look at that. It's freely available on the Lancet website. And in details um what the health impacts of climate change that we're seeing already are. Um So it, it's a two way thing, climate change can affect health but also health because globally it's estimated about 4.6% of carbon emissions are related to um healthcare delivery. So to reach net zero, globally, we can only do that if we are uh taking active measures to reduce the impact of he healthcare related emissions. The NHS was actually the first health system in the world to set a net zero target and that was for 2040 many other health systems or many other countries have followed the NHS as lead on that. But the challenge is how we can then translate this very high level ambitious target into some in into reality. And that will take very specific measures that we need to be implementing. Um trying to decarbonise the whole hospital is quite challenging. And so that's why we started with the operating theater as a starting point because it's a resource intensive environment, but it's also quite a controlled environment. It's focused on a single patient at a single time. Um It's, it's a bit less chaotic than a hospital ward, for example. So we're working with frontline teams. I'm a public health doctor. I don't work in a hospital. Um II but, but the strength of the research is that we can work together with frontline teams because they know where the challenges are in terms of waste, in terms of where tech could be made more efficient, where uh we could um reduce the impact of the emissions. Clinicians, particularly in the global South can be powerful leaders for change. Uh They can advocate and they can implement change on the ground. So it's, we're not gonna get anything done without the buying of clinic clinicians. And uh perhaps more of a point about health systems. Uh They can be quite influential on industry as a whole uh through procurement pro processes and, and frameworks uh lobbying and um just changing how we make decisions over what and why we buy things. Um And the NHS is already trying to do that. Um And it has its target not only for its own carbon footprint to be net zero, but by 2045 for it, all of its supply change to be decarbonising. So we have a few pillars in our work. Um We, we are very much focused on research. Um and one of our research pillars is around anesthesia II, we well on this because Anna and um Fiona will, will talk to you in a lot more detail about this, but that's one of our pillars. Er A second pillar is the dragon trial. Er So this again, Virginia will talk to you in more detail, but in a nutshell, it's a plus randomized trial comparing single use versus reusable drapes and gowns around the world. It's a very ambitious trial because we're looking to recruit 26,800 patients and I II believe and, and feel free to correct me if I'm wrong that this would be the largest ever surgical trial worldwide. Um And uh the great news is that our colleagues in Mexico last week started recruitment and the first patient is into the trial. So that means we've only got 26,799 more patients to go. So almost there. But uh Virginia will tell you a bit more about that. Um We also have a pillar on waste management and this has probably been our most challenging area because it's a very um systems level problem around what the pathways are for, what things we buy into the hospital, what materials they're made out of how they're packaged. Um And then how we dispose of that in a safe way, there's a lot of regulation to maintain patient safety around sterility. Um That means that it's quite difficult to change some aspects of, of how we package stuff, for example. Um There's also a lot of regulation over how we dispose of waste and making sure that's done safely. That also means it's not as easy to change things as you might think. However, the good news is that um Virginia has worked with a team at University Hospitals Birmingham to create a waste management starter kit. Uh This is a simple document um as you can see on the screen, which details a few basic actions that you can take in your hospital to start improving the way the waste is managed through the hospital. Um They're very simple steps, but actually, although they might sing common sense and, and can be quite challenging. So um have a look at that as well. Um And probably what I'm most excited about is our energy work stream. This comes from the realization that uh although we can try to make our care process more efficient, we can try to reduce waste, improve the way we design our procedures and, and, and the, and the things we use. Uh inevitably, we will always be highly energy dependent to deliver surgical services and, and hospital care in general. And therefore the only way to decarbonate health care is to move to net zero or clean energy sources. The NHS itself has recognized this because half the NHS emissions are related to building energy use. And it's estimated that if the NHS was to invest in more on site renewable energy and heat generation, it could reduce carbon emissions by 580 kg tons of carbon dioxide each year. However, energy isn't just about decarbonisation. It's also about energy security. Um And that is a challenge worldwide but particularly in the global south in our network, 88% of hospitals that responded to a survey um said they experienced regular power cuts with typically up to nine days of power cuts each month. Um You can see on the chart on the right uh at the top, you've got low income, then lower middle income, upper middle income and then at the bottom high income countries um showing the distribution of the number of days of power cuts a month. Um And although most hospitals have very few, if any power cuts, you can see that particularly in the low and the lower middle income countries, there is a long tail of hospitals that are having power cuts 1020 or even 30 days a month and that has a huge clinical impact. Um Because you can imagine that if you have a very unreliable power supply, you're not going to be able to deliver um a safe and effective care. That isn't just about surgery, it's about maternal care, it's about vaccines, all sorts of things. Um So we've come up with an initiative called A 100 for 100 which is around fundraising 100 million lbs to support secure clean energy for 100 hospitals in the global South. So if you happen to be generous and, and have a substantial amount of money uh free, then we'd love to hear from you about how we could work together. Um So finally, uh as well as clean energy, there are other projects that could go forward around um improving the supply chain and the sort of reducing the amount of transportation of stuff coming in and out of the hospital um and changing our waste contracts. So that is where I'm going to finish. Um, but one final thought is that in just over a month on the 17th of December, we're holding a research from Green, a surgery conference here in Birmingham. Um, it's free to attend. It's going to delve in deep on all of these different topics. Uh, we've got a Minister of State from the Department of Energy and, um, Security Net Zero coming. It's gonna be a really exciting day. So, um if you'd love to, if you'd like to register, then please get in touch and we can share the link with you or perhaps ju has it on her slides. So, thank you very much. Thank you so much for the brilliant presentation as I mentioned before. Uh Do you please leave your questions in the chat? We'll address them at the end. And without any further ado, we invite MS Virginia at a general surgery trainee and phd clinical research Fellow at the University of Birmingham to talk about uh the dragon trial and share the insights and hopefully how uh people listening in can potentially get involved. The floor is yours? Hello, I'm Virginia Edder and I'm one of the phd fellows at the NIH R Global Surgery Unit at the University of Birmingham. Thank you so much for inviting me today to talk on behalf of the unit about the dragon trial. The dragon trial is gonna focus on the use of reusable and disposable drapes and gowns in operating theaters. So why did we decide to focus on drapes and gowns? Well, we know that both single use and reusable options are used on a daily basis in operating theaters globally. And we also know that currently there is no robust evidence to tell us which type would be best to use. The who itself does not give any recommendation as to what type should be used in operating theaters. We know that disposable textiles have definitely gained more popularity, especially during COVID as it is thought they might lead to a lower rate of surgical site infections. However, they are also very likely to lead to increased costs and a higher carbon footprint. So the trial objective is really um the trial is really aiming to determine whether there is any difference in si rates between um disposable and the reusable drapes and gowns. We're also aiming to understand which one would be the most sustainable and cost effective option as we will collect information to determine clinical cost and carbon outcomes and those outcomes will all all be er present in the first paper of the trial, er which is really um probably the, the first time for um a trial this large. So um how are we gonna, are we gonna do this? So the dragon trial works as a multicenter noninferiority cluster randomized trial. So it's gonna involve um or aiming to recruit uh 26,800 patients in uh the UK and seven low middle income countries. The patients recruited are those that um have undergone surgery through a clean, contaminated, contaminated or dirty wound. Um, that is five centimeters or more or um three centimeters or greater in Children. We're aiming to recruit about 100 and 34 hospitals in each in total. And for each of those hospitals, we're aiming to include 200 consecutive patients. The hospitals are going to be randomized to either an intervention. So they are reusable drapes and gowns or a comparator, they're disposable single use drapes and gowns. The key out the primary outcome will be SSI rate at 30 days. Er But we're also gonna look at other clinical outcomes including er length of stay readmission, antibiotic use, er but also outcomes with regards to costs and carbon. So dragon is a cluster randomized trial and really um the that means that we're gonna randomize um the interven we're gonna randomize clusters rather than individual patients to the intervention or the comparator. So basically that means that each hospital is gonna be randomized as an individual cluster as such. Um the hospital, the the patient won't need uh to be consented for the intervention because the intervention will be deli delivered at hospital level. And this is really um also um helping making this trial kind of more streamline. Another way that we are aiming to achieve streamlining is with the data collection. So um there is mainly two set of case report forms. So the first one will be collecting intraoperative and baseline patient information. So information on the operation on the anesthesia provided and things like that and that will be done in in theater. And then we're going to have a 30 day follow up case report form. So in this case report form, at the follow up stage, we have condensed the clinical, the information that is going to be collected for clinical outcomes and for resource usage that we're going to use for the modeling of health economics and carbon. So there is not going to be any additional um any additional set of forms for the resource usage that again aims to streamline the whole um the whole trial pathway. Um because the follow up form really collects routine data that you would collect er normally for the patient, patient level consent will not be required for um data collection. So the trial has progressed. So we granted ethics approval from the UK um Research Ethics Committee. We have identified the first few sites that can start recruitment and we're we're ready to launch. Um We will, we are looking to start recruitment in Mexico, which is one of the seven low middle income countries that will collect that will recruit patients. And we're looking to start recruitment on the on Friday, the N of November. So this is all very exciting. So the trial is taking place, as I mentioned earlier in the UK and in seven low middle income countries which include Benin, Ghana, India, Mexico, Nigeria, Rwanda, and South Africa. And hopefully after my presentation, you'll be excited to join us or you think your center will be interested in taking part. If that's the case, then you can express your interest or um the site's interest by scanning the QR code that you can see that and um entering some information about yourself and the hospital that you work at. Uh and then our um trial team will go through that information and understand whether your site would be a suitable one to start drug and recruitment. So some of the questions that you might be asked are whether you think your site is covered by the NHS uh Research Ethics Committee approval. Er, and whether you've got a steady supply and availability of reusable and disposable drapes and gowns. Um As of course, er, you need to be able to um have both in case you randomized to one or the other. Another question that usually is asked by our trial support team is who do you think is going to perform the follow up? Of course, as I mentioned, it's very streamlined, but it is just making sure that all consecutive patients are recorded and information is entered on the database in a reasonable prompt time to allow accurate information recording. So most often this is a team of junior doctors, but it could also be a uh research nurse. So these are the questions that you're probably gonna be asked after completing the expression of interest form. So, thank you very much. And uh as a last uh kind of mention, we are um we have launched our second research for Greener Surgery Conference, which last year, which is going to be on the 17th of December 2024 at the Great Hall at the University of Birmingham. Last year, we had 290 among clinicians, sustainability officers, nurses, um managers attending. And it was a really good event and this year's agenda is I think very, very good. It's fantastic. So if you want more information, you can either register at the link or follow us on green surge on X and we'll hopefully see you there and I will be happy to take some questions now. Thank you very much. Do feel free to get in touch with green surgery if you're interested. So our third presentation is from Doctor and Doctor Sarah. They research fellows at the Queen Mary University of London Critical Care and peroperative medicine Research Group where they, they will discuss the Noble study which investigates uh environmental sustainability in the miniature of nitrous oxide, peacekeeper. Warm welcome to both of them. Hello, my name is doctor, I am an academic clinical fellow in intensive care medicine. You will also be hearing from my colleague, Doctor Anna Sak. We are two of the coinvestigator for the Noble trial which stands for nitrous oxide management to balance healthcare and environmental needs. Today, we will be covering sustainability and anesthesia as well as the Noble trial. Before we start, I'd like to briefly mention that we have no conflicts of interest. I'd also like to take a moment to thank Professor Pierce, the chief investigator for the trial, as well as the wider noble team and the Birmingham Clinical Trials Unit, all of whom have been invaluable in getting this trial off the ground. So what's the problem the challenge we are facing is that the NHS is aiming for a net zero healthcare service by 2045. In order to achieve this significant changes will need to be made. Any strategy to reduce carbon emissions in healthcare will need to send to operating theaters as one of the most resource intensive parts of the hospital operating theaters are a significant source of waste, producing approximately 2.3 tons of solid waste every year. They also use a vast amount of single use and disposable items which contribute to the problem. Further. Another source of significant carbon emissions and environmental impact is the use of inhalational anesthetic agents which are responsible for approximately 5% of acute hospitals carbon emissions. There have already been positive changes in this domain with many hospitals and anesthetists switching from using desflurane to zebra fluorine as the latter has a reduced environmental impact. However, one of the other anesthetic gasses with a significant environmental impact is nitrous oxide and this represents the focus of our clinical trial. Nitrous oxide is used less frequently in modern anesthetic practice, but it still has a role in pediatric and obstetric anesthesia. It carries a significant environmental impact. It remains in the atmosphere for over 100 years and causes nearly 300 times more global warming than an equivalent mass of carbon dioxide. Its breakdown products also contribute to the depletion of the ozone layer. It is therefore vital that we introduce strategies to mitigate the environmental harm caused by nitrous oxide without compromising patient outcomes. Nitrous oxide is typically delivered to operating theaters via a pipeline manifold system which involves a series of large cylinders which are connected by a network of pipes to the wall of each operating theater. The healthcare practitioner can then access nitrous oxide via a terminal unit. These pipeline systems are extremely prone to leaks with some observational studies identifying that between 83 to 100% of nitrous oxide within these pipeline systems is wasted. There's also significant waste when the cylinders which supply the pipeline manifold needs to be replaced as any residual nitrous oxide in each cylinder is vented to the atmosphere before the cylinders are refilled. Nitrous oxide can also be delivered via small portable cylinders. These cylinders are less prone to waste and would allow improved supply demand matching. They would also reduce cost related to the maintenance of the manifold. While some hospitals have already decommissioned their manifold systems and switched to alternative sources. We need to be sure that there is no impact on patient outcomes when we make this change as a result. The aim of our trial is to establish whether delivering nitrous oxide via portable cylinders impacts patient outcomes, post surgery as compared to nitrous oxide delivered via pipeline manifold system. And now I'd like to pass you over to Dr Anna Bosniak who will discuss the trial design, the trial outcomes and the future of sustainability in anesthesia. Thank you so much, Fiona. So over the next few minutes, I'm going to take you through the design of noble trial in a bit more detail and we're going to start with po framework. So our population will be adults and Children undergoing surgery under general anesthesia. And this interestingly will include those who do and do not have nitrous oxide as part of their anesthetic. The reason for that is to describe the frequency of use of nitrous oxide in general and to compare outcomes between patients with regards to delivery method and whether nitrous oxide was used as part of their anesthetic. We will exclude patients who opted out of anonymous data sharing or those undergoing repeat surgery within 30 days of their initial surgery. The intervention is supplying those oxide using portable cylinders and depending on the equipment available and local clinical use, these may be placed on portable trolleys in the cylinder cages attached to the anesthetic machines or attached directly to the anesthetic machines using a cylinder yolk. The control is nitrous oxide supplied via pipeline and this is the standard practice at the participating sites at the moment. The primary outcome will be days alive and at home within 30 days of the surgery. And this data will be collected from routine data, inpatient health records. This is a simplified diagram of the trial pathway. And as you can see participating hospitals will progress through two phases in a randomized order. One phase will involve nitrous oxide delivery via pipeline manifold. And that is the standard practice at the participating hospitals at the moment. The other phase, our intervention will involve nitrous oxide delivery via portable cylinders. Each phase will consist of a one week set up or washout period followed by four weeks of data collection. Our trial is a cluster randomized crossover trial and I would like to take a moment to explain the rationale for this design. The cluster design is for logistical reasons. As nitrous oxide pipeline infrastructure is part of the built environment with at the hospital level. Therefore, the trial intervention and modifications needed to carry it out must be at a hospital level rather than single operating theaters. A crossover design allows us to complete a trial with significantly fewer participating sites compared with a para group design. Since hospitals act as their own controls, talking a little bit more about the outcome measures. So primary outcome as I mentioned before. And some secondary outcomes will include the use of nitrous oxide anesthesia during surgery mortality within 30 days after the surgery, major complications during surgery, which we define as clain grade three or above duration of hospital stay. And we will also have some health economics data that will help us determine the NHS cost of nitrous oxide provision. So as you can see the outcomes focus on the patient safety. And this is because we do not want to compromise patient outcomes when making environmental changes, making our healthcare more sustainable, should be our priority. However, we need to make sure that the environmental changes are not made at the expense of patient safety. We know the first ones doing this type of research. There is an ongoing drug trial which focuses on disposable versus ra drugs and gowns during the surgery with an outcome being a surgical site infection within 30 days. This is done by our colleagues at their research unit on the global surgery at University of Birmingham. We also continue the battle to make our anesthetic gasses more sustainable. There are technologies for capture and resupply that are becoming available and they are actually currently being piloted within many, many NHS trusts. However, sustainability is everybody's business. I think we're quite privileged in anesthetics because it's a very hands-on specialty. Meaning that on a daily basis, we administer medication, handle disposables and equipment personally. However, this should allow us to reflect on the resource use and healthcare waste management, discussing challenges such as busy list and perhaps be the driving force for solutions to make it more sustainable. I hope that during this talk, Tiana and I demonstrated the environmental benefits of alternative nitrous oxide supply and encourage you to think a bit more about how you can make your practice more sustainable. And if you would like for your hospital to take part in the trial and thus take the first step towards the commissioning of nitrous oxide, please email us or scan the QR code below to get in touch with our trial management team. Thank you so much and we'll take some questions now. OK. Thank you very much for brilliant, really inspiring presentations. Um We'll conclude with a panel discussion featuring our speakers. So I want to thank Doctor Misled, Doctor Wozniak and doctors for beautiful, beautiful speeches. There's quite a few questions uh on the chest that we'll try and address personally. I found that this, she has shed definitely light on the innovative ways we can address sustainability challenges in surgery and anesthesia. It can be from material choices, professional collaboration and systemwide changes. Definitely and approaching this from a personal uh perspective in getting involved locally, starting with yourself and getting involved in this project in terms of getting more data and getting more information. Uh Before I ask my own questions. Uh So the questions that we do have uh from the floor. Uh uh The attendees are asking how realistic do you think is net zero in middle and low income countries? Um I can briefly answer on that on my personal uh views. So having uh done electives in different countries and having seen different experiences, I think that there are things that we can even learn from uh low end and middle income countries because they're very unique in their approach in terms of uh U using their resources very, very effectively and having less waste. That's my personality. But I'll let the speakers uh express uh their views and uh on that. So, Baby Demery, uh doctor Neur uh any insights on that. Uh Yeah. Yes, thank you. So, I think you're absolutely right. There's definitely um some loss that we can learn from different parts of the world that where, where um probably things are done differently to how they're done in the UK. Uh And there might well be lessons for how the NHS could improve. That said, I think the challenge is that uh if, if we um are serious about increasing access to healthcare for the many 100s of millions billions of people who don't have adequate healthcare present that will inevitably lead to increase in resource use and carbon emissions. So I think it's actually a very good time for low income countries to sort of plan how they're gonna grow the health sector in a sustainable way to mitigate that in the coming 1020 years um that's challenging um because no one's achieved it yet. Um So I think it, it will be really interesting to see what different countries do, what we can learn from each other. Thank you very much. Uh Any other comments from, from the panel? Uh Any other thoughts happy to welcome them. I am just agreeing with demetri, I think um having, you know, had the opportunity to um you know, um processes. Um It is definitely one of those, that sustainability is one of those topics that really lends itself to kind of um learning, um knows how learning kind of, you know, bringing in these practices. And I think um is just gives a lot of kind of reflection, like rooms for reflection about uh what how can the NHS or kind of health system in the global North move forward? Um In like, of course, as it was mentioned during the presentation, ensuring that patient safety is of course paramount. But um you know, we can't just ignore planetary health any longer. Brilliant. The next question probably more to the noble study uh researchers. So both me uh Wozniak and doctor. So, so what are the estimated cost difference uh for choice between the pipeline and the cylinder interventions, Tiana? Are you going for it? No, should I say uh II thought you would be better able to cover it because of the Anna has been more involved in um the intervention side of things, but in terms of the cost to the different trusts, um obviously, we're aware that changing the infrastructure of a hospital comes with significant cost and you know, that may represent a barrier for different hospitals participating um particularly in these challenging times within the NHS. Um What I would say is there are different kind of funding pots available for trusts who are going to be involved in the trial. So, um we're not expecting trust to fit the bill because obviously that would have a significant impact on which hospitals would be able to participate or willing to participate. And you know, would limit our ability to recruit for the trial, which would then compromise the data we're able to collect. Um So firstly, any modifications are made um so that they're minimally disruptive to the existing kind of set up within the hospital. Um But also there is funding available to help hospitals kind of mitigate the impact um of, of that transition. And ultimately, if we do decommission nitrous oxide from a hospital's, um you know, supply chain that is anticipated to have a massive cost benefit to the trust. So, you know, in the long term, I think we're looking at savings more than anything else um for different trusts. And from the trial point of view itself, we are providing 2000 lbs for each hospital. Um So that's in our budget. And as I said, the, the we're not expecting everyone to change their anesthetic machines to just plug the nitrous oxide cylinders in. Um We have uh sustainable ways and kind of cheaper ways. Um um to, to provide mobile um nitrous oxide cylinders. Um and on top of, you know, the the price of cylinders can, you can check it online but it's renting is around 100 lbs. Um And then you can use trolleys which can be few 100 lbs or you can mount bracket on your anesthetic machine, which might be a little bit more expensive, but it's uh hopefully we're not breaking a bank. Thank you very much. Uh And probably we've addressed, I believe all of the questions mentioned on the chat, a question for me where does one start as a trainee uh wherever you are in terms of getting involved in sustainable practices, how do you start the conversation? How, how do you get someone uh become part of change in the culture that we have at the moment? This is to all the panelists, uh pa panel members, I think, oh, sorry, here we go. I think um of course, there is things that you can do in your individual practice. So I would say engage in those behavior that you can, those behaviors that you can change uh daily in your practice just as an individual and then speak to your colleagues. Because chances are there's already somebody there that is having the same thoughts or the same concerns because you're seeing, you know, the effects of climate change every day now. So um it is impossible that people, for people not to think about it. So speak to your colleagues and team up and attending this conference is for example, a great step because I think it's all about, you know, engaging into research, finding out what the new ideas and innovations are and joining in. I think it is a big challenge. So it's, you know, um it is not a thing that is going to be solved easily with a simple solution, but as, as what um research prog projects are going on and yeah, change your individual behavior. That would be what I would suggest. Mhm. I agree. I think, you know, identifying what you could do better um will hopefully pull some of your colleagues who notice the change in your behavior and be like, oh, maybe I should, you know, reuse this thing or um within patient safety, of course. But II think, you know, if you start putting the trash in the right bin, I think some people will follow as well reading by example. Uh Absolutely. Any other last thoughts from uh uh Tiana or Doctor NG? And oh, we're out out of time. We're wrapping up. OK. Yeah. So we'll be, I personally believe we, we had quite a productive and meaningful discussion today. So we really want to thank all four speakers and my coa uh for, for you. Know, being part of this session and to all of you who are for attending. Thank you. Thank you for being part of this important conversation. Um Yeah, and we're just gonna take a five minute break before our next next session about entrepreneurship. Yeah. Thank. Thank you again for attending this session. Thank you. Thank you.