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Hello. Um Thank you for joining us this evening for the second um webinar in our sustainability webinar series. The topic today is Power Off. I'm Ginny Brick. I'm a vascular surgeon in Kent. Um And I'm co-chair of the Sustainability Committee at the Royal College of Surgeons of England. Um I'm also an elected council member for the Royal College of Surgeons of England. I'm joined today by Andy Stevenson, who is ATN O consultant surgeon and also the co-chair to the Sustainability Committee and Vicks, who is an academic ST one and general surgery um at Musgrave Park Hospital. So we'll be starting with an overview from Andy and then VN will carry on from there with a presentation before we get to the Q and A. So, and I think I hand over to you now. Great. Thanks very much Jody. Um Just to introduce myself again, I'm a, I'm ATN O consultant, but uh obviously a coa of the Sustainability group. Um and this power off uh webinar that we're delivering today, I'll give a quick overview um for the 1st 10 minutes or so going over. Why we're here, why we're talking about this? Um and then hand over to Vick who's gonna give us a AAA run through of, uh, how you can do your own power off, um, campaigns next time, please. So this is, this is why we're here, isn't it? Um, because that's, that's our home. Um, now, uh, the screens all changed, hasn't it? Can I have confirmation that we've still got the slides working, please. This is what could happen to the world if we don't act very impactful there, Jane or um Antonia, we've lost slides. There we go. We're back again. Ok. So, so this is our home and you, you would have seen lots of um banners and placards saying there is no planet B. Um Next slide, please. Um And our and our home's an amazing thing, but we are using an awful lot of power and we have been using er increasingly concentrated amounts of power um as can be seen from the view of the UK at night. Uh Next slide, please. Um And degeneration of this power for the last 175 years um from fossil fuels has had a profound effect on that thin white arc that you can see there. That is our atmosphere. Now, our atmosphere has been pretty stable um for tens of thousands of years and we are now rapidly changing its make up, please. Next slide. Um And as a result of this specifically putting greenhouse gasses principally carbon dioxide into our atmosphere, we are really warming up at an alarming rate. This graph is a data set, er, halfway, er, from, er, Copernicus, which is the European, er Climate Agency. And if you look along the y axis halfway along that's zero and that is global turp surface temperature, um, anomaly based on 1991. So we are about a degree warmer than that. We're probably over half a degree preindustrial and last year, as you can see that red line is several magnitudes greater than where we could, we, where we thought we would be increasing and we're getting, we're getting these ever bigger jumps. Next slide, please, that corresponds those, those temperatures have consequences. Um And we have got a significant er loss of ice density. Next slide, please. Um And back in 2022 in March, there was, and this is not a typo, a 30 to 40 degree above average temperature rise um that persisted for about a week. Um That's 30 to 40 degrees above temperature. So we've got about 12 degrees outside at the moment. That's if our temperature outside suddenly went to 52 degrees in the UK in spring. Um It's completely blown all climatologists brains because it's completely out of where they thought we might be. But it, it's where we are currently. Next slide, please. Um And this was this area Antarctica 40 degrees above normal. Um And it just shows that we are not in the realms of slow change. We are in the realms of rapid change. Next slide, please. Now, climate change is, is probably the most prescient. It's a II, think it a bit like ABC. So atmosphere, biosphere civilization, we can't have one without the other. So the atmosphere um, is principally affected by greenhouse gasses, CO2 being, er, the, the major contributor but also methane and nitrous oxide, but it doesn't happen on its own. We've also got, er, destruction of nature going on around us from all sorts of causes, whether it be through deforestation for, for industrialized agriculture or whether it be uh trawling the bottoms of the oceans or overfishing. You know, we, we are really plundering this planet's um natural resources and we're polluting it significantly air pollution, land pollution, sea pollution. Next slide, please. This is the, this is the slide that really got me thinking about this. There, there is no way of getting around it. You know, we are the cause of this. Um, the slide there on the X axis is from, this is ice core data that you can find on the NASA website essentially showing that we have accurate data for exactly how much CO2 was in the atmosphere all the way back to 800,000 years ago. And it never got over 315 I think, er, parts per million until we started burning fossil fuel. And we're now at about 420 I believe, 4, 19, 420 we need to change this rapidly. We need to see that graft coming down next slide, please. And this is it fossil fuels. We're burning too many of them. We're, we're, we're using them too much. Um, and regardless the, the, the, the, the stories you might hear there are alternatives. Next slide. We've known about this for a long time. Er, this is a great TED talk by Al Gore. Um, that I'd like to signpost you to, if you wanna figure out how the fossil fuel industry has managed to um, kind of subvert the conversation to something that doesn't implicate them as the main culprits for this next slide. Um, and BBC have done it as well. This is a great, er, three part series. You have to, I'd go, you know, I'd, I'd, I'd be psychologically prepared before you watch these because this is the classic, deny, uh cause doubt and then delay action. Next slide, please. Um And the Appalachian, er, that fossil fuel cause is now the single biggest killer from external causes, er, overtook smoking, er, three years ago. So it's not just climate change, it's pollution, it's air pollution, it's the plastic pollution. We see as well. Next slide, please. Um, and deforestation we must also remember is a really big problem. The Amazon quite astonishingly is now a net emitter. That's not a typo either of CO2 and the vast majority of deforestation in the world is being done. For er beef production and OCR agriculture to support um animal industrialized animal agriculture. Next slide please. It's all here. This is the sixth report of the IPCC 23,000 authors er involved in er in this. And it's, you know, it's, it's the biggest collaboration that science has yet seen to basically go into detail of what I've been talking about just now. Next slide, please. Um Now where do we fit in? We fit in? So obviously the climate change is going to feed into er, adverse health income outcomes. Er, but also we're a, we're a pretty big emitter and so we need to get our house in order if we're gonna, if we're gonna try and turn the ship around next slide, um, and operating theaters specifically are really energy intensive and that's what brings us on to today. Er, they use uh 3 to 6 times more electricity than er, most of the rest of the hospital. Next slide, please. The green surgery report, I'm just gonna sign post you two if you haven't heard of it or haven't seen it, I recommend you to, to have a look at this. This is um done by UK hat, but also in association with Brighton and Sussex Medical School, er, CS H er, and also the, the Medical Royal Colleges, er, er, the Royal College of Surgeons of England and Edinburgh coz this as well. Next slide please. And in that you'll find a, er, section on power off. And this is a graph directly taken from there showing you that the, er, the majority of the er, energy use in operating theaters is ventilation, anesthetic gas scavenging and also on the lighting. Next slide, please. Now this ii um I, where does our, where, where does our electricity come from? Ideally, we'd get it all from renewables. And actually last year, the U K's total, er, amount of renewable generation was 40% 40% which I think is absolutely amazing if we only invested in it more fully. Um We would be able to get this up to the eighties and 90%. And then we can really start making a big dent, but I just wanted to signpost you to the fact that if you type this in the national grid will show you daily what they're doing. And this was yesterday's next slide, please. So I'm posting you to this as well. The green checklist, you should all know about this. I hope this is why we're doing the power off because this is included in this next slide, please. And it's always worth uh going through the mantra of sustainability, which is reduce, reuse, recycle, rethink research. The next slide please and power off is in that higher. It is in the higher hierarchy, isn't it? If we use less energy, that's the, that's the most important thing that we can do next slide, please. And there it is at the bottom of the, of the checklist. It's power off next slide, please. So I'm gonna hand you over to big now. Um who is um a, an academic trainee, er, who works in the same hospital as me down in Somerset in Taunton. Um And he's got a, he's got an overview of power of projects, er, related to the operating theater vig over to you. Hey guys, um, nice to meet you all and thank you for taking the time to come and have a discussion with us about, about power off and, and the green this checklist. So um I'm vig um and I'll be talking to you guys today uh about specifically power off what that means and how you guys can start thinking about um doing a power off initiative uh within your local trust. So I've, I've uh lost fig there. Um Can you hear he's back? Hey, you're back on go again. Yeah, I'm not sure um where I got cut off but technical issues this evening. Sorry about that. Yeah, apologies for that. Hopefully you'll, you'll be able to, to hear us. Um So this, this just to start off. So I'm big. Um I'm a, I'm act one worker at Musgrove Parker together with Mr Stevenson and a few other trainees here. We've, we've tried to start implementing green theaters checklist initiatives um in our center. Um This is actually a picture of where I worked as an F one hospital, this is the off switch in theaters, er, horribly, confusing, but hopefully, um this won't be the case for most of you. Um Next slide, please. So um today we'll just be covering what power off is in the context of operating theaters. Uh Why you should be advocating for powering down theaters? So what are the actual benefits to power off um in the context of green theaters and sustainability? How you guys can practically start making this happen in your place of work? And then we'll round off by looking at how we can enable green theaters, checklist initiatives. Um and power of case studies that have already happened across centers in the NHS. Uh Next slide, please. So unfortunately, this will be me this weekend. Um So picture yourself as a, as a poor, poor surgical ho anesthetics ho theater team. It's, it's nine pm, 10 pm at night. Er you're freezing cold in the rest of the hospital, you're walking past theaters and, and you're drawn towards the, the warmth and the hum and the glow coming from there. But you have to ask yourself why that is everyone's gone home, it's completely empty. So why do we think it's OK to leave all of this equipment and machines running just in case we might need to do an operation overnight or on the weekend. Uh Next slide, please. So a bit of background to, to power off. So as, as um as Mr Stevenson mentioned, operating theaters are energy hotspots within the hospital. They're about 63 to 6 times more energy intense than other parts of the hospital. Uh And they're the main source of a carbon footprint. Um And the main source of the carbon footprint comes from energy consumption. Uh So a study looking at the an average tertiary UK operating theater complex, which is roughly 20 theaters, which is hopefully comparable to the number of theaters that most of you have in your local centers. It produces a staggering amount of uh of CO2. So 5200 tons of CO2 every year and it uses 10,600 megawatt hours of electricity every year. Now per theater. Just to, to put that into some context, this equates to 1,850,000 kilometers of driving. I'm not sure how far exactly that would get you, but multiple times around the earth would be my guess um 100 and 40 round trip flights from New York to Paris or it could power 37 homes for a year. So really per theater, this is a staggering amount of CO2 and electricity that we are using and wasting next slide, please. So I just wanted to highlight this the sort of issues there's a lot of different things out there about what the core issues behind power off are. Where is this waste coming from? Um And this, this graph here I think nicely summarizes it. So this is a study from a team at UCL who looked at multiple hospitals in London and looked at various settings within the hospital. So just going through the graph down here, we have the, I'm not sure if you can see my cursor, but um at the bottom, on the X axis, we have the different settings and the hospitals they were in. So on the left, we have main theaters, we have cardiology department on the right. We've also got day surgery labs and wards as well. On the Y axis, we have the annual electricity use in kilowatt hours. And we also have the, sorry, I'm telling my head to the side, we also have the percentage of proportion um that each of these things takes up when it comes to power off. So essentially the take home message from this is that there's multiple different sources of CO2 CO2 production and energy expenditure within the hospital. But the key take home, I think here is this white line that shows that operating theater use in particular main theater use is about 2 to 3 times higher than most other settings in our hospitals. If you're comparing an operating theater to, for example, even day surgery or a general ward, you're looking at 2 to 3 times more electricity use in theaters. Despite the fact that wards are running 24 hours, seven days a week and theaters mostly aren't running on weekends or at night. Now, if we look at the breakdown of where that, er, energy is being spent and where that electricity is being used, it's mostly, um, coming from heating ventilation, air conditioning and anesthetic gas scavenging system. So you may or may not have come across these before, but heating ventilation and air conditioning or HVAC is a sort of specialized air handling system. So you might have heard the term lamina flow before in theaters, it creates an environment of sort of filtered air. Oh, sorry, the slides have gone. But take my word that HVAC is, is that thing. Um It allows for control of temperature um and also humidity in theaters. Now, unfortunately, these are frequently left on in operating theaters in or in occupied mode. And I guarantee you if any of you were to go to your theaters. Now, it's likely that multiple of the main theaters would still have their heating ventilation, air conditioning on. Now, the anesthetic gas scavenging system is something that, um I was quite new to me. I didn't actually know fully what it meant until digging into this topic a bit more and speaking to our anesthetic and scrub team, but it's essentially a system that sometimes is integrated into the anesthetic machine, but often will be a separate set of cylinders or a pipe that's coming out of the machine connected to the wall that allows waste gasses in theater to be removed, there's a fan system that pumps out these gasses into the outside atmosphere outside of theater and keeps theater environment safe when we're using volatile gasses. Now again, this takes about 500 to 800 watts of power per hour and that's five times that of a 65 inch L ETV per hour. And we all switch our tvs off overnight. So why don't we turn off the anesthetic gas scavenging system when it's not being used either. I'm not sure I did a little spot audit of the different theaters earlier today. Um And all of our AGS S systems were on, even if we were using total intravenous anesthesia when you don't actually need, um, the AGS S system. Now, the last bit of uh the last bit of this, the other issue where there is CO2 production and energy consumption is in electronic equipment and lighting and it's probably the most obvious one out of the lot. Um And we can see, we know that about 75% of, uh, we, we could save up to 75% of electricity expenditure on electronic equipment if we actually turn them off and shut them down at the end of the day. Now, in our theater complex, which is about 15 to 20 theaters, we have nearly 100 computers that are often left on overnight, um, or left on standby have not actually turned off. Um So next slide, please. So, um, these are figures taken from the Royal College of Anesthetics manual that actually there's a mandatory manual that um the Royal College of Anesthetics have now put in as a module for anesthetic trainees to look at on sustainability and energy expenditure. Um And this is a typical orthopedic theater. So this is the Lamina Flow HVAC system which is on after hours. And the photo on the right here is the operational controls for the HVAC in the middle of the night. We can see that as it probably is the case in most of our theaters, it's set to operating mode instead of this setback mode, which is a standby mode that we can use, that will allow heating ventilation and air conditioning to be set up again within the space of about 20 minutes to half an hour in many hospitals. Unfortunately, these are left on many older units and older hospitals may not have a setback mode which are potential barriers, but this is just something that I thought I'd highlight next slide, please. So, um Mr Stevenson mentioned, um we've said all about all of those problems. What's the solution? So this is the Intercollegiate Green, the checklist. Um We'll talk more about that towards the end and I'll put a QR code so that anyone who hasn't come across it before can have a look at it. Um It was produced by the Surgical Royal Colleges as evidence based guidance to make surgery greener and help in the effort to reduce emissions. And it's a really nice starting place. If, if, if, if like me, you're quite new to all of this, new to training or you're just interested in it to look at what potential initiatives we could be targeting as teams. Um and as a hospital as a whole to help with sustainability, uh It takes into account everything from induction to through to how waste and used equipment is managed. Um And including I think the last webinar I spoke about R don't scrub. Um Again, we'll be talking about that a little bit at the end of this. Er but these are all the initiatives that are highlighted on the checklist um that you can have a look at next slide, please. Um So I sort of mentioned just to reiterate this, the main source of CO2 production and energy consumption comes from heating, ventilation, air conditioning. So over 80% of surgical theater energy use is because of that and we could potentially cut that by 50%. It's here in the green theaters checklist and we can see at the bottom that power off is one of the initiatives that is evidence based. One of the pieces of evidence in the Green surgery report is a economic and sustainability analysis carried out by NHS Scotland across the sort of 300 operating theater suites that are in Scotland and they estimated a saving of about 20,000 lbs per hospital if theater systems were turned off between 8 p.m. and 6 a.m. and even more if you calculate including weekends. So yet another incentive to be engaging with all the local stakeholders to be to carry on with power off. There's also lots of hidden benefits that are in the literature including reducing noise pollution. So your average HVAC unit produces 50 to 55 decibels of of noise at full power, which is the same as being stood right next to a washing machine with your air next to it. Um And a lot of the existing initiatives report that at actual hidden benefit was that patients were getting better night's sleep. Um Patients were much more comfortable and rested and this was something that actually newer studies have started measuring as a marker on their own um for improvement after power of initiatives. Next slide, please. So, uh I've said a lot about there being an evidence base, there's a lot of support for power off initiatives. So there's various e-learning um and guidelines from the Royal College of Anesthetists. Uh NHS Scotland, as I mentioned, the Royal Colleges with their green theaters checklist and NHS England have also produced a lovely 400 page um manual on how we can ventilate our healthcare premises better, which you're welcome to read if you would like to um next slide, please. So now we come on to sort of practically talking about how you can power off, we've hopefully outlined the problem. We've said what the potential benefits and solutions are. Now, how can you actually implement this on, on, on a local level, on an individual level? Um So the various, the various things that we've sort of been through and what we've seen from case studies is that one of the ideas is to produce a shutdown checklist. And we'll talk a bit more about this later on, we go through the case studies, there's already some existing work and checklist there. But essentially this involves engaging with the local scrub team, anesthetists there to support workers, surgeons. And at the end of the list, going through a shutdown checklist of the heating, ventilation, air conditioning, electronic equipment, et cetera and making sure all these things are turned off to actually act. I spoke to one of the P sport workers again today and to actually activate the check of machines, especially things like the AGS in the morning. They need to be turned off and on again and we are doing that in the morning. So actually, we're not really changing anything by asking people to switch off the ags at night. We're just changing when we switch it off rather than keeping it on all night, turning off in the morning and turning it on again to check that it's all working. We just switch it off at night instead. So that's one potential idea. Um Turning off individual appliances always helps as well. It's always good to start on an individual basis and inspire sort of the rest of the team and confidence that um this can happen. Um Setback mode I mentioned as well. Um A lot of older theaters potentially don't have this with their ventilation and air con systems, which is a potential barrier, but you should speak to your um local maintenance team and your local anesthetic, er support workers O DPS and see if this is possible. Um Other initiatives that can potentially say power are rub, don't scrub. So we know that a lot of heat, energy and water is wasted every time that we use water based scrub. So about 30 L of water is used every time that we scrub for 3 to 5 minutes and only about 5 L of that is actually used in the hand washing phase. So using alcohol based handrub, turning off the taps while we're scrubbing can save a lot of water and also um electricity in terms of heating water um and sustainability champions. So this is something that the Royal College are working to to initiate and integrate into local sites. So becoming a sustainability champion, coming to events like this, getting that discussion going is really important. Uh Next slide, please. Um the other aspects less on a maybe individual level but other things to consider are occupancy sensors. So some newer hospitals and newer surgical suites have occupancy sensors that will automatically switch off the lighting in theaters, hand wash sensors or pedal pumps. Again, to help with saving water and heat energy and retrofitting of setback into HVAC systems is something that's also possible and has been done in various hospitals, including places like Lister um in Stevenage um as possible as well um hospital level. So again, Lister have managed to get funding for switching all of their lights in the hospital and especially the operating theater suite to led lights instead of halogen lights, um energy efficient appliances and using renewable energy as Mr Stevenson mentioned. So as a, as a as a nation, as a, as a trust, er moving towards using renewable energy rather than um fossil fuels, next slide, please. Sorry. Um So who should you involve? So this isn't necessarily something that you can do on your own. Um It's, it's, it's, it's amazing to see so many people here, but definitely at Moscow Parker, we're a whole team of people working on this. Um It's been really nice meeting uh some of the other trainees um seeing. Um Yeah, getting to know a lot of the theater support workers, anesthetists, theater staff and managers throughout the initiatives we've been doing here. Um And I think it fosters a successful environment and successful initiatives if you can get all of these people vested and involved. Um So this is the sort of team to potentially start thinking about getting involved. And I think especially with power off, it's important to get estates and facilities involved from the case studies we'll talk about later on a big barrier is not knowing the energy expenditure, not knowing how to maintain HVAC systems, the AGS S what the actual logins are. Sorry, I'm back. Um So yeah, I was just saying about estate and facilities particularly being important and having theater staff and managers on board in this case, being particularly important. Infection prevention and control is is is one that's been highlighted in existing studies as well. Uh ongoing testing to validate. So I mentioned lamina flow units and HVAC um being part of being contributing to maintaining a sterile environment in theater. There's some concerns that potentially switching off these systems in between cases or overnight might create an environment that isn't as sterile as it could be, especially for procedures involving implants, especially orthopedic theaters with lamina flow. Uh but actually evidence shows that um as long as the HVAC system and lamina flow is up 30 minutes before theater starts and the patients on the table, um there isn't any actual increase in um the amount of um bugs grown on various testing, er but having infection prevention and control um involved in that can be useful. Next slide, please. So what are potential barriers to power off to think about before you potentially go off and think about doing these initiatives, er so inability to override existing control. So, in particular, with the anesthetic gas system, uh, with the HVAC system, you might not just be able to go up to something and press the off button. Er, but I encourage you guys to speak to your theater. Support workers, speak to the O DPS. Anesthetists, theater managers, scrub nurses and find out how those systems, um, are in place. Um, and how, how we can implement shut down checklist into them just in case measures. So that's often something that said is that, oh, what if we have to operate overnight? What if we have to rush someone to theater? And like I said, the evidence shows that as long as systems are up and running 30 minutes before patients arrive, which often is, is, is more than enough time to breathe for a case, even in an emergency setting to breathe for a case and get a patient into theater anesthetized from the anesthetic room. Um, we definitely have the time to be able to shut down our power off and then restart the equipment that's needed. Um I mentioned about sterility of theaters. So this is an excerpt from a paper that looked at, um, the level of contamination when HVAC systems are turned off versus when they're turned on and it shows there's actually no significant difference. Um, and as long as we, like I said, establish them 30 minutes before any surgical activity, er, it's all, it keeps the whole theater system sterile and hygienic. It takes too long to start. So, uh next slide, please, I think, sorry, there's a few animations on here. Uh Yeah, it takes too long to start. So we know that we can shut down all these systems and turn them off, turn them on again within 20 to 30 minutes and that's what happens every morning. Um So it's just about really hammering that home, um with your teams and saying that it is possible to do this emergency theaters and maternity theaters along a similar vein to these just in case measures, they could be difficult areas potentially to implement power off because of the nature of the type of surgery that's happening. Um Potential costs, so, and retrofitting of setback modes. So this is something to discuss on a sort of managerial level probably. Uh but there is funding available through NHS England streams for initiatives like this. Um And, and potentially people saying that actually we're building new theaters, we can't make change to old sites, limited knowledge of building maintenance and equipment. Um So if we go to the next slide, we can see that um Actually Lister and Steven Edges is a case study for um how we can actually improve existing operating theater complexes, switching to led lighting, implementing retrofitting a setback. All of these things have happened at Lister and have shown a significant saving in energy use and money. Um If we can go to the next slide, please. Yeah, thank you. Um So th this is part of the NHS net zero plan on how we can actually get to the point where we are reducing our carbon dioxide emissions. So this this bell on the left shows present day emissions and where we're at currently. And these are all the various avenues towards actually reducing and getting it by, by the year 2040 getting to the point where we actually reduce emissions significantly. And the reason that I wanted to include this graph is essentially showing that there's multiple different avenues so that yes, there is hospital level improvements. There is the issue of upgrading buildings but also actually generation of renewable energy and heat using, using sustainable ways of powering off on a local level can actually all contribute a significant amount to reducing the emissions that we have currently today. Next slide, please. So, oh, sorry, I think it's one more. So um these are some sort of practicalities and tips for powering off locally. Some of these are taken from case studies which we'll discuss in a bit and some of these are taken from our own experience. So myself, some other ct ones. Um Mr Stevenson, anesthetic colleagues, orthopedic colleagues have have, have made a sort of team here that would work together on specifically Rhone scrub initiatives um and moving on to other green surgery initiatives at Musgrove Park and these are some of the sort of tips and practicalities, I guess that that we we've all come across, I've asked the rest of the team to contribute to this, um, and so using, having a starting point to try so, potentially trying not to start everything from scratch. So having a look at the green surgery checklist, um, having a search online, especially um, at websites like Ecom Medics, er, the SAS qi website, which we'll talk about later as well. All have existing checklists or project templates which you can pick up and uh implement directly into your workplace. Um and working with engaged and interested parties. I think this is, this is probably the key thing. Um We we've met, met so many different people that we normally encounter day to day and work, but potentially don't engage with as much as we should be doing from theater support workers to scrub nurses to the lead nurses and managers for the operating theater units. It's important to get people engaged and have all of these parties invested um within that system. Uh It's also important to work within the system, so try and create things within the pathway, not more work. Um So like I said, trying to say that we can switch off things um in the evening and it still be the same amount of work as switching them on, switching them off and on in the morning um is potentially one way to create within the pathway and not more work. Um positive feedback, feeding that back to staff is really important. So locally, we've made sure to send um with our Rob don't scrub initiatives, feeding that back in audit meetings with posters. We've made a video with the Royal College of Surgeons that all shows the sort of change that we're making and the improvement that we're we're doing locally and it's getting people talking and engaged in those sort of initiatives. Next slide, please. So we'll just briefly talk about some case studies. So next slide please. Um So this is um a case study on an initiative called Operation TLC. This, this took place at the Barts NHS Trust back in 2013. Um And it essentially involved simple messaging from from higher up in the trust to all theater staff that essentially involves saying turn off lights and close doors, turn off electrical equipment. And that was implemented with various methods of sending that message across and empowering staff to make those changes. And over the course of four years, they managed to save half a million pounds in energy and reduce their carbon emissions by 2200 tons a year. And essentially, this was one of the first sort of case studies looking into power off and it shows that collective efforts and small behavior changes at an individual level can be really significant. Still, uh there were some challenges to note from this. So especially staff buy in availability and knowledge of the building facilities was quite difficult and this is what I mentioned before. The key learning from learning points from something like operation TLC are to make sure to feedback positive changes to consult staff regularly um to the people that are actually involved in power off. Um and also work closely with your estates team next slide, please. Uh So this is, this is a um green team competition that is on the SO SQ I website. So the Center for Sustainable Health Care, which is a great website to have a look at. Um if you want to have a read about some green theaters initiatives, uh and potential ideas for how to implement things locally. Um So this is a team at Swansea. Um It's two anesthetists and a ODP who got together, they have 22 operating theaters in their unit in Swansea, normal running time, 7 a.m. to 6 p.m. And essentially what they did was come up with this elective theater shutdown check. They did a baseline audit to see how much energy expenditure, how much excess energy expenditure there was by not shutting down equipment and then came up with this elective theater shutdown checklist, put posters up, engaged with theater managers and head scrub nurses for the day to make sure that this theater checklist was implemented and then did a re audit to see er, how much CO2 expenditure they'd saved, er, and potentially what the financial savings were. Er, there's a bit of a typo on this poster. It was actually 44,774 kg of CO2 per year and 26,000 lbs per year er were saved. Um at this, at this er er during this period of this audit, which was only the course um of a month, but this these data have been extrapolated to a year. Um Next slide please. So this is just an example of existing checklist that you can already use. Similar to the team at Swansea. This is also S this is the UCL team who I spoke about earlier with that graph. Er they've come up with this again, quite simple checklist that you can just print off and use locally. So you don't need to start from, from scratch. All these things exist online, they simple places to start. Um So in combination with engaging with your theater teams, you can print off these checklists and start using them next slide, please. This is a great um Q IP bank for those of you who are wanting to sort of do this as a way of measuring change locally, potentially writing this up or anything like that. Um This is an ECO Q IP bank run by Ecom Meics, which is a, a group of um trainees essentially who have gotten together. They've got various packages um across different aspects of the hospital. Their first project was a coffee cup project. So actually doing an audit on how many um, plastic coffee cups and non reusable coffee cups were used in theater environment and then, um, putting up posters and buying reusable coffee cups for theater stuff so that, um, we could reduce that amount of waste. But they also have a completely ready to go theater shut down checklist. Um, a way of collecting data including spreadsheets that already delineate how much energy usage, each individual, like a computer, the AGS S system, the HVAC system or use. And you can just plug numbers in for the number of each of those units in your own hospital and figure out quick, easy ways of how many savings you might be able to make. Um So I'd recommend looking at this website as well. Next slide, please, another um resource to use. So this is on the Center for sustainable health care website. Um So this is the AGS S project. So this is again a pre existing tool that you can just plug in figures for your local center to see how much energy is currently being used by your adss systems. Staying on overnight in between cases and on the weekends and how much potentially could be saved to help build the case locally and engage with your local stakeholders. Next slide, please. So that sort of brings us towards the end of the, the, the stuff that I have to say. So um the only this slide essentially is potentially looking at the future. Um So here in Taunton, we're building a whole new surgical wing, this a whole new surgical block with new theaters, new anesthetic rooms, um et cetera. And this I thought was quite an interesting paper published in. I can't actually remember what. Yeah, Future health journal, sorry, the Royal College Journal and it involves a Dutch hospital and implementation of a real time location system. Um So essentially the the theaters are patients are given bluetooth sensors. Um in order to find out where in the hospital they are, the theater automatically links to these Bluetooth sensors figures out where the patient is um and adjusts the heating, ventilation and air conditioning and AGS S systems automatically. Um Now this takes therefore the the whole strain of having shut down checklists and making sure each individual healthcare member of that of the theater team is invested and actually carrying out the shutdown checklist every day. This takes all of that and, and um automates it and this potentially could be the future. If we're looking at um building new operating theaters over the course of the four years that this has been implemented in the hospitals in Holland. They saved 1227 mega tons of CO2 and 5.78 gigawatts of electricity. So significant amount of CO2 saving and energy saved there as well. Next slide, please. So I'll just leave you guys with these QR codes er which hopefully worker but the, the one on the left is to the, er Royal College Green Theaters checklist and to sign up for any upcoming webinars. Um, the one on the right is our very chesi created but hopefully informative video on Rob. Don't scrub, er, involving some of our local theater team. Er, hopefully, um if, if you've not heard of Rob don't scrub it will give you a bit of information on that. So we'd love you to watch it. Um And yeah, thanks a lot for your time and listening. I hope it was slightly useful. And if you have any questions, please go ahead and ask. Thank you vig for coping with technical issues and keeping going. I think you get a major award for that. Um And Andy's back. So we're all here, Hurra. We've been in and out because of being cut out, in and out, but we're here for the questions. Um Please put some questions in the chat if you can. Um But I've got a few questions to start off with. Um If once in a while we're waiting for some contributions. So one of the first things to ask is whose responsibility do you think this is? Because what we don't want to do is send everyone off, turning everything off and upsetting anesthetist. There seems to be, there'll be a bit of coworking here, but whose responsibility, how can, how, what, what do you think should be? Um You would advise people to be doing rather than just flicking all the switches. Wait, should I, should I take that one? Yeah, of course. Um, so this is, I mean, it's a terrible thing to say. It's everyone's, but it, it kind of is, um, with regards to, er, power off, specifically everyone's at very different places, er, with regards to it. So, for example, one of our theaters, you know, the more orthopedic theaters already has a power off, um, and we've been doing it for some time but then in another theaters it, it isn't, isn't the case at all. It's, um, this is a classic example of finding allies, um, who, um, you can help to deliver this change and the key allies in this are your, your senior scrub nurses, um, your, your theater, your theater leads, um, and O dps. Um, because they are more often than not permanent members of staff, um, that know, um, how things work, uh, from a very practical point of view. Um, and for example, 11 of the instances we were completely unable to switch off the ventilation in one of our theaters because there isn't an off switch. Um, you know, it just, it just runs permanently. So when it comes, when it comes, if you want to, uh, start if you're listening to this and you think I wanna do a power off in our, in our, um, in our hospital, um, go to the center of sustainable health care, uh, have a look at the green theater checklist and then take that to the, the, the lead nurse, um, of the theaters and say I would like to do this. How do I do this? Um, and then just, and, and then just start the conversation because, um, unless you are a permanent member of staff there. Um, and actually, to be honest, it's not even if you are a permanent member of staff, the time spent in theaters is limited. So having allies, having people to, to, to help with pushing this change is, is absolutely one of the key steps. It almost feels like we need sustainability champions in every trust. Um You know, that that can take this forward and be able to lead and talk to those people that, that we need to need to talk to. Um so leading on from that, there's always that question and, and big you touched on it about safety, you know, this is going to cause more infection. Um We're not going to be able to power up. Um If you had a naysayer coming back at you saying this isn't safe, you know, um What, what do you think people, what data is there that you can signpost people to, to, to, to give that answer that it is safe. Yeah. So it's a great question. It's something that's definitely been sort of pre empted and addressed in the sort of existing guidelines and documents that are there. So in both the NHS Scotland report and also in the, in the Royal College of Anesthetics e learning guidelines on this, they both quote papers that have looked at the the amount of bacterial growth taken at various samples for when the HVAC systems are off, when lamina flow is off and when they're turned on again, and it, and it specifically has said that it's safe to be shutting down theaters, shutting down the HVAC systems. And then as long as we're turning them on again, the evidence shows that there should be no um that there should be no increase or worsening of sterility or increase in surgical site infections, et cetera. The other thing to say is that that's, that's one aspect of powering off. So things like turning off the lighting, turning off computers and other electronic equipment that isn't necessarily directly going to be unsafe to patient care or pose any sort of direct risk. So even starting at something like that is a, is a potential aspect, potential area that um if, if there, there are significant concerns about uptake because of sterility and things like that. Um starting somewhere like turning electrical equipment off still is some way is a way towards how off. Um I mean, yeah, the the orthopedic surgeon is always very concerned about infection, devastating effects of that. So it's really good that and is sort of leading for that as a, as an arthroplasty surgeon himself, you know, leading by example to show that it, that it's right. Um, but what about the effects of turning off the gas anesthetic gas scavenger, um, system that can, that, does, that have to be on all the time or is it safe to have that turned off at time? It's definitely it's safe to have it turned off. Um, I, I've spoken to so there might be some anesthetic colleagues here who, who, who know a lot more about this than I do. But um most of the time when using TIVA, which a lot of our cases are today, we don't use sort of um volatile gasses as often as we may be used to. So when using TIVA, we can definitely be turning the AGS S system off, which we often don't. Um All our cases on our list today were with TIVA. The AGS S system was on the whole day. Um And so that, that, that is definitely a possibility if we're using um volatile gasses, then yes, the system does need to be turned on. But again, after the patient's left theater, once the anesthetic machine has been scrubbed and then it, it's fine to turn it off. Thank you. You mentioned NHS Scotland there. And that was one of the things that when you were talking about the saving of 20,000 lbs per hospital was that per annum because when Barts did that, that was half a million pounds Barts is a massive trust because if people don't buy into the, this is good for the planet, they do buy into the economic part because we know that the NHS is pretty financially deplete. Let's call it that. So you've quoted two different figures at the moment. If someone wants to go to a trust and says this will save you money. What sort of figures can they be quoting and per year type of thing? So I think the the best evidence and the best sort of financial analysis that I've seen is on the NHS Scotland report and that was 20,000 per hospital per annum. It was probably an underestimate because they only looked at what the potential savings would be if the were turned off overnight, not including the weekends um at all into that analysis, the saving of 500,000 lbs from, from operation TLC was over four years. Um But, and I might be, I need to, I probably need to check this, but I believe it was over five different hospital site. So, um it was as a trust as a whole was 500,000 over four years over five sites. So it still equates roughly to 25 to 30,000 lbs if you're looking per hospital per year. Um And that fits with the, the team at Swansea who did another who did a financial analysis as well. Um And the AGS S tool that I mentioned on the center for sustainable healthcare can help you calculate potentially how much saving there might be for ags the ECOS tool can help you calculate for electronic equipment. Um how much potential saving there might be. But the best people to probably talk to and engage with are your estates and maintenance staff who will know the exact, hopefully the exact values of um sort of how many kilowatt hours are used and what that equates to in terms of cost. Yeah, we've lost Andy, but it sounds like that at the moment. Hopefully he'll come back, but it sounds like it's really getting a team together, building a number of people to enable this, you can't really do it alone and that's sort of coming out very loud and clear about co work. The different specialties theater as we know is one of the biggest issues. So working with the anesthetists and other specialties who are in the right up and going in and, and that is obvious that that, that's where your, your sort of key coworkers are going to be as well as the, as you say. Um, and I was going to ask and so I'm going to ask, you said this where street thing is talking about all sorts of things to get into private health care. Well, we work seven day but Alex Theaters more, this is going to increase all of that issue. So what are your thoughts on what they've been saying about we've got a backlog, we need to increase the amount we're working. We're going to open up more theaters that we can. Is this going to be more of a challenge? Does it make it more important that we should be doing this? I mean, what do you think? I think. Yeah, I, it's a, it's a really interesting question to ask and think about, um, there's, there's a lot of, there are a few papers out there and studies done about the potential environment, environmental impact of having waiting lists and having ongoing surgical pathologies that aren't treated. Um, bar bariatric surgery comes to mind of, of analysis that's been done as to, as to the, the CO2, er, expenditure versus, um, the savings when it comes to delayed bariatric lists, er, things like that. Um, I think, I think it is. Yeah, I agree. Waiting lists have to come down. We, we probably do, I mean, as, as a, as a, as a cohort, we'll be operating more on weekends, waiting list, initiative theaters and things like that. But if we can from now work to implement more sustainable practices, uh, making sure that if we are operating on the weekend we're still shutting down theaters in the evening. Um, doing that in the most sustainable way possible is, is, is, is quite important, I think. And it's probably something that we should be talking about if we are going to be increasing our operating. Um, II think we're going to be wrapping up soon, but I've just got one more thing I wanted to cover with you before we go. I mean, obviously you're in a trust where a lot is being done and for you to go and do a qi project or an audit is probably a little bit more straightforward than in a trust where there are more naysayers than agreeing with it. Um You mentioned that there were somewhere and I think a good place to start for trainees is with the Q I project to get this going and trust, get people talking from the perspective of the curriculum. I'm head of school down in KSS and I think people are concerned that it's not on the curriculum, it's not actually featured as written in the curriculum, but you could use sustainability using it in domain one professional behaviors, domain two about knowledge and there's four about health promotion so it can come into areas within it. So you can do AQ I project, you can extend your knowledge and you can still be achieving your generic professional capabilities and meeting the curriculum. Um from the perspective of the Q I projects. What's a good one to start with? And from your perspective, an easy, good one to start in a trust where nothing much has been done and then where else can just to recap where doctors in training, doctors, postgraduate doctors can go and have a look to see a list. Absolutely. Um, so yeah, our, our, our, our like the group, the group that we're working with here. So some of the other ct ones, um, consultants, orthopedic trainees, um, we, we all started this here just as people interested in making surgery more sustainable and actually ended up doing qi project as a result. Um I think for us the, the best place to start and the most logical place to start with the easiest sort of change from our point of view was Rob Don't scrub. There's already excellent evidence base out there for, for that, including in, in surgeries that needing implants. Um, and orthopedic theaters, we've got a lot of buy in from theater staff, orthopedic staff, various different specialties with that. And I think Rob Dodes Gove is a great place to start. Um, a good place if that's not an option. Gloves off is another thing that, um, recently has, has, has taken sort of, um, a bit more of AAA front role of potentially something that we're looking at doing here next. And that involves things like not using plastic gloves when we don't need to be using them, for example, transferring patients, um, when we're putting, uh, either moving them from their bed to the table or, or vice versa. Um, so that's another big one. A nice easy one that can be done locally. Um, the best place to look at where to start is the green, the checklist um that breaks it down almost step by step into where you can potentially target one of them is part of that in terms of waste. And I think that's a really good place to, to look at there's lots of things on there. So kit rationalization um is another big thing that some of us are looking at. It's a lot more difficult to do because you need to uh audit across various different surgeries, specialties, surgeons, what different types of kit are being used and we initially started trying to do something like that but found that quite difficult. Um So I think rub don't scrub gloves off is a great place to start power off. Um is definitely something that can be done as well. We're looking at like Mr Stevenson said, the orthopedic theaters have already started doing it. Some of our O dps and scrub nurses already in their shutdown checklist, do it themselves, but it's not implemented across theaters as a whole. So it's again another decent project to look at. I think that's great. Thank you. Let's get people started with those projects and they can build on that and we can get interest then building interests.