Clinical sustainability

In May 2021, our anaesthetists at the Royal and Broadgreen made a swap from disposable plastic caps to reusable fabric caps. This was extended to the wider theatre staff soon after. The  swap has removed 217,000 single-use caps from the Royal and Broadgreen per year and in turn will avoid over 1 tonne of clinical waste. It will also provide a cost saving of £86,000 over a 4 year period. Following their success, the caps have now also been rolled out to staff at Aintree Hospital.

The fabric caps, which include an individuals first name and role, have improved patient care. Patients can now easily identify who they are speaking to and using first names provides a more personable experience, which reduce anxiety that some of the patients may have and therefore improve their experience.

This change has also improved communication between members of the team within theatres. This is particularly important given that 70% of adverse events in theatre environments are due to some form of miscommunication. One of the Trust’s Consultant Anaesthetists, Dr Mruga Diwan, is taking part in a study with the University of Birmingham to assess whether the fabric caps can be washed at temperatures lower than 60°C  without compromising IPC standards. If this is successful, this would further reduce the environmental impact of the fabric caps. 

The project went on to win the '2022 Sustainability Award' at the North West Coast Research and Innovation Awards and the 'Reuse Award' at the national Sustainability Partnership Awards.

This study comes under number 12 of the Sustainable Development Goals set out by the United Nations.

Replacing the use of Entonox and Penthrox during frame removal and other minor procedures at Broadgreen Hospital with a nerve block, led by Dr Shiv Kumar Singh. This improved patient experience and streamlined care pathways, whilst reducing the burden on theatre capacity and reducing the use of environmentally harmful anaesthetic gases.

This project was initially identified to address theatre backlog as a result of COVID 19 and to reduce the environmental impact of anaesthetics at the Trust.

Previously frames were removed in theatre, using either Entonox or Penthrox for pain relief. Both of these have an environmental impact, with atmospheric lifetimes of 114 days and 54 days respectively. Procedures on average took around 1 hour, with approximately 2 hours of theatre time in total per case. Based on an indicative theatre running cost of £20/minute, each procedure in theatre cost approximately £2,400.

This project has been undertaken by Consultant Anaesthetist Dr Shiv Kumar Singh at Broadgreen Hospital, beginning in June 2022. Dr Singh had successfully applied for innovation funding for the project but the funding was not ultimately received by the Trust, so he decided to proceed with the project during his own non-clinical time.

Dr Singh set up designated space with the outpatient clinic to undertake the frame removal under a nerve block, lidocaine 1%, rather than using anaesthesia. This new method has been undertaken high risk cases, as well as standard procedures.

Based on the results from the first 60 cases, 88% of patients would opt for this method again. Feedback from patients includes the following comments: ‘100% satisfied and recommend it’, ‘didn’t feel a thing’, ‘brilliant’, ‘excellent’ and ‘fantastic’.

Advantages of this new technique are as follows:

• Improved patient experience and care pathway – generally 2-3 less visits to hospital required, quicker recovery than from anaesthesia and more reliable analgesic effects
• Reducing burden on theatre capacity, which is particularly useful given the backlog as a result of the pandemic
• Reduced costs from avoided theatre time
• Improved sustainability – reduced use of entanox and penthrox, reduced energy use from avoided theatre time and reduced patients miles due to less appointments required.

Entonox consumption is measured by the Trust Sustainability Team as part of the LUHFT’s ‘NHS Carbon Footprint’ and therefore the carbon benefits of this project will be captured.

This project links to a wider programme of works at the Trust where a group of consultants are reviewing the use of nerve blocks for surgeries, rather than under general anaesthetics.

A paper on the project has been accepted for national journal publication and for a podium presentation at the British Limb Reconstruction Society meeting, as Broadgreen Hospital is the only hospital in the country using this method. 

The project also won the 2023 Sustainability Award at the North West Coast Research and Innovation Awards.

Reduction of environmentally damaging anaesthetic gas desflurane at Aintree Hospital, Liverpool University Hospitals NHS Foundation Trust (LUHFT). LUHFT previously had one of the highest rates of desflurane use in the country and Consultant Anaesthetist Dr Leanne Callaghan led a multistrand project to reduce emissions from desflurane by over 99%.

Desflurane, a volatile anaesthetic gas which has been widely used in surgery, has a significant environmental impact, with a global warming potential 2,500 times greater than that of carbon dioxide. One hour’s use of this gas has an equivalent impact as driving 200-400km.

Liverpool University Hospitals NHS Foundation Trust (LUHFT) was historically the 3^rd the largest user of desflurane in the country and largest in the North-West, with Aintree Hospital’s use peaking at 369,840ml of desflurane in 2016/17. This equated to 969.9 tonnes CO2e.

In line with the national focus to reduce the use of desflurane within the NHS, a project has been underway to significantly change the use of desflurane within Aintree Hospital. This work has been led by Consultant Anaesthetist Dr Leanne Callaghan. Dr Callaghan has been pivotal in championing greener practices with Aintree Hospital theatres. 

The project considered many different elements, consisting of both physical changes within the theatre department and also behaviour changes, whilst still maintaining a high level of patient care. Of the options considered, the follow elements were ultimately implemented:

• education around the environmental impacts of desflurane
• assessment of gas flow rates
• removal of desflurane vaporisers from anaesthetic machines, now available on a sign out basis only
• purchase of new total intravenous anaesthesia pumps (a lower carbon alternative anaesthesia) and associated training of the machines
• removal of desflurane entirely for trainee use
• introducing a ‘trainee sustainability role’ within each cohort of rotating anaesthetic trainees

Collectively, the above actions had a significant impact. As of March 2023, use of desflurane at Aintree Hospital dropped to 2,880ml during 2022/23. This equates to 7.6 tonnes C02e, representing a reduction of 99.2% from the peak emissions in 2016/17. This drop of carbon emissions compares to approximately 1.5% of the Trust’s annual NHS Carbon Footprint, making it is a very substantial change from a single area in one of the Trust’s hospitals. Cumulatively, the carbon saving from 2016/17 levels equates to 3,611 tonnes C02e. A graph illustrating the savings is attached to this application.

Following the success of this project, changes to the use of desflurane has been rolled out to the other hospitals within LUHFT.

Local anaesthetic hand surgery - Safe, efficient sustainable orthopaedics in Broadgreen Day Case Treatment Room 

After the merger of legacy Aintree and Royal orthopaedic departments, and the subsequent COVID pandemic, hand surgery waiting times had significantly. The opening of a treatment room has allowed us to re-think all of the processes and our practices.

Extension of Local anaesthetic cases –Many hand surgery cases that are traditionally done under general anaesthetic can be done under local anaesthetic. General anaesthesia is used, because the tourniquet which is used to provide a bloodless field is only tolerated for up to 10 minutes in most patients. The use of local anaesthetic with adrenaline 30 minutes prior to the incision reduces bleeding, a technique referred to as wide awake local anaesthetic, no tourniquet (WALANT). This reduces the need for anaesthetic gases. Even Sevoflurane, a low warming effect gas, will have a warming effect of 800–1,600g CO2, the equivalent of a 5-10 km drive, per hour of anaesthetic, the typical length of a Dupuytren’s correction.Other operations traditionally done under general anaesthetic, which have benefited from this technique include excision of ganglia, finger fusions, tendon repairs and removal of plate and screws. Approximately 100 cases per year have benefited, a reduction of up to 1.6 tonnes of CO2 per annum.

Avoidance of a general anaesthetic also reduces the amount of consumables such as single-use airway devices such as laryngeal masks / ET tubes, oxygen masks, even cannulas and syringes. Also, in converting treatments to local anaesthetic, means that patients that were once deemed “unfit” for an operation because of the risk of a general anaesthetic, can now still have surgery.

Hand washing – The use of an alcohol-based surgical scrub rather than the traditional disinfectant and water-based scrub has been shown to me at least as, if not more effective. In doing so, this saves approximately 16 litres of water per case.For a single hand operating list when up to 14 cases can be done, this is saving up to 224 litres of water per list.

With the advent of the new treatment room, we have invested in smaller instrument trays which house fewer instruments from 26 to 14, but are utilised for the majority of local anaesthetic hand surgery cases. They are lighter, (weight being what the cost of washing the instruments is calculated on), are easier to transport, and store and use less water and cleaning materials. This also saves time on checking the tray, before and after each case.

In the treatment room, there is no requirement for the patients to wear a gown. This means that there is no need for a changing room, and no need to provide 14 patient gowns per day which would require washing. This has been done without any increase in infection rate.

Reducing waste – Using surgical gowns during minor local anaesthetic hand cases has not been shown to reduce the risk of infection. Not using them for the surgeon, the assistant and the scrub nurse saves 3 gowns per case and up to 42 in a single day. At £1.79 each, that’s a saving of £75 per list.

Reduced staffing levels – The treatment room works with only 3 members of staff in the room itself and a nurse to perform administrative duties. There is no need for an anaesthetist, or an Operating Department Practitioner (ODP).

Saving time between cases – All of the pathways have been re-thought, reducing the administrative burden on the admitting nurse. Whereas the general anaesthetic pathway, which was also being used for local anaesthetic cases comprised of 13 forms, the new pathway has only 5, which are also much shorter. The original pathway would take approximately 45 minutes to fill in, as opposed to the new form, which is closer to 10-15 minutes. The duplication that was in the checklists has been reduced to simplify and reducing the risk of complacency, as well as saving time.

Being able to start from scratch, the treatment room is now a few meters away from the treatment room, so the time taken to get the patients from the waiting / injection room to the treatment room is reduced.

Saving patient time – instead of getting all the patients in at the beginning of each session or day, the patients now have timed appointments, much like visiting the dentist.