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A team of masked surgeons in medical gowns and skull caps performing an operation beneath operating theatre lights

University of Birmingham experts worked with a surgical team at University Hospitals Birmingham NHS Foundation Trust to complete the first documented ‘net zero’ operation in the NHS - with the patient discharged safely and recovering well from a keyhole procedure to remove a bowel cancer.

Performed at Solihull Hospital, the operation introduced several changes to the team’s normal practice. This first net zero operation combines evidence-based approaches and documents using a carbon output calculator developed specifically for this task by experts, led by Dr Dmitri Nepogodiev, at the University of Birmingham.

Mr James Glasbey, a surgeon wearing scrubs and skull cap standing in front of medical monitors and equipment
Sustainable surgery: The first ‘net zero’ operation in the NHS

Title: First net zero operation in the NHS

Mr James Glasbey, Research Fellow:

Today we're doing the world's first net zero operation. But this is only the beginning, we need to ensure that the measures that we put in place, maintain the safety for every patient undergoing surgery in the NHS, and also that there's no effect on the capacity of operating theatres during the COVID recovery effort. Research is one of the useful tools we use to ensure this. We want to do a study across the NHS to engage theatre teams to understand why there are barriers in changing practice towards making theatres more green. And to ensure that patient safety is maintained during those processes.

[Shots of surgeons preparing theatre]

Elizabeth Li, Research Fellow:

Surgery is imperative for maintaining the health of the population as a whole. As we are recovering from the COVID pandemic and restarting our surgical operations, it is important that we are able to do this efficiently and do this with sustainability in mind.

[Shots of surgeons preparing medical equipment and sorting through surgical instruments]

Mr Simon Bach, Colorectal Surgery - Senior Lecturer:

Operating rooms generate more carbon than any other area of the hospital, which is why we think it's really important to evaluate what can be done to reduce carbon emissions from the operating room. Today, we're hoping to do the first documented carbon neutral operation in the NHS. And we're hoping that will be a starting point for creating standard operating procedures whereby everybody can adopt relatively simple processes that nudge us in the right direction towards a carbon-neutral future.

[Shots of doctors writing on forms and unsealing sterile equipment for use, throwing the packaging away in a waste sack]

Mr Aneel Bhangu, Consultant Colorectal Surgeon:

To achieve a net zero operation and to become a green operating theatre, we need to work with quite a big team of people that includes surgeons, anaesthetists, and the wider theatre team. And we definitely need to involve the patient. So to do this across operating theatres, in our hospital, of which there are at least 50, is quite a complex task.

[Masked doctors in scrubs helping a surgeon to prepare for theatre]

We need green champions to lead the way in healthcare. And these are people who feel passionately about the topic who can provide the leadership that's needed and can bring people together to create green operations.

Dr Catriona Frankling, Anaesthetic Consultant:

So in the future, with our green operating theatre, I hope that this is something that we can just achieve routinely on a daily basis throughout the NHS and beyond across the world as well.

[END]

Operating theatres are resource intensive environments, contributing to 25% of the Trust’s carbon output. We cannot achieve net-zero health systems without making surgery more green, so this is a vital proof of concept step.

Mr Aneel Bhangu, UHB Consultant Surgeon and Senior Lecturer at the University of Birmingham

Changes to normal practice

  • Using reusable gowns, drapes, and scrub caps
  • Giving medications through the veins for general anaesthesia rather than anaesthetic gases, which have a strong greenhouse effect
  • Implementing a plan for minimising electricity use, including heating and lighting
  • Recycling of single-use equipment used in surgery, working with industry partners
  • Recycling of ‘clean’ paper and plastic waste
  • Using individually packed equipment, and only opening items as they were required
  • One consultant surgeon ran to hospital and the other cycled

UHB Consultant Surgeon and Senior Lecturer at the University of Birmingham Mr Aneel Bhangu said: “Operating theatres are resource-intensive environments, contributing to 25% of the Trust’s carbon output. We cannot achieve net-zero health systems without making surgery more green, so this is a vital proof of concept step.

“Ensuring healthcare is environmentally friendly is important to patients and communities. These measures require changes in behaviour and care pathways across complex teams. We now hope to work with colleagues across the UK to create a wider impact across the whole NHS.”

“As a large NHS organisation, we know UHB has a significant carbon footprint, but we are committed to reducing this as much as possible whilst still providing the care and treatment our patients need. I hope this net zero operation is the first of many, not just at UHB but across the NHS.”

Tim Jones, Chief Innovation Officer at UHB

The net zero operation involved all members of the team including the surgeons, anaesthetists, nurses, cleaners, porters, and managers.

Tim Jones, Chief Innovation Officer at UHB, added: “I would like to thank Aneel and his colleagues for their work on delivering the first net-zero operation in the NHS.

“As a large NHS organisation, we know UHB has a significant carbon footprint, but we are committed to reducing this as much as possible whilst still providing the care and treatment our patients need.

“I hope this net zero operation is the first of many, not just at UHB but across the NHS.”

At the end of the operation, the team used the calculator to estimate the reduction in carbon output for the operation compared to the usual output. They calculated that the carbon output was reduced by almost 80%, with the remaining output then offset through a variety of verified carbon offsetting projects, including the planting of trees in the grounds of Solihull Hospital. This brought the total carbon output for the operation to net zero.

Safety and efficiency were maintained for the patient throughout, carried out within a full, day-long operating list, including surgery for three other patients.

The NHS contributes 6% of the UK’s total carbon footprint, and COP26 targets will not be achieved without moving towards a more sustainable future in healthcare. Operating theatres are an important focus – making up as much as 25% of hospitals’ contribution, despite less than 5% of hospital inpatients undergoing surgery.

As the NHS COVID-19 recovery plan for elective surgery is introduced and doctors across the NHS look to increase the volume of elective surgery, measures such as these will ensure that the impact on the planet is kept to a minimum.

Patient advocate and research involvement lead Dr Lesley Booth CBE said: “Reducing the environmental impact of surgery is hugely important to improving health more broadly. We know that climate change and air pollution has wide impacts on health, many of which aren’t measurable until years to come. I would want my operation in a hospital that cares about the environment, showing its commitment to patients and public health.”

Further net zero operations are planned at UHB in the coming weeks.

The University of Birmingham is ranked amongst the world’s top 100 institutions. Its work brings people from across the world to Birmingham, including researchers, teachers and more than 6,500 international students from over 150 countries.

Video footage including b-roll shots and interview clips are available on request.

Interviews with Mr Aneel Bhangu are also available.

Contact: thomas.hammond@uhb.nhs.uk / +44 (0)7557 759 959

Summary of what a typical NHS operation looks like compared to a net zero operation

Carbon source

Carbon output (kg CO2)

Typical operation

Net zero surgery

Anaesthetic and surgical gases

· Desflurane gas anaesthesia

· Carbon dioxide insufflation for laparoscopy

· Total intravenous anaesthesia using propofol

· Carbon dioxide insufflation for laparoscopy

Energy consumption

· Theatre lights and heating switched on 24 hours per day

· Theatre lights and heating switched off at night and weekends

Waste production

· No recycling

· Some non-contaminated waste disposed of in clinical waste bin

· All clean materials that are recyclable are recycled

· All non-contaminated, non-recyclable waste disposed of in household waste

Personal protective equipment

· Single use surgical gowns, drapes, and scrub caps

· Reusable surgical gowns and drapes

· Reusable scrub caps

Other

· Theatre team commute to hospital by car

· Materials wasted due to being opened despite not being needed

· Theatre team commute to hospital by active transport (walk, run, cycle)

· Materials only opened when required by surgeon

The table below compares the carbon output estimates carbon output for a 5.5hr laparoscopic operation based on typical NHS practices versus our Net Zero operation. Overall, the measures we took reduced the carbon footprint of the operation from 1,948 kg CO2 to 417 kg CO2, a 1,530.1 kg CO2 (79%) reduction. For context, 1,948 kg CO2 is equivalent to a diesel car travelling 7,000 miles, and 417 kg CO2 is equivalent to a diesel car travelling around 1,500 miles.

To ensure the operation was carbon neutral three trees will be planted which, over 30 years, will offset the carbon that was produced.

Carbon source

Carbon output (kg CO2)

Reduction in Net Zero surgery

Typical operation

Net zero surgery

Anaesthetic and surgical gases

1,270.1

0.9

99.9%

Electricity use

521.7

274.6

47%

Waste production

149.9

140.3

6%

Gown and drapes

6.0

1.8

70%

Total

1,947.7

417.6

79%

Carbon offsetting

-

-417.6

100%

 

UHB

University Hospitals Birmingham NHS Foundation Trust runs the Queen Elizabeth Hospital Birmingham, Birmingham Chest Clinic, Heartlands Hospital, Good Hope Hospital, Solihull Hospital and various community services across the region.

The Trust has regional centres for trauma, burns, plastics, neurosciences, dermatology and cancer. It also has centres of excellence for vascular, bariatric and pathology services, as well as the treatment of MRSA and other infectious diseases. We also have expertise in HIV/AIDS, premature baby care, bone marrow transplants and thoracic surgery.

UHB has the largest solid organ transplantation programme in Europe and runs Umbrella, the sexual health service for Birmingham and Solihull. It is also home to the West Midlands Adult Cystic Fibrosis Centre and a nationally-renowned weight management clinic and research centre.

The Queen Elizabeth Hospital Birmingham is a Major Trauma Centre treating the most severely injured casualties from across the region. The hospital’s single site 100-bed critical care unit is the largest in Europe.

The Trust hosts the Institute of Translational Medicine (ITM) and leads the West Midlands Genomics Medicine Centre as part of the national 100,000 Genomes Project.

UHB is also proud to host the Royal Centre for Defence Medicine (RCDM) at the Queen Elizabeth Hospital Birmingham. The RCDM provides dedicated training for defence personnel and is a focus for medical research.