[participants discuss other meeting conflicts while the facilitator prepares for the session].

Michaela, Facilitator: So I'd like to start by acknowledging the traditional owners of the land that we meet on. I pay my respects to elders past and present and any elders who are meeting with us today. Also I'd just like to say a big thank you to all of you for joining us today. I know there was a lot of interest in this. So just as a quick background and introduction, the system purchasing, and Matt or Kate, please feel free to jump in if I have got any of this wrong, but from what I'm aware the system purchasing branch at the Ministry of Health has been given responsibility over climate risk. In which they're looking at both adaptation: which is responding to and preparing for the effects of climate change, and mitigation: which is reducing our carbon footprint. So as part of this initiative they're looking to establish net zero clinical teams in each specialty or area that form part of existing governance structures to help drive change, and one of the quick wins they've identified is in the use of anaesthetic gases in public hospitals. Which is the subject of much international research and evidence.

We're lucky tonight to have Dr Matt Doan who is an anaesthetist at Royal North Shore Hospital and is working with the Ministry on this piece of work. And today Matt, please correct me if I'm wrong, but you'll be sharing some of your knowledge on this and then one of the aims of this meeting is to get a consensus amongst the group about what the system response could be. And Richard Halliwell, who is one of the coaches of the anaesthesia perioperative care network at ACI is just running a little bit late today but he'll be joining us to assist with that discussion. Actually I've just got a message and he's here. So Richard if you have anything else to add before I hand over to Matt.

Dr Richard Halliwell: No that's fabulous sorry everyone just caught in terrible traffic. Now I think it's a really important initiative and this is a great first step to see what we can do. So thanks so much Matt I'll hand it back to you.

Dr Matt Doane, Anaesthetist: Not a problem. I'm just gonna do a quick mic. Check can everybody hear me okay? [yep, yes, yes thank you]. Wonderful, so just to give everybody a bit of an introduction again my name is Matt Doane. I'm a full-time staff specialist anaesthetist at Royal North Shore. The accent is because I grew up in the US where I trained on the east coast, and then worked on the west coast, and I've been in Australia for about eleven years now. My position at the hospital is I'm departmental head of academics and research, and what that really means is I'm really trying to help facilitate and improve our engagement with projects. And one of the ways that I've become involved in sustainability is I think there's a lot of room for growth in both academics and research in this area that's kind of dually beneficial. I think it's something that we can make a impact in by engaging on the research side of things but also in addressing a really important topic.

Now I'll also acknowledge that on the list of invitations to this meeting there are a number of people who have actually authored papers that I'm going to be referencing here. Part of what I want to do today is go over a little bit of the evidence, most of which you already know, and I realize this is a fairly friendly environment so I'm preaching a bit to the choir, so I don't want to belabour those specific details too much. But talk a little bit about what's going on locally. Opportunities that you can take at your hospital. Opportunities that we've been sort of capitalizing on at our hospital. I'm actually going to introduce a couple of people who are online also from our hospital, and they're going to talk a bit about some of the work they've done. And then really kind of push things, and discuss where I think we can really make changes, and how we need to engage in looking at those.

So the title of the talk is 'Decarbonizing health care in the valley of death' and I'll explain where that comes from in just a minute. So again without going into it too much we know that climate change is a very significant issue, and we know that it's something that has to rapidly be addressed, and we've been talking about this as a society and as a planet for quite a while, and it's only now that we're really kind of getting to this desperate point as we probably talked to some people in Lismore who are still swimming around their houses, and we wonder about what the next flood is actually going to be. But what can we do. As clinicians, as academics, as people in healthcare. Well in healthcare we know that roughly seven percent of Australia's greenhouse gas emissions comes from healthcare, which is about five percent of its carbon footprint overall. Now that's significant as an industry, as far as the impact that we can actually have. It's even more significant in an Australian context because of the fact that that number is a little bit higher than what we see in other countries, which means that while this isn't fifty per cent, or if we eliminated health care entirely, it's not going to bring us to the targets we need to make a difference on a global climate scale. It does mean that we have a significant role that we can actually play and Australia as a whole has been very proactive, and one of the things I'm seeing and I'm sure a lot of you have too is there's a lot of buzz, there's a lot of energy, there's a lot of enthusiasm. There is a growth in colleges, specialties, levels of government, community to try and make an impact.

Now a great document if you actually want to look at it was the Royal Australian College of Physicians they put together the Climate Change and Australia's healthcare systems document. One of the things that came out from this, and the reference is from COP 26 where they looked at health initiatives, and essentially they called on health ministries around the world to make commitments to act on climate change through two major pathways: one building adaptation and resilience, and the second was setting a course for low carbon and sustainable health care. And that is where this really intersects with this group, and with the ACI, and a lot of what was just mentioned by Michaela as far as what the Ministry is really looking at potentially doing. Now you'll see little QR codes pop up in the bottom so as opposed to that traditional aspect of giving you a micro font reference, if anybody actually wants to look at any of these documents you'll be able to access them through this later on through the recording or now if you really want to. But the summary of this document by the RACP again said that there is an urgent need to address the health impacts of climate change.

So we have this dual obligation that as an industry, as a specialty, we are impacting our greenhouse gas emissions and it's a cyclical effect on us because we're dealing with the health impacts of this as well. But Australia itself is set up to face even more risks because of our geographic location and how we're actually positioned than some of the other parts of the world. In response to this we've seen a growing number of specialty colleges come forward with their own positions, their own groups to try and address this. ANZCA themselves have also really been pushing this they've got their own background paper, they've got the environmental sustainability network, they've got the working group to try and look at what we can actually do, to address sustainability in anaesthesia. And as Michaela mentioned, one of the hot button topics right now are volatile anaesthetics, which I'm going to go to later on. Now just to try and put a finer point on the impact, we actually have the carbon impact we actually have in the perioperative space. There are a huge number of consumables, and this has come about over time in response to efficiency, reliability of the products that we actually need, and reducing infection has always been a very big point so we're getting a lot more disposables.

Now some of you may or may not have seen this but there's an interesting artist from Scandinavia, and she did a project her whole thing is looking at waste, and she ended up needing a mastectomy or reconstruction, and throughout her entire hospital journey she collected every bit of disposable material that was used just for her operation and then put it on display. And the interesting thing in this photograph, and she's got a great video if you actually go to this link is that, that ring you see of gowns on the outside actually isn't where it stops it goes on beyond that. And this is just a lot of the surgical equipment. It's not the anaesthetic equipment, it's not the energy cost of the buildings, and the resources that go into it. What we actually found just from looking at her operation alone was that something like 60% of all the surgical equipment used was disposable, and a lot of it was high grade plastics. Now dealing with this and this sort of point of care, recycling, reducing our consumption is something that a lot of us are doing. We might see throughout the theatres, throughout the hospital space with recycling bins and whatnot, and it's a very time consuming and arduous process, and we've had a few champions at our hospital also that have really been addressing this. And we're lucky enough to have one of them online right now, and I want to highlight Erin Foulsham is one of our clinical nurse educators, and she's been working away in the background for a while pushing to try and get practice change. And I wanted to invite her for a second just to actually talk about some of her experience and the impact she's been able to make, as well as some of the hurdles she's had too. Erin are you there?

Erin Foulsham, Clinical Nurse Educator: Yes, I am. Hi, thanks for giving me the opportunity to talk today about my experience at North Shore. I became involved six years ago when I was approached as the CNE to be involved in the negotiations and planning for the recycling program at Royal North Shore. And this was pretty exciting because recycling was somewhat limited to just Kim Guard recycling wrap at that time. The following year the plan was implemented, and so far has continued successfully to this day. I would attribute the success of the program to ensuring engagement with all the stakeholder areas, however, this is not to say that we've not had some challenges along the way, and a couple of hurdles which I'm going to talk about today.

Erin Foulsham, Clinical Nurse Educator: Firstly, getting the initial changes in place, the size of the department, its staff is large. Royal North Shore has 20 theatres, anaesthetics also serve outlying areas - interventional areas. There are 220 nursing staff, at least as many medical staff, there's also students, radiographers, OAs, and cleaners that work in the department. The sheer number of staff is a challenge, not to mention also that they can be rotational, which presents another challenge because they're particularly hard to catch for education. We knew going into the project that we needed to make a plan that could reach as much staff as possible. One of the strategies was to enlist design and print to create simplistic and clear stickers and posters that were placed in areas of segregation. Bins, Morgan trolleys, dirty utility bays, these were all labelled and the hope was that any staff that had not had the opportunity to have that face-to-face training would still have a reference and guide of how to segregate correctly.

Erin Foulsham, Clinical Nurse Educator: Maintaining the program would probably be the second challenge. It's a consistent review process. Nursing staff have been the main focus of education, and that's purely because they are here day to day and we run an in-house perioperative clinical and professional day which now includes sustainability on the program. Refreshers and projects that are underway in the department are discussed to keep nursing staff current. Upgrading of the signage has been required over the years to include any changes, and there's also informal auditing of bins to assess the segregation compliance in the department. Unfortunately, the recycling program has been compromised in the last few years in that companies no longer will ship offshore to process these high quality plastics and local recyclers are only now starting to emerge. Most of our recycling is in fact processed engineered fuel (PEF), and in the imminent future there are going to be some changes to our recycling program as streams are pulled from their services and we'll need to search for a more viable option that actually takes the waste and maintains as much of that material value as possible. I'm hopeful that companies will come to the fore with better options in the future. At this stage we're also very limited by our hospital dock size and storage area. It would be great if future solutions could accommodate these limitations.

Erin Foulsham, Clinical Nurse Educator: Another issue has been the continuity of lead staff in the department. When we first were negotiating the recycling program back in 2016, I worked with Dr Zhang during his fellowship year and then subsequently with Fellow Duncan the following year, and while their enthusiasm and dedication was unquestionable, the nature of their position meant that at the end of their fellowship year they had moved on. Most recently two consultant anaesthetists have been appointed into the sustainability roles, which I think has been a great action to ensure the continuum of the projects and also some initiatives. Nursing wise, we have a sustainability committee with representation from anaesthetic nursing, scrub scout, PACU, education and management, and they're an interested group of individuals with a passion for sustainability. The group meets to plan educate and implement sustainability projects. A current project that we're working on is repurposing wrap from scrub packs to use as an alternate to you know the blues that we use in patient care, and we've renamed them greenies as just a play on words, and in the next six months we'll be able to review whether we have in fact reduced our consumption of blues and I'm hopeful, hopeful. It's important not just to focus on waste management though, but waste management has been a big focus due to the amount of physical waste that we generate in theatres. It's also been important to look at other ways that we can continue to be more sustainable. So at North Shore we have a lot of reusable instrumentation. In anaesthetics we reprocess laryngoscopes, glide scopes, c-mac blades, bronchoscopes and even soda lime canisters, and the aim is to continue to use them as they are processed in-house, and they are a sure supply when we're in a time where supply can be difficult. We reuse air trays, airway trays, and we also supplement with bio pack trays, which I think is something commonplace in most anaesthetic departments now. We were looking at switching to our seven-day circuits, but this has been on hold during the pandemic of course. But I'm looking forward to a time when we can re-initiate this. I've wholeheartedly enjoyed working on sustainability projects. I find that while not everybody wants to be a champion or a lead, they all want to help in whatever way that they can.

Dr Matt Doane, Anaesthetist: And Erin, I just wanted to kind of put things in perspective. You know you've been doing this for a while, and you've been really trying to kind of move the needle. What you're doing and what you hoped to achieve if you were to kind of put it on a percentage, what percentage of success do you think we've had at the hospital in getting to where you think we could be with the initiatives you've had?

Erin Foulsham, Clinical Nurse Educator: Well I guess that's a tricky question because if you'd asked me a couple of years ago I would have said that our percentage was so much higher because I feel like we thought that our waste was being recycled purposefully to other products. But now, I feel like these resources are not, so I feel like my percentage is going down, sadly. As a percentage, I really could not put a figure on it.

Dr Matt Doane, Anaesthetist: That's all right. Do you feel like there's a decent window for room for improvement?

Erin Foulsham, Clinical Nurse Educator: I think there's a great potential, there's a great potential basically.

Dr Matt Doane, Anaesthetist: And if you were to take all the work that you're doing and advertise it as a position, what kind of fraction do you think it would be? Would it be half-time? Full time? In other words what kind of time commitment.

Erin Foulsham, Clinical Nurse Educator: You could have someone doing this full-time easily. I would love to assess all the numbers and do you know, crunch numbers and do figures on improvements and changes and you know shift but I don't have the time or resource to do that.

Dr Matt Doane, Anaesthetist: Perfect, and that's exactly what I wanted to highlight. So Erin, I appreciate your time and I think one of the things to highlight is that there is a lot of room for making impactful change on this level, but it's happening in this case because you got someone who's dedicated like Erin. But if we want to make a change more broadly, acknowledging the need for having people in dedicated roles not just individually using their free time is probably going to be really important. Especially when you acknowledge the amount of work that goes into chasing down a couple key points that I think Erin made which is the infrastructure and the environment is constantly changing. Which means you're constantly having to respond to that whether it's how we can recycle things or where our supplies are coming from, and the fact that just the hospital itself, and the system, the supply chain wasn't built to really accommodate it. The fact that we don't have areas to store the volume of recycling that we actually need to allow it to actually get to where it needs to go. All of these things mean that the efforts we're taking on, the point of care to try and do what we can need to, be facilitated by changes in the infrastructure itself and that's one of the areas.

Dr Matt Doane, Anaesthetist: Now kind of moving on a little bit, this whole classic idea of reduce, reuse and recycle. It's been around for a long time - the green triangle. But the thing that I always find interesting is we always focus on the recycle. And it's not that it's not important, but recycle is the last option. Where what you're meant to do is reduce your consumption, reuse it when you can, and then once it's gone to that end use then you recycle it. And operating theatres produce roughly a quarter of all hospital waste, and of this anaesthetic specific waste could be as high 25%, so when it comes to reducing some of the waste looking at ways that we can reduce unnecessary consumption is going to be really important. But it all has to come back to also doing it in a way that doesn't impact our clinical care. Because in the end, again we could reduce our impact by just not providing any clinical care. But it kind of defeats the purpose of why we're here.

Dr Matt Doane, Anaesthetist: So some of the examples that you're seeing within Australia and within the UK, which are two very progressive areas, as far as things that you actually can do right now if you want to do some immediate changes to reduce our carbon footprint through consumables and what not, you've got a number of projects that have actually been laid out fairly well. Some of which Erin's already just mentioned. One of them is looking at paracetamol use. Paracetamol is kind of a high carbon cost medication we use it intravenously, the intravenous form has a lot of disposable packaging the attributes form has size and weight as far as shipping and there's a number of studies that are looking at switching to oral paracetamol use in the perioperative space instead of intravenous. A lot of the plastics that we use in healthcare are really high-grade plastics that have the potential to be recycled into other very functional products. Collecting them is an issue. Obviously one based on what Erin has said, that requires a lot more kind of effort to get those actually collected, but then changing the system so we can actually do something with them. You know a key thing that Erin mentioned is that a lot of it before was being done off shore. So it was being sent elsewhere. So we need to as advocates look at opportunities for possibly doing this within a more local environment. Again reducing the diesel-powered ships that have to truck it over to another country. Common things like anaesthetic trays, disposable and plastic. Looking at some of the more biodegradable options or reusable ones are another initiative that we're seeing a lot of audits and changes made. Blueys which are something that Erin focused on very specifically. Or even oxygen. And oxygen's sort of an interesting one because it's been a bit more pragmatic and topical lately.

Dr Matt Doane, Anaesthetist: On the issue of dogmatic care. And this is one of the things that I find kind of interesting that areas of dogma are things that we don't really think about too much because it's just what we do so we tend not to look at it with such a high scrutiny. But oxygen for labour and delivery, and oxygen for caesarean sections is actually something that's been investigated, and the carbon cost from just dogmatically providing oxygen for labour and delivery and for caesarean sections is actually really, really high. There was a recent study that just came out, and again the QR code is down below, but it just got published looking at the impact of eliminating routine supplemental oxygen for caesarean delivery. Now again, well the changes we make need to come at an environmental benefit but not a cost of the quality of our care. And there's been a number of studies that have actually looked at the fact that it doesn't really seem to impact care by not routinely providing supplemental oxygen in both labour and delivery, which has been done extensively in the UK but also caesarean sections. And again depending on the country that impact becomes more meaningful. There's roughly 23 million caesarean sections performed every year, and it's been fairly standard practice to administer supplemental oxygen as part of that, and that supplemental oxygen has an environmental cost from supplying the oxygen itself, but also the plastic that goes into the oxygen masks that come with it.

Dr Matt Doane, Anaesthetist: A common one though, and this is something that Michaela tapped into earlier, are volatile anaesthetics. Now this is a really hot button topic because of the greenhouse potential with our volatile anaesthetics, and a particular focus is being played on desflurane. One of the probably biggest return on investments if you want to make a massive shift in the anaesthetic side of environmental impacts is just eliminating desflurane. Now we've done a number of projects at Royal North Shore to reduce consumption by just getting people to be more conscious of the environmental impact, and it's been actually quite striking. Striking in two ends, one the impact we were actually able to make, and the cost savings because of that. But also how willing people were to actually engage with this and I think this shows two things that are important. One, there's an easy space for a lot of departments to play in, but it's a litmus test that demonstrates how willing people providing care at the bedside are willing to make changes. And this was run by one of our trainees who's now a provisional fellow and he's continued to run this audit.

Dr Matt Doane, Anaesthetist: Now this brings up sort of an important point because all the work that Erin's doing, all of the things that I've mentioned that you can do right now, these sort of immediate changes that you can do to reduce your carbon footprint are all about bringing us into this target of getting us to net zero. But it's interesting, because about 40% of the carbon footprint from healthcare actually comes from the buildings, energy, water, waste, catering, non-medical equipment. So renewable energy for the hospitals is going to make a big difference, but alone it's insufficient. Because 60% of the carbon footprint comes from how we deliver the clinical care itself: the tests, the treatments. The UK right now is leading the world in decarbonizing, but a major component of what they've actually done to move the needle has actually just been changing the infrastructure itself. Less reliance on fossil fuels, and again eventually getting to net zero is going to be a bit more difficult because once you've exhausted one pathway, you've got to look at some of the other areas you can actually move things around. And the mantra that I keep telling people that we need to keep in the back of our minds is why are we thinking about net zero, as opposed to net negative. Because in the end we can't eliminate the carbon footprint of what we do no matter what we do, no matter how efficient we make it there is going to be a carbon aspect to it. What we're trying to do is reduce the unnecessary carbon impact. We're trying to change some of the impact in ways that we can offset it more, but if in the end no matter what we do we have to offset things, why target zero, why not go net negative? Because in the end, we're not going to be able to recycle our way out of this problem, and this is where it comes back to potential and also struggle. Which was the title of the talk, which was the value of death.

Dr Matt Doane, Anaesthetist: So when it comes to point of care interventions, what you can do right now with what's going on I put up this little graph because I like pictures. And you've got impact on the y-axis and effort on the x-axis. And in the beginning what you'll actually find is that there are a number of really, really, good opportunities to make a significant impact which I call the slope of hope. You get people motivated, you see change, the effort isn't that great. And that is a window of opportunity that you can play with. But if you continue to focus just on point of care interventions, trying to recycle a little bit harder, trying to use one less syringe, trying to shut the lights off that are mostly LEDs now anyway, well they needed what I call the grind. You expend a little bit more effort, you try and enrol people, and engage them to actually make a difference, but your return on investment starts getting a little bit less. And then what you enter in if you still start pushing the system, the end users the people that are so busy occupying their bandwidth with every other aspect of clinical care, you hit what I call a valley of death. Which is just diminishing returns. The more effort you pour into it and the more effort you pour into it, you'll actually find that you can't really move the needle that much more. Again just like the UK, they've made a huge difference in decarbonizing, but it's been through fossil fuels. The next tranche they've got to hit is how do we change our clinical care, and unfortunately if you keep pushing the end users: the nurses, allied health, the clinicians, to try and again focus more of their thought process on how do we actually reduce our carbon footprint how do we reduce our environmental impact, then you kind of hit what I call a break point. And you'll actually find you disenfranchise people. Now this isn't unique to decarbonizing. This isn't unique to sustainability. This is actually a concept that's in sustainable clinical cultural change, and it's written about quite extensively. You've got to find ways to engage people, but then capitalize on that momentum. And leading off of what Erin had actually mentioned about having staff, about having consistent people to actually work with. One of the things that we've been actually working on within our district in our area, within our area, is actually appointing people who are responsible for this people. Whose bandwidth is meant to be occupied with this. We've got people like Kate Charlesworth, who's online. But we've also got one of our sustainability leads online which is Andy Lindberg. And Andy is kind of one of the efforts that's within this initial slope of hope, and I wanted to give him just the floor for a minute to talk a little bit about his position, and how it sort of evolved in his role.

Dr Andy Lindberg, Anaesthetist: Hi everyone. I'm here, thanks Matt. Can you hear me? Yes. So I'm Andy Lindberg. I'm an anaesthetic consultant at Royal North Shore Hospital. I'm a visiting medical officer there, and was appointed. I'm a relatively junior consultant, appointed 12 months ago and recently became appointed as one of the joint environmental sustainability leads at Royal North Shore Hospital along with another anaesthetic VMO Dr Hodges. So it was kind of a joint appointment because the view was that it's a reasonably big task and an important role. And as we're both visiting medical officers, we'd be able to both split our time to achieve it. Basically, I don't have any specific expertise in this area just an interest and the position came about as we've mentioned, Kate Charlesworth was appointed as a planetary health advocate for the region, and I believe she's appointed two days per week to work solely for the Northern Sydney Local Health District in driving the net zero target for the whole hospital, and then for a few days she works for the Ministry of Health in that role. Basically Kate identified a couple of main areas, where kind of big advantages could be could be made in a short period of time. And that was anaesthetics and in the respiratory department, and in that she advocated to have leads within those departments. So the heads of our department basically put out an expression of interest for interested consultants to put their names forward, and then I believe it was selected from the Executive at the hospital. We were probably appointed about three months ago and as alluded to previously, we've kind of had the benefit at Royal North Shore of having two people who were very involved in it previously, Erin Foulsham and also Max, who drove the project that we've kind of got the benefit of. And I believe Matt will refer to that in a moment about volatile reduction.

But basically our role is as lead people. Erin mentioned the challenges of having fellows as leads in previous years, and that they're transient in in nature, and they also have the challenges of being a fellow in a position and taking on some potentially uncomfortable decisions that may impact clinical decisions for other consultants. And maybe that's better placed for consultants in the department. What Penny and I have been doing so far is predominantly getting up to speed. It's quite a large area, there's a lot of research out there. I had the good fortune of doing a fellowship overseas. Which essentially spiked my interest in the area where I noticed that in Canada at least I felt like they were they were significantly ahead of where we were at Royal North Shore and had more department buy-in, and it had more involvement in the clinical, not so much the clinical decisions, they made but more the purchasing decisions they made, and it was more widely accepted across the whole operating theatre environment. And I made some contacts there and felt like that's something that we could improve on in our area. So basically we're a lead within the department, and the idea is it will be continuous and be a point of care for Erin and also any registrars that are involved, interested in improving this area and go forward from there basically. So Max has done fantastic work in reducing our desflurane use and Erin has done fantastic work in relation to recycling in theatres. Going forward from here, we need to continue making progress and it'll be up to Penny and I, and matt and other interested members of the department to decide where that will be. The hope is that we establish an environmental special interest group within the within the department. And through that we'll be able to mentor registrars and trainees in projects to both research the life cycle analysis of the products we use, and allow us to make better decisions in purchasing so that there's no compromise in clinical care. But what we are using is the best that we can that doesn't ultimately compromise clinical care as Matt has suggested. There's a lot of work to be done and I'm only just starting to find my feet in relation to it. So you know to be a long-term project that will potentially be with me and Dr Hodges for the rest of our careers if we wanted to be, and there's a lot of a lot of scope for improvement. That's basically all I wanted to say as means of introduction. But I'll go back to Matt with where he's at.

Dr Matt Doane, Anaesthetist: So a really important point that I wanted to bring up is you know we're lucky to have people like Kate Charlesworth and Andy Lindbergh. But the importance is they're a sign of the interest and commitment that we're seeing. Not just within our department, but around Australia, you know the working groups again that you're seeing within different specialties within government, they're all an indication that people are getting primed and ready to make change. But on the clinical side of things what we really need to do is help drive what that change is. You know our efforts at trying to make changes in the immediate environment are helpful, and that again kind of comes back to that picture I was saying before. You can use that momentum and motivation to actually drive change, and that change isn't important just in the environmental impact but it's important in showing an ability to make change. But what you need to do with that investment is use it to then generate buy-in to keep things going. So that we're not just taking recycling and clinical care and trying to constrain it to a point where we're tying ourselves in knots. And there's some really good recommendations, and I put this slide up for anaesthesia providers. But it's not unique to anaesthesia.

Dr Matt Doane, Anaesthetist: There's these seven concepts that they basically say we need to focus on if we really want to try and change the infrastructure so that what we're doing in the end doesn't involve having to think too much about the environmental choices we're making because they're already made. And having people in place like Michaela, and Kate and Andy are there to help make people aware of some of the changes that could be made, but also help provide feedback for when those changes are made. One of the things, and this these seven points actually come from the world federation of societies of anaesthesia consensus statement, is trying to reduce. So reducing and minimizing the impact of our clinical practice. And this can involve a number of different ways. Changing the medications we use, changing the disposables and consumables we actually use. Second thing we need to do is look at leading sustainability activity within the organizations. Providing people who can be point persons. People who can actually help specifically focus on these initiatives at the bedside, within the administration, within the infrastructure themselves. When it comes to using more environmentally preferable consumables, this is again where we need people at that point of those discussions so we can help identify what's going to be functional. We need people at the table having those conversations so when things are brought up we can help make suggestions, but we can also feedback on whether or not this is going to compromise care.

The other thing is waste. Now one of the things we're doing a lot is trying to minimize overuse and waste itself, but I'm going to come back to the concept of waste because waste has a number of different levels. There's waste in how we use things, packs that we open up that have six things in which we only use three of them, overuse equipment that sits on the shelf and actually never gets used and expires as a result. Training. Anybody that's on this call right now, you're most likely an advocate to some degree of what we're trying to do. But the reality is we've got our clinical expertise in acumen and we need to try and make changes. But one of the biggest things we can do is train the next generation so that as they're growing through this and going through their training they're already inoculated with this idea of what do I need to think about how do we actually incorporate this thinking into it. We need to make it part of the curriculum. Research. If you want to make it part of the curriculum if you want good changes we've got to actively incorporate research to understand where those changes can be made. And I'm going to touch on that a little bit more specifically too. And the last thing is collaborating. Because ultimately going back again to what Erin said, and what all of us understand, we work within a healthcare environment. We're reliant on the resources that are available to us, and those resources are produced by someone else. So if we want to make a change we have to learn how to collaborate with industry to actually get the changes that we want so that when it reaches our hands we're not thinking too much about can I recycle this, how do I recycle this, but we already know the system's been set up to accommodate that.

Dr Matt Doane, Anaesthetist: And one of the exciting things is I wanted to talk about three potential directions for collaboration, or more importantly directions for acceleration. If we want to get change in industry, if we want to get change in the environment we actually work in, we can look at three things. One adapting. There is technology out there ready to use and what we need to do is focus on accelerating adapting it to an Australian context. A simple example if you actually look in Scandinavia, they've already got methods in place for institutional destruction of nitrous oxide. A very potent greenhouse gas that's commonly used in hospitals. That technology exists functionally on a scale that works on a hospital level. But if we wait for normal market forces to bring it to us, if we're trying to meet these net zero targets by 2030, 2035 before 2050, we can't wait for it to come we need to work on actively adapting it. We need to accelerate its adaptation to an Australian environment. Second thing is we can look at scaling solutions. There are solutions out there, technologies and opportunities on the horizon that we know about that we need to make available on a health care size. One of them, there was a recent presentation about a group in New Zealand that are actually working on what's called sub-critical hydrothermal deconstruction. So essentially they're looking at wastewater that comes out of hospitals and ways of purifying it in a way that allows it to be more environmentally friendly and in a way that can be done through renewable energy.

Now the last one though, the third direction that we can look at for acceleration. This is kind of a difficult one, and this is how we invent. We're looking to invent solutions to a problem and that solution doesn't exist yet. And this is what I call the unicorns. The things that we don't know how to fix it, but this is exactly why we need people like us on the front lines having these conversations so we can bring it to industry that doesn't always understand exactly what it is that's going on our end because we're so specialized. One on the industry side, and the people that create and market, and on our side that are dealing with the pointy side of clinical care. We need to be able to bring them potential problems and then see what they can come up with for solutions. And this is some of the areas that we're starting to explore right now and we're already seeing in existence. Things like innovation accelerators. And I've talked to Kate about this one group that exists in New South Wales called Cicada Innovations. They're a med tech and biotech program. Now traditionally what they do is you come to them with your idea and they help you build it and upscale. NSW Health is actually already involved with them looking at stakeholder acceleration.

But what we can do is actually come back one step and instead of saying here's a product help us build it, bring the problems we have out there and find people that can build a solution to it and then accelerate those solutions. Invent solutions to the problems that we need in an Australian context. But if we're going to figure that out, one of the things we need to do is look at actually researching the area. Find what we have for specific hot spots. A lot of the evidence that's out there is in a context for other countries, the UK, the US. Australia is a unique environment. One of the ways that we can move forward right now is looking at doing things like life cycle assessments where we look at the clinical care provided, run a carbon calculation all the way through it where each piece of equipment comes from, the cost of producing it, extracting the minerals, getting it to Australia, recycling it. Again if recycling it in a high quality way means shipping it back to Germany, that's a much different cost than if you're actually in Germany itself. And there's opportunities right now again utilizing infrastructure that already exists. And one of the proposals that I've got moving forward right now is to look at this.

Dr Matt Doane, Anaesthetist: So I'm the department scholar role tutor which means that I'm in charge of trying to coordinate all the audit and research activities for our trainees as part of their fellowship. Now within ANZCA, in our college we have the environmental sustainability network and this is newly founded, very energetic and they're looking at making changes specific to this environment. Within ANZCA itself and the scholar role area., we have a number of staff and infrastructure to help coordinate our trainees. We have a network to actually get out to them. We've had proactive engagement with the development of a new environmental sustainability grant. So there's funds that can potentially be put forward as part of your training within ANZCA you have to do a study. And as the scholar world tutor, one of the things that I'm actually doing is I'm changing the focus that we have, and promoting that at least half the projects that we produce have to be on a sustainability focus. And one of the things I'm trying to do is come up with life cycle assessments. Pick something simple. You want to look at a really common operation that happens in large numbers all across Australia: hysteroscopies, cystoscopies. Something small but something easy to look at. Incorporate that so we can start getting an idea of where some of the hot spots are within the hospital, and possibly where we can then make interventions or change. But not only that. Not only do we get research out of that within the infrastructure that's already in existence, but you can disseminate it.

Dr Matt Doane, Anaesthetist: There's some great organizations like TRA2SH, which is one of the trainee research organizations< specifically focused on sustainability that already puts together portfolios that they're encouraging other trainees to do. You can start building up a network through them coming up with a template for life cycle assessments. So not only are you looking at your institution's impact on a subset of specific care pathways, but you can compare them now to other hospitals in the state, in the city, across the nation, and possibly start picking up differences as well. And now you're using infrastructure and motivation that's already there. So we can actually look at doing research within the existing infrastructure using a lot of pathways that already exist. It's just shifting it to focus on that. We can look at training people up and incorporate sustainability within the anaesthesia education. And again part of this is bringing us into the conversation with what's actually going on. And there is a great example of this in the UK through the Centre for Sustainable Healthcare. They have sustainability fellowships. These aren't limited to anaesthesia, they're in all aspects of medicine but it's a focused fellowship on sustainability practice, research, change that comes into it. This is another area we can start looking at if we want to train people up not just within their training but allowing them to focus on it straight from the beginning.

Dr Matt Doane, Anaesthetist: An interesting way that you can also look to advocate if you want when it comes to reducing the impact of clinical practice is sometimes you can just reframe the issue. Interestingly there's a lot of projects that people have been trying to push for quite a while and they haven't had success. But reframing it in a different way can get you to where you need to be. It could be that you are having futility on a sustainability lens, but if you reframe it as a different issue you can still get the result you want. For example wiser healthcare is a fantastic organization and one of the things they're looking at is reducing unnecessary care. In fact some of the research they've done has shown that roughly 30% percent of health care is low value. There's a pretty bad carbon cost to delivering care that really isn't of value and 10% of it could potentially even be harmful. So they've been looking for a while at how do we reduce unnecessary care that is low value to the patient low value economically. But more recently they've started reframing some of that and saying the other problem with low value care is also get a carbon footprint which makes it even worse. So they've now started a separate branch which is wiser carbon neutral looking at how we can incorporate reducing unnecessary care and as a result of that reframing it is an environmental issue. And some of the interesting research that they come out about has come and summarized in this article here which talks about this 60-30-10 challenge which is again saying that 30% of care delivered is roughly low value 10% could potentially be harmful and how do we actually work on changing that.

Dr Matt Doane, Anaesthetist: Now I've talked sort of in a bit of a circumlocutious pattern. But the point I really want to reiterate is as individuals on the pointy end of healthcare, we have the potential to make big changes in our carbon footprint. But we still have to deliver care, and the more effort it takes us the more it's going to be a strain or a distraction. We can use these initial gains, reductions in cost to possibly generate positions that can be focused just on sustainability to then engage in these higher level changes for how we can retool the infrastructure so that the care we're providing already has a carbon footprint lens in it. To do that though again means that we need to be able to come to the table with a vocabulary, common terms that we can all work on. And if anybody wants some light reading and just a great way to kind of scale up a little bit there's this great resource that was put out that's just a glossary of health and climate change. It's just a list of terms and their relevance to health care. It was published back in February 2021 so about a year ago came out of the University of Sydney, and it's a great way just to start as an individual so you can start framing the conversations you're having in terms that are going to be relatable to other people.

Dr Matt Doane, Anaesthetist: Now I'm at the end of what I came to say. I really value everyone actually giving me this platform to speak. I want to reiterate that again, this is a passion area for me but my engagement in it has always been how can I incorporate sustainability into the work that I already do. So reframing my work in research, in academic progression, so that it has a lens on sustainability and I think that's where we're going to start to see bigger changes. And what I hope I've highlighted is some of the opportunities that are actually out there. The talk's been recorded. I'm happy to take any questions. But looking at some of the people in attendance, I'd say there's probably levels of expertise when it comes to sustainability that are much higher than mine. Kate Charlesworth I'm looking at you specifically. So thank you very much.

[participants commence Q&A session, transcript of discussion not included as part of webinar recording].​