Towards net zero - clinical activity

A sustainability project in dentistry has led to a significant reduction in carbon emissions at the Eastman Dental Hospital. 

Having seen the impact of change across other areas of anaesthesia in the NHS, UCLH’s dentistry team realised that guidance did not currently exist within their specialism to make similar strides. The team took action and has made progress in adopting new practices that support UCLH’s net zero programme.  

“Back in October 2022, we decided to benchmark our carbon footprint at the Eastman Dental Hospital, to really understand what we were using nitrous oxide for,” explained paediatric dentistry consultant Lexy Lyne. “When we assessed activity using nitrous gas across the hospital over a period of one month, it was clear that the bulk of use was coming from paediatric dentistry, so that was where we really needed to focus our energies.” 

After the initial stages of their project, the team, led by dental sedation-trained nurses Monika Ozdoba and Petra Vassell, discovered that the procedures associated with the highest nitrous usage were the ones that took the longest, for example, root canal treatment.  

By training dentists and dental nurses on how to deliver nitrous oxide effectively, and encouraging the use of minimally invasive dentistry which does not require sedation, the dental hospital has reduced the carbon footprint from nitrous oxide by over 20 per cent within just a few months.

“We found that most patients that started dental treatment using nitrous oxide continued it for all their treatment visits, even if it was not always clinically necessary” explained Lexy. “So part of our training for the dentists and nurses in the dental hospital has been to really consider when it is clinically useful for patients, and when patients can be ‘weaned off’. We also began to reduce the volume of gas we were administering, which was not being noticed by the patients themselves, but was positively impacting our carbon footprint significantly. 

“We also looked at delivering different treatment options. For example, when inserting a crown on a baby tooth, you would normally do an injection to numb the tooth, drill the tooth to prepare it, and then fit the crown on top. As an alternative, we can offer a ‘hall crown’, which is a successful technique where the crown is placed over the tooth without the need for injections or drilling. This is less anxiety provoking for the children and doesn’t require sedation with nitrous oxide.” 

Postgraduate student, Sarah Ahmad, has been monitoring nitrous use on a quarterly basis since the initial benchmark, and the latest report shows a 23 per cent drop in nitrous per patient since the start of the project.  

Mrs Anand, another consultant in paediatric dentistry, has been piloting a new service at the Eastman Dental Hospital, to provide a different form of sedation to children aged 8 and above, which may offer an alternative to nitrous oxide for some children. However, there is no like-for-like alternative to nitrous oxide sedation in dentistry. 

In the future, the hope is that nitrous oxide capture technology improves for dentistry, and this would allow the team to reduce their carbon footprint even further. As the Eastman is a new building, the amount of gas currently being lost through the gas piping system is less than one percent, but as it ages, we expect this to increase. Dentistry would be the ideal service for capture technology, once this becomes evidence-based and reliable for use in the service. 

The team is now in the process of expanding this project nationally, in partnership with the British Society of Paediatric Dentistry (BSPD), with the long-term aim of producing practical guidance for other dental practices in the UK, covering everything from hospitals with a piped supply of nitrous to community and dental practice settings using individual cylinders. 

“My hope is that that all this work will ultimately feed into the next set of national guidance about nitrous oxide in anaesthesia and we can have a separate section for dentistry,” said Lexy. “It will make a real difference.”

UCLH has installed six mobile Entonox destruction units across its birthing centre and labour wards.

Entonox (‘gas and air’) is frequently used in maternity as an effective pain killer, but contains nitrous oxide, a greenhouse gas 300 times more potent than carbon dioxide. The new mobile destruction units, which collect and break up Entonox into harmless gases, are predicted to reduce emissions by up to 80 per cent in the rooms they are used. 

Director of innovation, Luke O’Shea said, “This is another positive step forwards towards becoming a greener UCLH. Last year we produced the same emissions from Entonox as over 400 flights from London to New York. These new mobile destruction units will make a significant difference to our carbon footprint, not only for our patients and staff today, but, fittingly, for the generations to come.”

Between April 2021 and March 2022, 40% of UCLH outpatient appointments took place virtually - a total of 484,872 appointments. Based on an average journey, this saved 13 million miles of patient travel, reducing local traffic pollution and congestion, and saving over 1,300 tonnes of CO2 from being released. 

Patients have still been able to see a clinician when they have not been able to travel and clinicians have been able to run clinics from home,  

One area that has embraced video appointments is the paediatric psychology department at University College Hospital. It offers a service for young people who are living with a chronic or acute health condition, such as diabetes, chronic fatigue or cancer. The team works with children, young people and their families to help them to navigate their relationship with their health condition. 

Prior to 2020, the team were seeing a lot of young people and families in person on a one-to-one basis and running a number of in-person groups. However, the service changed very quickly once the pandemic hit. As well as dealing with their illnesses, these children and young people were experiencing added isolation and other challenges, meaning that the psychological services became even more vital. 

The paediatric psychology team responded by setting up video clinics, for patients, parents, families and peers. They employed a lot of creative ways of working: being playful where possible, using whiteboards and emojis online and sending out packs in the post before a group session, which might include play dough or craft activities to do together. Although there are circumstances where seeing patients face-to-face is important (something the team still offers) the virtual service has been well received. 

20 year old Bella Matthews is one patient who has benefited from the change.  When she was 15 years old, Bella was diagnosed with a round cell sarcoma, and was treated by the team at University College Hospital due to the specialised nature of her condition. Bella is now in remission, but still accesses UCLH’s psychology service. 

“I have been having my appointments virtually for about a year now, both with my personal psychologist and also in virtual groups with other young people who have gone through cancer. 

“I'm studying paediatric nursing in Bristol at the moment and I'm on placement for half of the year, so if I had to come down to London multiple times for appointments, life would be much more stressful. 

“If I didn't have the online aspect, I just wouldn't be able to use the service any more. It's also the cost of getting to London every three weeks. It’s also lovely to speak to people while in my own home where I'm very comfortable. 

“The virtual service means I have been able to meet and make friends with people that I would have never been able to speak to before, which has been amazing. I actually met somebody through the sessions who also goes to the same university as me. We have since met up in person and become great friends. 

“As well as the personal benefits, climate change is massively important to me. So these virtual appointments also don’t make me feel guilty about the travel miles. I just press a button and I’m there.” 

Taking a moment to reflect on how the team could do things differently has led to eliminating the use of over 5000 plastic bottles of sterile water a year in UCLH’s endoscopy department.

According to a report in The Lancet, endoscopy is the third largest contributor of waste in hospitals, due to the vast amounts of disinfecting and flushing required in the diagnosis of gastrointestinal problems. Historically, sterile water has been used to flush out the bowels and stomachs of patients in readiness for endoscopic testing. That’s equivalent to around 200 plastic bottles of sterilised water being used every week.

“If I am honest, I never used to see environmental impact as part of my role as departmental lead for endoscopy,” said consultant in gastroenterology, Ed Seward. Once I started to see a focus on environmental issues in the wider endoscopic community it made me rethink my responsibilities.”

Ed had become aware of data suggesting that tap water was of no greater risk to patients than using the sterile water to do the same job. Clearly, this presented a massive opportunity for achieving green savings.

“I realised how easy it is for everyone to contribute to positive change – it just meant taking the time to look at how things have been historically and whether there is any opportunity to change that,” said Ed.

With the support of UCLH’s infection control team, the project was enthusiastically embraced by the wider endoscopy team, led by ward sister Edilyn Maceda. In a short space of time, their use of bottles of sterile water halved. The overall aim is to eliminate the use of sterile water entirely, but there are a few incidences where sterile water will continue to be used until further research proves otherwise.

“There is so much more we can do – for example, as a team we are getting so much better at general waste segregation in the department, which not only increases the amount we can recycle but has a direct impact on the amount of money we spend on waste disposal,”  said Ed.

“The team are really enthusiastic about continuing the trajectory to become a greener department; we just needed a nudge in the right direction.”

UCLH has introduced new, innovative and eco-friendly waste management technology into our theatres at University College Hospital at Westmoreland Street, improving safety for theatre staff and reducing our carbon footprint.

The hospital is largely dedicated to the care of patients with urological issues - problems with the bladder and urinary system. Many operations require the need to “irrigate” the urinary system and flush out unwanted waste products such as blood and urine.

Until recently, waste was removed from the patient’s body and into a series of interconnecting plastic cannisters. These were pre-filled with a liquid gel which solidified when it came into contact with waste product. These plastic cannisters were single use, so would need to be changed between each patient and put into infectious waste bags. With up to eight operations taking place in each theatre per day, the amount of plastics waste soon added up.

In 2022, University College Hospital at Westmoreland Street invested in seven new enclosed waste systems called Stryker Neptune. This filters the fluid which is collected inside the unit, enabling it to be safely disposed of down the drain rather than using waste bags. These new, self-contained units are able to hold significantly more fluid than the previous system, so they can safely be used for multiple operations before they need to be emptied.

 When it is full, the unit is attached to a docking station where the waste is safely drained away, eliminating not only the need for all the plastics and cardboard waste, but also a lot of the heavy lifting work that was needed to manage the old system.

“With the previous system some of the filled fluid bags could contain three litres or more”, said Nicola Sabey, service manager at the hospital. “Staff were lifting some seriously heavy weights to get rid of the waste, which can potentially lead to back injuries. We also had occasional spillages with the old system so it also improved our overall infection control. Plus of course, sending away less waste is also saving UCLH money in waste disposal costs.”

From a green perspective, Nicola estimates that replacing the units has saved over 60 tonnes of carbon from entering the atmosphere each year, compared with the previous system.

“Staff have been really supportive of the changes”, said Nicola. “It has been a really positive investment for the team.”

By its very nature an emergency department, or ED, can generate significant amounts of both waste and carbon emissions.

As part of her placement on UCLH’s graduate management programme Lizzy Cubitt recognised that with some focus, there were a range of opportunities to reduce the environmental impact of emergency care 

Working on the back of a pilot project which began at The Royal Free Hospital, Lizzy, with the support of UCLH’s sustainability team, introduced the Greener ED Framework to the team.

This simple document encouraged the department to consider all the ways that their impact on the environment could be improved. These areas were then banded into bronze, silver and gold categories, depending on how complex the issues would be to solve.

Lizzy then set up a working group with ED colleagues across both clinical and operational teams to look at tackling some of the more challenging aspects. All the opportunities were listed in a tracking document, so that mini projects could be assigned to individuals and progress could be reported on. “It was a really visual way to focus everyone’s minds on the task”, said Liz.

So far 14 mini projects have been assigned to the team to tackle.

“We started with issues that we could control in-house, like recycling bins being positioned in the most appropriate places. This means we will maximise the number of items we can recycle, and also, minimise the amount of contamination in the bins with non-recyclable materials”, said Lizzy. “We have completed an audit and these bins are now on order. We anticipate that this will significantly improve waste disposal in ED. We also know that this is a really popular solution with staff.”

Other wins for the team have been adding a sustainability module into the departmental induction programme, and replacing single use cutlery with stainless steel cutlery. They are also looking to install a dishwasher in the department to ensure there is an incentive to continue to use it. “We have to consider how easy we can make it to remain a greener department”, Liz explained. “There is no point in fixing a problem if we made it harder for staff to make it part of business as usual. So this has all been taken into account.”

Larger scale areas to address include the department adopting a model of sustainable procurement and an audit to see how much nitrous gas was being leaked into the atmosphere. Happily, the audit has shown that UCLH has no nitrous leaks, which means that this project can be set to complete. The team are also supporting UCLH-led initiatives, such as encouraging cycling to work.

The programme has been well received by colleagues and is well supported by senior management. There is now a plan to extend the framework for use more widely across UCLH, as with a bit of tweaking it can be used for teams working in office areas as well as in clinical spaces.