Developing environmentally sustainable operating theatres

Background Operating theatres contribute 25% of a hospital's carbon emissions.

The NHS has committed to net-zero targets by 2045 but this cannot be achieved without reducing the carbon-footprint of operating theatres. This is a challenging area, with worries about patient safety and sustainable behaviour change across complex teams.

Development to date We have performed a systematic review to identify effective interventions, co-prioritised these in a survey of 5734 theatre staff and 91 patients and conducted further feasibility work since Stage 1. We now propose a single multi-level behaviour change intervention with three components.

These are readily deliverable by frontline teams and we have already tested them in a world-first net-zero operation: Reducing the use of greenhouse gases and oxygen wastage during anaesthesia Routinely using reusable sterile gowns and drapes Recycling paper and plastic (also targeting plastic waste reduction) Patient and community involvement We co-produced a patient survey with our Patient Advisory Group (PAG) and held our first discussion forum. 97% of patients wanted an environmentally friendly operation and 95% felt this was important to their community.

Patients found the proposed changes acceptable, but were concerned about safety.

We have included a patient manager and a patient with lived experience as co-applicants, and funded patient partners are included in all programme management groups. We will also build community liaison groups through this programme to engage with the public.

Research plan We want to reduce NHS operating theatre's carbon output by half through this ambitious research programme.

The overall aim is to co-design, test and refine interventions targeting the whole theatre team and evaluate its implications for the NHS.

The research design will be efficient using short data collection forms and digital processes including virtual follow-up.

Aim 1: Iteratively co-design an intervention and its implementation strategy, using the COM-B and CFIR frameworks Aim 2: Test the intervention in an internal pilot cluster randomised trial with predefined STOP-GO criteria, then a large cluster randomised trial (~23,600 patients, 59 NHS hospitals) comparing carbon-reduced surgery to usual practice.

Aim 3: Complete parallel mixed-methods process evaluation to explore how and why behaviours change.

Aim 4: Determine whether target behaviours are maintained after the trial ends, through a post-trial cohort study and interviews. Aim 5: Use modelling to estimate NHS budget, carbon footprint, and carbon-offsetting implications of the trial.

Equality, Diversity and Inclusion We have a proactive plan to include a diverse range of hospitals and patients, including from marginalised and under-represented communities.` Team We have further strengthened our team since Stage 1, which includes surgeons, anaesthetists, behavioural scientists and methodologists from three UK Universities, supported by the Royal Colleges of Surgeons and Anaesthetists.

We are building a significant collaboration with the Birmingham institute for Sustainability and Climate Action, who will provide climate science expertise. We have also added several new collaborators with expertise in behavioural change techniques.

Impact This programme will provide a major step towards safe net-zero healthcare, up-skill a generation of researchers, and create transferrable lessons to upscale across the NHS.