Striking a Balance in Theatres
Referral to treatment figures for October 2024 show that the NHS waiting list stood at 7.54 million cases.[1] To deal with this backlog, the NHS has set up surgical hubs across the country to streamline patient assessment, treatment and recovery.
With more surgeries, comes more anaesthesia use, but theatres already account for 50-70% of total hospital waste.[2] How can we treat more patients without compounding environmental impact? And what tools could help anaesthetists manage the cognitive load and enhance patient safety?
Keeping More Patients Safe
In the 2024 Autumn budget, the Department for Health and Social Care (DHSC) was granted £22.6 billion, to deliver an additional 40,000 elective appointments a week.[3]
The cardiac surgery unit at Liverpool Heart and Chest Hospital NHS Foundation Trust (LHCH) is one of the busiest in the country, treating just under 2,000 patients per year.[4] Last year it installed a new fleet of Mindray A9 anaesthesia workstations.
Liverpool Heart & Chest Hospital
Dr Omar Al-Rawi, Clinical Lead for Anaesthesia, is the Consultant Anaesthetist who led the procurement, “We were looking for new anaesthetic machines to replace our previous fleet. Key features for our workflow were enhanced safety, reliability, ease of use and connectivity to electronic patient records.
“There are lots of features on the A9 that make a big difference for patient safety while helping alleviate some of the cognitive load for anaesthetists. A useful feature for our practice is Flowpause which allows us to safely stop ventilation during surgery and automatically restart after an adjustable period. In the past that was done manually with the risk of the machine being left off and the alarms staying silent. This tool provides an essential safety measure for patients requiring surgery and intermittent ventilation.
"In the cardiology catheter lab the A9 display can be connected to a remote monitor to provide clear patient anaesthesia data at the workstation in the lead proof zone. This enhances safety of anaesthesia in a non-theatre environment which has restricted access to the anaesthetic monitoring. Furthermore, we are excited about introducing the concept of remote control function of the A9 anaesthetic machines once approval is obtained from the regulatory bodies.
“The automation of the ACA and low flow provides seamless accurate titration of depth of anaesthesia at low flow without the need to manually adjust the gas flow, volatile agent and oxygen level to reach the target level. We’re expecting to see reduced consumption of anaesthetic gases from this and plan to use the Mindray M-IoT system to track inventory and usage going forward. This will then deliver both an environmental and financial benefit.”
To ensure the correct patient data is available and updated, Trusts are digitising data flows between monitoring devices and electronic patient record systems. Communication failures occur in approximately 30% of procedural communications in the OR[5], but connected workflows allow greater data visibility throughout the patient journey, minimising risks and improving patient care.
Dr Al-Rawi continues, “One of the key things for us was that the A9 could support our charting which automatically takes data from the anaesthesia machine and patient monitors to create an electronic anaesthesia record. The Mindray team have been very responsive getting the A9 machines integrated.”
Greener anaesthesia delivery
The NHS is committed to reach net zero by 2040, with an ambition to reach an 80% reduction by 2028-2032.[6] Currently, around 2% of all NHS emissions can be attributed to anaesthetic and analgesic gases like nitrous oxide.[7]
Every year in the UK, 97,000 tonnes of CO2e(t/CO2e) is released from volatile anaesthetic gases[8] for ~450,000 surgical procedures.[9] The environmental impact is significant - one of the most common anaesthetic gases is desflurane and using just one bottle has the same global warming effect as burning 440 kg of coal.[10]
“As a Trust we’ve committed to being as green as possible,” explains Craig Murdock, Senior General Manager Clinical Engineer at Castle Hill Hospital in Cottingham. In 2023, NHS Humber Health Partnership opened the first phase of its £40m day surgery centre (DSC) to help reduce waiting times and address the surgical backlog resulting from the COVID-19 pandemic. The Centre includes pre-assessment facilities and 10 operating theatres for planned procedures, ranging from ear, nose and throat procedures to joint replacements and spinal surgeries. Mindray’s A9 anaesthesia workstation is among the cutting-edge equipment at the centre.
Andi Richardson, Anaesthesia & Ventilation Product Specialist from Mindray with one of the A9 systems at Castle Hill Hospital
“The A9’s AnaeSight feature will help us monitor how much volatile agents are being used so we can accurately benchmark our environmental impact. Compatibility with SageTech’s gas scavenging system is a bonus too. We can capture exhaled waste volatile anaesthetic agents and reuse them before they are released into the atmosphere. Anything that can monitor and reduce our footprint is so useful.”
Castle Hill’s DSC will also benefit from a range of gas reduction tools on the A9 to efficiently manage leakages and gas delivery. Anaesthetic Gas Scavenging System (AGSS) terminals measure the flow of waste gas, and an e-AGSS system automatically turns the AGSS off during standby to prevent waste gases going to the atmosphere. Automatic Controlled Anaesthesia (ACA) also automatically adjusts the fresh gas and vaporiser output to quickly achieve preset target end-tidal agent and inspiratory oxygen concentration to avoid waste.
“It’s been quite a transition to using a whole new anaesthesia solution, and the Mindray team have been very responsive to our needs.” adds Craig. “Mindray proved to be the best and most cost-effective option during our procurement process, which was great as it also meant we could standardise equipment across the DSC, alongside the Mindray BeneVision monitors we already had in place. Efficiency and cost-effectiveness are key priorities for us with the DSC. The build is on phase 3 now and it truly is a state-of-the-art site with state-of-the-art equipment.”
Flexibility for the Future
As the population ages and patients become more medically complex, there are increasing numbers of diagnostic and therapeutic procedures performed outside the main theatres environment. This poses several new challenges. Anaesthetists may be physically distant from patients or colleagues, the workspace may be small and unfamiliar, and there may be a lack of manpower.
With this in mind, Mindray has released the A3 anaesthesia system. Its customisable gas supply options make it safer to work in unpredictable environments. To enhance patient safety further, high-flow nasal cannula oxygen (HFNC) can be delivered via integrated or standalone systems and gas flow can be precisely measured with the digital flowmeter.
To improve efficiency, the A3 anaesthesia system provides comprehensive connectivity and data management features for better visibility of patient statuses in each operating room and to streamline maintenance. For full flexibility, the A3 has four configurations to make the most of the space available, making it ideal for the induction room.
Stronger Together
So where does anaesthesia go next? David Britton, PMLS Marketing Manager for Mindray UK outlines the company’s approach, “It’s all about working with our customers. Understanding their initial pain points, where we can help, and what they see as the biggest challenges on the horizon. Advanced tools, convergence of equipment and interoperability will be key, while presenting data in user friendly formats.
“As a global business we invest 10% of our turnover into R&D across all our product lines. That doesn’t happen in a bubble. We always encourage conversations and knowledge exchange between our customers and R&D team. For anaesthesia at the moment, there’s rightly a lot of focus on managing the sustainability of theatres. As more Trusts digitalise we're actively collaborating with them to implement the right digital workflows so they can work efficiently, and ultimately, deliver excellent and safe patient care.”
References:
[1]. https://www.bma.org.uk/advice-and-support/nhs-delivery-and-workforce/pressures/nhs-backlog-data-analysis
[2]. Guetter CR, Williams BJ, Slama E, et al. Greening the operating room. Am J Surg. 2018;216:683-8. Yates EF, Bowder AN, Roa L, et al. Empowering surgeons, anesthesiologists, and obstetricians to incorporate environmental sustainability in the operating room. Ann Surg. 2021;273:1108-14.
[3]. https://www.gov.uk/government/news/new-funding-to-kickstart-delivery-of-two-million-extra-nhs-appointments
[4]. https://www.lhch.nhs.uk/why-surgery
[5]. Lingard L et al. Qual Saf Health Care 2004, 13:330e4.; Hu YY et al. J Surg Res 2012; 177:37e42
[6]. p 6, Delivering a Net Zero Service National Health Service, July 2022: https://www.england.nhs.uk/greenernhs/wp-content/uploads/sites/51/2022/07/B1728-delivering-a-net-zero-nhs-july-2022.pdf
[7]. https://www.england.nhs.uk/greenernhs/2023/01/putting-anaesthetic-emissions-to-bed/
[8]. Hu, X, et al, Resources, Conservation and Recycling 2021; Volume 167. The carbon footprint of general anaesthetic
[9]. Environment FAQs, Association of Anaesthetists: https://anaesthetists.org/Home/Resources-publications/Environment/Our-environmental-work/Environment-FAQs
[10]. Putting Anaesthetic Generated Emissions to Bed, NHS England, https://www.england.nhs.uk/greenernhs/whats-already-happening/putting-anaesthetic-generated-emissions-to-bed
As featured in Clinical Services Journal, February 2025.
