Mr Preetham Kodumuri & Mr Edwin Jesudason, Orthopaedic Consultants, Betsi Cadwaldr University Health Board
Carpal Tunnel Surgery – Introducing the Lean, Green, More Efficient Pathway
Innovation Overview:
This initiative introduces a “lean, green” approach to carpal tunnel surgery (CTS), increasing efficiency, reducing costs, and minimising the environmental impact of surgery in this domain. By implementing a streamlined surgical process, the innovative practice achieves a more sustainable way of delivering care while enhancing surgical outcomes.
Strategic Case for Adoption:
Climate change is the biggest threat humanity has ever faced (United Nations, 2021). The NHS accounts for 4% of the UK’s greenhouse gas emissions (NHS England, 2020). The health care industry is the fifth largest contributor to greenhouse emissions globally (ARUP, 2021). Medical equipment and instruments form the largest carbon footprint (13.2%) across the UK health and social sector (HSC data, 2017). Surgical theatres form a small physical footprint within a hospital, yet cause 20%-30% of an institution’s waste (Kwakye et al., 2011). The largest carbon footprint within theatres comes from packaging and consumables which are often unused (30%) (Lee and Mears, 2012), poorly segregated and recycled (90%)(Lee and Mears, 2012) and incinerated or sent to a landfill waste site.
CTS is the most common surgical procedure in the UK, with over 80,000 cases performed annually. The “lean green” pathway halves procedure times and resource requirements, enables quicker patient turnover, reduces clinical capacity requirements, leads to fewer hospital visits for patients, and minimises clinical waste. It also significantly lowers costs, creating a sustainable and scalable model that can be extended to more complex surgical procedures. This initiative aligns with Wales’s commitment to sustainable healthcare and planned care recovery by addressing surgical efficiency and environmental impact simultaneously.
The lean, green approach has been adopted across all three sites in Betsi Cadwaladr University Health Board and by a number of private health providers. Over 300 procedures have been completed successfully via the lean green method to date!
Methodology:
The “lean green” pathway incorporates a combination of interventions, which includes taking CTS out of theatres into day case rooms, reducing staffing requirements to one third (theatre team of 2 instead of 6), reducing procedural times significantly and resource usage and costs through smaller theatre drapes and less surgical equipment used.
Impact:
- Sustainability: A substantial reduction in the environmental footprint, including a decrease of 22.14 kg of CO2 per case, translating to an 80% reduction in the carbon footprint of CTS.
- Efficiency: Faster surgeries improve patient throughput and reduce waiting times.
- Scalability: The approach can be adapted to other surgical procedures and implemented across health boards, increasing theatre capacity and resource efficiency.
Economic and Environmental Impact:
The lean and green pathway offers significant cost savings while delivering environmental and social benefits:
Annual National UK Savings:
- Environmental: Reducing 12 tonnes of CO2 emissions
- Financial: £1.33 million in annual savings
- Indirect savings: Reduced energy costs from less reliance on hospital infrastructure
By using smaller theatre drapes and fewer instruments there is a direct saving of £37.42 per procedure. By moving CTS into minor ops rooms and reducing the resource utilisation through reduced appointments and surgical time, the initiative lowers the resource utilisation for each carpal tunnel release by £1,120 per patient with no complications reported.
Key Benefits:
- Reduced Environmental Impact: 80% decrease in the carbon footprint per procedure.
- Economic Savings: Two-thirds reduction in costs associated with traditional surgical setups.
- Improved Surgical Efficiency: Shorter procedure times and reduced hospital visits free up theatre capacity.
- Upskilled Staff: Training on sustainable surgical practices enhances team capabilities.
- Lower Waiting Lists: Streamlined processes reduce backlogs and improve patient access.
The Lean Green Pathway offers a practical, low-resource solution to improve healthcare delivery across Wales. Combining environmental responsibility with greater surgical efficiency and cost savings, it presents a scalable model with clear benefits.
Wider adoption across health boards and surgical specialties could significantly reduce the NHS’s environmental impact while enhancing patient outcomes and service capacity.
Relevant Policy/ Strategic Alignment:
NHS Wales Decarbonisation Strategic Delivery plan (2021):
Setting out “NHS Wales’ contribution towards a net zero public sector by 2030”
Our Programme for transforming and modernising planned care and reducing waiting lists in Wales (2022):
Goals:
- Effective referral
- Treat accordingly
Priorities:
- Transformation of outpatients
- Eliminating long waiters at all stages of the pathway
- Building planned care capacity
Welsh Innovation Strategy (2023):
Priorities:
- Reducing waiting lists
- Supporting a talented workforce
Promote, prevent and prepare for planned care (2023):
Supports:
- Efficiency of care
- Increased service capacity
- Collection of data
NHS Wales Technical Planning Guidance 2025 – 2028
Supports the ministerial priority of timely Access to Care and planning guidance for the optimisation of theatre usage.Regional Treatment Centres:
Day case surgical theatres are an integral part of plans for regional treatment centres and hand surgery along with hand therapy would lend itself ideally to such an environment.
BSSH GIRFT GUIDELINES FOR OPERATING OUTSIDE MAIN THEATRES (FEB 2022)
These guidelines will prove instrumental in reducing the carbon footprint of hand surgery across the country by promoting sustainable surgical practices. Operating outside main theatres reduces energy consumption, improves the ability to treat patients more efficiently utilising smaller surgical teams.
Service Presentation Material:
CTS Lean, Green Pathway Presentation
Service Implementation Material:
Adoption Case for Change
SOP
Over 300 patients benefit as hand surgery in Minor Operating Procedure Rooms expands across the Health Board – Betsi Cadwaladr University Health Board
Patient Testimony:
”I needed carpal tunnel surgery in my other wrist around a year ago but last time I was waiting on the ward before I went into theatre. This time was much more relaxed, I came straight into outpatients and I felt I was in and out of the procedure room very quickly and then I was fine to go home 45 minutes later. It’s fantastic that we have this available and I hope many more people like me benefit from this new way of working”.
Awards & Presentations
Shortlisted for an NHS Wales Award, October 2024
Bevan Commission Sir Mansel Aylward Award for Sustainable Working, June 2024
Winner – Betsi Cadwaladr University Health Board Sustainability Award, November 2023
Joint runner up in Green Surgery Challenge, 2021
Runner up in Green Health Wales, June 2022
Invited speaker at Welsh Orthopaedic Society in Chester, May 2024
Invited speaker at Federation of European Surgical Societies of the Hand, FESSH in Rotterdam, June 2024
Invited speaker, British Society for Surgery of the Hand in Leeds, April 2024.
Invited speaker at RSM – PLASTA Shaping the Future Congress, Oxford, July 2022
Invited speaker at Net Zero Operating Theatre (RCS) April 2022
Invited speaker at West Midlands Hand Society meeting, Birmingham, June 2022
