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Paper towels - Getting the basics right: choosing paper hand towels for use in one trust.

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Paul Raymond, RN, is a Clinical Purchasing Specialist working for the Bristol and Weston NHS Purchasing Consortium, which procures on behalf of three hospital trusts, four primary care trusts and the ambulance service in the Avon region.

Paul Raymond, RN, is a Clinical Purchasing Specialist working for the Bristol and Weston NHS Purchasing Consortium, which procures on behalf of three hospital trusts, four primary care trusts and the ambulance service in the Avon region.

Effective hand hygiene plays a major part in reducing infection in hospitals, such as outbreaks of diarrhoea and vomiting and the spread of methicillin-resistant Staphylococcus aureus.

A nationwide programme - Clean Hospitals, including Handwashing Initiative - aims, in conjunction with the Government's 'Clean Hospital' programme, to improve hand hygiene in the NHS. It promotes two key methods of hand cleansing (NHS Purchasing and Supplies Agency, 2003):

- With water and hand soap, followed by drying with single-use disposable hand towels

- Through use of alcohol-containing gels (but it is important to note that these are not effective for removing bodily fluids).

Discussions with my colleagues revealed that clinical staff were washing their hands up to 40 times during any one shift. Sore and chapped hands are common, so to encourage staff to carry out this basic function, it is important that the products supplied are of such quality as to promote frequent handwashing.

Most NHS acute trusts buy consumable items from the NHS Logistics Authority. Purchasing figures for the group of trusts where I work show that three paper consumable products come in the top 10 spends: pulp-based incontinence products, A4 printing/photocopying paper and hand towels.

Despite the low unit cost of paper products, acute trusts need to purchase vast quantities of them in order for organisations to function on a day to day basis. For example, in 2003-04 three of the trusts covered by Bristol and Weston NHS Purchasing Consortium spent more than £400 000 on paper hand towels.

In 2003, a significant change was made in the type of paper hand towels supplied through NHS Logistics. Single-ply, blue and green hand towels were no longer included in the list of products available to the NHS. They were replaced by a new range of single- and two-ply white towels, which is regarded as being more absorbent and kinder on the hands of nursing and medical staff when used frequently.

This change prompted North Bristol NHS Trust to introduce a new product. In 2002, the trust had started to consider replacements for the blue and green hand towels. Initial calculations indicated that potential increases in expenditure could be some £100 000, owing to the higher list price and a predicted rise in use. The potential rise in expenditure warranted the involvement of the clinical purchasing specialist to look into replacements.

The role of the clinical purchasing specialist is to ensure that evaluations of any particular product are meaningful and accurate. It also involves monitoring the decisions made by senior management/clinicians, which are based on this information, to assess effective implementation.

In evaluating products the priority is to balance the clinical needs of staff against the trust's financial constraints. This can mean having to make difficult decisions. The challenge faced in this instance was to find a replacement hand towel that provided a balance between quality and price, which meant making a judgement on whether one hand towel was more acceptable than another.

The audit process took five months. Part of this involved convening a Hand Towel Group, representing the groups that would be affected by any change. Infection control staff are probably most experienced at defining what product is most suitable for the clinical areas under their jurisdiction. They are also more likely than anyone else to be affected by the fall-out if an incorrect decision is made. Domestic service managers also needed to be involved because it is usually the responsibility of their staff to ensure an adequate supply of hand towels. In addition, the domestic service managers held the budget for the purchase of hand towels.

Setting the agenda
The first meeting of the Hand Towel Group was convened in December 2002 to discuss the imminent removal of the blue and green hand towels from the NHS Logistics Authority catalogue. The agenda included a discussion of issues arising from the NHS Purchasing and Supply Agency (PASA) initiative and other local initiatives, as well as cost. A plan was developed to evaluate all potential alternative hand towels available.

Demonstration meetings
Three companies distributing their hand-care products through the NHS Logistics Authority attended the group's second meeting. They were: Georgia Pacific, Kimberly-Clarke and SCA. The purpose was to allow them to present the benefits of their brand of hand towels and dispensers.

Each was asked to include a practical activity consisting of supplying soap and a bowl of water for members of the Hand Towel Group to use. This allowed all those present to gain a better understanding of the softness, strength and absorbency of each product. Another consideration was the ability to effectively clean the surface of the dispenser and the ease of dispensing towels individually, without contaminating the surface of the next towel.

This simple activity proved useful in narrowing down the dozen or so towels presented to the final three that would be subjected to a more in-depth evaluation. It also allowed us to focus on the clinical effectiveness of each product, as opposed to purely financial matters. Our intention was to later use the cost as the differentiating factor between the two most clinically effective products.

Three towels were selected for evaluation in different clinical settings: a surgical/trauma ward, a high-dependency unit and a general medical ward in hospitals in the North Bristol NHS Trust.

The towels were evaluated independently - one per setting. It was not deemed necessary to follow rigorous scientific protocols in this evaluation: it would have been time-consuming to set up effective control measures by sequential evaluation of all three towels in each ward, and impossible to remove staff subjectivity. We recognised that the hand towels previously used in each area would affect the results.

Staff in each ward were asked to complete evaluation forms, responding to specific questions about the softness, absorbency and strength of each towel. They were also asked to summarise their feelings about the product by answering the question: 'Do you think that the towel evaluated was clinically effective?' A clinically effective product was defined as one that they would use on a day-to-day basis and would be appropriate for use in their ward.

In my experience of such evaluations, clinical efficacy dictates which products are deemed worthy of closer examination. Opinions can be subjective, dependent on the experiences of the person making the decision. Therefore, the results of any evaluation have to be interpreted using quasi-quantitative means. As a result, the most useful outcome from these evaluations may be simply to establish the best and worst aspects of a particular product.

Analysis of results
The hand towels were evaluated for about three weeks, and just under 50 evaluation forms were returned. The responses were summarised, to enable comparison of how the towels had been received. This information was presented at the next meeting of the Hand Towel Group, where participants analysed the results and raised any questions. A summary of the results is presented in the box at the top of the page.

Any decision based purely on clinical performance would have resulted in the choice of Towel A. However, including a cost analysis made it possible to estimate the financial implications of adopting each brand of towel. Towel C was quickly eliminated. The cost increase of Towel A was not justified by its extra performance, and this position was (after considerable debate) agreed. Towel B was selected and the group chose to ratify the switch to the new product as soon as possible.

Implementation has been successful, with the general opinion of clinical staff being that the new towels are a considerable improvement on those previously used. The audit was relatively straightforward and trouble free, and it has been gratifying to hear staff say that they are pleased with the new products.

Added to that, the North Bristol NHS Trust has been able to avoid spending about £100 000 per year on this product, by comparison with the expenditure on hand towels at a neighbouring similar-sized trust.

The success of this project was the result of a collaborative approach to evaluation and implementation. The involvement of a number of relevant stakeholders allowed issues to be resolved before they became problems and gave legitimacy to the decisions of the group as a whole.

Author's contact details
Paul Raymond, RN, Clinical Purchasing Specialist, Bristol and Weston NHS Purchasing Consortium, Supplies Department, Level 1, The Greyfriars, Lewins Mead, Bristol BS2 1NS; email:

Latest Policy
North Bristol NHS Trust guidance on infection control

- Handwashing is an infection control practice with a clearly demonstrated efficacy and remains the cornerstone of best practice to reduce the spread of infection (ICNA, 1999)

- Routine handwashing removes transient organisms from soiled hands. It is essential to wash hands after they may have become contaminated, as micro-organisms are not visible to the naked eye

- Hospital-acquired infection costs the NHS millions of pounds each year. If the practice of handwashing was improved, the incidence of hospital-acquired infection could be significantly reduced.

- Towel A was the best performer, but also the most costly

- Towel B performed slightly less well, but was considerably more cost-effective

- Towel C was the poorest performer and significantly more expensive than Towel B.

PROCESS/ACTION Stimulus for change: Discontinuation of the product via NHS Logistics, and a Department of Health-backed programme to encourage more frequent handwashing by staff

Convene stakeholders: Infection control, domestic service managers, clinical staff to form a Hand Towel Group

Demonstration and review of alternatives: Companies invited to present products

Shortlist: Three products selected for trial in clinical areas

Audit: Products trialled for three weeks in high-dependency unit, surgical/trauma ward and medical ward

Implementation: Successful implementation of Towel B - cost avoidance estimated to be in the region of £100 000

Infection Control Nurses' Association. (1999)Guidelines for Hand Hygiene. York: ICNA.

NHS Purchasing and Supplies Agency. (2004)- Clean Hospitals, including Handwashing Initiative: National priorities. Available at: (accessed June 4).

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