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Quality as standard: the process of evaluating cannulae for trust-wide use

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Jackie Allain, RGN, DipNS.

Strategic Supply Manager, Hertfordshire Supply Management Confederation, St Albans, Hertfordshire

Standardisation is the process by which products are reviewed to evaluate how they work and consider their cost. It removes the fragmented and unco-ordinated approach to product choice that can occur in NHS settings. Not conducting full evaluations can result in poor practice, and products being used incorrectly (NHS PAS, 2002). Standardisation aims to improve patient care by making clinical staff more familiar with the catalogue of available products, ensuring they are used more efficiently and saving money.

Standardisation is the process by which products are reviewed to evaluate how they work and consider their cost. It removes the fragmented and unco-ordinated approach to product choice that can occur in NHS settings. Not conducting full evaluations can result in poor practice, and products being used incorrectly (NHS PAS, 2002). Standardisation aims to improve patient care by making clinical staff more familiar with the catalogue of available products, ensuring they are used more efficiently and saving money.

Hertfordshire NHS Supply Management Confederation (Box 1) is reducing the selection of products and introducing standardisation to:

- Make product selection consumer-led rather than supplier-led

- Encourage a rational approach to assessing replacement products

- Identify potential cost savings to the trust

- Improve the quality of services to patients.

Products are chosen to undergo the process on the basis of:

- High usage

- Extreme varieties: does the product offer variety of use within the trust and clinical areas?

- Cost. A range of questions should be asked when evaluating and considering a product (Box 2). Once it has been identified for standardisation, a product selection group undertakes the audit process. The group comprises clinical staff, with nurses and medics co-opted as required to look at an item. Trials are held in clinical settings and companies invited to give presentations. Cannulae
Many NHS nurses carry out cannulation and care of patients with intravenous access and therapy. But organisations such as the Royal College of Nursing (2003) have identified the need for a more co-ordinated approach to product choice. A review of the expenditure on cannulae in two hospitals within one Hertfordshire trust revealed that six types of peripheral cannula were in use trustwide. The review was prompted by three factors:

- The wish to reduce suppliers to achieve safer practice through familiarity

- Education and training needs

- The cost of using the product.

Some areas used more than one type of cannula, making it difficult for the trust training and development unit to establish a robust training programme. The importance of staff education and training in reducing hospital-acquired infections is highlighted in Winning Ways (DH, 2003). It states that insertion, manipulation and removal of cannulae should be carried out by trained, competent staff using a strictly aseptic technique. The education associated with the chosen product is as important as ease of use and patient safety. Following the review, the trust's product selection group decided to standardise cannula use across its services.

The audit
The product selection group called a meeting to determine the process for standardising cannulae. Each lead consultant and head of nursing for each clinical division were asked to pass invitations on to the appropriate representative for that area. Directors of nursing and medicine were also invited.

The initial meeting was poorly attended by medical staff. As a result, I approached the doctors in each area of high product usage to elicit views on the standardisation process. The outcome of these discussions with doctors - mainly anaesthetists - and nurses was a decision to rationalise the use of ported cannulae across the trust. Non-ported cannulae and safety devices would be addressed later. The staff identified four companies to take part in the cannula audit. This was based on current usage and costs, identified from information from NHS Logistics, the organisation through which we buy our products.

We felt that to change product brands as well as the types of devices used might result in poor compliance and co-operation from users.

Six clinical areas were chosen to pilot the cannulae, representing a good mix of areas: theatres, A&E, radiology, endoscopy and two surgical wards. One area subsequently withdrew from the trial.

The user group and a lead anaesthetist in the trust designed an evaluation form to assess the products for ease of use - for example, ease of insertion and removal, acceptability to the patient and how it compared with the product currently used in the area (Box 3).

Each department delegated a link person to liaise with me, as the strategic supply manager, and the companies. One week was allowed for the trial of each peripheral ported cannula.

Evaluation
Three weeks after the trials were completed the companies were invited to make 30-minute presentations, which included how they could support the trust's transition from the old to the new product. The capacity to offer ongoing support to the training and education department was crucial. The product selection group and co-opted anaesthetists and nurses completed an evaluation form after each presentation. The group then agreed an order of preference for the cannulae, based on a review of the two evaluation forms, clinical assessment of each product and each company's training provision. The group felt the least expensive cannula did not meet all our needs. The evaluation had indicated that up to three attempts were needed to cannulate a patient, increasing costs, until all relevant staff had been trained in its use. These difficulties, coupled with limited training and support, suggested the cheapest cannula would not be the most cost-effective, clinically effective and safe choice, in the views of the group. Other difficulties identified were:

- Limited educational support in two products

- Concern with flashback - the speed at which the blood returns up the cannula once it is inserted - in one product

- The sharpness of the needle on insertion in another product.

The cannula with the best clinical evaluation was one of the two more expensive ones listed in the NHS Logistics catalogue. But the company offered the trust good support with education and training. After completing the trial, we informed the director of nursing of the product selection group's findings. Although the chosen product was slightly more expensive, the group felt the ongoing support would make it more cost-effective in the long term.

The concerns expressed by the clinical area that withdrew from the trial were relayed to the director of nursing. This was to ensure the views of all clinicians were considered. Our recommendation was accepted.

Implementation
Standardisation began in April this year, with plans for the company to visit all clinical areas to offer staff training or product updates. The company also liaises with the trust's training and education department. I hold monthly review meetings with the company to ensure the transition occurs as smoothly as possible. We are encouraging online ordering via NHS Logistics, which allows the selected product to be viewed and ordered. Staff in the supplies department alert me if an attempt is made to order a product not on the standardised list. Ultimately best practice will be achieved through regular use of the same generic products.
Benefits of staff involvement
Setting up a product selection group ensures that all clinical areas have a stake in the choice of products. It also allows the relevant staff to be involved as each product is reviewed. Some staff will always be unhappy with the choices made because they involve retraining. The trust has since established a forum, led by the product selection group, to air any concerns. This forum is chaired by the director of finance, and product selection groups feed back to it. Decisions are then ratified through the strategic supply manager. We continue to monitor cannula use for compliance and to identify cost-saving benefits of our chosen cannula. As the standardisation only took place in April this year, it is too early to know if there has been any cost-saving impact. But by continuing to use standardised products, we aim to achieve value for money and to improve patient care.

Author contact
Jackie Allain, Strategic Supply Manager, HSMC, Tonman House, Victoria Street, St Albans AL1 3ER; email: jackie.allain@bedsandherts-ha.nhs.uk

Cabinet Office. (1998)NHS Procurement Review. London: The Cabinet Office.

Royal College of Nursing. (2003)Standards for Infusion Therapy. London: RCN.

Department of Health. (2003)Winning Ways. Working together to reduce healthcare-associated infection in England. (Report from Chief Medical Officer.) London: DH. Available at: www.dh.gov.uk/PublicationsAndStatistics/ (accessed April 29).

NHS Purchasing and Supplies Agency. (2002)Modernising Supply in the NHS. Available at: www.pasa.doh.gov.uk/modernisingsupply/ (accessed April 29)

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