Sue Lamont, RGN.
Clinical Procurement and Risk Management Co-ordinator for Surgical Services, University Hospitals of Leicester NHS TrustWhen three acute trusts in Leicester merged into one organisation in 2000 - the University Hospitals of Leicester NHS Trust - it soon became clear that each hospital was using different products for the same purpose and, on occasion, paying different prices for exactly the same product.
When three acute trusts in Leicester merged into one organisation in 2000 - the University Hospitals of Leicester NHS Trust - it soon became clear that each hospital was using different products for the same purpose and, on occasion, paying different prices for exactly the same product.
About 15 months after the merger, two developments took place - one was the creation of the role of clinical procurement and risk management co-ordinator for the surgical services directorate, the other was the setting up of a theatre procurement group. Membership of the group consisted of:
- The new clinical procurement and risk management co-ordinator for surgery (my role), working across the three hospitals - Glenfield Hospital, Leicester General Hospital and Leicester Royal Infirmary
- The theatre services manager (chair)- A surgical theatre manager from each of the three hospitals
- The procurement manager, who covers surgery as well as another directorate across the three hospitals
- The surgical accountant.
Our remit was to look at the standardisation of products and deliver value for money, while ensuring improved and consistency of patient care. Over the ensuing months, two further procurement groups were set up - one to cover the ward areas and the other the sterile services departments across the three hospitals.
Because we were planning to trial a large number of products covering all aspects of patient care, we devised our own evaluation form, covering factors such as packaging, instructions for use, and product performance. We included a scoring range from 1 ('very poor') to 5 ('very good'). During subsequent trials of various products, the form was modified, and extended to include two questions:
- Is the product 'worse', 'as good as' or 'better' than the one currently available?
- Is the product clinically acceptable?
The group decided that, for each product range, we would begin evaluation with the cheapest until we came to one with a clinically acceptable level of quality, after which we would focus on price. This principle has succeeded and has been accepted by clinical staff as a practical way to progress. It has been used in all product trials and tender evaluations.
We have carried out several major tender activities covering a variety of specialised products. Clinical staff, including consultants, have been heavily involved in all evaluations and make the final decisions. Because they are based on clinically led principles, substantial savings have been achieved without compromising quality, enabling standardisation and improving patient care.
In addition, with input from the procurement groups, in advance of the gloves trial we carried out a rationalisation of the stock types of product that are available from the NHS Logistics catalogue. However, it was difficult to enforce our choices while staff had access to the full catalogue.
The trial process
The first stock trial targeted examination gloves and was carried out in 2001. We planned to include every ward and department in the surgical directorate. To this end, we wrote to each service manager, enclosing copies of the evaluation forms, requesting that they copy them to their areas, and asking them to start the trial on a given date for a finite period. This exercise was not especially successful, but it was a valuable step in the learning process.
Despite the number of letters we distributed, many people only received them weeks later. The number of completed evaluation forms was small (and this continues to be a problem, in that many staff do not - for whatever reason - willingly complete the forms). We also underestimated the time it would take for wards to receive trial stock from NHS Logistics.
Eventually, we gained the agreement of senior staff across the directorate that 'an examination glove was an examination glove' and, as long as the trials were carried out in surgical areas within the directorate, and the glove did the job required without ripping, they would accept the procurement group's recommendations. However, the policy was still difficult to enforce because staff still had access to the full NHS Logistics catalogue and did not always receive the directions to change.
In 2002, a trust-wide audit was carried out by one of the glove suppliers. The company audited the number of brands we were using and why they were used. The exercise revealed disturbing practices: gloves were being used for inappropriate procedures and also worn when there was no need to (see box, above).
As a result of the audit, the lead nurse for infection control, the senior nurse for occupational health, the head nurse for surgery and myself met to discuss the way forward. We took into account recent legal cases and Health and Safety Executive (HSE) guidance, before deciding to continue to use latex gloves, except where staff or patients had a known latex allergy.
We then compiled a gloves matrix (pages 46-47) setting out procedures that 'require'/'do not require' the use of gloves. The matrix covers most procedures carried out across the three trust hospitals, and advises which gloves should be worn for specific procedures. It states when gloves are not necessary, and puts great emphasis on the thorough washing and drying of hands and the fact that gloves should be used for one procedure only before disposal.
We consider the risk of sensitisation is small if gloves are used properly and for the minimum period of time, particularly as powdered latex gloves, which carry the greatest risk, are no longer used anywhere in the trust, in line with HSE recommendations (see box, page 46).
The trust ratified our findings and the occupational health department monitors the situation.
The matrix has just been rolled out across the trust. It advises staff to consult the occupational health department about any problems they think may be caused by sensitisation to latex gloves, and will be put up in all wards and departments. Senior clinical staff had also long realised that nitrile gloves were being used inappropriately. These cost about twice as much as latex gloves, but were often used because staff liked their purple colour. However, nitrile gloves have had to be used when dealing with the chemical disinfectant gluteraldehyde, for example, as latex gloves do not provide an adequate protective barrier to the chemical. Following trials of various chemical disinfectants, the trust stopped using gluteraldehyde in 2003, and nitrile gloves are no longer required for this purpose.
This left the procurement groups with one remaining factor to address - instances of staff or patients who are either allergic to latex or the residual chemicals within them.
The new procurement system
In 2003, the trust introduced a trust-wide electronic ordering system, Logistics on Line, the new national NHS ordering system. Not only does this enable ward staff to order directly online, removing the need to use paper order forms, but it also provides the facility to mask products - with the consequence that some items can no longer be ordered routinely.
The only problem is that products have to be masked across the entire directorate, preventing anyone ordering these items. While it is possible to temporarily lift the mask, the procedure can be time-consuming and complicated.
The surgical directorate saw this as an opportunity to choose a standard latex examination glove, and enforce the ordering of that brand only, but accepted that alternative purchasing facilities would be needed in certain instances.
Our evaluation, which looked at several brands, concluded that the cheapest glove in the catalogue was not suitable. We chose to trial the next-cheapest latex glove - a brand that had been routinely used for several years without problems in one of the three hospitals.
To ensure the gloves were acceptable to staff in the other two hospitals, we trialled the gloves in two theatre departments, one in each hospital, which resulted in positive feedback.
Last March, we communicated with all staff across the surgical directorate and implemented the masking of all the other examination gloves. Because we still needed to purchase a small quantity of nitrile gloves for staff and patients with latex allergy, we entered into a contract with a third-party logistics company to purchase this product directly, thus overcoming the masking problems.
Despite all efforts, not all staff had received the message, and on occasion, people would ring the supplies department to complain they could not order the glove they wanted. This inadvertently turned out to be a good system for communicating the problems to us, if occasionally hard on the supplies department!
The only problem we encountered was in cases where the chosen standard gloves became slippery when wet, making them unsuitable for working with flexible endoscopes, for example. An alternative acceptable glove was found for endoscopy only. The surgical directorate's endoscopy department has its own materials management service operated by staff employed by the supplies department. Its Materials Management Computer System is separate from, though identical to, the Logistics on Line catalogue. This means selected departments can buy a product masked to others.
The trust has also decided to take this route, and this gives the advantage of total trust standardisation, as well as making substantial savings. We also benefit from a commitment discount, which reduces the price of individual pairs of gloves. We are now looking at the detail of last year's NHS Logistics purchasing, with a view to planning standardisation of other products with, potentially, similar benefits.
Health and Safety Executive advice on latex rubber sensitisation in health care
Advice from the Health and Safety Executive includes:
- If there is prolonged and close skin contact all natural rubber latex (NRL) gloves present a risk of sensitisation
- The proteins in the NRL glove leach into the powder, which becomes airborne when the gloves are removed. This creates a risk of a respiratory or asthma reaction to the user and to sensitised individuals in the vicinity
- This risk is almost completely eliminated in powder-free gloves with lower levels of proteins and process chemicals
- The HSE recommends a health assessment of staff before they commence the job to provide a baseline record, and an enquiry for dermatitis and asthma at least annually
- Purchasing policies should specify single-use NRL gloves with as low a level of extractable (or leachable) protein as reasonably practicable and that are powder free
- Trusts should prevent exposure by, for example, having a policy of only wearing gloves where there is an infection risk and that staff should wear NRL gloves only where there is a clear operational need, using a substitute where practicable.
Source: HSE, 2003 For more information see www.hse.gov.uk/latex.htm
What the initial audit revealed
- Gloves were being used for inappropriate jobs such as making beds
- Expensive surgeons' gloves were being used inappropriately, in some instances for procedures such as rectal examination
- Different glove practices were used for the same procedures across the trust, ranging from no gloves to the use of surgeons' gloves. These procedures included inserting a catheter, removing clips or sutures, and inserting a nasogastric tube
- 38 different types and brands of glove were being used across the trust, ranging from sterile and unsterile examination gloves in latex, vinyl and nitrile to surgeons' gloves
- Trust infection control policy was being contravened. Although the policy states that vinyl gloves are not to be used for any patient contact, because they are not felt to be adequate to protect the staff from body fluids, this policy was not being followed
- The use of so many different brands across a broad price range was not cost-effective
- Anecdotal evidence suggested that staff were wearing gloves when there was no need to do so: for example, when walking about the ward, between procedures.
Author's contact details
Sue Lamont, Clinical Procurement and Risk Management Co-ordinator, University Hospitals of Leicester NHS Trust, Radio Gwendolen Corridor, Leicester General Hospital, Gwendolen Road, Leicester LE5 4PW. Email: email@example.com
Health and Safety Executive. (2003)Natural Rubber Latex Sensitisation in Healthcare (Sector Information Minute SIM 7/2003/24). London: HSE.