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Green Ward Competition

Meat-Free Mondays Pledge - Renal Unit

By: Royal Devon and Exeter NHS Foundation Trust

460 kgCO2e (Estimated)

Background: meat, amongst all food, has a high carbon footprint and is more costly than other foods. The renal unit dietician wished to raise awareness amongst staff of the particularly high carbon footprint of meat.

Approach: Kidney Unit staff were invited to sign the ‘Meat-free Monday’ campaign pledge.

 

Results: 30 staff signed up to the pledge.

Environmental: if staff were not eating a portion of meat once a week this would amount to 598 kgCO2e per year. Eating vegetables instead has approximately 77% of the carbon footprint of meat so the savings would be approximately 460 kgCO2e per year (Carbon factor is 2.5 for meat and 1.73 for vegetarian meals).

Cost: savings to the Trust would depend upon whether the staff were buying food from the hospital or providing their own meals. Vegetarian meals tend to be cheaper than meat-based meals and so there would be a potential saving for the Trust if this measure was adopted at scale in the canteens.

Social: there are potential benefits to staff in joining a movement and in raising awareness of the environmental impacts of our daily choices and habits.

The Centre for Sustainable Healthcare runs the Green Ward Competition as a clinical engagement programme for NHS Trusts wishing to improve their environmental sustainability and reduce their carbon footprint.

Olivia Bush, olivia.bush@sustainablehealthcare.org.uk

Home haemodialysis – Renal Unit

By: Royal Devon and Exeter NHS Foundation Trust

194,700 litres of water/year

£ 1,577

177 kgCO2e

Goal: to assess the value of home haemodialysis compared to in-centre haemodialysis in financial, environmental and social terms. The service currently supports 18 patients to undergo home haemodialysis.

Background: the renal service has been aiming to increase the number of patients receiving haemodialysis at home to improve the financial and environmental impact of haemodialysis as well as to improve the patients’ experience of care. Home haemodialysis uses less water - 152 litres/week/patient on average compared with 360 litres/week/patient in conventional in-centre treatment. Consumables such as plastic and cardboard packaging can be recycled by the local council in the domestic recycling. Utility costs involved in the haemodialysis service are borne by the Trust and reimbursed to the patient. Renal nurses visit the patients at home to oversee care. The process of home haemodialysis is less demanding from a cardiovascular perspective (i.e. less stressful on the heart) as haemodialysis occurs over a longer time. There is evidence that patients undergoing haemodialysis at home:experience an improved symptom profile (improved energy, appetite and sleep), live longer and take fewer medications.

Results: The calculations assume savings as if all these patients were new to the service and would have been on in-centre dialysis. Note that results are based on water use as water use was the largest difference between in-centre and home haemodialysis. Travel (of patients travelling to the units and renal nurses visiting the patients at home) and electricity could also be considered in calculations. A reduction in medication also has a positive impact on the environment, but as there was no data available it has not been included in the calculations.

 

Cost: savings due to reduced water use amounted to £1,577 per year for the 18 patients.

Environmental: savings of water use per year were 194,688 litres, with a carbon footprint reduction of 177 kgCO2e.

Social/health: there is evidence from the literature of patients undergoing home having a better experience of haemodialysis, however no assessment of the social impact/patient experience was carried out as part of this project.

Renal Unit, RD&E

The project was part of the renal team's efforts in the Green Ward competition run by the Centre for Sustainable Healthcare

Centre for Sustainable Healthcare

Olivia Bush, olivia.bush@sustainablehealthcare.org.uk

Disposing of bicarbonate canisters in general rather than clinical waste – Renal Unit

By: Royal Devon and Exeter NHS Foundation Trust

£498

-280 kgCO2e

: used bicarbonate canisters (Bi-CART) weighing 100g/canister were being put into clinical waste for disposal, which was thought to be an unnecessary expense as disposing of clinical waste is much more costly than disposing of general waste.

Approach: The canisters are now being put in general waste. Results & discussion:

Cost: £498/year in Heavitree unit.

Environmental: The carbon cost of sending the plastic cannisters to landfill increased by 280 kgCO2e/year in the Heavitree unit. Some bicarbonate cannisters (e.g. manufactured by Baxter) can be recycled. Whilst recycling (at a cost of £233.23/tonne) is a more expensive way of processing waste than general waste (at £128.23/tonne), it is cheaper than clinical waste processing (at £350.oo/tonne) and is better from an environmental perspective.

Social: None identified for this project.

Heavitree haemodialysis unit, RD&E

The project was part of the renal team's efforts in the Green Ward competition run by the Centre for Sustainable Healthcare

Centre for Sustainable Healthcare's Green Ward competition

23/04/2017
Olivia Bush, olivia.bush@sustainablehealthcare.org.uk

Streamlining disinfection of dialysis machines – Renal Unit

By: Royal Devon and Exeter NHS Foundation Trust

52,416 litres of water/year saved in one dialysis unit.

£1790

4,406 kgCO2e

Background: 24 Gambro dialysis machines are used on the unit. Each day 3 patients use each dialysis machine. After each patient use the machine goes through a heat disinfection cycle to ready it for the next patient (i.e. 3 times/day). In addition, a ‘Hot C-CART’ cycle was run at the end of the day to remove calcium, with a further disinfection cycle overnight.

Approach: The third heat disinfect cycle has been eliminated and the Hot C-CART cycle started following the third patient. This saves 24 heat disinfection cycles saved each day and reduces water and energy use. 11 Results: are given for the savings made at Heavitree. Additional savings would be made if changes were spread to all sites (note that the size of different units varies so the potential for savings would be different at each site).

Cost: £1790/year in Heavitree unit.

Environmental: 4,406 kgCO2e/year at the Heavitree unit. 52,416 litres of water/year in Heavitree unit.

Social: None identified for this project.

Heavitre Dialysis Unit, RD&E

The project was part of the renal team's efforts in the Green Ward competition run by the Centre for Sustainable Healthcare

The Centre for Sustainable Healthcare runs the Green Ward Competition as a clinical engagement programme for NHS Trusts wishing to improve their environmental sustainability and reduce their carbon footprint.

23/04/2017
completed
Olivia Bush, olivia.bush@sustainablehealthcare.org.uk

Reduce Disposables on Abbey, Otter, and Dart Wards – Housekeeping Team

By: Royal Devon and Exeter NHS Foundation Trust

£1274

82kgCO2e (Estimated)

The housekeeping team carried out 2 projects on Otter ward and have since spread changes to Abbey and Dart wards.

Project 1:

Goal: To replace plastic teaspoons with reusable metal spoons.

Background: On the 24-bedded ward around 100 plastic spoons are used each day for three meals for patients & hot drinks for patients and staff. The housekeeping team suggested reducing waste by introducing metal spoons.

Approach: Buy metal teaspoons and stop buying plastic teaspoons.

Results: The cost of water and electricity used to run the dishwasher, the carbon conversion factors for the materials used to make the spoons and the cost of the waste recycling, together with the weight of the two types of teaspoons was used to calculate environmental and cost benefits of this project.

Cost savings: Over 1 year the cost savings would be £245 for a single ward and has the potential to save £7338 if this change was made successfully on 30 wards. These figures include costs of dishwasher use (energy and water) and a waste of 10% of spoons due to damage. If spoons were retained in the ward, then savings would increase year on year.

Environmental savings: 42 kgCO2e were saved by this change. 

Social savings: demonstrating good stewardship of resources and including environmental impact into decisionmaking about housekeeping in a healthcare setting.

Next steps: This project has been selected for the concept to be spread to other areas of the hospital.

 

Project 2:

Goal: to reduce plastics waste from serving orange juice on the ward.

Background: individual portions of orange juice are served in small plastic pots. These are handed out to, on average, 20 patients at lunchtime and at the evening meal.

Approach: instead of buying individual portions of orange juice the ward bought hard plastic tumblers and 1 litre cartons of orange juice. The cost of water and electricity used to run the dishwasher, the carbon conversion factors for the materials used to make the different packaging and the cost of the waste recycling, together with the weight of the two types of packaging was used to calculate environmental and cost benefits of this project.

Otter, Abbey and Dart wards - RD&E

This project was part of the Centre for Sustainable Healthcare's Green Ward competition

The Centre for Sustainable Healthcare runs the Green Ward Competition as a clinical engagement programme for NHS Trusts wishing to improve their environmental sustainability and reduce their carbon footprint.

23/04/2017
completed
Kevin Brown, Mary Drinkwater, Amanda Lawrence, Michelle Penna & Jason Maddocks, N/A

Minimising Inappropriate Use of Dietary Supplements - Nutrition and Dietetics

By: Royal Devon and Exeter NHS Foundation Trust

Goal: The aims of the project were to reduce the inappropriate use of oral nutritional supplements (ONS)

Background: ONS are easily accessible to ward staff and there has been very little monitoring or control over their distribution. The dieticians postulated that ONS were often given to patients, without a review by a dietician. This was confirmed by an audit in December 2017 that showed a discrepancy between the number of dietician prescriptions for ONS per week and the number ordered by the catering department.

Inappropriate use of ONS has the potential to have a negative impact on patient health, for example if sugarcontaining ONS are given to diabetic patients (ONS were given out by catering staff who do not have training on diabetes) or if patients are not assessed adequately and given professional advice on diet and nutrition (for example drinking milk rather than using ONS in patients less ‘at risk’ of malnutrition).

Furthermore, if patients are discharged to the community with inappropriately dispensed ONS this has the potential to incur large costs for GPs as ONS are cheap for hospitals to provide (1p each) but much more expensive to provide in the community. The prescriptions are sometimes, but not always, reviewed in the community. Where prescriptions are not reviewed unused ONS may accumulate in patient’s homes and go to waste.

Approach: establish a more effective management system for the supply and storage of ONS at the RD&E Wonford Hospital at ward level

 

Progress:

Designing a system:

• the team were aiming to devise a simple, reliable and uniform system to supply ONS to all wards, regulating distribution but also allowing for large volumes of ONS to be available for patients being discharged with little advanced notice.

• part of streamlining the system involved reducing the number of different ONS supplied by wards. It has been difficult to gain consensus on which reduced range of ONS to use in different locations and this work continues.

• When piloting the system, the Datix system was used to log any problems encountered. 

• Prior to the launch information was disseminated about the new system by arranging meetings open to clinical stakeholders (e.g. matrons, registered nurses, HCA’s, ward housekeepers, dietitians, logistics, catering). Meetings were poorly attended and some email addresses were out of date.

Launching the system: The ‘Top Up’ ordering system for ONS was launched in September 2018. Under the new system:

• all ONS ordered can be tracked and monitored using bar codes.

• The dieticians complete prescription forms for the ward housekeepers so that the housekeepers know which patients are prescribed ONS, which ONS are due and how frequently they should be given.

• There is also a section on the prescription form to help the ward housekeeper manage ward stock levels.

• The forms will also be used for monitoring. They will be returned monthly to the dietetics manager who repeat the audit carried out in December 2017 to see if the new system and communications with different teams has reduced the number of ONS being supplied to patients without dietetics advice.

 

Results: The re-audit is yet to take place, so results are awaited. The team have been learning about managing change including running a consultation process, decision-making in a large, diverse organisation and that disseminating information about change in an organisation is challenging and requires a multi-faced communication strategy.

Savings: In the long term it is hoped that the ‘Top-Up’ system will be embedded and that most ONS will be prescribed by dieticians. It is expected that this regulated distribution will have the down-stream effect that fewer patients will be discharged on inappropriately dispensed ONS, reducing the cost to NHS North, Eastern and Western Devon Clinical Commissioning Group and reduce the waste of unused ONS.

The Centre for Sustainable Healthcare runs the Green Ward Competition as a clinical engagement programme for NHS Trusts wishing to improve their environmental sustainability and reduce their carbon footprint.

Olivia Bush, olivia.bush@sustainablehealthcare.org.uk

Reducing Unnecessary Cannulation – Emergency Department

By: Royal Devon and Exeter NHS Foundation Trust

70% reduction in unnecessary cannulation

£ 27,830

8,400 kgCO2e

Goal: To reduce unnecessary cannulation in the emergency department (ED).

 

Background: before the project was carried out, inserting a cannula for a patient arriving in the emergency department was considered ‘routine’ care. Once a cannula is inserted the policy was for all cannula to be fitted with a Bionector, for infection control purposes. However, staff noticed when reviewing patients that many cannulae were inserted and not used or were used inappropriately (e.g. intravenous fluids or drugs used when the patient was able to drink and take oral medications). It was suspected that practice of inserting a cannula ‘routinely’ led to significant waste in terms of clinician time, waste of equipment required for cannulation, inappropriate use of intravenous fluids and medicines and unnecessary discomfort for patients. It was also noted that, where cannulae were likely to be short term, such as in theatres or the resus section of ED then Bionectors were not mandated, but in the main ED it was still expected that patients should have Bionectors attached to cannulae even though cannulation is often only required short term in ED.

 

Approach: The ED team planned to carry out an audit to test the hypothesis that a significant number of cannulations were unnecessary. ED consultants raised awareness of the audit prior and during the audit at the thrice-daily team handovers and with a poster campaign (posters put up around the department and on equipment trolleys where the cannulainsertion kit was kept). For 1 week doctors and nurses inserting cannulae recorded information on the patient’s main clinical problem on admission, the intended indication for insertion, number of attempts at insertion (i.e. number of cannulae used), whether the cannula was used in ED and what the cannula was used for. The 6 proforma for recording data was handed out at handover and was available on equipment trolleys. A collection tray for completed proformas was placed in ED. After the initial audit the results were presented. Informal (at handover) and formal (presentation) education was carried out on correct use of cannulae including raising awareness of a revised policy for ED, agreed with the infection control team, that if a cannula is likely only to be required short term then a Bionector did not need to be attached.

After a round of education the consultants stopped mentioning the changes and the audit was then repeated 1 month later, again over 1 week, to see if the project and education had been effective and if any changes had been embedded.

Emergency Department, RD&E

Staff noticed that cannulae and bionectors were being inserted or used inappropriately in the ED

The Centre for Sustainable Healthcare runs the Green Ward Competition as a clinical engagement programme for NHS Trusts wishing to improve their environmental sustainability and reduce their carbon footprint.

23/04/2017
completed
Olivia Bush, olivia.bush@sustainablehealthcare.org.uk

Medicine Waste Reduction - Ash Ward

By: Ashford & St Peter’s Hospital NHS Trust

£2,791

432kg CO2e

Goal: The aims of the project were to reduce wasted medicine and save staff time on medicine orders.

Background: The Team Leader identified that Ash Ward was wasting significant amounts of medicine and staff time on medicine orders. They decided to tackle the issue my addressing medicine order procedures and auditing medicine wastage.

Approach:

  1. The medicine cupboard was redesigned to help ease storage procedures and patient own medication.

  2. Montelukast was set a TTO prelabelled pack, meaning that patients did not have to return to the ward to

    collect it. This cut down on pharmacy time and saved time for patients,

  3. Antibiotic was kept in the fridge and stored for all patients, reducing antibiotic wastage.

  4. Changes were communicated to all staff on the ward.

Savings:

Medicine waste data was collected at baseline and again after the changes. Before changes, 92 medicine orders, not including inhalers, were wasted over six weeks. After the change, this number dropped to 25 over six weeks. The savings project across a year equate to 558 medication orders. Assuming a cost £5 per average medication order, this would create yearly savings of around £2,791. Using the SDU pharmaceuticals carbon conversion factor, this amounts to 432 kgCO2e. Carbon and cost savings do not take into account waste disposal as the information was not available at the time of writing. Unfortunately, exact time saving data is not yet available, however these would significantly add to savings and have been qualitatively noticed on the ward in terms of staff satisfaction. The total yearly savings for this project could be around £2,791 and 432 kgCO2e.

The Centre for Sustainable Healthcare runs the Green Ward Competition as a clinical engagement programme for NHS Trusts wishing to improve their environmental sustainability and reduce their carbon footprint.

Olivia Bush, olivia.bush@sustainablehealthcare.org.uk

Discharge Checklist Planning - May Ward

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By: Ashford & St Peter’s Hospital NHS Trust

£18,750 (Estimated)

4,757 kgCO2e (Estimated)

Goal: To reduce bed-blocking by training Band 5 nurses to conduct discharge checklists.

Background: The team found that patients who were ready to be discharged were taking up extra bed days in the ward due to senior nurses not having enough time to complete discharge paperwork. The team realised that by training band 5 nurses to do the same paperwork they would be able to help patients spend more quality time out of the ward and save bed days on the ward.

Approach: Although there was not enough time for the project to be run, the approach suggested was to include fast-track checklist training as part of zero-three month or six-month competency reviews.

Savings: It was estimated that this change could save 2.5 bed days per week. Assuming a cost of £150 per bed day, the yearly savings would amount to £18,750 and 4,757 kgCO2e.

May Ward

The Centre for Sustainable Healthcare runs the Green Ward Competition as a clinical engagement programme for NHS Trusts wishing to improve their environmental sustainability and reduce their carbon footprint.

Olivia Bush, olivia.bush@sustainablehealthcare.org.uk

Incontinence Pad Use Minimisation - Acute Medical Unit

By: Ashford & St Peter’s Hospital NHS Trust

£500

Goal: To reduce the unnecessary use of incontinence pads on the ward.

Background: When patients come from the Emergency Department to AMU they often have had incontinence pads fitted even when there is no history of incontinence. When they are on AMU incontinence pads are often continued even though the patients can get to the toilet.

Approach: A campaign to change the process of applying incontinence pads was run on the wards with posters and explanations during team meetings.

Savings: Savings identified through the minimisation of incontinence pads amounted to £500 per year. As the ward was exceedingly busy with a high turnaround of staff, the project was considered too time consuming to continue and stopped. It is advised that the project is restarted when staffing is settled and a successful campaign can be run.

The Centre for Sustainable Healthcare runs the Green Ward Competition as a clinical engagement programme for NHS Trusts wishing to improve their environmental sustainability and reduce their carbon footprint.

Olivia Bush, olivia.bush@sustainablehealthcare.org.uk