Mapping Greener HealthcareMapping Greener Healthcare

Team Members:

• Grace Crossland - PICU Staff Nurse
• Dr Jonathan Ince - Simulation Fellow, LTHT
• Dr Alex Olney - ST3, Paediatrics 

Aim: To reduce use of non-indicated sterile gloves during preparation and administration of oral and enteral medications on PICU.

Strategic choice of project: During the pandemic the use of personal protective equipment (PPE) has escalated to an unprecedented level, however there is reasonable evidence to suggest that frequent, untargeted glove use worsens hand hygiene (1) and increasestransmission of preventable infection in our hospital environments (2). The wider PICU team have recently declared their wish to actively work towards sustainability, therefore we felt well placed to collaborate on glove usage. We were also inspired by similar changes achieved by Great Ormond Street Hospital (GOSH), through their gloves off (3) campaign.

Data collection:

We completed audits of patient drug charts to determine the average number of medication preparation and administration events on average per patient per day. We assumed that one pair of gloves would be used per event. However, as many administrations require a second nurse to check the medication beforehand, a glove use factor of 1.5 was applied to these episodes (as multiple pairs of gloves are commonly worn). From this audit data we extrapolated the percentage of glove use attributable to oral and enteral medicine administration and what we could reasonably expect to reduce.

We collected qualitative data from staff on their views on the project and glove usage. We did not gather data from service users as this was deemed inappropriate in the PICU environment when most patients are too young or unwell to communicate, and parents/caregivers are under considerable stress with their child acutely unwell. We considered collecting data from patients, however decided against this due to most patients being intubated and sedated and/or too young to engage. It was also felt to be inappropriate to speak to parents and/or carers given PICU is an incredibly stressful place for them to be.

Changes implemented: 

Our audit and research identified non-sterile gloves are not required with certain medications. This was reviewed and agreed by one of the senior nurses on PICU and infection prevention. We commenced an awareness and education campaign focusing on reducing nurse glove use when administering medications. We completed presentations at staff meetings as well as to available staff during breaks. We also created and published a poster board and placed reminder posters at all glove sites on PICU.

Results:

As our trial phase is currently ongoing, we have used our audit data and data provided from the GOSH campaign to make assumptions on potential impacts. Our audit identified that an average of 93.6 individual gloves are used per patient in a 24-hour period. At the time of our audit, there was an average of 11 patients on PICU, equaling 1029.6 gloves used per day. At maximum capacity of 18 patients, this would increase to 1684.8 gloves used per day. There was an average of 9 drug administrations per patient per day. 85.3% of the time, there was a requirement for the medications to be ‘double checked’. We can assume a reduction of glove use in these instances as the nurse no longer needs to wear gloves for preparation and checks, only for administration.

The GOSH gloves off campaign reduced glove use hospital wide by 38.8%. GOSH removed the requirement for non-sterile gloves to be used for additional reasons to our campaign (e.g. when preparing and administrating intravenous medications). As we are focused on nursing preparation and administration of oral and enteral medications only, we do not expect a reduction of 38.8% at this time. However, based on our audit data and data provided by GOSH, we reasonably expect to reduce Glove use by 25% on PICU. A result ranging from PICU occupancy of 11 patients – 18 patients (full capacity) has been given to account for variability in admission numbers.

Environmental benefit: A 25% reduction would save between 2242.73 kgCO2e - 3997.19 kgCO2e per year. These estimates include the production, transport, and incineration of the gloves.

Financial benefit: Cost of gloves was obtained through hospital procurement data from 2019-2020 (pre-covid data). A reduction in use by 25% will save £1965.81 - £3216.79 per year. These estimates include the purchase and disposal (via incineration) of the gloves. There is an expected increase in the price of PPE following the rise in oil price and so the implementation of this project is also crucial from a cost avoidance perspective.

Social sustainability: When delivering the teaching to staff nurses on the unit we found there were many positive attitudes to the change, here are some examples: “Great idea, I think it would be really good to improve our hand hygiene, I feel I often see people not following the correct hand washing policy” “Really good idea, really good that there is such an environmental saving” Positive attitudes towards the project may lead to enhanced engagement and staff morale when knowing that we are making a positive change for our patients, the environment and the trust. There are also health benefits to staff, as the use of non-sterile gloves is known to increase the rate of workplace related contact dermatitis (4)

Clinical and health outcomes: Research shows that inappropriate use of non-sterile gloves decreases hand hygiene compliance due to staff not removing or changing gloves at key moments, therefore missing hand washing opportunities. We expect to see an improvement in hand hygiene and with this brings potential for reduced hospital acquired infections, reduced length of stay and reduced PICU bed days. We plan to retrospectively collect this data following our trial.

Steps taken to ensure lasting change:

To measure the actual impact of our education campaign, we will undertake repeat audits and further non-structured interviews with staff at 6 weeks and 6 months. We plan to provide further education to nursing staff and investigate the possibility of removing non-sterile gloves when preparing and administering IV medications. Internally, the project has gained the support of business management, pharmacy, and the infection control and prevention team. We have longer term goals to embed education of use of non-sterile gloves into new staff inductions; and in widening the project to include all front-line health care workers across the children’s hospital and trust. We have already had other clinical areas get in touch to state their interest in participation. With time, we aim to achieve a similar reduction in glove use as that seen by GOSH.

References

1. P.Loveday, S.Lynam, J.Singleton, J.Wilson, 2013, ‘Clinical glove use: healthcare workers' actions and perceptions ’Journal of Hospital Infection, Vol 86, No. 2, Pg. 110-116 
2. Ashley Flores, Martha Wrigley, Peter Askew, 2020, ‘Use of non-sterile gloves in the ward environment: an evaluation of healthcare workers ’perception of risk and decision making ’Journal of Infection Prevention, Vol. 21, No. 3, Pg. 108-114
3. Great Ormond Street Hospital (GOSH) The Gloves are Off campaign: Glove crackdown saves trust £90k and reduces waste | Nursing Times 4. Upton. 2021. https://www.rcn.org.uk/news-and-events/blogs/dermatitis-and-glove-use-make-one-change