Speaking at the Central Sterilising Club’s Annual Study Day last October, Paul Chivers, who heads up the PPE Innovation and Sustainability Team for NHS Supply Chain, explained some of the key initiatives his team has taken since its establishment in the pandemic’s early days to encourage development of more reusable PPE, and improve the sustainability and efficacy of such products already in use. Some of the developments, he explained, not only have the potential to substantially reduce the NHS’s procurement and waste disposal costs, but also to significantly cut carbon emissions.
Paul Chivers was introduced to delegates at the CSC Annual Study Day on 10 October last year by the Club’s Media Coordinator, Becky Hill, who in her professional role is Water Services Solutions manager for Healthcare at Veolia Water Technologies. She explained that with an engineering background, and extensive programme and project management experience, the speaker would be using his session, titled, ‘Innovation and sustainability in PPE decontamination’, to discuss how he and his team have successfully identified a reusable Type IIR mask, which has been piloted in line with NHS England’s National Infection Prevention and Control Manual for England, to support reusable mask safety. He had also – Becky Hill explained – been liaising closely with regulators to discuss standards and specifications for reprocessing PPE and some medical devices.
Paul Chivers began: “So, as Becky said, I head up the PPE Innovation and Sustainability Team within NHS Supply Chain.
Where to go for guidance?
“If you have a product or a novel idea, or want to manufacture something new in the way of, say, a reusable mask, and don’t know whether it’s PPE, or a medical device,” Paul Chivers continued, “you don’t really have anywhere to go to get that advice and guidance. For example, the Health & Safety Executive won’t give you it – because they regulate you, and if they give you the guidance, then they’re likely to be policing themselves should anything go wrong.”
Similarly, Paul Chivers said, the Department of Health & Social Care’s PPE Strategy in the Autumn of 2020 had indicated that there would be more onshore and nearshore production, more resilience, and more reusable products than had in fact transpired. He explained: “The backdrop to all this is the NHS’s Net Zero drive, and in 2023 we will be just five years away from the start of the service’s four-year target period of reducing its direct emissions by 80%. There is thus a lot to do.”
Reduction in glove usage
When the PPE Innovation and Sustainability Team was founded, Paul Chivers explained, it had seven members, but it now has just two. Moving to discuss what the team had achieved during its short time in existence, the speaker began with the so-called Glove MOOC, or ‘massive open online course’, which he explained was a one-hour education information package, based largely on what Great Ormond Street Hospital achieved in 2018, when staff there managed to reduce examination glove usage by 33%. He said: “33% of our glove usage across health and social care – currently six billion a year – is quite a sizable difference; a lot of carbon, waste, and procurement costs.” Having been launched in August 2021, the glove-related MOOC was now ‘live’, and available to everybody in health and social care and the independent sector. He said: “It’s currently being used by people in Australia and Hungary as well. To date over 1000 people have signed up to it, and we are continuing to promote it.”
Driving learning via an interactive tool
The goal of the Glove MOOC is to try to drive organisations to use the learning from what is quite an ‘interactive’ tool. Pointing to a slide (see Table 1), Paul Chivers said PPE demand data from early October 2022 showed that just a 15% reduction in the use of the examination gloves across the health and social care sector across England would bring a £24 m saving, and a 27,000 tonne carbon reduction. His team was now piloting a new dispenser – from which the user simply pulls the glove out, cuff first, from the bottom of the unit, puts it on, and then pulls out the next one. He said: “The dispenser only dispenses one glove at a time – rather than five dropping onto the floor, and the user then putting four of them in the bin.” Paul Chivers said the indications were that such a dispenser could reduce waste by about 10%, equating to a year-on-year financial saving of another £16 m. He added: “In fact the 15% figure is probably higher, because Great Ormond Street achieved that 33% reduction before the pandemic, and there is probably a lot more glove wearing now. So, that’s a 27,000 tonne potential carbon reduction via the Glove MOOC, and an 18,000 tonne saving from the dispenser.”
Reusable mask being piloted
Turning to the team’s ‘other achievements’, he said: “As Becky explained, we have identified a reusable Type IIR mask – which is currently being piloted in an acute setting at the Royal Devon & Exeter Hospital in Exeter, and we’re also looking at doing a community pilot – because community settings don’t readily have access to compliant laundries. We’re thus going to the laundry to try and make it compliant. This doesn’t, however, entail thousands of pounds’ worth of capital investment, but rather it’s about their processes, and making sure that they have got a quality management system in place. They have all the infrastructure and equipment, but we need to make sure they can be compliant with HTM 01-04, so we can ensure that these masks are laundered safely. They’re not allowed to be laundered at home, because they are classed as medical devices.
Reusable eye protection
Paul Chivers said the team was also working with Bollé on developing reusable eye protection, with the eyewear specialist designing and making a product specifically for health and care. He explained: “Bollé came to a lot of meetings with us, discussing the possible production of suitable reusable eye protection. It’s in fact a very smart development; we have seen four prototypes so far, and they look like cycling glasses. Designed to last at least two years, they’re scratch and fogresistant, but we are currently looking at how we clean and decontaminate them safely.”
The standard for eye protection, the speaker explained, is EN166. Paul Chivers said: “At the moment, we know people use wet wipes – some of which are harsher than others – to clean eye protection, and that some are damaging the seals that are incorporated for the aerosol-generating procedures.” Meanwhile he explained that he was due to meet later in the week with the Health and Safety Executive, to discuss some test scenarios for the Ozone cabinets, UVC cabinets, and hypochlorous acid sprays and cloths for cleaning masks, and the protection that the team was looking into.
P3 mask decontamination guidance
He continued: “I can’t take any credit for the P3 mask decontamination guidance that has been produced and signed off. Recently, Sulisti Holmes, head of Decontamination and Incident Reporting at NHS National Services Scotland, has undertaken a lot of testing with P3 dust masks, which I believe came from a building site, and are much used in heavy industry and construction. However, they are also now being quite widely used in healthcare, because people don’t like the FFP3, and you get a better chance of a Fit Test with them.” Paul Chivers noted that there was currently no specific cleaning requirement in the standard (EN140 mask and EN143 filter) for P3 masks. He said: “You can wear one for four hours. You’ll sweat in it a lot, and will have condensation and saliva in it. You can then wipe it with a wet wipe, go on holiday for two weeks. and hopefully when you come back and put it on, it might be clean.” This was, he said, “all part of the conversation with HSE” – ‘what is a good way to clean and decontaminate these products to make sure they’re safe and clean for users to use?’
His next topic was the development of a Decontamination catalogue, which he noted had been discussed ‘for a long time’. He said: “We’ve got many different health and care settings across the industry, and one size will not fit all. While the Decontamination guidance works on a washer-disinfector, many staff won’t have access to one, so it’s about looking at alternatives. While some UVC decontamination cabinets are compact, and work well for masks, in, say, a dental surgery, whether these will be effective for masks in a large acute healthcare setting is part of testing that we want to do.”
Recycling
Here Paul Chivers turned to recycling of PPE. He said: “So we’ve done the ‘reduce’ and the ‘re-use’, and we then have the ‘recycle’ part. The people making these products will be taking them away at the end of their life; they will not be classed as waste. Thus, if the mask has been washed 40 times, it will be going away for assessment and reprocessing.” He added: “Sometimes they’re made into blackout blinds, sometimes into mattresses for homeless people, and sometimes they’re shredded and made into other materials. Bollé also works with a recycling partner, and they will take away the products as well.”
Looking at some of the potential benefits of the team’s work, Paul Chivers said: “We saw the sort of procurement savings you’d get from the glove reduction. Looking at re-use, and in terms of the Type 11R masks we currently use, you’d save 5,184 tonnes of plastic going into waste, and – working on a £300 / tonne disposal cost – also save over £1.5 m, while simultaneously reducing carbon by 11,500 tonnes.”
Plastic aprons
Turning to the plastic aprons widely used in healthcare, the speaker said they created a lot of waste. Paul Chivers added: “Our key message is that if you do need to wear an apron, please wear a reusable one. They’re available; they can be laundered through the same process, and can be used up to 75 times. If we did that, reduced the number of aprons used by 80%, and went over to reusables, that’s nearly 10,000 tonnes of carbon, 3,264 tonnes of waste, and again, circa £1 m saved, year on year.” He emphasised that these figures were based on current usage, and were not as high as they had been at the pandemic’s peak.
Visors
Looking next at visors, the speaker said the response to current widely used visors in healthcare from 2,800 people questioned about them had been ‘shocking’. Paul Chivers said one of the other things the team was working on was a P3 respirator. He told delegates: “I showed you one earlier. If, as a patient, you have just come around from an aesthetic, and somebody approaches you wearing one of these, you could be petrified. However, we have had to adapt, and the one I am showing you now (here he showed a photo of a more ‘conventional-looking’, reusable mask made by Rev Zero and eScent) was manufactured for the military.” Paul Chivers explained that ‘these P3 respirators are much more lightweight, and the whole panel across the front is a filter’
Obscured vision
Unlike some existing respirators, these respirators also wouldn’t obscure staff’s vison. Health and care workers regularly looked down in the course of their work, and Paul Chivers said many existing P3 respirators incorporated sizeable filters on the front, which not only ‘got in the way’, but were also heavy to wear. He said: “Some clinicians can wear one for half a day, and then they get neck ache, and then they go back to the disposable.” The other key element on this mask, however, was how it could be optimally decontaminated, and what level of decontamination would be required. The speaker said he hoped to get some ‘steer’ from the HSE at his meeting with them.
Powered hoods
Powered hoods were another area being looked at. Paul Chivers stressed that he would not put a single product into a pilot, and thus onto a healthcare worker’s face, head, or body, until it had been certified. The team thus uses an independent body – currently Surgical Materials Testing Laboratory in South Wales – to provide validation that products submitted are indeed compliant
Need for funding
The speaker said: “Going on to the next point, if people want sustainability and innovation in the NHS, then education and behavioural changes are also needed.” Expanding on this, he said: “If I ask somebody to don a mask that I wore yesterday, which has since been through the laundry, about a third of people will be happy to do so, a third will ask how and when it was last cleaned, and a third will just say ‘no’.” A part of getting the message across thus needed to be about explaining that the mask in question had been through an approved process. The same would apply to both the P3 masks and the eye protection.
Support for specific health and care specifications and standards
The fact that there was no cleanliness standard in EN166, or in EN140 and EN143, pertaining to reusable masks and filters, made it very difficult for manufacturers to know what challenge to put such devices against, and therefore to recommend the products to clean them. Paul Chivers said: “For example, when the visors first emerged, some were deemed ‘reusable’, and somebody asked how to clean them. One answer given was: ‘You run it under a tap for five minutes and air-dry it.’ However, we don’t have many hospitals with clothes lines in a corridor, and at the end of the shift, you are not going to get clinicians and healthcare workers joining the queue for the sink to wash their visor.”
It was thus, he said, ‘about having appropriate processes that actually return something that’s safe’. The speaker said: “So, part of my conversation with the HSE will be about whether we can have health and care ‘specs’. They don’t take that long; we created the transparent facemask specification back in April last year, and it took just two months.”
Group sessions on the ‘MOOC’
Turning to ‘business as usual owners’ (or BAUs), Paul Chivers reiterated that the MOOC he had earlier referred to was ‘live’, and ‘up and running’, and that his team facilitated group sessions on it. He said: “If people have good case studies, we will upload them and make them live. Improved communication across organisations, meanwhile, was touched on again today. There needs to be a central repository of data about what people are doing – pilots and trials for instance, so that people can share both their learnings and any mistakes, for others’ benefit. It’s something we talk about, but the health service isn’t great at having a central contact point and a central communication channel.”
What are the next steps?
The last part of Paul Chivers’ presentation looked at ‘the next steps’. He said: “We are a temporary team stood up during the pandemic. We need to confirm the test scripts for the decontamination using ozone, UVC, and hypochlorous acid.” These were the ongoing conversations he and his colleague were having, so that it could be recognised what testing both the team, and suppliers, needed to undertake to demonstrate that each product is safe with the various components the team wants to put through it
He said: “We want to pilot the renewable eye protection using Ozone and UVC; we will choose two sites, installing an Ozone cabinet on one, and UVC on the other. We can then start to put them into a pilot to demonstrate that they’re safe, and get some user feedback, and all the other data too.”
Paul Chivers explained that the team also needed to develop reusable transparent masks, although it already has seven compliant single-use masks, having worked across the four nations and various manufacturers to reach this stage – i.e. meeting the transparent face mask specification on the gov.uk website, and the Essential Health and Safety Requirements of the MHRA.
He said: “Although these transparent masks are quite expensive compared with a single-use mask, if we can make them reusable, the cost per use comes down, and therefore makes it a more attractive proposition.” Currently, he added, there were a lot of people in the deaf community excluded, because they were struggling to obtain transparent face masks.
Ongoing pilots
The seven current compliant masks are all the subject of pilots running in England, Scotland, Northern Ireland, and Wales; the team would thereafter be pulling together the resulting information, for example to determine if and how the team-members need to further engage with the manufacturers. Paul Chivers said he had already touched on the agreed suite of approved and accepted decontamination cleaning processes, but added that there was a need to continue with the Innovation Hubs and Roadshows already under way. He explained that on the last Tuesday of each month he hosts a one and half-hour Innovation Hub, where other organisations update attendees on their trials, pilots, and any ‘innovative developments’. He said: “We’ve had a couple discussing hypochlorous gassing of rooms, as opposed to hydrogen peroxide decontamination, we’ve featured sustainable procurement, the MOOC, and glove use reduction.”
Roadshows
Moving to Roadshows, he said: “We’ve got 13 suppliers of PPE above the head, and some cleaning agents. We’ve been to Alder Hey and Birmingham, will be in Chichester in a couple of weeks’ time, and then in Manchester and UCL during November. Subsequently, we’ll hold roadshows in North Tees, Shropshire, and hopefully in Bristol, to get feedback.” He explained that the businesses involved in the Roadshows pay, and that the team then puts the suppliers in the room. “They are allowed to sell nothing,” Paul Chivers stressed. “They’re just there to listen to the users telling them how to improve our PPE now, so that we can then go and produce better PPE for the next generation. Currently – as you’ve seen from the two products I showed earlier – some of them are very much construction-orientated.” He added: “Most of these products are made for what’s called a Sheffield Head, of a 5’11’’ white male. However, the NHS has one of the most diverse populations of any employer worldwide, and these things don’t fit them.” Feedback he had received had included: ‘The P3 slipped off my face.’
That, Paul Chivers said, was ‘part of the education process’ too. “But it’s also,” he said, “the fact that a lot of these products are not made for small Filipino nurses, and people with very narrow faces. So, they’re currently just having to ‘make do’. We take 3-5 years to train a healthcare worker, and then we dress them head to toe in a ‘fiver’; that’s what it costs for a mask, eye protection, a plastic apron, and a pair of gloves.”
A clear ‘end-goal’
The end-goal, Paul Chivers emphasised as his presentation neared its end, was that staff get PPE products that keep them safe, are reusable and sustainable, and designed for them and the environments they’re working in. He added: “So that is what all the roadshows are all about.”
Noting that he had already discussed ‘standards and specifications for health and care settings’, he closed by stressing the need to ‘build on the networks’ with organisations including MHRA, HSE, TRA, IPC, RCN, IPS, and WDES. He said: “We do get on very well with them. They are an easy point of contact, and I can drop them a line and get answers quite quickly. So, in my opinion, based on the question for today, and the theme of this event, decontamination is indeed very sustainable. When I saw the question, I was going to ask instead: ‘Is not to decontaminate sustainable?’ When you see the tonnes and tonnes of single-use plastics we’re generating, it makes no sense not to have reusable products. Collectively, the interventions we have talked through could reduce CO2 by 47,000-96,000 tonnes every year.” Here he closed his presentation, and invited questions from the audience