Analysis of the International adoption of Moulded Paper Pulp Products for managing Patient Waste.

Analysis of the International adoption of Moulded Paper Pulp Products for managing Patient Waste. Date January 2013 Author: Clare Linstead, BA HONS (University of York) Environmental Pulp Products (E2P Ltd) Regus Building Herald Way, Pegasus Business Park Castle Donington DE74 2TZ Web: www.e2p.co.uk Email: info@e2p.co.uk Phone: +44 (0)1332 63 8017

Contents 1.0 Moulded Paper Pulp (MPP) in Healthcare. 1.1 Sector Overview. 1.2 Product Overview. 1.2.1 Urinals. 1.2.2 Care Products. 1.2.3 Receptacles. 1.2.4 Ancillary Products. 1.2.5 Innovation and product development. 2.0 Macerators 3.0 The benefits of MPP. 3.1 Reduced risk of infection heat tolerant pathogens. 3.2 Reduced risk of infection cross contamination. 3.3.1 Capital cost reductions by using MPP over plastic reusable products. 3.3.2 Reductions in running costs when using MPP over plastic reusable products. 3.4 Environmental Benefits from using MPPs. 3.5 Time efficiencies and benefits to staff. 4.0 Conclusion

1.0 Moulded Paper Pulp (MPP) in Healthcare 1.1 Sector Overview In the UK in excess of 140.8 billion pounds is spent annually by healthcare organisations 1. 97% of this is accounted for by the government funded National Health Service (NHS) while the rest is spent by private healthcare providers 2. In 2012 the total UK expenditure on Moulded Paper Pulp (MPP) products for healthcare provision was in excess of 22,000,000. The UK has used MPP in healthcare since the 1970 s. Globally, excluding the UK, in 2000 the MPP market worth a value of less than 2,000,000 with 3 product manufacturers. In 2012 the MPP market is worth in excess of 15,000,000 from more than 8 product manufacturers 3. In the UK 85% of healthcare organisations use MPP as opposed to the reusable (plastic) system. Other maturing MPP Medical markets include North America and Australia, with emerging markets in the Middle and Far East and South America, which based on a similar per capita usage would indicate medium term growth opportunity to an annual demand in excess of 100,000,000 at 60% market penetration. All MPP products used in healthcare in the UK must macerate to a fine slurry in 85 seconds in any standard macerator without the release of particles into the patient environment. This is in accordance with the British Standards Institute PAS29:1999 and avoids issues with drainage or sewerage treatment. 1.2 Product Overview Products included in this market are closed and open moulded, including: 1.2.1 Urinals There are three product designs used in the UK. The traditional round or bulbous type, the square type and the stackable type (design registered to E2P). Urinals are designed to facilitate dignified independent healthcare patient toileting, without catheterisation. The product is able to retain human waste for a minimum of 4 hours. The square and stackable urinal design enables the (full) product to be placed on a flat surface both horizontally and vertically, with the product and its contents remaining stable. The rear vertical plane of the stackable urinal is moulded which allows the products to be stacked during warehouse storage, transit and at a ward level. This product is perfect for export as it allows logistical savings of 17% over the square shape. 1 The Guardian Online, Spending on healthcare drops as proportion of GDP, 2 nd May 2012. Retrieved from http://www.guardian.co.uk/news/datablog/2012/may/02/uk-healthcare-spending-gdp 2 PendlePace Ltd, UK Market Review of Moulded Paper Pulp, The Waste Resources Action Programme, 2005, page 38. 3 Source MEDICA trade fair reports, companies house.

Fig 1. The Traditional Shaped Urinal. Fig 2. The Stackable Urinal Fig 3. The Square Based Urinal 1.2.2 Care Products Care products are used to allow patients to independently toilet and toilet with assistance. The predominantly used product in the care range is the Bedpan. E2P s Bedpan is graduated for easy contents measurements. Additionally, the Slipper Type Pan (Midi capacity 1.3 ltr and maxi capacity 2.0 ltr) is used to toilet bedbound patients and slips underneath the patient in situ. Finally the Commode Pan is used to provide a portable toileting solution. Fig 4. The Bedpan Fig 5. Slipper Type Bedpan 1.2.3 Receptacles Receptacles perform a wide variety of uses in the healthcare environment: Measuring Jug. The Measuring Jug is often used in Maternity Wards for the measurement of birthing fluids. It can also be used on any ward for accurate urine measurement. GP Bowl. The GP bowl is also known as a vomit bowl as it is often left with patients at risk of vomiting. E2P s GP bowl is graduated for easy contents measurements. Kidney Dish. The Kidney Dish is named because the product s design shape approximates that of a Kidney. The benefits of having a receptacle shaped as such are that the products sit easily against the patient s body, often at chest height. The kidney Dish is ideal for receiving soiled dressings or medical waste. Detergent Proof Washbowl. The detergent proof washbowl holds a large quantity of fluid (4 ltrs) and is designed to provide a single use patient bathing solution. In the UK the Detergent Proof Washbowl is used in conjunction with a surfactant such as body wash or shower gel or wipes. E2P s bowl is designed to allow sturdy transportation of a full bowl of liquid at a temperature of 45ᵒ. Urine Sampling Cup. The sampling cup is designed to take urine samples from both men and women. It is designed to be easy to carry and pour. 1.2.4 Ancillary Products Ancillary products used in conjunction with pulp often include product dispenser racks, product covers and bedpan supports.

1.2.5 Innovation and Product Development New single use products are continually being developed in order to extend the single use concept from the core patient waste products to other areas where the risk of contamination can be eliminated through disposal rather than washing, bringing additional benefits to the end user. These products are designed to be disposed in the same method and by the same macerators as the core products. Progress in particular relating the composition of pulp that allowed the recent development of the washbowl product indicates that there are considerable opportunities for further innovation and product development. 2.0 Macerators As a washer is used to allow the re-use of a plastic urinal, bedpan or receptacle; similarly a macerator is used to dispose of an equivalent MPP product. The macerator disposes of human faecal waste, urine and stomach contents with a view to reducing the transmission of nosocomial infections associated with the handling of reusable bedpans 4. Used urinals, bedpans and receptacles do not need to be emptied before being placed in the macerator. There are various makes and models of macerators available on the global market. Macerators can hold from one to four pulp products depending on the manufactures guidelines. The macerator cycle takes between 60 and 120 seconds and takes place as follows: 1. A high-pressure cold-water spray and cutting blades macerate the waste into a pulp (the pulp is flushed into the drainage system). 2. A final spray cleans the interior chamber of the macerator for later use. 5 3.0 The benefits of MPP. Healthcare organisations using MPP over plastic or metal alternatives take advantage of a wide spectrum of benefits predominantly encompassing a reduced infection rate and a cost reduction. These benefits were extensively tested in the UK by the NHS and integrated as part of the 'Deep Clean' project in 2008, the increasing adoption outside of the UK has based on the following total cost benefits, and infection control impact in the NHS. 3.1 Reduced risk of infection heat tolerant pathogens. Using the MPP and macerator system any contaminated human waste is simply disposed of (including contents) in the macerator. A new MPP is used each time, therefore eliminating the risks 4 Association québécoise des intervenants en hygiène et salubrité (AQIHS). Désinfection d'un macérateur de AQIHS-200733. Laval, Qc: AQIHS; 2007. Available at: http://site.voila.fr/salubrite/macerateur.html. FREE TRANSLATION 5 Lobè, C. Comparative Analysis of Bedpan Processing Equipment, AETMIS, 2009, Page 6.

associated with using washers to clean re-useable urinals, bedpans and receptacles. Known heat tolerant diseases include the bacterium Clostridium Difficile and the intestinal flora pathogen Nosocomial Enterococci. A study conducted in 2008 concluded that the currently accepted thermal decontamination parameters for all bedpan WDs (washer-disinfectors) are not adequate to eliminate C. difficile spores from bedpans 6. Furthermore an earlier study on the pathogen Nosocomial enterococci states our results showed that four strains of E. faecium were able to survive the British Standard (one minute) for heat disinfection of (plastic) bedpans 7. It has long been a concern of engineers, microbiologists, and infection control staff that maintaining an adequate time-temperature cycle for the short process time of a one minute disinfection cycle (as is required by the DOH in the cleaning of re-useable bedpans 8 ), is hard to achieve, particularly in view of such diseases as hepatitis and the healthcare acquired infection MRSA 9. The sheer mechanical action of some older washers has been recorded as being inefficient due to the fundamental design features of the bedpans: Evidence from users of washers, and from work study, showed that up to 22% of bedpans had to be reprocessed, because the first wash had failed to remove all faeces. Up to 10% of bedpans had to be hand scrubbed, because contents had baked onto the metal surface 10. Using MPP in the healthcare environment virtually eliminates the possibility of these infections being presented to the patient on the product itself as the patient is given a new product to use every time. 3.2 Reduced risk of infection cross contamination. The processes involved in re-using plastic or metal urinals, bedpans and receptacles are nonstandardised from ward to ward and complex. In some instances a washer is present on every ward, in others after the patient is discharged, the reusable items are sent to the central processing department to go through the washer-decontaminator cycle. It is the complexity of the processes involved (combined with the staff time, training required and frequent maintenance to ensure machine efficiency) that can lead to cross contamination of patients and staff as a result of using bedpans washers: 6 Alfa, MJ. Olson N. Buelow-Smith, L. Simulated-use testing of bedpan and urinal washer disinfectors: evaluation of Clostridium difficile spore survival and cleaning efficacy, Am J Infect Control, 2008, pages 5-11. 7 Kearnes, AM. Freeman, R. Lightfoot, NF. Nosocomial enterococci: resistance to heat and sodium hypochlorite, J Hosp Infect, 1995, pages 193-9. 8 UK Department of Health, General Specification for REQUIREMENTS and TESTS for WASHER DISINFECTORS employing THERMAL DISINFECTION for HUMAN WASTE CONTAINERS, 2009, http://www.dhsspsni.gov.uk/human_waste_container.pdf 9 Johnson, A. Bedpans: Disposable or re-useable, Nursing Times, 1999, page 2. 10 Johnson, A. Bedpans: Disposable or re-useable, Nursing Times, 1999, page 2.

Source: Lobè, C. During a recent comparative study of bedpan types, compiled by Christian Lobè in 2009, Lobè highlights Risk of cross-contamination of receptacles, risk of workplace and staff contamination during bedpan transport to CPD (central processing department) 11. Additionally, the UK Department of Health s own guidelines on Sluice and Dirty Utility Rooms states that there is a risk of cross contamination when transporting and cleaning plastic bedpans 12. Using MPP products not only eliminates the risk of cross contamination from a contaminated product, but also improves staff efficiencies by removing the need to wash, dry and store the product. Finally a study conducted in 2010 recommends that plastic commodes and bedpans must be handled very carefully to reduce spread of contamination of C. difficile spores from the commode/bedpan to the environment 13. Using MPP products enables even the busiest and newest members of staff to operate in the workplace with minimal risk of cross-contamination. 11 Lobè, C. Comparative Analysis of Bedpan Processing Equipment, AETMIS, 2009, Page 21. 12 Department of Health, Room description and layout (dirty utility room for bedpan processing), http://www.spaceforhealth.nhs.uk/articles/room-description-and-layout-dirty-utility-room-bedpan-processing 13 PIDAC Best Practices Document for the Management of Clostridium difficile All Health Care Settings, 2010

3.3.1 Capital cost reductions by using MPP over plastic reusable products. In addition to the clear benefits in infection control that using MPP s bring; the disposable system is also cost efficient in comparison to the reusable system. Costs associated with both systems can be categorised into capital costs (for example cost of machine, cost of ancillary products like plastic reusables, and installation costs such as drain alterations, provision of hot water supplies, steam venting etc) and the running costs. The following study shows an average comparison of costs across several major healthcare providers in the UK: Source: Johnson, A. It was identified that the capital costs of installing a washer were three to four times greater than those involved installing macerators. 3.3.2 Reductions in running costs when using MPP over plastic reusable products. The two main running costs associated with using both systems of disposal are electricity costs and the cost of water. Typically a washer uses around 90,000 litres of water per year. The macerator manufacturer Haigh Engineering, conducted a study to understand comparative water usage between macerators and washers. It was found that the Haigh Panaway macerator uses up to 50% less water than the washers used in the study (please see table below). In reality this saved 45,000 litres per year. The

scenario compared machines that are typically servicing 20 patient beds 14. d. Water useage / L 120,000 100,000 80,000 60,000 40,000 20,000 0 Washer 1 Washer 2 Macerator 1 Haigh Classic+ Haigh Panaway Source: Shepherd, L. Naturally, both types of machine also require electricity to operate. A similar study conducted by Haigh showed that macerators use approximately 5-10% less energy (0.35 kwh compared to 0.925 kwh) per cycle compared to washers, making them the most energy efficient machine. The reason for this is macerators do not require a source of hot water / steam to sterilise items, hence the great improvement in efficiency and environmental benefit compared to washing 15. e. kwh/10000 items 800 700 600 500 400 300 200 100 0 Washer 2 Macerator 1 Haigh Classic+ Haigh Panaway Source: Shepherd, L. 3.4 Environmental Benefits from using MPPs As previously mentioned, using the disposable system means using less water and energy on a day to day basis. As well as having a financial impact, this of course consequently has a positive environmental impact. In addition to this, by using disposable products composed of re-cycled paper pulp the healthcare organisation contributes towards the UNEP s (United Nations Environment Programme s) key objective of managing waste and reducing land fill sites 16. The North American healthcare market in particular has embraced the environmental benefits of the MPP disposable system. Prior to using Moulded Paper Pulp products, North America s use of plastic 14 Shepherd, L. Haigh Macerator Range, Document Pack, 2011, page 10. 15 Shepherd, L. Haigh Macerator Range, Document Pack, 2011, page 8. 16 UNEP, Agenda 21, ENVIRONMENTALLY SOUND MANAGEMENT OF SOLID WASTES AND SEWAGE-RELATED ISSUES, chapter 7.

bedpans, urinals and receptacles added thousands of kilos of waste to the country's landfills 17. As well as reducing waste produced as an output of the system, MPPs also use recycled raw material in the manufacture of the MPP product. E2P s Medical products are made from 80% post-consumer news print and 20% post-consumer printings and magazines. The cellulosic fibres (raw materials) are selected from the standard EN 643 list 18. Obviously, since MPP uses 100% re-cycled materials in its manufacture, choosing MPP products helps to contribute to a reduction of unwanted by-products produced in the manufacture of plastic and metal. In addition to a reduction in plastic landfill waste, the re-useable system can sometimes be dependent on corrosive chemicals which are used in addition to heat used to neutralise the pathogens found on bedpans. Chlorine in particular is used due to its low cost, fast acting and readily available nature. However, it is known to be corrosive to metal, is an irritant to skin and must only be used in well-ventilated areas. 3.5 Time efficiencies and benefits to staff. Most healthcare staff would agree that no one enjoys cleaning bedpans, or emptying urinals and medical receptacles used to collect human excrement and body fluids. However, the task makes up part of the nurse's daily tasks. Using the disposal system the used product is placed in the macerator, which is far more pleasant for staff members than cleaning the product. The system avoids any unpleasant splash backs or aerosolization than can be associated with cleaning a bedpan or commode pan. When using a washer in a re-useable system it has been proven that paying for regular maintenance is critical. Without regular maintenance the efficacy of washers has been proven to diminish critically 19, unlike when using disposable MPP and macerators. When a washer is being maintained it is out of service, leading to inefficient working conditions. The typical number of products that can be washed per cycle length in a washer is 8-17 bedpans per hour, depending on the quality of the cleaning process, I.E the number of times products have to be washed twice (or more). Macerators are capable of processing four MPP s and their contents each cycle, or a total of up to 120 bedpans per hour 20. The time efficiencies gained by using the disposable system as opposed to the re-useable system are clear. Nurse time is valuable in today s healthcare environment and the disposable system helps to maximise the nurse s efficiency in the workplace. 4.0 Conclusion The adoption of MPP and disposal by macerators has proven in numerous instances to be an effective alternative to washing systems in regard to managing patient waste in a healthcare environment. 17 Vernacare, Disposable Eco-Friendly Bedpans Increase Nurse Morale, 2009, http://www.vernacare.com/information/news/disposableeco-friendly-bedpans-increase-nurse-morale.aspx 18 European List of Standard Grades of Recovered Paper and Board. 19 Alfa, MJ. Olson N. Buelow-Smith, L. Simulated-use testing of bedpan and urinal washer disinfectors: evaluation of Clostridium difficile spore survival and cleaning efficacy, Am J Infect Control, 2008, pages 5-11. 20 Johnson, A. Bedpans: Disposable or re-useable, Nursing Times, 1999, page 3.

The increasing range of products and high quality product suppliers, is driving international adoption in parallel with the tangible benefits that the system brings to all parties, the patient, nurse, maintenance engineers and management. With marked increase in international usage of the system, the demand for a high quality range of MPP and disposal systems is set to continue to increase significantly over the next 5-10 years particularly in markets that prioritise the reduction of hospital acquired infection. Contact and enquiries Web: www.e2p.co.uk Email: info@e2p.co.uk Phone: +44 (0)1332 63 8017 Environmental Pulp Products (E2P) Ltd 2013.

References PendlePace Ltd. UK Market Review of Moulded Paper Pulp, The Waste Resources Action Programme, 2005 Alfa, MJ. Olson N. Buelow-Smith, L. Simulated-use testing of bedpan and urinal washer disinfectors: evaluation of Clostridium difficile spore survival and cleaning efficacy, Am J Infect Control, 2008 AQIHS-200733. Laval, Qc: AQIHS; 2007 Department of Health, Room description and layout (dirty utility room for bedpan processing) ; General Specification for REQUIREMENTS and TESTS for WASHER DISINFECTORS employing THERMAL DISINFECTION for HUMAN WASTE CONTAINERS Guardian Online. Spending on healthcare drops as proportion of GDP Johnson, A. Bedpans: Disposable or re-useable, Nursing Times, 1999 Kearnes, AM. Freeman, R. Lightfoot, NF. Nosocomial enterococci: resistance to heat and sodium hypochlorite, J Hosp Infect, 1995 Lobè, C. Comparative Analysis of Bedpan Processing Equipment, AETMIS, 2009 PendlePace Ltd. UK Market Review of Moulded Paper Pulp, The Waste Resources Action Programme, 2005 PIDAC. Best Practices Document for the Management of Clostridium difficile All Health Care Settings, 2010 Shepherd, L. Haigh Macerator Range, Document Pack, 2011 UNEP. Agenda 21, ENVIRONMENTALLY SOUND MANAGEMENT OF SOLID WASTES AND SEWAGE- RELATED ISSUES Vernacare. Disposable Eco-Friendly Bedpans Increase Nurse Morale