1. Management Summary of Proposal

The purpose of this example business case is to encourage and support the development of centralised 'Equipment Library' facilities in line with National Patient Safety Agency (NPSA) recommendations. These facilities will support the Trust in terms of patient safety, risk management and cost liabilities. Amongst other important issues, centralisation will assist the Trust in improving its rating for the Clinical Negligence Scheme for Trusts (CNST), now controlled by the NHS Litigation Authority (NHSLA).

This will also address recommendations from the:

• Medicines and Healthcare products Regulatory Agency (MHRA);
• National Audit Office;
• National Patient Safety Agency (NPSA) Safer Practice Notice (May 2004). http://www.npsa.nhs.uk/patientsafety/alerts-and-directives/notices/infusion-device

These recommendations direct Trusts to introduce risk management strategies to increase patient safety, improve efficiency and quality as well as reducing associated costs and risks of incidents that involve medical equipment. This centralisation and its benefits have been demonstrated in pilot sites and subsequently other sites, which have followed the development, and have shown a positive increase in safer practices and general management of medical equipment. Equipment Libraries predominantly contain infusion devices, which have proved to be the main source of clinical incidents.

This report will show that risk reductions and cost savings can be achieved with this improved medical equipment management and standardisation of devices. 

2. Strategic Context

Membership of the CNST scheme has significant cost implications to the Trust with premiums increasing dramatically in recent years. This is likely to continue to increase due to litigation costs. The average for a 400 bed acute NHS Trust is approximately £2M each year, however premium discounts are available for increased levels of CNST compliance - level one (10%), level two (20%), level three (30%). Each increase in CNST level saves the Trust approximately £ 300K.

Improving commitment towards patient safety is central to this proposal. Estimates throughout the NHS have shown that there are 10 deaths per annum as a direct result of infusion device errors and thousands of non-fatal over-infusion errors. Numerous other incidents have occurred which have had an adverse affect on patient care. Reducing or eradicating the risk of these potential errors would save lives and prevent unnecessary injuries to patients.

The NPSA (National Patient Safety Agency) has illustrated that a centralised equipment management system could reduce, in particular, the necessary infusion device holdings by 40%. This would assist the Trust in removing old or non-standardised devices and reduce the need for future purchases. Pilot sites have shown that up to 60% of infusion devices are idle at any one point in time when individual areas are responsible for their management.

Potential financial savings can be seen through:

• Better co-ordination of purchases by reducing the range of devices and harnessing our 'buying power';
• Reductions in associated maintenance costs. (estimates have shown that up to 80% of infusion devices reported as faulty were found to have no fault established);
• Less nursing time being spent searching for equipment;
• Less risk of clinical incidents and subsequent litigation costs.

3. Current situation

Currently many Trusts hold an inventory of mixed equipment models - many with no individual ownership, operating in an uncontrolled manner. Some clinical areas also hold their own stock of equipment and make new purchases as and when they have funds available. This has led to some areas having many varieties, which often lie idle, and other areas having low stocks, which has an impact on their functionality and patient care.

4. Option Appraisal / Financial Aspect

Some equipment is specialised, or in essential areas that would not be able to function correctly if their equipment stock was depleted. The three options below will take into account these areas of concern.

Option 1 Do nothing - continue with the current system.

Option 2 Centralise devices that are not specialised or in essential areas. This would leave areas such as: ICU, Theatres, Oncology, Neonatal, Paediatric, and Delivery Suite etc with a baseline of essential equipment, which they require.
This option would see the Equipment Library take ownership of some of the equipment.

Option 3 Centralise all of the devices into an Equipment Library.

This would mean that:

• Essential areas could hold equipment on a permanent loan basis and also utilise the Equipment Library for any additional equipment requirements that occur;
• To maintain a baseline stock of equipment some areas may require a long term loan facility;
• Equipment not required for the above would form the main pool of equipment, which would be utilised on a short-term loan basis.

This option would see the Equipment Library take ownership of all of the equipment listed in Table 1.

Selection of Option 2 or 3 If the options 2 or 3 were implemented they could also offer the following benefits to the Trust:

• The Librarian could take control of, and monitor any future purchases of equipment that it holds. This would be more coordinated due to the Librarian's knowledge of equipment use and needs. The Librarian would ensure that equipment has been decontaminated and function checked between patients.
• Purchases of consumable items such as: NIBP cuffs, ECG leads, SPO2 probes etc., could be carried out through the Library process. This would ensure that there was always a stock of these items reducing downtime of equipment. Also the Trust could purchase these items in bulk rather than single requisitions, reducing staff time wastage.
• Hazard / safety alerts, which effect the Library equipment, could be dealt with quickly because their deployment and location would be known.

4.1 Benefits analysis for all options: Score 0 (most unlikely to benefit) - Score 5 (most likely to benefit)

4.2 Library set-up costs Set-up costs for the Library would include adequate staffing and the provision of a facility.

Facility A room situated within the main hospital premises would be necessary (a minimum floor area of 15 square metres is required). 

4.3 Savings

• Standardisation savings (Based on purchases of cheaper admin sets than currently purchased)
• CNST and reduced litigation costs
• Reduction in nursing staff time wasted locating equipment
• Less delay in patient treatment
• Reduction in equipment downtime
• Better use of the EBME service provision

Year one Non pay revenue saving on sets Pay and set up cost (£ XX,XXX)

Year two Capital saving (No ad-hoc purchase of devices) Revenue saving (£50K+)

5. CONCLUSION

An initial financial commitment is required for the Trust to develop the preferred options with the benefits as highlighted. The current system is inefficient and more costly in non - pay revenue and risk terms. This report shows that, with the exception of option 1, this development will require capital to purchase pumps and set up the library facilities, but the onging costs could be absorbed by revenue saving. It will be easier to comply with MHRA and NHSLA recommendations. Risks associated with the use of medical equipment would be reduced and patient safety improved.

Options 2 and 3 offer a rationalised approach to how the NHS manages infusion devices, helping to standardise, reduce training needs and maintenance costs (less equipment, less no fault found/user error calls). Equipment turnaround times would be efficient and promote safety due to pre-use checks and decontamination being carried out before delivery.

This report was originally written by Stuart Norris, EBME Manager, Bedford NHS Trust. Edited by John Sandham. Feb 2008