Abstract
Background/Aim: Nosocomial infection is a substantial clinical, societal and economic burden, especially during the COVID-19 pandemic. Patients with cancer are required to change into patient gowns before receiving radiotherapy. To improve efficiency and infection control, we designed novel intelligent devices for both gown distribution and recycling. We conducted a pilot study to provide evidence for the device in healthcare quality improvement. Materials and Methods: We designed and set up intelligent machines with an infrared sensor for patient gown distribution and recycling. The performance of these machines was assessed by questionnaire survey of patients’ perceptions and handling by laundry personnel. Results: We composed a questionnaire to measure patient/personnel satisfaction upon gown handling based on the existing data of our hospital. Two generations of patient gown distribution machines were introduced. One was the novel automated device for both gown distribution and recycling. The other one was the conventional wooden cabinets and/or hamper stands with foot pedals. Survey results showed that approximately 90% satisfaction was achieved with the automated machines. Overall satisfaction with the new soiled gown recycling machines was significantly higher than that with the conventional receptacles (p<0.01). Conclusion: The automated patient gown distribution machines safely and efficiently provide patients with suitable gowns. The automated patient gown recycling machine reduces contamination of the gown recycling area. Using these machines improves infection control in the hospital environment and effectively reduces the risk of nosocomial infection.
- Automated gown handling system
- automatic recycling machine
- infection control
- radiotherapy
- soiled hospital gowns
The COVID-19 pandemic had infected more than 4.3 billion people and caused 6.9 million confirmed deaths as of May 31, 2022 (1). It has triggered large-scale governmental interventions and severe economic and social disruption around the world. Good patient safety culture is a critical core concept for medical institutions. The Institute of Medicine in Taiwan reported that medical behavior is highly uncertain and complex. Redesigning the working environment, eliminating nonessential operations, adjusting the work system, and improving the process is crucial for patient safety and quality improvement (2). The COVID-19 pandemic has highlighted the need to develop a safer and cleaner medical environment (3).
Advances in cancer treatment have greatly increased the number of patients receiving radiotherapy. Radiotherapy is typically administered 5 days a week for several weeks. Patients are required to change from their original clothes into patient gowns to enable the smooth administration of treatment. The conventional gown handling system in our radiology oncology department stacks the patient gowns in wooden cabinets, which are divided into different compartments according to size so that each patient can take the most suitable gown (usually the top one on the stack) by themselves. However, when taking the gown, patients may carelessly mess up other gowns stacked underneath. In addition, they may search through the stack of the gowns to find a newer one. During this process, not only the gowns may become messy, but patients’ hands may also contaminate other clean gowns after repeated contact. Therefore, an automated, efficient patient gown storage and distribution device is necessary for both patients’ convenience and infection control. In addition, infection control is also critical in the recycling of the used patient gowns (4). After finishing examinations or treatments, patients usually put the used, soiled gowns into a container in the gown collection area, often with the gowns exposed on the edges of the container. Because patients may experience coughs, sneezes, or excretions when wearing the hospital gowns, the exposed gowns may increase the risk of contamination of the environment and adversely affect the safety of other patients and hospital personnel.
Patients with cancer are usually vulnerable (5), and the conventional system in the radiology oncology department for storing/distributing clean patient gowns and recycling of used gowns seemed obsolete as well as harmful to infection control and patient safety. The service volume of patients in our hospital increases every year. Understanding patients’ behavior patterns and meeting patients’ needs when they take and/or discard the patient gowns is crucial. Here, we introduce an automated patient gown storage and distribution device as well as an automated patient gown recycling device to improve hospital infection control, patient safety, and quality of the medical environment, especially during the period of the COVID-19 pandemic.
Materials and Methods
Analysis of current gown handling situation. The current situation for storing and distributing patient gowns and for recycling used gowns was surveyed, and advantages and disadvantages of the system were evaluated. The average number of daily patients per month admitted to the Department of Radiation Oncology for treatments was also reviewed. For patient gown recycling, the Ishikawa diagram (also known as fishbone diagram) was adopted to track down the reasons for imperfections. A flowchart and an improvement schedule were designed based on the Ishikawa diagram.
Study design and participants. This prospective cohort study was conducted at the Department of Radiation Oncology of National Taiwan University Hospital between January 2014 and August 2020. For patient gown storage/distribution, we designed and set up automated gown storage/distribution machines to replace the conventional wooden cabinets used for gown storage, and designed questionnaires to survey patients’ perceptions of the improvements in convenience, infection control, and imperfections of the first and the second generation of the machines (Table I and Table II). For the patient gown recycling units, a simplified version of the patient satisfaction questionnaire short form (PSQ-18) (6) was used to survey the satisfaction of patients and caregivers (or laundry personnel) with the conventional gown recycling units. The PSQ-18 questionnaire focused on the domains of “safety”, “convenience”, “infection control problems”, and “recovery procedures”. The “overall satisfaction” domain was also evaluated. Responses to all the questionnaires were assessed using a 5-point Likert scale with the answer options “strongly disagree”, “disagree”, “neither agree nor disagree”, “agree”, and “strongly agree”.
Comparison of the two conventional types of soiled gown recycling devices.
Functional descriptions and aims of the improvement measures for the new patient gown recycling device.
Data analysis. Data were analyzed using SPSS, version 20.0 (IBM Corp., Armonk, NY, USA). Comparison of satisfaction rates between the conventional and new devices was performed using the Wilcoxon–Mann–Whitney rank test. Statistical significance was set at p<0.05.
Results
Current gown handling situation. The conventional wooden cabinet for storage and distribution of patient gowns as well as the wooden cabinet and/or the container stand with a foot pedal for patient gown recycling (Figure 1A, B and C). From January 2014 to July 2020, the average number of daily patients receiving radiotherapy at our department per month increased from 213 to over 330 (growth rate of 55%, Figure 1D). The enormous patient flow often resulted in the inability to provide suitable patient gowns in a timely manner. As a result, the gown recycling units were often overloaded and messy (Figure 2A and B). For patient gown recycling, patients’ actions and habits were surveyed, including discarding the used gowns and the handling methods used by the trained hospital laundry workers. A total of 253 valid questionnaires were collected. For all aspects, including “safety”, “convenience”, “infection control problems”, and “overall satisfaction”, less than 50% of patients rated the conventional gown recycling units with a score of 4 (agree) or higher (Figure 2C). These surveys indicated that more efficient and updated devices for patient gown storage and distribution and for recycling the gowns are required to improve the efficiency and decrease the risk of contamination leading to nosocomial infection.
The conventional units for patient gown provision and recycling. (A) Patient gowns are stacked in wooden cabinets according to the size of the gowns. (B) A wooden cabinet for the recycling of the used patient gowns. (C) A container stand with a foot pedal for the recycling of the used patient gowns. (D) The average number of daily patients treated at the department of radiation oncology of our hospital per month from Jan 2014 to July 2020. The patient number increased by 55% during this period.
The conventional units for patient gown provision and recycling in use. (A) and (B) Conventional units for patient gown recycling are often overloaded and messy. (C) Questionnaire survey of radiotherapy patients or caregivers for the conventional gown recycling units.
Introducing the first-generation automated patient gown storage/distribution machines. To improve the efficiency of patient gown storage and distribution and reduce the risk of infection, we cooperated with the engineering office as well as related professionals and introduced the first-generation automated patient gown storage/distribution machine (Figure 3). The characteristics of the first-generation machine include: 1) automatic detection of the number of patient gowns remaining in the storage trough and the automatic push of the gowns stacked in the trough upwards by the supporting plate for the gripper to pick the gown; 2) movable storage trough so that the hospital gown staff can first place the gowns in the movable trough in the warehouse, and then send them to the radiology oncology department for replacement; 3) connection of the patient gown distribution machine to a computer database, which is also connected to the check-in machine and the gown department (Figure 4A). In this way, when a patient registers in the radiology oncology department, the gown size information can be transmitted to the automatic gown storage/distribution machine, and the gripper of the machine can be activated and place the correct patient gown into the opening for the patient to take. In addition, by connecting with the hospital electronic information system, the automatic patient gown distribution machine emits a notification light to indicate its normal functional status and whether the stock of patient gowns in the machine is sufficient (Figure 4B). If the number of gowns is insufficient, the electronic information system will notify the gown department to fill the container with gowns via the indication light, internet, or text message. We surveyed our patients’ experiences and perceptions about the first-generation automated patient gown distribution machine (Table III). Thirty-six valid questionnaires were collected. The results showed that over 80% of patients strongly agreed or agreed that using the first-generation automated patient gown distribution machine was more timesaving, easier to identify the gown size, and more convenient and practical than the conventional way. In addition, all patients participating in the survey strongly agreed or agreed that unnecessary contact with other patient gowns can be reduced with the automated system (Figure 4C).
The design of the first-generation automated patient gown storage/distribution machine. (A) Every patient gown is folded into a long rectangular shape. (B) Schematic diagram of the supporting plate structure (left) and the gripper (right) under the gown drop opening. (C) Schematic diagram showing the movable gown container inside the machine. (D) The appearance of the machine.
The computer information system controlling patient gown storage/distribution. This system contains a database that is connected to the check-in counter, the department for providing patient gowns, and the gown distribution machines. (B) The light indicates that the machine is normal and there are enough gowns inside the container. (C) Patients’ responses to questionnaire survey on the first-generation automated patient gown storage/distribution machine. The questionnaire contents are listed in Table III.
Questionnaire for the first-generation automated patient gown storage/distribution machine.
Introducing the second-generation automatic patient gown storage/distribution machines. The first-generation automated patient gown storage/distribution machine was in operation for three months and some shortcomings were revealed. To improve the shortcomings, the first-generation machine was upgraded to the second-generation machine (Figure 5), which has the following characteristics: 1) shortened jaws of the gripper to prevent them from clamping two patient gowns at one time (Figure 5A); 2) an additional function to detect whether the patient gown was successfully clamped; 3) upon clamping the patient gown, movement of the gripper upward first and then towards the top of the opening to avoid collisions with other gowns during the movement; 4) shortened time of the gown-gripping process from 18-25 s in the first-generation machine to 5-7 s in the second-generation machine; 5) detection of whether the patient gown was successfully dropped at the opening and whether it was taken away by the patient (Figure 5B). The notification light system was simplified, and only the reminder light was retained to remind the patient to take the gown. However, considering that the movable storage trough is too heavy to be installed smoothly into the gown distribution machine when the trough is full of patient gowns, and that the hospital gown staff usually replenishes the gowns at the place where the machine is located, a transparent window was designed for the second-generation machine (Figure 5C). The transparent window design is convenient for notifying the hospital gown staff to replenish the gowns. In addition, the internal operating status can be viewed instantly. If an abnormality occurs, personnel in charge can immediately respond and resolve the problem.
The second-generation automated patient gown storage/distribution machine. (A) The structure of the shortened gripper. (B) The gown detection structure at the opening. (C) The appearance of the machine. (D) Patients’ responses to questionnaire survey on the second-generation automated patient gown storage/distribution machine. The contents of the questions are listed in Table IV.
Questionnaire for the second-generation automatic patient gown storage/distribution machine.
Patients’ experiences and perceptions about the second-generation automated patient gown storage/distribution machine were surveyed using a questionnaire (Table IV). Nineteen valid questionnaires were collected, and the results are represented in Figure 5D. The results showed that about 90% of patients and staff strongly agreed or agreed that, compared with first-generation machine, the operating method is easier to understand, and the transparent window is better for checking. About 80% of patients strongly agreed or agreed that the waiting time for the patient gown to be dispensed was reduced. Approximately 70% of patients strongly agreed or agreed that the problem of repeated falling out of the patient gowns was improved, and that machine failures occurred less frequently. More than 50% of patients strongly agreed or agreed that the second-generation machine was quieter during operation. It is noteworthy that 16% of patients strongly disagreed that the machine was less noisy, and 11% patients strongly disagreed that machine failures occurred less frequently.
Improvement of the process for the patient gown recycling system. The main problems of the conventional recycling units regarding “convenience”, “safety”, “infection control problems”, and “recycling procedures” were summarized based on results of the PSQ-18 questionnaire. Comparisons of the new machines with the wooden cabinet with a spring hinge door and the container stand with a foot pedal are presented in Table III.
The principal problems with the two conventional types of patient gown recycling units were as follows: regarding convenience, the habits and methods of all patients are not considered, and overall comfort needs to be improved; regarding safety, the poor design may cause injuries to patients and the accredited laundry staff; regarding infection control, the current design cannot prevent the cabinet or the container stand from being contaminated. Patients and the accredited laundry staff may contact the cabinet or the container directly with bare hands, resulting in impaired infection control; regarding the recycling procedure, the gown load cannot be judged from the outside. Consequently, the aspects of convenience, safety, and infection control required considerable improvements when designing the new system. The potential factors are displayed in the Ishikawa diagram (Figure 6). The design of both types of conventional recycling units was not user-friendly, which may lead to inconvenience, poor safety, and poor infection control when discarding the used patient gowns. The overloaded container would also create a disordered environment in the area.
Ishikawa diagram analysis of imperfections of conventional patient gown recycling units.
Improvement of procedures and introducing the automated patient gown recycling device. After understanding the problems with the conventional patient gown recycling units, we cooperated with the engineering office and related professionals to perform on-site surveys and assessments. The flowchart is shown in Figure 7A. A field investigation was conducted using a questionnaire survey on the conventional gown recycling units. Based on the identified imperfections, we designed an automatic gown recycling device and evaluated its feasibility. We then produced, implemented, and tested the new device. A thorough questionnaire survey on the automated patient gown recycling device was also performed. We continued research and developed a second-generation device. The improvement schedule is displayed in Figure 7B. The improvement measures and goals for the new patient gown recycling device were intended to improve the user-friendliness and resolve the problems of the existing device; they are listed in Table I.
The systemic approaches to introduce the patient gown recycling device. (A) Flowchart of improvements in patient gown recycling device. (B) The improvement schedule for the patient gown recycling device.
Figure 8 shows the new automated patient gown recycling device for disposing the soiled patient gowns. The automatic device was designed to have the following components: A) An infrared sensor that can control the automatic opening and closing of the inlet on the top of the cabinet. B) An input port equipped with an anti-pinch sensing device. If foreign objects (e.g., hands or dirty clothing) are sensed at the input port when putting in the patient gowns, the door will open automatically to avoid pinching the hands. C) A unique iron frame was placed inside the cabinet conforming to the specifications of the dirty clothes bag and equipped with a drag-type pulley chassis. One side of the cabinet was designed to have an additional opening. The chassis can be pulled out from the side to replace the dirty clothes bag. D) To balance the gown’s weight, the device is designed to have two cabinets, with a full-load indicator light. When the left side is fully loaded, the right side will automatically start to work. E) The cabinet is equipped with pulleys, and the installation location can be changed according to the users’ needs. In addition, the cabinet is combined with a power regulation system to set the power supply. The user can thereby ensure that the safety of electric power complies with the hospital regulations, which prevents the cabinet from being dumped with garbage or debris during nonworking hours. The automated gown recycling device has been appropriately tested.
The automated patient gown recycling machine. This machine contains the following design or components: (A) An infrared sensor device that can control the opening and closing of the door of the container. (B) An input port with an anti-pinch sensing device. (C) A unique iron frame inside the cabinet conforming to the specifications of the dirty clothes bag and equipped with a drag-type pulley chassis. (D) Two cabinets with a full-load indicator light. When one side is fully loaded, the other side will automatically start to work. (E, F) The cabinet is equipped with pulleys, and the installation location can be changed according to the users’ needs.
The automated machine was implemented in March 2017. A total of 216 valid responses were collected for the “Questionnaire for New Automatic Gown Recycling Device for Patients in Radiation Oncology Department”. The results, presented in Figure 9A, revealed that over 80% of patients agreed or strongly agreed that the new device meets the aspects of “safety”, “convenience”, “infection control problems”, and “overall satisfaction”. Approximately 90% of patients rated “overall satisfaction” as 4 or 5. Satisfaction with the new recycling system was significantly higher than that with the conventional devices (p<0.01). The new automated machine increased the effectiveness of recycling soiled gowns and prevented the buildup of filthy clothes, both of which contributed to the upkeep of the high standard of the medical environment in the public area (Figure 9B).
Comparison of the satisfaction survey between the new and conventional soiled patient gown recycling devices. (A) Satisfaction result for New Automatic Gown Recycling Device. (B) The medical environment in the public area.
Discussion
The present study introduced two generations of automated patient gown storage/distribution and recycling devices to replace the conventional wooden cabinets and/or the container stands with foot pedals used previously. A survey on users’ experience with the devices showed that these automated machines are safe and convenient and can improve infection control. More than 80% of patients surveyed agreed that using the automated patient gown storage/distribution machines was more time-saving than the conventional system, made it easier to identify the correct gown size, and reduced unnecessary contact with the remaining patient gowns. Further improvements in the second-generation patient gown storage and distribution machine included reductions in the long waiting time for the gown to drop out, the noise of the machine, the difficulties in understanding the operation method, and failures of the first-generation machine. For the automatic patient gown recycling machine, the survey results revealed a significantly higher percentage of agreement regarding the safety, convenience, improved infection control and improved recycling procedures of the new device. These results confirmed the expectations that both the automated patient gown storage/distribution system and the automated patient gown recycling device would be beneficial to patients, providing greater convenience and improving infection control to reduce the risk of nosocomial infection.
The scattered patient gowns that were often seen in the gown recycling area caused infection control problems, obstructed patients’ movements, affected patients’ perceptions, and inconvenienced the accredited laundry staff when they were collecting the gowns. The low quality of the medical environment also caused people to have a serious negative impression of the hospital. Patients are often required to change into a patient gown for medical and surgical procedures (7). In infection wards, the gown is often exposed to splashes of body fluids from the patients, especially blood, but also vomitus, sputum, pus, feces, and urine. During the severe acute respiratory syndrome pandemic in 2003, a laundry employee in Taiwan was infected, which resulted in a large outbreak because the washed and contaminated laundry was sent out to different departments (4). Hospital linens were identified as a vehicle for transmitting pathogens (8). The laundry process for the soiled gowns, contaminated linen, or reusable hospital textiles must be handled carefully. In the recycling process of soiled patient gowns, gown collection is the first and key step for infection control procedures. The automatic recycling device as described in the present study is believed to reduce the risk of infection and make the recycling process more effective.
Automated devices capable of different tasks have been used in the healthcare system (9, 10). The automated gown recycling machine with infrared sensor introduced in this study solved the potential problems involving the following four aspects: 1) Convenience: An infrared sensor is employed to automatically open the input port. Therefore, patients in wheelchairs and patients with limited mobility can easily use the machine without pushing the door or stepping on the cover. 2) Safety: The door flap or the flip-back can cause pinch injury. The automated recycling machine is equipped with an anti-pinch device. The machine’s inlet is opened again when a foreign object is sensed, thus increasing its safety. 3) Infection control problem: The patient does not need to touch the cabinet of the automated recycling machine when discarding the soiled patient gown. Furthermore, in the conventional device, overload causes random disposal and contamination. The inlet of the new automated device is designed to be horizontal and fully open, facilitating the input of dirty clothing. The inlet design can effectively block dirt without cabinet pollution. 4) Recycling procedure: The automated device is equipped with full-load signal lights to remind the accredited laundry personnel to replace the cloth bag, which improves the efficiency of the recycling device. The unique iron frame is adapted to the specifications of the existing dirty clothes bags, which facilitates the removal of the load directly from the bottom side opening. The laundry personnel can open the cabinet’s bottom side and drag the chassis outside the cabinet to replace the clothes bag. The alarm signal of the automated device reduces the possibility of overloading the soiled gown receptacle. The signal can effectively reduce the random discarding of clothes accumulated on the top of the cabinet. The contamination risk when laundry personnel perform replacement operations is also reduced.
The substantial effects of the automated recycling device can be classified as tangible benefits and intangible benefits. Survey responses of the satisfaction questionnaire indicated that the “safety”, “convenience”, “infection control problems”, and “overall satisfaction” were improved by 43.35%, 52.66%, 45.83%, and 59.45%, respectively (Figure 9), in the new device compared to those in the conventional devices; the overall satisfaction with the new device increased by nearly 60%. Since the March 2017 implementation of the new device, complaints of pinch injuries decreased from 10 to 0, with no reports of abnormal laundry operations. The safety of patients and laundry staff improved. The number of notification incidents associated with soiled gown recycling was zero. The new automated machine improved the efficiency of soiled gown recycling and avoided the accumulation of dirty clothing, which helped in maintaining the quality of the medical environment in the public area (Figure 9B). The intangible benefits of the automated recycling device are as follows: The new device combines human nature and technology to provide a safe and convenient dressing environment for patients, guarantee the safe operation of laundries, improve the appearance of the medical space, and improve the quality of the medical setting, thereby enhancing the professional image of the hospital. The patent license application of the automated gown recycling machine was approved (application number: 107201332).
The new device has some limitations in usability and cross-infection. We continued to develop the second-generation recycling device through a continuous collection of patient satisfaction feedback and close cooperation with relevant hospital units. We plan to design a robotic arm to increase dirty gown loading capacity and to add an internal ultraviolet disinfection lamp to increase infection control. We will continue to cooperate with the hospital to promote the use of this equipment in other units of the hospital.
Conclusion
Poor management in patient gown distribution and recycling leads to issues of nosocomial infection, especially during COVID-19 pandemic. The automated patient gown storage/distribution device efficiently and effectively provides suitable gowns to all registered patients, simplifies the registration procedures, and reduces the risk of contaminating other clean gowns. The automated patient gown recycling device reduces contamination of the gown recycling area and improves infection control, providing a high-quality and humanized medical environment.
Acknowledgements
This work was supported by National Taiwan University Hospital (NTUH 111-N0031, 110-N4838, 111-S0312 and 112-S0325). We thank the staff of the TRONCO ELECTRIC MACHINERY INC. for their technical support during the study.
Footnotes
Authors’ Contributions
SYW, CLT: Designed, performed, and analyzed the data, obtained funding for the project, compiled the figures, and wrote the manuscript; CWY, CFL, and YTL: analyzed the data, compiled the data, and performed statistical analysis/designed the figures; TJH, KMH, and SHK: analyzed the data and critically reviewed the manuscript; all Authors: read and approved the final version.
Conflicts of Interest
The Authors declare no competing interests in relation to this study.
- Received May 9, 2023.
- Revision received May 24, 2023.
- Accepted May 26, 2023.
- Copyright © 2023 The Author(s). Published by the International Institute of Anticancer Research.
This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY-NC-ND) 4.0 international license (https://creativecommons.org/licenses/by-nc-nd/4.0).
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