Hospital-acquired infections (HAIs) can be transmitted by common hospital human biological spills of, for example, urine, faeces, vomit, blood, saliva, breast milk, vaginal, amniotic, pleural, peritoneal and cerebrospinal fluids as well as bile and digestive juices (Palma and Young, 2020). Specific challenges posed by biological spills are that they are likely to contain microorganisms and or blood-borne viruses, increasing the risk of exposure to humans and the environment. A further challenge is that repeated encounters with biological waste can desensitise health professionals to potential infection risks.
In the UK, the risk of transmission of an HAIs most commonly occurs via blood-borne viruses, with the highest transmissions from infected patient to health professionals associated with hepatitis B (up to 30%), hepatitis C (1-3%) and HIV (0.3%) (Health and Safety Executive, 2025).
According to the World Health Organization (WHO) (2022) seven out of 100 patients in affluent countries and 15 patients out of 100 patients in less affluent countries will contract at least one HAI while hospitalised, with 1 in 10 affected patients dying. Across Europe, there are an estimated 3.5 million cases of HAIs, resulting in more than 90 000 deaths and 2.5 million disability-adjusted life years (DALYs); this exceeds the burden of other infections, such as influenza and tuberculosis (European Centre for Disease Prevention and Control, 2024).
In the UK, spill kits are designed to contain and manage hospital biological spills; they generally include a mix of polyacrylate granules, a chlorine-releasing agent and/or biocidal wipes and single-use plastic scoops (Goel et al, 2021). The currently available spill kits are also used alongside the implementation of safe management guidelines for body spills (NHS Education for Scotland, 2017). However, although a review for NHS National Services Scotland (Palma and Young, 2020) on the management of biological hazards identified legislative directives, educational practices and procedural guidance in relation to infection control, there was limited evidence on the efficacy of spill kits (King et al, 2016; Lutze et al, 2017; Lee, 2019; Ingram et al, 2021; Wasilewski et al, 2022; NHS National Services Scotland, 2022).
The study described in this article underscores the need to generate evidence to identify whether the spill kits currently in use are effective in meeting infection control needs and are fit for purpose, particularly because health professionals regularly care for patients with unknown blood-borne conditions (Dhama et al, 2021; Toren et al, 2021), and to evaluate the kits from an end-user perspective. Moreover, the spill kits (incumbent) that are currently in use are designed with plastic components, which is likely to impact negatively on the environment (Kibria et al, 2023). They are consequently less compatible with climate action and the United Nation's Sustainable Development Goals (https://sdgs.un.org/goals) for reducing plastic pollution (Walker, 2021).
This qualitative study aimed to explore the viewpoints of students/nurses/health professionals and simulated patients on two biological spill kit systems:
Methods
A qualitative approach, based on the principles of social constructivism (Barbosa da Silva, 2008), was used to understand participants' perceptions of the BIOPERL+ and the two incumbent spill kits. Prior to the recruitment phase, ethical permission was sought and approved in 2021 from the School of Health and Life Sciences ethics committee of University of the West of Scotland (approval number 10753). The recruitment process involved two of the authors (FS and KF) sending an ‘expression of interest’ form via email to the relevant divisional and nurse leads including line managers, providing information about the study.
Approval from the relevant leads allowed email access to students/nurses/health professionals. Opportunistic recruitment also involved posting through the routine university bulletin. If potential respondents expressed an interest in the study, an information sheet was emailed with contact details. A purposive sampling strategy was employed; the focus was to include students/nurses/health professionals who had expertise and experience in dealing with biological spillages in either hospital and or laboratory settings. New nursing students with no clinical experience in hospital settings were excluded from the study. Following the recruitment process, 12 simulated patients (adult nurses and laboratory technicians) and 12 health professionals (adult and mental health nurses, an operating department practitioner, an adult health practice manager, and student operating department practitioners) were included in the study.
The study involved participation in the simulated scenarios and follow-up interviews with the health professional participants. Signed informed consent was obtained from both patients and health professionals (video recorded during spillage containment).
The setting for the research was the University of the West of Scotland's purposefully built hospital environment.
Simulated spill scenarios
Simulated scenarios were deemed appropriate for this study because using of real urine, faeces, blood and vomit spills was deemed to present a health and safety risk to those involved (Chatterton, 2024). Furthermore, simulated practice is known to promote critical thinking and provide a high-quality experience that reflects that of a hospital setting (Koukourikos, et al, 2021). The decision was made to focus on blood, urine, faeces and vomit because these were identified as the most commonly encountered bodily excretions (NHS National Services Scotland, 2022).
The following simulated spills substitutions, matching the texture and consistency of the ‘real’ human spills as closely as possible, were used:
The two incumbent kits were compared with the BIOPERL+ kit. Each spill type was measured equally and placed twice within different areas on the clinic floor.
Simulated patients (not video recorded) observed the health professionals' (video recorded) containment of bodily fluid spills (faeces, urine, blood, vomit) using either the incumbent or BIOPERL+ kits. Each video recording lasted around 20 minutes. The resulting videos provided information on the appearance of spillages and the hand behaviours of participants, which informed the subsequent interviews. Observation of the hand behaviours demonstrated spill clean methods by participants and usefulness of powder application, scoop use and equipment disposal techniques.
Interviews
Informed consent was also obtained prior to interview to understand the health professionals' perceptions when using the two incumbent and the BIOPERL+ spill kits. The interview guide was informed by the National Infection Prevention and Control Manual (NHS National Services Scotland, 2022), current clinical practice and researcher expertise (Table 1). Each interview lasted between 10 and 30 minutes. Field notes were recorded after each interview for reflective purposes and to inform each interview.
| Patient themes |
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| Health professional themes |
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Ethical considerations
One of the authors (WM) obtained ethical approval from School of Health and Life Sciences Ethics Committee, University of the West of Scotland in 2021. This study was underpinned by the ethical principles of beneficence, nonmaleficence, autonomy, and justice – to do no harm (Varkey, 2021). All health professionals were provided with an information sheet about the purpose and procedures of the research, and therefore were able to provide informed consent for both the filming and the interviews. During filming, the anonymity of respondents was protected, because the camera was focused on the health professionals' hand behaviours and spillage. Moreover, each video was assigned a code, further ensuring anonymity and confidentiality. At interview, each audio/transcription was assigned a code to anonymise the data. Data were stored on a password-protected university computer, to which only the researchers had access, thereby protecting participant confidentiality.
Participation in the study was voluntary and participants were free to withdraw at any time during either the filming or the interview data collection phases. Anonymised data will be destroyed at the point of publication (Information Commissioner's Office, 2023). Interviewers who may have had knowledge of any respondents did not participate in the video or interview data collection process.
Data analysis
Data analysis was conducted using the framework method of analysis useful for its iterative approach. The process followed familiarisation with the data, and the codes were developed using an inductive approach (Gale et al, 2013). FS coded the transcripts and developed the coding framework for the responses (Table 2). WM with expertise in infection control confirmed the coding of the interviews. The completed Consolidated Criteria for Reporting Qualitative Research (COREQ) (Tong et al, 2007) was adhered to. The transcript coding legend can be found in (Table 3).
| 1. Health professional and patient views about body spillage and appropriate spill kit |
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| 2. Health professional and patients views about spill kits, component parts, contamination and personal protective equipment (PPE) |
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| 3. Health professional and patient views about the spill kits and instructions |
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| 4. Health professional and patient perceptions of spill kits powder absorption and odour |
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| 5. Health professional and patient perceptions about residual staining comparisons |
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| Identifier | Code |
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| Transcript (patients, n=12; health professionals, n=12) | T1–T12 |
| Patient | P |
| Health professional | H |
| Incumbent kit | I |
| BIOPERL+ kit | B |
| Blood | B |
| Faeces | F |
| Urine | U |
| Vomit | V |
Findings
Box 1 provides a summary of the key themes that emerged from the interviews with the health professionals in terms of the utility and ease of use of the two types of kit.
Main themes arising from the follow-up interviews with the health professionals
Identification of required spill kit
Overall, health professionals were clear that the BIOPERL+ kit facilitated rapid identification of which spill kit was required: it was considered to be a ‘one-size-fits-all’ kit that was suitable for all biological spills.
‘[The BIOPERL+ kit] seemed to be more efficient in terms of its one-size-fits-all approach.’
‘I opened the [BIOPERL+] kit knowing that it was for urine.’
However, not all health professionals were able to quickly identify which of the incumbent kits was appropriate for faecal and urine spills. This could be a concern as delay to spillage containment may exacerbate patients' feelings of embarrassment, including their emotional and social wellbeing (Assmann, 2024).
‘I couldn't establish quickly what was appropriate for a faeces spillage. So there was a bit of deliberation in choosing the appropriate product because neither [of the incumbent kits] specified for this type of spillage.’
‘One [incumbent] kit had an unclear [spillage] label. So I went into the yellow box and the first thing it said was “do not use on urine”. I thought that's out the window then.’
Instructions/learning styles
There were few comments from health professionals about the location of instructions, however, with regard to the BIOPERL+ kit a minority mentioned being unable to find these.
‘The [BIOPERL+ kit] instructions were tucked away underneath. So that was not as clear.’
Comprehending the incumbent spill kit instructions was also regarded as challenging for some of the health professionals. Comments from both health professionals and patients highlighted that the detailed additional steps delayed spillage containment.
‘The [incumbent kit] instructions seemed less straightforward – there was no instruction about PPE [personal protective equipment].’
‘There was a lot more back and forth [in terms of instructions]. I think using the [incumbent kit] had so many steps, [it] obviously adds to the clean-up time’.
Understanding the incumbent instructions was facilitated if the health professional had experience of spill kits and were therefore were familiar with the process of biological containment.
‘I was more familiar with the [incumbent] product because it was more reflective of what I'd used in practice previously.’
Health professionals perceived that the BIOPERL+ kit instructions were clear, highlighting the benefits of having very little text to read text, facilitating multitasking.
‘The [BIOPERL+ kit] was very clear, simple instructions … easy to make up, easy to follow the instructions.’
‘The [BIOPERL+] kit – you could read through it first, as you were just familiarising yourself with it, it was one page, one side, very little text, so you could look at it while you were putting on your PPE.’
A minority of patients responded that the BIOPERL+ kit instructions could be made clearer if the size of the instructions were improved because they saw that the nurse had challenges with reading the information:
‘I don't think the flat-pack instructions [of the BIOPERL+ kit] are clear, there's a small instruction on the back side of the cardboard, so maybe that needs to be a little clearer.’
Some health professionals were confused about the instructions relating to granule application. The following quotes highlight these perspectives with respect to comprehending the instructions relating to both the incumbent and the BIOPERL+ kits in terms granule application.
‘… or how much [of the spill] to cover [with the powder from incumber kit]’
‘Was I looking to put on a mountain [granules] or only a bit [from the BIOPERL+ kit]?’
Of note is that other health professionals simply referred to the diagrammatic section of the instructions, highlighting the differences in the learning style of individuals (Kolb, 1984).
‘The diagrams [in the incumbent kit] were what I was looking at more than the actual written part of it.’
Granule absorption
When health professionals referred to component parts of the kits, their key focus was on granule absorbency. Blood, for example, was perceived as being absorbed effectively by both the BIOPERL+ and the incumbent kits.
‘I used both sachets [of the BIOPERL+ kit], it was a big area and, even though it didn't look like it'd covered everything, it was solid, it came together really well.’
‘I thought the absorbency of the [incumbent kit] was good, you left that on for a minute and it absorbed all the fluid.’
For clearing up vomit, more granules were required from the incumbent kit, which delayed spillage containment, and this was thought likely to contribute to patient distress.
‘In the [incumbent kit] the crystals are smaller. You need more to take up the surface area. The waiting time for the powder to work could cause mental worry for the patient.’
Regarding clearing up urine and faeces, the health professionals thought that the efficacy of the larger granules of the BIOPERL+ kit in absorbing urine spillage was effective, and that the larger granules were also likely to be more appropriate at reducing respiratory risk.
‘In the [BIOPERL+] kit, the granules were bigger [for absorption], and it didn't feel as if you were breathing it in and it was going everywhere. It was easier to control.’
The health professionals were clear about their perceptions regarding granule absorbency and spillage containment. It was perceived that the incumbent spill kit was less effective for some types of spills. In their view, the BIOPERL+ kit granules were more effective in the containment of blood, urine vomit and faeces.
Granule odour and health risks
The granule odour of the spill kits was consistently referred to in this study, and the responses were varied. However, some health professionals perceived that the BIOPERL+ granules had a strong odour.
‘With [BIOPERL+] I was kind of hit with the smell of it. I found the smell quite strong, a bit stronger.’
Views on the granules provided in the incumbent kits were similar, with the health professionals describing these as having a strong odour. However, in the case of the incumbent kits both health professionals and patients expanded on this notion, suggesting that the kits also had a chlorine-type smell. Some respondents referred to health risks, which is pertinent because a chlorine-type odour may have the potential to cause respiratory distress (Clausen et al, 2020).
‘For the [incumbent], kit, you got that sort of chlorine hit. I could feel it in the back of my throat.’
‘The [incumbent] product, when you put the tablets into the bottle, you were making disinfectant, and that was more like a chlorine, bleach-type smell.’
‘[The incumbent kit] had the potential for asthma exacerbation.’
Scoop size
There was general agreement among the health professionals that the scoop size included with the BIOPERL+ kit facilitated its ease of use. When discussing BIOPERL+ kit's component parts, they consistently referred to the benefits of the large cardboard scoop size, which facilitated ease of use when containing simulated blood, urine and faeces.
‘The bigger scoop [in the BIOPERL+ kit] was better, the smaller scoop [in the incumbent scoop] was fiddlier.’
‘The actual scooping in the dustpan with the cardboard scraper [from the BIOPERL+ kit] was better in shape, [so] less scoops were required to clean the spill.’
‘The [BIOPERL+] scraper was fine, everything went in the bin [faeces], and then I did it again, and it easily took away all that mess.’
Indicative of health professionals' responses was that the incumbent scoop was too small, with some expressing worries about infection risk.
‘It was the little dustpan [in the incumbent kit] with the little plastic scraper, which was about a fifth of the size of the [BIOPERL+ kit] scoop. You had to repeatedly do it, it felt like your hands, your clothing was all close to the spill.’
However, some health professionals considered that the BIOPERL+ spill kit, with its cardboard scoop, was too flimsy, particularly when they were engaged in cleaning up the simulated vomit spillage.
‘[The BIOPERL+ kit's scoop has] a flimsy handle that bends when you're trying to scoop up the contents, then [there's] the solids to dispose into your bag, you've got to corner it all in, and it takes longer.’
Potential cross-contamination and reuse
With reference to the incumbent spill kits, participants highlighted issues in relation to the reuse some of their components parts and potential contamination risk. However, some health professionals suggested that there may need to be ongoing training and education on the use of the incumbent kits for spills management. According to NHS National Services Scotland (Palma and Young, 2020), the preferred method or technique for spillage containment is less clear in the literature. This highlights the need for further research in terms of end-user testing.
‘I took my bag out, my gloves out, and my apron out [of the incumbent kit], and then I had to go into the bag with my gloves on to get the wipe, so I kind of contaminated it ’cos I'd dirty gloves on.’
Plastic components and environmental impact
An emerging theme from the study arose from discussions by health professionals about the incumbent plastic kit versus the BIOPERL+ cardboard kit. A common concern expressed by health professionals was with regard to the impact of plastic on the environment.
This is a broader concern in the healthcare sector, with Rasheed and Walraven (2023) suggesting that now is the time to rethink the use of healthcare's use of plastics to produce environmentally friendly products.
‘… the cardboard one's [BIOPERL+ kit] is [made from] recyclable materials.’
Discussion
It is important to acknowledge that simulated patients were used for this study, therefore, the ‘real’ patient voice remains unheard. Similarly, the researchers were only able to provide simulated spillages, which is likely to impact on the transferability/reflectiveness of the findings to other hospital settings. Furthermore, the Hawthorne effect may have impacted some health professionals' behaviour when containing spills because they were aware of being observed by a ‘patient’ (a health professional colleague) (Berkhout et al, 2022). To date, this research is the first known study to discuss the perceptions of health professionals on the use of spill kits for various biological spills, thereby making a new contribution to research.
The perceptions of health professionals demonstrated that the BIOPERL+ kit was rapidly identified as a kit that could be used for containment of all the types of spills used in this study. A number of health professionals were unable to locate the appropriate incumbent kit for the right type of spill, which delayed spillage containment.
Clear and timely decision-making is integral to the containment of biological waste (Health Improvement Scotland, 2022). In this study, individuals demonstrated how they perceived and internalised spill kit instructions (Kolb, 1984). For instance, some considered that the incumbent kit instructions were too detailed and required reaffirmation, while others relied on the diagrams provided to complete the spill containment.
The BIOPERL+ kit instructions were considered mostly clear, with some improvements required with regard to presentation (text size). Differences in the way nurses learn can be associated with a decline in nursing competency. Therefore, nurse educators should be cognisant of the need for support for certain learning styles and the potential impact on clinical practice (Yang et al, 2016; Palma and Young, 2020; Lundell Rudberg et al, 2023; Mousavi et al, 2024). The Royal College of Nursing (2022) has stated that it is likely that 10% of the working population is neurodiverse, suggesting that neurodiverse individuals often lean toward nursing, highlighting the importance of instructions that are fit for purpose for all individuals.
The health professionals also considered that both the incumbent and BIOPERL+kits had minimal to strong granule odour, yet they placed more emphasis on the incumbent kits' chlorine-type smell, perhaps suggesting concerns over an increased respiratory health risk (Clausen et al, 2020; Morim and Guldner, 2022). More evidence is required in terms of the link between odour pollution and the impact on human health.
The large scoop included with the BIOPERL+ kit was the preferred method for spillage containment because it was easier to use compared with the incumbent kit's smaller scoop. The incumbent kit was also mentioned in relation to spill kit contamination, for example, when reusing component parts suggesting the need for further nurse education in clinical practice, for example with reference to the National Infection Prevention and Control Manual (NHS National Services Scotland, 2023).
A key strength of the BIOPERL+ spill kit was its cardboard material, which was seen as environmentally friendly, reinforcing the need to rethink plastic use. While items made of single-use plastics in infection control reduce the risk of cross-contamination between patients, the healthcare sector's reliance on them is contrary to efforts to reduce the sector's environmental impact (Hopkinson et al, 2021). This is important, because we are living in a time when the link between nursing care and the environment is gathering momentum (Moghbeli et al, 2024) There is a need for all health professionals to understand that changes in their healthcare practices can contribute to reducing the impact of climate change (Guihenneuc et al, 2024). Nurses make up around 60% of health professionals globally in various clinical and public health environments and can act as a conduit for change in the clinical environment. They can therefore be part of collective action contributing to changing the trajectory of climate change (Butterfield et al, 2021) and working towards meeting sustainable development goals (United Nations, 2024).
Although most published studies discuss disinfection in relation to the hospital environment, there is a dearth of evidence around spill kits and infection management. The available research relates to infection control standards and guidance that is applicable to hospital environments. There is limited evidence in terms of primary studies for novel interventions (Palma and Young, 2020). However, according to the WHO (2025) action for new infection control strategies, underpinned by patient safety and quality care, is imperative. The findings from this study could potentially contribute to further research in infection control practices.
Conclusion
It is well known that HAIs are a risk in healthcare environments; they not only affect patients' quality of life and mortality, but also the wellbeing of health professionals. The are policies and strategies in place to counteract HAIs, however biological hazards such blood, urine, faeces and vomit remain potential hazards to infection among patients and health professionals.
In this study, the aim was to understand the perceptions of health professionals in relation to the use of incumbent kits and BIOPERL+ spill kits. The ‘one-size-fits-all’ approach for all biological spills rapidly identified the BIOPERL+ kit as one to use, while preference for use of the incumbent kits depended on identifying spill type. Identifying, locating and understanding information in both kit types highlighted that individuals learn and internalise information differently, which may have implications for clinical practice.
Health professionals had the perception that both kits had minimal to strong odour, yet the incumbent kits emitted a chlorine-type odour, perhaps presenting potential health risks.
The BIOPERL+ kit's large scoop size was seen as the obvious choice for spillage containment compared with the smaller plastic scoop of the incumbent kits. Participants also considered that the incumbent kits could be a source of potential cross-contamination when component parts were reused. Health professionals also indicated that the BIOPERL+ kit's cardboard design was a benefit and would have less of an impact on the environment.
This study has highlighted that the BIOPERL+ kit is an effective, safe novel intervention that is not only appropriate for human spills, but that is also environmentally friendly.
Strengths and limitations
This is the first study of its kind to explore the perceptions of end-users of body fluid spill kits and infection control. There has previously been minimal research conducted to compare and contrast spill kits as a novel intervention in infection control. Rather, the focus has been on adherence to standards and precautions. The limitations of this study include using simulated patients and, as such, the ‘real’ patient voice remains unheard. Similarly, the authors were able to provide only simulated spillages for the scenarios, likely impacting transferability to other hospital settings.
The authors also acknowledge that the this study took place in a university purpose-built clinic using a specific population, which is another limitation to wider transferability. It is also worth noting that health professionals may have introduced some behavioural change while being observed by simulated patients (their colleagues) while they were engaged in containing the simulated spillages.
Relevance to clinical practice
Healthcare providers and practitioners must work with researchers to evaluate novel infection control interventions to ensure that they fit with current practice and guideline development.