The Link Between Adult Social Care and Hospital Discharges

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The NHS is currently facing a significant backlog that shows no sign of easing in the foreseeable future.

As a measure for easing the pressures, Prime Minister Rishi Sunak has discussed greater investment in social care.

In this post, we’ll explore the link between adult social care and hospital discharges. We shall explain how investing in social care may help free up hospital beds for other critical care patients.

How Can Adult Social Care Investment Free Up Hospital Beds?

Not all patients necessarily need to be in hospital to receive the care they need. Some patients can instead receive care in the community. Essentially, this means that they’ll leave hospital and go to either their home, a family member’s home, or a dedicated residential setting.

A care worker or nurse will then visit them routinely to give them the care they need. This might involve administering medication, supervising physiotherapy exercises, or simply checking up on them to see how they’re progressing following hospital treatment.

If need be, the care worker may refer the patient back to hospital to receive more intensive care or supervision. But in most cases, the patient can make a full recovery from the comfort of their own home.

Why Are Adult Social Care Issues Causing Hospital Bed Shortages?

Every patient receiving care in the community is a patient who is not taking up a hospital bed. This frees up hospital beds for more critical cases. It also increases the overall capacity of the hospital and its staff. This can make a difference to many of the crises the NHS is currently facing, from the backlog of care to the long ambulance waiting times.

How is the Government Investing in Adult Social Care?

During the 2020 pandemic, the Department of Health and Social Care (DHSC) was committed to freeing up as many hospital beds as possible. They aimed to reduce pressures on the NHS and to ensure that there would be capacity for any COVID patient who needed hospital care. And they did this via a fund that would allow patients to receive up to six weeks of free social care upon leaving hospital.

In September 2022, there were reportedly 13,000 people in hospital who could instead be receiving care in the community. So the Secretary of State for Health and Social Care unveiled a £500m grant for adult social care.

Will This Investment Make a Difference?

Unfortunately, the adult social care sector is itself going through some tough times.

Vacancies in adult social care rose by 52% in 2021-2022. So even if the government pledges to fund adult social care, there may not be the capacity to handle the increased caseload this would bring.

The DHSC has also discussed launching a domestic adult social care recruitment campaign. But given how long it takes to recruit and train specialist social workers to provide care in the community, it’s unlikely that this will make a difference in the short-term.

Investing in adult social care is a vital step to addressing the NHS’s backlog, and the numerous additional problems it brings. Though as is usually the case, things are far more complicated than they initially seem, and we’re unlikely to see any noticeable improvements in the near future.

How Can Hospitals Manage in the Short-Term?

While this issue continues to affect practice, hospitals and healthcare staff continue to work to the best of their ability to deliver efficient and high-quality care.

We have been working with healthcare professionals for over 20 years to find solutions and procedures to help improve efficiency through infection control and air quality monitoring as well as by providing products to help improve turn-around times and patient outcomes.

Get in touch to find out how we help hospitals and healthcare settings control and prevent infection while improving operational efficiency.

 

 

Why Are Ambulance Waiting Times Getting Longer?

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UK ambulance waiting times are bad, and they show every sign of getting worse.

Some cases have been so severe that they’ve made the news. For example, an 85 year old in Cornwall had to wait a total of 40 hours to get to A&E. This included 14 hours for the ambulance to reach her, and a further 26 hours before she was taken into the hospital. And even then, she did not receive treatment for hours.

This is an extreme case. But still, UK ambulance waiting times are long and getting longer.

What’s the Average UK Ambulance Waiting Time for Critical Calls?

The NHS sets a target response time of 7 minutes for critical calls. Through 2021/22, critical patients waited an average of 8 and a half minutes for a response. This might not sound like much, but it’s almost a fifth longer than patients had to wait in 2018/2019. Also, for critical patients, every second counts. An extra minute’s wait could mean life or death.

What’s the Average UK Ambulance Waiting Time for Non-Critical Calls?

For less urgent cases, waits have doubled over the past few years to an average of 3 hours.

And unfortunately, the situation does not look likely to improve anytime soon. Ambulance workers voted for strike action in early December 2022. Industrial action on the 15 and 20 December affected a quarter of frontline services in England, and nearly all services in Wales and Northern Ireland.

Scotland remained unaffected, as unions suspended industrial action to consider a new pay offer.

While there are rules in place requiring ambulance services to provide emergency care, these strikes  served to make a bad situation even worse.

Why Are Ambulance Waiting Times Getting Longer?

The main reason ambulance waiting times are getting longer is due to the immense backlog the NHS is facing following two years of government lockdowns.

Because of this backlog, ambulance services are facing an increased demand. And though the paramedic workforce has increased, absences related to poor mental health have increased from 5% in March 2019 to 9% in March 2022.

Plus, despite the increased workforce, ambulance crews have less capacity, as ambulances now have to wait longer with patients outside hospitals. According to one Health Foundation report, more than 10% of ambulances had to wait for over an hour outside hospitals in July 2022.

And because the whole service is stretched, even the smallest increase in handover times can result in a larger increase in the average response times.

How is the NHS Responding to this Problem?

The Health Foundation has issued a series of recommendations for addressing the issue:

  • Focus on handover delays. Increase hospitals’ capacity and flow-through with more beds and staff. Sunak’s pledge to invest in social care along with other out-of-hospital services could make a difference here.
  • Further increase the number of paramedics and address the causes of poor mental health in the workforce to reduce sickness absence.
  • Work to reduce the demand. This might be achieved through greater investment in community services, with an emphasis on addressing health conditions as early as possible before they require an ambulance response.

Prime Minister Rishi Sunak has claimed he plans to “sit down with the NHS” to discuss ambulance waiting times. He’s also announced that the government has put more money into the NHS, and more money into social care. The idea is that funding social care will allow more people to move out of hospitals and back into their own homes.

How Long Before Ambulance Waiting Times Improve?

Unfortunately, it’s likely that UK patients will face lengthy ambulance waiting times for the foreseeable future.

The NHS backlog is not going to get any better anytime soon. So there will be a high demand for services for some time yet.

Also, no matter what plans the government and NHS put into place to address the issue, changes won’t come overnight. And the strike action in December 2022 may serve to delay the implementation of certain improvements.

Get Help to Improve Efficiency and Care Standards in Healthcare

At Cairn Technology, we’ve been working with healthcare providers including NHS hospitals and care homes for over 20 years. We work with you to find solutions to help improve efficiency and standards through effective infection control, air quality monitoring and improvements.

Find out how we can help improve efficiency and care standards in your healthcare setting.

 

Absorbent mats for urology theatres and wards

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Whether you want to absorb blood, urine or irrigation fluid during urology procedures, using a high-performance absorbent mat can avoid a lot of mess and mopping up.

Of course, there are suction devices that can remove liquids from floors, but these can often be noisy and pose a trip hazard, neither of which can be said of absorbent mats.

What’s more, some absorbent floor mats can be cut to size, to suit your requirements exactly. In addition, sterile mats can be placed under or next to the patient.

In this article, we look at three kinds of absorbent mat that can help provide a drier and safer environment for both patients and staff:

1. The T-Mat for urology theatres and wards

Designed for urology theatre floors to collect fluids during wet procedures, the T-Mat collects and binds liquids hygienically, wicking liquid away from the surface and turning absorbed fluid into a gel in only two to three minutes.

Able to absorb up to 8.5 litres of water or 3.5 litres of saline, the T-Mat is the most absorbent mat on the UK market. Measuring 75 x 36cm, it is a convenient size to be positioned on the floor where you expect any fluids to pool.

By locking in fluids, the T-Mat effectively reduces the risk of hazards such as slips and trips, whilst also reducing the time needed to clean up post-procedure.

In fact, its non-drip design means that you can easily dispose of the T-Mat in clinical waste with minimal risk of cross-contamination.

2. The DryMax XL for urology theatre scrub rooms

If you are looking for an absorbent mat that you can stand on whilst scrubbing up or performing a procedure, then the DryMax XL is the ideal product.

Designed with an anti-skid barrier layer, the mat stays in place while you walk on it. You can even cut the DryMax XL to fit an area, whether you do that with the individual mats sized 100 x 75cm or with the DryMax XL on a 100cm x 5m roll.

The DryMax XL is also highly absorbent. Capable of absorbing up to 2 litres of fluid, the it locks in liquids, preventing slips on wet floors. What’s more, its non-drip design allows for quick and easy disposal, with minimum risk of cross-infection.

3. The DryMax Sterile for urology departments

The DryMax Sterile is the ideal choice, if you are looking for an absorbent mat that you can place beneath or next to the patient during wet procedures.

Measuring 72 x 37cm, this disposable mat can absorb up to 6 litres of fluids and 2.4 litres of saline.

What’s more, having a non-drip design, it can be easily disposed of as clinical waste, ensuring a faster turnaround and reduced clean-up time.

Trialling absorbent mats for your urology theatres

If you would like more information on the above mats or to discuss your fluid management requirements call 0845 226 0185 or email info@cairntechnology.com

Hospitals are also welcome to trial a couple of mats for free to see how staff find using them in their own urology theatres and wards, so if this is of interest, please feel free to contact us.

Rising concerns over air pollution in city hospitals

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If you are concerned about unsafe pollutions levels in your hospital then you are not alone. A recent study by Kings College London and the UK Health Alliance on climate change found that 60% of hospitals and NHS facilities in inner London are in areas that exceed air pollution limits.

What’s more, the environmental campaigning network UK100 has found that more that 17% of hospitals across the UK have unsafe levels of toxic particles in the air.(1)

The issue has become so serious that the Mayor of London, Sadiq Khan, is working with ten hospitals in the most polluted areas of London to install air quality monitors that will measure levels of toxic air to help protect patients and staff.(2)

Whilst this initiative forms part of Sadiq Khan’s Breathe London project to help improve air quality in the capital, it is clear that hospitals in toxic hotspots across the UK also need to take action.

How we can help you

 

If you are looking for a way to remove pollutants trapped inside your hospital, we offer a range of Blueair air purification systems to filter the air in a variety of room sizes, from offices to waiting rooms and wards.

The range includes purifiers that can deliver 99.97% filtration efficiency, all the way down to particulate of .01 micron, not only capturing hazardous smaller particles like viruses and bacteria but also pollutants from car fumes and Volatile Organic Compounds (VOCs).

To see our range of air purifiers for hospitals click here.

Helping you to create a Clean Air Hospital

With low noise, low energy consumption and high filtration efficiency, Blueair’s air purifiers can play an important part in the creation of your clean air hospital, as laid out in the Clean Air Hospital Framework.(4)

Developed in partnership by Global Action Plan and Great Ormond Street Hospital, this framework defines a ‘Clean Air Hospital’ as one that: “Improves air quality outside and inside the hospital by minimising sources of air pollution under its control” and that develops “a clean air action plan to improve air quality.”

If you are interested in discussing how Blueair air purifiers can improve air quality in your hospital, please contact our Air Purification Team on 0845 226 0185.

Why choose Cairn Technology?

Cairn Technology Ltd has spent two decades helping hospitals across the UK to monitor and improve indoor air quality in operating theatres, anaesthetic rooms and other areas.

Until recently the majority of this work has focused on workplace monitoring of hazardous substances to ensure that they do not exceed COSHH workplace exposure limits and help hospitals take effective action where they do.

In addition, we carry out sterile services cleanroom testing, bioburden testing, and the commissioning of hospital ventilation systems.

With growing concern over the impact of air pollution in hospitals, particularly in high traffic areas, it has become a natural progression for us to also start to help hospitals to tackle this problem and create a healthier environment for patients as well as staff.

References:

(1) https://www.uk100.org/10-5-million-hospital-patients-at-risk-from-toxic-fumes/

(2) https://www.london.gov.uk/press-releases/mayoral/mayor-installs-air-quality-monitors-at-hospitals

(3) https://breathequality.com/blueair-classic-605-review/

(4) https://www.globalactionplan.org.uk/clean-air/clean-air-hospital-framework

8 useful tips for surgical instrument care

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High quality surgical instruments can be an amazing investment. Offering exceptional performance and durability, some studies have shown such instruments can last for well over 30 years.(1)

However, even the finest surgical instruments will only last if they are carefully handled, properly maintained and professionally serviced. Follow these 10 tips to help ensure your instruments last for as long as possible:

1.      USE AS INTENDED

Never use a surgical instrument for anything other than the purpose for which it was designed. By misusing instruments, you can cause irreversible damage by stressing the parts and damaging the surface.

2.      HANDLE WITH CARE

Poor handling of surgical instruments is a sure-fire way to damage them, so don’t start throwing them around or leaving them in unsuitable conditions. If you do, you may quickly find that your instruments suffer fractures or become contaminated and corroded.

3.      AVOID DRIED RESIDUE

Clean used instruments quickly to avoid any residue drying onto the surface. This is because, blood and other secretions can cause discolouration and corrosion.

4.      AVOID LEAVING WET

Once cleaned, make sure the instruments are dried properly. Instruments left in liquid cause a galvanic current that can lead to galvanic corrosion.

5.      AVOID MECHANICAL STRESS

Don’t stress an instrument beyond its capabilities as this can lead to misalignment of instrument parts. It can also cause tension or stress corrosion: the spontaneous cracking of instrument parts subject to high tensile pressure, such as screws and welded sections.

6.      STICK TO PROCESS

Make sure that routines in the Central Sterilisation Department are strictly followed. This includes ensuring that instruments are cleaned at the correct temperature, using the correct detergent and that they are stacked and dried correctly.

7.      CLEAN AS ADVISED

Always adhere to manufacturer’s instructions for cleaning and sterilisation. In particular, it is important to stick to dosage and duration guidelines for the detergent you are using.

8.      AVOID POOR SERVICING

Always use a certified repair facility, as inexpert servicing can ruin valuable instruments. By having your surgical instruments professionally inspected, refurbished and realigned, you can help ensure that they are restored to top condition.

If you found the above tips useful, you can click here to view and download our handy infographic for surgical instrument care. 

WANT MORE SURGICAL INSTRUMENT CARE TIPS?

For ongoing tips on how to maintain your valuable surgical instruments just click here and follow our LinkedIn page. As well as tips on instrument care, we also post news on upcoming surgical events, advances in surgical technology and new product updates.

REFERENCES:

(1)   Dahl G, Ölveback T, Wiklung L. Quality surgical instruments best investment. Presented: SEORNA, Swedish Operating Nurse Association Conference Meeting, 29-30 November 2012

Choosing absorbent mats for your labour ward

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From amniotic fluid release to mild blood loss and intrapartum haemorrhage, there can be a host of reasons for having a high performance absorbent mat to hand in labour wards or obstetrics theatres.

Of course, there are suction devices out there that can remove fluids from floors, but these can often be noisy and pose a trip hazard, so absorbent floor mats can provide a better solution.

In this article, we look at three types of absorbent mat that can contribute towards a drier and safer environment for patients and staff:

1. The T-Mat for obstetrics theatres

Designed for obstetrics theatre floors to collect fluids during caesareans, the T-Mat collects and binds liquids hygienically, with excess fluid turning into a gel within only 2 to 3 minutes.

As the most absorbent mat on the UK market, the T-Mat can absorb up to 8.5 litres of water or 3.5 litres of saline. Measuring 75 x 36cm, the T-Mat should be positioned on the floor where you expect fluids to pool.

Its ability to lock in fluids reduces the risk of slips and trips, as well as the time needed to clean up post-procedure.

In addition, its non-drip design, which wicks liquid away from the surface, means that it can be easily disposed of in clinical waste with minimal risk of cross-contamination.

2. The DryMax XL for obstetrics scrub rooms

If you are looking for an absorbent mat that you can stand on whilst scrubbing up or performing an operation, then the DryMax XL is the perfect choice.

Designed with an anti-skid barrier layer, the mat stays in place and prevents absorbed fluids from passing through, thereby preventing slips on wet floors.

Measuring 100 x 75cm, the DryMax XL can be conveniently cut to fit an area. Capable of absorbing up to 2 litres of fluid, its non-drip design allows for quick and easy disposal, with minimum risk of cross-infection.

3. The DryMax Sterile for labour rooms and obstetrics theatres

If you are looking for an absorbent mat that can be placed under or close to the patient during labour or a caesarean, then the DryMax Sterile is the ideal solution.

Measuring 72 x 37cm, this disposable mat can absorb up to 6 litres of fluids such as urine, blood and amniotic fluid and 2.4 litres of saline.

Being non-drip, it can be easily disposed of as clinical waste, enabling a quicker turnaround and reducing the time needed for clean-up.

Trialling absorbent mats for your labour ward

If you would like more information on the above mats or to discuss your fluid collection requirements call 0845 226 0185 or email info@cairntechnology.com

Hospitals are also welcome to trial a couple of mats for free to see how staff find using them in their own labour rooms and obstetrics theatres, so if this is of interest, please feel free to contact us.

Poor quality instruments put patients at risk

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Fears that contaminated surgical instruments are causing unnecessary illness and deaths because of the risk of infection continue to hit the headlines.

From Alzheimer’s proteins to HIV, Hepatitis B or C and many more dangerous diseases, there seems to be a steady stream of stories about how patients’ health has been put at risk.

What is not often mentioned in conjunction with these stories however, is the fact that poor quality surgical instruments are often to blame for poor standards of infection control.

What’s more, despite a BBC documentary “Surgery’s Dirty Secrets” revealing several years ago that large numbers of surgical tools used in the NHS failed to meet quality standards, the problem of poor quality instruments is still rife.

In fact, Tom Brophy, a lead technologist with Barts Health NHS Trust went on record at the time to say that about 20% of all the instruments that he received were rejected because of flaws that could put patient’s health at risk.

So why do poor quality surgical instruments pose a risk?

Poorly manufactured surgical instruments can risk patient health for a number of reasons:

·         Micro-punctures in surgeons’ gloves

Poor quality surgical instruments are often machine-made and finished, leaving metal fragments and sharp burs that can lacerate surgical gloves.

As these punctures can be miniscule, they can easily go undetected during a surgical procedure, creating an easy pathway for infection to be transferred to the patient.

·         Defects that are invisible to the naked eye

In addition to revealing sharp burs and microscopic shards of steel, an inspection of a poor-quality instrument under a microscope will often reveal numerous other defects that can pose a risk to patients.

This is because by using low-grade steel, such instruments can easily become corroded or pitted and even develop hairline fractures.

This means that whilst an instrument might seem perfectly clean to the naked eye, a look under a microscope can reveal numerous areas that could be harbouring dangerous bacteria and viruses.

·         Unclean manufacturing facilities

Although Swedish craftsmanship and German-quality stainless steel may come to mind when one thinks of surgical instruments, two-thirds of the world’s instruments are actually made in Pakistan.

While some of these manufacturers adhere to high standards of manufacture, others have been found to operate in dust-filled environments near to open sewers, piling newly made instruments on the floor and failing even to carry out a visual inspection with a magnifying glass before marking their wares with a CE quality stamp.

Clearly this then begs the question just how clean these brand-new instruments are by the time they get into the hands of our UK surgeons.

·         Low grade materials

It is clear to see why both UK surgeons and NHS procurement teams would want to avoid poor quality instruments that pose such risks of infection and harm, even when the pricing can differ so significantly between high-quality and poor-quality instruments.

Of course, German stainless steel is recognised as the very best material for making surgical instruments, but in a time of ongoing budgetary pressures on the NHS, surely it makes sense to buy less expensive ‘German’ instruments than recognised brands?

However, due diligence is needed here as well, as the ‘Dirty Secrets’ documentary also revealed Pakistani representatives offering to sell tools made with Pakistani and French steel that are stamped “Made in Germany”.

The result is that hospitals may still end up paying a lot for substandard instruments that pose a risk to hygiene and health.

·         Design limitations that affect cleanliness

Another issue with poorly manufactured surgical instruments is that they have not been designed to be dismantled for cleaning and inspection.

As infection is harder to eradicate around instrument joints, being able to fully separate parts can significantly reduce the risk of cleaned instruments continuing to harbour germs.

LOOKING FOR HIGH QUALITY SURGICAL INSTRUMENTS?

Why not browse our range of Stille and Lawton quality surgical instruments by clicking here?

You can also contact the Cairn instrument team on 0845 226 0185 to discuss individual instruments, recommended instrument sets or to arrange for a demonstration of specific instruments.

Surgical Instrument Care Infographic

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Poor Air Quality in the Workplace: Is it Safe?

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This week, Transport for London announced that it will be introducing air filters on 100 London buses to help stop the spread of COVID-19 after 26 London transport workers have died from the disease.

The filters were originally designed to tackle air pollution but have been repurposed to remove 95% of airborne particles, including those carrying the virus.

Improving Air Quality with Air Purifiers in the Workplace

It seems that the organisation is one of the first to use this technology to safeguard its workforce and customers, however it is anticipated that thousands of businesses will follow suit, investing in air purifiers to prevent the spread of viruses and bacteria amongst staff.

More often than not, humans are the main source of airborne diseases in the workplace. When someone sneezes or coughs, tiny water or mucous droplets filled with viruses or bacteria scatter, easily entering the air, and then entering your lungs, making you ill. Even without a cough or sneeze, germs can travel up to six feet away. Some viruses stay suspended in the air for hours.

Reducing Staff Sickness Through Air Quality and Ventilation

In the months and years to come, in the wake of the COVID-19 crisis, businesses are likely to take the health and wellbeing of employees more seriously and implement additional measures to safeguard their workforce. Crowded conditions with poor air circulation, like public transport and office environments, make it easy for viruses like colds and flu to spread.

Research shows that airflow and ventilation can dramatically impact how diseases spread indoors. The more stagnant the air in your workplace is, the more likely diseases are to spread.

How to Introduce Air Purifiers to the Workplace

Blueair air purifiers have been advocated for use in the workplace for a number of years.  Testing by the accredited CAS Test Technical Services measured a 99.99% removal rate of the 12 most common viruses and bacteria by the Classic 280i, Classic 480i and Classic 680i, including swine flu (H1N1), E. coli, and Enterovirus (EV71).*

Not only do Blueair purifiers capture harmful airborne viruses and bacteria, but the proprietary HEPASilent™ technology actually kills germs. Internal tests measured 99% of germs were killed by the Blueair Classic family – leaving the bacteria and viruses unviable and unable to reproduce.

It is a relatively simple step – simply plug it in and let it do its thing, but it could make a huge difference to businesses and we anticipate a huge increase in demand over the coming months.

Find out more about our Blueair air purifer range or get in touch to discuss your requirements.

Clean Air: The Smartest Addition To Your Business

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Air pollution isn’t new, it’s something that most people are aware of and in bustling congested cities it has become a major health concern. Pollutants such as construction dust, and diesel particulate are trapped in the atmosphere along with smoke, pollen and manufacturing emissions can react with sunlight and create photochemical smog and ground level ozone.

This low down ozone can cause lung damage. It is especially unhealthy for children, whose lungs are developing, and for people with respiratory illnesses like asthma. Ozone can also cause itchy, burning eyes. What people don’t often realise is this pollution can become trapped indoors.

Add this to everyday indoor pollutants and allergens, such as dust, pet dander and bacteria, and the air in your workplace may be up to 5 times more polluted than the air you breathe out and about in the city.

Exposure to indoor air pollution has been linked to the development of everything from infections to asthma to lung cancer. It can also cause less serious side effects such as headaches, nasal congestion, nausea, fatigue and dry eyes. If you suffer from an existing lung condition you will be at a greater risk of experiencing symptoms.

Blue Air is leading the way in air purification and is an ideal addition to public areas such as waiting rooms, communal kitchens or meeting rooms; high traffic areas which have the potential to trap air pollution and hold it indoors. The purifiers catch airborne contaminants down to the size of viruses, plus pollen, dust, pet dander, mould spores, smoke, allergens and bacteria. The combination filter with active carbon even removes odours, gases and the volatile organic compounds (VOCs) which cause that ground level ozone.

This means that they are not only ideal for protection against the every day pollution which is part of modern life, but also help with conditions such as asthma, allergies, for example hayfever, they remove tobacco smoke and unwanted odours from the air.

Not only do Blue Air purifiers capture harmful airborne viruses and bacteria, but our proprietary HEPASilent™ technology actually kills germs. Internal tests measured 99% of germs were killed by Blueair HealthProtect – leaving the bacteria and viruses unviable and unable to reproduce.

The Blue Air HealthProtect range is suitable for spaces from 38m² to 62m² and will purify the air in your room up to five times per hour. Built in WiFi which enables performance monitoring via the Blueair Friend app through smartphone or tablet, plus voice control convenience via Alexa.

Unique HEPASilent™ technology combines two air purification technologies – electrostatic and mechanical filtration – to bring you the best of both worlds. The HealthProtect air purifiers combine the highest clean air delivery rate (CADR) with whisper-silent operation. In fact, HealthProtect works so quietly that you might have to check to make sure it’s switched on. And it uses less electricity than a light bulb.

As public health has never been more in focus, an investment in clean air will protect your team and visitors from all those pollutants that we associate with outdoors that we are unknowingly breathing indoors.