Glenfield Ward 20 Team

The SPACES protocol

A simple and scalable protocol to reduce staff exposure and PPE use while caring for COVID-19 patients

Thursday, June 11, 2020

COVID-19 is a novel highly infectious agent, causing catastrophic outcomes for some of the people that end up being infected by it. The main way the virus spread from patients is through droplets produced from cough, sneezes, but also aerosols generated during diagnostic procedures and some forms of ventilation. It then can go on to live for extended period of times on different surfaces if not disinfected.

Like many other COVID-19 wards around the country, in Glenfield Hospital Ward 20 we realised early on that caring for our patients had a real potential of transmission to staff, with obvious consequences. Managing the ward like we would in normal circumstances came with major drawbacks, we would burn through large amounts of PPE and unnecessarily expose most staff to infection several times on each shift.

The patterns of working on the medical wards has been established over decades, each team doing their bit, moving on with varying interactions between different staff members, that we were oblivious to how many staff interactions, small and large, there are with each individual patient per day: housekeepers delivering meals or drinks, nurses performing observations, a drug round and teams of medical staff performing ward rounds, all separately. We worked out that for an average ward bay of four patients, this amounted to up to 82 staff-patient contacts of varying intensity in each 24 hour period.

In a COVID-19 environment this is inefficient, it increases staff exposure and PPE usage, so the team came together, agreed that the current system was not delivering optimal staff safety and patient care, and thought about the simplest and most straightforward way of maintaining the highest level of care while reducing staff exposure.

We wanted to implement something that worked for everyone and that took into consideration the requirements of all the people working on the COVID-19 ward, based on the principle of maximum patient contact with minimum staff exposure. The “development” group* was multi-professional, and included nurses, medical trainees, consultants and physician associates.

The result was a set of two simple concepts:

  • When one healthcare worker is making patient contact, s/he should deliver all of the most basic aspects of patient care, check position and comfort, perform symptoms assessment and report/document this during each visit, irrespective of their "usual role" on the ward.
  • Where possible and not affecting quality of care, using "remote" patient assessments using walkie-talkies, room intercoms and mobile phones.

In practical terms, anyone on the ward making contact with a patient, would carry out any tasks required at that given time, including taking observations, bringing food trays, checking comfort and similar, even if not part of their usual role. The member of staff would check with other members of the team beforehand if there are any outstanding tasks before entering the room, that way reducing the number of entries in the room. We also had an additional member staying outside the door to provide support to the person going inside the room to see the patient, for example if they need any extra equipment, so they didn’t have to leave take off PPE, re-don PPE and return. That way there would be no need for multiple visits and other tasks for later in the day could be, likewise, co-ordinated. This applied to all healthcare workers on the COVID-19 ward, including medics, nurses, allied health professionals (AHPs) and healthcare assistants (HCAs).

We road tested the principles and practice on the ward with universal positive feedback.  Next we needed to make this into a standardised set of actions, easy to remember and to use in other wards managing COVID-19 patients, and possibly to share across other trusts in the UK. We decided to ask the British Thoracic Society (BTS) for their opinion and support, whose leadership team enthusiastically supported and endorsed it and helped us to refine it into a standard protocol.

After a few iterations over the best mnemonic…the SPACES protocol was born.  The power of the BTS also enabled us to receive endorsements from the Royal College of Physicians and the Royal College of Nursing. SPACES stands for:





Exposure for


It all happened extremely quickly. We developed the pathway between the 16th and 20th March and passed it on to BTS on the 22nd. By the 27th March, 11 days after we conceived the process, SPACES was officially published on the BTS website and endorsed.

SPACES protocol

SPACES was quickly implemented, road tested and promoted throughout Glenfield Hospital with universally positive feedback. Ward staff have described a much improved sense of teamwork, and a renewed sense of everyone working to help each other and keep the whole team safe.

We found that using SPACES to reduce multiple entries into rooms for "standard" procedures, observations, and assessments, minimised duplication but didn’t affect the quality of the care provided. Patients satisfaction remained high; Ward 20's Friends and Family feedback remained consistently high at 96% pre and 100% post SPACES.

Contact was reduced from 82 to 14-18 staff-patient contacts per 24 hours, dramatically minimising PPE usage and staff exposure. Translating each patient contact into one PPE usage, we estimated that we used approximately 78% less PPE than pre-SPACES, which not only reduced costs but allowed Ward 20 to be less affected by the difficulties in ensuring a consistent supply of PPE. Other wards applying SPACES reported similar results.

In addition to the various official endorsements, we have received positive feedback, institutionally from our own Trust, but also from other teams and organisations across the country and also internationally via email, Twitter, LinkedIn and Facebook. Our initiative even featured in the Nursing Standard and our local press (Leicester Mercury). From data provided to us by the BTS, we know that the SPACES Poster and Information Leaflet have been downloaded from their website over 13,000 times in just under a month.

It’s a piece of work the Ward 20 team are very proud of, and its success is a reflection of the commitment and dedication shown by everyone in the team.