Greener Inhaler Prescribing QI in Hospital setting - advice

Hi Katia

We carried out an audit into sustainable inhaler prescribing/use/disposal (this was as part of the national Sustainable Respiratory Care audit organised by Newcastle (https://networks.sustainablehealthcare.org.uk/networks/education-sustai…) national results still awaited). However we haven't yet got to the QI stage. If the audit results would be useful to you I would be happy to share with you by email (my email is j.nixon2@nhs.net). 

Other ideas include looking at the report from the post below (in primary care, but lots that could be replicated in secondary care eg use of the inflow check device to inform inhaler switch choice), and the ideas on the Green Inhaler website: https://greeninhaler.org/ideas-for-hcps/. 

Hope that helps and good luck with your project, it would be great if you could share your results here once it is complete. 

Dear Katia,

I'm a paeds reg just starting a 6 months QI fellow job looking at sustainability, and hoping this will be part of the work. The link below is for a project which was done in paediatrics at Wexham Park, and may have some useful ideas for you: https://qicentral.rcpch.ac.uk/resources/systems-of-care/reducing-the-en…

Hi Katia, 

Thank you for posting your questions, it's great to hear you are aiming to reduce the CO2e associated with your prescribing. 

We (Centre for Sustainable Healthcare) have recently worked with two teams as part of our Green Team Competition looking at this issue in primary care, here are links to their projects:

SusQI Project: Hywel Dda Medicines Optimisation Team, "Reducing the inhaler blues" | CSH Networks (sustainablehealthcare.org.uk)

SusQI Project: Incorporating decarbonisation into Pharmacist-led asthma clinics, Pharmacy Team | CSH Networks (sustainablehealthcare.org.uk)

We have also had a scholar working on inhaler decarbonisation. I will add the link very soon when her work is shared. 

Best wishes,

Rachel 

Hi Katia, I have emailed you but thought I would also share some thoughts here for eider network. 

It's harder to make change in hospital than in primary care I think and needs a different approach.

Here at King's we have tried these interventions:

• Added DPI salbutamol as stock on wards
• Updated ED asthma guidelines so that DPI included
• Added DPI as stock in ED for TTA packs
• Education sessions for Resp team (Drs and nurses/physios)
• Audit in Resp clinics of inhalers and any switches/why
• Posters up in clinics with QR codes to inhaler videos and logos showing green inhaler choices
• Recycling/return leaflet and stickers in prescription packs
• Influenced local and regional guidlines on asthma care to prioritise DPI as default where appropriate 

We are planning to:

• Add sustainability as part of template for Resp review by integrated respiratory team (specialist nurses and physiotherapists)
• Focus on aligning devices – eg find patients on DPI preventor and MDI reliever and offer either MART therapy (if asthma) or DPI salbutamol to match DPI preventor
• Create a quiz based on vignettes and use as a teaching aid
• Reduce single use pMDI in Chest unit for reversibility testing - this is challenging as many barriers to re-using inhalers and washing canisters in between.

Things that did not work:

• I tried to update our electronic prescribing system to create bundles/show DPI/MDI/low carbon – did not work and we are changing to new system (EPIC) later this year so not worth the effort!
• Raising awareness in acute med – tricky. Any ideas welcomed!

We are tracking data but even this took ages to extract and understand. Complex as on wards it’s not possible to know how many inhalers are actually given to patients and when – they are logged as ward stock and so you have to look at how often they are topped up.

I am hoping to work with NHS/UKHACC/BTS to create resources for secondary care in the style of the Greener practice toolkits. Anyone who has ideas and energy for this please get in touch!

Hi Laura-Jane,

Sounds like you've done an amazing amount of work on this. So many good ideas. I am wondering if you'd be interested in a Resp/Infection Control QI project done in Newcastle on how to reduce MDI wastage when testing for reversibility in resp clinics? Would be happy to meet and talk further, and would really like to hear more about your interventions too. 

Thanks,

Emily (emily.parker16@nhs.net)

Thanks Emily. It would be great to hear more about reducing MDI wastage - I'll email you directly. Then hopefully we can share all the learning as a resource for the network in the future!

All great ideas here. We have a simple policy whereby for patients who need to stay in hospital with an exacerbation, we do not routinely supply their usual inhalers for the first 48 hours. For example its so common for COPD patients to come in on (inappropriate) high dose inhaled steroids via pMDI and tiotropium in a separate inhaler. After respiratory review they are typically changed to single inhaler triple therapy, but if you resupply their usual pMDI as soon as they arrive it gets binned. They don't really need it for the first 48 hours as they are usually on regular nebs and oral steroids (if appropriate) anyway.