Can you tell us a little about your current role as Clinical Fellow in Sustainable Healthcare at University Hospitals Sussex NHS Foundation Trust?
Owing to the potent greenhouse gases within metered dose inhalers (MDI), inhalers form around 3% of the NHS’ carbon footprint. In my trust, reducing the use of MDI is a key step in meeting their obligations toward becoming net zero by 2045. In my role, I’ve been working to define a plan for how my trust can achieve this and start to implement change. Sustainable quality improvement, which is about improving clinical outcomes while improving or not having negative impacts on the triple bottom line (environmental, financial and social outcomes), has been the guiding principle in my approach. My role has involved audit, quality improvement, local guideline development, clinical governance and teaching MDT clinicians. I’ve worked on several projects including enabling prescribing of lower carbon inhalers in emergency departments (ED), an inpatient inhaler optimisation project, deferred dispensing of inhalers and reducing MDI use in the context of paediatric wheeze.
What are some of the key takeaways you have from working on improving inhaler practice?
Hospital utilisation has greater environmental impact than that of an inhaler, so our approach must centre that the most sustainable inhaler is the one that is indicated for the underlying diagnosis and achieves the best symptom control.
Reducing the environmental impact of inhalers is inextricably linked to improving patient care. Primary prevention of asthma/chronic obstructive pulmonary disease (COPD) prevents the need for inhalers. Hospital utilisation has greater environmental impact than that of an inhaler, so our approach must centre that the most sustainable inhaler is the one that is indicated for the underlying diagnosis and achieves the best symptom control. In the UK, asthma and COPD are among the commonest reasons for healthcare use and despite strategized improvements outlined by GINA/GOLD, our outcomes are poor compared with other countries [1]. Issues including SABA over-use, poor inhaler technique and prescribing of high-carbon devices remain prevalent [2]. This suggests system change is needed with an integrated strategy to delivering respiratory care across public health, primary and secondary care. We should consider how MDT clinicians who have knowledge in good inhaler practice are utilised and how education in safe inhaler prescribing/use can be improved and expanded.
Regarding delaying inhaler dispensing, can you elaborate on why this is important and the impact it may have on patients care, health system spend and the environment?
Delayed inhaler dispensing means that we avoid dispensing a patient’s usual inhaled therapies when they are admitted to hospital on concurrent nebulised therapy – dispensing only goes ahead if the patient is then prescribed a new inhaler compared to their existing device or if the patient is unable to bring their usual inhaler in from home prior to stopped nebulised therapy. The purpose of this is to reduce dispensing of duplicate inhalers and reduce waste, which has obvious benefits to spend (a pilot done in one respiratory ward in my trust previously demonstrated an associated cost saving of 28% [1]) and the environment, particularly where it reduces the number of MDI dispensed. Delayed dispensing can be done for these benefits alone or could potentially be joined up with wider interventions to improve patient care, such as ensuring patients have an inhaler review prior to stopping nebulised therapy.
What have you learned so far from your work in reviewing the pathways for inhaler use in ED and paediatric wheeze?
There is a big opportunity to improve patient and environmental outcomes in asthma and COPD by collaborating with emergency clinicians.
There is a big opportunity to improve patient and environmental outcomes in asthma and COPD by collaborating with emergency clinicians. ED clinicians are keen to ensure that they are implementing best practice and can be supported by succinct, accessible training and resources. These should cover inhaler technique and indications of different device types (DPI/MDI) and therapies (e.g. importance of ICS in asthma). Accessible patient materials and agreeing follow-up arrangements with primary care are also important. In paediatrics, there are often high rates of SABA and SAMA inhaler use owing to burst therapy for viral induced wheeze and asthma, but less than a quarter of the 200 doses of an inhaler may be used before it is disposed of. The safe re-use of inhalers between patients in this context should be examined and engagement with infection prevention teams and pharmaceutical innovation will be critical to achieve this as standard practice.
When reviewing your work, do you have any advice for others that might be interested in incorporating similar education and training-based interventions in their Trust?
I’d advise you to look at the Centre for Sustainable Healthcare’s Sustainable Quality Improvement Framework (they have courses available to learn more about this too). The first steps to successful projects are understanding the system (e.g. through audit and talking to people within it) and engaging with stakeholders – if you spend a good amount of time doing this and getting a good project team on board, your intervention is more likely to work well. I was supervised by Dr Sabrine Hippolyte throughout this fellowship, and I’d highly recommend having a supportive mentor within the relevant department to help you define projects, engage with other team members and troubleshoot barriers. I encourage other respiratory departments and trusts to consider supporting clinical fellow roles focusing on sustainable asthma/COPD care. There is so much urgent work to be done which can benefit patients, healthcare organisations, medical trainees and our planet - this can be achieved with the right engagement and support.
[1] Asthma + Lung UK (2022) Fighting for breath. London. Available at: https://www.asthmaandlung.org.uk/sites/default/files/2023-01/ALUK_Fighting_for_Breath_Strategy_to_2027_report_v6.pdf (Accessed July 2024)
[2] Wilkinson, A., & Woodcock, A. (2022). The environmental impact of inhalers for asthma: A green challenge and a golden opportunity. British Journal of Clinical Pharmacology, 88(7), 3016–3022. https://doi.org/10.1111/BCP.15135
[3] J Clark, D Eaton, J Congleton (2017) Effect of a ‘defer dispensing inhaled therapy’ programme in an acute hospital trust Thorax 72(Suppl) A238 doi: 10.1136/thoraxjnl-2017-210983.425