Reducing the environmental impact of inhalers in patients with asthma across a Primary care network (PCN)

SusQI project completed by the Woodberry Wetlands Primary Care Network (PCN) am as part of The North East London Health & Care Partnership Green Team Competition, 2023.

Summary:

Hydrofluorocarbon/hydrofluoroalkane propellants from MDIs contribute 3.5% of the total carbon footprint of the NHS. Dry powder inhalers (DPIs) have a carbon footprint 18 times lower than MDIs and clinically, DPIs have been proven to be as effective as MDIs. The NEL asthma guidelines have been adapted to reflect the importance of reducing the use of SABA (short acting beta agonists), switching to dry powder inhalers if a patient has appropriate inhaler technique, and focusing on maintenance and reliever therapy in those patients who are overusing SABA.

There are many reasons why patients might over-request SABA, including misunderstanding their asthma management plan, poor inhaler technique, not realising they still have medicine in their inhaler, and having poor asthma control due to lifestyle and environmental factors. Some patients with asthma may have anxiety which can result in overuse of inhalers.

The “Why Asthma Still Kills” National Review report recommends that all asthma patients who have been prescribed more than 12 SABA’s in the last 12 months be invited for an urgent review of their asthma control.

Team members: 

• Mareeni Raymond, GP at The Heron Practice
• Humairaa Said, PCN Pharmacist at The Heron Practice
• Ruth Hallgarten, GP at the Allerton Road Medical Centre
• Joe Larkai, PCN Pharmacist at the Allerton Road Medical Centre
• Bharat Uppala, Woodberry Wetlands PCN Pharmacist
• Anil Ramyead, Woodberry Wetlands PCN Pharmacist Lead

Aim:

To work together as a PCN to improve asthma care for patients using high levels of SABA inhaler to:

1. Improve understanding of new asthma guidelines in staff carrying out asthma reviews
2. Introduce a system that will promptly alert clinicians of SABA overuse (6 or more SABA per year).
3. Arrange asthma reviews with a view to improving asthma care, reducing overuse of SABA and reducing our PCN carbon footprint.

Method & Impact;

The team focused on a cohort of patients who had requested 6 or more SABA inhalers in the past 12 months and invited them via text messages for face-to-face reviews. The pharmacists at each practice were briefed about the asthma guidelines and how to discuss greener inhaler prescribing and asthma care and the intention was to incorporate this into discussions with the patient at their reviews.

In the competition timeframe 22 patients were reviewed by a clinical pharmacist or practice nurse. A range of changes were made as appropriate for the patients care including stepping up treatment, reducing overordering and switching to DPI’s. Based on the 22 patients, the team anticipate annual savings of £640 and 1,972 kgCO2e, equivalent to driving 5,824 miles in an average car. Changes made will improve, or at a minimum maintain, asthma control and treatment for patients.

Training sessions, to update staff knowledge on guideline-adherent asthma care, are planned in September for pharmacists and nurses which will be lead by Dr Raymond for the PCN prescribing and nursing team. Ongoing conversations with patients can empower patients to understand their asthma and control their asthma better, however staff and patients need to be aware of the many factors that might result in overprescribing and medication overuse.

The practices plan to increase their positive impact by widening the search to identify all asthma patients requesting 6 or more SABA in the past 12 months. The aim is to review all the patients and trialling a new prescription system for SABA inhalers.

Click here for more information on the Green Team Competition (including organisation impact reports)