Green Inhaler QI Project

QI

Allowing you to achieve incremental and measurable changes to make a real difference to patients

Green Inhaler QI Project

Please note - this is a supporting toolkit for the QIF Mandatory Green Inhaler QI Project

QI projects are built as a TWO-PART component

Part 1

Setup

Here you set up and understand the project, ensuring you have everything in place to start your project

Part 2

Project

Here you have all the tools and resources to keep track of your progress towards completing the project successfully

Better setup, better success

Setup

Getting started

Why is this important?

Inhalers account for 3-4% of the whole NHS carbon footprint. Of this, Metered dose inhalers (MDIs) use hydrofluoroalkanes (HFA) propellants which are potent greenhouse gases, 1000 – 3000 times more potent than carbon dioxide. In the UK approximately 70% of inhalers used are MDIs which is much higher than many other European Countries.

Climate change is one of the biggest challenges to health in medium and long-term and the consequences are likely to be wide and diverse.

Overuse of SABA inhalers, in asthma, is associated with increased risk of exacerbation and mortality as well as contributing hugely to the NHS carbon footprint. The RCP ‘National Review of Asthma Deaths’ report published in 2014 highlighted the dangers of SABA overprescribing. Of the patients whose deaths were investigated, 36% had been prescribed 12 or more SABA inhalers in the previous 12 months.

What will I get for completing this project?

On completion of this QI project, the surgery will have met the criteria for the mandatory QIF green inhaler project worth 35 QIF points.

You will also get a certificate for your work to show the number of patients you have impacted and be able to use this QI project as evidence towards CPD and professional revalidation.

Who is this project suitable for?

All surgeries in Wales

The aim of this QI project

This QI project will reduce the environmental impact of respiratory prescribing and help achieve the targets of the NHS Wales Decarbonisation Strategic Delivery Plan by:

1) A reduction in the use of inhalers with high Global Warming Potential (GWP) and instead greater use of inhalers with a lower GWP. Some inhalers have a greater carbon footprint than others. In general, MDIs have a higher carbon footprint than DPIs.

2) A reduction in the overreliance of Short Acting Beta Agonist (SABA) reliever inhalers where possible by improving prevention and reducing ineffective use/prescribing of SABAs

Getting started

Start by working through the set-up phase of this project, setting yourself a goal according to the time you have available to dedicate to this project.

Use the search tools and SPIRA decarbonisation dashboard to benchmark your work and monitor your progress.

Ensure your team are aware of the project and you have been given the authorisation from your practice manager to complete the project.

Mark Complete

Your capacity

Capacity is the most important aspect for the successful completion of any project – ensure you have the capacity, time and ability to complete your project in a suitable timeframe.

Start by outlining how much time you have to commit to this project.

For example: Over the next six weeks, I will commit 2-hours (Monday and Wednesday lunchtimes) to completing this project.

And use the calculator provided to work out how many patients you can review in this time.

How to calculate the time for each patient action

It is estimated that each patient action for this QI project will take 15 minutes, but adapt locally.

When estimating the time for each patient action on this QI project, think about how long it takes to review a patient with asthma or COPD.

When will my project start:

When will my project be completed by:

How much time do I have to dedicate to my project each week

Minutes Hours

Each patient action for the project will take 20 minutes

Recommended time is 20 minutes per patient.

Edit

Your current capacity

Please complete form to calculate capacity

* use the capacity calculator to edit or update your time frame

Mark Complete

Alignment

In order for your project to get underway and to be successful, your manager(s) will need to understand the importance of the project and agree your time commitment.

Sent email

Responded and signed off project

Sent email

Responded and signed off project

Mark Complete

Communication pack

It’s important that your colleagues know about the project.

You may want to include colleagues in the project, and they may need to know about other demands on your time. Let them know that you are focusing on QI with these useful resources.

Resources

QIF Green Inhaler QI Project

Slides for practices – internal discussion

Mark Complete

Milestone Map

Keep track of your set-up progress and make sure you are on track to getting started with your project with the timeframe you have added in your capacity calculator.

Your Progress

Getting started

Your capacity

Alignment

Communication pack

Milestone Map

Start Date

Not Set

End Date

Not Set

Mark Complete

Project

Project overview

The aim of this QI project

This QI project will reduce the environmental impact of respiratory prescribing and help achieve the targets of the NHS Wales Decarbonisation Strategic Delivery Plan by:

2) A reduction in the overreliance of Short Acting Beta Agonist (SABA) reliever inhalers where possible by improving prevention and reducing ineffective use/prescribing of SABAs

A recap on the evidence

Climate change is one of the biggest challenges to health in medium and long-term and the consequences are likely to be wide and diverse.

What will I get for completing this project?

On completion of this QI project, the surgery will have met the criteria for the mandatory QIF green inhaler project worth 35 QIF points.

You will also get a certificate for your work to show the number of patients you have impacted and be able to use this QI project as evidence towards CPD and professional revalidation.

Instructions

Project steps

Step 1

Identify high risk patients

Step 2

Review and optimise asthma and COPD care

Step 1 – Identify high-risk patients

Use tools and practice searches to identify high risk patients and review as a priority

Asthma

Patients prescribed 3 or more SABA inhalers in 12 months
Patients prescribed oral corticosteroids +/- antibiotics for an asthma exacerbation in past 12 month who have not been followed up
Patients who have attended A&E or been admitted to hospital following an asthma exacerbation in past 12 months who have not been followed up
Patients prescribed a SABA but no ICS
Patients prescribed inhalers without a diagnosis

COPD

Patients who are still smoking, are not fully vaccinated or who have not attended Pulmonary Rehabilitation despite being eligible
Patients who have been discharged from hospital following a COPD exacerbation
Patients prescribed inhaler regimes that are not in All Wales COPD Guidelines
- LAMA monotherapy inhalers
- Patients using multiple inhaled triple therapy inhalers rather than a single inhaled triple therapy inhaler
Patients prescribed oral corticosteroids +/- antibiotics for a COPD exacerbation in past 12 months who have not been followed up

Step 2 – Review and optimise asthma and COPD care

Important steps for this review:

Asthma

confirm diagnosis
assessment of symptoms, asthma control test, pefr, examination
education and empowerment of the patient
- asthma pathophysiology
- action and use of medication
- definition of good control
- dangers of SABA overuse
reviewing current regimen
- identify who is over-ordering SABA
- poor asthma control v over-ordering by patient or pharmacy
inhaler technique and adherence
consider stepping up exploring MART option
inhaler device choice
agree and issue an asthma action plan, promote apps
remove SABA inhaler from repeat or use a system that triggers a review if patient orders more than 2 SABA in 12 months

Whilst every patient should be prescribed an inhaler that they can and will use the default device should be a DPI.

COPD

Confirm Diagnosis

evidence of post-bronchodilator spirometry FEV1/FVC ratio less than LLN
blood eosinophil level and CXR is also recommended

Record the relevant information

smoking status
MRC score
CAT score
SpO2
Number of exacerbations in past 12 months
BMI

Optimise therapy

Non-pharmacological

Smoking cessation referral
Pneumonia/flu/covid vaccinations
Pulmonary rehabilitation referral (MRC3 and above)
Inhaler technique check

Pharmacological

Phenotype patient according to All Wales COPD Guidelines

Phenotype 1 – COPD with mainly breathlessness
Phenotype 2 – COPD with exacerbations (+/- breathlessness)
Phenotype 3 – COPD with asthma overlap

Optimal pharmacological treatment will depend on the patient’s phenotype.

Use dry powder inhalers or soft mist inhalers as first-line treatment options where clinically appropriate

Whilst every patient should be prescribed an inhaler that they can and will use the default device should be a DPI.

All inhalers and regimes prescribed should (where appropriate) be in the current All Wales Asthma or COPD guidelines.

Consider whether a MART regime would be a suitable option

If metered dose inhalers are needed then chose a brand and dosage regime with care to minimise carbon footprint

Some inhalers are worse than others. Ventolin MDI has almost twice the carbon footprint of Salamol MDI. If the most appropriate regime for the patient has a SABA MDI in it then prescribe Salamol by brand.

When prescribing inhaled corticosteroids select the most appropriate strength inhaler to minimise the number of puffs required for the same dose. For example prescribe 1 puff of 200mcg Soprobec twice a day rather than 2 puffs of 100mcg Soprobec twice a day. This can effectively halve the carbon footprint of treatment.

Look at multiple inhaler therapy vs single inhaler therapy in COPD

Patients with COPD on triple therapy have better outcomes when the triple therapy is in a single rather than multiple devices. Changing patients from multiple inhaled triple therapy inhalers to single inhaled triple therapy inhalers also reduces the carbon footprint and results in a cost saving.

Engage with Community Pharmacy and others involved in the ordering and processing in inhaler prescriptions

Let the local Community Pharmacy know that you are doing this project. Explain to them the aims and objectives and how they can help identify high risk patients. Send them a letter and go and see them.

Discuss the aims of the project with the wider surgery team. Ensure that everyone involved in the issuing of inhaler prescriptions is aware of the aims and objectives of the project.

Could SABA inhalers (that contribute 65% of the total inhaler carbon footprint) be removed from repeats? If not, can the prescriber only authorise two SABA inhalers per annum with patients requesting more this triggering a review.

What tools are available?

NHS Wales Respiratory Toolkit

NHS Wales Respiratory Self-Management Apps

Spira dashboard

EMIS and VISION searches

PCRS and ARC

Recording your progress

For every patient who you review, even if you don’t change their inhalers because you are happy they are fully optimised, be sure to record this in the ‘Progress’ section of the QI platform.

Resources

Attached below are a selection of resources to support you through your project.

Resources

QIF Green Inhaler QI Project

Slides for practices – internal discussion

Green Inhaler QI Project – template form

Letter to Community Pharmacy Teams

NICE Patient Decision Support Aid

Template letter – asthma review invitation (EN)

Progress

Add the number of patients that you have reviewed in this project.

You should see your progress bars increase as you get closer to your goal.

Your current capacity

Please complete form to calculate capacity

* use the capacity calculator to edit or update your time frame

Capacity Calculator

Click on the chevrons for more information on your progress

Project data not set. Please complete your project's capacity settings.

Certificate

Your dynamic certificate can be found below. You can generate a certificate at any point during your QI project, and the certificate will be updated when you make further progress.

Sign Off

This QI project can be signed off by yourself.

Please sign off by clicking the button below. This will make your certificate available.

Download Certificate

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