BLOG Taking the long view: Future-proofing healthcare
Published: 15 Dec 2022
Sustainable Respiratory Care Audit Team
Alice Fitzpatrick, Marsden Rd. Health Centre
Sustainable Respiratory Care Audit Team
In June 2022, the Sustainable Respiratory Care project I work with was named winner of the Future-proofing Healthcare category of the 2022 Clinical Audit Heroes awards, as part of HQIP’s Clinical Audit Awareness Week. Of course we were delighted that our work was recognised in this way, but perhaps what was more important was that we would get to raise the profile of the need for sustainable healthcare projects (and share details of our work, into the bargain). Many months have passed since we collected our award but the value of our work continues, and so I am sharing some key highlights in the hope that other professionals will be inspired to ‘take the long view’ and support sustainability in healthcare…
Savings of £8.2 million annually and 58 kilotonnes of carbon dioxide equivalent emissions could be made
In summary, the Sustainable Respiratory Care Audit project provides a structure for the audit of patients’ technique, preferences and knowledge about inhalers as well as the need for clinical review. Selecting appropriate inhaler devices and improving user technique are interventions which can reduce the carbon footprint of healthcare, while improving the quality of care. To improve the control of respiratory conditions and reduce both exacerbations and medicines wastage, it is important to review patients’ inhalers and technique and consider switching a patient’s inhalers where appropriate. It can also provide financial savings.
Commonly used inhalers include Metered Dose Inhalers (MDIs), which contain hydrofluoroalkane (HFA), and Dry Powder Inhalers (DPI) which do not contain HFA. DPIs have a much lower carbon footprint than MDIs; the carbon footprints of MDIs are 10-37 times higher than those of DPIs. While not all patients have sufficient lung function to use a DPI effectively, many patients will receive more effective dosing of inhaled medications using a DPI than using an MDI and prefer not to carry a spacer (MDIs should always be used with a spacer). However researchers have calculated (based on 2017 data) that savings of £8.2 million annually and 58 kilotonnes of carbon dioxide equivalent emissions could be made by replacing just one in ten MDIs in England with the cheapest equivalent DPIs.
More specifically, the audit had a number of key aims. Firstly, to assess whether inhaler technique has been checked regularly and effectively in patients with respiratory disease (as per BTS Asthma Bundle and NICE COPD guidance). Then, it was designed to allow patients to express attitudes and preferences towards inhalers in line with the approach outlined by NICE in their Asthma patient decision aid and the NICE Shared decision-making guidance. Finally, it established a baseline from which to improve the quality and environmental sustainability of respiratory care in the NHS.
So, what did we do in practice? An audit proforma, in the form of a survey that could be carried out with a patient within 10 minutes, was designed by the project team. A data collection spreadsheet was also designed. The proforma was reviewed by respiratory nurses and senior respiratory physicians, piloted on the respiratory ward at Newcastle hospitals, and improved based on patient and health professional feedback. Edits were made – for example, to the information about how to implement the audit, providing exact wording for questions and detailing the need to check with nursing staff about a patient’s cognition and any reasons not to invite a patient to take part before approaching a patient.
The creation of a network of clinicians across the country enabled the collection of national results to which local results could be compared
Next, clinicians from multiple hospitals were recruited using emails sent to professional networks, and introduced to the audit via an introductory webinar. They were provided with the audit proforma and given time and a further webinar in which to propose and discuss any revisions. As a result, minor revisions were made to the wording of questions about patient preferences and inhaler disposal. Clinicians then applied for Caldicott approval and implemented the audit locally.
We are particularly proud of the level of engagement achieved around this project. The creation of a network of clinicians across the country enabled not only collaborative development of an audit proforma, but also the collection of national results to which local results could be compared. The engagement of local teams (which were required to include one senior respiratory clinician and one junior clinician) meant that local solutions to challenges and opportunities for improvement could be identified. Furthermore, the audit engaged patients to give their preferences about their respiratory care and describe their knowledge, to demonstrate how they use their inhaler (thereby auditing patients’ practices, not simply proxies of practice or documentation of others’ practice). This provided information that could inform not only service-wide improvement, but also improvements for individual patients where the need for review or education was identified.
At the time of writing this article, this project is still very much on-going. However, we are already starting to gather some key insights. For example, clinicians found that reviewing patients’ prescriptions highlighted discrepancies between the inhalers that patients were taking and the inhalers prescribed. Importantly, we were able to engage pharmacists in remedying this issue for individual patients, and in considering how to improve practice going forward. The results of the audit will be published once available from all groups, to engage stakeholders in healthcare providers as well as national bodies influencing NHS care. In the meantime, we hope that you agree with the Clinical Audit Heroes award judges that our project demonstrates how incorporating a sustainability perspective in audit can identify opportunities to improve care for individual patients and reduce environmental impacts of healthcare.
Further information: Sustainable Respiratory Care
This project was a collaboration between Dr Sarah Walpole (Newcastle NHS Trust), Dr Lewis Standing (Newcastle NHS Trust), Dr Maria van Hove (University of Exeter), Dr Joseph McElvaney (previously Newcastle NHS Trust, now Greater Glasgow and Clyde) and Dr Anya Gopfert (Northumbria NHS Trust).