Computer generated transcript

Warning!
The following transcript was generated automatically from the content and has not been checked or corrected manually.

And Amy. Um Welcome to the breakout session. Number one, obviously the most important on medicines. And uh my name is Alison as um some of you will have seen in the initial introduction and I'm a member of the University of Brighton School of Sport and Health Sciences, sustainability, special interest group. My background is children's nursing, but I'm actually really interested in medication issues as well. So, um I'm chairing this session and with me co chairing, I've got my colleague Michael, who's uh one of our academic teaching staff in pharmacology. And we've also got Emma who's a nursing student in her third year tantalizingly close to the end of the course. Um So to start with, we have got a presentation on medicines waste from Claire and I'll get Claire to introduce herself in a second from Hampshire Hospital's NHS Foundation Trust. Hopefully everyone can see her slides um and Claire when you're ready off, you go. Right. Hello, everyone. Thank you for coming along to the um conference today. Um It's really exciting for us to be able to present our um project that we did that was supported by the Green Team project and the center for sustainable health care. So we were looking at reducing medication waste within our hospital setting. We, um, as a quick background, over 300 million lbs is wasted annually on unused or partly used medications within the NHS. This comes from a range of patients not taking their medications home or not being transferred with the patients once they're in the hospital settings. Um, these are a couple of pictures of actual good days of medicines that have been returned into our pharmacy departments that haven't been used on the wards are taken home by, um, patients, which is why we wanted to do this project to see if we could reduce this. So, a quick overview of a patient receiving medication, there's lots of steps to it. Um, but on the whole patient is admitted, um, doctors prescribe their medication, um, as a pharmacy technician, we'll do a drug, um, reconciliation with them and order any medication that they haven't brought in with them from home. Our pharmacies clinically check that that's ok for the patients to take and it's appropriate for them. We dispense it. The ward receiver, um, and the porters deliver the medication. Um, sorry, the medication, um, request comes to pharmacy, we dispense it, it gets delivered to the ward and then the, um, wards can keep it in their treatment room or put it into a patient's locker ready for use by the patient. Um, so what we've looked at were um, our medication doesn't always get transferred between patients. When patients move between wards, patients often miss doses of medications if they haven't had them, um, supplied to them. Um, regular medication gets reissued when patients, um, have a plenty of, um, full supply at home. Um, there's medication wastage of single use items like inhalers and eye drops. Uh, patient stockpile medications at home. This is something that we often see, um, delayed discharges due to respen of medicines that patients don't um actually need. And obviously this increases our dispensary workload and delays our discharges. So our aim of our project primarily was to reduce the medication was by moving patients medicines with them, um and returning any unused medications. So it doesn't go out of date, um and can be used for another patient within the hospital setting. And also we, a second aim was to review the impact of not supplying any patients, regular medication that they would normally get from their GP if their inpatient stay is less than 72 hours. So what we did we did um the project on both sides, uh two sites. So our trust has the three sites actually, but our two main hospitals are based in Basin State and Winchester. Um, we pick four wards on each side across all of our different specialities. Um And then we had a look at our current um SA PS and policies we had in place and then our medicines management support staff went up to the wards daily and gathered all returned medications, um, and kept a record sheet of any medications that they'd returned and reused. So we found that moving medication with patients and returning unused medication had positive benefits for patients and staff having a designated staff member for returns helped mean that that mountain of medication got reused in a timely manner. Um, it resulted in a new member of staff being employed at our Winchester site so that we can see that benefit to help support the project moving forward. We now report monthly into our green plan to our pharmacy board which then gets reported into our trust board as well. And we have a continuous monitoring of returned tt tt S discharge medicines. So if we see wards aren't routinely giving the discharge medication to patients, we can do further education and training with them. Um And we've shared the impact of our project with other trusts in the area. So the anticipated. So as our results, we did the pilot last summer. So between July and August, um our total savings um for that particular area was just over 40,000 lbs across the eight wards. Um because it hadn't been done before, we expected the figures to be a little bit high um because of the amount of medication that was still being stored on wards. However, we um project across the eight pilot wards, an annual saving of 83,000 lbs and 28 thou or just over 28,000 kg of CO2 equivalent, which is the equivalent to driving 83,000 miles in a car, which is 3.5 times around the world. It also meant that we weren't just destroying medicines that could be reused. And again, during the project, it saved us 324 lbs and another 384 kg of CO2 equivalent. So as I said, there was many different benefits to this, obviously, the financial benefit that I just went through, but also the environmental benefit to our annual savings in the CO2. Um we could reduce down our stockholding uh because we're using the medications on a more regular basis. Um it reducing this doses. So patients actually get the medication that they want on time and therefore it helps to reduce the impact on um inpatient bed days and stays in the hospital for social sustainability. It helped with job satisfaction. It build up some really good links with our um wards um having that regular contact, moving the medication and a better understanding of how pharmacy can support them. Um And obviously, the clinical outcomes is better for the patients with the mis doses. Any expensive medicines get reused in a timely manner. So there were some barriers, we had some sickness within the team and while we were trying to do um which impacted the data collection. Um, and we weren't able to complete surveys with the ward staff. Um, but however, it's meant that we were able to pull other people in to help support the team and it's now become embedded in our pharmacy department. Um, and the fact that it's now, um, was sort of like, you know, a good, almost a year on and we're still talking about the project and the impact that it's had. Um, so we're gonna take it further from there. Um And so, yeah, in conclusion, um, it was um, a lovely way. We got great support from the Center for sustainable Health Care, helping us with the CO2 calculations and everything like that. So it's definitely raised our awareness within the pharmacy department. Um, and I think it's gonna be sort of like a, a footprint for how we go forward and how we think about our medicines and what we do and how we work with our wards. Fantastic. Thank you so much Claire and we were 40 seconds to go. So we very well tied. Um, we are going to move straight on to the next presentation, but please do add questions um, in the chat, make comments, um, which we will be addressing at the end of um, our, er, er, of our speaker uh presentations and we'll address the questions, um, you know, together as they come up. So please do, um, add your question to the chart and we'll be pleased to, to address that a little bit later. Ok. On to our second session now. Um and we've got case here here from Sheffield teaching hospitals who's going to present on uh reducing paracetamol co prescribing with opioids in palliative care. So I can see your slide. It's all ready to go. Thank you. So, when you're ready if you go and um so I'm one of the Party medicine consultants in Sheffield. And where we started was that recent research has suggested that when patients already on a strong opioid paracetamol is limited additional benefit in analgesia and pain management line with who ladder for cancer pain management. Many patients are prescribed paracetamol to start with that escalates as time goes on, a lot of people are reluctant to um stop the paracetamol to think, oh, it might be doing something. Maybe we should not, you know, not stop it. Hello? It's often found sat in the po the patient bedside. It's perceived as more of a burden than a benefit. People think strong opiates, they agree do much more than paracetamol. Nurses will often leave it to last. If patients need help with the medication will give them the important ones first. So strong opiates, neuropathic agents and, and antibiotics, those sorts of things. And then paracetamol just like I would just leave that for the last patients then often too tired to take it. I was horrified to find that one bottle of paracetamol liquid will give five doses of a gram of paracetamol. So a two week stay on the Macmillan unit with regular liquid paracetamol will involve 12 bottles of, well, essentially 12 carpal bottles and the packaging. So a huge amount of, you know, waste at the end of it. And IV paracetamol needs a vast amount of consumables to be, you know, to give a single dose. And it takes a lot of time. The green team competition run by the Center for Sustainable Health Care was our nudge to act. It was just like, actually, we've got the support of the hospital to maybe try this. So we did. So we had a baseline snapshot on the MAC unit. It what it's an 18 bedded inpatient NHS funded hospice unit essentially at the Northern General, looked at the current paracetamol usage and looked at the stock requirements. We run it for 10 weeks plus or minus a bit of COVID. A junior doctor strikes and you leave a few other problems. So it's extended slightly. We implemented the change. We looked at paracetamol we used before paracetamol afterwards and projected the savings for six months. Um Our aim is to reduce the paracetamol usage by about 50%. We literally just pulled that figure out of the air and just to see if we could and and mainly to reduce the tablet burden for the patients, the administration time for the staff while reducing the environmental and the financial costs. Um So the intervention essentially it was when they came into the Mark unit. We see. Do you think your paracetamol helps if they said yes, it's great. We left on as a regular prescription. If they were not sure or said no, then we represcribed it as, as required rather than, um, regular. This meant it was available if they had a fever of a headache and just needed a wee bit of something that wasn't a strong opioid for their pain control. We looked at the carbon footprint of the pharmaceuticals based on cost and the consumables including the transport and disposal um and disposal that um Rosie helped us with that from the center for sustainable health care. And if you look at, you know, oral liquid, carbon footprints quite small, but you need a syringe to suck it up, you know, so you're wasting a bit of plastic with that tablets pop out into a paper cup. The effervescent again, you had to put it in a polystyrene cup because the paper cup didn't hold the water. You know, you had to go and get the water and, but the intravenous liquid required a vast amount of consumables, not very commonly used, but when it was, it was very burdensome. So look at the estimated cost of paracetamol over six months period. Did the snapshots estimated the costs? We established the nursing time spent administering each dose. So one of my juniors followed by the nurses and tell them popping out paracetamol, giving them to a well, patient, popping out paracetamol and giving them to someone who needed a bit more assistance or maybe changed to a different formulation. And it took ages to give IV paracetamol, especially if it was through a PICC line. Um, we asked the nurses what they thought of it. Um and we recorded the space used for the storage because um pace is a stock item on the unit. So what we found that we reduced the regular paracetamol co prescribing from 55% of patients to 19% of the patients, which was actually a 66% reduction in regular paracetamol prescribing of the 19 patients. They were monitored over a two week period, only six doses of P RN paracetamol required over two weeks. Um and no patient required the regular paracetamol reinstating, they were reviewed every day on our ward and that's just what we do. Um So, well, I didn't see any tons. I saved kilograms. So we drop of a carbon dioxide 141 a kilograms. A 76 months, which equivalent of driving an average fossil fuel car 417 miles in a year. We projected a return trip to London and Edinburgh not three times around the world, but it's a start. Um a reduction in using paracetamol would save us, you know, best part 200 lbs in six months, roughly 400 lbs in a year but we didn't take into account the cost of TT S. And actually, if we stopped the regular paracetamol when they were in an inpatient, they may then not take regular paracetamol for the last six months of their life. So actually, there's other savings that we didn't really have time to, you know, project up, um, the nursing time saved. If you just gave regular oral paracetamol to somebody who could take it themselves, we saved about two hours per month of nursing time. However, if you looked at the time taken for given IV paracetamol, we could save two nursing shifts, two whole nursing shifts in, you know, in two weeks. And when we asked the nurses at an audit me, we said, what do you think of this? And like, oh my God, we love it. So it's an obvious impact on, on their drug range. We didn't because of the duration of the project because we review the stock every year. We haven't seen the change in the stock supply just yet, but we anticipate, you know, a reduction in the stock used and in the space and that it will be taken up in the drug cupboard. So really, it was just a very simple intervention. Do you think your paracetamol works with one tick on the box and which benefits the patient, the team environment and the drug budget and, and the medical and nursing teams were very receptive to the change. It didn't make a big difference to, to the workload to implement the change. But um seems to make a big difference to the workload and given and we are planning to embed it in the clerk and documentation just put think paracetamol across the top of the drug bit to sustain it. And actually it's kick started a lot of other deprescribing conversations on the ward and then palliative care and that's me. Mhm. Um Alison, I think I can't hear you. Sorry, basic, don't unmute yourself. Thank you so much. I'm just gonna say you're out of time. But uh thank you. That was really, really interesting. Who knew that long paracetamol had um you know, potentially such a big savings impact. So again, um questions are coming in. So we'll address those at the end. Um Just to answer one as we go through, the slides will be available through um the medal platform. Um Heather will remind us of that again uh at the end and I'll put a couple of links in because um both so far I think have been involved with the Center for sustainable healthcare, carbon printing, correct me if I'm wrong. Um So I've got a couple of links to those um that information because a lot of um uh trusts and organizations are now using that. Great. Ok, we'll move on now. Thank you. Um Have we got Georgia? Yes. Hello, Georgia. Hi. Uh George is from South University NHS Foundation Trust and she's going to present for us on um uh of insulin um on obviously the care of patients with diabetes. So when you're ready, I've got a little two minutes notice that I'll hold up for you if you get that. Ok, thank you. Can you see my slides? Ok. Absolutely fantastic. So, yes, my name is Georgia. I'm diabetes dietician working in North Warwickshire. And once again, we were involved in the green team competition um with the support of the Center for sustainable health Care. Um So 4.9 million people in the UK are living with diabetes. All of those with type one diabetes and many with type two and other types of diabetes use insulin as a primary treatment for this condition. Um Most of these pens end up in landfill and 23 million medical pens each year in the UK are incinerated or in landfill. So we decided to take on a project to address this, this image here is taken from um the NHS England's delivering in zero NHS and it just kind of highlights where our project fits in a little bit. So um we did have 10 weeks for our project and we're quite a small team. So we were just looking at the community caseload in North Yorkshire. So our project had two separate arms um of what was going on. So the first was looking at reusable insulin pens. So swapping from the single use pen shown at the top of the slide to a reusable pen shown at the bottom, which has a um memory function on the end showing the dose. And how long ago that was given. And this requires a much smaller single use insulin cartridge to be used in it. And the second part of the project was using um pen cycle, which is promoted by an over all desk um whereby once the pen is empty, needles are removed and they're posted in the provided boxes and sent off to Denmark in existing transport links where they are recycled and the um materials are turned into chairs and lampshades. Um So initially, we studied our system and we identified 286 patients on the caseload who were on a suitable no, no insulin and some patients have multiple prescriptions. So this equals 343 different insulin prescriptions that we could either look at changing to a reusable pen or recycling the single use pens. Mm. Um So initially looking at patient outcomes with the reusable smart pens because they've got that memory function on the end, it provides a lot of reassurance to individuals that the insulin is given. Um gives them some independence over it as well because we were hoping that the district nurses would be able to dial up the insulin, the patient might give some of it themselves and we then had the reassurance that the correct dose was given. Um this also means that the individual could be more in control of the timing of their insulin. Therefore, matching it up better with the food that they were eating and resulting in a better blood glucose profile and therefore better diabetes management. Um for Pyle, there was no direct patient outcomes. So in terms of environmental sustainability, this data was provided by the NOVO a company. Um and they advised us that it was about 6.8 kg CO2 per year for each patient. On average that we switched to reusable pens. Obviously, this does vary more or less dependent on that individual's insulin usage. Um So we calculated if we could switch 80% of suitable prescriptions, this would save us 1863 kg of CO2 per year. The pen cycle project is actually carbon neutral when comparing disposing of a pen in household waste compared to the shipping it to Denmark where it's recycled. But the savings come later on down the chain when one ton of recycled plastic saves 780 kgs of CO2 compared to virgin plastic. So, although although these savings weren't directly attributable to us, they are certainly significant in terms of economic sustainability. We did actually identify that with some of the prescriptions, there was a saving from going from single use to the cartridges instead. Um And again, 80% of suitable prescriptions would be a 468 lb saving. However, more significantly than this, we were looking at trying to reduce district nursing visits. So for example, a really common insulin regime for our community caseload would be twice daily insulin. Well, actually, if we could reduce this to one visit by the nurse and the second dose provided by the patient themselves, that would save us 2 23.5 1000 lbs per in district nursing time, but also free up the district nurses to see other things as well. Um So this was a significant change which again, our district nursing team were very keen to get involved with. Um, there were no costs to us um because the smart pens were provided by the company. Um So overall, this did involve a bit of um investment in time in terms of searching our caseload for eligible patients, writing letters to GPS to change prescriptions from prefilled pens, training the district nurses on using these, um and also distributing out the pen cycle boxes. Additionally, when this project was ongoing, we had the pressure of one of our highly used insulins going out of stock in the single use pen. So that kind of pushed us to make that change to the the cartridges in the reusable pens as well. And actually, since this product has happened, we've had a similar issue with a different insulin. Um So it's just kind of forcing our hands to make the change that we want to change. Anyway, we did identify that not all patients were suitable to swap to reusable pens and have visits reduced. For example, if the district nursing visit was part of a wider wellbeing check for patients who might have um visual or dexterity issues. So we did have to look at this on a case by case basis. Um Only Novo Nordisk insulins could be used in the smart pen or be recycled through the Pyle scheme. However, since this project has um started, we have also learned that Sino, another big pharmaceutical company has a similar recycling scheme to Pyle. Um So we're just in the process of starting to use that as well. And as I mentioned, at the very beginning, we are a small team and we only cover the community side of North Warwickshire. So we were hoping to expand this to our colleagues in South Warwickshire and in the acute teens and we've been involved in presenting this project in various different meetings to hopefully encourage change elsewhere as well. Um So we're currently going through our caseload and looking more deeply at those individuals who could have district nursing visits reduced. So we've looked at those on twice daily visits, reducing to once daily. And we're currently looking at those on daily visits and seeing if we can go every other day instead. Um We were also looking at promoting Pyle elsewhere in the system. Um We were looking at trying to recycle um pens used on the wards or in outpatient clinics. However, we have unfortunately faced some issues with um kind of the rules around recycling on in the hospitals. Um So it is mainly through the district nurses that we are encouraging this recycling. Um Additionally, G LP one pens, it's another big uh family of medication used in diabetes management. And these can be recycled through the pent cycle scheme as well. And we're trying to promote our project as widely as possible and so hopefully encouraging the good work elsewhere. Thank you very much, perfectly timed. Thank you so much, Georgia. Um I don't know if I imagine this, but I thought that insulin pens always used to be when I started. So once upon a time, excellent. Again, um add your questions to the chat. We've got a good discussion going around um Paracetamol, which we'll come back to. So, thank you for that. Any questions for Georgia, please do. Add them. Everyone's doing a fabulous job of uh loading up their slides ready. So our next speaker should be Janine. Is that how I say your name? Yes, it's Jamie. Yes, Jamie. Yeah. Hello, welcome. Um And uh Jamie is going to talk to us about um medicines waste aggregation and she's from Northampton General Hospital. NHS Trust. So, um when you're ready, Jamie off, you go. Thank you. So, yeah, my name is Jamie. I'm a renal pharmacist um at Northampton General Hospital. This project is a collaborations with the Center for sustainable healthcare and is one of the green teams um competition. So in terms of the setting, this is a trial pilot in on the Renal ward. As far as collaboration with the pharmacy team is a quite a short um period of time because of the green team's competitions. Uh roughly around three months. It contains two different tasks. So first task is to reduce the dispensary staff, time processing medication red returns by educating the nurses how to segregate patients own medication and hospital supply medication into designated medication return boxes on the wall. This is because there's a lot of misconceptions that all medications which are not used can be returned to pharmacy and can be reused. But this is not true. The second task is to encourage patients to bring their own routine medications to hospitals, to reduce the need for hospital dispensing. So before the project, I have conducted um couple of surveys, I'm asking the ward nurses, pharmacy staff as well as patients. How did they find out about medications waste? And all agreed medications waste is a huge problem and they would like to address. So I've made uh display the posters on the ward in the treatment room. Educated nurses, what are the difference between the blue disruption bean and the green bean? So first of all, if patients own medications which cannot be reused, um ie some medications may be stopped, the dose may be changed. Then these should go to the Blue Destruction Bin on the board and they should not be sent down to pharmacy because they can be disposed by the company to get incinerated. Whereas medications which are full pack supplied by the hospital or any high cost medications, uh, which we will try to reuse it in the pharmacy. Then they should go to the Green Pharmacy return box. And this is another posters to educate nurses, how we actually put the medications in the bin. So we are not expecting them to just put the whole box in the blue box. We should be removing the outer package and remove the patient's confidential uh b um labels to the confidential bin and place the remaining out package to the recycling bin. And lastly, the medication strips to the blue bin. In terms of liquid bottles, we are definitely discouraging nurses to pour any liquids to the toilet or sink. So the label will go to the confidential bin, but the whole bottle will be in the blue bin so that it get dis incinerated. Totally the second task it involves patients. So we are trying to empower the patients to bring in their own regular medications such as when they go on holidays, they should be bringing their own medications in similar to when you, when you go to the hospital. If possible, you should bring your own medications in. We educated the nurse to try using out patients on medications during hospital stay instead of using WTO and return all the regular medications back to the patients on discharge. Apart from the nurses and patients, we also educate the pharmacist and pharmacy technicians at the drug history stage to encourage patients to order the regular medications from the GP rather than supply from the hospital on discharge. We explained to them because of the medication ways and help with the environmental and patients are very happy to bring in their own medications and not trying to order medications on discharge. So in terms of the results, um I have included all the triple bottom line which uh include patients outcomes. There's potential reduction in medication admission, especially critical medications such as antiepileptic and anti Parkinson's medications which encourage patients to bring in their own medication to be used in the hospital. That's quicker dispensing time because we are reducing the number of items dispensing and also positive patients outcome because patients can go home quicker. In terms of population outcome, there is currently a lot of national shortage. So by reducing the dispensing of patients routine medications can potentially improve the access of medications to divide the population. And in terms of financial and environmental impact on one board, we projected an annual saving of nearly 20,000 lbs and around 3500 kg carbon dioxide emissions which is equivalent to driving 10,000 miles in an average car. And in terms of social outcome, it has a lot of positive social impact on dispensing stuff because they are saving times to dispense the medications and they save them around two years in a year for one ward. And you have to imagine there are also 21 adult wards in NGH. So there will be significant uh potential savings. So the key learning point is there's good engagement with the world pharmacist nurses and other pharmacy colleagues. And from the staff Surfas majority has raised concerns about the environmental impact and they really want to do something about it. And in future, we would like to try this project into the wider uh w other wards as well. And um thank you if you want to hear more about this project. This is the QR code which can uh link to the Center for sustainable healthcare website. Thank you, Jamie. That was great. Um Lots and lots of common threads coming through um on some of these presentations and lots of good questions coming through on the chat. So, thank you everybody for that. So our last presenter is Jasmine from our very own uh university hospitals, Sussex NHS Foundation Trust. Now, uh Jasmine has two presentations, not because we're biased, but because we have a blind anonymized process for selection and yours were so good that they both got through. So we're going to um put them back to back um one on uh the carbon footprint of inhalers, which we've got there to go first and then um another on optimizing inhaler choice er or hospital admission for patients. So Jasmine will have obviously double the time. Um And then we'll again take questions on everything all at the end. So please continue to put your questions uh into the chat. Um Michael and Emma if I could get you to come in at the end and then we'll start to kind of sift through the questions once Jasmine has finished. OK, when you're ready. Thank you, Alison. Um Yeah, so my name is Jasmine Abbott. Um I'm a clinical fellow in Sustainable health Care at the University Hospital Sussex. Um I've been working across the last year to tackle um my trust carbon footprint from inhalers. So, um what I'm going to do is first of all, talk about the first stages to that uh in auditing our carbon footprint and trying to understand where that came from and the uh interventions that we have come up with and projects from that. And then I'm going to talk about one specific project um that I've carried out as part of this work. So, just a bit of background. Um So this is the NHS carbon footprint. Um And the reason that we're focusing on inhalers is because they make up around 3% of the N HSS carbon footprint owing to the greenhouse gasses contained within metered dose inhalers. Um So they're a key priority um for the NHS. Um And also within my trust green plan. Um while the majority of inhalers are prescribed within primary care settings, there hasn't been that much work that has focused on secondary care and what our role is within that. So that's what I wanted to explore. So the aims was to audit the number of type and types of inhalers dispensed within our organization across one financial year estimate, the carbon footprint and to identify the hotspots within our organization. The other aim was to engage with MDT stakeholders to develop a root cause analysis in order to inform the targeting of projects. So um my trust is a large teaching hospital. We've got five acute hospitals and two nonacute sites. So we looked at our dispensing data using inhalers selected from the BNF Chapter across the financial year 2022 to 2023. And that included includes most of our dispensing, but it does have some key exclusions and then we just match the device type. So whether a meter dose inhaler or dry powder inhaler or soft mist inhaler to the greener NHS emission factors for that financial year. Um Myself and Dr Hi um have come up with a root cause analysis. So we drafted that um using the combi framework. So that looks at things that address the capability, opportunity, motivation, and behavior. Um Yeah, and influence behavior, sorry. And then we um created a working group within our trust and that included consultants, pharmacists and um nurses from all of our sites and also had um stakeholders from the ICB, including um the respiratory GP lead and the medicines optimization pharmacist. So we presented that root cause analysis and we discussed it in order to revise that and come up with some key projects. So in the financial, the year that we audited, there were over 22,000 inhalers that were dispensed within our organization. And we estimated the carbon footprint was around 335 tons of CO2 equivalent, around 80% of inhalers that were dispensed 1 m dose. And that's largely in keeping with the the national prescribing of meter dose inhalers as the majority form of inhalers and around half of the inhalers that we dispense are short acting beta beta agonists. So for those not familiar, that's the reliever type inhaler. Um You can see from the diagram on the um right that um our emergency departments and medicine inpatient wards with the settings with the the highest rates of dispensing inhalers. Um but the carbon footprint was actually slightly higher in our emergency departments because they were using a higher proportion of metered dose inhalers in their dispensing and within medicine. Um the respiratory ward care of the elderly wards and acute towards what the the highest areas as you would expect. So this enables us to think about where we should be driving our projects in order to reduce the carbon footprint in terms of our root cause analysis. This diagram on the left is perfectly very small. Um This is actually the initial kind of driver diagram that we came up with. And we expanded this through the discussion that we had with our MDT inhalers working group. Um And I've summarized um what we discussed in this um fission bone diagram. So we recognize that we have high rates of um MDI dispensing and there are four key things that are affecting this. So there's the prescribing processes that we have dispensing processes that we have. And then there are patient factors and staff factors and those are um occurring across primary and secondary care. What's key to recognize for us is that um we have sort of two separate categories of, of inhalers. We have those that where we're prescribing inhalers for the first time in a patient that's never had them before or for just short term use within secondary care. But we also have um patients that come in for admissions and they already have inhalers and that the actual prescribing has taken place within primary care. And we think that the majority of the inhalers that we dispense are actually in the latter category, but there are things that we need to address within our settings. So particularly in our emergency departments, when we did this work, there was no options for being able to prescribe any dry powder inhalers, which are the low carbon alternatives to me to dose inhalers. We have a very large choice of inhalers within our region because our formulary is actually combined from multiple areas. And we don't have any local guidelines for asthma or COPD. We don't have any pathways within our hospitals for routinely reviewing inhalers. It's only patients that are admitted with exacerbations that we would expect would get a review and that might not always occur from a specialist nurse. We also recognize that there's um a deficit in knowledge and skills for many prescribers um around um safe inhaler prescribing and technique. Um And there's a lack of funding and opportunity for the training in order to address that and in order to carry out the actual reviews themselves. Um And this also just sits within a, a wider range of factors that increase the prevalence of asthma COPD and poor respiratory control which drive admissions which drive hour dispensing and also drive increased inhaler use. There are some limitations to the carbon footprint um that we've carried out in this. As I said, we had some things missing from our data. Um And we could have used more granular data to, to look at the actual emissions, but we've got a good estimate of where our hotspots are. Um We also didn't have any patients involved in looking at the root cause analysis, which is something that we could address. But I think that what this project shows is how um auditing and understanding the system as per CQ I methodology is really key to, to find out where hotspots are and to drive projects. And I think that we have shown that um we need collaboration across the region within primary care and with public health to reduce our footprint. But we have some specific projects that we've highlighted and particularly highlighting dry powder inhaler access within. We've reviewed our electronic systems and we've looked at deferred dispensing of inhalers to avoid duplicate dispensing if patient has inhalers that they can bring in from home. Um We've also explored looking at the reuse of inhalers within a pediatric setting where we might not be using the whole of an inhaler dose. So I'm now going to talk about one specific project within this. So I said that we don't have any routine um inhaler review pathway. And as far as I could see, um other care settings have also not explored how we could look at optimizing inhaler choice for patients that are coming into hospital for reasons other than their respiratory condition. So we thought that the patients that were coming into hospital who have inhalers, but who are not there primarily for their respiratory condition could be a really good opportunity for us to optimize inhalers and changing inhalers for somebody during an exacerbation is not necessarily the best thing for that person. What's really important is if they have an inhaler that they can use well, is to make sure that they can continue to do that um while they're recovering from their exacerbation. So we wanted to look at how we could optimize inhaler choice and and this is for both the environmental benefits but also for the clinical benefits for the patient. And as I've said that this is looking at um what is the role of secondary care in moving patients towards lower carbon regimens and using the principle of lean pathways within um sustainable health care methodology. We thought about how the one of patients actually in hospital um doing the review, there could actually potentially save um some kind of appointment when they're out of hospital. Um We know that patients tend to spend quite a lot of time um when they're on the ward, when there's not necessarily much happening and they're just waiting for the treatment or investigations, et cetera. So it's utilizing that opportunity. And we also want to think about the wider benefits to inhaler optimization other than just focusing on switching devices and how could these be incorporated into a single review process. So, the aims of this project was to develop a green inhaler review pathway for use within secondary care inpatient settings and pilot that in a non respiratory inpatient ward. Um And then we wanted to train an MBD T team to be able to run that pathway in order to try and build that process into routine care and then learn from this to see if this is possible for us to expand to other settings. So we came up with a pathway using national International guidelines and um a team of respiratory consultants kindly reviewed that for feedback and we modified the the um pathway uh based on the experience of utilizing it. And also that feedback, we tried implementing it on an acute stroke unit within our trust and we trained inhaler champions. So that included um 11 junior doctors and a stroke consultant, um occupational therapists and nurses and some pharmacists. Um And we piloted implementing this over a four month period, any patient that was admitted to that ward on inhalers, except those that were currently exacerbating. And we collected data for each patient review um and assess the carbon footprint and cost of inhalers matching it to prescript data which gives us a more granular view on the per inhaler type versus the emissions factors. Um So this demonstrates the overall pathway that we came up with and essentially it had some key stages. The first was to actually review the diagnosis and the reason for that is to make sure that we're not providing inhalers to patients that don't have an airways disease. So we reviewed that and if we felt that there was not sufficient evidence in the history or objective tests of asthma or COPD, we then referred the patient either back as their GP or as an inpatient review to be able to get that looked at. And we then looked at opportunities for optimization. So that was, was the in the choice of inhalers appropriate for the diagnosis? Was it appropriate for the current symptom and disease control? Um Did they have good inhaler technique? And we also looked at identifying high carbon inhalers and opportunities for simplifying regimes. Um And then this information was all brought together in a shared decision making process and discussion with the patient and we had some principles of optimization and those included making sure that we'd addressed any non pharmacological interventions for pa from control prior to making any change for inhalers. So there were 29 eligible patients during this time. Unfortunately, we only managed to review 19 of those. We also had some disruption due to industrial action and of those 19 patients, there were 37 inhalers. Um and most of those were dry powder, six patients, we felt required a further diagnostic review and we felt that that three patients inhaler choices did not meet best practice standards. We identified that 12 out of 19 patients had impaired inhaler technique and four of that was due to the reason of admission on the stroke ward and we made changes to inhalers for 11 patients. And as you can see, there was a reduction in the the carbon footprint and also in the cost of the inhalers that were chosen as a result of those reviews. There were loads of reasons that we change inhalers and actually environmental factors were usually lower down on the list. The main things, the main reasons we change inhalers was for technique and to simplify regimes. Um And we demonstrated a reduction in the carbon footprint and cost. Um Although the benefits of the carbon footprint over time is actually less than if you're just um dispensing all of those inhalers in those times, there was a variable time per inhaler review and some of them were actually very long and complex and unfortunately, no inhaler champions did feel able to independently review by the end of the process, they felt that they, they still needed more experience and more education. So I think what this has shown to us is that um we um can do a an inhaler review process in secondary care and it can have significant benefits in terms of the carbon footprint and cost of inhalers. And also patients were really open to this um intervention and um were really pleased to be able to get a face to face review and we found loads of different opportunities for optimizing inhalers. But the delivery in this setting was really challenging. It's a very resource intensive um intervention and it was really difficult to be able to integrate this into the day to day practice of the ward. Um And to be able to get the inhaler champions confident enough to be able to continue this process going forwards. Um So I think I will leave things there. I think I'm at the end of my time and thank you very much for listening. Thank you very much indeed. Jasmine for your uh double presentation. Um Inhalers is a big area of, of interest, isn't it? And there's been lots of work done. Um So lots and lots to think about there. Thank you. OK, before we go to um organizing the questions, maybe, um Michael and Emma could you perhaps um do you think you can find a good question to put off with while you do that? I'm going to um ask all the presenters really um a question and jasmine, you touched on it at the end, you said that the patients were open to, to change, uh which is great to hear. And I just wondered for, for all of you really, how much um did you discuss the reasons for making changes and implementing some of these new initiatives um and educate patients around the sustainability um basis for those interventions? And, and how, what, what they thought about that? Does anyone have any thoughts on on that side of things? I'm happy to start on that. Um Yeah, as I said, it was quite variable in the pilot that we did about whether we actually needed to discuss the environmental implications or not because actually a lot of the time it was all of the other factors. However, when we did discuss the environmental implications and I only had one patient that was a little bit, um, put off by that. Actually, everyone else that I spoke with was really interested and really surprised and also almost a bit annoyed that they hadn't heard about that before. And they were really keen to do what they could and also understood that it wasn't just about switching the inhalers, but about how they dispose of their inhalers as well. And none of the patients I spoke to were aware that they're meant to take their inhalers back to their pharmacy. Um So I would say, yeah, overall really positive engagement from patients with the environmental aspects. From my experience, I think you're right. I think it's a lack of awareness, a lot, a lot of the time. And in fact, it was this group in this original conference. So however many years ago that made me aware of the inhaler issue and I swiftly changed mine and I love it. Um Anyone else wants to, to touch on that issue around patient education or patient awareness of the sustainability issues, I would say with our um recyclable pens and the reusable ones because with the reusable pens, they had that extra function of the memory. On the end, people just wanted the new tech, they wanted to be up to date with things. So actually the fact that it had those benefits was just almost an add on like Jasmine was saying, um with the pens project that has relied a little bit more on both patients and district nurses being motivated to continue with that. Um because they've not really got any outcomes for themselves. But actually, we have found that people are continuing to ask for more boxes once they've filled one up. So they are, they are keen to get involved. But it takes a little bit more reminding and motivation from us from that side because there's nothing in it for them, I suppose. Thank you. And interesting the commented, she's found patients more receptive to environmental benefits and talking about financial benefits. That's, um, you know, it can disengage people if you're talking about money all the time, I guess. So it's another angle to come in on anyone else have any thought. Yeah, I was just gonna add, I think it, it's about expectations. I think a lot of patients we see with like take home medicines and their discharge medications, they feel they're entitled to have another set of medications to take home with them just in case. And I think it's managing those expectations. Actually, a lot of community pharmacies do repeat dispensing, um, because the way them managing their business. So actually there's very few people that have to do it themselves. So they will have a supply at home. So I think it is, it's getting better. But I think there is this expectation that you will come into hospital and you will get all of your regular medications and all your stuff again, I think. Yeah. And in, in the world of pediatrics, I know that that was a real system and, and culture change where parents would expect to go home with a bottle of paracetamol. Um which as we all know, is pretty widely available instead of the, the expectations there have to have to share anyone else on that point. Or are there other questions Michael and Emma that are screaming out to be answered? I can hold my hand up and say we did not educate the patients on the environmental impact. It was for them. It was just eight less tablets a day. Thank you very much. I really don't want them. So yeah, we didn't take it to the patients as an environmental project. Thank you uh for my medicine waste project. Yeah, we, yeah, we because of the time, we haven't had a lot of time to speak to patients, but a lot of the time they are very keen to um help with environmental impacts, but it's the lack of knowledge. Um and also expectation as well. And for example, people don't know that's when they step outside the community pharmacy, they can't return any of their medications. So there's um some projects now going on to say, make sure when you leave your pharmacy, check your bag first to see whether any items you don't need, give it back rather than take the whole things. So we have a lot of patients don't know that they can, for example, download the NHS app, use the app to order whatever you want rather than getting a whole lot of repeat prescription from your community pharmacy. So, yeah, I've found that, um, you know, from, uh sort of education of the patient from the prescriber point of view, also in the pharmacy, also from a nursing point of view, if you know, sort of, if everyone sort of points out that, you know, first of all p medication only ordered if you need it rather than, you know, we had this in quite a few pharmacies that I worked in. It was just always ordered and sort of, but if you don't, you know, some of the patients aren't, aren't asked. And so I think that, you know, ok, you know, yeah, sort of educating asking the patients because once they know, and they say, ok, so how many of these, uh, uh creams have you got at home? Do you really need another one again? Because I think also with waste that we get back in pharmacies. If patients pass away, you get so many creams because, you know, the, the emollients that are not used properly because most of the patients just use sort of a very small proportion of what they should use. And, um, so, you know, it's something that everyone has to say a little bit more so that the patient is educated because it's, you know, it seems like a lot of them haven't heard of many of those sort of possible problems for the environment. Ok, thank you. Um um I'm just picking up from the, from the chat. Um There's lots of discussion going on which is great. Um But Jasmine, you had a, a few questions directly with Claire at the beginning. So, um and, and that touches on a theme that, that appeared at the end around investing in staff to support some of these initiatives and the short sightedness of trust. Um not doing so. Um And you know, when we can see a, a longer term solution being achieved by perhaps a bit of investment in um in human resources. So um your question to Claire was um ex looks like extra support staff to support the project would pay for itself. Would you agree? And do you think the extra staff are necessary to support the project? Yeah. So we, we tried to be a little bit, I, I'm very lucky. My chief pharmacist is quite canny when it comes to getting sort of staffing and stuff like that. But what we did is we took people on as a fixed term contract. Um And we also tied it in with our discharge team. So actually when they were actively managing discharges, that was fine. But actually in the down time, they were doing more sweeps around the um hospital and returning those medications. And then as we have people leave, which you always do you get natural progressions, then we're able to flip those fixed terms into permanent positions. So we've now got um two permanent members of staff on both sides to be able to do that. But I think it is, it's, it's understanding the NHS system of recruitment and how you can do. But actually because of the early figures, we had as a trust, they were happy to do fixed term contracts for 1218 months, which gives us that community to prove just how much money is being saved by these individuals. And then they're more likely. And these were band three staff that were supporting. And again, there's that bit more flexibility around like some of the lower banding staff because of the pay and we've been able to do it that way. You just have to get creative. And hey, you've mentioned a similar, a similar um approach by the look of it and we put a proposal together for a pharmacy technician, worked out, you know, the savings for just recycling medications and, you know, being it dispensing for discharge, which um it is really difficult in the palliative care unit because our medications change so much you might come in and one opiate and go home on something completely different, different neuropathic agents, you know, so, and we couldn't really do the dispensing for discharge that happens in the hospital. We only maybe one or two things change by the end. And so we looked at the savings we thought we could make. We got a pharmacy technician in and she saved more money than, than way more money than she was worth. And so, yeah, but we got to, to do it. Um, but I've taken it to other wards and they've just rolled their eyes at me and said, well, that'll never happen, you know. So, but I've proven it. There you go. They don't listen. Thank you. And James um has, has posted a, a sort of related question. Could you envisage teamwork across primary and secondary care to undertake inhaler reviews and you know, potentially other types of um work around this issue? I guess this could help take workload off primary care teams and improve connection between the two settings. That sounds like an amazing ideal. Could it happen? I would love to see that happen? Um And I, to be honest, I really think that it's, it's the way to go. I think we have to recognize that even though inhalers are so common, that knowledge around their use has actually become fairly specialist. And there are a significant number of, of people including GPS that, that are not really sure about how to make sure someone's got the best inhaler for them. Um And so I feel like seeing really close collaboration between primary secondary care, possibly in the form of a joint service could be really beneficial to patients, particularly if we're looking at reviewing patients that have got uncontrolled respiratory symptoms. Um, so I think it's not impossible. I think it's quite a big system change. And so I don't know the way that, that we would go about that. But yeah, I certainly could envisage that and think that it would be a really good solution. Anyone else have any thoughts on, on collaboration between primary and secondary care? I thought one more thing, um, that's uh very underused is on uh websites like asthma UK, you get videos for each individual inhaler. And I think that, you know, patients are much more, you know, um likely to look at videos these days because they've got more um smartphones in that. And I think this is something that can really help because um also if you have patients and they've got a new inhaler, you might go through it with them. But if you don't also show them, this is where you can refresh your technique. I think this is something that could really, really help and something that more. Mhm And Janet's raised a really good, sorry, Jamie has been raised a really good point about the uh the procurement issue and um the costing uh between the NHS and community um around inhalers so that the choice available is going to be different. Um And that I guess could present some logistical problems. Um And that's really interesting because in my region we've got a joint formulary so it doesn't differ and we're actually in the process of reviewing our formula because as I said, one of the things we identified is that we've got way too many inhalers and it's really confusing. Um So perhaps that's something that needs to be addressed in other areas if that's different elsewhere. Ok. Oh. generally speaking your meat. Oh, yeah, sorry. I same active ingredient. But yeah, different brand NHS has um such a discount with community, don't. So yeah, we are still ongoing debate that to have a um same formulary choice is yeah, very difficult that yeah, we want to use the most environmental friendly inhalers but because of the pricings, that's yeah, we still haven't agreed. Thank you. There's a couple more questions that you posted judgment that I think apply to most of the of the projects one around um whether this was really transferable between, you know, the, the work that you did, the project that you, that you looked at, was it transferrable to different settings either within a hospital or, or we've already talked about perhaps a community application um and for any problems or safety concerns and how those are dealt with any of your projects. Does anyone want to offer anything on those? I think for us, I mean, obviously the returning of medicines because we've got to make sure the storage. So it's making sure we've got robust guidelines in place as to what we return back into stock for reuse with expiry dates. Um But I think, um on the whole, I think because the impact has been ongoing and like I say, we report to our pharmacy board and we're seeing sort of like we're saving sort of like between the walls of like 7 to 8000 lb a month still on returns. So, um, nothing really sort of like a safety point of view from our point of view. But yeah, just being aware of what could and couldn't be returned. And that's something that you mentioned, Jamie that, that, that patients are under the impression that things can be returned to pharmacy in New Zealand and other staff. Um thinking that things could be reused and that doesn't seem to be universal. It can happen in some areas and it can't in others. Is that correct? Have I got that right? Um I think routinely any patients on medication which has stepped out from the community pharmacy, it cannot be returned because of we can't guarantee the temperature and the moisture of it. But in terms of in the hospital, there are a lot of variations in terms of whether some hospital may be able to return an original pack, whereas some hospital can also return split packs as well depending on if they have staffing. So for example, in ultras, because we don't have the storage, um so we can't return any split boxes. And sometimes I think it's such a huge waste, for example, uh a box of 20 tablets. You only use one tablet or one file of antibiotics. The whole pack is gone to waste. And yeah, it's so significant that I don't know whether, yeah, how we can address on this. So for the meantime, we are just saying any high cost medications split pack will return. But yeah, it's huge for on there. Mhm. Thank you. I was just wondering if I could ask Claire directly Just I think because what we want to think about is we're obviously in this really urgent situation and I was just wondering about like, how ready to upscale do you feel like your project is like, do you think if you could share your protocols with other trust that they would just be like immediately implementable or do you think it's quite specific to your site and therefore there needs to be um personalization to each specific location? No, I think, I think because if you recognize that like someone's, I think in the chat about like investing in the short term has such long term benefits. Actually, if we can almost ring fence and members of staff or even an hour, hour and a half a day, actually, if that's returning stock that we're not having to order and then have to wait to get delivered. Actually, it has a huge impact, not just on sort of money but actually on the sustainability, especially where we have lots of medication that's going out of stock, there's some stuff I think in the hospitals that we're being told, um, that, you know, we're not going to get, there's a manufacturing issue and we're not going to get stuck back in, you know, until next year, actually having that awareness on the wards and those sets of eyes on the wards to see this stock and realize that there's a recall or we're going to be short of it to get it back into the system. I think it makes a huge, huge difference. Um So yeah, we're very keen and like I said, I've got a very supportive um chief pharmacist, he's very keen and we have actually is I've been involved in lots of these projects where we ring fence a team for a month and it's all amazing and we present it in nice presentations at board. Um And then it's normal business again and it will face by the by. But actually I think, and you said as well, we know what impact having an active pharmacy team on the ward makes both to patients and to the staff as well. But it feels like we just have to constantly try and prove it all the time. I think that's the biggest challenge. Um But I think one of the things also is um I don't know whether you guys are in our area. We have like the DMS and the discharge medicine service where we can send messages through to community pharmacies. So we do that for like blister pack patients. But we also had um a patient who literally bought in a bin bag, a black bean bag full of medication that they weren't taking boxes and boxes of the same medication. And actually having that communication with the community pharmacies to say, actually, we don't think they're compliant. Can you have a chat? Because sometimes hospital is not the best place to speak to an individual because they're out of their home environment. They've got a lot of other stuff going on. They don't want to be lectured about their medicines. Um Having those links, I think is a lot better and it's starting to build up that gap between primary and secondary care, which I think we have had for an awful long time. Thank you. And um just, just from a nursing perspective, if there's any other nurses in the room that lots of the projects have mentioned, the reduction in nursing time and nursing workload. And I'm really, really uh glad to hear that particularly. OK, your, your um projects around um preparation and administration of drugs and how much of a difference that made to, to the nurses. Um knowing that it, that it was best for patients as well, but, you know, it's, it's, it's on a, on a, on a, a new basis, isn't it? Those patients that still needed and benefited from the paracetamol were obviously still getting it, but just not that unnecessary word for something that wasn't providing much of a benefit. Um We have six minutes left. I just wanted to pick up on the, on the discussion as well that there was a bit of an offshoot. Really. Um Fiona mentioned um just this point around paracetamol and opiates and the symbiotic relationship between the modes of action or the, the, the uh enhanced effectiveness of one on the other, which was something I was always taught as well. Um, and some interesting, um, uh, studies showing that that wasn't always the case. I don't know if you wanted to just pick up on that and summarize it a little bit. OK? Because that was a really random study. Um, it's just, it was a, a paper in the GPS, the general of pain and symptom management and, and we, we discussed our journal club and was part of care and we're also going, oh, so paracetamol doesn't really help because we were always told that it's like use the paracetamol, use the Ibuprofen, use the other things and bring down the opiate use. I mean, you know, I mean, I've been doing palliative care since 1999. So I'm a bit, you know, had quite a good go at it and quite a lot of the things that we were taught when I first started, um, have been proven to be nonsense. So, you know, for example, we gave a, or a more four hourly and a double dose at bedtime because that would get you through the night. Actually, it just makes you really drowsy and you do get up, you fall over and break something. So, you know, it's taking other people to approve things. So, you know what we were learning before for, well, we think this, therefore we do that, um, gradually things have sort of come through to see. Actually, you know, it doesn't help and, but, you know, we all know people, I've got patients at the moment who a terrible pain in her pelvis and the thing that she thinks works the most is IV paracetamol. She's on methadone, she's on all manner of neuropathic agents. And she says, please, can I have the IV paracetamol? It's amazing. So, and we look after sickle cell patients and some of them really see we had was amazing. Actually, the other stuff you give us is ok. But the part is amazing. So there are some people who love it who see it's a, makes a difference. We keep them on it. But if it's like, no, we don't. So, but you know, it all kind of started with that paper going, it doesn't make much difference. So, yeah, what we learned a long time ago and because of the wo pain LA, it's like, you know, if you've got sore head, you take some paracetamol, then you add in some ibuprofen and then, you know, if you've got some you'll maybe take some codeine, you know, you'll, you'll, you know, escalate up. Um, but yeah, there, there's some people that works great for some people. It doesn't. So, um yeah, it's not overall if you take however many people are in that study, overall paracetamol doesn't add to a strong opiate. So, very interesting that my big learning point from a clinical point of view today. So, thank you for that. And I guess again, it highlights the importance of holistic assessment from, from that people are in their choices and, and we're listening to what for some people and not others. And then the the side impact is this incredible reduction in cost and um and environmental impact. So that thank you. Any other burning questions that anyone hasn't yet put in the chat or that I have. Um If there's a massive uh omission that I've made my iphone, Amazon, anything I've missed around some of these themes, everything we've covered everything. Ok? Anyone wants to make any final comments, questions from the speakers. If not, then we'll have our two minutes extra added to our lunch break. Um I'll just remind you that uh the posters are open in the