ED inhaler revolution: a simple method to substantially reduce the carbon footprint and cost of inhaler use in the emergency department.

Objectives: As global warming intensifies, the healthcare industry faces a parallel need to treat climate-related illness and scrutinize our greenhouse gas emissions. Metered-dose inhaler medications for reactive airways diseases constitute a substantial portion of healthcare emissions. Metered-dose inhalers are often overprescribed, underlabeled, and lost after a few actuations in the emergency department (ED). Lower greenhouse gas alternatives of similar cost and efficacy are readily available, such as dry-powder inhalers, and numerous guidelines support practice change, yet no published work has shown attempts to change practice patterns in the ED. This quality improvement initiative sought to improve inhaler prescribing, use, and disposal in our ED through a staff education campaign.

Methods: In a tertiary care ED, we implemented a two-staged education campaign for ED nurses and doctors. Passive education techniques (posters, emails, presentations) were followed by active education (one-on-one sessions, simulated cases). Objectives included improvement of green-prescribing practices, medication labeling, patient education, proper disposal, and pulmonary function testing prior to prescribing. We encouraged practice change only in mild and moderate cases of reactive airway disease.

Results: We showed a 19% reduction over the first 6 months, and a 43% reduction the following 6 months in salbutamol metered-dose inhaler dispensations, relative to the same period the year prior. This may correspond to the carbon equivalent of driving approximately 96,000 km by car, or nearly 2.5 times the Earth's circumference. Process measures revealed increased dispensations of dry-powder inhalers and a quick improvement in prescriber knowledge and comfort with alternatives.

Conclusion: Overburdened ED staff remain willing and able to change practice toward environmental sustainability. The rapid success of this project should encourage expansion of sustainability considerations across Canadian EDs, and into clinical and administrative decision-making at all levels of healthcare.