About the Project
In her work as an internal medicine physician, Dr. Valeria Stoynova was conscious of the many health effects of climate change, including respiratory illness, cardiovascular stress, and mental health challenges. Yet she was also aware that the process of delivering medicine is very greenhouse gas intensive. When looking at easily attainable, high impact initiatives to reduce greenhouse gas emissions in the hospital, she noted the practice of dispensing metered-dose inhalers as particularly carbon intensive. Approximately 3.5% of all health-care related greenhouse gas emissions come directly from these inhalers.
As a treatment for patients with respiratory disorders (e.g. asthma, obstructive lung disorders, cystic fibrosis), inhalers are invaluable and irreplaceable for patient care. Valeria partnered with her colleague Dr. Celia Culley, Clinical Coordinator of Pharmacy at Royal Jubilee Hospital to secure a SIFEI grant to learn more about inhaler use within the hospital, so they could look for opportunities to optimize inhaler use without compromising excellent patient care.
Recognizing that engaging stakeholders across the spectrum of hospital staff would be essential, they used the seed funding to sit down with physicians, trainees, pharmacists, pharmacy technicians, nurses, respiratory therapists, porters, housekeepers, administrators, and pharmacy informaticists to better understand the lifecycle of inhaler use. They learned that there is a significant amount of inhaler waste, what they termed the ‘inhaler attrition rate’. Some inhalers would be used a single time before being thrown away as the patient was transferred from ambulance to ER, then from ER to the ward. In fact, previous studies have shown that up to 98% of doses per inhaler dispensed in hospital are wasted .
The team used these insights to create The Critical Air Project, the first and largest inpatient climate-conscious medication management initiative in Canada. This innovative work was recognized with a grant from CASCADES Canada, a non-profit organization funded through Environmental and Climate Change Canada. They have since been able to tackle a series of initiatives to reduce inhaler wastage, including changing the location of the tamper seal to reduce the incidence of accidental disposal of unused inhalers, and advocating for the renewal of a lower greenhouse gas inhaler contract across all BC health authorities.
At the time of writing, on a provincial level, this initiative has kept 1,850 tonnes of CO2 emissions out of the air annually. This is equivalent to driving 6.4 million km in a standard gasoline powered vehicle.
The Climate Conscious Deprescribing Initiative has also had personal impacts for the project leads. “This quite literally changed the course of our careers”, says Valeria. Both point to the initial seed funding from SIFEI as instrumental in moving the ideas into action: “The sense that someone thought this idea was worth supporting, and worth investing in, that gave us the confidence to keep going, to keep moving forward”. Celia concurred: “There is just no time in our regular workdays to do QI work. The SIFEI funding was a springboard, so we could say “let’s start with this”.
The project leads highlight the many key stakeholders who participated in the project, as well as the inspiring example set by a previous SIFEI project led by Dr. Caroline Stigant and Dr. Jean Maskey, whose work focused on promoting a planetary health agenda in Victoria-area hospitals.
For more information about the Critical Air Project, please see this presentation by the project leads for CASCADES Canada, and these slides prepared for the UBC Therapeutics Initiative.
Drs. Stoynova and Culley’s This Changed My Practice” about metered-dose inhalers is also available.
 Imogen Tennison, Sonia Roschnik, Ben Ashby, Richard Boyd, Ian Hamilton, Tadj Oreszczyn, Anne Owen, Marina Romanello, Paul Ruyssevelt, Jodi D Sherman, Andrew Z P Smith, Kristian Steele, Nicholas Watts, Matthew J Eckelman, Health care’s response to climate change: a carbon footprint assessment of the NHS in England, The Lancet Planetary Health, Volume 5, Issue 2, 2021, Pages e84-e92.
 Sakaan S, Ulrich D, Luo J, Finch CK, Self TH. Inhaler Use in Hospitalized Patients with Chronic Obstructive Pulmonary Disease or Asthma: Assessment of Wasted Doses. Hosp Pharm. 2015 May;50(5):386-90. doi: 10.1310/hpj5005-386. PMID: 26405325; PMCID: PMC4567205.