Dr. Val Stoynova wasn’t always a climate advocate. The Island Health internist was about a year into her practice when she met “Beth” in 2018. They worked together to regain Beth’s health, addressing her high blood pressure and diabetes. She was thriving. Then, during the heat dome in 2021, Beth showed up in the hospital emergency department; she was struggling to breathe. Her question to Dr. Stoynova was, “What am I doing wrong?” Beth was one of thousands of British Columbians who came into hospitals that week; the heatwave was especially difficult for older and frailer people.

That event was followed a few months later by an atmospheric river that nearly flooded Saanich Peninsula Hospital where Dr. Stoynova was working. Generators, oxygen concentrators, and the electronic mainframe were impacted. This disrupted the staff’s capacity to care for their patients and affected Dr. Stoynova profoundly. It may have been the moment that she became a climate advocate. Today she and her colleague Dr. Celia Culley, a clinical pharmacist, lead the Critical Air Project, the first and largest climate-conscious inpatient medication management initiative in Canada, with a grant from CASCADES where she chairs the national Sustainable Inhalers Community of Practice.

“Health care is the fifth largest contributor to greenhouse gas emissions worldwide,” Dr. Stoynova told VPSA members who joined her in person and online recently for a presentation on climate-conscious medication management. “When we think of how health care contributes to the carbon footprint, we might picture mountains of garbage or the energy costs of running our buildings. A quarter of Canadian health-care-related greenhouse gas emissions are actually directly related to medications. This is one of our biggest opportunities. So much carbon comes from the tip of my prescribing pen, and I have direct influence over this.”

Dr. Stoynova went on to give a history of metered dose inhalers (MDIs), noting that five per cent of health-care carbon emissions come from anaesthetic gases and metered dose inhalers. Depending on the type, one aerosol inhaler can be equivalent to driving up to 170 kilometres in terms of its carbon footprint. However, not all inhalers are the same and that’s where VPSA members can make a difference. CASCADES has developed a five-step framework targeting accurate diagnosis, disease optimization, and safe disposal practices.

“We have control over this lifecycle; there is a lot of room for improvement,” said Dr. Stoynova.

She emphasizes that inhalers are necessary and irreplaceable in the inpatient setting. However, Dr. Stoynova is equally emphatic that inhaler waste and inhaler loss contribute disproportionally to the carbon footprint of inpatient care without contributing meaningfully to it. She cites studies showing that up to 80 per cent of patients have more than one identical inhaler dispensed during their hospital stay and that up to 97 per cent of doses per inhaler are wasted. At Island Health, where Dr. Stoynova works, enough inhalers are dispensed each month to drive around the Earth’s circumference 4.5 times.

Through the Critical Air Project, Dr. Stoynova is working on an education campaign as well as towards policy and procedural changes. Upon learning that the provincial contract for inhalers was up for negotiation in 2023, the team calculated the difference we could make if the switch was made to low-volume MDIs (which have a much smaller carbon footprint) in the inpatient setting. They wrote a briefing note and made a presentation; the decision to use low-volume MDIs saves 1,847 tonnes of carbon emissions each year province wide. This is the equivalent of driving 6.4 million kilometres by car.

Dr. Stoynova and her colleagues are currently working to make adjustments on automated dispensing cabinets (ADCs) to alert health-care providers that inhalers have a climate impacts, to ask them if an inhaler is really necessary, and to check the bedside/med drawer before removing inhalers from the ADC.

These ideas are now creating systems-level change across Canada. The Critical Air Project began in Victoria and is now supporting projects in Vancouver, Kelowna, Toronto, Ottawa, and all the way to the Atlantic Canada. What started as a small idea has affected meaningful change. 

Dr. Stoynova’s presentation was recorded. You can view it here. She has also shared a copy of her PowerPoint presentation with us that you can check out here.

What’s happening in our health authority?

VPSA members are part of the VA/VC Medical Staff Planetary Health Committee. A multidisciplinary team under the committee is working on climate-conscious inhaler transition in the CTU. The group has applied to the inhaler collaborative training offered by Health Quality BC. In addition to this, our members are also involved in bringing this change within the community clinics.

The next speaker in the Planetary Health series is happening March 13. Dr. Annie Lalande will talk about ways to improve the inpatient diet. Look for details in upcoming issues of your weekly Checkup e-newsletter.

Feedback from the event

• 14 of the 41 people who attended the event completed a follow-up survey.
• They gave the event a net promoter score of 93%.
• The vast majority of attendees agreed they will apply content from the session to their work.
• Comments included:
  • I did not realize a component in the inhaler was so damaging to the environment.
  • Eye opener on the effects of inhalers especially the waste in discharge from hospital….
  • [We] really have a responsibility and opportunity for meaningful change.
  • Would like to hear what is being done about recycling the PPE such as gloves and masks as there are methods available from local companies not used in hospitals.