Roadmap
A guide to (de)implement sustainability interventions. On this page, you’ll find additional information on implementing and measuring sustainability interventions for medication. You can download the full step-by-step guide here (NL).
Implementation plan
An implementation team will be set up for each hospital, including at least one doctor and a pharmacist. These act as drivers of the intervention and are responsible for formulating objectives, local implementation and evaluating the intervention.
Composition of the implementation team (depending on the intervention):
- Prescriber (s) of the department concerned. Involve content experts from another department where relevant, such as an MDL doctor (for interventions involving proton pump inhibitors) or an anesthesiologist (for pain medication interventions).
- Hospital pharmacist, A (N) IOS hospital pharmacy and/or outpatient pharmacist.
- For further support (if necessary), consider: medication safety coordinator, quality officer, green team, nurse consultant, member of the medicine committee, etc.
Task and role distribution
The chairman is responsible for evaluating (including reporting) at the end of the intervention and submitting it to Greening Care Together.
Implementation
To carry out the (de) implementation of sustainability interventions, this program uses the 'step-by-step plan for implementing sustainability interventions'. In short, this step-by-step plan consists of the following six steps:
- Step 1. Preparation - Make the goal concrete
- Step 2. Situation - Investigate the setting
- Step 3. Plan — Define the strategy (s) and draw up an implementation plan
- Step 4. Implementation — Execute the plan
- Step 5. Evaluation — Evaluate effects and process
- Step 6. Assurance — Embed into the organization
Further explanation can be found via “step-by-step plan for implementing sustainability interventions”.
Evaluation of drug sustainability interventions
Evaluating a drug intervention is an essential part of the implementation process. Each intervention requires its own measurement method to show how much the intervention has contributed to reducing drug use and optimizing the use of sustainable forms of administration (Table 1). Using the environmental impact calculation tools, changes in prescribing and administration data are then converted into an estimated CO₂ reduction. This shows to what extent the intervention has contributed to reducing the hospital's environmental impact. Through the implementation supervisor, the results are shared with the Greening Care Together program.
Choose the right data source based on the intervention.
The chosen data source must include both the number of units and the strength and dosage for a defined period of time, for example 3 months, of the relevant department. Table 1 provides an overview of appropriate data sources per intervention. In general, the following applies:
- Clinical interventions: request EPD administrations via the hospital pharmacy;
- Outpatient interventions: request EPD prescriptions from the hospital pharmacy, unless otherwise indicated in the intervention described.
Pre-measurement: analyse drug (s) prescriptions/administrations before implementing the intervention.
- For the department concerned, calculate the number of patients with prescriptions or administrations of the drug in question and the total (cumulative) dose (in grams) over the defined period (e.g. three months).
Table 1: Overview of drug sustainability interventions and measurement methods
After testing: analyse drug (s) prescriptions/administrations after implementation of the intervention.
- Use the pre-set SMART objective to determine the expected outcome and timeline (see: 'roadmap for implementing sustainability interventions').
- Choose a fixed period after implementation, preferably three months, in which the effect will be measured.
- Preferably use the same period as for the pre-measurement.
- If circumstances differ (e.g. a difference in the number of patients admitted), choose an alternative period that is representative.
- Recalculate the number of patients with prescriptions or administrations of the drug in question and the total (cumulative) dose (in grams) over the defined period (see example 1).
- Calculate the difference in cumulative dosing compared to the pre-measurement.
Complete the environmental impact calculator.
- Complete the environmental impact calculation tools with the difference between the cumulative doses of the pre- and post-measurement.
- The environmental impact is calculated as the difference in drug use converted to CO₂ emissions, extrapolated to a period of one year, as illustrated in example 2.
Example 1: Targeted prescribing proton pump inhibitors
During the pre-measurement (April to June 2024), a total of 270 new outpatient prescriptions for proton pump inhibitors were registered. In the post-test (April to June 2025), this fell to 170 new regulations.
- Esomeprazole: from 90 to 55 starts (— 39%) with a cumulative dose of 54 g to 33 g.
- Omeprazole: from 120 to 80 starts (— 33%) with a cumulative dose of 72 g to 48 g.
- Pantoprazole: from 60 to 35 starts (— 42%) with a cumulative dose of 36 g to 21 g.
On average, this amounts to a reduction of 100 new regulations. If this trend continues over a year, this means that around 400 fewer prescriptions will be started and 240 grams less active ingredient will be prescribed. Using the environmental impact calculator, the environmental impact of this decrease can then be calculated.
Example 2: Paracetamol orally rather than intravenously
The Table summarizes the administration data for the surgical department of a hospital. During the pre-measurement (April to June 2024), 150 patients received a total of 900 doses of 1 gram (=900 g paracetamol), 600 grams of which were administered intravenously. In total, this led to 197 kg of CO₂ emissions. After implementation (April to June 2025), 170 patients received 1,000 g acetaminophen, equivalent to 92 kg CO₂.
The proportion of intravenous injections fell from 67% to 20%. For an average of 160 patients, this corresponds to a CO2-reduction of approximately 105 kg per three months, or approximately 420 kg per year. This is roughly comparable to the effect of approximately 4,000 car kilometres.
Ensures the transfer of information between hospital and primary care
Clear transmission of information about (stopping) drug use is essential to prevent unnecessary drug use. Information transfer to primary care, specifically with general practitioners and public pharmacists, therefore plays an important role in various sustainability interventions involving medication.
For some interventions, such as restrictively prescribing opioids with an indication and intended treatment duration and sharing the indication and intended treatment duration of multiple anticoagulation, good communication itself is the intervention. This is because sharing the indication and intended treatment duration prevents medication from being used for an unnecessarily long time.
In other interventions, such as discontinuing unnecessarily used proton pump inhibitors, the intervention focuses on hospital deprescribing and effective information transfer is needed to maintain this effect and continue in primary care.
Communication routes
Depending on the local situation and available systems, information can be transferred via, for example, the medical discharge letter, a prescription note, the Current Medication Overview (AMO) or the pharmaceutical resignation letter. Tailor the right communication route for each intervention that suits your hospital's way of working.
Contents
When communicating to primary care providers, please include at least the following changes in drug use, preferably with the additional information below:
- Newly started medication: including indication and intended treatment duration
- Modified medication: including reason for change, indication and intended treatment duration
- Discontinued medication: including the reason for quitting and, if relevant, advice on a possible restart or follow-up policy.
Footnotes
1 These can be doctors (assistants), medical specialists, nursing specialists and/or physician assistants.
