PA30327 lectures Flashcards
Define Supplementary prescribing
- A voluntary prescribing partnership between an independent prescriber and a supplementary prescriber
- To implement an agreed patient-specific clinical management plan with the patient’s agreement
Describe who is involved in Supplementary Prescribing
Indepent prescriber
- doctor or dentist
Supplementary prescriber
- registered nurse, midwife, pharmacist, optometrist or allied healthcare professional
Independent and supplementary prescriber share, have access to, consult and use the same patient record
What is included in Clinical Management Plan (CMP)?
- Name of patient
- Illness or conditions
- date on which plan is to take effect
- reference to class or description of medicinal product
- restriction/limitation as to strength or dose of meds
- relevant warnings
- arrangement for notification of
: suspected or known ADR
What are the disadvantages of Supplementary prescribing?
- Very time consuming
- Very prescriptive
- Only really suitable for stepwise management of chronic conditions
Define ‘Independent Prescribing’
- prescribing by a practitioner responsible and accountable for the assessment of patients with undiagnosed or diagnosed conditions and for decisions about clinical management required including prescribing
What should a Treatment Plan include?
- Process of differential diagnosis
- Assessment of severity of staging
- Diagnostic tests
- Stages of treatment
- Medicines intended to be prescribed and evidence for this
- How you will check for patients safety associated with this decision
- How response to treatment will be monitored
- Referral indicators and associated process
what is a Compentency framework?
- There are 10 competencies split into 2 domains
- The Consultation
- Assess the patient
- Consider the options
- Reach a shared decision
- Prescribe
- Provide information
- Monitor and review - Prescribing Governance
- Prescribe safely
- Prescribe professionally
- Improve prescribing practice
- Prescribe as part of a team
What are the examples of Legal frameworks?
Criminal law
- prove that a crime has been committed
Civil law
- prove duty of care owed to a patient has been breached (tort)
Professional body
- competence to remain registered (GPhC has statutory powers)
Employer
- vicarious liability
Describe Human Rights Act (1998)
- is relevant to health care providers since it regulates the relationship between individuals and public authorities
- when a practitioner is making a decision about healthcare provision, it should be focused on patients’ wishes and interests
What are the 5 underlying principles of ethical decision making?
- Beneficence
- to do good
- HCP should balance the benefits of treatment against risks and costs in a manner which benefits the patient - Nonmaleficence
- to do no harm
- HCP should not harm the patient and, as all treatment has some associated harm, the harm should not be disproportional to benefits of traetment - Respect for autonomy
- self converning or independent
- HCP should respect patient’s ability to make a reasoned and informed choice by respecting the decision-making capabilites of an autonomous individual - Justice
- being fair
- HCP should note all patients in similar situation should be treated in similar manner, and that benefits, risks and costs should be distributed fairly - Respect for the patient
What factors might cause you to make a prescribing error?
- slips of action
- lapses of memory
- rule-based mistakes
- knowledge-based mistakes
- routine
- situational
- exceptional
What are the skills required for a pharmacist?
- consultation skills
- patience
- empathy
- shared decision making
- evidence based medicine
- creative thinking
- precision
Why is Calgary-Cambridge Guide so good?
- actively determines and explores patient’s ideas, concerns and expections
- accepts legitimacy of patient views
- shares thinking with patient to encourage patient involvement
- gives information in chunks
- check patient understanding of information
- involves patient by making suggestions, not directives
- encourages patient to contribute their ideas, suggestions, preferences and beliefs
- offers choices
- negotiates a mutually acceptable plan
- next steps, safety netting, summarsing
Why is effective communication important?
More effective gathering of ALL/RIGHT information
- revealing a hidden agenda that patient may be reluctant to share easily
- informing a more reliable/accurate/correct diagnosis
Establishing TRUST between you and the patient
- More likely to get the information you need
- More efficient consultation
- More likely to achieve a CONCORDANT outcome
More effective PROVISION of information
- patient has understanding of condition / risks and benefits of treatment / treatment
How do we become effective communicators when talking to patients/clients?
- body language
- open Qs
- probing questions
- closed Qs as needed
- identifies patient agenda/concerns
- active listening
- looking for verbal and non-verbal cues
- rapport
- management of environment
- confident structure
What are the barriers to effective communication?
Poor questioning technique
- chain Qs
- closed Qs
- Leading/negative Qs
Listening
- not actively listening
- stepping on silences
Not identifying patient agenda/concerns
- poor identification of CUES/CLUES
Distractions
- conscious of trying to get it right
- environment
- other cognitive pressure
Describe therapeutic empathy
- ability to identify an individual’s unique situation, to communicate that understanding back to the individual and to act on that understanding in a helpful way
Define ‘Differential diagnosis’ and ‘Provisional diagnosis’
Differential diagnosis
- list of possible medical causes behind the presenting symptoms or physical findings
Provisional diagnosis
- most likely diagnosis based on symptoms, findings and information gathering but not a fully committed diagnosis
What information do you need to get when taking full medical history?
- previous surgery or hospital admission
- medical condition
- allergies
- family history
- medications
- social history
What are RED FLAG symptoms for Cardiovascular system?
- SOB
- Exercise tolerance
- Orthopnoea
- Paroxysmal nocturnal dyspnoea (PND)
- Chest pain/Angina
- Palpitations
- Diziness/blackouts
- ankle swelling
- calf/leg pain
- tiredness
What are RED FLAG symptoms for Respiratory?
- SOB
- Exercise tolerance
- Wheeze
- Chest pain
- Cough
- Phlegm
- Haemoptysis
- Stridor
- Hoarse voice
What are RED FLAG symptoms for GI?
- Weight loss or gain
- Appetite
- Indigestion/heartburn
- Dysphagia
- N & V
- Hematemesis
- Abdominal pain
- Jaundice
- Swellings
- Change in bowel habit
- Description of stool
What are RED FLAG symptom for CNS?
- Headaches
- Fits/faints/loss of consciousness
- Dizziness
- Vision-acuity
- Hearing
- Weakness
- Numbness/tingling
- Loss of memory/personality change
- Anxiety/Depression
Describe the following pain assessment tool
SOCRATES
S - Site O - Onset C - Character R - Radiation A - Associations T - Time course E - Exacerbation/relieving S - Severity
Why is taking accurate medical history important?
- Helps build the therapeutic relationship
- Determines how the illness may have affected the patient and their family
- Explores the patients ideas, concern and expectations
- Eliminates serious problems
- Determines more accurately what is wrong with the patient
- Finds a solution
When is Decision Aids used?
- Sometimes it can be difficult for patients to make a decision
- Patients sometimes need clear, concise and unbiased information in an easy to read formate to help them reach a decision
for example, smiley faces
What are definitions for the following terms?
- Decision Making
- Reasoning
- Judgement
Decision making
- cognitive process resulting in the selection of a belief or course of action.
- The act of choosing between two or more courses of action
Reasoning
- process of forming conclusions
Judgement
- ability to make considered decisions or come to sensible conclusions
What are the 9 GPhC Standards for Pharmacy professionals?
- Provide person-centred care
- work in partnership with others
- communicate effectively
- maintain, develop and use their professional knowledge and skills
- use professional judgement
- behave in a professional manner
- respect and maintain the person’s confidentiality and privacy
- speak up when they have concerns or when thngs go wrong
- demonstrate leadership
What is Berwick Report?
- place quality of patient care, especially patient safety, above all other aims
- engage, empower, and hear patients and carers at all times
Describe Selective and Creative clinical decision making
Selective
- options already exist and we use a structured process
- decision involves selecting from a choice
- a cognitive process
Creative
- allowed to think more freely
- need to generate solutions from the information gained
- can induce emotion and bias
- can be more risky
What are the common stated reasons for wrong diagnosis?
- too much hurry
- not listening enough to patient’s story
- too much attention to one finding
- didnt reassess the situation when things didnt fit
- overly influenced by similar case
Reasons for wrong decisions?
- made in haste
- made without consultation
- over-analysed
- based on past experiences rather than new situations
- based on other people’s decisions
Describe the Wingfield’s 4 stage approach to decision making
- gather relevant facts
- priorities and ascribe values
- generate options
- choose an option
Describe O’Neill’s 6 stage approach to decision making
- gather all relevant information
- identify and clarify the ethical problem
- analyse the problem by considering the various ethical theories and approaches
- explore the range of options or possible solutions
- make a decision
- implement and then reflect on decision
What are the core skills of clinical decision making?
- pattern recognition
- critical thinking
- communication skills
- evidence based medicine
- team work
- sharing
- reflection
Define ‘Leadership’
the art of motivating a group of people to act towards achieving a common goal.
What are the benefits of leadership in Pharmacy?
Individual level
- encourages self-reflection, identifies areas for further development, aids career progression
Local level
- enhances the effectiveness of a team, builds multi-disciplinary team working and improves the services/process being delivered
National level
- drives change and improvement across healthcare and organisations, ensures the profession takes a consistent approach to leadership development that is alinged with other HCP and strengthens the profession’s reputation and standing
What is Monitoring regarding prescribing?
- periodic measurement that guides the management of a chronic or recurrent condition
- establishing benefit for patients is important
- Monitoring can refer to blood monitoring, condition monitoring or patient monitoring which can be used to ensure patient safety
Why is monitoring required?
- increase in patient safety and reduction in avoidable hospital admissions
- improvement of adherence
- better selection of treatments based on individual response
- better titration of treatment
- patients’ learning about non-treatment factors that alter condition’s control
Monitoring must be balanced against the downsides of monitoring such as…
- inconvenience and costs
- the impact of false positive and false negative results which that can lead to inappropriate or delayed actions
What are the key biochemistry tests (for monitoring) for a generalist pharmacist?
Blood tests monitoring
- FBC
- U&Es, in elderies calculate CrCl
- Creatinine and urea
- Lipids
- TFTs (Thyroid function test)
- LFTs (Liver function test)
- Creatinine kinase
- HbA1c
- ACR
What are the physical examinations that pharmacist independent prescriber is expected to be competent at?
- Manual/electronic blood pressure
- Pulse
- Respiratory examination
- Blood glucose
- Urinalysis
- BMI
- Peak flow
- Temperature
What is monitoring requirements for Ramipril (ACEi)
BNF
- For all ACEi, renal function and electrolytes should be checked before starting (or increasing dose) and monitored during treatment
SPC
- Renal function should be assessed before and during treatment and dose adjusted especially in initial weeks of treatment
- Hyperkalaemia
- Hyponatremia
- Neutropenia
- Cough
What is Frailty?
- a state associated with low energy, slow walking speed, poor strength
- Common (30% of those over 80yrs old)
- Progressive (5-15 yrs)
- Episodic deteriorations
- Preventable components
- Potential to impact on QoL
- Expensive
What are the examples of Assessment Tools for identifying Frailty?
- Gait speed <0.8m/s
- Timed-up-and-go test <12s
- Grip strength
- PRISMA 7 questionnaire
- Clinical frailty scale
- Edmonton frail scale
- Clinical frailty scale
- Reported Edmonton frail scale
- ISAR tool
Describe PRISMA 7 Questions
- seven-item, self- completion questiionaire
- Are you more than 85yrs old?
- Male?
- In general do you have any health problems that require you to limit your activities?
- Do you need someone to help you on a regular basis?
- In general do you have any health problems that require you to stay at home?
- In case of need, can you count on someone close to you?
- Do you regularly use a stick, walker or wheelchair to get about?
READ (STATISTICS)
about frailty
For severe frailty average practice list per GP
- 7% of population over 65 yrs are likely to be severely frail
- In average practice this is about 27 patients per GP
Is frailty amenalbe to prevention and treatment? if so how?
Yes
- healthy ageing reduces risk of fdeveloping frailty
- Good nutrition
- Not too much alcohol
- Staying physically active
- Remaining engaged in local community / avoiding loneliness
- Patients can be signposted to NHS England and Age UK publications
Define Multi-morbidity and Co-morbidities
Multi-morbidity
- multiple long-term conditions
Co-morbidities
- when two disorders or illness occur in the same person, simultaneously or sequentially, they are described as comorbid.
- Comorbidity also implies interactions between illness that affect the course and prognosis of both
What is Multi-morbidity?
Presence of two or more long term health conditions, which can include
- physical and mental health pathologies
- ongoing conditions such as learning disability
- symptom complexes such as frailty or chronic pain
- sensory impairment such as sight or hearing loss
- alcohol and substance misuse
How is Multi-morbidities managed?
- Care for people with multi-morbidity is complicated because different conditions and their treatments often interact in complex ways
- Despite this, the delivery of care for people with multiple long term conditions is still often built around the individual conditions, rather than person as a whole
- Offer care that is tailored to the person’s personal goals and priorities and seeks to address the complexities surrounding the person’s multiple conditions and treatments
What are the tests needed prior to starting treatment of ACEi and ARB?
- U&E and eGFR
- in patinets with CKD, measure serum potassium and eGFR
What are the monitoring required until patient is stabilised on ACEi and ARB?
Heart failure
- measure serum urea, creatinine and electrolytes 1-2 weeks after initiation
CKD
- measure serum urea, creatinine and electrolytes 1-2 weeks after initiation
What are the Ongoing Monitorings needed for ACEi and ARB?
Heart failure
- measure serum urea, creatinine and electrolytes every 3 months
Post-MI
- measure renal function, electrolytes and BP at least annually
What is Malnutrition?
- state of nutrition in which a deficiency or excess (or imbalance) of energy, protein and other nutrients causes measurable adverse effects on tissue/body form (body shpae, size and composition) and function and clinical outcome
