PHAR1821-Personal-notes PDF

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1821 Lecture notes: Week 1: Lecture 1: PHAR1821 -

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Lecture 2: Information sources for pharmacists. Evidence based medicine (EBM) The conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual patients. The practice of evidencebased medicine requires the integration of individual clinical expertise with the best available external clinical evidence from systematic research and our patient’s unique values and circumstances. - Research-based evidence. - Clinical expertise (i.e., the clinician’s accumulated experience, knowledge, and clinical skills). - Patient’s values and preferences.

Evidence based practice (EBP) Evidence based clinical practice is an approach to decision making in which the clinician uses the best scientific evidence available, in consultation with the patient, to decide upon the option which suits the patient best.

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Current, systematic review of the science. Integrate science with clinician’s experience. Active and informed participation by the patient.

Formulating a research question (PICO): P: Identify the P (Problem/Patient). -> 72 year old woman with osteoarthritis of the knee and moderate hypertension. I: Define the I (Intervention). -> COX-2 Inhibitor. C: Consider a C (comparison). -> Other NSAIDS. O: Define the O (Outcome). -> Less GI bleeding while maintaining pain control. Research question based on PICO: In a 72 year old woman with osteoarthritis of the knee, can COX-2 Inhibitor use decrease the risk of GI Bleeding compared with other NSAIDs?

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Information sources: Type

Examples

Primary

Secondary

Tertiary

Original research publications.

Abstracts, databases.

Textbooks, review articles.

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Written by the researchers themselves. But the strength of the evidence can differ.

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AusDI. MIMS online (different to eMIMS). AMH. eTG. MedicinesComplete. APF. RWH paediatric pharmacopedia. King’s guide to admixtures. Goodman and Gilman – The pharmacological basis of therapeutics. De Piro – Pharmacotherapy. Hale – Medications and mother’s milk. Briggs – Drugs in pregnancy and lactation. Trissel - Handbook on Injectable Drugs. Stockley – Drug Interactions. SHPA Injectable Drugs Handbook. Clarke’s –Analysis of Drugs and Poisons. Meyler's Side Effects of Drugs.

Search strategy for an enquiry: 1) Identify/ formulate a research question. 2) Depending on the main topic, you can use specific sources/sites to navigate an answer much faster. e.g. A question on Pregnancy/Lactation, you could use the following sources: PI, eTG, Briggs (drugs in pregnancy and lactation), Hale (medication and mothers milk).

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Levels of Evidence: Level 1a

Grade A

1b

A

2a

B

2b

B

3a

B

3b 4

B C

5

D

Example Systematic Review (i.e. Meta-analysis) with homogeneous RCTs. Individual RCT with narrow confidence intervals for primary outcomes. Systematic Review with homogeneous cohort studies. Individual Cohort Study (including low quality RCT- e.g. you DO take into account appearance. - R: Refer. - E: Explain. ASMETHOD: Establishes presenting complaint, AND if patient has had it before. - A: Age/ appearance - S: Self or someone else? - M: Medication? - E: Extra Medicines? - T: Time persisting? - H: History? - O: Other symptoms - D: Danger Symptoms? SIT DOWN SIR: Establishes severity, nature and previous history. - S: Site or location - I: Intensity or severity - T: Type or nature - D: Duration - O: Onset - W: With? (other symptoms) - N: Annoyed or aggravated (????) - S: Spread or radiation - I: Incidence or frequency, pattern? - R: Relieved by? Acronyms: Help structure consultation however are limiting (All fail to establish social, lifestyle and family).

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Why is communication so important? - Poor communication leads to medication or treatment errors -> leading to serious consequences for the patient and clinician. - Customer loyalty. Barriers to communication: 1) Physical: Time, place, space, climate, noise, choice of medium. 2) Cultural barrier: Cultural diversity, language. 3) Psychological/attitude: Moods, attitudes, relationships. 4) Varying perception of reality: Levels of understanding and comprehension. How to overcome barriers: - Appropriate language. - Listening skills: If the sender conveys a message through oral communication then the receiver should pay attention to decode the message. Fake attention, interrupting, poor listening habits and distracting actions lead to ineffective communication. Good listening skills help in reducing the efforts to reach the desired objectives. - Be sensitive: Sensibility in communication increases the chances of loyalty. Any organization’s success depends on its trust towards the society. - Appropriate channel: Noise and disturbance can make the communication ineffective and useless. - Get comfortable: The more you talk about it the less embarrassed you’ll be. - Communication aids: Verbal + written aids, include carers/ family members.

Lecture 2/3: Communications.

Professional vs. social relationships: Professional - Planned, formal- (eg. specific health issues). - Adaptive to the client’s needs. - Educational. - Often brief and short term, can be superficial. - Uses technical language. - Often less self-disclosure. - Different boundaries to a friendship i.e. confidentiality ethical & privacy issues covered by law. - Potential power imbalance.

Benefits of patient focused communication:

Social - Spontaneous or planned. - Focused on your needs. - Language less formal, technical but can be jargonised i.e. use of text (c u @ 6 ☻). - Often involves a deeper level of self disclosure and intimacy. - Can last for many years. - Choice.

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Open vs. Closed ended question: Open ended question A closed ended question is one in which you provide the response categories, and the respondent just choses one. Yes/no type of questions. Yes or No, Are you currently taking any blood pressure medications.

Definition

Example

Closed ended question WWWWWH type of questions.

When was the last time you’ve taken this medication and how long were you on the medication. Describe your symptoms.

Behavioral styles: Aggressive, Assertive, and Passive. Aggressive - Does not respect rights, beliefs, and values of others. - Physically and/or verbally dominating. o Body language. o Verbal language. - Eg. interrupts, loud, ‘standover’ tactics. - Eg. blames, criticizes, threatening.

Assertive - Respects rights, beliefs, values of self and others. - Use ‘I’ statements. - Expect to be respected and respects others. - Willing to communicate. - ‘Own’ their feelings and ideas.

Passive - Belief that do not have the right to express own thoughts and beliefs. - Will ‘do as told’. - Allow others to make decisions/choices.

Define and give examples of Rapport, Empathy and active listening:

Definition

Example

Rapport A close and harmonious relationship in which the people or groups concerned understand each other's feelings or ideas and communicate well. Strong 2 way connection. The first goal of the newly hired CEO was to build a good rapport with her colleagues. The longtime doubles tennis partners had developed such a rapport that they managed to best all opponents with superior technique!

Empathy The ability to understand and share the feelings of another.

Active listening Fully concentrating on what is being said rather than just passively 'hearing' the message of the speaker. Active listening involves listening with all senses.

I felt a powerful surge of empathy as I watched Justin fumble through his PowerPoint slides, remembering how stressful my own presentation had been the day before.

Examples that show you are actively listening: - Paraphrasing what they say back to them. - Asking specific questions. - Eye contact. - Focus on the person without distractions.

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Week 3: Lecture 1: TBC. Lecture 2: Ethical communication in healthcare. Code of ethics for Pharmacists:

The art of effective communication: 1) Active listening. 2) Relevant questions. 3) Respect. 4) Sensitivity. 5) Non-judgmental. 6) Body language. 7) Patience. 8) Smile. Principles of bioethics: For treating anyone, even if its life threatening, DNR, etc. Autonomy: Informed consents, privacy, dignity, right to decide. Justice: Fair dealings. Beneficence: Best interests. Non-maleficence: Do no harm. Social media as a tool in medicine: - Use secure closed systems with data encryption. - Avoid third-party open systems (e.g.Facebook and Twitter). - Inform patients of privacy protections in place. - Establish expectations of message response time, how emergencies should be handled, and issues that should be handled online vs in-person. - Have patients agree to terms before use.

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Lecture 3: Cultural competence.

Culture: the ideas, customs, and social behaviour of a particular people or society.

Australia’s cultural diversity: Religion: 52% reported an affiliation with a Christian religion – predominantly Catholic (23%) and Anglican (13%). New South Wales and Queensland remain the most Christian states, but there is an overall decline in the percentage of Australians reporting their faith as Christian. About 8.2% of us reported a religion other than Christianity, with Islam (2.6%) and Buddhism (2.4%) the most common. Ethnicity: The Census shows that Australia has a higher proportion of overseas-born people (26%) than the United States (14%), Canada (22%) and New Zealand (23%). Effect of culture on health and health care: Patient’s perspective: - Culture and health beliefs/belief systems. - Religious beliefs and health. - Beliefs about death. - Need for self-autonomy. - Need for shared decision making – decision making shared with family. - Health literacy (and language). Professional perspective: - Ethical issues – patient best interest vs. respect for patient beliefs. - Personal culture and religious/spiritual beliefs. - Communication styles. - Stereotyping.

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Cultural competence: Definition: A set of congruent behaviors, attitudes and policies that come together in a system, agency or among professionals and enables that system, agency, or those professionals to work effectively in cross-cultural situations. Stages: 1) 2) 3) 4) 5)

Cultural awareness. Cultural knowledge. Cultural skills. Cultural encounters. Cultural desire.

Principles of culturally competent communication: 1. Be respectful. 2. Recognize that people’s past experiences may shape their health beliefs and expectations’ 3. Be mindful of communication practices (eye to eye contact, shaking hands, interpersonal distance, use of first names). 4. Explore what the patient thinks. 5. Explain your view-point and health care provision strategy. Language diversity and Pharmacy, Strategies that pharmacists may employ: - Using professional translators –but one needs to make an appointment with the translator. - Checking with patient’s doctor. - Google translate (not satisfactory). - Using simple language and using cartoons and drawings to help communicate. - Translated labels. - Using informal translators e.g. staff in pharmacy that speak Mrs Vladislova’s language x against NSW Policy.

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Week 4: Lecture 1: MASUS. -

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Lecture 2: Decision making.

Model for decision making: 1) 2) 3) 4)

Assessment. Analysis. Decision. Outcome.

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Lecture 3: S2/S3. Supply procedures, symptom based request, example protocol. Scheduling:

S2: Pharmacy Medicines. -

Only available at a pharmacy. Easily accessible by the public. Regarded as safe if used appropriately, and may be advertised.

S3: Pharmacist only medicines. “Substances which are for therapeutic use and: i. About which personal advice may be required by the user in respect of their dosage, frequency of administration and general toxicity, ii. With which excessive unsupervised medication is unlikely; or iii. Which may be required for use urgently so that their supply only on the prescription of an authorized practitioner would be likely to cause hardship.” -

Stored out of reach of the public. Pharmacist MUST personally hand out. Pharmacist must ensure appropriate use and safety for indication. Pharmacist must check understanding.

S4: Prescription Only medicines. “Schedule 4 (Restricted Substances) Substances which in the public interest should be supplied only by, or upon the written prescription of, an authorized practitioner.” Responsibility for OTC medicines; - Ensure Appropriate use. - Ensure effective use. - Ensure most convenient use. - Provide accurate health and medicines information. - Facilitate referral to more appropriate therapies. Supply of OTC medicines; - Direct product request. - Symptom based request. Gather information, process information, make recommendation, and provide info. Supply of OTC -> WWHAMM. Direct product request:

S8: Drugs of Addiction.

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Week 5: Lecture 1: Pharmacy services. Roles of Community Pharmacists - Supplying without prescription (primary care). - Dispensing – In response to prescription or chart. - Non-supply related functions.

Dispensing related supply roles - Compounding. - Re-packaging (Dose administration aids). - Medication management apps. - Opiate substitution therapy. - Staged supply. - Recording clinical interventions. - Continued dispensing (limited re-prescribing). - Hospital dispensing (including reconciliation, discharge & counselling).

Non – supply roles: - MedsCheck & diabetes medscheck. - Diabetes & asthma disease state management. - Atrial dibrillation screening in pharmacies using an iphone ECG. - Weight management services. - Immunisation. - Needle exchange programs. - Return of medicines – yellow bins. - Health checks, BP testing. - Pharmacogenomics (personalized medicines). Dispensing: Dispensing is the preparation, packaging, labeling, record keeping and transfer of a prescription drug to a patient, their agent, or another person who is responsible for the administration of the medicine to that patient. Staged supply:  Staged supply is a clinically-indicated, structured pharmacist service involving the supply of medicine to a patient in periodic instalments as requested by the prescriber or carer.  These instalments are less than the originally prescribed quantity at agreed intervals (e.g. daily or weekly).  The balance of the prescribed quantity is held by the pharmacyto fulfil subsequent instalments. More complex pharmacist services: - Residential medication management reviews & QUM services. - Home medicines review. - Continuity of care – Liaison pharmacist. - ATSI QUM services (QUMAX). - Public health promotion. How to attract patients and keep them: 1) Patient centred care, 2) Convenience, 3) Price, 4) Personal trait or preference, 5) Service/medication need. Communication tips: - Use peoples preferred names often, respectfully. - Re-direct conversations to “patient experience” (living with medicines) – Demonstrates empathy. - Listen, pause, check understanding, listen. - Respect = concerns about medicines are real. - Try to be reassuring but do not dismiss concerns.

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Lecture 2: Patient-centered care. Patient centered care: - Understanding the patient as a unique human being. Elements of patient centered care:  Biopsychosocial perspective.  The ‘patient-as-person’.  Sharing power and responsibility.  The therapeutic alliance.  The ‘doctor-as-person’.

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Lecture 3: Nutrition and Obesity. Definitions & Interpretation: Overweight/obesity: Excess of fat. Interpretation: (Weight (kg) / Height (m2) )  40 Obese. Identify appropriate resources to manage weight in primary health care – Make appropriate recommendations based on relevant guidelines for uncomplicated cases – Describe factors contributing to overweight and obesity – Explain the benefits of lifestyle change and weight loss –Discuss OTC weight loss options including VLEDs and orlistat Appropriate resources to manage weight in primary health: Prevalence of Obesity and overweight and high risk groups: Prevalence  63.4% of adults were overweight (35.5%) or obese (27.9%).  27.4% children (5-17 years) were overweight or obese.  It is estimated that by 2020, 75% of Australians will be overweight or obese.

High risk groups - Aboriginal & Torres Strait islander people. - Southern and eastern Europe. - Oceania region. - Socioeconomic disadvantage. - Regional and remote areas (69.2% compared to major cities 61.1%).

Medicines associated with weight gain: -

Glucocorticoids. Diabetes medications. First & Second generation antipsychotics. Neurologic and mood stabilizing agents. Anti-histamines. Antidepressants. Hormonal agents. Beta-blockers. Alpha-blockers.

5 A’s approach to weight management:

1) Ask: Identify who would benefit, ask permission to discuss weight. 2) Assess: Assess current lifestyle behaviors. 3) Advise: Advise about risks and explain benefits of modest weight loss, explore all treatment options. 4) Assist: Assist in setting up tailored weight loss programs. 5) Arrange: Review and monitoring, support long term weight management.

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Treatment pathways: 1) Lifestyle intervention: (1) Reduce energy intake, (2) increase physical activity, (3) behavioral change. 2) BMI > 30 or 27 with comorbidities: Add pharmacotherapy adjunct to lifestyle intervention. 3) BMI > 40 or 35 with comorbidities: Refer to physician to discuss bariatric surgery as an adjunct to lifestyle intervention.

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Week 6: Lecture 1: RACA. Lecture 2/3: Skin health. Skin anatomy:

Epidermis: - Outer thin layer of varying thickness. - Prevents water loss, protects. - Pigment protects from UV radiation (melanocytes). - Keratinocytes formed cons...