Lectures Flashcards
how many health boards are in NHS scoltand?
14 geographical health boards
7 special health boards (e.g. NES or HIS)
all of them are accountable to scottish ministers (even the ones that aren’t geographical locations)
there is an annual accountable meeting for each of the health boards
what is the responsibility for each of the geographical health boards?
Each health board is responsible for the protection and improvements of their populations health and for the delivery of frontline health care services
what is the scottish governments aim for 2020
that by 2020 everyone is able to live longer and healthier lives at home or in a home setting
Health care system has…
integrated health and social care
focus on prevention/anticipiation
supported self management
if hospital admission is required (because patient cannot be treated in the comity) then day case treatment become the normal (reduce hospital stays and prevent if possible)
whatever the setting, care is always provided to the highest standards of quality and safety
person/patient at the centre of all decisions
focus to try and get patients back to their home as soon as appropriate
minimal risk of re-admission
implementation of a quality strategy
required actions to improve efficiency and achieve financial stability
what is the Public Bodies (Joint Working) (Scotland) Act 2004 for?
Orgnaisaiton designed to bring multidisciplinary groups together within a locality
Form health and social care partnerships (31 across Scotland)
Can be totally joint partnerships or one (health or social) can be identified as taking the lead (if this is the case then subject to interrogation scrutiny to ensure that both parties are still working together)
Bringing together healthcare and social care to get the best possible result for the patient , work out the best devision of functions, coordinate visits to the patient and improve integration between health can social care
what are the 5 points involved in prescription for excellence?
vision
patient centred pharmaceutical care and medicines
safety in pharmaceutical care and medicines
effectiveness of pharmaceutical care and medicines (make best use of pharmacists knowledge)
making it happen- infrastructure to deliver pharmacueitcl care
a vision and action plan for the right pharmaceutical care through integrated partnerships and innovation
what are the 9 commitments for achieving excellence in pharmaceutical care
increasing access of pharmacy as a first port of call
integrating pharmacists
creating conditions to transform pharmacy services
providing resources to support the safer use of medicines
improving the pharmaceutical care of patients in care homes and patients being cared for in their own homes
enhancing access to pharmaceutical care in remote and rural communities
building the clinical capacity and capability of the pharmaceutical work force
optimising the use of digital information, data and technologies
planning for sustainable pharmaceutical care in scotland
what does CMS dO
chronic medication service
- facilitate shifting of balance of care
- improve multidisciplinary and collaborative working
- minimise the duplication of effort
- establish a framework to improve monitoring and continuity of care
- improve the efficiency of information transfer
who are “high risk patients” as according to SIGN
patients >50yrs is care homes
patients >75 years on multiple medications
what medicines are especially high risk
NSAIDS anticholinergics sedatives analgesics anti-psychotics
what are the aims of a medication revieq
structured clinical examination of a patients medication…
optimising the impact of their medicine
minimising the number of medicine related problems
reducing waste
(also helps to improve health outcomes)
please state the 7 steps of medication review
1) Identify aims and objectives of drug therapy
2) Identify essential drug therapy
3) Does the patient take any unnecessary drug therapy?
4) Are the therapeutic objectives being achieved?
5) is the patient at risk of ADRs
6) is the drug therapy cost effective?
7) is the patient willing and able to take drug therapy as intended?
what is the differnence between adherence and compliance
ADHERENCE presumes that the patient is in agreement with the recommendation and the taking of the medicines
COMPLIANCE implies patient passivity
What factors influence adherence with medication
Age Culture Religion Cognition Physical Visual Compliated medication regimes Understanding/motivation Illness
What factors can cause unintentional non-adherence, will a compliance aid help in this situation?
forgetfullness
dexterity issues
confusion
dementia
Yes a compliance aid may help
What factors can cause intentional non-adherence, will a compliance aid help in this situation?
Mental health
avoidance of side effects
belief that the medication isn’t working
belief system
A compliance aid will not help if it is these issues that are causing the non-compliance
What happens if patient has poor health literacy
poorer health outcomes
patient wait until they are more unwell before seeking help
harder to access the service they need
harder to understand labelling or directions
less able to communicate with HCPs
Less able to take part in decisions about their own health
Less likely/ableto engage in health promotion activities (flu-jab or breast cancer screening)
higher rates of avoidable and emergency admissions
higher risk of hospitalisaion
longer in-patients stays
difficulty managing their own health and their family
What are the problems associated with use of MCAs
Evidence supporting MCA interventions as increasing adherence is inconclusive
Lack of evidence for general benefit of MCA
Use is service driven not person centred
High Risk
Lack of evidence of barrier properties/ medicine stability/ interactions between medicines in the MCA
IF person also takes Prn medicines too then there is a risk of the patient having to take multiple medicine administration systems (if other ones aren’t suitable for conclusion)
Product licence is revoked when remove medicine for OP so the pharmacist is responsible
De-skilling of the patient, lack of patient choice and emoweremnet (should first conduct a medication review to establish the issues resulting in poor compliance)
patient choice is comprimised (doesnt automatically improve compliance)
non adherence soul be a prompt for review, not automatic blister pack!
pharmacist are professionally responsible if something goes wrong
sustainability? high workload and workforce pressure for community and hospital services
what is aspiration pneumonia
Pulmonary aspiration is when you inhale food, stomach acid, or saliva into your lungs.
what different types of stroke are there?
ischemic or haemorrhage
Ischemic can either be thrombotic or caused by emboli
what is the FAST acronym for stroke
Face
Arms
Speect
Time
what is a thrombotic stroke
a type of ischemic stroke where a thrombus forms at the site in one of the arteries that supplies blood to the brain
what is an embolic stroke
a type of ischemic stroke that occurs when a blood clot that has formed elsewhere in the body travels to the brain via the blood stream and it lodges in an artery, blocking the flow of blood causing a stroke
what is a common cause of embolic strokes
atrial fibrillation
how does arrhythmia cause an an embolic stroke
atrial beats are irregular (although peripheral pulse may be normal due to regular ventricular beats maintaining a reasonable cardiac output)
spamming atria only pumps out a tiny bit of blood into the ventricle each time it contracts therefore the rest of the blood pools and in the atria and starts to coagulate
every now and again the heart/atria will revert to sinus rhythym, the blood clot that has formed in the atria is forced out into the ventricles, it then travels through the aorta to the brain and causes an embolic stroke due to occlusion of blood flow
what is a TIA
sometimes thought of as a mini stroke, a temporary occlusion of blood flow
risk factor for a full stroke
what is a cerebral heamorrhage
a type of haemorrhage stroke caused by an artery in the brain bursting and causing localised bleeding in the surrounding tissues
the bleeding kills brain cells
what are some modifiable risk factors for a stokr
smoking drug use hypertension diabetes high cholesterol atrial fibrillation alcohol diet/exercise
what are some non-modifiable risk factors for stokr
age
sex (jemals)
race
PFO
can hypo perfusion case a stroke?
yes, as it cases an increased risk of coagulation (but this is rare)
what steps are needed in acute stroke care
1) admit to a stoke unit
2) imaging
3) assess swallow
4) assess medicines (stop everything)
5) thrombolysis using TPA (alteplase)
6) 24 hours after thrombolysis put on high dose aspirin 300mg for 2 weeks
7) after 2 weeks stop the aspirin and start clopidogrel 75mg per day
name the steps of secondary stroke prevention
A (antiplatlets) B (blood pressure) C (cholesterol) D(diabetes) E (exercise and lifestyle)
what additional step is required if a patient that has had a stroke also has AF
anticoagulant e.g warfarin or DOAC
what is used to assess stroke risk in patients with AF
CHADS2 or CHA2DS2VAS
what is the CHADS2 score
CHF (1) Hypertension (1) Age >75 (1) Diabetes (1) Stroke (2)
Score >2 means anticoagulation is necessary
wat is the CHA2DS2VAS score?
CHF -1 Hypertension -1 Age >75 -2 Diabetes -1 Stroke/TIA -2 Vascular disease (e.g. peripheral artery disease, myocardial infarction, aortic plaque) -1 Age (64-75)-1 Sex (female)-1
Score >2 means anticoagulation is necessary
what its the calgary-cambridge approach to assessing a patients medicines?
initiating session gathering informaion physical exam (if appropriate) explanation and planning closing the session
what is drug testing
quantitative test targeted specifically at a specific drug or dug class can can detect substances only when present at above cut-off levels
what is drug screening?
qualatative immune assay test to distinguish specimens that test negative for a drug or metabolite from positive specimens
Drug screening is often the initial test and theyn they do drug confirmatory test to identify and quantify the presence of a specific drug
what is test SENSITIVITY
proportion of positive results a testing method correctly identifies
what is SPECIFICITY
proportion of negative results a testing method correctly identifies
what is limit of detection
lowest amount of analyte in a sample that can be detected but not necessarily quantified
what is the limit of quantification?
lowest amount of analyte in a sample that can be quantified with suitable precision and accuracy
what is the window of detection
length of time a substance or their metabolite can be detected in a biological matrix
what factors affect the window of detection
chemical properties of the substance that is being detected
individual metabolism and excretion rates
route of administration, frequency of use, amount of use of the drug that is being tested for
sensitivity and specificity of the test
cut off concentration
biological specimen thats ued
patient health, weight, gender, fluid intake etc.
what is the window of detection foe breath
mins
what is the window of detection for blood
mins
what is the window of detection for oral fluid
mins- hours
what is the window of detection for urin
mins-weeeks
what is the window of detection for sweat
hours-days
what is the window of detection for hair
days-years
what is the window of detection for meconium
weeks-months
what is a point of care test
a test that is conducted where the sample is collected (for example in the doctors room)
quickly reveal the test results (not quantitive only qualitative)
positive POCT should be followed up by lab test especially if legal ramifications fro the patient will results from the findings
what is a specimen validity test
determines whether a sample specimen has been diluted, adulterated, or substituted to obtain a negative result
how is the validity of urine tested
labs always preform a pH and creatinine test on urine sables
compare creatinine level and reflex specific gravity with sample and normal characteristics for urine
check for common aduleterants
what is adulteration/substitution or dilution of tests
diluting the samples to the point that the drug is below the cut off concentration to achieve a negative test result
consuming larger than normal volumes of water
taking diuretics
adding water from toilet or tap
what are the two types of renal failure
acute and chronic
what are the different types of acute renal failure
pre-renal renal failure
intra renal renal failure
post-renal renal failure
what is pre-renal renal failure
reduction in renal perfusion due to fluid loss, blood loss, reduced BP due to chock, cardiac failure
can be caused by prostaglandin inhibition by NSAIDS etc
remember : REDUCITON IN RENAL PERFUSION LEADING TO ACUTE ONSET RENAL FIALURE
what is intra-renal renal fialur
damage to kidney in some way
damage to renal tubules (e.g. nephrotoxicity by aminogllycoside antibiotics)
interstitial nephritis (caused by penicillins)
glomerulonephritis
what is post renal renal fialure
urinary tract obstruction (kidney stones, thrombosis, tumours), back pressure causes damage to the kidneys
what is chronic renal failur
chronic progression of renal fialure over weeks or months (symptoms initially start to appear when eGFR <30ml/min)
what is drug tolerance
pharmacological phenomenon where identical doses of a drug gradually produce decreasing levels of effect
higher doses of drug are required to produce the same level of effect
what is drug dependence
results from chronic use of a drug that has produced tolerance and adverse physical symptoms (withdrawal) occur from sudden discontinuation or rapid dose reduction of the drug
what is addiction
compulsive and repetitive use of a drug often at potentially harmful doses
tolerance and physical dependence may develop as a reults
how can you prevent hydrolysis
exclude moisture from the formulation (by including as little water in the formulation as possible)
protect the product from moisture , pH, heat (using appropriate containers)
store in appropriate places (fridge, dry areas)
use by dates to ensure no decomposition has occurred)
how do you prevent autoxidation?
exclude oxygen from blister packs
protect from light using opaque containers
use optimum pH
use a cheating agent (EDTA) to suppress heavy metals for example copper, that will accelerate autooxidation
use an antioxidant (to “mop up” any free radicals that can also contribute to autooxidaiton)
draw a fishbone diagram for why medicines have to be stored under specific conditions
time moisture light air temperature ---> unstable drug product production distrubution storage
what factors need to be considered when deciding whether covert administration is suitable for a patient
adults with incapacity (scotland) act 2000
benefit for patient
least restrictive
take patients wishes into account
consultation with others (should be a team decision and family involved too)
what is the remit of the MHRA
to ensure medicines, medical devices and blood products for transfusion meet the applicable standards for safety, quality and efficacy
what do the MHRA do to fulfil their remit
ensure medicines supply chains are safe and secure
promote international standardisation
help to educate public and HCP on risks
do inspections of manufacturers, wholesale dealers, clinical trial sites, laboratories
inspections can be routine, product related or triggered
what are the 3 possible results of a MHRA inspection
critical
major
other
what does the EMA do
european medicines agency
established to harmonise different national legislation between countries in the europe
central procedure for liscencing medicines across the EU
who are the FDA
american regulators
name some of the MHRA licences that you can get
marketing authorisation wholeslae dealer importer active substances (manufacture, distribute, import) broker registration clinical trial autohrisaion manufacture liscence parallel imports liscnec brokers liscence specials liscence registration of homeopathic medicines and traditional herbal medicines THR
what information does the product lisence for a medicine include?
indications dose formulation safety issues (side effects and contraindications) storage and stability information
what is a manufacturer/importer lisence
a lisence to manufacture and/or assemble licensed medicinal products (including export to a country outside the EEA)
what is a manufacturer special lisence
lisence to manufacture unlicensed medicines ‘specials” that are for a named patient
what is a manufacturer lisence for IMP
licence to manufacture investigational medicinal products for use in clinical trials
what is a manufacturer licence exempt ATMP
licence to manufacture exempt advanced therapy medicinal products on a non-routine basis for UK hospitals
what do specials manufacturers have to operate to
have to operate under a manufacturers specials liscnce
have to operate to GMP and have QMS and QC but they do not need a QP to release the finished product
what is a parallel import lisence
a licence to import the exact same medicinal products from the EU to the UK
simple
standard
complex
what is the role of the QP
no batch product is released for sale or supply prior to certification by a QP that the product is in accordance with the requirements of the relevant authorisation
samedi on the site licence and manufacture licence
expected to be operationally familiar with the site (although they may not be there full time)
do all steps of the supply chain need a QP?
all stages except
brokers
wholesale distributors
specials
what is an unliscenced medicine
a medicine that hasn’t been approved by the relevant medical authority for the treatment of a specific disease state
what do the MHRA check for in a product to grant it a marketing authorisation
quality
efficacy
safety
what different types of unliscnecded medicines are there
products that have been administered to patients under terms of a clinical trial (not yet liscenced, early access included in this category)
products that are licensed in other countries but not in the UK
products that are manufactured under the terms of a manufacturers specials license
Products manufactured under Reg4 of HMR 2012
repackaged/overlaelled medicines
are unlicensed medicines and off label the same
no, unlicensed medicines have no marketing authorisation in the UK
off-label medicines is the use of a product that has a marketing authorisation in the UK but you are using it for an indication which it has no marketing authorisation for/ is not listed in its SPC
(licensed medication used outwit the terms of its marketing authorisation)
what legislations allow for the use of unlicensed mediciens
Legislation 65/65/EEC
S11344/1994
what is the decision heirarchy for using unlicensed medicines?
licensed medicine within the UK
licensed medicine used off label
imported medicinal product with a license in its country of origin
specially manufactured unlicensed product (special)
extemporaneous preparation
explain the process of manufacturing specials in NHS scotlant
Request Formulation Process development Validation Documentation Manufacture Packaging/labelling QC (as appropriate) Release (Product release) Storage Distribution to customer for administration to named patient
what is the definition of a carer
a carer is someone who, without payment provides help and support to a partner, child, relative, friend or neighbour who could not manage without their help
the person that is recieving care could need help because of age, physical or mental illness, addiction or disability
how many unpaid carers are there estimated to be in scotland
over 750,000
doing unpaid work worth more than £10.3 billion
how can being a carer affect the carer themselves
sinificant impact on carers mental and physical health
especially young carers, it may affect their studies or make them feel that they cannot go out and socialise with their friends and have to care instead
adult carers may need to give up their employment or career to care
may be able to access support
what government legislations are in place for carers
carers (scotland) act 2016
determines carers that are eligible for support
carers must be involved in the planning of care services for the person they are caring for
also must be involved in discharge planning for the person they are caring for
what HSCP support is available for carers
glasgow city health and social care partnership
prepare an adult carer support plan
prepare a young carers statement
emergency and future planning, support etc
how can pharmacies support carers
form professional relationships
be understanding
pro-active in informing the carers about pharmacy services that may be helpful for them (flu jag, CMS, doxette box deliveries
provide information for a local carer centre
discuss medicines and side effects (carer and patient will need to sign a consent form that provides clarity and security to the pharmacy re. information sharing, this needs to be signed before the pharmacy can discuss things with the carer
communicate with other healthcare professionals (hespecially helpful in hospital discharge and admissions)
be relialble, a trustworthy place where carers know the will get excellent service
can help alleviate stress through good organisation, flexibility and communication
valuable source of support and service precision
medicines adherence information
what are pharmacokinetic drug interactions
interactions involving how drugs are absorbed, distrubuted, metabolised or excreted (affect ADME processes)
(there will be a change in drug level)
what are pharmacodynamic drug interactions
interactions where the effect of drug A is altered by the presence of drug B without affecting its pharmacokinetics
(there will be no change in drug level)
how do you calculate log D for acids
Log D = Log P + Funionised
F(unionised) acid = 1/(1+10)pH-pKa
how do you calculate log D for based
Log D = Log P + Funionised
F(unionised) bases = 1/(1+10)pKa-pH
