Definitions Flashcards
(74 cards)
1
Q
Beneficence
A
Act in patients best interest
2
Q
Non-Maleficence
A
Do no harm
3
Q
Autonomy
A
Choose what they want
4
Q
Justice
A
Treated fairly
5
Q
Competence
A
Legal judgement, can only take consent from competent patients
6
Q
Capacity
A
Medical judgement
1. Understand proposed management
2. Comprehend risks/benefits
3. Retain information to make decision
7
Q
Delirium
A
Transient, confused mental state with reduced awareness of surroundings
8
Q
Code of conduct
A
Defines professional behaviour expected of all surgeons, reflects RACS values
9
Q
Capacity
A
Medical judgement that they can understand proposed management, comprehend risks/benefits and retain information long enough to make choices
10
Q
Informed Consent
A
Access to appropriate and understandable information about treatment options (and alternatives), associated risks and expected outcomes, without coercion
11
Q
Maori Health Equity Causes
A
○ Colonisation
○ Land/resource loss
○ Environmental degradation
12
Q
Equity
A
Different groups require different resources to achieve the same outcome
13
Q
Screening Test
A
- The condition should be an important health problem.
- There should be an accepted treatment for patients with recognized disease.
- Facilities for diagnosis and treatment should be available.
- There should be a recognizable latent or early symptomatic phase.
- There should be a suitable test or examination.
- The test should be acceptable to the population.
- The natural history of the condition, including development from latent to declared disease, should be adequately understood.
- There should be an agreed policy on whom to treat as patients.
- The cost of case-finding (including a diagnosis and treatment of patients diagnosed) should be economically balanced in relation to possible expenditure on medical care as a whole.
- Case-finding should be a continuous process and not a “once and for all” project.
- Needs to have a high sensitivity
14
Q
Women in Surgery
A
Goal of 40% women into surgery by 2021
40:40:20, with aim to get 50% by 2027
15
Q
Barriers to women in surgery
A
- Work life balance - family, partner
- Lack of role models
- Unconscious bias
-Not family friendly
16
Q
Improvements to Women in Surgery
A
- Flexible training
- Mentoring of trainees, junior reg’s and students
- Promoting women in surgery
- Supportive colleagues and departments with parental leave and return to work
- Women in leadership roles
17
Q
Environmental Sustainability
A
- Reduce
- Reuse
- Recycle
- Rethink
- Research
18
Q
How to achieve environmental sustainability
A
Materials:
- Reusable theatre
- Research into sustainability
Workforce:
- Keeping people in NZ and maintain training
- Preventing burnout with good working conditions
- Good work environment
- Aging population increase in demand, build infrastructure and teams with pathways to treatment faster
19
Q
Surgeon Wellbeing
A
Wellbeing Charter for Doctors:
Practicing self-care
- Setting boundaries to ensure work life balance
Coping strategies
- Recognizing burnout and how to manage it
- Coping with stress
- Time management
- Conflict resolution
- Self-care strategies
Maintaining support networks
20
Q
GSET
A
Curriculum - overall content (covers knowledge, attitude, behaviours, manner, performance and skill) - competency and milestone based
Syllabus - topics and subjects covered in program (medical, technical expertise, clinical judgement)
Pros - competency feedback based, clear picture of progression, flexible, individualised approach, identify weaknesses
Cons - resource intensive from consultants
21
Q
Clavien-Dindo Classification
A
Order of ranking of complication in objective and reproducible manner
5 grades
1. Any deviation from normal postoperative course e.g. wound infection
2. Requiring pharmacological treatment with drugs, or blood products or TPN
3. Requiring surgical, endoscopic or radiological intervention
4. Life threatening complication requiring ICU management with end organ dysfunction
5. Death
22
Q
SAC rating
A
Severity assessment code
Rating and triage tool for adverse event reporting
Rate severity of adverse events on actual outcome (near-miss SAC4)
1. Severe SAC 1 - Death or permanent severe loss of function 2. Major SAC 2 - Permanent major or temporary severe loss of function 3. Moderate SAC 3 - Permanent moderate or temporary major loss of function 4. Minor SAC 4 - Requiring increased level of care 5. Minimal SAC 4 - Near misses - No injury or increased level of care/length of stay
23
Q
Always report and review
A
- Wrong site
- Wrong implant/prosthesis
- Retained foreign object post procedure
- Wrong consumer
- Child/infant abduction or discharge to wrong family
- Unconsented treatment (e.g. seclusion while not subject to mental health act, ECT without consent)
24
Q
SAC 1-2
A
- Report event to Health Quality and Safety Commission
- Complete adverse event brief with CEO
- Within 15 working days adverse event brief- Review even and send summary of findings to commission
- Involve consumer and whanau and share their story
- Independent consumer representation during review
- Develop recommendations and action plan
- Share review
- Review even and send summary of findings to commission
25
SAC 3-4
- If Always Report List then follow SAC 1-2
- If not
- Report even within organisation's reporting, review and learning system
- Review event according to organisational review guidelines
- Share lessons learned and actions taken, this includes sharing with consumer and family
- For national learning encouraged to complete adverse event sharing learning tool and send to commission for
- Near miss events with high potential for causing serious harm
- Adverse events where there is value for national learning
- Other system issues that should be alerted at a national level
26
Audit
process comparing clinical practice against set standards
27
Research
aim is to create new knowledge that can be used to develop new standards of care
Research helps establish best practice, audit checks that best practice is being applied
28
Evidence-based medicine
integration of best research evidence with clinical expertise and patient values
29
Standard
defined level of quality that must be achieved
30
Guideline
recommendations to assist clinicians in making decisions
31
Protocol
must be followed, step-by-step approach
32
Strengths
1. Teamwork
a. Played in sports teams
b. Collaborative approach, with roles and expectations
2. Leadership
a. Used to leading a team within sports environments
3. Teaching
a. Involved with surgical teaching currently
b. Previously sports coaching
c. Important to give back and provide supportive learning
4. Cultural competency
Working in a predominantly Māori population during my house officer years, taught valuable lessons about Māori views on health and importance of whanau and 4 pillars
33
Weaknesses
1. Delegation of tasks with teamwork - booking scans myself after patient not booked for CT oral contrast to check for leak when asked
2. Well-being worklife balance, regularly taking breaks away from work, finding extra-curricular activities - cycling
Finding difficult to say no - other specialities declining patient eg head trauma but needs to be admitted for concussion cares. Becoming more assertive about referral guidelines
34
Clinical Governance
System for improving standard of clinical practice
Clinical audit, education/training, research/development and risk management
35
Surgical Audit
- Collection of clinical activity and outcome data
- Analysis and comparison of standards, performance indicators and outcome parameters
- Peer review to identify areas of potential improvement
- Facilitating self-reflection through audit results and feedback
36
Treaty and Health
1. Tino Rangatiratanga - representation
2. Equity - outcomes
3. Active protection - social determinants of health, institutionalised racism
4. Options - right to choose
5. Partnership - involving Maori at all levels
37
Maori health inequities
* Institutionalised racism
* Social determinants of health
* Health literacy
* Colonisation, racism and privilege are fundamental determinants of indigenous health
* Poorest health of any NZ group
* Higher mortality rate, higher rate of illness, higher rate of death from cancer
* Lower rates of diagnosis and lesser access to effective treatment
* Lower standards of health lead to suboptimal outcomes for individual Maori and influence Maori communities negative perceptions of health system as a whole
* Unconscious bias within healthcare system, less likely to receive tests and treatment
38
Te Rautaki Maori
Indigenous health committee and Māori Advisory group Action Plan
1. Pae ora - healthy futures
○ Platform for Maori to live well and healthy
2. Matauranga Maori - Maori knowledge and capability
○ Capable surgical workforce and increasing Maori knowledge of RACS governance groups and staff on issues relating to Maori
○ Cultural training for non-Maori staff
3. Workforce development
○ Increasing and maintaining Maori surgical workforce
- Increasing workforce to reflect 15%
4. Research and development
○ Using kaupapa Maori metholody to undertake research that is beneficial for Maori and increases understanding of Maori worldview
- Undergo research that identifies levels of racism and unconscious biases
5. Stronger policy and development
○ Policies that will produce better results for Maori and reflect their needs and aspirations
6. Partnerships
○ Developed and maintained to support progression of Te Rautaki Maori
39
HEAT tool
- Tool to enable assessment of policy, programme or service interventionss for their impact on health inequities
10 question tool
40
Hui process
1. Mihimihi - initial greeting and engagement
2. Whakawhanaungatanga - build relationship and make a connection
3. Kaupapa - attending to clinical purpose of the session (goals
4. Poroaki - closing the session
41
Meihana Model of Health
Two waka - patient and whanau
5 bridges between
1. Tinana - physical
2. Hinengaro - emotional/psychological wellbeing
3. Hauora - health services
4. Wairua - connectdness
5. Taio - physical environment
4 winds affecting
1. Marginalisation
2. Migration
3. Colonisation
4. Racism
4 ocean currents affecting course
1. Ahua - personalised indicators
2. Whenua - connectedness to land
3. Whanau - roles and responsibilities within family
4. Tikanga - cultural protocols
42
End of Life Eligibility Criteria
1. >18yr
2. Citizen or permanent resident
3. Suffering from terminal illness likely to end their life within 6 months
4. In an advanced state of irreversible decline in physical capacity
5. Experience unbearable suffering that cannot be relieved in a manner that the person considers tolerable
6. Competent to make an informed decision about assisted dying
43
End of Life Act
Competent
Terminal event
Support and Consultation for End of Life in NZ Group
2 doctor consent process, psychiatrist if required
44
Rural Health Equity Strategy Plan
- Increase rural surgical workforce and reduce workforce maldistribution, through select for rural, train for rural and retain for rural
○ Select for rural - rural origin, rural medical schools, rural trainees
○ Train for rural - train in rural, with rural curriculum at all points in career pathway (medical school, prevocational, vocational, PFET)
○ Retain for rural - surgeons, education, regulation, financial, personal and professional
○ Collaborate for rural - with rural communities and people, with surgical systems and colleges
45
Barriers to rural health
- Distance
- Cost
- Less likely to get time off work - farmers
- Smaller workforce with less flexibility
- Lower SES
○ Social determinants of health
- Higher maori population
Lack of available medical care
46
Solutions to rural health
- Outreach clinics, virtual clinics
- Petrol vouchers, or bus services
- Collating appointments and investigations together, reduce need for return trips
- Teleheath
Rural training and retaining workforce - selection, placement, fellowship
47
Advanced Directive
Specific statements about treatment e.g. JW declining blood products
Obliged to follow unless reason to question validity
Full treatment default option
48
EPOA
The ability to appoint a proxy decision maker in event of loss of mental competence
49
CAMP - Background/Motivation Questions
Clinical - develop specific clinical skills or interest
Academic - academic interest or want to develop skills
Management - gain further experience in certain areas
Personal - any relevant skills or hobbies
50
STAR - Skills-based Questions
Situation - what is the context of the story
Task - what did you have to achieve
Action - what did you do? How did you go about achieving it, and why did you do it that way?
Result/Reflect - what happened at the end? Why did you feel you did well? What did you learn?
51
SPIES - Colleagues/Conflicts
Seek Info
- Understand the problem
- Discuss with individual or colleagues
Patient safety
- Make sure patients are protected
Initiative
- Anything you can do yourself to resolve the problem
Escalate
- If too serious to deal with then involve more senior colleagues
Support
- Support the person dealing with the problem
Patient's safety needs to come first, but handle situation sensitively
52
Bullying
Repeated behaviour over time that intimidates, threatens or offends
53
Discrimination
Treating a person less favorably on basis of legally protected attributes or personal characteristics
54
Harassment
- Unwanted behaviour that makes a person feel humiliated, intimidated or offended.
- Based on specific attributes or characteristics
- Single incident can amount to harassment
55
Sexual harassment
Unwelcome sexual advances which offends, humiliates or intimidates a person or group
56
Unacceptable behaviour
- Decided by reasonable persons test
○ Whether a reasonable person in same circumstances would consider behaviour bullying, discrimination or harassment
It is the impact and nature of behaviour on person affected not the intent or motive
57
Management of unacceptable behaviours
- Seek support from peer network, mentor, colleagues or RACS
- Ask someone you trust to speak to person who demonstrated unacceptable behaviour to see if opportunity to find out their perspective. That person if unaware can reflect and amend their behaviour
- Document event or nature of behaviour
- Discuss with manager, health and safety or someone in authority to understand your rights and options
Consider reporting event or making formal complaint to relevant department
58
NZ Risk Score
- Calculation of mortality at 30 days, 1 and 2 years
- Based on NZ data from Auckland City Hospital
- Non-cardiac surgery, excludes acute laparotomy
- 8 risk factors
1. Age
2. Gender
3. Ethnicity
4. ASA
5. Acuity
6. Cancer
7. Specialty
Procedure
59
P-Possum
- UK calculation for morbidity and mortality risk score
- Can overestimate morbidity and mortality
- Operative and patient factors
1. Age
2. Cardiac
3. Respiratory
4. ECG
5. sBP
6. HR
7. Hb
8. WCC
9. Urea
10. Sodium
11. Potassium
12. GCS
13. Operation type
14. Number of procedures
15. Operative blood loss
16. Peritoneal contamination
17. Malignancy status
18. Elective vs acute
60
NELA risk score
UK risk calculation took of risk of death within 30 days of emergency abdominal surgery
Takes into account risks of procedure and information about patients
More accurate than P-POSSUM
1. ASA
2. Albumin
3. HR
4. sBP
5. Urea
6. WCC
7. GCS
8. Malignancy
9. Respiratory
10. Urgency
11. Peritoneal soiling
12. Indications - bleeding, other (relook, laparostomy, dehiscence, compartment syndrome), obstruction, sepsis, ischaemia
61
Revised Atlanta Criteria for pancreatitis
- 1st week clinical parameters important for treatment planning
- After 1st week CT findings and clinical parameters help determine care
- Helps guide management and monitor success of treatment
Definition (2 of 3 present)
1. Abdominal pain suggestive of pancreatitis
2. Elevated serum lipase/amylase >3x upper limit
3. Characteristic findings on CT/MRI/USS
Two phases
1. Early phase within 1st week
1. Severe pancreatitis - organ failure that lasts >48hrs
2. Late phase after 1st week (may extend for weeks-months), increasing necrosis, infection and persistent multiorgan failure
1. Local complications - sepsis, bacteraemia
2. Systemic complications - SIRS, multiorgan failure
Categorisation of various pancreatic collections
62
Mass transfusion protocol
- Any situation resulting in acute blood loss and haemodynamic instability
- Goal to limit complications and limit critical hypoperfusion while surgical haemostasis can be achieved
- Want to avoid lethal triad
1. Coagulopathy
2. Hypothermia
3. Acidosis
- Monitor - FBC, ABGs, coag, electrolytes (esp Ca), lactate and TEGs (thromboelastogram)
63
Emotional intelligence
human ability to recognise, understand and manage one's emotions in positive ways
1. Empathy
2. Social skills
3. Self awareness
4. Self regulation
5. Motivation
64
Waiting list times
- Multiple factors leading to this
- Clear backlog initially - outsource lists
- Systemic
○ Healthcare workforce shortage
§ Train and retain new staff
§ Import staff from overseas, immigration
§ Incentivize to train in health
○ Theatre efficiency - motivation with fee for service
○ Working groups - forming teams familiar with each other to improve efficiency
○ Paid per case rather than hourly rate, working group into business
○ Create good team environment
○ New training regime for anaesthetic tech's
- Prioritisation element
Audting new prioritisation system and making changes as required
65
Te Aka Whai Ora
Maori Health Authority
- Helps ensure everyone has same access and good health outcomes
- Strengthening mana motuhake for whanau - supporting them to take control of their own health and wellbeing
- Responsible for
○ Leading change in way entire health system understands and responds to Maori health needs
○ Developing strategy and policy to rive better Maori health outcomes
○ Commissioning Kaupapa Māori health services and other services targeting Maori communities
○ Co-commissioning other services alongside Health NZ
○ Monitoring overall performance of system to reduce health inequities for Maori
66
Pae Ora
Aims to create a more equitable, accessible, cohesive and people-centered system
1. Te Whatu Ora
2. Te Aka Whai Ora
3. Public health agency
67
New waitlist algorithm
5 factors, only for priority 3 not urgent elective or cancer cases
1. Ethnicity (Maori or Pacific)
2. Clinical priority
3. Time on waitlist
4. Geographic location (isolated areas)
5. Deprivation level
Need to overcome inequities, we know Maori have poorer outcomes, less likely to be referred or booked and then spend longer on waiting lists
Need to reduce inequities
But need to make sure we audit outcomes and change as required
68
Maori Research
Kaupapa Maori research and evaluation is done by Maori, with Maori, for Maori
Informed by tikanga
Principles of kaupapa Maori ethical framework
1. Whanaungatanga - building relationships
2. Manaakitanga - sharing with collaborative research
3. Aroha - respect
4. Mahaki - humility, sharing of knowledge
5. Mana - dignity, respect
6. Look, listen and then speak
7. Kia tupato - cautious, culturally safe
Being a familiar face
69
Access to elective assessment and surgery
Inappropriate delays can cause increased risk of morbidity and mortality
Finite resources, considerations
1. Impact of condition on patient
2. Likely benefit of surgery
3. Risk to patient
4. Impact on patient should surgery not be undertaken
Need to report and reflect on data
70
Aging surgeons
Bring in medical assessment to practice similar to aviation >65yrs
Poorer outcomes with older surgeons when performing lower volumes of certain procedures
71
Bowel Cancer Screening
New Zealand has one of highest rates in the world
Maori have poorer outcomes when diagnosed with bowel cancer
Faecal occult blood test used as screening test
Relatively high false positive rate
Evidence suggests screening should be available to all over 50yrs every 2 years (currently 60-74yrs)
Shift towards earlier detection rate of bowel cancer with screening, and a survival improvement
72
Implications of obesity for outcomes of non-bariatric surgery
Awareness of increased risks, especially with metabolic syndrome
1. Timing of surgery - involve anaesthetists and physicians, weightloss prior to elective surgery
2. Preoperative assessment - anaesthetic, diabetic control, assessment of CVS/resp status
3. Location of procedure - bariatric equipment, adequate monitoring, transfer if required
4. Postoperative care - CPAP, monitor for complications, analgesia and VTE prophylaxis dosing
73
Open Disclosure
- Apology or expression of regret
- Factual explanation of what happened
- Opportunity to ask questions
- Opportunity for patient, family to relate their experience
- Discussion of potential consequences of adverse event
- Explanation into steps being taken to manage adverse event and prevent recurrence
74
Practicing while impaired
Key issues
1. Patient safety
a. Need to ensure safety of patient
2. Code of conduct
a. Breaches code of conduct to be practicing while impaired
3. Mandatory reporting
a. RACS is obligated to report practitioner if believe they are unable to perform functions required for practice
