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1
Q

definition of clinical governance

A

Clinical governance is the term used to describe a systematic approach to maintaining and improving the quality of patient care within a health system

“A framework through which NHS organisations are accountable for continuously improving the quality of their services and safeguarding high standards of care by creating an environment in which excellence in clinical care will flourish

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2
Q

name dimensions of quality healthcare (6)

A 
person centred
efficient
effective
safe
equitable
timely
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3
Q

define dimensions of quality healthcare

A

Person-centred
Partnership between patient, families and those delivering healthcare which respects individual needs and values and demonstrates compassion, continuity, clear communication and shared decision-making

Safe
No avoidable injury or harm from healthcare received
Appropriate, clean and safe environment provided for delivery of healthcare services

Effective
Does the intervention work?
The most appropriate interventions, support and services provided to everyone

Efficient
Is the output (benefit) maximised for the given input (costs)?
Wasteful or harmful variation eradicated

Equitable
Are all patients fairly treated ?
Is the distribution of care based on need ?
High quality services provided to everyone, no matter who they are or where they live.

Timely
Appropriate treatment, support and services provided at the right time for everyone

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4
Q

factors contributing to adverse events

A

human factors such as teamwork, communication, stress and burnout;
structural factors such as reporting systems, infrastructure, workforce loads and the environment;
clinical factors such as complexity of care and length of stay.

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5
Q

components of clinical governance

A 
Research and development
education and training
clinical audit
clinical effectiveness
openess
risk management
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6
Q

how can the dimensions of healthcare/clinical governance be implemented

A

Setting quality standards

Delivering quality standards

Monitoring quality standards

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7
Q

definition of a clinical guideline

aim

A

Systematically developed statements which assist in the decision-making about appropriate health care for specific clinical conditions”
-Aim
To improve the quality of healthcare

Clinical guidelines can:

provide recommendations for the treatment and care of individuals
be used to develop standards for clinical audit
be used in education & training of health professionals
help patients to make informed decisions
improve communication between patient and health professional

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8
Q

how much CPD should be carried out and how is this recorded/monitored

A

Mandatory CPD (2017 onwards):
Requirement: 100 hours verifiable CPD within 5-year cycle and at least 10 years verifiable every 2 years
Enhanced CPD scheme
Dentist to maintain own records
Verifiable = concise educational aims & obj / ILOs / quality controls (provide documentary evidence (certificate)
Checked by GDC
If requirements not met, can be taken off GDC register and not allowed back on until met all CPD requirements

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9
Q

name some formats of CPD

A 
Courses and lectures 
Training days 
Peer Review 
Clinical Audit 
Reading journals 
Attending conferences 
E-learning activity
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10
Q

name some highly recommended CPD topics

A

a. Medical Emergencies: at least 10 hours in every CPD cycle – and we recommend that you do at least two hours of CPD in this every year;
b. Disinfection and Decontamination: we recommend that you do at least five hours in every CPD cycle; and
c. Radiography and radiation protection: we recommend that you do at least five hours in every CPD cycle. If you are a Dental Technician you can do CPD in materials and equipment instead of radiography and radiation protection: at least five hours in every CPD cycle.

We also recommend that you keep up to date by doing CPD (verifiable or general) in the following areas:
■ Legal and ethical issues
■ Complaints handling
■ Oral Cancer: Early detection
■ Safeguarding children and young people / safeguarding vulnerable adults

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11
Q

definition of clinical audit

A

Clinical audit is a process that has been defined as “a quality improvement process that seeks to improve patient care and outcomes through systematic review of care against explicit criteria and the implementation of change”.

The key component of clinical audit is that performance is reviewed (or audited) to ensure that what should be done is being done, and if not it provides a framework to enable improvements to be made.

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12
Q

clinical audit steps

A

Select topic
Set agreed standards & decide on data requirements
Observe practice and collect data
Analyse data and determine any deviation from standard
Identify any areas of change required
Make necessary changes
Repeat audit process and determine whether improvements have occurred

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13
Q

clinical audit cycle

A
  • identify problem/issue
  • set criteria and standard
  • observe practice/data collect
  • compare performance to criteria/standard
  • implement change
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14
Q

what is peer review

A

Peer review provides an opportunity for groups of dentists to get together to review aspects of practice.

The aim is to share experiences and identify areas in which changes can be made with the objective of improving the quality of care/service offered to patients, share learning and implement change

Has a structured process for setting up, conducting, and reporting

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15
Q

how is alcohol disributed in body
where is conc’ greatest and why
when is absorption quickest

A

distributed through body water
Concentration in liver is greater because blood
comes directly to it from the stomach and small
intestine via the portal vein
Very little alcohol enters body fat
Water soluble
¡ Slowly absorbed from the stomach
¡ More rapidly absorbed in small intestine
¡ Rate of absorption quicker on empty stomach at
concentration of 20-30% (sherry)
¡ Spirits (40%) delay gastric emptying and are absorbed
more slowly
¡ Aerated alcohol e.g. champagne gets into the system
more quickly
¡ Food retards absorption

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16
Q

where is alcohol metabolised

A

90% metabolised in liver
¡ 2-5% excreted in sweat, urine or
breath

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17
Q

what drugs increase/decrease gastric absorption of alcohol

A

Drugs like cimetidine will delay gastric emptying
and reduce absorption
Drugs like antihistamines have the opposite effect

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18
Q

when is peak blood alcohol conc’
how long does it take to reduce
what rate is it excreted at

A

Peaks 1 hour after drinking on empty stomach
Declines over next 4 hours
Removed at rate of 15mg/100ml/hr
Detectable levels still present for several hours
After 3 pints of beer blood alcohol will be detectable in the morning

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19
Q

how are heavy drinkers affected - metabolism

A

Normal metabolism increases
¡ Microsomal ethanol oxidising system comes into
play i.e. enzyme induction occurs, this system can
also be induced by drugs (gamma GT will be
increased in heavy drinkers)

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20
Q

how does intoxication affect a person

what is the current legal driving limit in the uk

A

Mild sedative
Mild anaesthetic
Stimulates dopamine and serotonin
Sense of wellbeing relaxation and dis-inhibition
50mg/100ml is current legal driving limit in the
UK

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21
Q

How is a person affect by ingesting
100mg/100ml
200mg/100ml
>400mg/ml

what can occur that causes consumption to become fatal

A 
100mg/100ml people become elated and
aggressive
¡ 200mg/100ml slurred speech and unsteadiness
¡ >400mg/100ml commonly fatal
§ atrial fibrillation
§ respiratory failure
§ inhalation of vomit
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22
Q

safe daily alcohol limits for:
men
women
pregnant women

A 
Men- no more than 2-3 units per day spread
over more than 3 days(14 units per week)
Women- no more than 2-3 units per day
spread over more than 3 days (14 units per
week)
Pregnant women-no alcohol during
pregnancy. Can also cause problems with
conception
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23
Q

medical issues associated with heavy drinking

A 
GI tract
§ Acute gastritis
§ Liver problems
§ GI bleeding
§ Oral, oesophageal, stomach, bowel
cancer
§ Pancreatic disease
§ Obesity and
malnutrition
§ Vitamin deficiencyfolic acid, Vits B1, B2,
B6, E, B1 and D 
Heart
§ Cardiomyopathy
§ Cardiac arrhythmias
§ Hypertension
§ Increased triglycerides and LDL cholesterol
Traumatic injuries
¡ Skin, muscles, nerves
and bones
§ Acute or chronic
myopathy
§ Osteoporosis
§ Osteomalacia
¡ Blood
§ Macrocytosis
§ Thrombocytopenia
§ Leucopoenia
¡ Chest
¡ Gynaecological
problems
¡ Obstetric problems
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24
Q

medical conditions with a dental effect in association with chronic alcohol consumption

A 
Bleeding
¡ Poor wound healing
¡ Drugs
§ Drug metabolism
§ Drug interactions
§ Non-compliance
§ Interactions with illicit
drugs
¡ Patients with Hepatitis C
¡ Hormones and metabolism
§ Pseudo-Cushing's
syndrome
¡ Immune system
¡ Mental health
¡ Nervous system
§ Epilepsy
§ Wernicke-Korsakoff
syndrome
§ Cerbral atrophy
¡ Renal
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25
oral issues with chronic alcohol consumption
``` Salivary gland enlargement-sialosis ¡ Xerostomia ¡ Poor wound healing and osteomyelitis § Suppression of immune system by alcohol § Dental erosion- § Bruxism ```
26
liver issues in realtion to dentistry
``` Reduced synthesis of clotting factors in damaged liver Combined with reduced absoption of Vitamin K II, VII, IX, X Thrombocytopenia due to splenomegaly associated with portal hypertension Megakaryocyte maturation is also reduced also leading to fewer platelets Platelet aggregation is reduced Both will lead to prolonged bleeding Drug metabolism In patients without liver damage Heavy drinking induces liver enzymes This may increase the metabolism of some drugs More rapid destruction Reduced plasma concentration Lack of effects In patients with liver damage Reduced drug metabolism LA, analgesia, sedatives and antibiotics ```
27
how can alcohol interact with drugs | -why is paracetemol contraindicated with alcohol
Alcohol will interact with drugs producing a sedative effect on the nervous system and increase or prolong the effect -In heavy drinkers paracetemol can be converted to anintermediate metabolite which is very hepatotoxic
28
why should patient with hepatitis c abstain from alcohol
25% patients with hepatitis C will develop cirrhosis ¡ Alcohol in any amount leads to more rapid development of severe liver disease ¡ Patients with hepatitis C should abstain from alcohol completely
29
alcoholics are generally malnourished, explain some of their nutritional deficits
``` Alcoholics are generally malnourished § General neglect § Substitution of food with alcohol § Deficiencies of ▪ Thiamine-beriberi,Wernicke’s encephalopathy ▪ Folic acid-macrocytosis ▪ Vitamin C-scurvy ```
30
what kinds of cardiac issues can alcohol cause
``` Cardiomyopathy ¡ Cardiac arrhythmias ¡ Hypertension ¡ Stroke ¡ Protective effects ```
31
what is cardiomyopathy
Degenerative heart disease with no coronary artery disease-various aetiologies ¡ Well-established complication of chronic alcohol abuse ¡ Most cases asymptomatic ¡ Can lead to arrhythmias, cardiomegaly and congestive heart failure (dyspnea and peripheral oedema)
32
name some cardiac arrythmias
``` ECG changes can be marked § Atrial fibrillation § Prolonged Q-T interval § Inverted T waves § Heart block § Ventricular arrhythmias ¡ ‘Holiday heart syndrome’ and sudden death ```
33
how can chronic drinkers be affected by hypertension - how much a day can > risk - cessation of alcohol intake takes how long to reduce risk
Chronic intake of 30 g/day or more alcohol ¡ Hypertension reverses within 2 to 3 weeks of cessation of alcohol intake even in heavy drinkers
34
how can alcohol contribute to oral cancer
Ethanol metabolite acetaldehyde promotes tobacco initiated tumours § Damages DNA and alters oncogene production § Alcohol facilitates absorption of carcinogenic substances across the oral mucosa § Partly due to thinning of oral mucosa due to nutritional deficiency
35
how can alcohol cause NCTSL
``` Alcohol is very acidic ¡ Gastro oesophageal reflux disease (GORD)- acid in alcohol directly relaxes the oesophageal sphincter ¡ Vomiting ¡ Multifactorial-bruxism ¡ Restoration difficult until problem controlled ```
36
what is one unit of alcohol
``` One unit § One standard measure of spirits (pub measure) § One standard 125ml glass of wine § Half pint of beer/lager ```
37
what is the definition of screening
The purpose of screening is to identify people who need more comprehensive assessment for substance misuse disorders. It does so by uncovering indicators of serious substance-related problems among adolescent. As such, it covers the general areas in a client’s life that pertain to substance use without making an involved diagnosis or assessment.
38
what is the CAGE intervention method for alcohol screening
Have you ever felt you ought to Cut down on your drinking? ¡ Do you get Annoyed at criticism of your drinking? ¡ Do you every feel Guilty about your drinking? ¡ Do you ever take an Early morning drink first thing in the morning to get the day started or eliminate the shakes? Yes’, ‘sometimes’ or ‘often’ to 2 or more questions may indicate an alcohol problem
39
name some alcohol screening tools
CAGE FAST AUDIT
40
How does AUDIT score a patient
Scores for each question are beside each response ¡ Minimum score is 0 for non-drinkers with a maximum score of 40 ¡ =/> 8 indicates strong likelihood of hazardous alcohol consumption ¡ =/> 13 women =/> 15 men indicates harmful alcohol consumption ¡ =/> 20 indicates possible alcohol dependence
41
definne - hazardous - harmful - depedant drinking
Hazardous drinking-at risk of developing problems due to alcohol Harmful drinking problems due to alcohol are evident Dependent drinkingdisplays symptoms of dependence on alcohol
42
what are the stages of change
Precontemplation What problem? There’s no need to change. My friends drink more than me. Contemplation I hear what you are saying. I know it is bad for me, but I enjoy drinking. Preparation I am going to cut down after new year/ next week. Action I have cut down my drinking. Maintenance I‘ve only been drinking once a week for the last 6 months. For the last 6 months I’ve only drank 2-3 drinks per night.
43
what are brief motivational interviews
Behaviour change style of counselling ¡ Typically an interaction lasting between 5 and 20 minutes ¡ Suitable as an opportunistic intervention for patients whose main reason for contact is not their drinking behaviour i.e. dental patients ¡ Pioneered by Miller and Rollnick who see BMI as not a technique, but as way of being with people ¡ Patient encouraged to recognise ambivalence between their actual and ideal behaviour and that the responsibility of change rests with them
44
What is the frames style of motivational interview
¡ FRAMES style § Feedback § Responsibility § Advice § Menu of options § Empathic § Self-efficacy Feedback is given to patient about behaviour ¡ Responsibility for change is placed on the patient ¡ Advice to change is given by practitioner ¡ Menu of self-directed change options/treatment is offered ¡ Empathic style using warmth, respect and understanding ¡ Self-efficacy is engendered to encourage change
45
fluoridation optimum in water
1ppm (1mg/l)
46
fluoride delivery methods
-varnish - 22600ppm, >2yr, 2-4x year -fluoride mw 225ppm, >7yr - fluoride supplement >6yr, 1mg F/day 3-6yr - 0.5mg/day 6mth-3yr - 0.25mg/day 0-6mg, 0mg/day
47
toothpaste strength for ages
``` first tooth-3yr - 1000ppm 4-16yr - 1000-1500ppm (standard risk) <10yr - 1500ppm >10yr - 2800ppm >16yr - 5000ppm ```
48
protected characteristics under equality act
age/diability/race/religion/sex/sexual orientation/marriage or civil partnership
49
primary definition of inequalities eg. socio economic
education/income/occupational social class/housing/area based measures
50
what is SIMD, what does it depend on
Scottish Index of Multiple Deprivation | education, employment, income, crime, geographic access to services, housing
51
what is the inverse care law
availability of good medical care tends to vary inversely with need for it
52
social determinants of OH (4)
1. economic and environmental - poverty/housing 2. social and community context - religion/social norm 3. oral health related behaviour - smoking/diet/alcohol 4 individual - sex/age/genetics
53
name an example of: upstream policy midstream policy downstream policy
- upstream: smoking ban in public places - midstream: community development/dental health support workers - downstream- smoking cessation serviced
54
adverse childhood events, examples - abuse - neglect - household dysfuntion
- abuse - physical/emotional/sexual - neglect - physical/emotional - HD - mental illness/substance abuse/divorce
55
signs of domestic abuse
``` repeated injuries bruises at various healing stages facial bruising TMJ issue unlikely explanation for injury partner speaking on behalf/strange relationship insist on female clinician contact partner during appt ```
56
How to enquire about abuse (pneumonic)
Ask - private setting Validate - show concern Document - specific and detailed Refer (signpost)
57
oral cancer aetiology
``` smoking alcohol HPV sunlight pre-existing mucosal abnormalities ```
58
Examples of nicotine replacement therapy (NRT)
Champix | Zyban
59
2 examples of brief advice for smoking cessation
- 5A's - ask, advise, assess, assist, arrange follow up | - 2A's & R - Ask, Advise and Refer
60
where to refer smokers for cessation
smokeline NHS GGC Smoke free Pharmacy Specialist
61
smoking effect on mouth
staining/smoker's palate/greater risk of perio or tooth loss/delayed healing/halitosis/oral cancer risk/black heairy tingue
62
``` benefits of stopping 20 min 8hrs 24hr 2-12week 1yr ```
20 mins - BP/HR return to normal 8hr - o2 levels return to normal 24hr - nicotine gone, taste and smell return 2-12 week - greater circulation 1yr - chance of heart attack reduced by 1/2
63
9 GDC standards
1. Put patient's interests first 2 Communicate effectively with patients 3.Obtain valid consent 4. Maintain and protect patient information 5 Have a clear and effective patient complaint system 6. work with colleagues in a way that is in patients' best interests 7. maintain, develop and work within your professional knowledge and skills 8. raise concern if patients at risk 9. make sure personalbehaviour maintains patients in you and profession
64
2 conditions for consent
valid and legal
65
3 components of VALID consent
- Specific for dental procedure - remains current (patient still agrees) - was obtained recently enough
66
3 components of LEGAL consent
=Ability - The patient has the ability to make an informed decision =Informed - The patient has enough information to make a decision =Voluntary - The patient has made the decision
67
6 main components of consent
- voluntary - with capacity - not coerced - not manipulated - informed - valid
68
5 components of capacity
- to act - to communicate - to retain - to make a reasoned decision - to understand decision
69
what are the ages of presumed consetn in Scotland and england/wales
There is a presumption of capacity in all patients from age 16 unless they are assessed otherwise Parental responsibility ends at age 16 (in Scotland) or age 18 (in England & Wales
70
who has parental responsibility
When an adult is giving consent for a child’s treatment, you must be satisfied that the person has parental responsibility: Mum — this is automatic Dad — must be married to mum or named on birth certificate after 4 May 2006 (Scotland), 15 Apr 2002 (N.I.), 1 Dec 2003 (E&W) Others, including step-parents — requires court authority, parental responsibility agreement, or adoption; similarly foster parents
71
what should a patient know before making a decision about a treatment
- benefits/risks of treatment - consequences of not having treatment - other options - cos - likely prognosis - how long it's guarenteed for - recommended option - reminder that patient can change mind at any time
72
what is a material risk
Material risks are where: | A reasonable person, if warned of the risks, would be likely to attach significance to these
73
-24 people skiing, 6 fall what's the risk of falling -whats the formula for risk
6/24 = 25% risk of falling | no. of events of interest/total no. of events
74
-24 people skiing, 6 fall what's the odds of falling -what's the formula for odds
6/18 = 0.33 chance of falling = 3 against 1 -no. of events of interest/no. without event
75
``` How to calculate absolute risk difference for pain relief eg. -no pain relief paracetemol - 23 / placebo -22 -pain relief paracetemol -40 / placebo -5 -total paracetemol - 63 / placebo - 27 ``` -what is the value of no difference in absolute risk difference
Absolute risk difference - difference of risk between groups -pain relief 40/63 =63% / 5/27=18% 63-18 = 45% -ARD value of no difference = 0% means no benefit of paracetemol over placebo
76
what is number needed to treat | -how is this calculated
the number of patients needed to treated in order to produce 1 desired effect
77
When would a confidence interval show insufficient evidence of difference
when the confidence interval straddles the value of no difference
78
how to calculate the odds ration eg -paracetemol 40 success, 23 no success -placebo 5 success, 22 no success -what the value of no difference for this
success/non success then divide the 2 results by the desired investigation 40/23=1.74 5/22=0.23 - 1.74/0.23 = 7.56 - value of no difference = 1
79
study types | order of evidence levels
1. systematic review/meta analysis 2. RCT 3. Cohort study 4. Case-control study 5. Cross sectional study 6. Case series/report
80
what is a case report/study - what does it identify - disadvantages
reports on single/series of patients - identify disease outcome/hypotheses generation - dis - lack of control group
81
what is a cross sectional study - what does it identify - disadvantage
observe defined populationat single point in time/interval -exposure/outsome identified so can identify prevalence of disease/risk factors dis - recall bias
82
what is a case control study - what does it dentify - dis
people with a disease vs a control group, exposure to risk factors -cause of a disease dis - time relationship/recall bias
83
what is a cohort study - what does it identify - dis
establish a group, measure exposures and follow up throughout disease -incidence if disease and prognosis -dis - blinding difficult/control difficult to identify
84
4 important elements to an RCT
blinding randomisation control specification of participants
85
what are the elements of PICO
Population Intevention Comparison Outcome
86
ADV and DIS of a split mouth study
ADV - patricipant acts as own control/requires less people DIS - carry across effect /selsct patient with bilsteral caries/need greater sophistication of statistical analysis
87
Describe the 5 step process to conducting a Systematic Review
1. well formulated question 2. comprehensive data search 3. unbiased selection/abstraction process 4. assessment of papers 5. synthesis of data
88
explanation of a well formulated q
USE PICO!!
89
explain comprehensive data search
You want to find ALL the relevant papers/data- published and unpublished that deal with the PICO • Avoid cherry picking (examples in lecture) • Lots of different databases. • Some databases more comprehensive than others/but none singularly definitive • All languages (why?) • Hand searching • Unpublished-why? • Use a Trials Search Coordinator
90
explain unbiased selection/abstraction process | -what criteria are included
Called the “screening” phase. Where all papers identified by the detailed search are screened for relevance/inclusion. PICO is used. Inclusion and Exclusion criteria are predefined (in protocol) and agreed on. Data extraction form produced and piloted. Screeners (at least 2) will calibrate. Disagreements will be discussed with third party. Clear reasons given for Including or Excluding a study. PRISMA Flow diagram
91
explain assessment of papers (risk of bias) | -hosw is this worked out
Cochrane formalises this process using a Risk of Bias tool that allows us to assess RoB for each included study-and provides a visual tool to assess the overall RoB of the included studies. - Should be done in duplicate (at least) with disagreements discussed with a third party.
92
what do they weights in a meta analysis account for (3)
- number if study participants - number of events - standard deviation ofof outcome measures
93
what is the I squared value
the level of statistical heterogeneity
94
SICPs
1. Patient placement 2. Hand hygiene 3. Cough and reap hygiene 4. PPE 5. Safe management of care environment 6. Safe management of care equipment 7. Safe management of linen 8. Safe management of waste 9. Safe management of blood and bodily fluid spillage 10. Occupational and sharps management
95
GDC standards (9)
- Put patient 1st - effective communication with patient - obtain valid consent - maintain and protect patient info - have effective and clear complaints procedure - work with colleagues to work for what’s best for patient - maintain/develop/work within skills and knowledge - raise concern if patients is at risk - ensure personal behaviour maintains patients confidence in you and profession

PMHP - all years (3 decks)

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