H+S Y3 Flashcards
Characteristics of specific food poisoning organisms?
Cryptosporidium - Protozoa, reservoir is GIT, associated with foreign travel. Recreational exposure - water (swimming pools), land (camping) - SEVERE illness in immunocompromised, oocytes resist chlorination
Norovirus - RNA virus, most common cause of infectious gastroenteritis, occurs at any age and in semi-closed environments (hospitals, care homes, schools, cruise ships). Reservoir = man. 24hrs D+V
Clostridium perfringens - part of the normal gut flora. Associated with slow cooking and un-refridgerated storage > spores germinate, toxin producing (like botulinum and diff) > vegetative cells of which cause gastroenteritis. Also causes gas gangrene
Campylobacter - commonest reported cause of infectious intestinal disease. Reservoir = GIT of birds (particularly poultry). Undercooked/raw meat, unpasteurised milk/bird-pecked milk on doorstep. 48-96 hours incubation
Food poisoning investigation?
Preliminary phase - is there an outbreak? confirm diagnosis. What is nature and extent of outbreak?
Immediate steps - who’s ill? how many? case finding - contact those who have been exposed (i.e. set menu at large event). Sx profile? Cause? Proper care arranged? Immediate action (get rid of food)
Collecting data/descriptive epidemiology > time, place, person, no. affected, Sx, common factors, usually use questionnaires (chance of recall bias)
Food Hx - poor recall, structured, lying (if on diet), buffets, snacks
Environmental investigations - environmental health officers visit restaurants and inspect premises, take samples, equipment swabs, and staff not cooking properly
Analytical Epidemiological Studies
used to ID probable cause in absence of lab confirmation.
Point source outbreak = cohort study
Common source = case-control study
Food safety > concerns: food-borne illnesses, nutritional adequacy, environmental contaminants, naturally occurring contaminants, pesticide residues, food additives
Risk factors for chronic liver disease?
Alcohol - prevent with public health campaigns, minimum unit price, taxation, licensing restrictions, sale restrictions (price, placement, promotions)
Obesity - prevent with P.H.C’s, taxation (i.e. sugar tax), sale restrictions (P.P.P), legislature forcing reformulation of foods, community food/exercise regimes, education, healthy snacks at school/work
Viruses - vaccinate (Hep B/Yellow fever), free condoms, screen blood products, decrease needle-sharing, contraception, disposable sharps, licensing/laws for tattoos
Drugs - needle banks, decrease OTC availability (paracetamol, blister packs)
Management of hospital food poisoning outbreaks?
decrease spread with hand washing, bare below elbows, clean equipment, aseptic technique, general ward hygiene, alcohol gel, prohibit potential reservoirs (i.e., cooked food, flowers, etc)
Barrier nursing - use PPE
Side rooms - quarantined bay
Restrict ward access/visiting times - or close to visitors/ new admissions
Lift new cases after 72 hrs symptom free
PHA exclusion from work if ^ risk of spreading = age extremes, immunosuppressed, pregnant women, food industry workers, doubtful hygiene/acceptful levels of hand0washing
Control of infection committee
Infection control officiers
What do you do as a Dr. if you suspect a case?
- report to consultant responsible
- notify local food safety authority
- manage as PTO in hospital
Summary of food poisoning outbreaks?
Incident in which 2+ thought to have a common exposure, experience similar illness or proven infection
General outbreak - members > 1 household/residents of institution are affected
Suspect outbreak - look for common features, identify and isolate source:
> Person - school, workplace, etc.
> Place - been to same event, restaurant
> Time - date/time of onset = can draw curve to show associations and may be able to identify outliers (often key similarity between cases)
Dr’s role of food poisoning:
- treated affected individuals > including how to prevent spread, staying off work until 48hrs Sx-free, fluid replacement
- report to consultant responsible
- inform Food Safety Authority - will isolate and shut down offending source, section 11 of Public health (control of disease) Act 1984 - states you need to notify local authority
Types of food poisoning outbreak?
Common source - people exposed continuously or intermittently to a common source (e.g., infected water)
Point source - sharped upward slope, all cases occurring in one incubation period
Propagation - spread via person-to-person, recurring increases, multiple waves, faecal-oral spread
Summary of Food Safety Act (1990)?
defines food and enforcement authorities and their responsibilities
Food includes - drinks, articles of nutritional value but for human consumption > chewing gum, ingredients
Offences under act:
> sale of food rendered injurious to health, unfit for consumption, not of quality demanded by purchaser
> display of food with label falsely describing food or likely to mislead as to nature of substance/quality
Epidemiology of smoking
In UK 2019, 14.7% of 7.2 million population smoked
M>F, 16.5% men, 13% women
highest proportion 25-34 yr olds
2019 - 74,600 deaths attributable to smoking and 506,100 hospital admissions
NI has highest proportion proportion of smokers in UK, England lowest
Only 2-3% smokers stop each year due to the addictive nicotine
every year >40 they continue smoking, life expectancy decreases by 3 m’s
Never too late to stop smoking
20 mins - HR and BP drop
12 hrs - CO levels drop to normal
2-12 wks - circulation and lung function ^
1-9m - cough and SOB decrease
1 yr - CHD is half of a smoker
5-15 yrs - stroke risk decrease to that of non-smoker
10 yrs - cancer risk half of a smoker
Life expectancy
- quit @ 30 > gain 10 years
- quit @ 40 > gain 9 yrs
- quit @ 50 > gain 6 years
- quit @ 60 > gain 3 yrs
- quit after MI > 50% lower risk of recurrence
Why stop smoking?
^ life expectancy
lower risk of cardio, respiratory and neoplastic disease
lower chance of spontaneous abortions, still birth and growth restriction if stopped in pregnancy
reduces risk of SIDS and illnesses of children
saves money
Smoking cessation
Motivational interviewing - facilitated by any healthcare professional and plants seed to help seeking
Stop smoking groups - sessions run by HCP, giving advice and group sharing own tips.
One to one counselling - involve GP/murse explaining benefits, leaflets + helplines, or regular sessions with smoking cessation counsellor or group therapy
NRT - double chances of stopping, less addictive, doesn’t cause ca, available via prescription or OTC as gum, patches, tablets, spray, lozenges, inhalers
Bupropion - reduces cravings and helps withdrawal Sx
Varenicline - blocks nicotinic receptor so smoking doesn’t produce desired effect
Lung cancer epidemiology
most common cause of cancer death in UK, 22% of all cancer deaths
third most common cancer in the UK (1 breast 2 prostate 3 lung 4 bowel)
third most common cause of death in the UK after IHD and CVD
mortality decreasing in men, increasing in women
more common in men, 1.2:1, M:F
peak incidence 85-89
smoking directly related
other RFs - dust, coal, tar, radiation, radon, asbestos, FHx
Stop smoking campaigns
education in school and to pt’s
tobacco TV and printed adverts are banned
^ taxes to deter
adverts on packs about risks
age restrictions
smoking banned in public enclosed spaces
mass media campaigns about benefits of stopping
wider access to smoking cessation services
whilst relatively ineffective, smoking cessation is cost effective, even brief <3 mins in consultation has x2 better rate than simply asking
Smoking cessation in unwilling pt
5 Rs
Relevance - why important, 2nd hand exposure, health finances
Risks - remind of -ve consequences
Rewards - benefits of quitting, financial, regaining taste, decrease mortality
Roadblocks - identify what’s stopping them, withdrawal Sx, weight gain etc
Repetition - every time you see them
Smoking cessation in willing pt
5 As
Ask to quit at every visit
Advise to quit
Assess willingness to quit
Assist quitting > pharmacotherapy and counselling (gold standard)
Arrange follow up
Occupational lung disease implications for pt:
- employers must make work safe and create a work environment and practices that will not cause further problems
1 - may need to change job - continual exposure can cause permanent damage
2 - may be entitled to benefits and/or compensation (industrial injuries disablement benefit if a recognised disease)
3 - compensation can include before/after death = these conditions have a poor prognosis > British Lung Foundation can help with this as well as the Department for Work and Pensions
Causes of occupational lung disease
Asbestos - roofers/plumbers
Coal - miners
Aspergillus - malt worker, farmer
Cigarette smoke - bar work
Radiation - radiographer
Silica - metal mining, pottery manufacture
Arsenic - paint factory
Role of Dr in occupational lung disease
diagnosing/testifying in court
if diagnose rare condition, or cluster of more common, notify Public Health authority
reporting Injuries, Diseases or Dangerous outcomes regulations (RIDOR) = legal requirement for incident reporting
Preventing occupational lung disease
HSE (health and safety executive) has a working group on Action to Control Chemicals (WATCH)
WATCH to consider evidence on occupational exposure and health effects of substances, this includes:
1 - whether max exposure limit (MEL) or occupational exposure standard (OES) would be appropriate and setting limits where indicated
2 - cases recommend measures based on a couple of cases, including looking at long term, consequences
3 - it is probably impossible to prevent all industrial dust disease, but they can certainly be reduced by following appropriate safety precautions, including adequate ventilation, keeping down dust levels in work place, and the wearing of facemarks. In addition ca have limited exposure to a pathogen and appropriate cleaning of work areas
When is post-mortem a legal requirement?
1 - sudden death 2 - unknown cause of death 3 - unnatural death - accident/suicide/suspicious 4 - death from industrial disease 5 - death from negligence 6 - death during surgery/anaesthesia 7 - death within 24hrs admission 8 - not seen by a Dr for 14 days 9 - any pt. detained under MHA
SAD SUN DUI
Why are post-mortem beneficial?
gain deeper insight into pathological processes - improve prognoses for future pt’s
learn how to prevent patients death in future > teaching and medical research
further understand long term effects of drug therapy
explore how certain diseases progress or how they can be stopped from progressing
study and monitor levels of chemical and radioactive elements absorbed from the environment
Role of HM Coroner
investigate and ascertain causes of deaths occurring in suspicious circumstances - body can’t be released under coroner satisfied with cause of death
Consent to post-mortem
Coroner’s post mortem/inquest does not need consent (i.e. if there’s criminal investigation)
Hospital post-mortems do need consent
consent may otherwise be from - deceased before died, a nominated representative, a qualifying relationship (spouse/partner, parent/child, brother/sister)
Impacts of obesity
social - low self esteem and poor body image, bullied, social outcast, not suitable for certain jobs, hard to find clothes, stigma, exclusion from certain activities, can’t have surgeries/IVF
economic - ^ health resources, new equipment to account for ^ in society, reduced productivity
Causes of weight gain in Western society
high saturated fat diet - too expensive to eat healthy (School meals not healthy), time constraints on eating healthy, social expectation of large portions and unacceptable to be hungry, unhealthy options advertised in shops, labelling systems don’t highlight what food is healthier
sedentary lifestyle - less active jobs, less commuting to work due to transport, more lifts/elevators so less walking, not safe on roads for cyclists
less exercise - most passive leisure activities, lack of affordable community venues for exercise, lack of attractive outdoor areas for walking/playing with kids
lack of education - how to budget, what is important to eat, why it’s important, poor provision of physical activity in and out of curriculum, poor management of bullying/fat teasing
role of genetics/ethnicity - black/hispanic more susceptible that caucasian
Diabetes Prevention programme trial (DPPT)
risk of conversion of IGT and DM is 5% annually and 50% lifetime risk - WHO IGT criteria - impaired fasting = 6.1-7.9 mol/L, impaired 2hr test = 7.8-11 mol/L
association with ^ weight and risk of developing diabetes
early aggressive lifestyle interventions (58% decrease) in obese patient with IGT was more effective at preventing onset of DM compared to placebo or metformin (31% decrease)
trial highlighted importance of lifestyle interventions in preventing DM = better than pharmacology
Diabetes control and complications trial (DCCT)
compared standard and intensive insulin therapy in large prospective controlled trial
epidemiology of diabetes interventions and complications (EDIC) was follow up study on 90% participants, looking at CVD and effects of intensive control of QoL and cost. Helped establish metabolic goal of diabetes care and the means to achieve these goals
conclusions - intensive Tx aiming for glycemic control like non-DM, decrease development and progression of DM complication, intensive Tx decreases measures of atherosclerosis and probably CVD over time, intensive Tx most effective when implemented early in course of DM, if delayed complications are harder to slow
Diabetes and Impaired Glucose Tolerance (IGT)
long period of IGT that precedes development of DM
screening tests can identify who are at risk of progressing to DM and hence use effective interventions and address modifiable RFs = obesity and body fat distribution, physical inactivity, elevated fasting and 2hr glucose levels
Complications of DM
microvascular - retinoapthy, nephropathy, neuropathy
microvascular - peripheral vascular, cardio, cerebrovascular
others - impaired wound healing and ^ susceptibility to infection
Screening programmes for DM
for retinopathy + podiatry
clinics monitor renal function, HbA1c, lipids, BP
Diabetes Prevention Programme
primary goal - prevent or delay development of T2DM in patient with IGT
secondary goal - reduce CVD events, reduce CVD RF’s, reduce atherosclerosis
findings
- intensive lifestyle modification more effective than met form at decreasing DM development
Psychological impact of DM
grief - loss fo freedom (dietary), change to self image, can’t escape condition (lifelong, can lead to depression)
denial - interferes w/ pt self management, significant issue in teens with T1DM = don’t comply as rebelling
stress - a lot of responsibility, especially for young patients, needs trade off of short vs long term benefits, may cause family conflict, burden on family, anxiety for future if have hypo
can neglect insulin if eating disorder
social perception > stigma (T2DM - obesity, amputation), invisible disease so less empathy, embarrassment if have hypo
hormone deficiency can manifest as lethargy and malaise = decreased social mobility/intercation, increase in social withdrawal
Independent Assessor in organ donation
all liver donors and organ recipients are required to see an independent assessor who is trained and accredited by Human Tissues Act (HTA). Will submit report to Human Tissue Authority. they are distinct to the acting health care team
Role:
- interview both parties, together and individually to establish: nature of relationship, not being forced, no incentive, donor has capacity
conditions met to be living donor - should be competent and >18, risk to donor is low, decision is fully informed, decision voluntary and not coerced or incentivized, transplant must have good chance of successful outcome
Impact of dialysis on pt
disruption to life = travel time and cost (Takes up large periods of day (lead to isolation/depression), limitation of travel due to Tx
often pt still heavily symptomatic as only 10% renal function - doesn’t replace endocrine function
have restrictions on fluid and salt intake
quality of life vs. quantity
uncertainty of waiting for transplant - pt may also give failed transplant
Outline Transplants in the UK
governed by human tissue authority (HTA)
Human tissue act 2004 - act regulates the removal, storage and use of human tissues for following reasons: research, transplantation, education
requires consent for the above - either either before death (opt in) or after death from family
includes - allowed to take minimum steps to preserve organs of deceased person, whilst steps taken to determine persons wishes, or to obtain consent from someone in qualifying relationship
However - is offence to remove material form dead body w/o consent (other than autospy reasons), organs/tissues should be stored in line w/ current good practice on: security, traceability, and H+S
The act makes it unlawful to treat as ‘waste’, any relevant material which has come from a person who was: receiving medical Tx, undergoing diagnostic testing or participating in research
Summary of organ donation in UK
Currently in UK for receiving organs: resources scarce > decisions have to be made on opportunity cost = loss of alternatives, the one option is taken
With relevance to transplantation this means this means some pt’s are to be denied transplant over others who would benefit more = more cost effective
Currently - DBD (donation after brainstem death) allocated via national allocation scheme (NHSBT)
DCG (donation after coronary death) = allocated regionally - one kidney always offered preferentially to local transport centre
Currently based on points system:
Tiers A+B prioritised first, then goes to below points based system
- points for compatibility (HLA) and age = favours younger, well matched individuals
- time on transplant list
- age difference between donor/recipient = want to be close
- location = favour closer pt., social factors also considered > alcohol abstinence in pt. needing liver transplant = likelihood of success
Tier A - 000 mismatched, paed’s pt’s highly sensitised or HLA-DR homozygous
Tier B - 000 mismatched paed’s pt’s, others
Tier C - 000 mismatched adult pt’s, highly sensitised or HLA-DR
Tier D - 000 mismatched adult pt’s, favourably matched paed’s pt’s
Tier E - all other eligible pt’s
Donor scheme based on altruism
Summary of opt-out system
20 May 2020
as average wait for donor organ is 3 yrs
excluded groups - under 18, lack capacity, visitors to England and those not living here voluntarily, people living in England for less than 12m’s before death
For
- will include those can’t be bothered to volunteer
- reduces pressure on grieving family
- still allows to deny permission
- cost effectiveness (i.e., vs dialysis)
- supply currently doesn’t match demand
- QoL better w/ transplant that dialysis
Autonomy
- shouldn’t assume pt. choices > autonomy
- human rights when dead + right not to donate
- decisions could be based on different groups
- risking state becoming authoritative - removing pt. freedom
- issue is stigma w/ not opting out
Should age be considered in transplant process?
- Tx of elderly expensive (burden of cost not related to age per se, more costs of illnesses/incapacity in final years, but even so, isn’t this price with paying for equal society? > devalues elderly, causing inequality between young + old
- fair innings argument - they’ve had their time and young people haven’t BUT what is a full life? have they had QoL? why does length bear an impact if outcomes better for elderly?
- elderly less likely to respond to Tx - but age alone is not a good predictor of responsiveness to Tx or prognosis, denying Tx based on age is discrimination (illegal under Equality Act 2010)
> direct discrimination - 1 person being treated in less favourable that another in comparable situation
> indirect discrimination - seemingly neutral provision has harmful repercussions on a person
> GMC - you must not unfairly discriminate
Arguments for and against the blood market?
Against
- represses altruism
- erodes sense of community
- redistribution supply from poor to rich (^ infection rates, decreases quality)
- pt. may make unwise decision due to financial incentive
- sanctions profits in health care - may result like US where poor have less access to healthcare
For
- everyone has the right to choose what to do with their body
- increases supply
- financial rewards may be exemption from any future payment
- not different from any other traceable good
Argument re: market for organs
Improves QoL of more pt
Cheaper than expensive mechanical Tx and long term complications from not treating
suggestion - use opt out instead
paying for transplants have same -ve’s as blood market
Strengths and limitations of ICD-10/DSM
Strengths
- standardisation of diagnostic criteria
- allows epidemiological studies, geographical comparisons of prevalence and incidence
- alphanumerical format - allows quick referral and easy addition to categories
Limitation
- 2 different criteria sets, so who uses what
- Schizophrenia diagnosis relies on many psychotic Sx, which are a common final pathway in other disease
- groups commonly co-existing Sx pattern, without understanding of underlying cause/nature
What is advocacy?
everyone detained under MHA legally entitled to a professional MH advocate = statutory advocate
independent MH advocate (IMHA) or an IM capacity advocate (IMCA)
otherwise can be professional, family, friend, carer or you can be your own (self advocacy)
helps ensure the patient’s opinions and ideas are articulated clearly and taken seriously
role of advocate:
- listen to views and concerns
- help explore options/rights (without advising)
- give info to help informed decision making
- help you contact people, or contact on your bhealf
- accompany and support you in meetings/ appointments
Epidemiology of DSH and suicide
DSH F>M
suicide M>F
previous attempts ^ risk of success by x40
rates ^ fastest in western countries
common - evenings, weekends, spring and autumn
divorced/widowed
SES 1+5
unemployed
uni students
Dr, lawyer, farmer, police
> 90% have psychiatric illness
recent loss
chronic illness
Role of MH teams in management of depression
MDT approach
GP - diagnosis and community management
CPN - talk through problems, offer advice + support, give meds, monitor SFx
psychiatrists - diagnosis and primary assessment > prescribe medication
OT - teach skills, help ^ confidence and independence
social workers - money, housing, childcare
pharmacists - dispensing meds, advice to Dr’s and nurses
key workers - manage cases
Health promotion strategy for alcohol and drug misuse
Education - less effective, PSHE in schools, TV/radio ads, provision of info in GPs, online. or 2’ or 3’ care centres
Policy - effective - minimum unit pricing, taxation, restrict availability, restrictions on promotions and placement on shop floor, stricter licensing laws, restrict advertising, getting ‘big money’ out of policitics
Mass medical campaign - less effective - Drink Aware - still encourages drinking, just responsible drinking
Support and info - Frank
Health care worker role - ID and brief advice , CAGE q’s, hospital alcohol health workers, hospital admission/ED is teachable moment, can implement screening, detox, brief intervention, referral and support other staff
specialist Tx - CBT, ^ nutritional status
Community, residential and nursing home support for pt’s suffering from psychiatric disorders in old age
Community support - CPN and care assistants visits so people can stay in own home, helps relatives, can be expensive
- day centres - available for socialising, provide food, place of contact with MH practitioners
- respite care - give caters a break
Sheltered housing - semi-independent living, in apartment complexes with a warden, offer group activities and HC worker visits
Residential home - 24 hour staffing, usually with HCPs who help with ADLs and provide meals, not suitable for those with high level of medical care needs
Nursing home - highly dependent, residents who are unable to care for themselves, regular Dr. visits and ^ nursing stage compared to other styles
Psychiatic inpatient unit - elderly with psychiatric conditions
Effects of caring for someone with dementia
Looks after someone unpaid (formal/unformal), women>men, 50-64 has highest proportion of carers, highest proportion in more economically deprived areas
Initial impact - emotional initial response (fear, angry, grief), determined by understanding, pt. reaction, nature of relationship
Longterm impact - spouse = relationship skewed as one partner contributes less (practically, companion, emotionally, sexually, financially), child (role reversal, conflict with family members, can reduce child’s opportunities), generally (isolation, less time with F+F, stressful, emotionally straining, anticipatory grief
Health effects - chronic stress, poor sleep, burnout, no breaks, physical effects of doing everything, less care for own health
What support is available for those caring with dementia?
Policy + legislation:
(carers (recognition and services) act 1995)
Carers has right to assessment of own needs, despite refusal by recipient of care - carers must be aware of this
carer’s special grant - funding for respite/short breaks
assessments must consider carer’s wishes, i.e., employment, education, leisure etc. - wellbeing not just health
Employment support:
Work and families act 2006 > carers of adults can request flexible hours
Emotional support
Counselling, support groups
Financial support
- carer’s allowance
- bedroom tax
- welfare reform act 2012
Practical support
- moving + handling training
- education - S+S, natural Hx,
- respite
- social services/community nursing - cleaning, personal care
Impact of MH in primary care
MH condition reduces QoL
Interfere w/ other health conditions - can be caused and cause co-morbidities, complicate Tx
Misdiagnosed/not-detected
Large economic burden - medication and lost working days
Organisation of UK MH services
most MH services require GP referral
95% of MH managed by GPs
Coordinated system @ local level
Build around individual’s needs and views
Rapidly accessible
Community based (formerly psychiatrist @ centre w/ long inpatient stay)
Reasons for referral to 2’ care:
- moderate-severe mental illness > BPD, severe depression, schizophrenia
- pt’s at serious risk to themselves or others
- uncertainty re: diagnosis
- poor response to standard Tx/specialist Tx required
Not including:
- IAPT (improving access to psychological therapies)
- pt’s who have drug and alcohol problems
- community mental health team (systematic assessment, plan to address needs, allocation of care coordinator)
Impact of race/ethnicity + age on psychoses?
Schizophrenia = ^ young men>women, BME groups ^, ^ in socially disadvantaged groups
Affective psychoses = M+F, no evidence for geographical/neighbourhood effect on incidence, rest same as schizophrenia
Points of care in MH services
outpatient clinics
day hospitals - non-residential units, require pt. to have supportive home environment to return to can also be used to slowly discharge pt. back to community
assertive outreach teams - effectively high level CMHTs for challenging patient (pose real threat of harm + does not want to engage with MH services)
in-patient units > admitted when high risk (to self or others), grossly disturbed behaviour, or period of assessment needed (diagnosis/ Tx efficacy) for severe psychiatric disorder
early intervention services - works with young people over the age of 14 (<35) to deal with first episode of psychoses as evidence earlier Tx improves prognosis - have more intensive input
crisis resolution + home team - team that can support you at home during a MH crisis (suicidal ideations, mania, psychotic episodes, severe panic attacks) - available 24/7, can provide intensive + flexible homes support to prevent admission
Members of CMHT
Psychiatrist - prescribe meds, may be involved in administering psychotherapy
CPN - visit pt. at home, see pt’s in outpatient departments, help co-ordinate the care for a pt, they can administer meds and monitor effects
Social worker - allow pt’s to talk through their needs + consider social care implications. Includes ensuring pt. rights under MHA are considered
OT - help improve ADLs, identify what pt can’t do, what support they need etc to allow them to become independent + regain skills etc
Clinical psychologist - person giving psychotherapy (counselling can be given by counsellors w/ less training)
Primary MH worker - assess + sign-post pt, can also provide with short-term Tx
Role of key teams in MH
CAMHS - look after children + adolescents
Addiction - substance misuse specialists, community clinic
LD service - adults and young people
Liaison psychiatry teams - mainly work in general hospitals and 1’ care - bridge gap between physical + psychological Sx
Assertive outreach team - community team for severe + personality disorders
Forensic
Early intervention for psychosis - deal with 18-35 years w// 1st episode psychosis
Memory assessment - old age psychiatrists, treating/advising dementia care
Primary health promotion strategies for MH wellbeing
parenting programmes - for children w/ conduct disorder to avoid PD
health visitor info - for women with ^ risk of postnatal depression
school-based programmes - preventing violence, bullying, offending and re-offending
screening + brief intervention - alcohol CAGE q’s, brief advice
debt advice
physical activity campaigns
anti-stigma campaigns
promote well-being + early depression detection at work
Role of Schoo, HV + educational psychologist in managing child MH
school - train school staff to recognise onset of psychiatric difficulty (low performance, withdrawal, quiet etc.) - talk and advise, teach interpersonal skills + intervene where necessary > SAFEGUARDING, provide report/assessment of behaviour to medical/social services, facilitate development
HV - qualified nurse in community, monitor and ID problem at early age, via visiting home + observing interactions w/ parent, help parents cope with child’s mental illness > educate, advise, signpost to other services
Educational psychologist - assess educational level + suggest interventions to help ^ learning ability, observe behaviour in class > REPORT
Social services - provide initial assessment in certain circumstances (severe behavioural/emotional disturbance, families w/ ^ danger, very young children, where child/abuser have severe communication problems, where parents/care fabricate or induce illness, where multiple victims included), provide assessment/Tx for people with MH that offend, provide range of psychiatric + psychological assessment/Tx for children + families
Summary of CAMHS tiered system
1 - any professional who sees children in their everyday life (teachers, GP) > role to support the emotional + social development of the child, these members can refer to primary MH workers who: advise tier 1 staff, assess + refer appropriately (other tiers/agencies), administer brief support
2 - individual CAMHS therapists, e.g., nurses, psychiatrists, psychologists, social workers etc
3 - CAMHS therapists working in teams, e.g., promote family Tx, for LDs, attentional problems, self-harm etc
4 - National/regional serves, e.g., for deaf pt., severe ED’s, psychosis (pt. cannot be managed at home)
Importance of prevention in child MH - including normalising of professional/parental anxiety
promote self-esteem + self-efficacy through secure + supportive personal relationships
need to ID risk factors in child’s life (unstable home, lack of secure attachment relationships, stressful early life events, abuse, FHx of psych, low self esteem, LD)
protective factors to help individuals cope and avoid development to MH illness - secure attachment relationships, higher intelligence, communication skills, religious faith, clear firm and consistent discipline from parent, wide supportive network of F+F
Socio-cultural factors in MH
Depression
- Ethnicity - Afro-Caribbean (present less frequently), Mediterranean (present with somatic Sx), Chinese (present with tiredness, makes greater use of body language, suffering for greater good), Japanese (seen as black mark, shameful)
Migration - due to language barrier + social isolation
Culture - where woman housewife and man sole breadwinner, death of spouse causes depression as role change is significant, some cultures think shouldn’t grieve as disrespectful, others think should mourn for long time, some cultures may not accept Western themes for depression and therefore not accept treatment for it
Psychoses
- ethnic minorities, particularly Afro-caribbean in America have x4 higher rate of psychosis, while Latin Americans have a x3 higher rate
- reasons for mis-diagnosis - failed understanding for cultural differences (e.g., may seem psychotic to Western cultures), racism (clinical bias, racism may make groups less trusting, presenting as paranoia), social isolation, racism, not speaking language, lower class etc. (higher stress level to develop, no ^ incidence, when ethnicities in country of origin), hearing voices spiritual not pathological in some cultures
Individual + societal factors in genesis + maintenance of addiction
origins of addictions - genetics (way you metabolise and how the drugs affects you, we differ in inherent susceptibility), social (peer pressure, family, influence-learned acceptable behaviour) occupation (^ in unskilled labourers) social stressors (debt, stressful life events)
maintenance - conditioning (taking drugs removes -ve SEs of withdrawal (-ve reinforcement), physiological (tolerance develop = ^ need for same effect), psychological crutch (becomes habitual method of dealing with stress = -ve coping mechanism), social (peers + socialising becomes drug orientated)
Summary of sensory impairment
Many deaf people feel socially excluded + isolated, can impact on MH and accessibility of MH services
May impact ability to communicate how they’re feeling, so both missed and mis-diagnosis
High levels of unemployment which is known to affect psychological wellbeing of pt.
Liver disease epidemiology
since 1970 deaths from LD have ^ by 400%
3rd leading cause of premature death in UK
90% of LD is preventable
3/4 diagnosed at late stage
alcohol related 60% of LD
1/3 has NAFLD early stage
180,000 people chronically infected with Hep B
143,000 carry Hep C
40-50% w/ viral hepatitis are thought to be undiagnosed
90% of Hep C are due to drug misuse
Liver Ca - 6000/yr diagnosed, Fastest rising cause of Ca death in UK
How to control spread of TB?
Prompt ID and treatment, with effective surveillance to monitor disease and outbreaks
Targeted prevention with BCG
Screening (CXR) for ^ risk groups entering UK
Focus on key populations - migrants + deprived urban communities
^ awareness amongst those working w/ high risk groups (e.g., housing support, migrants, prisons, substance misuse groups)
ID and educate high risk groups - Sx, how its spread, TB is treatable + curb;e, common HIV co-infection
Public info made available - online, leaflets in different languages, interpreters for non-English speaking patients
Summary of BCG Vaccination
Vaccination goal = lower mortality + morbidity from vaccine preventable infections
Strategic aim - selective protection of the vulnerable, elimination (herd immunity), eradication
Pragmmatic aim - prevent deaths, infection, transmission (2’ cases), clinical cases
Neonates (0-4 wks) at high risk
Routine Vaccinations non-recommended for 10-14 years
ID unvaccinated ^ risk before 16 who would have had neonate BCG,
Healthcare professionals w/ pt contact
People in contact w/ someone who has active TB
What is DOTS
directly observed therapy short-course
WHO strategy
5 components:
- government commitment
- case detection by sputum
- standardised treatment + regimen observed by HCP for at least 2 months
- stable + reliable drug supply
- standardised recording + reporting system
Lola’s triggers to health seeking
interference with work or physical activity
interference with social relations
Assigning arbitrary time limit
Interpersonal crisis (deaths, divorce, etc.)
Sanctioning
Barriers to health seeking
Inverse care law (poor areas = less provision)
Geographical distance (transport costs, time)
Previous bad experience (staff, waiting times)
Childcare (availability, costs)
Psychological factors (refusal to believe, worried, lack of education)
Context of event (Xmas, bday, wedding)
Perception/evaluation of Sx. as harmless
Overcoming barriers to healthcare access
Quality improvement - identify barriers, think about changes, implement change, audit (PDSA cycle) > think about from user’s perspective
Community outreach programmes - ^ provision in the community, rather than centralised provision which may be ^ difficult to access
Transport - volunteer drivers, discounted hospital buses
Ways people access healthcare services
GP + self-referral (A+E, online) Social services + local authority Emergency > ambulance Educational institution > welfare Dental practitioner Charity/community programme Lay referral Pharmacists
What is patient pathway?
describes the best route from 1st contact with services > stages of investigation/treatment > definitive treatments > discharge from NHS + social services
useful to guide clinicians and to inform pt’s what is to happen next
Health promotion strategies for substance abuse
Primary - stop people taking drugs - education (schools), made illegal, ID those at-risk (children and friends of known drug users), mass-media campaign about risks
Secondary - reduce harms with drug use - Hep B immunisation, provide condoms, needle exchange, supervised drug centres, confidential tel no 24/7
Tertiary - get people off drugs - reduce stigma around getting help, self-help groups, relapse prevention schemes, court-enforced drug testing + treatment orders
Epidemiology of CVD
Developing countries catching up = will be global disease - still variation in Western world (e.g., low in Japan), low mortality in UK (most common cause of death in UK)
Variations in UK
- highest prevalence in N. England, Central Scotland + S. Wales - low SES in these deprived areas
- lowest in S. England
- SE Asian in UK have 50% higher risk of CHD
- Bangladeshi > Pakistani > Indian for worst outcomes
- Black individuals in UK have 1/2 IHD risk of European UK population, but double incidence of CVA especially in men
Prevention of CVD
Primary
- prevention of disease in pt’s who don’t have CVD
- lifestyle modifications: smoking cessation, exercise, diet modification, weight loss, reduce alcohol consumption
Secondary
- prevention of MI/stroke in pt’s w/ CVD
- atherosclerosis evidence
- further lifestyle modifications - drug management, HTN, hypercholesterolaemia, diabetes
Tertiary
- prevention of further MI/stroke in pt’s who have already had one
- cardiac rehab
- anti-thrombotic therapy
- CABG
- coronary angiogram
- stent/endartectomy
What is prevention paradox
preventative measure which brings great change to population, but offers little to participating individual
prevention strategies can be aimed at high risk groups or the whole population
High risk strategy:
pro’s - appropriate interventions, cost-effective use of resources, favourable benefit:risk ratio
con’s - cost/difficulty of screening, limited potential for change in the population
‘Population’ strategy
pro’s - large potential for change, radical
con’s - small benefit for individuals, little motivation for pt’s, questionable benefit:risk ratio
to create biggest effect, every little helps - but not everyone benefits
contradictory situation where majority of cases of a disease come from population at low/moderate risk of disease, and only minority come from high risk population - as no of people at high risk are small
therefore preventative measures brining large benefits to community offers little to each participating individual
Assessing CVD risk
anyone 40-74 who has not been diagnosed with CVD, DM, CKD are invited every 5 years for free health check > CVD risk assessment, assessment of alcohol consumption, physical activity, cholesterol, BMI and screening for dementia if 65-74. Additional screening for DM + CKD in those at risk of developing these conditions
QRISK3 - 10 year CVD risk, risk assessed every 5 years, assesses sex, ethnicity, smoking status, FHX, co-morbidities, drugs (atypical antipsychotics/regular steroids)
Primary prevention if 10 year risk > 10% - atorvastatin 20mg OD
Framingham Heart study - 10 year risk of stroke/MI, tendency to under-estimate low risk and over-estimate high risk, fail to take into account other RF’s, e.g., ethnicity and SES, use w/ clinical judgement, important to apply to age as biggest risk factor
QRISK measures more RF’s, uses UK GP data
INTERHEART study - 5 main risk factors - abnormal lipids, diabetes, smoking, HHTN, lack of exercise, created by looking at population w/ and w/o risk factors, good to show pt’s how risk can change, to use need to know: smoker? diabetic? age? gender? HDL/LDL ratio?
- illustrates visually to pt., red = bad, informs clinicians who to treat/emphasis which RF’s important
Epidemiology of CVD
most common cause of death in UK, 1/5 deaths in men, 1/6 deaths in women
mortality from CVD decreased over last 25 years, mainly due to lifestyle changes (i.e., smoking) and ^ effectiveness of MI + CHF treatment
trends in some RF’s ^ (obesity/physical inactivity), impact CVD in future
burden of CVD not from deaths, but from treatment/support of those living with it
prevalence of CVD varies across UK, associated with lower SES, association with S. Asian ethnic groups, so ^ in areas with larger S. Asian population
non-modifiable RFs - age, men, FHx, social disadvantage, S. Asian ethnicity
modifiable RFs - smoking, HTN, diabetes, hyperlipidaemia, physical inactivity, obesity, diet high in salts + fats, stress, hypercholesterolaemia, RA, CKD, excessive alcohol consumption
Assessing risk:
Framingham cohort charts - based on N. American, 10-yr risk of MI/stroke
GRACE - 6 month mortality following ACS event
HASBLED - risk of bleeding in AF pt’s on anticoag’s
QRISK2 - based on UK GP data, addresses more RF’s than Framingham > ethnicity, FHx, deprivation, BP treatment, BMI, RA, CKD, AF - 10 year risk of MI/stroke
How do epidemiological differences affect population health?
larger populations of those at ^ risk = ^ average population risk
should be used to target intervention where it’s needed most (i.e., community education in areas with ^ population of those at risk)
need to address other barriers - to focus on prevention (i.e., provision of info, interpreter access)
Epidemiology of IHD and reasons for differences in IHD
UK incidence is falling, in line with most of developed world
Eastern Europe has reverse pattern
Continual flux of race/ethnicity in our population, comes w/ it changing risks for various diseases
Differences in access in health-seeking behaviour - different ethncities may hold from firm health beliefs, less likely to seek Dr. help
Inaccessible to due to language barrier
Genetic susceptibility
Discrimination - inverse care law
^ DM prevalence in S. Asians
Smoking prevalence ^, decrease in F+V consumption
Low exercise levels in Bangladeshi population
Oestrogen may have protective effect (HRT= lower IHD, but maybe selection bias as HRT users typically healthier in general)
How are RFs for CVD changing across time?
smoking - decreasing numbers but ^ teenage female smokers - factor with one of highest population attributable risk
poor diet/obesity - thought to be responsible for 25-50% of CVD deaths per year, prevalence ^ rapidly worldwide, factor with one of highest population attributable risk
DM - ^ prevalence across Westernised world, also has high population attributable risk
smoking, cholesterol, population BP fall, deprivation - all have fallen recently, accounts for reduction from 70’s
social deprivation - behavioural relationship w/ smoking, poor diet etc.
Negotiate lifestyle modification w/ pt
visual aids + demonstration of how altering lifestyle can decrease risk (JBS2 or QRISK online aids, 2mmHg ^ = 7% ^ in CV and 10% ^ in cerebra VD)
inform that diet and exercise are most effective methods of lowering CVD risk = if lower risk, less or no need to take medications (i.e. statins)
Summary of exercise
Has role in many diseases - obesity, HTN, DM, CVD and stroke, depression hip fracture, breast ca, Alzheimer’s, colon ca
Dr’s only need to advise 1/12 to get them to exercise more, versus 1/100 for stop smoking
34% men not active enough, 42% women
^ in prevalence.more in disabled/regional variation (Hull worst)
as country, have worst rates in similarly matched in similarly matched nations (e..g, France, Australia)
has been shown to have similar role on mortality of CVD as high glucose + obesity
Guidelines
need 150 mins of moderate intensity exercise a week - min. 30 mins so at least 5 times
x2 muscle strengthening activity per week
limited time sat sedentary
balance + co-ordination x2/wk in elderly, biggest gains in health for pt’s completely inactive
Improving CHD outcomes
National service frameworks - is any of several policies set by NHS to define standards of care for major medical issues, such as: cancer, COPD, CHD, DM, CKD, MH
Developed in partnership w/ HCPs/patient/carers/managers/voluntary agencies
2 main roles - set clear quality requirements for care based on the best available evidence fo what Tx and services work most effectively - offer strategies + support to help organisations achieve these
Achieve this through:
- extensive consultation with above people to establish > priorities, evidence based change, ways of achieving change
- further subdivided into 3 main areas based on CVD patient pathway:
1 - prevention and risk management
2 - acute care
3 - living with CV disease
Aims of guidelines in healthcare
1 - improve quality of healthcare = variety of outcomes, provide recommendations based on evidence
2 - provide standards for HCPs assessed against
3 - helps to make informed decisions
4 - improve communication between pt and HCP
Assessing efficacy of guidelines
SSRI-AC
1 - scope and purpose (what intends to do)
2 - stakeholder involvement - has it considered user preferences/target population
3 - Rigor of development - formed using systematic approach
4 - independent (editorial) = recommendations not due to external influence
5 - applicability = tools/advise on how to implement, and ID barriers to implementation
6 - clarity - does it make clear recommendations
Barriers to implementation of guidelines
1 - issues with adopters (lack of awareness of how current practice is inappropriate, attitudes (doubts over credibility of source), skills and abilities (over reliance on trusted/convenient sources, confidence in skill set)
2 - organisation + environment (limitations + constraints (time, resources), organisational culture (behaviour, pressure to act/follow certain rules) social influence (teams norms/influential peers)
How to encourage people to adopt: multifactorial approach, actively disseminating info and decreasing barriers in best way to change, includes involving pt, educational sessions, audio/visual aids
Why are complains handled badly
failure to acknowledge validity of complaint
failure to apologise
response to complaint does not explain what has been done to prevent recurrence
response to complaint contains medical jargon
failure to involve the staff directly concerned in the complaint throughout the investigation
Common complains in NHS
patients have right to complain about any aspect
encouraged as improves services
safety of clinical practice poor/insufficient information ineffective clinical practice poor handling of complaints lack of dignity and respect poor attitudes of staff
What works in supporting behaviour change?
beneficial - advice from HCPs re: low sodium/cholesterol diet, antismoking interventions (NRT, bupropion, varenicline), exercise advice
Likely to help - counselling to ^ activity levels, self-help materials, telephone advice service on smoking cessation
Ineffective/harmful - acupuncture in smoking cessation, antioxyltics in smoking cessation
studies of these influences are bound to be susceptible to confounding factors + also are v. heterogenous, making meaningful meta-analyses difficult to access. Trials have showed benefit
Public Health Act
allows exclusion from work of ppl posing ^ risk of spreading GIT
persons with doubtful personal hygiene/unsatisfactory toilet hand-washing
children in nurses or pre-school groups
people whose work involves food prep
H+S care staff who have contact with highly susceptible persons (extremes of age, pregnancy, immunosuppressed)
UK food law - based on 1’ objectives, high level of protection of human life + health, protection of consumer’s interests, fair practices in food trade
Food safety act (1990) - defines food and enforcement authorities + their responsibilities. Food includes drink, articles with no nutritional value but for human consumption, chewing gum, ingredients
Offences under act - sale of food rendered injurious to health, unfit for consumption, net of quality demanded by purchaser. Display of food with label falsely describing food or likely to mislead as to nature of substance/quality
What is primary and secondary prevention?
Primary - requires you to know what modifiable factors are associated with diseases
Secondary - screening - requires understanding of the epidemiology of diseases (place, time, person) and the effectiveness of screening approaches
How are risk tables generated?
Joint British Societies (JBS) 10-year CVD risk prediction charts were most widely accepted
- based on data from Framingham study - cohort study looking at RFs + outcomes
- 10,000 subjects analysed for BP, diabetic status, smoking status, + outcomes measured
- found numerous factors were associated with ^ risk of CHD, CVA, HF and PVD
Role of risk calculators
illustrates visually to pt (red=bad)
informs clinician who to treat
emphasises what’s important in terms of modifiable RF’s (more important stop smoking than eat veg)
Cycle of change
relates to MH as often use drugs/alcohol as a coping mechanism - this needs to be addressed, however underlying MH illness must be treated or relapse likely
1 - pre-contemplation (no intention on changing behaviour)
2 - contemplation (aware problem exists but no commitment to action)
3 - Preparation (intent on taking action to address the problem)
4 - Action (active modification of behaviour)
5 - Maintenance (sustained change, New behaviour replaces old)
6 - Relapse (fall back to old patterns of behaviour)
Impact of addiction on society, family, individuals
addiction closely follows levels of criminal activity
clinics + provision of medical Tx costs billions each year
alcohol-related harms - £ million admissions, cost NHS £3.5 billion - death and hospital admissions - some conditions wholly attributable (e.g. liver disease), some partially (colon ca), impossible to tell if alcohol has caused a partially attributable illness > causal impact of alcohol estimated from epidemiological studies + expressed as Alcohol Attributable Fractions (AAFs) + applied to deaths and hospital admission
- slow ^ in wholly attributable deaths, mirrored by similar ^ in alcoholic liver disease
- psychological effects - depression
- large ^ in admissions since 2000 - cost £3.5 billion to NHS
Crime + disorder - alcohol particularly implicated in violent crimes (assault, DV, robbery, criminal damages) 50% DV perpetrators alcohol-dependent
Workplace - impact of drunkenness and hangovers on productivity, absence/leave for alcohol-related reasons (10.5m-26m days lost)
Family - 2.5m adults drinking at ‘harmful levels’ (50+ units/week), adverse effects on wider family > 1.3m children affected by parenteral drinking problems (abuse/neglect), associated arguments, violence, debt and relationship problems > psychological morbidity + ^ 1’ care attendance
Trends in drinking
^ since 60’s, slightly decrease since 2004 (now 53.8% more affordable)
UK doesn’t have higher total consumption than other similar Western countries; Frances, Italy etc
UK tend to start drinking earlier, and they drink heavily from young age
Drink more in one go = binge drinking which has more serious health effects
Health promotion in psychiatry
Focuses on promoting +ve mental health
Improving QoL (health protection) - reducing stressors causing MH: minimum wage, better housing, working hours limit, good physical health
Educating population on how to maintain mental well-being: mass media campaigns on importance of good health + increased awareness, advertising what help is available, simple stress techniques (shown by GP/schools/employer), also more focus on HCP being aware of potential poor mental health = better education of HCP
Perinatal and postnatal visits - prevent child abuse, postnatal depression, improve parent-child attachment
Childhood - education of teachers, school curriculums, promotion of body size acceptance, reducing stigma, education about bad health behaviours
Tackling socioeconomic inequalities - parental unemployment associated with 2-3 fold increase in risk of emotional or conduct disorder in childhood, poorer households, poor MH have impact on future generations, contributing to further cycles of inequality
National Cancer Research Institute
established 2001
promotes co-operation between government, charities, and industry to identify where research is most needed > for benefit of pt’s, public + scientific community
maintain research database to track and analyse all current research > avoid duplicated work, and inform decisions for new research
helps avoid unnecessary effort
develops research initiatives and help coordinate clinical trials
Organisation of cancer services in UK
Primary care - screening, diagnosis, treatment support, follow up
Cancer units - diagnose + treat common cancers, diagnose intermediate cancers + refer to specialists, provide advanced diagnostic procedures, provide common surgeries + non-complex chemotherapy
Cancer centres - treat more rare cancers with complex chemotherapy+ radiotherapy, provide specialist treatment, also provide cancer unit services
Organisation of blood transfusion
Structure
- NHS blood + transplant service (accountable to the DOH):
- 15 centres - collect 2.1 million donations per year
A - test blood, process, store it and distribute it to every NHS trust
B - encourage donors to donate every 12-16 weeks
C - recruit new donors
D - manage the supply of blood + deliver it to hospitals
Blood Safety + Quality Regulations 2005
enforced by MHRA regulates blood storage + transport, following key concepts:
- blood must only be transferred in the appropriate clinical scenario
- blood transported/packaged in accordance with validated procedures to ensure product quality + safety
- transfer of blood must be correctly documented to maintain proof of cold chain of blood passage
- vein to vein traceability maintained
- role + responsibility of dispatching + receiving hospitals, clearly defined
- transport of blood optimally managed via transfer from on transfusion laboratory to another
- wastage of blood minimised
Cancer MDT
importance - modern management involves many disciplines and allied health professionals, MDT streamlines + co-ordinates care so it’s not fragmented over several sites > BETTER OUTCOMES
structure:
core - medical staff (physician, oncologist, radiologist, histopathologist), specialist nurse, MDT co-ordinatory
extended - physio, dietician, palliative care, chaplain, social worker
Function: discuss all new diagnoses decide on management plan + inform 1' care develop guidelines designate specialist nurse to pt audit
Epidemiology of cancer
Globally:
prevalence = lung > breast > colorectal > prostate
causes of death = lung > colorectal > breast > prostate
33,000 deaths a year from lung malignancy
UK:
prevalence: breast/prostate, lung, bowel
causes of death - lung > bowel > breast > prostate > pancreas
1/5 of all cancer deaths are from lung cancer
incidence of most ^ with age
bladder ca decrease due to less occupational exposure to dyes
lung decreasing overall, but still ^ in women
liver ^ due to alcoholism
melanoma ^ due to holidays abroad
childhood cancers - peak 2-5 years, leukaemia > brain/CNS > lymphomas, ALL most common
Cancer registration
National cancer registration and analysis service (NCRAS) is run by PHE
conducted by 4 cancer registries which collect/collate data + submit to office for national statistics (ONS)
national cancer intelligence network (NCIN) at ONS coordinates this and carries out 2’ analysis - attempt to identify all new cancer diagnoses and follow up pt’s
allows comparisons in incidence of death and survival - in different places and population groups, and allows researchers to examines the long term outcome under different Tx’s or between population groups
Dr responsible for reporting this - have to inform pt.
functions - monitoring trends in incidence, survival + variation between areas and social group, e.g, 5 year survival, evaluate effectiveness of screening programme, evaluate quality and outcomes of current care, evaluate impact of environmental and social factors on cancer risk
survival data in cancer pt:
% of study population alive at end of given period of time (usually 5 years)
relative > estimate based on mortality data
observed > actual number following observational period
net cancer specific survival - probability of surviving cancer in absence of other illness
crude survival - probability of death from cancer in presence of other causes of death
confounding factors + death rates:
- age is major one, 2 ways of dealing:
indirect standardisation - how many deaths would we expect in age group? how many were there? - observed/expected mortality rate
- >100% is more than expected
- direct standardisation - weight average of ‘stratum-specific- rates. weight usually based on standard population
Psychological consequences of cancer
Tx changing physical appearance - loss of hair w/ chemo, mastectomy
destruction of assumptive world theory - benevolence theory - bad things happen to good person, so point of being good is shattered, assumption of invulnerability = nothing bad happens to me (can’t rely on body), loss of control of fate
F+F death forces to confront own mortality
worry about leaving people behind
grief
uncertainty - life on hold
demanding physical demands of chemo + socially isolating
stress of being carer/being cared for
Cancer reform strategy 2007
6 key areas for improvement
1 - prevention
2 - early diagnosis - overcome barriers, preventing late presentation to GP, education of GPs, more screening, new referral guidelines, decision aiding tools
3 - ensuring better Tx - reduce waiting times (2ww), improve clinical trials, better training
4 - living with + beyond cancer - partnership w/ charities, clinicians and pt to ^ support and services for survivors (ended 2003)
5 - reducing cancer inequalities
6 - delivery care in most appropriate settings - locally for pt. convince when possible, but centralised for better quality of care
National cancer research institute
created to develop common plans for cancer research and to avoid duplication of studies/effort
est 2001
roles - invest in facilities + resources for research, maintain cancer research database + analyse new research, develop research initiatives, coordinate clinical trials for new drugs
Cancer networks
organisational model to implement NHS cancer plan 2000 - drive Ca plan and Ca reform strategy
34 cancer networks - 12 strategic clinical networks over not just cancer (include CVD, dementia, less staff)
primary aim - decrease inequalities in care of cancer
‘networks are to ensure that all commissioners + providers of cancer care, the voluntary sector and local authorities within network work effectively together to deliver high quality care
Aims of strategic cancer networks
reduce incidence of cancer maximise survival of cancer patients enhance QoL of ca. pt's and families ^ pt. experience of ca services provide high quality services focused on needs of pt's and carers
Role of cancer registry
responsible for collection, analysis and dissemination of cancer data for their region
collect information of all new diagnoses - follow from diagnosis until death
submit to office of national statistics
essential to cancer plan as providing reliable data of incidence, prevalence, and survival rates
What is national cancer research network
support recruitment of patients for trials and improve speed, quality, and integration of research into care services
^ infrastructure in NHS for ca. clinical research
integrates and supports work from cancer charities
Benefits of strategic cancer networks
accurate studies on epidemiology of different caners
less ‘postcode lottery’ and inequalities seen in cancer care provision
lower incidence of cancer by better screening programmes and greater focus of cancer in primary care
maximise survival of ca pt’s
^ QoL of patients and families
^ pt’s experience of cancer services
Role of strategic cancer networks
development of strategic plans
bring together those who use, provide and commission services
implementation of national policies
provide a channel for communication between groups across the network
provides resources for audits and research
deliver improvements in care
Organisation of cancer services
EUROCARE study - collects data on 5 year survival of cancer pt;s in different countries, UK had one of worst survival statistics in Europe, reasons being:
- differences in data collection
- UK has older population
- pt’s present later in UK
- lower social classes don’t access services
- poor access to Tx = delay in diagnostic pathways
thus, expert advisory group from chief medical officers called for Calman-Hine (1995) report, which concluded:
- unacceptable variation between hospitals in quality of Tx - services disjointed and outcomes poor > better to centralise Tx to ^ quality, w/ primary care at centre of this
- should ensure all pt have equal access to care
- public and professionals educated on recognising early signs
- services pt centred - give clear info on Tx options and outcomes
- cancer registration + monitoring of outcomes is essential
- psychosocial needs of carers and pt recognised
Solutions from Calman-Hine report
resulted in formation of cancer networks (34 in total) w/ 3 levels of care:
- primary - prevention and early diagnosis
- cancer unit - 1/250,000 - treat common ca, make diagnosis (non-complex chemo and surgery)
- cancer centre - 1/1 mil - treat rare cancers, complex chemo and surgery
all 3 use MDTs, meeting weekly to discuss new patients
Reasons for centralising cancer care
not cost effective to have resources for everything everywhere
clinicians become experts so better outcomes (as see more rare ca’s, and easier to have alliance between providers = share best procedure knowledge, less variation)
patients will receive better care for specific condition = can get more holistic care as can integrate all services
issues
- some hospitals get neglected with worse care due to lack of resources
- cost to pt of travelling
partnerships (2002) - combine: pt, former pt, carers, HCP > allow them to have their own input on how services should be developed
What is adverse event, near miss and never event?
an unintended event resulting from clinical care + causing physical or psychological harm to pt, e.g., prescribing errors, delay in diagnosis, treatment/procedure error
near miss - events or omissions arising during clinical care but not developing far enough to cause injury to patient. Should be reported
never event - serious pt safety incidents that should not occurs if the available preventative measures have been implemented, e.e.g, wrong surgery site, leaving surgical instrument in pt. misplaced NG tube not detected prior to use
Explain complaints system
2 step process
local resolution - hospital/GP provide copy of complaints procedure.
first step - raise matter with care provider, NHS England or local CCG
Escalation - parliamentary + health service ombudsman (independent of NHS and government)
What is patient advice and liaison service
first port of call for complaints
offer confidential advice, support and information on healthcare related matters
provide a point of contact for patients, their families and carer
give information on health-related q’s, complaints procedure, support groups outside NHS
Ways to report adverse events
National patient safety agency (NPSA) - collects information from staff, pt’s and carers on adverse events across country. they ensure solution are produced to prevent harm when risks are identified, specifying national goals and tracking progress
National reporting and learning system (NRLS) - is on anonymous reporting system run by NPSA
Yellow card system - used for reporting adverse drug reactions, run by MHRA and commission on human medicines, gathers info on adverse effects to medicines, can be reported by range of HCPs, must report: death/serious illness, any w/ new medicine, any w/ children
Why monitor adverse events?
AE common (1/10 hospital admissions) and have important consequences
up to 50% are preventable
learning opportunities
opportunity to introduce preventative measures
Barriers to learning from adverse events
lack of communication (usually between members of MDT)
lack of responsibility - especially ‘top level’, scape goat culture
focus on immediate cause, not root cause - could prevent recurrence
pride and rigid attitudes of staff
Patient safety (in regards to adverse events in medicine)
7 steps to pt safety: (+ barriers)
1 - build safe culture (adverse events continue to happen if focus on immediate events and not root cause)
2 - lead and support staff (top level have to take responsibility for systematic roles - don’t create individualist approach of blame, improve communication between staff)
3 - integrate your risk management activity
4 - promote reporting - rigid attitudes can prevent this and fear/scape-goat culture
5 - involve and communicate w/ pt’s and public
6 - implement solutions to prevent harm
7 - learn and share safety systems
other aspects of pt. safety
1 - FTP
2 - reporting near miss and adverse events - learn from these
3 - incentivise good quality - commissioning for quality and innovation (CQUIN) payment, e.g., GPs, paid for vaccinating etc.
measures of quality
1 - structure - good quality because right things are present
2 - process - good quality because right things are done
3 - outcome - good quality because things turn out right
Adverse events in medicine
Swiss cheese model - many events aligning for an adverse event to occur
active failures
- unintentional errors - knowledge-based (wrong plan due to inadequate knowledge/experience, e.g., Jr Dr misdiagnosis), rule based (misapplication of good rule/guideline), skill based (attention/memory lapse = unintended deviation from good action/plan)
- intentional errors (violation) - routine (normalisation of bad practice) situation (context dependent (i.e shortcuts if overwhelmed), reasoned (deliberate deviation from protocol thought to be best interest at time), malicious (deliberate act intended to harm)
latent failures - many things, management decision, organisational process, e.g., working environment, staff training, staff hours
What is food poisoning
gastroenteritis w/ infectious cause w/ presumed source being from food
time from eating to Sx onset = incubation period - can inform what organism/toxin it is
- toxins/heavy metal - v quick onset of D+V, viruses and bacteria are slower
burden of infection
- campylobacter
- rotavirus (mainly U5s, but now vaccine)
- C diff
- norovirus (short lived so underreported
- nosocomial - c diff, MRSA, norovirus
Characteristics of specific causative gastroenteritis organisms
Salmonella - G -ve, incubation 12-72 hours, contaminated food of animal origin, or faecal from infected person. Reservoir is mainly eggs. Clinically > cause enteric fever (typhoid fever) + enterocolitis. Incidence decreases through public health measures, peaks in late summer
E. coli - various types, can cause renal failure in children, haemolytic uraemia, 0157H7 (enterohaemorrhage) is v. dangerous. Reservoir in cattle, can be through food/animal contact. Incidence steady. 12-48 hours incubation
Bacillus cereus - 1-6hours, cooked rice
S. aureus - G+ve cocci. Previously cooked food contaminated w/ skin/nasal flora. Produces toxin > rapid incubation (2-4 hours)
highest burden of infection (CRCN) = campylobacter > rotavirus > C diff > norovirus
Roles of members of Diabetes Care team
Diabetic specialist nurse - provide care, support + advice to pt’s in GP practice, residential homes or pt’s own home - involved in developing + participating in education programmes
Podiatrist – screening for foot problems which have significant impact on QoL of diabetics. Provide footwear recommendations, education, referral to chiropody/orthotics and manage/debride foot wounds
Dietician - help patients make informed and practical choices about their diet, provide health promotion, work with those who have special dietary needs
Doctors:
- endocrinologist - treat complex cases with hard to control glucose levels
- nephrologist - monitor and treat renal complications
- ophthalmologist - monitor for diabetic retinopathy and treat
- cardiologist - monitor and treat cardiovascular complications
- neurologist - manage strokes and diabetic neuropathy
Merits and limitations of publicly available performance indicators
public scandals ^ pressure for outcomes to be published and used
other public sectors (schools, police) make this information available - right to access it?
expectation to collect outcome data + publish it - arrival of coded computerised clinical databases means data is there to be used
Keogh report - pt. safety published hospital standardised mortality rate (SMR’s) - wrong approach
Pro’s
- ^ information about health care providers
- informs pt, ^ and encourages choice - Caveat emptor
- transparency, honest and open ^ trust in health providers
- may ID outliers > learn from hospitals with low mortality to improve those with high mortality
- quantitative - clear numerical figures
Con’s
- hospital SMR’s are not fit for purpose
- only work when considered alongside avoidable deaths (PRISM study)
- dependent on non-hospital care (i.e., prehospital and variation in planned place of death)
- data varies (inexplicable changes in definition/coding)
- choice of case mix adjustment model > results varying dependent on which you use
- relationship w/ QoL (validity) not demonstrated
- each pt. unique so even if uniform care there will be random variation
- must be adjusted for co-founders (i.e. age)
- doesn’t influence pt’s, influences clinicians and managers
- incentivising targets may pervert practice, i.e. avoid complex cases
Summary of audits
form of quality improvement that aims to ^ clinical care by critically examining existing practice and identifying any areas of concern
systematic critical analysis of quality of medical care, including: procedures for diagnosis (including pathways), procedures for Tx, care of pt.
how does it measure quality?
- outcomes, eg. survival
- QoL for pt
- cost-effectiveness
stages: 1 - identify current standards 2 - measure current performance 3 - collect data and compare performance v. standards 4 - make improvements 5 - re-evaluate
interventions that tend to be successful:
- ones that take into account barriers - sometimes occurs during 2nd cycle
- education + reminder systems are both effective in ^ quality of care
Why do an audit?
improve patient care
encourage teamwork
financial benefits
assess progress against national standards
provides opportunity for clinical education
fulfils contractual obligations
Limitations of an audit?
only compares service to best current practice
may not always help
costs time, money, resources
if nothing changes, then resources wasted
small sample size may decrease usefulness of results
takes time to implement change
National Service Frameworks
policies set by NHS to define care standards for major disease (ca, CHD, COPD, DM, etc), or for specific patent groups (elderly, palliative care)
2 main roles:
- set formal quality requirements (based on best evidence for/against Tx/services)
- offer strategies/support to help organisations attain these
Who is involved?
- DoH create strategy, after IDing need for one
- strategic health authority implement + manage it
- consultation w/ pt’s, carers, public, charities, HCPs - what factors go into developing CHD strategy? - look at RF’s + pt. pathway and ID areas for improvement, ID priorities, evidence in support of proposed interventions, clear SMART goals, outline what measures used to monitor, how change can be implemented
Outline strategy to address to CVD risk
Strategic planning:
- where are we now? - baseline data, how many have disease? how many at risk? WHO is affected?
- where do we want to go? - we want less, how much? is that realistic? will we have balanced decreased across demographic/SES? where do we draw the line, between treating well people for a disease they don’t have?
- how to get there? evidence base should inform us what’s effective - diet? exercise? medications?
- how will we know if we’re there? - measures of death? cashed precipitation? NSFs
