Health and Society (11 and 12) Flashcards
When was the Midwives Act made?
Who was it made by?
What 4 things did it state?
In 1902
Made by the Midwive’s Institude (1881)
Stated that midwives controlled normal labour and obstetricians abnormal labour
Educated midwives
Ensured pay
Equal access to midwives and doctors for all women
What was the intended use of a partogram?
To monitor women in developing countries on their way to the hospital
Define active management of labour
4 things it involves
Normal birth but intervention
- Labour at 2cm dilated
- Early artificial rupture of membranes
- 2 hourly vaginal examinations
- Syntocinon when progress less than 1 cm / hour
and in stage 2 if contractions are weak
11 things which may not be classed as a normal birth
Epidural, Episiotomy, Directed pushing, Hospital, Artificial membrane rupture, Induction, In bed, Oxytocin, Anaesthesia, Reduced maternal effort, Instrumental/Operative assistance
What is the problem with giving birth in bed?
Squishes the birth canal
What does NICE state about C-sections?
May be offered a C-section if it is not medically needed if it has been discussed and is in the mother’s best interest
How is oxytocin naturally produced during birth?
What reflex is involved?
Increased pressure on cervix, vagina and pelvic floor
Ferguson reflex: positive feedback (increased stretch = increased oxytocin)
5 things which suppress oxytocin production
Epidural inhibits ferguson reflex Induction floods receptor sites (decreases sensitivity) Poor foetal position reduces stretch Episiotomy Separation (reduces milk)
What are the 3 classes of childhood illness?
Acute illness in a previously well child
Acute illness in a child with an underlying chronic illness (e.g. asthma exacerbation)
Chronic long term illness
What are the rates of childhood illness like in the UK compared to Europe?
High
11 non-intentional causes of child death
Drowning, Falls, Head injury, Fire, Suffocation, Aspiration, Strangulation, SIDS, Poisoning, CNS disease, Cancer
7 intentional causes of child death
Infanticide, Homicide, Physical assault, Abuse, Neglect, Deprivation, Maltreatment
Define avoidable death
A problem in care which leads to death
What are the 3 causes of avoidable death
Act of omission (failure to treat according to best evidence)
Act of commission (incorrect treatment/management)
Unintended harm (complications in care e.g. poor monitoring, diagnostic error, inadequate drug/fluid)
What are the 3 types of medical error?
Medical: wrong dose or drug
Surgical: wrong procedure or site
Infection control: HAI
3 words to describe the profession of a doctor
Professional, Transparent, Self-regulated
Define casemix adjustement
Adjusts riskiness for surgeons
3 deficiencies in medical care
Weak evidence base
Large variations in clinical practise
Failure to meet outcomes
What is the summary hospital level mortality indicator?
1 problem with them
Ranks all hospitals based on their deaths (within 30 days of discharge)
Can be corrupted e.g. hospice data
Define PROMs
Patient Reported Outcome Measurement
Before and after procedure QOL
7 organisations involved in patient protection
Care Quality Commission NHS Improvement (formerly monitor) NICE Royal Collages Department of Health and NHS England Health Protection Agency General Medical Council
What is the role of NHS Improvement?
Financial stability of hospitals
Patient safety
What is the role of the Health Protection Agency?
What is the role of the DoH and NHS England?
Oversight and control of cost and quality
How often does the GMC revalidate doctors?
Every 5 years
What is the role of CQC?
Regulate the quality of health and social care
Unannounced visits
Define an adverse / patient safety event
5 examples
Unintended event resulting from clinical care causing patient harm
e.g. wrong diagnosis, hospital infection, fall, side effects, pressure ulcers
Define a near miss event
Events / omissions from clinical care fail to develop further preventing patient harm
Define a serious incident
Consequences on patients, relatives and staff are so significant investigation is warranted
Define a never event
Serious incidents that are entirely preventable due to guidance or safety recommendations providing a protective barrier
5 methods to know how safe a hospital is
Hospital mortality data Avoidable deaths Reports of never events and serious incidents (not all reported) Patient safety Inspections
4 problems with standardised mortality data
1 benefit
Doesn’t look at quality of care
Dependent on patients planned place of death
Can include hospice data
Choice of standardisation
Better than hospital mortality data as standardised for population skew
Why is harm bad?
Can be interpreted as the result of incompetence and negligence
Explain the 5 levels you must go through before an accident occurs
> Latent failures (e.g. management decision or organisation process)
Conditions of work (workload, communication, training, equipment, ability)
Active failures
Lack of barriers and defences
Accident
Define an active failure
Unsafe acts committed by people in direct contact with the patient
Define the 3 types of errors
Knowledge: Wrong plans due to inadequate knowledge
Rules: Familiar problem but wrong rule (misapplication of good rule or application of bad rule)
Skills: Attention and memory lapses > unintended actions
Define the 4 types of violations
Routine: Violation become the normal behaviour
Situational: Context (no time or lack of staff)
Reasoned: Deliberate deviation thought to be in the patients best interest
Malicious: Deliberate and intended to cause harm
Define a latent failure
Development over time and lay dormant until they combine with other factors to cause an adverse event
e.g. lack of staff or poor working conditions
Define blame culture
Individuals cover up errors for fear of retribution
5 words to define safety culture
Learning, leadership, teamwork, patient centered, honesty
5 situations which cause increased risk of error
Unfamiliarity and inexperience Lack of time Not checking Poor procedures Poor human-equipment interface
What is NHS Resolution?
National safety and learning service
6 ways to improve patient safety
Early detection of deteriorating patient
Hand hygiene
Increase staff
Safety culture (be open and learn from mistakes)
Safer prescribing
Standardise procedures
Explain human factors thinking
Avoids reliance on memory
Makes things visible
Standardises and simplifies common procedures
Checklists
What are the 4 stages of a critical appraisal?
- Create an answerable question (PICO)
- Search for best evidence
- Appraise the evidence
- Make a decision on the basis of evidence, available resources, patient preference and clinical expertese
What does PICO stand for?
Patient / Popualtion / Problem
Intervention
Comparator / Control(or exposure)
Outcome
What study design would you use to find a:
- Therapy
- Prognosis
- Diagnosis
- Cause
- Patient’s thoughts
- Intervention
- Therapy: RCT
- Prognosis: Cohort study
- Diagnosis: Cross sectional analytic or Comparative study
- Cause: Cohort/population study
- Patient’s thoughts: Qualitative research
- Intervention: Comparative study
What studies are systematic reviews created for?
All studies (RCT most common)
6 benefits of systematic reviews
Includes ALL primary data
Includes evidence from non-English journals
Increased sample size
Increased variation among studies
Sensitivity analysis (quality)
Sub group analysis (e.g. treatment for moderate/severe depression)
Define bias
Systematic introduction of error into a study which can distort results in a non-random way
Is not returning results bias?
No, it is error
It is random, not systemic
6 things to assess the results for
Applicability, Bias, Believability, Credibility, Limits and Value
What are the 3 steps for appraising evidence?
- Are the results valid?
- What are the results?
- Can I apply this to patient care?
What do you assess the results of ___ for?
- Therapy
- Prognosis
- Diagnosis
- Cause
- Therapy: relative and absolute risk, confidence intervals
- Prognosis: likelihood of outcomes over time
- Diagnosis: Sensitivity, specificity, PPV, NPV
- Cause: relative risk, odds ratio
How do you answer the questions in an appraisal?
Yes, No, Can’t tell
- Did the review have a clearly focused question?
Did they use PICO?
- Did the review include the right type of study?
Which addresses the research design
- Did the reviewers identify all relevant studies?
Hand-searching Contacting authors Conference proceedings Reference lists Unpublished studies Non-English studies
- Did the reviewers assess the quality of the studies?
2 people use standardised criteria and scoring systems to ensure that all studies are of good quality and no studies have been missed
- If the results were combined, was it reasonable?
Meta-analysis only combine SMILAR results > stronger evidence
Not doing a meta-analysis does not make a bad review
- How are the results presented and what is the main result?
Can you sum up the result in one sentence?
- How precise are the results?
Confidence interval that doesn’t cross zero is statistically significant
P-values
- Can the results be applied to the local population?
Generalisability (paticularisability) of results
Is the research beneficial to a specific patient
- Are your and the studies patients similar?
- Can the local health service provide it?
- Benefits and costs?
- Were all the important outcomes considered?
Individual > Professional > Family > Community
- Should the policy change as a result of the review?
Benefit / Harm / Cost
What did the second OECD waiting times project do and discover?
Reviewed countries policies
Policies to reduce waiting times do work but there is a sacrifice for reducing times (e.g. quality of care)
What did the OFOECD report discover (3)
Most common policy is a maximum wait time guarantee
Maximum waits differentiatedd for certain conditions
Policies only work when demand is controlled
What was the UK’s waiting time policy?
Was it a success?
Wait time with a target and penalties if they are not met
DoH states 90% of patients treated within the target and a 5% reduction in revenues if there is a breech
Successful
3 problems with the UK’s waiting time policy
Mis-prioritisation of patients
Patients seen at target time
Once they breech they’re not a priority
What did the NHS constitution state in 2010?
Patient has a right to access services within the max wait time
How long is referral to treatment in the UK?
18 weeks
What is the policy in Finland?
Penalisation of districts not meeting targets
What is the policy in Portugal and Denmark?
Wait time reaches 75% of max > treatment at another public or private provider at original hospitals expense
What is the policy in the Netherlands?
Socially acceptable wait time
Explain the difference between a fixed budget scheme and output based payment
Fixed budget: hospital paid on patient number
Output based: More patients seen = more money
What is the policy in NZ, Australia, Canada and Norway?
Maximum wait depends on entitlement group decided upon by prioritisation checklist e.g. CPAC
Why is the median shorter than the mean with wait time policies
Very few people will wait a very long time
What becomes a problem when you have shorter wait times?
Supply and demand becomes a problem
Explain the difference between unconditional and conditional guarantees
Unconditional: same for everyone, easy to implement, cannot prioritise
Conditional: based on severity, difficult to implement, can prioritise
6 most common fracture sites
Hip, Humerus Pelvis
Radius, Femur, Vertebrae (spontaneous)
Which fracture site is increased just after menopause?
Distal radius
What do QALY measure?
Disease burden through health economics
What does 0 QALY mean?
Death
What happens to the levels of trabeculae in osteoporotic bone?
Decrease
What retains bone strength?
Scaffolding of bone remains intact (even if density decreases)
What drug increases the risk of osteoporosis?
Steroids
Is calcium and vitamin D useful for helping reduce fracture rates?
No
Define confounding
When a relationship between an exposure and outcome is distorted by their shared relationship with something else
4 characteristics of observational studies
No intervention
Analysis of spontaneous events
Group assignments are not random
Explores cause
What is the difference between a cohort and case-control study?
Cohort: Exposure > Compare outcome
Case-control: Outcome > Compare exposure
Define risk
Probability an event occurs in a given time
What does it mean if the risk ratio is less than 1
The intervention decreases risk
Define a null situation
Risk is the same in both groups
Risk ratio = 1
What does confounding do?
Increases or decreases the apparent association between the exposure and outcome > distortion of the true relationship
2 scenarios where there is no confounding
No association between exposure, outcome and cnfounder
If the ‘confounding factor’ is on the ‘casual pathway’ between exposure and outcome
What are the 4 methods of accounting for confounding
- Restriction/Exclusion
- Matching
- Stratification
- Multiple Variable Regression
When does restriction not work well?
If there is more than 1 confounding factor
Explain how the matching method works
What study is it often used in?
Problem?
Create a comparison group based on the confounder
Used for strong counfounders e.g. age and sex
Case control
Confounding may still exist
Explain how the stratification method works
Sub divide the population into levels of exposure
Analyse exposure to outcome association in different sub-groups of the confounder
Adjust for confounding if number variables involved are relatively small
Give an example of the stratification method
Risk of heart disease in joggers vs non-joggers who eat pie
Risk of heart disease in joggers vs non-joggers who
don’t eat pie
Define adjusted risk ratio
Formed when the stratified results are recombined
A weighted average of the effect seen in each stratum
Explain how the multiple variable regression method works
Plot the results on a y = a + bx graph
B is the regression coefficient so x can have multiple variables e.g. jogging, pies, smoking, drinking
Coefficients = estimate measures e.g. risk/odds ratio
Compensating for confounding via adjustment
What do you need to ensure researchers have done when appraising a study containing confounding factors?
Recognised the confounding
Measured and addressed confounders
Looked at the results with and without confounding
4 reasons why we need evidence
1 problem with evidence
Personal experience biased
Research sees more patients than practise
Research involves scientific methods
Recommendations assessed for clinical cost and effectiveness
Most medicine has no direct evidence
What are the 4 stages of the research cycle
> Clinical problem (who, why, what)
(Basic research)
Applied research
Clinical Care
Give an example of an organisation who sets research priorities
James Lind Alliance
What are the 2 research gaps?
Who are they managed by?
Implementation gap: Gap from getting evidence from trials into practise (NICE)
Gap from getting evidence from labs to clinical trials (Medicines Research Council)
How can you solve the research gaps?
Increased funding of trials and research
4 evidence > practise gaps
Identify need for knowledge
Synthesis and application of knowledge
Development of routine
Clinical actions or policy
8 barriers to uptake of evidence
- Belief that patients will resist new recommendations
- Clinicians unaware current practise is inappropriate (set in ways)
- Complex recommendations
- Confidence in current skill set & resistance to change it
- Expensive
- Over-reliance on trusted/convenient sources of information & doubts over credibility of new resources
- Time constraints and lack of resources specified
- Too many guidelines
2 characteristics of guidelines
Easy to follow
Compatible with existing norms and values
Define quality improvement
Facilitates uptake and continuing use of evidence-based policy into practise
Focuses on recurrent problems to improve performance, professional development and service user outcomes
‘Act, Plan, Check, Do, Standard’
5 characteristics of quality improvement
Interactive Engages participation across all levels Environment where improvement considered normal Empowers staff to strive for change Removes barriers to change
When does quality improvement work / not work?
Works when you actively implement multi-faced interventions involving patients and reminders which act on different levels of barriers
Doesn’t work when you give passive information (unless given with the active)
3 initiatives targeting networks
Audits to identify variations in practise and outcomes
Recognition for high quality practise
Promote communication, collaboration and competition
3 initiatives targeting professionals
Educational meetings / outreach visits to promote
Reminders
Surveys and focus groups
2 initiatives targeting organisations
Introduction of MDT
Improve skill mix, service delivery and financial incentives
Give 2 examples of financial initiatives
CQUIN: Commissioning for Quality and Innovation Network
QOF: Quality and Outcomes Framework
Explain what CQUIN does
Links income to achievement of local quality improvement goals:
Schemes tailored to needs
Improves staff well-being
Supports practise
Improves patient safety and well-being
Explain what QOF does
Annual reward and incentive programme based on GP practise achievement:
Compares care delivery to previous years
Increases standards of care
Rewards excellence across key domains
Improvements detrimental to small aspects of care not incentified and removal > reduced performance
Difference between what the patient and family notices in dementia
Patient - social embarrassment (can’t keep up), can’t find the right word, forget names
Family - repetition, forgets social arrangements, poor skills, withdrawing
Define delirium
Physical illness precipitates acute confusion with fluctuating consciousness, agitation and hallucinations
Why do patients see a dementia diagnosis as a relief?
They know what they’re up against
They can plan ahead
What is the impact of a dementia diagnosis on the patient?
Denial (with/without insight - they forget they forget)
Anger that you’re suggesting something is wrong
Grief reaction
What determines the response to the dementia diagnosis on the patient and carer?
Patient - insight and stage of illness, type of dementia, previous personality, support and relationships
Carer - understanding, patients reaction, relationship to patient
5 benefits of a dementia diagnosis
Access to treatment and support Assess and manage risks e.g. driving Information Know what you're dealing with Planning for the future
4 reasons why dementia is different to other illnesses
Cannot share the burden of illness
Length of the disease
Personality change
Psychiatric problems
6 effects of dementia on the partner/spouse
Emotional
Finances
Physical / Sexual
Practical (never cooked or managed finances before)
Relationship becomes skewed
Relationships with people outside fade (dementia patient is irritable)
4 effects of dementia on the family
Conflict
Demands
Effect on young children
Role reversal
6 effects of dementia on the carer
Can't take time off Constantly on their feet No support from partner Physical care Sleep Stress
When is a loving relationship undermined?
When the patient:
Does not recognise the carer
Doesn’t behave as themselves
Has lost all dignity
Has no response
Define person-centred care
Tailored around the individuals needs, preferences, values, beliefs, life, history and identity
Define personhood
Knowing the person behind the dementia
Define BPSD
Behavioural and Psychological Symptoms Dementia
What helps in dementia management? (4)
Managing co-morbidities
Medication
MDT and team work
Supporting the patient and carer e.g. respite
