Health and Society (11 and 12) Flashcards
1
Q
When was the Midwives Act made?
Who was it made by?
What 4 things did it state?
A
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
2
Q
What was the intended use of a partogram?
A
To monitor women in developing countries on their way to the hospital
3
Q
Define active management of labour
4 things it involves
A
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
4
Q
11 things which may not be classed as a normal birth
A
Epidural, Episiotomy, Directed pushing, Hospital, Artificial membrane rupture, Induction, In bed, Oxytocin, Anaesthesia, Reduced maternal effort, Instrumental/Operative assistance
5
Q
What is the problem with giving birth in bed?
A
Squishes the birth canal
6
Q
What does NICE state about C-sections?
A
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
7
Q
How is oxytocin naturally produced during birth?
What reflex is involved?
A
Increased pressure on cervix, vagina and pelvic floor
Ferguson reflex: positive feedback (increased stretch = increased oxytocin)
8
Q
5 things which suppress oxytocin production
A
Epidural inhibits ferguson reflex Induction floods receptor sites (decreases sensitivity) Poor foetal position reduces stretch Episiotomy Separation (reduces milk)
9
Q
What are the 3 classes of childhood illness?
A
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
10
Q
What are the rates of childhood illness like in the UK compared to Europe?
A
High
11
Q
11 non-intentional causes of child death
A
Drowning, Falls, Head injury, Fire, Suffocation, Aspiration, Strangulation, SIDS, Poisoning, CNS disease, Cancer
12
Q
7 intentional causes of child death
A
Infanticide, Homicide, Physical assault, Abuse, Neglect, Deprivation, Maltreatment
13
Q
Define avoidable death
A
A problem in care which leads to death
14
Q
What are the 3 causes of avoidable death
A
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)
15
Q
What are the 3 types of medical error?
A
Medical: wrong dose or drug
Surgical: wrong procedure or site
Infection control: HAI
16
Q
3 words to describe the profession of a doctor
A
Professional, Transparent, Self-regulated
17
Q
Define casemix adjustement
A
Adjusts riskiness for surgeons
18
Q
3 deficiencies in medical care
A
Weak evidence base
Large variations in clinical practise
Failure to meet outcomes
19
Q
What is the summary hospital level mortality indicator?
1 problem with them
A
Ranks all hospitals based on their deaths (within 30 days of discharge)
Can be corrupted e.g. hospice data
20
Q
Define PROMs
A
Patient Reported Outcome Measurement
Before and after procedure QOL
21
Q
7 organisations involved in patient protection
A
Care Quality Commission NHS Improvement (formerly monitor) NICE Royal Collages Department of Health and NHS England Health Protection Agency General Medical Council
22
Q
What is the role of NHS Improvement?
A
Financial stability of hospitals
Patient safety
23
Q
What is the role of the Health Protection Agency?
What is the role of the DoH and NHS England?
A
Oversight and control of cost and quality
24
Q
How often does the GMC revalidate doctors?
A
Every 5 years
25
What is the role of CQC?
Regulate the quality of health and social care
| Unannounced visits
26
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
27
Define a near miss event
Events / omissions from clinical care fail to develop further preventing patient harm
28
Define a serious incident
Consequences on patients, relatives and staff are so significant investigation is warranted
29
Define a never event
Serious incidents that are entirely preventable due to guidance or safety recommendations providing a protective barrier
30
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
```
31
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
32
Why is harm bad?
Can be interpreted as the result of incompetence and negligence
33
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
34
Define an active failure
Unsafe acts committed by people in direct contact with the patient
35
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
36
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
37
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
38
Define blame culture
Individuals cover up errors for fear of retribution
39
5 words to define safety culture
Learning, leadership, teamwork, patient centered, honesty
40
5 situations which cause increased risk of error
```
Unfamiliarity and inexperience
Lack of time
Not checking
Poor procedures
Poor human-equipment interface
```
41
What is NHS Resolution?
National safety and learning service
42
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
43
Explain human factors thinking
Avoids reliance on memory
Makes things visible
Standardises and simplifies common procedures
Checklists
44
What are the 4 stages of a critical appraisal?
1. Create an answerable question (PICO)
2. Search for best evidence
3. Appraise the evidence
4. Make a decision on the basis of evidence, available resources, patient preference and clinical expertese
45
What does PICO stand for?
Patient / Popualtion / Problem
Intervention
Comparator / Control(or exposure)
Outcome
46
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
47
What studies are systematic reviews created for?
All studies (RCT most common)
48
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)
49
Define bias
Systematic introduction of error into a study which can distort results in a non-random way
50
Is not returning results bias?
No, it is error
| It is random, not systemic
51
6 things to assess the results for
Applicability, Bias, Believability, Credibility, Limits and Value
52
What are the 3 steps for appraising evidence?
1. Are the results valid?
2. What are the results?
3. Can I apply this to patient care?
53
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
54
How do you answer the questions in an appraisal?
Yes, No, Can't tell
55
1. Did the review have a clearly focused question?
Did they use PICO?
56
2. Did the review include the right type of study?
Which addresses the research design
57
3. Did the reviewers identify all relevant studies?
```
Hand-searching
Contacting authors
Conference proceedings
Reference lists
Unpublished studies
Non-English studies
```
58
4. 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
59
5. 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
60
6. How are the results presented and what is the main result?
Can you sum up the result in one sentence?
61
7. How precise are the results?
Confidence interval that doesn't cross zero is statistically significant
P-values
62
8. 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?
63
9. Were all the important outcomes considered?
Individual > Professional > Family > Community
64
10. Should the policy change as a result of the review?
Benefit / Harm / Cost
65
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)
66
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
67
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
68
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
69
What did the NHS constitution state in 2010?
Patient has a right to access services within the max wait time
70
How long is referral to treatment in the UK?
18 weeks
71
What is the policy in Finland?
Penalisation of districts not meeting targets
72
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
73
What is the policy in the Netherlands?
Socially acceptable wait time
74
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
75
What is the policy in NZ, Australia, Canada and Norway?
Maximum wait depends on entitlement group decided upon by prioritisation checklist e.g. CPAC
76
Why is the median shorter than the mean with wait time policies
Very few people will wait a very long time
77
What becomes a problem when you have shorter wait times?
Supply and demand becomes a problem
78
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
79
6 most common fracture sites
Hip, Humerus Pelvis
| Radius, Femur, Vertebrae (spontaneous)
80
Which fracture site is increased just after menopause?
Distal radius
81
What do QALY measure?
Disease burden through health economics
82
What does 0 QALY mean?
Death
83
What happens to the levels of trabeculae in osteoporotic bone?
Decrease
84
What retains bone strength?
Scaffolding of bone remains intact (even if density decreases)
85
What drug increases the risk of osteoporosis?
Steroids
86
Is calcium and vitamin D useful for helping reduce fracture rates?
No
87
Define confounding
When a relationship between an exposure and outcome is distorted by their shared relationship with something else
88
4 characteristics of observational studies
No intervention
Analysis of spontaneous events
Group assignments are not random
Explores cause
89
What is the difference between a cohort and case-control study?
Cohort: Exposure > Compare outcome
| Case-control: Outcome > Compare exposure
90
Define risk
Probability an event occurs in a given time
91
What does it mean if the risk ratio is less than 1
The intervention decreases risk
92
Define a null situation
Risk is the same in both groups
| Risk ratio = 1
93
What does confounding do?
Increases or decreases the apparent association between the exposure and outcome > distortion of the true relationship
94
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
95
What are the 4 methods of accounting for confounding
1. Restriction/Exclusion
2. Matching
3. Stratification
4. Multiple Variable Regression
96
When does restriction not work well?
If there is more than 1 confounding factor
97
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
98
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
99
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
100
Define adjusted risk ratio
Formed when the stratified results are recombined
| A weighted average of the effect seen in each stratum
101
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
102
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
103
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
104
What are the 4 stages of the research cycle
> Clinical problem (who, why, what)
> (Basic research)
> Applied research
> Clinical Care
105
Give an example of an organisation who sets research priorities
James Lind Alliance
106
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)
107
How can you solve the research gaps?
Increased funding of trials and research
108
4 evidence > practise gaps
Identify need for knowledge
Synthesis and application of knowledge
Development of routine
Clinical actions or policy
109
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
110
2 characteristics of guidelines
Easy to follow
| Compatible with existing norms and values
111
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'
112
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
```
113
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)
114
3 initiatives targeting networks
Audits to identify variations in practise and outcomes
Recognition for high quality practise
Promote communication, collaboration and competition
115
3 initiatives targeting professionals
Educational meetings / outreach visits to promote
Reminders
Surveys and focus groups
116
2 initiatives targeting organisations
Introduction of MDT
| Improve skill mix, service delivery and financial incentives
117
Give 2 examples of financial initiatives
CQUIN: Commissioning for Quality and Innovation Network
QOF: Quality and Outcomes Framework
118
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
119
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
120
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
121
Define delirium
Physical illness precipitates acute confusion with fluctuating consciousness, agitation and hallucinations
122
Why do patients see a dementia diagnosis as a relief?
They know what they're up against
| They can plan ahead
123
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
124
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
125
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
```
126
4 reasons why dementia is different to other illnesses
Cannot share the burden of illness
Length of the disease
Personality change
Psychiatric problems
127
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)
128
4 effects of dementia on the family
Conflict
Demands
Effect on young children
Role reversal
129
6 effects of dementia on the carer
```
Can't take time off
Constantly on their feet
No support from partner
Physical care
Sleep
Stress
```
130
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
131
Define person-centred care
Tailored around the individuals needs, preferences, values, beliefs, life, history and identity
132
Define personhood
Knowing the person behind the dementia
133
Define BPSD
Behavioural and Psychological Symptoms Dementia
134
What helps in dementia management? (4)
Managing co-morbidities
Medication
MDT and team work
Supporting the patient and carer e.g. respite
