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Medicine - Year 2 > Health and Society (11 and 12) > Flashcards

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

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2
Q

What was the intended use of a partogram?

A

To monitor women in developing countries on their way to the hospital

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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

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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

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5
Q

What is the problem with giving birth in bed?

A

Squishes the birth canal

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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

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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)

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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)
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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

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10
Q

What are the rates of childhood illness like in the UK compared to Europe?

A

High

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11
Q

11 non-intentional causes of child death

A

Drowning, Falls, Head injury, Fire, Suffocation, Aspiration, Strangulation, SIDS, Poisoning, CNS disease, Cancer

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12
Q

7 intentional causes of child death

A

Infanticide, Homicide, Physical assault, Abuse, Neglect, Deprivation, Maltreatment

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13
Q

Define avoidable death

A

A problem in care which leads to death

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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)

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15
Q

What are the 3 types of medical error?

A

Medical: wrong dose or drug
Surgical: wrong procedure or site
Infection control: HAI

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16
Q

3 words to describe the profession of a doctor

A

Professional, Transparent, Self-regulated

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17
Q

Define casemix adjustement

A

Adjusts riskiness for surgeons

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18
Q

3 deficiencies in medical care

A

Weak evidence base
Large variations in clinical practise
Failure to meet outcomes

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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

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20
Q

Define PROMs

A

Patient Reported Outcome Measurement

Before and after procedure QOL

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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
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22
Q

What is the role of NHS Improvement?

A

Financial stability of hospitals

Patient safety

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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

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24
Q

How often does the GMC revalidate doctors?

A

Every 5 years

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25
Q

What is the role of CQC?

A

Regulate the quality of health and social care

Unannounced visits

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26
Q

Define an adverse / patient safety event

5 examples

A

Unintended event resulting from clinical care causing patient harm
e.g. wrong diagnosis, hospital infection, fall, side effects, pressure ulcers

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27
Q

Define a near miss event

A

Events / omissions from clinical care fail to develop further preventing patient harm

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28
Q

Define a serious incident

A

Consequences on patients, relatives and staff are so significant investigation is warranted

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29
Q

Define a never event

A

Serious incidents that are entirely preventable due to guidance or safety recommendations providing a protective barrier

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30
Q

5 methods to know how safe a hospital is

A 
Hospital mortality data
Avoidable deaths
Reports of never events and serious incidents (not all reported)
Patient safety
Inspections
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31
Q

4 problems with standardised mortality data

1 benefit

A

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

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32
Q

Why is harm bad?

A

Can be interpreted as the result of incompetence and negligence

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33
Q

Explain the 5 levels you must go through before an accident occurs

A

> 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

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34
Q

Define an active failure

A

Unsafe acts committed by people in direct contact with the patient

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35
Q

Define the 3 types of errors

A

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

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36
Q

Define the 4 types of violations

A

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

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37
Q

Define a latent failure

A

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

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38
Q

Define blame culture

A

Individuals cover up errors for fear of retribution

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39
Q

5 words to define safety culture

A

Learning, leadership, teamwork, patient centered, honesty

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40
Q

5 situations which cause increased risk of error

A 
Unfamiliarity and inexperience
Lack of time 
Not checking
Poor procedures
Poor human-equipment interface
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41
Q

What is NHS Resolution?

A

National safety and learning service

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42
Q

6 ways to improve patient safety

A

Early detection of deteriorating patient
Hand hygiene
Increase staff
Safety culture (be open and learn from mistakes)
Safer prescribing
Standardise procedures

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43
Q

Explain human factors thinking

A

Avoids reliance on memory
Makes things visible
Standardises and simplifies common procedures
Checklists

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44
Q

What are the 4 stages of a critical appraisal?

A
  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
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45
Q

What does PICO stand for?

A

Patient / Popualtion / Problem
Intervention
Comparator / Control(or exposure)
Outcome

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46
Q

What study design would you use to find a:

  • Therapy
  • Prognosis
  • Diagnosis
  • Cause
  • Patient’s thoughts
  • Intervention
A
  • Therapy: RCT
  • Prognosis: Cohort study
  • Diagnosis: Cross sectional analytic or Comparative study
  • Cause: Cohort/population study
  • Patient’s thoughts: Qualitative research
  • Intervention: Comparative study
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47
Q

What studies are systematic reviews created for?

A

All studies (RCT most common)

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48
Q

6 benefits of systematic reviews

A

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)

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49
Q

Define bias

A

Systematic introduction of error into a study which can distort results in a non-random way

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50
Q

Is not returning results bias?

A

No, it is error

It is random, not systemic

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51
Q

6 things to assess the results for

A

Applicability, Bias, Believability, Credibility, Limits and Value

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52
Q

What are the 3 steps for appraising evidence?

A
  1. Are the results valid?
  2. What are the results?
  3. Can I apply this to patient care?
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53
Q

What do you assess the results of ___ for?

  • Therapy
  • Prognosis
  • Diagnosis
  • Cause
A
  • Therapy: relative and absolute risk, confidence intervals
  • Prognosis: likelihood of outcomes over time
  • Diagnosis: Sensitivity, specificity, PPV, NPV
  • Cause: relative risk, odds ratio
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54
Q

How do you answer the questions in an appraisal?

A

Yes, No, Can’t tell

55
Q
  1. Did the review have a clearly focused question?
A

Did they use PICO?

56
Q
  1. Did the review include the right type of study?
A

Which addresses the research design

57
Q
  1. Did the reviewers identify all relevant studies?
A 
Hand-searching
Contacting authors
Conference proceedings
Reference lists
Unpublished studies
Non-English studies
58
Q
  1. Did the reviewers assess the quality of the studies?
A

2 people use standardised criteria and scoring systems to ensure that all studies are of good quality and no studies have been missed

59
Q
  1. If the results were combined, was it reasonable?
A

Meta-analysis only combine SMILAR results > stronger evidence
Not doing a meta-analysis does not make a bad review

60
Q
  1. How are the results presented and what is the main result?
A

Can you sum up the result in one sentence?

61
Q
  1. How precise are the results?
A

Confidence interval that doesn’t cross zero is statistically significant
P-values

62
Q
  1. Can the results be applied to the local population?
A

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
Q
  1. Were all the important outcomes considered?
A

Individual > Professional > Family > Community

64
Q
  1. Should the policy change as a result of the review?
A

Benefit / Harm / Cost

65
Q

What did the second OECD waiting times project do and discover?

A

Reviewed countries policies

Policies to reduce waiting times do work but there is a sacrifice for reducing times (e.g. quality of care)

66
Q

What did the OFOECD report discover (3)

A

Most common policy is a maximum wait time guarantee
Maximum waits differentiatedd for certain conditions
Policies only work when demand is controlled

67
Q

What was the UK’s waiting time policy?

Was it a success?

A

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
Q

3 problems with the UK’s waiting time policy

A

Mis-prioritisation of patients
Patients seen at target time
Once they breech they’re not a priority

69
Q

What did the NHS constitution state in 2010?

A

Patient has a right to access services within the max wait time

70
Q

How long is referral to treatment in the UK?

A

18 weeks

71
Q

What is the policy in Finland?

A

Penalisation of districts not meeting targets

72
Q

What is the policy in Portugal and Denmark?

A

Wait time reaches 75% of max > treatment at another public or private provider at original hospitals expense

73
Q

What is the policy in the Netherlands?

A

Socially acceptable wait time

74
Q

Explain the difference between a fixed budget scheme and output based payment

A

Fixed budget: hospital paid on patient number

Output based: More patients seen = more money

75
Q

What is the policy in NZ, Australia, Canada and Norway?

A

Maximum wait depends on entitlement group decided upon by prioritisation checklist e.g. CPAC

76
Q

Why is the median shorter than the mean with wait time policies

A

Very few people will wait a very long time

77
Q

What becomes a problem when you have shorter wait times?

A

Supply and demand becomes a problem

78
Q

Explain the difference between unconditional and conditional guarantees

A

Unconditional: same for everyone, easy to implement, cannot prioritise

Conditional: based on severity, difficult to implement, can prioritise

79
Q

6 most common fracture sites

A

Hip, Humerus Pelvis

Radius, Femur, Vertebrae (spontaneous)

80
Q

Which fracture site is increased just after menopause?

A

Distal radius

81
Q

What do QALY measure?

A

Disease burden through health economics

82
Q

What does 0 QALY mean?

A

Death

83
Q

What happens to the levels of trabeculae in osteoporotic bone?

A

Decrease

84
Q

What retains bone strength?

A

Scaffolding of bone remains intact (even if density decreases)

85
Q

What drug increases the risk of osteoporosis?

A

Steroids

86
Q

Is calcium and vitamin D useful for helping reduce fracture rates?

A

No

87
Q

Define confounding

A

When a relationship between an exposure and outcome is distorted by their shared relationship with something else

88
Q

4 characteristics of observational studies

A

No intervention
Analysis of spontaneous events
Group assignments are not random
Explores cause

89
Q

What is the difference between a cohort and case-control study?

A

Cohort: Exposure > Compare outcome

Case-control: Outcome > Compare exposure

90
Q

Define risk

A

Probability an event occurs in a given time

91
Q

What does it mean if the risk ratio is less than 1

A

The intervention decreases risk

92
Q

Define a null situation

A

Risk is the same in both groups

Risk ratio = 1

93
Q

What does confounding do?

A

Increases or decreases the apparent association between the exposure and outcome > distortion of the true relationship

94
Q

2 scenarios where there is no confounding

A

No association between exposure, outcome and cnfounder

If the ‘confounding factor’ is on the ‘casual pathway’ between exposure and outcome

95
Q

What are the 4 methods of accounting for confounding

A
  1. Restriction/Exclusion
  2. Matching
  3. Stratification
  4. Multiple Variable Regression
96
Q

When does restriction not work well?

A

If there is more than 1 confounding factor

97
Q

Explain how the matching method works
What study is it often used in?
Problem?

A

Create a comparison group based on the confounder
Used for strong counfounders e.g. age and sex

Case control
Confounding may still exist

98
Q

Explain how the stratification method works

A

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
Q

Give an example of the stratification method

A

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
Q

Define adjusted risk ratio

A

Formed when the stratified results are recombined

A weighted average of the effect seen in each stratum

101
Q

Explain how the multiple variable regression method works

A

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
Q

What do you need to ensure researchers have done when appraising a study containing confounding factors?

A

Recognised the confounding
Measured and addressed confounders
Looked at the results with and without confounding

103
Q

4 reasons why we need evidence

1 problem with evidence

A

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
Q

What are the 4 stages of the research cycle

A

> Clinical problem (who, why, what)
(Basic research)
Applied research
Clinical Care

105
Q

Give an example of an organisation who sets research priorities

A

James Lind Alliance

106
Q

What are the 2 research gaps?

Who are they managed by?

A

Implementation gap: Gap from getting evidence from trials into practise (NICE)

Gap from getting evidence from labs to clinical trials (Medicines Research Council)

107
Q

How can you solve the research gaps?

A

Increased funding of trials and research

108
Q

4 evidence > practise gaps

A

Identify need for knowledge
Synthesis and application of knowledge
Development of routine
Clinical actions or policy

109
Q

8 barriers to uptake of evidence

A
  • 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
Q

2 characteristics of guidelines

A

Easy to follow

Compatible with existing norms and values

111
Q

Define quality improvement

A

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
Q

5 characteristics of quality improvement

A 
Interactive
Engages participation across all levels
Environment where improvement considered normal
Empowers staff to strive for change
Removes barriers to change
113
Q

When does quality improvement work / not work?

A

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
Q

3 initiatives targeting networks

A

Audits to identify variations in practise and outcomes
Recognition for high quality practise
Promote communication, collaboration and competition

115
Q

3 initiatives targeting professionals

A

Educational meetings / outreach visits to promote
Reminders
Surveys and focus groups

116
Q

2 initiatives targeting organisations

A

Introduction of MDT

Improve skill mix, service delivery and financial incentives

117
Q

Give 2 examples of financial initiatives

A

CQUIN: Commissioning for Quality and Innovation Network
QOF: Quality and Outcomes Framework

118
Q

Explain what CQUIN does

A

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
Q

Explain what QOF does

A

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
Q

Difference between what the patient and family notices in dementia

A

Patient - social embarrassment (can’t keep up), can’t find the right word, forget names

Family - repetition, forgets social arrangements, poor skills, withdrawing

121
Q

Define delirium

A

Physical illness precipitates acute confusion with fluctuating consciousness, agitation and hallucinations

122
Q

Why do patients see a dementia diagnosis as a relief?

A

They know what they’re up against

They can plan ahead

123
Q

What is the impact of a dementia diagnosis on the patient?

A

Denial (with/without insight - they forget they forget)
Anger that you’re suggesting something is wrong
Grief reaction

124
Q

What determines the response to the dementia diagnosis on the patient and carer?

A

Patient - insight and stage of illness, type of dementia, previous personality, support and relationships

Carer - understanding, patients reaction, relationship to patient

125
Q

5 benefits of a dementia diagnosis

A 
Access to treatment and support
Assess and manage risks e.g. driving
Information
Know what you're dealing with
Planning for the future
126
Q

4 reasons why dementia is different to other illnesses

A

Cannot share the burden of illness
Length of the disease
Personality change
Psychiatric problems

127
Q

6 effects of dementia on the partner/spouse

A

Emotional
Finances
Physical / Sexual
Practical (never cooked or managed finances before)
Relationship becomes skewed
Relationships with people outside fade (dementia patient is irritable)

128
Q

4 effects of dementia on the family

A

Conflict
Demands
Effect on young children
Role reversal

129
Q

6 effects of dementia on the carer

A 
Can't take time off
Constantly on their feet
No support from partner
Physical care
Sleep
Stress
130
Q

When is a loving relationship undermined?

A

When the patient:

Does not recognise the carer
Doesn’t behave as themselves
Has lost all dignity
Has no response

131
Q

Define person-centred care

A

Tailored around the individuals needs, preferences, values, beliefs, life, history and identity

132
Q

Define personhood

A

Knowing the person behind the dementia

133
Q

Define BPSD

A

Behavioural and Psychological Symptoms Dementia

134
Q

What helps in dementia management? (4)

A

Managing co-morbidities
Medication
MDT and team work
Supporting the patient and carer e.g. respite

Medicine - Year 2 (19 decks)

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