Theme C Flashcards
Features of Abortion Act
Abortion Act 1967
2 medical professionals (need to sign HSA1)
Pregnancy < 24 weeks
- continuing the pregnancy is a greater risk than termination and injury to mental or physical health to her or any other children OR
- prevent grave permanent injury to physical or mental health OR
- risk life of pregnant woman OR
- substantial risk if the child is prn would suffer from abnormalities that would causes serious handicap
There is no upper limit on gestation if due to 2,3, or 4
What form is required for abortion?
HSA1
When can termination be granted in under 16s
Without parental consent if:
- understand all aspects and implications
- cannot persuade them to tell parents
- physical or mental health with suffer if they don’t
- best interests to receive without parental consent
What should happen before a termination?
Confirm pregnancy Discuss methods and choices available Consider alternatives Allow time for decision (but earlier has less complications) Screen for chlamydia and STIs (positive in 13%) Discuss future contraception Check Rh status Check if requires smear
Describe conscientious objection of abortion
Section 4 of Abortion Act Can refuse Must provide treatment necessary to save a life Must explain the objection Cannot express disapproval
Epidemiology of Down’s syndrome
1 in 1500 at 20 years
1 in 100 at 40 years
>1 in 50 at 45 years
Screening methods for Down’s syndrome
Serum screening - 10 to 14 weeks
Ultrasound - nuchal translucency - 11 weeks to 14 weeks
Quadruple test - 14 to 20 weeks
Once a test has been performed, the chance of the foetus having Down’s is calculated
If > 1 in 150 then offer diagnostic testing
- Amniocentesis - 12 to 18 weeks (most common after 15 weeks)
- Chorionic villus sampling - 11 to 13 weeks
Who provides antenatal care?
If uncomplicated - midwife and GP led
Small group of medical professionals
Women should carry their own case notes
10 visits - uncomplicated nulliparous
7 visits - uncomplicated multiparous
What do the outcomes framework monitor in relation to pregnancy?
Infant mortality (up to 1 year) Perinatal mortality (including still births), pregnancy, immediately after birth
Define fertility rate
births per 1000 women per year aged 15-44
Define number of conceptions
total maternities + legal abortions + admissions for miscarriage + ectopic pregnancy
- 75% are live or still births
- 18% legal termination
- 7% miscarriage or ectopic
Define maternity
Any pregnancy that results in birth of live or still born child
Define live birth
Complete expulsion of product of concetion from mother, regardless of duration which shows any signs of life
- HR, breathing, umbilical cord pulsation, movement
Define abortion
Complete expulsion of foetus showing no signs of life prior to 24 weeks gestation
Triennial report - types of maternal mortality
Direct - death from obstetric complications
Indirect - resulting from previous existing disease, aggravated by pregnancy
Fortuitous - incidental but during pregnancy
Define maternal mortality
Deaths per number of maternities
Most common causes of maternal mortality
Hypertensive disease PE Haemorrhage Amniotic fluid embolus Early pregnancy Sepsis Anaesthesia
Define perinatal mortality
Deaths occurring during the first 7 days of life and still births per 1000 births
8 per 1000
Define neonatal mortality
Deaths during the first 28 days per 1000 births
Define infant death
Death within the first year of life
Causes of infant death
Low birth weight Prematurity <37 weeks Increased age of maternal mother (over 35, increased still birth) lethal or severe congenital malformation Infection SIDS Accident/trauma
Reasons for choosing home birth
Familiar, relaxing environment Wear own clothes, take shower, eat, drink, move freely Don't want medical intervention Cultrual or religious norms Hisotry of fast labour Lower cost
When is home birth not recommended
Diabetes HTN Epilepsy Past C-section prengnacy complication e.g. pre-eclampsia Breech or abnormal lie < 37 weeks or over 41 Multiple pregnahcy
Where can a woman give birth
ANY WOMAN CAN CHOOSE ANY BIRTH SETTING
- home, midwifery led, obstetric led
Problems with obstetric led birth
Increase itnerventions, not necessarily better outcomes e.g. more episiotomies and C-section
Reasons to transfer home or midwife led to obstetric birth
Delay in labour Abnormal foetal HR Request for regional anaesthesia Merconium staining Retained placenta Repair of perineal trauma Neonatal concerns post-partum
Impact of living with uncertain prognosis
Psychologically difficult
Worrying about future may impede ability to enjoy present
Hyperawareness of physical changes
Acquiring information to learn more (excessively)
Increased anxiety
Depression
Concerns over job, situation or career
Referral criteria for heart failure nurses
Over 18 with confirmed diagnosis and one of:
Need to be started on ACEi or beta blocker
Symptomatic on current meds
palliative care needs
New diagnosis and needs information
Recent hospital admission with exacerbation
Struggling with self-management
Role of heart failure nurses
Improves care and management
provides consistent care, readily accessed
- observation and management of side effects- provides understanding of meds
- makes them aware of symptom deterioration
- provides support
- first point of call
- encourage lifestyle changes
Causes of death in children
- Injuries and poisoning
- Malignant disease
- Neurological disorders
- Congenital malformations
- Respiratory disorders
- Infections
- Congenital disorders
Causes of fatal injuries in children
- RTA
- Other
- Drowning
- Assault
- Fire
- Falls
- Poisoning
Methods of accident prevention
RTAs - correctly fitting car seats, compulsory for under 135cm. Speed bumps. Play areas for children. Pedestrian priority
Bike accidents: helmets
Falls - stair guards, window safety catches
Drowning - fences around water
Fire- flame resistant materials. smoke alarms
Poisoning - child resistant bottles
Examples of big child protection cases
Victoria Climbie
- 8 year old girl murdered in 2000
- Post mortem shows 128 separate injuries
- Inspired Every Child Matters Campaign meaning organisations should share information
Baby P
- 17 month old died in 2007
- 50 injuries at death
- 35 contacts with healthcare professionals
Laming report - better sharing of information required
Dealing with drug addicted parents
Assess: substances taken, treatment therapies, withdrawal, abstinence
- If inadequate - referral to social care
When pregnant - planning meeting within 32 weeks
MDT in planning meeting in addicted parents
GP Obstetrics Midwife Drug and/or alcohol worker Probation Family workers Parents Children's centre Social worker
Concerning features in drug addicted parents
Defaulting drug/alcohol service appointments
Defaulting appointments for support agencies
Significant physical, obstetric or mental health problem
Drug use chaotic
Homelessness
Family network breakdown
STI epidemiology
- Chlamydia
- Genital warts
- Non-specific genital infections
- Gonorrhoea
- Other 19%
Increasing prevalence Most common in 15-24 years Rising syphilis and gonorrhoea Decreasing genital warts Increased in MSM
Prevention of STIs
- Counselling: safe sex
- Comprehensive sex ed
- Target at risk populations: sex workers, MSM, IVDU
- Barrier contraception
- Vaccinations: hep B and HPV
Make services free /affordable
Population based national plans
High risk groups for STIs
15-24 MSM Blacks and ethnic minorities Learning disability Homeless Custodial setting In care
Opportunities for sexual health promotion
Open access to health professionals Screening for chlamydia Target high need communities In school Sexual health clinics During routine consultations During pregnancy
Child Development Services
- MDT of predominantly heath professionals
- Multi agency
- co-ordinated service
- predominantly pre-school with mod-severe difficulties
- can provide support until 19
- maintains register of children with special needs
- nominated key worker
MDT in special needs
Paediatrician Physio OT SALT Clinical psychologist Specialist health visitor Dietician Social worker
At what ages are vaccinations given?
8 weeks 12 weeks 16 weeks 1 year 3 years 4 months 12-13 years 14 years
Vaccinations give at 8 weeks
5 in 1 vaccine
Men B
Meningococcal
Rotavirus
Vaccinations given at 12 weeks
5 in 1 vaccine
Rotavirus
Vaccinations given at 16 weeks
5 in 1 vaccine
meningococcal
men B
Contents of 5 in 1 vaccine
Diphtheria Tetanus Polio Pertussis Haemophilus Influenza
Vaccinations given at 1 year
haemophilus influenza Men B Pneumococcal MMR Men C
Vaccinations given at 3 years 4 months
MMR
5 in 1 vaccine
Vaccinations given at 12-13
Only in females
HPV 16 and 18
Vaccinations given at 14 years
Tetanus, diphtheria, polio
Men A, C, W & Y
Vaccinations given at 65 years
annual influenza
Pneumococcal
Ethics of vaccination
Autonomy and liberty - parental automony, raise child as they see fit
Neglect - child should not be exposed to disease or illness or denied medical care
Autonomy - mandatory vaccination will infringe on autonomy
Utalitarianism - best outcome for the largest number of people. Mandatory vaccinations increase herd immunity.
Harm principle - only justification for interfering with liberty is to prevent harm to others.
Vaccinations protect the most vulnerable
Preventing harm to individuals - vaccines should not put people at risk of harm. if already vulnerable or sick do not give.
Reasons against vaccinations
Unnatural
mistrust of pharmaceutical companies
Fears of unsafe
Decreased communicable disease only due to increase hygiene
Cannot force them
Does not want them - liberty and autonomy.
Reasons for and against mandatory vaccinations for health workers
Cannot force vaccinations
But can limit the work of someone who has not had the vaccine
It has decreased mortality by 40%, decreased work hours lost, cost saving
FOR
- Duty to not harm others
- Herd immunity is an institution
- Public trust in health care system may diminish
- Consistency between preaching and own actions
AGAINST
- Autonomy - freedom of choice
- Alternatives - increased hygiene levels
- Costs of finding non-compliers
- better staff education and incentives should increase uptake without mandate
Contraindication to vaccinations
Not in severely compromised (BCG, measles, yellow fever)
Not in pregnancy (measles, yellow fever, polio)
MMR - not in gelatine allergy
Chemoprophylaxis for meningococcal infection
Highest risk is first 7 days to household members
Without prophylaxis risk is 1 in 300
It is given to household members and partners
Aims to decrease risk of invasive disease - eradicates carriers and newly acquired disease
Rifampicin and ciprofloxacin
Needs to be given within 24 hours
Not required if:
- school/class members/nursery
- work colleagues
- friends
- kissing on cheek
- travelling together
Management of meningococcal infection
Cases referred early to CCDC promptly
Contact tracing
Education
Chemoprophylaxis
Preventing spread of disease
EDUCATION vaccinations isolations when treating hand hygiene PPE during contact with infected Regular cleaning of environment
Social implications of epilepsy
Depression Anxiety Low self esteem Social isolation Decreased sexual relationships Stigma Decreased employment (financial issues) Limits activities - swimming, heights, cycling on roads (if uncontrolled) Poor compliance Altered family dynamic - focus on the ill child (altered sibling relationships) Embarrassment about having a seizure Having to identify the fact you are epileptic Reduced quality of life Worries about becoming a parent - effect of drugs on baby - providing adequate care - inheriting epilepsy Limits alcohol and drug use Restricted driving privileges
Driving and epilepsy
For a group 1 licence - must be seizure free for 12 months
If a single seizure (isolated) after 5 free years then can continue to drive - only works once
If you have a seizure
- stop driving
- inform DVLA
- Send licence back voluntarily (can start reapplying 10 months after being seizure free
Group 2 licence (HGV) - must be seizrure free for 10 years and not have taken epilepsy medication in this time
To apply for a licence
- Provide medical report
- Details for last seizure
- Once you receive your licence it will be medically restricted and valid for 1, 2 or 3 years. Can apply for a long term licence after 5 years seizure free.
Driving and Stroke
Cannot drive for 1 month
Do not need to inform DVLA immediately but after 1 month (allows time to see lasting stroke effects)
Can drive again once a doctor says yes
If multiple TIAs must have 3 months TIA free to drive
Cannot drive HGV for 1 years
When to inform DVLA in neurology
Multiple TIAs in short time Worsening condition Epilepsy Brain surgery More than 1 stroke in 3m If doctor expresses concern about ability to drive HGV licence
Hearing screening in the newborn
Automated Otoacoustic Emissions Test (AOAE)
At birth - tests reflections from tympanic membrane, pass or fail
Automated Auditory Brainstem Response test (AABR)
Detects brain activity from sound, tests cochlea and nerve supply.
Done in any failed AOAE or NICU patients
If both failed then refer within 4 weeks for audio logical assessment
Evidence for treatment in otitis media with effusion
No proven benefit from any treatment or alternative therapy.
Hearing aids - NICE recommended if bilateral and hearing loss where surgery no acceptable or contraindicated
Pharmacological - non recommended.
- No oral or nasal steroids
- No antihistamines or decongestants
- no antibiotics (Cochrane)
Auto-inflation. NICE does not oppose but evidence base is limited. Valsalva manoeuvre
Surgery - if >3m and bilateral, if hearing loss >30dB or developmental difficulties
- Grommets provide initial improvement but no long term effects, increased infection risk and increased chronic perforation
prevention of hearing loss
Decreased noise trauma (ear protection in noisy environments)
Avoid ototoxic medications
Early treatment of causes
Screening of elderly to decrease consequences
Noise cancelling headphones rather than increasing volume
No objects in ears - cotton buds, tissue
Stroke rehabilitation
Starts in hospital
Aims to increase QoL
Increase independence for physical and psychological well being
NICE recommends:
- Treat in dedicated stroke in patient unit
- MDT
- Assess moving and handling, pressure risk, continence, communication, nutritional risk and hydration
- Psychological function
- Vision and hearing
- muscle tone, strength, sensation and balance
Physiotherapy, strength training - Impairment of body function
Including swallowing - SALT, swallowing therapy - Activity limitations
Long term
Set goals
Stroke MDT members
Neurologist Neurosurgeon Nurses Physiotherapy Occupational therapist Pharmacist SALT Psychologist Social worker Incontinence advice Dietetics Liaison psychiatry Orthoptics Orthotics Podiatry Wheelchair services
Stroke prevention
PRIMARY - Lifestyle: 2 portions of fish/week, 5 fruit and veg a day, 30 minutes of exercise 5 days per week, weight loss, decreased alcohol, smoking cessation - QRISK2 for CV risk - Treat hypertension - Antithrombotic if MI/AF/valve disease - Consider aspirin - Statins if QRISK2 indicates - If AF - CHA2DS2VASc. Females >1 and males >0 anticoagulate
SECONDARY
- Reinforce lifestyle
- Manage hypertension
- If AF and non haemorrhagic - anticoagulate
- If non-haemorrhagic - clopidogrel
- Statins for all
- Carotid endarterectomy if carotids >50%
- Carotid angioplasty and stents
Advantages of the randomised control trial
- Allows rigorous evaluation of a single variable in a precisely defined patient group
- Prospective design
- Uses hypotheticodeductive reasoning
- Potentially eradicates bias by comparing 2 otherwise identical groups
- Allow for meta-analysis at a later date
Diadvantages of a randomised control trial
- Expensive and time-consuming
- Many are not carried out
- Or performed on too few people
- Or sponsored by drug companies who dictate research agenda
- end points may not reflect outcomes that are important to patients - May introduce hidden bias
- Imperfect randomisation
- Failure to randomise all eligible patients
- Failure to blind assessors to randomisation status
When is an RCT inappropriate
- Where the study is looking at the prognosis of a disease
For this analysis it is best to use a longitudinal survey - Where the study is looking at the validity of a diagnostic or screening test (best to use cross sectional)
- Where the study is looking at quality of care in which criteria for success have not been established (better with qualitative)
Describe cohort study
2 or more groups of people are selected on the bases of differences of exposure to a particular agent and followed up to see how many get the disease, complication or outcome.
Follow up period is usually years.
Started on normal people
Describe case-control study
Patients with a particular disease or condition are identified and matched with controls.
Data is then collected by looking back through medical records or asking them to recall history.
Best option for looking at rare disease
Cannot be used to determine causality
Hierachy of evidence
- Systematic reviews and meta analysis
- RCTs with definitive results (CI do not overlap)
- RCTs with non-definitive results
- Cohort
- Case-Control
- Cross-sectional survey
- Case report
Was the study original, questions to consider?
There is no point testing a scientific hypothesis that someone else has already proved.
It needs to add something to the current body of literature
- Is this one bigger, continued for longer or more substantial?
- Are the methods of this study more rigorous, does it address any specific methodological criticisms of past studies?
- Will the numerical results of this study add to meta-analysis of previous studies?
- Is the population different?
- is the clinical issue of sufficient importance or any doubt requiring further study?
Paper appraisal
Is it relevant to your population?
Were those being studied?
- More or less ill than your patient
- Were they from a different ethnic group
- Do they live a different lifestyle
- Did they receive more or less attention that your population
- is there any comorbidities in your patient, not seen in the study
- Number of smokers, alcohol etc.
Define palliative care
Approach that improves the quality of life for patients and their families at the end of life.
Treatment of pain and problems physical, psychosocial and spiritual
Aims of palliative care
- Provides relief from pain and symptom
- Affirms life and regards dying as normal process
- Intends to neither hasten or postpone death
- Integrates psychosocial and spiritual aspects of care
- Offers support system to allow patients to live as actively as possible until death
- Offers support for the family to cope during illness and bereavement
- Uses a teams approach
- Enhances quality of life
- Is applicable early in course of illness in conjunction with other therapies that can prolong life e.g. chemo and radiotherapy
End of Life Strategy
Published by Department of Health in 2008
It identified a number of significant issues affecting dying and death
Patients will have
- Opportunity to discuss needs and preferences
- Have a recorded care plan
- Co-ordinated care and support
- Rapid service and clinical assessment
- high quality care and support
- Treated with dignity
- Appropriate support for carers and families
- Services will be monitored and assess to ensure quality. National Intelligence Network to collect, analyse and publish data
- Services to be informed by experience of others: VOICES survey
Define good death
- Being treated as an individual with dignity and respect
- Being without pain and other symptoms
- Being in familiar surroundings
- Being in the company of close family and or friends
Where do deaths occur?
58% in hospital
18% at home
17% in care homes
4% in hospices
Palliative care pathway steps
- Identify people approaching end of life and initiate discussion about preferences for end of life care
- Care planning: assess needs and preferences, agree to care plan and review regularly
- Co-ordination of care
- Delivery of high quality services in all areas
- Management of last days of life
- Care after death
- support for carers during and after illness
What is the Gold Standards Framework and what are its aims?
It is recommended by the End of Life Strategy 2008
It is a way of working that has been adopted across the UK with regards to palliative care;
- Identify people in need of special care
- assess and record their needs
- Plan and provide care
AIMS
- Physical symptoms are reduced
- Patients have a choice and control over place of care
- Patients feel sense of safety and security and feel supported
- Family and carers feel supported, enabled and informed
- primary care team work effectively with other health professionals
What are the 7 C’s of Gold Standards Framework
- Communication
- Coordination of care
- Control of symptoms and ongoing assessment
- Continuing support
- Continued learning
- Carer and family support
- Care in final days
RCT - assessing allocation
Was there random allocation?
Is the method of allocation described?
How was the randomisation schedule generated?
How was a participant allocated?
Were the groups balanced?
Any differences address and accounted for?
If there were any differences - could they be confounders?
RCT - assessing blinding?
Consider that blinding is not always possible
Has every effort been made to achieve blnding?
Does it matter in this study?
RCT - were all who entered the trial accounted for in its conclusion?
- If any intervention group participatns were given a control group option of vice versa
- If all participatns were followed up in each study group (any loss to follow up)
- Analysis through intention to treat?
- What additional information would be valuable?
RCT - were all participants treated in the same way?
Reviewed at same time periods?
If they received the same amount of attention?
Any differences? Could this have affected the results?
RCT - is it applicable locally?
Are the people in the trial different to your population
Does the local setting differ
Can the same level of treatment be provided
Consider outcomes from point of view of individual, policy maker, professionals, family and wider community
- Any benefit, does it outweight any harms or costs
COST ANALYSIS
Should policy be changed.
Define guidelines
A consensus of best practice based on available evidence in health care
Features of an effective guideline
- Wide range of clinical and user perspectives
- External reviews incorporated
- Time limit used
Methods of implementing guidelines
Computer messages Audio visual aids Electronic publications Educational Outreach visits Local opinion leaders (consultants) Computer Decision Support systems
Groups that need special precautions with food poisoning
Pregnant women Very young Very old People who work with food People who work with immunocompromised (healthcare)
Common food poisoning causative agents
Campylobacter (from milk and poultry) Shigella (salad, veg and dairy) salmonella (eggs, meat, poultry) Clostridia (spores in meat) Listeria (meat, dairy, fish, shellfish)
Dealing with an outbreak of food poisoning
Identify and isolate the source
Identify and treat infected individuals
Advse and further treatment and prevention of spread
- Hygiene
- Off work for 48 hours
- Notify HPA - Public health (control of disease act) 1984
Common causes of nosocomial diarrhoea
Clostridium difficile Norovirus Rotavirus E.coli Klebsiella MRSA
Factors considered when allocating organs
Tissue type matching (ABO and HLA)
Type of organ
Location or organ and nearest recipient (ischaemic time)
Factors leading to increased transplant rates
Large number of transplant centres
High percentage of the population university educated
High percentage of Roman Catholics
Proactive donor detection programme
Economic reimbursement for hospitals
High number of RTAs
Assessing cost effectiveness of screening
Estimate costs in relation to calculated number of years saved (cost-effectiveness analysis)
- Cost of equipment
- Cost of additional examination (depends on false + rate)
- Prevalence and mortality in the examined population
- Compliance rate
- Cost of primary therapy
- Costs saved by reducing number of cost-intensive therapies for advanced stages
- Effect of years gained on GNP, income and taxes
Diabetes MDT
Diabetes specialist nurse Podiatrist Dietician Doctor Endocrinologist Nephrologist Ophthalmologist Cardiologist Neurologist
Medical conditions more common in obese patients
Arthritis T2DM CVD Cancer End stage renal disease Chronic venous insufficiency Gout Sleep apnoea Stroke DVT/PE HTN Urinary stress incontinence Surgical complications
SMART targets
Specific Measureable Achievable Realistic Time bound
National Obesity Forum
Established to raise awareness of the growing impact of obesity on our patients and NHS
- Create recognition of obesity as a serious medical problem
- Produce education on obesity management
- Provide guidelines for obesity management in primary care
- Provide a network for support and in information resource
- Convince the government to give obesity a high priority
- Highlight health inequalities of obesity
National Service Framework for Mental Health
Set of policies created to define standards of care for major medical issues
- Help drive up equality and remove the wide variations in provision of care
- Set national standards and define service models
- Put in place programmes and support local delivery of services
- Establish milestones and performance indictors to measure.
NICE recommendations for fertility treatment
Women under 40 unable to conceive after 2 years of regular unprotected intercourse get 3 cycles of IVF
Women aged 40-42 are offered 1 cycle but only if they have not had IVF in the past and they DO NOT have low ovarian reserve
Ovarian stimulation can be given in unexplained fertility
Intrauterine insemination can be used if endometriosis, mild male infertility or a physical or psychological problem with having sex
Risks associated with fertility treatment
Multiple pregnancy
Ectopic pregnancy
ovarian Hyperstimulation syndrome
Complaints in the NHS
2 stage process
- Ask GP, hospital or trust for a copy of complaints procedure
- Raise the matter verbally or written with the practioner or to NHS England or to local BBG (local resolution)
Most are sorted at this stage
If still unhappy can refer to Parliamentary and Health Service Ombudsman who is independent of the NHS and government
Common complaints in NHS
- Safety of clinical practice
- Poor or insufficient information
- Ineffective clinical practice
- Poor handling of complaints
- Discharge and co-ordination of care
- Lack of dignity and respect
- Poor attitudes of staff
- Failure to follow consent procedures
- Poor environment including poor hygiene
- Lack of access to personal clinical records
Problems in handling of complaints
Failure to acknowledge validity of complaint
Failure to apologist
Response do not explain what has been done to prevent recurrence
Response contain medical or technical jargon
Failure to involve staff directly concerned in the complaint in the investigation
High risk groups for STIs
Young Black/ethnic minority Gay/bisexual IVDU HIV positive Sex workers Prisoners
Down’s screening
Combined test between 10 and 14 weeks
- Blood test: beta hcg and PAPP-A
- Nuchal scanning
Quadruple test after 14 weeks
- beta hcg
- AFP
- Inhibin A
- Unconjugated oestradiol
Raised beta hcg and inhibin A in Down’s
Low UE3, AFP and PAPP-A
If result shows risk > 1/150 then amniocentesis or chorionic villus sampling is offered
Current antenatal and neonatal screening
Anencephaly Spina bifida Cleft palate/lip Diaphragm hernia Gastrroschisis Exomphalos Cardia and renal complication Edward's Patau's
Sickle cell and thalassaemia
Hep B, HIV, rubella, syphilis in pregnancy
Newborn blood spot - CF, PKU, hypothyroidism, MCAD
Newborn hearing
New born and 6 week baby check
Contraindications to live vaccines
Receiving cancer treatment or finished in the last 6 months
Taking immunosuppressive drugs
Bone marrow transplant in last 6 months
Taking high dose steroids
Evidence of immune impairment
HIV positive
Vaccinations given at 2 months
Rota virus
5 in 1
Pneumococcus
Vaccinations given at 3 months
Rotavirus
5 in 1
Men C
Vaccinations given at 4 months
5 in 1
Pneumococcal
Vaccinations given at 1 year
Hib
Men C
MMR
Pneumococcal
Every Child Matters Key Outcomes
Healthy - physical/mental/lifestyle Safe - from harm and neglect Enjoy & achieve - most out of life Contribute - to society and community Economic wellbeing - full potential
Purpose of MDTs for child safety
Children get the help they need when they need it
Professionals take timely action to protect children
Professional ensure children and listened to and respected
Agencies and professionals work together to assess needs and risk and develop effective plans
Professionals are competent and confident
Agencies work with members of the community
Psychosocial issues regarding back pain
Constant discomfort from the pain Loss of income Depression Loss of independence Feeling of guilt/like a fraud Side effects from medications Relationship issues Decreased social/ leisure activities Inability to care for the family Decreased libido
Epidemiology of falls
30% over 65 suffer from falls
Incidence is increasing with ageing population
In residential care fall are 3x higher
RFs Parkinsons Stroke Arthritis Joint disease Muscle weakness/myopathy Incontinence Gait abnormality Incontinence Postural hypotension Low BMI
Poor lighting Steep stairs Rugs/ loose carpet Slippery floors Cluttered areas Poorly fitting footwear
Polypharmacy
Sedatives
Antihypertensives
Dementia
Visual impairment
Diabetic neuropathy
Hearing impairment
Consequences of falls
Fractures NOF
Head/ eye injuries
Wrist #
Spinal #
Long lie
- hypothermia
- pressure sores
- rhabdomylysis
- dehydration
Loss of confidence, immobility, isolation, depression, decreased independence, long term care
Methods for preventing falls
Homes based strength and balance training Daily cleaning of spectacles Regular vision checks Staff monitoring in nursing homes Home safety assessment and modifications Podiatry Walking aids
Benefits of blind registration
Blue badge parking permit Leisure centre consessions bus and rail ticken concessions TV licence concessions Career and employment advice Disability Living Allowance
Blind registration
Can only occur if recommended by consultant ophthalmologist
Registration is voluntary, only 30% register (stigma, unaware of system)
Principles of Quality Standards for Older People
- Remove age discrimination
- person centred care
- Integrate services to promote faster recovery
- Specialist services in hospital
- Reduce incidence of stroke
- Reduce incidence of falls
- Promote good mental health
- Extend healthy life expectancy
NICE technology appraisal
Assess the evidence base and clinical and cost effectiveness of new and existing healthcare technologies with a view to providing single, authoritative source of advice on interventions and procedure
Technology appraisal is mandatory to gain funding
Technologies that can be appraised are:
- Drugs
- Diagnostic tests
- Clinical devices
- Surgical and clinical procedures
- Health promotion interventions
Technology appraisal process
- Topic selection - through consultation with industry and NHS and patient groups
- Data submission - industry is required to submit all trial data according to NICE criteria
- Data review - NICE appraisal committee allocates data to an academic centre to report on clinical and cost effectiveness
- Call for contributions = from interested parties including stakeholders (manufactures, Royal colleges, patients, carers)
- Funding. If mandatory CCGs must fund the service if it is required
Quality standard criteria for dementia
- Care from specialist dementia staff
- memory assessment
- written information
- personalised care plan
- opportunity to discuss advanced decisions
- assessment and management of non-cognitive symptoms
- Special dementia liaison services
- Assessment of palliative care
- Address carers emotional, psychological and social needs
- Respite services
Quality standard for suspected stroke patients
- Screened with validated tool
- Receive brain imaging within hour
- Admitted directly to acute stroke unit, assess for thrombolysis
- Swallowing assessment before feeding
- Ongoing rehabilitation
- Minimum 45 minutes of active therapy per day
- Treatment plan for incontinence
- Scree for cognitive and mood disturbance within 6 weeks
- Specialist stroke rehabilitation services after discharge
- Carers given contacts and information
Criminal Transmission of HIB
Intentional - deliberate transmission with aim to cause harm
Reckless - not deliberate but careless
Accidental - unaware of condom failure
Hard to prove
HIV is not a notifiable disease
Doctor has a duty of care to the patient, but also to protect those that might be at harm
Doctor has a duty of confidentiality to the patient
Doctors may breech this if they are protecting another from serious harm
Ask advice from medical defence union or GU consultant
Why monitor adverse events?
Common - important consequences
Up to 50% are preventable
Can learn from adverse events
Can reduce in future and improve care
National patient safety agency
It is the body responsible for handling adverse events and adverse events should be reported to them.
Example
- Yellow card reporting for drug side effects
Never events
Wrong site surgery
Wrong implant/prosthesis
Retained foreign object post-op
Selection of a high potassium solution
Wrong route of administration
Overdose of insulin due to abbreviations or incorrect device
Overdose of methotrexate for non-cancer treatment
Mis-selection of high strength midazolam during conscious sedation
Failure to install functional collapsible shower or curtain rails
Falls form poorly restricted windows
Check or neck entrapment in bed rails
Transfusion of ABO incompatible blood
Mis placed NG tube (that is then used)
Scalding of patients
Criteria for consent
For consent to be valid it must be:
- Voluntary
- Informed
- patient must have capacity
When is consent not required?
Additional procedures - if it is too dangerous to wake the patient to get consent (surgery)
Emergency treatment
mental health condition under mental health act 1983
Risk to public health (Public Health (Control of Diseases) Act 1984)
Severely ill and living in unhygienic conditions (National assistance act 1948) - taken to a place of care with or without consent
Consent and children
Over 16 - make own decisions
Under 16s can consent to treatment if they are Gillick competent.
If a child refuses treatment then their decision can be overruled by the Parents of Court of protection
If a parent refused to consent for a treatment for their child that prevents injury/death this can be overruled by the courts
Only one parent needs to consent
Consent not required in emergency
4 ethical principles
Justice
Autonomy
Non-maleficence
Beneficence
Situations where can break confidentiality
DVLA if patient will not inform themselves
Required by law
Gunshot and knife wounds reported to police
Communicable diseases
Risk to child’s safety
General principles
- Protect children
- protect public from acts of terrorism
- Under Drug Trafficking Act 1986
- Prevent or detect a crime
- In life threatening situations
- Protect service provider e.g. violent patient
Define euthanasia
Deliberately ending a person’s life to relieve suffering
- Active
- Passive (withdrawal of treatment)
- Voluntary - asking for help
- Non-voluntary - unable to give consent e.g. coma
Define assisted suicide
Act of deliberately assisting or encouraging another person to commit suicide
Arguments for euthanasia
Ethics - freedom of choice (AUTONOMY)
- DNACPR is a form of passive euthanasia
- Palliative sedation - likely shortening lifespan
Beneficence = acting in the patient’s best interests
Doctrine Double Effect
An act is allowed if it brings about a good consequence that can only be achieved at risk of a harmful side effect
Arguments against euthanasia
Religious - only god has that right
Slippery slope
- Ill people may feel pressure to accept euthanasia to not be a burden
- Discourages research into palliative care
- Misdiagnosis or prognosis could lead to unnecessary euthanasia
Violates ethical code of doctors - do no harm
Non-maleficence
Lack of compassion
Alternatives are available
- Palliative care and mental health care
- Can still have painless death with dignity
Reasons for abortion
AUTONOMY - women have the right to decide what happens to their body
JUSTICE - right to abortion is vital for women to achieve full potential e.g. teen pregnancy
BENEFICIENCE - force women to use illegal and unsafe abortionists
JUSTICE and BENEFICIENCE - avoid emotional harm of bearing a child from rape
NON-MALIFICEINCE - foetus is immature entity and would not survive outside of uterus
BENEFICIENCE - undesired pregnancy can decrease quality of life and psychological harm for mother
Reasons against abortion
JUSTICE - all forms of human life have the right to life
NON-MALIFIENCE - deliberate ending of another’s life is no different to murder
NON-MALIFEINCE - medical complications later in life
JUSTICE - many couples are looking to adopt and abortion denies them this opportunity
Research ethic principles
Nuremburg code for research ethics principles
- Voluntary consent from all involved
- Should yield results beneficial to society that cannot be acquired by other means
- Based on animal experimentation and knowledge of natural history of disease
- Avoid all unnecessary physical and mental suffering
- Should not be performed if there is a prior reason to believe the intervention is harmful
- Risk should not exceed humanitarian importance
- Preparation and facilities should be provided to protect subjects from injury, disability or death
- Conducted by scientifically qualified people
- Can leave whenever they wish
- Scientist in charge should be prepared to end experiment if harm comes to subjects
When to report under age sexual activity
Child under 13
Belief that they are abused or exploited
Lacks capacity
Define confidence interval
Range of values that is 95% likely to contain the true value
Describes the level of uncertainty in the sample.
What information is required to interpret a confidence interval?
Confidence level e.g. 95%
Statistic
Margin or error
Sample statistic +/- margin or error
Define p value
Likelihood that the observed result is due to change
P > 0.05 is not statistically significant
What results in a change to the size of the confidence interval
Variation in sample data
Chosen % interval
Sample size
Define power
The probability that it will reject a false null hypothesis
It is inversely related to the probability of making a type 2 error
It is the likelihood that a study will detect an effect when there is an effect to be detected.
It is affected by the size of the effect and the size of the sample used to detect it.
Purpose of blinding
Eliminates
- Investigator bias
- Evaluation bias
- Hawthorne effect - participant may exaggerate the effects
Types of blinding
Single = only the participant is unaware about which treatment they are receiving
Double = both the participant and the investigator are unaware about the intervention
This eliminates observer bias
Triple = in addition, the evaluator is not aware of the process
Define null hypothesis
No difference
No effect
Define randomisation
The allocation of treatments to patients using a random process
- Allocation should be unbiased
- Treatment groups should be balanced
This is so there is a fair test of efficacy
Types of randomisation
Restricted randomisation
Block randomisation
Minimisation
Stratification
Define restricted randomisation
Number of patients in each group are chosen in advance
Define block randomisation
This ensures similar numbers of paitents are in each group. For each block, half to treatment, half to placebo
Block size can be changed and it can be stratified into subgroups
Define stratified randomisation
Stratification gives an equal distribution of risk factors between groups in an attempt to reduce confounding.
Why randomise?
Ensures investigator cannot influence who is in which group
In the long run the groups and comparable in known and unknown factors
Any observed effect is due to treatments.
Define selection bias
This occurs if the likelihood of enrolling a certain patient is influenced by knowing which treatment they might receive
Define responder bias
Knowledge of which group a person is in can influence response.
Based on placebo effect.
Common confounding factors
Age
Sex
Demographic characteristics
Intention to treat analysis
Once a patient has been randomised they must be analysed in their allocated group regardless of whether they followed the protocol correctly
Per protocol analysis
Reports who actually got which treatment and analyses as such
Does not reflect real life
What is a confounder
They are factors that influence treatment and outcome measures and include demographic characteristics, prognostic factors and other characteristics that may influence someone’s likelihood of participating or withdrawing from the trial
Define internal validiyu
Accuracy
how well the study was conducted
taking into account confounders and removing bias
Define external validity
Generalisability
How well the study can be applied to different scenarios
Type 1 error
Null hypothesis is rejected when it is true
(result of trial wrongly shows a difference(
False positive
Not affected by sample size
Increased by increased number of end points
Probability of type 1 error = alpha
Type 2 error
Null hypothesis is ACCEPTED when it is false
Result of trial fails to show the true difference
False negative
Decreased by a smaller sample size
Probability of type 2 error = beta
Define absolute risk
Risk of disease among the population being studied
Define relative risk
Risk if disease among exposed compared to that of non-exposed
Define risk ratio
Probability of disease in the at risk group / risk of not at risk group
Define odds ratio
It is a the measure of an association between exposure and outcome.
It represents the odds that an outcome will occur given a particular exposure
When is an odds ratio used
In case control studies Mostly
Can sometimes be used in cross-sectional and cohort studies
What does an odds ratio >1, <1 and equal to 1 mean
OR = 1. Exposure does not affect odds of outcome
OR > 1. Exposure is associated with higher odds of outcome
OR < 1 exposure is associated with lower odds of outcome
Calculating odds ratio
ad/bc
a = positive outcome, positive exposure b = negative outcome, positive exposure c = positive outcome, negative exposure d = negative outcome, negative exposure
Absolute risk reduction
risk in exposed - risk in unexposed
Number needed to treat
1/ absolute risk reduction
Number of patients needed to be treated to produce 1 improved outcome
Round up for benefit
Round down for harm.
