Handover communication and continuity of care for chronic disease patients in India: a mixed-methods investigation

This thesis research investigated handover communication and continuity of care for patients with chronic, non-communicable diseases (NCDs) in Himachal Pradesh and Kerala states, India. A systematic review explored the literature on quality of handover communication and interventions for handover communication in low and middle-income countries (LMICs). Mixed-methods were employed to investigate the following in Himachal Pradesh and Kerala states, India: handover and healthcare communication within and between levels of care for chronic NCD patients, the association between quality of discharge handover communication and chronic NCD patient outcomes, healthcare provider (HCP) training and protocols for handover communication and possible strategies to improve the storage and exchange of healthcare information for chronic NCD patients. The systematic review found a relative dearth of LMIC literature and that sub-optimal recording and/or transfer of patient information was a commonly reported issue in all areas of handover communication (i.e. shift-change, discharge, referrals and transfers). A number of system, organisational cultural and individual healthcare provider issues were described as affecting the quality of each area of handover. The majority of interventional studies were non-randomised, of medium to low quality and reported improvements in handover communication. Regarding handover and healthcare communication in Himachal Pradesh and Kerala states, India, the mixed-methods outpatient and quantitative inpatient studies evidenced that most patients who visited public healthcare outpatient clinics (OPC) and who were discharged from public hospitals received unstructured patient-held medical documents that contained deficient information for facilitating effective continuity of care. In the mixed-methods outpatient and the qualitative and prospective inpatient studies, patient reports indicated notable inconsistencies regarding HCP healthcare management communication. In the mixed-methods outpatient, qualitative inpatient and cross-sectional HCP studies, HCP reports revealed a lack of standardised procedures for handover communication between levels of care across public and private healthcare facilities. Factors affecting the quality of handover communication were also identified; HCPs in the mixed-methods outpatient study reported that public healthcare OPCs did not maintain in-house patient records. In both the mixed-methods outpatient and qualitative inpatient studies the following factors were identified by HCPs/patients: time constraints, inconsistent referral practices, unstructured medical documents, inconsistent patient transportation of medical documents and deficient HCP handover training. In the cross-sectional HCP study, the following factors were most frequently reported as “highly applicable” to referral and discharge communication: excessive workload and poor health systems and integration. Regarding discharge handover communication and patient outcomes, the prospective inpatient study evidenced significant associations between low-quality documented discharge communication and death (AOR=3.00; 95% CI 1.27,7.06) and low-quality verbal discharge communication and self-reported deterioration of chronic NCD/s (AOR=0.46; 95% CI 0.25,0.83) within 18 weeks of follow-up. Regarding HCP training and protocols, the majority of HCPs in the cross-sectional HCP study reported that they had not received structured training for shift-change, discharge or referral. HCPs in both the mixed-methods outpatient and qualitative inpatient studies also reported an absence of handover training and structured referral protocols. One private tertiary hospital in Kerala was found to have policies and structured documents for clinical handover. Other than standards/guides for voluntary quality accreditation schemes, no further handover-specific protocols, policies, guidelines or training documents were identified across Himachal Pradesh and Kerala. Regarding strategies for improving handover communication, HCPs in the qualitative inpatient study reported the following: increased public healthcare resources, formal referral systems and computerised “e-health” systems. In both the mixed-methods outpatient and qualitative inpatient studies, patients and HCPs supported the idea of structured patient-held booklets for storing and transporting medical documents. In conclusion, the findings suggest that continuity and safety of chronic NCD patient care are likely being compromised by suboptimal recording and transfer of patient information, as well as a lack of standardised handover communication protocols and HCP training. They have also highlighted a context-relevant and acceptable intervention for improving patient information exchange and the need for further highquality handover communication research in India and other LMICs

Novel bioanocatalysis for chromium (VI) remediation

Many industrial wastewater' s contain carcinogenic and mutagenic Cr (VI). Conversion to Cr(III) reduces toxicity. Desulfovibrio vulgaris NCIMB 8303 and Microbacterium sp. NCIMB 13776 immobilized in agar reduced Cr(VI) at initial rates of 127 and 15 nmol h$^{-1}$ mg dry cell wf$^{-1}$ in batch, and for 160 h in continuous-flow packed-bed columns. Similar columns containing agar-immobilized Bio-Pd(O) (Pd(II) was reduced to ceil-bound Pd(O) using growth decoupled cells of D. vulgaris) reduced Cr(VI) in excess of 1334 h. Bio-Pd(O) produced using Desulfovibrio species was catalytically superior to Bio-Pd(O) produced using Escherichia coli species. Application of enzyme kinetics to the immobilized Bio-Pd(O) system gave an apparent K$_{m}$ value of 650 μM for batch reduction, and 430 μM for continuous-flow. Magnetic Resonance Imaging (MRI) was used to demonstrate immobilization matrix integrity, homogeneity within agar beads, and to distinguish between columns containing Cr(III) and Cr(VI), suggesting it may be possible to study Cr(VI) reduction non-invasively in vivo using MRI. Biologically produced hydrogen was used in conjunction with resting and palladised cells of D. vulgaris for Cr(VI) reduction, and a system proposed for the concurrent treatment of industrial sugar wastes, precious metal scrap and Cr(VI)

Practice supervisors and assessors experiences in the Covid 19 pandemic

The roles of practice supervisor and practice assessor were introduced in 2018, with a greater focus on students taking responsibility for their learning. Staff in these roles have had to support learners during a time of additional challenges because of the Covid-19 pandemic. To capture these experiences at Bournemouth University, we conducted a survey and collected anecdotal evidence. We identified some challenges to the role, alongside positive outcomes for learners. These findings will be instrumental in planning future training and support for practice supervisors and assessors

Patient and healthcare provider knowledge, attitudes and barriers to handover and healthcare communication during chronic disease inpatient care in India:a qualitative exploratory study

Objectives 1. To investigate patient and healthcare provider knowledge (HCP), attitudes and barriers to handover communication during inpatient care. 2. To explore potential interventions for improving the storage and transfer of critical healthcare information. Methods Design: Qualitative study comprising 41 semi-structured, individual interviews. Thematic analysis using the Framework Method with analyst triangulation. Setting: Three hospitals in Himachal Pradesh and Kerala, India. Participants: 20 male (n=10) and female (n=10) chronic NCD patients and 21 male (n=15) and female (n=6) HPCs. Purposive sampling was used to identify patients with chronic NCDs (Chronic Respiratory Disease, Cardiovascular Disease, Diabetes or Hypertension) and HCPs working in the study hospitals. Results For chronic NCD patients, three themes emerged: (1) Public healthcare service characteristics; (2) HCP-patient communication; (3) Attitudes regarding medical information. For HCPs, three themes emerged: (1) System factors; (2) Information exchange practices; (3) Quality improvement strategies. Whilst some content within themes was unique to each participant group, there was substantial overlap. Both patients and HCPs recognised constraints affecting public healthcare; deficient primary care services placed increased pressure on hospitals, subsequently limiting HCP consultation times. HCP and IP reports also indicated an absence of structured referral formats, resulting in fragmented information transfer. Additionally, whilst patient-held documents were a key vehicle for information exchange between HCPs, not all patients transported them and HCPs stated that this hindered continuity of care. Inpatient descriptions of HCP communication indicated notable inconsistencies and a lack of patient-centeredness. HCPs reported systemic issues such as absence of formal handover communication systems and training. Conclusions Handover communication for chronic NCD patients visiting public hospitals in India is currently suboptimal. Structured information exchange systems are urgently required to improve quality, continuity and safety of care. Our findings indicate that well-designed patient-held record booklets may be an acceptable and effective part of the solution

Efficiency and safety of varying the frequency of whole blood donation (INTERVAL): a randomised trial of 45 000 donors

Background: Limits on the frequency of whole blood donation exist primarily to safeguard donor health. However, there is substantial variation across blood services in the maximum frequency of donations allowed. We compared standard practice in the UK with shorter inter-donation intervals used in other countries. Methods: In this parallel group, pragmatic, randomised trial, we recruited whole blood donors aged 18 years or older from 25 centres across England, UK. By use of a computer-based algorithm, men were randomly assigned (1:1:1) to 12-week (standard) versus 10-week versus 8-week inter-donation intervals, and women were randomly assigned (1:1:1) to 16-week (standard) versus 14-week versus 12-week intervals. Participants were not masked to their allocated intervention group. The primary outcome was the number of donations over 2 years. Secondary outcomes related to safety were quality of life, symptoms potentially related to donation, physical activity, cognitive function, haemoglobin and ferritin concentrations, and deferrals because of low haemoglobin. This trial is registered with ISRCTN, number ISRCTN24760606, and is ongoing but no longer recruiting participants. Findings: 45 263 whole blood donors (22 466 men, 22 797 women) were recruited between June 11, 2012, and June 15, 2014. Data were analysed for 45 042 (99·5%) participants. Men were randomly assigned to the 12-week (n=7452) versus 10-week (n=7449) versus 8-week (n=7456) groups; and women to the 16-week (n=7550) versus 14-week (n=7567) versus 12-week (n=7568) groups. In men, compared with the 12-week group, the mean amount of blood collected per donor over 2 years increased by 1·69 units (95% CI 1·59–1·80; approximately 795 mL) in the 8-week group and by 0·79 units (0·69–0·88; approximately 370 mL) in the 10-week group (p<0·0001 for both). In women, compared with the 16-week group, it increased by 0·84 units (95% CI 0·76–0·91; approximately 395 mL) in the 12-week group and by 0·46 units (0·39–0·53; approximately 215 mL) in the 14-week group (p<0·0001 for both). No significant differences were observed in quality of life, physical activity, or cognitive function across randomised groups. However, more frequent donation resulted in more donation-related symptoms (eg, tiredness, breathlessness, feeling faint, dizziness, and restless legs, especially among men [for all listed symptoms]), lower mean haemoglobin and ferritin concentrations, and more deferrals for low haemoglobin (p<0·0001 for each) than those observed in the standard frequency groups. Interpretation: Over 2 years, more frequent donation than is standard practice in the UK collected substantially more blood without having a major effect on donors' quality of life, physical activity, or cognitive function, but resulted in more donation-related symptoms, deferrals, and iron deficiency. Funding: NHS Blood and Transplant, National Institute for Health Research, UK Medical Research Council, and British Heart Foundation

Effects of antiplatelet therapy on stroke risk by brain imaging features of intracerebral haemorrhage and cerebral small vessel diseases: subgroup analyses of the RESTART randomised, open-label trial

Background Findings from the RESTART trial suggest that starting antiplatelet therapy might reduce the risk of recurrent symptomatic intracerebral haemorrhage compared with avoiding antiplatelet therapy. Brain imaging features of intracerebral haemorrhage and cerebral small vessel diseases (such as cerebral microbleeds) are associated with greater risks of recurrent intracerebral haemorrhage. We did subgroup analyses of the RESTART trial to explore whether these brain imaging features modify the effects of antiplatelet therapy

A 19-SNP coronary heart disease gene score profile in subjects with type 2 diabetes: the coronary heart disease risk in type 2 diabetes (CoRDia study) study baseline characteristics

Background The coronary risk in diabetes (CoRDia) trial (n = 211) compares the effectiveness of usual diabetes care with a self-management intervention (SMI), with and without personalised risk information (including genetics), on clinical and behavioural outcomes. Here we present an assessment of randomisation, the cardiac risk genotyping assay, and the genetic characteristics of the recruits. Methods Ten-year coronary heart disease (CHD) risk was calculated using the UKPDS score. Genetic CHD risk was determined by genotyping 19 single nucleotide polymorphisms (SNPs) using Randox’s Cardiac Risk Prediction Array and calculating a gene score (GS). Accuracy of the array was assessed by genotyping a subset of pre-genotyped samples (n = 185). Results Overall, 10-year CHD risk ranged from 2–72 % but did not differ between the randomisation groups (p = 0.13). The array results were 99.8 % concordant with the pre-determined genotypes. The GS did not differ between the Caucasian participants in the CoRDia SMI plus risk group (n = 66) (p = 0.80) and a sample of UK healthy men (n = 1360). The GS was also associated with LDL-cholesterol (p = 0.05) and family history (p = 0.03) in a sample of UK healthy men (n = 1360). Conclusions CHD risk is high in this group of T2D subjects. The risk array is an accurate genotyping assay, and is suitable for estimating an individual’s genetic CHD risk. Trial registration This study has been registered at ClinicalTrials.gov; registration identifier NCT0189178

Genetic polymorphisms of MMP1, MMP3 and MMP7 gene promoter and risk of colorectal adenoma

BACKGROUND: Matrix metalloproteinases (MMP) have been shown to play a role in colorectal cancer (CRC). More recently, MMP1, MMP3 and MMP7 functional gene promoter polymorphisms have been found to be associated with CRC occurrence and prognosis. To document the role of MMP polymorphisms in the early step of colorectal carcinogenesis, we investigated their association with colorectal adenoma risk in a case-control study comprising 295 patients with large adenomas (LA), 302 patients with small adenomas (SA) and 568 polyp-free (PF) controls. METHODS: Patients were genotyped using automated fragment analysis for MMP1 -1607 ins/del G and MMP3 -1612 ins/delA (MMP3.1) polymorphisms and allelic discrimination assay for MMP3 -709 A/G (MMP3.2) and MMP7 -181 A/G polymorphisms. Association between MMP genotypes and colorectal adenomas was first tested for each polymorphism separately and then for combined genotypes using the combination test. Adjustment on relevant variables and estimation of odds ratios were performed using unconditional logistic regression. RESULTS: No association was observed between the polymorphisms and LA when compared to PF or SA. When comparing SA to PF controls, analysis revealed a significant association between MMP3 -1612 ins/delA polymorphism and SA with an increased risk associated with the 6A/6A genotype (OR = 1.67, 95%CI: 1.20–2.34). Using the combination test, the best association was found for MMP3.1-MMP1 (p = 0.001) with an OR of 1.88 (95%CI: 1.08–3.28) for the combined genotype 2G/2G-6A/6A estimated by logistic regression. CONCLUSION: These data show a relation between MMP1 -1607 ins/del G and MMP3 -1612 ins/delA combined polymorphisms and risk of SA, suggesting their potential role in the early steps of colorectal carcinogenesis

Adaptive Significance of the Formation of Multi-Species Fish Spawning Aggregations near Submerged Capes

BACKGROUND: Many fishes are known to spawn at distinct geomorphological features such as submerged capes or "promontories," and the widespread use of these sites for spawning must imply some evolutionary advantage. Spawning at these capes is thought to result in rapid offshore transport of eggs, thereby reducing predation levels and facilitating dispersal to areas of suitable habitat. METHODOLOGY/PRINCIPAL FINDINGS: To test this "off-reef transport" hypothesis, we use a hydrodynamic model and explore the effects of topography on currents at submerged capes where spawning occurs and at similar capes where spawning does not occur, along the Mesoamerican Barrier Reef. All capes modeled in this study produced eddy-shedding regimes, but specific eddy attributes differed between spawning and non-spawning sites. Eddies at spawning sites were significantly stronger than those at non-spawning sites, and upwelling and fronts were the products of the eddy formation process. Frontal zones, present particularly at the edges of eddies near the shelf, may serve to retain larvae and nutrients. Spawning site eddies were also more predictable in terms of diameter and longevity. Passive particles released at spawning and control sites were dispersed from the release site at similar rates, but particles from spawning sites were more highly aggregated in their distributions than those from control sites, and remained closer to shore at all times. CONCLUSIONS/SIGNIFICANCE: Our findings contradict previous hypotheses that cape spawning leads to high egg dispersion due to offshore transport, and that they are attractive for spawning due to high, variable currents. Rather, we show that current regimes at spawning sites are more predictable, concentrate the eggs, and keep larvae closer to shore. These attributes would confer evolutionary advantages by maintaining relatively similar recruitment patterns year after year