A qualitative study of patient involvement in medicines management after hospital discharge: an under-recognised source of systems resilience

YesIntroduction: There are risks to the safety of medicines management when patient care is transferred between healthcare organisations, for example when a patient is discharged from hospital. Using the theoretical concept of resilience in healthcare, this study aimed to better understand the proactive role that patients can play in creating a safer, resilient medicines management at a common transition of care. Methods: Qualitative interviews with 60 cardiology patients six weeks after their discharge from two UK hospitals explored patients’ experiences with their discharge medicines. Data were initially subjected to an inductive thematic analysis and a subsequent theory-guided deductive analysis. Results: During interviews twenty-three patients described medicines management resilience strategies in two main themes: identifying system vulnerabilities; and establishing self-management strategies. Patients could anticipate problems in the system that supplied them with medicines and took specific actions to prevent them. They also identified when errors had occurred both before and after medicines had been supplied and took corrective action to avoid harm. Some reported how they had not foreseen problems or experienced patient safety incidents. Patients recounted how they ensured information about medicines changes was correctly communicated and acted upon, and identified their strategies to enhance their own reliability in adherence and resource management. Conclusion: Patients experience the impact of vulnerabilities in the medicines management system across the secondary-primary care transition but many are able to enhance system resilience through developing strategies to reduce the risk of medicines errors occurring. Consequently, there are opportunities – with caveats – to elicit, develop and formalise patients’ capabilities which would contribute to safer patient care and more effective medicines management

Bore collapse and wave run-up on a sandy beach

Wave run-up on beaches and coastal structures is initiated and driven by collapsing incident bores, this process is often considered to define the seaward limit of the swash zone. It is hence a key feature in nearshore wave processes as extreme run-up can lead to structure overtopping and coastal inundation during storm conditions. In addition, the turbulent nature of incident bores and their collapse suspends and advects sediment, resulting in a highly morphologically dynamic swash zone. The cross shore bore collapse location varies from wave to wave and the process is very limited in both spatial and temporal extent, making direct measurement problematic. This paper presents high spatial-temporal resolution LiDAR field measurements of the evolving free-surface in the surf and swash zone which enable the bore collapse detection for 166 waves. These measurements are used to investigate the link between broken wave properties at bore collapse and wave run-up. Incident bores are identified at the seaward boundary of the LiDAR profiles and tracked through the inner surf and swash zones to the run-up limit. It is found that the vertical run-up height exceeds that which would be expected for a perfect conversion of potential to kinetic energy during bore collapse for 24% of the bores measured. By returning to an existing ballistic-type model to describe the run-up of individual waves, we show that wave run-up can be divided into three components: the bore collapse, terminal bore celerity and their non-linear interaction. For the present dataset, the contribution of the bore collapse and terminal bore celerity is 26% and 27% respectively, while non-linear interactions between the two dominates and account for 47% of the measured run-up. By including the terminal bore celerity, the ability to predict run-up is increased by 30% with the determination coefficient r increasing from 0.573 to 0.785. Likewise, the RMS-error for the wave run-up shows an approximately 10% reduction from 0.325 to 0.295 m

Life cycle assessment of lignocellulosic biomass pretreatment methods in biofuel production

Purpose: In converting lignocellulosic biomass into biofuel, a pretreatment stage is required in order to make the biomass more readily available for the transformation. There are numerous pretreatment techniques that can be chosen, which are broken down into four categories: chemical, physical, physicochemical, and biological. The aim of this work is to provide a new assessment for some of the emerging technologies using life cycle assessment (LCA) combined with an analysis of the overall product yield. Methods: Using literature data, an LCA of four different pretreatment methods was carried out. Liquid hot water (LHW), steam explosion (SE), dilute acid (DA), and organosolv (OS) were chosen as the most common techniques with high scalability potential. Models were constructed using GaBi software. A cradle-to-gate analysis was selected with a common model of the corn stover growth and harvesting cycle being combined with the individual models for each pretreatment. Four impact categories were analyzed, and a selection has been discussed based on relevance to the biofuel production process. Results and discussion: In nearly all of the impact categories, DA performs the worst due to the length of the process (12 h) and the amount of electricity required to elevate the temperature to 60 °C for that time period. In many of the other categories, the remaining three pretreatments perform comparably to each other with the exception of LHW which has significantly reduced CO2 emissions. LHW has slightly higher water depletion rates than both SE and OS, which is to be expected given the nature of the process. In terms of product yield, LHW produced twice as much total sugar than any of the other processes. Conclusions: The project concluded that while LHW and SE are viable options for the pretreatment of biomass, LHW is the most suitable technique for the pretreatment of corn stover. This pretreatment was environmentally friendly as it produced the lowest CO2 emissions, aligning with the main objective behind developing biofuels from agricultural residues. The process was also technically the most effective as it resulted in the highest sugar yields. Methods: Using literature data, an LCA of four different pretreatment methods was carried out. Liquid hot water (LHW), steam explosion (SE), dilute acid (DA), and organosolv (OS) were chosen as the most common techniques with high scalability potential. Models were constructed using GaBi software. A cradle-to-gate analysis was selected with a common model of the corn stover growth and harvesting cycle being combined with the individual models for each pretreatment. Four impact categories were analyzed, and a selection has been discussed based on relevance to the biofuel production process. Results and discussion: In nearly all of the impact categories, DA performs the worst due to the length of the process (12 h) and the amount of electricity required to elevate the temperature to 60 °C for that time period. In many of the other categories, the remaining three pretreatments perform comparably to each other with the exception of LHW which has significantly reduced CO2 emissions. LHW has slightly higher water depletion rates than both SE and OS, which is to be expected given the nature of the process. In terms of product yield, LHW produced twice as much total sugar than any of the other processes. Conclusions: The project concluded that while LHWand SE are viable options for the pretreatment of biomass, LHWis the most suitable technique for the pretreatment of corn stover. This pretreatment was environmentally friendly as it produced the lowest CO2 emissions, aligning with the main objective behind developing biofuels from agricultural residues. The process was also technically the most effective as it resulted in the highest sugar yields

Experience-based co-design - Adapting the method for a researcher-initiated study in a multi-site setting

YesBackground: Experience-based co-design (EBCD) brings patients and staff together to co-design services. It is normally conducted in one organization which initiates and implements the process. We used the traditional EBCD method with a number of adaptations as part of a larger research study in the British National Health Service.Methods: The primary aim was to assess the feasibility and acceptability of conduct-ing research-initiated EBCD, to enhance intervention development prior to testing. As well as embedding the method in a research study, there were 3 further key adap-tations: (a) working across primary and secondary care sectors, (b) working on multi-ple sites and (c) incorporating theory-informed analysis.Results: We recruited four sites (covering both primary and secondary care) and, on each site, conducted the initial traditional EBCD meetings, with separate staff and patient groups—followed by a single joint patient-staff event, where four priority areas for co-design were agreed. This event was driven by theory-informed analysis, as well as the traditional trigger film of patient experiences. Each site worked on one priority area, and the four co-design groups met over 2-3 months to design prototype tools. A second joint event was held (not usually undertaken in single-site EBCD) where they shared and compared outputs. The research team combined elements of these outputs to create an intervention, now being tested in a cluster randomized controlled trial.Conclusions: EBCD can be successfully adapted for use across an entire patient pathway with multiple organizations and as part of a research process to identify an intervention for subsequent testing in a randomized trial. Our pragmatic approach used the patient experience to identify areas for improvement and co-designed an intervention which directly reflected patient priorities.National Institute for Health Research programme ‘Improving the safety and continuity of medicines management at care transitions (ISCOMAT)’ RP‐PG‐0514‐2009

Rural Pharmacy not delivering on its health promotion potential

Objective: To investigate the level and perceived quality of health promotion advice received from rural pharmacists.Design: Self-administered written survey on access to and quality of pharmacy services in rural Western Australia completed by rural residents.Setting: Rural Pharmacy.Participants: Four hundred and eighty-three respondents who regularly used a pharmacy.Outcome measures: Items in the survey included frequency of receiving prevention advice and satisfaction ratings on health and pharmacy services.Results: Eighty-eight per cent of respondents had never discussed exercise or diet with their pharmacist and 65% had never discussed preventing health problems. Receiving good prevention advice predicted satisfaction with health services in general but not satisfaction with pharmacy services.Conclusion: Pharmacies are being underutilised with respect to their capacity to deliver heath prevention advice and ways to capitalise on this potential need to be investigated

Cardiology patients' medicines management networks after hospital discharge: A mixed methods analysis of a complex adaptive system

YesIntroduction: The complex healthcare system that provides patients with medicines places them at risk when care is transferred between healthcare organisations, for example discharge from hospital. Consequently, under-standing and improving medicines management, particularly at care transfers, is a priority.Objectives: This study aimed to explore the medicines management system as patients experience it and determine differences in the patient-perceived importance of people in the system.Methods: We used a Social Network Analysis framework, collecting ego-net data about the importance of people patients had contact with concerning their medicines after hospital discharge. Single- and multi-level logistic regression models of patients' networks were constructed, and model residuals were explored at the patient level.This enabled us to identify patients' networks with support tie patterns different from the general patterns suggested by the model results. Qualitative data for those patients were then analysed to understand their differing experiences.Results: Networks comprised clinical and administrative healthcare staff and friends and family members.Networks were highly individual and the perceived importance of alters varied both within and between patients. Ties to spouses were significantly more likely to be rated as highly important and ties to community pharmacy staff (other than pharmacists) and to GP receptionists were less likely to be highly rated. Patients with low-value medicines management networks described having limited information about their medicines and alack of understanding or help. Patients with high-value networks described appreciating support and having confidence in staff.Conclusions: Patients experienced medicines management as individual systems within which they interacted with healthcare staff and informal support to manage their treatment. Multilevel models indicated that there are unexplained variables impacting on patients' assessments of their medicines management networks. Qualitative exploration of the model residuals can offer an understanding of networks that do not have the typical range of support ties.National Institute for Health Research (NIHR) Yorkshire and Humber Patient Safety Translational Research Centre (NIHR Yorkshire and Humber PSTRC

Evaluating recruitment methods of patients with advanced cancer: a pragmatic opportunistic comparison

YesBackground: Recruitment of patients with advanced cancer into studies is challenging. Objective: To evaluate recruitment methods in a study of pharmacist-led cancer pain medicines consultations and produce recommendations for future studies. Method: Two methods of recruitment were employed: 1) community-based (general practitioner computer search, identification by general practitioner, community pharmacist or district nurse and hospital outpatient list search), and 2) hospice-based (in and outpatient list search). Patients identified in method 1 were invited by post and in method 2 were invited face-to-face. Information was designed in collaboration with patients and carers. Results: 128 patients were identified (85 from the community and 43 from the hospice), 47 met the inclusion criteria. Twenty-three agreed to take part and 19 completed the study, 17 of whom were already under specialist palliative care. Recruitment rates were 7% for community-based methods and 40% for hospice. The recruitment methods differed in intensity of resource use. Recruitment via letter and a lack of engagement by healthcare professionals were found to be barriers. Facilitators included the researcher having personal involvement in recruitment. Conclusion: The overall recruitment rate was in line with other studies for this patient cohort. Attempts to identify and engage patients through community-based postal contact were less effective than where personal contact with patients was both possible and occurred. Methods were less successful at recruiting patients who were not already engaged with hospice services.Programme Grants for Applied Research. Grant Number: RP-PG-0610-1011

Analysis of nonlinear shear deformations in CFRP and GFRP textile laminates

Carbon fibre-reinforced polymer (CFRP) and glass fibre-reinforced polymer (GFRP) woven composites are widely used in aerospace, automotive and construction components and structures thanks to their lower production costs, higher delamination and impact strengths. They can also be used in various products in sports industry. These products are exposed to different inservice conditions such as large tensile and bending deformations. Composite materials, especially ±45° symmetric laminates subjected to tensile loads, exhibit significant material as well as geometric non-linearity before damage initiation, particularly with respect to shear deformations. Such a nonlinear response needs adequate means of analysis and investigation, the major tools being experimental tests and numerical simulations. This research deals with modelling the nonlinear deformation behaviour of CFRP and GFRP woven laminates subjected to in-plane tensile loads. The mechanical behaviour of woven laminates is modelled using nonlinear elasto-plastic as well as material models for fabrics in commercial finite-element code Abaqus. A series of tensile tests is carried out to obtain an in-plane full-field strain response of [+45/-45]2s CFRP and GFRP laminates using digital image correlation technique according to ASTM D3518/D3518M-94. The obtained results of simulations are in good agreement with experimental data

The impact of a supplementary medication review and counselling service within the oncology outpatient setting

The impact on the care of breast cancer patients, of a pharmacy technician-led medication review and counselling clinic, provided in an outpatient setting, was investigated using a controlled randomised study. Compared to the controls, clinic patients showed a significantly improved level of understanding of their chemotherapy support medication (95% CI for difference in mean knowledge rating scores=2.165–2.826, P<0.001) and a significant reduction in the median number of support items required (two compared to five in the control, P<0.001). This resulted in a significant reduction in mean medication expenditure per patient (£26.70 vs £10.20, 95% CI for the mean difference in cost £6.72–£26.26, P<0.001). The clinic was also associated with significant reductions in chemotherapy delays (P<0.001) and dose reductions due to side effects (P=0.003). Other benefits from the clinic were a reduction in pharmacy dispensing time and a highly significant reduction in pharmacy time spent resolving post-clinic prescription queries (P<0.001). Taking into account the initial technician training cost, the scheme represented an annual saving to the Trust of over £15 000. The clinic serves as a model for those wishing to improve outpatient services to breast cancer patients

The roles of transparency and trust in the relationship between corruption and citizen satisfaction

Reducing corruption and improving citizen satisfaction are important aims of government, yet the link between these two policy aims has rarely been explored. This article reports a study into the roles played by transparency and trust in the relationship between governmental corruption and citizen satisfaction with public services. The study was based on data gathered in South Korea to evaluate a specific initiative that had sought to reduce corruption and increase citizen satisfaction with public works programmes. The data indicated that the relationship between corruption and satisfaction was moderated by transparency and partially mediated by trust. Points for practitioners: The study sheds light on the roles of transparency and trust in the relationship between corruption and citizen satisfaction with public services, and thus provides insights for developing policy aimed at curtailing corruption and improving satisfaction