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Objectives: Poor discharge communication is associated with negative health outcomes in high-income countries. However, quality of discharge communication has received little attention in India and many other low and middle-income countries., Primary Objective: To investigate verbal and documented discharge communication for chronic non-communicable disease (NCD) patients., Secondary Objective: To explore the relationship between quality of discharge communication and health outcomes., Design: Prospective study., Setting: Three public hospitals in Himachal Pradesh and Kerala states, India., Participants: 546 chronic NCD (chronic respiratory disease, cardiovascular disease or diabetes) patients. Piloted questionnaires were completed at admission, discharge and five and eighteen-week follow-up covering health status, discharge communication practices and health-seeking behaviour. Logistic regression was used to explore the relationship between quality of discharge communication and health outcomes., Primary: Patient recall and experiences of verbal and documented discharge communication., Secondary: Death, hospital readmission and self-reported deterioration of NCD/s., Results: All patients received discharge notes, predominantly on sheets of paper with basic pre-printed headings (71%) or no structure (19%); 31% of notes contained all the following information required for facilitating continuity of care: diagnosis, medication information, lifestyle advice, and follow-up instructions. Patient reports indicated notable variations in verbal information provided during discharge consultations; 50% received ongoing treatment/management information and 23% received lifestyle advice. Within 18 weeks of follow-up, 25 (5%) patients had died, 69 (13%) had been readmitted and 62 (11%) reported that their chronic NCD/s had deteriorated. Significant associations were found 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., Conclusions: Sub-optimal discharge practices may be compromising continuity and safety of chronic NCD patient care. Structured protocols, documents and training are required to improve discharge communication, healthcare integration and NCD management., Competing Interests: The authors have declared that no competing interests exist.

Objective: The irrational use of antibiotics is a leading contributor to antibiotic resistance. Antibiotic stewardship (AS) interventions predominantly focus on prescribers. This study investigated the influence and participation of inpatients in infection‐related care, including antibiotic decision‐making, within and across two tertiary hospitals in South Africa (Cape Town) and India (Kerala). Methods: Through ethnographic enquiry of clinical practice in surgical pathways, including direct nonparticipant observation of clinical practices, healthcare worker (HCW), patient and carer interactions in surgical ward rounds and face‐to‐face interviews with participants (HCWs and patients), we sought to capture the implicit and explicit influence that patients and carers have in infection‐related care. Field notes and interview transcripts were thematically coded, aided by NVivo 12® Pro software. Results: Whilst observational data revealed the nuanced roles that patients/carers play in antibiotic decision‐making, HCWs did not recognize these roles. Patients and carers, though invested in patient care, are not routinely involved, nor are they aware of the opportunities for engagement in infection‐related decision‐making. Patients associated clinical improvement with antibiotic use and did not consider hospitalization to be associated with infection acquisition or transmission, highlighting a lack of understanding of the threat of infection and antibiotic resistance. Patients' economic and cultural positionalities may influence their infection‐related behaviours. In the study site in India, cultural norms mean that carers play widespread but unrecognized roles in inpatient care, participating in infection prevention activities. Conclusion: For patients to have a valuable role in AS and make informed decisions regarding their infection‐related care, a mutual understanding of their role in this process among HCWs and patients is crucial. The observed differences between the two study sites indicate the critical need for understanding and addressing the contextual drivers that impact effective patient‐centred healthcare delivery. Patient or Public Contribution: Ethnographic observations and interviews conducted in this study involved patients as participants. Patients were recruited for interviews after obtaining signed informed consent forms. Patients' identities were completely anonymized when presenting the study findings. [ABSTRACT FROM AUTHOR]

Quality Problem or Issue: To assess impact of medical emergency team (MET) in reducing "out-of-ICU" cardiopulmonary arrests and identify barriers to its optimal utilization. Initial Assessment: Frequently observed critical clinical signs and laboratory values of "out-of-ICU" crashes were used to develop Amrita Early Warning Criteria. Choice of Solution: A physician-led MET was established to respond to code MET, activated by a primary nurse. Implementation: Rates of "out-of-ICU" cardiopulmonary arrests per 1000 admissionswere compared in pre-MET (2013-2014) and post-MET periods (2014-2016) along with disposition following MET and mortality. Descriptive statistics and logistic regression were used for comparative analysis. Evaluation: For continued quality improvement, a Likert agreement scale questionnaire collated the nurse's feedback on MET. 386 Code MET were recorded with an activation rate of 18.8 per 1000 inpatients for 2014-2016. CommonMET triggers were desaturation (53%), seizure (10%), and syncope (9%). Seventy-one percent of activations were attended within 5 minutes, with 45% reported during nurse's night shift hours. Medical emergency team interventions resulted in 59% being shifted to ICU. In the "post-MET" period, "Cold Blue" dose reduced from 6.9 in 2013-2014 to 2.6 (P= .0002) in 2014-2015 and 3.2 (P= .01) in 2015-2016. Ninety-three percent of the Code Blues with priorMET calls were "delayedMET" and 28% of the Code Blues without prior MET activation were "missed MET." Nurse's feedback revealed that 46% lacked knowledge of correct MET activation process while 31% expressed a fear of reprisal for inappropriate activation. Lessons Learned: Although MET intervention was successful in significantly reducing "out-of-ICU" Code Blues, focused training of nurses is required for continued quality improvement. [ABSTRACT FROM AUTHOR]