UIUC - paper
Process evaluation of a wireless wearable continuous vital signs monitoring intervention on two general hospital wards: a mixed methods study
Abstract
Background
Continuous monitoring of vital signs (CMVS) using wearable, wireless sensors is increasingly available to general ward patients, and has the potential to improve outcomes and reduce nurse workload. In order to assess the potential impact of such systems successful implementation is important. We developed a CMVS intervention and implementation strategy and evaluated its success on two general wards.
Objective
To assess and compare intervention fidelity on two wards (internal medicine and general surgery) in a large teaching hospital. Methods A mixed-methods sequential explanatory design was used. After thorough training and preparation, CMVS was implemented -in parallel to the standard intermittent manual measurements- and executed for six months at each ward. Heart rate and respiratory rate were measured by a chest-worn wearable sensor and vital signs trends were visualized in a digital platform. Trends were routinely assessed and reported each nursing shift without the use of automated alarms. Primary outcome was intervention fidelity defined as proportion written reports and related nurse activities in case of deviating trends comparing early (month 1-2), mid (month 3-4) and late (month 5-6) implementation periods. Explanatory interviews with nurses were conducted.
Results
The implementation strategy was executed as planned. A total of 358 patients were included, resulting in 45,113 monitored hours during 6142 nurse shifts. In total, 10.3% (37/358) of the sensors were replaced prematurely because of technical failure. Mean intervention fidelity was 70.7% (SD 20.4%) and higher in the surgical ward (73.6%, SD 18.1% vs 64.1%, SD 23.7%; P<.001). Fidelity decreased over the implementation period in the internal medicine ward (76%, 57%, and 48% at early, mid-, and late implementation, respectively; P<.001) but not significantly in the surgical ward (76% at early implementation vs 74% at midimplementation [P=.56] vs 70.7% at late implementation [P=.07]). No nursing activities were needed based on vital sign trends for 68.7% (246/358) of the patients. In 174 reports of 31.3% (112/358) of the patients, observed deviating trends led to 101 additional bedside assessments of patients and 73 consultations by physicians. The main themes that emerged during interviews (n=21) included the relative priority of CMVS in nurse work, the importance of nursing assessment, the relatively limited perceived benefits for patient care, and experienced mediocre usability of the technology.
Conclusions
We successfully implemented a system for CMVS at scale in 2 hospital wards, but our results show that intervention fidelity decreased over time, more in the internal medicine ward than in the surgical ward. This decrease appeared to depend on multiple ward-specific factors. Nurses’ perceptions regarding the value and benefits of the intervention varied. Implications for optimal implementation of CMVS include engaging nurses early, seamless integration into electronic health records, and sophisticated decision support tools for vital sign trend interpretation.