Wearable monitors for patients following discharge from an intensive care unit: practical lessons learnt from an observational study

Introducing a Remote Patient Monitoring Usability Impact Model to Overcome Challenges

Telehealth and remote patient monitoring (RPM), in particular, have been through a massive surge of adoption since 2020. This initiative has proven potential for the patient and the healthcare provider in areas such as reductions in the cost of care. While home-use medical devices or wearables have been shown to be beneficial, a literature review illustrates challenges with the data generated, driven by limited device usability. This could lead to inaccurate data when an exam is completed without clinical supervision, with the consequence that incorrect data lead to improper treatment. Upon further analysis of the existing literature, the RPM Usability Impact model is introduced. The goal is to guide researchers and device manufacturers to increase the usability of wearable and home-use medical devices in the future. The importance of this model is highlighted when the user-centered design process is integrated, which is needed to develop these types of devices to provide the proper user experience.

Introducing the Pi-CON Methodology to Overcome Usability Deficits during Remote Patient Monitoring

The adoption of telehealth has soared, and with that the acceptance of Remote Patient Monitoring (RPM) and virtual care. A review of the literature illustrates, however, that poor device usability can impact the generated data when using Patient-Generated Health Data (PGHD) devices, such as wearables or home use medical devices, when used outside a health facility. The Pi-CON methodology is introduced to overcome these challenges and guide the definition of user-friendly and intuitive devices in the future. Pi-CON stands for passive, continuous, and non-contact, and describes the ability to acquire health data, such as vital signs, continuously and passively with limited user interaction and without attaching any sensors to the patient. The paper highlights the advantages of Pi-CON by leveraging various sensors and techniques, such as radar, remote photoplethysmography, and infrared. It illustrates potential concerns and discusses future applications Pi-CON could be used for, including gait and fall monitoring by installing an omnipresent sensor based on the Pi-CON methodology. This would allow automatic data collection once a person is recognized, and could be extended with an integrated gateway so multiple cameras could be installed to enable data feeds to a cloud-based interface, allowing clinicians and family members to monitor patient health status remotely at any time.

Safer and more efficient vital signs monitoring protocols to identify the deteriorating patients in the general hospital ward: an observational study

Background

The frequency at which patients should have their vital signs (e.g. blood pressure, pulse, oxygen saturation) measured on hospital wards is currently unknown. Current National Health Service monitoring protocols are based on expert opinion but supported by little empirical evidence. The challenge is finding the balance between insufficient monitoring (risking missing early signs of deterioration and delays in treatment) and over-observation of stable patients (wasting resources needed in other aspects of care).

Objective

Provide an evidence-based approach to creating monitoring protocols based on a patient's risk of deterioration and link these to nursing workload and economic impact.

Design

Our study consisted of two parts: (1) an observational study of nursing staff to ascertain the time to perform vital sign observations; and (2) a retrospective study of historic data on patient admissions exploring the relationships between National Early Warning Score and risk of outcome over time. These were underpinned by opinions and experiences from stakeholders.

Setting and participants

Observational study: observed nursing staff on 16 randomly selected adult general wards at four acute National Health Service hospitals. Retrospective study: extracted, linked and analysed routinely collected data from two large National Health Service acute trusts; data from over 400,000 patient admissions and 9,000,000 vital sign observations.

Results

Observational study found a variety of practices, with two hospitals having registered nurses take the majority of vital sign observations and two favouring healthcare assistants or student nurses. However, whoever took the observations spent roughly the same length of time. The average was 5:01 minutes per observation over a 'round', including time to locate and prepare the equipment and travel to the patient area. Retrospective study created survival models predicting the risk of outcomes over time since the patient was last observed. For low-risk patients, there was little difference in risk between 4 hours and 24 hours post observation.

Conclusions

We explored several different scenarios with our stakeholders (clinicians and patients), based on how 'risk' could be managed in different ways. Vital sign observations are often done more frequently than necessary from a bald assessment of the patient's risk, and we show that a maximum threshold of risk could theoretically be achieved with less resource. Existing resources could therefore be redeployed within a changed protocol to achieve better outcomes for some patients without compromising the safety of the rest. Our work supports the approach of the current monitoring protocol, whereby patients' National Early Warning Score 2 guides observation frequency. Existing practice is to observe higher-risk patients more frequently and our findings have shown that this is objectively justified. It is worth noting that important nurse-patient interactions take place during vital sign monitoring and should not be eliminated under new monitoring processes. Our study contributes to the existing evidence on how vital sign observations should be scheduled. However, ultimately, it is for the relevant professionals to decide how our work should be used.

Study registration

This study is registered as ISRCTN10863045.

Funding

This award was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme (NIHR award ref: 17/05/03) and is published in full in Health and Social Care Delivery Research; Vol. 12, No. 6. See the NIHR Funding and Awards website for further award information.

Excessive Oxygen Administration in High-Risk Patients Admitted to Medical and Surgical Wards Monitored by Wireless Pulse Oximeter

The monitoring of oxygen therapy when patients are admitted to medical and surgical wards could be important because exposure to excessive oxygen administration (EOA) may have fatal consequences. We aimed to investigate the association between EOA, monitored by wireless pulse oximeter, and nonfatal serious adverse events (SAEs) and mortality within 30 days. We included patients in the Capital Region of Copenhagen between 2017 and 2018. Patients were hospitalized due to acute exacerbation of chronic obstructive pulmonary disease (AECOPD) or after major elective abdominal cancer surgery, and all were treated with oxygen supply. Patients were divided into groups by their exposure to EOA: no exposure, exposure for 1-59 min or exposure over 60 min. The primary outcome was SAEs or mortality within 30 days. We retrieved data from 567 patients for a total of 43,833 h, of whom, 63% were not exposed to EOA, 26% had EOA for 1-59 min and 11% had EOA for ≥60 min. Nonfatal SAEs or mortality within 30 days developed in 24%, 12% and 22%, respectively, and the adjusted odds ratio for this was 0.98 (95% CI, 0.96-1.01) for every 10 min. increase in EOA, without any subgroup effects. In conclusion, we did not observe higher frequencies of nonfatal SAEs or mortality within 30 days in patients exposed to excessive oxygen administration.

Clinicians' Perspectives of Wearable Technology to Detect and Monitor Exacerbations of Chronic Obstructive Pulmonary Disease: Mixed-Method Survey

Objective

To investigate clinicians' perspectives on the current use of wearable technology for detecting COPD exacerbations, and to identify potential facilitators and barriers to its adoption in clinical settings.

Methods

A mixed-method survey was conducted through an online survey platform involving clinicians working with COPD patients. The questionnaires were developed by an expert panel specialising in respiratory medicine at UCL. The questionnaire evaluated clinicians' perspectives on several aspects: the current extent of wearable technology utilisation, the perceived feasibility, and utility of these devices, as well as the potential facilitators and barriers that hinder its wider implementation.

Results

Data from 118 clinicians were included in the analysis. Approximately 80% of clinicians did not currently use information from wearable devices in routine clinical care. A majority of clinicians did not have confidence in the effectiveness of wearables and their consequent impact on health outcomes. However, clinicians highlighted the potential value of wearables in helping deliver personalised care and more rapid assistance. Ease of use, technical support and accessibility of data were considered facilitating factors for wearable utilisation. Costs and lack of technical knowledge were the most frequently reported barriers to wearable utilisation.

Conclusion

Clinicians' perspectives of the use of wearable technology to detect and monitor COPD exacerbations are variable. While accessibility and technical support facilitate wearable implementation, cost, technical issues, and knowledge act as barriers. Our findings highlight the facilitators and barriers to using wearables in patients with COPD and emphasise the need to assess patients' perspectives on wearable acceptability.

Continuous Vital Signs Monitoring with a Wireless Device on a General Ward: A Survey to Explore Nurses' Experiences in a Post-Implementation Period

BACKGROUND

Nurse engagement, perceived need and usefulness affect healthcare technology use, acceptance and improvements in quality, safety and accessibility of healthcare. Nurses' opinions regarding continuous monitoring appear to be positive. However, facilitators and barriers were little studied. This study explored nurses' post-implementation experiences of the facilitators and barriers to continuously monitoring patients' vital signs using a wireless device on general hospital wards.

METHODS

This study employed a cross-sectional survey. Vocational and registered nurses from three general wards in a Dutch tertiary university hospital participated in a survey comprising open and closed questions. The data were analysed using thematic analysis and descriptive statistics.

RESULTS

Fifty-eight nurses (51.3%) completed the survey. Barriers and facilitators were identified under four key themes: (1) timely signalling and early action, (2) time savings and time consumption, (3) patient comfort and satisfaction and (4) preconditions.

CONCLUSIONS

According to nurses, early detection and intervention for deteriorating patients facilitate the use and acceptance of continuously monitoring vital signs. Barriers primarily concern difficulties connecting patients correctly to the devices and system.

Unraveling implementation context: the Basel Approach for coNtextual ANAlysis (BANANA) in implementation science and its application in the SMILe project

BACKGROUND

Designing intervention and implementation strategies with careful consideration of context is essential for successful implementation science projects. Although the importance of context has been emphasized and methodology for its analysis is emerging, researchers have little guidance on how to plan, perform, and report contextual analysis. Therefore, our aim was to describe the Basel Approach for coNtextual ANAlysis (BANANA) and to demonstrate its application on an ongoing multi-site, multiphase implementation science project to develop/adapt, implement, and evaluate an integrated care model in allogeneic SteM cell transplantatIon facILitated by eHealth (the SMILe project).

METHODS

BANANA builds on guidance for assessing context by Stange and Glasgow (Contextual factors: the importance of considering and reporting on context in research on the patient-centered medical home, 2013). Based on a literature review, BANANA was developed in ten discussion sessions with implementation science experts and a medical anthropologist to guide the SMILe project's contextual analysis. BANANA's theoretical basis is the Context and Implementation of Complex Interventions (CICI) framework. Working from an ecological perspective, CICI acknowledges contextual dynamics and distinguishes between context and setting (the implementation's physical location).

RESULTS

BANANA entails six components: (1) choose a theory, model, or framework (TMF) to guide the contextual analysis; (2) use empirical evidence derived from primary and/or secondary data to identify relevant contextual factors; (3) involve stakeholders throughout contextual analysis; (4) choose a study design to assess context; (5) determine contextual factors' relevance to implementation strategies/outcomes and intervention co-design; and (6) report findings of contextual analysis following appropriate reporting guidelines. Partly run simultaneously, the first three components form a basis both for the identification of relevant contextual factors and for the next components of the BANANA approach.

DISCUSSION

Understanding of context is indispensable for a successful implementation science project. BANANA provides much-needed methodological guidance for contextual analysis. In subsequent phases, it helps researchers apply the results to intervention development/adaption and choices of contextually tailored implementation strategies. For future implementation science projects, BANANA's principles will guide researchers first to gather relevant information on their target context, then to inform all subsequent phases of their implementation science project to strengthen every part of their work and fulfill their implementation goals.

Clinical impact of vital sign abnormalities in patients admitted with acute exacerbation of chronic obstructive pulmonary disease: an observational study using continuous wireless monitoring

Early detection of abnormal vital signs is critical for timely management of acute hospitalised patients and continuous monitoring may improve this. We aimed to assess the association between preceding vital sign abnormalities and serious adverse events (SAE) in patients hospitalised with acute exacerbation of chronic obstructive pulmonary disease (AECOPD). Two hundred patients' vital signs were wirelessly and continuously monitored with peripheral oxygen saturation, heart rate, and respiratory rate during the first 4 days after admission for AECOPD. Non-invasive blood pressure was also measured every 30-60 min. The primary outcome was occurrence of SAE according to international definitions within 30 days and physiological data were analysed for preceding vital sign abnormalities. Data were presented as the mean cumulative duration of vital sign abnormalities per 24 h and analysed using Wilcoxon rank sum test. SAE during ongoing continuous monitoring occurred in 50 patients (25%). Patients suffering SAE during the monitoring period had on average 455 min (SD 413) per 24 h of any preceding vital sign abnormality versus 292 min (SD 246) in patients without SAE, p = 0.08, mean difference 163 min [95% CI 61-265]. Mean duration of bradypnea (respiratory rate < 11 min^-1) was 48 min (SD 173) compared with 30 min (SD 84) in patients without SAE, p = 0.01. In conclusion, the duration of physiological abnormalities was substantial in patients with AECOPD. There were no statistically significant differences between patients with and without SAE in the overall duration of preceding physiological abnormalities.Study registration: http://ClinicalTrials.gov (NCT03660501). Date of registration: Sept 6 2018.

The SMILe integrated care model in allogeneic SteM cell TransplantatIon faciLitated by eHealth: a protocol for a hybrid effectiveness-implementation randomised controlled trial

Background

While effectiveness outcomes of eHealth-facilitated integrated care models (eICMs) in transplant and oncological populations are promising, implementing and sustaining them in real-world settings remain challenging. Allogeneic stem cell transplant (alloSCT) patients could benefit from an eICM to enhance health outcomes. To combat health deterioration, integrating chronic illness management, including continuous symptom and health behaviour monitoring, can shorten reaction times. We will test the 1st-year post-alloSCT effectiveness and evaluate bundled implementation strategies to support the implementation of a newly developed and adapted eICM in allogeneic stem cell transplantation facilitated by eHealth (SMILe–ICM).

SMILe-ICM has been designed by combining implementation, behavioural, and computer science methods. Adaptions were guided by FRAME and FRAME-IS. It consists of four modules: 1) monitoring & follow-up; 2) infection prevention; 3) physical activity; and 4) medication adherence, delivered via eHealth and a care coordinator (an Advanced Practice Nurse). The implementation was supported by contextually adapted implementation strategies (e.g., creating new clinical teams, informing local opinion leaders).

Methods

Using a hybrid effectiveness-implementation randomised controlled trial, we will include a consecutive sample of 80 adult alloSCT patients who were transplanted and followed by University Hospital Basel (Switzerland). Inclusion criteria are basic German proficiency; elementary computer literacy; internet access; and written informed consent. Patients will be excluded if their condition prevents the use of technology, or if they are followed up only at external centres. Patient-level (1:1) stratified randomisation into a usual care group and a SMILe-ICM group will take place 10 days pre-transplantation. To gauge the SMILe–ICM’s effectiveness primary outcome (re-hospitalisation rate), secondary outcomes (healthcare utilization costs; length of inpatient re-hospitalizations, medication adherence; treatment and self-management burden; HRQoL; Graft-versus-Host Disease rate; survival; overall survival rate) and implementation outcomes (acceptability, appropriateness, feasibility, fidelity), we will use multi-method, multi-informant assessment (via questionnaires, interviews, electronic health record data, cost capture methods).

Discussion

The SMILe–ICM has major innovative potential for reengineering alloSCT follow-up care, particularly regarding short- and medium-term outcomes. Our dual focus on implementation and effectiveness will both inform optimization of the SMILe-ICM and provide insights regarding implementation strategies and pathway, understudied in eHealth-facilitated ICMs in chronically ill populations.

Trial registration

ClinicalTrials.gov. Identifier: NCT04789863. Registered April 01, 2021.

Context-specific adaptation of an eHealth-facilitated, integrated care model and tailoring its implementation strategies-A mixed-methods study as a part of the SMILe implementation science project

Background

Contextually adapting complex interventions and tailoring their implementation strategies is key to a successful and sustainable implementation. While reporting guidelines for adaptations and tailoring exist, less is known about how to conduct context-specific adaptations of complex health care interventions.

Aims

To describe in methodological terms how the merging of contextual analysis results (step 1) with stakeholder involvement, and considering overarching regulations (step 2) informed our adaptation of an Integrated Care Model (ICM) for SteM cell transplantatIon faciLitated by eHealth (SMILe) and the tailoring of its implementation strategies (step 3).

Methods

Step 1: We used a mixed-methods design at University Hospital Basel, guided by the Basel Approach for coNtextual ANAlysis (BANANA). Step 2: Adaptations of the SMILe-ICM and tailoring of implementation strategies were discussed with an interdisciplinary team (n = 28) by considering setting specific and higher-level regulatory scenarios. Usability tests were conducted with patients (n = 5) and clinicians (n = 4). Step 3: Adaptations were conducted by merging our results from steps 1 and 2 using the Framework for Reporting Adaptations and Modifications-Enhanced (FRAME). We tailored implementation strategies according to the Expert Recommendations for Implementing Change (ERIC) compilation.

Results

Step 1: Current clinical practice was mostly acute-care-driven. Patients and clinicians valued eHealth-facilitated ICMs to support trustful patient-clinician relationships and the fitting of eHealth components to context-specific needs. Step 2: Based on information from project group meetings, adaptations were necessary on the organizational level (e.g., delivery of self-management information). Regulations informed the tailoring of SMILe-ICM`s visit timepoints and content; data protection management was adapted following Swiss regulations; and steering group meetings supported infrastructure access. The usability tests informed further adaptation of technology components. Step 3: Following FRAME and ERIC, SMILe-ICM and its implementation strategies were contextually adapted and tailored to setting-specific needs.

Discussion

This study provides a context-driven methodological approach on how to conduct intervention adaptation including the tailoring of its implementation strategies. The revealed meso-, and macro-level differences of the contextual analysis suggest a more targeted approach to enable an in-depth adaptation process. A theory-guided adaptation phase is an important first step and should be sufficiently incorporated and budgeted in implementation science projects.

Evaluating the Validity and Utility of Wearable Technology for Continuously Monitoring Patients in a Hospital Setting: Systematic Review

BACKGROUND

The term posthospital syndrome has been used to describe the condition in which older patients are transiently frail after hospitalization and have a high chance of readmission. Since low activity and poor sleep during hospital stay may contribute to posthospital syndrome, the continuous monitoring of such parameters by using affordable wearables may help to reduce the prevalence of this syndrome. Although there have been systematic reviews of wearables for physical activity monitoring in hospital settings, there are limited data on the use of wearables for measuring other health variables in hospitalized patients.

OBJECTIVE

This systematic review aimed to evaluate the validity and utility of wearable devices for monitoring hospitalized patients.

METHODS

This review involved a comprehensive search of 7 databases and included articles that met the following criteria: inpatients must be aged >18 years, the wearable devices studied in the articles must be used to continuously monitor patients, and wearables should monitor biomarkers other than solely physical activity (ie, heart rate, respiratory rate, blood pressure, etc). Only English-language studies were included. From each study, we extracted basic demographic information along with the characteristics of the intervention. We assessed the risk of bias for studies that validated their wearable readings by using a modification of the Consensus-Based Standards for the Selection of Health Status Measurement Instruments.

RESULTS

Of the 2012 articles that were screened, 14 studies met the selection criteria. All included articles were observational in design. In total, 9 different commercial wearables for various body locations were examined in this review. The devices collectively measured 7 different health parameters across all studies (heart rate, sleep duration, respiratory rate, oxygen saturation, skin temperature, blood pressure, and fall risk). Only 6 studies validated their results against a reference device or standard. There was a considerable risk of bias in these studies due to the low number of patients in most of the studies (4/6, 67%). Many studies that validated their results found that certain variables were inaccurate and had wide limits of agreement. Heart rate and sleep were the parameters with the most evidence for being valid for in-hospital monitoring. Overall, the mean patient completion rate across all 14 studies was >90%.

CONCLUSIONS

The included studies suggested that wearable devices show promise for monitoring the heart rate and sleep of patients in hospitals. Many devices were not validated in inpatient settings, and the readings from most of the devices that were validated in such settings had wide limits of agreement when compared to gold standards. Even some medical-grade devices were found to perform poorly in inpatient settings. Further research is needed to determine the accuracy of hospitalized patients' digital biomarker readings and eventually determine whether these wearable devices improve health outcomes.

Development of an integrated model of care for allogeneic stem cell transplantation facilitated by eHealth-the SMILe study

Purpose

Allogeneic stem cell transplantation would benefit from re-engineering care towards an integrated eHealth-facilitated care model. With this paper we aim to: (1) describe the development of an integrated care model (ICM) in allogeneic SteM-cell-transplantatIon faciLitated by eHealth (SMILe) by combining implementation, behavioral, and computer science methods (e.g., contextual analysis, Behavior Change Wheel, and user-centered design combined with agile software development); and (2) describe that model’s characteristics and its application in clinical practice.

Methods

The SMILe intervention’s development consisted of four steps, with implementation science methods informing each: (1) planning its set-up within a theoretical foundation; (2) using behavioral science methods to develop the content; (3) choosing and developing its delivery method (human/technology) using behavioral and computer science methods; and (4) describing its characteristics and application in clinical practice.

Results

The SMILe intervention is embedded within the eHealth enhanced Chronic Care Model, entailing four self-management intervention modules, targeting monitoring and follow-up of important medical and symptom-related parameters, infection prevention, medication adherence, and physical activity. Interventions are delivered partly face-to-face by a care coordinator embedded within the transplant team, and partly via the SMILeApp that connects patients to the transplant team, who can monitor and rapidly respond to any relevant changes within 1 year post-transplant.

Conclusion

This paper provides stepwise guidance on how implementation, behavioral, and computer science methods can be used to develop interventions aiming to improve care for stem cell transplant patients in real-world clinical settings. This new care model is currently being tested in a hybrid I effectiveness-implementation trial.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00520-021-06328-0.

Validation of a New Contactless and Continuous Respiratory Rate Monitoring Device Based on Ultra-Wideband Radar Technology

Respiratory rate (RR) is typically the first vital sign to change when a patient decompensates. Despite this, RR is often monitored infrequently and inaccurately. The Circadia Contactless Breathing Monitor™ (model C100) is a novel device that uses ultra-wideband radar to monitor RR continuously and un-obtrusively. Performance of the Circadia Monitor was assessed by direct comparison to manually scored reference data. Data were collected across a range of clinical and non-clinical settings, considering a broad range of user characteristics and use cases, in a total of 50 subjects. Bland-Altman analysis showed high agreement with the gold standard reference for all study data, and agreement fell within the predefined acceptance criteria of ±5 breaths per minute (BrPM). The 95% limits of agreement were -3.0 to 1.3 BrPM for a nonprobability sample of subjects while awake, -2.3 to 1.7 BrPM for a clinical sample of subjects while asleep, and -1.2 to 0.7 BrPM for a sample of healthy subjects while asleep. Accuracy rate, using an error margin of ±2 BrPM, was found to be 90% or higher. Results demonstrate that the Circadia Monitor can effectively and efficiently be used for accurate spot measurements and continuous bedside monitoring of RR in low acuity settings, such as the nursing home or hospital ward, or for remote patient monitoring.

Noninvasive Continuous Monitoring of Vital Signs With Wearables: Fit for Medical Use?

BACKGROUND

Wearables (= wearable computer) enable continuous and noninvasive monitoring of a range of vital signs. Mobile and cost-effective devices, combined with powerful data analysis tools, open new dimensions in assessing body functions ("digital biomarkers").

METHODS

To answer the question whether wearables are ready for use in the medical context, a PubMed literature search and analysis for their clinical-scientific use using publications from the years 2008 to 2018 was performed.

RESULTS

A total of 79 out of 314 search hits were publications on clinical trials with wearables, of which 16 were randomized controlled trials. Motion sensors were most frequently used to measure defined movements, movement disorders, or general physical activity. Approximately 20% of the studies used sensors to detect cardiovascular parameters. As for the sensor location, the wrist was chosen in most studies (22.8%).

CONCLUSION

Wearables can be used in a precisely defined medical context, when taking into account complex influencing factors.

Non-contact vital sign monitoring of patients in an intensive care unit: A human factors analysis of staff expectations

BACKGROUND

Infra-red and thermal imaging enable wireless systems to monitor patients' vital signs and absence of wires may improve patient experiences. No studies have explored staff perceptions of the concept of this specific type of technology in the adult population. Understanding existing working systems before introducing technology could improve adoption.

METHODS

We conducted semi-structured interviews with Intensive Care Unit (ICU) staff exploring perceptions of wireless patient monitoring. We used the Systems Engineering Initiative for Patient Safety (SEIPS) model to guide thematic analysis.

RESULTS

We identified usability themes relating to staff perceptions of current patient monitoring experiences, staff perceptions of patient/relative expectations of ICU care, troubleshooting, hierarchy of monitoring, and consensus of trust.

CONCLUSION

The concept of wireless monitoring has perceived benefits for patients and staff. The Systems Engineering Initiative for Patient Safety model guided a systems-based exploratory evaluation. Results highlight the social and environmental factors which may influence usability, adoption, or abandonment of wireless technology in the ICU.

Implementation Science Meets Software Development to Create eHealth Components for an Integrated Care Model for Allogeneic Stem Cell Transplantation Facilitated by eHealth: The SMILe Study as an Example

PURPOSE

To describe a process of creating eHealth components for an integrated care model using an agile software development approach, user-centered design and, via the Behavior Change Wheel, behavior theory-guided content development. Following the principles of implementation science and using the SMILe project (integrated care model for allogeneic stem cell transplantation facilitated by eHealth) as an example, this study demonstrates how to narrow the research-to-practice gap often encountered in eHealth projects.

METHODS

We followed a four-step process: (a) formation of an interdisciplinary team; (b) a contextual analysis to drive the development process via behavioral theory; (c) transfer of content to software following agile software development principles; and (d) frequent stakeholder and end user involvement following user-centered design principles.

FINDINGS

Our newly developed comprehensive development approach allowed us to create a running eHealth component and embed it in an integrated care model. An interdisciplinary team's collaboration at specified interaction points supported clear, timely communication and interactions between the specialists. Because behavioral theory drove the content development process, we formulated user stories to define the software features, which were prioritized and iteratively developed using agile software development principles. A prototype intervention module has now been developed and received high ratings on the System Usability Scale after two rounds of usability testing.

CONCLUSIONS

Following an agile software development process, structured collaboration between nursing scientists and software specialists allowed our interdisciplinary team to develop meaningful, theory-based eHealth components adapted to context-specific needs.

CLINICAL RELEVANCE

The creation of high-quality, accurately fitting eHealth components specifically to be embedded in integrated care models should increase the chances of uptake, adoption, and sustainable implementation in clinical practice.

Wearability Testing of Ambulatory Vital Sign Monitoring Devices: Prospective Observational Cohort Study

Background

Timely recognition of patient deterioration remains challenging. Ambulatory monitoring systems (AMSs) may provide support to current monitoring practices; however, they need to be thoroughly tested before implementation in the clinical environment for early detection of deterioration.

Objective

The objective of this study was to assess the wearability of a selection of commercially available AMSs to inform a future prospective study of ambulatory vital sign monitors in an acute hospital ward.

Methods

Five pulse oximeters (4 with finger probes and 1 wrist-worn only, collecting pulse rates and oxygen saturation) and 2 chest patches (collecting heart rates and respiratory rates) were selected to be part of this study: The 2 chest-worn patches were VitalPatch (VitalConnect) and Peerbridge Cor (Peerbridge); the 4 wrist-worn devices with finger probe were Nonin WristOx2 3150 (Nonin), Checkme O2+ (Viatom Technology), PC-68B, and AP-20 (both from Creative Medical); and the 1 solely wrist-worn device was Wavelet (Wavelet Health). Adult participants wore each device for up to 72 hours while performing usual “activities of daily living” and were asked to score the perceived exertion and perception of pain or discomfort by using the Borg CR-10 scale; thoughts and feelings caused by the AMS using the Comfort Rating Scale (CRS); and to provide general free text feedback. Median and IQRs were reported and nonparametric tests were used to assess differences between the devices’ CRS scores.

Results

Quantitative scores and feedback were collected in 70 completed questionnaires from 20 healthy volunteers, with each device tested approximately 10 times. The Wavelet seemed to be the most wearable device (P<.001) with an overall median (IQR) CRS score of 1.00 (0.88). There were no statistically significant differences in wearability between the chest patches in the CRS total score; however, the VitalPatch was superior in the Attachment section (P=.04) with a median (IQR) score of 3.00 (1.00). General pain and discomfort scores and total percentage of time worn are also reflective of this.

Conclusions

Our results suggest that adult participants prefer to wear wrist-worn pulse oximeters without a probe compressing the fingertip and they prefer to wear a smaller chest patch. A compromise between wearability, reliability, and accuracy should be made for successful and practical integration of AMSs within the hospital environment.

An Evaluation of Biometric Monitoring Technologies for Vital Signs in the Era of COVID-19

The novel coronavirus disease 2019 (COVID-19) global pandemic has shifted how many patients receive outpatient care. Telehealth and remote monitoring have become more prevalent, and measurements taken in a patient's home using biometric monitoring technologies (BioMeTs) offer convenient opportunities to collect vital sign data. Healthcare providers may lack prior experience using BioMeTs in remote patient care, and, therefore, may be unfamiliar with the many versions of BioMeTs, novel data collection protocols, and context of the values collected. To make informed patient care decisions based on the biometric data collected remotely, it is important to understand the engineering solutions embedded in the products, data collection protocols, form factors (physical size and shape), data quality considerations, and availability of validation information. This article provides an overview of BioMeTs available for collecting vital signs (temperature, heart rate, blood pressure, oxygen saturation, and respiratory rate) and discusses the strengths and limitations of continuous monitoring. We provide considerations for remote data collection and sources of validation information to guide BioMeT use in the era of COVID-19 and beyond.

Wireless monitoring and real-time adaptive predictive indicator of deterioration

To assist in the early warning of deterioration in hospitalised children we studied the feasibility of collecting continuous wireless physiological data using Lifetouch (ECG-derived heart and respiratory rate) and WristOx2 (pulse-oximetry and derived pulse rate) sensors. We compared our bedside paediatric early warning (PEW) score and a machine learning automated approach: a Real-time Adaptive Predictive Indicator of Deterioration (RAPID) to identify children experiencing significant clinical deterioration. 982 patients contributed 7,073,486 min during 1,263 monitoring sessions. The proportion of intended monitoring time was 93% for Lifetouch and 55% for WristOx2. Valid clinical data was 63% of intended monitoring time for Lifetouch and 50% WristOx2. 29 patients experienced 36 clinically significant deteriorations. The RAPID Index detected significant deterioration more frequently (77% to 97%) and earlier than the PEW score ≥ 9/26. High sensitivity and negative predictive value for the RAPID Index was associated with low specificity and low positive predictive value. We conclude that it is feasible to collect clinically valid physiological data wirelessly for 50% of intended monitoring time. The RAPID Index identified more deterioration, before the PEW score, but has a low specificity. By using the RAPID Index with a PEW system some life-threatening events may be averted.

Clinicians and patients perspectives on follow-up care and eHealth support after allogeneic hematopoietic stem cell transplantation: A mixed-methods contextual analysis as part of the SMILe study

PURPOSE

We report on our contextual analysis's methodology, as a first step of an implementation science project aiming to develop, implement, and test the effectiveness of an integrated model of care in SteM-cell transplantatIon faciLitated by eHealth (SMILe).

METHODS

We applied an explanatory sequential mixed-methods design including clinicians and patients of the University Hospital Freiburg, Germany. Data were collected from 3/2017 to 1/2018 via surveys in 5 clinicians and 60 adult allogeneic stem-cell transplantation patients. Subsequently, we conducted 3 clinician focus groups and 10 patient interviews. Data analysis followed a 3-step process: (1) creating narrative descriptions, tables, and maps; (2) mapping key observational findings per dimension of the eHealth-enhanced Chronic-Care Model; (3) reflecting on how findings affect our choice of implementation strategies.

RESULTS

Current clinical practice is mostly acute care driven, with no interdisciplinarity and weak chronic illness management. Gaps were apparent in the dimensions of self-management support and delivery-system design. Health behaviors that would profit from support include medication adherence, physical activity and infection prevention. The theme "being alone and becoming an expert" underpinned patients need to increase support in hospital-to-home transitions. Patients reported insecurity about recognizing, judging and acting upon symptoms. The theme "eHealth as connection not replacement" underscores the importance of eHealth augmenting, not supplanting human contact. Synthesis of our key observational findings informed eight implementation strategies.

CONCLUSION

Stakeholders are willing towards a chronic care-focused approach and open for eHealth support. The contextual information provides a basis for the SMILe model's development and implementation.

Physiological abnormalities in patients admitted with acute exacerbation of COPD: an observational study with continuous monitoring

Acute exacerbations of chronic obstructive pulmonary disease (AECOPD) may rapidly require intensive care treatment. Evaluation of vital signs is necessary to detect physiological abnormalities (micro events), but patients may deteriorate between measurements. We aimed to assess if continuous monitoring of vital signs in patients admitted with AECOPD detects micro events more often than routine ward rounds. In this observational pilot study (NCT03467815), 30 adult patients admitted with AECOPD were included. Patients were continuously monitored with peripheral oxygen saturation (SpO₂), heart rate, and respiratory rate during the first 4 days after admission. Hypoxaemic events were defined as decreased SpO₂ for at least 60 s. Non-invasive blood pressure was also measured every 15-60 min. Clinical ward staff measured vital signs as part of Early Warning Score (EWS). Data were analysed using Fisher's exact test or Wilcoxon rank sum test. Continuous monitoring detected episodes of SpO₂ < 92% in 97% versus 43% detected by conventional EWS (p < 0.0001). Events of SpO₂ < 88% was detected in 90% with continuous monitoring compared with 13% with EWS (p < 0.0001). Sixty-three percent of patients had episodes of SpO₂ < 80% recorded by continuous monitoring and 17% had events lasting longer than 10 min. No events of SpO₂ < 80% was detected by EWS. Micro events of tachycardia, tachypnoea, and bradypnoea were also more frequently detected by continuous monitoring (p < 0.02 for all). Moderate and severe episodes of desaturation and other cardiopulmonary micro events during hospitalization for AECOPD are common and most often not detected by EWS.

Patient acceptability of wearable vital sign monitoring technologies in the acute care setting: A systematic review

AIMS AND OBJECTIVES

To examine patient acceptability of wearable vital sign monitoring devices in the acute setting.

BACKGROUND

Wearable vital sign monitoring devices may improve patient safety, yet hospital patients' acceptability of these devices is largely unreported.

DESIGN

A systematic review.

METHODS

Cumulative Index to Nursing and Allied Health Literature Complete, MEDLINE Complete and EMBASE were searched, supplemented by reference list hand searching. Studies were included if they involved adult hospital patients (≥18 years), a wearable monitoring device capable of assessing ≥1 vital sign, and measured patient acceptability, satisfaction or experience of wearing the device. No date restrictions were enforced. Quality assessments of quantitative and qualitative studies were undertaken using the Downs and Black Checklist for Measuring Study Quality and the Critical Appraisal Skills Programme Qualitative Research Checklist, respectively. Meta-analyses were not possible given data heterogeneity and low research quality. Reporting adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines and a Preferred Reporting Items for Systematic Reviews and Meta-Analyses checklist was completed.

RESULTS

Of the 427 studies screened, seven observational studies met the inclusion criteria. Six studies were of low quality and one was of high quality. In two studies, patient satisfaction was investigated. In the remaining studies, patient experience, patient opinions and experience, patient perceptions and experience, device acceptability, and patient comfort and concerns were investigated. In four studies, patients were mostly accepting of the wearable devices, reporting positive experiences and satisfaction relating to their use. In three studies, findings were mixed.

CONCLUSION

There is limited high-quality research examining patient acceptability of wearable vital sign monitoring devices as an a priori focus in the acute setting. Further understanding of patient perspectives of these devices is required to inform their continued use and development.

RELEVANCE TO CLINICAL PRACTICE

The provision of patient-centred nursing care is contingent on understanding patients' preferences, including their acceptability of technology use.

Towards a decision support tool for intensive care discharge: machine learning algorithm development using electronic healthcare data from MIMIC-III and Bristol, UK

OBJECTIVE

The primary objective is to develop an automated method for detecting patients that are ready for discharge from intensive care.

DESIGN

We used two datasets of routinely collected patient data to test and improve on a set of previously proposed discharge criteria.

SETTING

Bristol Royal Infirmary general intensive care unit (GICU).

PATIENTS

Two cohorts derived from historical datasets: 1870 intensive care patients from GICU in Bristol, and 7592 from Medical Information Mart for Intensive Care (MIMIC)-III.

RESULTS

In both cohorts few successfully discharged patients met all of the discharge criteria. Both a random forest and a logistic classifier, trained using multiple-source cross-validation, demonstrated improved performance over the original criteria and generalised well between the cohorts. The classifiers showed good agreement on which features were most predictive of readiness-for-discharge, and these were generally consistent with clinical experience. By weighting the discharge criteria according to feature importance from the logistic model we showed improved performance over the original criteria, while retaining good interpretability.

CONCLUSIONS

Our findings indicate the feasibility of the proposed approach to ready-for-discharge classification, which could complement other risk models of specific adverse outcomes in a future decision support system. Avenues for improvement to produce a clinically useful tool are identified.

Technology Experience of Solid Organ Transplant Patients and Their Overall Willingness to Use Interactive Health Technology

BACKGROUND

The use of interactive health technology (IHT) is a promising pathway to tackle self-management problems experienced by many chronically ill patients, including solid organ transplant (Tx) patients. Yet, to ensure that the IHT is accepted and used, a human-centered design process is needed, actively involving end users in all steps of the development process. A first critical, predevelopment step involves understanding end users' characteristics. This study therefore aims to (a) select an IHT platform to deliver a self-management support intervention most closely related to Tx patients' current use of information and communication technologies (ICTs), (b) understand Tx patients' overall willingness to use IHT for self-management support, and investigate associations with relevant technology acceptance variables, and (c) explore Tx patients' views on potential IHT features.

DESIGN AND METHODS

We performed a cross-sectional, descriptive study between October and December 2013, enrolling a convenience sample of adult heart, lung, liver, and kidney Tx patients from the University Hospitals Leuven, Belgium. Broad inclusion criteria were applied to ensure a representative patient sample. We used a 35-item newly designed interview questionnaire to measure Tx patients' use of ICTs, their overall willingness to use IHT, and their views on potential IHT features, as well as relevant technology acceptance variables derived from the Unified Theory of Acceptance and Use of Technology and a literature review. Descriptive statistics were used as appropriate, and an ordinal logistic regression model was built to determine the association between Tx patients' overall willingness to use IHT, the selected technology acceptance variables, and patient characteristics.

FINDINGS

Out of 139 patients, 122 agreed to participate (32 heart, 30 lung, 30 liver, and 30 kidney Tx patients; participation rate: 88%). Most patients were male (57.4%), married or living together (68%), and had a mean age of 55.9 ± 13.4 years. Only 27.9% of Tx patients possessed a smartphone, yet 72.1% owned at least one desktop or laptop PC with wireless Internet at home. On a 10-point numeric scale, asking patients whether they think IHT development is important to support them personally in their self-management, patients gave a median score of 7 (25th percentile 5 points; 75th percentile 10 points). Patients who were single or married or living together were more likely to give a higher rating than divorced or widowed patients; patients who completed only secondary education gave a higher rating than higher educated patients; and patients with prior ICT use gave a higher rating than patients without prior ICT use. Tx patients also had clear preferences regarding IHT features, such as automatic data transfer, as much as possible, visual aids (e.g., graphs) over text messages, and personally deciding when to access the IHT.

CONCLUSIONS

By investigating Tx patients' possession and use of ICTs, we learned that computers and the Internet, and not smartphones, are the most suitable IHT platforms to deliver self-management interventions for our Tx patients. Moreover, Tx patients generally are open to using IHT, yet patient acceptance variables and their preferences for certain IHT features should be taken into account in the next steps of IHT development. Designers intending to develop or use existing IHTs should never overlook this critical first step in a human-centered design.

CLINICAL RELEVANCE

Before considering using eHealth technology in clinical practice, professionals should always check whether patients are familiar with using information and communication technology, and whether they are willing to use technology for health-related purposes.