Continuous Versus Intermittent Vital Signs Monitoring Using a Wearable, Wireless Patch in Patients Admitted to Surgical Wards: Pilot Cluster Randomized Controlled Trial

The Effect of Early Warning Systems for Sepsis on Mortality: A Systematic Review and Meta-analysis

BACKGROUND

The Surviving Sepsis Campaign strongly recommends that all hospitals screen for sepsis as part of performance improvement. The effect of screening for sepsis on mortality, time to antibiotics, and length of stay is uncertain.

METHODS

A systematic literature search was conducted using Cochrane Library, Google Scholar, Ovid Embase, Ovid Medline, Scopus, and Web of Science Core Collection from earliest entry to June 1, 2024. We included all randomized controlled studies of any type of alert system to screen adult patients for sepsis. Risk of bias was assessed using the Cochrane Risk of Bias Tool. Outcomes were pooled using random effects meta-analysis. Strength of evidence was rated using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system.

RESULTS

In total, we found 7 studies of 3409 patients with sepsis. The pooled odds ratio for mortality for patients randomized to early warning systems was 0.84 (95% CI, 0.60, 1.18). The average time to antibiotics was reported in 4 studies and found to be 0.08 h faster in the screening group (95% CI, - 0.44, 0.28). Length of stay was reported in 4 studies and found to be 0.27 days less in the screening group (95%, - 1.21, 0.66). All differences were non-significant. Overall strength of evidence was low due to risk of bias and imprecision.

CONCLUSIONS

Based on the current body of randomized controlled studies, there is insufficient evidence to recommend screening for sepsis. Guidelines should reconsider current recommendations for screening for sepsis.

PROSPERO REGISTRATION

CRD42024563222.

Monitoring Vital Signs With Continuous Monitoring After Major Gastrointestinal Surgical Procedures: The Patient, Nurse and Physician Perspective

BACKGROUND

Patients undergoing major abdominal surgical procedures are at risk of postoperative complications, requiring early recognition. Clinical deterioration is preceded by changes in vital sings, which are measured three times a day by a nurse. Due to the intermittent measuring, this may result in a delay in the recognition of clinical deterioration. Continuous vital sign monitoring through wireless sensors offers a potential solution for earlier recognition.

AIM

To evaluate user satisfaction of a new wireless monitoring system measuring vital signs continuously, by both patients and healthcare providers.

DESIGN

A prospective, questionnaire-based study.

METHODS

From December 2021 to November 2022, user experience questionnaires were administered to patients who underwent major abdominal surgical procedures and received the patch postoperatively. Questionnaires were administered as well to nurses and physicians working on a surgical ward with the patch. Continuous measurements of heart rate, respiratory rate, and temperature were taken using the Sensium wireless patch.

RESULTS

A total of 298 respondents completed the questionnaire, 191 patients, 88 nurses, and 19 physicians. Of the patients, 69% had a positive experience with the patch, and 74% felt safer. Sixty-three percent of the nurses were positive, and 65% had the feeling that they could monitor the patients better this way. Of the physicians, 63% were positive, 32% believed clinical deterioration could be identified earlier.

CONCLUSION

The use of the Sensium wireless patch for continuous monitoring of vital signs postoperatively was found to be feasible and well-tolerated. Patients, nurses, and physicians reported a positive experience with its use.

Continuous vital sign monitoring of patients recovering from surgery on general wards: a narrative review

Most postoperative deaths occur on general wards, often linked to complications associated with untreated changes in vital signs. Monitoring in these units is typically intermittent checks each shift or maximally every 4-6 h, which misses prolonged periods of subtle changes in physiology that can herald a critical downstream event. Continuous monitoring of vital signs is therefore intuitively necessary for patient safety. The past five decades have seen monitoring systems evolve rapidly, and today entirely wireless, wearable, and portable continuous surveillance of vital signs is possible on general wards. Introduction of this technology has the potential to modify both the sensing (afferent) and response (efferent) limbs of monitoring, and will allow earlier detection of vital signs perturbations. But this comes with challenges, including but not limited to issues with connectivity, data handling, alarm fatigue, information overload, and lack of meaningful clinical interventions. Evidence from before and after studies and retrospective propensity-matched data suggests that continuous ward monitoring decreases the risk of intensive care unit (ICU) admissions, rapid response calls, and in some instances, mortality. This review summarises the history of general ward monitoring and describes future directions, including opportunities to implement these devices using artificial intelligence, pattern detection, and user-friendly interfaces. Pragmatic, well designed and appropriately powered trials, and real-world implementation data are necessary to make continuous monitoring standard practice at every hospital bed.

Wearable devices as part of postoperative early warning score systems: a scoping review

Postoperative deterioration is often preceded by abnormalities in vital parameters, but limited resources prevent their continuous monitoring in patients with no indication to ICU admission. The development of new technologies allowed the introduction of wearable devices (WDs), enabling the possibility of postoperative monitoring in surgical wards. We performed a Scoping Review to determine the current use of wearable devices as part of Continuous Remote Early Warning Score (CREWS) systems and their efficiency during postoperative period. This Scoping Review was conducted according to PRISMA-ScR guidelines. PICO framework was used before the search to define the review protocol. Systematic literature research has been performed on PubMed, MeSH, MEDLINE and Embase, considering a period between 2018 and February 2024. Prospective and retrospective studies involving patients undergoing cardiac and non-cardiac surgery are included. A total of 10 articles were included in the review. 11 different CE/FDA approved wearable devices were used in the studies analyzed. In all studies the WDs were applied the day of the surgery. The use of WDs as part of CREWS systems is feasible and safe. Furthermore, with the aid of other technologies (LoRa and Artificial Intelligence), they shorten Length of Stay (LOS) and reduce the number of ICU admissions with a reduction in healthcare costs. Continuous monitoring in surgical departments can facilitate the correct and timely identification of postoperative complications. This article is a starting point for the development of new protocols and for the application of these monitoring systems in clinical practice.

Wearable biosensors for pediatric hospitals: a scoping review

As wearable biosensors are increasingly used in healthcare settings, this review aimed to identify the types of wearable biosensors used for neonate and pediatric patients and how these biosensors were clinically evaluated. A literature search was conducted using PubMed, CINAHL, Embase, Web of Science, and Cochrane. The studies published between January 2010 and February 2024 were included. Descriptive statistics were used to present counts and percentages of types, locations, clinical evaluation methods, and their results. Seventy-nine studies were included. 104 wearable sensors and 40 devices were identified. The most common type of biosensor was optoelectrical sensors (n = 40, 38.5%), and used to measure heart rate (n = 22, 19.0%). The clinical evaluation was tested by a combination of validity (n = 68, 86.1%) and reliability (n = 14, 17.7%). Only two-thirds of the wearable devices were validated or reported acceptable reliability. The majority of the biosensor studies (n = 51, 64.5%) did not report any complications related to wearable biosensors. The current literature has gaps regarding clinical evaluation and safety of wearable biosensor devices with interchangeable use of validity and reliability terms. There is a lack of comprehensive reporting on complications, highlighting the need for standardized guidelines in the clinical evaluation of biosensor medical devices. IMPACT: The most common types of biosensors in pediatric settings were optoelectrical sensors and electrical sensors. Only two-thirds of the wearable devices were validated or reported acceptable reliability, and more than half of the biosensor studies did not report whether they assessed any complications related to wearable biosensors. This review discovered significant gaps in safety and clinical validation reporting, emphasizing the need for standardized guidelines. The findings advocate for improved reporting clinical validation processes to enhance the safety of wearable biosensors in pediatric care.

Discrepancies between Promised and Actual AI Capabilities in the Continuous Vital Sign Monitoring of In-Hospital Patients: A Review of the Current Evidence

Continuous vital sign monitoring (CVSM) with wireless sensors in general hospital wards can enhance patient care. An artificial intelligence (AI) layer is crucial to allow sensor data to be managed by clinical staff without over alerting from the sensors. With the aim of summarizing peer-reviewed evidence for AI support in CVSM sensors, we searched PubMed and Embase for studies on adult patients monitored with CVSM sensors in general wards. Peer-reviewed evidence and white papers on the official websites of CVSM solutions were also included. AI classification was based on standard definitions of simple AI, as systems with no memory or learning capabilities, and advanced AI, as systems with the ability to learn from past data to make decisions. Only studies evaluating CVSM algorithms for improving or predicting clinical outcomes (e.g., adverse events, intensive care unit admission, mortality) or optimizing alarm thresholds were included. We assessed the promised level of AI for each CVSM solution based on statements from the official product websites. In total, 467 studies were assessed; 113 were retrieved for full-text review, and 26 studies on four different CVSM solutions were included. Advanced AI levels were indicated on the websites of all four CVSM solutions. Five studies assessed algorithms with potential for applications as advanced AI algorithms in two of the CVSM solutions (50%), while 21 studies assessed algorithms with potential as simple AI in all four CVSM solutions (100%). Evidence on algorithms for advanced AI in CVSM is limited, revealing a discrepancy between promised AI levels and current algorithm capabilities.

Complication Timing, Failure to Rescue, and Readmission After Inpatient Pediatric Surgery

BACKGROUND

Complications are associated with postoperative mortality and readmission. However, the timing of complications relative to discharge and the extent to which timing is associated with failure to rescue (FTR) and readmission after pediatric surgery is unknown. Our goal was to describe the timing of complications relative to discharge after inpatient pediatric surgery and determine the association between complication timing, FTR, and unplanned readmission.

MATERIALS AND METHODS

National cohort study of patients within the NSQIP-Pediatric database who underwent inpatient surgery (2012-2019). Complications were categorized based on when they occurred relative to discharge: only pre-discharge, only post-discharge, both. The association between perioperative outcomes and the timing of postoperative complications was evaluated with multivariable hierarchical regression.

RESULTS

Among 378,551 patients, 30,213 (8.0%) had at least one postoperative complication. Relative to patients with pre-discharge complications, post-discharge complications were associated with significantly decreased odds of FTR (odds ratio 0.21, 95% confidence interval [0.15-0.28]) and significantly increased odds of readmission (odds ratio 19.37 [17.93-20.92]). Odds of FTR and readmission in patients with complications occurring both before and after discharge were similar to that of patients with only post-discharge complications.

CONCLUSIONS

FTR and readmission are associated with complications occurring at different times relative to discharge (FTR primarily pre-discharge; readmission primarily post-discharge). This suggests a 'one size fits all' approach to surgical quality improvement may not be effective and different approaches are needed to address different quality indicators.

Validity and Reliability of Wearable Sensors for Continuous Postoperative Vital Signs Monitoring in Patients Recovering from Trauma Surgery

(1) Background: Wearable sensors support healthcare professionals in clinical decision-making by measuring vital parameters such as heart rate (HR), respiration rate (RR), and blood oxygenation saturation (SpO2). This study assessed the validity and reliability of two types of wearable sensors, based on electrocardiogram or photoplethysmography, compared with continuous monitoring of patients recovering from trauma surgery at the postanesthesia care unit. (2) Methods: In a prospective observational study, HR, RR, SpO2, and temperature of patients were simultaneously recorded with the VitalPatch and Radius PPG and compared with reference monitoring. Outcome measures were formulated as correlation coefficient for validity and mean difference with 95% limits of agreement for reliability for four random data pairs and 30-min pairs per vital sign per patient. (3) Results: Included were 60 patients. Correlation coefficients for VitalPatch were 0.57 to 0.85 for HR and 0.08 to 0.16 for RR, and for Radius PPG, correlation coefficients were 0.60 to 0.83 for HR, 0.20 to 0.12 for RR, and 0.57 to 0.61 for SpO2. Both sensors presented mean differences within the cutoff values of acceptable difference. (4) Conclusions: Moderate to strong correlations for HR and SpO2 were demonstrated. Although mean differences were within acceptable cutoff values for all vital signs, only limits of agreement for HR measured by electrocardiography were considered clinically acceptable.

Early detection of deteriorating patients in general wards through continuous contactless vital signs monitoring

Objective

To assess the efficacy of continuous contactless vital signs monitoring with an automated Early Warning System (EWS) in detecting clinical deterioration among patients in general wards.

Methods

A prospective observational cohort study was conducted in the medical unit of a tertiary care hospital in India, involving 706 patients over 84,448 monitoring hours. The study used a contactless ballistocardiography system (Dozee system) to continuously monitor heart rate, respiratory rate, and blood pressure. The study assessed total, mean, and median alerts at 24, 48, 72, 96, 120 h, and length of stay (LOS) before patient deterioration or discharge. It analyzed alert sensitivity and specificity, average time from initial alert to deterioration, and healthcare practitioners (HCP) activity. Study was registered with the Clinical Trials Registry-India CTRI/2022/10/046404.

Results

Out of 706 patients, 33 (5%) experienced clinical deterioration, while 673 (95%) did not. The deterioration group consistently had a higher number of alerts compared to those who were discharged normally, across all time-points. On average, the time between the initial alert and clinical deterioration was 16 h within the last 24 h preceding the event. The sensitivity of the Dozee-EWS varied between 67% and 94%. HCP spend 10% of their time on vital signs check and documentation.

Conclusions

This study suggests that utilizing contactless continuous vital signs monitoring with Dozee-EWS in general ward holds promise for enhancing the early detection of clinical deterioration. Further research is essential to evaluate the effectiveness across a wider range of clinical settings.

PeriOperative Quality Initiative (POQI) international consensus statement on perioperative arterial pressure management

Arterial pressure monitoring and management are mainstays of haemodynamic therapy in patients having surgery. This article presents updated consensus statements and recommendations on perioperative arterial pressure management developed during the 11th POQI PeriOperative Quality Initiative (POQI) consensus conference held in London, UK, on June 4-6, 2023, which included a diverse group of international experts. Based on a modified Delphi approach, we recommend keeping intraoperative mean arterial pressure ≥60 mm Hg in at-risk patients. We further recommend increasing mean arterial pressure targets when venous or compartment pressures are elevated and treating hypotension based on presumed underlying causes. When intraoperative hypertension is treated, we recommend doing so carefully to avoid hypotension. Clinicians should consider continuous intraoperative arterial pressure monitoring as it can help reduce the severity and duration of hypotension compared to intermittent arterial pressure monitoring. Postoperative hypotension is often unrecognised and might be more important than intraoperative hypotension because it is often prolonged and untreated. Future research should focus on identifying patient-specific and organ-specific hypotension harm thresholds and optimal treatment strategies for intraoperative hypotension including choice of vasopressors. Research is also needed to guide monitoring and management strategies for recognising, preventing, and treating postoperative hypotension.

Health in a Virtual Environment (HIVE): A Novel Continuous Remote Monitoring Service for Inpatient Management

The aim of this study was to describe the implementation of a novel 50-bed continuous remote monitoring service for high-risk acute inpatients treated in non-critical wards, known as Health in a Virtual Environment (HIVE). We report the initial results, presenting the number and type of patients connected to the service, and assess key outcomes from this cohort. This was a prospective, observational study of characteristics and outcomes of patients connected to the HIVE continuous monitoring service at a major tertiary hospital and a smaller public hospital in Western Australia between January 2021 and June 2023. In the first two and a half years following implementation, 7541 patients were connected to HIVE for a total of 331,118 h. Overall, these patients had a median length of stay of 5 days (IQR 2, 10), 11.0% (n = 833) had an intensive care unit admission, 22.4% (n = 1691) had an all-cause emergency readmission within 28 days from hospital discharge, and 2.2% (n = 167) died in hospital. Conclusions: Our initial results show promise, demonstrating that this innovative approach to inpatient care can be successfully implemented to monitor high-risk patients in medical and surgical wards. Future studies will investigate the effectiveness of the program by comparing patients receiving HIVE supported care to comparable patients receiving routine care.

Application of non-contact sensors for health monitoring in hospitals: a narrative review

The continuous monitoring of the health status of patients is essential for the effective monitoring of disease progression and the management of symptoms. Recently, health monitoring using non-contact sensors has gained interest. Therefore, this study aimed to investigate the use of non-contact sensors for health monitoring in hospital settings and evaluate their potential clinical applications. A comprehensive literature search was conducted using PubMed to identify relevant studies published up to February 26, 2024. The search terms included "hospital," "monitoring," "sensor," and "non-contact." Studies that used non-contact sensors to monitor health status in hospital settings were included in this review. Of the 38 search results, five studies met the inclusion criteria. The non-contact sensors described in the studies were radar, infrared, and microwave sensors. These non-contact sensors were used to obtain vital signs, such as respiratory rate, heart rate, and body temperature, and were then compared with the results from conventional measurement methods (polysomnography, nursing records, and electrocardiography). In all the included studies, non-contact sensors demonstrated a performance similar to that of conventional health-related parameter measurement methods. Non-contact sensors are expected to be a promising solution for health monitoring in hospital settings.

Impact of Remote Patient Monitoring Systems on Nursing Time, Healthcare Providers, and Patient Satisfaction in General Wards

INTRODUCTION

Remote patient monitoring systems (RPMS) are increasingly integrated into hospital wards to improve patient safety and reduce the workload on healthcare professionals (HCPs). This study evaluates the efficacy of RPMS in general wards, focusing on their impact on nursing efficiency, patient care, HCPs, and patient satisfaction.

METHODS

A comprehensive time-motion study was conducted along with surveys targeting HCPs and patients in M.S. Ramaiah Memorial Hospital, Bangalore, India, which has implemented RPMS in general wards. The study involved observing and comparing nursing activities in RPMS-equipped wards versus control wards without RPMS across various shifts. In addition, feedback on the system's impact on patient safety, overall care quality, and usability was gathered through a survey form.

RESULTS

RPMS decreases the amount of time nurses spend on routine monitoring, communication, and coordination, enabling a 43.11% increase in time available for patient care. More than 89% of HCPs noted improvements in the level of care and overall patient safety. More than 80% of the HCPs also noted improvement in the patient's experience. More than 50% of HCPs find RPMS easy to use and user-friendly. More than 60% of the patients noted an overall improvement in care quality.

CONCLUSION

RPMS has proven to be a valuable asset in hospital wards, enhancing patient monitoring and safety while reducing the workload on staff. In addition, significant time savings on routine tasks and high satisfaction levels from both staff and patients underscore the system's benefits.

Barriers to and Facilitators of Key Stakeholders Influencing Successful Digital Implementation of Remote Monitoring Solutions: Mixed Methods Analysis

BACKGROUND

Implementation of remote monitoring solutions and digital alerting tools in health care has historically been challenging, despite the impetus provided by the COVID-19 pandemic. To date, a health systems-based approach to systematically describe barriers and facilitators across multiple domains has not been undertaken.

OBJECTIVE

We aimed to undertake a comprehensive mixed methods analysis of barriers and facilitators for successful implementation of remote monitoring and digital alerting tools in complex health organizations.

METHODS

A mixed methods approach using a modified Technology Acceptance Model questionnaire and semistructured interviews mapped to the validated fit among humans, organizations, and technology (HOT-fit) framework was undertaken. Likert frequency responses and deductive thematic analyses were performed.

RESULTS

A total of 11 participants responded to the questionnaire and 18 participants to the interviews. Key barriers and facilitators could be mapped onto 6 dimensions, which incorporated aspects of digitization: system use (human), user satisfaction (human), environment (organization), structure (organization), information and service quality (technology), and system quality (technology).

CONCLUSIONS

The recommendations proposed can enhance the potential for future remote sensing solutions to be more successfully integrated in health care practice, resulting in more successful use of "virtual wards."

TRIAL REGISTRATION

ClinicalTrials.gov NCT05321004; https://www.clinicaltrials.gov/study/NCT05321004.

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.

Effectiveness of current perioperative telemonitoring on postoperative outcome in patients undergoing major abdominal surgery: A systematic review of controlled trials

BACKGROUND

Perioperative telemonitoring of patients undergoing major surgery might lead to improved postoperative outcomes. The aim of this systematic review is to evaluate the effectiveness of current perioperative telemonitoring interventions on postoperative clinical, patient-reported, and financial outcome measures in patients undergoing major surgery.

METHODS

For this systematic review, PubMed, CINAHL, and Embase databases were searched for eligible articles published between January 1, 2009 and March 15, 2021. Studies were eligible as they described: (P) patients aged 18 years or older who underwent major abdominal surgery, (I) perioperative telemonitoring as intervention, (C) a control group receiving usual care, (O) any type of postoperative clinical, patient-reported, or financial outcome measures, and (S) an interventional study design.

RESULTS

The search identified 2958 articles of which 10 were eligible for analysis, describing nine controlled trials of 2438 patients. Perioperative telemonitoring comprised wearable biosensors (n = 3), websites (n = 3), e-mail (n = 1), and mobile applications (n = 2). Outcome measures were clinical (n = 8), patient-reported (n = 5), and financial (n = 2). Results show significant improvement of recovery time, stoma self-efficacy and pain in the early postoperative phase in patients receiving telemonitoring. Other outcome measures were not significantly different between the groups.

CONCLUSION

Evidence for the effectiveness of perioperative telemonitoring in major surgery is scarce. There is a need for good quality studies with sufficient patients while ensuring that the quality and usability of the technology and the adoption in care processes are optimal.

Surveillance of high-risk early postsurgical patients for real-time detection of complications using wireless monitoring (SHEPHERD study): results of a randomized multicenter stepped wedge cluster trial

Background

Vital signs measurements on the ward are performed intermittently. This could lead to failure to rapidly detect patients with deteriorating vital signs and worsens long-term outcome. The aim of this study was to test the hypothesis that continuous wireless monitoring of vital signs on the postsurgical ward improves patient outcome.

Methods

In this prospective, multicenter, stepped-wedge cluster randomized study, patients in the control group received standard monitoring. The intervention group received continuous wireless monitoring of heart rate, respiratory rate and temperature on top of standard care. Automated alerts indicating vital signs deviation from baseline were sent to ward nurses, triggering the calculation of a full early warning score followed. The primary outcome was the occurrence of new disability three months after surgery.

Results

The study was terminated early (at 57% inclusion) due to COVID-19 restrictions. Therefore, only descriptive statistics are presented. A total of 747 patients were enrolled in this study and eligible for statistical analyses, 517 patients in the control group and 230 patients in the intervention group, the latter only from one hospital. New disability at three months after surgery occurred in 43.7% in the control group and in 39.1% in the intervention group (absolute difference 4.6%).

Conclusion

This is the largest randomized controlled trial investigating continuous wireless monitoring in postoperative patients. While patients in the intervention group seemed to experience less (new) disability than patients in the control group, results remain inconclusive with regard to postoperative patient outcome due to premature study termination.

Clinical trial registration

ClinicalTrials.gov, ID: NCT02957825.

Outcomes in patients receiving continuous monitoring of vital signs on general wards: A systematic review and meta-analysis of randomised controlled trials

Objective

The timely identification of deterioration on general wards is crucial to patient care with each hour of delay independently associated with increased risk of death. The introduction of continuous monitoring of patient vital signs on general wards, currently not standard care, may improve patient outcomes. Our aim was to investigate whether patients on general wards receiving continuous vital signs monitoring have better outcomes than patients receiving usual care.

Methods

Meta-analysis of randomised controlled trials comparing non-critical care patients receiving continuous monitoring of vital signs to usual care. We searched Medline, Embase, and Web of Science, and assessed risk of bias with version 2 of the Cochrane risk-of-bias tool for randomised trials. In addition to measures related to the early detection of deterioration, we planned to present all patient outcomes reported by the clinical trials included.

Results

We included seven trials involving 1284 participants. There were no statistically significant differences in the four outcomes pooled. Comparing continuously monitored to normal care, the pooled odds for hospital mortality, major event/complication, and HDU/ICU admission was 0.95 (95% CI 0.59-1.53, p = 0.84; 660 participants, 3 studies), 0.71 (95% CI 0.38-1.31, p = 0.27; 948 participants, 4 studies) and 0.82 (95% CI 0.25-2.67, p = 0.74; 655 participants, 4 studies), respectively. The mean difference for length of stay was 2.12 days lower (95% CI -5.56 to 1.32, p = 0.23; 1034 participants, 6 studies).

Conclusion

We found no significant improvements in outcomes for patients continuously monitored compared to usual care. Further research is needed to understand what modalities of continuous monitoring may influence outcomes and investigate the implications of a telepresence service and multi-parameter scoring system.

Registration

PROSPERO CRD42023458656.

Initiatives to detect and prevent death from perioperative deterioration

PURPOSE OF REVIEW

This study indicates that there are differences between hospitals in detection, as well as in adequate management of postsurgical complications, a phenomenon that is described as 'failure-to-rescue'.In this review, recent initiatives to reduce failure-to-rescue in the perioperative period are described.

RECENT FINDINGS

Use of cognitive aids, emergency manuals, family participation as well as remote monitoring systems are measures to reduce failure-to-rescue situations. Postoperative visit of an anaesthesiologist on the ward was not shown to improve outcome, but there is still room for improvement of postoperative care.

SUMMARY

Improving the complete emergency chain, including monitoring, recognition and response in the afferent limb, as well as diagnostic and treatment in the efferent limb, should lead to reduced failure-to-rescue situations in the perioperative period.

Detection and Diagnostic Accuracy of Cardiac Arrhythmias Using Wearable Health Devices: A Systematic Review

Photoplethysmography (PPG) is the wearable devices' most widely used technology for monitoring heart rate. The systematic review used the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) standards and guidelines. This systematic review seeks to establish the effects of wearable health devices on cardiac arrhythmias concerning their impact on the personalization of cardiac management, their refining effect on stroke prevention strategies, and their influence on research and preventive care of cardiac arrhythmias and their re-evaluation of the patient-physician relationship. The population, exposure, control, outcomes, and studies (PECOS) criteria were used in the systematic review. This review considered studies that covered the tests conducted on individuals who presented with cardiovascular diseases (CVD) and also healthy people. The intervention for studies included wearable health devices that could detect and diagnose cardiac arrhythmias.  The study considered articles that reported on the personalization of cardiac management, stroke prevention strategies, influence in research and preventive care of cardiac arrhythmias, and the re-evaluation of the patient-physician relationship. Two independent researchers were used in the extraction of the data. In case of dispute, the issue was resolved using a third party. The study's quality analysis was conducted using AXIS. The management of atrial fibrillation (AF) lies heavily in the prevention of stroke. The accuracy being reported in the prediction of arrhythmias and the monitoring of heart rates makes wearable devices an efficient means to personalize health care. Personalization of health and treatment in preventing and managing arrhythmias becomes possible due to the portability of smart wearable devices. However, limitations may be observed due to the high costs incurred in their purchase and use. Using smart wearable devices for the detection of cardiac arrhythmias was very significant.

Exploiting Electronic Data to Advance Knowledge and Management of Severe Infections

Purpose of Review

To identify opportunities and recent advances in the use of multicentric digital data sources and networks to investigate the epidemiology and management of patients with infections admitted to intensive care units (ICUs).

Recent Findings

Electronic surveillance systems for a range of serious infections have been reported from large cohorts with evident improvements in efficiency, objectivity, and comprehensiveness of coverage as compared to traditional methods. Electronic data, most notably from electronic health records, has been used to define the epidemiology and outcomes of severe infections in several settings and conditions and has facilitated population-based evaluation. Automated alerts and notifications hold promise to identify patients at risk for sepsis and bloodstream infection although demonstration of efficacy in interventional trials is needed.

Summary

Exploitation of electronic data in ICUs has led to a better understanding of the epidemiology of severe infections and holds promise for future interventional clinical trials.

Wearable devices for remote monitoring of hospitalized patients with COVID-19 in Vietnam

Patients with severe COVID-19 disease require monitoring with pulse oximetry as a minimal requirement. In many low- and middle- income countries, this has been challenging due to lack of staff and equipment. Wearable pulse oximeters potentially offer an attractive means to address this need, due to their low cost, battery operability and capacity for remote monitoring. Between July and October 2021, Ho Chi Minh City experienced its first major wave of SARS-CoV-2 infection, leading to an unprecedented demand for monitoring in hospitalized patients. We assess the feasibility of a continuous remote monitoring system for patients with COVID-19 under these circumstances as we implemented 2 different systems using wearable pulse oximeter devices in a stepwise manner across 4 departments.

Continuous pH monitoring using a sensor for the early detection of anastomotic leaks

Anastomotic leaks (AL) and staple line leaks are a serious post-operative complication that can develop following bariatric surgery. The delay in the onset of symptoms following a leak usually results in reactive diagnostics and treatment, leading to increased patient morbidity and mortality, and a clinical and economic burden on both the patient and the hospital. Despite support in literature for pH as a biomarker for early detection of AL, the current methods of pH detection require significant clinician involvement and resources. Presented here is a polyaniline (PANI)-based pH sensor that can be connected inline to surgical drains to continuously monitor peritoneal secretion in real time for homeostatic changes in pH. During this study, the baseline peritoneal fluid pH was measured in two pigs using the PANI sensor and verified using a benchtop pH probe. The PANI sensor was then utilized to continuously monitor the changes in the pH of peritoneal effluent, as a gastric leak was simulated. The inline sensors were able to detect the resulting local changes in drainage pH within 10 min of leak induction. The successful implementation of this sensor in clinical practice can both enable high efficiency continuous monitoring of patient status and drastically decrease the time required to detect AL, thus potentially decreasing the clinical and economic burden incurred by gastric leaks.

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.

Comparing Continuous with Periodic Vital Sign Scoring for Clinical Deterioration Using a Patient Data Model

To evaluate a minute-by-minute monitoring algorithm against a periodic early warning score (EWS) in detecting clinical deterioration and workload. Periodic EWSs suffer from large measurement intervals, causing late detection of deterioration. This might be prevented by continuous vital sign monitoring with a real-time algorithm such as the Visensia Safety Index (VSI). This prospective comparative data modeling cohort study (NCT04189653) compares continuous algorithmic alerts against periodic EWS in continuous monitored medical and surgical inpatients. We evaluated sensitivity, frequency, number of warnings needed to evaluate (NNE) and time of initial alert till escalation of care (EOC): Rapid Response Team activation, unplanned ICU admission, emergency surgery, or death. Also, the percentage of VSI alerting minutes was compared between patients with or without EOC. In 1529 admissions continuous VSI warned for 55% of EOC (95% CI: 45-64%) versus 51% (95% CI: 41-61%) by periodic EWS. NNE for VSI was 152 alerts per detected EOC (95% CI: 114-190) compared to 21 (95% CI: 17-28). It generated 0.99 warnings per day per patient compared to 0.13. Time from detection score till escalation was 8.3 hours (IQR: 2.6-24.8) with VSI versus 5.2 (IQR: 2.7-12.3) hours with EWS (P=0.074). The percentage of warning VSI minutes was higher in patients with EOC than in stable patients (2.36% vs 0.81%, P<0.001). Although sensitivity of detection was not significantly improved continuous vital sign monitoring shows potential for earlier alerts for deterioration compared to periodic EWS. A higher percentage of alerting minutes may indicate risk for deterioration.

Continuous vital sign monitoring in patients after elective abdominal surgery: a retrospective study on clinical outcomes and costs

Aim: To assess changes in outcomes and costs upon implementation of continuous vital sign monitoring in postsurgical patients. Materials & methods: Retrospective analysis of clinical outcomes and in-hospital costs compared with a control period. Results: During the intervention period patients were less frequently admitted to the intensive care unit (ICU) (p = 0.004), had shorter length of stay (p < 0.001) and lower costs (p < 0.001). The intervention was associated with a lower odds of ICU admission (odds ratio: 0.422; p = 0.007) and ICU related costs (odds ratio: -662.4; p = 0.083). Conclusion: Continuous vital sign monitoring may have contributed to fewer ICU admissions and lower ICU costs in postsurgical patients.

The impact of continuous wireless monitoring on adverse device effects in medical and surgical wards: a review of current evidence

Novel technologies allow continuous wireless monitoring systems (CWMS) to measure vital signs and these systems might be favorable compared to intermittent monitoring regarding improving outcomes. However, device safety needs to be validated because uncertain evidence challenges the clinical implementation of CWMS. This review investigates the frequency of device-related adverse events in patients monitored with CWMS in general hospital wards. Systematic literature searches were conducted in PubMed and Embase. We included trials of adult patients in general hospital wards monitored with CWMS. Our primary outcome was the frequency of unanticipated serious adverse device effects (USADEs). Secondary outcomes were adverse device effects (ADEs) and serious adverse device effects (SADE). Data were extracted from eligible studies and descriptive statistics were applied to analyze the data. Seven studies were eligible for inclusion with a total of 1485 patients monitored by CWMS. Of these patients, 54 patients experienced ADEs (3.6%, 95% CI 2.8-4.7%) and no USADEs or SADEs were reported (0%, 95% CI 0-0.31%). The studies of the SensiumVitals® patch, the iThermonitor, and the ViSi Mobile® device reported 28 (9%), 25 (5%), and 1 (3%) ADEs, respectively. No ADEs were reported using the HealthPatch, WARD 24/7 system, or Coviden Alarm Management. Current evidence suggests that CWMS are safe to use but systematic reporting of all adverse device effects is warranted.

Association Between Postoperative Complications and Long-term Survival After Non-cardiac Surgery Among Veterans

OBJECTIVE

To evaluate the relationship between postoperative complications and long-term survival.

SUMMARY AND BACKGROUND

Postoperative complications remain a significant driver of healthcare costs and are associated with increased perioperative mortality, yet the extent to which they are associated with long-term survival is unclear.

METHODS

National cohort study of Veterans who underwent non-cardiac surgery using data from the Veterans Affairs Surgical Quality Improvement Program (2011-2016). Patients were classified as having undergone outpatient, low-risk inpatient, or high-risk inpatient surgery. Patients were categorized based on number and type of complications. The association between the number of complications (or the specific type of complication) and risk of death was evaluated using multivariable Cox regression with robust standard errors using a 90-day survival landmark.

RESULTS

Among 699,002 patients, complication rates were 3.0%, 6.1%, and 18.3% for outpatient, low-risk inpatient, and high-risk inpatient surgery, respectively. There was a dose-response relationship between an increasing number of complications and overall risk of death in all operative settings [outpatient surgery: no complications (ref); one-hazard ratio (HR) 1.30 (1.23 - 1.38); multiple-HR 1.61 (1.46 - 1.78); low-risk inpatient surgery: one-HR 1.34 (1.26 - 1.41); multiple-HR 1.69 (1.55 - 1.85); high-risk inpatient surgery: one-HR 1.14 (1.10 - 1.18); multiple-HR 1.42 (1.36 - 1.48)]. All complication types were associated with risk of death in at least 1 operative setting, and pulmonary complications, sepsis, and clostridium difficile colitis were associated with higher risk of death across all settings. Conclusions: Postoperative complications have an adverse impact on patients' long-term survival beyond the immediate postoperative period. Although most research and quality improvement initiatives primarily focus on the perioperative impact of complications, these data suggest they also have important longer-term implications that merit further investigation.

A wearable patch based remote early warning score (REWS) in major abdominal cancer surgery patients

INTRODUCTION

The shift toward remote patient monitoring methods to detect clinical deterioration requires testing of wearable devices in real-life clinical settings. This study aimed to develop a remote early warning scoring (REWS) system based on continuous measurements using a wearable device, and compare its diagnostic performance for the detection of deterioration to the diagnostic performance of the conventional modified early warning score (MEWS).

MATERIALS AND METHODS

The study population of this prospective, single center trial consisted of patients who underwent major abdominal cancer surgery and were monitored using routine in-hospital spotcheck measurements of the vital parameters. Heart and respiratory rates were measured continuously using a wireless accelerometer patch (HealthDot). The prediction by MEWS of deterioration toward a complication graded Clavien-Dindo of 2 or higher was compared to the REWS derived from continuous measurements by the wearable patch.

MAIN RESULTS

A total of 103 patients and 1909 spot-check measurements were included in the analysis. Postoperative deterioration was observed in 29 patients. For both EWS systems, the sensitivity (MEWS: 0.20 95% CI: [0.13-0.29], REWS: 0.20 95% CI: [0.13-0.29]) and specificity (MEWS: 0.96 95% CI: [0.95-0.97], REWS: 0.96 95% CI: [0.95-0.97]) were assessed.

CONCLUSIONS

The diagnostic value of the REWS method, based on continuous measurements of the heart and respiratory rates, is comparable to that of the MEWS in patients following major abdominal cancer surgery. The wearable patch could detect the same amount of deteriorations, without requiring manual spot check measurements.

Continuous wireless pre- and postoperative vital sign monitoring reveal new, severe desaturations after vascular surgery

OBJECTIVES

Postoperative deviating physiologic values (vital signs) may represent postoperative stress or emerging complications. But they can also reflect chronic preoperative values. Distinguishing between the two circumstances may influence the utility of using vital signs in patient monitoring. Thus, we aimed to describe the occurrence of vital sign deviations before and after major vascular surgery, hypothesising that preoperative vital sign deviations were longer in duration postoperatively.

METHODS

In this prospective observational study, arterial vascular patients were continuously monitored wirelessly - from the day before until 5 days after surgery. Recorded values were: heart rate, respiration rate, peripheral arterial oxygen saturation (SpO₂ ) and blood pressure. The outcomes were 1. cumulative duration of SpO₂  < 85% / 24 h, and 2. cumulative duration per 24 h of vital sign deviations.

RESULTS

Forty patients were included with a median monitoring time of 21 h preoperatively and 42 h postoperatively. The median duration of SpO₂  < 85% preoperatively was 14.4 min/24 h whereas it was 28.0 min/24 h during day 0 in the ward (p = .09), and 16.8 min/24 h on day 1 in the ward (p = 0.61). Cumulative duration of SpO₂  < 80% was significantly longer on day 0 in the ward 2.4 min/24 h (IQR 0.0-4.6) versus 6.7 min/24 h (IQR 1.8-16.2) p = 0.01.

CONCLUSION

Deviating physiology is common in patients before and after vascular surgery. A longer duration of severe desaturation was found on the first postoperative day in the ward compared to preoperatively, whereas moderate desaturations were reflected in postoperative desaturations. Cumulative duration outside thresholds is, in some cases, exacerbated after surgery.

Wearable devices for remote monitoring of hospitalized patients with COVID-19 in Vietnam

Patients with severe COVID-19 disease require monitoring with pulse oximetry as a minimal requirement. In many low- and middle- income countries, this has been challenging due to lack of staff and equipment. Wearable pulse oximeters potentially offer an attractive means to address this need, due to their low cost, battery operability and capacity for remote monitoring.  Between July and October 2021, Ho Chi Minh City experienced its first major wave of SARS-CoV-2 infection, leading to an unprecedented demand for monitoring in hospitalized patients. We assess the feasibility of a continuous remote monitoring system for patients with COVID-19 under these circumstances as we implemented 2 different systems using wearable pulse oximeter devices in a stepwise manner across 4 departments.

Advantage of Vital Sign Monitoring Using a Wireless Wearable Device for Predicting Septic Shock in Febrile Patients in the Emergency Department: A Machine Learning-Based Analysis

Intermittent manual measurement of vital signs may not rapidly predict sepsis development in febrile patients admitted to the emergency department (ED). We aimed to evaluate the predictive performance of a wireless monitoring device that continuously measures heart rate (HR) and respiratory rate (RR) and a machine learning analysis in febrile but stable patients in the ED. We analysed 468 patients (age, ≥18 years; training set, n = 277; validation set, n = 93; test set, n = 98) having fever (temperature >38 °C) and admitted to the isolation care unit of the ED. The AUROC of the fragmented model with device data was 0.858 (95% confidence interval [CI], 0.809−0.908), and that with manual data was 0.841 (95% CI, 0.789−0.893). The AUROC of the accumulated model with device data was 0.861 (95% CI, 0.811−0.910), and that with manual data was 0.853 (95% CI, 0.803−0.903). Fragmented and accumulated models with device data detected clinical deterioration in febrile patients at risk of septic shock 9 h and 5 h 30 min earlier, respectively, than those with manual data. Continuous vital sign monitoring using a wearable device could accurately predict clinical deterioration and reduce the time to recognise potential clinical deterioration in stable ED patients with fever.

Feasibility and patient's experiences of perioperative telemonitoring in major abdominal surgery: an observational pilot study

BACKGROUND

Telemonitoring during the perioperative trajectory may improve patient outcomes and self-management. The aim of this study is to assess the feasibility of and patient's experiences with telemonitoring before and after major abdominal surgery to inform future study design.

METHODS

Patients planned for elective major abdominal surgery wore a sensor and answered well-being questions on a tablet daily for at least 2 weeks preoperatively up to 30-days postoperatively. Feasibility was assessed by participation and completion rate, compliance per day, weekly satisfaction scores, and reasons for nonscheduled contact.

RESULTS

Twenty-three patients were included (participation rate of 54.5%) with a completion rate of 69.6%. Median compliance with the wearable sensor and well-being questions was respectively: 94.7% and 83.3% preoperatively at home; 100% and 66.7% postoperatively in-hospital; and 95.4% and 85.8% postoperatively at home. Median weekly satisfaction scores for both wearing the sensor and well-being questions were 5 (IQR, 4-5). Contact moments were related to absence of sensor data and technological issues (76.0%) or patient discomfort and insecurity (24.0%).

CONCLUSIONS

In this study, telemonitoring showed high satisfaction and compliance during the perioperative trajectory. Future trial design regarding the effectiveness of telemonitoring requires embedding in clinical practice and support for patients, relatives, and healthcare personnel.

Effectiveness of automated alerting system compared to usual care for the management of sepsis

There is a large body of evidence showing that delayed initiation of sepsis bundle is associated with adverse clinical outcomes in patients with sepsis. However, it is controversial whether electronic automated alerts can help improve clinical outcomes of sepsis. Electronic databases are searched from inception to December 2021 for comparative effectiveness studies comparing automated alerts versus usual care for the management of sepsis. A total of 36 studies are eligible for analysis, including 6 randomized controlled trials and 30 non-randomized studies. There is significant heterogeneity in these studies concerning the study setting, design, and alerting methods. The Bayesian meta-analysis by using pooled effects of non-randomized studies as priors shows a beneficial effect of the alerting system (relative risk [RR]: 0.71; 95% credible interval: 0.62 to 0.81) in reducing mortality. The automated alerting system shows less beneficial effects in the intensive care unit (RR: 0.90; 95% CI: 0.73-1.11) than that in the emergency department (RR: 0.68; 95% CI: 0.51-0.90) and ward (RR: 0.71; 95% CI: 0.61-0.82). Furthermore, machine learning-based prediction methods can reduce mortality by a larger magnitude (RR: 0.56; 95% CI: 0.39-0.80) than rule-based methods (RR: 0.73; 95% CI: 0.63-0.85). The study shows a statistically significant beneficial effect of using the automated alerting system in the management of sepsis. Interestingly, machine learning monitoring systems coupled with better early interventions show promise, especially for patients outside of the intensive care unit.

Outcomes of Vital Sign Monitoring of an Acute Surgical Cohort With Wearable Sensors and Digital Alerting Systems: A Pragmatically Designed Cohort Study and Propensity-Matched Analysis

Background: The implementation and efficacy of wearable sensors and alerting systems in acute secondary care have been poorly described.

Objectives: to pragmatically test one such system and its influence on clinical outcomes in an acute surgical cohort.

Methods: In this pragmatically designed, pre-post implementation trial, participants admitted to the acute surgical unit at our institution were recruited. In the pre-implementation phase (September 2017 to May 2019), the SensiumVitals™ monitoring system, which continuously measures temperature, heart, and respiratory rates, was used for monitoring alongside usual care (intermittent monitoring in accordance with the National Early Warning Score 2 [NEWS 2] protocol) without alerts being generated. In the post-implementation phase (May 2019 to March 2020), alerts were generated when pre-established thresholds for vital parameters were breached, requiring acknowledgement from healthcare staff on provided mobile devices. Hospital length of stay, intensive care use, and 28-days mortality were measured. Balanced cohorts were created with 1:1 ‘optimal’ propensity score logistic regression models.

Results: The 1:1 matching method matched the post-implementation group (n = 141) with the same number of subjects from the pre-implementation group (n = 141). The median age of the entire cohort was 52 (range: 18–95) years and the median duration of wearing the sensor was 1.3 (interquartile range: 0.7–2.0) days. The median alert acknowledgement time was 111 (range: 1–2,146) minutes. There were no significant differences in critical care admission (planned or unplanned), hospital length of stay, or mortality.

Conclusion: This study offered insight into the implementation of digital health technologies within our institution. Further work is required for optimisation of digital workflows, particularly given their more favourable acceptability in the post pandemic era. Clinical trials registration information: ClinicalTrials.gov Identifier: NCT04638738.

Nursing staff perspectives of continuous remote vital signs monitoring on surgical wards: Theory elicitation for a realist evaluation

RATIONALE, AIMS AND OBJECTIVES

Continuous remote monitoring (CRM) provides a novel solution to the challenges of monitoring patients' vital signs in hospital, but the results of quantitative studies have been mixed. Acceptance by staff is a crucial determinant of the success of healthcare technologies and may explain these discrepancies. Drawing on the approach of realist evaluation, this paper aims to identify theories about how, why and in what conditions nursing staff perceptions vary regarding the CRM of patients' vital signs.

METHODS

Multiple methods were used to elicit theories about factors likely to facilitate or impede the successful implementation of continuous remote vital signs monitoring. This included a literature review, consultation with patients and observational work conducted during a randomized controlled trial (RCT) of CRM. In addition, a priori theories developed through informal interactions with patients and ward staff during the day-to-day set-up of the trial were included.

RESULTS

The findings suggest that the perceptions of nursing staff regarding remote monitoring can be influenced by the type of patients under their care and their previous experience of telemetry. Factors which may undermine the engagement of staff are perceived staff burden, which can be dependent on contextual factors such as staffing levels, time of day and senior staff attitudes. Staff attitudes are also likely to be influenced by patient perspectives and the utility of the devices associated with remote monitoring. The successful implementation of CRM may be dependent on staff training, research staff input and hospital culture.

CONCLUSIONS

Theories regarding nursing staff engagement with remote monitoring are numerous, varied and contradictory. The theories elicited in this initial phase will be refined during interviews with the nursing staff involved with the RCT.

Sepsis Mortality Prediction Using Wearable Monitoring in Low-Middle Income Countries

Sepsis is associated with high mortality-particularly in low-middle income countries (LMICs). Critical care management of sepsis is challenging in LMICs due to the lack of care providers and the high cost of bedside monitors. Recent advances in wearable sensor technology and machine learning (ML) models in healthcare promise to deliver new ways of digital monitoring integrated with automated decision systems to reduce the mortality risk in sepsis. In this study, firstly, we aim to assess the feasibility of using wearable sensors instead of traditional bedside monitors in the sepsis care management of hospital admitted patients, and secondly, to introduce automated prediction models for the mortality prediction of sepsis patients. To this end, we continuously monitored 50 sepsis patients for nearly 24 h after their admission to the Hospital for Tropical Diseases in Vietnam. We then compared the performance and interpretability of state-of-the-art ML models for the task of mortality prediction of sepsis using the heart rate variability (HRV) signal from wearable sensors and vital signs from bedside monitors. Our results show that all ML models trained on wearable data outperformed ML models trained on data gathered from the bedside monitors for the task of mortality prediction with the highest performance (area under the precision recall curve = 0.83) achieved using time-varying features of HRV and recurrent neural networks. Our results demonstrate that the integration of automated ML prediction models with wearable technology is well suited for helping clinicians who manage sepsis patients in LMICs to reduce the mortality risk of sepsis.

Early diagnosis of sepsis using an E-health application for a clinical early warning system outside of the intensive care unit: a case report

Background

Elderly and frail patients who are unable to call for help in case of vital distress can develop complications during their hospitalization. As a supplement to clinical monitoring by the nursing staff, these patients can also be monitored in real time, with the Sensium E-health technology. An application notifies clinical staff of any change in their vital signs (heart rate, respiratory rate, temperature) outside of normal ranges, suggestive of physiological decline. Nurses and physicians are notified of these abnormal changes by email and also via mobile application (iPhone or iPad), allowing early intervention to prevent further deterioration.

Case presentation

An 86-year-old Caucasian female, with chronic kidney disease, was hospitalized in our medical unit for pyelonephritis associated with a moderate deterioration of serum creatinine. Remote continuous monitoring allowed us to diagnose clinical deterioration early and adjust her treatment. The treatment improved her clinical condition and amended the secondary sepsis with circulation failure in 2 days.

Conclusions

The prognosis for patients with acute complicated pyelonephritis is much worse than for those with uncomplicated pyelonephritis. Remote continuous monitoring might be helpful to early diagnose urosepsis. This technology leads to improved prognosis of patients without initial vital distress, allowing early treatment and admission to intensive care unit.

Nurses' experiences with continuous vital sign monitoring on the general surgical ward: a qualitative study based on the Behaviour Change Wheel

Background

To support early recognition of clinical deterioration on a general ward continuous vital signs monitoring (CMVS) systems using wearable devices are increasingly being investigated. Although nurses play a crucial role in successful implementation, reported nurse adoption and acceptance scores vary significantly. In-depth insight into the perspectives of nurses regarding CMVS is lacking. To this end, we applied a theoretical approach for behaviour change derived from the Behaviour Change Wheel (BCW).

Aim

To provide insight in the capability, opportunity and motivation of nurses working with CMVS, in order to inform future implementation efforts.

Methods

A qualitative study was conducted, including twelve nurses of a surgical ward in a tertiary teaching hospital with previous experience of working with CMVS. Semi-structured interviews were audiotaped, transcribed verbatim, and analysed using thematic analysis. The results were mapped onto the Capability, Opportunity, Motivation – Behaviour (COM-B) model of the BCW.

Results

Five key themes emerged. The theme ‘Learning and coaching on the job’ linked to Capability. Nurses favoured learning about CVSM by dealing with it in daily practice. Receiving bedside guidance and coaching was perceived as important. The theme ‘interpretation of vital sign trends’ also linked to Capability. Nurses mentioned the novelty of monitoring vital sign trends of patients on wards. The theme ‘Management of alarms’ linked to Opportunity. Nurses perceived the (false) alarms generated by the system as excessive resulting in feelings of irritation and uncertainty. The theme ‘Integration and compatibility with clinical workflow’ linked to Opportunity. CVSM was experienced as helpful and easy to use, although integration in mobile devices and the EMR was highly favoured and the management of clinical workflows would need improvement. The theme ‘Added value for nursing care’ linked to Motivation. All nurses recognized the potential added value of CVSM for postoperative care.

Conclusion

Our findings suggest all parts of the COM-B model should be considered when implementing CVSM on general wards. When the themes in Capability and Opportunity are not properly addressed by selecting interventions and policy categories, this may negatively influence the Motivation and may compromise successful implementation.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12912-022-00837-x.

Feasibility of wireless continuous monitoring of vital signs without using alarms on a general surgical ward: A mixed methods study

Background

Wireless continuous vital sign monitoring by wearable devices have recently become available for patients on general wards to promote timely detection of clinical deterioration. Many continuous monitoring systems use conventional threshold alarm settings to alert nurses in case of deviating vital signs. However, frequent false alarms often lead to alarm fatigue and inefficiencies in the workplace. The aim of this study was to determine the feasibility of continuous vital sign monitoring without the use of alarms, thereby exclusively relying on interval trend monitoring.

Methods

This explanatory sequential mixed methods study was conducted at an abdominal surgical ward of a tertiary teaching hospital. Heart rate and respiratory rate of patients were measured every minute by a wearable sensor. Trends were visualized and assessed six times per day by nurses and once a day by doctors during morning rounds. Instead of using alarms we focused exclusively on regular vital sign trend analysis by nurses and doctors. Primary outcome was feasibility in terms of acceptability by professionals, assessed by the Usefulness, Satisfaction and Ease of Use questionnaire and further explored in two focus groups, as well as fidelity.

Results

A total of 56 patients were monitored and in 80.5% (n = 536) of nurses’ work shifts the trends assessments were documented. All deviating trends (n = 17) were recognized in time. Professionals (N = 46) considered continuous monitoring satisfying (4.8±1.0 on a 1–7 Likert-scale) and were willing to use the technology. Although insight into vital sign trends allowed faster anticipation and action upon changed patient status, professionals were neutral about usefulness (4.4±1.0). They found continuous monitoring easy to use (4.7±0.8) and easy to learn (5.3±1.0) but indicated the need for gaining practical experience. Nurses considered the use of alarms for deviating vital signs unnecessary, when trends were regularly assessed and reported.

Conclusion

We demonstrated that continuous vital signs trend monitoring without using alarms was feasible in the general ward setting, thereby avoiding unnecessary alarms and preventing alarm fatigue. When monitoring in a general ward setting, the standard use of alarms may therefore be reconsidered.

Wearable devices to monitor recovery after abdominal surgery: scoping review

BACKGROUND

Wearable devices have been proposed as a novel method for monitoring patients after surgery to track recovery, identify complications early, and improve surgical safety. Previous studies have used a heterogeneous range of devices, methods, and analyses. This review aimed to examine current methods and wearable devices used for monitoring after abdominal surgery and identify knowledge gaps requiring further investigation.

METHODS

A scoping review was conducted given the heterogeneous nature of the evidence. MEDLINE, EMBASE, and Scopus databases were systematically searched. Studies of wearable devices for monitoring of adult patients within 30 days after abdominal surgery were eligible for inclusion.

RESULTS

A total of 78 articles from 65 study cohorts, with 5153 patients were included. Thirty-one different wearable devices were used to measure vital signs, physiological measurements, or physical activity. The duration of postoperative wearable device use ranged from 15 h to 3 months after surgery. Studies mostly focused on physical activity metrics (71.8 per cent). Continuous vital sign measurement and physical activity tracking both showed promise for detecting postoperative complications earlier than usual care, but conclusions were limited by poor device precision, adherence, occurrence of false alarms, data transmission problems, and retrospective data analysis. Devices were generally well accepted by patients, with high levels of acceptance, comfort, and safety.

CONCLUSION

Wearable technology has not yet realized its potential to improve postoperative monitoring. Further work is needed to overcome technical limitations, improve precision, and reduce false alarms. Prospective assessment of efficacy, using an intention-to-treat approach should be the focus of further studies.

Continuous remote patient monitoring in heart failure patients (CASCADE study): mixed methods feasibility protocol (Preprint)

Background

Heart failure (HF) is a prevalent chronic disease and is associated with increases in mortality and morbidity. HF is a leading cause of hospitalizations and readmissions in the United States. A potentially promising area for preventing HF readmissions is continuous remote patient monitoring (CRPM).

Objective

The primary aim of this study is to determine the feasibility and preliminary efficacy of a CRPM solution in patients with HF at NorthShore University HealthSystem.

Methods

This study is a feasibility study and uses a wearable biosensor to continuously remotely monitor patients with HF for 30 days after discharge. Eligible patients admitted with an HF exacerbation at NorthShore University HealthSystem are being recruited, and the wearable biosensor is placed before discharge. The biosensor collects physiological ambulatory data, which are analyzed for signs of patient deterioration. Participants are also completing a daily survey through a dedicated study smartphone. If prespecified criteria from the physiological data and survey results are met, a notification is triggered, and a predetermined electronic health record–based pathway of telephonic management is completed. In phase 1, which has already been completed, 5 patients were enrolled and monitored for 30 days after discharge. The results of phase 1 were analyzed, and modifications to the program were made to optimize it. After analysis of the phase 1 results, 15 patients are being enrolled for phase 2, which is a calibration and testing period to enable further adjustments to be made. After phase 2, we will enroll 45 patients for phase 3. The combined results of phases 1, 2, and 3 will be analyzed to determine the feasibility of a CRPM program in patients with HF. Semistructured interviews are being conducted with key stakeholders, including patients, and these results will be analyzed using the affective adaptation of the technology acceptance model.

Results

During phase 1, of the 5 patients, 2 (40%) were readmitted during the study period. The study completion rate for phase 1 was 80% (4/5), and the study attrition rate was 20% (1/5). There were 57 protocol deviations out of 150 patient days in phase 1 of the study. The results of phase 1 were analyzed, and the study protocol was adjusted to optimize it for phases 2 and 3. Phase 2 and phase 3 results will be available by the end of 2022.

Conclusions

A CRPM program may offer a low-risk solution to improve care of patients with HF after hospital discharge and may help to decrease readmission of patients with HF to the hospital. This protocol may also lay the groundwork for the use of CRPM solutions in other groups of patients considered to be at high risk.

International Registered Report Identifier (IRRID)

DERR1-10.2196/36741

Usability of Wearable Multiparameter Technology to Continuously Monitor Free-Living Vital Signs in People Living With Chronic Obstructive Pulmonary Disease: Prospective Observational Study

Background

Vital signs monitoring (VSM) is routine for inpatients, but monitoring during free-living conditions is largely untested in chronic obstructive pulmonary disease (COPD).

Objective

This study investigated the usability and acceptability of continuous VSM for people with COPD using wearable multiparameter technology.

Methods

In total, 50 people following hospitalization for an acute exacerbation of COPD (AECOPD) and 50 people with stable COPD symptoms were asked to wear an Equivital LifeMonitor during waking hours for 6 weeks (42 days). The device recorded heart rate (HR), respiratory rate (RR), skin temperature, and physical activity. Adherence was defined by the number of days the vest was worn and daily wear time. Signal quality was examined, with thresholds of ≥85% for HR and ≥80% for RR, based on the device’s proprietary confidence algorithm. Data quality was calculated as the percentage of wear time with acceptable signal quality. Participant feedback was assessed during follow-up phone calls.

Results

In total, 84% of participants provided data, with average daily wear time of 11.8 (SD 2.2) hours for 32 (SD 11) days (average of study duration 76%, SD 26%). There was greater adherence in the stable group than in the post-AECOPD group (≥5 weeks wear: 71.4% vs 45.7%; P=.02). For all 84 participants, the median HR signal quality was 90% (IQR 80%-94%) and the median RR signal quality was 93% (IQR 92%-95%). The median HR data quality was 81% (IQR 58%-91%), and the median RR data quality was 85% (IQR 77%-91%). Stable group BMI was associated with HR signal quality (r_s=0.45, P=.008) and HR data quality (r_s=0.44, P=.008). For the AECOPD group, RR data quality was associated with waist circumference and BMI (r_s=–0.49, P=.009; r_s=–0.44, P=.02). In total, 36 (74%) participants in the Stable group and 21 (60%) participants in the AECOPD group accepted the technology, but 10 participants (12%) expressed concerns with wearing a device around their chest.

Conclusions

This wearable multiparametric technology showed good user acceptance and was able to measure vital signs in a COPD population. Data quality was generally high but was influenced by body composition. Overall, it was feasible to continuously measure vital signs during free-living conditions in people with COPD symptoms but with additional challenges in the post-AECOPD context.

The Use of Wearable Pulse Oximeters in the Prompt Detection of Hypoxemia and During Movement: Diagnostic Accuracy Study

Background

Commercially available wearable (ambulatory) pulse oximeters have been recommended as a method for managing patients at risk of physiological deterioration, such as active patients with COVID-19 disease receiving care in hospital isolation rooms; however, their reliability in usual hospital settings is not known.

Objective

We report the performance of wearable pulse oximeters in a simulated clinical setting when challenged by motion and low levels of arterial blood oxygen saturation (SaO₂).

Methods

The performance of 1 wrist-worn (Wavelet) and 3 finger-worn (CheckMe O2+, AP-20, and WristOx2 3150) wearable, wireless transmission–mode pulse oximeters was evaluated. For this, 7 motion tasks were performed: at rest, sit-to-stand, tapping, rubbing, drinking, turning pages, and using a tablet. Hypoxia exposure followed, in which inspired gases were adjusted to achieve decreasing SaO₂ levels at 100%, 95%, 90%, 87%, 85%, 83%, and 80%. Peripheral oxygen saturation (SpO₂) estimates were compared with simultaneous SaO₂ samples to calculate the root-mean-square error (RMSE). The area under the receiver operating characteristic curve was used to analyze the detection of hypoxemia (ie, SaO₂<90%).

Results

SpO₂ estimates matching 215 SaO₂ samples in both study phases, from 33 participants, were analyzed. Tapping, rubbing, turning pages, and using a tablet degraded SpO₂ estimation (RMSE>4% for at least 1 device). All finger-worn pulse oximeters detected hypoxemia, with an overall sensitivity of ≥0.87 and specificity of ≥0.80, comparable to that of the Philips MX450 pulse oximeter.

Conclusions

The SpO₂ accuracy of wearable finger-worn pulse oximeters was within that required by the International Organization for Standardization guidelines. Performance was degraded by motion, but all pulse oximeters could detect hypoxemia. Our findings support the use of wearable, wireless transmission–mode pulse oximeters to detect the onset of clinical deterioration in hospital settings.

Trial Registration

ISRCTN Registry 61535692; http://www.isrctn.com/ISRCTN61535692

International Registered Report Identifier (IRRID)

RR2-10.1136/bmjopen-2019-034404

Remote Monitoring of Chronic Critically Ill Patients after Hospital Discharge: A Systematic Review

Background: Over the past few decades, critical care has seen many advancements. These advancements resulted in a considerable increase in the prevalence of chronically critically ill patients requiring prolonged medical care, which led to a massive increase in healthcare utilization. Methods: We performed a search for suitable articles using PubMed and Google Scholar from the inception of these databases to 15 May 2021. Results: Thirty-four articles were included in the review and analyzed. We described the following characteristics and problems with chronic critically ill patient management: the patient population, remote monitoring, the monitoring of physiological parameters in chronic critically ill patients, the anatomical location of sensors, the barriers to implementation, and the main technology-related issues. The main challenges in the management of these patients are (1) the shortage of caretakers, (2) the periodicity of vital function monitoring (e.g., episodic measuring of blood pressure leads to missing important critical events such as hypertension, hypotension, and hypoxia), and (3) failure to catch and manage critical physiological events at the right time, which can result in poor outcomes. Conclusions: The prevalence of critically ill patients is expected to grow. Technical solutions can greatly assist medical personnel and caregivers. Wearable devices can be used to monitor blood pressure, heart rate, pulse, respiratory rate, blood oxygen saturation, metabolism, and central nervous system function. The most important points that should be addressed in future studies are the performance of the remote monitoring systems, safety, clinical and economic outcomes, as well as the acceptance of the devices by patients, caretakers, and healthcare professionals.

The Impact of Wearable Technologies in Health Research: Scoping Review

BACKGROUND

Wearable devices hold great promise, particularly for data generation for cutting-edge health research, and their demand has risen substantially in recent years. However, there is a shortage of aggregated insights into how wearables have been used in health research.

OBJECTIVE

In this review, we aim to broadly overview and categorize the current research conducted with affordable wearable devices for health research.

METHODS

We performed a scoping review to understand the use of affordable, consumer-grade wearables for health research from a population health perspective using the PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews) framework. A total of 7499 articles were found in 4 medical databases (PubMed, Ovid, Web of Science, and CINAHL). Studies were eligible if they used noninvasive wearables: worn on the wrist, arm, hip, and chest; measured vital signs; and analyzed the collected data quantitatively. We excluded studies that did not use wearables for outcome assessment and prototype studies, devices that cost >€500 (US $570), or obtrusive smart clothing.

RESULTS

We included 179 studies using 189 wearable devices covering 10,835,733 participants. Most studies were observational (128/179, 71.5%), conducted in 2020 (56/179, 31.3%) and in North America (94/179, 52.5%), and 93% (10,104,217/10,835,733) of the participants were part of global health studies. The most popular wearables were fitness trackers (86/189, 45.5%) and accelerometer wearables, which primarily measure movement (49/189, 25.9%). Typical measurements included steps (95/179, 53.1%), heart rate (HR; 55/179, 30.7%), and sleep duration (51/179, 28.5%). Other devices measured blood pressure (3/179, 1.7%), skin temperature (3/179, 1.7%), oximetry (3/179, 1.7%), or respiratory rate (2/179, 1.1%). The wearables were mostly worn on the wrist (138/189, 73%) and cost <€200 (US $228; 120/189, 63.5%). The aims and approaches of all 179 studies revealed six prominent uses for wearables, comprising correlations-wearable and other physiological data (40/179, 22.3%), method evaluations (with subgroups; 40/179, 22.3%), population-based research (31/179, 17.3%), experimental outcome assessment (30/179, 16.8%), prognostic forecasting (28/179, 15.6%), and explorative analysis of big data sets (10/179, 5.6%). The most frequent strengths of affordable wearables were validation, accuracy, and clinical certification (104/179, 58.1%).

CONCLUSIONS

Wearables showed an increasingly diverse field of application such as COVID-19 prediction, fertility tracking, heat-related illness, drug effects, and psychological interventions; they also included underrepresented populations, such as individuals with rare diseases. There is a lack of research on wearable devices in low-resource contexts. Fueled by the COVID-19 pandemic, we see a shift toward more large-sized, web-based studies where wearables increased insights into the developing pandemic, including forecasting models and the effects of the pandemic. Some studies have indicated that big data extracted from wearables may potentially transform the understanding of population health dynamics and the ability to forecast health trends.

Continuous Monitoring of Respiratory Rate with Wearable Sensor in Patients Admitted to Hospital with Pneumonia Compared with Intermittent Nurse-Led Monitoring in the United Kingdom: A Cost-Utility Analysis

BACKGROUND

Respiratory rate (RR) is one of the most important physiologic measures for predicting patients' deterioration of clinical condition and final prognosis. In several studies, RR has been the most important predictor of patients' prognoses.

OBJECTIVES

The objective of this study was to conduct a cost-utility analysis to estimate the cost and effectiveness of automatic respiratory rate monitoring (ARRM) with a non-invasive sensor (RespiraSense™) plus intermittent nurse-led RR monitoring (ARRM strategy) compared with intermittent nurse-led RR monitoring (IM strategy) in patients admitted to hospital in the UK with pneumonia.

METHODS

A decision analytic model was developed based on a hypothetical cohort of patients who were admitted to hospital with pneumonia. After admission, the patients could be monitored with either ARRM or IM strategies. The outcomes of interest included total costs and total effectiveness of each strategy, including length of stay (LoS) in hospital, LoS in intensive care unit, quality-adjusted life-years (QALYs), deaths, and incremental cost per QALY gained. An incremental cost of £20,000 or less per QALY gained was considered cost effective. A lifetime time horizon (38 years) was used to capture the long-term benefits. Probabilistic and deterministic sensitivity analyses were performed.

RESULTS

Total costs of patient care in ARRM and IM strategies were £1986.9 million and £2079.4 million, respectively. Total incremental QALYs lived were 3548 higher in the intervention arm (ARRM), meaning that the ARRM strategy was dominant (i.e., less costly [£92.6 million less] and more effective). The results were stable in probabilistic and most of the deterministic sensitivity analyses. Results from threshold analysis indicated that a minimum of 7 and 10% improvement in percentage of early detection of respiratory compromise is required for ARRM to become cost effective and cost saving, respectively.

CONCLUSIONS

Our results indicate that ARRM using RespiraSense, in addition to intermittent nurse-led monitoring of RR, in patients admitted to the hospital with pneumonia could be a cost-saving and cost-effective intervention if the minimum clinical thresholds are met.

Accuracy and reliability of a wireless vital signs monitor for hospitalized patients in a low-resource setting

Objective

The purpose of this study was to evaluate the accuracy and reliability of neoGuard in comparison to a conventional bedside monitor on patients in a low-resource clinical setting.

Design

This was a single-arm methods comparison study involving the use of a wearable vital signs monitor (neoGuardTM) versus a conventional bedside monitor (Edan iM8).

Setting

The study was conducted at Jinja Regional Referral Hospital, a tertiary care hospital situated in Eastern Uganda.

Participants

Thirty patients (10 male, 20 female) were enrolled from the adult recovery ward at JRRH. Participants were eligible for the study if they were at least 18 years of age, had 2 sets of normal vital sign measurements obtained 1 h apart, and were able and willing to provide informed consent.

Main Outcome and Measures

The primary outcome measures were (i) bias (mean deviation) and (ii) limits of agreement [95% CI]. Bland-Altman plots were generated to illustrate the level of agreement between the neoGuardTM technology and the Edan iM8 monitor.

Results

Bland-Altman analysis was performed for 24 participants; datasets from six participants were excluded due to missing or invalid measurements. Findings showed a moderate level of agreement for measurement of SpO2, PR, and RR, with >80% of subject means falling within the predefined acceptability limits. However, there was also notable variation in accuracy between subjects, with large standard deviations observed for measurement of all four parameters. While the level of agreement for measurement of temperature was low, this is partly explained by limitations in the comparison method.