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Implementing the IMPALA continuous monitoring system for paediatric critical care in Malawi: A mixed methods study of
Daniel Mwale1,2,3,4, Christopher Pell3,4,5, Jobiba Chinkhumba1
1Kamuzu University of Health Sciences, Private Bag 360, Chichiri, Blantyre, Malawi.
Insights
The IMPALA continuous monitoring system in Malawi improved pediatric care by reliably measuring vital signs and saving healthcare provider time. Addressing alarm fatigue and caregiver concerns is key to optimizing its use.
Area of Science:
- Pediatric critical care
- Health technology implementation
- Low-resource healthcare settings
Background:
- Continuous vital sign monitoring is crucial for critically ill children but often limited in low-resource settings.
- Intermittent monitoring compromises the quality of care for vulnerable pediatric populations.
- The IMPALA system offers a locally adapted, low-cost solution for continuous monitoring.
Purpose of the Study:
- To assess implementation barriers and facilitators of the IMPALA continuous monitoring system in Malawi.
- To evaluate the impact of IMPALA on healthcare provider workflow and patient care.
- To understand healthcare provider and caregiver perceptions of the IMPALA system.
Main Methods:
- A mixed-method implementation study conducted in a tertiary hospital's pediatric high-dependency unit.
- Data collection involved over 300 hours of observation, interviews with 14 healthcare providers and 9 caregivers, and surveys from 24 providers and 72 caregivers.
- Qualitative data were thematically analyzed, and quantitative data were analyzed using descriptive statistics.
Main Results:
- Healthcare providers and caregivers reported improved care due to IMPALA's reliable multi-vital sign measurement, backup power, and alarms.
- Healthcare providers spent less time on manual monitoring post-IMPALA implementation (3.3 hours vs. 1.8 hours pre-IMPALA).
- Barriers included alarm fatigue, limited technological knowledge, staff shortages, and some caregiver concerns about reliability.
Conclusions:
- The IMPALA continuous monitoring device was generally well-received, perceived to save time and enhance care quality.
- Enhancing caregiver knowledge and involvement can address mistrust and misconceptions.
- Minimizing false alarms and providing ongoing training are crucial for sustained effective use by all staff.
Introduction:
Continuous monitoring of critically ill children is essential for the timely identification of deteriorating vital signs. However, monitoring is often intermittent in low-resource settings, affecting the quality of care. This study assessed the implementation barriers and facilitators of a locally adapted, robust, low-cost continuous monitoring system (IMPALA) in Malawi.
Methods:
A mixed-method implementation study of the IMPALA system in the paediatric High-dependency unit of a tertiary hospital from November 2022 to October 2023. Data were collected through over 300 hours of observations, in-depth interviews with 14 healthcare providers and nine caregivers of admitted children, and questionnaire-based surveys from 24 healthcare providers and 72 caregivers. Qualitative data were analysed thematically using inductive and deductive approaches. Descriptive statistics (frequencies, percentages, means, and standard deviations) were calculated for categorical and continuous variables.
Results:
Healthcare providers and caregivers indicated that the IMPALA monitors improved care by providing the ability to measure reliably multiple vital signs, with long-lasting (4 hours) backup power and alarm provisions. Healthcare providers reported spending less time on child monitoring after the introduction of IMPALA (1.8 hours per day pre-IMPALA (95% CI: 1.19-2.48) compared to 3.3 hours post-IMPALA (95% CI: 2.36-4.23; p < 0.00). Still, they recognised alarm fatigue, limitations in knowledge of the technology, and staff shortages as barriers to the use of IMPALA. Some caregivers expressed concerns about the reliability of the monitoring system.
Conclusion:
The continuous monitoring device was well-received overall by healthcare providers and caregivers. It was perceived to save time and improve the quality of care. Opportunities to further enhance engagement with the device include strengthening caregivers' knowledge and involvement to address their mistrust or misconceptions about the device, minimising false alarms, and providing ongoing training to healthcare providers so that new, existing, and rotating staff know how to engage with the device.
