More Than a Tool: How Context Shapes the Implementation of Digital Diaries in the Intensive Care Unit

Despite the potential benefits of digital intensive care unit (ICU) diaries (e-diaries), their implementation remains challenging due to barriers such as workload, digital literacy and staff resistance.

To explore the real-world, tailored implementation of an e-diary in adult ICUs.

A multicentre, mixed methods study was conducted across the ICUs of four Dutch hospitals. The following outcomes were assessed: adoption and engagement, normalisation, fidelity of use and the implementation process. Data were collected through usage metrics, a questionnaire and semi-structured interviews with ICU nurses and champions.

A total of 159 ICU professionals participated, including 25 interviewees and 134 survey respondents. The median e-diary activation rate was 22.6% [IQR: 14.8%-32.3%], with notable variation across hospitals. Adoption and engagement composite scores ranged from 41 to 51 (scale: 11-55). Normalisation and fidelity of use demonstrated clear disparities between hospitals. The implementation process data indicated that 61.5% of participants agreed that the e-diary had been implemented correctly in their ICU. Qualitative findings revealed that the involvement of champions, training methods, use of reminders and management of resistance varied across hospitals.

Successful implementation of e-diaries requires clear communication, ongoing training, continuous follow-up and sustained champion support. Variations in implementation success were influenced by hospital-specific factors, such as champion engagement, staff motivation, team dynamics and leadership support.

Tailored implementation strategies should address ICU-specific challenges, with an emphasis on continuous reinforcement, effective training and consistent follow-up to ensure the sustained use of digital health tools like ICU e-diaries. A deep understanding and strategic management of contextual and organisational factors can enhance the implementation and long-term sustainability of such interventions.