title: Study protocol for evaluating the implementation and effectiveness of an emergency department longitudinal patient monitoring system using a mixed-methods approach.
abstract: Early detection of patient deterioration is a key element of patient safety as it allows timely clinical intervention and potential rescue, thus reducing the risks of serious patient safety incidents. Longitudinal patient monitoring systems have been widely recommended for use to detect clinical deterioration. However, there is conflicting evidence on whether they improve patient outcomes. This may in part be related to variation in the rigour with which they are implemented and evaluated. This study aims to evaluate the implementation and effectiveness of a longitudinal patient monitoring system designed for adult patients in the unique environment of the Emergency Department (ED).
  
  
  
  A novel participatory action research (PAR) approach is taken where socio-technical systems (STS) theory and analysis informs the implementation through the improvement methodology of 'Plan Do Study Act' (PDSA) cycles. We hypothesise that conducting an STS analysis of the ED before beginning the PDSA cycles will provide for a much richer understanding of the current situation and possible challenges to implementing the ED-specific longitudinal patient monitoring system. This methodology will enable both a process and an outcome evaluation of implementing the ED-specific longitudinal patient monitoring system. Process evaluations can help distinguish between interventions that have inherent faults and those that are badly executed.
  
  
  
  Over 1.2 million patients attend EDs annually in Ireland; the successful implementation of an ED-specific longitudinal patient monitoring system has the potential to affect the care of a significant number of such patients. To the best of our knowledge, this is the first study combining PAR, STS and multiple PDSA cycles to evaluate the implementation of an ED-specific longitudinal patient monitoring system and to determine (through process and outcome evaluation) whether this system can significantly improve patient outcomes by early detection and appropriate intervention for patients at risk of clinical deterioration.
authors.affiliation: School of Nursing, Midwifery and Health Systems, College of Health Sciences, University College Dublin, Belfield, Dublin 4, Ireland. M.ward@ucd.ie.
authors.forename: Marie
authors.identifier: 0000-0002-6638-8461
authors.initials: M
authors.lastname: Ward
authors.affiliation: School of Nursing, Midwifery and Health Systems, College of Health Sciences, University College Dublin, Belfield, Dublin 4, Ireland.
authors.forename: Eilish
authors.initials: E
authors.lastname: McAuliffe
authors.affiliation: Emergency Care Research Unit (ECRU), Division of Population Health Sciences (PHS), Royal College of Surgeons in Ireland (RCSI), Dublin 2, Ireland.|Department of Emergency Medicine, Beaumont Hospital, Dublin 9, Ireland.
authors.forename: Abel
authors.initials: A
authors.lastname: Wakai
authors.affiliation: Department of Emergency Medicine, St James's Hospital, Dublin 8, Ireland.
authors.forename: Una
authors.initials: U
authors.lastname: Geary
authors.affiliation: Department of Epidemiology and Public Health, University College Cork, Western Rd, Cork, Ireland.
authors.forename: John
authors.initials: J
authors.lastname: Browne
authors.affiliation: Department of Emergency Medicine, Cork University Hospital, Cork, Ireland.
authors.forename: Conor
authors.initials: C
authors.lastname: Deasy
authors.affiliation: Institute for Clinical Evaluative Sciences, G1 06, 2075 Bayview Avenue, Toronto, ON, M4N 3M5, Canada.
authors.forename: Michael
authors.initials: M
authors.lastname: Schull
authors.affiliation: Division of Population Health Sciences, Royal College of Surgeons in Ireland, Dublin, Ireland.
authors.forename: Fiona
authors.initials: F
authors.lastname: Boland
authors.affiliation: Department of Emergency Medicine, Naas Hospital, Naas, Co, Kildare, Ireland.
authors.forename: Fiona
authors.initials: F
authors.lastname: McDaid
authors.affiliation: Department of Epidemiology and Public Health, University College Cork, Western Rd, Cork, Ireland.
authors.forename: Eoin
authors.initials: E
authors.lastname: Coughlan
authors.affiliation: School of Medicine, University College Cork, Western Rd, Cork, Ireland.
authors.forename: Ronan
authors.initials: R
authors.lastname: O'Sullivan
mesh_terms: D003422:Critical Care / Q000458:organization & administration; D016638:Critical Illness; D003695:Delivery of Health Care / Q000592:standards*; D018450:Disease Progression; D004636:Emergency Service, Hospital / Q000458:organization & administration* / Q000592:standards; D019983:Guideline Adherence; D006302:Health Services Research; D006801:Humans; D007494:Ireland / Q000453:epidemiology; D008137:Longitudinal Studies; D008991:Monitoring, Physiologic / Q000379:methods; D017063:Outcome Assessment, Health Care; D018802:Patient-Centered Care / Q000592:standards*; D016730:Program Development; D015397:Program Evaluation; D012306:Risk
keywords: Early warning score; Emergency department; Longitudinal patient monitoring; Participatory AR; Process and outcome evaluation; Socio-technical systems