Implementing the IMPALA continuous monitoring system for paediatric critical care in Malawi: a mixed methods study of barriers and facilitators.

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. No formula was used to calculate the weights, apart from using STATA Response Rates: In total, 23 observations and in-depth interviews (IDIs) were conducted at Zomba Central Hospital's paediatric HDU, with healthcare providers (n = 14) and caregivers (n = 9) of nine critically ill children (aged 3 months to 5 years old) admitted to the HDU. The sampling frame for the questionnaire-based caregiver survey consisted of all caregivers of critically ill children aged three months to five years who were admitted to the HDU. The sampling frame for the questionnaire-based healthcare provider survey comprised all healthcare workers (i.e., the complete census of nurses and clinicians) working in the HDU. There was a 100% response rate among the caregivers and healthcare providers, as all participants were willing to share their experiences with the monitor's usage. Presence of Common Scales: None The sampling frame for the questionnaire-based caregiver survey consisted of all caregivers of critically ill children aged three months to five years who were admitted to the HDU. The sampling frame for the questionnaire-based healthcare provider survey comprised all healthcare workers (i.e., the complete census of nurses and clinicians) working in the HDU from January to May 2023. We estimated the minimum detectable effect size of the change in hours spent on monitoring children before and after IMPALA for a sample of n = 24 healthcare workers, based on a one-sample mean t-test power calculation with α = 0.05, β = 0.80, and a standard deviation of 1.1025, to be 0.597. Though the sample size was small, it was appropriate for the exploratory, early-stage nature of this study. It was chosen to balance statistical power with feasibility in a resource-constrained setting. Caregivers above 18 years old of critically ill children admitted to the high dependency unit
Healthcare providers above 18 years working in the high dependency unit. Smallest Geographic Unit: Zomba, Malawi face-to-face interview; web-based survey;