Academic Background

In Africa, postoperative mortality is twice that of high-income countries, with most deaths occurring on hospital wards after patients develop postoperative complications. The primary reason for this is inadequate postoperative monitoring, leading to delayed recognition and intervention when patients deteriorate. In Africa, healthcare resources are limited, with nurse-to-patient ratios as high as 60:1, making close postoperative monitoring extremely challenging. However, family members of patients often stay by their bedside in the wards, sometimes even sleeping next to the patient’s bed. Therefore, researchers hypothesized that training family members to assist nurses in basic vital signs monitoring could increase the frequency of postoperative monitoring, enabling early detection of deterioration and reducing postoperative deaths.

Source of the Paper

This paper was authored by Adam Hewitt-Smith et al., with contributors from the Faculty of Medicine and Dentistry at Queen Mary University of London, the Department of Anaesthesia and Critical Care at Busitema University in Uganda, the Elgon Centre for Health Research and Innovation (ElCHRI) in Uganda, and other institutions. The paper was published on July 27, 2024, in the British Journal of Anaesthesia, titled Family supplemented patient monitoring after surgery (SMARTER): a pilot stepped-wedge cluster-randomised trial.

Study Design and Methods

Study Design

The SMARTER study was a stepped-wedge cluster-randomised trial aimed at evaluating the effectiveness of an intervention that trained family members to assist nurses in postoperative vital signs monitoring. The study was conducted at Mbale Regional Referral Hospital in Uganda over six months (April to October 2021). The hospital is a 470-bed teaching hospital serving a population of 4.5 million. The study included four postoperative wards: two surgical wards and two mixed obstetric/gynecology wards.

Study Participants

The study enrolled 1,395 postoperative patients, with a mean age of 28.2 years, 85.7% of whom were female. The most common surgical procedure was cesarean delivery (74.8%). Patients or their family members needed to speak one of five commonly used languages and provide written informed consent during the intervention phase. Exclusion criteria included patients under 5 years old, those discharged on the same day as surgery, and those identified more than 24 hours postoperatively.

Intervention

The intervention involved training family members to perform basic vital signs monitoring every 4 hours, including heart rate, respiratory rate, level of consciousness (using the AVPU scale), and oxygen saturation (SpO2). Family members were also trained on how to record vital signs, and color-coded posters were displayed in the wards to help them determine whether the vital signs were normal. Family members had access to a shared pulse oximeter for monitoring. The intervention began when patients arrived on the postoperative ward and lasted until the end of the third postoperative day.

Data Collection and Analysis

The primary outcome was the frequency of completed vital signs measurements per 24 hours during the three-day postoperative period. Secondary outcomes included all-cause in-hospital mortality within 30 days of surgery and length of hospital stay. Data were analyzed using a negative binomial mixed-effects model, adjusting for intervention, time period, cluster, surgical risk, and other factors.

Results

Primary Outcome

In the intervention group, the frequency of vital signs measurements per 24 hours during the three-day postoperative period increased significantly. The median number of measurements in the control group was 0 (0-1), compared to 3 (1-8) in the intervention group, with an incidence rate ratio of 12.4 (95% CI 8.8-17.5, p<0.001). This indicates that family involvement significantly increased the frequency of vital signs monitoring.

Secondary Outcomes

For in-hospital mortality, the rate was 0.84% (⁶⁄₇₁₈) in the control group and 1.77% (¹²⁄₆₇₇) in the intervention group, with no significant difference between the two groups (OR 1.32, 95% CI 0.1-14.7, p=0.821). There was also no significant difference in the length of hospital stay between the two groups (control: 2 [2-3] days, intervention: 2 [2-4] days; HR 1.11, 95% CI 0.84-1.47, p=0.44).

Discussion and Conclusion

Key Findings

The SMARTER study demonstrated that training family members to assist in postoperative vital signs monitoring is feasible and significantly increases the frequency of monitoring. Although there was no significant difference in in-hospital mortality or length of stay between the intervention and control groups, the potential for family involvement in monitoring warrants further investigation.

Significance of the Study

This study provides new evidence for family involvement in patient care in low-resource settings. Active participation of family members in postoperative monitoring may help alleviate the workload of nurses and increase the frequency of monitoring for postoperative patients. However, future research is needed to further validate the actual impact of this intervention on patient outcomes, particularly in reducing postoperative mortality.

Highlights of the Study

1. Innovative Intervention: This is the first systematic evaluation of the feasibility of family involvement in postoperative vital signs monitoring in a low-resource setting.
2. Significant Increase in Monitoring Frequency: The intervention group showed a 12-fold increase in the frequency of vital signs measurements, indicating that family members can effectively assist nurses in monitoring.
3. Potential for Application in Low-Resource Settings: This intervention offers a new approach to postoperative care in low-resource settings, especially where nursing resources are scarce.

Conclusion

The SMARTER study demonstrated that family involvement in postoperative vital signs monitoring significantly increases the frequency of monitoring, although its impact on in-hospital mortality and length of stay was not significant. This intervention has significant potential for application in low-resource settings, and future larger-scale effectiveness trials are needed to further validate its impact on patient outcomes.