98 Chapter 4 with the expectation that these key users would, in turn, train their colleagues. The implementation plan was structured into six phases, further specified in table 4. Table 1 The causal assumptions of the smart functions in the medical beds Smart function Causal assumptions of the smart functions Weight function Obtaining an accurate weight of the patient is a nursing task and is vital for different reasons. For one, weight is a factor to take into account for dosing medications with a narrow therapeutic window, and dosing for the very young, elderly and morbidly obese patients. Second, the weight of patients with heart or renal failure needs to be strictly monitored because of the risk of hyper hydration. Third, it is important for nutritional assessment in the under and overweighed patient groups. Flentje, Knight [13] found that workload and lack of effective weighing equipment, among other things, were barriers for nurses to systematically record weight. As quite a few patients are already in a poor nutritional status on admission to the hospital, the risk of losing weight during hospitalization is also significant; rates from 20-65% have been reported [14, 15]. Fall detection alarm Falls are the most reported adverse events in hospitalized older patients. Reported occurrences range from 3 to 13 falls per patient days, depending on the department or population. No fall is harmless, even when there is no physical damage, the effect on the confidence of the patients is just as important, so prevention is important [16]. The bed-exit alarm serves as a non-invasive freedomrestricting intervention to prevent delirious or fragile patients from stepping or falling off the bed. This alarm can be linked to the nurse’s call system. Head-of-bedangle alarm Ventilator Acquired Pneumonia (VAP) is one of the most frequent life-threatening hospital-acquired infections in the intensive care unit [17]. Elevation between 30° and 45° is an important component of the bundle of interventions [18] to prevent the occurrence of VAPs. The head-of-bed-angle alarm allows setting an alarm when the bed head elevation is lower than 30 or 45 degrees. This alarm is aiming to enhance adherence to clinical guidelines for VAP prevention. Chair position Transforming the bed to chair position allows the nurse to mobilize bedridden patients, earlier and without physical burden. Mobilizing patients is important in preventing hospital acquired pneumonias, loss of balance while sitting, and muscle loss [19]. Methods Nature of this process evaluation A mixed-methods study was carried out to perform the process evaluation. The UK Medical Research Council (MRC) process evaluation framework was deemed suitable given the complexity of the intervention and the need to use diverse types of data to generate a comprehensive data set. Outcomes were assessed at one and four years after the introduction of the smart beds, using observational data and self-reported questionnaires. Additionally, semi-structured interviews were conducted one-year post-implementation.
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