{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,9,23]],"date-time":"2026-09-23T17:29:13Z","timestamp":1790184553736,"version":"4.1.0"},"reference-count":50,"publisher":"Public Library of Science (PLoS)","issue":"8","license":[{"start":{"date-parts":[[2025,8,12]],"date-time":"2025-08-12T00:00:00Z","timestamp":1754956800000},"content-version":"vor","delay-in-days":0,"URL":"http:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"funder":[{"DOI":"10.13039\/501100001713","name":"European and Developing Countries Clinical Trials Partnership","doi-asserted-by":"publisher","award":["RIA20201-3294 - IMPALA"],"award-info":[{"award-number":["RIA20201-3294 - IMPALA"]}],"id":[{"id":"10.13039\/501100001713","id-type":"DOI","asserted-by":"publisher"}]}],"content-domain":{"domain":["www.plosone.org"],"crossmark-restriction":false},"short-container-title":["PLoS One"],"abstract":"<jats:sec id=\"sec001\">\n<jats:title>Introduction<\/jats:title>\n<jats:p>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.<\/jats:p>\n<\/jats:sec>\n<jats:sec id=\"sec002\">\n<jats:title>Methods<\/jats:title>\n<jats:p>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.<\/jats:p>\n<\/jats:sec>\n<jats:sec id=\"sec003\">\n<jats:title>Results<\/jats:title>\n<jats:p>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\u20132.48) compared to 3.3 hours post-IMPALA (95% CI: 2.36\u20134.23; p\u2009&lt;\u20090.00). 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.<\/jats:p>\n<\/jats:sec>\n<jats:sec id=\"sec004\">\n<jats:title>Conclusion<\/jats:title>\n<jats:p>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\u2019 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.<\/jats:p>\n<\/jats:sec>","DOI":"10.1371\/journal.pone.0329265","type":"journal-article","created":{"date-parts":[[2025,8,12]],"date-time":"2025-08-12T17:34:28Z","timestamp":1755020068000},"page":"e0329265","update-policy":"https:\/\/doi.org\/10.1371\/journal.pone.corrections_policy","source":"Crossref","is-referenced-by-count":5,"title":["Implementing the IMPALA continuous monitoring system for paediatric critical care in Malawi: A mixed methods study of barriers and facilitators"],"prefix":"10.1371","volume":"20","author":[{"ORCID":"https:\/\/orcid.org\/0009-0003-6511-0542","authenticated-orcid":true,"given":"Daniel","family":"Mwale","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Christopher","family":"Pell","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Jobiba","family":"Chinkhumba","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Happiness","family":"Mandala","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Jessica","family":"Chikwana","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-5354-2039","authenticated-orcid":true,"given":"Josephine","family":"Langton","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Alice","family":"Likumbo","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Michael Boele","family":"van Hensbroek","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"name":"IMPALA Study Team","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Job","family":"Calis","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Wendy","family":"Janssens","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Lucinda","family":"Manda-Taylor","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"340","published-online":{"date-parts":[[2025,8,12]]},"reference":[{"issue":"1","key":"pone.0329265.ref001","doi-asserted-by":"crossref","first-page":"595","DOI":"10.1186\/s12913-024-11050-8","article-title":"The role of healthcare providers and caregivers in monitoring critically ill children: a qualitative study in a tertiary hospital, southern Malawi","volume":"24","author":"IMPALA Study team","year":"2024","journal-title":"BMC Health Serv Res"},{"key":"pone.0329265.ref002","doi-asserted-by":"crossref","DOI":"10.3389\/fped.2018.00049","article-title":"Pediatric Critical Care in Resource-Limited Settings\u2014Overview and Lessons Learned","volume":"6","author":"TM Slusher","year":"2018","journal-title":"Front Pediatr"},{"issue":"3","key":"pone.0329265.ref003","doi-asserted-by":"crossref","DOI":"10.1136\/bmjgh-2019-001675","article-title":"Achieving affordable critical care in low-income and middle-income countries","volume":"4","author":"HC Turner","year":"2019","journal-title":"BMJ Glob Health"},{"issue":"1","key":"pone.0329265.ref004","doi-asserted-by":"crossref","DOI":"10.1136\/bmjpo-2023-002404","article-title":"Comprehensive assessment of pediatric acute and inpatient care at a tertiary referral hospital in Malawi: opportunities for quality improvement","volume":"8","author":"E Fitzgerald","year":"2024","journal-title":"BMJ Paediatr Open"},{"issue":"1","key":"pone.0329265.ref005","doi-asserted-by":"crossref","first-page":"75","DOI":"10.1186\/s12887-018-1051-9","article-title":"A pediatric death audit in a large referral hospital in Malawi","volume":"18","author":"E Fitzgerald","year":"2018","journal-title":"BMC Pediatr"},{"key":"pone.0329265.ref006","doi-asserted-by":"crossref","first-page":"1397232","DOI":"10.3389\/fped.2024.1397232","article-title":"Etiology of hospital mortality in children living in low- and middle-income countries: a systematic review and meta-analysis","volume":"12","author":"TB Kortz","year":"2024","journal-title":"Front Pediatr"},{"issue":"4","key":"pone.0329265.ref007","doi-asserted-by":"crossref","first-page":"240","DOI":"10.1080\/20469047.2018.1536873","article-title":"Paediatric deaths in a tertiary government hospital setting, Malawi","volume":"39","author":"C Harris","year":"2019","journal-title":"Paediatr Int Child Health"},{"issue":"10160","key":"pone.0329265.ref008","doi-asserted-by":"crossref","first-page":"2203","DOI":"10.1016\/S0140-6736(18)31668-4","article-title":"Mortality due to low-quality health systems in the universal health coverage era: a systematic analysis of amenable deaths in 137 countries","volume":"392","author":"ME Kruk","year":"2018","journal-title":"Lancet"},{"issue":"1","key":"pone.0329265.ref009","doi-asserted-by":"crossref","first-page":"43","DOI":"10.1007\/s10916-023-01934-3","article-title":"The Effect of Continuous Versus Periodic Vital Sign Monitoring on Disease Severity of Patients with an Unplanned ICU Transfer","volume":"47","author":"Y Eddahchouri","year":"2023","journal-title":"J Med Syst"},{"key":"pone.0329265.ref010","unstructured":"Hands C, Reid E, Meredith P, Smith GB, Prytherch DR, Schmidt PE, et al. Patterns in the recording of vital signs and early warning scores: compliance with a clinical escalation protocol."},{"key":"pone.0329265.ref011","article-title":"Feasibility, performance and acceptability of an innovative vital signs monitor for sick newborns in Western Kenya: A mixed-methods study","author":"A Nantume","year":"2023","journal-title":"Digit Heal"},{"issue":"2","key":"pone.0329265.ref012","article-title":"Expectations for nursing care in newborn units in Kenya: moving from implicit to explicit standards","volume":"3","author":"GAV Murphy","year":"2018","journal-title":"BMJ Global Health"},{"issue":"1","key":"pone.0329265.ref013","doi-asserted-by":"crossref","DOI":"10.7189\/jogh.08.010409","article-title":"An observational study of monitoring of vital signs in children admitted to Kenyan hospitals: an insight into the quality of nursing care?","volume":"8","author":"M Ogero","year":"2018","journal-title":"J Glob Health"},{"issue":"3","key":"pone.0329265.ref014","article-title":"Factors affecting sustainable adoption of e-health technology in developing countries: An exploratory survey of Nigerian hospitals from the perspective of healthcare professionals","volume":"2018","author":"MA Zayyad","year":"2018","journal-title":"PeerJ"},{"key":"pone.0329265.ref015","unstructured":"National Statistical Office. Preliminary Report. Malawi Popul Hous Census. 2018. Available from: www.nsomalawi.mw"},{"key":"pone.0329265.ref016","doi-asserted-by":"crossref","first-page":"270","DOI":"10.1016\/j.jcrc.2016.07.015","article-title":"What is an intensive care unit? A report of the task force of the World Federation of Societies of Intensive and Critical Care Medicine","volume":"37","author":"JC Marshall","year":"2017","journal-title":"J Crit Care"},{"issue":"2","key":"pone.0329265.ref017","first-page":"50","article-title":"Parental satisfaction with the quality of care in a South African paediatric intensive care unit","volume":"34","author":"C Mol","year":"2018","journal-title":"South African J Crit Care"},{"issue":"9","key":"pone.0329265.ref018","doi-asserted-by":"crossref","first-page":"1045","DOI":"10.1016\/j.jclinepi.2013.02.010","article-title":"The shortened empowerment of parents in the intensive care 30 questionnaire adequately measured parent satisfaction in pediatric intensive care units","volume":"66","author":"JM Latour","year":"2013","journal-title":"J Clin Epidemiol"},{"issue":"6","key":"pone.0329265.ref019","article-title":"Current evidence for continuous vital signs monitoring by wearable wireless devices in hospitalized adults: systematic review","volume":"22","author":"JPL Leenen","year":"2020","journal-title":"J Med Internet Res"},{"issue":"1","key":"pone.0329265.ref020","doi-asserted-by":"crossref","first-page":"760","DOI":"10.1080\/13696998.2023.2219156","article-title":"Cost savings through continuous vital sign monitoring in the medical-surgical unit","volume":"26","author":"JW Beard","year":"2023","journal-title":"J Med Econ"},{"issue":"1","key":"pone.0329265.ref021","doi-asserted-by":"crossref","DOI":"10.3390\/bioengineering10010037","article-title":"Assessment of remote vital sign monitoring and alarms in a real-world healthcare at home dataset","volume":"10","author":"N Zahradka","year":"2023","journal-title":"Bioengineering"},{"issue":"3","key":"pone.0329265.ref022","doi-asserted-by":"crossref","first-page":"810","DOI":"10.1111\/jan.15055","article-title":"Experiences of current vital signs monitoring practices and views of wearable monitoring: A qualitative study in patients and nurses","volume":"78","author":"C Areia","year":"2022","journal-title":"J Adv Nurs"},{"key":"pone.0329265.ref023","doi-asserted-by":"crossref","first-page":"9","DOI":"10.1016\/j.ijnurstu.2015.12.007","article-title":"Vital signs monitoring and nurse\u2013patient interaction: a qualitative observational study of hospital practice","volume":"56","author":"M Cardona-Morrell","year":"2016","journal-title":"Int J Nurs Stud"},{"key":"pone.0329265.ref024","doi-asserted-by":"crossref","first-page":"6","DOI":"10.1186\/s40985-020-00124-7","article-title":"Barriers and facilitators to implementing bubble CPAP to improve neonatal health in sub-Saharan Africa: a systematic review","volume":"41","author":"M-LW Kinshella","year":"2020","journal-title":"Public Health Rev"},{"issue":"11","key":"pone.0329265.ref025","first-page":"579","article-title":"Integrated technology implementation model: examination and enhancements","volume":"38","author":"R Schoville","year":"2020","journal-title":"Comput Inform Nurs"},{"issue":"3","key":"pone.0329265.ref026","doi-asserted-by":"crossref","first-page":"99","DOI":"10.1097\/CIN.0000000000000130","article-title":"Guiding healthcare technology implementation: a new integrated technology implementation model","volume":"33","author":"RR Schoville","year":"2015","journal-title":"Comput Inform Nurs"},{"issue":"7","key":"pone.0329265.ref027","doi-asserted-by":"crossref","DOI":"10.2196\/19126","article-title":"Information overload in emergency medicine physicians: A multisite case study exploring the causes, impact, and solutions in four North England National Health Service trusts","volume":"22","author":"L Sbaffi","year":"2020","journal-title":"J Med Internet Res"},{"issue":"1","key":"pone.0329265.ref028","doi-asserted-by":"crossref","DOI":"10.1186\/s40537-019-0217-0","article-title":"Big data in healthcare: management, analysis and future prospects","volume":"6","author":"S Dash","year":"2019","journal-title":"J Big Data"},{"issue":"1","key":"pone.0329265.ref029","doi-asserted-by":"crossref","DOI":"10.1186\/s13054-019-2485-7","article-title":"Automated continuous noninvasive ward monitoring: future directions and challenges","volume":"23","author":"AK Khanna","year":"2019","journal-title":"Crit Care"},{"issue":"1","key":"pone.0329265.ref030","article-title":"Impact of wearable wireless continuous vital sign monitoring in abdominal surgical patients: before-after study","volume":"8","author":"JPL Leenen","year":"2024","journal-title":"BJS Open"},{"issue":"5","key":"pone.0329265.ref031","doi-asserted-by":"crossref","first-page":"857","DOI":"10.1016\/j.bja.2022.01.036","article-title":"Effect of continuous wireless vital sign monitoring on unplanned ICU admissions and rapid response team calls: a before-and-after study","volume":"128","author":"Y Eddahchouri","year":"2022","journal-title":"Br J Anaesth"},{"issue":"2","key":"pone.0329265.ref032","doi-asserted-by":"crossref","DOI":"10.2196\/16491","article-title":"Augmenting Critical Care Patient Monitoring Using Wearable Technology: Review of Usability and Human Factors","volume":"8","author":"E Andrade","year":"2021","journal-title":"JMIR Hum Factors"},{"issue":"4","key":"pone.0329265.ref033","doi-asserted-by":"crossref","first-page":"378","DOI":"10.4037\/NCI.0b013e3182a903f9","article-title":"Alarm fatigue: a patient safety concern","volume":"24","author":"S Sendelbach","year":"2013","journal-title":"AACN Adv Crit Care"},{"issue":"6","key":"pone.0329265.ref034","doi-asserted-by":"crossref","first-page":"685","DOI":"10.1097\/ACO.0000000000000260","article-title":"Alarm fatigue: impacts on patient safety","volume":"28","author":"KJ Ruskin","year":"2015","journal-title":"Curr Opin Anaesthesiol"},{"issue":"1","key":"pone.0329265.ref035","doi-asserted-by":"crossref","first-page":"36","DOI":"10.1097\/DCC.0000000000000220","article-title":"Assessment of clinical alarms influencing nurses\u2019 perceptions of alarm fatigue","volume":"36","author":"EM Petersen","year":"2017","journal-title":"Dimens Crit Care Nurs"},{"issue":"3","key":"pone.0329265.ref036","doi-asserted-by":"crossref","first-page":"160","DOI":"10.1097\/DCC.0000000000000357","article-title":"Research outcomes of implementing CEASE: an innovative, nurse-driven, evidence-based, patient-customized monitoring bundle to decrease alarm fatigue in the intensive care unit\/step-down unit","volume":"38","author":"CL Lewis","year":"2019","journal-title":"Dimens Crit Care Nurs"},{"issue":"10","key":"pone.0329265.ref037","doi-asserted-by":"crossref","DOI":"10.1371\/journal.pone.0205901","article-title":"Testing physiologic monitor alarm customization software to reduce alarm rates and improve nurses\u2019 experience of alarms in a medical intensive care unit","volume":"13","author":"H Ruppel","year":"2018","journal-title":"PLoS One"},{"issue":"3","key":"pone.0329265.ref038","doi-asserted-by":"crossref","first-page":"713","DOI":"10.1016\/j.clp.2017.05.005","article-title":"Alarm safety and alarm fatigue","volume":"44","author":"KR Johnson","year":"2017","journal-title":"Clin Perinatol"},{"key":"pone.0329265.ref039","doi-asserted-by":"crossref","first-page":"2511","DOI":"10.1111\/jocn.13605","article-title":"The effectiveness of nurse education and training for clinical alarm response and management: a systematic review","volume":"26","author":"L Yue","year":"2017","journal-title":"J Clin Nurs"},{"issue":"2","key":"pone.0329265.ref040","doi-asserted-by":"crossref","first-page":"21","DOI":"10.4037\/ccn2024797","article-title":"Critical Care Alarm Fatigue and Monitor Customization: Alarm Frequencies and Context Factors","volume":"44","author":"LZ Arkilic","year":"2024","journal-title":"Critical Care Nurse"},{"issue":"22","key":"pone.0329265.ref041","doi-asserted-by":"crossref","first-page":"1","DOI":"10.3390\/ijerph17228409","article-title":"Impact of Alarm Fatigue on the Work of Nurses in an Intensive Care Environment\u2014A Systematic Review","volume":"17","author":"K Lewandowska","year":"2020","journal-title":"Int J Environ Res Public Health"},{"issue":"5","key":"pone.0329265.ref042","doi-asserted-by":"crossref","first-page":"1223","DOI":"10.1055\/s-0042-1759513","article-title":"A Scoping Review of Integrated Medical Devices and Clinical Decision Support in the Acute Care Setting","volume":"13","author":"JB Withall","year":"2022","journal-title":"Appl Clin Inform"},{"issue":"3","key":"pone.0329265.ref043","first-page":"275","article-title":"Wearable wireless continuous vital signs monitoring on the general ward","volume":"30","author":"JPL Leenen","year":"2024","journal-title":"Curr Opin Crit Care"},{"issue":"8","key":"pone.0329265.ref044","article-title":"High Dependency Units (HDUs) in Pediatrics: Need of the Hour in Resource-Limited Settings","volume":"16","author":"S Pundhir","year":"2024","journal-title":"Cureus"},{"issue":"1","key":"pone.0329265.ref045","doi-asserted-by":"crossref","DOI":"10.1186\/s12912-021-00684-2","article-title":"A literature-based study of patient-centered care and communication in nurse-patient interactions: barriers, facilitators, and the way forward","volume":"20","author":"A Kwame","year":"2021","journal-title":"BMC Nurs"},{"issue":"1","key":"pone.0329265.ref046","doi-asserted-by":"crossref","DOI":"10.1186\/s13643-019-1010-z","article-title":"Patient and family-initiated escalation of care: a qualitative systematic review protocol","volume":"8","author":"A McKinney","year":"2019","journal-title":"Sys Rev"},{"key":"pone.0329265.ref047","doi-asserted-by":"crossref","first-page":"04005","DOI":"10.7189\/13.04005","article-title":"Family participation to enhance care and tackle health worker shortages in resource-limited hospitals: A systematic review","volume":"13","author":"JJ Determeijer","year":"2023","journal-title":"J Glob Health"},{"key":"pone.0329265.ref048","doi-asserted-by":"crossref","first-page":"69","DOI":"10.1016\/j.ijnurstu.2018.07.006","article-title":"Patient- and family-centered care interventions for improving the quality of health care: A review of systematic reviews","volume":"87","author":"M Park","year":"2018","journal-title":"Int J Nurs Stud"},{"issue":"3","key":"pone.0329265.ref049","doi-asserted-by":"crossref","first-page":"288","DOI":"10.1136\/archdischild-2013-305469","article-title":"Fear of oxygen therapy for children in malawi","volume":"100","author":"AC Stevenson","year":"2015","journal-title":"Arch Dis Child"},{"issue":"3","key":"pone.0329265.ref050","doi-asserted-by":"crossref","first-page":"305","DOI":"10.1016\/j.ajic.2013.09.012","article-title":"Family caregivers in public tertiary care hospitals in Bangladesh: risks and opportunities for infection control","volume":"42","author":"MS Islam","year":"2014","journal-title":"Am J Infect Control"}],"updated-by":[{"DOI":"10.1371\/journal.pone.0339889","type":"correction","label":"Correction","source":"publisher","updated":{"date-parts":[[2025,12,30]],"date-time":"2025-12-30T00:00:00Z","timestamp":1767052800000}}],"container-title":["PLOS One"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/dx.plos.org\/10.1371\/journal.pone.0329265","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2025,8,12]],"date-time":"2025-08-12T17:34:37Z","timestamp":1755020077000},"score":1,"resource":{"primary":{"URL":"https:\/\/dx.plos.org\/10.1371\/journal.pone.0329265"}},"subtitle":[],"editor":[{"given":"Nik Hisamuddin","family":"Nik Ab. Rahman","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"editor"}]}],"short-title":[],"issued":{"date-parts":[[2025,8,12]]},"references-count":50,"journal-issue":{"issue":"8","published-online":{"date-parts":[[2025,8,12]]}},"URL":"https:\/\/doi.org\/10.1371\/journal.pone.0329265","relation":{},"ISSN":["1932-6203"],"issn-type":[{"value":"1932-6203","type":"electronic"}],"subject":[],"published":{"date-parts":[[2025,8,12]]}}}