Healthcare provider experiences of deploying a continuous remote patient monitoring pilot program during the COVID-19 pandemic: a structured qualitative analysis

ObjectiveTo describe the healthcare provider (HCP) experience of launching a COVID-19 remote patient monitoring (CRPM) program during the global COVID-19 pandemic.MethodsWe conducted qualitative, semi-structured interviews with eight HCPs involved in deploying the CRPM pilot program in the Military Health System (MHS) from June to December 2020. Interviews were thematically audio recorded, transcribed, and analyzed using an inductive approach. We then deductively mapped themes from interviews to the updated Consolidated Framework for Implementation Research (CFIR).ResultsWe identified the following main themes mapped to CFIR domains listed in parentheses: external and internal environments (outer and inner settings), processes around implementation (implementation process domain), the right people (individuals domain), and program characteristics (innovation domain). Participants believed that buy-in from leadership and HCPs was critical for successful program implementation. HCP participants showed qualities of clinical champions and believed in the CRPM program.ConclusionThe MHS deployed a successful remote patient monitoring pilot program during the global COVID-19 pandemic. HCPs found the CRPM program and the technology enabling the program to be acceptable, feasible, and usable. HCP participants exhibited characteristics of clinical champions. Leadership engagement was the most often-cited key factor for successful program implementation

Evaluation of Individualized Functional Electrical Stimulation-Induced Acute Changes during Walking: A Case Series in Children with Cerebral Palsy

Functional electrical stimulation (FES) walking interventions have demonstrated improvements to gait parameters; however, studies were often confined to stimulation of one or two muscle groups. Increased options such as number of muscle groups targeted, timing of stimulation delivery, and level of stimulation are needed to address subject-specific gait deviations. We aimed to demonstrate the feasibility of using a FES system with increased stimulation options during walking in children with cerebral palsy (CP). Three physical therapists designed individualized stimulation programs for six children with CP to target participant-specific gait deviations. Stimulation settings (pulse duration and current) were tuned to each participant. Participants donned our custom FES system that utilized gait phase detection to control stimulation to lower extremity muscle groups and walked on a treadmill at a self-selected speed. Motion capture data were collected during walking with and without the individualized stimulation program. Eight gait metrics and associated timing were compared between walking conditions. The prescribed participant-specific stimulation programs induced significant change towards typical gait in at least one metric for each participant with one iteration of FES-walking. FES systems with increased stimulation options have the potential to allow the physical therapist to better target the individual’s gait deviations than a one size fits all device

When and what to stimulate? An evaluation of a custom functional electrical stimulation system and its neuroprosthetic effect on gait in children with cerebral palsy

Lee, Samuel C. K.Atypical gait patterns are commonly observed in children with cerebral palsy (CP), a neuromuscular disorder affecting the development of movement and posture and impacting approximately 764,000 people in the United States. Resulting from the absence of one or more of the components that make up a typical gait cycle, gait patterns in CP have been characterized by atypical lower extremity kinematics. Surgical and non-surgical interventions are used to treat these gait deviations. Surgical interventions produce improvements in function that are modest at best and may result in iatrogenic crouch gait while more conservative interventions (non-surgical) have successfully improved spatiotemporal deviations but have not shown changes in kinematics. Walking interventions using functional electrical stimulation (FES) have demonstrated improvements in spatiotemporal, kinematic, and kinetic parameters. Current FES systems, however, are limited in flexibility and number of muscle groups capable of being targeted with FES; potentially limiting gait improvements attainable with use of FES. The overall goal of this dissertation was to develop a FES system, programmable with individualized stimulation algorithms, to assess the feasibility of using it as a neural orthosis during walking in children with CP. ☐ In Aim 1, we successfully developed a FES system and systematically quantified its system performance to validate the system as an accurate device for assisting gait before implementing it in a patient population. By combining commercially available devices and custom software, we have developed a closed-loop FES system, capable of detecting 7 phases of gait and stimulating 10 muscle groups while walking. The FES system was validated in 7 typically developing children, during treadmill walking at self-selected speed, by comparing the FES system’s gait phase detection and delivery of stimulation to the desired timing derived from the ‘gold standard’ (motion capture system). Overall root mean square errors (RMSEs) of average gait phase detection and duration were 7.23 ± 2.38% and 4.58 ± 2.68% of the gait cycle, respectively. Modifications were made to the stimulation trigger to account for system delays in gait phase detection, resulting in the actual FES output to the desired stimulation timing having an average difference of 0.67 ± 4.25% of the gait cycle. The FES system accurately delivered stimulation, and our ability to detect all 7 phases of gait number of gait phases detected provided independent control over the delivery of stimulation. This development allowed the flexibility for the physical therapist to choose the muscle groups targeted with FES when using the system as a neuroprosthetic device. ☐ In Aim 2, we effectively deployed the FES system as a wearable device during walking in subjects with CP in which immediate effects were made to joint angles when muscle groups were stimulated during FES-assisted walking. To evaluate the immediate changes created during FES-assisted walking, six children with CP donned our custom FES system and walked on a treadmill at their self-selected speeds. Kinematic data were collected for walking conditions without FES and with FES applied using individualized stimulation programs. The results demonstrated that targeting major muscle groups during FES-assisted walking changed the lower extremity kinematics; responses to FES varied between subjects. ☐ This dissertation work illustrates the importance of improving existing FES devices and contributes to the evidence supporting positive kinematic changes produced during FES-assisted interventions in CP.Ph.D.University of Delaware, Biomechanics and Movement Science Progra

Evaluation of Gait Phase Detection Delay Compensation Strategies to Control a Gyroscope-Controlled Functional Electrical Stimulation System During Walking

Functional electrical stimulation systems are used as neuroprosthetic devices in rehabilitative interventions such as gait training. Stimulator triggers, implemented to control stimulation delivery, range from open- to closed-loop controllers. Finite-state controllers trigger stimulators when specific conditions are met and utilize preset sequences of stimulation. Wearable sensors provide the necessary input to differentiate gait phases during walking and trigger stimulation. However, gait phase detection is associated with inherent system delays. In this study, five stimulator triggers designed to compensate for gait phase detection delays were tested to determine which trigger most accurately delivered stimulation at the desired times of the gait cycle. Motion capture data were collected on seven typically-developing children while walking on an instrumented treadmill. Participants wore one inertial measurement unit on each ankle and gyroscope data were streamed into the gait phase detection algorithm. Five triggers, based on gait phase detection, were used to simulate stimulation to five muscle groups, bilaterally. For each condition, stimulation signals were collected in the motion capture software via analog channels and compared to the desired timing determined by kinematic and kinetic data. Results illustrate that gait phase detection is a viable finite-state control, and appropriate system delay compensations, on average, reduce stimulation delivery delays by 6.7% of the gait cycle

Real-Time Detection of Seven Phases of Gait in Children with Cerebral Palsy Using Two Gyroscopes

A recently designed gait phase detection (GPD) system, with the ability to detect all seven phases of gait in healthy adults, was modified for GPD in children with cerebral palsy (CP). A shank-attached gyroscope sent angular velocity to a rule-based algorithm in LabVIEW to identify the distinct characteristics of the signal. Seven typically developing children (TD) and five children with CP were asked to walk on treadmill at their self-selected speed while using this system. Using only shank angular velocity, all seven phases of gait (Loading Response, Mid-Stance, Terminal Stance, Pre-Swing, Initial Swing, Mid-Swing and Terminal Swing) were reliably detected in real time. System performance was validated against two established GPD methods: (1) force-sensing resistors (GPD-FSR) (for typically developing children) and (2) motion capture (GPD-MoCap) (for both typically developing children and children with CP). The system detected over 99% of the phases identified by GPD-FSR and GPD-MoCap. Absolute values of average gait phase onset detection deviations relative to GPD-MoCap were less than 100 ms for both TD children and children with CP. The newly designed system, with minimized sensor setup and low processing burden, is cosmetic and economical, making it a viable solution for real-time stand-alone and portable applications such as triggering functional electrical stimulation (FES) in rehabilitation systems. This paper verifies the applicability of the GPD system to identify specific gait events for triggering FES to enhance gait in children with CP

Assessment of Remote Vital Sign Monitoring and Alarms in a Real-World Healthcare at Home Dataset

The importance of vital sign monitoring to detect deterioration increases during healthcare at home. Continuous monitoring with wearables increases assessment frequency but may create information overload for clinicians. The goal of this work was to demonstrate the impact of vital sign observation frequency and alarm settings on alarms in a real-world dataset. Vital signs were collected from 76 patients admitted to healthcare at home programs using the Current Health (CH) platform; its wearable continuously measured respiratory rate (RR), pulse rate (PR), and oxygen saturation (SpO2). Total alarms, alarm rate, patient rate, and detection time were calculated for three alarm rulesets to detect changes in SpO2, PR, and RR under four vital sign observation frequencies and four window sizes for the alarm algorithms’ median filter. Total alarms ranged from 65 to 3113. The alarm rate and early detection increased with the observation frequency for all alarm rulesets. Median filter windows reduced alarms triggered by normal fluctuations in vital signs without compromising the granularity of time between assessments. Frequent assessments enabled with continuous monitoring support early intervention but need to pair with settings that balance sensitivity, specificity, clinical risk, and provider capacity to respond when a patient is home to minimize clinician burden