By the book or beyond? Lessons on implementation fidelity in remote patient monitoring within a hybrid hospital-at-home feasibility study.

Abstract

Hybrid hospital-at-home (HaH) models, combining remote patient monitoring (RPM) with home visits, offer an alternative to inpatient care. Yet, evidence on how RPM is delivered is limited. This paper reports a substudy embedded within a feasibility study, examining RPM quality in a hybrid HaH programme for patients with lower respiratory tract infections before a large trial. We analysed 19 patient trajectories in a multimethod feasibility study (April 2022-May 2023). We hypothesised that effective RPM implementation enables the timely detection of deterioration, prompting patients' return to the hospital and preventing harm. Quality was assessed via implementation fidelity and patient safety. Fidelity referred to adherence to RPM protocols for virtual ward rounds and alert management. Data sources include telemedicine logs, electronic health records, clinical observations and clinician feedback. No severe adverse events occurred. Four patients (21%) returned to the hospital. A total of 48 virtual ward rounds were scheduled, and 46 (96%) were provided, 37 of which (77%) were conducted via video. Most RPM alerts were logged outside protocol-defined timeframes, as clinicians prioritised clinical action over documentation. We demonstrate a gap between protocol assumptions and real-world clinical workflows. Ultimately, rigid performance metrics may overlook essential adaptive practices, underestimating true quality. Despite protocol deviations, our findings suggest that RPM practices may have supported timely detection of deterioration during early-phase testing. This study underscores the need to balance protocol adherence with clinical flexibility, emphasising core functions over administrative compliance in complex interventions like hybrid HaH. NCT05087082.