While survival of critical illness, and particularly critical cardiac conditions, has improved dramatically we have limited data about how contributing technological innovations are disseminated and implemented in the PICU. In this study, we performed qualitative investigation into the initial impressions and issues encountered by early adopters of the AtriAmp, a new health technology device, in a pediatric intensive care unit on patients who are postoperative from cardiac surgery. In our study, the AtriAmp was overwhelmingly perceived as a significant improvement in patient care by all early adopters, regardless of their role in the PICU. When we spoke to this select group, common themes emerged around the device’s ease of use, accuracy, reliability, and educational utility.
The AtriAmp eliminated many of the cumbersome intermediate steps of acquiring an atrial electrogram following a postoperative arrhythmia event in the PICU. The providers interviewed in this study described that the new technology, by being continuously in line with the surface ECG, eliminated diagnostic difficulties with intermittent or episodic arrhythmias. In doing so, the AtriAmp accelerated the time between arrhythmia event and diagnosis, allowing for more rapid initiation of appropriate treatment and more rapid identification of whether the treatment had a beneficial effect. In addition, by using available resources more efficiently and focusing more time and energy on the patient rather than diagnosing an arrhythmia, many of pediatric intensivists described that AtriAmp created a safer and more secure environment for their patient. These findings are consistent with the literature on diffusion of innovation, which suggests that innovations that demonstrate a relative advantage, are compatible with the adopters’s need, and provide tangible results are most likely to diffuse through the population.
The AtriAmp also provided an unforeseen benefit as an educational tool for teaching about postoperative arrhythmias and in interpreting atrial ECGs. Many of the PICU NPs and PICU RNs commented on how their understanding of post-op arrhythmias and their ability to interpret atrial ECGs had improved since the introduction of the new device[19]. One of the PICU physicians also noted he was receiving more questions from the bedside RNs regarding things seen on the atrial waveform since initiation of the AtriAmp. Several providers commented on how ongoing education and review of atrial waveforms would benefit them. Learning and skill development are ongoing processes that are embedded in the PICU environment, and the use of the AtriAmp as an educational tool may have contributed to the development of new practices and habits in rhythm identification. These findings are consistent with the literature on early adopters of health technology, which suggests that these individuals often become opinion leaders and are more receptive to new technologies due to their intrinsic motivation to improve patient care and advance their own knowledge and skills[17].
Although all providers received a lecture on device setup and atrial ECG interpretation prior to the introduction of the AtriAmp, some unforeseen learning curves were encountered. The PICU RNs noted that it took some practice to get used to how to insert the temporary pacing wires into the device, and for neonates and infants, careful planning was required in positioning the device in the bed with the patient to avoid pulling on the wires or getting the patient tangled in the wires. However, all nurses were able to overcome these challenges with additional practice, and none of them felt like the device significantly interfered with their care of the patients. These findings are consistent with the literature on the adoption of new inventions in healthcare, which suggests that while new inventions may require some learning and adaptation, healthcare providers are generally receptive to new technologies that are relatively simple to learn how to use, can be easily experimented with, and demonstrate tangible improvements to patient care[20–22].
This study highlights the importance of understanding the environment in which new health technologies are introduced. Diffusion of innovation theory teaches that new healthcare technologies are most likely to be adopted if: 1) they demonstrate a relative advantage to the current standard of care, 2) they are compatible with the values and needs of the population, 3) they are relatively easy to understand and learn how to use, 4) they can be tested and experimented on and allow for adaptations, and 5) they produce tangible results[17, 18]. As demonstrated, the AtriAmp met all five of these criteria. While it is relatively unusual for new technologies to be readily adopted in the PICU, early adopters of different roles seized hold of various criterion and the learning healthcare environment created by AtriAmp. PICU RNs took more stock in the device’s simplicity and trialability, whereas the intensivists and cardiologists saw its relative advantage, compatibility with needs, and the results.
Our analysis suggests that AtriAmp could expand to standard of care in pediatric critical care units like our own. However, for technological innovations to be widely adopted amongst all PICUs, there are additional factors that must be considered and additional hurdles that may be faced[23, 24]. The additional factors are outlined in Figure 2, an adaptation of diffusion of innovation theory, more specifically for the adoption of new healthcare products and technologies. The stages of awareness, information gathering, and understanding technology remain the same, but the subsequent stages have been modified to reflect unique considerations. For example, compatibility with clinical needs, ease of use and training, and social influence are all important factors in adopting medical technologies in the PICU. Additionally, trialability and piloting have been added as a stage to reflect the importance of testing the technology in this setting before making an adoption decision. Finally, the diagram includes the importance of continuous improvement as a final stage, as ongoing evaluation and refinement of the technology are critical for long-term success in the PICU context.
The additional hurdles are outlined in Tables 4 and 5, which list several lessons that were learned from two previously adopted and now widely used healthcare technologies, the electronic health record (EHR) and near-infrared spectroscopy (NIRS).[25–29] Other barriers to widespread adoption of AtriAmp could include the lack of established learning health system infrastructure, ambivalence toward adoption outside of academic centers, or variability in staffing across PICUs.
Table 4. Lessons from the adoption of the Electronic Health Record
Lesson
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Comments
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Usability
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One of the biggest challenges with EHRs in the PICU has been usability. The complexity of the technology and the number of features it offers can be overwhelming, and clinicians may find it difficult to navigate the system efficiently. It is essential that AtriAmp is designed to be intuitive and user-friendly to avoid these issues.
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Training and support
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Clinicians need adequate training and ongoing support to use the EHRs effectively. The same applies to AtriAmp. Training sessions and continued support can ensure that users are confident in using the technology, which can lead to better adoption rates.
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Interoperability
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In the PICU, EHRs may not communicate with other systems, leading to problems with data transfer and patient care. AtriAmp should be designed to integrate seamlessly with existing EHRs and other clinical information systems to ensure that all data is accessible and accurate.
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Data Security
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Data security is a significant concern with EHRs in the PICU, and this is also relevant to AtriAmp. Robust security protocols must be put in place to protect patient data and ensure that only authorized users have access.
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Change Management
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The introduction of new technology can be disruptive, and change management is critical to ensure a smooth transition. It is essential to involve key stakeholders in the planning and implementation of AtriAmp to ensure buy-in and reduce resistance to change.
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Table 5. Lessons from the adoption of Near Infrared Spectroscopy
Lesson
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Comments
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Address Concerns
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Introducing new technologies can raise concerns among the users. In the case of NIRS, there were concerns regarding the accuracy of the readings, the comfort of the device, and the cost. These concerns were addressed through training and education, and by providing evidence of the benefits of using NIRS. Similar concerns may arise with the introduction of AtriAmp, and it is important to address them proactively.
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Evaluate the impact
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It is important to evaluate the impact of the new technology. In the case of NIRS, studies showed that it helped to improve patient outcomes, reduce the length of stay in the CICU, and reduce healthcare costs. The same approach could be taken when evaluating the impact of AtriAmp in the CICU.
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Collaborate with Vendors
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It is important to collaborate with vendors when introducing a new technology. Vendors can provide training and education, technical support, and assistance with implementation. In the case of NIRS, vendors worked closely with the hospital to ensure that the device was integrated into the workflow and that staff were trained on its use. The same approach could be taken when working with the vendor for AtriAmp.
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This study has several limitations.[30–32] Because our goal was to learn about the experiences of early adopters who are at the forefront of a new technology introduced into the PICU, we purposively recruited a total sample of individuals with the most experience with AtriAmp. Consequently, this is not a representative sample and likely does not reflect the practices of all multidisciplinary PICU teams. In contrast, the early adopters studied here reflect the small size and gendered division of our PICU. Among our early adopters, the pediatric intensivists were all were male, while the NPs and RNs were all female. Previous research has shown that new technologies can reproduce gender inequities that impact women’s participation and change in health systems[33]. This may be underrepresented in our study, where the sample reflects the current gender imbalance of many multidisciplinary teams and especially in PICU leadership[34]. Second, our results reflect self-reported practices. Because we did not observe the providers using AtriAmp, we do not know to what extent self-reported practice reflects actual practice where robust observational research is an important future direction.