Digitally Enabled Nursing: Evaluating Remote Patient Monitoring for Post-Discharge Risk Reduction
DOI:
https://doi.org/10.61978/curatio.v2i3.1401Keywords:
Remote Patient Monitoring, Transitional Care, Nursing Workflow, Readmission Prevention, Digital Health, Early Warning SystemsAbstract
Transitional care presents heightened risks of readmissions and adverse events. Remote Patient Monitoring (RPM) offers a promising solution by enabling continuous data collection and real-time alerts during this vulnerable period. This study evaluates the impact of RPM on nursing workflow efficiency and patient safety in post-discharge settings. Using a mixed-method observational design, 200 discharged patients were divided into RPM and non-RPM groups. Nurses tracked patient vitals, workflow time, and clinical outcomes, while interviews captured qualitative insights into system usability and staff adaptation. RPM integration reduced readmission rates from 15% to 8% and increased early clinical interventions by 116%. Nursing time for manual vital checks decreased by 72%, while time spent interpreting data increased. Although nurses reported increased cognitive load and occasional alarm fatigue, they also expressed greater confidence in decision-making. Data analysis tools and alert customization were cited as key enablers. Challenges included false positives and the need for enhanced training. Workflow redesign and policy support emerged as critical factors in sustaining RPM’s benefits. RPM significantly improves patient safety and nursing efficiency in transitional care when supported by appropriate training and organizational alignment. These findings highlight the need for systemic integration strategies that promote sustainability and clinical impact.
References
Acosta, A. M., Nora, C. R. D., Fontenele, R. M., Aued, G. K., Silveira, C. d. S., & Sanseverino, A. X. (2023). Transition and Continuity of Care After Hospital Discharge for COVID-19 Survivors. Revista Da Escola De Enfermagem Da Usp, 57. https://doi.org/10.1590/1980-220x-reeusp-2023-0083en DOI: https://doi.org/10.1590/1980-220x-reeusp-2023-0083pt
Araya, A., Thornton, L. R., Kwon, D., Ferguson, G. M., Highfield, L., Hwang, K. O., Holmes, H. M., & Bernstam, E. V. (2023). Medication Reconciliation During Transitions of Care Across Institutions: A Quantitative Analysis of Challenges and Opportunities. Applied Clinical Informatics, 14(05), 923–931. https://doi.org/10.1055/a-2178-0197 DOI: https://doi.org/10.1055/a-2178-0197
Basch, E., Stover, A. M., Schrag, D., Chung, A. E., Jansen, J., Henson, S., Carr, P., Ginos, B., Deal, A. M., Spears, P. A., Jönsson, M., Bennett, A. V, Mody, G. N., Thanarajasingam, G., Rogak, L. J., Reeve, B. B., Snyder, C., Kottschade, L. A., Charlot, M., … Dueck, A. C. (2020). Clinical Utility and User Perceptions of a Digital System for Electronic Patient-Reported Symptom Monitoring During Routine Cancer Care: Findings From the PRO-TECT Trial. Jco Clinical Cancer Informatics, (4), 947–957. https://doi.org/10.1200/cci.20.00081 DOI: https://doi.org/10.1200/CCI.20.00081
Bashi, N., Karunanithi, M., Fatehi, F., Ding, H., & Walters, D. (2017). Remote Monitoring of Patients With Heart Failure: An Overview of Systematic Reviews. Journal of Medical Internet Research, 19(1), e18. https://doi.org/10.2196/jmir.6571 DOI: https://doi.org/10.2196/jmir.6571
Bunch, A., Ardila, F., Castaño, R., Quiñonez, S., & Corzo, L. (2020). Through the Storm: Automated Peritoneal Dialysis With Remote Patient Monitoring During COVID-19 Pandemic. Blood Purification, 50(3), 279–282. https://doi.org/10.1159/000511407 DOI: https://doi.org/10.1159/000511407
Burke, R. E., Whitfield, E., Hittle, D. F., Min, S., Levy, C., Prochazka, A. V, Coleman, E. A., Schwartz, R. S., & Ginde, A. A. (2016). Hospital Readmission From Post-Acute Care Facilities: Risk Factors, Timing, and Outcomes. Journal of the American Medical Directors Association, 17(3), 249–255. https://doi.org/10.1016/j.jamda.2015.11.005 DOI: https://doi.org/10.1016/j.jamda.2015.11.005
Chen, L., Dubrawski, A., Wang, D., Fiterau, M., Guillame-Bert, M., Bose, E., Kaynar, A. M., Wallace, D. J., Guttendorf, J., Clermont, G., Pinsky, M. R., & Hravnak, M. (2016). Using Supervised Machine Learning to Classify Real Alerts and Artifact in Online Multisignal Vital Sign Monitoring Data*. Critical Care Medicine, 44(7), e456–e463. https://doi.org/10.1097/ccm.0000000000001660 DOI: https://doi.org/10.1097/CCM.0000000000001660
Cho, H., Sagherian, K., Scott, L. D., & Steege, L. M. (2022). Occupational Fatigue, Workload and Nursing Teamwork in Hospital Nurses. Journal of Advanced Nursing, 78(8), 2313–2326. https://doi.org/10.1111/jan.15246 DOI: https://doi.org/10.1111/jan.15246
Chu, F., Stark, A., Telzak, A., & Rikin, S. (2024). Patient Experience in a Remote Patient Monitoring Program for Hypertension: A Qualitative Study. American Journal of Hypertension, 37(11), 861–867. https://doi.org/10.1093/ajh/hpae086 DOI: https://doi.org/10.1093/ajh/hpae086
Coffey, J., Christopherson, L. A., Glasgow, A. E., Pearson, K. K., Brown, J. K., Gathje, S. R., Sangaralingham, L. R., Porquera, E. M. C., Virk, A., Orenstein, R., Speicher, L. L., Bierle, D. M., Ganesh, R., Cox, D. L., Blegen, R. N., & Haddad, T. C. (2021). Implementation of a Multisite, Interdisciplinary Remote Patient Monitoring Program for Ambulatory Management of Patients With COVID-19. NPJ Digital Medicine, 4(1). https://doi.org/10.1038/s41746-021-00490-9 DOI: https://doi.org/10.1038/s41746-021-00490-9
Couture, V., Germain, N., Côté, É., Lavoie, L., Robitaille, J., Morin, M., Chouinard, J., Couturier, Y., Légaré, F., Hardy, M., Chartier, L. B., Brousseau, A.-A., Sourial, N., Mercier, É., Dallaire, C., Fleet, R., LeBlanc, A., Melady, D., Roy, D., … Archambault, P. (2024). Transitions of Care for Older Adults Discharged Home From the Emergency Department: An Inductive Thematic Content Analysis of Patient Comments. BMC Geriatrics, 24(1). https://doi.org/10.1186/s12877-023-04482-0 DOI: https://doi.org/10.1186/s12877-023-04482-0
Craig, K. J. T., Willis, V. C., Gruen, D., Rhee, K., & Jackson, G. P. (2021). The Burden of the Digital Environment: A Systematic Review on Organization-Directed Workplace Interventions to Mitigate Physician Burnout. Journal of the American Medical Informatics Association, 28(5), 985–997. https://doi.org/10.1093/jamia/ocaa301 DOI: https://doi.org/10.1093/jamia/ocaa301
Dcruz, J. G., & Yeh, P. (2024). The Accuracy of Pulse Oxygen Saturation, Heart Rate, Blood Pressure, and Respiratory Rate Raised by a Contactless Telehealth Portal: Validation Study. Jmir Formative Research, 8, e55361. https://doi.org/10.2196/55361 DOI: https://doi.org/10.2196/55361
Duncan, I., Fitzner, K., Zhao, E., & Shtein, Y. (2021). Patient Post-Discharge Transitions and Inpatient Readmissions Impose Costly Burdens for Employers and Carriers. Population Health Management, 24(6), 722–726. https://doi.org/10.1089/pop.2021.0037 DOI: https://doi.org/10.1089/pop.2021.0037
Es, V. A. A. van, Lathauwer, I. L. J. De, Kemps, H., Handjaras, G., & Betta, M. (2024). Remote Monitoring of Sympathovagal Imbalance During Sleep and Its Implications in Cardiovascular Risk Assessment: A Systematic Review. Bioengineering, 11(10), 1045. https://doi.org/10.3390/bioengineering11101045 DOI: https://doi.org/10.3390/bioengineering11101045
Gao, X., He, P., Zhou, Y., & Qin, X. (2024). Artificial Intelligence Applications in Smart Healthcare: A Survey. Future Internet, 16(9), 308. https://doi.org/10.3390/fi16090308 DOI: https://doi.org/10.3390/fi16090308
Gilmartin, H., Warsavage, T., Hines, A., Leonard, C., Kelley, L., Wills, A., Gaskin, D. E., Motta, L. U., Connelly, B., Plomondon, M. E., Yang, F., Kaboli, P. J., Burke, R. E., & Jones, C. D. (2022). Effectiveness of the Rural Transitions Nurse Program for Veterans: A Multicenter Implementation Study. Journal of Hospital Medicine, 17(3), 149–157. https://doi.org/10.1002/jhm.12802 DOI: https://doi.org/10.1002/jhm.12802
Guilcher, S. J. T., Fernandes, O., Luke, M. J., Wong, G., Lui, P. C., Cameron, K., Pariser, P., Raco, V., Kak, K., Varghese, S., Papastergiou, J., & McCarthy, L. (2020). A Developmental Evaluation of an Intraprofessional Pharmacy Communication Partnership (PROMPT) to Improve Transitions in Care From Hospital to Community: A Mixed-Methods Study. BMC Health Services Research, 20(1). https://doi.org/10.1186/s12913-020-4909-0 DOI: https://doi.org/10.1186/s12913-020-4909-0
Hazim, A., Ruan, G., Pritchett, J. C., Anderson, B., Leventakos, K., & Egan, A. (2024). Remote Patient Monitoring for Early Detection of Immune Checkpoint Inhibitor Therapy-Related Pneumonitis in High-Risk Patients: A Pilot-Feasibility Study. Journal of Clinical Oncology, 42(16_suppl), e13806–e13806. https://doi.org/10.1200/jco.2024.42.16_suppl.e13806 DOI: https://doi.org/10.1200/JCO.2024.42.16_suppl.e13806
Howell, D., Rosberger, Z., Mayer, C., Faria, R., Hamel, M., Snider, A., Bryant‐Lukosius, D., Montgomery, N., Mozuraitis, M., & Li, M. (2020). Personalized Symptom Management: A Quality Improvement Collaborative for Implementation of Patient Reported Outcomes (PROs) in ‘Real-World’ Oncology Multisite Practices. Journal of Patient-Reported Outcomes, 4(1). https://doi.org/10.1186/s41687-020-00212-x DOI: https://doi.org/10.1186/s41687-020-00212-x
Ivziku, D., Ferramosca, F. M. P., Filomeno, L., Gualandi, R., Maria, M. D., & Tartaglini, D. (2021). Defining Nursing Workload Predictors: A Pilot Study. Journal of Nursing Management, 30(2), 473–481. https://doi.org/10.1111/jonm.13523 DOI: https://doi.org/10.1111/jonm.13523
Khoiriyati, A., Sukartini, T., Kusnanto, K., & Kurniawati, N. D. (2021). Barriers in the Process of Care Transition From Hospital to Home in Post-Acute Coronary Syndrome: Patients’ Perspective. Bali Medical Journal, 10(3), 1308–1312. https://doi.org/10.15562/bmj.v10i3.2908 DOI: https://doi.org/10.15562/bmj.v10i3.2908
Layman, S. N., Elliott, W. V, Regen, S. M., & Keough, L. A. (2020). Implementation of a Pharmacist-Led Transitional Care Clinic. American Journal of Health-System Pharmacy, 77(12), 966–971. https://doi.org/10.1093/ajhp/zxaa080 DOI: https://doi.org/10.1093/ajhp/zxaa080
Marko, K., Krapf, J. M., Meltzer, A. C., Oh, J., Ganju, N., Martinez, A., Sheth, S., & Gaba, N. D. (2016). Testing the Feasibility of Remote Patient Monitoring in Prenatal Care Using a Mobile App and Connected Devices: A Prospective Observational Trial. Jmir Research Protocols, 5(4), e200. https://doi.org/10.2196/resprot.6167 DOI: https://doi.org/10.2196/resprot.6167
McNab, D., Bowie, P., Ross, A., MacWalter, G., Ryan, M., & Morrison, J. (2017). Systematic Review and Meta-Analysis of the Effectiveness of Pharmacist-Led Medication Reconciliation in the Community After Hospital Discharge. BMJ Quality & Safety, 27(4), 308–320. https://doi.org/10.1136/bmjqs-2017-007087 DOI: https://doi.org/10.1136/bmjqs-2017-007087
Moradian, S., Krzyzanowska, M. K., Maguire, R., Morita, P. P., Kukreti, V., Avery, J., Liu, G., Cafazzo, J. A., & Howell, D. (2018). Usability Evaluation of a Mobile Phone–Based System for Remote Monitoring and Management of Chemotherapy-Related Side Effects in Cancer Patients: Mixed-Methods Study. Jmir Cancer, 4(2), e10932. https://doi.org/10.2196/10932 DOI: https://doi.org/10.2196/10932
Morgan, J. M., Kitt, S., Gill, J., McComb, J. M., Ng, G. A., Raftery, J., Roderick, P., Seed, A., Williams, S. G., Witte, K. K., Wright, D. J., Harris, S., & Cowie, M. (2017). Remote Management of Heart Failure Using Implantable Electronic Devices. European Heart Journal, 38(30), 2352–2360. https://doi.org/10.1093/eurheartj/ehx227 DOI: https://doi.org/10.1093/eurheartj/ehx227
Omboni, S., Ballatore, T., Rizzi, F., Tomassini, F., Panzeri, E., & Campolo, L. (2021). Telehealth at Scale Can Improve Chronic Disease Management in the Community During a Pandemic: An Experience at the Time of COVID-19. Plos One, 16(9), e0258015. https://doi.org/10.1371/journal.pone.0258015 DOI: https://doi.org/10.1371/journal.pone.0258015
Park, C., Otobo, E., Ullman, J., Rogers, J., Fasihuddin, F., Garg, S., Kakkar, S., Goldstein, M., Chandrasekhar, S. V, Pinney, S., & Atreja, A. (2019). Impact on Readmission Reduction Among Heart Failure Patients Using Digital Health Monitoring: Feasibility and Adoptability Study. Jmir Medical Informatics, 7(4), e13353. https://doi.org/10.2196/13353 DOI: https://doi.org/10.2196/13353
Racy, S., Davidson, P. M., Peeler, A., Hager, D. N., Street, L., & Koirala, B. (2021). A Review of Inpatient Nursing Workload Measures. Journal of Clinical Nursing, 30(13–14), 1799–1809. https://doi.org/10.1111/jocn.15676 DOI: https://doi.org/10.1111/jocn.15676
Redley, B., Douglas, T., & Botti, M. (2020). Methods Used to Examine Technology in Relation to the Quality of Nursing Work in Acute Care: A Systematic Integrative Review. Journal of Clinical Nursing, 29(9–10), 1477–1487. https://doi.org/10.1111/jocn.15213 DOI: https://doi.org/10.1111/jocn.15213
Schnipper, J. L., Samal, L., Nolido, N., Yoon, C., Dalal, A. K., Magny‐Normilus, C., Bitton, A., Thompson, R., Labonville, S., & Crevensten, G. (2020). The Effects of a Multifaceted Intervention to Improve Care Transitions Within an Accountable Care Organization: Results of a Stepped-Wedge Cluster-Randomized Trial. Journal of Hospital Medicine, 16(1), 15–22. https://doi.org/10.12788/jhm.3513 DOI: https://doi.org/10.12788/jhm.3513
Schroeder, K., Norful, A. A., Travers, J., & Aliyu, S. (2020). Nursing Perspectives on Care Delivery During the Early Stages of the Covid-19 Pandemic: A Qualitative Study. International Journal of Nursing Studies Advances, 2, 100006. https://doi.org/10.1016/j.ijnsa.2020.100006 DOI: https://doi.org/10.1016/j.ijnsa.2020.100006
Selvaraju, V., Spicher, N., Wang, J., Ganapathy, N., Warnecke, J. M., Leonhardt, S., Swaminathan, R., & Deserno, T. M. (2022). Continuous Monitoring of Vital Signs Using Cameras: A Systematic Review. Sensors, 22(11), 4097. https://doi.org/10.3390/s22114097 DOI: https://doi.org/10.3390/s22114097
Sezgin, D., Ó’Caoimh, R., Liew, A., O’Donovan, M., Illario, M., Salem, M. A., Kennelly, S., Carriazo, A. M., López-Samaniego, L., Arnal, C., Rodríguez‐Acuña, R., Inzitari, M., Hammar, T., & Hendry, A. (2020). The Effectiveness of Intermediate Care Including Transitional Care Interventions on Function, Healthcare Utilisation and Costs: A Scoping Review. European Geriatric Medicine, 11(6), 961–974. https://doi.org/10.1007/s41999-020-00365-4 DOI: https://doi.org/10.1007/s41999-020-00365-4
Smith, W. H., Caven, D., Ewing, A., & Albano, A. W. (2023). Abstract P332: Asynchronous Management of Hypertension: The Effectiveness of Remote Patient Monitoring in Mixed Populations. Hypertension, 80(Suppl_1). https://doi.org/10.1161/hyp.80.suppl_1.p332 DOI: https://doi.org/10.1161/hyp.80.suppl_1.P332
Vegesna, A., Tran, M.-Q., Angelaccio, M., & Arcona, S. (2017). Remote Patient Monitoring via Non-Invasive Digital Technologies: A Systematic Review. Telemedicine and E-Health, 23(1), 3–17. https://doi.org/10.1089/tmj.2016.0051 DOI: https://doi.org/10.1089/tmj.2016.0051
Wray, C. M., & Jones, C. D. (2023). Bridging the Know-Do Gap in Hospital Care Transitions. Jama Internal Medicine, 183(5), 424. https://doi.org/10.1001/jamainternmed.2023.0069 DOI: https://doi.org/10.1001/jamainternmed.2023.0069
Yang, R., Xu, Y., Hou, W., Wang, L., Xiao, S., Li, C., Shao, H., Fei, X., & Wang, Z. (2022). Transitional Care for Patients With Portal Hypertension: A Multicenter Study of Intervention for Post-Tips Patients. Clinical Nursing Research, 32(4), 785–796. https://doi.org/10.1177/10547738221112746 DOI: https://doi.org/10.1177/10547738221112746
Downloads
Published
How to Cite
Issue
Section
License
Copyright (c) 2026 Curatio : Journal of Advanced and Specialized Nursing, and Care Planning
This work is licensed under a Creative Commons Attribution 4.0 International License.
