The use of advanced medical technologies at home: a systematic review of the literature

In this category, 22 articles described the psychosocial impact on patients or informal caregivers from the use of medical technologies at home. Living at home with the assistance of medical technology needs a range of adjustments. Fex et al. [25, 26] state that self-care is more than mastering the technology, in terms of the health-illness transition, it requires ‘…. an active learning process of accepting, managing, adjusting and improving technology’. When it comes to children, they have to learn to incorporate disability, illness and technology actively within their process of growing up [27]. It seems that the use of medical technologies in the home can have both a positive and a negative psychosocial impact on patients and their families, which in turn causes ambivalence in experiences [27, 28]. On the one hand, patients in general gain more independence, an enhanced overall health and a better quality of life [29‐34]. On the other hand, for some patients the experience is one of dependency on others for executing daily activities, and these circumstances, to some extent, a social restricted live and perceived stigmatization [29, 30]. The situation in which patients need to use medical technology at home also affects family functioning and requires next of kin responsibilities [35‐37]. As a result, next of kin caregivers are frequently faced with poor sleep quality and quantity, and/−or other significant psychosocial effects [38‐41]. Nevertheless, family members had a positive attitude to the concept of bringing the technology into the home [42]. Knowledge of how to use the technology and permanent access to support from healthcare professionals and significant others, enabled next of kin caregivers to take responsibility for providing necessary care and to facilitate patients learning to provide self-care [25, 36, 42‐44]. Bezruczko et al. [45, 46] developed a measure of mothers’ confidence to care for children assisted with medical technologies in their homes. To provide high quality sustainable care, nurses have to recognize and understand the psychosocial dimensions for both patients and family members which arise as a result of changing role and providing care for the patients. The need to provide emotional support and support with appropriate coping strategies is a key professional role [25, 26, 47]. Insight into the psychosocial effects on those involved can be used to assist designers of medical devices to find strategies to better facilitate the integration of these technologies into the home [28].

Seven articles reported on the usability, barriers and accessibility experienced by patients or informal caregivers. Findings in these studies showed that several technologies were rarely perceived as user-friendly and that home medical devices inadequately met the needs of individuals with physical or sensory deficits [48, 49]. An accessible design which meets the diversity of individual user needs, characteristics and features would be better able to help patients manage their own treatment and so could contribute to the quality of care and safety of patients and lay users [50, 51]. Munck et al. [52] stated that restricted patients were reminded daily of the medical technology and were more dependent on assistance from healthcare professionals than masterful patients.

In contrast to the group of patients or informal caregivers, only two papers in this content category focused on the user experiences of nurses or other professional caregivers. The review demonstrates that to maintain patient safety, more education on application of medical devices for users is needed together with improved awareness and understanding of how to use the medical technology correctly in a patient-safe way [53, 54]. More collaboration between all involved ‘actors’ in the process of care is also requisite. Continuity among carers, trust between patient and carers and supportive communication between informal and professional caregivers are important factors for the successful implementation of medical technologies in the home environment while maintaining patient safety [44, 51, 53‐55].

Three articles regarding this topic focused on nurses or other professionals and four on the patients or informal caregivers. The results showed that successful use of advanced medical technologies at home requires adequate staff education and training programmes. Although many topics in educational programmes are suitable for different types of professionals in care provision, the focus for the level and application of information can vary for Registered Nurses and unregistered care staff. In addition, for overall learning experiences to be of maximum benefit there is a need for a clear focus on the specific client groups [56]. According to Sunwoo et al. [57], in the case of home non-invasive ventilation the degree of clinical support needed is extremely variable given the mixed indications for this respiratory support. A relatively simple procedure, such as the replacement of a feeding tube, can be performed by nurses, the patient and informal caregivers, provided they are trained well [58]. However, several studies revealed the complexity of the education needed by patients and informal caregivers for the use of advanced medical technologies at home [59, 60]. Nevertheless, the studies revealed that a structured education programme, specific training, or the support of a dedicated discharge coordinator has several advantages [59, 61, 62]. It was evident that good preparation by patients or informal caregivers may result in a shorter length of stay in hospital, a better performance with regard to the use of the equipment or less requests by patients and/or families for assistance.

Most articles regarding this topic (n = 13) reported on safety in general, like aspects of safe use, factors affecting safety, complications and prevention of incidents in the home. Some identified the risk factors and the complications that may arise [63‐65], where Stieglitz et al. [66] also emphasize that human error is the main reason for critical incidents and that regular instruction for medical staff and patients is necessary. To prevent untoward and adverse events, evidence based guidelines, recommendations on the preferred methods for managing the equipment, troubleshooting techniques for potential complications and monitoring activities are necessary [67, 68]. Faratro et al. [68] added that key performance and quality indicators are important mechanisms to ensure patient safety when using a medical device in the home. Methods to address or evaluate patient safety issues are for example, a home visit audit tool, a nationwide adverse event reporting system, programs such as the Medical Product Safety Network HomeNet, or, in the case of peripherally inserted central catheters (PICCs) a central catheter stabilization system [69‐72]. However, a study conducted by Pourrat and Neuville [73] in France found that there are very few internal medical devices vigilance reports found within organizations that deliver devices for home parenteral nutrition and that safety management could be improved. The safe transfer of medical devices from a hospital setting to the home and vice versa, comes with several challenges regarding technological, environmental and human factors [14]. While many hospitals have developed policies to control the pathways of home-used devices in the hospitals, in case patients take them into the hospital when they are admitted for treatment [74]. Improvement of the safety of devices intended for use in home settings, implies also improvement of safety when their transfer to the hospital settings is urgently needed.

One article considered the technological factors, three the environmental and two the human factors. An example of research on the technological factors of safety related aspects of medical technologies used in home settings by Hilbers et al. [75] found that manufacturers pay insufficient attention to safety-related items in technical documentation for the use in the home setting. For instance, the environmental factor of electricity blackout leads to electrically powered medical devices failing. Studies show that this type of event causes a dramatic increase in appeal for access to emergency or hospital facilities, and that disaster preparation needs to include the specific needs of patients reliant on electrically driven devices [76‐78]. Regarding human factors impacting on safety aspects, one article assessed the suitability of a particular theoretical framework for understanding safety-critical interactions of patients using medical devices in the home [79], while Tennankore et al. [80] described adverse events in home haemodialysis by the use of patients. It was remarkable that none of the articles focused on human factors with regard to the use of medical technologies at home by nurses or other professional caregivers.

Of those articles that focused on this topic, ten reported on the comparison between different types of medical technologies, or their advantages and disadvantages. The comparison of different devices for oxygen therapy was made by two articles [81, 82] and one reported on the comparison of two types of enteral nutrition tubes [83]. Some studies regarding respiratory support considered the process of making a choice between different types of devices [84‐86] while one paper considered the conditions for home-based haemo dialysis [87]. A minority, explored the individual characteristics and the clinical applications of several devices for respiratory support [88, 89] and one considered devices for insulin pump therapy [90]. Seven papers discussed the technological development or effectiveness of medical technologies. The testing of devices for external electro-stimulation was described in two papers [91, 92], with the testing of a new design patient lift was subject of one study [93]. Hanada and Kudou [94] explored the current status of electromagnetic interference with medical devices in the home setting, an issue of importance as more devices are considered for home use. The technological development of respiratory support for home use was part of one study [95], as were the possibilities of solar-assisted home haemo dialysis [96]. While the study by Pourtier [97] describes the advantages of analgesia pumps that can be read remotely by nurses, but also emphasizes the central position of a professional nurse in the transfer of information within a multi-disciplinary team.

All articles described several aspects that need to be considered for use, such as clinical characteristics of the patients, indications for the use in the home setting, the technical availability of devices, the extent of their use at home or eventual complications and morbidity. It was important to note that all but one article (n = 6) were about children or related to adults with what are usually regarded as paediatric diseases. Results show that the use of AMTs at home among children after hospital discharge is common (in 20%–60% of cases), or is standard for patients with some disorders [98‐101]. The timely application of advanced home medical technology benefits patients and can help to reduce respiratory morbidity [102]. Nevertheless, the rate of death of patients with Möbius syndrome using the devices at home was high (30%) [98], as was that of patients with intestinal failure dependent on home parental nutrition therapy in Brazil (75% for 5 years) [103]. The average cumulative survival of children needing home ventilation was found to be between 75 and 90%, depending on the medical diagnosis [104].

Three of the papers were concerned with costs and/or reimbursement. The application of medical technologies in the home environment can be cost-effective when compared to institutionalized care [22, 105, 106]. Nevertheless, successful employment of medical technologies in the home necessitates medical guidelines for the indicators for use, careful identification of patients as well as careful planning and attention to details [105‐107]. Two studies concerned the dilemma’s for implementation of the technologies in home healthcare and emphasized the importance of cooperation in the chain of key stakeholders to maximize efficiency of high-tech healthcare at home, one with regard to the purchasing policy of medical technologies [108] and one with regard to the interventions of local community service centres and hospitals supporting optimal use of these technologies in the home setting [5].