Table 2

Concept and implementation of intervention building blocks 3 and 4: remote monitoring and equipment and technology

Remote monitoring
Concept	Implementation
Monitoring plan Remote patient monitoring allows healthcare providers to monitor symptom progression and clinical deterioration at home. This remote monitoring should be executed within the limits of a pre-defined monitoring plan. In reaction to monitoring parameters, care plans can be adapted to cope with the change in the patient’s condition.	Monitoring plan Key elements of the monitoring plan and an example of the monitoring protocol are described below. Monitoring protocol example If a patient reports an SpO₂ 1–2% below the target SpO₂ (usually 94%), the monitoring centre will advise to increase oxygen treatment with 1 L/min and repeat measurement after 5 min. Deviations from the monitoring protocol The supervising physician will be contacted in case of deviations from the standard monitoring protocol. For questions or deterioration during the evening and night, patients/carers can contact regular acute care facilities, that is, the out-of-hours primary care facility.
Vital parameters The key parameter is the patient’s SpO₂ measured with a medically validated pulse-oximeter. Additional parameters are heart rate, respiratory rate, temperature, shortness of breath, cough and general well-being scales. Pulse oximeters Pulse oximetry has been used successfully in the home setting.3–6 22 Assessment of respiratory rate by patients or care givers may be unreliable because awareness of assessment often inadvertently changes the respiratory rate.35 36 Moreover, there is large observer variability. Devices for measuring respiratory rate are available but not validated for use in the home context.37	Vital parameters Three times daily the patient registers the SpO₂ (after 5 min of rest), heart rate, temperature, and he/she fills out the visual analogue scale for shortness of beath. The general well-being and visual analogue scale for cough is filled out once daily (see online supplemental table 3). Communication with monitoring staff The monitoring staff checks the parameters and scores during office hours, either by the app or by twice daily telephone contact in case of diary use. All patients are called at least once daily for a check-up and to communicate, if needed, any changes in treatment, for example, up or down titration of oxygen or changes in medication use.
Remote monitoring facility A remote monitoring facility includes staff that can ‘coordinate’ the monitoring, which entails both checking and communicating about the collected health status data with the patients, supervising physicians, and other healthcare personnel.	Remote monitoring facility Remote monitoring will be provided by the Medical Control Centre (MCC), located in the University Medical Centre Utrecht, serving all patients in the vicinity of all four regional hospitals. Monitoring staff includes students from (bio-)medical training programmes, supervised by both specialised nurses and trained GPs affiliated with the research team. Office hours: 9AM to 5PM, 7 days a week. Patients are instructed to contact regular acute care facilities, that is, the out-of-hours primary care facility, in case of urgent medical problems or questions, or when SpO2 deteriorates below 90% in the evening and night.
Digital vs analogue monitoring Data exchange in remote monitoring can be organised digitally, for example, via an app, or through diary keeping with follow-up by phone, or a combination of both methods. Digital monitoring requires adequate patient/carer skills and availability of devices which may fail to cater to elderly patients. Follow-up by phone is more time intensive for monitoring personnel.	Digital vs analogue monitoring Patients can choose to register their parameters and scores in a written diary or in an app (Luscii Healthtech BV, Amsterdam, the Netherlands).

Equipment and technology
Concept	Implementation
Timely oxygen equipment delivery Home-based acute care requires timely equipment delivery. Oxygen support system such as an oxygen concentrator should be delivered at home shortly after ED visit, if applicable.	Timely oxygen equipment delivery For oxygen therapy at home, an oxygen concentrator (DeVilbiss Healthcare LLC, CE-certified; supplied by a company for home delivery of medical equipment) and standard nasal cannula will be delivered to the patient’s home within 4 hours after requisition. The oxygen concentrator supplies a maximum of 4–6 litres of oxygen per minute.
Monitoring equipment Validated pulse oximeters should be at the patient’s disposal for measurement of SpO₂ and pulse rate. Other equipment that should be considered: thermometer (ear of rectal), a temporary height-adjustable bed, or other amendments to the home setting (eg, sanitary adjustments). Equipment used should be validated for medical use. Non-validated pulse oximeters do not perform adequately at lower SpO₂, e.g. below SpO₂ 94%.38–40	Monitoring equipment To self-measure SpO₂, patients will be provided with one of two types of pulse oximeters: Nonin type 3230 (CE-certified, Nonin Medical Inc) or the iHealth air pulse (CE-certified, iHealthlabs Europe). Both pulse oximeters are validated for medical use according to the Food and Drug Administration (FDA) and follow International Organisation for Standardisation (ISO) guidelines. To self-measure temperature, patients will receive ear thermometers (ThermoScan 3, IRT 3030, Braun).

ED, emergency department; GP, general practitioner; SpO₂, peripheral oxygen saturation.