Family supplemented patient monitoring after surgery (SMARTER): a pilot stepped-wedge cluster-randomised trial

Mortality after surgery in Africa is twice that in high-income countries. Most deaths occur on wards after patients develop postoperative complications. Family members might contribute meaningfully and safely to early recognition of deteriorating patients. This was a stepped-wedge cluster-randomised trial of an intervention training family members to support nursing staff to take and record patient vital signs every 4 h after surgery. Adult inpatients across four surgical wards (clusters) in a Ugandan hospital were included. Clusters crossed once from routine care to the SMARTER intervention at monthly intervals. The primary outcome was frequency of vital sign measurements from arrival on the postoperative ward to the end of the third postoperative day (3 days). We enrolled 1395 patients between April and October 2021. Mean age was 28.2 (range 5–89) yr; 85.7% were female. The most common surgical procedure was Caesarean delivery (74.8%). Median (interquartile range) number of sets of vital signs increased from 0 (0–1) in control wards to 3 (1–8) in intervention wards (incident rate ratio 12.4, 95% confidence interval [CI] 8.8–17.5, P