Introduction: Learning from other countries identified a cohort of patients who were at risk of sudden deterioration, although they did not require active intervention (oxygen/CPAP). Under normal circumstances, the respiratory teams would admit these patients for observation, but given the anticipated pressures for hospital beds it was recognised that these patients could be allowed to go home safely provided that they were being monitored regularly. A telephone review virtual ward to monitor these patients at home was designed.
Objectives: The aim of the virtual ward was to monitor patients discharged from hospital (either from the ‘ RED COVID’ zone at the front door or from the ward). There was a cohort of patients with COVID who were well enough to be at home, but are at risk of deteriorating.
Following the launch of the virtual ward the team agreed that the patients were received a telephone call at 4 hours, 24 hours 4 and 7 days at a minimum. As the respiratory physicians gained personal experience of managing the disease, the protocol was adapted. It became clear that the critical period for the patients was week 2 of the illness, so we redesigned the template to ensure that patients were receiving reviews at appropriate intervals.
In designing the virtual ward, several factors were considered:
•Manpower – who would staff the virtual ward, given that GPs and hospital doctors’ workload was likely to increase significantly during the COVID outbreak?
•Referral criteria – how would the patients suitable for the ward be selected by the respiratory teams? Were we sure about our cohort?
•Referral process – how would patients be referred from the hospital to the virtual ward?
•IT – what IT would we need to support the virtual ward?
•Would we have enough pulse oximeters to give to the patients to take home, and how would we train the patients how to use them. How would we collect the pulse oximeters back at the end?
•How would we communicate the patient’s journey with the patient’s GP?
•The physicians selected the patient for the virtual ward once they have been assessed in hospital.
•The patient was given a pulse oximeter to take home.
•The HCPs from the ward will email
•The referral to the ward clerk on the agreed generic email address
•The ward clerk will work out when the reviews are due and email the appropriate virtual ward
•The virtual ward clinician will contact the patient and either speak by phone, or arrange a video consultation.
•The clinician will complete the review template and email it back to the ward clerk visa the generic email address
•If a patient is unwell and needs hospital review the virtual ward doctor will phone AMAU to arrange readmission.
•If a patient is unwell in between phone calls they will contact the ward clerk who will telephone the virtual ward doctor
•Direct access to oncall consultant via designated telephone number to AMAU directly if they are deteriorating out of hours
Learning from our experience
•The role of the virtual ward clerk was vitally important.
•Designed the virtual ward utilising expertise from both secondary and primary care.
•Recruitment of retired GPs was not straightforward.
•The pathway became complicated when other agencies became involved.
•Small PDSA cycles
•Linking directly into the 9am hospital clinical meeting
•Communication with the on call medical team was essential
•Access to the on call consultant in the red team 24/7 gave the GPs confidence that any issues they could review rapidly with them.
•Having only one ward clerk and the CCM lead linking to the 9am hospital ward round identified that we had to increase their support as neither were having any time off.
•We designed information leaflets on;
What the Virtual Ward was and what to do should they
How to take a pulse oximetry reading correctly,
Information on health and wellbeing support,
Coping with breathlessness and fatigue
•These leaflets were sent to every patient referred in the post as another means of support. The pulse oximetry form is also given with the pulse oximeter on discharge
•Provide a safe and effective service
•Prevent readmissions to hospital
•patient and carer satisfaction
7 readmissions with one patient being admitted twice from 56 patients
Results from postal questionnaire
A patient and his wife agreed to give their experience of using the service; ‘The Virtual Clinic was a good way of supporting those who could be discharged and freeing up hospital spaces but still being monitored and this is something I think should continue even after the restrictions are lifted and this pandemic has lessened.’
The service was well received by both staff and patients. It was also shown to be safe, clinically effective and cost effective. Excellent communication between COVID team and virtual ward team ensured the appropriate decisions were made. Our VBHC team undertook took a cost analysis and identified comparable savings of £71,038.25.
Implications for applicability/transferability, sustainability, and limitations
•Reinstated Virtual ward for second wave utilising decision tree text messaging following learning from first wave
•Consider virtual ward concept for improving early discharge for respiratory patients from hospital with a view to expanding to other specialities in the future