Respiratory virtual wards – squaring the circle

When the first UK pandemic lockdown came into effect, the shared uncertainty and anxiety amongst my colleagues working in community respiratory care was palpable. ^[1]

Our community service at Liverpool Heart and Chest Hospital supported people with a diagnosis of COPD or bronchiectasis. The circulation of social media posts at the time encouraging ‘anyone with a pre-existing respiratory condition’ to contact their GP for a rescue pack resulted in a huge surge in contacts from our patients. ^[2] Patients were concerned about the pandemic’s impact and sought assurance and rescue packs from the team.

In less than a month, the team were reacting well to the challenges that were being presented by hospitalised (and hospital-suitable) COVID-19 patients. We had a pathway in place to support the early discharge of COVID-19-positive patients, and hospitalised COVID-19 patients from neighbouring hospitals were supported by this service – with the first such case a mere 21 days after the lockdown, just as Captain Tom Moore completed his 100^th garden lap.^[3]

This early discharge scheme, informed by our previous community service admission avoidance experience, evolved into a comprehensive virtual respiratory ward.^[4]

The virtual ward model

The concept of virtual wards preceded the pandemic, with early models being developed in Croydon in 2006,^[5] although these can perhaps be seen as evolutions of earlier telehealth-supported models and hospital at home pathways for patients with COPD (which arose in the last decade or so of the 20^th century).^[6]

A variety of these models supported patient care across the country and were seen as a potentially useful adjunct to secondary care for patients carefully selected for home-based care. However, the onset of the COVID-19 pandemic and ensuing pressure on inpatient beds brought the concept(s) back to the forefront as a potential tool to support patient care.^[7]

Step-up and step-down pathways were rapidly developed across the country to meet the surging demand, utilising home oximetry and regular clinician telephone calls. The initial reported success of these pathways in terms of potential bed day savings ensured further development of this alternative approach, ^[8] with NHS England standardising oximetry at home services and full COVID virtual wards shortly thereafter, in part as a response to the second wave.^{[9], [10], [11]}

The expansion of virtual wards

Early learnings from the implementation of these wards supported the expansion of virtual wards. NHS England produced guidance thereafter initially (however not limited to) acute respiratory infection (ARI) and frailty, with a more formalised framework to differentiate between a virtual ward and more traditional community or hospital at home services.^[12]

Core principals of the virtual ward include technology enablement (management via a digital platform) alongside:^[12]

• acute clinical care provided by a multidisciplinary team (MDT) led by a consultant practitioner – including nurses, Allied Health Professional (AHP) consultants or GPs
• clearly defined admission criteria and patient information
• access to specialty advice and guidance/ diagnostics
• delivery of time-limited interventions and monitoring
• alignment with other services such as same day emergency care (SDEC) or urgent crisis response (UCR)/ unscheduled care services
• facilitating patient choice of where to receive hospital expertise (home or hospital setting).

Analysis by NHS improvement suggested additional secondary care bed delivery and bed days saved,^[13] with opportunities for more flexible/ blended staff roles as potential benefits to the expansion of virtual ward programs.^[12]

Research into the effectiveness of virtual wards is currently limited. Some studies suggest possible benefits in terms of bed day saving and survival, however with cautions on potential cost savings and increases in workload.^{[14], [15]}

The challenges and opportunities of virtual wards

Locally, challenges have included staffing recruitment (an issue not limited to virtual wards of course), and working across former CCG boundaries. This has, I believe, provided an opportunity to ‘start again’ when considering geographical or ‘place’ boundaries and to forge new working collaborations with neighbouring services, in an attempt to provide more seamless patient care.

Generally, the evolution of the respiratory virtual ward presents many opportunities to improve respiratory care for suitable patients including:^[16]

• providing hospital level care within the community
• decreasing the burden on secondary care beds
• providing an alternative to admission to primary care partners
• allowing greater autonomy and choice for our patients.

Local review has identified other benefits for virtual wards, including a reduction in 30-day secondary care readmission for patients managed with an exacerbation of COPD or community-acquired pneumonia.^[17],[18] Patient feedback has also been positive, especially in patients where hospital inpatient care is not the preferred option, allowing greater patient choice and autonomy.^[19][20]

We are developing the virtual ward further by integrating earlier identification and support for patients suitable for pulmonary rehabilitation with dedicated staffing to support this.

Conclusion

There are many challenges to providing this level of care, which rely on adequate and appropriate staffing, and communication between clinicians across primary, community and secondary care. But these challenges also offer the opportunity to reimagine existing pathways and overcome previous barriers to provide a more seamless journey for our respiratory patients.

Any advice given and opinions expressed in this article are those of the author and do not reflect the view of Chiesi Limited (Chiesi).  All content in this article is for informational and educational purposes only.  Although Chiesi strives to always provide accurate information, it is not responsible for and does not verify for accuracy any of the information contained within.

[1] UK Legislation. The Health Protection (Coronavirus, Restrictions) (England) Regulations 2020. Available at: https://www.legislation.gov.uk/uksi/2020/350

[2] Reuters. False claim: patients with respiratory conditions can receive ‘rescue packs’ from their doctor. Available at: https://www.reuters.com/article/idUSKBN21D2TZ/

[3] BBC. Coronavirus: Capt Tom Moore’s NHS fundraiser hits £17m. Available at: https://www.bbc.co.uk/news/uk-england-beds-bucks-herts-52303859

[4] NHS Cheshire & Merseyside. Virtual Wards. Available at: https://www.cheshireandmerseyside.nhs.uk/your-health/virtual-wards/

[5] The Kings Fund. Case study : virtual wards at Croydon Primary Care Trust. Available at: https://archive.kingsfund.org.uk/concern/published_works/000040452#?cv=0

[6] Ram FS, Wedzicha JA, Wright J, et al. Hospital at home for patients with acute exacerbations of chronic obstructive pulmonary disease: systematic review of evidence. BMJ. 2004; 329(7461): 315

[7] Nunan J, Clarke D, Malakouti A, et al. Triage Into the Community for COVID-19 (TICC-19) Patients Pathway – Service evaluation of the virtual monitoring of patients with COVID pneumonia. Acute Med. 2020; 19(4): 183-191

[8] Thornton J. The “virtual wards” supporting patients with covid-19 in the community. BMJ. 2020; 369: m2119

[9] NHS England. COVID-19 guidance note: COVID Oximetry @home. Available at: https://www.england.nhs.uk/coronavirus/documents/covid-19-standard-operating-procedure-covid-oximetry-home/

[10] NHS England. Supporting hospital discharge: Establishment of COVID virtual wards. Available at: https://www.england.nhs.uk/coronavirus/documents/supporting-hospital-discharge-establishment-of-covid-virtual-wards/

[11] NHS England. Readiness for responding to a second wave of COVID-19. Available at:

https://www.england.nhs.uk/coronavirus/documents/readiness-for-responding-to-a-second-wave-of-covid-19/

[12] NHS England. Virtual ward including Hospital at Home. Available at: https://www.england.nhs.uk/wp-content/uploads/2021/12/B1478-supporting-guidance-virtual-ward-including-hospital-at-home-march-2022-update.pdf

[13] Schultz K, Vickery H, Campbell K, et al. Implementation of a virtual ward as a response to the COVID-19 pandemic. Aust Health Rev. 2021; 45(4): 433-441

[14] Jalilian A, Sedda L, Unsworth A, Farrier M. Length of stay and economic sustainability of virtual ward care in a medium-sized hospital of the UK: a retrospective longitudinal study. BMJ Open. 2024; 14(1): e081378

[15] Norman G, Bennett P, Vardy ERLC. Virtual wards: a rapid evidence synthesis and implications for the care of older people. Age Ageing. 2023; 52(1): afac319

[16] Primary Care Respiratory Society. Virtual wards – Friend or foe? Available at: https://www.pcrs-uk.org/sites/default/files/2022-December-PCRU-virtual_wards.pdf

[17] Barber D, Frost F, Wat D, et al. P227 Community acquired pneumonia and readmissions from the virtual ward. Thorax. 2023; 78: A249-A250

[18] Barber D, Frost F, Wat D, et al. P230 Predicators of COPD exacerbation readmissions from the virtual ward. Thorax. 2023; 78: A251

[19] NHS Confederation. Realising the potential of virtual wards. Available at: https://www.nhsconfed.org/publications/realising-potential-virtual-wards#:~:text=There%20is%20considerable%20enthusiasm%20among%20clinicians%20
and%20local,clinical%20time%20and%20give%20patients%20autonomy%20and%20choice

[20] NHS England. Making the most of virtual wards, including Hospital at Home. Practical guidance for clinicians to maximise use of virtual wards for the benefit of patients. Available at: https://gettingitrightfirsttime.co.uk/wp-content/uploads/2023/11/Making-the-most-of-virtual-wards-incl-heart-failure-FINAL-V2-November-2023.pdf