Can we avoid hospitalisation with the use of virtual wards?

The use of virtual wards grew significantly during the Covid pandemic, when many vulnerable people were required to shield at home. With pressures on the NHS and emergency services higher than ever, virtual wards offered a unique way of freeing up hospital beds.

A new Panorama documentary, The NHS Crisis: Can It Be Fixed?, has unearthed some of the key issues facing the health service and what doctors and nurses are doing to relieve some of the pressure in hospitals.

Caring for the older population who are living longer and with multiple long-term conditions was a particular focus of the programme. The BBC’s social affairs editor, Alison Holt, speaks to NHS staff who are increasingly providing care in the community, rather than in the hospital.

‘Virtual wards’, also known as ‘hospital at home’, are becoming increasingly used as a method to treat patients who do not need, or want to be, treated in hospital.

Last year, Professor Margot Gosney, Honorary Consultant in Elderly Care Medicine at the Royal Berkshire NHS Foundation Trust, discussed the role of community geriatrics in the NHS at the GM Conference 2022. This article summarises Professor Gosney’s talk and highlights just how valuable virtual frailty wards are to older, frail patients.

The different types of virtual wards

Professor Gosney explains that there are different forms of virtual wards. One type involves a smaller standalone team with a doctor, an Advanced Nurse Practitioner (ANP) and a nurse team. This team works independent from therapy and social services, and since you work as part of a smaller team, you all typically know each other well and communication between the team is typically very good. However, Prof Gosney notes that a disadvantage to this style of virtual ward is that if the patient needs physiotherapy or occupational therapy, you will need to liase with other departments.

The second type involves a fully integrated team, including a doctor, ANP, nurse, physiotherapist occupational therapist and support workers. This makes it easier to organise all the patient’s care needs and install any equipment the patient may need. However, Prof Gosney notes that certain team members may not be available when required and social services may not act as quickly to get a care package put it place because they know the patient has support on hand.

What do virtual wards look like in practice?

Request for at-home care can come from GPs, community nurses, palliative care staff, nursing and residential homes, and paramedics. It is common for emergency services to request an at-home visit if the patient does not need hospital treatment, but still needs to be closely monitored.

These patients are then triaged by the advanced nurse practitioner (ANP) and the consultant. They will usually have access to the community and hospital notes so that they can see past medical history and make an informed decision about where the patient can be treated.

Sometimes, the consultant will advise that it is not safe for the patient to be cared for in the community and the best place for them is the hospital. In this case, doctors should still try and make every effort to move the patient into the community as soon as it is safe to do so.

Which treatments can patients receive at home?

Patients being treated in the community can be given IV fluids, and pre-packed drugs including laxatives, diuretics and antibiotics, and antiemetics. Healthcare professionals providing community care can also obtain end of life anticipatory drugs by requesting this from the patient’s GP.

Healthcare professionals working in the community must ensure that patients fill out a respect form. This includes DNACPR decisions, when a patient will be willingly admitted to hospital and what kind of treatment the patient wants to receive (for example, IV or oral medication).

Discussing respect forms with the patient and their family gives the patient the opportunity to have an open discussion with their family members and make decisions about sensitive matters (such as where they want to die).

The form will then be uploaded to community notes and can be forwarded to the ambulance service in case the patient needs emergency care. It may also be helpful for nursing and residential homes to have these respect forms so staff have clear guidance to work with.

Who benefits the most from virtual wards?

The patients who benefit the most from virtual wards are:

• The very frail (age does not matter)
• Those with cognitive impairment
• Those with life limiting conditions
• Those not wishing further hospital admission
• Those with a complex care plan in situ
• Those with recurrent need for intensive (short term) input for long term conditions
• Those with sensory impairment e.g. vision or hearing

Professor Gosney highlights that decreased cognition affects decision making. These patients may want over or under treatment, and staff may be ore reluctant to treat the patient.

In these circumstances, healthcare professionals must encourage families to understand the difference between curative vs palliative treatment.

“What is really difficult is when we are referred somebody to a hospital at home and they’ve got challenging behaviour, particularly due to dementia. [We have to consider] whether the cannula will stay in. If we put the cannula in somebody who won’t keep their clothes on, they’re not going to keep the cannula in.”

Intravenous antibiotics or fluids therefore may not be an option for these patients. However, Prof Gosney says it is always best to assume the patient has the ability to make a decision and work backwards.

Assessing capacity

Capacity assessments are an important factor when working with patients in the community. Healthcare professionals must have a consultation with their patient and work together to try and achieve the best outcome for their patient.

Many patients will have mild cognitive impairment that does not progress to dementia, and many patients with early dementia are fit and well and not on any medications. “This should not stop us treating them in the community,” Prof Gosney says.

The right language

Professor Gosney notes that choice of language is very important and must be carefully chosen. For example, instead of discussing DNR decisions, healthcare professionals can instead discuss whether the patient would like to be ‘saved’ if they die a natural death.

Patients must also be given the choice about where they want to die. Older people usually die in hospital, despite wanting to die at home. It is therefore important to ask and not presume people’s end of life wishes.

Many patients have not had these discussions before, Professor Gosney says, and some specialists shy away from these discussions. However, these discussions are extremely important to have and decisions must be made about which medication to stop or continue with.

Patients must also be asked about their pain levels, and an assessment must be taken, particularly with patients who have dementia or delirium, when pain is often underestimated.

The same standard of care as in hospital

Professor Gosney says virtual frailty wards are extremely beneficial for some patients, however, it is crucial that the care provided in the community is the same if not better than what is provided in hospital.

“[Frailty wards] have got to have highly qualified staff. This is not about patching together a service that is inadequate. There needs to be senior input at the same level as what is expected in a hospital setting,” she concludes.

If you missed out on getting a ticket for the GM Conference 2022, it’s not too late. You can access recordings of the full CPD-certified conference using our online conference hub. To find out more, please contact [email protected].