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Covid Virtual Ward (secondary care)

The Covid Virtual Ward model is a secondary care led initiative to support early and safe discharge (step down) for Covid patients. It has already been implemented in some - but not all - parts of the country where it is having an impact in reducing emergency admissions (Greater Manchester, Liverpool, Tees, North London, Berkshire, Hampshire, West Herts); and builds on the Covid Oximetry @home model previously approved by the National Incident and Response Board (NIRB), and now implemented by all CCGs.

We are supporting local healthcare systems prepare to establish or expand Virtual Ward pathways. Find out more and join our monthly National Learning Network webinars here: https://www.ahsnnetwork.com/national-learning-network-for-virtual-wards.

NHS England and Health Education England elearning for healthcare have launched an elearning programme on virtual wards, to support doctors, nurses and allied professionals in the use of technology to provide safe, acute-level care to patients at home. This supports the NHS’s ambition in the 2022/23 NHS planning guidance to increase the number of virtual wards across England.

The elearning is for clinicians to gain an understanding of implementing and running a virtual ward enabled by technology. It should be used alongside organisations' own local policies. Complete the programme on HEE’s elearning for healthcare platform in around 30 minutes.

If you have any questions about virtual wards more broadly, contact england.virtualward@nhs.net.

NHS England and Improvement has now written out to all ICSs and trusts in the country; outlining why this work must be implemented, and how to do it. You can see these documents here, or in the resources section on the right-hand side.

As with the Covid Oximetry @home roll-out, the south east AHSNs are supporting our systems to set up the secondary care model. There is a special area of resources on FutureNHS, and most resources are here - on this page - too. If you're not sure how to access the resources toolkit on FutureNHS, read the guidance here.

What is the secondary care Virtual Ward model, and how is it different to CO@h?
Covid Oximetry @home is a primary care based pathway for patients who are required to ‘self monitor’ and escalate if their oxygen saturations fall below 95%, and who have generally not been admitted or assessed by secondary care.

The key difference between Covid Oximetry @home and the Covid Virtual Ward (secondary care) is the enhanced remote monitoring (supervised from secondary care/community providers) with daily calls and hospital treatments for patients (including Dexamethasone, anti-coagulation +/- trial drugs, and in a small number of cases, home oxygen therapy) on the Covid Virtual Ward. Please also see the below table:

The patients for the secondary care virtual ward are at significantly higher risk of deterioration, and this enhanced monitoring and treatment gives confidence to discharging clinicians and patients that they will be safely cared for virtually during the ‘step down’ process.

Covid Virtual Wards are not designed to be part of the ‘step up’ or escalation pathway for Covid Oximetry @home.

The on-boarding process for both pathways should include a patient-held escalation plan that should assist remote assessment by 111/999/CVW team, and help reduce inappropriate re-admission or re-attendance.

Based on existing services, providing a safe and robust Covid Virtual Ward ideally requires staffing for at least 12 hours a day (8am to 8pm), seven days a week, with locally arranged out-of-hours cover.

Patients are given a hospital phone number to call for any advice or support required during these hours which is provided by non-registered members of nursing staff (HCAs). These staff are clinically supervised by an experienced registered nurse, who is also responsible for making the proactive daily calls i.e. the virtual ward round.

The Covid Virtual Ward is led by a named consultant or ST3+ doctor with relevant Covid experience (usually an acute or respiratory physician). The workforce requirements are significantly less intensive than the patients remaining in an NHS bed.

Why do we need to do this?
From 31 December 2020, all CCGs have gone live with Covid Oximetry @home pathways which can help reduce critical bed use through patient self-monitoring.

However, the secondary care wards must also be implemented at scale, and with consistent coverage within CCGs, so that every PCN is covered. A secondary care ward can further relieve pressure on acute hospital beds by facilitating early supported discharge for patients with confirmed (or suspected) Covid-19. Based on clinical advice from existing CVW services, this proposal could free-up to 1,500 beds across England; equating to an average of 10 beds per trust, between now and the end of March 2021.

Who is it for?
Early supported discharge should be considered for adults in hospital with confirmed (or suspected Covid-19), who have an improving clinical trajectory (symptoms, function, oxygen saturation) and have no fever for 48-hours consecutively (without medication to reduce fever).

Patients who meet these criteria, with oxygen saturations of 95% or higher, may be suitable for discharge onto the:

Covid Oximetry @home pathway, and GP follow-up, in the event of recovery;
Or the secondary care Covid Virtual Ward, if they are deemed at ongoing high risk of acute deterioration and/or are on ongoing hospital treatments (e.g. dexamethasone, anti-coagulation, trial drugs).

93% or higher maybe suitable for discharge onto a Covid Virtual Ward @home pathway;
92% or lower are generally unsuitable for early supported discharge (unless this is their baseline oxygen level in which case they may be considered for the CVW)

How many patients and oximeters?
Clinical advice suggests that up to 300 patients could be suitable for early supported discharge each day between now and the end of March 2021, equating to 1,500 beds or 135,000 bed days, assuming an average hospital LOS saved of five days per patient.

Each ICS should create Covid Virtual Wards capable of supporting up to 25 patients at any one time. It is recommended that CCGs should ensure each acute trust should have enough oximeters available for use on Covid Virtual Wards. To support this, NHS England will push out a further 50,000 oximeters to CCGs to ensure there are sufficient oximeter stocks available for all acute NHS trusts.

Who is responsible?
As a provider-led initiative, and a safe alternative to hospital based care, the default expectation is the service will be provided by NHS acute trusts OR community providers. It will be for ICSs to determine the best local delivery arrangements to implement the CVW model; working with their local acute NHS trusts with flexibility to develop alternative local arrangements should they wish.

How much does it cost?
No additional costs are expected. The cost of the oximeters required for establishing CVWs has already been met (as previously approved by NIRB for the purchase of 501,000 additional oximeters), and made available to all acute NHS trusts via their CCG. NHS trusts are expected to absorb the cost of the staffing for the CVW pathway by redeploying staff already employed by the trust, and using them to help manage a greater number of patients using the CVW model which require a lower staff to patient ratio.

Six steps to setting up a Covid Virtual Ward
Using the experiences of Covid Oximetry @home, six key steps are recommended to set up a secondary care virtual ward:

1. Engage the local pathway through your AHSN

Find out more about how Wessex Patient Safety Collaborative can support you, and contact us here. If you work outside the Wessex area, please see the bottom of the page for KSS and Oxford contacts.

2. Form a stakeholder delivery group

3. Design and agree your model; this includes example standard operating procedures

4. Develop your implementation strategy and implement it; this includes examples of system wide strategies

5. Request pulse oximeters early; guidance on where to get pulse oximeters and how to manage logistics

6. Developing a local learning system

Local learning systems for Covid virtual wards

Additional resources

CVW and CO@h definitions for the purposes of evaluation

UCL Evaluation of 17 pilot and early adopter sites of both CO@h and CVW models

Covid Isolating at home safety netting leaflet

Covid-19 information leaflet in Hindi - Brighton and Sussex Medical School

Covid-19 information leaflet in Nepali - Brighton and Sussex Medical School

Learning disability resources for Covid oximetry (via FutureNHS)

Translated and accessible Covid-19 patient diaries (NHS England)

Multilingual Covid-19 guidance for households with possible coronavirus infection (Gov.uk)

Managing the Covid-19 pandemic in care homes - British Geriatrics Society

Covid-19 NHS clinical support for care homes - gov.uk

What next?
The AHSNs in the south east (Kent Surrey Sussex; Oxford; and Wessex AHSNs) are working at rapid pace to support our ICS and NHS colleagues to set up the Covid Virtual Wards (secondary care) during January 2021.

For support or questions, please get in touch with the Wessex team (contacts at the bottom of the page), or:

Ursula Clarke at KSS AHSN: ursula.clarke@nhs.net
Oxford AHSN: patientsafety@oxfordahsn.org

Resources to support implementing the Covid Virtual Ward (secondary care) are on the right-hand side. Please be aware, these resources are live and may be updated as the response to the pandemic evolves.

Covid Virtual Ward (secondary care)

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