Introduction

This guidance, for integrated care boards and virtual ward providers, identifies the main diagnostic requirements for the delivery of effective virtual wards; showcasing good and promising practice. It has been co-created with a range of virtual ward clinicians specialising in acute medicine, frailty, acute respiratory infection, heart failure and end of life, as well as specialists in imaging, pathology and physiological sciences.

This guidance does not provide a comprehensive list of diagnostics for virtual wards or a technical guide to their use. Rather it lists the main diagnostics that virtual wards currently access and focuses on adult virtual wards; the diagnostic access needs of paediatric virtual wards may be different.

Access to diagnostics is key to enabling high quality personalised care, with the clinician able to accurately assess, treat and monitor a patient and proactively include them in shared decision-making about their care. This is as relevant to virtual wards as it is to any care setting in which patients are cared for.

All virtual wards require timely access to diagnostic tests and their results. The types of diagnostic tests and measures a virtual ward needs to have access to, and the speed with which they need access, will depend on the individual needs of its patients, and how they are referred to the ward.

For example, a patient with heart failure discharged to the virtual ward from inpatient care will have had any required imaging while in hospital. Similarly, an individual admitted to a virtual ward from the emergency department (ED) may have had any required imaging while in the ED, but someone referred from 111, urgent community response or primary care may not.

All access to diagnostics requires good underpinning governance, and all virtual wards, no matter their structure or set up, must have standard operating procedures in place for diagnostics.  

The integration of diagnostics into a virtual ward service should be considered in the service’s equality and health inequalities impact assessment.

All our virtual wards guidance can be found on our virtual wards webpage, and for further information and support please visit our virtual wards FutureNHS platform or contact us at england.virtualward@nhs.net

Recommended priority tests, measures and assessments

This section identifies the main tests, measures and related assessments that all virtual wards should consider making available to their patients.

Importantly, the identified tests do not constitute a minimum (or maximum) set that all patients should have; rather they are indicative of current good practice on virtual wards and are for providers’ consideration as part of a value-based approach to diagnostics; whereby the clinician identifies when a test is clinically indicated and could change patient management.

It is important that all patients on a virtual ward are assessed for acute deterioration, including frailty syndrome and end of life; and that this contextual understanding is the basis for any diagnostics undertaken.

Assessments for frailty include:

• Clinical frailty score; this is particularly important for those over 65, although frailty syndrome does occur in younger age groups.

Assessments for end of life include:

• The Supportive palliative care indicators tool and the Gold standard framework proactive identification guidance.

Recognising that a patient may be approaching the end of their life is particularly important in the virtual ward setting. In these circumstances, tests, measurements and assessments may not be appropriate and/or may provide results that adversely influence care decisions, such as further unnecessary tests and treatment, avoidable hospital admissions, and delivery of care and support that does not meet the patient’s wishes and preferences for the end of their life.

Priority measurements

The following measurements are a basic requirement for patients on a virtual ward:

• temperature
• pulse
• blood pressure
• respiratory rate
• oxygen saturation
• weight; this is particularly important for those with heart failure.

These can be taken by the clinician, the individual or their carer, or by wearable devices that can automatically transfer results to the remote monitoring hub system. Further guidance is available on setting up technology-enabled virtual wards and managing medical equipment within virtual wards.

While each of these measurements can be clinically significant on its own, assessments that combine them, such as the NEWS2 score, can clarify and add value to the clinical picture, provided they are personalised to the patient and the decision-making context.

Pathology and priority point of care tests

All virtual wards need access to a pathology laboratory (and network) and to consider how samples taken at home will be transported to the laboratory for testing. As part of the standard operating procedure with their pathology network, virtual wards will need to agree turnaround time for test analysis and reporting of results and consider how they will access results.

Alongside arrangements for laboratory analysis, virtual wards are encouraged to work with pathology networks to ensure access to appropriate in vitro (IVD) point of care testing (PoCT) devices. These can enhance care on virtual wards by accelerating clinical decision-making, initiating treatment sooner, and optimise healthcare professional time reducing the necessity for repeat home visits.

The main portable PoCTs virtual ward providers are typically using within their kit bag to aid clinical decision-making are:

• creatinine and estimated glomerular filtration rate (eGFR)
• urea and electrolytes (U&E)
• haemoglobin and haematocrit
• C-reactive protein (CRP)
• blood glucose and ketones
• venous blood gas analysis (VBG)
• NT-proBNP (or BNP)
• D-dimer
• international normalised ratio (INR)
• lactate
• white blood cell (WBC) 5 part diff
• influenza and COVID-19

This list is not exhaustive. Some virtual wards also use other IVD PoCTs such as troponin and respiratory syncytial virus (RSV). New devices and tests are regularly being made available to the market and virtual wards are encouraged to discuss required solutions with their pathology network.

Please see the guidance on integrating in vitro point of care diagnostics into virtual ward services for information on governance of PoCT devices.

Priority tests in a home or in a care setting

Virtual ward providers are typically accessing the following tests:

• CT scan
• X-ray
• MRI
• Ultrasound, including point of care ultrasound (POCUS)
• bladder scanner
• 12-lead electrocardiogram (ECG)
• handheld ECG (typically 1 or 6 lead, predominantly for cardiac rhythm assessment)
• echocardiogram (echo).

For access to these tests many virtual wards partner with care settings such as same day emergency care (SDEC), and community diagnostics centres (CDCs). Alongside this many include portable medical devices in the kit bag that staff take to a patient’s home. This is particularly common for bladder scanners and ECG monitors, and a growing number of virtual wards are using point of care ultrasound (POCUS) to support their assessment of patients’ clinical needs, and some are exploring portable X-ray.

Logistics related to care settings

Where the patient is visiting a care setting for the test, this requirement includes:

• access to the relevant booking systems
• ability for a range of virtual ward staff to request the tests
• timely access to transport
• access to the results.

When setting up pathways to access these tests, it is important to avoid hospital admissions for the sole reason of accessing a test. Patients should, where possible, remain under the care of the virtual ward while tests are carried out. Patient wishes also need to be respected when considering where a test takes place.

Virtual ward providers tell us that building good relationships with lead clinicians in other care settings is key to overcoming any operational issues.

Where patients need to travel to a setting (such as SDEC or CDC) to have a test, their timely access to transport is critical. It is important integrated care board commissioners work with their colleagues who are responsible for transport and their transport provider, to ensure that the required access to transport is part of the virtual ward design and planning process, and that the requirements of virtual wards are subsequently included in the local transport policy and the commissioned transport service.

Non-emergency patient transport services (NEPTS) are pre-booked services that are underpinned by an eligibility criterion. Bookings should be made the day before the journey to ensure a timely service is provided. If there is a need for same day transport for an urgent test, such as a head CT, this may require additional transport capacity with an additional funding requirement.

It is not a given that patients in virtual wards will be eligible for NEPTS so a wider consideration of transport may be required. Failure to integrate transport into the planning phase may result in delayed access to tests if a patient needs to be transported.

Often the patient has a friend or family member who can drive them to the setting for the test, and some virtual wards have also partnered with local voluntary and community sector partners to provide transport, when this is an appropriate option for the patient.

Consideration of the patient’s experience once in a care setting for tests is also important. Some virtual wards have a dedicated treatment and assessment area for their patients, and this facility is particularly valued by patients who are having multiple tests or who need to wait for the results before being conveyed back home.

Governance

Robust governance of all diagnostics carried out on a virtual ward is of paramount importance. This section provides a high-level overview of requirements, not the technical detail.

Clinical leadership

There should be clear clinical leadership, and standard operating procedures clearly setting out how patients access diagnostics and overall accountabilities. It is expected that the governance underpinning any diagnostic tests and measures carried out on a virtual ward, whether that is in a setting such as same day emergency care (SDEC) or the patient’s home, is as robust as that underpinning patient care in a hospital. The team carrying out the tests must have all appropriate education and training, and any medical devices used in the home must be fit for purpose.

Where tests take place in a care setting, the standard operating procedures should set out the booking procedures (who and how), the requirements for access to the tests and analysis of results (including timing) and access to results (who and how). As part of this providers should consider having a specific member of staff who is responsible for ensuring the results are received in a timely manner and acted on. Should a patient be discharged from the virtual ward before the results are received, a policy needs to be in place for agreeing responsibility for reviewing and acting on the test results.

The virtual ward service manager and lead clinician should develop good working relationships with key partner services such as pathology, clinical engineering, physiological science service, imaging, SDEC, community diagnostics centres (CDCs) and transport, seeking their advice as appropriate to ensure good governance and ensuring that standard operating procedures are in place. Further guidance is available on clinical leadership on virtual wards.

Standard operating procedures should ensure best practice is followed for imaging reporting turnaround times (TATs) as specified in the national TAT guidance. For virtual wards, the standards should reflect as far as practicable those for urgent inpatient care, with a maximum TAT of 12 hours, and under 4 hours post acquisition of images for emergency/acutely unwell patients (this includes radiologist trainee provisional reports). However, the level of urgency associated with TATs will depend on the symptomatic presentation and clinical opinion of what is required for each patient, in line with the TAT guidance.

Clinical safety and reporting

NHS England’s What good looks like framework indicates that it is best practice for all NHS providers to have at least one clinical safety officer (CSO) in post, to consider the risk to patients of any new platform, service, pathway or digital solution.

CSOs must be registered with a professional body and be a qualified and experienced clinician. Specific clinical safety training is available to support providers. Having a clinical risk management process minimises the potential for design flaws or user error resulting in patient harm, and having standards also recognises the need for organisation commitment and management support.

Any patient safety incidents must be reported to the organisation’s local risk management system. The organisation should then ensure that this data is provided to the national reporting and learning system or its successor, the Learn from Patient Safety Events Service. This also applies to any medical devices used to support diagnostics in the patient’s home. Medical device issues also need to be reported to the Medicine and Healthcare products Regulatory Agency (MHRA) yellow card system.

Management of and response to any patient safety incidents should form part of the organisation’s wider clinical governance/risk management activities. From autumn 2023, all organisations providing care under the NHS Standard Contract are expected to plan for and respond to patient safety incidents in line with the Patient safety incident response framework.

Information governance, data capture and interoperability

As part of the overall service design, robust data governance is required for the integration of different types of diagnostics.

It is of paramount importance when considering digital interoperability of test results that the whole patient journey is considered. Many patients who are admitted to a virtual ward will also be under the care of other health services and these will need access to the results of any diagnostic tests undertaken on the virtual ward. All diagnostic results should be recorded on the patient’s electronic patient record, shared care record, and any other relevant recording system such as the picture archiving and communication system (PACS) for imaging results and the local information management system (LIMS) for pathology results.

Technical standards to support interoperability are outlined in the Digital technology assessment criteria (DTAC) guidance.

Where technology such as middleware is being used, virtual wards should specify who the chief clinical information officer/CSO is for risk assessment of implementation of device/software application as per DCB0160: clinical risk management: its application in the deployment and use of health IT systems (NHS Digital). Guidance on reviewing technology-enabled models is provided in the clinical risk management standards.

Data protection information agreements will be required to ensure appropriate governance over the transfer of patient data, and the virtual ward will need to work with the clinical safety team to ensure that any digital-related clinical safety risks are appropriately managed.

Good practice guidelines to support the management of data-driven healthcare are available as well as information governance guidance. Specific guidance is available for information governance on virtual wards.

Use of medical devices in a patient’s home   

Where medical devices are used to support diagnostics in the patient’s home, the virtual ward needs to work with clinical engineering and pathology respectively to ensure that these are fit for purpose, and all governance requirements are in place.

All medical devices used in a patient’s home must be registered and regulated by the MHRA and carry a UKCA mark. (Note: subject to parliamentary approval, we expect that the CE marking will be recognised until certificates expire or 30 June 2030, whichever is the sooner). Further information is available on Regulating medical devices in the UK.

Any service considering using POCUS devices must follow the British Medical Ultrasound Society and the Royal College of Radiologists Recommendations for specialists practising ultrasound independently of radiology departments: safety, governance and education (2023) . Further information is also available on the Virtual Wards FutureNHS platform.

The use of an ECG should be delivered in accordance to the standards of the Society for Cardiological Science and Technology available on their website. Any ECHO should be delivered in accordance to the standards of the British Society of Echocardiography.

All physiological science services should meet the regulatory and accreditation requirements set by UKAS through the Improving Quality in Physiological Services (IQIPS) scheme.

For information on the governance requirements for IVD PoCT, please see the published guidance for virtual ward services. For other medical devices, please see guidance on managing medical equipment within virtual wards. 

All clinicians using these devices must have been trained to the appropriate competencies in their use. Appropriate management of the devices must be in place, including quality assurance with regular testing and calibration of the devices.

Case studies

Oxford University Hospital NHS Foundation Trust

Oxford’s ‘Acute Hospital at Home’ service uses a blend of virtual and face-to-face assessment and treatment of patients on its frailty virtual ward. Frontline healthcare professionals (nurses, advanced paramedics, physicians if required) visit patients at their home (including care homes) and carry out diagnostic tests using point of care devices to inform management, such as intravenous treatment.

In addition, some patients are supported to carry out self-monitoring if required. All patients are monitored both in person and virtually via a remote monitoring hub.

As part of the diagnostic offer, point of care ultrasound is being used to assess for clinical problems such as pleural effusions, urinary tract obstruction, presence of ascites and left ventricular function in housebound patients with a new diagnosis of heart failure with fluid overload.

A lead physician with FAMUS (Focused Acute Medicine Ultrasound) and FUSIC (Focused Ultrasound in Intensive Care) Heart accreditations is overseeing the development of competencies in the Hospital at Home nursing team using the FAMUS standards accreditation.

The team is able to share the ultrasound images virtually with the hospital’s specialty consultants, for example cardiologists, to agree a course of action. The results are saved to the patient’s electronic patient record (EPR).

Contact AOT@ouh.nhs.uk for further information.

City Healthcare Partnership Community Interest Company (CIC), Hull and East Riding of Yorkshire

Hull and East Riding of Yorkshire’s frailty virtual ward covers 1,000 square miles and 4 hospitals (Hull, York, Scarborough, Doncaster).

City Healthcare Partnership CIC provides a joined-up frailty ward and UCR service, which is also integrated with 111, 999 and proactive care. Its model of care uses a team of frontline healthcare professionals (primarily Band 3 clinical support workers, as well as paramedics and advanced nurse practitioners) who visit patients at home. Their decision-making and point of care testing (PoCT) result interpretation are supported by a remote hub staffed by consultants and GPs specialising in frailty.

The team use a range of PoCT, physiological measurement and imaging devices to support rapid clinical decision-making, including:

• IVD PoCT (blood glucose and ketones, c-reactive protein, haemoglobin and haematocrit, lactate, U&Es, VBG)
• bladder scanner
• electrocardiogram
• digital stethoscope and high-definition camera to carry out remote examination
• remote physiological measurements – blood pressure.

Remote consultations are also supported by video technology.

In terms of access to wider diagnostics, the service has:

• agreement for rapid analysis of pathology results
• next day access to the integrated care centre for basic X-ray facilities
• same day access to and rapid results from Hull Same Day Emergency Care and Emergency Department for CT, trauma X-ray, ultrasound
• transport: 24 hours’ notice to request; for same day the patient is either driven by their carer or conveyed by ambulance.

Contact chcp.virtualward@nhs.net for further information.

Acknowledgements

This guidance has been developed with the following NHS England specialty teams: digital patient safety, imaging, pathology, patient safety, physiological measurement, transport and virtual wards.

Special thanks to:

• Dr Anna Folwell, Consultant Community Geriatrician, City Healthcare Partnership CIC, Hull and East Riding of Yorkshire
• Dr Catherine Monaghan Medical Director NENC ICB, Consultant in Acute Medicine, North Tees and Hartlepool NHS Foundation Trust
• Professor Daniel Lasserson, Consultant in Acute Medicine, Clinical Lead – Acute Hospital at Home, Oxford University Hospitals NHS Foundation Trust
• Dr Jim Moore, GP with Special Interest in Cardiovascular Disease, Immediate Past President Primary Care Cardiovascular Society
• Katy Heaney, Consultant Clinical Scientist, Frimley Health NHS Foundation Trust
• Dr Martin Myers, Consultant Clinical Biochemist, Joint Pathology Getting It Right First Time Lead NHS England
• Dr Niall Keenan, Consultant Cardiologist, Clinical Lead for Virtual Hospital, Associate Medical Director (Quality and Innovation), West Herts Teaching Hospitals NHS Trust
• Dr Raj Thakkar, President and Chronic Kidney Disease lead, Primary Care Cardiovascular Society, GP, Bourne End and Wooburn Green Medical Centre, Primary Care Cardiology Lead, Oxford & Thames Valley Health Innovation Network
• Dr Rajiv Sankaranarayanan, Consultant Cardiologist and Heart Failure Lead, Liverpool University Hospitals NHS Foundation Trust, Liverpool Centre for Cardiovascular Science and University of Liverpool
• Dr Sarah Mitchell, GP, White House Surgery, Sheffield, National Clinical Director for Palliative and End of Life Care, NHS England
• Dr Shelagh O’Roidan, Consultant Community Geriatrician, Kent Community Trust, Whitstable and Tankerton Hospital

Publication reference: PRN01121