Introduction

People of all ages presenting with suspected acute respiratory illness including acute respiratory infections (ARI) and chronic obstructive pulmonary disease (COPD) exacerbations make up a significant proportion of urgent care and primary care attendances, and hospital admissions.

Virtual ward care, including hospital at home, for those with confirmed or suspected ARI, including COVID-19 and non-infective COPD exacerbations, builds on the learning from COVID-19 virtual wards and COPD hospital at home services. Virtual wards support personalised care for people of all ages who are stable or improving but require acute level care and choose to be cared for at home after a shared decision-making conversation. They do this by providing an alternative to a hospital admission and/or a safe early discharge pathway for people who require ongoing hospital level monitoring and treatment.  Virtual wards require a combination of face-to-face care and digital technology in the place a person calls home, including care homes. Patients are supported by clinical monitoring, are provided with sufficient information to feel supported at home and have access to timely specialist advice and guidance as required.

Systems have made and implemented plans for the expansion of virtual ward/hospital at home capacity with consideration of local needs and existing services. These plans will expand capacity to support people with confirmed or suspected respiratory tract infections and exacerbation of conditions such as COPD and bronchiectasis and should be supported by digital platforms.

Virtual ward including hospital at home teams should link to community respiratory teams and work towards providing oxygen, oxygen weaning, and nebuliser support for people on a virtual ward or on discharge as per Chronic obstructive pulmonary disease in over 16s: diagnosis and management.

Systems should also consider implementing paediatric respiratory pathways as part of the development of children’s virtual wards. ARI’s account for over a third of admissions to children’s virtual wards nationally.

Implementation should be led by the integrated care board and delivered by appropriate secondary care providers, community health services and primary care working collaboratively. Virtual ward models and pathways should effectively integrate with local same day emergency care, urgent community response services, acute respiratory infection hubs, single point of access and, for children also paediatric assessment units. Systems are asked to establish respiratory virtual ward pathways in conjunction with integrated respiratory pathways and existing community respiratory services.

This guidance note sets out a minimum requirement for care of respiratory conditions on virtual wards. It should be used to supplement any established arrangements where these are functioning well, including alternative pathways to admission, integrated pathways and/or condition-specific pathways.

It should be read in conjunction with the acute respiratory infection guidance for combined adult and paediatric acute respiratory infection (ARI) hubs (previously RCAS hubs).

Overview of the acute respiratory infection virtual ward

What

Personalised in-person care/treatment with technology-enabled remote monitoring and supported self-management/escalation.

Where

In the person’s home or usual place of residence, supervised by a dedicated clinical team with rapid access to specialist advice and guidance.

Who

People of all ages with confirmed or suspected acute respiratory infection also including non-infective exacerbations of respiratory conditions such as chronic obstructive pulmonary disease who require ongoing care and monitoring that can be safely provided in their home or usual place of residence.

When

Admission alternative, early discharge or integrated model as agreed locally.

Why

• Improved person and carer experience and outcomes.
• Shared decision-making and personalised care.
• Improved flow by reducing admissions and length of stay.
• Reduced nosocomial transmission of infections including COVID-19.

How

• Technology-enabled and/or in-person care from a multidisciplinary
• Early deterioration recognition and appropriate clinical input.
• Person and carer empowerment to self-monitor and escalate.

Clinical assessment for virtual ward admission

This service is for people who require acute level care and would otherwise be in hospital; it is not for non-acute long-term chronic disease management. The acute respiratory infection (ARI) virtual ward can provide both an alternative to hospital admission and allow early supported discharge from hospital.

Services will need to develop their own admission and discharge criteria for acute level care in line with the age and needs of their population, available workforce, governance structures, confidence and competencies.

Care on a virtual ward should be available as an option for clinicians to refer people who have a primary diagnosis of suspected/confirmed respiratory infection and a wider respiratory cohort including non-infective exacerbations of chronic obstructive pulmonary disease and interstitial lung disease (ILD) and are:

• stable or have an improving clinical trajectory but require ongoing acute level monitoring and care or
• unstable but choose home care after careful shared decision-making, incorporating advance care planning or
• end of life care for whom care at home is the preferred choice of person.

The main referral routes into the ARI virtual ward are likely to be community respiratory services, emergency department, same day emergency care, early discharge from hospital and community health services (including urgent community response), 999/111, primary care, acute respiratory infection hubs and single points of access. There should be a clear referral pathway during the ARI virtual ward’s operating hours.

Children’s virtual wards should develop pathways to treat children and young people with ARI and other paediatric respiratory illness.

Suitability for admission to a virtual ward should be determined with an in-person clinical assessment and diagnostics. Clinical judgement in association with shared decision-making with the person and/or their carer remains paramount for all assessments, particularly for those at higher risk of reversible serious illness.

The following assessments may help risk stratify the appropriateness of virtual ward care, but should not be used on their own to exclude a person from virtual ward admission:

• Calculation of national early warning score in adults or paediatric early warning score in children. Or clinical observations, such as blood pressure and oxygen saturations in instances where aggregate scores are not utilised.
• Clinical severity scoring appropriate to condition (for example, CURB-65 for community‑acquired pneumonia in hospital setting).
• Frailty screening, with calculation of clinical frailty score for people aged 65 or over.
• 4AT (rapid test for delirium).
• Assessment of the safety of the person and their family or carers, and the family’s or carer’s ability to provide support; consider any capacity, consent or safeguarding concerns, referring to appropriate services.
• Review of clinical records and relevant investigations to understand medical history, presenting complaint and usual level of functioning.

To support assessment diagnostic tests as required or subject to clinical judgement – include chest X-ray, blood tests, ECG, peak flow and point of care tests for respiratory viral infections, including COVID-19, respiratory syncytial virus and influenza.

Pregnancy should be considered in any person of reproductive age who presents with breathing difficulties. There should be early obstetric involvement for any pregnant person who presents with breathing difficulties, including those with symptoms of respiratory infection.

People who require immediate assessment and treatment in hospital should be transferred to emergency department without delay, for example, suspected sepsis, cardiac chest pain or pneumothorax.

Staffing and oversight

Acute respiratory infection (ARI) virtual ward models should be implemented through a partnership between one or more acute trusts and/or community health services with appropriate and timely specialist involvement.  Systems must consider development of step up models where they do not exist at scale, with standardised approaches for referral from care homes, urgent community response and 999/111 as well as ARI hubs.

The ARI virtual ward should be led by a named consultant (including a nurse or allied health professional consultant) or suitably trained GP, with access to timely specialist advice and guidance. Virtual ward models may draw on staff from multiple settings, including appropriately trained registered professionals and staff who may not normally be clinical facing.

Virtual ward staff should perform daily board rounds with senior decision makers to highlight any concerns. Virtual wards should run at least weekly multidisciplinary team meetings discussing patients recovery and onward pathway.

Virtual ward staff should have access to specialist advice and guidance when they need it; for example, accessed from acute medicine, emergency medicine, respiratory, cardiology or other specialist clinicians using telephone/digital/video.

A safe and robust virtual ward needs to be staffed for a minimum of 12 hours a day (8am to 8pm), 7 days a week. Operating procedures should be in place to ensure out of hours (OOH) support is available so that patient safety is maintained, and any deterioration managed 24 hours a day. In many cases operating procedures will need to be integrated with existing procedures and services, including community night nursing team services or GP OOH services where appropriate. Further information on OOH support can be found in Supporting clinical leadership in virtual wards.

Clear pathways for referral and escalation should be developed with same day emergency care, emergency department, primary care/OOH, community health services, community respiratory teams and NHS111/999.

Local infection specialty teams should be engaged in the development of ARI virtual ward models to ensure oversight of infection prevention and control, antimicrobial stewardship and the diagnostic pathway for infection-specific tests such as blood cultures and point of care tests.

Legal responsibility, including for ensuring appropriate clinical governance, remains with the lead provider. Each system should have a named executive responsible for the establishment of the service in their area. Clinical, governance and administrative responsibilities across the pathway can be undertaken by any appropriately trained and competent person. See Supporting clinical leadership in virtual wards for more information on clinical governance.

Further support

For further guidance on implementation of virtual wards, please refer to the supporting information for virtual wards and the NHS England virtual wards site.

To access digital tools, resources and ongoing updates, visit the virtual ward NHS Futures page (log in required). Please email england.virtualward@nhs.net if you have any problems accessing this site, or queries.

Digital platforms should meet relevant standards including the digital technology assessment criteria DCB0129 and DCB0160 assessment.

Appendix: acute respiratory infection (ARI) pathway

The ARI pathway can be split into five stages:

Stage 1: clinical assessment and referral

A clinician should assess in person a person’s suitability for admission to a virtual ward.

A senior clinician on the virtual ward should decide, after a shared decision-making conversation whether the person is admitted to a virtual ward. This decision should be based on the same level of clinical assessment and decision-making as if the person were being admitted to a hospital bed. This may be done in consultation with other specialty clinicians.

Stage 2: admission

People admitted to the ARI virtual ward will agree a person-held personalised escalation and discharge plan, including monitoring arrangements. In the event of deterioration, the person-held escalation plan should assist remote assessment by NHS 111/999/ARI virtual ward teams and help reduce inappropriate readmissions.

The person should be provided with:

• An information leaflet including clear information around escalation should be provided at admission and in supporting information. Escalation may include calling the ARI virtual ward telephone number provided, NHS111/999 or out of hours, or attending their nearest emergency department.
• Loan of any remote monitoring devices/equipment (which meet relevant ISO and CE approvals), supported by relevant instructions on use.
• A telephone number to call for advice or support at least between 8am and 8pm, 7 days a week.
• Instructions on who to contact outside these hours.
• For specific groups, relevant safety netting and escalation advice, for example, pregnant women, vulnerable adults, and children and young people.

Discharge planning should start on admission. The person’s GP should be notified of their admission to the ARI virtual ward.

Stage 3: assessment and monitoring

Where appropriate, a person may self-monitor using the device(s) provided in line with the agreed monitoring plan, with carer support as required. People should be reviewed daily by a senior clinician with the support of a multidisciplinary team.

Patients entering a virtual ward should receive appropriate assessment in line with quality elements of defined clinical pathway, for example, chronic obstructive pulmonary disease (COPD) bundle. Assessments carried out while on a virtual ward should include:

• start a comprehensive geriatric assessment (CGA) for CFS ≥5 where appropriate
• COPD bundle respiratory assessment
• medicines review.

A personalised care and support plan should be developed for those with frailty/multi-morbidity, those with more advanced brittle long-term conditions or with end of life clinical indicators This document should be regularly reviewed and updated so that it includes all the assessment and intervention information, ideally in one place.

Where required the summary plan for emergency care and treatment, treatment escalation plan and do not attempt resuscitation forms should be reviewed. Personalised goals of care conversations with advance care planning should be explored with the person and their family/carer, with appropriate plans completed and shared where they are not already in place.

Stage 4: recovery and discharge

The discharge criteria from acute level virtual wards should be in line with acute hospital discharge criteria. Virtual wards are time-limited interventions, and the person must be discharged when they no longer need this level of care. The multidisciplinary team should work towards an estimated date of discharge.

Suitable arrangements should be made for transferring care from the virtual ward to alternative pathways that can meet a person’s care needs. Care could be transferred to primary care, community or social care-led services such as:

• community nursing and respiratory teams
• rehabilitation including pulmonary rehabilitation teams
• oxygen discharge teams
• proactive care teams
• secondary/tertiary long-term conditions pathways
• primary care provider/GP end of life care
• those responsible for completing CGA where appropriate.

Where a CGA, COPD bundle, or advance care plan has been started, this must be clearly communicated to the services taking over a person’s care to enable continuity of care and completion of assessment as part of ongoing care within a primary or community care setting.

When developing services, transitions of care between virtual ward services and end of life services should be a high priority, with clear pathways between services and agreed care planning to ensure delivery of high quality end of life care.

Publication reference: PRN00633