One of our new Clinical Leads, Rebecca Winterborn is also Clinical Lead for North Bristol Trust’s Hospital at Home service. Over the last few months, she has helped develop the new Covid Virtual Ward service across Bristol, North Somerset and South Gloucestershire (BNSSG).
In this blog, Rebecca shares their story of setting up the system at pace and the lessons they learned along the way.
As we head into spring, it is hard to believe that it is already four months since I took over as Clinical Lead for Hospital at Home (H@H) at North Bristol NHS Trust (NBT). It is an absolute pleasure to be part of such a cohesive, honest and courageous team. The service was developed three years ago as part of the plan to reduce inpatient bed occupancy and improve patient flow, recognising that patients would generally much rather be at home than in hospital.
It has been incredibly successful and the feedback from patients has been just fantastic.
The hope has always been that the service would expand over time. It is funded by the Anaesthesia, Surgery, Critical Care and Renal division but has spread into the Neurological and Musculoskeletal Sciences division. The majority of our patients, so far, have been emergency admissions, but recently we have also started supporting a number of elective surgical pathways.
Creating a Covid Virtual Ward within Hospital at Home
Patients referred from the medical division were isolated to those requiring long courses of intravenous antibiotics. However, in October, Consultant in Infectious Diseases, Ed Moran and the Clinical Lead for the acute medical team, Ella Chaudhuri, approached Lucinda Saunders, Senior Sister for H@H, about setting up a Covid Virtual Ward.
Lucinda was delighted to be able to offer a service that would help with the challenges related to the Covid-19 pandemic. In the first wave, many staff were pulled to the Intensive Care Unit, reducing capacity within H@H. By demonstrating that H@H could assist with patient flow, particularly related to capacity in blue (Covid positive) beds in the most recent wave, she was able to continue at full capacity.
By the time I came into post, the majority of the paperwork was completed and the Covid Virtual Ward at NBT went live on the 9 November 2020. 25 patients were admitted in the first two months, with a total of 188 bed days saved. Eight patients required readmission.
A direct route back into secondary care
The beauty of the H@H team and its clear pathways is that patients have a direct route back into secondary care, rather than having to go back through a GP or 111. We’ve still got the 999 service if we need it in a dire emergency, but most of the time problems are picked up in daytime hours and the patient can get straight back into the right bed at the right time.
It is very much that concept of ‘right patient, right place, right time’ and if that right place is home, then why not allow it to be at home?
Now, as a vascular surgeon I was not hugely au fait with the management of Covid-related illness, so I attended a webinar on the role of home oximetry. I also started following the development of Covid Virtual Wards around the country on Twitter.
I contacted Charlie Kenward, a local GP, who I knew would be up to speed with what was happening in our local community. He introduced me to Dan Offord, the project lead for Covid Oximetry @Home within Healthier Together, the integrated care system for Bristol, North Somerset and South Gloucestershire.
I was keen to find out from Dan what was happening on the community side. I didn’t want to tread on toes, but equally I didn’t want to miss the opportunity for joint working or for there to be two silos of wards going on and for us not to know what each other was doing.
Extending the reach
Dan and I met up in December to swap notes and at the end he said almost jokingly, “Wouldn’t it be great if your H@H Covid Ward could also take patients from University Hospitals Bristol and Weston!” My response was, “Well, why can’t they? It’s all about patients at the end of the day.”
That same afternoon Kathryn Bateman, Consultant in Respiratory Medicine and Clinical Lead for Transformation at University Hospitals Bristol and Weston (UHBW) rang me and we had a really useful conversation. We were both on exactly the same page and agreed that the quickest way to get this up and running for patients from UHBW was to accept them into our service.
At this time the number of inpatients with Covid-related illness was really starting to climb.
I spoke to Lucinda and she agreed it could work. In terms of the nursing resource, it was just the referral phone call and one telephone call per day to check the patient’s oxygen saturation that they’d measured themselves every six hours.
Lucinda and the whole of our H@H team are such go-getters. They asked the right questions to make sure everything was safe, but nothing was too much trouble.
We said, “Let’s see if we can do this!”
Whilst the nursing time to receive referrals, make the calls and do the administration for each additional patient was not huge, the logistics of having the appropriate access to patient information, arranging the IT, figuring out how the transfer pathway would work, safety and governance, not to mention staff training at UHBW, were more challenging.
But, we agreed it was worth doing, for the sake of patients.
The simple act of picking up the phone rather than just emailing was where it all started.
Before Christmas, we started working it all up. Multiple iterations of the standard operating procedures went back and forth, along with the patient information leaflets. By the middle of January we had reached versions 8 and 12.
One of the biggest challenges was the IT. At NBT we use a system called Lorenzo and at UHBW they have a system called Medway. We both have a system called Careflow Connect, which is the handheld system that allows us to do handover and see all of our patients. But our system doesn’t talk to UHBW’s system and vice versa. So we had to work out how UHBW were going to do the referrals to us.
Patients under the care of H@H remain as inpatients on the bed board so we decided the best solution would be for UBHW patients to be transferred to NBT.
Referrals from UHBW were by telephone with an email handover using a pro forma.
Having figured out the best way to transfer patients we then had to think about the readmission pathway. We needed to ensure that patients transferred from UHBW would be readmitted back to the Bristol Royal Infirmary (BRI) if this became necessary. We already had a clear pathway for H@H patients both in and out-of-hours. Patients are given the site team number which they can call at any time out-of-hours and they will automatically be readmitted. We worked through this for UHBW patients and agreed that the Acute Medical Unit coordinator at UHBW would be the point of contact out-of-hours.
Working with the ambulance service
We also considered the potential increased burden on the ambulance service. I spoke to Rhys Hancock, clinical lead for the South West Ambulance Service and, having reviewed our standard operating procedures and the clear readmission criteria, he agreed for us to go ahead.
Rhys also advised us regarding their dedicated clinician phone line, which is a quicker process than calling 999. The call handler has a shorter set of question to ask and is able to give a priority status which can be challenged by the clinician if they feel it is not high enough. It also ensured that patients would be taken to the correct ward in the correct hospital. So that gave us all reassurance that we weren’t putting patients at risk from a safety point of view – once again following the principle of ‘right patient, right place, right time’.
Safety and governance
Safety and governance were other key considerations. At NBT, the H@H team have access to the named consultant looking after the patient. For patients on the Covid Virtual Ward this was either Ed Moran, Ella Chaudhuri or one of the other consultants in acute medicine. We gained agreement from UHBW that advice for their patients could be gained from their acute medical consultant on call.
We also had to think about contingency plans. What would happen if there was an issue, serious incident or death related to a patient who was originally from UHBW? What would the governance look like? Ed Moran had kindly agreed to be the nominal consultant under whom the patient would be ‘admitted’ to the Virtual Ward but he would not be the person providing clinical advice for that cohort of patients.
I spoke with the patient safety and quality governance team at NBT who were happy that we had a good structure in place and clear standard operating procedures, so that if something did happen, we could report the incident and they would contact the governance team at UHBW to work it out between the two trusts.
Clear visibility of patients
The final piece of the jigsaw was ensuring that the H@H nurses had clear visibility of which patients were on the Covid Virtual Ward and which were standard H@H patients.
We asked the Clinical Systems team to create a Covid Virtual Ward on Lorenzo, which would pull through to Careflow Connect. The team completed this in record time, responding to the ‘sense of urgency’.
This was true of every conversation I had. Everyone recognised the value of the Covid Virtual Ward and if they were not able to help me they put me in touch with the right person who always rang me back, often the same day.
On 13 January 2021 there was a letter from NHS England and NHS Improvement recommending that all acute trusts establish a Covid Virtual Ward.
We were ahead of the game – by this time we were almost ready to go-live.
There was another week of tidying up the paperwork, making sure the SOPs were aligned, patient information had the right headings, governance was signed off and training arranged.
All that was left was to gain agreement through NBT, UHBW and the Integrated Care System command and control structure. Any changes that were seen to be beneficial in relation to the response the Covid pandemic could be submitted in a Situation, Background, Assessment, Recommendation (SBAR) format to Silver Command.
I presented the one-pager at NBT on 25 January 2021, and it was accepted. Kathryn Bateman, presented to UHBW on 26 January. A couple of days later it was signed off by gold command, and then later than week by System Silver, on the proviso that they had feedback after a few weeks and the lessons learned would be used to develop ongoing system level pathways.
Working at speed
We were commended on the speed with which we developed the pathway.
Our joint Covid Virtual Ward went live on Monday 1 February 2021, less than two months after our initial meeting.
The largest number of patients on the ward at any one time was 11 and in January we had 24 NBT patients go through the Virtual Ward. 10 of those patients required readmission.
In February, 24 patients were admitted to the Covid Virtual Ward, including nine from the BRI and five from Weston General. One required readmission to the BRI and One to NBT.
The total bed days saved in 2021 was 340.
The feedback from patients has been excellent. Comments included:
“I rated the experience as excellent due to the regular monitoring, daily calls and access to the available team. I didn’t feel the burden of taking up a bed that could be used by someone worse off.”
“My family felt reassured, particularly as I live on my own.”
“Thank you, such a great service and idea… I would be happy to have it in the future if needed.”
So what have we learned during this process?
On reflection, we actually demonstrated many of John Kotter’s steps for leading change!
1. Create a sense of urgency. We didn’t need to create one, it already existed! The numbers of patients in hospital with Covid-related illness was rising and we wanted to develop a solution that would benefit all patients.
2. Build a guiding coalition. We very quickly had the right stakeholders in the room. Representatives from NBT, UHBW, Sirona, BNSSG Clinical Commissioning Group (CCG), the West of England AHSN, South West Ambulance Service. We kept the core team quite small, there weren’t lots of people constantly talking, trying to give their opinion. We were able to go away, complete our actions, and come back. It worked much better, dividing and conquering. We all played our part. It just seemed to work in terms of the personalities that happened to end up in the room together. Having Eleanor Powell from the AHSN and Dan Offord from the CCG allowed us as clinicians to stay in the detail, whilst they provided the overarching framework. Completion of actions in a timely manner was ensured.
3. Form a strategic vision. Keep it simple. Don’t reinvent the wheel. Having a really clear vision and well-articulated raison d’être is essential. Consistently ask yourself the question that aligns with your vision. For example, ‘Will this conversation/meeting mean that we will be closer to providing an equivalent service for all patients in BNSSG?’ If the answer is no, change tack.
4. Enlist a volunteer army. There was no additional resource for this project. It required good will and a belief that it was the right thing to do. Everyone involved was passionate and enlisted others who also wanted to join us for the journey. As networkers we were able to pull in the right people to champion the project.
5. Enable action by removing barriers. Focus on the patients, not on the barriers, to delivering the service. It’s not about the barriers between this trust and that trust.
It shouldn’t matter whether a patient lives in Bristol, North Somerset or South Gloucestershire; they should all be afforded the same care. We kept coming back to that. That was the linchpin – making sure there was equity of access.
6. Generate short term wins. We knew the model worked as H@H had been running for three years. We had weekly meetings to keep on track and ensure actions were completed. We celebrate even the small successes along the way.
7. Sustain acceleration. The challenge now is to demonstrate the benefits of the Covid Virtual Ward and recognise the value of working as an integrated care system. Just because the numbers of patients with Covid-related illnesses are falling, we should not lose sight of the benefits of a virtual ward set up for other medical conditions. We are taking part in evaluation being coordinated by University College London and there is a national desire to keep the wards open.
8. Institute change. By reflecting and articulating how we achieved the set-up of the Covid Virtual Ward for both trusts within two months, we can start to understand the behaviours that have led to the success. If we can keep the momentum going we can ensure that the new behaviours and can-do attitude replace the old habits and silo working.
I would also advocate that knowledge sharing is better for patients than competition. Do not be afraid of reaching out to other groups doing a similar thing. Why would you be doing something brilliant in one place and not share that across the board?
My new role as Clinical Lead at the West of England AHSN allows me to live and breathe this philosophy.
Pick up the phone and talk to people. You don’t want to put extra burden on people, who are already busy, but sometimes that’s the best way. Benjamin Franklin said, “If you a want something done, ask a busy person!”
Don’t be afraid to stick your neck out and act without asking for permission. If now is the right time, the right place and the right thing for patients, say ‘yes’ and then figure out the how.
If it is right for patients and the stakeholders believe in the vision, the resource and money will follow.
Finally, during the last few months we have demonstrated that we are able to work as an integrated care system.
Retaining a sense of urgency
We need to retain that sense of urgency or that hook that draws people in to say, look come on! This is really worthwhile.
It was the will to make it work for the patients that was the most important thing. By being proactive rather than reactive we were able to be confident that if the worst case scenario occurred we had the right stakeholders to develop the Covid Virtual Ward further and reduce burden on hospital beds, whilst safely providing care at home.
My hope for the future is that we can continue to push the boundaries of wrap around patient care at home – together.
Thank you to everyone who has been involved in driving forward the Covid Virtual Ward. There are too many champions to mention everyone, but you know who you are.