Service innovations in the era of COVID-19: IMPACT+ goes virtual

Wednesday, September 9, 2020

The Derby and Burton NHS Foundation Trust is not new to innovation in patient services. Respiratory Futures previously covered their new IMPACT+ programme, a community centred, proactive respiratory service grounded in prevention.

Planning ahead of the outbreak

As we caught wind of a possible UK outbreak of COVID-19 in early March, we made a number of changes in the way we work and the services we offered.

One of these changes involved developing a virtual respiratory ward model, rather than a supported discharge model. Led by a consultant, this allowed early discharge of those patients that would usually require inpatient treatment (eg still requiring oxygen or nebulisers), this in anticipation of a flow of COVID-19 patients. The plan was to safely discharge patients from hospital quicker to reduce the risk of them becoming infected and to reduce the pressure on the Trust.

The first patients to be accepted onto the virtual ward were patients that were COVID-19 negative, presenting with an exacerbation of a chronic respiratory condition (eg COPD or asthma) or pneumonia. These patients were assessed by a specialist nurse and a respiratory consultant, who decided if patients were suitable to receive the rest of their treatment safely at home.

  • The criteria was then widened to include COVID-19 positive or suspected patients. They would be suitable for the respiratory virtual ward if they met the following criteria:
  • Deemed safe for treatment at home by medical team.
  • Over seven days from the onset of symptoms.
  • Falling oxygen requirement in last 48 hours AND requiring supplementary oxygen of ≤ 3 l/min to maintain SpO2 within their target range.
  • Apyrexial and with a National Early Warning Score (NEWS) of three or under for the 48 hours prior to discharge.

Once on the virtual ward, the patients received regular clinician face to face reviews and remote support and were discussed during virtual ward rounds twice daily for up to two weeks. The work of the virtual ward was supported by the rapid development of patient group directives (PGDS) to allow visiting nurses to assess the patient conditions and provide emergency medications that would otherwise have required a visit to the hospital or GP.

Patients were constantly assessed for their ongoing needs, and referrals were made to other domiciliary rehabilitation services to further support recovery.

A holistic mental health support service

Upon discharge from the virtual ward patients were offered a referral to our newly developed Wellbeing Service, which was run over the phone by an integrated team of occupational therapists and assistants, fitness instructors and team administrators.

The Wellbeing Service was definitely one of the main changes in our service. It is a more psychologically focused service, designed to address mental health issues caused by shielding and recovery from COVID-19. It is supported by a varied skill mix of staff, as multidisciplinarity is essential to its success in supporting patients with post viral fatigue and to cope with the psychosocial impact of the virus.

Each patient was contacted regularly by a member of the Wellbeing Team and was offered help with effective inhaler techniques, breathlessness and fatigue management, but also offered motivational interviewing, smoking cessation advice, home exercise programmes or just a friendly regular call to help with isolation.

For many of these patients, in fact, contact from the Wellbeing Team was the only contact they have had from anyone during the pandemic. Maintaining good psychological health is an essential component of the service, which has been very well received.

We had plenty of positive feedback, and our evaluations found the virtual ward model safe and effective, so we plan to keep this model going through the winter. We have also began to work on incorporating an effective admission prevention service into this virtual ward model.

Moving support groups online

Since the beginning of the pandemic, we have adapted a number of other services to work remotely.

We have a long running group for fatigue and breathlessness for people with advanced respiratory disease, run by a consultant, a respiratory nurse and an occupational therapist. This is now run regularly over Microsoft Teams.

We had a few teething problems with patient adoption of the technology, but we managed to help them all to use the software with confidence now. The group used to run three-four times a week, but thanks to it being done remotely, we are now able to run it more often and offer it to more people.

We also have a Lung for Life group which is an asset based clinic to reduce social isolation. This is now being delivered via Zoom. Unfortunately we are yet to restart the singing group “Singing to Beat Breathlessness”.

Prior to the pandemic we held monthly face to face MDTs in primary care, these have also now gone virtual.

Looking at the future

One last adaptation we are currently looking at is our Pulmonary Rehabilitation programme, which we used to run face to face in a number of gyms across the county, but that we are now unable to provide. We have worked to move as much of it as possible online, and we are just about to open this revamped service to our patients. We have developed a handbook form of the programme, designed for those patients who have no access to the internet. Each of these patients will receive weekly remote support and contact from a physiotherapist or fitness instructor to progress patients through the programme.

The next progression of pulmonary rehabilitation will be to develop a new online platform with a video link, which will include videoconference training sessions, and an repository of videos to help people practice and exercise on their own. There will also be weekly assessments with a physiotherapist or a fitness instructor, to evaluate individual progression

We really hope to be able to keep most of these new services to complement the usual service delivery models, as we have found they are very useful to patients that would not otherwise take part in exercise or join support groups because of work commitments or travel issues.