Hospital stay prevented thanks to virtual ward team

More than 1,200 hospital admissions have been avoided over the last year by providing the same level of care for patients at home.

Swansea Bay’s virtual wards look after frail, elderly and vulnerable people where they live rather than on a ward.

This eases pressure on hospitals by reducing avoidable admissions, supports earlier discharges home when people have been admitted and reducing the risk of readmission.

Pictured: Afan LCC virtual ward clinical manager Cheryl Griffiths, Mary Duggan and Afan LCC virtual ward assistant nurse practitioner Steve Jones.

A multidisciplinary team comprising doctors, nurses, pharmacists, therapists and others, discusses how to plan and manage each patient’s care, with face-to-face assessment and intervention still carried out.

Over the last 12 months, the team has received 3,559 referrals with 55 per cent coming from hospitals and 45 per cent from primary and community care.

During that time, the virtual wards have prevented 1,236 unnecessary hospital admissions.

They are available in all eight of Swansea Bay’s Local Cluster Collaboratives (LCCs) – Afan, Bay Health, City Health, Cwmtawe, Llwchwr, Neath, Penderi and Upper Valleys.

They were introduced in 2021 and trialled in four of the LCCs. They succeeded in reducing the number of hospital admissions.

As a result, they were expanded into the four remaining LCCs in 2022 following a significant investment from the health board.

Now, each virtual ward looks after up to 30 patients, equating to 240 hospital beds in total in the community.

Mary Duggan recently avoided a prolonged wait for a hospital bed and was instead cared for at home thanks to the virtual ward service.

The 78-year-old, from Port Talbot, was taken to Morriston’s Emergency Department after waking and not being able to sit up properly in bed.

After being told she faced an extended wait for a hospital bed to become available for her, she returned home with plans in place for a follow-up assessment.

At her appointment a few days later, a member of the hospital-based in-reach team suggested referring Mary to the virtual ward.

The in-reach team identifies Morriston patients suitable for earlier safe discharge, helping to avoid unnecessary admissions and freeing up beds for more patients.

They then refer them to the relevant cluster’s virtual ward so they can be cared for at home instead.

Mary said: “I was in bed one morning and I couldn’t sit up. I was concerned as it hadn’t happened before.

“My daughter drove me to the Emergency Department and after being there for quite a while I was told there weren’t any beds available.

“I didn’t want to sit in the waiting room for hours and potentially wait overnight for a bed.

“The doctor suggested I could be put in touch with the virtual ward. He said I could be at home with people coming back and fore to monitor me.”

Mary decided to return home under the care of the virtual ward’s multidisciplinary team.

She had barely made it through her front door before Afan LCC virtual ward assistant nurse practitioner Steve Jones was contacting her to plan her care.

“As I was coming through the door the phone was ringing and it was Steve,” Mary said.

“He said I would receive the care at home that I needed. I felt as if I’d been thrown a lifeline.

“That was late afternoon on the Friday and on the Monday the staff arrived to take my blood pressure, among other things.

“I had regular visits from that moment on. It worked like clockwork and gave me so much confidence and security.

“All of the nervousness of the situation was taken away and I felt so valued.”

Steve added: “Having spoken with Mary on the phone upon her discharge from hospital, I explained the referral and how we could help her.

“I heard the relief in her voice knowing she was going to receive the care she needed in the comfort of her own home, which is what we as a team within Swansea Bay provide.”

After discovering Mary had low blood pressure, the team made numerous adjustments to her existing medication.

They continued to visit her at home to monitor her progress with the new medication she had been prescribed.

Mary said: “I was being monitored at home very closely. It was so reassuring.

“I knew that if I needed any help, I only had to pick up the phone.

“I am very grateful to the team for everything they did to make it such a reassuring situation.”

Mary said she felt privileged to be able to receive her care in the comfort of her home, instead of being in hospital.

Virtual ward staff work not only to prevent unnecessary hospital admissions but also to facilitate safe earlier discharges too, helping to free up beds for patients who really need them.

“I was so grateful to be in my own home and I feel that I benefited from it,” Mary added.

“It meant there was a hospital bed I wasn’t using and I was at home with the treatment I needed.

“Due to the difficulties hospital staff are facing with the lack of beds, it is helping to free up beds for others.

“I am also very grateful to the hospital staff for the care they gave me.

“People are having the best of both worlds by being able to be at home and having such a good level of care.”

Cheryl Griffiths, Afan LCC virtual ward clinical manager, said: “Being able to treat people how they want to be treated, in their homes, is fulfilling for our teams.

“Our main aim is to prevent hospital admissions and to facilitate earlier discharges wherever possible.

“Our multidisciplinary teams work holistically to identify the support patients need.

“It is very rewarding when we hear how people like Mary have been supported.”