Better value and a better night's sleep: keeping acutely unwell children and adults out of hospital

At Bradford Teaching Hospitals NHS Foundation Trust (BTHFT) we are supporting people to stay out of hospital wherever possible. And where patients do need an admission, we aim to reduce their length of stay. To support this, we have developed the concept of a ‘virtual hospital’ that adds value by both improving quality (using patient experience and outcomes as key indicators) and reducing costs.

So how do things work differently in a ‘virtual hospital’? In short, it means that patients can continue to receive consultant-led medical care in their own home rather than staying in hospital. For example, rather than waiting in a hospital bed for several nights for their next test or procedure they are now sent home and return only for active hospital management. This allows us to deliver better value care for patients, and it means patients can get a better night’s sleep in their own bed.

In my specialty, paediatrics, interest in virtual hospital care has increased over the past ten years as acute trusts struggle to manage the pressures of increasing demand, resolute accident and emergency targets and a scarcity of paediatric acute inpatient beds. Many national policy initiatives to streamline urgent care provision have focused mainly on adult urgent care provision. However, across the country paediatric ambulatory urgent care (defined as the provision of same day care for children and young people who would otherwise be considered for an emergency admission) is gaining traction.

At the BTHFT I lead a service that is designed to keep children out of hospital – the Ambulatory Care Experience (ACE). The service has been coproduced with families and with community and secondary care teams. It offers an alternative to hospital referral or admission for children who are unwell. If children meet set referral criteria on a care pathway they are managed at home by a specialist children’s nurse under the remote (‘virtual’) guidance of a paediatric consultant. The consultant takes clinical responsibility for all children referred into the service.

Fundamental to this approach are the development of new clinical roles and responsibilities for nursing and medical staff and greater collaboration across community and secondary care services. In this model of virtual care, referrals are accepted from primary care, the emergency department and our Children’s Clinical Decision Area. Our experienced children’s nurses, after receiving bespoke training and assessment on all pathways, provide care and support to children in their own homes. Health education and promotion are key aspects of each pathway. We aim to prevent readmission and – importantly – to create a healthier community.

The pilot is only in its first year. We have tested our governance policies, processes and protocols and in the last nine months there have been no adverse events within the service. During this period we have looked after children with wheeze/asthma, croup and gastroenteritis, with a plan for several more pathways in the next few months.

I have been really encouraged with the reaction of families using the service. We have had 100 per cent satisfaction from our feedback. In particular, the comments we have gathered indicate how well the service is being received.

Referral numbers into the service demonstrate the wider value ACE has to the Trust. We have been able to keep 87 per cent of appropriately referred patients at home with the service saving over 220 bed days. The majority of referrals have come from primary care with 34 different surgeries referring into the service.

In some areas of care this approach is already routine. Since 2015, our virtual ward for care of the elderly has prevented multiple admissions and reduced our average length of stay in hospital. On any given day, there may be as many as 100 frail older people being cared for in the virtual ward. There are many other models of virtual care across the Trust. These include the Diagnostic Virtual Ward and Virtual Trauma Clinic, similarly taking new approaches to ensure that people are not in hospital waiting for specialist investigations or procedures unless they absolutely need to be.

It is notable that the Trust’s senior leaders did not decide to become a virtual hospital and then pilot the approach with individual clinical services. They built on the innovative work already under way in some specialties. They sought to promote a culture encouraging a robust approach to clinical risk and models of care that were short-stay by design. And they sought to promote a culture that looked at improving the value of services – rather than only focusing on saving costs or improving quality in isolation.

I have been really encouraged by the initial results of this approach in my own specialty, and believe it is replicable in all acute trusts across the country. At BTHFT we see the potential for the virtual model to continue to expand into many other specialties to release capacity and improve flow, maximising value for the Trust and delivering a quality patient experience.