Establishment of a post-discharge virtual ward to optimise care for copd patients following admission to hospital

Aims and Objectives: An integrated respiratory team (IRT) was established as a service innovation pilot project to improve outcomes for patients with COPD. A virtual ward was established to care for patients in Oxford City for 30 days following hospital discharge, with input from a multi-disciplinary team (MDT) to optimise care, in addition to existing follow-up from community respiratory nursing team, and reduce re-admissions. Methods: Following hospital discharge, patients referred to the virtual ward were discussed at a weekly MDT. Patients received standard post-discharge follow-up, and in addition smoking cessation, advanced care planning (ACP), pulmonary rehabilitation (PR) or home exercise support (HE), psychological therapy and housing needs were addressed. Results: 98 patients with 137 admissions admitted to virtual ward from June to November 2019. 77% had a single admission, 17% of re-admissions within 30 days of hospital discharge. Smoking cessation: 58% ex-smokers, 19% referred for smoking cessation, 19% declined. PR: 5% had completed PR in last 3 months, 17% referred for PR, 18% referred for HE, 42% declined PR or HE, 11% referral inappropriate. Psychological input: 15% referred, 19% declined, 44% input not required, 19% need not assessed. ACP: 16% had ACP in place, 26% agreed to ACP being made, 9% declined, 16% not indicated and 34% not assessed. Housing needs: 15% referred, 2% previously referred, 56% required no input and 26% not assessed. Conclusions: A virtual ward approach allows a holistic approach to factors leading to hospital readmission in COPD patients to be addressed.