Background

Respiratory disease treatment requires significant healthcare resources. In Ireland during 2021, there were 10,417 respiratory disease admissions to hospital for Moderate and Severe COPD. The average per admission cost ranged from €2,902 to €5,776 with an averaged range of length of stay between 5 to 11 days. In the UK, respiratory disease accounted for the highest proportion of inpatient hospitalisations and bed days compared to other diseases between 2009- 2016. In 2016, there were 92,391 hospitalisations and 578,319 in-patient bed days [1]. Diseases of the respiratory system are one of the main causes of death in the European Union (EU) ^[1] . The majority of admissions with respiratory disease are classified as emergencies. Chronic Obstructive Pulmonary Disease (COPD) is the main reason for admission to the respiratory ward as some individuals have multiple admissions and become well known to all members of the respiratory team during their final years of life [1].

Nationally and internationally, the rising prevalence of COPD is responsible for significant healthcare use and patient morbidity and mortality [2,3]. The economic and social burden of COPD in Ireland is quite substantial. Relative to other Organisation for Economic Co-operation and Development (OECD) countries, Ireland continues to have highest rates of COPD hospitalisations of the recorded countries in 2020 [4]. Although the exact prevalence of COPD in Ireland is unknown, it is medically accepted that there is a very large number of undiagnosed COPD cases within the Irish population. It may be as high as 10% of the adult population with COPD, both diagnosed and undiagnosed [3,5]. Nationally pre-pandemic 15,000 patients were hospitalised with COPD with a predicted mortality rate from COPD in the region of 1,500 annually [5]. Acute exacerbations are the key drivers of direct costs for COPD, accounting for over 70% of COPD-related costs for hospitalisations including emergency visits [3]. The cycle of readmission is very common with a third of patients hospitalised for acute exacerbation COPD returning to the hospital within ninety days [1]. As per Letterkenny University Hospital In-Patient Enquiry (HIPE) data COPD admissions demonstrated that 35% of patients with COPD were readmitted within 90 days. In addition, longer inpatient stays demonstrated a correlation with readmission and death among this patient group.

The challenge that exists within hospitals nationally is to find a way to break this cycle and develop an ability to predict readmission and offer an alternate care pathway. This was the key motivation for designing a Community Virtual Ward (CVW+cRR) proof of concept to examine the feasibility and functionality of an alternate care pathway for COPD patients in this cycle of care.

[1] Eurostat. Respiratory diseases statistics

The target population consisted of individuals with a pattern of repeated illness culminating in hospital admissions due to COPD exacerbation(s). The increasing frequency of presentation is associated with a declining state of health and can increase the burden on resources [1]. A CVW+cRR with a bespoke platform that incorporated the novel use of cRR trends was designed, implemented, and offered as an alternative to inpatient care in Co Donegal from May to August 2022 to a cohort of eligible individuals with severe COPD.

With an alternate pathway these hospitalisations are avoidable once substantial provision and access to specialist community care is established [4]. This community model is the primary focus of the Irish national health policy “Sláintecare”, aimed at developing and progressing an integrated model of care across all health settings [6,7]. Recent challenges of the COVID-19 pandemic and the Health Services Executive (HSE) cyber-attack of 2021 [8] have focused the need for flexibility in patient care delivery.

Outcome Measures

The key objective of the CVW+cRR is to deliver innovation in healthcare with a primary care focus that will support and treat individuals with COPD allowing them to remain at home to receive their care. Exacerbations were assessed based on a mixed method of objective scoring using eMRCD extended MRC dyspnoea method and qualitative observations during verbal communication. It was anticipated that the CVW+cRR should improve patient care through early detection of exacerbation, offering a choice for patients and their families, respiratory physicians, nurses, and General Practitioners (GPs) to progress integrated respiratory care.

The design of the model of care did not focus on economies of scale but rather about the right care at the right time in the right place. If such a model of care proved to be cost-effective, it should be considered for standardisation.

The key patient-specific outcomes of the CVW+cRR were to:

1. Reduce attendance to Emergency Department or out-of-hours general practitioners (GPs) services.
2. Improve patient outcomes by offering an alternate care pathway.
3. Empower people with COPD to become a partner in the management of their health.
4. Reduce hospital admissions.
5. Reduce the length of stay for in-patients if applicable.

The CVW+cRR should improve channels of communication through well-established systems with GPs and ambulance teams to help avoid hospital admissions. The CVW+cRR should provide equipment, which will support patients to monitor their oxygen saturation levels, RR, and heart rate. It is anticipated that patients will be able to manage their exacerbations with rescue medications. Additional support where necessary will be provided through multi-disciplinary team (MDT) referrals, to support patients to reduce anxiety and improve their coping skills.

Development of the CVW+cRR

A preliminary proof-of-concept audit was undertaken by the RANP prior to the pilot commencement. This was used to establish a needs analysis to determine the consumption of acute hospital resources by patients living with COPD in Letterkenny University Hospital. The findings showed that nine (9) patients had a total of five hundred and forty (540) bed days over the previous year (an average of sixty (60) bed days per patient) with seven (7) average number of admissions per patient.

A Design Thinking Approach to Pathway Creation

The Digital Transformation Team of the Health Service Executive (HSE) is mandated to Empathise, Define, Ideate, Prototype, Test upon solutions that meet the quadruple aim of improvements in the quality of care, in quality of life, reduction in costs, and improvement in the clinician/patient experience. Working in partnership with industry to deploy “Design Thinking” methodologies with a patient centric approach, underpinned by a ‘Why Statement’. Design-thinking workshops were undertaken with a project team consisting of hospital respiratory consultants, community clinical leads, both regional and senior directors of nursing, GP’s, industry, and patient representatives.

Workshops involved multidisciplinary problem statement exercises and patient interviews to identify a patient persona, and their pains and gains within the existing area of COPD care locally.

Internationally CVW+cRR has become an alternative way of providing care to high-risk patients using a combination of specialist care and telehealth, employing “systems, staffing, and daily routines of a hospital ward…” in a community-based care model [9,10]. However, as we attempted to answer the challenge statement - “How might we empower people with exacerbating COPD to become a partner in the management of their health and ensure that they receive the right care at the right time as close to home as possible?” - we realised that we would require a bespoke solution as there were no digital solutions available currently in the market place to meet the project needs.

The CVW+cRR provides delivery of acute medical care in the home of patients, who would otherwise require admission to hospital [11-14]. Previous studies have reported significant reductions in hospital admissions [11,15, 16] and improvements in quality of life [15,17] among patients with chronic diseases treated in a CVW+cRR. A recent Irish study has reported significant improvements in symptoms and health status among patients admitted to a CVW+cRR with chronic respiratory disease [18]. Similarly, the CVW+cRR model has been adopted recently to support mild COVID-19 patient infections at home [19-22]. The introduction of remote monitoring equipment to record oxygen saturation has relieved the strain on overburdened acute hospital services by allowing patients to be discharged while also ensuring the development of respiratory failure in these community-based patients is detected and treated early [12].

The design, implementation, and evaluation of CVW+cRR for individuals with a history of exacerbating COPD started with a comprehensive assessment of the patient’s journey through the health service using existing care pathways. This challenged the pains and gains associated with developing an innovative solution to patient care in the home setting. This project was designed with continuous monitoring of RR as an essential predictive clinical observation in the care and management of this patient group.

The unique approach to monitoring the RR in conjunction with a digital platform with active caseload management by a RANP represented, as showing in Figure 1, a world first in primary care. The vendor, PMD Solutions, who offers a unique RR monitoring technology, worked in partnership with HSE Digital Transformation. This secured a partner that would provide a remote management platform which integrates with RespiraSense^TM, Oximetry, and other tools such as spirometry. This allowed for gathering other assessments, patient education, and patient collaboration, through a health platform myPatientSpace^TM. 

Figure 1: Interconnected patient centric process of linking patient accessible technology with collaborative clinical oversight to empower all stakeholders to improve outcomes.

Key responsibilities of the RANP

The CVW+cRR for individuals living with severe COPD was led by a RANP, an integrated nurse based in Community Healthcare, Co Donegal affiliated with Letterkenny University Hospital. The RANP was responsible for providing a choice to assist patients to remain at home, supported by technology as opposed to previous care options. Specifically, the RANP was responsible for:

• Reviewing and assessing patient’s status each day, using a Red-Amber-Green risk based approach for identification of intervention using both patient-reported and objective physiological data.
• Acting as a case manager, where a full episode of care included a complete respiratory assessment of physical health and current medication, breathlessness management, a home visit if indicated to assess equipment, and family supports.
• Identifying any barriers to better self-care and addressing these with actions wherever possible and within the scope of practice.
• Using the data promptly to implement a management plan or intervention.
• Establishing a pathway to medication such as steroids and antibiotics faster for the patient group by providing a rescue prescription if indicated by and in collaboration with the GP.
• Delivering patient information and education, face-to-face presentation, patient focus groups and the development of written information and videos to support upskilling throughout the project.
• Acting as an identified champion driver which involved weekly meetings with all key stakeholders throughout the process.
• Assessing, planning and implementing care, advice and patient-specific education as required throughout the process.

Patients selected for the CVW+cRR were identified from the caseload of high healthcare users identified by Letterkenny University Hospital In-Patient Enquiry (HIPE) data. Eligibility for the study was determined from a review of patient HIPE data. Patients demonstrating frequent exacerbations and those enrolled in a pulmonary rehabilitation clinic with advanced levels of COPD were deemed eligible. The inclusion and exclusion criteria are summarised in Table 1.

Community Virtual Ward Inclusion and Exclusion Criteria & Pathway
Inclusion Criteria	Red Flags - Hospitalisation Criteria
• Over 16 years of age • No active addiction or members of household with active addiction • Known to one of the Letterkenny University Hospital respiratory consultants • Spirometry diagnosed COPD • Physical examination completed by RANP • History of exacerbation or ongoing decline from baseline • Optimal home care supports in place, to support activities of daily living • Does not require an intensive programme of case-management • Tested negative for COVID-19 and no clinical suspicion of same	Depending on baseline of clinical observation: • Stridor • HR >120 pm, RR>30 pm, SpO2<88% • Worsening resting dyspnoea • Unable to complete sentences • Distress and elevated RR for prolong periods causing concern • Desaturation from normal oxygen levels and associated signs of hypoxia • Acute respiratory failure • Onset of new physical signs (cyanosis, peripheral oedema) • Failure of exacerbation to respond to initial medical management • Evidence of de-compensation of a long-term condition (e.g., heart failure, arrhythmia) with acute symptoms that requires acute hospital direct interventions and monitoring due to the presence of serious co-morbidity (heart failure, new occurring arrhythmias, etc.)

Table 1: Summary of patient inclusion and exclusion criteria.