Evaluating discharges and readmissions using a COVID Virtual Ward model: a retrospective data study assessing patient outcomes and the likely staffing commitment

  1. Suzy Gallier
  2. Catherine Atkin
  3. Vinay Reddy-Kolanu
  4. Dhruv Parekh
  5. Xiaoxu Zou
  6. Felicity Evison
  7. Simon Ball
  8. Elizabeth Sapey

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Abstract

Background

COVID-19 has placed a catastrophic burden on acute hospitals. In an attempt to reduce admissions and enable safe early discharge, a COVID virtual ward (CVW) care pathway has been supported by NHS England. This includes discharging people who meet objective criteria based on acuity scores and oxygen saturations, with pulse oximeters and daily phone calls for up to 14 days. Observational studies have reported the safety of this system, but without describing the outcomes from usual care.

Methods

A retrospective study using routinely collected health data from all adults with a confirmed positive severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) swab result between 1 st June 2020 and 31 st Jan 2021 who attended the Emergency Department or Acute Medical Unit at QEHB, which does not have a CVW service. Criteria for CVW were applied using data from the first 24 hours of presentation to hospital and subsequent health outcomes were included for 28 days, including re-presentation, re-admission, ITU escalation and death. Results were compared to reported studies based in secondary care.

Results

During the study period, 26,127 patients presented to QEHB hospital. 2301 had a positive SARS-CoV-2 swab. Of these, 1730 (75.2%) did not meet the criteria for the CVW and 571 (24.8%) did. Of the 571, 325 (56.9%) were discharged home within 24 hours and 246 (43.1%) were admitted for 24 hours or longer. Those admitted were older, with increased co-morbidities, 80.9% required hospital-supported acute therapies after the first 24 hours and 10.6% died. Of the 325 discharged, 44 were readmitted (13.5%), 30 (9.2%) with COVID-related symptoms, 5 (1.5%) required ITU and 1 patient (0.3%) died. These results were comparable to published studies with a CVW service.

Discussion

In the current study, discharging patients without a CVW did not confer a greater risk of re-presentation, re-admission, ITU escalation or death. The majority of patients who remained in hospital despite meeting the CVW criteria did so for the provision of treatments or acute assessments. It remains uncertain whether a CVW delivers improvements in hard outcomes, and further research is needed.

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  1. ScreenIT

    SciScore for 10.1101/2021.07.16.21260651: (What is this?)

    Please note, not all rigor criteria are appropriate for all manuscripts.

    Table 1: Rigor

    Ethicsnot detected.
    Sex as a biological variablenot detected.
    Randomizationnot detected.
    BlindingDecisions as to whether a patient met not did not meet the criteria for the CVW were made against objective parameters by one person clinically qualified person and ratified by another (both acute medicine trained), with both being blind to patient outcomes (including re-presentation, escalation to ITU care and death).
    Power Analysisnot detected.

    Table 2: Resources

    Software and Algorithms
    SentencesResources
    Statistics: Statistical analysis was performed using STATA (SE) version 15 (StataCorp LLC, Texas, USA).
    STATA
    suggested: (Stata, RRID:SCR_012763)
    StataCorp
    suggested: (Stata, RRID:SCR_012763)

    Results from OddPub: We did not detect open data. We also did not detect open code. Researchers are encouraged to share open data when possible (see Nature blog).

    Results from LimitationRecognizer: We detected the following sentences addressing limitations in the study:
    This study has limitations. First, by comparing outcomes across studies, there is an assumption that patient populations including demography, burden of disease and impact of COVID-19, are similar across published studies. Most studies to date have not presented in depth demography and therefore these direct comparisons should be reviewed with caution. Second, in the current paper, the objective criteria for the CVW were applied using the granular electronic health record at QEHB without the benefit of seeing the patient or considering the time of the initial presentation, and all these factors are important when making the decision to admit or discharge. Third, it is possible that more of the patients who met the CVW criteria might have been discharged were the CVW in place. Fourth, when assessing staffing needs it has been assumed that all patients will require follow up for 14 days, as described in the NHSE SOP. It is highly likely that some would require much less follow up prior to discharge. Fifth, this is not a formal health economic review, which would form part of the evaluation of any new service. The study has significant strengths. Decisions as to whether the patient met the CVW criteria were made independently by two researchers, without knowledge of outcomes, thus reducing bias. All patients were included in the study, reducing the population bias which can hinder consented studies. As data includes all medications and electronic noting, reasons for continued ad...

    Results from TrialIdentifier: No clinical trial numbers were referenced.

    Results from Barzooka: We did not find any issues relating to the usage of bar graphs.

    Results from JetFighter: We did not find any issues relating to colormaps.

    Results from rtransparent:
    • Thank you for including a conflict of interest statement. Authors are encouraged to include this statement when submitting to a journal.
    • Thank you for including a funding statement. Authors are encouraged to include this statement when submitting to a journal.
    • No protocol registration statement was detected.

    Results from scite Reference Check: We found no unreliable references.

    About SciScore

    SciScore is an automated tool that is designed to assist expert reviewers by finding and presenting formulaic information scattered throughout a paper in a standard, easy to digest format. SciScore checks for the presence and correctness of RRIDs (research resource identifiers), and for rigor criteria such as sex and investigator blinding. For details on the theoretical underpinning of rigor criteria and the tools shown here, including references cited, please follow this link.

  2. Version published to 10.1101/2021.07.16.21260651v1 on medRxiv