Since the arrival of COVID, the way we approach things as medical professionals has had to change, almost beyond recognition.
As a clinical fellow on ITU, you would expect me to be in the thick of it – intubating, inserting central lines, learning how covid patients respond to the various ventilator settings. But that is not the case.
I was very lucky to find out I was pregnant with baby number 2 at the start of this year, but unfortunately, this was about 6 weeks before COVID hit our hospital. At first, I thought it would be manageable, but once the RCOG guidelines were released, my incredibly supportive department, advised me to keep me and my baby safe and work from home.
Initially I was working on writing the emergency rota and the recruitment of medical students to help with the increase in workload, but I then found myself in this very strange situation, where I was unable to use any of my skills for any benefit.
Luckily, it was at this point, I found out about the Home Monitoring Service which was being set up at NGH.
Dr Fiona McCann is a respiratory consultant at Northampton General and invited me to become involved in this innovative project. This finally made me feel useful in the battle against this awful virus.
The plan was to use a service, developed by the company Doccla, to monitor patients who had covid and were borderline for requiring admission, at home, 24 hours a day, 7 days a week.
The Doccla service contained an armband that could continuously monitor the patient’s vital signs via Bluetooth and send the data to an app on a pre-configured mobile phone. This data would then be displayed on a dashboard, which could be accessed remotely by the team. Doccla also provided the patients with a manual thermometer and a pulse oximeter. Patients would be asked to input their readings 3 times a day via the app. Doccla would arrange the delivery of these devices, as well as the safe collection once they were no longer required. This would all be done by a courier in appropriate PPE.
The service would allow patients who may otherwise require admission to hospital for monitoring, to stay at home whilst still being under the care of a medical team. We wanted it to be almost like a ‘virtual ward’. The patients would go home, wearing the DOCCLA band which would allow their observations to be monitored 24 hrs a day, whilst also having access to an advice line, should they need it.
I became involved with various Zoom calls between ourselves and the team at Doccla. From here, we set a plan in place as to how we were going to man a rota, how we would hand-over, who would be involved in the team, patient selection criteria and the logistics of escalation should we need to. I wrote a rota, which allowed us to man the fort 24 hours a day, 7 days a week. The team comprised respiratory nurses, consultant physicians and myself as a junior doctor. These were members of staff who were either having to work at home (like myself), or from teams whose normal roles had seen a reduced workload during the pandemic.
I think it’s fair to say we were all a bit nervous about how it would work, as it was so far removed from our usual practice, but we were keen to help in any way we could.
We decided upon selection criteria for patients who we would accept. These were:
- Sats over 94% (88% if COPD)
- NEWS less than 3
- RR less than 24
- Able to cope at home or have an appropriate carer
- Patient and associated consultant happy for them to go home with the service
We have since had to add other points to consider, having gained some experience in this now. These include:
- How the patient will cope with technology – I think we incorrectly assumed that everyone would be able to work a smartphone!
- The state of the patient’sd mental health – some patients struggled to cope with feeling like they were ‘being watched’.
- How long they had been off oxygen – This became important because we now accept quite a few patients from the wards, whereas originally, we assumed we would only accept them from A&E.
- Co-morbidities – we have accepted quite a few complex patients. Some have been fine to manage, but others have required an MDT approach, which has been tricky to co-ordinate from home.
The shift patterns have evolved as we have gained more knowledge into how the system works. The initial plan was for this service to be managed completely remotely. We really tried to make this happen, but it was often really difficult to assess the suitability of a patient, without having someone ‘on the ground’. The nurses from the RESTART team became invaluable in going to review the patients, measure them up for the band and answer any questions the patient may have. For that reason, we now run shifts which allow the restart team, who are in the hospital, to cover 8 am-4 pm Mon-Sat and then use the team members who are shielding at home to cover the out of hours work. Although working constant nights has been tricky, it does mean that I haven’t had to sort out childcare for my toddler, which I have been very grateful for.
Although we were nervous to roll out this initiative, we have been so well supported, which has helped make the process so much easier. We have had 24-hour access to the Respiratory Support Group at the hospital. This is made up of consultant physicians (usually respiratory or intensivists), again who are often shielding and are there to offer advice on COVID patients. Whenever we have had any concerns about a patient or wanted to clarify any aspects of their care, they have been fantastic and the support has really helped to build our confidence.
The team at Doccla have also been brilliant. We were initially informed that their customer service team would be available until 1830, but whenever I emailed them, day or night, there was always a swift response and an efficient answer. They have been brilliant at troubleshooting any problems and putting the patients’ minds at ease.
During our busiest time, we had around 15 patients on the system, but usually, we have between 5 and 10. Depending on their stage and severity of illness, we typically speak to them between 1 and 4 times a day. We have had a few patients who have required re-admission to hospital and we have worked with the team in A&E to ensure this all runs smoothly. We have also had quite a few who have needed treatment from the GP, and we have been able to facilitate this for them remotely.
The demographics of the patients we have had on the system, have been quite varied.
- The average age has been 50 (range being between 30 and 75)
- More males than females.
- Common co-morbidities
- Asthma, hypertension, obesity and diabetes.
- The average number of days that the patients stay on the system has been 7 days (range between 1 and 13).
We do feel that this service has kept patients out of hospital on multiple occasions, although we accept this is difficult to prove. We have been told multiple times by patients that they would have felt very alone without us. I can think of at least 3 patients who I am sure would have re-presented to A&E just for reassurance and instead, we were able to offer that over the phone. Equally, we have been able to arrange antibiotics for the patients without them having to go back into hospital. We have also been able to identify patients who are struggling and get them seen in a timely fashion at the hospital. We can only speculate how these patients would have acted without the support of the Home Monitoring Team, but we do feel that we have helped to get them assessed quickly when it has been needed.
Currently, our number of patients is reducing each day and we are seeing fewer referrals coming through. We don’t know if this is because there is second wave starting and people are too sick to be referred, or in fact, the number of COVID patients is just dropping. Either way, we have started to wonder what will happen with regards to this system once COVID is a thing of the past. We have learnt many things from using the system and we all feel there is a place for this in other areas of medicine, although the exact nature is unclear.
I am so glad that I was able to become part of this team. It has been brilliant working with new staff members and trialling new technology. It has also meant that I have been able to feel like I have played a part in the fight against COVID, even though not physically present on the front line.
Don’t get me wrong, I am desperate to get back to ITU, once my baby is here safely and the pandemic is under control, but I am excited to see how and where this technology can be used going forward.
So, we hope these patients never truly felt they were Home Alone!
Author: Dr Hannah Gardner (Clinical Fellow in ICU)
Peer reviewed by Dr Jonny Wilkinson
We plan to update this section with a patient experience vignette tomorrow.