Virtual Ward
Care Within
the Community
Kay Jeynes, Head of District Nursing
Cardiff and Vale NHS Trust
Ymddiriedolaeth GIG Caerdydd a’r Fro
ACUTE RESPONSE TEAM
 Team established in 2001
 Direct funding from the Welsh
Assembly Government to reduce
pressure on acute hospital inpatient
beds
 Intermediate care initiative Wanless
review 2002 Design for Life (WAG
2005) National Framework for older
people (DOH 2001)
Cardiff and Vale NHS Trust
Ymddiriedolaeth GIG Caerdydd a’r Fro
Definition of Intermediate Care
… Health Services that do not require
the resources of a general hospital but
are beyond the scope of the traditional
Primary Health care team (Royal
College of Physicians Black et al 2000)
Care within people’s own home
environment promoting speedier
recovery and preventing unnecessary
hospital admission. (Steiner A 2001)
“Hospital at Home”
Cardiff and Vale NHS Trust
Ymddiriedolaeth GIG Caerdydd a’r Fro
Who we are and what we do
• Physiotherapists and occupational
therapists with support staff
• Qualified nurses supported by trained
support staff
• Provide intensive packages of care for up
to ten days, in order to facilitate early
transfer of care home from hospital or
prevent hospital admission.
• Based at Lansdowne site covering the
GPs Cardiff and Vale geographical area
Cardiff and Vale NHS Trust
Ymddiriedolaeth GIG Caerdydd a’r Fro
NURSING
Maintain and provide
antibiotics, monitoring
blood levels, liaising
with lead Physician
Insertion of
peripheral lines
and IV Cannula
Nurse led monitor
ongoing suitability
and safely for
home treatment
Qualified
Nurses
High level
palliative care
for complex
patients
DVT Protocol
led service
Liaising with
inpatient/outpatient
services
Microbiology/Pharmacy
Prescribing
Cardiff and Vale NHS Trust
Ymddiriedolaeth GIG Caerdydd a’r Fro
NURSING
Unsupervised
Lone workers
responsible to
team manager
Phlebotomy
Baseline
Observations
Trained NVQ III
Provide Social
Support
Unqualified
Nurses
Wound care
Clip/Suture
removal
Variety of
skills/experience
working in
community
environment
Support/trained
to follow
OT/Physio rehab
careplans
Cardiff and Vale NHS Trust
Ymddiriedolaeth GIG Caerdydd a’r Fro
REHABILITATION
Facilitate a
problem solving
approach
towards ADL
Risk
Assessments
– manual
handling/falls
Functional
Assessments
Occupational
Therapy
Provide safe
transfer of care
from home to
hospital
Equipment
Assessment and
Provision
Liaise with
voluntary &
Statutory services
Cardiff and Vale NHS Trust
Ymddiriedolaeth GIG Caerdydd a’r Fro
REHABILITATION
Provide physio to
CF patients
between the unit
and home
environment
Co-ordinate safe
transfer from
hospital to home
Detailed
physiotherapy
assessment
Physiotherapy
Rehabilitation
within a 10 day
period
Liaise with other
teams and
disciplines
Treatment for trauma
and orthopaedics
patients following
surgery
Cardiff and Vale NHS Trust
Ymddiriedolaeth GIG Caerdydd a’r Fro
Action Plan
Mr. Andrews
Age: 62
Lives Alone
Referred From: W4
Diagnosis: Exacerbation of
Bronchiectasis
Treatment:
Intravenous
Antibiotics/Physio
Ceftazidime 1g TDS
Gentamycin 240mg OD
Nursing visits 3 times a day to administer the intravenous
Antibiotics.
Take routine Bloods: U & E’s CRP LFT’s. FBC. Random Glucose.
Assay for Gentamycin levels.
Physio visits once daily to administer chest physio
Occupational Therapist (OT) to call once on admission to assess
equipment needs to facilitate independent activities of daily living
Community support nurses to call once daily to assist with personal
care needs and rehabilitate at home.
OT to review 5 days post treatment to assess progress and discuss
ongoing referral to other community rehabilitation teams or social
services.
Bed days saved -
12
Welsh Assembly
Government (2005)
Designed for life:
Creating world class health
and Social Care for Wales
In the 21st Century
Mrs. Wiltshire
Age: 84
Lives with husband
Referred from: GP
Diagnosis:
Falls
Reduced mobility
Patient and husband not
coping
Treatment:
Falls prevention
Rehabilitation
Action Plan
Initial assessment completed by OTPossible intrinsic and extrinsic factors to falls highlighted.
Health Promotion/Falls Prevention information provided and
discussed.
Equipment provided to promote safety and facilitate
independence
Twice daily visits from Community Support Nurses to assist with
hygiene needs in morning and evening
Physiotherapy assessment and intervention programme
implemented
Liaison with Social Services and voluntary organisations for on
going support on discharge from ART
Bed days saved- unknown admission prevented
Aimto reduce the number of falls which
result in serious injury and ensure
effective treatment and rehabilitation
for those who have fallen.
National Service Framework for Older
People 2001
Cardiff and Vale NHS Trust
Ymddiriedolaeth GIG Caerdydd a’r Fro
Action Plan
Mr Rees
Age: 68
Lives with wife
Referred from:
CAVOC
Diagnosis:
Elective total knee
replacement
Treatment:
Intensive Physiotherapy &
Rehabilitation
Assess on ward for appropriateness and consent to
treatment
Assessment of home environment following discharge
(review of equipment requirements)
Assess mobility and progress
Maximising range of movement and strength through the
use of a graded exercise programme
Baseline observations, Wound monitoring and pain
management
Provide advise regarding possible complications
i.e. Chest infection, DVT, contractures, infection
Removal of clips (if required)
Liaise with out patient physiotherapy department
regarding future intervention
Bed days saved-
up to 5 days if uncomplicated
Cardiff & Vale
Orthopaedic
Protocols
Ms Brown
Age: 27
Referred to Doppler via GP
Referred from: medical
admissions unit
Diagnosis: Acute Popliteal
DVT
Treatment: Administer
heparin, monitor INR and
dose Warfarin
Action Plan
Daily visits from qualified nurses.
At each visit ART will Provide education and literature to support related issues i.e.
alcohol, contraception.
Obtain capillary INR via the near patient testing ‘Coagucheck
S’
Adjust Warfarin dosage as per nomogram
Administer subcutaneous low ,molecular weight heparin
(Clexane) as per nomogram
Measure for compression hosiery as per best practice
guidelines ( Prandoni at al 2004) and provide a prescription
Bed days saved- variable would not of been admitted but
avoiding daily trips to A/E
Brandjes DP, Buller HR, Heijboer H et al (1997) Randomised trial of effect of
compression stockings in patients with symptomatic proximal-vein thrombisis.
Lancet 349 (9054), 759-762.
Medical Devices Agency (2201) Evaluation of the Roche CoaguchekS
Coagulometer MDA 01026 ISBN number : ISBN 1 8482 344 9
Prondoni P, Lensing AWA, Prins MH, Frulla M, Marchiori A, Bernardi E, Tormene D,
Mosena L, Pagnan A, (2004) Below-Knee Elastic Compression Stockings to
Prevent the Post-Thrombotic Syndrome. Annals of Internal Medicine 141 (4) 249256.
NPSA guidelines 2007 British Society of Haematology NHS UK
Cardiff and Vale NHS Trust
Ymddiriedolaeth GIG Caerdydd a’r Fro
Mr Jones
Age: 52
Referred from: Whitchurch
Hospital
Diagnosis:
Cellulitis of both legs
Treatment:
Benzopenicillin 1.2 gram
QDS
Flucloxacillin
1 gram QDS
Action Plan
Qualified nurses visit 4 times daily
to admin IV antibiotics
Liaise with ward staff re any
change in condition
Monitor blood results and liaise
with staff at Whitchurch
Bed days saved _ length of
treatment prevent admission to
acute medical bed with escort
D.D saved variable
dependent on
patients response
Welsh Assembly Government
(2005) Designed for life:
Creating world class health and
Social Care for Wales
In the 21st Century
Mr Robertson
Action Plan
Age: 57
Due to length of time IV
antibiotics required
assessed for mid line
insertion as per RCN best
practice guidelines
Referred from:
Llandough Hospital
Diagnosis:
Revision of Total Knee
Replacement
Treatment:
6 week IV Teicoplanin
prophylactically
Physiotherapy
Bed days saved up to 6
weeks
Hamilton HC (2000) Selecting the
correct IV device : Nursing
Assessment British Journal of
Nursing : 9 (15) 969-978.
RCN ( 2005) Standards for
Infusion Therapy
RCN IV Therapy Forum
Cardiff and Vale NHS Trust
Ymddiriedolaeth GIG Caerdydd a’r Fro
ACUTE RESPONSE TEAM
Virtual ward 7.30 until midnight every day
Cardiff and Vale district nurses available for emergency
calls after these hours
Referrals please telephone: 20932676
Mobile: 07976050069
08.30 - 5pm daily
(Or messages may be left after hours)
THANK YOU FOR LISTENING
Cardiff and Vale NHS Trust
Ymddiriedolaeth GIG Caerdydd a’r Fro