Discussion
The MVW brought benefits for patients, healthcare professionals, and the
hospital system. It offered monitoring and reassurance for pregnant
women positive for COVID-19. However, as the pandemic disrupted the
normal schedule of antenatal care in the UK, it was also a route to
antenatal services for women who were self-isolating, vulnerable, or
otherwise struggling to access care. It brought a degree of continuity
known to improve satisfaction, and reduce intervention rates. (8) As a
safety net, it allayed anxiety for patients and providers alike, and
offered a ‘third option’ between primary care and admission, that helped
ease pressure on hospital infrastructure and general practice. The
technological aspects of the virtual ward performed well, and staff
judged the triage criteria and alarm settings to have had the right
balance of sensitivity and specificity.
The key challenge was digital transformation. The initial set up and
coordination of the MVW required dedication, and a degree of “internal
marketing” from enthusiastic individuals to bring the rest of team
onboard. The key barrier to engagement was a lack of perceived
importance of remote monitoring. Maternity services, especially during
COVID-19, did not sit in isolation, so care pathways also had to be
coordinated with respiratory, acute and general medicine. Healthcare
professionals beyond the MVW team needed to understand that any
temporary adjustments to their workflow would be rapidly offset by a
reduction in demands on their time once the service had shouldered the
load.
The MVW also relied on a core group of midwives skilled in telephone
triage and emotional support. Even with clear admission criteria and
escalation pathways, the midwives needed experience and confidence to
make composite judgments that integrated the results of the monitoring,
the patients’ clinical trajectories and the services available. Midwives
were not trained in this, and they had to balance expectations of ‘usual
care’ with the capacity of the hospital during the exceptional
circumstances of the pandemic.
Clinical leadership is essential for driving this kind of digital
transformation. The pandemic created an overwhelming sense of urgency
but building a coalition for change starts with strong and credible
clinical leaders. Clinical leaders should then build out a team of
trained individuals responsible for the execution of the programme. In
the NNUH programme, a strong team ethos was essential to maintaining
morale, even when working remotely. When working remotely, staff should
also have access to the usual services of the hospital (for example,
arranging ultrasound scans), so they are not limited in the care that
they can offer.
Clinical pathways should include triage criteria, triggers for
escalation, pre-agreed admitting locations, and allocation of
responsibility for patients at each stage. Pathways must equally build
in a degree of flexibility, and a process for rapid evaluation and
change control, so they can adapt to a rapidly moving situation. The
pathways, and the virtual ward service should be ‘marketed’ within the
institution, so those peripherally involved are aware of its
availability, capability, and potential benefits.
Technology should be chosen that can monitor the desired parameters
using validated, CE-marked sensors. Facilities for video calling,
simultaneous translation or cellular (as well as WiFi) connection may be
essential, particularly in areas of social deprivation. A solution that
is easily integrated with existing workflows and maternity systems, and
that can maintain patient confidentiality while facilitating clinical
handover is also desirable. Alarms should be set to balance sensitivity
with specificity, as false alarms can be more laborious and disruptive
to resolve when the patient is remote. In the MVW alarm settings, a time
window of 60 minutes, and combination alarms from multiple vital sign
parameters were used to add specificity to continuous monitoring alarms,
to ensure that any alerts reflected the patient’s true physiological
state and not a temporary derangement from activities of daily living.
Attention should be given to how patients will be contacted if they
cease transmitting data, and involvement of the community midwifery
service at an early stage is helpful.