During Admission to Cardiology Virtual Ward
Patients will have commenced the following assessments during their time on the virtual ward:
- Assessment of required interventions provided by the MDT – these will include:
- pressure area care, nutrition and hydration, personal hygiene, continence, wound care, mobility, and rehabilitation.
- Nutritional assessment.
- Pressure area risk assessment.
- Assessment for the provision of equipment.
- Prescription of medication if required.
- Rapid access to appropriate medical treatments available at home including any required anticipatory medications required.
- Medicine’s optimisation assessment
- RESPECT
- Personalised care and support planning – advanced care plans.
Holistic assessment will take place via telephone or video consultation, identifying outstanding needs / risks. Necessary onward referrals will be made which may include community nursing teams, AHPs, palliative care services, social services, Community Specialist Practitioners and other specialist services.
Heart Failure education will be commenced; self-monitoring and management plan with Pumping Marvellous literature will be posted to the patient via Patient administration System.
In all patients the clinical management plan will be discussed and agreed. In patients known to the Community Heart Failure Service the latest consultation, examination and clinical management plan will be documented in the patient’s electronic record.
The frequency of remote monitoring; parameters for blood pressure, pulse and oxygen saturation and frequency of answering question sets will be determined by the patient’s heart failure nurse, based on clinical need, risk, patient’s wishes and patient’s ability. This will be programmed into the remote monitoring system and documented on their remote monitoring care plan. The remote monitoring system will create alerts if monitoring is not completed as per the management plan.
