Care professionals are using their shared care record to proactively support Covid-positive patients on their Pulse oximetry @home and virtual ward programmes.
Using the detailed information held about patients, clinicians are able to identify and reach out to those patients most at risk from the complications of Covid, ensuring care is targeted to where it is of greatest benefit.
Patients record their pulse oximetry readings and symptoms electronically using their Personal Health Record (PHR) app, or can opt to keep a paper diary. Those who use their PHR app benefit from receiving timely remote advice and support.
Care professionals have access to the latest patient recordings through the shared record. This means that, should their patient’s condition suddenly deteriorate, they can escalate the level of care. Other care professionals, such as GPs, A&E and respiratory doctors, can also have sight of the history leading up to someone presenting to them in an urgent care setting, and are able to admit them for remote monitoring themselves, if they feel their patients require further support for their recovery on their return home.
Being able to identify and recruit patients using the information routinely held in the shared care record allows for a nuanced and granular response to a patient’s individual wishes, needs and risks. Care communities without a shared care record typically rely on a daily list from NHS Digital of patients in their area who have tested positive, with indicators for those who meet the recommended age criteria and/or those considered Clinically Extremely Vulnerable.
CareCentric users are able to be much more holistic in their approach. They can target people with confirmed or possible Covid who live alone and who might therefore need greater support, for example. They are also able to identify patients with underlying clinical conditions such as cardiovascular disease, or a high Body Mass Index, which could not only put them at higher risk but affect their convalescence and recovery. Benefits include the prospect of better outcomes and the more efficient targeting of care and resources.
For every day of delay in hospital admission the chance of death increases by 1%, observational data suggests (Source: NHS Digital).
How it works
Our population health platform presents care professionals with a potential candidates list and an overview of all patients on their virtual ward. They can select a patient from the list and click directly into that patient’s shared care record. This provides a more holistic view, with details such as recent Covid test results, current status and full details of symptoms, assessments, and trends of results to help track progress and date of admission.
The clinician can either go through the questionnaire and record that day’s assessment directly into the patient record, or patients are able to do this directly by downloading an app which is integrated with the shared care record. This app allows them to remotely enter their readings, symptoms and feelings where they can be viewed by their clinician. Clinicians are able to send messages to their patient via the app, such as a request to increase the frequency of oximetry readings. There are automated prompts - for example, if entries are very different to previous recordings, the patient is asked to rest for five minutes and redo. And if their readings and symptoms are deteriorating, it provides advice (based on national guidance) on actions the patient ought to take. The PHR app also provides people with the opportunity to record their wishes and presents them with a summary view from their shared care record.
Across the wider NHS, this same model could be applied in support many other community-based care pathways. Graphnet is working with its customers to identify these applications.
"I had a 45 year old male of BAME background with underlying diabetes whose son developed COVID and, a few days later, my patient developed symptoms and tested positive as well...We enrolled him in the pulse oximetry programme and after day 11 his symptoms suddenly deteriorated from 95% saturations to 80% saturations. He was taken straight into hospital and he had a covid-related pulmonary embolism. Without the pulse oximetry programme, we wouldn't have known he had deteriorated and this has saved the patient's life”
Dr Priya Kumar, Connected Care, Frimley ICS and Berkshire West ICP
Optimising clinical systems and enabling patients to self-monitor, to aid the early identification and timely management of deteriorating patients (including those with Covid-19) in the community is a critical step in reducing avoidable deaths from all conditions.
Source: AHSN Network