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.