Virtual wards to safely treat atrial fibrillation could prevent thousands of hospital admissions per year and help patients recover faster and more comfortably at home, according to the results of a pioneering project in Leicester that’s seeing significant expansion. Saša Janković and Helena Beer explain.

Atrial fibrillation (AF) is the most common arrhythmia seen in clinical practice, affecting approximately 2-3% of the UK population – around 1.5 million people – and the numbers are rising as the population ages.

Between 2001 and 2017 there were nearly 11.3 million hospital admissions for AF in England alone, yet for many non-complex cases, it may be possible to provide hospital-level care in a patient’s own home if the facility of a virtual ward were to be available.

While virtual wards existed for conditions such as chronic obstructive pulmonary disease, none had been established specifically for cardiology patients until inspiration struck the team at Leicester’s Glenfield Hospital during the Covid-19 pandemic.

Now, their virtual ward model for patients with AF is being further extended to include three other NHS sites around the country, with the aim of creating an adaptable blueprint for nationwide implementation.

Getting the AF virtual ward project off the ground

The Leicester AF virtual ward, led by principal investigator and academic cardiologist Professor André Ng, was the first of its kind to treat acute AF patients safely and effectively in their own homes using digital ECG technology and a remote care platform.

‘The project started in 2021 when my team examined 211 patients admitted to the hospital over two months with a diagnosis of AF and found 105 had AF alone, with no other complicating conditions, which made us think they would be ideal for managing in a virtual ward,’ Professor Ng explains.

The project gained momentum through a combination of local innovation funding and academic support. Initial seed funding came from the local clinical commissioning group (now integrated care board) and the Biomedical Research Centre, followed by a Digital Healthcare Partnership Award from NHS X. An additional evaluation fund from the Health Innovation Network enabled crucial early independent assessment of the model’s safety and effectiveness.

‘The funding was key for us,’ says Sue Armstrong, advanced clinical practitioner and clinical lead of the AF virtual ward. ‘It meant we could employ advanced nurse practitioners to work within the service so that we could progress and increase our numbers substantially.’

Reimagining AF care

During a pilot trial between January 2022 and January 2023, the service prevented 127 unplanned hospitalisations and saved an estimated 444 hospital bed days.

The model works specifically for patients with AF and fast heart rate as their primary presenting condition, once other serious pathologies such as heart attacks, lung clots, severe infections or other acute conditions requiring hospital treatment have been ruled out. The team is very clear about the boundaries of what can be safely managed remotely.

Patients are discharged with a comprehensive kit including an ECG recorder, a Bluetooth-enabled blood pressure monitor and a pulse oximeter, all connected to a digital platform via smartphone or tablet. They submit readings daily, with continuous access to specialist clinical advice during working hours, twice-daily virtual ward rounds and clear escalation pathways outside those times.

A multidisciplinary team structure further underpins the model’s clinical rigor, with Sue and Professor Ng supported by three advanced nurse practitioners with extensive cardiology experience who manage the day-to-day patient care including medication titrations and monitoring.

Technological support

Technology sits at the heart of the virtual ward model, but Sue says any initial patient scepticism typically dissolves once the system is demonstrated.

‘We do see some patients who are worried they are not very good at technology,’ she acknowledges. ‘But when you demonstrate the platform and actually show them how to use the kit and the tablet, it’s very intuitive. We provide hands-on training before patients leave the hospital and are available to talk patients through any difficulties by phone if they prefer.’

In one notable example, the team successfully looked after a 96-year-old woman at home, who, with minimal support from her son, was able to navigate the technology and successfully submit readings. ‘We managed to keep this lady at home who was relatively independent at the age of 96, able to still do her own cooking and washing and everything else she wanted to do, so she wasn’t in hospital becoming deconditioned,’ Sue recalls.

However, the digital infrastructure itself has presented unforeseen challenges. The original platform provider withdrew from the UK market mid-project, forcing a painful data migration and switch to a new system. ‘That was a big learning for us about digital platforms,’ says Professor Ng. ‘Now, we regularly back up data and prepare for potential provider changes – and we’ve learned that you can’t presume that the platform is going to stay there forever.’

With a move to a third platform imminent, the team has implemented a robust archival process by ensuring that all the data and discharge summaries are downloaded properly and married up with the electronic patient record to keep indefinitely for review as necessary and for informing further development and research.

Measurable impact of the AF virtual ward

The virtual ward’s impact has exceeded initial expectations, particularly in preventing hospital admissions by enabling patients to have hospital specialist care in their own home.

Over the past three and a half years, the team has treated more than 700 patients, and analysis of the data revealed a striking pattern.

‘When we looked at our first 200 patients, about 60% were actually patients from outpatient settings. They presented with fast AF while attending the same-day emergency care unit, emergency department, outpatient routine clinic visits, or echo and ECG appointments. Without the virtual ward they would have been admitted to a hospital bed, but because of the virtual ward, they didn’t need to be,’ says Professor Ng. ‘This finding has remained consistent across the current 700-patient cohort we have seen so far, with 58% coming from outpatient settings. By avoiding these hospitalisations, the bed-day savings is not zero, it’s minus, because we didn’t even have to use a bed.’

For patients who do step down from hospital wards, the virtual ward significantly reduces length of stay. ‘Traditional AF admissions typically last two to five days, which the virtual ward eliminates by enabling early discharge. However, the true value extends beyond bed-day savings to encompass the entire patient pathway,’ says Professor Ng.

In fact, an external evaluation funded by the Health Innovation Network showed that the virtual ward was at least as safe as traditional care at 30 days, with patients even faring better at 90-days post-discharge, Professor Ng explains.

‘Plus, population studies have shown that 60% of the AF healthcare cost is for hospitalisation costs, whether it is admissions or attendance and investigations,’ he adds, highlighting substantial financial benefit in addition to better patient outcomes.

Optimising the patient journey

Beyond the numbers, the virtual ward has fundamentally disrupted the traditional patient journey. ‘Approximately 50% of virtual ward patients proceed to procedures such as cardioversion or ablation within 12 weeks – remarkably fast given NHS waiting times often exceed 12 months,’ says Professor Ng.

Sue adds: ‘It’s not because we’re getting those patients jumping the queue, it’s because we’re optimising their care from day one, preventing prolonged delays that characterise traditional AF management, while also reducing repeat emergency presentations.’

With all of these benefits, it’s no surprise that patient response to the virtual ward has been positive. ‘Patients were delighted with it from day one because of the opportunity to go home, be with their relatives, and send their readings twice a day,’ Sue explains. ‘The Friends and Family Test consistently returns strong approval ratings, with patients particularly valuing the personalised care and direct access to specialist expertise.’

Implementation challenges

In addition to the platform migrations, the team faced other challenges in implementing the virtual ward.

‘Especially at the beginning there was definitely scepticism from colleagues because it’s a new pathway,’ Professor Ng recalls. ‘People said, “do we really need this?”’

Sue acknowledges an element of naivety at the beginning and a lack of understanding about how labour intensive the project would be.

‘The reality is that only two of the four advanced clinical practitioners are funded through the virtual ward,’ she says. ‘The others have redistributed their existing roles across the seven-day service,’ which adds an extra layer of complexity that needs careful management.

In addition, funding sustainability remains a challenge and Professor Ng says that virtual wards have got to continually justify their worth.

However, the evidence of the pilot project’s success led to the receipt of £312,000 funding from the British Heart Foundation’s Healthcare Innovation Awards earlier this year, which has enabled Professor Ng and his team to expand the project so more patients can benefit.

Replicating and scaling the project

Their Multicentre Atrial fibrillation Virtual ward Implementation Across NHS Hospital Sites (MAVIA-NHS) study is now examining the model’s replicability across different hospital settings.

Research manager Rachel Hobson leads the governance and regulatory work for the latest research project. She is based at the University of Leicester, along with project manager Sarah Anthony who coordinates the evaluation across four hospitals: Chelsea & Westminster Hospital, Royal Bournemouth Hospital and Chesterfield Royal Hospital, as well as host Glenfield Hospital.

The other three hospitals were selected as they had existing projects in place that were similar to the Leicester AF virtual ward, which meant they were ready to start for the timeframe of the two-year funding.

‘They're all different kinds of hospitals, so we've got tertiary centres and district general hospitals, some have a more generic virtual ward treating up to 12 different conditions, and some have a wider cardiology virtual ward that also treats heart failure,’ explains Sarah. ‘They're also at different stages and have different digital platforms that they use – one site doesn’t actually use a digital platform at the minute, although they’re onboarding one pretty soon.’

National ambitions for the AF virtual ward

This diversity means a range of different metrics and insights can be gathered to scale the project even further. The team is currently establishing patient and public involvement work at each site.

‘We want to understand on the ground the patient and carers feedback from their individual settings as well, because the geographical spread and just the nature of the population that each of those sites served would be vastly different,’ says Rachel.

As such, the ultimate goal is not a single prescriptive blueprint, but a flexible AF virtual ward framework that could be rolled out nationwide and be tailored to different organisational contexts.

‘Let’s start simple,’ says Professor Ng. ‘We believe in this new patient pathway in the way that we’ve set it up, so hopefully we will see this being adopted by all NHS hospitals.’

With AF admissions increasing by approximately 100 patients annually in Leicester alone, and the condition affecting 1.5 million people across the UK, the potential impact of widespread implementation is substantial – watch this space.