Hospital initiated and monitored pathways for managing acute on chronic conditions in the community
Coventry Guidance 
Heart Failure Pathway
Hospital at Home is a wraparound service providing medical support for the patient within the home environment rather than in the hospital when unwell.
It may also enable earlier discharge from the hospital, facilitating the patient to remain at home for treatment if this is the preferred place of care. The heart failure team will decide if this is safe.
About the Pathway
- The patient will be monitored remotely on a daily basis through the Docobo telemonitoring system and will be taught by a member of the Heart Failure Hospital at Home team on how to use this before being admitted to the Virtual Ward.
- The patient will feedback and upload observations (BP, heart rate, weight, temperature, and oxygen levels) by 9am each day.
- The Heart Failure Team (which includes Consultants and Heart Failure Specialist Nurses) will monitor patients daily.
- The Community Heart Failure Specialist Nurse will assess at least once.
About the treatment
- Intravenous diuretics administered once or twice a day,
- The Heart Failure Team will monitor patients daily, performing (and checking results of) regular blood tests at home to monitor renal function.
Patients will be given:
- BP monitor
- Pulse oximeter
- Thermometer
- Electronic tablet device (to answer short questions asking about how symptoms). If unable to work the Docobo system, paper documents an be used.
- Any hospital records and medical equipment will be supplied in a plastic box for storage.
Duration of the Heart Failure Pathway
Typically up to 10 days but is judged individually for each patient.
Complications
Monday- Friday: observations monitored by a member of the Heart Failure Virtual Ward Team.
If deterioration, an alert will be sent and the patient contacted to review symptoms and give clinical advice if required.
If concern during working hours Mon-Fri 9:00am – 4:00pm contact:
- Coventry Community Heart Failure Service 0300 3032444
- Rugby Heart Failure Team 01788 663944.
- If out of hours call 111, or in case of an emergency call 999.
Equipment doesn’t work or is broken?
Call the heart failure team or the number on the Docobo leaflet provided
Abnormal parameters
- Oxygen levels
- Respiratory rate
- Blood pressure
- Temperature
If parameters fall outside of the agreed range, patient contacts the Heart Failure Team (within working hours) or 111/999 out of hours.
Discharge from the Pathway Virtual Ward
GP will be informed and we the Team will arrange to pickup the equipment.
The patient will automatically be followed up 2 weeks after discharge from Hospital at Home by the Community Heart Failure Team.
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Rugby & South Warwickshire
North Warwickshire
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