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MSGM Case discussion July 2024

Navigating the Virtual Ward: A Case Journey

Prepared by: Dr Amanda Goh Mae Ching

Supervisor: Dr Khor Hui Min

Location: Pusat Perubatan Universiti Malaya


Mdm K, 72 years old lady


UNDERLYING

  • Intermitted complete heart block on pacemaker

  • Paroxysmal atrial fibrillation

  • Senile cataract

  • History of fragility fracture (L3 compression fracture) in 2021 started on S/C Teriparatide since September 2021


Recent hospitalization in December 2023 for decompensated heart failure secondary to parainfluenza pneumonia.

  • Presented with worsening exertional dyspnea for 3 days associated with productive cough, lethargy and reduced appetite

  • Pro BNP: 4468 • Highest oxygen requirement was facemask 5L/min. No intubation/ ICU admission required.

  • She was discharged home well with an outpatient ECHO appointment and cardiology clinic appointment in March 2024

Total length of hospitalization was 9 days.


DRUG HISTORY

  • T Rivaroxaban 15mg OD

  • T Bisoprolol 1.25mg OD

  • T Perindopril 8mg OD

  • T Atorvastatin 40mg ON

  • T Amlodipine 10mg OD

  • T Frusemide 20mg PRN

  • T Calcium carbonate 500mg BD

  • Oral Cholecalciferol 50000u monthly

  • S/C Teriparatide 20mcg OD


PREMORBID CONDITION

Clinical Frailty Score: 6


bADL

- Semi dependent

- Requiring assistance with bath/

toilet needs

- Able to eat on her own when food

being prepared



iADL

- Fully dependent

- Medications are handled by her

daughter - Able to help out in the kitchen in

sitting position such as peeling/

cutting vegetables

- Unable to use smartphone

Cognitive

- Daughter noticed that she has been

asking repetitive questions

- Forgetful and misplaces her things

- Able to engage in complex

conversation

Mood and Behaviour

- Appear happy and cheerful most of

the time

Continence

- Dual continence

- Nocturia 2-3x/night

Mobility / Fall

- Ambulating with 1 person assist

within short distance at home

(refuse for walking aids)

- Homebound

- No recent history of fall

Diet

- Takes a balance diet with good

portion of vegetables and meat

- No recent loss of weight

Sensory impairment

- Hearing impairment (Left > Right)


SOCIAL HISTORY

Widower

Housewife

Blessed with 4 children

Living with her youngest daughter (Main Carer) in a double-storey terrace house at Petaling Jaya – room in on the ground floor with an ensuite bathroom


PRESENTATION

Presented to Geriatric Clinic 6 weeks post discharge with complaint of worsening

orthopnea, bilateral lower limb swelling and reduced effort tolerance for 1-week duration. She has been compliant to her medications and restriction of fluid ~800ml-1L/day since being discharged home. Denied any cough, fever, chest pain but she felt lethargy with generalized weakness. Unable to ambulate to the toilet and has been on diapers for the past 3 days. Blood test investigation revealed potassium level of 2.4mmol/L and Chest X-ray had evidence of mild bilateral pleural effusion and cardiomegaly.


PHYSICAL EXAMINATION

Alert, orientated with place/person and time, not in respiratory distress with respiratory rate of 16 breaths/min, good hydration, good peripheral perfusion.

  • BP: 134/75mmHg

  • PR: 100 beats/minute

  • T: 36.6 degrees Celcius

  • SpO2: 94% under room air

  • Capillary blood glucose: 4.7mmol/L


  1. Cardiovascular: Grade 3 Systolic murmur heard over LLSE, S1S2 heard

  2. Respiratory: Fine crepitation over bilateral lower zone

  3. Abdominal: soft, no tenderness, no hepatosplenomegaly/ mass palpable, no ascites, bowel sound present

  4. + Pedal edema up to knee level bilaterally with no overlying skin changes


INVESTIGATIONS

  1. Renal Profile:

2. Liver Function Test

3. Complete Blood Count

HbA1c: 5.3%

UFEME: no abnormalities


Chest X-Ray

ECG:



Echocardiogram:

  • LV normal in size. Left ventricular hypertrophy.

  • Normal LV systolic function.

  • LVEF 69%

  • No regional wall motion abnormalities

  • Dilated right ventricle. Pacemaker lead seen in situ. Normal RV systolic function.

  • Enlarged left and right atrium

  • Trivial mitral regurgitation

  • Moderate tricuspid regurgitation

  • Mild aortic regurgitation

  • Mild to moderate pulmonary regurgitation

  • No pericardial effusion


PATIENT PROGRESS

  1. Patient was diagnosed with decompensated heart failure secondary to suboptimal diuretics and hypokalemia. During her admission to the geriatric ward, she received correction of potassium level and intravenous diuretics. Her antihypertensives were withheld due to borderline hypotension.

  2. Throughout this hospitalization, highest oxygen requirement was facemask 5L/min and managed to taper down to nasal prong 2L/min with SpO2 94%. Despite improvement in symptoms, her oxygen level would fluctuate to 88% on air.

  3. On day 5 of admission, patient was assessed for suitability to transfer to the Virtual Ward for continuation of care.


Criteria for transfer to virtual ward include the following:-

- Patient 65 years

- Carer support

- Access to smartphone/internet

- Living within 15km radius from PPUM


Exclusion criteria:-

- Acutely ill (High Early Warning Score)

- Requiring parenteral treatment

- Oxygen supplement – case to case basis

- Daily nursing and therapy input

- Consults from other specialties

- Cognitive impairment- case to case basis


VIRTUAL WARD JOURNEY

On day 6 of admission, Mdm K was admitted to virtual ward at home.

- Daily virtual ward round was conducted in the morning via Google meet video

conferencing by the medical specialist to review patient’s symptoms and advise on titration of medication and oxygen level. Patient was accompanied by her daughter (main carer) as well as her son who is living in Johor.

Daily virtual ward consultation


- Regular vital signs monitoring of blood pressure, heart rate, SpO2 and temperature was performed by patient’s carer every 6 hourly which will automatically be fed into the hospital’s electronic monitoring system. If vital signs monitoring was incomplete, reminder via telephone call will be conducted by the nursing staff.

- 24-hour nursing support was available and contactable via Whatsapp message or phone call.

- While weaning her off oxygen support, Mdm K was haemodynamically stable and T Spironolactone 12.5mg OD was introduced as part of her heart failure management.


  • Vital sign monitoring equipment and electronic dashboard.

Patient successfully weaned off oxygen support after 5 days of virtual ward admission and was subsequently discharged on day 6.


Her discharge medications:

  • T Atorvastatin 40mg ON

  • T Bisoprolol 1.25mg OD

  • T Rivaroxaban 15mg OD

  • T Perindopril 2mg OD

  • T Spironolactone 12.5mg OD

  • T Calcium carbonate 500mg BD

  • Oral Cholecalciferol 50000u monthly

  • T Frusemide 20mg OD

  • S/C Denosumab 60mg 6 monthly

Mdm K expressed heartfelt gratitude for the virtual ward, appreciating the convenience and comfort of receiving medical care in the familiar surroundings of her own home. Family’s feedback was: "The whole virtual experience was amazing! We could seek for help easily.. Virtual ward is great to have and patient get to rest at the comfort of their home.. ”


Total duration of admission: 6 days in hospital, 5 days in virtual ward.


DISCUSSION

  1. How can we prevent future readmission for Mdm K with HFpEF and frailty score of 6?

  2. What are the key benefits, both to patients and healthcare institutions, of having a virtual ward service?

  3. What are the essential ingredients or components needed to successfully develop a virtual ward service?

  4. What could be the challenges faced when creating such a model of care?


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