Inpatient care and treatment - virtual capacity: interview findings

Methodology

This section provides an overview of the methodology used in this report. Part one describes the qualitative interviews undertaken with pathway representatives and part two details the rapid evidence review process.

Part 1: Qualitative Interviews

Qualitative interviews with staff working on key VC pathways were undertaken in to order to better understand the nature and development of Virtual Capacity pathways in Scotland. The pathways are: Connect Me (which includes covid remote health monitoring which is focused on in this report), Hospital at Home, Heart Failure, OPAT, and Respiratory.

Two key research questions were developed to guide the interviews and are as follows:

1. How have the five VC pathways developed in Scotland?

2. What are the barriers to implementing VC in Scotland?

Semi-structured interviews were conducted with six representatives from the five pathways in March and April 2023. The participants who engaged in the interviews had detailed knowledge at a strategic level, as well as understanding of implementation within the respective pathways. Participants were also asked to review the content of the findings and provided additional information following the interviews via email. It should be noted that the interviews were not designed to be representative, but instead to provide an in depth understanding of the pathways from key experts in the area. Members of the Hospital at Home expert working group also provided feedback.

The Scottish Government social researcher ethics checklist and the Health Research Authority (HRA) decision tool were completed. This piece of work constitutes evaluation and therefore National Research Ethics Service (NRES) ethical approval was not required.

The interviews were conducted via Microsoft Teams and participants provided consent to these being recorded. The questions focused on the nature and development of the pathways to generate understanding of the Virtual Capacity landscape in Scotland. Questions also focused on barriers to implementation to elucidate what practical issues have impacted delivery.

The interviews were transcribed and thematically analysed. NVivo version 1.6.1 qualitative software was used to support coding. An inductive approach to coding was adopted and codes were subsequently deductively categorised as outer macro contexts, inner micro and meso contexts, outcomes, and innovation which relates to how VC and the pathways work. Due to the small number of participants, no demographic information or details of participant roles is provided to ensure anonymity.

The findings section related to the interviews begins with a case study description of each pathway before providing an overview of the main themes that were identified during analysis. Some literature has also been incorporated into the pathway descriptions to triangulate the findings.

Part 2: Rapid Evidence Review

This rapid evidence review examines whether VC services are effective at reducing the need for hospital admissions and lengths of stays (LoS), thereby enabling earlier discharge. It also examines how VC shapes patient experience. This review does not consider cost-effectiveness or safety as this was not within the scope of this research report. Furthermore, it focuses only the use of pulse oximeters for people with Covid-19, and not the wider Connect Me pathway.

The research questions that guided the evidence review were as follows:

1. Do VC services reduce numbers of bed days and/or other hospital resources?

2. Do VC services provide alternatives to hospital stay or reduce length of stay and enable earlier discharge?

3. Do VC services reduce readmissions and support admission avoidance?

4. How do patients experience VC services?

Two literature searches were conducted^[3] on VC in the UK, and where available, specifically Scotland. The following databases were searched: Idox, KandE, Knowledge Network, Policy Commons, ProQuest, and Google Scholar. Search terms included:

• Virtual capacity
• Hospital at Home
• Outpatient parenteral antimicrobial therapy, OPAT, infectious diseases, antivirals
• Respiratory pathway, respiratory programme, respiratory care, respiratory service
• Covid remote monitoring
• Cardiology
• Geriatrics
• Anti-virals
• UK, Britain, England, Wales, Northern Ireland, Scotland

Peer reviewed and grey literature papers published between 2017 and 2022 were included if they reported primary or secondary qualitative or quantitative evidence on at least one of the research outcomes (hospital readmissions, length of stay, hospital resources/bed days, and patient experience). No language restrictions were placed on the search.

With regards to limitations, assessment of methodological rigor was not conducted since as this was not a systematic review, although strengths and limitations in the research are reflected upon throughout, and this should be considered when reading the findings. Additionally, it is possible that empirical evidence for these areas was not identified in the search terms utilised for this piece of work or within the time period selected. The evidence is also predominantly focused on Scotland and the rest of the UK, resulting in wider international literature being excluded. It should also be noted that there are variations in terminology and how outcomes are measured. Finally, this report had a narrow focus on the use of pulse oximeters for covid remote monitoring, and therefore omits wider work being progressed through Connect Me.

Almost 200 publications were identified as part of the search and an additional 30 sources were identified by the authors^[4]. A review was also undertaken of literature available on the Healthcare Improvement Scotland (HIS) website. In total 233 studies were identified, with 42 meeting the inclusion criteria.

It should be noted that literature addressing the research questions was not always available for all five services. Table 1 shows the services which were covered by literature addressing each research question.