Virtual Ward, Crisis Response Team and MDTs

The Sutton Community Virtual Ward offers a ‘wrap-around’ service to people in their homes, including in care homes, ensuring they receive care that meets their needs in a timely fashion with the aim of accepting early facilitated discharge from hospital, including those with COVID, therefore reducing length of hospital stay and avoiding hospital readmissions.

Led by the 4 Sutton Primary Care Networks and bringing together staff across Primary Care, Social Care, Community Services and Voluntary sector organisations.  The Virtual Ward is a Multidisciplinary Team of St Helier Hospital Consultants, Specialist Community Health and Care Professionals who, with the patient’s GP, work together to coordinate virtually the best wrap-around after-hospital care for patients including Remote Monitoring and Pulse Oximetry.

Interventions of Virtual Ward:

  • Intensive short-term support in patient’s home, 7 days a week, 8am-6pm, including bank holidays.  Service covered out of hours by on-call GP and Night Nursing (24/7). Referrals accepted 9am to 4pm.
  • 3 weekly VWRs – Every Monday, Wednesday and Friday starting at 13:30.  At the Virtual Ward Huddle at 08:30, the list of patients is prepared with the clinicians and the coordinators will then arrange the patient’s GP or representative to attend the ward round.  The coordinators will complete the Patient Summaries, which are checked by the chair and pharmacist.  They will also share the VCare remote monitoring records and complete/monitor Data gathering spreadsheets.
  • Virtual MDT ward rounds with GPs, Advance Nurse Practitioner/Clinicians, hospital consultants, other specialist professionals such as palliative care/heart failure/diabetes, social prescribing, phlebotomist, pharmacists and with links to proactive MDTs.
  • Pharmacy review – medicine management.
  • Review of patient management and escalation plan – accessible on EMIS records/Coordinate My Care/Remote Monitoring Dashboard.
  • Additional Core services including Social Prescribing, District Nursing and Mental Health access.

Referral Criteria

  • Patients with Complex Medical Care needs at high risk of readmission e.g. Cardiac Disease, COPD, Covid & Long Covid, Infections (Cellulitis, Pneumonia, Osteomyelitis, Urosepsis), Mental Health, Palliative Care, Social Care & Therapy needs
  • Frailty Syndrome: CFS 5-9​
  • ​Patients who would benefit from ongoing real time virtual monitoring
  • COVID patients – virtual ward supportive care, MDT discussion and Pulse Oximetry

How to Refer from GP/External 

Tel 0208 296 4111 or via [email protected] . Please state Pulse Oximetry or Virtual Ward on the referral form.

How to Refer from Hospital

Via Clinical Manager (iCM) -> Select Patient -> Orders -> Type ‘SUTTON COMMUNITY VIRTUAL WARD’ -> Complete Online Form -> Submit Form. Also, Email Discharge Summary & Discharge Medications to [email protected]

For any further information, please contact Alexandra Martin – email: [email protected].

en English

Members area