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COVID-19 has necessitated the implementation of innovative health care models in preparation for an influx of patients. A virtual ward model delivers clinical care remotely to patients in isolation. We report on an Australian cohort of patients with COVID-19 treated in a virtual ward.
The aim of this study was to describe and evaluate the safety and efficacy of a virtual ward model of care for an Australian cohort of patients with COVID-19.
Retrospective clinical assessment was performed for 223 patients with confirmed COVID-19 treated in a virtual ward in Brisbane, Australia, from March 25 to May 15, 2020. Statistical analysis was performed for variables associated with the length of stay and hospitalization.
Of 223 patients, 205 (92%) recovered without the need for escalation to hospital care. The median length of stay in the virtual ward was 8 days (range 1-44 days). In total, 18 (8%) patients were referred to hospital, of which 6 (33.3%) were discharged after assessment at the emergency department. Furthermore, 12 (5.4%) patients were admitted to hospital, of which 4 (33.3%) required supplemental oxygen and 2 (16.7%) required mechanical ventilation. No deaths were recorded. Factors associated with escalation to hospital care were the following: hypertension (odds ratio [OR] 3.6, 95% CI 1.28-9.87;
Our results suggest that a virtual ward model of care to treat patients with COVID-19 is safe and efficacious, and only a small number of patients would potentially require escalation to hospital care. Further studies are required to validate this model of care.
On March 11, 2020, the World Health Organization declared COVID-19, a respiratory infection due to SARS-CoV-2, as a global pandemic [
To provide care to patients safely and effectively through a virtual care model, it is important to understand the clinical course of COVID-19 [
Predictors of disease exacerbation during acute COVID-19 have been proposed in early retrospective cohort studies on patients with COVID-19 pneumonia or severe disease [
The aims of this study were as follows: (1) to describe the clinical characteristics of an Australian cohort of patients with COVID-19, (2) to evaluate the clinical care provided to this cohort through a virtual ward model, and (3) to identify any possible predictors of deterioration.
A retrospective single-center clinical assessment was performed for patients admitted to the Metro North Virtual Ward from March 25 to May 15, 2020. This study was deemed at low/negligible risk by the Royal Brisbane and Women’s Hospital Human Research Ethics Committee. No formal power calculations were performed, owing to the inclusion of all patients meeting the study criteria.
All patients admitted to the virtual ward during the specified period were assessed in accordance with the following inclusion criterion: a laboratory-confirmed diagnosis of COVID-19 through polymerase chain reaction (PCR) detection of SARS-CoV-2 RNA on a diagnostic nasopharyngeal swab (NPS). Patients were excluded if they had a preliminary positive or inconclusive PCR result but a negative result on subsequent confirmatory PCR testing. Patients were admitted to the virtual ward from the community after notification of a positive PCR result by the Metro North Public Health Unit, Herston, Australia, or following hospital discharge, in cases of confirmed disease.
Patients remained in out-of-hospital isolation during their virtual ward admission with nursing observations obtained through telephonic consultations. Virtual ward staff were located in a secure dedicated hospital workspace with medical records maintained in accordance with local hospital procedures and protocols. Patients were risk-stratified by age, comorbidities, and symptom burden to determine the frequency of telephonic consultations: low-risk patients, once daily; high-risk patients, twice daily. Observations were structured to monitor patient symptoms and identify potential deterioration. During each consultation, patients were asked to rate (on a scale of none, mild, moderate, or severe) the following symptoms: shortness of breath, cough, fatigue, sputum production, nausea/vomiting, headache, myalgia, and sore throat. These symptoms were numerically scored at each review. Patients’ general well-being, social situation, and adherence to isolation were also assessed.
Clinical reviews were conducted by medical officers when the following prespecified escalation criteria were met: (1) the patient reported severe symptoms related to shortness of breath, cough, or fatigue; (2) symptoms became more severe either on 1 observation of patients aged >65 years and having comorbidities or over 2 observations in those without comorbidities; or (3) any staff or patient concerns regarding disease exacerbation. If required, hospital referral was arranged for further assessment. All patients were reviewed by a medical officer prior to discharge. Multidisciplinary care was provided, with pharmacists ensuring patient access to medications and social workers offering psychosocial support.
In accordance with the Communicable Diseases Network Australia (CDNA) COVID-19 guidelines [
Data on patient demographics, epidemiological history, comorbidities, medication history, COVID-19 symptoms, clinical reviews, pathology results, hospital assessment, and treatment outcomes were collected from existing medical records.
We expressed descriptive statistics as number (%) values for categorical data and median or mean (range) values for continuous variables. We performed Pearson
A total of 223 patients with a median age of 45 (range 14-78) years (female n=118, 52.9%) were assessed in this study (
Baseline characteristics of the study population (N=223).
Characteristics | All patients | Patients not referred to hospital (n=205) | Patients referred to hospital (n=18) | |
Median age, years (range) | 45.0 (14-78) | 42.0 (14-78) | 54.0 (23-71) | |
Female sex, n (%) | 118 (52.9) | 108 (52.7) | 10 (55.6) | |
High riska, n (%) | 63 (28.3) | 54 (26.3) | 9 (50) | |
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Overseas travel | 178 (79.8) | 167 (81.5) | 11 (61.1) |
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Contact with a confirmed case | 47 (21.1) | 43 (21) | 4 (22.2) |
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Locally acquired | 43 (19.3) | 35 (17.1) | 8 (44.4) |
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Unknown | 3 (1.3) | 3 (1.5) | 0 (0) |
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Any | 100 (44.8) | 87 (42.4) | 13 (72.2) |
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Hypertension | 38 (17) | 31 (15.1) | 7 (38.9) |
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Asthma | 24 (10.8) | 23 (11.2) | 1 (5.6) |
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Diabetes mellitus | 13 (5.8) | 12 (5.9) | 1 (5.6) |
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Immunosuppressionb | 6 (2.7) | 5 (2.4) | 1 (5.6) |
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Chronic obstructive pulmonary disease | 3 (1.3) | 3 (1.5) | 0 (0) |
Medication (angiotensin-converting enzyme inhibitors angiotensin II receptor blockers, total 135), n (%) | 25 (11.2) | 19 (9.3) | 6 (33.3) | |
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Cough | 163 (73.1) | 149 (72.7) | 14 (77.8) |
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Fever | 117 (52.5) | 104 (50.7) | 13 (72.2) |
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Headache | 103 (46.2) | 97 (47.3) | 6 (33.3) |
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Sore throat | 97 (43.5) | 90 (43.9) | 7 (38.9) |
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Fatigue | 84 (37.7) | 74 (36.1) | 10 (55.6) |
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Rhinorrhea | 82 (36.8) | 76 (37.1) | 6 (33.3) |
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Myalgia | 78 (35) | 70 (34.1) | 8 (44.4) |
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Shortness of breath | 52 (23.3) | 46 (22.4) | 6 (33.3) |
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Nausea/vomiting | 37 (16.6) | 33 (16.1) | 4 (22.2) |
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Diarrhea | 37 (16.6) | 35 (17.1) | 2 (11.1) |
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Anosmia | 36 (16.1) | 35 (17.1) | 1 (5.6) |
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Ageusia | 30 (13.5) | 27 (13.2) | 3 (16.7) |
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Sputum | 24 (10.8) | 18 (8.8) | 6 (33.3) |
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Arthralgia | 24 (10.8) | 19 (9.3) | 5 (27.8) |
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Chest tightness | 20 (9) | 17 (8.3) | 3 (16.7) |
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Initial assessment by a medical practitioner, n (%) | 100 (44.8) | 90 (43.9) | 10 (55.6) |
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Initially admitted to hospital prior to virtual ward admission, n (%) | 32 (14.3) | 29 (14.1) | 3 (16.7) |
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Median time from symptom onset to initial nasopharyngeal swab (n=177), days (range) | 4 (0-23) | 4 (0-23) | 1 (0-5) |
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Median cycle threshold of polymerase chain reaction analysis of initial nasopharyngeal swabs (n=135) (range) | 23.88 (11-36) | 24.00 (11-36) | 18.04 (14.6-33) |
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Chest radiography, n (%) | 21 (9.4) | 20 (9.8) | 1 (5.6) |
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Blood tests, n (%) | 22 (9.9) | 21 (10.3) | 2 (11.1) |
aHigh risk was defined as age 65-85 years with any comorbidity or age 49-65 years with chronic lung disease, cardiovascular disease, immunosuppression, diabetes, or hypertension.
bImmunosuppression was defined as patients taking immunosuppressive medication or having a primary immunodeficiency.
Cases epidemiologically linked to overseas or interstate travel (n=178). *Others: Argentina, Cuba, Egypt, Hong Kong, Indonesia, Japan, Myanmar, Norway, the Philippines, Singapore, South Africa, Sweden, Turkey, and the United Arab Emirates.
Of the 223 patients in the virtual ward, 205 (92%) were discharged after clinical recovery without escalation to hospital care (
Several factors were associated with a length of virtual ward stay >7 days. These included having any comorbidity (OR 2.0, 95% CI 1.15-3.40;
Virtual ward patient outcomes (N=223).
Outcome | Patients |
Median length of stay, days (range) | 8.0 (1-44) |
Median time to clinical recoverya, days (range) | 16 (10-52) |
Discharged without complication, n (%) | 205 (91.9) |
Requiring hospital assessment, n (%) | 18 (8.1) |
Admitted to the in-patient ward, n (%) | 12 (5.4) |
Mean length of in-patient hospitalization, if admission to the intensive care unit was not requireda, days (range) | 3.5 (1-15) |
Admitted to the intensive care unit, n (%) | 2 (0.9) |
Mortality, n (%) | 0 (0) |
aTime from symptom onset to clinical recovery in accordance with the Communicable Diseases Network Australia guidelines (at least 10 days since symptom onset and 72 hours of being asymptomatic).
Clinical characteristics of patients requiring hospital care upon admission to the virtual ward (N=18).
Characteristics | Hospitalized patients | |||
Median age, years (range) | 54 (23-71) | |||
Female sex, n (%) | 10 (55.6) | |||
High riska, n (%) | 9 (50) | |||
Median day of illness upon referral to hospital, days (range) | 8.50 (3-20) | |||
Previous medical review on initial presentation, n (%) | 10 (55.6) | |||
Initial median polymerase chain reaction cycle threshold on diagnostic nasopharyngeal swab tests, n (range) | 18.04 (14.61-33) | |||
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Shortness of breath | 10 (55.6) | ||
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New or ongoing fevers | 4 (22.2) | ||
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Chest pain or chest tightness | 3 (16.7) | ||
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Median oxygen saturation (n=13), % of ambient air (range) | 96 (88-100) | ||
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Median heart rate (n=10), beats per minute (range) | 80 (57-105) | ||
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Median respiratory rate (n=9), breaths per minute (range) | 19 (16-28) | ||
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Fever (>37.5°C; n=11), n (%) | 4 (22.2) | ||
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Clear | 9 (60) | |
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Unilateral crackles | 2 (13.3) | |
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Bilateral crackles | 4 (26.7) | |
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No acute abnormality | 8 (53.3) | ||
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Unilateral consolidation | 2 (13.3) | ||
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Bilateral consolidation | 2 (13.3) | ||
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Elevated lactate dehydrogenase (n=15) | 9 (60) | ||
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Elevated C-reactive protein (n=6) | 5 (83.3) | ||
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Lymphopenia (n=16) | 4 (25) | ||
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Assessed at the emergency department and discharged | 6 (33.3) | ||
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Admitted to the in-patient ward | 12 (66.7) | ||
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Prescribed antibiotics | 8 (44.4) | ||
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Required supplemental oxygen upon admission | 4 (22) | ||
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Admitted to the intensive care unit | 2 (11.1) | ||
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Received mechanical ventilation | 2 (11.1) | ||
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Mortality | 0 (0) | ||
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Liver function derangement (n=16) | 6 (37.5) | ||
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Respiratory failure | 3 (16.7) | ||
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Acute kidney injury (n=13) | 3 (23.1) |
aHigh risk was defined as age 65-85 years with any comorbidity or age 49-65 years with chronic lung disease, cardiovascular disease, immunosuppression, diabetes, or hypertension.
In total, 18 patients with a median age of 54 (range 23-71) years (females: n=10 [55.6%]; high-risk: n=9 [50%]) were assessed in hospital upon virtual ward admission (
On hospital presentation, 4 (22%) patients had fever, and 4 (22%) had hypoxia and required supplemental oxygen on or shortly after presentation. Of the 18 patients presenting to hospital, 16 (88.9%) most commonly had an elevated lactate dehydrogenase level, liver function derangement, an elevated C-reactive protein level, or lymphopenia on blood tests. Furthermore, 15 (83.3%) patients underwent chest radiography, of which 4 (26.7%) had features of consolidation
Several possible predictors of deterioration associated with escalation of care were identified, including the presence of hypertension (OR 3.6, 95% CI 1.28-9.87;
This retrospective study describes the characteristics and clinical course of an Australian cohort of patients with COVID-19 treated in a newly established virtual ward. To our knowledge, this is the first study to evaluate a community virtual ward model for patients with COVID-19 and the largest clinical assessment of patients with COVID-19 in Australia to date.
Epidemiologically, most cases were attributed to overseas travel, particularly to the United Kingdom, the United States, or cruise ships, consistent with a previous report from Australia [
Our results suggest that a virtual ward model is safe for patients with COVID-19. Overall, 205 (92%) patients recovered without escalation to hospital care. Furthermore, 18 (8.1%) patients required hospital assessment, of which only 12 (5.4%) were admitted to hospital and 2 (0.9%) were admitted to the ICU. This reflects a lower severity of COVID-19 in our cohort (0.9%) compared to that reported previously (5%) [
Timely identification of disease exacerbation is imperative for safe virtual care. Several studies have reported high diagnostic agreement between virtual and in-person consultations [
Our hospital-referred patients had a higher median age of 54 (range 14-78) years, being referred to hospital at a median of 8.5 days (range 3-20 days) into their illness. Preexisting hypertension, a proposed risk factor for severe COVID-19, was associated with a 3.6-fold increase in hospitalization rates. Initial symptoms of sputum production and arthralgia were associated with hospital referral, which have not been previously reported. Patients with a PCR Ct for SARS-CoV-2 RNA of ≤20 on diagnostic NPS were 5-fold more likely to be referred to hospital. Although a lower Ct indicates a higher RNA sample quantity, the implication of this value for disease progression is unclear. Further studies are required to validate these findings.
The 2 (0.9%) patients admitted to the ICU had risk factors associated with severe COVID-19 [
The limitations of this study include its observational design and retrospective data collection, which resulted in missing data across several variables reported herein. Few patients in our cohort had severe COVID-19. There may have been an ascertainment bias as patients with more severe COVID-19 may have been directly admitted to hospital for the duration of their illness, bypassing the virtual ward.
To our knowledge, this is the largest cohort study of COVID-19 patients in Australia to be described to date and the first to evaluate a virtual ward model of care. This study provides evidence regarding the safety and feasibility of a virtual ward setting to treat patients with COVID-19. Further studies are needed to identify the early predictors of COVID-19 exacerbation and to validate this health care model.
acute respiratory distress syndrome
Communicable Diseases Network Australia
cycle threshold
intensive care unit
nasopharyngeal swab
odds ratio
polymerase chain reaction
We acknowledge all the staff involved in the design, implementation, and delivery of care at the Metro North Virtual Ward. We thank the Metro North Emergency Operations Centre, executive staff, and the Metro North Public Health Unit involved in the COVID-19 response.
OF, EM, and OS collected and analyzed the data and drafted the manuscript. GW and CB contributed to data interpretation and critically revised the manuscript. All authors designed the study, critiqued the manuscript, and approved the final version for submission.
None declared.