Exploring how a new way of managing crucial diagnostic images without the use of an RIS, devised for the London Nightingale COVID-19 hospital, is helping to solve bigger problems in other hospitals
NHS Nightingale hospitals were created at a remarkable pace in spring 2020.
But could the impact of these field hospitals, and new ways of working, be long lived?
When Barts Health NHS Trust was given the mandate to establish the very-first COVID-19 field hospital in London it was tasked with rapidly finding new ways to deliver vital hospital functions in extraordinary circumstances.
One of these functions related to the way crucial radiology imaging needed to be captured.
“We needed a new workflow for this environment,” said Brian Turner, who was the trust’s picture archiving and communication system (PACS) manager at the time.
“In a standard radiology workflow requests are created in your order comms system. They are then sent to the radiology information system (RIS).”
The RIS ordinarily handles departmental workflow, helping to book in scans and to send exams from the scanner with appropriate context to a PACS – the system used by staff to view and analyse patient imaging.
“The professional then goes back to the RIS to confirm what they have performed, enter dose details, and other pertinent information,” said Turner.
“And, while that’s fine in an ordinary setting; in a setting with potentially 4,000 ICU patients, we needed to streamline a lot.”
NHS Nightingale Hospital London – in effect a very-large intensive care unit – required mobile chest X-rays and point-of-care MRI scans to be carried out on patients.
With many Nightingale staff unfamiliar with the trust’s traditional RIS, an alternative way of managing imaging workflow was needed
“Staff were mobile and didn’t have access to tools to book patients in,” said Turner. “And, with many Nightingale staff unfamiliar with the trust’s traditional RIS, an alternative way of managing imaging workflow was needed.
“We had a lot of staff from different trusts and, in London, the Sectra PACS is very familiar, but very few staff had seen the Sectra RIS.
“We wanted to create a system where someone who knew how to take a chest X-ray could come in and deliver the goods. They didn’t need to know about RIS and they didn’t have to know how to log into it in order to book a patient in, or enter anything.”
Turner turned to the trust’s imaging technology provider, Sectra, to help.
Turner said: “We asked the question: Is there a way to get the worklist on the mobile machine populated as soon as the exams are requested through the order comms system?
“This is not a normal radiology or imaging workflow, but Sectra had that up and running in a couple of hours.”
Getting the workflow right at Nightingale was key to being able to deliver effective care.
Turner explains: “We were building this for 4,000 patients and even a one-minute saving on the clinical pathway would be really significant and make a huge difference in an ICU where it was a one-to-one match for patient and clinician due to the high acuity of patients.”
The process of removing the traditional RIS for NHS Nightingale Hospital London was certainly not typical of how a hospital runs, but it was not entirely without precedent.
In 2017, Salisbury NHS Foundation Trust faced challenges around mini image intensifiers – mobile imaging devices which were being used by the trust’s plastic surgeons to help them perform surgery on patients that had suffered hand injuries.
With surgeons not accustomed to using a RIS system, images captured by the devices were sent to the trust’s PACS without the patient information or corresponding order numbers traditionally supplied by the RIS.
This resulted in orphaned images appearing in the PACS that would have to be manually allocated to a patient record by a member of staff, creating additional work and potential for error.
With the RIS also being the trust’s means to track radiation doses, a potential lack of visibility of radiation doses administered by the mobile image intensifiers also became a point of concern.
The trust turned to its PACS supplier, Sectra, to create a standards-based modality worklist for the mini image intensifiers using messages directly from the trust’s order comms systems.
The trust used a system from Sectra, known as the Connectivity Hub, to enable the new process to work.
We were building this for 4,000 patients and even a one-minute saving on the clinical pathway would be really significant and make a huge difference in an ICU
With surgeons very familiar with the order comms systems for other routine tasks – such as ordering blood tests – this solved the challenge and with theatre staff no longer needed to use the RIS as an additional step in order for imaging to be appropriately sent to the PACS with necessary patient context, order numbers, dose information, and other required data.
It was this seemingly-routine response to a customer request that equipped Sectra with the knowledge to support the rapid requirement at the Nightingale hospital.
Since the new workflow has been adopted at NHS Nightingale Hospital London, Barts Health is now looking to adopt the process into other hospitals to support point of care testing, where the majority of clinicians capturing imaging will be unfamiliar with the RIS.
Barts Health is by no means the only trust to be doing this. One notable example is University Hospitals of Morecambe Bay NHS Foundation Trust.
Emma Jackson, the trust’s lead for digital imaging, explained that although the RIS is still essential for radiology; the potential of a RISless workflow now presents an opportunity to overcome pervasive challenges in bringing imaging from different diagnostic disciplines away from departmental silos and into the imaging record in the PACS.
“We have been looking for a way to get other ologies onto the PACS,” she said.
“Other ologies don’t use the RIS – they use the electronic patient record as their main workflow tool. To introduce an extra system, purely to get the images onto PACS, was just going to be a nightmare.
“We have been able to create a whole new workflow that bypasses the RIS. Any information goes straight from the EPR to the Sectra PACS.”
The potential demonstrated by the RISless process highlighted by the Nightingale approach is highly significant, said Jackson.
She adds: “We saw it had worked and we decided we wanted to do the same. This has opened up a whole new world for us.
“ It was going to be quite complicated beforehand. But this has made bringing more ologies into the PACS into a simple process.”
Staff at Morecambe Bay are already starting to put this into practice.
“Our tissue viability nurses are using the Sectra Uniview app to take photography using a RISless workflow,” said Jackson.
We saw it had worked and we decided we wanted to do the same. This has opened up a whole new world for us
“They would generate a request on the EPR, it then goes to the Sectra Connectivity Hub, which generates a folder for them to store the images.”
Initially a pilot project, three nurses are using tablets and mobile phones on the wards and uploading those images direct to the server from those devices.
“From a clinician point of view those images are all visible through the EPR,” said Jackson.
“The work Sectra has done with me to sort this out is brilliant – it fully automates everything and makes this really easy for the end users.”
Jackson wants to enable all nursing staff on the ward to start taking imaging as required with as little disruption for patients as possible.
“If a nurse is on the ward changing a dressing they can take an image as they are doing it. This means that staff on a ward round can view the images without the need to take off a fresh dressing.”
The development offers significant potential to alleviate pressure on medical photography teams and to allow them to focus time on more-complex and specialist work.
Demand is now spreading across the hospital to take advantage of this new way of working – with departments including A&E seeing the potential to capture images of wounds as patients arrive so staff can more easily see if the patient is progressing or deteriorating.
The work Sectra has done with me to sort this out is brilliant – it fully automates everything and makes this really easy for the end users
Jackson also sees potential for the new process to support work in the community.
“If we can make the system work securely outside of the trust, we can work with community staff for photography – and help to provide dermatology or wound care advice from consultants in the hospital to care homes, for example,” she said.
For Jackson, the new way of working is accelerating progress in creating a richer imaging record, with conversations already underway with colposcopy, hysteroscopy, ophthalmology, cardiology, and beyond the hospital in general practice.
In the case of the latter example, work is starting to ‘break down those barriers’, says Jackson, with the potential for patients themselves to provide images to GPs that can be fed to the hospital PACS for specialist opinion.
“We want to get expertise to patients that need it, wherever they may be,” she said.
“At the moment a lot of patients don’t want to come into hospital. Dermatologists can potentially look at the image, diagnose, and issue a prescription. For some cases this will be the only interaction the dermatologist needs.”
The possibilities, she said, are now very real.