Technology for diagnostic imaging typically takes months to deploy into a hospital.
But Barts Health NHS Trust and medical imaging provider, Sectra, launched a picture archiving and communication system (PACS) for the NHS Nightingale Hospital London in just three days, creating entirely-new ways of working for radiographers and radiologists at the frontline of the COVID-19 response.
Speaking to BBH Barts Health NHS Trust chief information officer, Sarah Jensen; said: “The trust embarked on a monumental technology programme when it took charge of creating the very-first NHS Nightingale field hospital at London’s Excel conference centre.
barked on a monumental technology programme when it took charge of creating the very-first NHS Nightingale field hospital at London’s Excel conference centre
“The informatics team quickly mobilised, alongside other colleagues in the trust, to deliver the technology required to make the 4,000-bed NHS field hospital work.
Delivered in an extremely-short window of time, the project saw digital patient records in place in five days, the delivery of an entirely-new hospital infrastructure, 26km of network cables, more than 500 switches, 4,500 PCs, specialist telephony, imaging modalities, printing for diagnostic labels, wristbands and patient labels for scanning, and an extensive integration of systems.
The complex imaging requirement
The Nightingale hospital needed a unique approach that required Barts Health to work with its imaging technology partner to deliver the PACS extremely quickly and to develop entirely-new ways of working.
Most hospitals typically manage approximately 20-50 intensive treatment unit beds. But the Nightingale needed technology capable of supporting imaging for 4,000 ITU beds, spread across a large site, and with the added complication of people using the system to manage a highly-infectious and deadly disease.
While most PACS deployments take several months, the team had just a couple of days.
And, while a hospital would ordinarily have time to train staff and familiarise them with the system; they had no staff to train at first as the unit was being built.
But the team did have things in its favour: including the fact they were treating a single condition, for which the majority of patients would only require a mobile chest X-ray. And there were no appointments to manage.
Creating a field hospital workflow
Jenson said: “We came up with a new field hospital workflow, eliminating standard steps and processes – all the things that could go wrong.
Considering staff spent time donning PPE before X-rays could be captured, our average turnaround time was 45 minutes for a chest X-ray to be completed and a further 45 minutes for the report
“In a standard radiology workflow requests are created in your order comms system. These are then sent to the radiology information system, or RIS, which receives requests and handles departmental workflow.
“Scans would then be booked in, with exams selected from a modality worklist and sent to the PACS.
“The radiographer then goes back to the RIS to confirm what they have performed, and enters radiation dose details. Only at that point is the status updated to complete.
“That’s fine in an ordinary setting, but in a setting with potentially 4,000 patients we needed to streamline the process significantly to prevent staff becoming overwhelmed.”
Eliminating RIS
Removing the RIS altogether from the perspective of the professionals carrying out examinations was the biggest win.
Jenson said: “Requests for exams were still generated through the EPR, but then immediately appeared on the imaging modality worklist without staff having to book the exam into RIS.
“We automated a great deal, meaning staff spent less time entering details.
“When requesting in the order comms system, all that staff entered was the reason they needed the exam. Everything else was pulled from the EPR. And ward information allowed the radiographer to find the patient without the RIS.”
Automatic forwarding of DICOM-structured reporting dose objects to the system used to track radiation exposure for patients also removed the need for radiographers to manually manage dosage.
We removed workflow stages for people under pressure in a challenging physical environment, where even using a phone was not easy
And eliminating the RIS eliminated the training need, so long as staff knew how to take an X-ray, they could do their job.
Jenson said: “Removing the RIS definitely helped speed things along and was very popular with radiographers.
“Considering staff spent time donning PPE before X-rays could be captured, our average turnaround time was 45 minutes for a chest X-ray to be completed and a further 45 minutes for the report.
“The whole process took just an hour and half – significantly faster than our six-hour turnaround target.”
More impressive still is that the total number of missing RIS (misfiled imaging) during the time Nightingale was in operation was zero.
Solving the imaging communication challenge
NHS Nightingale London became a huge field hospital and it could easily take 20 minutes just to walk from one end to another. Added to this, staff had to operate wearing PPE, and had to navigate ‘dirty’ areas. This posed significant communication challenges, something the team was able to use the PACS to start to overcome.
Jenson explains: “We removed workflow stages for people under pressure in a challenging physical environment, where even using a phone was not easy. Mechanisms in the PACS became invaluable.
“A chat window enabled radiologists and clinicians to send messages and for people delivering care to talk directly with the person who produced the report.
“And an information panel equipped staff with user guides, maps, and a phone directory.”
Lessons learnt
Critical results were managed in a new way at the Nightingale. In normal circumstances this involves securely emailing a referring clinician. But the Nightingale needed something more robust.
Sectra very quickly adapted its system, allowing radiologists to easily indicate critical findings requiring urgent action. That automatically triggered an email to a ward group and placed a flag in the worklist. And, straight away, everyone on the ward could see there was a critical result.
“In Nightingale things could become more urgent very quickly,” said Jenson.
“A button was created to allow people to escalate or descale an examination very quickly. It meant patients could be prioritised for all manner of different reasons – whether that’s potential turnaround time breaches, or clinical priorities.”
She added: “Going forward this escalation approach is likely to be of great value to workflow prioritisation post-COVID, outside of Nightingale, offering the potential for our other hospitals to better manage imaging for cancer referrals and imaging requests from other specialities.Going forward this escalation approach is likely to be of great value to workflow prioritisation post-COVID, outside of Nightingale, offering the potential for our other hospitals to better manage imaging for cancer referrals and imaging requests from other specialities
“The flexibility of the PACS enabled us to create a very-efficient workflow with minimum training and maximum efficiency. This was significantly aided by the agile response of all involved, including our industry partner that committed significant resource without charge to support our needs.
“People would come to us with requests, and we could reply ‘yes, we can do that’. We were able to do things people would not think were possible. We never got to test with 3,500 to 4,000 patients, but if it had, our new imaging set up would have held up.”