Integration of ECG devices into existing electronic patient record systems: Countess of Chester Hospital NHS Foundation Trust

As part of the 23/24 wireless trial intake, NHS England collaborated with Countess of Chester Hospital NHS Foundation Trust to support upgrading their Electrocardiograph (ECG) Devices and automate integration with the existing Electronic Patient Record (EPR) system. This digitises the entire system of requesting ECG tests.

By using their wireless connectivity in this way, the trust can show

• elimination of redundant ECG tests
• up to 95% fulfilment rate for ECG requests Potential application to other medical observation devices

The Countess of Chester Hospital NHS Foundation Trust,one of the first foundation trusts in England, provides healthcare services to approximately 343,000 in the Chester and West Cheshire. Their trial aims to explore how medical diagnostic devices can update patient records and inform specialists automatically as tests are taken.

The trust upgraded to a new EPR system in 2021, allowing for the integration of diagnostic devices. This means results from bedside observations can be uploaded to a patient’s records as soon as they are complete. Examples of devices allowing for integration include haemodynamic observation machines and integrated anaesthetics machines.

This integration reduces operational risk and administrative time for clinicians. ECG machines, which record the electrical activity of a patient’s heart, are the main targets for integration into the EPR system. Integration supports diagnosis by facilitating the sharing of results with any clinician who needs to see them. Previously, results had to be manually transcribed, introducing significant risk of miscommunications or transcription errors. An earlier pilot by the trust explored ECG integration, but the initial operation was limited because test results were not visible on the device. This Wireless Trial investigates the selection and usage of ECG devices when integrated into the trust’s EPR system.

Following this initial pilot, the trust identified multiple device requirements:

• clear patient presentation user interface
• support for work orders
• sufficient patient data for pre-test check
• EPR integration, including result uploads
• adherence to cyber security and information governance standards

These requirements support the choice of devices that minimise patient risk whilst also improving clinical effectiveness by minimising administrative overhead.

User testing was performed with multiple devices to identify those that best meet these requirements, while also assessing usability and additional features of these devices. Clinical user buy-in was obtained early on to ensure user needs were understood and realised.

A device model was selected, and rollout is expected to occur over the next few months across multiple departments, realising multiple benefits across the clinical workflow.

Deployment occurred without delays on 27th August 2024. Despite concerns that the ED would be too busy for the go-live, prior clinical buy-in and training meant the ED Lead approved the go-live. Before deployment, the trust identified 20 super users (16 nurses and clinical site workers, and 4 doctors) who received early training on the new system and helped to create a quick reference guide for regular users post launch.

Multiple ECG devices were replaced as part of a “big bang” rollout, taking the ED from 2 old devices to 5 connected ones. This occurred during a time of record-breaking demand for clinical services, so the trial would receive a true test of its effectiveness in improving clinical efficiency.

The department used the more robust ELI280 model of ECG Machine. However, it became clear after deployment that it did not have the full range of connectivity functionality as the initially planned (but more expensive) ELI380. This was addressed by adding steps in the quick reference guide to refresh the devices regularly.

This was not the only adjustment required because of the new devices 

Device storage

The devices can store several days’ worth of tests, but in a busy ED, storage quickly became full, causing connectivity issues. The device configuration was changed on the second day of deployment to reduce the storage duration, resolving the issue. In less busy environments, the capability of storing multiple days of results might be useful.

This functionality may still be useful for deployments into other areas with fewer devices and smaller teams.

Patient selection at time of ECG

The integrated ECG solution aimed to mirror the gold standard of positive patient identification (PPID) using barcode data. Initially, staff were taught to barcode scan the patient’s wristband to filter the electronic worklist and assign the scan to the correct patient.

However, staff were more familiar with scanning the QR code on the wristband for other observations. Despite refresher training, changing this ingrained workflow proved unachievable. The trust updated their guidance to focus on correctly selecting the patient from the electronic worklist instead of achieving gold standard PPID.

The outcome of this change has been effective with fewer staff needing to resort to the contingency route of printing the ECG out (as per the old solution).

Incorrect order configuration

The ECG solution is “order driven”, meaning an order must be placed by a clinician in the core patient record for it to appear on the ECG device’s worklist, where it is then automatically populated with the scan results once taken.

Shortly after go-live, the electronic worklist began to become populated with unnecessary orders for patients who had been discharged or did not require an ECG.

An internal investigation revealed that orders for discharged patients or those no longer requiring an ECG were not automatically discontinued.

Once this configuration was corrected, the electronic worklist remained manageable (30-40 orders on screen), leading to easier patient selection.

It is natural for a solution that impacts such a core procedure to require many adjustments to best suit clinician ways of working,. The trust managed these adjustments by balancing staff habits, improving workflows through training, and resolving technological requirements.

The trust’s ability to respond quickly to issues after deployment has led to significant benefits:

• elimination of lost or incomplete ECG results that occurred in the paper-based process.
• remote monitoring of order status. clinicians can now place a scan request and receive digitised results through the same system, with relevant roles notified automatically through the process.

• reduced repeated and unnecessary ECGs. The rate of ECG requests that are correctly fulfilled is 95%, a record high for the trust.
• digitised results integrated directly into patient records, improving the operational workings of the emergency department.

The popularity of the solution with clinical staff is exemplified by the team referring to the new integrated ECG devices as “their system”. The devices have been also a positively received by the trust’s management, who even after a short time seeing the benefits are looking to expand the concept of integrated devices to other departments and device types.

Previous digital implementations have been seen as ‘IT’ led, but engagement with clinicians at an early stage of the project and making them key in the design and delivery of the solution maintained their enthusiasm and support.

A key lesson was that not all device functionality is appropriate unless it specifically supports the clinical workflow. The introduction of barcode scanners diluted the value of checks and hampered patient selection from the electronic worklist. On reflection, the initial scope of the project was unrealistic, aiming to digitise processes in multiple busy departments. Re-evaluating the scope allowed for proper focus on relevant workflows and rapid changes to the solution.

With the solution fully operational and supported by IT and Electro-Bio Medical Engineering teams, Countess of Chester NHS Foundation Trust is confident it can expand integration to additional ECG and medical observation devices.

This trial has provided a tested, scalable model to enhance efficiency and patient care across the trust.

This use case highlights the transformative potential of modern connectivity in delivering better healthcare, and the Trust’s experience serves as a valuable blueprint for similar initiatives within the NHS.