Question 1
Do you think that all hospitals should have a legal form that puts 100% of the responsibility on the order doctor when they are insisting that a patient gets a MRI scan when the patient is unable to fill out a screening form or has a potentially unsafe device implanted?

In the United States, the legal responsibility for the safety of a radiologic exam typically lies with the radiologist (and the radiology service provider), not with the referring physician. This is part of the patient’s expectations of care, so unless a waiver includes the patient waiving their rights to have the radiologist / radiology provider be responsible for the exam, I would imagine that an agreement just between the provider and the referring physician would, from a legal standpoint, be worthless.

Question 2
Is there a certain distance that oxygen tanks are supposed to be away from the MRI scanner? Any specific signage on the cart that holds the tanks?

If we’re discussing ferrous medical gas cylinders, I strenuously suggest that they be kept outside the control room (Zone 3) and never be permitted inside the magnet room (Zone 4). If we’re talking about non-ferrous / MR Conditional cylinders (and valve / regulator assemblies), then the tanks can be as close tot he magnet as you want and as the MR Conditional conditions allow. Please be aware that the valve or regulator for a gas cylinder may have different / more restrictive MR Conditional conditions than the tank body. Follow the most restrictive MR Conditional conditions for the entire assembly.

Question 3
When do you expect the ACR White Paper 2019 update to be released?

I think late summer (August) is the earliest that we might see it publicly released. Fall (September – October) is probably more realistic. It is actively in process as we speak, and a document summarizing several of the major changes may be published in the literature a short while before the main document is realeased.

Question 4
Can you please share the document where the Joint Commission mentioned that the FMD is must?

The Joint Commission references a ‘default’ design and construction standard, the 2014 FGI. It’s the FGI document that says that FMD systems are requisite elements in MRI suite construciton / renovations. The article is available on the Metrasens resources website, or can be found directly here – https://www.metrasens.com/why-ferromagnetic-detection-systems-are-now-a-requirement-for-all-joint-commission-accredited-facilities/

Question 5
What all would be included in the risk assessment? Would working with 1 tech per scanner part of that?

The elements of your risk assessment should include everything that may cause or contribute to risk of harm to patients, visitors, or caregivers. There are the obvious elements of the MRI scanner, itself (static magnetic field, time-varying gradients, and RF field), but then there are also patient concerns (mobility, size, acuity, monitoring / intervention requirements), acuity concerns (intervention, infection control, life-support / code procedures), facility concerns (zones, cryogens), operational concerns (screening, changing, staff training), and more. Your site’s risk assessment should really be based on setting, magnet, patient mix, and clinical demands of your service. As such, it’s going to be fairly tailored to your particular conditions.

Question 6
Where can one get a risk assessment document to consider for use?

See my prior answer on risk assessments,

Question 7
Do you mean Patient screening or Patent screening?

Forgive any typos, I’m sure I meant patient screening.

Question 8
Can we get a copy of these slides for my MR safety binder? I am working on a better safety program at our CAH hospital – this will hopefully help get admin on board

Better than the slides, alone, the recorded webiar will be available for on-demand viewing any time you want at https://www.metrasens.com/news-resources/#mri-safety-resources

Question 9
Missing the “We change 98% of patients, with some folks not having to change at tech discretion (have trouble moving)” option

To keep the questions easy to answer in less than a minute, we distill the options down to just a few. We expect that the provided options will only roughly fit the majority of answers, but we’re really just looking for the broad outlines of trends and practices.

Question 10
Do you check on Len Implants or ask

If you meant lens implants, as in lens replacements, I’m not aware of any that have demonstrated risks in MR. I think it’s probably prudent to make sure that the implant in question is the type that the patient says it is… while I wouldn’t be concerned about a lens replacement, I might have concerns about other orbital implants or prostheses. In that sense, it would be worth investigating the type of implant, and then deciding how to proceed based on the initial information obtained.

Question 11
Regarding “blanket” cardiac stents, are you aware if that includes 3T … and for contiguous stent chains?

Both Dr.s Kanal and Shellock have said that they treat coronary stents as safe *up to* 3.0 Tesla. Dr. Shellock has said that he has no concerns based on the number of contiguous / adjacent stents, but Dr. Kanal has stated that his categorical policy applies to ‘onsie / twosie’ stents, and that if there is a long train of stents beyond a few cm in length, that he would want to review and approve outside of the exemption.

Question 12
Most Facilities do not use Magnivist and optimak any more. Most use Mutihance , Gadavist, & Dotarem andProhance

Indeed, the agents available in the US (and elsewhere) is changing. In the webinar I referenced Magnevist, Omniscan, and Optimark as those agents were specifically grouped in a higher risk category by the FDA.

Question 13
Is a sheet or the patient gown good enough to be between the thighs and arm/body to prevent burns?

Up until about 6 months ago I would have siad yes, but recently I’ve heard of large-calibre body loops occurring through thin wet material (a sweat-soaked sheet), and through thin dry material (yoga pants). I think these anecdotes suggest that a few folded layers of a bed sheet (at a minimum) might be more effective than a single layer.

Question 14
Changing patients into gowns makes almost all patients more apt to be subjected to thigh to thigh burns. Is “everyone” placing towels, etc between thighs? I would say no, at least with my observations.

Some sites are using scrub pants in conjunciton with gowns. Some are using disposable paper shorts. Some are using sheet / towel between the patient’s legs. However, if you’re doing a brain or C-spine on an adult patient) there is a significantly reduced risk of large caliber body loop burns below the waist. Be aware of the spatial distribution of the RF energies for your system, and the potential for e-field propagation within the patient’s tissues based on the MR study being performed.

Question 15
I have a concern with team members starting IVs with patient on the table in Zone IV. Are people restricting IV starts to Zones I-III?

As a general practice, I strongly recommend starting all indicated IVs / catheters prior to the magnet room. If a non-contrast study reveals something worrisome for which contrast is indicated, it may be faster / better to start that patient’s IV in the magnet room, but that practice – in my opinion – should be the exception and not the rule.

Question 16
Is it required on 1.5T to provide both earplugs AND headset?

What is required by the FDA is that the sound pressure level at the patient’s eardrums be 99 dB, or less. The way that sites should identify what hearing protection they provide for their patients is to identify the loudest sequences that are run on each magnet (your service engineer should be able to tell you, if that information is not in your manual), and then provide hearing protection that gets the patient’s exposure down below 99 dB. So if the loudest sequence your magnet runs is 124 dB, then you should be providing your patients with a minimum of 25 dB of attenuation / hearing protection. Be aware, however, that 99 dB is still quite loud, and may be painful or even cause damage to some people’s hearing. To the extent practical, I recommend shooting for a patient exposure of 85 dB.

Question 17
Should you monitor vitals on self medicating patients in an out patient setting?

That is a medical decision and should be made by the supervising physician (radiologist) for the MR exams. I would urge any such decisions to be codified in your policies and procedures.

Question 18
My facility just recently switched from Omniscan to Gadavist. I am just wondering what your opinion is on obtaining bun/creatnine for patients receiving Gadavist. Thanks!!

My personal opinion, given swirling concerns about gadolinium retention and potential toxic effects, is that renal clearance is important, even with the higher-stability agents. If I was the patient, I would want a radiologist making the choice of the agent and dose with the knowledge of my renal function.

Question 19
Is there a JC requiement that there is documented annual training specific to NSF fo techs?

As a part of the patient screening requirement, yes. The specific language of TJC for this screening point is, “Patient screening criteria that address ferromagnetic items, electrically conductive items, medical implants and devices, and risk for Nephrogenic Systemic Fibrosis (NSF)”

Question 20
Are ferromagnetic detection systems required for existing MRI suites?

Today, there is not a retroactive requirement for FMD to be placed in existing facilities that I’m aware of. However, FMDs have been required in the FGI Guidelines, which is the most widely used hospital / healthcare design standard in the US, since 2010. If you have a facility built or renovated under the 2010 FGI standards (or more contemporary editions), the site was required under those criteria to have FMD. If it wasn’t part of those projects, it could still be required as an unfulfilled requirement from the construction. Of course in addition to the FGI Guidelines requirement, the ACR recommends the use of FMDS in all MRI facilities

Question 21
When in the Holy Heck are you guys going to send out the grades from the MRSO exam on June 5?

:-) Metrasens, while a supporter of MR safety in general and the ABMRS in particular, has no influence over the ABMRS’ exams or their processes. Typically, initial results of the exams are made available ~3 weeks following the exam, after a QA/QC review of the exam based on the results.

Question 22
in zone 3 are there any regulation regarding water coolers and ferromagnetic chairs? I have a water cooler in zone 3 and it was questioned on a mock survey.

To the best of my knowledge, no. Your mock-surveyor may be picking up on reports of actual TJC surveys where surveyors get worked up about ferrous objects in the control room / Zone 3. To be clear, however, TJC standards do not say anything about proibiting ferromagnetic objects in Zone 3. The Diagnostic Imaging Standards say that you’re to be trained on equipment and supplies that are acceptable for use in the MRI environment, but not that there are specific restrictions. This is an area where – in my opinion – TJC surveyors and your mock-surveyor are going off-script and making up their own standards. I do think it’s appropriate to have a policy as to how ferromagnetic materials in Zones 3 or 4 will be handled.

Question 23
Do you have a recommendation or know of any resources out there for a template for FM intrusion tracking?

I know of different sites that use different mechanisms… from a notebook, to an excel spreadsheet, to regular notes on an electronic office calendar, to the electronic documentation features in some Metrasens ferromagnetic detection systems. I’m not aware of TJC having a requirement – or even an expressed preference – for any specific recording method.

Question 24
IS IT REQUIRED TO HAVE REGULAR QUENCH PIPE INSPECTIONS

Under TJC standards? No. However, I believe every major manufacturer of superconducting systems specifically state that it’s the site’s obligation to inspect the quench pipe on an annual basis. I also strongly recommend these regular inspections.

Question 25
Do we only track metal entering the room if it caused an injury or any time, even if there was not an adverse event?

TJC’s standard is to record an event each and every time a ferromagnetic object that wasn’t prospectively cleared crosses the threshold into the magnet room. A subset of those events, where an injury results from the ferromagnetic object intrusion into Zone 4, must *also* be recorded.

Question 26
When will MRSO or/and MRMD become a requirement?

That’s a great question. Look for some further guidance on this in the forthcoming ACR Guidance Document. Given that there’s zero direct cost associated with designating people to these roles, I hope that the accreditation / regulatory bodies require people in the roles before too long. If that happened, I would expect that many of them would seek out training / certification to demonstrate competency in their designated roles.

Question 27
What training programs are out there for MRI Safety Officer training, which do recommend

There are several, and the numbers keep growing. There are regular recurring in-person seminars offered by each Dr. Kanal and Bill Faulkner / Kristan Harrington, intermittent conferences have been offered by MTMI, Some of Bill Faulkner’s courses have also had live-streaming options. There are also online (self-directed) training programs from ImagingU and MRSOprep. And there have been intermittent training options provided by other groups, and will be a hybrid online and live event by ImagingU this fall.

Question 28
Is there a limit to how many MRI exams a patient can have in one day?

Not a limit by the number of exams. Some systems may have limits on the total amount of RF energy a patient can be exposed to in a 24 hour period. This is (today) determined by each MR system manufacturer, individually. I recommend everyone get from their manufacturer what their system(s) SED warning and lockout settings are for each magnet.

Question 29
Is there a sample MR safety risk assessment you could provide?

Please see my earlier answer on the MRI risk assessment.

Question 30
Requirement of having FMD system, is that NEW construction?

The requirement under the FGI criteria is for new construction or renovation (that requires a building permit), which typically also means magnet replacements. Of course in addition to the FGI Guidelines requirement, the ACR recommends the use of FMDS in all MRI facilities

Question 31
Where can I print a list of the 7 things the Joint Commission is looking for?

“This is from TJC’s Diagnostic Imaging Standard: “”The [critical access] hospital verifies and documents that technologists who perform magnetic resonance imaging (MRI) examinations participate in ongoing education that includes annual training on safe MRI practices in the MRI environment, including the following:

  • Patient screening criteria that address ferromagnetic= items, electrically conductive items, medical implants and devices, and risk for Nephrogenic Systemic Fibrosis (NSF)
  • Proper patient and equipment positioning activities to avoid thermal injuries
  • Equipment and supplies that have been determined to be acceptable for use in the MRI environment (MR safe or MR conditional) *
  • MRI safety response procedures for patients who require urgent or emergent medical care
  • MRI system emergency shutdown procedures, such as MRI system quench and cryogen safety procedures
  • Patient hearing protection
  • Management of patients with claustrophobia, anxiety, or emotional distress

Question 32
How do you perform a risk assessment? Is there an example of what one looks like?

Please see my earlier answer on the MRI risk assessment.

Question 33
If a patient comes sedated, drove themselves, they refuse us to call a cab service can we prevent them from driving?

You’re getting into specific legal requirements and obligations, which likely vary by jurisdiction and situation. I don’t think I can answer that other than to say that your site should have a converstaion between the MRMD and the site’s attorney. A policy should be drafted to specifically deal with how these types of situations are handled.

Question 34
Where can I find a good yearly training video that includes both quench/power off and claustrophobia?

You may want to ask your MR manufacturer if they have anything that they recommend (or provide) that will meet your needs.

Question 35
Has anyone developed a risk assessment checklist or rating scale for conducting a risk assessment for MRI

Please see my earlier answer on the MRI risk assessment.

Question 36
Just a comment, I find staff techs are reluctant to report minor incidents of unintentional ferromagnetic materials entering the room (bobby pins etc) because they fear repercussions from the employer, or just don’t want to “look bad” in their supervisor’s eyes..

I understand, but the Joint Commission considers each of those things as a recordable event. As with any error reporting, it’s up to the employer and supervisors to create a ‘just culture’ environment to – at worst – be agnostic about employees reporting errors (no punishment). Preferably they regard these events as gifts that allow them to error-proof their practices without costly accidents or injuries.

Question 37
Is X-raying a patient to clear them for an mri exams, the best course of action, if the patient is unable to complete a screening form?

This is a clinical decision. I would recommend reviewing the ACR Guidance Document for their suggestions on how to handle screening of unconscious / altered patients, and build a local policy informed by those ACR recommendations.

Question 38
Any updates in the ACR vs FDA controversy regarding screening renal function for group 2 agents?

Not that I’m aware of, no. I, personally, am more closely aligned with the FDA position on patient screening for Group 2 agents.

Question 39
What is the best education course to take to become a MRSO?

Please see my earlier answer on training options.

Question 40
screening forms – in the age of paperless – is it recommended patients sign this form – our legal team states the patient does not need to but the techs like the “back up” of having the patient’s sign.

I think it’s wise to have some means of recording the patient’s confirmation of the accuracy of the information recorded on the screening form.

Question 41
Tobias Do you know Magnevist is no more in use?

… in the United States.

Question 42
how do we do or start a MRI Risk Assessment process?

Please see my earlier answer on the MRI risk assessment.

Question 43
Are there any future webinar’s available?

Metrasens makes new webinar content available roughly every month, and all of the prior webinars are available for on-demand viewing on the Metrasens webiste within a few days of each live event.

Question 44
When is newly implanted titanium hardware completely MRI safe?

“MR Safe” is a specific classification / term that means safe under all conditions. To be designated as MR Safe, an object can’t be magnetic (or magnetizeable), be electrically conductive, or RF reactive. Pretty much any metal object is precluded from being classified as MR Safe, including titanium implants. If you’re asking about waiting periods before scanning non-ferromagnetic implants or devices, if the instructions for use (IFU) for the implant don’t specify a waiting period, or if the implant / system is made wholly from non-ferromagnetic materials, then I’m not aware of any particular risk to scanning the patient immediately, if indicated.

Question 45
Will TJC certify a site as good if individuals are hired solely in the capacity as an MRSO/MRSE/MRMD?

If your question is whether a dedicated MRMD, or MRSO, or MRSE would be viewed by TJC as outright proof of conformance with TJC’s Diagnostic Imaging Standards (such that they won’t bother to check the specific elements of performance), I don’t think that would happen. That said, I have heard from many facilities that when they have overt demonstrations of their attention to MR safety (ABMRS certificates hanging on the walls, or FMD systems being correctly used, etc…) the sureveyors’ demeanor often changes towards a presumption that the site has their ducks-in-a-row for MR safety.

Question 46
Most all implants that are MRI Safe or conditional are listed up to either 1.5 or 3 Tesla. What do you think will occur when higher strength magnets become the normal operating equipment that would exceed these parameters?

A small but important correction… most implants that are idenfied as MR Conditional are conditional *at* either 1.5T or 3.0T. There are few implants that have labeling that specifically says ‘up to 3.0T’, though conditionality for torque and translation, as well as time-varying gradient magnetic fields, should be understood as being ‘up to’ the highest indicated values. RF, however, should be understood to be conditional *at* specific field strengths (really the RF frequency used, which is a function of the field strength). For your question, we’ve already dealt with exactly this in our recent history. Ten years ago very few implants that were labeled for 1.5T had conditions for 3.0T, and implant and device manufacturers often had to scurry to re-test and re-label existing products for 3.0T. If and when 7.0T gains clinical traction, I imagine the exact same thing will repeat, and implant and device manufacturers will again scurry to get their products re-tested for 7.0T, too.

Question 47
Do you recommend changing everyone’s clothes every time? into gowns or scrubs?

I recommend that patients at least gown / scrub in the regions that will be exposed to RF energies, as removal of any worn / carried items that could conceavably have ferromagnetic content. If a patient showed up for a brain scan in a T-shirt, running shorts, and athletic shoes, as long as the site could effectively screen the clothing of the patient from the waist, down, for ferromagnetic content, I think there’d be no safety compromise for just changing the patient’s top to a scrub top or gown. If you’re looking for a ‘one size fits all’ patient practice, then yes, I’d say change every patient into scrubs, every time.

Question 48
For patients that come in with adult diapers, should they change and put a dry diaper on if it is wet to prevent burns?

If the lumbar / pelvis / groin area will be in the region of RF deposition, yes. If you’re doing a brain on a near-average height adult patient, I would have little concern for burns developing at the pelvic area.

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