Live Q&A responses

Fundamentals of MRI Safety: Satisfying the Joint Commission's Requirements for Annual Training

Live Q&A responses

Fundamentals of MRI Safety: Satisfying the Joint Commission's Requirements for Annual Training

Webinar Questions and Answers

Our recent webinar with Tobias Gilk included a Live Q&A session. Below you will find details of all the MRI safety questions asked as well as responses from Tobias.

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.

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.

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.

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/

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.

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

See my prior answer on risk assessments,

Do you mean Patient screening or Patent screening?

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

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

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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)”

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

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.

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.

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.

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.

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.

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.

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.

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.

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

Please see my earlier answer on the MRI risk assessment.

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

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

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.

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.

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.

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.

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.

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.

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.

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

Please see my earlier answer on training options.

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.

Tobias Do you know Magnevist is no more in use?

… in the United States.

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

Please see my earlier answer on the MRI risk assessment.

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.

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.

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.

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.

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.

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.

What is your view on using standard metal detector wands rather than ferromagnetic wands?

The ACR Guidance Document specifically recommends *against* the use of standard ‘airport style’ detection (pass through or wands). ‘Airport style’ detectors should not ever be confused with FMDS, or be seen as equivalent substitutes. While they may have similar appearances, they serve very different functions.

Is there a TJC standard for Level 1 or Level 2 safety training for MRI Staff versus Hospital Staff. This is identified in the ACR Safety document. Should this be identified in competencies/CE?

TJC only requires MR safety training for MR system operators, so TJC does *not* explicitly recognize “Level 1” and “Level 2” training. In contrast to TJC’s minimums, I vigorously recommend MR safety training for *all* persons whose regular duties have them within the controlled access parts of the MRI suite (Zones 3 or 4). I also believe that sitting someone down in front of a 20 minute video once a year does not demonstrate competency. I recommend some form of MR safety competency testing to accompany annual MR safety training.

We have a policy where everyone gets screened prior to entering Zone III. Our screening process includes a questionnaire, hand wanding and then ferromagnetic screening as they enter Zone IV. How do you recommend handling screening of MRI level 1 and level 2 trained personnel (RN, registrar) who enter Zone III many times per day? Should they be questioned and hand wanded each time or only at first contact with the MRI suite each day? Considering that they are safety trained, they should be aware of bringing contraindicated items into the MRI suite.

I believe that the level of screening and error-checking should be, in part, based on the level of understood competency of MR safety trained individuals. As I said in the prior question about levels of safety training, watching a video does not – in my mind – make someone MR safety trained. If there are demonstrable competencies, then a person should be considered MR safety trained. Before answering the question about your site’s policies regarding trained ancillary staff, I would want to know much more about the level to which those staff are trained and the level of competency that they’re required to demonstrate.

What are the most common TJC citations/infractions in MRI?

Historically, the greatest number of citations have been for ferromagnetic materials inside Zone 3. Some of TJC’s citations for this have been quite silly (e.g., citations for the wire ties used on fire extinguisher inspection tags). I expect that TJC is learning and will, in the future, alter what they focus on to be more meaningful for real MR safety.

Do organizations with hospital centers and out-patient sites have to maintain a log of incidents in the site of the incident or can the use of a centralized incident reporting system maintain those incidents within this system and pull the data when/if requested by a surveyor?

TJC hasn’t clarified the level of granularity they require in their incident reporting. To be safe, I would recommend making sure that each incident is identifiable with the individual site / scanner where it happened, if your site wants to aggregate all of the incidents into a common database.

Are clothes (gowns / scrubs ) sufficient barriers for skin-to-skin contact with concern for burns?

Generally speaking, dry cloth *is* sufficient barrier. However, if a garment / sheet gets soaked, the mositure reduces the electrical insulation. Pads are recommended by the MR system manufacturers even for skin-to-skin contact because they are also waterproof.

Is there a form that can be used to record unintentional ferromagnetic objects entering into room?

TJC requires recording these events, but they have not provided a standard form or identified what information they want collected for these types of incidents. That suggests that each facility can create their own recording system… from a centralized enterprise-wide event database, down to a spiral notebook at the console. Metrasens’ MRI Safety Manager can record this information for you.

Do TJC or ACR require Zone signage?

While it is true that neither requires signage in their written standards, TJC does require zones (though their text is an over-distilled description of the zones), and TJC surveyors have frequently asked to see sites’ zone signage (even though TJC doesn’t require it in their Standards language). Personally, I don’t think identifying the zones as “Zone 2”, “Zone 3”, alone, does anyone any good. I think that signage should identify, in plain language, what the zone *means*. So a sign that read only “Zone 3” would, in my opinion, be pretty worthless. But a sign that described what Zone 3 represented, such as, “Warning: Areas of potential magnetic field hazard beyond. Only MRI screened persons beyond this point…” *that* would be helpful.

How many MRSO’s do you recommend per site?

An MRSO should be viewed as similar to a Radiation Safety Officer (RSO), and should be a resource whenever MR patients are being scanned. While there may be a single designated MRSO on the org-chart for your site, depending on the size of an organization, it may be wise to have a number of people with MRSO skills to help make sure that MRSO knowledge is available when needed for all MR patients.

Should bras always be taken off?

I don’t perceive there being universal consensus on the issue of removing undergarments. I think that, as a best practice, all garments that will be in the volume of RF deposition should be removed. So, if the patient is having a study between pelvis and brain, using the body coil for transmit, then yes, the bra should be removed. If the patient is having a knee or ankle study, there isn’t an RF safety benefit to removing the bra. One should also consider how they wish to use their Ferromagnetic Detection System (FMDS). An increasing number of sites are moving towards ferromagnetic-free dress policies which are making screening with FMDS more effective at identifying materials that could potentially be hazards by reducing rates of spurious alarms.

Is there a standard risk assessment procedure that we can use as a template for our facility?

I don’t know of a specific risk assessment procedure that is freely available. The ACR Guidance Document can be used as an outline for potential risks, and a site can essentially walk-through the Guidance Document and evaluate it’s policies and practices against the criteria identified within. Alternatively, Metrasens offers expert comprehensive MR risk assessments. An outside perspective may be very helpful.

Can you address hearing protection for babies – confirming appropriate fit?

Hearing protection should be provided for all patients where the sound pressure level of the scan is 99 decibels or higher (many ‘silent scan’ sequences will be much quieter than this). Hearing protection for infants hasn’t been tested to levels of attenuation comparable to that of adult hearing protection, and the infant can’t really verify function for us. When the scan is indicated, it is advisable to use the best hearing protection that is appropriate to the age of the patient.

What is the recommended action for patients who are unable to answer questions, with no family or POA available to answer questions for them?

The ACR Guidance Document spells out an examination process when an MR exam is indicated for a patient who can not provide a medical history, and for whom there is no reliable mechanism of obtaining that history.

Can the facility MRSO train staff in meeting ACR annual training guidelines?

I don’t believe that the ACR has established specific criteria for minimum qualifications for an MR safety trainer, so yes, I believe that an MRSO would be an appropriate person. I would recommend that the MRSO be certified, so that there is a base understanding of the knowledge / competencies of the person providing the training.

I am the only MR Tech at a small hospital and have many radiologists but only one is MRMD and another facility oversees safety and credentialing, that person is MRSO. Should I attend class for the MRSO for this site since I am here at all times?

In short, yes. Each site should have immediate and direct access to an individual with MR safety expertise above and beyond the levels that are a part of RT(R) or RT(R)(MR). I believe that each site should have their own MRSO, and enough MR staff trained as MRSOs that there is always someone to help with these types of questions whenever there is an MR patient being prepared or scanned.

Can you cite exactly which TJC standard references FDMS?

TJC’s requirement for FMDS is by reference. TJC requires that it’s accredited sites follow the planning and design criteria in the 2014 Facility Guidelines Institute (FGI) standards. The 2014 FGI calls for FMDS for all new MR construction / renovations. While it’s not in TJC’s own standard language, it is a requirement through reference to the FGI.

When screening implants for an open scanner, when implants are tested on horizontal scanners, how does that relate to vertical scanners? Currently our radiologists don’t do implants on our open scanners due to non testing, but if I had some information or recommendations I feel I could change my radiologists thought process. Do you recommend anything?

There is not, to my knowledge, a ‘Rosetta Stone’ that helps translate MR testing data from horizontal 1.5T or 3.0T horizontal systems to vertical field systems. There *are* quite a number of implants and devices that can be safely scanned on vertical field systems, but today the process of making that determination really relies on MRMD, MRSO, and MRSE training.

Could you provide some more information about RF blankets?

RF blankets are flexible materials that have RF absorbing or RF reflecting properties. Used properly, they can be quite effective at limiting the amount of RF that reaches a particular body part (or the implant / device within that body part). Used incorrectly and they can wind up focusing RF power in a small spot, causing thermal injury. They can also cause errors with MR systems as they monitor reflected and absorbed RF power (values which can be significantly distorted from normal through the use of RF blankets).During quench, if there is nobody in the room after evacuating the room, should we close the room and avoid the spread of helium outside the room in case there is failure of the pipe or should the door should stay opened?

Ideally every superconducting magnet room should have three things: (1) a quench pipe to expell the vast majority of the escaping helium; (2) an exhaust fan to exhaust the (hopefully) small quantity of helium that does escape into the room; and (3) an overpressure relief mechanism in case the quench pipe fails. If these three items are in place, hopefully any helium escape into the occupied area is minimal. Assuming proper construction, my recommendation would be to turn the exhaust fan for the magnet room on, and leave the door to the magnet room propped open for a short while.

Questions from previous webinars:

Does the ACR require any specific training for MRI /Radiologist staff for performing exams on MRI compatible pacemakers?

I am not aware of any requirement from the ACR for specific training for the MR imaging of patients with active implanted cardiac devices (pacemakers or ICDs).

Is this requirement for training also applicable for the DNV?

To the best of my knowledge, no other accreditation organization (DNV, IAC, ACR) has specific MRI safety training subject requirements. While this information is applicable to all MRI services, this webinar only fulfils the minimum annual training requirements of the Joint Commission Diagnostic Imaging Standards.

Is a template risk assessment available?

I’m not aware of a template for an MR Risk-Assessment. In my opinion an MR Risk-Assessment should look in three areas: Physical Safety (zones, access controls, gauss markings, situational awareness, ferromagnetic detection); Operational Safety (training, screning protocols, staffing, policies & procedures); and Clinical Safety (implants & devices, MR imaging bioeffects, RF heating, contrast). If a site feels comfortable, they can research these risk ‘families’ and develop a risk assessment in-house. I offer, and I know Metrasens offers, consulting services that include risk assessments.

How would we codify the risk screening process in policy?

My recommendation is to start at the ends, and work your way towards the middle. Begin by defining the practices that you feel are approaching 100% safe (e.g. “scanning patients with MR Conditional implants when we can fully meet all of the stated conditions”), and those that seem far too dangerous to warrant scanning (e.g. “scanning a patient with an old, unidentified cereberal aneurysm clip”). Write each one of these down in a policy. Then start to explore the areas in-between and decide what of the ‘grey areas’ the supervising physician(s) feel comfortable with, and under what circumstances. Document the process for ‘yes’, ‘no’, or ‘consult with the supervising physician on-call’ decisions.

What are your thoughts on the distribution of the med guides for the specific GBCA’s to patients and how the FDA worded the requirements for outpatients vs inpatients?

In my opinion, the medication information sheets should be made available to all patients who receive GBCA upon their first administration of each agent following the implementation of the policy. While the FDA is presently only requiring the distribution of the medication information sheets to outpatients, I believe that inpatients deserve the information, as well. That fact, plus the fact that giving the page to all patients means only a single workflow (instead of two), are parts of my recommendation to give the information to everyone who receives contrast.

Would a ferrous detector have detected the ferrous clip that caused the fatality?

There are quite a number of variables in play when the question is ‘would a ferromagnetic detector detect…?’ Unfortunately it’s not a question that can really be answered in the abstract. Are there FMDS devices that could detect the aneuryism clip? Yes, there are. But the specifics (how sensitive, how close, what rate of motion, what orientation, etc…) make all the difference in being able to answer whether this particular object would have been detected.

In the case of extremely large patients who, when placed in the magnet, have absolutely no room for padding the arms from the bore, you say a pillowcase is not sufficient? Should they not be scanned? We do change all patients, so in a large patient case, their thighs/calves will touch. Padding with Philips magnets are all too thick. Do you have any suggestions?

As per your MR system manufacturers’ guidance, there ought to be a minimum separation between the patient and the body coil. If you can’t achieve that minimum separation, then there is a potential risk of injury to the patient. The decision to go ahead with the study, or to not complete the study, is a risk : benefit decision and should be made by the supervising physician… potentially with the informed consent of the patient, depending on the physician’s assessment of the risk of proceeding.

Are all stents and coils MRI compatible?

Firstly, under correct current terminology, items are classified as MR Safe, MR Conditional, or MR Unsafe. The following answer relates to the term MR Conditional:  In short, no. Stents, by themselves, come in a large variety of sizes and shapes, and are made from a variety of materials. There is also the potential for nested and overlapping stents, potentially creating composite structures that have very different heating potentials than single stents, alone. For these reasons I’m not aware of anyone who has extended a categorical exemption to MR screening of implants to any stents beyond coronary stents.

MRI conditional devices with specific SAR requirements. Do you have a chart we can refer to for SAR and Gauss lines? I heard there is a chart to assist with questions related to certain safety elements?

Within your MR system operators manual you should find drawings, charts, and graphs that depict the distribution of RF energy, static magnetic fields, and magnetic spatial gradients. If you don’t find that information in your manual, contact your MR system account rep or service engineer and ask them to provide you with a copy of the information for your MR system.

Should there be a record kept of practicing mock codes? Like the date it was last done.

I personally believe that it is a good idea to keep a record of when critical drills are performed.

Where can we find what is required for hearing protection? Such as decibel reduction.

The IEC and FDA say that a person in the magnet room should only have their hearing exposed to a maximum of 99 dB. Contact your MR manufacturer and ask them what is the sound pressure of the loudest sequence that your system can run. Subtract 99 dB from the number you get from your manufacturer, and that should be the lowest noise reduction rating for the hearing protection you provide to your patients.

Could you share your thoughts on the knowledge gap of technologists and radiologists when it comes to interpreting spatial gradient maps?

Spatial gradient maps come in a variety of different forms and presentations, so reading them and understanding them can be challenging. Technologists, in my experience, are often more comfortable with the technical aspects of MR imaging than are radiologists, and are therefore more accustomed to reading and interpreting spatial gradient maps. However, the supervising physician has the legal responsibility for the safe execution of the MR exam, so s/he should get instruction on the use and interpretation of spatial gradient maps if they aren’t very comfortable with them.

In a 1.5T, should we give BOTH earplugs AND headphones?

Depending on the noise reduction rating of each, you may need one or both to achieve the maximum patient exposure of 99 dB, as described in the earlier hearing protection question.

Are there specific policies that require all employees fill out an MRI screening sheet? There is some difference in opinions for new employee orientation.

In my opinion, only persons going into the controlled access portions of the MRI suite (zones 3 and 4) need to complete the screening form. That screening form should be current, but it is up to the individual facility to decide how often they need to be reviewed / revised to be current.

Can you comment on renal function (eGFR) thresholds and the need for pre-hydration or preclude a scan all together

To the best of my knowledge, there have been no risk mitigation benefits demonstrated from pre-hydrating patients prior to receiving contrast. I’m not sure that levels of hydration should play a role in the decision to administer GBCA to a particular patient.

Do you recommend all MRI techs be MRSO or just a lead tech?

It is recommended that each facility have the services of each a designated MRMD, MRSO, and MRSE. There are advantages if there are multiple people trained with the knowledge and skills of each of these designations, but there shouldn’t be a situation where there are MRSO decisions being made by committee. For the MRSO organizational role, there should be a clear understanding of which individual is fulfilling that role, even if there are several people trained for it.

Does the entrance into Zone 3 need to be locked?

Yes. Per the ACR Guidance Document the entry into the secured access portions of the MRI suite (Zone 3 and 4) needs to be restricted. The Joint Commission’s Diagnostic Imaging Standard has very similar language.

Is the site required to collect a MRI screening form each time a member of the anesthesia team is working in the MRI suite?

The frequency of review and updating of staff screening forms should be set by facility policy. My personal recommendation is that screening forms should be reviewed and updated at least annually, and that staff should be instructed that they have a responsibility to update their screening form at any time their condition changes (e.g. a new implant or surgery).

Who should conduct the safety assessments and what qualifications should they have?

The Joint Commission doesn’t have any specific qualifications for who should conduct the MRI risk-assessment. In my opinion it is best to have someone who has done safety risk-assessments, before, or MRI safety audits. You may also want to seek out someone who has an MRMD, MRSO, or MRSE credential.

Do I need to worry about burning on an open 0.25T system?

A 4 W/kg scan is 4 W/kg, whether the patient is being scanned on a 0.25T system, or a 7T system. Total RF power deposition is not intrinsically lower at lower field strengths. What *is* different is the RF frequency being used. This means that the length of an electrical conductor must be MUCH longer at 0.25T to experience the same heating as a much shorter conductor at 1.5T, or even shorter at 3.0T (resonant circuit heating… one of the three burn causes from the presentation). While 0.25T makes resonant circuit burns much more difficult / unlikely, the other two burn causes, near field and large-caliber body loop, are likely not significantly different from the risks at 1.5T, for example.

How long do we need to keep the log of things going into the MRI room?

The Joint Commission (TJC) hasn’t specified how long the records of ferromagnetic intrusions into the magnet room ought to be kept. I would recommend keeping it for at least three years (the duration between TJC surveys) to show that you’ve been complying with their requirement.

When a patient is in the room being positioned, should the door be closed behind you?

I don’t know that there’s a ‘right’ answer to this question. If you have concerns that unscreened or untrained individuals might be able to enter the magnet room while your back is to the door, then perhaps closing the door while positioning the patient is a good idea (although that need would suggest to me problems that need addressing by something more significant than closing the door).

Burns should be tracked as well as ferrous entries, is that correct?

Indeed, you are correct! TJC is requiring the tracking of three MR-related performance improvement initiatives: 1. Ferromagnetic intrusions into the magnet room; 2. Injuries that result from #1; 3. Thermal injuries to the patient.

Our patients fill out the safety questionnaire before their exam. The day they come, we have them sign the form and go over it again, but in Zone 3, is this appropriate?

The process of reviewing their screening form is excellent. I would advise having the review of the screening form take place in Zone 2, however, to better conform to the ACR Guidance Document’s recommendations.

We don’t have a “power” button readily accessible, do we use the “quench” button?

So the emergency power off button has limited use. It is essentially a circuit breaker that shuts off electricity to the MR system and components. It is really there to protect the equipment from electrical fires and, potentially, power surges (although we almost never know about power surges, prospectively). I would consult with your MR system vendor as you *should* have both.

When do you use the power button down vs. quench button?

Please also see my answer to the other emergency power question, above. But the use of the quench button should be established by your site’s policies and procedures. In my opinion, the quench button should be used when a person is trapped against the magnet, and in clinical jeopardy that couldn’t wait a few hours to have them extracted. It may be possible to ramp the magnet down (though the equipment to do so may not be readily available) and avoid the potential risks of a quench.

Anything specific we should do for pregnant patients and time of scans with regards to SAR to foetus?

I am not aware of any requirements or recommendations to restrict SAR for MR imaging of pregnant patients due to risk concerns for the child.

Does the management of claustrophobic patients condition specifically state we have to have a policy on self medicating out-patients?

No, the Joint Commission does not state in the Diagnostic Imaging Standards that accredited sites need to have a policy on self-medicating patients. I would strongly recommend having one, however.

We are having trouble with getting documentation on implants. I have noticed that the op notes are not putting the entire name or complete info to safely clear an implant. My question is are doctors being informed on how important it is to note complete info on the implant that is being implanted?

To the best of my knowledge there is no broad effort to inform surgeons on the importance of documenting the implants / devices that they put within the patient. Some hospitals with EMRs are getting better about documentation. I have suggested that hospitals may want to make it policy that a surgical procedure is defined as including the thorough documentation of all objects placed within the patient, and that a failure to document means that the procedure is not complete… therefore, no procedure-based compensation for the surgeon. That would motivate better documentation, I believe.

Could you share the actual requirement for 5 gauss line marking?

To the best of my knowledge there is no requirement to physically mark the extents of the 5 gauss line. You are required to control access into all areas where a person could be exposed to static magnetic fields of 5 gauss or greater. But if the room / area is secured, I know of no requirement to mark the line.

If there is metallic susceptibility on scan and the patient is unaware that they have a small metal shaving in that body area, should this instance be documented on the graph for metal getting into Zone 4?

In my opinion, yes this is an example of a ferromagnetic intrusion.

Can a pregnant patient be scanned on the 3T?

To the best of my knowledge there is no indication that higher field strengths pose any specific risk to pregnant patients.

We use Magnevist for MR arthrogram procedures. Is medication guide required for intr-articular injections?

I don’t know that the FDA has clarified. My expectation, in the absence of FDA clarification, is that Gad for arthrograms is still injecting an FDA approved drug into a patient, and therefore should be treated similarly to IV administration of Gad.

When is the ACR putting out an updated guidance document?

The ACR’s MRI Safety Committee is presently working on an updated version. I’m hopeful that we will have it completed and released late this year.

Are coronary stents a concern on low field, open MRIs?

In my opinion, no, individual or paired coronary stents are not of significant concern on any open MR systems… low-field or high-field.

I would like to know more about the specific differences about the various MR conditional description.

Unfortunately there now appear to be more exceptions to the ASTM template for MR Conditional labelling than implants / devices that follow the template. This means that there is tons of variability in labelling terms and the way it is presented. For passive devices, we’re generally concerned about static magnetic field strength (exposure limits in tesla, gauss, and spatial gradient values in G/cm or T/m), time-varying gradient magnetic field (gradient amplitude – usually in mT or gauss, and slew rate), and RF (usually represented as SAR / W/kg or B1+rms / mT). In addition to these, active implanted devices may also have specific conditions for the effective performance of the device.

Are you recording in the patients’ chart that they received the med guide? Are you to give the guide each time they are injected or is it just done once?

The FDA says that the patient information sheet is to be given to the patient upon the first administration of the drug (following the availability of the sheet). I’m not aware that the FDA has made any requirements about documenting it.

Where can we get medication handouts for handing out to patients?

The patient information sheets for gadolinium contrast agents can be found on the FDA’s website (look for the “new” labels). The documents on the website may include the full label information, which is NOT required to give to the patient. Look towards the ends of the files downloaded from the FDA’s website for a page or two that is specifically identified as patient information. That’s what sites are required to provide to the patient.

Free Guide to MRI Safety & Ferromagnetic Detection Regulations

With multiple professional and accrediting bodies involved, it can be difficult to keep track of what the various published safety recommendations and guidelines in the US say. Metrasens is pleased to assist by providing this summary of the present status as it relates to the growing adoption of ferromagnetic detection systems (FMDS) for the prevention of MRI projectile incidents.

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