Webinar Questions and Answers
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.