SDMC Radiologic Technologist Best Practices Questions

In

Read:          History of FDA Regulation

1. Have there been any patient fatalities (deaths) associated with MRI?

2. What event led to the development of the first national MR safety guidelines?

3. Both fatalities mentioned in the ASRT white paper involved the introduction of what item into the MRI environment?

4. What decade was MRI technology introduced?

5. What decade was MRI available for clinical use?

6. MR images are created by exposing patients to a strong _______________ _______________ and applying ________________ _____________.

7. In response to the Michael Colombini tragedy, what did the American College of Radiology (ACR) release in 2002 and update in 2013?

8. Which organization updated its alert on MR safety in 2013?

9. What two things must MR technologists understand and apply to ensure a culture of safety?

10. Define static:

11. (True or False) The static magnetic fields used in MRI are always on, unless a resistive magnet is used.

12. What 3 magnetic fields, mentioned under the mechanisms of MR adverse Events section, are used in MRI? And list the adverse effect associated with each one.

Magnetic Field:

Adverse Effect:

Magnetic Field:Adverse Effect:Magnetic Field:Adverse Effect:

13. Is there a possibility of an adverse event, from minor to life-threatening with the use of MRI contrast media?

14. The 2017 ASRT MR Safety Survey reported what percentage of respondents said a radiologist is always on site when patients receive contrast injections.

15. Is it required to have a physician, physician assistant, radiologist, radiologist assistant, or nurse practitioner present when MRI technologists administer Gadolinium based contrast agents (GBCA’s). Answer yes or no and explain your answer.

16. Has the use of MRI expanded or contracted in the last 30 years? How many MRI examinations were performed worldwide in 2012?

17. Is MRI technology used in emergency departments?

18. Use of MRI technology for head scans in the MRI increased by which percentage between 1994 and 2015?

19. Is MRI technology used during surgeries? What is is called?

20. Is MRI used for radiation therapy? If yes, what is its role and its impact?

21. How many MR technologist members of ASRT participated in the 2017 ARST MR safety survey?

22. How many respondents to the 2017 survey reported having a MRSO certification?

23. Define MRSO

24. MRI technologists perform MR examinations at the request of ________________ ________________ and under ________________ supervision.

25. The Medicare Improvements for Patients and Providers Act of 2008 requires medical imaging facilities to be accredited to be able to receive Medicare reimbursement. For a medical imaging facility to be ACR certified, the MRI technologists must be registered with: ____________ or ______________ or _____________.

26. Choose one specific MR utilization advancement: MR use, MR in the emergency room, intraoperative MRI, Hybrid operating room, PET MR, Diffusion, 3D guided radiation treatments, MR-Linac, Adaptive radiation therapy. Research and create a 1-2 paragraph summary describing the technological advancement and how MRI is used within it.

WHITE PAPER
Radiologic Technologist Best Practices
for MR Safety
Lorenza Clausen, R.T.(R)(CT)(MR), MRSO(MRSC), CRT; Joy Cook, MS, R.T.(R)(CT)(MR);
Amanda Garlock, MS, R.T.(R)(MR); Ashley Perkins, MHA, R.T.(R)(MR);
Bartram Pierce, BS, R.T.(R)(MR), MRSO(MRSC), FASRT; Kristin Seitz, BSMI, R.T.(R)(CT)(MR), MRSO(MRSC);
Jacqueline Turk, MEd, R.T.(R)(CT)(MR); Allyson Worthington, BS, R.T.(R)(CT)(MR);
Ellen Lipman, MS, R.T.(R)(MR), CAE; Teresa Odle, BA, ELS
©2018 ASRT. All rights reserved.
Published by the American Society of Radiologic Technologists, 15000 Central Ave. SE, Albuquerque, NM 87123-3909.
Reprinting all or part of this document is prohibited without advance written permission of the ASRT.
Send reprint requests to the ASRT.
WHITE PAPER
Radiologic Technologist Best Practices
for MR Safety
Lorenza Clausen, R.T.(R)(CT)(MR), MRSO(MRSC), CRT; Joy Cook, MS, R.T.(R)(CT)(MR);
Amanda Garlock, MS, R.T.(R)(MR); Ashley Perkins, MHA, R.T.(R)(MR);
Bartram Pierce, BS, R.T.(R)(MR), MRSO(MRSC), FASRT;
Kristin Seitz, BSMI, R.T.(R)(CT)(MR), MRSO(MRSC); Jacqueline Turk, MEd, R.T.(R)(CT)(MR);
Allyson Worthington, BS, R.T.(R)(CT)(MR); Ellen Lipman, MS, R.T.(R)(MR), CAE; Teresa Odle, BA, ELS
I
n January 2018, Rajesh Maruti Maru carried an
oxygen tank into a magnetic resonance (MR)
imaging suite to accompany a relative having an
examination in BYL Nair Charitable Hospital in
Mumbai. Maru and the oxygen tank were pulled into
the MR opening by the powerful magnet inside the
equipment. He died within 2 minutes when the tank
leaked and emitted a sudden and excessive amount of
oxygen, which caused asphyxiation.1 Investigations
into the incident uncovered lapses in safety practices,
including a metal detector that was not functional at
the time of the man’s death and existing piped oxygen
in the examination room.2
The Mumbai event occurred 17 years after the most
well-known MR adverse event in the United States. In
2001, 6-year-old Michael Colombini was killed when
an MR-unsafe oxygen tank was brought into the MR
examination room while the boy was having an MR
examination at Westchester Medical Center in New
York. The sentinel event catapulted development of the
first national guidelines for MR safety.3,4
MR imaging technology was introduced in the
1970s, and MR imaging has been an increasingly
important clinical tool since the 1980s. 5 MR imaging
assists physicians in diagnosing diseases, injuries, and
conditions. The images produced by MR technologists are created by exposing a patient to a strong
magnetic field and applying radiofrequency (RF)
energies to produce a signal that creates an image from
reconstructed data. 6
Radiologic Technologist Best Practices for MR Safety
National and international standards and guidelines
were developed following Michael Colombini’s death
to improve safety of all patients, visitors, and workers
who enter the MR zones (see Box 1). 8-10 The American
College of Radiology (ACR) released guidance on
MR safety in 2002 and updated the guidance a third
time in 2013. 8 In the same year, The Joint Commission
updated its sentinel alert on MR safety to correlate
with the 2013 ACR safety standards.11 Although safety
guidelines and standards lead to improved safety and
more consistent practice, no standardized regulations
exist with specific requirements for MR safety.11 MR
technologists must understand and apply physics principles and safety standards to ensure a culture of safety
in their MR facilities. 5
Mechanisms of MR Adverse Events
Several risk factors are associated with MR imaging. The first hazard is the powerful magnet housed in
most MR equipment; the equipment’s static magnetic
field remains on continuously and can attract magnetically sensitive (ferromagnetic) objects. However,
some systems use resistive magnets that can be turned
off. Aside from the static magnetic field, MR equipment has a time-varying gradient and RF magnetic
fields. The gradient field provides spatial encoding
of the signal, which makes the loud knocking sounds
patients hear. Time-varying gradient fields can intensify rapidly and cause electrically induced currents that
can cause peripheral nerve stimulation in patients or
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Box 1
MR Safety Standards
In the United States, MR imaging facilities must follow strict
quality and safety standards for MR equipment, set by the FDA.
The FDA places limits on patient safety factors in MR, such as
maximum magnetic field strength and noise, as well as the
maximum radiofrequency power reaching patients. The FDA
approves and regulates MR imaging equipment and handles
incident tracking.5
Further, the following organizations accredit MR facilities and
publish MR quality and safety standards that include minimum
staff qualifications, equipment standards, equipment safety,
recordkeeping, patient privacy, and patient and family or visitor safety7:
 American College of Radiology (ACR)
 Intersocietal Accreditation Commission
 RadSite
 The Joint Commission
Accreditation from 1 of these organizations is required for
Medicare reimbursement.5 It is important for facility leaders and MR technologists to be familiar with the standards
required by their accreditors, as well as the requirements of
state and federal law. Documents such as the ACR MR Safety
Guidelines promote safety and serve as de facto industry standards but are not legally enforced.8 For this white paper, the
ASRT chose to use the ACR recommendations as an example
because they are the oldest published MR safety standards.
Other organizations provide different guidelines, and each MR
facility should ensure compliance with the standards of their
own accrediting body.
affect electronic and metallic devices. 5,12,13 The RF field
enables technologists to acquire images by applying
energy to induce signals to receiver coils, or to antennas; this energy can cause tissues to heat. 5,13
Adverse events from the gadolinium-based contrast
media used in MR scanning can be minor or life-threatening. The risks and benefits of contrast administration
have been studied extensively and safety recommendations established for use of the agents.14 It is within the
scope of the MR technologist’s practice to determine
contrast amount and type based on established protocols and to administer the agent intravenously as
prescribed by a licensed practitioner.14,15 In the 2017
2
American Society of Radiologic Technologists (ASRT)
MR Safety Survey, 74.5% of respondents said a radiologist is responsible for deciding whether to use contrast,
and 54.4% said a radiologist is always on site when
patients receive contrast injections. Contrast media
considerations are within the MR technologist’s practice standards but are not within the scope of these best
practice recommendations.
MR Utilization
Because of continued technological advancements, and because MR imaging produces detailed
images without using ionizing radiation, the use of MR
examinations has expanded in purpose, scope, and
volume.5 The number of scans performed in the United
States exploded from 7.7 million in 1993 to 22 million by 2002.16 In 2012, more than 60 million MR
examinations were performed around the world.5 MR
examinations are replacing invasive procedures across
medical specialties.17
As technology has improved and become more
available, MR scans are being used more in emergency
departments for head and neck injuries. Between
1994 and 2015, use of emergency department MR
scans of the head increased 1451%.18 Among patients
admitted for observation in emergency departments,
approximately 19% have at least 1 MR scan.19 Reduced
scan times have led to expanded use of MR scanning
protocols. For instance, intraoperative MR has led to
advanced surgical approaches and improved patient
care in hybrid operating rooms.20
MR technology also has been combined with other
imaging methods, such as positron emission tomography (PET)-MR, to provide physicians images with the
detail of MR scans and information on pathological
functions in the body.21 Diffusion techniques and wider
availability have attributed to increased use of PET for
examining complex neurological disorders.22 Newer 3-D
techniques for radiation therapy have led to increased
use of MR imaging to guide radiation treatments.23 In
addition, MR-linear accelerator (MR-LINAC) equipment combines an MR scanner and linear accelerator
in a single system. The technology facilitates real-time
imaging for adaptive radiation therapy, improving accuracy and treatment efficiency.22,24
Radiologic Technologist Best Practices for MR Safety
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ASRT Survey of MR Technologists
In 2017, ASRT President Amanda Garlock, MS,
R.T.(R)(MR), made technologist-focused MR safety a
priority initiative. The ASRT conducted a nationwide
survey of MR technologists and convened the MR
Safety Best Practices Committee, consisting of MR
technologists and safety officers, to create a report on
MR safety issues and technologist-driven best practices
(see Appendix A).
In August 2017, the ASRT invited 22 139 ASRT
members employed as MR technologists to participate
in an MR safety survey. When the survey closed in
October 2017, ASRT had received 2637 responses, for
an 11.9% response rate. At its widest, a sample size of
947 yields a margin of error of +3.2% (at the 95% confidence interval).
Most survey respondents (92.5%) were certified
in MR imaging, and 3.4% reported having Magnetic
Resonance Safety Officer (MRSO) certification from
the American Board of Magnetic Resonance Safety
(ABMRS). A total of 62.3% of respondents identified
as staff technologists, 20.3% stated they were senior or
lead technologists, and 7.7% reported that they served
as supervisors or managers.
The average survey respondent was aged 47.9
years, worked in radiology for more than 22 years, and
worked in MR for 15.4 years. A majority of respondents (58%) indicated they worked in hospitals; 19%
worked in clinics, and the remainder listed their
primary work environment as physician offices, universities, and other settings. Respondents replied to
several questions about staffing and MR safety policies
and procedures in their workplaces. The technologists
offered insight on safety in some responses. Both quantitative and verbatim responses were incorporated into
this best practices report.
Background: MR Technologists
According to the ASRT MR Safety Survey, technologist practice standards and codes of ethics, and
national or international MR safety standards, MR
technologists must maintain a high degree of accuracy
in positioning and technique for optimal care during
diagnosis and treatment. According to Kanal et al and
the ASRT survey, technologists implement, maintain,
Radiologic Technologist Best Practices for MR Safety
and improve MR safety policies to ensure patient, visitor, and colleague safety in the MR environment. 8
Although technologists conduct MR examinations at the request of referring physicians and
under radiologist supervision, technologists are
responsible for ensuring adherence to MR safety
guidelines and policies. 8,15 To perform their jobs, MR
technologists receive training in and demonstrate
understanding of 15:
ƒƒ human anatomy and physiology
ƒƒ pathology
ƒƒ pharmacology
ƒƒ medical terminology
ƒƒ MR technique
ƒƒ patient positioning for MR
MR technologists also must possess knowledge of
MR safety and revise their knowledge as technological
developments and manufacturing of medical devices
evolve. The technologist is the primary contact person
for MR patients and a liaison between patients, staff,
and other health care professionals. MR technologists
have a wide scope of practice (see Box 2) and must
respond to emergencies as needed. In addition, ACR
accreditation recommends that MR technologists who
perform cardiac examinations maintain basic life support certification.25
Agencies outside the professional discipline further define technologist qualifications. The Medicare
Improvements for Patients and Providers Act of 2008
requires providers of outpatient technical components of advanced diagnostic imaging services to be
accredited by a Centers for Medicare & Medicaid
Services–designated organization to receive Medicare
reimbursement.26 To be ACR-accredited in MR imaging, a facility’s MR technologists must be licensed
within their state or other jurisdiction, assuming the
state has MR-specific licensing for technologists. In
addition, MR technologists must meet 1 of the following requirements25:
ƒƒ be registered as an MR technologist with the
American Registry of Radiologic Technologists
(ARRT), the American Registry of Magnetic
Resonance Imaging Technologists (ARMRIT),
or the Canadian Association of Medical Radiation
Technologists (CAMRT)
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Box 2
MR Technologist Scope of Practice
15
MR technologists’ scope of practice includes responsibilities
common to all imaging technologists, including but not
limited to:
 providing optimal patient care
 receiving, relaying, and documenting patient care orders
 verifying informed consent and corroborating orders
or clinical history
 taking care of patient needs during applicable examinations
or procedures
 preparing patients for procedures
 performing venipuncture and managing intravenous access
or administering medications as prescribed
 evaluating medical images for quality and to ensure patient
identification
 identifying and responding to emergency situations
 educating and monitoring students or other
health care providers
 performing ongoing quality assurance activities
 applying principles of patient safety throughout all
aspects of patient care
In addition, MR technologists:
 perform examinations or procedures (for diagnostic
interpretation or therapeutic intervention) under the order
of a licensed practitioner
 apply principles of MR safety to minimize risk to patients,
self, and others
 research implanted devices
 select appropriate pulse sequences with consideration of
established protocols and other factors that influence data
acquisition parameters
 assist licensed practitioners with interventional procedures
 perform postprocessing of digital data from patient scans
for display or hard-copy records, ensuring patient identification is correct and evident
 maintain archival storage of digital data as appropriate
ƒƒ be registered with ARRT or have an unlimited
state license, along with 6 months’ experience in
supervised clinical MR scanning
ƒƒ have an associate or bachelor’s degree in an
allied health field and certification in another
clinical imaging field (such as ARDMS or
NMTCB), and 6 months’ experience in supervised clinical MR scanning
4
ƒƒ have performed MR imaging continuously since
1996 and been evaluated for competence by a
responsible physician
MR technologists working in facilities seeking cardiac MR accreditation have additional requirements
for supervised experience in clinical cardiac MR and in
administering contrast intravenously. ACR accreditation requires facilities to document the qualifications of
personnel in the department, including MR technologists.25 MR technologists who work in specialized areas
such as breast imaging, nuclear medicine, interventional
radiology, radiation therapy, or hybrid operating rooms
also participate in training related to their specialty,
such as working in and managing safety in the hybrid
operating room environment.20
The MRSO is an additional certification available
to MR technologists through the ABMRS. The MRSO
typically is responsible for implementing all safety procedures and policies in an MR department under the
direction of the MR medical director (most often a supervising radiologist).11 This responsibility includes ensuring
that policies and procedures for MR safety are followed
every day and that MR technologists and other personnel have access to written instructions, safety procedures,
and emergency procedures.10 The MRSO also helps
decide, per MR medical director guidance, whether it is
safe to scan a patient in unique and specific situations.27
The ABMRS awards MRSO certification to an MR
technologist after he or she successfully completes the
ABMRS examination, which includes content on28:
ƒƒ magnetic field principles
ƒƒ cryogen safety
ƒƒ implant safety
ƒƒ standards
ƒƒ non-MR personnel in the MR environment
ƒƒ screening
ƒƒ zones
ƒƒ emergencies
ƒƒ safety concerns for special populations
The MR safety expert (MRSE) is another designation
of the ABMRS, and this professional serves in a technical consulting role. The MRSE designation typically
is awarded to medical physicists, although no specific
requirements exist for education or experience if a professional passes the MRSE examination.27
Radiologic Technologist Best Practices for MR Safety
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MR technologists usually are the primary personnel
involved in managing patient, visitor, and staff access
to safety zones surrounding MR equipment. Under
direct authority of the MR medical director, MR
technologists are responsible for ensuring adherence
to the ACR MR Safety Guidelines. The technologists are charged with tasks such as restricting area
access, screening patients and others who need access
to the equipment or areas in the magnetic field, and
observing and controlling the room (and safety of individuals) in which MR examinations occur. 8
MR Scanning
MR imaging systems produce images by applying
strong magnetic fields and RF energy to the body’s
atoms. Most clinical MR systems are superconducting
systems that use liquid helium to eliminate electrical
resistance in the wires that generate the magnetic field.
Once the magnetic field is established, it is on continuously, even when not in use. Superconducting magnets
can have a cylinder (tube) or open design. Permanent
magnets, which do not require electrical current, typically have an open design.
When technologists place a patient in the center of
the MR scanner, or bore, a slight majority of hydrogen
nuclei align with the scanner’s magnetic field. Applying
RF energy at the appropriate frequency causes the
atoms in the targeted volume to flip out of alignment
with the field. When the RF is stopped, the nuclei
realign with the magnetic field, producing a signal that
is received by the antennas of receiver coils and is then
transmitted to a computer.29 Coils are designed to work
with specific sizes and anatomic areas of the body.5
Applying other time-varying gradient magnetic fields
leads to the spatial localization of the MR scan. These
gradient magnetic fields are turned off and on rapidly
during MR scanning.5 Each MR field contributes to safety concerns in patients. MR technologists are educated
to understand how the fields affect imaging and safety.
Technologists also must be familiar with scanner design.
MR Safety Concerns
Despite its overall safety and effectiveness, MR scanning poses potentially serious risks for patients, their
family members, and medical personnel who enter the
Radiologic Technologist Best Practices for MR Safety
MR environment if the examinations are not performed
by properly educated personnel.8 MR safety concerns
involve several factors not found in other clinical environments. Without strict adherence to safety policies
and procedures, the fields or energies used in the imaging process can injure patients, family members, or staff.
Static Magnet
The magnetic field of the static, or primary, magnet used in MR imaging averages a strength of 30 000
to 60 000 times stronger than the magnetic field of
Earth. 3,30 The strength of the magnetic field in clinical
scanners range from 0.2 Tesla (T) to 7 T. Tesla is the
measure of magnetic field strength where 1 T is equal
to 10 000 Gauss. For many years, most MR scanners
had 1.5 T magnets, but 3 T magnets now are common
in hospitals because of the improved diagnostic performance of the stronger systems. 5,31 The first research
system with a 10.5 T magnet performed examinations
on humans in early 2018.32 The 5-Gauss line of powerful research magnets can extend outside the scanner
magnet’s room.5,13
Risks of injury or other adverse events often are
related to the static magnetic field, which interacts
with human tissue and ferromagnetic equipment. 33
Implanted devices or presence of metal materials in MR
zone IV can lead to injury for the patient and anyone
in the room, as well as damage to the scanner. Further,
MR technologists must supervise and control access to
zone III or any area physically within the 5-Gauss line.5
Several adverse events were reported following entry of
objects such as ferromagnetic anesthetic gas or oxygen
cylinders, beds, chairs, and IV poles. An instance also
was reported of a gun being pulled into the MR bore
and discharging despite the safety being engaged.5
Although modern MR systems have magnetic field
shielding to minimize field strength outside the bore,
the field strength increases rapidly as a person or object
approaches the bore. 5 The magnet rapidly and forcefully can accelerate ferromagnetic objects toward the
bore in a missile effect. The magnet can attract metallic objects such as coins, scissors, or hairpins.13,34 Of all
projectiles, heavy objects such as oxygen tanks, stretchers, and wheelchairs can do the most harm to people
and the scanner.17
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If a patient has implanted metal devices or other
ferromagnetic materials in the body that enter a static
or changing MR magnetic field, the magnet can cause
the implanted device to move and twist (torque).
Translational and rotational forces can vary depending
on factors such as the amount of ferromagnetic material
that is in the object and the total mass of the object.5
Implanted medical devices such as aneurysm clips are
attached to soft tissue only, and it is critical to identify
clips and other metal devices accurately to determine
the amount of ferromagnetic material they contain.5
The magnet also can affect the function of critical
implanted devices. For example, effects on the function of cardiac implanted electronic devices are among
the most common types of adverse events reported in
patients who have MR scans. Each device contains a
magnetic switch that turns it on or off upon detection of
an external magnetic field, which can affect whether the
device functions as it should to control heart pacing and
detect tachyarrhythmias.17
Gradient Field
Time-varying gradient fields are used in MR imaging to spatially localize and encode the MR signal. The
changing electrical fields produce a magnetic field that
changes in strength depending on position.5,35 Modern
systems carry currents as high as hundreds of amperes
that induce voltage and can cause heating in implanted
devices.5,36 Time-varying gradients can interfere with
some implants or monitoring devices and can lead to
peripheral nerve stimulation (ie, induction of electrical
fields in a patient’s nerves and muscles).13,33 The gradient
field frequency, flux densities, distribution in the body,
and other factors affect the potential for and severity of
peripheral nerve stimulation.13
Acoustic noise from the gradients requires use of
headphones or earplugs for patients having MR scans.13
Use of 3 T MR scanners is becoming common in the
clinical setting as some providers replace aging 1.5 T
units with 3 T scanners.37 A 2018 report from a Chinese
study of 3 T MR scanners found that acoustic noise
caused temporary hearing loss in patients who had
clinical neurological examinations in MR scanners,
despite their wearing ear protection. 38 The researchers
used 6 techniques, including diffusion tensor imaging
6
and T1-weighted fast spoiled gradient-recalled echo
imaging, with an average scan time of 60 minutes. The
study found that hearing returned to normal by an average of 25 days after scanning. However, the authors
emphasized the crucial nature of hearing protection for
patients scanned with 3 T magnets.38
Radiofrequency Energy
Radiofrequency waves are created by transmitters
integrated into an MR system. Placing an antenna, or
receiver coil, in the path of the changing magnetic field
induces a current, and the coil then emits an RF pulse.13
Radiofrequency pulses are present only during scanning, but the pulses can occur hundreds of times per
second.3,5 The RF energy can cause heating in human
tissue; the heating effect is measured by a unit called
specific absorption rate (SAR) and is expressed in watts
per kilogram.5 Different levels of heating can be harmful to infants, small children, or patients who have
disorders of their thermoregulatory systems.13 MR personnel should take special considerations with certain
medical or dental implants to reduce the risks of heating
and burns. 31,33 Burns of every degree are recorded as
MR adverse events.3
The RF pulses emitted by MR scanners also can
affect nonferromagnetic implants, requiring careful
screening by MR personnel. The pulses can induce
electrical currents in the leads of cardiac implanted
electronic devices, for example, and can affect how the
leads sense heart changes and inhibit responses such
as pacing; they also can inhibit or induce cardioversion therapy when not approriate.13,17 Leads on cardiac
implanted electronic devices perform like antennas for
the pulses and push electrical current through the lead
and into surrounding tissues. The tissue resists the current at the site of the lead, causing the tissue to increase
in temperature. Temperature increases of 44 F (7 C)
to 145.5 F (63.1 C) were documented for cardiac
implanted electronic device leads and other types of
endovascular wires.17 Patients also can receive burns on
their skin from patches, tattoos, permanent cosmetics,
nail polish, and monitoring devices. Zippers, snaps, and
metallic microfibers in clothing also can burn patients. 39
In addition, an RF coil and its connecting cables can
burn a patient’s skin if in direct contact.5 The risk of
Radiologic Technologist Best Practices for MR Safety
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radiofrequency heating increases with longer scan times
and higher static field strengths.13,39
Safety Zones
The ACR 2002 MR safety documents established 4
demarcated safety zones in MR facilities that become
increasingly restricted in relation to MR scanner proximity. The Joint Commission has adopted these zone
definitions and safety recommendations.8,11,40 Managing
access to zones is critical to preventing adverse events in
the MR department. MR personnel must ensure adherence to zone demarcation, screening, and other safety
policies to protect patients and the public. Emergency
personnel and non-MR hospital staff might bypass
screening steps if they are not trained in MR safety
and if an MR technologist is not in the immediate area
to control access.5 A summary of ACR recommended
zones follows (see Appendix B)5,8:
ƒƒ Zone I – the least restricted and public zone, furthest from the MR equipment. Zone I typically
includes the reception area, patient waiting room,
restrooms, and admission.
ƒƒ Zone II – the buffer between public areas and
more strictly controlled zones. Zone II typically
includes changing and storage areas for patient
belongings, patient transfer areas, and patient
history and screening. MR personnel should
supervise patient movement throughout zone II.
ƒƒ Zone III – this zone contains potentially hazardous energies, and access to the zone is strictly
restricted and controlled by MR personnel as
defined by safety guidelines. Entry of unscreened
individuals or ferromagnetic materials can result
in serious injury or death from the static and time
gradient fields. Physical barriers help control
entry. Zone III typically includes waiting areas for
screened patients, the control room, and the hallways or vestibule leading to the scanner room.
ƒƒ Zone IV – the most restricted zone; contains the
MR scanner room. Zone IV presents the greatest
safety risks because of energies associated with
MR imaging. Access to zone IV by non-MR personnel is permitted only after proper screening.
The area should be marked clearly and entrance
allowed only with a badge or passcode. Anyone
Radiologic Technologist Best Practices for MR Safety
other than MR personnel must be accompanied
or supervised by a staff person designated as
trained (level 2) MR personnel while in zone IV.
All zones should be marked clearly with signage. 5
It should not be possible for patients or staff to skip a
safety zone by an alternative entrance.13 Further, magnetic fields extend in all dimensions, not in a single
straight line. As a result, safety zones can extend into
non-MR areas above, below, or adjacent to the MR
scanner room.13
In the ASRT MR Safety Survey, 90.3% of respondents said their MR department uses a 4-zone system,
and 7.3% said their department does not use the zones.
In addition, 2.4% reported that they did not know
whether the department used the zone system.
MR Personnel Levels
MR imaging personnel include an MR medical
director, medical safety officer, and levels of MR personnel (see Appendix B). These levels and zone access
for each level are defined by the ACR as8:
ƒƒ Non-MR personnel – anyone who has not complied with MR safety instruction guidelines, and
specifically anyone who has not undergone designated MR safety training within the previous
12 months.
ƒƒ Level 1 MR personnel – staff members who have
passed minimal safety education that ensures
their safety while in zone III.
ƒƒ Level 2 MR personnel – individuals who have
completed extensive education in broad MR safety issues related to all MR energy fields.
The MR medical director is responsible for identifying and overseeing the training needs of those in
the department who should be educated to qualify as
level 2 MR personnel. A department’s MR safety officer also is responsible for defining MR safety issues
included in training. 8
The Joint Commission recommends appointing a
safety officer who is responsible for implementing and
enforcing MR safety procedures.11 The supervising MR
physician should review these written procedures at
least once a year.41 The facility’s medical physicist/MR
scientist must assess the MR safety program annually,
including matters such as access control and cryogen
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safety, and inspect the MR equipment for physical and
mechanical integrity.25 The Joint Commission also
requires annual training for all MR personnel that
informs all non-MR personnel, families, and patients
about potential harms of the MR environment.11 Having
a certified MRSO in each department is voluntary.
Screening
Devices
In 1997, the U.S. Food and Drug Administration
(FDA) introduced the first standards for terms regarding imaging device safety in MR. In 2005, the American
Society for Testing and Materials introduced the following designations, which the FDA later adopted5,11,42:
ƒƒ MR safe – an item that poses no known hazard in
the MR environment; typically any items that are
not metallic, magnetic, or conductive.
ƒƒ MR conditional – items that pose no hazard if
used as specified. Safety of conditional items is
based on specific information such as static field
strength, maximum gradient field strength, maximum SAR, and other conditions in which the
item was tested. These items should be brought
into safety zones III and IV only when using
extreme caution.
ƒƒ MR unsafe – items that pose hazards in all MR
environments and are contraindicated for MR
examinations.
MR-conditional devices have become increasingly
common as manufacturers have made changes to software or hardware to support low-risk use of the devices
in MR scanners under specific conditions.17 Early pacemakers could malfunction and lead to death, especially
if a patient was not monitored.36 The first conditional
pacemakers for the MR environment were approved in
Europe in 2008 and in the United States in 2011.42
Although new implantable devices can be used
safely near the MR scanner, many patients still have
older devices that are not safe for MR scanning and
contraindicate an MR examination. 43 Approximately
2 million people in the United States have implanted
devices that are not considered MR conditional; more
than half of these people are expected to need an MR
examination because of clinical indications. 44 A 2016
study reported that 81% of patients who had a cardiac
8
device when presenting for an MR examination had a
conventional device. 42
Some devices are deemed safe based on known
materials. However, any metal or electronic device
potentially can cause harm in the MR environment
(see Box 3).5 The potential for injury from implants in
patients is affected by the implant’s proximity to vital
tissues (eg, blood vessels or nerves).13 Further, although
some cardiac implanted devices are FDA approved for
safe use in the MR setting, neither manufacturers nor
the FDA supports MR scans for patients whose devices
are not MR conditional or MR safe.48
Therefore, approval of some devices for entry into
the MR room requires complex and critical decisionmaking, involving both potential patient injury and
device malfunction. However, numerous reports in
recent years have shown that conventional devices
cause no long-term, clinically significant adverse effects,
and that most cardiac implanted electronic devices not
labeled MR conditional can be scanned safely if preexamination evaluation and examination monitoring
procedures are followed.17,49 Strom et al evaluated 123
patients who had 189 MR scans and implanted cardiac
devices that were not considered MR conditional. 48
They reported 1 major adverse event and 3 minor
adverse events. The authors found a small decline in
battery value over years of remaining battery life and
effects on right atrial lead threshold potential at 6
months following the MR scan. 48
Decisions to proceed with examinations for patients
should be made individually based on risk vs benefit,
with careful consideration of research on specific
devices and their reported safety designation. 42 Not all
implanted devices are approved or alike, and research
typically is conducted on scanners with 1.5 T static
magnets.17,42 Industry-wide and facility-level efforts
must balance ensuring patient safety with preventing
denial of indicated MR examinations when possible.8,45
Safety of patients presenting for an MR examination
is optimized when risks from devices or other issues
are weighed carefully with medical indications for
examinations and when all conditions are met for
MR-conditional devices.
MR technologists most often research devices for
designated safety evidence, and level 2 MR personnel
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Box 3
Sample List of Implants and Foreign Objects of Concern in MR Scanninga
Policies and procedures should address possible contraindications to MR scanning,9 including the following devices:
Implanted cardiac devices such as pacemakers and cardioverter defibrillators.9 Pacemakers received early attention in MR
safety. Conventional devices have been associated with adverse events.3,45 Implanted cardiac devices can lead to adverse events such
as ventricular arrhythmias during examinations or problematic changes in pacing and sensing.45 Also of concern are nearly all prosthetic
heart valves, including mechanical valves, and coronary stents. Evaluation of devices at 3 T strength continues.34
Other mechanical, magnetic, or electronic devices such as certain neurostimulators and cochlear implants.9 The FDA
has noted incidents of serious injury, including permanent neurological impairment or coma, from implanted neurological stimulators exposed to MR scanning; the electrode tips heated to the point of causing damage to patients.8 Electrophysiologic monitoring
equipment can be used intraoperatively, but surgeons hesitate to use the monitoring with intraoperative MR because of concerns
about burning or torque effects on electrodes during MR. Breitkopf et al reported safe use of continuous intraoperative monitoring in
intraoperative MR-guided surgery on 110 patients.46 Cochlear implants can be demagnetized in the presence of an MR magnetic field,
depending on the position of the implant in relation to the static field.31 Breast tissue expanders can have a ferromagnetic port that
subjects the expanders to torque forces in the presence of MR magnets that cause pain, burning, or migration of expanders. Some
devices are less apt to migrate, and in magnets at 1.5 T strength, filling the device with saline and placing the patient in a prone position can add to procedure safety and image quality.6
Medical and dental hardware. Ferromagnetic clips, stents, and ocular implants can move or dislodge during MR scanning.9 Several
types of dental hardware use magnets (a magnetic assembly and keeper). The ability of the dental magnetic assemblies to maintain
force and retention is decreased with 3 T scanners. Effects depend on the angle at which magnets are positioned.31 Brackets are
cemented to teeth for some braces or implants. Brackets can be ferromagnetic and cause artifacts on neuroimaging; all removable
parts of magnetic dental devices should be removed before MR examinations.3,31
Medication patches. Some medication patches contain a metallic foil, which can cause burn injuries when a patch is exposed to the
radiofrequency field.8
Tattoos and tattooed makeup. These inks can contain metals that heat up when exposed to radiofrequency energy.8 Makeup and
tattoos are not part of typical medical histories, and tattoos located within the region of the body scanned can introduce safety risks.3
Body piercing. Piercing hardware can be identified by ferromagnetic detectors and can be partially removed, but hardware might be
anchored with a metal post through the skin, which should be identified and assessed for ferromagnetic properties before MR examinations. Multiple body piercings or surgical staples can create a circuit or voltage pathway that causes burning.3 Patients with staples or
superficial metallic sutures can have an MR examination if the materials are deemed not to be ferromagnetic.8 Heat sinks (ie, materials
that disperse potentially hazardous temperature rises, such as ice packs) can be used when they must stay in place and are not in the
area of the examination to be performed.
Foreign objects. Some patients are exposed to metal fragments on the job or through injuries. In 1985, there was a report of serious
eye injury to a patient who had a small piece of metal move in his eye during an MR scan. Medical history and patient screening forms
help reduce risk.3
Clothing. Attire and accessories can contain metal snaps or other fixtures. In addition, manufacturers have increased use of metal
fibers in clothing, and there have been reports of patients with second-degree burns from metallic threads in clothing worn during MR
examinations.3
Fitness trackers. Popular step and fitness tracking devices, such as Fitbit, can contain ferromagnetic materials; the Fitbit manufacturer
recommends that patients and personnel not wear the device near an MR scanner.47
Orthopedic hardware. Orthopedic hardware should be included in screening questionnaires, primarily for concerns about artifacts
on images. Most orthopedic hardware is made of nonferromagnetic metals.3
a
For information only; more complete lists are available from MRISafety.com.
Radiologic Technologist Best Practices for MR Safety
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are among those who can recommend safety of an
implant or foreign object based on predetermined criteria. The final decision to proceed with an examination
is made by an MR level 2-designated attending radiologist, MR medical director, or specifically designated
level 2 MR personnel.8 MR technologists must carefully
follow institutional and ACR recommendations on
patient and device screening, consent, and monitoring
even in the presence of safe labels or FDA approval.17,42
Results of the ASRT MR Safety Survey showed that
94.4% of respondents indicated the MR technologist is
responsible for researching implants. In addition, 92.3%
said the MR personnel in their facility spend at least 5
minutes researching patients’ individual implants, and
48.9% spend more than 15 minutes on the research.
Patient Screening
All nonemergent patients or volunteer research
subjects should complete screening questionnaires
(see Appendix C for a sample form) that are reviewed
by registration staff with MR personnel training
and later reviewed by MR technologists or MR level
2-trained personnel. 39 Screening recommendations
for nonemergent patients also include at least 2 safety
screenings on site, 1 of which should be performed by
level 2 MR personnel, and 1 of which should be verbal
or interactive. Emergent patients and non-MR personnel accompanying them can be screened only once
if the single screening is performed by an individual
designated as MR level 2 personnel.8 A total of 55.4% of
survey respondents said that, on average, fewer than 2
technologists were scheduled per MR scanner at their
facilities. A total of 38.1% reported having 2 technologists scheduled per scanner, and 6.5% reported more
than 2 technologists per scanner. Most said 2 or more
MR suite personnel are required to screen patients
before the patients enter the room with the MR scanner.
MR technologists question patients about any device
that could pose a danger in the MR environment. In
addition, patients are questioned about any implanted
device that is activated magnetically or electrically,
such as pacemakers.11,39 To determine the MR safety
of implants and devices, technologists rely on device
identification cards, medical records, manufacturer
websites, and searchable device lists (see Box 3).39
10
Technologists visually should inspect patients for the
presence of unsafe items such as metal or conductive
attire. 40 Specific procedures for reviewing a patient’s
answers and investigation should be outlined in department policy before allowing a patient to advance to each
corresponding zone and should serve to review and verify information provided by patients or referrers.11,39,40
Safety guidelines recommend further investigation
for patients who have a history of ferromagnetic foreign
object penetration or medical history of orbit trauma
from a possible ferromagnetic material. The investigation might include radiography or evaluation of prior
CT or MR examinations showing the area of the foreign object. 8 When patients are unconscious or unable
to answer screening questions, MR technologists can
question family members or surrogate decision makers,
examine available patient history, and look for signs
(eg, surgery or injury scars) of possible MR-unsafe
devices or ferromagnetic materials. When appropriate,
use of radiography and ferromagnetic detectors can aid
in the investigation.11
Personnel Safety and Screening
All non-MR personnel entering the MR environment should be screened through a screening
questionnaire and with ferromagnetic detection when
available (see Appendix C).8 Non-MR personnel are
subject to injury from projectiles and loud gradient
sounds. Thoroughly screening and supervising these
personnel help to ensure patient and personnel safety.3,50
Radiologic science education program students
participate in clinical training in radiology departments. The Joint Review Committee on Education in
Radiologic Technology has adopted standard interpretations to promote student and patient safety in the MR
environment. The standards state that students will use
magnetic field safety measures. 30,51 In addition, students
should receive training and supervision by department staff, safety information as part of the classroom
training, and a required safety screening protocol by
education programs. 30
Accompanying Family or Personnel, Special Situations
Any family member or caregiver accompanying a
patient into the MR scanning room must be screened
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using the same criteria for zone IV that are used for
patients and personnel. It is recommended that only
1 adult accompany a patient into zone IV. Other situations include prisoners or parolees with metallic
restraining devices, RF identification, or tracking
devices. Safety recommendations state MR technologists should request appropriate authorities accompany
the patient into a designated MR area to remove
restraint devices before the study and replace them
immediately following the study. These personnel
must be screened the same as any accompanying adult
or non-MR personnel. 8
Some patients present special situations. According
to a discussion on the online MR forum for ASRT
members and to ASRT MR Safety Survey verbatim
responses, for example, MR technologists are looking for guidance on the presence of service animals in
the MR environment. Although patients with service
animals cannot be denied medical service under the
Americans With Disabilities Act and must be allowed
“anywhere else in a hospital where public and patients
are allowed to go,”52 MR technologists are charged with
limiting public access to MR safety zones. This suggests
denial of service animal entry when patients, staff, or
others are unsafe because of ferromagnetic materials
and other MR-unsafe devices. Service dogs have ferromagnetic halters and other metal in collars or leads.
Further, hospital staff are not responsible for handling
dogs or other service animals. It is the responsibility of the handler to supervise and care for the dog.52
MR technologists also are concerned about harm to
dogs or other animals from the noises generated by
MR equipment or by identification chips implanted in
dogs (ASRT Communities discussion, December 9,
2016-January 5, 2017).
Emergency Responders
ACR safety recommendations state that all emergency events, such as fire alarms or cardiac arrests,
in the MR suite should be managed by a designated
MR-trained individual. If possible, designated individuals should be on site before emergency responders
arrive to control the responders’ access to MR zones III
and IV. The guidelines suggest designating MR technologists as security personnel in the facility.8
Radiologic Technologist Best Practices for MR Safety
Although MR departments train and assign designated emergency responders from within their facilities
in MR safety, training of outside personnel is less frequent or consistent. In the ASRT MR Safety Survey,
15.8% of respondents mentioned failure to limit access
as the most frequent type of noncompliance, and 12.4%
reported noncompliance with emergency response as
most frequent. Respondents reporting annual training of
emergency personnel using safety videos and MR technologist presentations covering MR safety annually or at
orientations. The range of efforts and requirements varies widely; some emergency responders have no formal
training, and other MR departments invite community
emergency personnel, but not all attend. Regardless of
emergency responder training, physical barriers and MR
level 2 personnel supervision should restrict entry to
zone IV, according to survey verbatim responses.
ASRT MR Safety Survey respondents described
policies that included firefighters and emergency medical services personnel in level 1 MR personnel training
and allowing only prescreened staff into zone III. MR
technologists should evacuate patients in emergency
situations to zone II. Further, some respondents report
policies that include ensuring MR level 2 personnel
are trained in emergency and evacuation procedures,
including annual drills.
Metal Detection
Despite thorough screening, unsuspected ferromagnetic materials might enter MR safety zones. 39 As
an additional screening level, guidelines recommend
use of a handheld magnet or ferromagnetic material
detection device. The detecting magnet should have
a strength of at least 1000 Gauss and be designed to
detect ferromagnetic objects. Use of ferromagnetic
detection systems is demonstrated as highly effective and was evaluated in a 2014 study. 8,53 The author
found that the system used in the study (Ferroguard
Screener) was 100% sensitive and 98% specific at
detecting ferromagnetic objects. 53 Studies show
that current ferromagnetic detectors also can detect
implanted devices and external metallic objects. 8,40,54
Ferromagnetic detection is shown to be helpful
in screening non-MR personnel from other medical
departments who might or might not have MR training.
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Staff easily can forget to remove pins, clipboards, or
other personal objects and attire before entering the
MR safety zones, and a detector serves as a quick
reminder and screener.53
The ACR suggests use of ferromagnetic detectors
in zone II or at the entrance to zone III.8,53 To date, ferromagnetic metal detectors are not approved by any
government entity but are considered a useful tool to
assist in MR safety screening.55 The physical screening for ferromagnetic objects is an adjunct to, but not a
replacement for, screening questionnaires, interviews,
and visual inspections.8,40
Reporting and Documentation
MR technologists are responsible for participating in
routine patient care documentation and in documenting adverse events that occur in the department. They
follow institutional policies, as well as standards and
regulations that pertain to their facility.
Routine Documentation
MR safety standards recommend or require MR
personnel to document the examination. They must
maintain a permanent record of the full examination in
an archive and archive images for a designated period
according to procedures. Examination retention must
satisfy clinical needs and relevant facility requirements,
regulations, or legal needs.15 The ACR stated in its
MR practice parameter that “high-quality patient care
requires adequate documentation.”41 Further, ASRT
Practice Standards include documentation of orders,
corroboration of clinical history, the examination or
procedure, and outcome.15
MR technologists are responsible for documenting all diagnostic, treatment, and patient data in the
medical record in a timely manner.15 MR technologists
who are ASRT members have expressed concerns
about the lack of a consistent industry guideline on
documentation of screening efforts and device safety
research (ASRT Communities discussion, September 1,
2016-December 13, 2017).
Site-specific Documentation
MR facilities must write, enforce, and annually
review and document safety guidelines, policies, and
12
practices. The supervising physician must approve
the documentation, and the medical physicist/MR
scientist must assess MR safety as part of annual performance evaluation. This responsibility also includes
matters such as signage, control of access to safety
zones, screening procedures used, and cryogen safety
policies and practices.25
Facilities must have procedures in place for documenting MR personnel qualifications and continuing
education. Documented training should include fire
and electrical safety, hazard or emergency communication, safety reporting tool training, knowledge of safety
manual documentation, and infection control.8,50 They
also must have policies for personnel to report traumas
or procedures that might affect their safety in the MR
environment. In addition, they must follow documentation requirements related to quality management.8,25
Adverse Event Documentation
Intersocietal safety standards require a procedure to
identify patients or other individuals who experience an
adverse event or complication from an MR examination
or from entry into the MR environment. The facility
must maintain documentation of the incident.9
The ACR safety recommendations state that procedures should be in place for reporting all adverse
events, safety incidents, and near incidents to the medical director within 24 hours. Sites also must report
adverse events to the FDA. 8 Device-user facilities
(eg, hospitals, ambulatory surgical facilities, nursing
homes, outpatient diagnostic facilities, and outpatient
treatment facilities, but excluding physician offices)
must report a suspected medical device-related death
to the FDA and the manufacturer. User facilities must
report a medical device-related serious injury to the
manufacturer, or to the FDA if the medical device
manufacturer is unknown.
A user facility is not required to report a device malfunction, but it can voluntarily advise the FDA of such
product problems using a voluntary MedWatch form
under the FDA’s Safety Information and Adverse Event
Reporting Program.
The Manufacturer and User Facility Device
Experience (MAUDE) searchable database contains
mandatory reports filed by device manufacturers and
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importers from August 1996 to present, all mandatory
user facility reports from 1991 to present, and voluntary
reports filed after June 1993. Any information suggesting the device could be likely to cause serious injury or
death in a patient must be thoroughly reported by the
manufacturer or imported to MAUDE. The MAUDE
database houses medical device reports submitted to
the FDA by mandatory and voluntary reporters such
as health care professionals, patients, and consumers.
However, MAUDE does not include events reported
through other channels.56,57
The ACR has stated that adverse events in MR are
under-reported. 8 The Joint Commission’s safety policies and procedures state that facilities must report all
MR accidents and near misses to the equipment vendor
and the FDA.11
Summary of MR Technologist Role
Level 2 MR technologists are responsible for:
ƒƒ ensuring that patients comply with pre-examination preparation instructions
ƒƒ screening for contraindications
ƒƒ selecting scanning parameters based on order and
protocols
ƒƒ obtaining images as scheduled and ordered
ƒƒ assuming the comfort and care of patients in the
scanner
ƒƒ recognizing signs of an emergency
In addition, MR technologists administer first
aid or provide life support to patients as needed and
monitor patient reactions to contrast media or medications.15 They are responsible for proactively planning
for critical care patients with assigned staff to ensure
monitoring and life-sustaining equipment is available
and can be used safely.11,41 MR technologists respond
to emergency codes by limiting access to the scanner
room and safely and rapidly moving a patient who
requires resuscitation out of the scanner and zone IV
before resuscitation begins.11
MR technologists must prepare and position patients
for examinations, placing coils and leads safely as part
of the positioning.15,41 Technologists determine whether
services are performed in a safe environment and work
to minimize potential hazards,15 including taking recommended precautions to prevent burns during MR
Radiologic Technologist Best Practices for MR Safety
scans. This task can involve ensuring no closed-circuit
loops are formed in the MR scanner bore, using nonconducting foam pads between patient skin and the bore,
or placing a cold compress on leads, tattoos, and other
potentially conductive materials. Technologists also provide ear plugs or headphones for hearing protection.11
Level 2 MR personnel also are responsible for ensuring safety of all personnel or family members who
enter safety zones; this responsibility includes screening and providing hearing protection and MR-safe or
MR-conditional seating for a family member accompanying a patient.8 In addition, MR technologists usually
are the primary people responsible for researching and
documenting MR safety of implants under the supervision of the MR medical director.
Staffing
After screening patients and personnel to optimize
safety in MR zones III and IV, technologists conduct
the MR examination. MR suites are designed so that
access is controlled by MR technologists and that
technologists can monitor patients continuously.
Technologists also must ensure images are acceptable for diagnosis by a radiologist.15 MR technologists
must remain attuned to ferromagnetic detector
alarms and respond appropriately, even though falsenegative alarms occur. 39
The ACR recommendations for MR safety state
that at least 2 MR technologists or 1 MR technologist and another MR personnel-designated person
be in the zones closest to the MR scanner, except in
emergent cases, in which case the recommendations
state an MR technologist can be alone as long as
in-house emergent coverage from a designated department is ready; the recommendations do not require
a minimum of 2 technologists at all times. 8 Further,
The Joint Commission’s performance criteria for MR
providers includes the objective of having 1 specially
trained MR staff person familiar with MR-specific
safety issues accompany “all patients, visitors and
other staff who are not familiar with the MR environment” in the 2 zones closest to the MR scanner.11
The ASRT MR Safety Survey reported as many as
55% of facilities have fewer than 2 technologists scheduled per MR scanner per day. Only 27.3% of the survey
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participants report employment of patient aides who
help with patients in the MR department.
The professional ethics of radiologic technologists,
per the ARRT, guide the professional behavior and
represent the values of MR technologists. The code
includes ethical conduct and protecting a patient’s right
to quality care. In addition, a technologist “assesses
situations; exercises care, discretion, and judgment;
assumes responsibility for professional decisions; and
acts in the best interest of the patient.”58
MR technologists have reported being torn between
administrative policies assigning departmental staffing
and a firm resolve to monitor and help patients. They
also believe that having fewer MR personnel than recommended on staff compromises patient and personnel
safety. For example, the MR technologist on duty must
control access to the scanner room and safety zones
while simultaneously attending to a patient in the scanner, which can distract from patient monitoring and
can be physically impossible to maintain, depending
on the layout of an MR department. The technologist
should never leave a patient in the MR scanner unattended, yet technologists might be needed to assist in
emergency situations requiring more than 1 individual
who is level 2 MR personnel, such as removing a patient
safely from the room if a patient has a cardiopulmonary
arrest. Some MR technologists described nurse-topatient ratios on inpatient floors as a patient care and
safety issue and wondered why a similar policy does not
apply industry-wide to MR department staffing (ASRT
Communities discussion, February 28-December 29,
2017). New language addressing technologist staffing
is included in proposed updates to ASRT practice standards as of May 2018.
Best Practices
Safety guidelines such as those released by the ACR
and The Joint Commission serve a broad audience,
including supervisors, physicians, physicists, and hospital safety officers. It is clear that managing patient,
visitor, and personnel safety falls within the responsibility of MR technologists. Standard guidance lacks
recommendations for MR technologists who document device screening, research, and decisions made
or precautions taken for MR scanning for patients and
14
personnel. Although guidelines require reviewing and
revising departmental or institutional policies and procedures, the MR Safety Best Practices Committee (see
Appendix A) recommends the following best practices:
ƒƒ All individuals in safety zones III and IV must
be continuously supervised by MR-trained personnel. Further, MR technologists should never
leave the scanner or control room when a patient
is in the MR scanner bore or room. This practice
requires appropriate staffing support from department and facility administrators.
ƒƒ Nonemergent patients should be MR safety
screened on site by at least 2 MR-trained individuals, at least 1 of which is designated level 2 MR
personnel. Level 2 personnel should verbally or
interactively screen patients before they enter zone
IV. This recommendation requires departmental
support for adequate staffing and addressing or
revising institutional screening policies.
ƒƒ All patients should change into facility-provided
attire before entering zone III. This ensures no
metal objects on clothing or in clothing material
enter the magnetic field.
ƒƒ MR technologists should document all
safety screening in a permanent record, such
as the patient’s electronic medical record.
Documentation includes:
• patients, accompanying individuals, staff
screening forms
• implant documentation (cards, operative
reports, vendor information)
• implant MR safety requirements (SAR,
maximum spatial gradient, field strength)
• summary of interactions between radiologist
and MR technologists as to the safety of implant
• evidence of MR guidelines compliance
• status of patient pre-examination and
postexamination
• adverse events
ƒƒ Hospital and community responders, as well
as others who might access MR safety zones
for emergencies or nonemergencies (eg, nurses,
housekeeping staff, or physicians), should receive
MR safety training at least annually, and the
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training should be documented. MR technologists, supervisors, administrators, and community
liaisons should provide appropriate training for
staff and local community emergency responders.
ƒƒ Considering the lack of guidance and information
about service animals, MR technologists should
refuse entry of service animals to zone IV; the reason includes danger to the animal from acoustic
noise. Technologists should ensure appropriate
supervision of entry of animals to zone III to follow safety standards regarding public access to
the zones. Patients should be advised when making an appointment to bring a handler to the MR
facility or department who can supervise the animal. Adhering to this recommendation requires
adopting a policy and procedure for service
animals and following state regulations and institutional policies that govern the official process.
8.
9.
10.
11.
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Appendix A
MR Safety Best Practices Committee
Lorenza Clausen, R.T.(R)(CT)(MR), MRSO(MRSC), CRT, Senior Special Procedure Technologist, Mercy Hospital of Folsom, Dignity Health, Folsom, California
Joy A Cook, MS, R.T.(R)(CT)(MR), Clinical Associate Professor of Radiologic and Imaging Sciences, University of
Southern Indiana, Evansville
Amanda L Garlock, MS, R.T.(R)(MR), Lead Imaging Technologist, Whidbey Health, Coupeville, Washington;
ASRT President 2017-2018
Ashley M Perkins, MHA, R.T.(R)(MR), Clinical Radiology Educator, Franciscan Health, Indianapolis, Indiana
Bartram J Pierce, BS, R.T.(R)(MR), MRSO(MRSC), FASRT, MRI Safety Officer, The Corvallis Clinic, Corvallis,
Oregon
Kristin L Seitz, BSMI, R.T.(R)(CT)(MR), MRSO(MRSC), MR and CT Technologist, Westerville Medical
Campus, Westerville, Ohio; Ohio Society of Radiologic Technologists Board of Directors Member; ASRT Magnetic
Resonance Chapter Delegate
Jacqueline Turk, MEd, R.T.(R)(CT)(MR), MR Operations Manager, Philips Healthcare, Highland Heights, Ohio
Allyson Worthington, BS, R.T.(R)(CT)(MR), Cross-sectional Supervisor, Catholic Medical Center, Manchester,
New Hampshire
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Appendix B:
Glossary of MR Safety Terms
8,11
Personnel:
Non-MR personnel – anyone who has not successfully complied with MR safety instruction guidelines, specifically anyone who has not
undergone designated MR safety training within the previous 12 months.
Level 1 MR personnel – those who have passed minimal safety education that ensures their personal safety when in zone III.
Level 2 MR personnel – individuals who have completed more extensive education in broad MR safety issues related to all MR energy
fields.
MR medical director – physician responsible for identifying and overseeing training needs of those personnel in the department who
should be educated to qualify as level 2 MR personnel.
MR safety officers – certified MR personnel typically responsible for implementing all safety procedures and policies in an MR department under the direction of the MR medical director.
Safety zones:
Zone I – the least restricted zone open to the general public and furthest from the MR equipment. Zone I encompasses areas outside the
clinical MR environment through which patients and staff access the MR area, such as the reception area, patient waiting room, restrooms, and an area for patient admission.
Zone II – patients are greeted by MR personnel in zone II, which typically includes changing and storage areas for patient belongings,
patient transfer areas, and patient history and screening. MR personnel should supervise patient movement throughout zone II.
Zone III – this zone can contain potentially hazardous energies and access to the zone is strictly restricted and controlled by MR personnel as defined by safety guidelines. Entry of unscreened individuals or ferromagnetic materials can result in serious injury or death from
the static and time gradient fields. Physical barriers such as doors with coded access help control entry. Safety zone III typically includes
waiting areas for screened patients, the control room, and the hallways or vestibule leading to the scanner room.
Zone IV – the MR scanner room. Zone IV presents the greatest safety risks because of energies associated with MR imaging. Access to
the zone by non-MR personnel is permitted only after proper screening and the area should be clearly marked and physically accessible
only with a badge or passcode. Anyone other than MR personnel must be accompanied or supervised by a staff person designated as
trained (level 2) MR personnel the entire time present in zone IV.
Radiologic Technologist Best Practices for MR Safety
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Appendix C:
Screening Form From MRIsafety.com
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
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 
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 
 
 
 
 
 
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 
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20
Radiologic Technologist Best Practices for MR Safety
WHITE PAPER


 

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
 

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 

 

 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
  
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 
 
 

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 

 

 
  

  
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  
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 
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 
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