In this issue, Robert E. Watson Jr., MD, PhD, FACR, Chair of the ACR® Committee on MR Safety, discusses the recently released update of the ACR Manual on MR Safety, which builds on prior editions with substantial new content and safety recommendations.
Tell us about the new MR safety manual and why updates were needed at this time.
Initially published in 2002, the ACR MR Safe Practices Guidelines established de facto industry standards for safe and responsible practices in clinical and research MR environments. Subsequently, these guidelines have been reviewed and updated throughout the years to become the ACR Manual on MR Safety. The manual addresses feedback from practitioners in the field and has adapted to changes in the MRI industry since the original publication.
MR safety continues to evolve and, in response, the ACR Committee on MR Safety just released a much-needed update to the ACR Manual on MR Safety with critical new guidelines and safety procedures. The intent of the revised manual is to address new challenges that face contemporary MR practices, while at the same time increase readability and instructional value. The committee reorganized the manual into chapter format, with more images and “key point” boxes in an effort to enhance clarity.
We’ve added more figures, tables and references, because some of the material is quite complicated. So we're trying to make it more of a teaching tool, more user friendly. As a specialty, we can use that updated knowledge for the safety of our patients, our employees in the field and everybody else affected.
What are some of the major new updates geared to improving MR safety?
In addition to complete reorganization of the manual into a chapter format with updated references, key changes to the manual include:
- Updated MR personnel training levels and associated level-specific elements of MR safety training.
- Updated MR personnel staffing recommendations, including in routine, emergency and remote scanning scenarios.
- Updated guidance on “full stop/final check” processes in routine and emergency/complex situations, with associated elements of final patient/subject preparation.
- Expanded and updated information related to objects, equipment and implanted devices; recommendations to help minimize projectile risk with use of pocketless attire for MR personnel and tethering of external equipment in Zone III/Zone IV.
- New MR Risk Assessment Appendix as it pertains to management of patients with implanted devices with unclear MR conditions for safe scanning.
- New extensive checklist of elements to consider for site MR safety policies and standard operating procedures patterned on the ACR MR safety checklist required for ACR MR-accredited facilities.
Who should use the updated MR safety manual and how?
The manual is intended for use by MR practitioners, technologists, medical physicists, administrators and other healthcare personnel. The principles found within the manual apply to clinical diagnostic imaging, research and atypical MR settings (e.g., linear accelerator MR and interventional MR), and they encompass information for patients, research participants and healthcare personnel.
Today, there should be (and we recommend) a well-defined organizational structure around management of MR safety. This includes a Medical Director for MR Safety (MRMD), who works in concert with MR Safety Officers (MRSOs), who are often highly trained technologists. In addition, rounding out this group are MR Safety Experts (MRSEs), who are typically highly trained medical physicists, and often the people with whom we consult for the real “nuts and bolts” of the physics behind the scanning and about what we need to do to get a patient with complicated implanted devices scanned properly.
The manual should be used as a template and a guide to follow in the development of a safety program, with site-specific MR policies and standard operating procedures.
What are the challenges and risks of MRI that make a tool like the MR safety manual critically important in helping radiology practices improve the quality and safety of their patient care?
There are definite significant risks in the MR environment, not only for the patient but also for the attending healthcare professionals, accompanying family members and others, including security officers, housekeeping personnel, firefighters, police, etc., who might encounter the magnetic fields and other energy sources associated with MR scanners. Knowledge about these risks and putting in place necessary MR safety policies and standard operating procedures as addressed in the manual are key to creating a safe environment.
What are some examples of the safety issues related to MR that are covered in the manual?
The issue with MRI is that there are various fields in MRI, and they are not seen. For example, an MRI has an incredibly strong magnet associated with it, and it’s “on” at all times — not only when a patient is being scanned. So if someone goes into the MRI room and they happen to be carrying something metal that is attracted to a magnet, or, in an extreme example, wheeling a gurney, it could be attracted to the MRI with tremendous force, and it can be lethal if someone were caught between it and the machine.
There are a host of other safety issues, including the strong radiofrequency fields given off by the MRI machine, which have the ability to cause burns in a patient if their skin is not protected and contacts the wall of the bore inside the MRI. There's a vast amount of knowledge that technologists and others need to have when a patient goes into the MRI in terms of positioning them properly. We also scan patients under anesthesia, so if you don't have a patient properly padded, they could be subject to severe burns that develop during the scan, as they wouldn’t be able to respond to a developing burn. Then we have the issues associated with the ever-increasing numbers of implanted devices. Manufacturers are doing their best to design them, so we can scan patients safely, provided we accurately perform the scan with the appropriate conditions. We always need to know the specific make and model of all devices implanted in our patients, and then figure out whether or not we can safely scan the patient employing the appropriate scanning parameters.
In terms of scanning patients with complex, sometimes multiple, implanted devices, one of the taglines I use at Mayo is that we try to be “intelligently aggressive” about getting patients their MRIs. It's very easy to just throw your hands up and say, “Forget it, we're not going to scan this patient” because we want to maintain safety. But there's another side in that patients absolutely need scans to receive their diagnoses. With the knowledge in the MR safety manual, we try to keep everybody safe while getting patients the diagnoses that they need.
What is the role of the ACR Committee on MR Safety with regard to updating the manual?
The ACR Manual on MR Safety represents the consensus of individuals from the ACR Committee on MR Safety. The committee comprises professionals representing diverse fields and backgrounds, including research/academic radiologists, private practice radiologists, MRI medical physicists and MR technologists. It should be noted that the recommendations in the manual are aligned with the real-world considerations we face in terms of complex patient care and throughput, staffing issues, financial pressures and other considerations.
With this revision, we sent the updated manual out for public comment, and we got back 770 comments, which the committee painstakingly reviewed and used to incorporate changes, as needed. We're increasingly comfortable that this type of process helps create a dialogue with our colleagues in the community who are going to be using the manual. We want to have the best communication about the safest practices that we can. I know this public comment period helped us make the product even better.
What’s next for the MR safety manual?
There are some interesting new developments in the MR safety world. We’ve been trying to be especially mindful of our MR technologists, because they’re really our most valuable resource, and there is a nationwide shortage of technologists today. One of the issues in this connected world that we're now looking to get our arms around is the notion of remote scanning, where you have a patient in an MRI in one location and a technologist working at another location who is connected through the software and communication tools to actually push the buttons to run that MR machine and perform the scan remotely. We need to make sure that guardrails are in place, so that proper safety precautions are occurring at the site where the patient is going into the scanner. Remote scanning is one of the hot topics we are confronting in this manual, and we want to try to get it right knowing that there are clear benefits of that, and we want to keep patients, employees and staff safe in the process. We are aware that this is a rapidly developing field.
Now that the manual is an online resource, the beauty is that as new things emerge — like remote scanning or new environments where MR is being used, such as interventional radiology suites where surgical procedures are being done under MRI guidance — you don't have to change the whole manual. The committee can make spot updates and additions and get an update out to the community quickly. We're hoping that permits us to be nimble in getting the best practices out there, and the manual can be evergreen as new things emerge.
What advice do you have for radiology practices in terms of taking advantage of the MR safety manual?
I’d say a good first step is to download the manual and appoint someone on your team to run a policies and procedures update process. That person would go through all the recommendations, understand what’s new and convene an MR safety committee (or similar group) to design safety policies and standard operating procedures that best mesh with the specific and unique features of their own site. Use the checklists to ensure they haven't forgotten anything, put out their own set of policies and standard operating procedures, and train people on them. Establish a strong culture of safety, in which safety events are reported in a blame-free environment. That way everybody can get on the same page, and the whole team can work in an integrated, functional and safe way.
