MRI Metal Detector Blog

There are a number of startling statistics related to MRI safety that I’ve been wanting to weave into a posting or two. In bits and bites, these data points are interesting, but it’s when they’re taken all together that they tell the greatest story. So, at the risk of writing my driest entry to date, here’s the picture painted by a slew of statistics…

The population of the United States is approximately 300,000,000 (data).
The number of MRI’s performed in the US in 2007 was approximately 27,500,000 (data).
The rate of increasing utilization has been fairly consistent at around 3% per year (data).
If this growth-rate is consistent for 2008, this year there will be approximately 28,300,000 MRI exams in the US.

Based on these recent trends, this means that the odds of a person in the US getting an MRI in 2008 was approximately 1 in 10.6, or a number nearly equivalent to 10% of the US population received MR exams in one calendar year.

The rate of officially-reported MRI accidents has grown from 40, in 2004, to 114, in 2007. (data). This represents an increase of 185% in three years of reporting. This means that the risk of an adverse outcome during an MRI exam has nearly tripled in a three-year period!

And while the gross numbers of officially-reported MRI accidents appear low, it is widely believed by MR safety experts that something on the order of 1% of the actual number of accidents are reported (source), perhaps fewer. The FDA’s numbers are so low, in fact, that the extrapolating numbers reported by those hospitals participating in the Pennsylvania Patient Safety Authority reporting (not all MRI providers in the state, by the way), Pennsylvania’s reports would appear to represent nearly twice of the total number of MRI accidents in the FDA database (source).

So, if we multiply the FDA’s reports of accidents by two orders of magnitude, a more accurate estimate of the actual number of annual MRI accidents (based on 2007 calendar year reports) would appear to be 11,400. Assuming an equal number of MRI exams (and accidents) each day of the year, this suggests that every day there are, on average, just over 31 MRI accidents per day! This is enough for most states in the Union to have a daily MRI accident.

The upshot of all of this is that if you (or a loved one) are told to get an MRI next year, it’s truly a game of Russian roulette. Has the MRI accident occurred in your state for that day already?

This is the state of things today, but it doesn’t need to remain that way.

There are a number of improvements to be made… but none of them are mysteries. Work with referring physicians to inform them of contraindication risks. Educate patients regarding screenings before they show up at your doorstep. Screen for clinical and physical risk factors. Use ferromagnetic detection. Provide hearing protection. Position patients correctly.

If we do these for each and every MR patient and visitor, we can slash MR accident rates and reduce the aerobatic growth trend, making MRI safer for every patient, including ourselves for our 1 in 10 chance of a 2009 MRI.

27.5 million people… That’s how many people the healthcare market research company IMV estimates received MR exams in the US in 2007. Other estimates put the number over 30 million, but regardless of whichever number you use, we’re talking about a lot of people (27.5 million is roughly equivalent to those living inside all of the 13 most populous cities in the US)!

And when I say that these millions of people don’t want the 175% raise they’ve received, I’m not referring to their salary. No, the raise that these millions of people got — and most definitely don’t want — is in the rate of MRI accidents!

Actually, the rate of increase in MRI accidents from 2004 is a mind-blowing 185%. But if we allow for a 10% growth in accidents to coincide with the 10% growth in patient volume over the three-year period ending in 2007, we still wind up with a net increase of 175%.

Given the growth in MR imaging, odds are good that a relative or acquaintance of yours will have an MRI in 2009. Is it acceptable that this person has nearly a three-times greater chance of being the victim of an MRI accident than just 4 years ago?

All manner of accidents are reported (burns, tinitus, near-field effects), but projectile accidents are conspicuously under-represented in the FDA’s numbers. And given the flurry of pictures of projectile accidents and the accounts of MRI safety experts who are often called to give tesimony in projectile accident legal action, many believe that this trend applies to what are likely the most common types of MRI accidents… ferromagnetic materials brought into the magnet room.

Many of the reported MRI accidents can be prevented through a more effective implementation of existing policies and procedures. Ferromagnetic projectiles, however, often seem to find their way into the magnet room courtesy of people who are unaware that the object presents a risk. Would asking the unaware person prevent the accident? Would it help prevent the accident that is caused by the person who willfully ignores the screening instructions?

Treating patients like prisoners, subject to strip-searches, is clearly not the way to go, not when there are technological tools at our disposal, just waiting to be put into use.

Ferromagnetic detection systems can provide valuable feedback to aid in the screening of the unaware, the uncooperative, and those who — for whatever reason — can’t participate effectively in their own screening.

Combining ferromagnetic detection with improved education and conformance to existing policies and procedures can help to make a dramatic improvement in overall patient safety.

And for providers who are responding to reimbursement cuts by looking for their own raise in patient volumes, we need to make sure that increasing financial pressures don’t further exacerbate what is already an unacceptable safety trend. Ferromagnetic detection should be a part of the screening for every person approaching the MRI magnet, every single time.

How I long to be judged for my content… my substance… and not just how I look!

No, not me, the author, but the figurative ‘me‘, this blog…

I don’t know if you’ve ever used them, but all of the major internet search engines have tools that you can use to find images that match your search criteria. Every so often there’s a new paparazzi picture of some starlet in mid-wardrobe-malfunction or a politician with a facial expression that looks like they just smelled something awful that become the ‘it’ picture of the day.

Well, based on the number of hits our blog has been getting recently, and the image search tools that many of these hits are coming from, apparently we have a lesser ‘it’ picture, and it has nothing to do with politics or racy nudity…

It’s a picture of an ICU bed stuck to the face of an MRI.

Pictures of things stuck to magnets often generate wide-eyed looks, even laughter. After all, the juxtaposition can be pretty silly. But each of these pictures is only possible because of horrible mishaps that can each result in serious injury, or even fatality.

We encourage people to find and view these pictures, not to have a larger number of viewers snicker at them. We put them up to help deflate the ‘that could never happen here’ mythology that is dangerous. If you can see magnets, floor polishers, oxygen cylinders, wheelchairs or, as above, ICU beds that look like ones in use at the hospital or imaging center, then maybe the internal monologue becomes something more like, ‘what would have to happen here for us to have a similar accident?’

Most importantly, we hope that all of these efforts work to motivate Technologists, Radiographers, Imaging Managers, Radiologists, Risk-Managers and Compliance Officers to imagine which steps they could take at their locations to reduce the likelihood of these sorts of accidents.

There are many steps that can be taken to help improve the effectiveness of pre-screening for magnet hazards. One of the most obvious is also one of the easiest, the use of ferromagnetic detectors.

We encourage you to view and share the information contained on these pages and we hope that each of these resources, even the racy pictures of MRI missile accidents, help shape improvements to MRI safety at your facilities.

After all, I’m lot more than just a pretty face…

As much as I often like to eat, breathe and talk about ferromagnetic detection, it isn’t the only aspect of MRI safety that providers should be attuned to. One other issue that has been getting a lot of attention in the trade publications lately has been that of infection control.

Seems that one of the least-often cleaned parts of a hospital may be the MRI suite and there’s new speculation that some hospital-acquired infections may actually be contracted during MRI exams.

A recent article in Radiology Today featured an article on just this topic, with information on MRI suite design and appointment, all the way down to the patient positioning pads.

Radiology Today - Magazine Cover

Just as I recommend ferromagnetic detection as a part of the pre-screening process for everyone entering the MRI magnet room (ACR Zone IV), I would also recommend that everyone with an operational role in MRI services read this article and reflect on how well their own cleaning protocols are implemented.

To view the article, simply click on (or copy and paste) the URL below…

http://www.radiologytoday.net/archive/rt_102008p14.shtml

For any other MRI safety concerns, I hope that you’ll contact Mednovus.

Last month, I was honored to have been given the opportunity to present to one of the national American Healthcare Radiology Administrators (AHRA) meetings. In October I gave a presentation on the current state of MRI Safety, including regulatory, legal and accreditation changes that are all in the works.

The full presentation was 90 minutes, including an extensive audience Q&A, but I’ve pulled out one particular section that is particularly relevant to our topic at hand, ferromagnetic detection for MRI pre-screening.

The video excerpt below addresses forthcoming changes to the ‘Guidelines for Design and Construction of Health Care Facilities’, a poly-cyllabic mouthful that roughly translated means the healthcare building code, and changes regarding MRI suite design…

 

 Tobias Gilk on MRI Building Codes at 2008 AHRA Fall Meeting: Play Now | Play in Popup | Download

As mentioned in the video above, the proposed changes to the healthcare building code are currently open for public review and comment. The proposed language includes references to the ACR 4-zone principles as well as planning for ferromagnetic detection.

If you would like to see, review or even comment upon the proposed changes to the hospital and healthcare provider building code, public comment for the ‘Guidelines’ is open until December 15th, 2008.

Ahh the four seasons… Winter, Spring, Summer, and MRI Safety Planning.

What, you’ve only heard it referred to as ‘Autumn‘ before? Well, that’s not terribly surprising. We’re so inundated with honorary days, weeks, and even months, that the season of MRI Safety Planning fails to get its fair share of media time. But here’s why MRI Safety Planning season should be tops on your list right now.

First, while there is a growing awareness of MRI Safety Week, a single week doesn’t really afford the time needed to plan for improvements to MRI safety. Real improvements come from refinements in operations and process, coupled with effective tools and training. That sort of interdisciplinary approach often requires more than a couple days to put together.

Second, MRI Safety Week falls in the middle of summer when budget-wrangling loses the attention-span battle to thoughts of barbecues and coco-butter suntan lotion. It is precisely now, when so many organizations are hammering out their financial priorities for next year’s budget, that MRI safety planning should be in full-swing.

By combining the operations planning with the budgeting, you can reap some real multi-task benefits from these synergistic efforts, and - buoyed by the support of our whole Mednovus organization - I’m here to help you make it as productive as possible.

When making your MRI safety plans, it’s important to know what new criteria are going to be expected of your facility. Accrediting bodies are all looking at MRI safety in a new way, and this is starting with the Joint Commission’s Environment of Care requirements, effective January of 2009.

There is also the flurry of recent MRI safety Best-Practice recommendations from a number of documents, all of which should be part of the Administrator / Technologist library of reference materials. One common element to the Joint Commission’s Sentinel Event Alert #38, the ACR’s Guidance Document for Safe MR Practices, and the recent Veterans Administration MRI Design Guide, is the recommendation for the use of ferromagnetic detection (see below).

While ferromagnetic detection systems can be readily incorporated into both new and operational MRI facilities with minimal muss & fuss, even the most easily-installed and cost-effective systems typically require advanced budgetary planning.

The upshot? Please start thinking today about your planned MRI safety improvements for 2009 and budget accordingly.

Whether you’re considering the newly-released Mednovus Sentinel® GS 2.0 portals (both the 24-inch Patient Sentinel® GS 2.0 and the 48-inch Entry Sentinel® GS 2.0) or our SAFESCAN® hand-held Target Scanner™ (or the optimal combination of both), it would be a privilege to be at your service.

We at Mednovus are delighted to announce our new association with Siemens Medical Solutions, a world leader in MR imaging, and we encourage you to contact your local Siemens sales rep to get product quotes for your budgeting purposes. Alternatively, simply let us know where you are located, and we will put you in touch with the appropriate Mednovus product expert from Siemens’ national accessories division. Contact us soon so that we can arm you with the information you need to secure MRI safety improvements in next year’s budget.

Yes! Please put me in touch with the right Siemens’ accessories product expert!

By reviewing your current MRI safety protocols against published best-practices, and soon-to-be accreditation standards, you can prioritize the areas for improvement in 2009. In many cases, no-cost operational changes will help you achieve your goals, but whether it’s a new MRI-friendly infusion pump, improved signage, or the thrice-recommended ferromagnetic detector, you will probably need to have a few MRI safety line-items in next year’s budget.

Please contact us if we can be of any assistance in helping you with your observances of MRI Safety Planning season.

Many facilities planning for ferromagnetic detectors, particularly existing MRI providers who must retrofit the new technology into tight-fit suite layouts, have a hard time finding optimal locations for the new MRI pre-screening instruments.

Real estate within the outer walls of the hospital is at such a premium that a good proportion of MRI providers are already working within MRI suites into which their large (and frequently growing) operational requirements have been shoehorned-in. They could really do with several hundred additional square feet, so the addition of anything to the suite can trigger a domino series of complications.

Pass-through ferromagnetic detection portals, such as the Mednovus Sentinel® series products, can be sited as either free-standing or doorway-mounted instruments. One caveat for doorway-mounted versions is that the door should not swing through the aperture of the portal (door hardware, even on most RF-shielded doors for MRI suites, has ferromagnetic components and would set off the detector). This means that there is one side of the doorway that is ill-suited to receive a mounted portal.

For MRI suites where space is already at a premium, it is sometimes felt that mounting a ferromagnetic detector at the door into the magnet room is the only place where both existing operations and available space will permit.

But if the door to that room swings out (as is currently recommended by the majority of MRI equipment manufacturers), can you put the detector on the other side of the doorway; on the inside of the MRI scanner room? Physically, yes, you can put the instrument there. Physically, you could also use your MRI scanner room as a waiting area for patients with unknown medical implants and devices, but both ideas would have grave dangers.

The intention of ferromagnetic detection is to alert you to the presence of magnetically attracted materials before they get close to the magnet. Placing a ferromagnetic detector inside the room would only be less effective if were mounted at the face of the bore of the magnet.

Since it often takes a moment to react to the alarm of a ferromagnetic detector, the step or two that a person may take past the ferromagnetic detector isn’t typically a problem outside the MRI scanner room, but in the room where inches can make enormous differences in the magnetically attractive effects, those couple steps can make the difference between avoiding an accident or cleaning-up after one.

Couple the compromised effectiveness with the fact that - at one time or another - everything needs servicing, and you’ve introduced another object into the MRI scanner room that may necessitate servicing from workers with tools. The attempt at increasing safety has actually introduced a new opportunity for accidents.

Lastly, MRI equipment manufactures are (justifiably) nervous about the introduction of equipment into the room which supports the MRI scanner. Does this other equipment emit RF noise that might interfere with the MRI images? Is it going to compromise the function of the scanner? Will the magnetic fields of the scanner adversely effect the other equipment?

In response to these concerns, MRI equipment vendors typically prohibit equipment or devices that haven’t been tested and deemed non-disruptive. Even just placing a ferromagnetic detector inside the MRI scanner room would very likely void significant portions of your MRI manufacturer’s warranty.

The fact is that there are often alternate locations for siting of a pass-through ferromagnetic detectors. It may take a little creative thought or a willingness to slightly modify operational protocols, but typically there are a handful of possibilities for each site. There is no reason - whatsoever - to place a ferromagnetic detector inside the MRI scanning room, and it is extremely ill-advised to do so.

Starting in January of 2009, the drought of MRI safety regulation will begin to end.

It surprises many that the Joint Commission has no specific MRI safety accreditation standards. Surveys of accredited MRI providers have, over the past many years, focused largely on general safety standards, adapted for the MRI environment. Historically, a surveyor’s check for a non-magnetic portable fire extinguisher was the only MRI-specific safety check provided by the Joint Commission.

Despite the fact that many MRI-specific safety articles, recommendations, and, most recently, Sentinel Event #38 have been offered by the Joint Commission and its allied Joint Commission Resources educational arm, there have not previously been specific MRI safety standards for accreditation, and it is only through the new Environment of Care requirements that MRI safety will become an implicit standard for Joint Commission accredited facilities.

Starting this coming January 2009, inpatient and outpatient accredited facilities will need to abide by the new Risk Management provisions of the Joint Commission Environment of Care standard. The Standards Improvement Initiative will require facilities to prospectively define the physical hazards within the facility and develop specific responses to manage and mitigate those hazards.

The new standard specifically cites Sentinel Event Alerts as one external reference that must be considered in defining risks. For MRI, this automatically means Sentinel Event Alert #38. And since SEA #38 draws so heavily from the ACR Guidance Document for Safe MR Practices: 2007, it only follows that the ACR Guidance Document is the underlying industry standard document for defining MRI safety. Another external reference that specifically addresses MRI physical hazards which should be used as a basis for risk analysis is the VA MRI Design Guide.

What do Sentinel Event Alert #38, the ACR Guidance Document, and the VA MRI Design Guide all recommend? Well, lots of common elements, actually, but one of the key recommendations is for the use of ferromagnetic screening (click here to download a PDF document that outlines many of the recent recommendations for ferromagnetic detection).

While it is starting with the Joint Commission Environment of Care, my expectation is that MRI-specific patient safety requirements will spread to other accreditation requirements, building codes, and standards of practice. This will include not just recommendations, but requirements for the use of ferromagnetic detection for MRI pre-screening.

Over the next few months, all Joint Commission accredited MRI providers will need to review the standards of practice in the ACR Guidance Document for MR Safe Practices. Specific actions must be taken to identify, document, and respond to the unique hazards in the MR environment. One of those immediate actions should be planning for ferromagnetic detection at your MRI facility.

If you have any questions about the new MRI safety standards, the best-practice recommendations for ferromagnetic equipment siting, and incorporating these vital safety instruments in your MRI screening practices, I recommend that you heed the advice of the ACR Guidance Document, the VA MRI Design Guide, and other safety practice documents. If you still have questions about these standards, I invite you to contact me.

Ferromagnetic detection is a vital part of the pre-screening for persons about to enter the MRI magnet room, but it’s only one part of the overall sequence.

First, before we jump into the issue of where in the sequence ferromagnetic detection is best deployed, it’s important to break pre-MRI screening into its two constituent parts: clinical screening and physical screening.

Clinical Screening:

Before being brought to the MRI magnet, everyone (and this means patients, visitors and staff) needs to be screened for contraindications. Most often we think of pacemakers, but other contraindications include nerve stimulators, insulin pumps, prosthetics, halo vests, and a number of other objects. The screening is typically accomplished through the use of forms to help the subject identify any clinical risks for the MRI provider. The screening form is then to be reviewed between the patient and the MRI Technologist.

Once clinically cleared of contraindications for the MRI exam, then the subject should proceed to the next step…

Physical Screening:

Contrasted with the widespread uniformity of the clinical screening, the physical screening takes very different forms at different provider. However, all have the same objective, namely, to remove ferromagnetic materials from the subject and keep them away from the MRI scanner. Even small quantities of ferromagnetic material can cause artifacts in the MRI scan when near the imaging volume. Small ferromagnetic items, such as bobby pins and nail clippers, have caused serious harm when propelled by the magnetic force of an MRI magnet. And obviously, large items such as oxygen cylinders and floor polishers can have catastrophic consequences if brought to the MRI room.

Some MRI providers have outpatients simply empty their pockets, others provide gowns or scrubs for MR patients to change into, and all should use ferromagnetic screening to help verify patients’ compliance with screening instructions.

When performed in the above order, providers avoid gowning patients only to find out that the patient can’t receive the MR exam. Additionally, when clinical screening is accurately completed first, the Technologist has done everything within his or her human capabilities to mitigate the contraindication risks associated with exposure to magnetic fields. Although it is impossible to completely eliminate the chances of accidents, by following the recommended industry-standard procedures of  conscientious clinical and physical screenings followed by properly-performed ferromagnetic detection, the safety of your MRI center has been significantly enhanced.

Some of the most sensitive ferromagnetic detectors currently available use passive magnetic fields to improve sensitivity. These GS (Greater Sensitivity) detectors use a localized DC field (i.e. stronger versions of a similar type of the permanent magnet that holds your notes on your refrigerator door). While the magnetic field strength very close to the GS detector can exceed the 5-gauss threshold, that limit is for persons who haven’t been successfully cleared for MRI contraindications (a step which was just completed if the pre-MRI screening was conducted in the proper order).

While patients and caregivers should be concerned about exposing unscreened persons to the extraordinarily powerful magnetic fields around the MRI, momentary exposure of post-screened persons to the passive “fridge-door” magnetic fields of a GS ferromagnetic detector is very, very small on the relative risk-o-meter. And this minute risk comes with an enormous potential safety upside…

No ferromagnetic detection system on the market from any manufacturer is intended (or approved) for finding objects internal to the body of the patient. However as an incidental finding, ferromagnetic detectors have alarmed on the ferromagnetic content of implants (including pacemakers) that were disavowed by the patient in the clinical screening process. While ferromagnetic detection should never be used in lieu of conscientious clinical screening, they have helped to identify critical contraindications that may have otherwise jeopardized the safety of the MR patient — had they not been found by the ferromagnetic detector.

And the relative risk of being exposed to 5, 10 or even 100 gauss as a part of a physical pre-screen (particularly when already cleared of clinical contraindications) is microscopic, when compared to either the risk of the planned exposure to 15,000 / 30,000 gauss, or the potential benefit of identifying a contraindication that the patient themselves didn’t communicate.

The take-home messages from this are these:

• MRI providers should provide as thorough and comprehensive clinical screening as humanly possible for everyone approaching the MRI.
• Once the clinical screening is complete, the provider’s standard physical screening (emptying pockets, changing into scrubs, etc…) should be conducted as appropriate to the MR patient / visitor.
• And following the clinical and physical screenings, patient / visitor compliance should be verified with a ferromagnetic detector.
• If these industry-standard procedures are correctly followed, there should remain only minute (accepted) risks associated with exposure to any magnetic field, either the enormous field of the MR or the comparatively tiny field present in GS detectors.

Clearly, providers should feel free to use whatever ferromagnetic detection they wish - from their choice of manufacturer - in order to conform with ACR, VA and Joint Commission guidance, whether it be an instrument which relies on only the trace-magnetism of the Earth’s own magnetic field, or one in which the detection sensitivity has been enhanced through the use of a locally-provided, passive DC magnetic field as found in GS ferromagnetic detectors.

My recommendation is always to use a detector with the greatest possible sensitivity. Because, while they are wonderful instruments that can make a substantial improvement in a provider’s MR safety protocols, ferromagnetic detectors are dumb. They can’t differentiate ‘good’ ferromagnetic material from ‘bad’. These sorts of value judgments should be made by a trained MR technologist and not by a machine.

In my opinion, ferromagnetic detectors should be used to help find every piece of ferromagnetic material that they can, so that the Technologist knows what is about to enter their magnet room (and can make re-screening decisions as appropriate). The greater the sensitivity of the detector, the more informed those Technologist decisions will be.

Pass-through ferromagnetic detection systems, such as the newly released Mednovus Sentinel® GS 2.0 portals, also have user-adjustable sensitivity settings, so that the system can be ‘dialed back’ as needed for special circumstances, further supporting the concept of having the instrument with the greatest sensitivity, and tuning it to meet your specific needs.

As evidenced by repeated, and increasing MRI projectile accidents, there is enormous room for improvement from the prior standards. Effective pre-screening of MRI patients, including the use of ferromagnetic detection at the appropriate point, can make an significant difference in the safety of the MR exam. Providers should turn to the current best practice guidance and compare their pre-MRI screening processes, making any indicated changes to help assure the safety of their patients, visitors, and staff.

As mentioned in an earlier post, noted MR safety guru Dr. Emanuel Kanal gave a brilliant presentation at the 2008 annual meeting of the American Healthcare Radiology Administrators (AHRA). While his session, “MR Safety Update, 2008″ addressed several different MR safety issues, below is a video excerpt, which marries the audio recording with his presentation slides, showing information on ferromagnetic detection that Dr. Kanal presented.

 

 Excerpt from Dr. Emanuel Kanal "MR Safety Update 2008" at AHRA: Play Now | Play in Popup | Download

Among the ACR Guidance Document on Safe MR Practices: 2007, the recent Joint Commission Sentinel Event Alert #38 on MRI Accidents and Injuries, and other standards and expert recommendations, it is abundantly clear that ferromagnetic detection is a potent part of an effective MR screening program.

A PDF transcript of the above video is available for download at http://MRImetaldetector.com/blog/wp-content/uploads/Transcript_of_Dr_Kanal_Edited_video.pdf.