Yes, I’m talking about the ACR…

Before I launch into what they do that makes me crazy, it is only fair that I acknowledge what they do for which I am tremendously proud. The ACR has released the industry standard set of safety practices to address virtually every element of MRI safety. These practice standards could virtually eliminate all MR and MR-related adverse events, they’re that comprehensive and well developed. Three editions of these safe practice guidelines have already been published, and a fourth is in the final pre-publication steps as I write this. For one of these, the ACR deserves the industry’s thanks. For an ongoing effort that is about to produce the fourth iteration of this document, the ACR deserves praise and accolades. I wish that’s where this story stopped, but it isn’t.

While the ACR has gone to significant lengths to develop and keep current their MR safe practice guidelines, they don’t actually require them for their own accreditation clients (this despite an explicit request to do so from their MR safety committee, and even public promises that they would do so in 2009). That fact, however, hasn’t stopped the organization from promoting itself as the standard-bearer for MRI safety. Below is a screen capture of the press release that comes in the ACR’s ‘congratulations, you’ve been awarded MR accreditation’ package for all newly (re-)accredited sites.

Standard ACR Press Release For MRI Accreditation

For those who can’t read ‘microscopic’, you can click on the image to see it larger. The key phrase is in the lead sentence of the 2nd paragraph, which reads:

“The ACR gold seal of accreditation represents the highest level of image quality and patient safety.”

Click here to download the Word document template that the ACR provides on its website (which, as of December, 2011, reads exactly as the image above). Click here to see a Google search for items with exactly that sentence (will only show a couple of months of news items).

Grouping an assurance of image quality (for which the ACR does have some of the most exacting standards in the industry) with MR safety is erroneous, at best, if not outright deceit.

In order to obtain ACR accreditation for MRI, a site needs to go through rigorous image quality testing and validation. Highly specific imaging sequences must be recorded, both on quality-control phantoms (special test objects which, when scanned, can reveal several quality measures of images) and patients. A long series of images must be submitted for review, and regular followup must be done to assure that the MRI system sustains high levels of image quality.

In order to obtain ACR accreditation for the MRI physical safety criteria… well… just promise to do a safe job. That’s it!

• No requirement to have or use table pads / positioning aids (to prevent burns).
• No requirement to screen patients for clinical or physical contraindications.
• No requirement to provide patients with hearing protection.
• No requirement to label unsafe items kept in the controlled access areas of the suite.
• Heck, there’s not even a requirement to have a controlled access area of the suite!

It dumbfounds me that the ACR can put image quality and safety in the same sentence that extolls the value of their MRI accreditation program. Is it just their PR people running amok?

The ACR has been remarkably busy in the last couple of years. I mean they’ve been busy lobbying congress to require their accreditation services of all advanced imaging modalities (see the ACR’s own press release here). They might not be aware of the MRI safety situation and the constructive role that their own optional accreditation standard could have… except that it was presented to them at their Quality and Safety forum over a year ago (see the video recording here).

Personally, I find it unfathomable (and morally indefensible) to promote ACR accreditation as a safety advantage when the accreditation criteria don’t actually respond to the systemic (and preventable) accidents and injuries.

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For those of you who aren’t familiar with the Guidelines, they are the design requirements that are cited by the Joint Commission and, at last count, 42 of the 50 U.S. State Departments of Health. Technically, they aren’t a building code, but the function in almost the exact same way. For the first time, the Guidelines are going to have specific MRI suite design requirements for patient safety.

2010 Guidelines

The 2010 edition of the Guidelines are purported to codify the single most often cited MRI suite safety design criteria, the 5-gauss line (or three-dimensional bubble, more accurately). The design must necessarily control access to locations where the static magnetic field is present at strengths of 5-gauss or more.

the 2010 Guidelines will also define situational-awareness requirements for suite layouts. These will include a requirement that the patient can be seen inside the scanner from the operators’ console location, and that the operator has direct visual control of the entrance to the MR scanner room.

The unique challenges of infection control and handwashing in the MRI environment are also explicitly addressed, for the first time, in the new Guidelines.

And one of my favorite provisions is the new requirement that MRI suites be designed to follow the ACR 4-Zone model for screening and access controls, including ferromagnetic detection systems!

The Guidelines publication is undergoing a significant organizational overhaul along with the regular content update, so I don’t have specific section citations to where the new MRI safety design requirements will be (though MRI probably won’t have the same section numbers as the current, 2006, edition has). My understanding, however, is that the publication will be released on schedule in January, so it is only a very short time until we can verify the specific contents and section numbers.

It is particularly encouraging that these new requirements validate what the some of the best MRI providers have been doing for years. Clearly MRI site-safety, including ferromagnetic detection, can no longer be regarded as simply “a good idea.” With the 2010 edition of Guidelines, we will have one more codified example of how these elements are truly part of the contemporary standard of care.

If you would like more information about the Guidelines, including information on how to order a copy of the document, please click here.

Link

The first special event is a presentation that AHRA invited me to give entitled ‘MRI Safety, Liability, and Best Practice.’ If you received the conference program mailers a few weeks ago that indicated that I am giving this presentation on that first Sunday of the conference, don’t believe it! I am not giving this presentation on Sunday, but I am giving it on Monday, August 10th, from 2:30 – 4:00. (They’ve done a little juggling that changed a few scheduled presentations.)

The program will touch on a number of the MR safety developments of the last several years, though even more from a management perspective than any of my prior presentations to AHRA.

This is the first special invitation and I would very much love for you to join me on Monday afternoon. There are lots of other great sessions, however, and I understand if you have your eyes on another program scheduled for the same slot. I’ll miss you though, and will stare wistfully at your empty chair in the presentation.

Which brings me to my ½-event invitation. It’s actually a full event. It’s 90-minutes long, just like my Monday presentation. In fact, it’s almost exactly like the 90-minute Monday presentation because AHRA has asked me to offer this program twice! If you can’t make Monday afternoon, please come by Tuesday morning, from 8:00 – 9:30, to see ‘MRI Safety, Liability, and Best Practice’. I’ll actually feel much better on Monday if you’re not there, since we have this opportunity to meet up on Tuesday. And if you’re a glutton for punishment, or if you just want to see what I do to mix it up from one day to the next, you’re welcome to attend both sessions.

The last special event to which this post invites you is actually a revolving, ongoing set of conversations that I would love to share with you. When I’m not on the podium in front of large audiences, I will be in the Mednovus booth on the exhibit hall floor (booth #828 / 830), having one-on-one and small group conversations. I invite you to come by and join in a personal conversation with me and my colleagues about how best to prepare your MRI facility for the rapid-fire changes that are in process.

Though it’s only 4 weeks until AHRA, the great people at Mednovus are diligently working on special announcements that will be released in the lead-up to the annual meeting. Please stay tuned to be among the first to learn of what’s going on.

I hope to have the chance to see you at the annual meeting. Please do join me in one (or both) of my presentations, and do visit with me and my colleagues in our booth. I’m really looking forward to it.

The Technologist, Laura Price, claims that her former employer, Horizon Diagnostic Center in Orange Park, FL, ignored repeated requests from Ms. Price and other Technologists to repair the coils on the MRI, and that the image quality was so poor as to compromise the clinical value of the scans. She was purportedly fired for insisting that the coils be repaired. She is suing for wrongful termination and has taken her efforts public in an interview with a local television news station.

What is particularly interesting (to me at least) is that there is not currently any claim of injury or misdiagnosis based on the claimed failure to keep the MRI equipment in operational condition. Therefore, this is strictly a claim against the practices of the provider and their adherence to standards of care and best practices.

Though the MRI fatality case has yet to go to trial (having been postponed ad nasuem for years, now), the Technologists are named defendants in that suit, suggesting at least that Techs have a legal obligation for safety and the standard of care.

This Florida suit is intriguing because it puts operations squarely in the legal crosshairs. When legal liability is tied only to injury, it fosters an ‘ends justify the means’ culture of safety. Something akin to, “if we haven’t hurt anybody, it proves that we’re doing things right.”

Many patient safety experts decry this sort of ‘negative proof’ of safety. Getting all the way across the freeway unscathed, on foot, blindfolded, is not proof that walking blindfolded across the freeway is a safe practice, yet this is the logic that prevades MR safety at many locations.

Whatever you may think of this one case, or the Technologist who is bringing it, I am very interested simply because it does put safety practices in the spotlight. I’m also very interested in what you may think of this, so please share your comments, below.