December 2015

Training Staff in MRI Safety
By Kathy Hardy
Radiology Today
Vol. 16 No. 12 P. 20

Comparisons between working in a magnetized MR environment and flying an airplane are rare. That's where radiologist and pilot Emanuel Kanal, MD, FACR, FISMRM, AANG, director of MR service and a professor of radiology and neurology at the University of Pittsburgh Medical Center, provides a unique perspective. He sees commonality between the two disciplines, particularly in regard to safety.
"In flying, many accidents are the result of pilot error," he says. "When you look at MRI, about 100% of the accidents are due to user error, not a malfunction of the machine. MRI-related accidents are almost always avoidable."

Another similarity Kanal finds between flying and imaging is the role training and certification can play in bringing a standard of performance to each profession. He and Tobias Gilk, senior vice president of Kansas City, Missouri, imaging consulting firm RADIOLOGY-Planning, recognize a need for leaders within radiology to take the helm and help to mitigate accidents in the MR arena. Both say that while more is understood today about MRI safety and there is a greater capacity to control the effects of MRI, increased knowledge is not reflected in a reduction in MRI accidents.

Accidents Grow Faster Than Exams
"We are imaging patients at a rate higher than ever," Gilk says. "But with that, the rate of accidents is growing five times the procedure rate. MRI has the distinction of being a modality where the more we know about it, the worse we are doing as an industry in preventing injuries."

While there are various MRI safety training videos and manuals available, as well as best-practice guidelines to follow, there remains a gap in the cultivation of trained, certified leaders within hospitals and imaging facilities to oversee MRI safety.

Gilk points to increased magnet strengths and advancements in implantable medical devices as factors in why MRI risks have grown. He says that in the last 15 to 20 years there has been no feedback mechanism for measuring how changes in MRI were impacting patients and practitioners. In addition, he believes that reductions in reimbursement rates are resulting in budget cuts that leave radiology departments with reduced staff numbers, less supervision, or less-experienced technologists.

"With the proper training, there is enormous potential to improve safety and do so in a more cost-effective manner," Gilk says. "For example, without training regarding the effect of the latest implanted medical devices in patients who need MRI, imaging personnel can spend eight to 81/2 hours per magnet per week researching MRI best practices for those patients. Training provides personnel with the knowledge to reconcile the impact of each medical device in less time, reducing weekly research time to as little as two hours. With understanding come efficiencies."

A boost to the MRI safety effort is the American Board of Magnetic Resonance Safety (ABMRS). Founded by Kanal, ABMRS is the first organization to credential "the individuals whose charge it is to ensure the safety of magnetic resonance clinical and research environments" utilizing standardizing testing in MRI safety. ABMRS is an independent, not-for-profit organization that works in liaison with numerous governmental, professional, and industry organizations but is not affiliated with any other credentialing boards or associations.

Kanal, who serves as ABMRS' chair, explains that program materials cover safety steps for radiologists, technologists, patients, and anyone who could potentially enter the MRI suite. To be certified, participants must be able to identify MRI safety risks, analyze their relative significance and threat levels, and take steps to significantly mitigate or remove these risks. Standardized tests focus on basic science knowledge and practical ability to apply science and clinical knowledge to real-world MRI safety situations that could occur in the imaging environment.

Target Audience
In his work, Gilk recommends that the best place to start when establishing an MRI safety program is to educate MRI medical directors (typically radiologists) and safety officers (which in many cases are senior technologists) as to what MRI risk profiles are and the various means that exist to respond to those risks. With that consideration, Kanal says they divided personnel for certification into three categories that follow international convention: magnetic resonance medical director/physician (MRMD), magnetic resonance safety officer (MRSO), and magnetic resonance safety expert (MRSE). The MRMD role is designed for radiologists, who would most likely be the individuals overseeing safety of an MRI suite and the MRI examinations performed therein; the MRSO represents those with a supervisory role in the MRI suite executing the safety policies and guidelines as established by the MRMD—this role is most often served by a technologist; and the MRSE covers someone, typically an MR medical physicist, who operates as a technical expert consultant who serves as a resource to help determine the safety of complex conditions. Each group has its own exam. MR safety certifications are valid for 10 years from the date of successful examination.

"A major obstacle to hospitals and imaging facilities in naming MR medical directors and safety officers has been a significant dearth of individuals with the requisite knowledge and background to undertake the responsibilities that would accompany such titles and positions," Kanal says. "There are written, online, and live educational opportunities available for MRI professionals to gain the knowledge and decision-making skills required to undertake the responsibility that these positions carry, but there is no objective means via which professionals can document or certify their MR safety."

Kanal says that by the end of October, almost 300 candidates will have sat for the MRMD or MRSE examinations. Much of the safety information overlaps the certification categories, but there is some information that is more specific to each category.

"Safety certification is upon us," Kanal says. "Every site—both clinical and research centers—should have, or should have access to, an MRI safety director, officer, and expert. We certify the hardware, the software, and the site itself, but no one, until now, has certified the most important part of the process—the operators."

ABMRS plans to have at least three examination administrations for 2016, and, if requesting sites meet the requirements, will enable institutions, universities, and MR sites to schedule certification at their own locations.

"In this manner, there's no limit to how many certification sessions could be scheduled, as we attempt to meet the pent up demand for certification of the individuals charged with overseeing safety in MR environments," Kanal says.

International Effort
Despite its name, ABMRS was created with a vision of international standardization of MRI safety guidelines. To that end, Kanal and others within the organization are establishing formal liaisons with MRI safety experts, societies, and agencies worldwide. For example, there appears to be particularly strong interest from radiographers in Australia and New Zealand, he says, in the implementation of such an examination on their continent.

"We need to see how we could implement credentialing in other countries," Kanal says. "For example, for Australia, it is my opinion that the testing and credentialing should ideally be established by Australian officials, but the ABMRS could assist in this process by sharing our experience, knowledge, and/or examination contents with them to help make that happen."

As Gilk points out, the science-related risks of MRI know no geographic boundaries.
"Credentialing is part of the bigger picture, dealing with the science-related effects of MRI," he says. "Whether it's magnetic fields, radiofrequency, or implanted medical devices, none of the risks are country-specific. That's what's at the heart of ABMRS."

Another universal aspect to reducing MRI accidents is education. Kanal says many people aren't used to dealing with a device that involves a large magnetic field. This lack of knowledge makes it difficult for MRI users to comprehend the magnitude of the magnetic field involved.

"You can't smell, see, touch, or taste the magnetic force, but in an instant it can become dangerous," Kanal says. "Similarly, there is a basic unfamiliarity with working with relatively strong radiofrequency and gradient magnetic fields, and their potential risks."

Kanal says there has always been an interest on the part of most imaging professionals to continue their education and to stay abreast of the latest developments in the field. Many have purchased MR safety textbooks or attended MR safety courses online or in person, but there has been no method to date of determining how well that knowledge is retained, how it is being applied, or whether such individuals are keeping current in this ever-advancing field.

"Hundreds of people may have attended an MR safety class but once they left society had no idea how well they had understood and/or were applying their newfound knowledge," he says. "There was no method in place that would allow us to see how they perform in the field. Certification helps address that."

In addition, Kanal says that in some cases individual radiologists and technologists have been named to take on these MR safety leadership roles within their facilities. However, they do so without certification that they have the knowledge required to execute the responsibilities of these positions.

"We've had no way to differentiate trained personnel from anyone else in the imaging department," Kanal adds. "Someone could be named an "MR safety officer" by a site, but until now there would have been no way to differentiate among those with at least a minimal threshold level of MR safety knowledge and those without it."

Kanal says that for several years there have been numerous attempts to increase standardization of MRI safety practices and knowledge. In 2001, the ACR assembled a panel of MRI experts from various medical specialties and academic communities to review existing MRI safe practices and guidelines and to issue new guidelines as deemed appropriate. Initially published in 2002, the ACR Guidance Document for MR Safe Practices established de facto industry standards for safe and responsible practices in clinical and research MRI environments. As the industry has evolved, so too have the guidelines. The document was reviewed and updated in 2004, again in 2007, and most recently in 2013.

The ACR Guidance Document for MR Safe Practices has always encouraged facilities to designate someone to serve as a medical director for MRI safety. In addition, as part of the ACR's accreditation process, the supervising physician is to "develop, implement, and enforce policies and procedures in compliance with the ACR White Paper on Magnetic Resonance (MR) Safety."

In addition to ACR guidelines, the Joint Commission also addresses MRI safety in its latest diagnostic imaging services requirements for accredited hospitals, critical access facilities, and ambulatory health care organizations. The new standards, which went into effect July 1, 2015, outline performance elements for MRI safety regarding identifying and managing MRI safety risks associated with such patients as those who suffer from claustrophobia, those who require urgent medical care, and those with medical implants or other imbedded metallic objects. The new standards also address ferromagnetic objects entering the MRI environment and acoustic noise associated with undergoing an MRI.

The new Joint Commission standards also require that facilities restrict access to the scanner room and the area immediately preceding the entrance to the scanner room for everyone not trained in MRI safety or screened by staff trained in MRI safety. These restricted areas must remain under direct supervision of staff trained in MRI safety. In addition, signage is required to be posted at the entrance to the MRI scanner room stating that potentially dangerous magnetic fields are present in the room.

Knowledge Where Needed
Those associated with ABMRS stress that the organization's goal is to help ensure that MRI professionals educated in MRI safety issues oversee the operations of every MR site.

"The challenge is not a lack of information or the quality of information that's already out there," Gilk says. "The challenge is that safety information is not being disseminated to troops on the ground. ABMRS has no intention to become the default body for MRI safety documents. We're focused on being a conduit through which the information flows."

Another challenge Gilk sees to the widespread dissemination of MRI safety measures is the nature of many radiologists' roles. With technologists on the front lines performing the MRIs and radiologists sitting in reading rooms interpreting images, there can be a level of unfamiliarity among radiologists when it comes the impact of accidents in the MRI suite, and their potential liability relating to such events.

"Radiologists need to understand how they're exposed to liability issues," Gilk says. "Staying in the reading room doesn't insulate them from liability. They may see obtaining certification as a burden, but it's also their burden to make sure that safety measures are being addressed. They have a direct fiduciary duty to the patient and I hope they would take a proactive role in identifying and following best practices at the point of care."

Kanal turns again to his flying background when discussing the importance of MRI safety certification. Imaging professionals need to stay ahead of advancements in the industry in order to learn what effects these changes will have and what safety measures need to be considered to keep personnel and patients safe in the MR suite.

"As you learn to fly, pilot trainees are taught to stay ahead of the airplane," Kanal says. "For example, there's so much going on when you're landing a plane and you need to anticipate what will be happening several steps in advance, prepared to make the appropriate reconfigurations from cruise flight to descent to landing many miles before reaching the destination airport. As you move from training-level aircraft to more advanced, faster, and more powerful aircraft, your preparation for landing needs to be performed far sooner and many dozens of miles earlier than it would have been in slower, entry-level aircraft.

"Just as with flying, in MRI, as the equipment and implants become more powerful, varied, capable, and flexible, we need to stay ahead of the field to keep our sites safe," he says.

— Kathy Hardy is freelance writer based in Phoenixville, Pennsylvania.