The Joint Commission’s Sentinel Event Alert #38 represents the organization’s first foray into the realm of MRI safety. While they’re to be commended for their action, there are a number of points where their specific recommendations miss the mark.
Within the body of their alert and immediately prior to introducing the Joint Commission’s 10 recommendations, they identify three recommendations from Dr. Emanuel Kanal, FACR and principal author of the ACR’s Guidance Document for Safe MR Practices: 2007. Dr. Kanal’s recommendations, supported by the ECRI Institute, include the appointment of a MRI safety officer, establishment of MRI-specific policies and procedures to enhance safety, and adherence to the ASTM / FDA testing and labeling conventions for devices and equipment in the MRI suite.
Despite identifying Dr. Kanal’s recommendation, the Alert fails to communicate that these are specific recommendations of the ACR’s Guidance Document and conspicuously fails to either endorse Dr. Kanal’s recommendations or the Guidance Document.
The 10 recommendations of the Sentinel Event Alert are all superb in spirit, but many leave us wanting for specificity or direction as we have outlined below:
1) “Restrict access to all MRI sites by implementing the four zone concept as defined in the ACR Guidance Document…”
We couldn’t agree more. I’m pleased that the Joint Commission has chosen to endorse at least this portion of the ACR Guidance Document. We would have liked for them to have gone further and endorsed the entire document.
2) “Use trained personnel to screen all non-emergent patients twice…”
This directly echoes the recommendations of the ACR. The Joint Commission makes a point of citing research by Dr. Kanal which found ferromagnetic detection (FMD) systems to have 99 percent sensitivity and offers them as an example for verifying screening, but falls short of recommending them as did the ACR.
3) “Ensure that the MRI technologist has the patient’s complete and accurate medical history to ensure that the patient can be safely scanned…”
The Joint Commission recommendation continues to say that implants should be checked against published data regarding its safety. Sometimes this requires exceptions to providers’ internet firewall policies to allow technologists to search out information for implants.
4) “Have a specially trained staff person who is knowledgeable about the MRI environment accompany any patient, visitors and other staff… at all times.”
This recommendation is ambiguous because it fails to identify where in the MRI suite these visitors are to be accompanied. Additionally, there are logistical issues and staff safety concerns about accompanying patients in the MR magnet room during MRI examinations. This recommendation would have been clearer and more appropriate had it followed the ACR Guidance Document recommendations that are specific to supervision by zone within the MRI suite.
5) “Annually, provide all medical and ancillary staff… with safety education about the MRI environment and provide all staff and patients and their families with appropriate materials that explain the potential for accidents and adverse events in the MRI environment.”
While there should be no dispute that any and all staff who’s duties may bring them into the MRI suite (housekeeping, engineering, maintenance, transport, security, etc…) should receive annual MRI safety refreshers, it may be insufficient training to offer it only once per year. In many facilities staff turnover rates for ancillary positions can be extremely rapid and it would be a mistake to bring any staff into the MRI suite without prospective MRI safety training if they were hired in the week after a regularly-scheduled annual training session.
6) “Take precautions to prevent patient burns during scanning…”
This recommendation fails to identify one of the most frequent contributing factors to patient burns, that of large patients in small MRI apertures. If a patient is too large to fit inside the opening of the MRI scanner without touching the sides of the scanner (either by distance or through the use of appropriate padding), that person should likely be referred to an alternate scanner or have the imaging obtained by another modality.
7) “Use only equipment that has been tested and approved for use during MRI scans.”
The Joint Commission recommendation doesn’t identify what the testing and approval criteria are, or what providers should look for either on their existing equipment or for new purchases. The issue of testing and labeling has been dangerously confused as a result of competing nomenclature and a barrage of marketing terms. It would have been appropriate for the Joint Commission to cite the current ASTM / FDA standard and labels.
8) “Proactively plan for managing critically ill patients…”
This suggests that patient management isn’t an issue for patients who are less than critically ill. The fact is that MRI is being used with increasing frequency for patients with a continuum of co-morbidities that may require some level of clinical management. Whether this is IV medication, supplemental oxygen, vital-signs monitoring, ventilation, there should be a plan that can address a broad-range of patient care issues during MRI exams.
9) “Provide all patients with hearing protection.”
Given the extraordinary sound pressure levels that many contemporary scanners are capable of producing, it isn’t enough to simply make hearing protection available, it ought to be required for anyone inside the MR magnet room during imaging.
10) “Never attempt to run a cardio-pulmonary arrest code or resuscitation within the MR magnet room itself.”
This recommendation should have followed the precedent set by the ACR Guidance Document and called upon MRI providers to prospectively designate an area in which clinical codes are to be run, in addition to MRI staff having basic life support (BLS) training. Additionally, code drills should be conducted annually, if not more frequently, to address the unique safety issues in the MRI environment.
Our intention here is not to poke holes in the Joint Commission’s effort to elevate MRI safety in the minds of providers, but rather to try and maximize the value of their recommendations by capitalizing on informational resources that are already available and providing specific examples which are likely to improve the applicability of the individual recommendations of the Sentinel Event Alert.
If you have questions about the overall safety and efficiency of your MRI suite, you would be wise to have a MRI Suite Survey which can help you identify safety, throughput and operational improvements.
