0:01

This section is on MRI safety structures and tools,

0:05

the object of which is to help identify policies

0:10

and practices, staffing structures,

0:14

communication hierarchies,

0:16

or organizations that allow the radiologists to

0:20

more effectively manage best practices for

0:25

MRI safety at the point of care.

0:28

So if you are in fact the captain of the ship, which you are,

0:33

who are your executive offices,

0:36

who do you turn to to make sure that practices

0:41

get exercised as appropriate?

0:44

So if we start with the fact that there is a radiology group

0:49

and somewhere there are a collection of Mr. Technologists,

0:55

how does that relationship between the radiologist and the technologist

0:59

performing the scans, how does that relationship work out?

1:04

We could have 20 points of contact from the radiologist to 40

1:08

or 50 points of contact with the MRI technologists,

1:12

or we could do something different.

1:16

We could essentially appoint an individual on behalf of the radiology

1:20

group who is the MR. Medical Director, Mr. Md,

1:25

and we could from the technologist,

1:27

appoint an individual or a role that is the MR.

1:31

Safety officer.

1:34

And the primary point of communication or

1:38

discussion with respect to MRI patient safety related

1:43

concerns would then be between the safety officer and the MR

1:48

Medical director. Now we can't have Mr.

1:53

Medical Director or Mr. Safety officer working 24 hour shifts,

1:56

365 days a year.

1:59

So there are going to be times when the MR Technologists

2:04

will bypass the safety officer to get to the medical director or to get

2:09

to other radiologists in the group.

2:12

But establishing the structures for clinical decision making

2:17

can go a long way to providing a higher degree of uniformity

2:23

in terms of patient care decisions.

2:25

There will also come times when there are particularly

2:30

troubling questions,

2:32

questions that can't really be effectively answered by the disclosures or

2:37

information from the implant or device manufacturer.

2:41

Maybe this patient has an entire alphabet of

2:46

different implants and devices,

2:49

and all we can find are information from individual

2:53

manufacturers about the individual device safety for one

2:58

particular

2:58

Object and nothing about how we go about assessing the safety of a patient

3:03

in whom there are multitudes of different implants or devices.

3:08

So between the MR Medical Director and the MR Safety officer,

3:13

when we are unable to fully respond to

3:18

risk assessments or questions about safety,

3:20

it may be important to bring in an MR. Safety expert,

3:25

somebody who as a consultant to the teams, the radiologists,

3:30

and the MR Technologists and their representatives,

3:33

the MR Medical Director and the MR Safety officer.

3:37

It may be appropriate to bring in the MR Safety expert a phone, a friend,

3:42

if you will,

3:43

that can bring to the discussion a higher degree of

3:48

understanding of the physical properties of MR Safety

3:53

and the interactions between the electromagnetic fields of the MRI

3:58

and various implants, devices, and foreign bodies.

4:03

One of the most essential elements for a safe operating

4:09

facility is to have documented MR Safety policies and

4:14

procedures. It is vitally important that these are documented.

4:19

We want to be able to share them between and among administration,

4:23

radiologists and Mr.

4:25

Technologists and any support staff because we want to have everybody

4:30

working from a common playbook.

4:33

If you feel as though your policies or standard

4:38

practices shouldn't be documented,

4:42

ask yourself the question, why do you feel they shouldn't be documented?

4:47

If you're representing them as best practice,

4:51

what would be the reservation against having them documented?

4:55

Your policies and procedures really should be part of a triangle, right?

5:00

Your policies and procedures need to be informed by best practices,

5:04

and they need to be reconciled against the site

5:09

practices. If your policy says, we always do this,

5:14

but the practice is eh, sometimes we do that, sometimes we don't.

5:19

Then there is disagreement between the policy and practice.

5:24

If your policy says something different than industry best

5:29

practices, then God forbid something goes wrong,

5:33

you are going to have a hard time reconciling what your policy says

5:38

against industry best practices or widely regarded safety

5:43

best practices.

5:44

So we want to form a triangle between industry best practices,

5:49

industry standard, MR Safety guidance,

5:52

your local policies and procedures and the actual

5:57

Practices at the point of care.

5:59

And all three of those need to agree to greater or

6:04

lesser extents. You need to be able to reconcile one against the other.

6:08

We wanna review those policies and reconcile policies against

6:13

best practices and practices on a regular basis.

6:18

I recommend at least annually in addition to that,

6:22

anytime there is a big change, a new MR system,

6:26

new clinical capabilities,

6:28

a new referring physician who wants you to do something you've never done before

6:33

under any of those prompts, MR.

6:37

Safety best practices and your site practices really

6:42

need to be re-reviewed and reconciled against one another given the new

6:47

equipment or new clinical demands.

6:50

One thing you may find very helpful as an element of your policies

6:56

and procedures are documented decision support tools.

7:01

Previously we discussed how training for radiologists in

7:05

MRI safety might be all over the map.

7:08

You may have radiologists within your practice who have wildly

7:13

different understandings of MRI safety based on wildly different

7:19

trainings that they might have received during their residency.

7:23

So how do we deliver a more uniform form of patient

7:27

care?

7:28

Decision support tools can be excellent tools in that they can get

7:34

practitioners who have multiple different levels of experience or expertise.

7:39

We can get them on the same page.

7:42

Decision support tools generally won't cover the the far out stuff,

7:46

the once in a blue moon stuff,

7:49

but we can pretty regularly build decision support tools that will

7:54

reliably cover 70 80% of our MR patient

7:58

population without much trouble.

8:02

When you have these decision support tools,

8:05

it can dramatically reduce the variability in care.

8:09

I've worked with sites that essentially the rad techs knew

8:14

where to shop for the answer that they were expecting or that they wanted

8:19

between and among the radiologists who were on that day that there were

8:23

radiologists who they could be guaranteed to postpone a study

8:28

because the radiologist was concerned about putting their name to going

8:32

forward and their radiologist they knew to call because that guy will approve

8:38

anything. I would argue that you don't want to be at either end of the spectrum,

8:43

either scared of your own shadow or so cavalier, you approve everything.

8:47

I think each of those are dangerous in different ways.

8:51

You wanna really move towards capturing best practices and

8:56

decision support tools can turn many of the best practices into

9:01

algorithms.

9:03

This is one example of a decision support tool.

9:08

This is one that I developed with a radiology practice and

9:13

the hospital that the practice worked with.

9:16

This essentially takes a patient with an implant, a device, a foreign body,

9:21

and runs through a series of yes no questions

9:26

to get you to a resultant answer.

9:30

And I wanna point out for you that the resultant answer doesn't have to be yes,

9:34

no, that in this case there are four possible outcomes.

9:40

There are proceed without any limitations.

9:45

There are proceed with some prescribed limitations.

9:50

In this particular case,

9:51

this hospital had both 1.5 and three T magnets.

9:55

And so the proceed with limitations is you're gonna scan this patient on the

10:00

1.5, not on the three in normal operating mode,

10:04

which is gonna limit you to two watts per kilogram sar maximum 15 minute

10:09

per pulse sequence,

10:10

unless you're doing some kind of therapeutic something or other 15 minutes per

10:14

pulse sequence is really not that much of a restriction.

10:17

So this site had yes without restriction, yes,

10:21

with radiologist imposed restriction or what we call the yellow

10:26

flags, call the radiologist for review. We're not saying no,

10:30

but we're also not saying yes, at least not without a consult.

10:35

So collect as much information as you can about the relative risks,

10:40

the implant, the device, the foreign body,

10:42

the study that we're going to hopefully proceed with and the radiologist will

10:47

direct, yes or no. There are a small number,

10:50

but there still are some conditions where it's really not

10:55

ambiguous that this patient really should not receive an MR study.

11:01

So yes, without restrictions, yes,

11:03

with radiologist defined restrictions, uh,

11:07

call us before making a decision to go forward or not,

11:12

and no, we're not scanning this patient.

11:15

So your decision support tools can be as

11:21

simplified or as complicated as you wish them to be.

11:26

I think that this is generally speaking,

11:28

a good balance between simplicity and complexity.

11:33

It covers a wide range of implants. Devices in foreign bodies,

11:37

again, doesn't cover everything.

11:40

But at this particular facility with this radiologist practice,

11:44

this decision support tool does cover probably three quarters of

11:49

the patients and their potential complications.

11:53

My apologies to the Dummies Guides folks.

11:56

This is not a real publication. I wish it were.

12:01

But I think our policies and procedures,

12:04

we need to think of them in different terms. They need to not be

12:10

a super short bullet pointed list of

12:15

do this, don't do that.

12:16

But I think we should look at our MRI safety policies and procedures

12:22

as an onboarding tool for the new radiologist, the new MRI technologist.

12:28

We should be able to sit a brand new hire down with

12:33

our policy and procedure manual and instruct them that

12:37

following just the written direction in the policy and procedure manual,

12:42

they should make determinations about the care of individual patients.

12:47

If you look through your policy and procedure manual and you don't feel

12:52

like it achieves that, in my opinion,

12:57

the reason for that is probably because it's not detailed enough.

13:00

And I would encourage you to rethink the intent behind your policies and

13:05

procedure manuals. Now,

13:07

while I am laying a lot of the responsibility for MRI safety

13:12

at the feet of radiologists,

13:15

and I expect that there is a natural reaction to say,

13:20

but MRI safety is everybody's responsibility.

13:24

I wanna share with you this story.

13:26

The woman whose picture is on the screen right now,

13:29

her name was Kitty Visi and I believe she was a nurse and works

13:34

second shift in New York City.

13:37

So she gets off shift at somewhere around midnight,

13:40

makes it home to her apartment,

13:43

a large multi-story U-shaped apartment building,

13:47

and you enter into the central courtyard and you pass the central courtyard to

13:51

go into the back of the U to enter the building.

13:55

And then you go up to your various apartments.

13:57

So there are dozens and dozens of apartments that look into the central

14:02

courtyard and dozens and dozens that look out into the rest of the city.

14:07

So Kitty Jeni comes home at,

14:11

we'll say one o'clock in the morning after her shift at the hospital,

14:16

and she encounters a mugger in the central courtyard of her apartment

14:21

building, and the mugger attacks her and she screams for help,

14:27

and the mugger silences her by beating her to death in the central courtyard

14:32

of the apartment building.

14:34

The police are not called until five o'clock in the morning when some early

14:38

risers make their way out and discover her corpse in the central courtyard

14:43

of the apartment building. The police arrive and they're just dumbfounded.

14:48

How on earth could nobody

14:50

Have called when this woman was being assaulted?

14:54

A bunch of psychology researchers are also curious about this.

14:58

And so parallel to the police investigation,

15:02

they begin a research project where they go house to house or apartment

15:07

to apartment throughout the apartment building,

15:10

identifying folks who saw or heard anything about Ms.

15:15

Genovese's attack.

15:17

Turns out that they positively identified 37

15:23

individuals who saw her being attacked and murdered.

15:27

37 people who didn't call the police.

15:32

And each and every one of them individually when

15:36

interviewed said,

15:38

there are so many apartments overlooking this central courtyard,

15:43

surely somebody else called the police.

15:46

The reason that I bring up this anecdote that on its surface has

15:51

absolutely nothing to do with MRI safety is because there is this

15:56

pervasive, I don't want to call it an excuse,

15:59

but there is this pervasive theory that MRI safety is

16:05

everyone's responsibility.

16:07

That shared sense of responsibility without

16:11

individual accountability is the exact same recipe

16:17

as the residents in Kitty Genovese's apartment complex,

16:22

right?

16:23

MRI safety is not everybody's responsibility.

16:28

It is your responsibility.

16:31

Specifically radiologists have an affirmative responsibility,

16:36

an affirmative duty to the safe delivery of MRI care.

16:41

It may seem a challenge given the time

16:46

and space that radiologists are separated from exam administration.

16:51

It may seem an impracticability given Mr

16:56

Technologists proximity to MR Studies,

17:00

and surely they should be the ones who are responsible.

17:04

And while they should have individual accountability for performing

17:09

the actions described in the policies and procedures by following the direction

17:14

of the supervising physician,

17:16

it is ultimately the captain of the ship, the supervising physician,

17:21

the radiologist in most cases for mri,

17:25

who has the ultimate responsibility for the delivery of safe

17:30

care in the MRI environment.

17:33

So if this makes you feel nervous about your responsibilities,

17:38

there's some good news.

17:40

Good news is that there are many excellent resources that can

17:45

help you manage this. One of the top,

17:48

If not the top on the list, not only just because I've listed it here first,

17:53

but in terms of its depth and breadth,

17:56

is the ACR manual on MR. Safety

18:00

for contrast related safety issues,

18:04

the ACR contrast manual also excellent,

18:07

and obviously the contrast manual includes guidance for

18:12

all different forms of contrast. And for mri,

18:15

we're particularly interested in the gadolinium contrast portion.

18:20

There are a amazing publications from the Heart Rhythm Society

18:25

and the American Society of Anesthesiology covering MRI

18:31

and interaction with active implanted cardiac devices,

18:35

pacemakers and defibrillators from the Heart Rhythm Society,

18:39

and patients undergoing heavy sedation or general anesthesia

18:43

from the asa brilliant publications, both of them.

18:48

If you're looking at a situation with a more specific question,

18:53

can I scan a patient who has this particular implant?

18:57

Can I go off label in the following manner?

19:00

There are multitudes of peer reviewed publications

19:05

on specific concerns and some on much broader related

19:10

MRI safety guidance.

19:12

All you need is Google and you can retrieve all kinds of excellent

19:17

resources that will inform your clinical decision making.

19:22

So in summary, MRI accidents,

19:26

they continue and they can have grave consequences

19:30

despite the fact that we continue to identify M R MRI as the quote

19:35

unquote safe modality.

19:37

If we are expecting licensure or accreditation or

19:42

regulation to offer some sort of acceptable floor

19:48

defining minimum best practices for safety of our patients and our caregivers.

19:54

Think again, regulation, accreditation, licensure.

19:58

These have not kept up with changes in the MRI risk

20:03

profile, and that change is not slowing down, that change is accelerating.

20:09

There are many different attributes of MRI risk from

20:14

the MRI systems,

20:15

scanners and hardware and software to the clinical changes in the way

20:20

we use MRI to operational struggles,

20:24

to questions about implants or devices and going off label or staying

20:29

on label.

20:30

Each of these require effective management to help assure the safety of

20:35

our MRI patients, and ultimately,

20:39

despite time and space separation from the administration of the MRI exam,

20:44

the radiologist has a direct

20:47

Responsibility for the safe delivery of care in the MRI environment.

20:52

With that, I would like to thank you very much for your time and attention.

20:57

I hope that this mastery course has been valuable to you and has set you on a

21:01

course to learn more about MRI safety and the role of the

21:06

radiologist.

21:08

If you have any questions outside of the context of this particular course,

21:13

I invite you to contact me.

21:15

I would also like to extend to you an invitation if you would,

21:19

would like to join the Facebook MRI Safety Group page.

21:24

This is an incredible peer-to-peer resource where many

21:29

MRI safety questions or concerns or patient care scenarios can be addressed

21:34

by peers and experts from around the world. Thank you very much.