Radiation and overall imaging safety are very important when it comes to patient care and health care provider care. ICE Magazine reached out to imaging leaders to gain more knowledge about the latest regulations as well as tips and advice that other leaders can use to keep themselves, their staffs and patients safe.
Participants in this Director’s Circle article on radiation safety are:
- Beth Allen, director of clinical operations with Banner Imaging
- David V. Buczkowski, MSA, RT (R/CT), with Corewell Health
- Aletha Ewing, CT associate manager with Banner Imaging
- Tobias Gilk, senior vice president of RAD-Planning and founder of Gilk Radiology Consultants
- Shannon Luck, R.T.(R)(CT)(ARRT), BA, CRA, RSO; manager, radiation and MR safety; UT Southwestern Medical Center
Note: Allen and Ewing worked together to complete the Q&A.
Q: How have radiation safety practices changed over the years?
Allen & Ewing: Radiation safety has changed over the years, first by adopting the ALARA principle. Secondly by new research that has identified that medical radiation exposure is different than previously assumed based on historical evidence of radiation exposure from atomic bombs. Based on this we have different shielding guidance from the AAPM. We still utilize risk versus benefit to determine the best use of medical radiation.
Buczkowski: From the end user not a lot of change. But as far as CMS new guidelines, required fields and radiologist reporting that seems to be the most movement of change. Some insurance carries will reach out and advise on patients that may have had too many CTs.
Gilk: One of the biggest safety practice changes in MRI we’re seeing is a shift from the idea that 5 Gauss (0.5 milliTesla) ought to be the safety threshold for unscreened persons (sometimes referred to as the ‘pacemaker line’), to 9 Gauss (or 0.9 mT) which is now reconciled with standards developed for the active implanted device industry. This modestly shrinks the volume of space that must be protected from unscreened individuals. The standard shift from 5 Gauss to 9 Gauss happened in a 2022 IEC standard update, which governs the design and manufacture of MRI scanners. While the new standard has been recognized and adopted by the FDA, because it’s a manufacturing standard it may yet be a couple of years before newly developed MRI systems reach market that are required to identify 9 Gauss as the new safety threshold.
Luck: Radiation practices have changed over the years on several fronts: Practices and principles, such as ALARA, Image Wisely, and Imaging Gently have solidified their place as the foundation of radiation safety practices. Regulations have been enhanced over time to ensure a downward trend of ionizing radiation exposure which ensures safety at a greater capacity. Advancements in protective wear and monitoring devices shield users from exposure while also more accurately tracking radiation exposure in real time. The best part is the improvement in education and knowledge users bring to the exam room. Technologists, physicians and physicists take their role in protecting themselves and their patients from unnecessary radiation exposure seriously. They are spending more time learning about updates and training on better safety practices. This exemplifies how radiation safety measures have not only changed but improved over the years.
Q: How can an imaging department stay current on the latest radiation safety guidelines?
Allen & Ewing: Imaging departments can stay current by monitoring articles and forums such as ICE Magazine, the AHRA forum and the ACR.
Buczkowski: Have a robust physics department and monthly RSO meetings. Going over new requirement and talking about radiation safety.
Gilk: In MRI, I always encourage following the safety guidance in the 2024 ACR Manual on MR Safety. But be aware that if your site has ACR MRI accreditation that, alone, is not an indication that your site is complying with the practices outlined in the 2024 Manual. Compliance with the safety criteria in the Manual is not a minimum site compliance requirement for their MRI accreditation.
Luck: More imaging departments are subscribing to journals or newsletters from professional bodies for their staff to keep current on the latest radiation safety guidelines. Empower staff to get involved in their local and state societies by partnering with these organizations to provide meeting spaces which often include educational opportunities. One of the benefits of representing their organization and themselves in the industry is receiving prompt updates about cutting-edge research and emerging trends. What a great way to show you care about their future as an imaging professional!
Encourage attendance at conferences, like the Society of Cardiovascular CT (SCCT) Annual Scientific Meeting which brings together global experts on cardiac CT. They are increasing their collaboration on ways to lower radiation exposure for patients undergoing cardiac studies. They are not the only ones! The American College of Radiology (ACR), the Association for Medical Imaging Management (AHRA), and American Society of Radiologic Technologist (ASRT) recognize their members have a growing desire to protect themselves, their colleagues and their patients. In response, they offer various online and tactile educational resources on radiation safety.
Organizations and departments also have a responsibility to regularly review and update their department’s protocols to align with the latest guidelines. Creating interdepartmental committees with stakeholders outside of the imaging department is a creative way to ensure they are meeting the needs of other service lines in terms of radiation safety. For instance, involving frontline OR staff or the radiation safety officer (RSO) can provide valuable external insights. They can raise questions about the policy that might highlight areas that need clearer explanation.
Q: What are some tips for achieving the As Low as Reasonably Achievable (ALARA) principle, defined by federal regulations?
Allen & Ewing: Tips to achieve ALARA are to use automatic exposure control and precise positioning.
Buczkowski: Always distance when you can. Having remote fluoroscopy, rotation staff between fluoro and general imaging. Same holds true for IR.
Luck: The ALARA principle is a key concept in radiation safety. Having a RSO on your team that is passionate about exceeding the status-quo should include someone that is continuously evaluating and improving radiation safety practices within the organization. The role should also be filled by someone that never tires of educating and then re-educating staff on safe radiation practices. I feel like a broken record talking about wearing your waist dosimeter under the lead apron, but I love it. ALARA is not a one-time effort but an ongoing commitment to enhance radiation safety practices for staff and patients.
Q: What are some MRI safety plans a health care facility should have in place?
Allen & Ewing: Health care facilities should use the ACR MRI Safety Manual as a guide to delineate safety zones, create a coordinated device research and clearance process and a safety focused team.
Buczkowski: Make sure all zones are labeled. Work with local fire departments and security to be well informed on the MRI environment. Have an internal modular training course for ancillary staff EVS, MA’s RN’s etc. Put it on your annual compliance training for every employee.
Gilk: Last year’s ICU bed accident investigation indicates that hospitals who think meeting their accreditation minimums are enough can still find themselves in big trouble. That hospital got skewered by CMS, the state department of health, and OSHA for a number of factors that I think should be standard for all MRI providers:
Name dedicated MR Safety Officer (MRSO) and MR Medical Director (MRMD), and make sure you can demonstrate the training or credentialing for the individuals in those roles.
If your documented policy says ‘we always’ do something (in this case it was keeping the MRI scanner room door closed), make sure that those performance criteria are actually being done how you describe them.
Have distinct MRI safety training content based on the roles/needs of different individuals, and make sure the site is verifying retention or competency. (The new 2024 ACR Manual on MR Safety has a great new minimum training knowledge table that you might find helpful.)
Make sure your MRI suite physical facilities (i.e., access controls, zones) and equipment (i.e., ferromagnetic detection, MR Conditional equipment) follow current standards.
Luck: MRI safety plans in a health care facility are equally important to radiation safety guidelines. Some plans that a facility should have in place include:
Increasing and ensuring ample time for screening at the time of the appointment. This may be an unpopular opinion with some managers; however, to help cut down on the number of incidents of patients and non-MRI personnel introducing ferrous materials into zone IV despite asking the patient to change or screening staff at the Zone III doors, staff need to be provided ample time to check and recheck everyone before entering an MRI suite.
Organizations that have a blame-free reporting system encourage individuals in health care settings to report errors and adverse events without fear of punishment. An increased number of reports is a good indication that staff feel psychologically safe enough to report near-misses and adverse events. “When in doubt report it out” is a great motto to empower staff to ask questions related to MRI and radiation safety.
Drills in emergency procedures is another safety plan that a health care facility should have in place. We have fire drills, adverse weather and even active shooter drills. It is important to have training that includes drills that cover emergency procedures related to MRI incidents such as quenching, patient evacuation, and how to handle ferrous materials erroneously introduced into Zone IV.
Q: How has new technology enhanced safety for staff and patients?
Allen & Ewing: New technology we have incorporated for safety are ferr alert wands, Trophons, and systems within our EMR to alert us to potential dangers for each patient such as allergies or implanted devices.
Buczkowski: CT we now put in ceiling mounted lift for any new construction. Also put this in zone 2 in MRI for transfer patients.
Gilk: In MRI quite a number of the technology and clinical advancements have actually increased risks. As compared to 20 years ago, we’re seeing stronger magnets, more powerful gradients and RF transmitters. Couple that with the proliferation of patients with high acuities, or implants & devices, and often both. Many technological and clinical shifts in recent MRI have actually ratcheted-up risks for staff and patients!
Luck: There are several technological advancements that enhance safety for staff and patients:
Automated dose tracking to monitor radiation exposure in real-time help ensure exposure is within safe limits and provides data for continuous improvements.
Technologies like SPECT/CT and advanced MRI reduce the need for repeated scans by providing clearer pictures on the first attempt.
AI is now used to personalize treatment plans which also optimize radiation doses, ensuring that the effective dose is used while still achieving diagnostic or therapeutic goals reducing unnecessary exposure to both patients and staff.
Q: What else should ICE Magazine readers know about safety in the imaging department?
Allen & Ewing: Everyone needs to put safety first. We are all busy and can easily be distracted, but safety for our patients and our team members needs to be a priority.
Buczkowski: MRI- hire a single MRSO that is dedicated to the system. He/she is the face of MRI safety to the entire organization. Corewell has a robust MRI safety program and have spoken at RSNA/AHRA this year.
Gilk: Those with responsibility for department or enterprise safety should know that minimum safety standards are profoundly unequal across modalities. For ionizing radiation there are licensure, accreditation, and state and federal regulatory requirements (depending on the modality). For non-ionizing modalities, particularly MRI, there are typically zero state or federal regulatory requirements, often little or no licensure safety requirements, and too often the accreditation requirements are fig-leaves, at best. If you want to keep your MRI practice safe, you shouldn’t rely on the external standards, but instead should make sure that your people are appropriately trained and your policies are up to date.
Luck: Just as it’s beneficial to build a good relationship with your human relations representative, it’s equally important to do the same with your RSO/MRSO. Adopting a team approach to uphold radiation and MRI safety practices ensures the department is well-prepared for JC or state surveyors’ visits. It’s far better for your RSO to identify and address issues proactively than to receive avoidable deficiencies.
