When you think of the safest and most dangerous areas in the hospital, would you believe they could be the same place? If not, it’s time to adjust your thinking about imaging safety, says John Posh.
Posh is the director of education and MRI safety officer with ferromagnetic detection systems manufacturer MetraSens of Lisle, Illinois. Throughout his career, Posh has designed more than 20 different imaging facilities, although his exclusive focus is on magnetic resonance imaging (MRI) systems. His claim – that the MR suite holds the dubious distinction of being both the safest and most dangerous area of the hospital – is based in an understanding and healthy respect for the fundamental forces at work in the technology.
Most laypeople and hospital staff are aware that a computed tomography (CT) imaging system can pose certain environmental dangers; namely, those of exposure to ionizing radiation. Much has been written, policy- and practice-wise, about the pursuit of the lowest possible radiation dose required to produce an optimal imaging study at the least risk to the patient. In an MR suite, there’s no ionizing radiation because the device doesn’t require it to operate. However, Posh points out, the forces generated by a high-powered magnet can be just as deadly.
“There’s no radiation; there’s nothing that can hurt you physically,” he said. “But you can walk in [with a relatively mild injury], and then be dead if something flies across the room. No one can come to your aid until they can turn off the magnetic field. It requires specialized education and training.”
One of the most well-known examples of such an accident came in July 2001, when six-year-old Michael Colombini of Croton-on-Hudson, New York, was killed during a routine MR exam at the Westchester Medical Center. A metal oxygen tank that had been left in the imaging suite became magnetized, and flew into Colombini’s head at a rate of 20-30 feet per second, The New York Times reported. The tank crushed the boy’s skull, killing him, and resulting in a $2.9-million settlement for his family and a $22,000 fine from the New York State Health Department, according to the New York Post.
Worst, Posh said, the incident caused an entirely preventable death that became a sentinel event in the history of radiology. Afterwards, the American College of Radiology (ACR) developed design guidance that designates four safety zones within MRI facilities. Each corresponds to a level of “increasing magnetic field exposure (and hence potential safety concern),” the ACR notes in its documentation. In order of increasing risk/security, they range from Zone I (the outside world, where no security controls exist), to Zone IV (the highest-security zone, in which the MR magnet itself resides, and which contains the greatest level of ferromagnetic activity).
Zone II covers public-facing areas, like reception and waiting rooms, where technologists can supervise MR safety education and access to Zones III and IV can be regulated. Zone III is where patients can change and technologists can control access to Zone IV; being closer to the magnet itself, Zone III may present “fringe, gradient, or RF magnetic fields [that] are sufficiently strong to present a physical hazard to unscreened patients and personnel,” ACR notes. Patients and staff in Zone III should be supervised at all times by those trained in imaging safety.
Designing for safety involves a lot of consideration about the work that must be done in each of these zones, and the flow of staff and patient traffic throughout them. Posh describes what can happen when those considerations aren’t managed in the build-out of an imaging room.
“A facility I went with recently had worked with an architect that was good at hospitals, but didn’t know MRI very much,” he said. “Zone III was so short that, in order to get a patient on a stretcher, you’d have to open the Zones III and IV doors. You’d have to open a corridor from a public access area to the most secure area.”
“Let’s say the patient stops breathing,” Posh continued. “No resuscitation efforts are possible in Zone IV. You can’t bring in equipment or people to help you because of the magnet. The code says, run it into Zone III; do it in private. This facility has such a small Zone III that they have to run it into the hallway.”
“The space is efficient, but if the design team had included anyone who’s worked in these spaces, they would never have signed off on that,” Posh said. “It’s the problem between people who know the specifications and people who’ve practically lived in the space. An architect can design your space, but when it involves a bespoke knowledge of what needs to be done in that space, you need a specialized architect.”
Under such circumstances, Posh can only recommend writing workaround policies designed to overcome the limitations of the space. For facilities that are in the planning phase, he can offer additional support, much of it centered on ferromagnetic detection; i.e., finding ways to identify material containing iron, steel, nickel, or cobalt, which could adversely interact with the magnetic field of an MR device. Installed in Zone III, that detector can tell technologists whether a patient has anything from an implanted medical device, like a pacemaker or pulse generator, to a forgotten hairpin or piece of jewelry. Even street clothing, which was once regarded as a non-issue, must be taken into consideration, Posh noted, citing synthetic fabric treatments that sometimes can cause an antenna effect.
“There’s copper, silver, and some kind of other treatments that involve colloidal silver,” he said. “The problem is those things are conductive. You can heat up conductors to the point of creating a fire. It’s really basic high-school physics, but patients’ clothing is now no longer presumed to be safe.”
As a secondary defense, Posh recommends installing a second metal detector before the entrance to Zone IV; one that will detect the approach of ferromagnetic metal and sound an alarm in its presence. The double redundancy can be a lifesaver not just for imaging patients, but for at-large staff who don’t frequent the imaging suite.
“The way we make these spaces safer is through specific training,” Posh said. “We’re not concerned about the 20-year technologists who do this every day, and who are drilling this. The problem is all the support people who are intimately involved in what we do on a daily basis, but they don’t spend enough time down there to have the muscle memory for safety.”
To that end, Posh recommends a basic level of training for everyone in the hospital – details that indicate what the magnet is, its potential risk factors, and instructions like, “the magnet is very dangerous if you don’t know what you’re doing; stay away.” He recommends that untrained personnel be forbidden to enter a Zone III or IV area without supervision and clearance from specialized, trained imaging personnel.
Architect and radiology/MRI safety consultant Tobias Gilk, senior vice president at RAD-Planning of Kansas City, Missouri and past chair of the American Board of Magnetic Resonance Safety (ABMRS), said that long-term planning during the construction of an imaging facility pays dividends not just over the lifespan of the building, but of all the generations of equipment that will be housed there.
“If we look at the lives of brick-and-mortar hospital buildings, they have an anticipated lifespan of 50 to 100 years,” Gilk said. “A piece of imaging equipment today has an average lifespan of 10 years. We’re going to replace that piece of equipment four times in the lifespan of that building.”
When designing imaging facilities, Gilk recommends making plans that allow for the evolving clinical utilization of the space, as well as changes to its broader physical needs. As more imaging-guided procedures come online, facilities must be built to accommodate the technology required to conduct them. Switching out a space principally used for diagnostic studies to one that might perform even minimally invasive procedures requires considerations about infection controls at the least, “and a lot of the facilities don’t harmonize,” he said.
“It is technically difficult to put a hand sink in an MR room,” Gilk said. “Most facilities’ infection control protocols say if there is potential exposure to blood product, you have to have either a sink with a drain in that room, or hands-free access to go from that room to a scrub area. A lot of facilities didn’t ask the questions about what that means we need to provide in the room – seamless flooring; washable, scrubbable surfaces, hand-washing stations – and so there’s been a bit of scope creep. Without really recognizing, we’ve modestly changed the way that we use the space over time, and before you know it, we’ve made some pretty significant changes from whatever our previous benchmark was.”
Simply increasing the diversity of exams and procedures in radiology environments won’t work without giving appropriate consideration to the same in the facility planning and design process, “and appropriateness for the level of acuity and intervention,” Gilk said. Most inpatient procedures are conducted on patients who are sicker than they may have historically been, he noted; a failure to consider the way those patients interact with the equipment and environments could expose them to additional risks.
“In terms of the nature of the risks presented to the patient, surgery hasn’t changed in 100 years,” Gilk said. “In imaging, the risks are relatively new because imaging is relatively new in medicine. Because they’re technologically driven, the risks are constantly evolving as the technology pushes forward.”
“The way in which the equipment is designed and used, potential collateral risks to patients as acuities increase are moving targets,” he said. “It changes from facility to facility, and, within the same facility, from year to year. It’s vitally important that the structures around imaging, and the policies and procedures that speak to risk management, are continuously reviewed based on changing technologies, changing staffing and changing clinical utilization.”
“All those pieces should create a retrospective view as to where are we today, where are we planning for the future, and what do we put in place to accommodate for the future – or don’t get in the way of what we want to do for the future,” Gilk said.
Typically, capital projects, like a redesigned imaging suite, are driven by a push for increased capacity and subsequent revenues. But when the only consideration is the number of scanners, or how to increase the potential to perform more studies, safety issues can slide to the bottom of the list of considerations.
“What are the defining features of an idealized solution?” Gilk asked. “Going through that process may map out options previously unconsidered on how to reallocate resources, or give a much better picture of how to judge new facilities against their own best-practices model instead of counting the number of scans. It’s not the only metric sites should use.”
Architect Sara Ridenour, an associate principal at Ballinger of Philadelphia, Pennsylvania, said a good partner on any facilities project is one who will walk the client through goals and aspirations for their space before the design kicks off.
“We start with projected patient volumes to program the space, and that’s how we determine the square footage required,” Ridenour said. “While we’re doing that, we start the Facilities Guideline Institute (FGI) code review, including life safety for patients and staff.”
Next comes considerations of patient experience – how the space feels, from the outside in – which is just as much related to reimbursement as any other aspect of the conversation about revenues. Ridenour said her firm works to create “a more serene environment” in the study room itself, while focusing equally on creating areas of respite for the comfort and safety of staff.
“We look at how the environment affects healing and impacts how staff and clinicians work,” she said. “We also look at the future use of the space, because as soon as you design the perfect space, a few years later you have a new piece of equipment coming in.”
Ridenour also pointed out that the scope and timing of capital projects can evolve over years, and with them, leadership and technology needs similarly can change. She recommends that clients find not only firms who are technically savvy to assist them with the building and design of their spaces, but are also partners who understand the guiding principles of their clients, and who have “excellent follow-through.”
“It’s one thing to plan it, but to get it built, you want to be there all the way through for the client,” Ridenour said.