After reading this article, you will be able to:
- Explain how safety hazards have restricted cleaning the MRI suite
- Describe infection prevention considerations when building a plan for the MRI
- Identify what Joint Commission surveyors will look for in the MRI suite
If a patient walked into a physician's office or a hospital and saw evidence that the facility lacked adequate infection control, it wouldn't be surprising to see that patient turn around and walk out.
The MRI suite doesn't seem to have that problem, says Peter Rothschild, MD, president and founder of Patient Care Systems, Inc., in Newark, CA. For years, many MRI suites in hospitals and outpatient facilities have operated without proper infection control procedures, primarily because the dangers of the MRI's magnetic field bar almost all employees from entering the room, Rothschild says. As a result, the area has flown under the infection control radar.
In June 2008, Rothschild released Preventing Infection in MRI: Best Practices for Infection Control in and Around MRI Suites, a white paper that detailed some of these infection control concerns, which include a lack of cleaning procedures and a detailed infection control plan specific to the MRI. In May, Rothschild released another paper, Survey of Infection Control in the MRI Environment, in which he questioned 100 hospitals and outpatient imaging centers to determine the state of MRI-specific infection control policies.
"Unfortunately, it's an area that has just been ignored," Rothschild says. "I think that's the nicest way to say it."
Rothschild surveyed 53 hospitals and 47 independent outpatient imaging centers and asked three questions:
- Do you have written infection control procedures, and are they posted where everyone can see?
- If so, do you follow them for every patient?
- What do your infection control procedures say? Are your procedures specific for the MRI suite? (For this, the surveyor was listening for whether staff members washed their hands or cleaned the pads.)
Of the 53 hospitals, 35 stated they have a written policy, three said it was clearly posted, and only seven stated that staff members wash their hands after every patient interaction. Of the 47 outpatient centers, 18 said they have a written policy, although five stated that it was in the employee manual and two said it was clearly posted; not one facility said its staff members wash their hands between patients.
Rothschild notes that even though a few facilities said they had detailed infection control procedures, they would not send a copy to the surveyor.
"This should not be a secret. This should be told to everybody," Rothschild says. "Not a single one of any of the 100 places we called sent us anything. They said they would, but they didn't. We can only assume they didn't have one or didn't have access to it."
Ensuring employee safety
Employee safety is one of the main reasons that the MRI suite lags behind in infection control and environmental cleaning, says Tobias Gilk, M. Arch, president and MRI safety director at Mednovus, Inc., an MRI safety consulting firm in Leucadia, CA.
Because the MRI houses a powerful magnet (tens of thousands of times more powerful than Earth's magnetic field, according to Gilk), it creates a hazard for those unaware of how it operates.
On February 14, 2008, The Joint Commission (formerly JCAHO) issued a Sentinel Event Alert regarding MRI safety for employees and patients. Click here to read the alert.
The Joint Commission said that of the five MRI-related cases in the Joint Commission's Sentinel Event database, four deaths resulted, including a case that involved a projectile.
Since these dangers exist, the suite is usually restricted to MRI technologists and operators.
"We restrict access to it, and a lot of times this means that we restrict access such that infection control officers or chief nursing officers or directors of medical care don't spend the same amount of time or have the same degree of day-to-day oversight for the MRI part of an enterprise that they do for, say, the patient care floors," Gilk says.
The machine's magnetic field can be harmful to people with pacemakers or orthopedic inserts, such as metal plates, rods, or screws. Further, the incredible strength of the magnet draws in anything ferromagnetic with dangerous strength and speed, meaning equipment used by environmental services should be restricted.
"Let me tell you, a floor polisher is going to do six figures' worth of damage to the MRI if it's brought into the room," Gilk says.
Establishing proper cleaning procedures
Rothschild places some of the blame on the MRI manufacturers. Nearly every piece of equipment in the hospital comes with cleaning instructions, but cleaning one of the most expensive and most dangerous is left up to the judgment of the MRI technologist.
"One of the funny stories is 'I bought a frying pan for $10, and it came with cleaning instructions. I bought a $1.5 million MRI, and it had no cleaning instructions. What is wrong with this picture?' " says Rothschild.
Couple that with the long bore of the MRI, which makes cleaning very difficult. Additionally, the pads and coils can suffer extensive damage from potent cleaning chemicals.
"It's a catch-22," Rothschild says. "What happens is the older pads are sewn together with cotton threads, and the cleaning materials will eventually seep in them and destroy those threads, causing them to deteriorate even faster. If [the MRI] is cleaned wrong, [the chemicals] can damage the magnet or damage these coils, and it's quite expensive to fix, so there's reluctance, especially with outpatient imaging centers, to clean these coils and tables very aggressively because a new coil could be $150,000 or $200,000."
Click here for information on preventing MRSA in the MRI.
Creating a plan
The safety hazards make it easy to ignore MRIs altogether, but the risks make it essential to create a detailed plan that includes specific responsibilities and procedures. Gilk and Rothschild agree that infection control professionals should be involved in three-way collaboration with environmental services and the MRI staff.
"I do not think we want to have infection control dictating how cleaning is going to be done in the MRI environment because there are so many risks in bringing people and tools and equipment and material into the MRI suite that ultimately, I feel, in the interest of safety, it's best that the MRI staff control that aspect of it," Gilk says. "That's not to say we divorce the infection control officer from any responsibility to this area."
Rather, infection control should provide performance specifications, standards interpretation, and best practices, which will assist in creating a detailed cleaning procedure. From there, the MRI staff can decide how to handle each job, but the infection control professional should be available to help ensure compliance, check for efficacy, and provide guidance. "Our push is it needs to be in writing," Rothschild says. "There needs to be written infection control procedures that technologists and operators are required to follow. It can't be left up to best judgment."
Click here to read an article from the Institute for Healthcare Improvement on how hospital environmental services staff are important drivers of the infection control agenda.
Complying with Joint Commission standards
For accredited organizations, there may be much more focus on implementing a specific infection control plan for the MRI suite, because The Joint Commission may begin looking for one. (See "Passing a Joint Commission survey" at the bottom of this article for some helpful tips.)
The February Environment of Care, a Joint Commission-published newsletter, included an article about infection control in the MRI suite that indicated surveyors would pay closer attention to this area.
Louise Kuhny, RN, MPH, MBA, CIC, senior associate director of the Standards Interpretation Group at The Joint Commission, says the MRI suite is treated the same as any other part of the hospital.
"The MRI suite is considered an integral part of any Joint Commission survey," Kuhny says. "All Joint Commission standards apply to care in the MRI suite in the same way that they apply to other areas of a hospital or ambulatory center. Some compliance areas that prove particularly challenging for accredited organizations are HR (particularly competence), PC (verifying the correct order for testing), and [infection control] (cleaning of equipment and the general environment, as well as hand hygiene)."
Kuhny says surveyors are trained annually to survey effectively, and "problems unique to the MRI suite have been a recent focus of surveyor education."
However, Gilk remains frustrated with The Joint Commission and the accreditor's apparent lack of attention to MRI safety.
He says he has solicited input from facilities that have undergone surveys this year, and in his opinion, there hasn't been an evident focus on the MRI.
"They wanted to see a fire extinguisher and shadowed a patient, but none of the things that were really identified in that Sentinel Event Alert or infection control issues appear to be on the radar of most surveyors," Gilk says.
Passing a Joint Commission survey
The Joint Commission has said it is shifting its focus to the MRI setting, particularly concerning IC protocols.
The following are five elements a surveyor is likely to look for:
A detailed plan. The IC plan should be specific to the MRI suite, taking into consideration elements of safety as well as specific procedures for cleaning the bore and the pads. Louise Kuhny, RN, MPH, MBA, CIC, senior associate director of the Standards Interpretation Group at The Joint Commission, said in Joint Commission Resources' Environment of Care News that the requirements of IC.01.05.01 would apply in this case.
The following is Kuhny's outline of this approach:
First, every accredited organization must have a unique and specialized infection prevention plan that meets its specific needs. Second, each organization must have a risk assessment strategy, along with methods for evaluating the success of that strategy. In the case of the MRI, accredited organizations could assess this as a risk point and would be expected to have goals and strategies to address these risks.
Established goals and strategies. This is similar to the requirement to establish IC goals in other areas of the hospital, but these goals should be specific to the MRI suite.
A person designated for cleaning. One person should be in charge of cleaning the MRI equipment, most likely an MRI technician who understands the associated hazards. The MRI staff may choose to assign tasks such as floor cleaning to environmental services, says Tobias Gilk, M. Arch, president and MRI safety director at Mednovus, Inc., in Leucadia, CA, but there should be specific training and screening procedures in place to ensure safety, and IC should have a hand in making sure the plan is followed correctly.
Documented cleaning. Once you have established your cleaning schedule for the pads, coils, bore, and the room, develop a documentation system, says Peter Rothschild, MD, president and founder of Patient Care Systems, Inc., in Newark, CA. With documentation, if a surveyor asks about the last time the pads were cleaned, there is evidence to fall back on.
Pads checked and replaced. MRI pads that are torn or frayed are sure to be a red flag for surveyors, Rothschild says. Set up a schedule for someone to inspect the pads and a procedure for ordering new ones if needed.
1. The Joint Commission. 2008. "Preventing accidents and injuries in the MRI suite." Sentinel Event Alert. Available from www.jointcommission.org/SentinelEvents/SentinelEventAlert/sea_38.htm.
2. Medical News Today. 2009. "11 steps for preventing superbug MRSA infections in MRI: New video released on superbug infections in radiology." Available at www.medicalnewstoday.com/articles/123142.php.
3. Institute for Healthcare Improvement. 2009. "Hospital environmental services staff are important drivers of the infection control agenda." Available at www.ihi.org/IHI/Topics/CriticalCare/IntensiveCare/ImprovementStories/HospitalEnvironmentalSvcsStaffDriversInfectionControl.htm.