In our January 2017 What's New in the Patient Safety World column “” we cited a presentation at the 2016 RSNA meeting that showed the use of MRI scanning in pediatric patients has been increasing in the emergency department at a major New York City hospital (Hulkower 2016). We suspect that is a trend we’d see at many hospitals across the country. The reasons for more MRI scans are mostly due to the increased availability of MRI, the campaigns to reduce the use of ionizing radiation, particularly in children, such as the Imaging Gently® campaign, and the fact that some diagnoses are more readily found on MRI than on CT scan. In the Hulkower study the increase in MRI was primarily driven by neurological imaging and there was a corresponding decrease in the use of CT scanning.
But how about MRI utilization in accountable care organizations? A recent study in an accountable care organization caring for children actually had relatively flat MRI utilization from 2009 to 2014 (Uffman 2017). However, they did encounter a somewhat bothersome trend: the percentage of pediatric MRI’s requiring patient sedation or general anesthesia increased from 21% to 28% of encounters over 2011 to 2014. The increase was shared across 1- to 6-year-old, 7- to 12-year-old, and 12- to 18-year-old subgroups. The authors also noted that the increasing need for anesthesia could not be attributed to secular trends in patient demographics or types of examinations ordered.
The need for sedation or general anesthesia in pediatric patients undergoing MRI scanning has cost, workflow, and patient safety considerations.
In the Uffman study, paid cost data were available for outpatient MRIs, and MRIs with sedation accounted for an increasing share of these costs (from 22% in 2011 to 33% in 2014). That posed a challenge to ACO cost containment. Costs related to sedation are a concern not only for ACO’s but for hospitals as well. In our August 2010 What's New in the Patient Safety World column “Sedation Costs for Pediatric MRI” we discussed a study (Vanderby 2010) that addressed the financial impact of sedation for MRI scanning in pediatrics. They analyzed the workflow, personnel, and costs involved in MRI scanning of children at Hospital for Sick Children in Toronto, Ontario. They found that the average time spent in the MRI suite was 2 hours and 21 minutes for children scanned awake, 3 hours 38 minutes for those sedated, and 4 hours 7 minutes for those anesthetized. Corresponding average costs (in Canadian dollars) were $54.68, $177.27, and $522.73 respectively. The Toronto group used their analysis to significantly redesign workflow and scheduling. This article has a good discussion about those workflow and personnel issues and has some good lessons learned that you may apply in your organization. To their recommendations we would again add that strong consideration needs to be given to the appropriateness of the MRI scan, in light of the patient safety and cost issues involved.
Use of sedation is probably the most serious issue in pediatric MRI safety. The Uffman study does not discuss any actual incident data or potential safety issues associated with pediatric sedation. In our January 17, 2017 Patient Safety Tip of the Week “” we noted a study that showed that the prevalence of safety reports in MRI performed in children is increased relative to previously published data on adults (Jaimes Cobos 2016). The researchers found the rate of such reports was 0.53%, compared to a 0.35% rate of incident reporting for adults at the same hospital (Mansouri 2016). Jaimes Cobos and colleagues found that younger children had higher rates of safety reports: newborns (1.1%), infants (1.1%), and young children (0.9%). Children below the age of 6 years, inpatients, and use of sedation or general anesthesia were all factors associated with higher safety report rates.
Our August 2016 What's New in the Patient Safety World column “” discussed the updated American Academy of Pediatrics (AAP)/American Academy of Pediatric Dentistry (AAPD) “Guideline for Monitoring and Management of Pediatric Patients During and After Sedation for Diagnostic and Therapeutic Procedures” (Coté 2016). We refer you to our prior column and the updated guideline itself for all the details needed in performing safe sedation in pediatric patients for any procedure. But the guideline has an excellent section on sedation in the MRI suite, which is a very restricted environment and has needs for special equipment and monitoring techniques as we have discussed in our numerous columns on patient safety issues in the radiology and MRI suites. It notes that MRI-compatible pulse oximeters and capnographs capable of continuous function during scanning should be used in any sedated or restrained pediatric patient. Appropriate precautions must be taken to avoid thermal injuries. For example, the practitioner is cautioned to avoid coiling of all wires (oximeter, ECG) and to place the oximeter probe as far from the magnetic coil as possible to diminish the possibility of injury. It notes that ECG monitoring during MRI has been associated with thermal injury and that special MRI-compatible ECG pads are essential to allow safe monitoring. If sedation is achieved by using an infusion pump, then either an MRI-compatible pump is required or the pump must be situated outside of the room with long infusion tubing so as to maintain infusion accuracy. All equipment must be MRI compatible, including items such as laryngoscope blades and handles, oxygen tanks, and any ancillary equipment. In addition, all individuals, including parents, must be screened for ferromagnetic materials, phones, pagers, pens, credit cards, watches, surgical implants, pacemakers, etc, before entry into the MRI suite.
We’d also like to reiterate a few points from the American Society of Anesthesiologists Practice Advisory on Anesthetic Care for Magnetic Resonance Imaging (ASA 2015). It states that the anesthesiologist needs to develop a plan for implementing anesthesia care before each individual case. Such a plan should be done in collaboration with other personnel who will be involved in the care of the patient, including the MRI technician, radiologist, radiology nurse, other clinical personnel accompanying the patient and even the facility biomedical engineer. In addition to the anesthetic plan, preparation includes a plan for optimal positioning of equipment and personnel in the MRI suite during the procedure. We refer you to that guideline for details. The anesthesiologist should also prepare a plan for rapidly summoning additional personnel in the event of an emergency.
We suggested a few additions to this otherwise excellent ASA practice advisory. First is the importance of determining up front whether the MRI is truly indicated, whether the potential benefits of performing the MRI outweigh the potential risks, and whether alternative safer imaging modalities might suffice. In many of the incidents we’ve seen occurring in ICU patients transported to the MRI suite or radiology suite, we’ve been surprised at how often the scan being done was really of marginal value.
Second is the need for a huddle/timeout before the procedure is performed. We should approach doing MRI on these critically ill patients in the same manner in which we approach patients going to the OR. A “huddle” or whatever else you’d like to call a pre-procedure briefing is very important in such cases. Not only do you need to know you have all the equipment needed, but you also need to know everyone’s role and have contingency plans for emergencies. This is where you ensure all parties know what to do if there is a fire or if there is a cardiopulmonary arrest or a “quench”. You discuss what location you will need to move the patient to in such events. You discuss the availability and location of equipment and medications you may need. You discuss the line of sight required and where the monitoring equipment will be deployed. You may need to discuss also how you will communicate (with both staff and patient) given the high noise levels associated with MRI scanning. You should probably even discuss the potential impact of the lighting levels in the various zones (and fact that you may not be able to wear your ferromagnetic glasses in Zones III and IV).
Third, really related to the above, is use of a checklist. To remember all the needs for the procedure (which vary be individual patient) and the contingencies you have to plan for is really too much to expect for any individual or group of individuals. That’s where the simple checklist comes in: it helps you to remember details you might otherwise overlook.
Fourth, you need to practice for emergencies. We wonder how many MRI facilities, particularly hospital-based ones, actually simulate an emergency during MRI scanning.
Lastly, don’t forget that the trend toward more pediatric MRI patients needing sedation or general anesthesia has workflow issues for the MRI suites as well. A recent review on unexpected events during MRI (all patients, not just pediatrics) focused more on issues impacting workflow than on actual patient safety events (Sadigh 2017). The authors found that unanticipated events occurred in 16.7% of all scans. Of those, 10.4% were labeled non-contrast-related patient events and 11.9% of those were related to the need for sedation or general anesthesia.
The authors found that the rate of overall unanticipated events was significantly higher in university-affiliated sites than at community-affiliated sites (18% vs. 5%), in scans performed in the mixed outpatient/inpatient settings than those strictly outpatient settings (22.3% vs. 12.6%), and in scans performed during weekends/holidays than on business days (21.5% vs. 16.2%). The higher weekend/holiday rate was largely driven by patient events unrelated to contrast, which include the need for sedation or general anesthesia.
Note that the Hulkower study noted above (Hulkower 2016) also had some workflow implications. They found the highest pediatric MRI volume was during the evening and early nighttime hours with peak volume occurring during the 10 PM hour when 8.2% of MRI exams were performed. That suggested the need for deployment of additional resources at certain times and need for availability of radiologists, particularly those with expertise in neurological MRI, to read the MRI scans.
We again refer you to the study that analyzed the workflow, personnel, and costs involved in MRI scanning of children at Hospital for Sick Children in Toronto, Ontario (Vanderby 2010). This article has a good discussion about those workflow and personnel issues and has some good lessons learned that you may apply in your organization.
Note also that a new scale for pediatric sedation has recently been developed and validated (Cravero 2017). The Pediatric Sedation State Scale (PSSS), developed by American Academy of Pediatrics and American Society of Anesthesiologists, is intended to specifically meet the needs of pediatric procedural sedation providers to measure effectiveness and quality of care. But it may be difficult to implement while patients are undergoing MRI scanning. The six sedation states defined are:
In particular, assessment of facial expression may not be possible during MRI scanning. Maybe future MRI design might incorporate video facial imaging!
Some of our prior columns on patient safety issues related to MRI:
Some of our previous columns on pediatric sedation issues:
Hulkower M, Taragin B, Davoudzadeh R, et al. Pediatric MRI in the Emergency Department Over Five Years: An Analysis of Usage and Trends. Program SSQ17-06. Radiological Society of North America 2016 Scientific Assembly and Annual Meeting, November 27 - December 2, 2016, Chicago IL
Imaging Gently® Campaign
Uffman JC, Tumin D, Raman V, et al. MRI Utilization and the Associated Use of Sedation and Anesthesia in a Pediatric ACO. J Am Coll Radiol 2017; 14(7): 924-930
Vanderby SA, Babyn PS, Carter MW, et al. Effect of Anesthesia and Sedation on Pediatric MR Imaging Patient Flow. Radiology 2010; 256(1): 229-237
Jaimes Cobos C, Murcia D, Miguel K, et al. Identification of Quality Improvement Areas in Pediatric MRI from Analysis of Patient Safety Reports. Radiological Society of North America 2016 Scientific Assembly and Annual Meeting, November 27 - December 2, 2016, Chicago IL
Mansouri M, Aran S, Harvey HB, et al. Rates of safety incident reporting in MRI in a large academic medical center. Journal of Magnetic Resonance Imaging 2016. 43(4): 998-1007
Coté CJ, Wilson S, American Academy of Pediatrics, American Academy of Pediatric Dentistry. Guidelines for Monitoring and Management of Pediatric Patients Before, During, and After Sedation for Diagnostic and Therapeutic Procedures: Update 2016. Pediatrics 2016; 138(1): e2016121
ASA (American Society of Anesthesiologists). Practice Advisory on Anesthetic Care for Magnetic Resonance Imaging: An Updated Report by the American Society of Anesthesiologists Task Force on Anesthetic Care for Magnetic Resonance Imaging. Anesthesiology 2015; 122(3): 495-520
Sadigh G, Applegate KE, Saindane AM. Prevalence of Unanticipated Events Associated With MRI Examinations: A Benchmark for MRI Quality, Safety, and Patient Experience. J Am Coll Rad 2017; 14(6): 765-772 Published online: March 26, 2017
Cravero JP, Askins N, Sriswasdi P, et al. Validation of the Pediatric Sedation State Scale. Pediatrics 2017; 139(5): e20162897