Assessment of MRI Safety Awareness and Practice Standards in Bangladesh

Objectives: The objective of this study was to evaluate the current MRI safety knowledge, awareness and practice standards among MRI technologist in Bangladesh and to perceive if the identified safety principles related to MRI management are in line with international standards.

Materials and Methods: The study was carried out with consent option among MRI technologist in Bangladesh. A self-structured questionnaire was used to collect data through email, the questionnaire contained ten parts and 47 questions in all. MRI technologist voluntarily consented and filled out the questionnaire. The questions were to explore knowledge about MRI safety policy and accessories, patient screening, adverse reaction, Infection control, Device labeling, Equipment safety, signage and barriers, access and communication, and MRI safety during pregnancy generally. The collected data were analyzed with the help of Microsoft Excel.

Results: Regarding knowledge of MRI equipment, 34% of respondents were unaware of the symbols or signs used to denote the various zones in your MRI suit, and 27% were unaware of the negative effects of quenching magnets. About 45% of respondents, who were asked about emergency/safety accessories’ availability, answered that crash carts and MRI-compatible anesthetic equipment aren’t present in the department. In case of awareness of different zones of the MRI suite, which is crucial for an MRI unit, 46.08% of respondents were unaware in this issue. 50% of respondents do not believe that MRI has any harmful effect to people who are pregnant. This study revealed that many MRI facilities generally are not aware of departmental/equipment safety notices & obstacles.

Conclusion: The study showed that awareness about MRI safely and practice standards were not encouraging with many of the MRI technologists due to their insufficient knowledge. They need training along with other supporting staff connected to patient to enhance their knowledge in implementation of safety policy, patient screening tools and exposure of MRI during pregnancy.

Introduction

Among all radiological imaging procedure, Magnetic Resonance Imaging, MRI is one of the most advanced imaging methods. It has the advantage of a painless, non-invasive imaging technique without any mentionable negative changes in the body cells unlike some other imaging modalities and soft tissue diagnosis. In MRI strong magnetic field and radio waves are used to get detailed images of the internal organs and tissues of body. Its great advantage is to have soft-tissue contrast compared to other radiological imaging modalities and its physiological and functional applications have led to a significant increase in MRI scans worldwide [1]. At present 1.5T and 3T MRI equipment has been used for routine clinical imaging. 7T scanners, increasingly used in the research setting, have been proposed for use in clinical care [2]–[4]. However, although MRI is considered a safe imaging technique, some safety precautions is needed to take in the MRI scanning room. An MRI machine with a magnet having 1.5 Tesla is 30,000 times the geomagnetic field. So any magnetic object coming close to the scanner can cause serious injury or maybe death to the patient in the scanner bore. When referring to a patient for safety precautions in the magnetic field of an MRI scan, some preliminary tests advised by physician should be done.

Safety questions should be repeated by a radiographer before entering the MRI room. For a patient with ferrous metal foreign bodies or implanted electrical medical devices, such as pacemakers, braces or cochlear implants, entering into the MRI scanning room should be prohibited. Nowadays some MRI machine compatible devices such as pacemaker or cochlear implant have been developed. Still the radiologist and the MRI technologist should be aware of the device model in the patient’s body. It should be confirmed prior that there is no room for doubt in this particular case, and then the patient shall enter the MRI room. Many times, Gadolinium contrast agent needs to be pushed to enhance the MRI images in order to confirm a better diagnosis. Though Gadolinium rarely shows allergic reaction, as it doesn’t contain iodine, still people with kidney failure, kidney transplant, liver transplant, kidney disease and maybe with other conditions should be kept in mind prior introducing the patient to the contrast.

Generally, during pregnancy MRI is not advised, especially during the first trimester. In this case, it is needed to justify having a discussion with the radiology department. Moreover, for pregnant or breastfeeding patients contrast agents should be avoided. MRI tends to be safer but as it has a ferromagnetic nature, safety guidelines should be followed. Due to this, such knowledge and awareness regarding its safety must be present among those who are associated in operating the MRI machine.

Materials and Methods

Research questionnaire was used as instrument for collecting data. It was developed from ACR MRI safety guideline 2013 and self-developed questions. The questions included here were on general knowledge of MRI, policy on MRI safety and patient screening, emergency accessories and adverse reaction, infection control, MRI safety accessories, device labeling, equipment safety, signage and barriers, contrast usage and adverse reaction, access and communication, MRI safety during pregnancy. The information was collected from the MRI technologists of each MR facility by filling out the questionnaire. The questionnaire was sent to the MRI technologists by email as well as hand to hand. For the respondents it is strongly maintained the confidentiality, anonymity by providing consent options. The data were analyzed with MS Excel and the results were presented using descriptive statistics in the form of graphs and frequency tables.

Results and Discussion

Total 125 MRI facilities were included in this study. Out of them 102 MRI center responded; response rate was 81.6%. Regarding the knowledge on MRI Equipment, 34% responders replied that they do not know about symbols or signs used for indicating different zones in MRI Suit and 27% do not know about the harmful effect of quenching of magnet (Table I). Moreover, from this study it is revealed that most of MRI units (75%) have no handheld magnet. In the case of review & update of safety policy, 42% responded that they have no such system.

Table I. Knowledge on MRI Physics/MRI Equipment

Question	Yes	No
MRI uses a form of radiation	21%	79%
There is a harmful effect of magnetic field & radio frequency in biological tissue	19%	81%
The magnet always remain on	91%	9%
There are different symbols/signs used for indicating different zones in your MRI Suit	66%	34%
Have knowledge about quenching of magnet	88%	12%
Quenching of magnet is harmful or cause accident	73%	27%
Have knowledge about the location and function of the two emergency buttons: a) Emergency Stop/Shutoff and b) Quench or Emergency Run Down	96%	4%

The results indicate varying levels of awareness among respondents regarding MRI physics and equipment. A substantial majority (79%) mistakenly associate MRI with radiation. Concerningly, 81% believe that magnetic fields and radio frequencies are harmful to biological tissue. However, a high percentage (91%) correctly understand that MRI magnets remain on. Knowledge about the use of symbols to indicate MRI safety zones is relatively better (66%). Notably, the majority (88%) are informed about quenching but hold misconceptions about its potential for harm (73%). Fortunately, most respondents (96%) are well-informed about the location and function of emergency buttons, ensuring safety.

Regarding availability of emergency/safety accessories, 45% respondents said that they have no crash cart and 60.80% have no MRI compatible anesthesia equipment. Only 55% have emergency resuscitation equipment. 53.93% of units have no emergency exit door. About different zones of MRI suite which is very important for an MRI unit, 46.08% respondents do not have any knowledge about this. It was found from this study that overall many MRI facilities are not aware about department/equipment safety signage & barriers. 31.08% have no screening procedure before use of contrast.

Regarding MRI safety during pregnancy, most of respondents, 59.80% have no written policy on exposure of pregnant patient and 69.6% have no written policy on exposure of pregnant health workers (Fig. 1). 50% participants do not think that MRI is harmful for pregnant patient.

Fig. 1. Attitude towards MRI safety during pregnancy.

From Table II, it can be seen that the majoirity of the participants are male (97%) and age group is 20–30 years (59%). Education level of most of the participant is Diploma (68%). This table demonstrates that 60% participant have experience less than 5 years and 63% are working in 1.5 Tesla MRI. In this study, among the 102 MRI centers, 81% are private and only 19% are government centres (Figs. 2–4).

Table II. Socio-Demographic Data of All Respondents (N = 102)

Demographic data	Variables	Number (N)	Percentage
Sex	Male	99	97%
	Female	03	3%
Age of participants	20–30 years	60	59%
	31–40 years	31	30%
	41–50 years	09	9%
	51–60 years	02	2%
Educational qualification	Diploma degree	69	68%
	BSc degree	33	32%
Working experience	0–5 years	61	60%
	6–10 years	29	28%
	11–15 years	07	7%
	16–20 years	04	4%
	21 + years	01	1%
MRI field strength	0.3 Tesla	24	21%
	0.4 Tesla	01	1%
	1.5 Tesla	74	63%
	3 Tesla	18	15%
Year of operation	0–5 years	58	57%
	6–10 years	31	30%
	11–15 years	13	13%
Types of MRI center	Govt. center	19	19%
	Private center	83	81%

Fig. 2. Types of MRI scanner.

Fig. 3. Educational qualification of the participants.

Fig. 4. Sex distribution of participants.

In our research it was observed that 79% of the participants claimed to possess an MRI safety policy, but only 58% of them reported actively reviewing and updating this policy (Fig. 5). The relatively low percentage could be attributed to a lack of awareness and knowledge concerning MRI safety within these healthcare facilities. Opoku et al. [12] identified deficiencies in the effectiveness and efficiency of safety policies and guidelines at a teaching hospital in Ghana. Their findings [5] also highlighted a knowledge gap among MRI radiographers regarding the proper use of MRI equipment, indicating a potential absence of comprehensive institutional policies and guidelines. The authors [12] additionally noted that the absence of a functional safety framework might significantly impede safe practices within MRI units at hospitals. It is essential for every healthcare institution to have well-documented policies that provide clear guidance on safety practices and their proper implementation. In line with this, the American College of Radiology (ACR) recommended in its 2013 guidance documents on MRI safety practices [11] that all MRI facilities establish, enforce, and regularly update their MRI safety policies.

Fig. 5. Availability of safety policy, update and review of it and patient screening tools.

For all non-emergent medical examinations, it is crucial to conduct a thorough screening of patients at least twice to identify any presence of metal, implantable devices, medication patches, tattoos, body piercings, and any electrically, magnetically, or mechanically activated devices [6]. In our research, we discovered that 25% of respondents employ handheld magnets, while 75% utilize ferromagnetic detection systems for patient screening. However, it’s important to note that handheld magnets may not effectively identify large objects with sparse metal distribution [19] and struggle to differentiate between ferrous and non-ferrous materials. Currently, ferromagnetic detection systems are recommended because they can detect small ferromagnetic objects outside the patient’s body [12]. High magnetic field strength can lead to thermal burns if metallic objects come into contact with the patient’s skin or are in close proximity to them. Common patient injuries include burns related to wires, pulse oximeters, pain relief patches, cardiorespiratory monitors, and tattoos [6], [7], [8], [10]. The proper implementation and use of a Ferromagnetic Detection System (FMDS) have proven to enhance safety in clinical MRI settings [15]. Interestingly, 82% of the respondents in our study incorporate patient screening questionnaires as part of the screening process. The use of questionnaires and verbal screening is essential in identifying both implanted and external metallic objects. However, it’s worth noting that patients and their families may not always be aware of inserted or implanted devices [14], which places them at risk of potential burns or dynamic injuries. Although this percentage is relatively high, it raises concerns that non-MRI staff members may enter the MRI scanner room without undergoing further safety screening procedures, putting them at risk. Opoku et al. [12] also observed a similar situation in their study, where accompanying family members and other healthcare personnel (such as nurses, doctors, and anesthetists) were not consistently subjected to mandatory screening, except for the removal of metallic objects before entering the MRI scanner room. It is well-established that many incidents in this context have occurred due to deficiencies in screening methods and a lack of adequately controlled access to the MRI suite.

In our research, a majority of the participants reported having firefighting equipment and backup power sources available (Fig. 6). However, there is a notable scarcity of crash carts and emergency resuscitation equipment. In certain cases, such as with pediatric patients or those with unstable health conditions, sedation, anesthesia, or even instances of MRI contrast reactions may be necessary during MRI scans. Consequently, there is a potential for emergency situations to arise. This underscores the importance of having emergency medications and resuscitation equipment readily accessible within the MRI suite, especially in Zones II or III. These emergency scenarios can be challenging to address and respond to promptly when patients are positioned within the magnetic bore [9].

Fig. 6. Availability of emergency accessories.

Among the respondents, 87% indicated that they have hand washing sink and 99.01% indicated the availability of hand sanitizers (Fig. 7). Wall mounted sanitizers is less available (53%). The ACR [11] provided guidance on the implementation of infection control policies in the clinical application of MRI. This will prevent cross infection between staff and patient.

Fig. 7. Infection control practices.

In our study most of the respondent indicated that they have MRI compatible wheelchairs, trolley and headphones, where 39.20% have MRI compatible anesthesia system (Fig. 8). Availability of those MRI compatible equipment’s reduces the risk of accident and easy movements of patients. Headphones are employed to minimize the sound produced by the gradient coils within the scanner room. Anesthesia is needed for doing MRI of abnormal patients or Childs.

Fig. 8. Availability of safety accessories.

It is concerning that 60.80% of the respondents have noted that the equipment utilized in the MRI suite lacks color coding, and 54.90% have mentioned that they permit equipment that isn’t color-coded (Fig. 9). Opoku et al. [12] similarly observed that none of the respondents reported the use of color-coded equipment within the MRI suite. The ASTM International standard has introduced new terminology and symbols to identify medical devices for use in MRI environments in order to reduce incidents related to MRI procedures [13]. Devices categorized as “MR Safe” pose no known hazards in any MRI environment and are recognizable by a green square (Fig. 10). These encompass non-conductive, non-metallic, and non-magnetic items. “MR Conditional” items, represented by a yellow triangular label, have been demonstrated to present no known hazards in specific MRI settings under defined conditions of use. Conversely, “MR Unsafe” items, identified by a red circular label, are known to pose risks in all MRI environments.

Fig. 9. Device labeling (MR safe, conditional and unsafe).

Fig. 10. Symbols and categorization employed for implants and medical devices concerning their compatibility with the MRI environment, as established by the American Society for Testing and Materials (ASTM) International in 2005 [3].

It is of utmost importance to thoroughly inspect the equipment before bringing it into the MRI suite. In our study, 83.33% of the respondents indicated that they conduct equipment checks prior to entering the MRI suite, while 46.07% mentioned the presence of emergency exit doors (Table III). Similarly, Opoku et al. [12] reported that 75% of their respondents confirmed the practice of equipment checks in the MRI suite, and a majority (67%) stated the availability of emergency exit doors.

Table III. Equipment Safety, Signage & Barriers

Questions	Yes	No
Inspect all equipment before bringing it into the MRI suite.	83.33%	16.67%
Have emergency exit door.	46.07%	53.93%
Know about different zone of MRI suite.	53.92%	46.08%
Know about lighted sign used in different MRI zone.	49.01%	50.99%
Zone 4 is conspicuously labeled with illuminated signs indicating that “The Magnet is Active”.	57.84%	42.16%
Zone 3 is delineated and distinctly labeled as an area with potential hazards.	50.99%	49.01%
Every entrance is clearly designated to signal the existence of magnetic field risks.	76.48%	23.52%
Physical obstructions should be in place to stop unauthorized entry into Zone 3 and Zone 4.	70.59%	29.41%

The American College of Radiology (ACR) recommends a four-zone model for the layout of MRI facilities [11]. It is concerning that only 53.92% of the respondents in our study are aware of the different zones within the MRI suite, and only 49.01% are knowledgeable about the use of illuminated signs in these various MRI zones. According to the ACR guidelines, MRI sites are conceptually divided into four Zones [11]. In our research, 57.84% of the respondents indicated that Zone 4 is appropriately marked with a lighted sign stating “The Magnet is On”, and 50.99% acknowledged that Zone 3 is demarcated and clearly identified as potentially hazardous. Zone III, particularly the area where the static magnetic field strength exceeds 5 Gauss, should be delineated and prominently marked as potentially dangerous [11]. Zone IV should be conspicuously marked with a red light and illuminated signage indicating, ‘‘The Magnet is On’’. Ideally, such signage should convey to the public that the magnetic field remains active even when the facility’s power is deactivated [11]. Furthermore, access to Zone III and IV areas should be physically restricted to the general public [11].

Gadolinium-based contrast agents are commonly used in MRI studies to enhance tissue contrast. However, the administration of these agents to patients can lead to side effects like nausea, headaches, and in severe cases, severe allergic reactions. In our research, 68.62% of the respondents mentioned the existence of a screening procedure before using contrast, and 70.59% reported checking the e-GFR or serum creatinine levels before administering MRI contrast agents (Table IV). Interestingly, 52.94% of the respondents had a history of contrast reactions, despite the initial belief that Gadolinium-based contrast agents were safer compared to other options. Notably, there have been reports linking the use of GBCAs with nephrogenic systemic fibrosis, a rare multisystem fibrosing disorder, particularly in patients with renal impairment, and gadodiamide, a high-risk GBCA, has been most frequently associated with this condition. GBCAs can also lead to acute kidney injury, especially when used at high doses for angiography [17]. Additionally, gadolinium administration has been associated with various laboratory artifacts, with pseudohypocalcemia being the most significant [17].

Table IV. MRI Contrast Usage and Report of Adverse Reactions

Description	Yes	No
Have screening procedure before use of contrast	68.62%	31.38%
Check e-GFR or Serum Creatinine before using contrast	70.59%	29.41%
History of contrast reaction	52.94%	47.06%
History of projectile incidents in MRI suite	37.26%	62.74%
History of fire outbreak	15.69%	84.31%
Administrate MRI contrast without orders from radiologist or referred physician	73.52%	26.48%

According to the ACR Manual on Contrast Media [18], adverse events following gadolinium administration appear to be more prevalent in patients with a history of previous reactions to MR contrast agents. Patients with asthma, allergic respiratory histories, or prior reactions to iodinated or gadolinium-based contrast agents are at an increased risk of experiencing contrast reactions. While there aren’t specific policies for patients at higher risk of adverse reactions to MR contrast agents, it is recommended that such patients be closely monitored, as they face a demonstrably greater risk. Patients who have previously reacted to one MR contrast agent may be injected with another if they require further studies, and at-risk patients can receive premedication with corticosteroids and occasionally antihistamines [11], [18]. In our study, 37.26% of the respondents reported incidents involving projectiles, and 15.69% indicated a history of fire outbreaks. MRI safety relies on thorough screening for ferromagnetic materials, as the risk of injury or death from projectiles inadvertently brought into Zone IV has been well-documented. Injuries resulting from implanted ferromagnetic materials have also been extensively recorded [20]–[24]. Projectiles can cause injuries, damage costly equipment, and disrupt imaging procedures, leading to loss of valuable time.

It is concerning that 73.52% of the respondents in our study administered MRI contrast without orders from a radiologist or referring physician. According to ACR guidelines, no patient should receive prescription MR contrast agents without proper orders from a licensed physician. The administration of these agents should strictly adhere to ACR policies, and the injection of contrast material and diagnostic levels of radiopharmaceuticals should be carried out by certified and/or licensed radiologic technologists and radiologic nurses under the supervision of a radiologist or their designate d physician [16].

Current data do not definitively establish any harmful effects of exposure to MR imaging on the developing fetus. Consequently, there is no specific preference recommended for the first trimester over any other trimester during pregnancy [16].

Pregnant patients can undergo MR scans at any stage of pregnancy if, as determined by an attending radiologist designated as level 2 MR personnel, the potential benefits of the study outweigh the associated risks. The radiologist should consult with the referring physician and record the following information in the radiology report or the patient’s medical records:

1. Non-ionizing methods, such as ultrasonography, cannot provide the required information from the MR study.
2. The data obtained from the MR study has the potential to impact the care of the patient or the fetus during the pregnancy.
3. The referring physician believes that waiting until the patient is no longer pregnant to obtain this data is not advisable [16].

Pregnant healthcare practitioners are allowed to work in and around the MR environment during all stages of pregnancy. However, it is recommended that they avoid staying within the MR scanner bore or Zone IV during actual data acquisition or scanning [16].

The routine administration of MR contrast agents to pregnant patients is discouraged. The decision to use a gadolinium-based MR contrast agent in pregnant patients should be based on a well-documented and careful analysis of the risks and benefits. Studies have shown that some gadolinium-based MR contrast agents can readily cross the placental barrier and enter the fetal circulation [16].

Conclusion

Based on the findings of this study, it is evident that there is a crucial need for training for MRI technologists and other supporting staff in terms of MRI safety and patient safety. Additionally, it is essential for all MRI facilities to establish and implement MRI safety policies, ensuring the proper utilization of patient screening tools. Furthermore, the current approach to MRI exposure during pregnancy requires adjustments to align with international recommendations. It is imperative to raise awareness about this matter among both healthcare staff and patients.