What "Immediate Availability" Means Relative To Zones & Staffing In ACR Manual on MR Safety

Disclaimer: While I have twice served on the ACR's MRI Safety Committee and am a named co-author for three of that committee's publications (2007 ACR Guidance Document, 2019 Updates & Critical Information, and 2020 ACR Manual on MR Safety), what follows is my own personal opinion and is not intended to represent the formal position of the ACR on these issues.

Staffing in MRI has been a growing challenge. Between scarcity of MR credentialed techs in many parts and the financial squeeze of increasing costs and decreasing reimbursements, many MRI providers have chosen to address these conditions by reducing head-count in MRI areas, often even below that of the standard of care.

Before we go any further, let's clear up some ambiguities, shall we?

"We can't afford two MRI techs per scanner on shift at all times!" Let's be clear... the ACR never set that as a minimum. The +1 staffing model (appropriated from the US Veteran Affairs' MRI Safety Directive) says that however many MRI scanners you have in a shared suite, you must have a technologist to run each operational scanner plus one person (minimally) in support. That additional person does not need to be an MRI tech. They only need to be trained to what the ACR describes as Level 1 MRI safety training. The 2024 ACR Manual includes a minimum training content for each Level 1 and Level 2 to even help sites adjust what they provide, accordingly.

"The ACR's MRI safety guidance is a recommendation, not a requirement!" The ACR's protestations notwithstanding, this document has become the MRI safety standard of care in the United States. Additionally, if you're in a hospital that gets reimbursed for care for Medicare / Medicaid patients, your facility is bound by the "conditions of participation" which require that the hospital "must meet professionally approved standards of safety" for radiologic services, including MRI (42 CFR §482.26). CMS actually identifies the organizations that it recognizes as having standing to define "professionally approved standards" for safety in radiology, and these include FDA, NIH, RSNA, ASNR, and others. Of all the alphabet-soup organizations in CMS's list, only one has ever published a broad standard document for point-of-care MRI safety: the ACR. No, your state license requirements probably don't mention the ACR's criteria (many of us live in states where state licensure doesn't even mention MRI, much less safety standards), and your hospital's or IDTF's accreditation organization may only include some weak-sauce references to the document, but don't let that lull you into the thinking that it's not the standard you'll be held to if something goes sideways.

Returning to +1 Staffing

So the ACR Manual describes a standard for minimum staffing. Over time in it's publications it has described the general position of the supporting person as being in the areas of Zone II (typically MRI patient prep area) through Zone IV (the MRI scanner room) or, more recently, as being in the areas of Zone III (often the MRI control room) and Zone IV, acknowledging that the support person may episodically need to step out of the locked Zone III / Zone IV area and pop-into Zone II to screen or collect MRI patients.

So let's construct the 'worst case' scenario, shall we? Let's assume a single MRI scanner, with a single MRI tech operating it and scanning a patient. The support person (the +1) has exited the secured part of the MRI suite (Zones III & IV) to attend to an incoming patient. What if, in this scenario, the MRI patient in Zone IV suddenly becomes combative and is attacking the MRI tech? What if the tech has an awkward fall and badly breaks their ankle?

"Immediate Availability"

In my mind, there are three elements to immediate availability, and what it requires of MRI providers in this situation:

Proximity: Because the ACR isn't prescriptive about how facilities define their MRI safety zones, facilities sometimes feel that they can be extremely creative in how they label their spaces. Zone II spaces are supposed to be MRI-specific spaces. A shared radiology corridor (much less an entire radiology department) should not be considered Zone II. Stretching Zone II boundaries to make substandard staffing models "compliant" is effectively cheating. The +1 support person being 'across the hall in CT' or 'down the corridor in the read room' is not meeting the intent of "immediate availability."

Communications: If, as in my 'worst case' scenarios, the MRI tech isn't able to exit the access-controlled part of the MRI suite (Zones III & IV), the availability of help outside is pointless if we can't actually alert that person of the need for assistance. Particularly given the loudness of MRI scanners, MRI suite construction is often some of the most soundproofed in the hospital, so simply yelling for help may not be sufficient. The MRI's magnetic field risks for carrying metal objects mean that the +1 support person may not be issued a Vocera or conventional portable comms device. MRI facilities may want to look into telephone-based paging systems in MRI areas or, even better, voice-activated comms or personal duress alarms that can automatically alert an area or individuals directly. If a facility doesn't have a demonstrated communications method between the access-controlled parts of the MRI suite and Zone II spaces, you're hard-pressed to demonstrate functional "immediate availability."

Access: Per the ACR, only persons with Level 2 MRI safety training should be given independent access to the controlled-access parts of the MRI suite. In other words, someone only trained to Level 1 should be able to freely exit Zone III to Zone II, but they shouldn't be able to re-enter on their own. Only Level 2 personnel should have 'keys' to Zone III. It should be noted that while all MRI techs are required to have Level 2 MRI safety training, there's nothing in the ACR's guidance that restricts that training to only MRI techs. Additionally, there's nothing that would restrict a site and MRMD from having a technologist and a non-technologist versions of Level 2 training. So while the ACR Manual on MR Safety says that the +1 person only minimally needs to be trained to Level 1, local facility designs and practices may indicate the need for +1 personnel to have a higher level of training, if only to ensure that they can appropriately access the access-controlled parts of the MRI suite in an emergency. *

With Flexibility

To be clear, I am not advocating for the MRI equivalent of "lonely cockpit" (many airlines have implemented rules that, for two-person flight crews, if one crew member steps out of the cockpit, to use the bathroom, for example, a member of the cabin crew will step into the cockpit so that there's never only one person in the locked cockpit), or two-staffer minimum occupancy at all times. I recognize that there may be moments, such as bathroom breaks, where only a single MRI-safety trained staffer will be present or immediately available, but these conditions should be viewed as the exception and not the rule.

I fully support the notion of at least two tiers of Level 2 MRI safety training... in fact, I think it's often the minimum needed in inpatient settings. There should be conversations among senior MR techs, department management, and MRMDs to identify the levels of training that would represent the best-fit for an institution, both for the MRI 'regulars,' as well as allied clinicians (anesthesia, respiratory, cardiology / EP, etc...) depending on your site's operational and clinical demands.

"Necessary, But Not Sufficient"

The failure modes in MRI that can allow horrible accidents to happen are many. This means that there is no single 'silver bullet' of MRI safety practices to effectively manage all of the different risks. Insufficient staffing (either in numbers, or in the degree of safety training, or both) is often a grave weakness, but it must be said that facilities should also be building operational structures for MRI safety (policies, screening practices, radiologist involvement, etc...) that distribute the burden of safe practices across more than the front-line MRI staff.

Wrap Up

There are a few essential take-aways from this. The first is that -like it or not- your site will likely be held to the ACR Manual on MR Safety as the standard of care... this is despite whatever your license or accreditation might say. Take a hard look at your staffing practices and ask yourself the tough questions about the degree to which you do (or don't) meet the standard of care. Second, if you meet the staffing guideline 'on paper,' take a close at each of the three criteria, above (proximity, communications, and access) , to see if you're practically meeting the needs. Third, if you have any questions or concerns about about your MRI safety training for MRI techs, tech aides (+1s), radiologists, or allied clinical personnel, gather a working group to identify who you want to receive what level of MRI safety training, even if that means creating your own subdivisions of Level 1 or Level 2 training.

If your site could use any assistance in assessing your current situation, developing tailored MRI safety training curriculum for your unique needs, or even providing training to clinical or operational staffs, please contact me through GilkRadiologyConsultants.com

*Thanks to Kellye Mantooth RT(R)(MR), MRSO(MRSC), MRSE(MRSC) , who pointed out after I published this article that the ACR Manual does not prohibit independent access of Level 1 MRI safety trained personnel to Zone III / Zone IV spaces. Per the ACR Manual on MR Safety (and its antecedents), the controlled access parts of an MRI suite are to be under the supervision of a Level 2 person. This implies that a Level 1 individual shouldn't have independent access when the suite is otherwise unoccupied, but the ACR's guidance does not suggest or imply that a Level 1 person couldn't be given access while the suite was occupied by / under the supervision of a Level 2 person. Thank you, Kellye, for your keen eye and for helping to clarify this issue for me and everyone!