Policy 1: Safety Precautions

It is the policy of the Center for MR Research to provide the following safety procedures for the subject and staff members.

Procedure

  1. A. Subject Safety
    1. Transportation of UICMC subjects between UICMC Buildings will be done in compliance with CC 3.04 and CC 3.05 of hospital policy.
    2. Every effort will be made to observe the patients/subjects at all times while in the imaging room or hallway.
    3. Side rails or restraining devices must be used for patients transported by stretcher.
    4. Patients shall be properly immobilized while on the examination table.
    5. Proper assistance must be given when transferring the patient from the stretcher or wheelchair for an imaging exam.
  2. Fire & Explosion
    1. In the event of fire, the fire alarm must always be activated and proper personnel shall be notified. All patients/subjects must be placed in a safe area, not left in the hallways.
    2. In the event of fire in an examination room, immediately turn off the main power switch.
    3. Always follow hospital fire instructions. Center for MR Research will always be in compliance with Hospital policy EC 1.01 and EC 1.02.
  3. Personnel Safety
    1. When a staff member notices a defect in the equipment it should be reported immediately to the supervisor.
    2. If sparking or burning odor is noted the equipment should be turned off, the circuit breaker should also be turned off. It should be reported to the supervisor.
    3. If equipment that slides or rolls seems difficult to move or unstable, it should be reported to the supervisor.
    4. Equipment with sharp edges, missing guards or bent guides should be reported to the supervisor.


Sponsor: Director
Date: 05/13_rev2

Policy 2: Subject/Visitor/Medical Staff Safety

It is the policy of the Center for MR Research to provide guidelines for patient/subject and members of the healthcare team and visitor safety while in the MR environment.

Procedure

  1. All individuals entering the MR suite
    1. Screening must be completed on all subjects prior to entering the magnet room. The assessment form must be completed and signed. Orbital CT, x-ray, etc will be required on all subjects who have a history of metal in the eyes before entering scan room. *NO INDIVIDUAL MAY ENTER THE MR SUITE WITHOUT THE PRESENCE OF LICENSED MR PERSONNEL.
    2. Subject will be observed at all times while in the magnet.
    3. Subject shall be properly immobilized while on the MR table.
    4. Proper assistance must be given when transferring the subject from the stretcher or wheelchair for an MR exam.
    5. If there is a reason to believe a subject may be pregnant, she will not be examined. The PI will be notified immediately.
    6. Subject should be notified to advise staff of warm or strange sensations while in the magnet.
    7. Subjects with aneurysm clips and/or any implanted device will not be placed in the Center for MR Research scanner until we are in possession of documentation stating that the aneurysm clip and/or implanted device has been tested safe for 3T. The document must include the following information:
      1. manufacturer of the medical device
      2. make and model,
      3. where the surgery was done.
    8. Any subject participating in MRI imaging must have hearing protective devices IN PLACE before proceeding with scan.
    9. Staff is required to check under EKG patches and gating devices at patient contact locations at regular intervals throughout the exam on patients sedated or unable to communicate a problem.
    10. Subject exposed regions should not be allowed to come into contact with the bore of the magnet (housing) itself. Pads will be placed between subject and the bore.
    11. All unnecessary/extraneous electrical conductors should be removed from the bore during imaging.
    12. Care should be taken to ensure that no unnecessary loops are made by any electrical conductor in the imaging system. These include such entities as EKG, gating wires, surface coil leads, etc.
    13. The Subject’s skin should not be involved in any electrical conductive loop. EKG lead should be braided around each other to decrease the possibility of forming a large radius loop. However, EKG, surface coil and pulse oximeter cables should not be braided together as this may interfere with monitoring capabilities. These wires should also be kept as far as possible from the walls of the magnet bore.
    14. EEG fMRI: Subject needs to consult PI of the study.
    15. Thermal insulators (including space/air) should be used between any electrical conductor device and the subject to ensure that the potential for burns from the thermal conductivity from electrical conductors in the imaging system with the subject would be minimized.
  2. Subject Medical Emergency
    1. All medical emergencies involving patients in the magnet room should observe the following procedures:
      1. Check subject status.
      2. Press Stop Scan button on console immediately.
      3. Open Scan door. If the subject is in cardio insufficiency then, notify emergency personnel (Call 9-911. Say “, 980 Building, 2242 Harrison (AIC).” specify adult or pediatric depending on age of subject. Provide your name, telephone number, and subject name, if known, and specify that we are a MRI facility)
      4. Evacuate subject by depressing the emergency release located at the foot of table. Push table slightly forward and pull cradle out of magnet until fully retracted. Unlock table by pushing emergency release button.
      5. If surface or head coil is in use, disconnect prior to removing table from position.
      6. Transfer subject to the waiting area just outside the 3T MR Suite.


Sponsor: Director
Date: 5/13_rev2

Policy 3: Guidelines For Handling Sharps

It is the policy of the Center for MR Research to provide guidelines for the handling of sharps, reusable sharps, and the safe and proper disposal of contaminated and other sharp material. This is consistent with the UIC Policy.

Definition
Sharps are generally disposable items, which are used to puncture or cut through the skin for medical/surgical procedures. All sharp items when handled improperly may cause not only a laceration but also infection.
  1. Disposable sharp items include but are not limited to:
    1. Disposable plastic syringes with needles.
    2. Disposable glass syringes with needles.
    3. IV administration sets (intercath, butterfly needles, etc.)
    4. Blood collecting needles.
    5. Lancets, pinprick, suture needles.
    6. Disposable cutting blade (razors/scalpels)
    7. Glass ampoules, broken glass
    8. Disposable metal pharmaceutical seals, i.e. as on IV bottles
    9. Pipettes

Procedure

  1. Storage of Sharps
    1. Unused syringes and needles are kept in a location in order to prevent unauthorized use.
  2. Handling of Sharps
    1. Wash your hands prior to handling sharps. This decreases the chances of infection. Wear gloves to protect you from surface contamination, when appropriate.
    2. Avoid touching the sharpened edge/point.
    3. Keep the protective covering in place (while transporting the sharps) until the sharp item is needed.
    4. Never carry sharps in a pocket without a plastic cap in place.
    5. Discard all the disposable sharps according to instructions below.
    6. Remove all full contaminated boxes as outlined below.
  3. Guidelines for disposing of disposable sharps
    1. To discard disposable needles/syringes or any other potential sharps that have been used in normal situations or isolation cases.
      1. After injection do not recap the needle.
      2. Take the used sharp to the nearest sharp disposal box
      3. Place entire needle and syringe in container
      4. Take care not to overfill the box
      5. Never place used sharps in the regular trash.
    2. Procedure for disposable needles/syringes ampoules contaminated with radioactive materials.
      1. After injection recap the needle, except butterflies. Safe needle recapping is required.
      2. Place entire item in the red cover sharps box provided for that purpose.
      3. Never place used sharps in the regular trash.
  4. Procedure for removing full contaminated boxes
    1. Needle boxes or Sharps containers.
      1. Close opening and secure.
      2. Contact housekeeping for pick up of the full box. The full box should be picked up by housekeeping services
      3. Place the new empty box in service immediately.
    2. If the disposable needle box contains radioactive material
      1. Close the lid, label and date.
      2. Place the entire box in the area for holding radioactive decay storage.
      3. When the material is safe radiation safety will supervise the incineration.
  5. Guidelines to follow when a cut or puncture wound occurs when handling sharps:
    1. Press a few drops of blood to minimize contamination.
    2. Wash site for 10 minutes with antibacterial soap and running water.
    3. Apply cold water to area to stop bleeding.
    4. Try to determine if the item involved was clean or contaminated. IF the case is unknown, consider it contaminated. Try to determine if used on a particular patient. If used on an outpatient, request that the patient wait for potential blood work.
    5. Immediately inform the supervisor and secure a medical evaluation per HMPP HR 1.01 (At all times to Emergency Services Department (ESD) for severe injuries and for serious work related injuries. During normal business hours to University Health Services (UHS). During non-business hours and on weekends and holidays ESD. An employee initially seen in ESD must report to UHS on the next business day.)

    SEE ALSO HMPP IC 3.01A for Management of Employee Exposure to Blood and Body Fluids.


Sponsor: Director
Date: 05/13_Rev2

Policy 4: Infection Control/Universal Precautions

It is the policy of the Center for MR Research to protect both the subject and the department staff by minimizing the exposure to communicable disease. Further, it is the policy of the Center for MR Research to provide a safe environment for patients, subjects, employees, students, and volunteers through minimizing the risk of transmission of infectious diseases that are blood/body fluid borne. To facilitate these policy objectives, universal precautions will be maintained as described in UIC Policy.

Definition

Universal precautions
Universal precautions define any patient as potentially infectious and recommend the use of barrier protection and equipment where appropriate.
University of Illinois at Chicago Hospital
In addition to the use of Universal Precautions for all subjects, the UICH utilizes additional Isolation/Precautions described below.
Isolation Precautions
  1. Strict – to prevent transmission of all highly communicable diseases that are spread by both contact and airborne routes of transmission.
  2. Respiratory – to prevent transmission of organisms by means of droplets and droplet nuclei that are coughed, sneezed or breathed into the environment.
Precaution Types
  1. Direct Contact – to prevent transmission of epidemiologically significant microorganisms by personnel having direct contact with patient/subject body sites colonized or infected with such organisms.
  2. Chicken pox/Shingles – to prevent employees susceptible to chicken pox from acquiring infection from patients/subjects with chickenpox/shingles.

Procedure

  1. Strict Isolation – highly communicable disease transmitted by both the respiratory route and by direct contact.
    1. The imaging and waiting room to receive a strict isolation patient should have all unnecessary ancillary equipment removed.
    2. The strict isolation patient will be taken directly into the designated exam room and will not be left in the halls or waiting area.
    3. The patient should be wearing a gown and a mask.
    4. Only a limited number necessary imaging staff will be in the room during the procedure.
    5. Precautions:
      1. Gowns – individual gown technique is imperative for all persons entering the room.
      2. All persons entering the room must wear masks.
      3. Hands must be washed with Betadine for at least 30 seconds before and after contact with he patient.
      4. All persons entering the room must wear gloves.
      5. All disposable dressings, or other contaminated disposable items should be put into red hazardous waste bags prior to leaving the room. Linen should be put into the red plastic bags and handled as contaminate/biohazardous.
      6. All needles and sharps should be placed in impervious plastic needle boxes available in each room. Needles should never be recapped. See Safety Policy 4.
      7. Special procedure trays and special instruments should be separated into: a) disposable, b) autoclavable, c) linen, etc. The instruments and trays should be seen to Central Service for decontamination/sterilization. Routine inspection of holding areas for outdated trays and supplies is mandatory. Linen should be placed in blue linen bags and handled as contaminated.
      8. During or immediately following the procedure, the Housekeeping Department should be notified that the exam room and equipment must be cleaned.
      9. No personnel should enter the exam room until it has been cleaned.
  2. Respiratory Isolation – infectious droplets that are coughed, sneezed or breathed into the environment. Childhood diseases including mumps, rubella (German measles), and measles are put into this category.
    ATTENTION: Pregnant staff members should not perform examinations of rubella patients
    1. Imaging room should be ready to receive the patient as soon as possible upon his/her arrival.
    2. Patient should be wearing a mask during transport and the procedure, if possible.
    3. Precautions:
      1. Gowns are not necessary, unless dictated by Universal Precautions needs.
      2. Masks are necessary while in close proximity with the patient. (This includes all persons entering the exam room.)
      3. Hands must be washed with Betadine for at least 30 seconds.
      4. Gloves are not necessary, unless dictated by Universal Precautions needs.
      5. Needles and syringes – needle box – disposed by Housekeeping.
      6. Dressings and tissues should be put in red hazardous waste bags to be incinerated without being opened.
      7. Linen – blue plastic bags.
      8. The patient’s chart may be taken into the room
      9. Normal housekeeping procedures.
  3. Cleaning Procedures in Patient Care Areas
    The pulse oximeter and sensor, dynamap, etc. should be cleaned after every patient use with a low level disinfectant. Visible contamination with blood should be cleaned with 10% Clorox solution.
    Instrumentation is cleaned after each patient use with alcohol or bleach solution. Patient restraints are soaked in a Clorox solution for disinfection.
    Any employee who experiences a needle stick or cut with a sharp instrument or a splash of blood or body fluids into a mucous membrane (eye, nose, mouth) should report to their supervisor and University Health Services. See Safety Policy 4.
    Outdated materials and items must be discarded appropriately.
    Please see Hospital Policy IC 1.02, 1.03, 2.01, 2.02, 2.03, 2.04, 2.05, 3.01A, 3.01B, 3.02, and 4.00 for more detailed information regarding any of the above items. The Center for MR Research will always comply with UICMC Hospital policies on infection control.


Sponsor: Director
Date: 05/13_Rev2

Policy 5: Equipment Safety

It is the policy of the Center for MR Research to provide guidelines for maintaining equipment safety. There is an equipment management program designed to assess and control the clinical and physical risks of fixed and portable diagnostic equipment. Written criteria will include the characteristics of equipment function, clinical application, maintenance requirements and equipment incident history.

Procedures

All patient care monitoring equipment shall tested prior to use when new, after any repairs are made, and at intervals not to exceed 6 months thereafter.

Before a new piece of equipment is used, the medical physicist in Radiology evaluates it, and the evaluation is documented. In compliance with University of Illinois at Chicago Radiology Policy 05-02-0005

Equipment such as leads, EKG, pulse oximeter, surface coils, should be checked by Center for MR Research staff prior to each patient application.

Staff shall report any defective equipment.

Equipment with sharp edges or missing guards should be reported to the supervisor.

If the oxygen alarm sounds, immediately open the scan room door. Stop scan by pressing the Stop Scan button on the MR console. Evacuate the area. In the event that the scan room door should ever jam, access to the scan room can be achieved through the view window.

Notify equipment service engineer to remove any metal object(s) that may be in the field or stuck to the side of the magnet. Trying to remove the objects yourself could result in a serious personal injury or spontaneous quench of the magnet.


Sponsor: Director
Date: 05/13_rev2

Policy 6: Power Failure – Emergency

To continue essential services during a power failure, Center staff should be aware of and observe emergency procedures applicable to power failure.

Procedure

Electrical service maintained by emergency power:
  1. Minimal hallway lighting
  2. Emergency hallway lighting (red lights)
  3. ID Activated doors
  4. Telephones
  5. Selected wall receptacles (red plates)
ACTIONS TO BE TAKEN
  1. Identify immediate priorities –subject and staff safety
  2. Organize available resources to meet immediate priorities
  3. Determine extent of power failure
    1. local failures such as circuit breakers affecting an outlet, room or a small section
    2. major failure affecting entire building or portions of the campus
  4. If emergency power is available, plug life sustaining equipment into receptacle on emergency power system (red plates)
FOR ALL POWER FAILURES
  1. Notify Steve Cross at 312-355-0879
  2. Notify Facilities Management at 6-7511
  3. Notify Director or designate on call/duty
  4. Reassure subjects that they are in no immediate danger.


Sponsor: Director
Date: 5/13_rev2

Policy 7: Cardiopulmonary Resuscitation

The Center for MR Research recognizes that the patient, staff, or visitor who experiences the sudden, unexpected cessation of cardiopulmonary functions, is best managed by an interdisciplinary team trained and equipped to implement cardiopulmonary resuscitation (CPR). All Center for MR Research staff will be certified in Basic Life Support (BLS – Adult/Pediatric); Advanced Cardiac Life Support (ACLS); Pediatric Advanced Life Support (PALS) and will maintain current certification throughout their employment with the Center. Documentation of current certification must be maintained in each staff member’s human resource file.

Procedure

  1. In the event that someone within the care or vicinity of the 3T MR Research Service experiences an unexpected cessation of cardiopulmonary functions, DIAL 9-911.
    Say “980 Building, 2242 Harrison (AIC).” Specify adult or pediatric depending on age of subject. Provide your name, telephone number, and subject name, if known, and specify that we are a MRI facility)
  2. Any Center for MR Research staff who initiates CPR must be trained as a basic life support provider.


Sponsor: Director
Date: 5/13_rev2

Policy 8: Quality Assurance Procedures

Policy 3T Scanner and SCS Quality Assurance is performed daily or a minimum of every other day.

Procedure

Daily QA
  1. Daily EPI & DWI QA
    1. Setup the red TLT sphere (with “fill hole” at bottom) in 8ch Head coil and landmark at center of phantom
    2. Advance to scan and make sure all ancillary room equipment is powered off (Allow the TLT sphere to sit for 5-10 minutes prior to running to allow the fluid to “settle”)
    3. Close scan door and turn off all room lights
    4. Start a new exam and download/run “Daily QA” protocol located under the “Other” category
    5. Transfer data to the SCS and process and save
SCS QA
  1. Turn on all equipment and check to see if functioning properly:
    1. Boot up SCS: PC Workstation, LCD Monitor, and SCS control box.
    2. Turn on Pulse oximetry.
    3. Turn on eye camera and LCD viewer.
    4. Install and check LED illumination on coil.
    5. Turn on projector: Apply power and press POWER button to operate projector lamp.
    6. Start the SCS software.
  2. Perform projector QA and image alignment:
    1. Check visor transparency – Install the transparency if it has been removed. The transparency on the visor must be checked to make sure that it is in the proper position. The position of the fixation cross on the transparency should be 10.6 cm from the left screen inside edge and 4.5 cm from the top screen inside edge.
    2. Check the projector trolley wheels for dust – this can offset vertical alignment.
    3. Check that cables do not interfere with projector movement.
    4. Confirm that the Head Coil base is correctly seated and clamped on the patient table. This affects the visor screen alignment.
    5. Line up the projected cross with the cross on the visor. The file “QA paradigm.avi” is projected and is used to align the projected fixation cross with the cross on the visor.
  3. Run the QA paradigm to check the projected image:
    1. The width of the projected image should be 7 inches when land marked according to the QA marker located on the visor.
    2. Check for dust in the lens. Look for color specks in a dark background.
    3. Check for any delays within the paradigm or any flashing of the projected image.
  4. The SCS system is used to record the following data to a file. File is then checked.
    1. Respiratory
    2. Cardiac
    3. SpO2 level
    4. Trigger signal from GEMS 3T
    5. Finger switches


Sponsor: Director
Date: 05/13_Rev2

Policy 9: Subject Safety and Screening for 3T Examinations

All subjects for 3T MRI studies must have proper screening documentation. It is the responsibility of the technologist performing the exam to read all attached subject documentation prior to placing any subject into the 3T scan room.

Procedure

Contraindications

* Any subject with a known and well documented medical device that is NOT deemed SAFE at 3T will not be scanned at 3T. Note: The steps listed below are consistent with standard practice.

Research Subject Exams

  1. All subjects MUST have the "Subject Screening Form" filled out in its entirety.
  2. The person scheduling any subject will be responsible for obtaining the responses from the subject or guardian for the “Subject Screening Form” prior to scheduling an appointment.
  3. All aneurysm clips, heart valves, and other well known MRI medical device safety hazards will require proper identification and documentation prior to scheduling or entering the 3T scan room.
  4. All questionable medical devices will require full documentation of the Make, Model, and date the device was implanted without exception.
  5. The technologist is to bring the subject screening form to either a board certified Radiologist or Research Manager to check for potential risks prior to taking any patient in the 3T room.
  6. It will be the responsibility of the scanning technologist to evaluate continued patient safety throughout the exam.
  7. All unknown artifacts seen on an image(s) should be immediately questioned and the scanning technologist should seek expert advice from a radiologist and/or another qualified technologist before proceeding with the exam.


Sponsor: Director
Date: 05/13_rev2