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Name: MRI Infection Control White Paper click here to read

Preventing infection in MRI Print this

Hospital-and community-acquired infections are a major and growing
problem in the United States as well as throughout the world.
Unfortunately, the radiology department, in particular, can be a hub for
highly communicable diseases. Most patients with dangerous infections will
have an imaging procedure performed within the radiology department some
time during their course of treatment, where often the most basic safeguards
against infection are not present.

Methicillin Resistant Staphylococcus Aureus (MRSA)

MRSA was originally discovered in 1961 and is now widespread throughout
hospital and outpatient settings. The most common source for transmission
of MRSA is by direct contact with people who have MRSA infections or
asymptomatic carriers. In 1974, MRSA accounted for only 2% of the total
staph infections; in 1995 it had risen to 22% and by 2004 had reached 63% of
all staph infections. MRSA is among those infectious diseases commonly
known by the term “super bug”. MRSA may be community acquired, CA-
MRSA, or hospital acquired, HA-MRSA.

The morbidity and mortality of these bacteria is staggering. On average,
hospitalizations for the treatment of MRSA versus other infections have a
length of stay approximately 3 times longer and are 3 times more expensive.
Additionally the risk of death is 3 to 5 times greater.

A major concern for imaging centers is that MRSA can be carried by
asymptomatic patients. Therefore, any patient lying on an imaging table
without a known history of MRSA could actually be a carrier spreading these
aggressive bacteria. Worldwide, it is estimated that up to 53 million people
are asymptomatic carriers of MRSA; of these it is estimated that 2.5 million
reside in the United States.

Also, of concern is the fact that MRSA and other pathogens can live on
inanimate surfaces such as common table pads and positioners for months.

Center for Disease Control (CDC)

The Center for Disease Control (CDC) has developed guidelines for
environmental infection control in healthcare facilities. The CDC and the



Healthcare Infection Control Practices Advisory Committee (HICPAC) issued
a 249 page document extensively detailing their recommendations
concerning, in part, the principles of cleaning and disinfecting various
surfaces even including carpeting and cloth furnishings. A chapter focused
on laundry and bedding discusses how mattresses and pillows become
contaminated and harbor bacteria, viruses and parasites and even how
healthcare workers are becoming infected.

The CDC has done numerous well-controlled studies showing that MRSA can
be spread by contaminated pads.

They recommend:

“Standard mattresses and pillows can become contaminated with body
substances during patient care if the integrity of the covers of the items is
compromised... A linen sheet placed over the mattress is not considered a
mattress cover. Patches for tears or holes in mattress covers do not provide an
impermeable surface over the mattress...Wet mattress in particular can be a
substantial environmental source of microorganisms. Infections and
colonizations by MRSA have been described.”

This report also went on to describe contaminated textiles and fabrics.

“2. Epidemiology and General Aspects of Infection Control

Contaminated textiles and fabrics often contain high numbers of
microorganisms from body substances, including blood, skin, stool, urine,
vomitus, and other body tissues and fluids. When textiles are heavily
contaminated with potentially infective body substances, they can contain

bacterial loads of 106–108 CFU/100 cm2 of fabric. Disease transmission
attributed to health-care laundry has involved contaminated fabrics
…..Bacteria (Salmonella spp., Bacillus cereus), viruses (hepatitis B virus
[HBV]), fungi (Microsporum canis), and ectoparasites (scabies) presumably
have been transmitted from contaminated textiles and fabrics to workers via
a) direct contact or b) aerosols of contaminated lint generated from sorting
and handling contaminated textiles.”

The MRI Suite

The area of greatest challenge for preventing MRSA and other infections is
the MRI suite. Due to the high magnetic field, most centers and hospitals do
not allow cleaning crews to enter, and pads are rarely if ever cleaned .



The attention to MRI safety has significantly increased since the 2001
incident where a 6-year old boy, Michael Colombine died from blunt force
trauma after an oxygen container was drawn by the magnetic field into the
MRI where he was being scanned. This catastrophic event is considered a
watershed event in MRI history. MRI safety is now considered extremely
important and limiting who can have access to the scan room is crucial in
ensuring the integrity of the process. The number of accidents appears to be
a growing problem with a 100% increase in the MRI accidents reported to the
FDA between mid 2005 and mid 2006, again emphasizing the dangers
associated with MRI. The major risks involve metal objects being brought in
by unauthorized and untrained personal. The technologist who runs the MRI
is the one responsible for this access control. Therefore, when the
technologist is not present, all access should be denied to the MRI suite. This
would include after hours cleaning crews.

At almost all MRI centers, there exists the false belief that merely placing a
clean sheet over their table pads, without actually cleaning them between
patients, will prevent the spread of infectious agents. To put this into
perspective, “a clean sheet on unclean pads is like putting icing on a mud
pie.” This clearly will not protect the patient from soiled and contaminated
pads. Very few MRI centers clean their pads once a day, much less between
patients. Cleaning pads during working hours has a very low priority, since
it is time consuming (with often over 20 table pads and positioners as well as
multiple pillow), slowing throughput and thus decreasing the center’s
productivity. Additionally MRI technologist are rarely trained or experienced
in proper cleaning procedures as a nurse would be.

An average MRI may scan 3,000 to 5,000 patients a year. CT scanners
usually scan double or triple that number. The probability is that many of
these patients are infected with or carry MRSA.

Another area of exposure to infectious agents is the use of IV contrast
material for both CT and MRI, which significantly increases the risk of blood
contamination. The simple task of removing a needle from a patient’s arm
and placing it into the sharps container has great risk. Blood can drip from
the needle or from the puncture wound onto the pads, table and floor. This
blood can often be unnoticed by a busy technologist or doctor performing the
injection resulting in a contamination risk.

There is also concern for spreading infectious bacteria by direct contact both
among the imaging staff and the patients within the imaging department or
center. MRSA can be acquired by staff, through a simple cut or other break
in the skin that may not be noticed during a busy day. Therefore, hand-
washing between patients as well as hand sanitizer use for the entire staff is



of crucial importance. On mobile MRIs ensuring proper hygiene is even more
difficult since they rarely even have a sink or running water.

Bacteria and Table Pads

One much overlooked concern is the torn and frayed pads used in imaging
departments and centers. Once the covering material has been breached,
pads cannot be properly cleaned and should be immediately removed and
replaced. This is clearly demonstrated by Oie in his article Contamination of
Environmental Surfaces by Staphylococcus aureus in a Dermatological Ward
and Its Preventive Measures “Items with smooth surfaces can be repeatedly
used without problems if disinfected, however, on items with porous surfaces
made of spongy materials, S. aureus was detected even after disinfectant had
been done. Thus, for surfaces made of such material cannot be disinfected.
Because the surfaces have structures of dense pores and bacteria form
biofilms on these pores.

In the late 1980’s and early 1990’s when most of the pad systems were
developed, they were not designed to take the wear-and-tear of five to ten
thousand patients a year for so many years. As a result, pad coverings have
worn out exposing the foam core, making them impossible to clean. Also,
some of the pads covers have lost their ability to prevent penetration of
bacteria into the central core, where it is not possible to be cleaned.

Only in the last 5 to10 years have hospital-acquired infections become so
significant. Before that time there was very little concern for contamination
and MRSA had far from the prevalence it has today. Therefore, pads on most
tables do not incorporate newer technologies developed to assist in infection
control. Permanent antimicrobial agents should be incorporated into all table
pads and positioners. For added protection, the seams of the table pads
should not only be tightly sewn but also welded closed. The integrity of these
seams is crucial in protecting patients.

Another area of great concern is that of airborne Methicillin-Resistant
Staphylococcus aureus. Table pads inherently have air trapped within them.
When a patient lies down on the pads this air is forced out of the pads
through any hole in the covering materials. This can cause the MRSA
growing in the central core to become ejected from the pad and aerosolized
into the room environment. There have been numerous articles discussing
the possibility of MRSA becoming airborne in such areas as bed making and
thus the possibility that MRSA can be recirculated among patients through
the air (Shiomori.). There is also a suggestion that airborne MRSA may play
a role in MRSA colonization of the nasal cavity or in the respiratory tract.



Wilson showed that the presence of airborne MRSA in an area is strongly
related to the presence and number of MRSA colonies or infected patients in
that area. Shiomori states that measures should be taken to prevent the
spread of airborne MRSA to control nosocomial MRSA infection.

This is clearly another reason why any pads with holes or loss of the integrity
of the covering material in any way must be replaced.

Black Light Detection of Body Fluid Contamination that
may Indicate Fraying

It is also important that all pads be tested using a black light to detect
contamination by body fluids. A black light provides light in the ultraviolet
wavelengths that is especially sensitive in detecting biological material such
as blood, fingerprints, body fluids, etc. Biological material remaining on the
pads will light up under black light exposure. This is an excellent way to
confirm that the cleaning procedures are adequate.

The next step is to clean these pads using a standard hospital cleaning
solution. If the black light continues to show biological material, this may
indicate that the covering material has been frayed and breached, allowing
body fluids to seep into the fabric itself and possibly penetrate to the
underlying foam. This also demonstrates the necessity for pads and
positioners to contain permanent antimicrobial agents.

Procedures

The cleanliness of free-standing imaging centers and hospital radiology
departments is crucial in reducing the spread of MRSA and other acquired
infections. The following are 10 simple procedures to institute that can
prevent the spread of these infections.

Infection control procedures for free-standing imaging
centers and hospital radiology departments

1. Implement a mandatory hand washing / hand sanitizing procedure
between patient exams for technologists and any others who come
into contact with patients.
2. Clean the pads with an approved disinfectant at least once a day or
more often if possible.
3. Inspect the pads with a magnifying glass, particularly at the seams,
to identify fraying or tearing. If present, the pads should be
replaced.
4. Regularly check all padding material with a black light and make
sure that any biological material detected on the pads can be
removed.
5. Replace damaged or contaminated pads with new pads incorporating
permanent antimicrobial agents.
6. Clean the MRI tables, tourniquets and any other items that come
into contact with a patient.
7. Replace all pillows every few weeks at a minimum and enclose them
in water proof coverings containing antimicrobial agents.
8. Promptly remove body fluids, and then surface disinfect all
contaminated areas.
9. If a patient has an open wound or any history of MRSA:
a. Gloves should be worn by all staff coming in contact with the
patient. These gloves must be removed before touching other
areas not coming in contact with the patient, i.e. door knobs,
scanner console, computer terminals, etc.
b. The table and all the pads should be completely cleaned with
disinfectant before the next patient is scanned. For patients
with any known infectious process, add 10-15 minutes onto the
scheduled scan time to allow enough time to thoroughly clean
the room and all the pads.
10. Periodically clean the upholstered furniture and furnishings in the
patient dressing rooms and waiting areas
11. Have a written infectious disease control policy and have it posted
throughout the center.

Conclusion

Protecting patients and staff takes a concerted effort and constant diligence
by all. There is no question that this issue has not received the attention of
the radiology community it deserves. There is a growing concern that at least
some of the spread of infectious agents could be coming from outpatient
imaging centers and radiology departments in hospitals, especially the MRI
suite.


References


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due to methicillin-resistant Staphylococcus aureus (MRSA). 1: J Hosp Infect.
1998 Jan;38(1):67-9. Comment in: J Hosp Infect. 1998 Jul;39(3):243-4.
• Boyce JM, Potter-Bynoe G, Chenevert C, King T. Environmental contamination
due to methicillin-resistant Staphylococcus aureus: possible infection control
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Radiology Web site. http://apps2.acr.org/mcpr/pr/level_util.html. Accessed
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of Environmental Surfaces by Staphylococcus aureus in a Dermatological Ward
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Checklist for Technologist for Infection Control:

1. Wash/sanitize hands between patients and before touching the
keyboard, magnet controls, MRI table or any of the positioners or coils
to avoid cross contamination.
2. All pads and coils are visually inspected between patients and any
body fluids that are seen are cleaned with disinfectant immediately.
3. Have all patients change into clean scrubs prior to their examination.
4. Clean all surfaces of table pads, positioners and coils with disinfectant
wipes, at least once a day; more often if possible.
5. Once to twice a month inspect all pads with a magnifying glass to
check for fraying or tearing. If present, the pads should be replaced.
6. At least weekly check all pads and positioners with a black light to
make sure that all biological material has been removed. If is found
attempt to remove with hospital approved cleaning agent. If any
biological material is unable to be to removed, the pads should be
replaced.
7. Replace all pillows every few weeks at a minimum and enclose them in
water proof coverings containing antimicrobial agents.
8. If a patient has an open wound or any history of MRSA:
a. Gloves should be worn by all staff coming in contact with the
patient. These gloves must be removed before touching other
areas not coming in contact with the patient, i.e. door knobs,
scanner console, computer terminals, etc.
b. The table and all the pads should be completely cleaned with
disinfectant before the next patient is scanned. For patients
with any known infectious process, add 10-15 minutes onto the
scheduled scan time to allow enough time to thoroughly clean
the room and all the pads.
9. Periodically clean the upholstered furniture and furnishings in the
patient dressing rooms and waiting areas.
10.Have a written infectious disease control policy and have it posted
throughout the center.





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