Harbor:STAT MRI

Outpatient MRI

  • For DHS patients who do not have COVID symptoms, if a consultant feels a MRI can be ordered within 72 hours which can avoid an admission or calling in the MRI tech on off hours, here is the process:
    • Have the RN complete the MRI checklist to ensure no contra-indication to MRI; if there are any questions about a contraindication, call the MRI center at x64800 or MRI tech 3xx-218-2379 after hours
    • Consultant orders the desired MRI ("Order for future visit", in approximately 2 days, grace period +/-2 days)
    • ED physician calls MRI center x64800; staffed M-F 7a-10p
    • If no answer:
      • Leave a message (option 1 for English, option 1 for scheduling) AND
      • email harborfrontdesk@insighthealth.com and copy Dr. Chappell
  • The consultant who orders the study is responsible to f/up on the study; alternately can message empaneled PCP and "save to chart"
  • OOP patients should be referred to their PCP/health network for imaging

Ordering STAT MRI

  • The decision to order a STAT MRI will be made after discussion with an attending physician AND for which MRI results will alter the current treatment plan (including admission vs discharge decisions - Drs. Lewis, Mahajan, & Munn 4/2018); external services may be consulted, but their "permission" is not necessary to order the study
  • PLEASE RELAY TO THE MRI TECH if the study needs to be done IMMEDIATELY or can wait until 7am
  • Once the MRI is ordered
  1. 7a-7p, Monday to Friday: call the MRI building x64800; Rosalinda on-site manager
    1. Mobile MRI x64899 ... call the MRI building (x64800) for any weekday scheduling questions/updates
      1. If unable to get a response during daytime hours, call the manager at 3xx-666-9625
  2. After hours: MRI tech 3xx-218-2379 (rings 6x, voicemail has back-up numbers listed - please leave voicemail)
    1. If no answer, call 3xx-803-3702 (please leave voicemail)
      1. If no response, call 3xx-938-8553 for Chief Tech (Daisy) - please leave voicemail
        1. Last resort, call 3xx-666-9625 for Manager (Bernadette) - please leave voicemail
          1. If still no response after 15 minutes, call Dr. Chappell's cell
  • Expected response time is 1 hour from contact to arrival (Trauma Criteria - CD 11-46, ACS COT VRC)

The tech will need the following information from the ED attending

  • Patient's name, MRUN, DOB, the type of MRI (you may want to discuss with the radiology resident to ensure the optimal type of scan +/- if contrast is needed), and suspected diagnosis
  • Does the patient have a pacemaker?
  • Past surgical history
  • Does the patient have any electronic implants?
  • Does the patient have any retained metallic fragments in the eyes (or anywhere else)?
  • Are the patient labs (creatinine) in the computer? (if elevated, the MRI tech may request a communication order to give contrast)
  • Patient's weight for dosing purposes
  • Patient's room nurse should complete the MRI safety form: https://emedharbor.labiomed.org/private/Contact%20Info/ED%20Documents/HUCLA%20Safety%20Screening%20Form%20English%20and%20Spanish%2011-2018.pdf
    • If the patient is incapacitated and unable to answer questions on the form, the ED resident/attending must help complete the empty sections of the form (evaluate CT head or XR orbit for metallic FB, evaluate for pacemaker, etc)

Policy 367b REDLINE

  • REDLINE MRI may be requested by attending only from the following services (EM, Trauma, IR, NS, CTS, Ortho, & Neuro)
  • REDLINE when high likelihood that the MRI finding will result in an emergent procedural or operative intervention
    • ED or trauma attending should call the radiology resident who will notify the MRI tech
    • Notify charge RN who will then notify the house supervisor
    • Timestamp the REDLINE request time in the MRN
    • The MRI tech will notify the patient's RN when MRI is ready for the patient


MRI for Patients with Pacemakers

There is no official HUMC policy

  • Call the Cardiology Fellow on call to see if the pacemaker can go through the MRI and if it needs to be reprogramed.
  • Then call the MRI tech to arrange the MRI and set a time for it.
  • Then call the Cardiology Fellow on call back to have them talk to the Pacemaker Tech (e.g. Medtronic) and let them know they have to come in, what they need to do and get the Pacemaker Tech's name and phone number.
  • Then call the MRI Tech back and give them the name and number of the Pacemaker Tech and have them both talk to each other to arrange the timing.


  • Contraindications:
    • Patients with cardiac devices implanted prior to 2000
    • Patients with implanted devices that do not meet manufacturer specifications for required time interval post implant for MRI scanning (varies by manufacturer usually 6 weeks)
    • Patients with epicardial lead
    • Patients with leads that are abandoned or broken
    • Patients with leads to the abdomen
    • Patients with suboptimal pacing parameters (battery at end of life or lead malfunctioning i.e., high capture thresholds >2V)
    • Other imaging studies are available to adequately evaluate the clinical question
    • Thoracic region MRI exams
  • Protocol:
    • Scheduler to request device Model and Serial Number from referring physician/ordering team. Imaging Center staff will contact manufacturer to determine MRI conditionality of device. Should it be determined that device is NOT MRI conditional, the ordering physician will be notified that the MRI will NOT be performed
    • Two Weeks Prior to MRI:
      • Should it be determined that device is MRI conditional, scheduler will advise the ordering team that patient will need to undergo chest x-ray and evaluation in the device clinic prior to MRI procedure unless the patient has been seen in the device clinic within 6mos, and the clinic visit is reviewed in Orchid and found to be within normal limits
      • Chest x-ray will be evaluated for any residual non-MRI conditional leads
      • Subsequent to clearance by the radiologist (x-ray results) and cardiologist (device clinic evaluation) the scheduler will contact the patient and schedule the procedure
      • The scheduling team will coordinate with the device representative, and the transportation nurse to be present at the scheduled MRI time. The Cardiology/EP Fellow will be available, not present
      • MRI staff will send an email with the date and time of scan to Michelle Martinez (MiMartinez@dhs.lacounty.gov) Michelle Martinez will coordinate both the device clinic appointment if needed, and notify the EP fellow. Her phone number is 310-222-5159.
      • She will send a confirmation email to Alma Flores (Aflores@insighthealth.com and bkay@insighthealth.com )
    • Immediately Prior to MRI:
      • All MRI procedures to be performed in the mobile MRI unit on the 1.5 Tesla scanner
      • Cardiologist or cardiology fellow representative to be available prior to and subsequent to MRI procedure to confirm device settings with device representative
      • All patients will undergo device interrogation in the mobile MRI tech area by the device representative and the findings will be communicated to the Cardiac Fellow
      • Device representative to place device in MRI mode prior to procedure
      • Transport nurse and device representative to be present throughout procedure
    • During the MRI:
      • All patients will be monitored throughout the procedure by the transport nurse who will monitor continuous cardiac rhythm recording and pulse oximetry results
    • MRI Parameters:
      • MRI system set to “Normal Operating Mode” and lowest SAR will be used (<2.0 W/kg body, <3.2 W/kg head)
      • MRI protocol should be obtained by Radiologist
      • Avoid surface coils if possible
      • Device parameters will be set by qualified personnel which may include cardiologist, cardiology fellow, cardiology nurse practitioner and/or device representative per device specific guidelines
    • Immediately After the MRI:
      • Initial pacemaker parameters will be restored
      • Pre and Post scan interrogation printout will be given to the transport nurse who will have it scanned into Cerner HIM of the patient
      • Interrogate device for pre-scan settings by the device representative

Proposed by Insight Imaging (Bernadette Kay 10/22/18 in collaboration with J.Chung, M.D.)

Policy 367B: Priority for the portable MRI will be given to the following groups of patients

  1. Emergency Department patients
  2. Acute Trauma or ICU patients
  3. Any Pediatric or Adult patient (including outpatients) requiring sedation or Anesthesiology support for monitoring or provision of sedation
  4. Inpatients with potentially treatable neurological or neurosurgical emergencies
  • WITH one of the following documented indications:
  1. Acute spinal cord injury
  2. Suspected spinal instability
  3. Suspected spinal compression or ischemia
  4. Concern for epidural abscess or discitis
  5. Suspected acute/subacute myelopathy or focal neurological deficit
  6. Concern for acute/subacute cauda equina/conus medullaris syndrome
  7. Acute stroke symptoms with non-diagnostic head CT
  8. Suspected meningitis, encephalitis, or CNS vasculitis
  9. Concern for CNS tumor or abscess with acute change in neurological status
  10. Evaluation for cerebral hemorrhage
  11. Emergent arterial imaging (aortic dissection, aneurysm leak, etc.) when contraindication to IV CT contrast
  12. Pregnant female with equivocal physical examination and ultrasound for appendicitis
  13. Urgent Magnetic Resonance Cholangiopancreatopgraphy (MRCP)
  14. Assessment of VP shunt malfunction

Downtime

  • When the portable trailer is down, patients will need county trans to take to MRI building
  • Follow the normal pathways, but also include radiology resident p5814 to help prioritize studies
    • 7a-7p, Monday to Friday
  1. page radiology resident p5814 (not for approval but to help prioritize the competing needs (ED, ICU, etc)
  2. call MRI building x64800
  3. MAC for county transport to MRI building (866-941-4401 - specifically for county trans)
    • after hours
  1. page radiology resident p5814 (not for approval but to help prioritize the competing needs (ED, ICU, etc)
  2. MRI tech 3xx-218-2379 (rings 6x, voicemail has back-up numbers listed - please leave voicemail)
    1. If no answer, call 3xx-803-3702 (please leave voicemail)
    2. If no response, call 3xx-938-8553 for Chief Tech (Daisy) - please leave voicemail
    3. Last resort, call 3xx-666-9625 for Manager (Bernadette) - please leave voicemail
    4. If still no response after 15 minutes, call Dr. Chappell's cell
  3. MAC for county transport to MRI building (866-941-4401 - specifically for county trans)

MRI Size Limitations

  • 350 lb weight limit
  • 15 inches high, 21 inches wide
  • MRI lift 1000 lbs total for gurney, staff, equipment, etc.

Open MRI Transfers

  • If patient is too large for MRI at HUCLA, they will likely need transfer to Insight Imaging at Downey (open MRI)

order. Below is the process:

    • 1 - Place your MRI order in Orchid
      • Insight Downey Open MRI is open 7a-11p; 562-904-1340; 8515 E Florence Ave, Downey, CA 90240
      • Open System Imaging (714) 543-7643; 1401 N. Tustin Ave, Santa Ana, CA 92705
      • Beach Imaging Center (714) 894-7300; 12600 Beach Blvd, Stanton, CA 90680
    • 2 - Call the MRI center to let them know the patient's weight and girth (height above table and width) and your Spectralink number - x64800 during daytime, use the after hours process as described above
      • MRI sends the request to Downey and Downey will contact you with date and time for MRI (we are unlikely to get a same-day open MRI)
    • 3 - Confirm date and time with our MRI center (both Harbor MRI and Downey are owned by Insight Imaging) and they will arrange transport with county trans (866-941-4401)
      • The patient will be transferred back to HUCLA after imaging is completed.

Transport to MRI (Policy 367B)

  • Mobile Unit
    • CODE BLUE
      • Hospital gurney will be left on the lift while patient is getting scanned if ambulatory patient and they will be transferred from MRI table to gurney for transport to ED
      • If critical/ICU patient, gurney will not stay on the lift during the scan; in case of code, the MRI table will be used to transport the patient to the ED
      • CODE BLUE Team should receive the patient at the loading dock, move patient to the ED, and ED team assists with resuscitation
      • Move to trauma bay for resuscitation and use paper code sheet, quick reg all patients (outpatient, inpatient)
      • Patients who are admitted as inpatient and in an inpatient bed will be re-registered using the same MRN and an ED FIN will be created. The inpatient FIN will stay active and the ED FIN will be used for the stay in the ED and discharged when the patient is stable enough for transfer and the inpatient FIN will be used when the patient returns upstairs.
    • TRANSPORT
      • Ambulatory patients may be taken to MRI via wheelchair or gurney
      • Need for physician accompaniment determined by the ATTENDING
      • R1 or above to assure maintenance of spinal precautions at times of transport only; need not stay during entire study
      • RN will assist with transport of adult patients to MRI but only needs to be present during MRI if sedation is occurring
      • RN will remain with ALL pediatric patients during the entirety of the MRI regardless of need for sedation
      • ED Physician proximity in the AED meets the requirement for physician presence during the administration of IV contrast
    • SEDATION
      • Anxiolysis to be provided by anesthesia (attending, resident, or CRNA) - Anesthesia attending must be present for pediatric sedations
        • Place order in ORCHID “Request for Out of OR Anesthesia”; if issues, call Operating Room Scheduling Center at x65203 during regular hours and OR Front Desk x65200 after-hours
        • Anesthesiologist running the board Spectralink x65942 can also assist
        • Assessment by anesthesia will occur in the ED room as well as post-MRI sedation monitoring/recovery
        • Sedation is defined as IV pushes, and excludes IV drips maintained at a stable rate or oral anxiolytics(Policy 367b, Section IV)
      • If the patient is on a ventilator and only requires continuous sedation drips, only nursing is required (no ED or anesthesia physician)
      • If patient is unstable, must be accompanied by physician (R2 and above) AND nurse

American College of Radiology Appropriateness Criteria for MRI

numbers below in parenthesis - ranked 0-10, with 10 most appropriate study

  • Emergent (to Portable MRI Trailer)
    • Neurology
      • Stroke within therapeutic window with negative head CT (9)
        • MRI brain w/o contrast
        • Consider MRA
      • Vertigo with concern for posterior fossa infarct (9)
        • MRI brain w/o contrast
      • New myelopathy or plexopathy (9)
        • MRI spine w/o contrast
      • Venous sinus thrombosis (if CT Venogram is contra-indicated); (9)
        • MRV brain with and w/o contrast
    • Trauma
      • Traumatic cord injury/cord syndrome (9)
        • MRI spine w/o contrast
      • Spinal cord compression/ischemia
        • MRI spine w/o contrast
    • Neurosurgery
      • Cauda Equina Syndrome or suspected spinal tumor with motor loss (9)
        • MRI spine w/o contrast
        • MRI spine with contrast if infection suspected
      • Epidural abscess/hematoma or discitis (8)
        • MRI spine with and w/o contrast
      • Non-traumatic SAH with contra-indication to IV contrast to assess for aneurysm (8)
        • MRI brain w/o contrast + MRA brain w/o contrast (8)
      • Intracranial AVM with intraparenchymal hemorrhage (when CTA contra-indicated)
        • MRI brain with and w/o contrast + MRA brain w/o contrast
      • Concern for subdural empyema/intracranial abscess (8)
        •  MRI brain with and w/o contrast
      • Brain tumor with acute change in mental status (8)
        • MRI with and w/o contrast
      • Spinal tumor with acute change in neurological status
        • MRI with and w/o contrast
    • Surgery
      • Emergent arterial imaging with contra-indication to IV contrast (carotid, vertebral, or aortic dissections/aneurismal leaks); (8)
      • MRA head and neck with and w/o contrast
    • Pediatrics
      • Assessment of VP Shunt malfunction
        • MRI brain w/o contrast (T1/T2)
  • Urgent (to Portable MRI trailer)
    • Neuro
      • Suspected meningitis/encephalitis (unable to perform LP); (8)
      • MRI brain with and w/o contrast
    • Trauma
      • Spinal instability due to ligamentous injury (9)
        • MRI spine w/o contrast
      • Concern for spinal fracture with equivocal CT (9)
        • MRI spine w/o contrast
      • Suspicion of diffuse axonal injury (8)
        • MRI brain w/o contrast
    • Neurosurgery
      • CT equivocal for intracranial hemorrhage
        • MRI brain w/o contrast
      • Post-op intracranial surgery to evaluate for abscess
        • MRI brain with and w/o contrast
      • Concern for posterior fossa mass (8)
        • MRI brain with and w/o contrast
    • Surgery
      • Pregnant female with equivocal exam/US for appendicitis (vs. enroll in CODA/empiric antibiotic treatment); (7)
        • MRI Abdomen/pelvis w/o contrast
    • Pediatrics
      • Concern for Septic Hip/Joint (7)
        • MRI pelvic w/o contrast
    • GI
      • MRCP
    • Pulmonology
      • PE in pregnancy (if CTA or VQ contra-indicated or not feasible); (3)
      • MRA chest with and w/o contrast
    • OB
      • Stable patients with equivocal US/HCG where outpatient evaluation is not feasible (extenuating circumstances) or concern for ctopic/heterotopic pregnancy
        • MRI pelvis w/o contrast
  • Urgent (to MRI building)
    • Neurology
      • Stroke outside therapeutic window (8)
        • MRI brain w/o contrast
      • Opthalmoplegia (9)
        • MRI brain and orbits with and w/o contrast
      • Concern for Multiple Sclerosis (8)
        • MRI brain/spine with and w/o contrast
    • Neurosurgery
      • Concern for pituitary apoplexy (8)
        • MRI brain with and w/o contrast with multiplanar thin sellar imaging
      • Post-op brain tumor to evaluate for residual tumor
        • MRI brain with and w/o contrast
      • Spinal compression fractures (7)
      • MRI spine w/o contrast
    • Ortho
      • Osteomyelitis (9)
        • MRI with and w/o contrast
      • Concern for hip fracture with negative CT (9)
        •  MRI w/o contrast
      • Septic arthritis (unable to perform arthrocentesis)
        • MRI with and w/o contrast (T1/T2)
    • Pediatrics
      • Slowly progressive vision loss (8)
        • MRI brain and orbits with and w/o contrast
    • Medicine
      • Evaluate for brain metastasis with equivocal CT (9)
        • MRI brain with and w/o contrast
      • Concern for Primary CNS lymphoma (9)
        • MRI brain with and w/o contrast
      • Concern for opportunistic CNS infection (9)
        • MRI brain with and w/o contrast
  • Outpatient (to MRI building)
    • Any stable patient not requiring sedation
    • All outpatient imaging orders
    • Ortho
      • Ligamentous injuries of the extremities
        • MRI w/o contrast

Chappell, Wu, 2/2017


See Also

References

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