Industry Insights from Those in the Know
MRI Productivity Challenges with NICU Patients
An Interview with Featured Expert Kelsey Gentile
We had the opportunity to speak with Kelsey Gentile, operations manager at Massachusetts General Hospital. Kelsey has extensive experience as an MRI technologist, having worked at Boston Medical Center, Tufts Medical Center, and Shields Health Care Group. In addition, she currently supports the Boston Children’s Hospital in that capacity part-time.
Scroll down for insights from our Q&A session.
Q. Let's talk about productivity issues relating to scanners. What are general productivity expectations for MRI scanners?
A. We always want the magnets fully booked. Depending on the MR systems you have, your scan times might require, on average, from 30 minutes to an hour and a half. That’s based on the scanner model you’re working with, its limitations or capacity, or the restraints within the hospital.
You always want to have staff available to make sure the magnet’s not idle. We typically don’t want to have any downtime.
Q. Do you have any parameters around how many scans you want to do in a day?
A. I run a 16-hour operation, for example. We have four units and scan about 25 patients a day on each scanner. So, we try to complete 100 scans per day across all four units.
Q. What challenges do you run into in delivering on those expectations?
A. Most of our challenges are based on patients and whether they’re mobile. Can they walk into the room themselves, or do they need assistance? Will they have difficulty holding still?
Patients aren’t getting an MRI for fun. They have physical limitations. Maybe they’re undergoing cancer treatment or have some other condition preventing them from holding still – or as still as we need them for an MRI.
Motion, or the need to limit movement, is crucial because it degrades image quality and the result from their scan. So when the patient has difficulty remaining still, we constantly repeat imaging, stop the scan, and help the patients to capture the best images we can.
Q. Do you find one type of patient may be more challenging than another type of patient?
A. Inpatients typically have more acute conditions than we see in outpatient settings. So even waiting on another department to bring an inpatient to you can be a big challenge. Then there’s patient screening.
Sometimes the patients are not able to fill out the MRI paperwork themselves. We rely on a family member or nurse in that inpatient setting versus the outpatient setting, where the patient to be scanned completes it. All of that delays the scan and potentially every patient scheduled after that one patient.
Q. Let's talk about neonatal patients. Are they difficult to scan? Do they tend to impact your scheduling?
A. Yes, they do impact our schedule because they’re unpredictable. Unlike most patients, you can’t tell them to hold still. The scan generally involves a wrap and feed with neonates to help keep the baby sleep. You want to be on the baby’s schedule and do the MR scan after being fed and swaddled to encourage the baby to sleep. So that way, they would have their MRI immediately following the feeding.
They’re most comfortable after feeding and would potentially sleep through the MRI. So you’re more at the mercy of the patient with a neonate because it comes down to what they need at that moment.
And then there’s also the nursing schedule in the NICU. You have to make sure they have time and can come down for the allotted MRI for that patient. So it involves much greater coordination with NICU patients.
Q. With a neonatal patient, are there other elements that get in the way, like equipment transported with them?
A. Yes. The infant could be on a ventilator. They could have specific medications they’re receiving at a specific rate. So, they would need to come down with IV pumps attached. And then, they’d have to have those pumps changed to an MR safe pump to go into the scanning room.
If they didn’t want to change out the pumps, they’d have to extend tubing, adding extensions lines onto their IV lines. That way, their pump would stay outside the room. The tubing would go through a waveguide in the wall to keep it continually attached to the patient. That process results in product waste relating to medication and materials only needed during the MR scan. The IV line extensions get removed after the scan. They aren’t required after the baby is taken out of the MR suite.
If the baby is intubated, you’d have to get respiratory care first. That requires vents and preparation before the patient goes into the room. You cannot scan someone during that time because you need that room to be prepped and ready for the baby. It takes two to three time slots to scan an inpatient, especially a NICU patient, rather than having outpatients scheduled back-to-back.
Q. I assume that creates a significant impact on your scheduling, yes?
A. It does. Even if you plan for it with a dedicated inpatient magnet, you cannot scan as many patients. It becomes more money. So, you’re not able to produce as much revenue on that system.
Q. Let's talk about NICU patients a bit more. I assume it isn't easy to keep them comfortable to get the best quality scan. What happens if they get cold, for example? What other things might impact them during scanning?
A. Noise definitely has an impact. The babies wear earplugs and mini-muffs in any system where they’re getting an MRI. But that noise from the scanner is alarming and can startle the baby. So, you might have to go in and calm them down.
If they’re crying, it could be because the MRI room is very cold. We generally use heated blankets in the suite where we can wrap the baby before going in for the scan. We might even have additional blankets on top of them. But, even with these steps, babies can get cold, keeping them from staying asleep or still.
You also have to make sure they are fed or that we don’t disrupt their sleep schedule. If that happens and the baby gets restless, we would stop the scan and console the baby. That might mean giving them sweeties or even medication to hold still.
Generally, we’d give them extra ounces of formula to help make sure that they’re comfortable. Plus, we wouldn’t send the patient back to their room immediately if the scan is interrupted. You would wait, provide all that care to the baby, and then continue with the scan. It can create major delays.
Q. And that creates a significant impact on your scheduling?
A. Exactly. You wouldn’t just move the baby along. You would take your time and make sure you got appropriate imaging for the providers.
Q. How far in advance do you schedule NICU patient scans?
A. Usually, the morning of – the NICU team will do rounds and then determine which babies need imaging that morning or within that week. You might know a few days ahead of time, but generally, after rounds, about 10:00 AM in my facility.
Q. What happens if a scan gets delayed and a NICU patient is scheduled for a scan? How do you care for them while they wait?
A. Each practice is different. If you have space, which not all areas do, you first want to ensure the baby is away from the general public. You don’t like to introduce any infections. You don’t even want anyone from the outside to be able even to see the baby.
The nurse might keep the infant in the control room if it’s large enough until ready. They might also keep the infant in a hallway, right outside the door, if there isn’t room in the control room.
If the baby has a critical condition and the nurse isn’t comfortable waiting, they might go back to the NICU and wait. Then when the previous MRI was complete, they would recall the patient. That creates multiple trips for the baby and the team, multiple phone calls from the MRI team, and a further delay on the scanner.
Q. What other challenges might you face when dealing with a NICU patient?
A. A failed scan. You could go through all the work to transport the infant, comfort it, give it medication, and then still not be able to go through with the exam. Maybe the infant was inconsolable for some reason.
You would have to schedule the imaging for another day or another time. Even then, it doesn’t mean the baby will remain still to get a successful MRI on the next attempt. That results in a lot of lost time and a delay in obtaining critical information the providers need to make clinical decisions.
Q. Does it pose any dangers transporting a NICU patient for scanning?
A. It does. The actual issues are more about nursing. Anytime you take a baby from the comfort of the NICU and move them to a regular floor, there could be issues. It comes down to the amount of help you have once leaving the NICU floor. The level of care is potentially compromised during transport. It’s all timing and speed.
Q. When they transport the baby, how many people are typically involved in that transport?
A. Generally, it would just be one, a nurse for a critical patient. But, it could potentially be up to three people. So, for example, it could be a nurse, fellow, and doctor. Or it could be two nurses and an MD.
Q. Does that create any challenges from a space standpoint having to accommodate the additional staff members?
A. It can, but it’s usually not considered a restriction when you have a critical patient, and that doctor wants to get the MRI. So you want the doctor there.
You accommodate the staff because you want to make sure you have the proper care for that patient. It can, however, create a safety concern for the MRI techs making sure that nobody enters zone four (the MRI room) with metal. That means removing their stethoscope, electronics, watches, and other items. It’s more about MRI safety restrictions than having too many people in one space. It is definitely a bigger responsibility for the MR Tech to manage screening on multiple people.
Q. Would having a point-of-care system localized in the patient care area allow for more repeated imaging to support care?
A. Yes. It would support repeated imaging and make imaging possible for extremely fragile patients.
It also helps with determining a patient’s eligibility even to continue care. Maybe the doctors would stop treatment based on how the delivery went with the baby and mom. By conducting an MRI, they could determine the brain injury wasn’t as bad as expected. That would change their direction of care for that patient.
If they didn’t have imaging, it would diminish the information to make these decisions. It sheds light on treatment by being able to scan those infants.
Q. Any other insights you can offer regarding the MRI productivity and NICU patients?
A. Having a point-of-care system specifically on a floor allows for additional patients to be scanned. But, again, we’re talking about the effort it takes just for one NICU patient to get a scan, let alone if a provider might want to have two babies scanned on a given day. Most hospitals don’t have the nursing or staff resources to be off the floor for that amount of time.
A dedicated point-of-care scanner allows physicians to offer MRIs for more infant patients than previously, based simply on scanner access. In addition, nurses stay in the NICU. That improves scheduling, productivity, and overall care.
You would never delay when the patient needs imaging, The NICU owns the magnet, and there’s not going to be a patient before or after them.
Let’s say there’s concern the baby had a stroke. Timing is critical. And physicians like to follow up. Once the infant has received medication, they might see any changes in the brain afterward. It’s vital to get that imaging to make a specific diagnosis.
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