Douglas Arditti, M.N., M.S.N., FNP, CRNA
Peter Schulman, M.D.
APOM Grand Rounds
January 26, 2015

What is the average delay for the time an MRI is scheduled and the actual time it begins?
74 minutes
(range: 28-116 minutes)
How long does it take to start an MRI after induction of anesthesia?
31 minutes
(range: 6-93 minutes)
What is the average anesthesia time for an MRI?
116 minutes
(range: 51-272 minutes)

» OHSU Department of Anesthesia & Perioperative
Medicine (APOM) & OHSU Department of Diagnostic
Radiology-MRI
» Analyze causes of delays for adult undergoing MRI with anesthesia
» Efficiency & safety
• Improve staff satisfaction
• Identify safety hazards

» Non-OR anesthesia presents unique challenges
» MRI Suite
• Hazardous Environment
– Safe anesthesia care requires specialized equipment and procedures
• Sequence/protocol for scan often lengthy (2-5+ hours)

» Process mapping
• Technique for making work visible
• Identifies sequences of activity and decision points
• Reveals areas where potential bottlenecks or delays occur
Start
&
End
Steps
• Activities
• Tasks
• Steps
Decision
AHRQ. Developing a high-level process map and swim-lane diagram. http://www.ahrq.gov/professionals/systems/hospital/red/swimlane.html.
Updated August 2011. Accessed December 30, 2014.

Process Map:
Ordering an MRI
Scan with
Anesthesia

» Fish bone diagram (Ishikawa diagram)
• Explore potential or real causes that result in a single effect
• Assists in searching for root causes and identify problem areas
• Depicts relationships or hierarchy of events
• Compare relative importance of different causes
AHRQ. Building your cause and effect diagram. http://www.ahrq.gov/professionals/systems/hospital/red/swimlane.html. Updated August 2011. Accessed December 30, 2014.

Anesthesia Related Delays in MRI Department

Anesthesia supply cabinet located in holding area
• To be stocked by anesthesia technicians
• Combination lock installed (same combination as anesthesia cart)

» Providing anesthesia services in
MRI suite requires coordination of many different individuals and departments
• Lead MRI technologist
• Radiologist
• Radiology scheduling
• OR scheduling
• Anesthesia D-1
• Anesthesia provider(s)
• Anesthesia technicians
• Inpatient nursing staff
• IRU nursing staff
• PACU nursing staff (sometimes)
• Transportation services

» The process for scheduling an MRI scan for patients requiring anesthesia care is complex and inefficient
• Multiple challenges arise because our EHR
(EPIC) interfaces with multiple information systems at OHSU (e.g., OR scheduling, radiology scheduling, billing systems)
• Inpatient vs. outpatient protocols are very different
• Stakeholders each had a different understanding of when the MRI scan would actually begin

MRI Table Time
• Time that the MRI scan will start (analogous to
“incision time”)
Your schedule in EPIC
• Now scheduled 45 minutes prior to
MRI Table Time

Time seen in
EPIC
Total time 135 min

» For inpatients: Clinicians ordering MRI scans now encounter a “Soft Stop” when placing orders in EPIC
• Requires confirmation that anesthesia D-1 has been contacted prior to processing the order
» Outcome
• Virtual elimination of Lead MRI
Tech involvement prior to D-1 approval

» Anesthesia Technician to arrive in holding area 30 min. prior to MRI scan “Table Time”
• Remain during induction and patient transfer
• Available to assist with emergence
» Holding area to be clear during induction and emergence
• 15 minutes prior to “Table Time”
• 15 minutes after MRI scan complete
» Prior to completion of scan
• MRI Technologist contacts IRU (or PACU) and
Anesthesia Technician

» MRI Techs have a different perspective than us
» Amongst anesthesia providers, there is often variation in clinical practice
» There is an opportunity for team building between our departments

»
Introduction of MRI Tech(s) (MRI Tech)
» Confirm planned scan (MRI Tech/Anesthesia)
• Potential ‘intra-scan’ changes/issues (MRI Tech)
» Introduction of anesthesia team (Anesthesia)
•
Attending
• CRNA/Resident
• Anesthesia technician
»
Quick review of plan and roles (Anesthesia)
• Induction plan
•
Monitoring needs
• Logistics (transport of patient in and out of scanner)
•
Emergence
– Location
• Special concerns/patient issues/positioning concerns
»
Confirm reservation for recovery (Anesthesia/MRI Tech)
• IRU vs PACU

» Familiarize yourself with
MRI compatible infusion pump and Invivo monitor
• MRI Tech and Anesthesia
Tech can assist with troubleshooting

»
Confirm that AGM and monitoring equipment is functional; check suction equipment in Holding Area (Zone II)
» Team Pause
»
Induction
• Monitors: Use MRI compatible placed at foot of trolley
•
O
2
: Use wall source with O
2
» Transport to Scanner extension tubing
•
Switch O
2 source at Zone IV entry (or place on AGM)
• Positioning supervised by anesthesia provider
• Anesthesia cart moved to Zone III
»
Exit Scanner
• Anesthesia cart: Move to Holding Area (Zone II)
•
Monitors: Transfer patient using the MRI compatible monitor
• Switch O
2 source at Zone III entry
•
Emergence from anesthesia in Holding Area (Zone II)
• Transport patient to IRU/PACU with transport monitor and O
2
E-cylinder

Team Leader : Douglas Arditti, MN, MSN, FNP, CRNA (Instructor, APOM/Student, University of Washington DNP Program)
Team Members :
Wayne Smith, ARRT RT (Supervisor, MRI Department)
Michelle Greenberg (Support Services Manager, Radiology Scheduling)
Joseph Bussiere (Lead MRI Technologist)
Mike Burrell (Lead MRI Technologist)
Project Sponsor : Peter Schulman, MD (Director OOR Anesthesia-APOM )
Project Liasons : Tina Foss, MHA (Surgery Scheduling); Dawn Anderson (Surgery Scheduling);
Liza Kamps (Senior Project Specialist-EPIC); Matthew Davis (Supervisor, Anesthesia Technicians);
Tara Menon, RN (IRU Nursing Manager); Laurie McKeown, MD (Program Manager, Patient Safety);
Rob Miller (APOM-System Application Analyst),
Executive Liasons : Jeffrey Kirsch, MD (Chairman-APOM); Stephen Robinson, MD (Clinical Director-APOM);
Fergus Coakley, MD (Chairman-Diagnostic Radiology), Brock Price (Director-Radiology Department)