MRI Safety: Four Zones for Dummies

Today theres a standard expectation that MRI facilities will conform to the Four Zone model for safety in the MRI suite. This Four Zone concept was initially proposed in the 2007 ACR Guidance Document for Safe MR Practices, subsequently endorsed by the Joint Commission and reiterated in the ACR 2013 Guidance Document. While great in principle, there hasnt been a lot of effe ctive communication as to what this model is (and isnt), and how it can be flexibly implemented in planning and operations to actually improve safety. Initially and most importantly, the Four Zone model is not a cut-and-paste template; rather it is simply a guiding structure. If you dont know what each of the successive zones is supposed to do, you cant readily adapt it to fit your specific needs. In principle, the Four Zone model requires greater levels of screening, access control, and supervision as untrained persons approach the MRI Scanner Room. In order to reach the MRI Scanner Room (Zone IV), one should pass through zones two and three, sequentially. First thing you may notice, above, is that I dont describe passing through Zone I. Thats because from an operational or facility planning standpoint, Zone I is completely inconsequential. Lets jump straight to the definition of what Zone I is, so that we can explain how irrelevant it is to MRI safety within a facility Zone I: Areas with no direct relationship to an MRI service, and no associated physical hazards. The entire world outside of MRI providers facilities would be Zone I. This means that the Hoover Dam, the Eiffel Tower, your living room at home, the summit of Mt. Fuji, and the dark side of the moon are all Zone I areas. These are areas for which there are no relationships (proximity or functional) with any MR devices. There are no MR-related risks, and nobody would every go to one of these locations with the expectation of getting an MRI exam. Zone I is, by definition, the entirety of the universe that has nothing to do with MRI. So if you feel compelled to put up a sign in your facility that identifies Zone I, that sign is equally valid if you put it in the corridor outside the radiology department, or if you hang it at the hospital loading dock, or the helipad, or the cafeteria, or the parking lot. Said another way, there is no practical reason to identify your Zone I. Zone II: Areas within an MRI providers imaging suite where persons selfselect to enter the MRI area, and where both physical and clinical screenings of persons who will be proceeding further are conducted. There are to be no physical hazards associated with MRI (static magnetic field, time-varying magnetic fields, or RF fields) in Zone II areas.

Aegys Pro-MRI 2013

Zone II is an area where people can start their MRI experience (not the exam, itself). Often this comes in the form of a reception desk and waiting area. Because there are no MRI-related physical hazards present in Zone II, it isnt important that persons in this area have all been successfully screened for MRI safety. In fact, you could have a shared, pre-screened, radiology patient waiting area that could be part of your Zone II. In it could be a few MRI patients, a few CT patients, a Dexa patient, and assorted family members or friends. The unsupervised maintenance person with their tool belt, the pacemaker patient, and the person with hearing aids are all fine in Zone II (though each of these people would present real safety risks, to themselves or others, if we let them continue to the MRI Scanner Room). It is in Zone II that we also conduct physical and clinical screening for persons who are going to proceed on to Zone III. Changing rooms and patient consult areas are also frequent elements found in an MRI departments Zone II. Once a person has been successfully screened for MRI, it is important that they remain segregated from unscreened individuals. After successful screening, MRI patients should proceed into Zone III. Zone III: Areas in proximity to the MRI scanner (though not the MRI Scanner Room) that meet one or both of the following criteria must be treated as Zone III areas: Areas in which a person may access static magnetic fields in excess of 5 Gauss, or areas from which a person can directly access the MRI Scanning Room. Apart from the two mandatory criteria, above, a facility can elect to include whatever functional spaces they wish to within Zone III, as long as everyone entering those spaces is screened for MRI risks. One of the key elements of Zone III areas is that they must be physically restricted from Zone II areas. Anyone who hasnt successfully cleared screening should not be able to accidentally or inadvertently find themselves in Zone III. Signage, alone, is insufficient for defining Zone III within the building, there should be a locked doorway(s) between Zone II and Zone III areas. Physical restriction, in some manner, is absolutely necessary as constant monitoring of the border of Zone III is not operationally feasible. It is important to note that the magnetic field around an MRI scanner is threedimensional, and that it is entirely possible (often likely) that magnetic fields at or above the 5 Gauss threshold project into ceiling areas below the MRI, and potentially to areas above the MRI scanner. Even if a magnetic field hazard projects into a space that is functionally outside the MRI suite, that area is still a Zone III area and should be identified / restricted as such. If anyone who hasnt been successfully screened for MRI risks can enter this area, it can not be considered a Zone III area! One of the fundamental principles of Zone III is that persons in this area are all presumed to be safe to enter Zone IV (or have had specific risks made known to the MR staff). If an area were to be, for example, a Aegys Pro-MRI 2013

shared area for MRI and CT patients, it can not be considered a Zone III area if the CT patients arent also screened for MRI related risks. Independent access to / within Zone III is to be provided only to facility-designated personnel who have demonstrated competence in MRI safety. Patients or other nonMRI personnel within Zone III must always be under the direct supervision of facility-designated personnel who have demonstrated competence in MRI safety. Zone IV: The MRI Scanner Room, itself. It is within this room that the physical hazards related to MRI are the greatest. Zone IV is the only zone that is specifically tied to one room the room in which the MRI scanner resides (this gets tricky when, for some intra-operative MRI scanners, the MRI system moves between rooms). Because the MRI-related risks are the greatest inside that room, it is the beneficiary of the greatest level of security and supervision. Nobody should be permitted to enter Zone IV if they havent successfully cleared the screening process. Similarly, equipment, devices and appliances should not be brought into the MRI Scanner Room unless they have been prospectively tested for MRI safety risks. As an added layer of protection, it is recommended that the door to the MRI Scanner Room be provided with a keyed lock (separate from the facilitys master keying system, if possible). The Four Zone principle was intentionally structured to allow a high degree of flexibility in its implementation. There is tremendous site configuration variability between MRI facilities, even within the same network, and the utilization of the principle as a conceptual layered access restriction model with greater restriction as you move physically closer to the MRI room allows for standardization. For example, if you had an inpatient holding area for your MRI service, that area could be in Zone II, if patients were brought to the MRI unit unscreened, or it could be in Zone III if the MRI screening was completed before the patient was brought to the unit. The specifics of each providers clinical and operational needs should result in a custom tailored Four Zone solution, and not a cookie-cutter replication of a template. Because of this, its critical that radiologists, technologists, and managers fully understand what the Four Zone is supposed to accomplish, and how to adapt it to your individual needs. If you would like further information about the Four Zone principles, we recommend that you also review Appendix 3 of the 2013 ACR Guidance Document on MR Safe Practices, MRI Facility Safety Design Guidelines (http://onlinelibrary.wiley.com/doi/10.1002/jmri.24011/pdf) for a narrative description of the sequencing of Zoned spaces within the MRI suite.

Aegys Pro-MRI 2013