Possible Exposing Infants to Superbug Infections
CHICAGO, Illinois — December 2, 2008 — During the third day of the Radiologic
Society of North America (RSNA 2008) conference, Chicago, IL, Dr. Peter Rothschild,
one of the world’s foremost MRI experts, is alerting the public to a common practice that
endangers young immunosuppressed patients by exposing them to damaged pads and
possible Superbug infections during MRI.
Peter Rothschild M.D. is considered one of the world’s foremost MRI experts. He
formerly served as Medical Director of the research laboratory at the University of
California, San Francisco, where he helped develop the first commercially available
Open MRI scanner. He is the editor of the first textbook on Open MRI and the author of
the landmark paper “Preventing Infection in MRI: Best Practices for Infection Control in
and Around MRI Suites.”
Rothschild warns that a common procedure in hospitals and free standing MRI centers is
to tape infants and young children directly to the MRI pads, to keep them from moving
during their scans. Any movement during an MRI scan will degrade the resulting image,
making it difficult or impossible to make the proper diagnosis. This is especially
important for babies due to their already small size, thus the need for the best image
resolution possible.
Additionally, MRIs are very loud, therefore if the babies are sedated, they must be deeply
sedated/anesthetized and monitored constantly to make sure they do not stop breathing.
The high magnetic fields in MRI make it difficult and very dangerous to use much of the
standard monitoring equipment. Recently a child was killed in an MRI, when an oxygen
container was carried into the room, flew into the bore of the magnet and crushed him.
While taping infants eliminates the risks associated with sedation, Rothschild says the
poor condition of the MRI pads makes this an extremely dangerous procedure by
increasing the risk of infection from prolonged exposure to contaminated pads, especially
for a premature infant without a fully developed immune system. MRI table pads often
have tape and tape residue on the surface of the pads, which itself is an opportunistic
breeding ground for bacteria and is difficult, if not impossible, to clean. Over time, pad
surfaces become torn and frayed exposing the foam core, which is very porous and
impossible to properly clean. Thus, the foam core is another excellent breeding ground
for deadly Superbug bacteria.
The Centers for Disease Control (CDC) have clear and unambiguous guidelines, stating
that since it is impossible to adequately clean pads in this condition, they must be
immediately replaced. It is estimated that 80-90% of MRI pads currently in use are torn
and frayed; however few MRI centers perform routine inspections of the diagnostic pads
to determine if they need to be replaced.
Rothschild says, “After seeing the pads with tape and tape residue from a well-known
children’s hospital, I realized that they were taping the babies, IV tubing and other
material directly to the pads. I couldn’t believe that someone with any infection control
training would ever do such a thing when the MRI pads are in such an appalling
condition. It is not a surprise that MRSA is spreading like wildfire through hospitals and
outpatient facilities. These babies can then spread this dangerous Superbug throughout
the hospital from direct contact or through blankets and other material they come in
contact with. I assert contaminated MRI pads are a threat to the entire hospital and must
be replaced.”
Dr. Rothschild adds, “If you visit http://Superbug.smugmug.com, you can see the actual
pads that infants were taped to. You can clearly see the holes in the covering material
where the underlying foam is exposed and discolored. The tape was not only used to hold
the babies in place, but it was also used in a vain attempt to repair these pads. Obviously
the technologists working at the hospital realized there was a problem, however for years
the administration would not purchase new pads, even though the cost was minimal, less
than the fee charged for two MRI exams. This is a common scenario I hear all the time.”
Dr. Rothschild warns that infection control has had a very low priority at most MRI
facilities for a variety of reasons. Infection control has been locked out of the MRI
magnet rooms due to compelling safety concerns due to the magnetic fields. Budgets are
tight and some MRI centers have been able to become accredited without an infection
control policy and with torn and contaminated pads
He further states that most often, inspectors did not even enter the MRI room, much less
seriously look at the pads or ask for an infection control policy. Even if they would walk
into the scan room, the pads would be covered with a clean sheet and unless they took the
time to look underneath the sheet, they would simply pass the MRI center.
Many administrators and technologists know that accreditation agencies will not look
closely inside the MRI suite. Combined with radiology administrators’ limited
knowledge of infection control and their position as decision makers to determine where
and how to spend money and other resources, they therefore have simply ignored the
problem instead of trying to fix it. The end result is the administrator’s refusal to replace
pads or bring in experts to develop an infection control policy for their imaging centers.
“I have never heard of an MRI facility failing accreditation because of torn and
contaminated pads or lack of an infection control policy. However, even though as many
as 80-90% of the pads in use today are torn and frayed and few, if any MRI centers have
an infection control policy, clearly none of the inspectors are looking in this critical area,”
said Dr. Rothschild.
“Unfortunately, accreditation does not mean that a MRI center is clean and safe,”
emphasized Richard Nolan M.D., a well known orthopedic surgeon with 25 years of
experience with MRIs, who has been concerned for years over the lack of infection
control at MRI facilities. “I have no idea how the Joint Commission or the American
College of Radiology (ACR) can accredit any MRI facility that is in such clear violation
of even the most basic infection control practices. Until they (Joint Commission and
ACR) take seriously the threat of worn out contaminated table pads and lack of infection
control procedures, this situation will only get worse.”
Nolan advises, “They must immediately make every effort to thoroughly evaluate the
pads and demand an infection control policy. Until then, it will remain up to the
individual patients and referring doctors to determine if an MRI facility is clean and safe.
I encourage any patient undergoing an MRI to examine the pads they are lying on, since I
can assure you that if they are torn and frayed that the radiology department or hospital
gives infection control a very low priority, if any such policies exist at all. The fact that
the children’s hospital Dr. Rothschild refers to passed a Joint Commission inspection
while using these torn and contaminated pads clearly means that these inspectors are not
going into the MRI suite and magnet room looking at the conditions of the pads.”
Finally, Dr. Nolan adds “The lack of infection control in the MRI suite can result in a
threat to the entire hospital as well as the outpatient community.”
In his recently released white paper published in July 2008, Rothschild calls for more
infectious disease control policies in the industry and patient education on how to prevent
contracting a superbug infection from their MRI scan. He also provides an 11-step
checklist for radiology technologists that were developed with the help of the nation’s top
infection control experts.
To request a copy of Dr. Rothschild’s white paper, titled “Preventing Infections in MRI:
Best Practices for Infection Control in and around MRI Suites,” contact Doug Kohl,
Sierra Communications, (209) 586-5887, or . More information on
superbug infections in MRI can be found at http://www.promedical.org./blog
About Peter Rothschild, MD
Dr. Peter Rothschild is considered one of the world’s foremost MRI experts. He formerly
served as Medical Director of the research laboratory at the University of California, San
Francisco, where he helped develop the first commercially available Open MRI scanner.
He is the editor of the first textbook on Open MRI, authored numerous papers on the
subject and is a sought after speaker who lectures on MRI and its future. Dr. Rothschild is
a Board Certified Radiologist and served as an Adjunct Assistant Professor of Radiology
at the University of California at San Francisco. He earned his MD degree in 1981 from
the University of Louisville, in Louisville, Kentucky. He is founder and president of
Patient Comfort Systems, Inc., a company dedicated to patient comfort and safety.
Photography
To view photographs of the worn pads from a well-known children’s hospital, visit
http://Superbug.smugmug.com
The pictures accompanying this press release clearly show tape and tape residue on torn
contaminated pads. These pads were used for many years at a well known children’s
hospital. During this time the MRI facility was accredited by both American College of
Radiology and the Joint Commission for hospital accreditation.
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