Capital Project Proposal: Magnetic Resonance Imaging

Capital Project I Capital Project I Capital targeted for technology enables hospitals to move ahead and provide valuable services to customers (Sandrich, 2008). This facility serves veterans and the capital project proposal is for a Magnetic Resonance Imaging (MRI) compatible monitor and a program for sedation services for patients. Nursing support is necessary for monitoring patients during magnetic imaging for patients receiving oral and intravenous conscious sedation or pain management. In some cases anesthesia support may be necessary and a physician or radiologist to provide orders and supervision for needed sedation to complete imaging. Several studies reveal that 14% to 20% adults need sedation to complete this type of
procedure successfully (Medical Advisory, 2003). Patients’ inability to maintain the necessary immobility during the diagnostic imaging and distress contributing to adverse health outcomes, cause suboptimal imaging secondary to motion. This causes decreased productivity of the Magnetic Resonance Imaging facility because of delays, repeat imagining, and cancellations. Understanding MRI Imaging An MRI (or magnetic resonance imaging) scan is a radiology technique that uses magnetism, radio waves, and a computer to produce images of body structures (MRI, 2010).
The imaging scanner is a tube surrounded by a giant circular magnet. The patient is lies on a moveable bed inserted into the magnet. The magnet creates a strong magnetic field that aligns the protons in the tissues (hydrogen atoms), which are then exposed to a beam of radio waves. This spins the various protons of the body, and they produce a faint signal detected by the receiver portion of the scanner. These signals produce diagnostic images by the computer. Magnetic Resonance imaging poses no radiation to the patient. Noise is a big problem for some patients during the procedure even with the use of ear plugs and headphones. This technology takes longer to acquire images, times required between 30 to 50 minutes per procedure. Images obtained by radiograph are very fast and require less patient cooperation to
acquire. Magnetic Resonance Imaging poses little risk to the patient, but studies highlight the risk of life-threatening adverse events related to sedation. Principles of Magnetic Resonance Imaging are important to understand. The standard unit of measurement of the magnetic field strength is a Tesla (T). One Tesla is equal to 10,000 Gauss (G). The earth’s magnetic field at the surface is equal to 0.5G to 2.0G and MRIs have field strength of 0.15T to 2.0T. Magnetic imaging acquisition takes longer and patient’s ability to remain in one position and motionless is imperative to obtain optimal imaging. This magnetic field disables or impedes the function of conventional monitoring equipment. Conventional monitoring equipment will not work in the magnet suite because of the strong magnetic field and conventional monitors and infusion pumps have parts made of ferrous materials. The magnet is always on. The ferrous materials can become dangerous projectiles that could kill a patient and damage the MRI unit and potential patient injury related to burns. Saturation of equipment monitors (magnets) can cause the motor to stop, slow down or accelerate causing the motor to burn-out. Conventional equipment has electronic circuitry may contain components that are affected by static magnetic fields such as transformers, switches, and relays. The magnetic field will stop a watch, erase magnetic strips on credit cards, cause burns for patients who have metallic paint on tattoos, and permanent eyeliner because of the ferrous content. Some patients cannot have this type of imaging because of pacemakers or other implanted devices. The Problem Patients have special needs related to acuity, claustrophobia, inability to stay motionless during the imaging acquisition, positional pain, cognitive deficits, psychological deficits, and need conscious sedation to complete this type of imaging. This facility does not have a program to serve patient’s need for conscious sedation for this procedure. This facility does not have needed monitoring equipment and lacks a program to accommodate the sedation needs of patients for magnetic imaging. Patients requiring conscious sedation need to be fee based out to private institutions at increased costs for this diagnostic service. Investigation reveals that approximately five percent of patients at this facility cannot successfully complete this procedure. No data is available on how many patients require repeat imaging or are rescheduled in private facilities that provide intravenous conscious sedation and pain management. Many of this facilities magnetic imaging reveals motion artifacts that make the imaging less diagnostic, and this is a waste of resources and the patient’s time. The technologist indicates that some patients are taking oral anxiolysis medications in an attempt to cooperate to complete imaging. A high percentage of the veteran population has anxiety disorders, post traumatic stress disorders, positional pain frequently unrelieved by oral medications, psychotic disorders, sleep apnea, schizophrenia, and with a high percentage of older patients with many cognitive deficits. All of these types of issues make it difficult for the patient to remain motionless for the time required to complete the imaging in a confined space with loud noises. Some patients do not show up for the appointment and probably many of these patients fail to come because of anxiety issues. When the magnet is not imaging, it is a loss in productivity and revenue. Many patients are taking large amounts of medication to treat these disorders and additional anxiolysis may not be a safe practice without monitoring the patient for problems related to oxygenation. Severe chronic pulmonary disease, congestive heart failure and other medical problems create cause for patient safety related to oxygenation and ability to remain motionless in a supine position for the length of the imaging without monitoring. Critical care patients cannot be done because of the inability to monitor that patient during the imaging and these patients must be sent out to private facilities at additional cost. Patient safety during imaging is a risk management issue for a high percentage of this facilities patient population. The other issue for critical patient imaging is no magnetic imaging compatible intravenous infusion devices. Professional and national standards of care associated with conscious sedation and monitoring provides guidelines to reduce and prevent risk to patients. Joint Commission (JCAHO) guidelines are clear on conscious sedation requirements for patient safety. JCAHO mandates that all patients receiving sedatives or anesthesia be monitored and recovered prior to discharge from the facility to ensure patient safety. The Safety Committee of the Society of Magnetic Resonance Imaging has published clear guidelines and recommendations concerning the monitoring needs for patients receiving any type of sedation in preparation for or during magnetic imaging (Medical Advisory, 2003). The recommendation is patients receiving any level of sedation require monitoring and observation during and post sedation. The American Society of Anesthesiologists Task Force on Sedation and Analgesia by non-anesthesiologists developed practice guidelines. The levels of sedation identified include minimal sedation (anxiolysis), moderate sedation, deep sedation/analgesia, and general anesthesia. The American Society of Anesthesiologists Task force states that non-anesthesiologists performing sedation and analgesia must be able to rescue patients from any level of sedation because the sedation may become deeper than the initial intent. The task force shows that appropriate monitoring of vital signs is an essential component of patient care, and should be maintained for all sedated patients to reduce the risk of adverse outcomes (Medical Advisory, 2003). A magnetic imaging compatible monitor would improve the patient safety; provide the ability to serve patient needs, and to develop a program for providing conscious sedation in the magnetic imaging. It would reduce the need to fee basis patients out to private facilities and eliminate the cost of transfer and travel to another facility. Many patients at this facility are taking oral sedation prior to reporting for scheduled magnetic imaging without monitoring during the procedure increasing the potential risk to the patient and the organization with the possibility of adverse outcomes. Organization Strategic Plan Capital spending on equipment is a significant investment for most organizations.
How well these capital dollars are aligned with strategic business goals influences the success of the organization (VFA, 2010). The Veteran’s Administration (VA) is the largest health care system in the United States of American. The VA health care system includes 153 hospitals, more than 773 community- based outpatient clinics, and 260 Vet centers (Strategic Plan, 2011). Veteran’s Administration’s strategic plan for 2011-2015 is to improve quality, accessibility of health care, benefits, and increase veteran satisfaction for all services provided for veterans (Strategic Plan, 2011). The transformation outlined in the strategic plan includes a comprehensive review of organization processes, technology to prepare for new times and new demographic realities. Part of the strategic planning for the Veteran’s Administration is improving the quality, improving access, and increasing the value of services provided. This proposal would be in line with the strategic plans for the organization. The VA commits to providing timely high quality care for veterans while controlling costs. Because of this commitment any services that can be provided without referring patients to the private sector is desirable. Referrals and transferring patients to outside facilities increases the cost for veteran’s health care. Additional cost is associated to poor quality imaging related to motion and
repeating the procedure. This poor quality imaging wastes resources and patient’s time. Proposal Improving services to veterans is clearly the mission and part of the strategic plan for the VA. This proposal includes the purchase of magnetic imaging compatible monitoring equipment to be used to monitor patients with high risk conditions, those needing sedation, and pain management. This acquisition would include a monitor of blood pressure, ECG, oximetry, and end-tidal CO2 monitoring capability. Acquisition of magnetic compatible intravenous pump is necessary to accommodate critical care patients requiring vasoactive infusions and also for the patients requiring anesthesia supported sedation. Normal infusion pump devices malfunction in the magnetic field, and can become missiles with the potential of injuring the patient or the scanner. Creating a position for a Radiology nurse would be beneficial to prepare, screen, provide comfort, and monitor patients during magnetic imaging procedures. Nursing support staff may be possible through the operating and recovery room staff with education in magnetic resonance imaging safety and environment. Daily scheduled procedures usually average eight to 11per day, approximately 1,040 to 1,430 examinations per year. Five percent, 52 to 71 patients must be sent to outside facilities that provide conscious sedation. This does not include the critical care patients who have to be transferred to another facility for diagnosis and treatment. Suboptimal imaging numbers are not available at this time because the service is relatively new to this facility. No available data on the number of repeat imaging is available. Three magnetic imaging compatible monitors identified to satisfy the need for monitoring for this facility including Datex-Ohmeda, Maglife C Plus, and Millennia. Table one demonstrates each monitors features.
Table 1. MRI compatible patient-monitoring systems
| |Datex-Ohmeda |Maglife C Plus |Millennia |
|Compatibility with MRI |Up to 1.5 T |Up to 3.0 T |Up to 3.0 T |
|Limitation |Must be outside of 2 mT |Must be outside of 40 mT |Can work in 0.5T |
|Features |ECG, Pulse oximetry, capnography, |ECG, Pulse oximetry, capnography, |ECG, Pulse oximetry, capnography, |
| |non-invasive blood pressure, 2 |non-invasive blood pressure, 2 |non-invasive blood pressure, 2 |
| |invasive blood pressure, 5 anesthetic |invasive blood pressure, 5 anesthetic|invasive blood pressure, 5 anesthetic|
| |agents |agents |agents |
|Cost used/refurbished |$8,000 |$9,800 |$19,000 |
|Cost includes |Monitor |Monitor |Monitor, remote monitor |

The monitor desired is the Millennia (Invivo) because of less distance limitation, greater availability of replacement parts, warranty available, and customer support, and additional monitor cables valued at $4,000. Customers report less monitor artifact with this monitoring system. The cost of the compatible monitor is approximately $22,000 and includes warranty and service for two years. The price includes one set of replacement monitor cables. The intravenous infusion pumps cost is $1200 each and a minimum of two needed. Infusion pumps are warrantee for one-year and the price includes charger and extra batteries. Supply costs include magnetic compatible EKG electrodes, end-tidal C02 tubing, infusion pump tubing, and potential monitoring cable replacement costs. A radiology nurse position would cost approximately $70,000 per year. The total cost for acquisition of equipment is approximately $24,400 (monitor, infusion pumps, and supplies). Indirect costs include development of policies and procedures for patients requiring conscious sedation during Magnetic Resonance Imaging procedures based on existing conscious sedation and pain management policies for the organization. Another cost is staff education in use of equipment and verification of competency for equipment use and comprehension of sedation policies and procedures. Invivo’s Millennia monitoring systems has a new price tag of $76,000. The new cost may be negotiable, and would probably be around $50,000 to $55,000. Purchase of a refurbished model for $19,000 would reduce the acquisition cost over $30,000. The return on investment would be less than one year if the service is provided by purchasing the refurbished monitoring system. The life of the refurbished monitoring system would probably exceed five years, data collected could show that this is an effective program and a new monitor placed in the budgeting process for the future Stakeholders The stakeholders in this project include patient services, director of radiology, imaging staff, risk management, medical director, radiologist, anesthesia, financial officer, chief nursing officer, providers, operating room and recovery room manager, pharmacist, and radiology nurse. Time to gain support for the program from stakeholders is require to ensure the success of the program. Working with the chief financial officer may help to obtain the needed data on the number of referrals to outside institutions and the cost of those referrals. This program requires gaining support for the program would be essential because I am not part of radiology at this institution but do have 15 years of radiology nursing experience. I have policies and procedures that are compliant with professional and accrediting agencies to share with the committee. Refinement and verification of the benefits of this type of program would need to be supported by the stakeholders to proceed. The development of the program to provide conscious sedation for magnetic imaging will take approximately a year or two to implement because policies and procedures required, staff education, recruitment of experienced radiology nurse to help develop program, competency development for monitoring equipment and procedures. Acquisition of needed monitoring equipment is required prior to implementation of service. The decision to invest in new projects or assets usually requires investigation of the cost to finance the program, and estimated cash flow generated over the coming years. In this case the savings to the organization based on cost of referrals, repeat imaging, suboptimal images, and risk management are clearly beneficial. Benefits The most obvious benefit is to improve quality of magnetic imaging by reducing motion artifact and decreasing suboptimal diagnostic images. Reducing the patient risks for adverse effects from oral sedation and providing needed intravenous conscious sedation to support and provide improved patient satisfaction and safety during the magnetic imaging. Decreasing the number of examinations that need to be repeated improves productivity and opens schedule to more patient examinations. Fewer patients will need to be sent to outside facilities. After investigation of imaging costs in the area it is discovered that the average costs for magnetic imaging in the area range from $1300 to $2250 depending on the type of procedure required (MRI costs, 2010). The addition costs for radiologist interpretation range from $350 to $800 per procedure. If the patient requires conscious sedation for the procedure additional costs include medication, anesthesiologist charges, and recovery charges, history and physical, and may average $500 to $1200 per patient. The charges for one patient in a private facility would range from $2150 to $4050 per patient requiring conscious sedation. Fifty patients needing conscious sedation or anesthesia services for magnetic imaging at a private facility would cost $107,500 to $202,500 per year. The cost of suboptimal and less than diagnostic images averages $1300 to $2250 per procedure. Magnetic Resonance Imaging provides an enhanced diagnostic tool for this facility and two other facilities patients and coincides with the mission and strategic goals of the organization to provide up-to-date services for veterans. It is important that this imaging tool provides quality information and patient safety. Another benefit is the addition of a radiology nurse to provide education, comfort measures, and monitoring for patients during the magnetic imaging. Having worked in radiology for 15 years many patients respond very positively with a person in the imaging suite that can touch and talk to patients during the procedure. This reassurance is frequently as effective as sedation. Patients frequently describe experiences in this type of imaging as anxiety producing because of the isolation, patients become frightened alone, quickly become panicked, and have the sensation that they cannot breathe. A simple touch and spoken word can prevent these panicky feelings for many patients, and they can remain motionless for longer periods. Tender loving care frequently is better than versed and fentanyl that are the drugs frequently used for conscious sedation. Watson’s theory on nursing identifies the science of caring as complementary to curing and the therapeutic relationship of the nurse and patient as “healthogenic,” effective caring promotes health, and caring consists of factors that result in the satisfaction of human needs (Nursing Theories, 2010). Research on therapeutic touch is also supportive of the interpersonal relationship between nurse and patient. Nurses recognize the benefits of touch and caring on patient care and the benefits identified in the literature include stress reduction, diminished pain, increased sense of well-being, boosting the immune system, and soothing mind, body and spirit. Touch and caring improve patient satisfaction. Data collection on caring and touch effects provides an opportunity to further develop nursing theory, and the concept of therapeutic touch in nursing, and is a good topic for clinical research. Organizational and Management Goals VA strategic plan for 2011 to 2015 clearly supports the development of the program to provide monitoring for patients requiring any form of sedation for magnetic imaging. This program meets the criteria of the plan; improving the quality, improving access, and increasing the value of services provided. Management goals of quality imaging, patient safety, providing the best services for veterans support this program. Conclusions Magnetic Resonance Imaging monitoring, conscious sedation support for patients, and a dedicated radiology nurse can improve patient safety, patient satisfaction, productivity, quality of imaging, and decrease costs associated with referrals to outside agencies for repeat examinations. The economic values to the organization are reduced referral cost amounting to greater than $200,000 per year, less financial risk related to adverse outcomes to patients having magnetic imaging, and improved patient satisfaction by reducing anxiety associated with magnetic imaging. Clinical research possible on effectiveness of comfort measures during magnetic imaging provided by nursing involvement in the patients care during imaging could be beneficial to the health care environment and support the development of nursing theory. The cost of this program could eliminate repeat imaging that costs between $1,300 to over $2,000 per procedure. Only 10 repeat procedures justify the equipment cost and the value of reduced risk to patient safety.

Reference
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