GE Healthcare was forced to shut a production plant in April because of a COVID-19 outbreak in Shanghai, China. This plant supplies most of the iodinated contrast media (ICM) used in the United States for imaging studies and image-guided treatments. Over 40% of computerized tomography (CT) studies use these agents, and many healthcare systems only have limited supplies.
Recommendations from the American College of Radiology® (ACR®) that guide imaging providers and their institutions on how to address this emergency locally appear in the Journal of the American College of Radiology (JACR), published by Elsevier. JACR also presents case studies from two healthcare systems that were able to reduce their ICM usage by at least 50%, providing helpful data to help practices prioritize and inform health system decision making during the crisis.
In the statement from the ACR, lead author Carolyn L. Wang, MD, University of Washington, Department of Radiology, Seattle, WA, USA, and colleagues stated, “Our recommendations are not exhaustive or prescriptive. They are intended as a resource for healthcare providers to provide high-quality patient care during times of shortage of contrast media.”
Recommended risk mitigation strategies include:
- Use alternative studies, such as non-contrast CT, MR with or without gadolinium-based contrast media, and ultrasound with or without ultrasound contrast agents, and use of PET/CT when feasible.
- Look for alternative vendors and versions of contrast agents, which may be marketed under a different brand name or clinical use.
- Use a single vial for more than one patient only under the guidance of qualified healthcare personnel from the institutional pharmacy because of the risk of contamination and infection.
- Minimize individual dosages to reduce waste. Options include weight-based dosing for CT in available vial sizes and/or using lower doses in conjunction with low peak kilovoltage protocols or dual-energy protocols to improve contrast brightness.
- Reserve higher concentration agents for angiographic and multiphase studies, which require optimal vascular visualization.
- Use alternatives to nonionic contrast for oral, rectal, and genitourinary administration.
According to Dr. Wang, it is important to note that these agents are used by departments other than radiology, including urology, radiation oncology, pain management, gastroenterology, vascular surgery, and cardiology. Prioritization of limited supplies must be coordinated throughout the system.
When the shortage was announced, Vanderbilt University Medical Center (VUMC) identified a reserve of seven to 10 days’ worth of ICM on hand. They recognized immediately that extraordinary steps would be needed to conserve the remaining supply. Laveil M. Allen, MD, Executive Medical Director and Section Chief of Emergency Radiology, and Reed A. Omary, MD, MS, Chair of the Department of Radiology and Radiological Sciences, VUMC, Nashville, TN, USA, and co-authors share actions taken to develop mitigation, communication, prioritization, and procurement strategies.
“Imaging services are the eyes of medicine and preserving our ability to diagnose the most critically ill patients is essential to quality care,” explained Dr. Allen.
A radiology command center team (RCCT) was created immediately. They tracked contrast exhaustion risk (CER) levels, which were updated each day to reflect the volume of contrast on hand and estimated supply remaining. A tiered strategy for outpatient imaging centers was created to identify patients whose need for a contrast image was critical and patients whose studies could be delayed or replaced by an alternative study. Outpatient CT orders across the system were collected centrally and reviewed by a subspecialty radiologist on the RCCT to confirm the tier level or suggest a tier change with the referring clinician. Communication across the health care system was key.
VUMC’s combined strategy of setting up an RCCT, forming multidisciplinary partnerships, and implementing contrast mitigation strategies reduced contrast use by 50% in less than seven days. “Hopefully, our shared mitigation strategies can provide clarity on a path forward in this time of crisis,” noted Dr. Omary.
At the University of North Carolina, Chapel Hill, the Department of Radiology’s mitigation strategy made protocol changes across the board to conserve ICM for uses in which alternative options are not available. Every contrast-enhanced CT examination already scheduled is being scored by a radiologist as “contrast-enhanced,” “non-contrasted,” “reschedule,” or “route to alternative examination to prioritize contrast administration.”
Some patients are being redirected to an MRI or ultrasound study. Because MRI requires pre-authorization, institutional leadership is engaging with payer leadership to explain the potential increase in MRI orders to hasten the authorization process and prevent unnecessary delays.
With improved workflows, reduced inefficiencies, and nursing staff freed up from intravenous line placements for contrast-enhanced CT redeployed to MRI, the department has achieved significant contrast use reduction, exceeding their target of 50%.
“Navigating the COVID-19 pandemic has helped radiology departments become more nimble and develop rapid response functionality to manage crises, including the iohexol contrast shortage, and potential future crises that we will face,” observed senior author Mahmud Mossa-Basha, MD, Professor, Vice Chair, Quality and Safety, and Medical Director, MRI, Department of Radiology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.
While most reports published about the ICM shortage have been clinically focused, a group of researchers has published a new study using empiric utilization data that could help prioritize and inform health system decisions by focusing mitigation efforts on areas in which contrast media are more frequently used. They obtained and retrospectively analyzed data from the Medicare Physician/Supplier Procedure Summary Limited Data Set for 2019. This dataset includes 100% of 2019 Medicare Part-B fee-for-service claims.
Researchers extracted national counts for services for all contrast-enhanced CT services by body region and site of service (inpatient and outpatient hospital, office, and emergency department) and separated those codes into CT angiography (CTA) and nonangiographic CT services. They found that utilization of contrast-enhanced CT was highest in the hospital outpatient and emergency department settings. Overall utilization was highest for the abdomen/pelvis and chest in those settings, with abdomen/pelvis the most frequently rendered by far. The ratio of CTA to nonangiographic contrast-enhanced CT was greatest by far for the brain in the emergency department followed by the inpatient hospital setting. Across all places of service, this ratio is highest for brain, head/neck, and chest.
“Radiology practices and departments may find their greatest mitigation impact focusing on abdominal/pelvic and chest CT in the emergency department and hospital outpatient settings, as well as brain and head/neck CTA in the emergency department and hospital inpatient settings,” explained lead investigator Richard Duszak, Jr, MD, Professor and Vice Chair and Director of the Imaging Policy Analytics for Clinical Transformation (IMPACT) Research Center, the Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, GA, USA.
“We believe that the highlighted site of service and body region differences may help guide the creation of the most impactful specialty teams. Identification of settings and scenarios where CTA is most frequently used may help guide alternative imaging care pathways and most effectively and safely re-allocate resources to alternative modalities,” Dr. Duszak added.
“The field has responded rapidly to the contrast shortage. Any lasting changes, such as patterns of referral or utilization remain to be seen,” commented Ruth C. Carlos, MD, MS, Professor, University of Michigan, Ann Arbor, MI, USA, and Editor-in-Chief of the Journal of the American College of Radiology.