Rapid Response to the Acute Iodinated Contrast Shortage During the COVID-19 Pandemic: Single-Institution Experience.

Description of Problem

Modern health care depends upon the use of radiologic imaging for diagnostic and therapeutic purposes. Iodinated contrast media (ICM) is used in radiology primarily for CT and fluoroscopy-guided procedures. Outside radiology, other services that use ICM include cardiology, vascular surgery, neurology, urology, and gastroenterology. Quaternary care academic medical centers with level I trauma services, comprehensive stroke centers, and ST-segment elevation myocardial infarction services all rely heavily upon a steady supply of ICM to treat patients.

In April 2022, a coronavirus disease 2019–related lockdown in Shanghai, China, stopped production of Omnipaque (iohexol) at a major GE Healthcare production plant, disrupting supply chains and resulting in a global shortage of all types of ICM [1]. GE Healthcare notified customers to expect an 80% reduction in order fulfillment that could last 6 to 8 weeks [2]. Upon receipt of this information, Vanderbilt University Medical Center (VUMC) identified a reserve of 7 to 10 days’ worth of ICM on hand. This estimate of total contrast reserves was based on inventory and average weekly contrast use rates.

The VUMC Department of Radiology and Radiological Sciences immediately recognized that extraordinary steps would be needed to conserve the remaining supply of ICM. We present our approach, outcomes, and limitations in this report.

What Was Done

Step 1: Establish a Radiology Command Center

Initially, a radiology command center team (RCCT) of eight members was assembled (six radiologists and two administrative personnel). The RCCT used a team pager, a shared Exchange mailbox in Outlook, and a centralized workspace. As conservation efforts spread hospital-wide, the RCCT collaborated with a larger group of 86 stakeholders across the health system, including pharmacy, IT, nursing, and patient scheduling, as well as radiology managers at affiliated hospitals. This group met daily to provide updates on ICM stores, use, and downstream effects such as increased demand for MR and ultrasound imaging.

We modeled the RCCT approach after command centers established during the early peaks of the coronavirus disease 2019 pandemic [3, 4, 5]. The RCCT focused on developing mitigation, communication, prioritization, and procurement strategies. These strategies paralleled the recommendations later released by the ACR [6]. Additionally, the RCCT proposed response strategies on the basis of contrast exhaustion risk (CER) and estimated days of remaining ICM on hand.

Step 2: Develop Contrast Mitigation Strategies

The RCCT’s mitigation tactics (Table 1 ) have been previously described in the literature, including eliminating contrast waste, recommending alternative examinations, developing reduced contrast dosing protocols, and dilution or substitution of ICM in interventional settings [7].

Table 1

Contrast shortage mitigation strategies by service

Service	Strategies
Pharmacy and infectious disease	Divide IV iodinated contrast doses from a single bottle using sterile technique
Diagnostic radiology	Decrease IV iodinated contrast dose by examination type and patient body habitus
	Perform multiple examinations from a single contrast bolus (ie, level I trauma assessment starting with CTA neck, followed by CT chest, abdomen and pelvis, and delated CT abdomen and pelvis assessment of the urinary tract)
	Reinterpret outside imaging studies to avoid repeating examinations
	Protocol all examinations regarding need for contrast
	Use ionic ICM as available for nonintravascular procedures
Interventional radiology	Use alternative contrast agents, such as gadolinium, air, and CO2; use ionic ICM for nonintravascular procedures
	Dilute iodinated contrast as much as possible (ALARA-like protocol)
Radiology technologists	Determine if similar contrast-enhanced CT examinations were recently performed
Outpatient clinicians	Consult with radiologists and ACR Appropriateness Criteria regarding iodinated contrast–free alternative examination options, such as ultrasound, MRI, and PET/CT
	Review upcoming orders and consider rescheduling, changing examination modality, performing without contrast, or scheduling at a different facility
Emergency medicine	Increase use of ultrasound and noncontrast CT for assessment of upper abdominal pain, superficial abscess, and others
	Require stroke resident approval for CTA/CT perfusion
	Restrict code stroke designation for patients within tPA window or suspected large-vessel occlusion
Trauma surgery	Order noncontrast trauma CT chest, abdomen, and pelvis for lower yield indications such as ground-level fall mechanism, isolated head trauma, and isolated extremity orthopedic trauma
Urology	Prioritize contrast imaging to new renal mass evaluation with no priors
	Recommend ultrasound or noncontrast CT for initial hematuria workup
	Consider noncontrast CT imaging for cancer staging
Oncology	Delay any contrast-enhanced follow-up imaging scheduled >9 mo from the previous imaging until anticipated end of shortage
	Recommend ordering any CT chest imaging without contrast unless there is concern for pulmonary embolism
Interventional cardiology	No left ventriculography on “healthy hearts”
	Limit angiography of the left and right coronary systems to two runs each
	Request pharmacy assistance to dilute contrast 50:50
	Use gadolinium contrast for balloon inflation device use

Note: ALARA = as low as reasonably achievable; CTA = CT angiography; ICM = iodinated contrast media; IV = intravenous; tPA = tissue plasminogen activator.

Multiuse Vials

Pharmacy repacked large volume single use vials into smaller volume syringe aliquots to prevent waste. They also separated large-volume contrast vials into smaller aliquots. Both processes required institutional approval from the infection prevention team before implementation.

Alternative Examinations

Using the ACR Appropriateness Criteria guidelines, the RCCT provided 24/7 consultation to referring clinicians to identify alternative imaging modalities to contrast CT. A hospital-issued pager served as the method to directly communicate with the RCCT for examination consultations. The pager number was included in all recurring institution-wide updates on the ICM shortage. An attending radiologist carried the pager Monday to Friday, 7 am to 7 pm. Outside those hours, the pager was stationed in the reading room and answered by the on-call in-house resident or attending radiologist. Radiologists educated ordering clinicians on the use of alternative examinations and helped develop new pathways for diagnosis and treatment.

Reduced Dosing

Following a method similar to the principle of “as low as reasonably achievable,” the volume of contrast administered for each examination or procedure was reduced to the lowest dose possible that would still provide adequate results. For example, the dose for abdominal and pelvic CT with contrast was reduced from 100 to 75 mL Omnipaque 350. Doses were not reduced for patients with body mass index greater than 35 kg/m2. Examination protocols were optimized for low–tube voltage and dual-energy techniques with the help of physicist, technologist, and physician specialists.

Contrast Dilution and Substitution

Procedural areas including interventional radiology, cardiology, neuroradiology, and fluoroscopy used gadolinium, CO2, and air when permissible as alternative diagnostic agents. Other mitigation efforts included dilution of iodinated contrast and altering protocols to reduce contrast use (eg, eliminating routine aortic root imaging during cardiac catheterization).

Step 3: Develop a CER and Tiering System for Outpatient Imaging

CER levels were developed and linked to institutional contrast supply. Each day, the CER was updated to reflect the volume of contrast on hand and associated estimation of days of contrast supply remaining. The CER was updated in real time to reflect the changing rate of contrast use as mitigation strategies were implemented in a process known as quantity forecasting [5]. Quantity forecasting involved predicting the required daily demand for ICM on the basis of factors such as patient demographics, geographic location, the anticipated time frame of ICM shortage, and minimum needs of our quaternary care services.

A tiering system was developed to determine the real-time radiology response strategy for outpatient imaging centers (Table 2 ). Emergency department and inpatient services were not curtailed by the tiering system.

Table 2

Tiering System

CER Level	Tier Designation	Description	Examples
Critical (<7 d of contrast on hand)	Tier 1	EmergentNo adequate alternativeDelaying will likely result in significant patient harm	▪ Stroke ▪ Level I trauma ▪ Acute MI ▪ Aortic dissection ▪ AAA rupture ▪ Massive transfusion requirement ▪ Inpatients with hemodynamic instability ▪ Septic shock with unclear source ▪ Pulmonary embolism
High risk (7-20 d of contrast on hand)	Tier 2	UrgentPriority status for alternative modalities, noncontrast examinations, scheduling elsewhereDelay of 1-6 d may not affect patient care	▪ New cancer workup in stable patients (especially aggressive cancer types such as large renal cell, pancreatic, melanoma, etc) ▪ Transplantation workup ▪ Infection in a stable patient ▪ Postprocedural complication in a stable patient ▪ Preoperative workup for a patient scheduled for surgery in >24 h
Moderate risk (21-30 d of contrast on hand)	Tier 3	Routine subacuteMay delay 1-3 wk without significantly affecting patient care	▪ Patients with cancer in clinical trials or needing study to determine next step in management ▪ Chronic infection requiring regular follow-up
Low risk (>30 d of contrast on hand)	Tier 4	Routine delayed subacuteMay delay 4-6 wk without significantly affecting patient care	▪ Cancer follow-up in patient responding to treatment on previous examination without new or concerning symptoms ▪ Unexplained microscopic hematuria
	Tier 5	ChronicDelaying 2-3 mo is unlikely to result in significant patient harm	▪ Annual cancer or lesion follow-up in patients in remission or uneventful clinical status ▪ Annual follow-up of syndromic condition with no new clinical concerns ▪ Adrenal nodule workup in asymptomatic patient without high-risk features ▪ Characterization or follow-up of a renal mass <2 cm

Note: AAA = abdominal aortic aneurysm; CER = contrast exhaustion risk; MI = myocardial infarction.

Step 4: Centralize Outpatient Contrasted CT Orders

Clinicians used REDCap electronic data capture tools hosted at VUMC to request outpatient contrast-enhanced CT examinations. This survey was supported by hospital IT specialists and sent to all medical providers within the VUMC enterprise. The survey is included in the Supplemental Material. Each survey response was reviewed by a subspecialty radiologist on the RCCT who confirmed the study tier level or else contacted the clinician to discuss a tier change. The order could then be sent on to scheduling.

Step 5: Communicate Across the Health System

Numerous documents were drafted by the RCCT, edited by administrators, and distributed institution-wide by the chief of clinical staff. An e-mail to medical providers included attachments with frequently asked questions, a description of the prioritization tiering system, a link for the REDCap survey, and contact information for the RCCT. Software specialists used a best-practice advisory in the electronic medical record to alert providers about the contrast shortage when an examination that required ICM was ordered. To assist providers and schedulers in explaining the situation to patients, scripts of suggested language to use and FAQs were created.

Radiologists also added an operational level agreement in the examination report that described the examination limitations on the basis of either the noncontrast or reduced contrast technique used and any associated examination recommendations for after the resolution of the contrast shortage. These communications are included in the Supplemental Material.

Outcomes and Limitations

Outcomes

The combined strategy of setting up an RCCT, forming multidisciplinary partnerships, and implementing contrast mitigation tactics successfully reduced contrast use by about 50% in less than 7 days (Fig. 1 ). In the setting of a global ICM shortage, these results preserved contrast for the most critically ill patients.

Fig. 1

Weekly contrast use before and after the implementation of coronavirus disease 2019–induced shortage mitigation efforts. Light blue color denotes weekly contrast use before mitigation efforts (April 1, 2022, to April 28, 2022). Dark blue color denotes weekly contrast use after contrast mitigation efforts (April 29, 2022, to May 6, 2022). The percentage decrease in weekly contrast use is listed above postmitigation totals. VUAH = Vanderbilt University Adult Hospital.

During this crisis, we learned that forming an RCCT is vital for crisis management. The success of our team in implementing ICM mitigation tactics across our health system required partnerships outside radiology. Also, determination of a daily CER was essential to apply examination requests to our tiered prioritization system.

Limitations

This case study involved a single academic institution facing an acute contrast shortage, with only 7 to 10 days of remaining ICM. Other institutions with increased days of remaining supply and/or reduced demand (presence or absence of trauma, stroke, or ST-segment elevation myocardial infarction services, etc) may seek alternative approaches.

Future studies can compare contrast mitigation tactics, assess the sustained impact on the utilization of imaging, and determine the effect on patient outcomes.