American College of Radiology and Health Care

Philadelphia, June 23, 2022 – GE Healthcare was forced to close a production plant in April due to an outbreak of COVID-19 in Shanghai, China. This facility supplies most of the iodinated contrast agents (ICMs) used in the United States for imaging studies and image-guided treatments. More than 40% of computed tomography (CT) studies use these agents, and many health systems have only a limited supply.

Recommendations from the American College of Radiology® (RAC®) that guide imaging providers and their institutions on how to deal with this emergency locally appear in the Journal of the American College of Radiology (JACR), published by Elsevier. JACR also presents case studies of two healthcare systems that were able to reduce their use of ICM by at least 50%, providing useful data to help practices set priorities and inform healthcare system decision-making. health during the crisis.

In the ACR statement, lead author Carolyn L. Wang, MD, University of Washington, Department of Radiology, Seattle, WA, USA, and colleagues said, “Our recommendations are neither exhaustive nor prescriptive. . They are intended to serve as a resource for healthcare providers to provide high-quality patient care during times of contrast media shortages.

Recommended risk mitigation strategies include:

  • Use alternative studies, such as CT scan without contrast, MRI with or without gadolinium-based contrast, and ultrasound with or without ultrasound contrast agents, and use of PET/CT when possible .
  • Research other 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 direction of trained healthcare personnel from the institutional pharmacy due to 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 non-ionic 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 constrained supplies needs to be coordinated across the system.

When the shortage was announced, Vanderbilt University Medical Center (VUMC) identified a seven to 10 day supply of ICM available. They immediately recognized that extraordinary measures would be required to conserve the remaining supply. Laveil M. Allen, MD, Executive Medical Director and Section Chief of Emergency Radiology, and Reed A. Omary, MD, MS, Chairman of the Department of Radiology and Radiologic Sciences, VUMC, Nashville, TN, USA , and the co-authors share steps taken to develop mitigation, communication, prioritization, and sourcing strategies.

“Imaging services are the eyes of medicine and preserving our ability to diagnose the most critically ill patients is essential for quality care,” said Dr Allen.

A Radiology Command Center Team (RCCT) was immediately created. They tracked contrast depletion risk (CER) levels, which were updated daily to reflect available contrast volume and estimated remaining supply. 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 with another study. CT scan orders from outpatients across the system were collected centrally and reviewed by an RCCT subspecialist radiologist to confirm level level or suggest a level change with the referring clinician. Communication throughout the health care system was essential.

VUMC’s combined strategy of establishing an RCCT, forming multidisciplinary partnerships, and implementing contrast attenuation strategies reduced contrast usage by 50% in less than seven days. “I hope our shared mitigation strategies can clarify the way forward in this time of crisis,” noted Dr Omary.

At the University of North Carolina, Chapel Hill, the Department of Radiology Mitigation Strategy has made protocol changes across the board to retain ICM for uses where other options are not available . Each previously scheduled CT examination with contrast is scored by a radiologist as “with contrast”, “without contrast”, “reschedule” or “direct to an alternate examination to prioritize contrast administration”.

Some patients are referred for MRI or ultrasound. Because MRI requires pre-authorization, facility management is engaging with payer management to explain the potential increase in MRI orders to expedite the authorization process and avoid unnecessary delays.

With improved workflows, reduced inefficiencies, and nursing staff freed from intravenous line placements for contrast-enhanced CT redeployed to MRI, the department achieved a significant reduction in contrast usage, exceeding its goal 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 we will face. “, observed senior author Mahmud Mossa-Basha, MD, professor, vice president, Quality and Safety, and medical director, MRI, Department of Radiology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina , United States.

While most published reports on the shortage of ICM have focused on the clinic, a group of researchers has published a new study using empirical usage data that could help prioritize and inform healthcare system decisions in focusing mitigation efforts on areas where contrast media are most frequently used. They obtained and retrospectively analyzed data from the limited Medicare Physician/Supplier Procedure Summary dataset for 2019. This dataset includes 100% of 2019 Medicare Part-B fee-for-service claims.

The researchers extracted national service counts for all contrast-enhanced CT services by body region and service site (hospital, practice, and inpatient and outpatient emergency department) and separated these codes into computed tomography angiography (CTA) and non-angiographic computed tomography. They found that the use of CT scans with contrast was highest in hospital outpatient and emergency departments. Overall usage was highest for abdomen/pelvis and chest in these contexts, with abdomen/pelvis being by far the most frequently rendered. The ratio of CTA to non-angiographic CT with contrast was by far the highest for the brain in the emergency department, followed by the hospital setting. Across all service locations, this ratio is highest for brain, head/neck, and chest.

“Radiology practices and departments may find their greatest mitigation impact by focusing on abdominal/pelvic and thoracic CT scans in hospital emergency departments and outpatient departments, as well as brain and head/ neck CTA in emergency departments and inpatients,” explained principal investigator Richard Duszak, Jr, MD, professor and vice president and director of the Imaging Policy Analytics for Clinical Transformation (IMPACT) Research Center, Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, Georgia, USA.

“We believe that the differences in service site and body region highlighted can help guide the creation of the most impactful specialty teams. Identifying the settings and scenarios where the CTA is most frequently used can help to guide alternative imaging care pathways and reallocate resources in the most efficient and safest way to alternative modalities,” added Dr. Duszak.

“The field reacted quickly to the shortage of contrast. Any lasting changes, such as baseline or usage patterns, remain to be seen,” commented Ruth C. Carlos, MD, MS, Professor, University of Michigan, Ann Arbor, MI, USA, and Editor-in-Chief from Journal of the American College of Radiology.

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