What would you do if your hospital was going to run out of iodinated contrast? Reduce the amount of IV contrast used for each CT scan? Administer multiple doses of IV contrast from a single-use vial? Defer non-urgent contrast-enhanced CT? Utilize alternative modalities, such as ultrasound, MRI, or PET/CT?

In March of last year, supply chain disruptions in China resulted in an unexpected 80% reduction in global supply of iohexol (Omnipaque, GE Healthcare). Hospitals needed to make immediate decisions about ways to conserve contrast. Otherwise, they may run out. The American College of Radiology [1], Radiological Society of North America [2], and American Hospital Association [3] released statements, and AJR continues to publish all of its research regarding the contrast media shortage as free and open access [4]. 

The situation was rapidly evolving, but getting more inventory wasn’t an option. As part of the response to the contrast shortage, our hospital system created and implemented an electronic health record (EHR) -based solution to help reduce iodinated contrast usage by targeting referring provider CT ordering patterns [5]. 

First, we added a sidebar to the ordering panel that presented an alert describing the shortage (Fig. 1), including the following strategies for imaging patients (Intervention 1; May 10, 2022): 

Fig. 1—Screenshot from electronic health record shows sidebar text displayed to referring clinicians after placing orders for body CT (defined as CT of neck, chest, or abdomen and pelvis) that describes iohexol shortage and provides appropriate strategies for iodinated contrast media conservation.

Oncologic Imaging

• Avoid contrast for chest CT done alone to assess metastatic disease, unless primary is thoracic malignancy
• For chest/abdomen/pelvis restaging exams, consider combining non-contrast CT chest with abdominal MRI
• Consider abdominal MRI for assessment of hepatic metastases

Non-Oncologic Imaging

• CT for pulmonary embolism (PE)—utilize risk scoring methodology, such as Wells criteria or pulmonary embolism rule-out criteria (PERC), before pursuing CT
• CT chest for lung parenchymal disease does not require IV contrast
• In case of suspected musculoskeletal infection, use MRI

Emergency Imaging

Neuro

• CTA head/neck—contrast needed to assess large vessel occlusion in patients within stroke treatment window. For subacute stroke outside window, please consider non-contrast head CT, followed by MRI, when appropriate
• Reconsider CTA utilization for low-yield indications, including headache and dizziness

Thoracic

• CT for PE—utilize risk scoring methodology (i.e., Wells or PERC)
• CT chest for lung parenchymal disease doesn’t require IV contrast

Abdomen/pelvis

• Pancreatitis and pyelonephritis—CT rarely indicated for these diagnoses
• For primary hepatobiliary concerns, right upper quadrant ultrasound remains an excellent choice, unless high likelihood that CT also needed to explain symptoms
• GI Bleeding—reserve CTA for patients with bright red blood per rectum or hemodynamic instability in whom acute intervention might be needed

Trauma

• CT torso with IV contrast is needed to assess for parenchymal or vascular injury.
• Consider non-contrast CT torso imaging (or radiography) in patients with low suspicion for parenchymal or vascular injury, such as elderly patients with ground-level fall and suspicion for rib fracture or thoracic/lumbar spine fracture

Next, we required referrers to enter additional clinical information into a free text field describing why iodinated contrast was needed for the CT (Intervention 2; May 16, 2022).

The number of patients undergoing contrast-enhanced CTs per day decreased from 726 prior to the interventions, to 689 after intervention 1, to 639 after intervention 2 (Fig. 2). 

Fig. 2—Box-and-whisker plots show changes during preintervention and postintervention periods in number of patients who underwent contrast-enhanced CT examinations per day. Centerlines represent medians, ends of boxes represent interquartile ranges, ends of whiskers represent interdecile ranges, and dots beyond ends of whiskers represent outliers.

The overall number of patients undergoing CT per day decreased, as did the percentage of CT exams performed with IV contrast. These decreases were seen for all CT, as well as body CT alone (neck/chest/abdomen/pelvis). As expected, there was a decrease in requests for contrast-enhanced CT and a corresponding increase in requests for non-contrast CT.

In summary, an EHR intervention was able to reduce the number of contrast-enhanced CTs per day by 12%, the total number of CTs performed per day decreased 2.7%, and the percentage of CTs performed with IV contrast per day decreased from 53.8% to 48.6%. This simple intervention was implemented within weeks of the onset of the shortage and led to rapid practice change. Along with other conservation strategies, our health system was able to avoid rationing and continue near normal operations.

References

1. Wang CL, Asch D Cavallo J. Statement from the ACR Committee on Drugs and Contrast Media on the Intravenous Iodinated Contrast Media Shortage. J Am Coll Radiol 2022; 19:834-835 
2. Grist TM, Canon CL, Fishman EK, Kohi MP, Mossa-Basha M. Short-, mid-, and long-term strategies to manage the shortage of iohexol. Radiol 2022; 304:2 
3. Shortage of Contrast Media for CT Imaging Affecting Hospitals and Health Systems. American Hospital Association website. www.aha.org/advisory/2022-05-12-shortage-contrast-media-ct-imaging-affecting-hospitals-and-health-systems. Published May 12, 2022. Accessed August 8, 2023
4. Contrast Media Shortage (Free). AJR website. www.AJRonline.org/topic/article-collection/cms1. Updated June 21, 2023. Accessed August 8, 2023
5. Glazer DI, Lucier DJ, Sisodia RC. Electronic health record order entry–based interventions in response to a global iodinated contrast media shortage: impact on contrast-enhanced CT utilization. AJR 2022; 220:1