Temporary Guidelines for Ordering Images with Contrast

This memo outlines temporary guidelines for ordering patient imaging that includes contrast.

Recently we sent out a message to alert ordering providers of ongoing supply chain issues with contrast. In follow up, we want to provide a status update regarding iodinated contrast shortages due to a factory closure in Shanghai, China that has affected GE Healthcare’s production of Omnipaque and Visipaque. VMC contracts with GE for contrast and thus we have been impacted by this disruption.

Please review the guidelines below for how we propose conserving our limited supply of contrast, followed by the details about contrast supply limitations.

Imaging Contrast Conservation Measures

General Guidelines:

1. Determine whether IV and oral contrast are necessary to get the needed information for diagnosis. If you have specific questions, “Browse” in Voalte for Radiologist or use following numbers:
   • ER: x5004 (Fluoro/Late/Night rad): 24/7
   • IP: x6904404 (NM rad): 7:30 AM-5 PM
   • OP: 425-336-5054 (Oly CT rad): 7:30-5 PM

2. Consider the conversion of contrast-based imaging to non-contrast imaging or alternative modality imaging (e.g., ultrasound or MRI). Please consult with a radiologist.
3. We will follow existing policy and procedure to notify you of necessary changes to orders.  We can’t estimate the volume in this dynamic environment. 
4. Please ensure all CT contrast orders placed by medical residents and/or APPs are reviewed by a supervising or collaborating physician.
5. Repeat CTs when initial evaluation negative is typically low yield. If performed, strongly consider without contrast.

Specific Asks:

Oncology: Oncology staging exams should not be performed in the ED or inpatient setting. Outpatient oncology staging: (1) defer CT with contrast for several weeks, and/or (2) perform alternative imaging such as non-contrast CT, MR, or PET/CT, with potential for short interval follow-up with contrast CT if needed once shortage is stabilized.

Stroke: Ensure correct application of code stroke criteria and seek alternate to CTA as much as possible. For patients with lower risk of LOV and non-code stroke scenarios, perform non-con head CT< followed by MRI and/or MRA or cerebrovascular Doppler for evaluation of presence of stroke and vascular occlusion (utilize neuro-hospitalist consult and/or radiologist to guide decision making).

PE: Reserve CTPA for unstable patients and/or patients with high pretest probability. Otherwise, use VQ scan. The nuclear medicine department is staffed until 8pm.

PNA: CT chest without contrast is typically sufficient for characterizing radiographic infiltrates. Technologists are asked to change CT chest with contrast to CT chest without contrast (1) if ordered for infection evaluation, or (2) if patient has CT chest with contrast within 1 year. Please call radiologist for assistance if needed.

Abdominal pain: If possible, begin with US and/or NM hepatobiliary exam. For diffuse nonlocalized abdominal pain or suspected appendicitis, diverticulitis, retroperitoneal bleed, or hernia, strongly consider non-contrast CT abdomen/pelvis. In rare cases, a repeat exam with contrast may be warranted. Pediatric patients (<18) proceed as usual.

Superficial abscess/cellulitis: Use US or MR rather than CT.

CT enterography: may be changed to MR enterography.

Multiphase abdominal CTs: may be changed to multiphase MR.

AAA follow-up: Follow-up for size evaluation may be performed without contrast (use contrast if postoperative or intervention evaluation).

Background and Next Steps

 We are actively tracking our inventory and working with GE to ensure allocation of supply. We havebeen told to expect an allotment of 20% usual supply. Additionally, we are working with other vendors who might have inventory available. It’s important to note that this issue is impacting most of the United States right now. The shortage is expected to last through July.

We have performed initial projections based upon the latest information we have. Based on the contrast we have in hand and what we expect to receive, we feel that we will have enough contrast to last through the end of May. At that point, we may run out of iodinated contrast at VMC and/or may need to ration contrast for only the highest priority cases.

While we would like to be optimistic, given challenges and irregularities with shipping and potential for overpromising and underdelivering, we are pursuing a strategy that accounts for contrast in hand only. Given the potential that contrast-based imaging can facilitate life-saving information and intervention, we need to implement actions now to preserve inventory and plan if we run out of iodinated contrast.

To that end, our leadership team met this week and has defined the prior Conservation Measures based on (1) prioritization of emergent and urgent angiography-based procedures and imaging, and (2) focus on the most common contrast-utilizing procedures which have alternative modes of imaging. These recommendations are supported by the American College of Radiology position statement on the global shortage and are on par with measures at other hospitals in the community.

While these measures are employed, VMC will be taking multiple additional steps to conserve contrast, including a global reduction in dose used for common non-angiographic exams, substitution of oral contrast agents, and other logistical strategies.

The VMC Radiology and Vantage leadership teams will receive detailed weekly updates on the contrast inventory.

We have also identified an inventory threshold which, if reached, will trigger an emergency multidisciplinary meeting to identify Rationing steps that may be needed. It is our hope that with the above Conservation Measures, this will not be necessary. We commit to providing regular updates as the situation changes. Thank you all for your support as we manage this situation together. If you have questions, contact John_Wagner@valleymed.org.

Here is a local news story about the imaging contrast shortage.
NOTE: The details included about UW Medicine do not necessarily reflect the situation and supply status at Valley Medical Center.