My name is Linda Moy, and I am a breast imager from New York University. I'm also the senior deputy editor for a journal Radiology. I want to thank all of you for joining us today on this webinar entitled Strategies to Manage the Shortage of Iohexyl. This is a town hall style meeting, and our goal is really to answer your questions, see how our whole community is addressing this shortage. So what I'd like to do first is to introduce our renowned group of speakers, then we have a short poll, try to identify where all of you from so we can tailor our answers. And then throughout this zoom call please put in all your questions into the chat, it will be monitored and we will try to answer as many questions if you have a lot, I will follow up with it after the end of this webinar so without further ado, I'd like to introduce our first panelist, Dr. Andy Beerholz, he's Professor of Radiology at WashU, Director of Cardiothoracic Imaging, Vice Chair of Quality and Safety at Mellon Cron. And Dr. Beerholz, can you go ahead and just sort of tell us about your practice setting, and whether you have been affected by this shortage of the Iohexyl Ionated Contrast media please. Yes. So, like everybody, we have been affected probably less in certain respects than some institutions, but still have been affected. We, Mellon Cron, WashU, we cover mostly Barnes Jewish Hospital, eight hospitals in the system for BJC, of which there are seven others that we don't cover. So a lot of our policies procedures and ways to address the shortages really required us to work within the enterprise but also collaborate with other private practice groups that cover multiple hospitals within our network or within our enterprise. In addition, we cover a small rural hospital outside of the network which has been very challenging working in a more rural community to address a lot of these shortages which is probably our biggest effort that we had to deal with throughout this issue. Great, thank you so much. That was a nice summary. Next is Dr. Elliot Fishman. He is a professor of radiology, surgery, oncology, and urology at Johns Hopkins. He's a renowned expert in CT. Dr. Fishman? Yeah, thanks. It's great to be here. I guess I have sort of a similar comment. I mean Hopkins, you know, I mainly work at the hospital downtown, but we have several other hospitals, we have multiple imaging centers. And I think the challenge is, you know, trying to coordinate everything where everyone has the same policy that we don't do something one way at an outside hospital or an outpatient center compared to the main hospital. Trying to get the information to everybody and getting everybody on board from the techs to the radiologists to the referring physicians. So it's a challenge and I think as everyone else ended up saying today is, I think radiologists doing a good job and meeting that challenge. Great, thank you. Our next expert panelist is Dr. Mahmood Mosavasha. He's a professor of radiology at UNC. He's also the vice chief of quality and safety and director of MR. Thank you, Linda. And we're in a similar situation where within the UNC healthcare system, there's something like 18 to 20 hospitals. And they're all set, they all have the same formulary, they all have the same, you know, information systems, in terms of Epic and the same, you know, formulation of it. But similarly, we manage two of those hospitals. And in that setting, they're all Iohexol focused, you know, they all have Iohexol as their identity contrast agent on formulary. And so throughout the system, we're all dealing and managing with with this issue. Thank you. And our last panelist is Dr. Jeff Rubin. He's chair and professor, University of Arizona. He's a chief service. He's a clinical service chief of medical imaging at Banner University. Thank you very much, Linda. Hello, everybody. Great to be with you this morning. Our organization, Banner Health, operates 30 hospitals across four states in the southwestern, mostly part of the United States. And we also have a large outpatient imaging practice that includes over 30 outpatient imaging centers. And we have a fairly diverse supply chain for our contrast medium, as interestingly, there are variations across our organization in terms of which is the primary contrast material that is available. And so that has provided us with a diversity of opportunity and options. We have certain parts of the organization that have felt the pinch to a much greater extent, whereas others that have full inventory. And so a lot of our early activity has been focused upon a coordination and centralization of inventory and being able to assure that we have contrast material available to all the sites that to be able to use for patients in need. And then following that is a number of protocol actions, both to conserve contrast and to determine when we can use alternative imaging procedures. So look forward to unpacking these details with the fellow panelists over the next hour. Wonderful. Thank you so much. This is sort of nice for us to really get a sense of where we're going. So right now we just have a poll up, which is showing you what is your practice setting. And I've also started a chat for all of us to just to indicate where we're from. So I see that aside from others, we seem to have a pretty even mix of those in private practice, academia, and a multi-hospital system. Okay, and this is changing. I will let this run for a few more seconds and then Okay, terrific. So we get a sense of where, that there's a whole variety of us with a little bit more people that are in academia on the chat. I met you through to see that there are people that are in industry as well, who are joining us, you know, and I'd actually would love to hear if we had some technologists that were involved with this. So let me go ahead and start. So I'm gonna go ahead, I have this poll running for a few more minutes, just for another minute, and maybe we can go ahead and start answering the questions. Our first question, I thought maybe Dr. Fishman could begin. And here, my question is really, can you give us a sense about, you know, how many weeks of CT contrast do you have left? What options have you implemented, knowing as what Dr. Rubin just said, there's coordination and centralization of contrast. So with this in mind, do you have an incident command center? Do you have daily huddles, similar to what we did with our response to COVID? Yeah, I can't tell you how many days we have. That's like the secret of, I think more as no one really knows, probably. I think as many people know, GE has said they were shipping about 20% of typically what you have. Most places end up with a week or two weeks of contrast, which I'm sure will change after this clears away, and you'll probably be doing more like six months. But I think Hopkins has a combination of things. I think, you know, one third of contrast, a little bit more than one third of contrast is used by non-radiologists. So it really is beyond radiology. And it does take a central theme to it. There's a note today I got this morning, for example, that went to all the physicians and nurses and everybody in the hospital system, talking about the contrast issues, talking about the importance of ordering studies correctly, of putting studies off, kind of really spreading it around. So I think the good news is no one's really pointing fingers at radiology or anything to that event. I think internally and within the department, particularly in the individual divisions, let's say CT, you know, you look back at all of your studies, you know, what could you go from 110 CCs to 75 or to 50? Again, the key, and this note from Hopkins says the same thing is, what we don't want to do is compromise quality of care. So you can lower the dose to a point where you're not going to get a quality study where someone's going to get the wrong diagnosis or the wrong staging. So it's a little bit of a balance, but I think it's multi-level. I think, you know, it's, you know, the people, the techs, the radiologists in CT, there's department administration, and then there's the institutional administration and all of them trying to kind of coordinate the policy to, you know, a little bit, you're right, a little bit, it's like COVID, for example, taking larger bottles of contrast and having the pharmacy divided in half, let's say 150 to 275s. I mean, radiology wouldn't have the power to do that. You know, you need somebody who can tell the pharmacy to please do that. So I think getting everybody involved, I think is really a good way of, you know, creating support and making the process work well. Okay, great, thank you. So before I have Dr. Mosavasha answer a question, I'm trying to reframe my first question, which is coming from the audience, which is, do you have some numbers on the size of the contrast media shortage? And, you know, for example, how many doses are usually used and what is the gap? Just to sort of fine tune what I was saying, in addition to my original question is what opt changes have you implemented? And I guess there's, in the chat, there are really specific questions about how, you know, what are some of the numbers in the contrast media shortage? Yeah, so I was trying to find that, go ahead. Yeah, so I think in terms of the size of the shortage, I think that's, as Dr. Fishman mentioned, I think others had mentioned earlier, it really is different institution to institution. We know that the vendor that, you know, the Iohexol shortage, it was the contrast agent that was used in terms of 50% of the market share in the US. And so while their production, you know, has persisted and it's progressively ramped up, I think each institution had different levels of reserves. I know I've heard of some institutions with a week of contrast reserves as we were going through this, while others had a few weeks of contrast supply. And it's dynamic, you know, now shipments have started back from that facility as they've ramped up production to 50%, from 20% to 50% now. And the projection is that maybe in a few weeks, they'll be back up to nearly 100% production. So it is a dynamic issue. And I think it really depends on the severity of your shortage and the planned shipments that you're gonna be receiving, as well as the rate of your utilization that's gonna determine what steps you need to take and what actions you really need to do to mitigate the shortage. And do you have a daily huddle or pre-ops? We do, we do. We have a leadership committee that they're tasked with a couple of things. One is its task is to address radiology shortage, to engage with other departments that use contrast. And this is a multidisciplinary leadership committee. In addition, the responsibility is to review reserves that we have of contrast, to look at utilization rates and determine remaining contrast reserve that we have. And really calculate from there what next steps are needed in terms of our tiered approach to, and the various levers we can pull in terms of conservation of contrast. Thank you. Dr. Rubin, will you share with us your experience? Sure. So our organization coordinates through clinical consensus groups that are focused on large specialty domains. And so we have a medical imaging clinical consensus group that has partnered with pharmacy and has partnered with cardiology in particular to help to develop some of our early actions. IT would be an important other element that have been involved. And so I think that our first steps have centered on first understanding our inventory, which remains a work in progress across our organization. We were originally receiving contrast through two primary mechanisms, supply chain and pharmacy. And we have worked to consolidate that all under pharmacy. And the goal of these actions is to essentially create the kind of centralization and aggregation so that we have an understanding of exactly how much inventory we have as a system. And we have also worked with infection control to pilot a procedure to take single use vials that are larger volume, for example, 100 ML vials and to be able to split them into 50 ML vials. And that has been a successful pilot and we'll be rolling out through our organization. It's important to understand that INATED contrast material is supplied both in multi-use packs, which are larger volume, as well as single use. And the big difference is the multi-use packs are designed for multiple withdrawals of the contrastation, but they also have a preservative that provides the longer life. The single vials have a more limited shelf life. And so as we build the 50 ML vials, but also creating 10 ML syringes that are intended to be small aliquots used, particularly in cathangio, those can have a shelf life anywhere from 48 hours. And so operationalizing that element to really break down our contrast savings has been a big focus. And in fact, in piloting the use particularly of those 10 ML syringes, over the course of several days, we saw a reduction in contrast medium usage in our interventional practices of 75%, which is an indication of the amount of waste that was going on on the table just by opening larger bottles of contrast. So we are seeing a similar savings with the 50 ML vials as well in CT. And I think it's important to recognize that these kinds of savings are available even before anyone makes any changes in patient care or where patients are potentially being referred. Another important operational element for us is to get upstream and to inform our referring physicians to be sure that at the time of placing the order, that they understand that we are experiencing this shortage. And so we have an alert now that comes up in our electronic health record at the time of ordering CT scans that provides an explanation of the current condition of contrast medium availability, but also provides them a link to recommendations for alternative imaging studies and consideration for the request of unenhanced CT scans so that we're trying to avoid the condition of having to try to change orders after they've been created, which puts a lot of burden on the radiologists and the radiology department to change orders and to get upstream and hopefully to help our docs order alternative exams. And so it's all a dynamic process. It's all kind of happening at once. And it will be sort of a cascading series of actions as we learn to see just how much each of these individual actions bring an impact to our contrast conservation. The last thing I'll mention at this point is that we have established a tiered approaches across our organization to how aggressively to potentially limit the ability to order contrast enhanced CT scans. We're currently in a tier two state, which means that there is a restriction in outpatient imaging requests for contrast enhanced CT. It's limited to circumstances of acute or urgent indications as well as patients with cancer follow-up. And otherwise it is needing to go through a radiologist for approval. And as we move through to greater stages of limited supply and hopefully we don't have to do that, but if it does happen, we have further tiers that help to inform everybody about the policy to be followed in terms of limiting contrast utilization. Thank you for that comprehensive response. Dr. Beerholz? Yes, thank you for the opportunity to be involved in this and speak here. So I'm gonna probably echo a lot of things that was already kind of stated by other speakers here, but first and foremost, I really wanna kind of reemphasize what Dr. Fishman pointed out, which is we wanna provide safe quality studies and really not negatively impact our diagnostic capabilities when we are developing these workflows to conserve contrast. So much like other institutions, we have developed or have a weekly huddle at an enterprise level, and as well as throughout the week, we are having kind of smaller huddles with different service lines, whether it's CT or interventional, the technical or professional side to kind of disseminate the information. But at a higher level, we have taken a multi-step approach. One, kind of what Dr. Ruben had mentioned is messaging to our referring providers throughout the enterprise of the shortage that is out there and kind of advising them what we are dealing with to kind of encourage them, if possible, to order on the front end alternative imaging studies, whether it's ultrasound or MR that might not use iodinated contrast. In addition, we've worked with the different groups, whether it's cardiology, radiology, pain management, to change formularies, if possible, away from the agents that are limited and kind of moving over to other agents that we have supplies of when it is safe to allow that to be distributed. In addition, kind of what Dr. Ruben has mentioned, we have gone and worked with pharmacy, especially for selected agents for intrathecal injection to break down into smaller aliquots, the single-use vial into multi-use vials that is done by the pharmacy. And I just, again, this is the purpose of having these multidisciplinary huddles that involve in our institution, pharmacy, supply chain, professional radiology, technical side, really to ensure that everyone is on the same page, but to coordinate efforts, because the goal here is to maximize your supply or minimize your waste. And to do that, you really have to coordinate the different groups. For instance, if you are changing imaging protocol, CT lowering from 100 mLs to 75 mLs, you need to have agreement across the different radiologists, if you have multiple groups as to what the pharmacy is going to be things down into, but also have understanding from the pharmacy as what they can do supply-wise. So that's kind of just rehashing a lot of what's already been said. And one of the other things we were unique that we have a small community hospital kind of outside of our enterprise that's been much more difficult for them to get supplies. So we've been working, again, in a similar vein, kind of having two different huddles to ensure that the policies, procedures can be organized across even different hospital systems. So thank you. Thank you all for this comprehensive response. So it seemed as though the two takeaway points is it really involves coordination amongst all of your practices to really make the best use of the contrast agent. And it seems that all of us are having a tiered approach for urgent cases. Those can wait a little bit, and those that may be not urgent can wait a little bit longer. Let me get a next question, but begin with Dr. Mosabasha, which is, can you tell me which services have been most impacted, for example, the emergency room? And specifically, what changes have you made with scheduling? For instance, extended ultrasound or MR hours? Have you implemented shorter MR protocols? So in terms of MR, we have not modified our template schedule yet. I think we do have contingency plans to reorganizing the template if there is a need going forward. We have shortened a number of our protocols, including some body protocols and neural protocols, especially the heavy use protocols. And we've created strategies to divert specific types of exams to MR, including stroke code to an abbreviated MR stroke, MRI brain and neck, and some indications for MRCP. We also created workflows where non-contrast exams can serve as the initial screening exam for things such as concern for infection or superficial infection. And if there are any soft tissue changes or any indications for concern that infection may be present, then a follow-up MRI will be performed. That way, that non-contrast study screens out the completely negative studies and the MR would help confirm the presence of an infection in that setting. Now, with these shortened exams, even with our schedule staying the same, they provide increased gaps within the outpatient and inpatient schedules, creating more flexibility and providing increased opportunities to fit exams within the blocks. I believe the other part of the question was which ordering providers have been most affected. And I think the emergency department is certainly one. I think where rapid diagnoses are needed and a lot of their studies do rely on contrast, I think in terms of cancer evaluation, that's another area that's been certainly impacted. I think another area where we have a lot, had a lot of give and take is with providers that use contrast themselves with interventional cardiology and with orthopedic surgery, intraoperatively using iodinated contrast, endocrine for various applications, and pain services. And with those providers, I think they are used to doing their procedures in one way, providing them alternative approaches, alternative imaging options, and also just discussing with them and emphasizing to them the need and the shortage that we're experiencing so that they really understand what needs to be done and how we can go about doing it and incorporate them into the decision-making process. A lot of times they'll have insights in terms of their procedures and their approaches that will really help guide our thinking and guide their process as well. Thank you so much. Dr. Rubin, anything else you'd like to add in terms of changes you've made specifically with scheduling of the imaging exams? So I think our approach has been to protect the most vulnerable patients and services. And so in a sense, our ED and our oncology service lines have not been impacted yet because we're trying to focus our resources towards serving those populations. And at this point, we have not made any changes to our imaging protocols other than our contrast-enhanced CT protocols, where we have reviewed the amount of contrast that we use per exam and particularly set a BMI threshold for reducing dosing down to 50 mLs. And currently, that threshold is a BMI of 30 or less. For a number of focused examinations, we are using 50 mL. I think it's important to understand that to a certain extent, if this threshold, and for us, it is a lower dose than we're usually giving, that we're very vigilant to make sure that we are not going too far and having insufficient contrast medium delivery that results in non-diagnostic exams or at least exams of limited diagnostic quality. So that is an evolving and dynamic process for us to make that evaluation. But from the standpoint of alterations in our MR or our ultrasound or our PET-CT schedules, no, we're just absorbing as best as we can. And one other thing I'll mention, and I noticed a question in the chat, is about regional impact. And although the Veterans Administration Hospital is not a direct part of Banner Health, we work very closely with the Southern Arizona VA Hospital here in Tucson, and they ran out of contrast fairly early. And so we have been prioritizing making available slots for people from the Veterans Hospital. We definitely want to support our veterans here in Tucson. And so assuring that we are creating those slots. We have other providers within the city that have varying degrees of availability of contrast. And that's an interesting dynamic from a market perspective in terms of how individual organizations can potentially help to offload and offset other programs that have lesser degrees of supply. It's complicated, as everybody, I imagine, can imagine. But our goal, of course, is to accommodate whoever comes through our doors and needs contrast-enhancing T. Thank you so much, Dr. Beerholz. Anything else? Just, you know, again, kind of rehashing quickly what other people have said, but we have not yet changed our workflow for MR or PET or ultrasound scheduling. We haven't felt the impact, but we have made a concerted effort for the emergency room in particular to not be changing the workflow. Again, those are emergency situations that really require, you know, our attention and our, you know, to make sure that we have the appropriate diagnostic capabilities. You know, we have contingency plans if things do get tighter, to start altering contrast dosaging and amounts, working with pharmacy. At our, one of our, the remote hospital that we cover, it's been a little bit more challenging where the elective cases have been rescheduled in a short term to ensure, you know, that supplies come in. And we have done some changes in education for things like ensuring in the rural locations for things like lung nodule follow-ups, that those get, you know, only done without contrast. So there is differences in approach from a rural community and an inner city approach that it seems like there's definitely how the availability of product, and I think, you know, it was referred to regionally, the availability of product in different locations is probably does impact how you are going to approach these solutions. Linda, can I make one other comment? And that is something I neglected to mention before. And that is, is that as we've gone to the possibility of using lower doses of contrast for certain exams, we have strongly emphasized the routine use of saline flush for every scan. And I think it's important to recognize that upwards of 15 to 20 mLs of contrast material can pool within the brachial vein, axillary vein, as well as in the connecting tubing from the injector. And so, you know, if we're really gonna maximize our use of contrast, not just for angio studies, but for all studies, we should be implementing a saline flush. Great practical tip. I'm gonna ask Dr. Fishman to respond. And also if you could respond, there's two questions in the chat about reducing KBP or going back to lower contrast dose, as well as either dual energy CT or multi-energy CT, please. Right. Yeah, so first, I think the biggest, I mean, a lot of what we do now is really trying to make sure people are comfortable that their patients are still getting the best quality of care. I think particularly in oncology, that comes up all the time, particularly people on trials or people who are getting preoperative scans for surgery. I think if you're gonna err on the side of giving a little bit more contrast, it would be those situations. In terms of, as Jeff mentioned, saline flushes is a great example. Dual energy CT, particularly things like runoff studies. People wrote articles years ago where you can use 20 CCs for doing runoffs with dual energy. Now, I never believed that. Now, the pictures look pretty impressive, but you can lower your doses substantially and do a really good job with dual energy in those scenarios. Also, particularly depending on your scanner, you can go from 120 to 100 kVP in most cases, and that'll help you a little bit as well, but a lot depends on your scanner and choosing the right parameters. But I think optimizing all of the techniques you have become very critical. I think also, as everyone has mentioned, it's really patient selection who really needs... We don't know how long this is gonna last. Is it another two weeks or is it another four weeks or somewhere in between? So I think you're trying to be really cautious, but again, it's that balancing between patient care. We don't want to make a mistake on any patient by not making the right diagnosis or not staging correctly. So I think it's a little bit of a balancing act, and I think it takes a little bit more work on our part. It takes a little bit more work on referring clinicians' part. It's a little bit more stressful on the technologists who kind of seem to be in the middle of everything, so it's a little bit of a challenge. Great, thank you. I think all of you, again, some recurring themes that you can lower the contrast dose and still really get pretty good imaging. So another question we have, Julie, what's been the response from the patients and referring physicians regarding the shortage, especially thinking about patients where you cannot go for the CTS contrast? And for that, I'll begin with Jeff, please. So you say particularly for patients who you cannot refer? Who you cannot give CT contrast, you know, when they... Yeah. They think they went out, but they go on the internet and they know that that's the best test to rule out right upper quadrant, right lower quadrant pain. Yeah, so, you know, there is a lot of heterogeneity in terms of the awareness of this current crisis amongst the public. And even though I think the news outlets have sought to help to educate folks, that variation still exists. And so I don't have line of sight on every physician-patient interaction or technologist-patient interaction around this. All I can say at a high level is, is that we have not had any major disruptions that have been raised related to patient concerns. I think that, you know, like any circumstances in healthcare delivery, there are unexpected circumstances that come up around the performance of imaging exams or any kind of services that we do. And so having a gentle touch and approach with the patient and having a staff that is trained to be respectful in helping the patients understand when alternatives need to be presented and when alterations occur. And that goes a long way toward helping patients gain acceptance. The other thing is to have our radiologists at the ready to be able to step in and provide explanations when patients would like to have more of a conversation around it. And just essentially preparing our team for those interactions prepares us to best be able to handle them as they occur. But at this point in time, we haven't really had any concerns or pushback. And I think as has been pointed out, a lot of what we've gone through over the last several years with shortages with COVID, whether it was PPE, whether it was oxygen, whether it was other supplies, I think have helped orient both our medical staffs as well as our patients to lean times. And so it's not perhaps the shock it might have been had this happened four or five years ago. Thank you. Dr. Behrooz, what's been the response from your patients and referring physicians? Thank you. From the patient perspective, we have not seen, at least I have not heard of, and again, at a higher level, really much impact or concerns from the patient perspective. From our referring physicians, we have really done and put out a lot of education, and they've been very receptive to working or collaborating with radiology to ensure that the patients get the best care they can. Again, there's a lot of more communication, I think, coming from offices and the outpatient setting to the reading rooms to discuss with radiology what are alternatives, what are options, can this be done with or without contrast to really maximize the supply and not negatively impact patient care. And I really want to stress, we did a large amount of education prepping the referring physicians as to what to expect and kind of what our limitations are and really gave them direct or more direct communication pathways to the radiologist to really, I think, temper some of their concerns or fears to make sure that we are caring for their patients. Thank you, Dr. Fishman. Anything else you'd like to add? No, I think probably the best way of thinking about it is kind of what Jeff said. I think this past two and a quarter years or whatever we've been going through, every day there's something else, whether it's a car or something breaks in your house and you can't get it fixed. Everyone is recognizing shortages exist throughout the supply chain. So, you know, if you would have said this three years ago, they would have pointed the finger at radiology and said, you guys have mismanaged. Now people, I think, are much more understanding that these things are happening. You know, even GE has not gotten a lot of grief. No one's blaming GE in the papers. Normally, you always blame the manufacturer. But, you know, whether you look at NVIDIA's report yesterday talking about ship shortages or you look at Apple not selling enough iPhones because they can't make them or Ford not selling cars, you read about it in the paper every day. So I think people are, what they're happy about is that we're concerned and that we recognize the problem and we're trying to mitigate any situation so that everyone is getting quality of care. And I think it's that understanding that we're on top of it, I think, makes people feel a little bit more comfortable. Thank you. Mahmoud, anything else you want to add? Yeah, so I completely agree with the statements that have been made. I think a major component is education and communication of our ordering providers. I think in terms of, you know, specific changes to specific protocols, indicating that, indicating the wisdom behind it. For us, for example, you know, targeted reductions, I think reducing contrast where it'll reduce waste is certainly necessary. But across the board, reduction in protocol contrast dosage certainly doesn't make sense. You know, if it results in, you know, utilization of a single-use vial or multi-uses from a single vial, that's great. But otherwise, you know, fitting within that schema. I also think, you know, as has been mentioned a number of times, you know, reduction while maintaining image quality is very important. And communicating that to the ordering providers that these steps we're taking will not compromise the image quality that you expect and you're receiving. So I think, again, it's come across that we need to do this messaging clearly to our patients, referring physicians, let them know that we are, you know, have active communication and education with them. And I think things that we've all mentioned, like decreased contrast dose and other things, these can probably incorporate it into our practices to improve efficiency, you know, going forward. The next question which I'd like to ask, and I'll begin with Dr. Bierholz, is that what imaging exams have you seen a significant increase in volume due to shorter contrast? For instance, you know, I've heard anecdotally that for rural IPEs that there's been increases in pulmonary MRAs and VQ scans. Have you noticed anything within your networks? So we have not actually seen a shift in the types of studies that have been done, such as VQ scans or GI bleeding studies for nuclear medicine. We have been able, especially for those emergent type cases, to really maintain the imaging and the workflow for the patients so there is no impact to patient care. We've been lucky enough with our supply chain to be able to manage what we have with that. On the procedural side, again, there have been a few, I don't want to say delays, but rescheduling of elective types of studies on the procedural side to delay with regards to the contrast shortage, as well as, you know, just going back to working with pharmacy to split up and maximize our utilization for things like intrathecal injections and minimize the waste. But overall, I can say that we really haven't seen in the urgent emergent cases that are necessary any delays or realignment or redistribution to other modalities. Elliot, any redistribution that you've seen? No, I agree with that. I think we've gone through all the different thought processes of, well, what can you replace from PE study? We've thought about everything, but at this point, it's not really happened. I think everyone is getting the study they need. I think there's been some of the oncologists have spoken a little bit about putting studies off, you know, the routine lymphoma yearly follow-up for a month or so, so little things like that. But in general, everyone's getting the study they would have gotten before. They would have been getting it with a little bit less contrast, perhaps, but they're still getting the studies. Mahmoud, anything you wish to add? Yeah, so I think when this all first started and the concerns first started, we did delay elective imaging that we triaged cases into need to happen versus could be delayed by a month or two. And so initially, we did see a reduction in volume. We did not see shifting of volume to other modalities. And then since then, I think volumes have picked up. As we've had plans for additional shipments of contrast coming, I think our confidence in terms of being able to weather this has improved. And in that setting, there hasn't really been a shift. We're continuing, and we really didn't need to activate our contingency plans for increased MR utilization. Thank you. Jeff? Yeah, I think that we have certainly communicated with our referring physicians for the most common exams, alternative approaches. And VQ scanning, in particular, in the setting of pulmonary embolism and in the setting of people who have normal chest radiographs is one area, pulmonary MRA another. What you find out pretty quickly when you seek to encourage certain non-standard pathways is when they are feasible and when, from an operational perspective, they're challenging. For example, do you have nuclear medicine technologists available overnight to be able to do VQ scans? And do you have the MR technology at any given hospital or any given site to effectively diagnose venous thromboembolism in patients that are suspected of having it, particularly patients that might be dysmic? And so I think we're trying to be really mindful and not make blanket statements and sort of have triage approaches that are facility-specific, time-of-day-specific, and patient-specific so that we don't essentially create more problems by disrupting our normal operational flow. Okay, great. Thank you. So I'm going to address a question that's from the chat. So in a scenario where, let's say, you order a non-contrast CAT scan of the abdomen and pelvis for abdominal pain and it's negative, Elliot, do you include verbiage in your reports about the shortage of INA contrast and recommend a follow-up study with contrast if necessary? You know, is there a hedge that you're putting to your reports? No, I think you kind of have to read the reports the way you, you know, dictate the way you always have. I've not put in, we have a contrast shortage, so please don't ask me for another study. I think, you know, it's almost the other way around. I think that we had the discussion last night about that, that some of the clinicians have heard about the contrast, and so they're ordering studies that need contrast and asking for them without contrast, you know, rule out the section or rule out a PE or rule out a GI bleed, and maybe they're trying, you know, typically when it comes from residents, they heard there's a contrast shortage, they shouldn't order with contrast, where literally the technologists have to call them up and say, hey, you need IV contrast, could you reorder it? So I think it's almost the other way around, you know, we've spoken to our techs, if something doesn't seem like it makes any sense, you know, you know, you got to call the doctor, because we're not at that point where we're so short of contrast that we can't do it, you know, we're just trying to be frugal with everything, but sometimes people are ordering studies incorrectly by leaving out the need for contrast when they need to have it. So I think that may be something people are experiencing also, that the technologists need to be aware that if they see something, it's kind of, if you see something, say something, just don't do the study if it makes no sense. Thank you. I'm going to ask them the same question and also tie in a question from the chat. So again, what do you do if it's a negative, you know, non-contrast CT or negative, you know, MR, do you hedge? And also people are facing issues with pre-cert for MRs, have you experienced that? So they're denying it's an MR staging when a CT would normally be ordered. Thank you. Yeah, so I think in terms of, in terms of reporting, you know, we've been trained a certain way throughout our careers, you know, report what you see, report the limitations that you see, you know, if the study that was performed and that you end up having in front of you is limited in terms of that evaluation and you have concerns, I think you certainly communicate that. I think you don't change your reporting style just based on the shortage. You know, we have not been reporting within our reports that there is a shortage or any verbiage to that matter. I think you just, you know, continue to report as you, as you have all along to convey what you see. And you can certainly recommend follow-up studies. If a contrast enhanced study could get you the answer, you know, you need to recommend that or MR or, or whatever else would be the next step. In terms of payers and insurance, I think this requires both, I think it's institutional leadership and, you know, hospital leadership and departmental leadership really being at the forefront in terms of having this, these discussions and then subsequently institutional leadership having discussions with the payers and the insurers to, to really ensure that they are, you know, they understand the circumstances as I'm sure all of them do. And, and they're willing to, to work with us in regards to the, the current circumstances. Because in the setting of, you know, a contrast shortage performing an MR, if the MR is, is really the option that you have, I think really conveying that message and getting them on board as necessary. Thank you, Jeff. What do you think? You have a big network that you're having a lot of pre-search issues. Well, it's something that we're working on as an organization with the insurance companies to see if we can get automatic prior authorization for some MRs. And that's a work in progress. As I mentioned, I think at this stage we're not seeing a tremendous amount of alternative exams being ordered by the radiologists having to change them. We're trying to get that done up front. And in that instance, then, you know, the prior authorization is less of a problem. And we haven't had anything come to light in particular of a delay in service because of prior authorization, as long as it is attempted to happen at the time of the primary order for the exam and not some sort of urgent action within the radiology department when someone shows up for an exam where contrast isn't absolutely necessary. And Andy? Yeah, so first I just want to echo what others have said about the reporting. Not change, we have not changed our reporting style or structure or add any caveats that there is a contrast shortage. And I just, you know, to put it out there, we've done non-contrast studies, things get ordered all the time, maybe either incorrectly and the tech technologists do not catch it and it gets through to us. And you make the appropriate recommendation based upon what you're identifying on that individual study. So I think we just need to keep in mind while there is a shortage, you know, we really just need to be evaluating what is placed in front of us and make the recommendations appropriately. As far as the pre-certifications, again, we have not seen a shift with our current construct from CT or, you know, from CT to MR for restaging and noted any issues. All of our pre-cert work is done on the front end before the study is scheduled. If this does become a problem though, it really does need to be handled at a higher either hospital or enterprise level with the insurance companies. But the other thing I'll put out there, you know, if these changes are going to happen or if we're going to do this as an enterprise, you probably need to be showing to these insurance systems that it is going to be allowing you to extend the utilization of your CT contrast for more emergent studies. So you're going to have to make a really good argument when you start working with them either to get pre-auths automatically done or to make these individual pre-auths to have the data to support this extent, you know, how this is going to positively impact their other patients in their system or in their insurance plan. Great, thank you all for the comprehensive response. So we were chatting, you know, before this and it seems as though there are, you know, extensive supply chain issues and that disruption is the new norm. So Mamoud, I'll begin with you. What are your future plans for supply chain issues, whether it's supplies or even with staff for, let's see, radiologists or technologists? Well, so in terms of, so looking beyond contrast, I think just having flexible, nimble systems, I think to be able to address these challenges, I think in terms of equipment and supply, certainly consideration for diversifying the suppliers and the vendors that you use will be really important for contrast, for needles, for various things. I think it's certainly getting a number of different options on your formulary would be beneficial. I think in the short term, it probably would be more expensive for the institution, but in the long term, it certainly would be protective in terms of dealing with these shortages. I think in terms of staffing, both techs, radiologists, I think really thinking outside the box and looking at alternative approaches, you know, I know a lot of institutions are looking at increasing bonus pay, increasing various other forms of reimbursement to faculty and staff, providing flexibility, and I know, you know, NYU, NYU has certainly done this quite a bit, but hiring faculty to work remotely for your institution, providing that flexibility, providing various options in terms of career structure for faculty in order to, you know, really retain and be able to recruit in that setting. So it really has to do with just being a nimble system and being to take on, being prepared as much as you can and be being ready to take on new issues as they arise, and I think a lot of large academic institutions through dealing with COVID and through these additional crises in supply chain have become much more nimble than they historically were. Thank you, Jeff. Jeff, what do you do? So I think that we're going to learn a lot from this experience that should help us inform us about how we address inventory in the future. It's hard to make a blanket statement at this stage that, oh yes, we should increase diversification of our supply chain and we should maintain a larger inventory. Inventory costs are substantial, and when you think across a health system at all the kinds of supplies that can potentially be in shortage, you know, just because it happened with Ionated Contrast this time, it might be something completely different next time. And so, you know, ideally there is a coordinated and organized approach to try to identify the key supplies that put the organization at greatest risk, and then to use some standard operational tools to essentially calculate how inventory can impact the ability of the organization to function in the setting of no supply, of 50% reduction in supply, and essentially to do some scenario planning, I think is really what's required here. And I think the danger for an organization is to just say, oh, here's this experience that we had, this very specific one. One manufacturer, reduction of contrast delivery over the course of a six to eight week period with a slow ramp up in supply from an international factory, and assume that that's the scenario that we're going to see in the future. So I think that it's a wake-up call and that we should all undergo some introspection and build cross-disciplinary teams to be able to evaluate the scenarios, but I think that we would be remiss if we didn't first ask the question of what are our most at-risk scenarios moving forward, and what can we pragmatically implement as an organization in order to hopefully protect us in the future. I'm getting a lot of personal chats. Jeff, can you talk specific about staffing issues? How are you pivoting when you're short of techs or radiologists? So staffing, that's a whole other kettle of fish, and essentially we're doing everything we can from the standpoint of local and the national marketplace for experts, whether it's technologists, whether it's nurses, whether it's radiologists. I will say that as an academic center we have the tremendous advantage of growing our own, and I can't overstate the value of setting up a pipeline of people to develop from a very early stage, even from before they might even enter residency, and to build a culture within the department that is one that emphasizes retention and value of the people who are here as much as it does external recruitment. It is a huge investment to recruit people from the outside, and first and foremost is to eliminate or minimize the need to recruit by assuring that we're retaining all the great people we have. So those are some of the strategies we're taking. Of course, when we have urgent needs, we look at market dynamics, and we try to make sure that we're offering packages that are competitive, particularly within our local market, and putting all those things together to hopefully respond as best as possible to some of the manpower shortages that we've been experiencing. Okay, thank you. Andy? So yeah, I'm going to rehash probably things that have already been said, but we need to, moving forward, I think COVID as well as some other supply chain disruptions, now with contrast, and last fall we had some other disruptions, having at institutional levels, understanding of what is, you know, in different departments, what are necessary or critical items that you may want to have strategic reserves on, as well as having plans or scenarios that you need to develop and have it pre-packaged. So if you do have a limited supply of a certain item, you have very quickly ways to address it, rather than reinventing the wheel or building the plane as you're flying as the event is happening. So again, I think that it's going to be regional or institutional specific, but there are those key critical elements and devices and equipment that's going to be necessary to maintain functioning in multiple departments, and I think it's a multi-pronged approach, one having some component of a strategic reserve, as well as having plans or ways to address shortages in the short term until you can identify big, you know, bigger either supply chain or workflow workarounds. As far as, you know, the technical staffing and staffing from a faculty or a physician point of view, I think what Dr. Rubin said is important, you know, especially from a technical or technologist side, at least in St. Louis, we have a very closed market, so technologists are going to be moving from site to site to site based upon wages or hours or benefits, so developing some type of institutional culture of retention and developing additional training programs really to allow technologists or nursing to really grow throughout your ranks and to rise within your organization, I think is very important. As far as, you know, the radiology, you know, from a faculty or radiologist point of view, again, rehashing what was already said, having some degree of flexibility for all of that is very important, you know, whether it's benefits or remote working, flexibility and schedules, I think are things that we all need to really consider moving forward, as well as, you know, what is our staffing model, do you need additional staffing as faculty either need time off, get sick, pandemics happen to allow you to keep, you know, providing the same quality service without burning out your staffing. Thank you. I see it's almost two o'clock. Elliot, do you have any? Yeah, so real quick on the supply issues, I think you do need to rethink about how much storage you have. I know storage is expensive, but you just need to have reasonable supplies. A weak supply is not really a good thing. I think also radiology in general at higher level, whether it's RSNA or the ACR, really needs to be speaking to the vendors like GE, for example. I mean, obviously, you couldn't predict what was going to happen in Shanghai, but you can't let it happen second time. And we see this across industries from technology, whether Intel is building a factory or Western Digital or Tesla, you know, I think GE is going to have to be looking and I wouldn't doubt that within a year, they'll probably announce they're building a plant somewhere in Milwaukee or somewhere in between the coasts. I think you just need to really, they need to get around the supply issues themselves. And I'm sure they're probably thinking about that. They're not thinking about it, we need to tell them to think about it. That's one. In terms of staffing, I agree with Jeff, the number one thing you need to do, I don't care what business you're in, is retention. The cost of hiring, I mean, the reason companies like Google do so well is their turnover rate is 1.5%. When you're having a large turnover rate, it's, first of all, depresses everybody. And it's not a good thing. So retention is number one. I will say what COVID has done, if you told me that we would be hiring people who are remote to read the films at Hopkins, I would have told you you were a crazy person. But I think what COVID has done basically is changed what would have taken 30 years has made it happen in under three. I mean, we have, we're hiring people who are in Washington or California to read films. I think it's great and maybe it's what you need to do. But the question is particularly for academic institutions where reading films is the one thing of what we do, you're teaching, you're doing academic productivity. You can't be teaching over Zoom or whatever else you want to use. The way to teach is you're sitting next to somebody. So I think it's a real challenge. I think there's two different things. One is getting the work done. The other thing is building up the next generation of radiologists. I know when you speak to residents, I mean, that's their biggest concern. They feel they're not getting what they should be getting. So I think hopefully things will clear up a bit over the next couple of years. But I think the staffing thing is the thing that concerns me the most, quite frankly. Well, we're out of time. I just want to thank all the panelists for their excellent, excellent comments. And I know I didn't get through everything in the chat. I did copy them down and I'll try to follow up all these questions. So thank you all for your attention. Thank you very much. Take good care, everyone. Bye-bye.

Iohexyl shortage

iodinated contrast media

radiology strategies

healthcare collaboration

diagnostic quality

alternative imaging

supply chain management

staffing challenges

remote work in radiology

patient care impact