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Clinical Resources for Emergency Shortages of Treatments and Supplies (CRESTS)
Topic Collection
April 10, 2026

Topic Collection: Clinical Resources for Emergency Shortages of Treatments and Supplies (CRESTS)

Shortages of pharmaceuticals, sterile supply, and other medical equipment increasingly require health care facilities and providers to conserve and allocate treatments and supplies. ASPR TRACIE developed the CRESTS Resource Page to be a central hub for rapid dissemination of subject matter expert vetted strategies and clinical best practices during current shortages.

This Topic Collection complements the CRESTS Resource Page by highlighting general and product specific resources that may be helpful planning for and addressing medical product shortages. Many of the resources included were developed during past shortages and reflect the lessons learned of the authors. The Topic Collection also includes resources that help define the scope of medical supply shortage challenges and identify issues to consider to help mitigate future supply chain disruptions.

ASPR TRACIE/CRESTS is an effort to offer best practice allocation strategies available from clinical experts and from published sources. These strategies must be adapted and adopted for local practice based on the situation. Shortages are dynamic and require adjusting strategies over time. ASPR TRACIE/CRESTS is not responsible for the accuracy of the information posted. The end user is fully responsible for the clinical implementation of any allocation strategies. 

If you are unable to find what you are looking for, or if you would like to submit a resource for possible inclusion, please contact our Assistance Center.

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Supply Chain Disruption

Ananthakrishnan, L., Kay, F., Zeikus, E., et al. (2022). What the Baby Formula and Medical Contrast Material Shortages Have in Common: Insights and Recommendations for Managing the Iodinated Contrast Media Shortage. Radiology. Cardiothoracic Imaging. 4(3): e220101.
This journal article describes how a large, academic safety net county health system conserve iodinated contrast media by optimizing use and changing ordering patterns of referring providers.
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Bammer, R. and Amukotuwa, S. (2022). Navigating Supply Chain Disruptions of Iodinated Contrast Agent for Neuroimaging and How Business Intelligence Can Help the Decision Process. American Journal of Neuroradiology. 43(7):944–950.
This journal article discusses solutions for reducing iodinated contrast material for stroke imaging, in the context of supply chain disruptions during the contrast shortage in Australia in 2022.
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Bertagnoli, S., Shastay, A., and Jew, R. (2025). What Does the Institute for Safe Medication Practices’ Survey Tell Us About the Impact of Shortages on Patient Safety? (Abstract only.) The Cancer Journal. 31(5):e0789.
The authors surveyed practitioners on their experiences with drugs, supplies, and equipment in the previous six months. They found nearly half reported shortages of hematology and oncology medications that affected chemotherapy regimens and impacted their organizations’ clinical and operational resources, risk of medication errors, and quality of patient care.
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Eastern Research Group, Inc. (ERG). (2025). Analysis of Drug Shortages, 2018-2023. Office of the Assistant Secretary for Planning and Evaluation, U.S. Department of Health and Human Services.
This data brief analyzes information from Food and Drug Administration (FDA) Drug Shortages resources and the FDA National Drug Code Directory. The report identified and characterized drug shortages between 2018 and 2023, including trends in the frequency of new and ongoing shortages, estimation of shortage durations, and evaluation of the prevalence of essential medicines in new and ongoing drug shortages.
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Office of the Assistant Secretary for Planning and Evaluation. (2024). Policy Considerations to Prevent Drug Shortages and Mitigate Supply Chain Vulnerabilities in the United States. U.S. Department of Health and Human Services.
This report provides background information on drug shortages, identifies administrative actions taken by the U.S. Department of Health and Human Services to address them, and suggests additional actions to consider to address the underlying causes of shortages.
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Office of the Assistant Secretary for Planning and Evaluation (ASPE). (2023). Impact of Drug Shortages on Consumer Costs. U.S. Department of Health and Human Services.
This report summarizes the findings of a study conducted by the RAND Corporation, which outlines existing and potential tools to address the cost disparities and shortages of drugs. Some data on prescription sales from the Food and Drug Administration (FDA) drug shortage database is also presented. The report also highlights potential policies to address cost increases during shortages and to ensure a sufficient generic drug supply.
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Pineda-Moncusi, M., Rekkas, A., Martinez Perez, A., et al. (2025). Changes in Use and Utilisation Patterns of Drugs with Reported Shortages between 2010 and 2024 in Europe and North America: A Network Cohort Study. The Lancet Public Health. 10(10):E835-E847.
The authors estimated annual incidence rates and period prevalence of medication use during reported shortages. Of 57 medications reported in shortage, they found 33 percent or more declines in rates of initiation of eight, prevalence of use in nine, and changes in indication, duration, and dose of some medications.
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Santhireswaran, A., Chaudhry, S., Ho, M., et al. (2025). Impact of Supply Chain Disruptions and Drug Shortages on Drug Utilization: A Scoping Review. Pharmacoepidemiology and Drug Safety. 34(7):e70178.
This scoping review summarizes findings from sixty published and gray literature observational studies on drug supply shortages. The authors identify the settings in which the shortages occurred, the drugs affected, and changes in drug use resulting from the shortages.
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Analgesia

American Society of Anesthesiologists. (2023). Statement on Neuraxial Medication Shortage and Alternatives.
This statement provides detailed tables for relative equivalence or alternatives to neuraxial medications commonly used in obstetric anesthesia that have been on drug shortage lists in recent years.
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American Society of Health-System Pharmacists. (2018). Injectable Opioid Shortage FAQ.
This fact sheet answers frequently asked questions related to managing shortages of injectable hydromorphone, morphine, and fentanyl.
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Khatib, H., Edwin, S., Paxton, R., et al. (2023). Enteral Sedation in Patients Requiring Mechanical Ventilation During an Intravenous Analgesic and Sedative Shortage. (Abstract only.) Journal of Pharmacy Practice. 37(3): 696-702.
The authors conducted a single center, retrospective, observational study comparing mechanically ventilated intensive care unit patients who received either a combination of enteral and intravenous (IV) sedatives or IV monotherapy during a shortage of sedatives. They found that enteral sedation may be an effective strategy to decrease IV analgesia needs during a shortage.
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Antibiotics

American Academy of Pediatrics. (2022). Amoxicillin Shortage: Antibiotic Options for Common Pediatric Conditions.
This page recommends alternative therapies during a national shortage of amoxicillin suspensions. It identifies non-suspension amoxicillin products and formulations and provides a table of other alternatives by condition when amoxicillin cannot be used.
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Pandey, A., Cohn, J., Nampoothiri, V., et al. (2025). A Systematic Review of Antibiotic Drug Shortages and the Strategies Employed for Managing These Shortages. Clinical Microbiology and Infection. 31(3):345-353.
This systematic review identified studies on antibiotic shortages, characterized the products in shortage and the causes, discussed the effects of the shortages on clinical and health system outcomes, and identified strategies to mitigate future shortages.
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Ramgopal, S., Rosenman, M., Zhang, L., et al. (2025). Alternative Antibiotic Selections During the 2022 Amoxicillin Shortage in the United States. Journal of the Pediatric Infectious Diseases Society. 14(1):piae122.
The authors studied the effects of a shortage of amoxicillin powder for liquid suspension on antibiotic use at seven children’s hospitals. They found an increase in the use of nonsuspension amoxicillin and broad-spectrum antibiotics, which in some cases did not align with practice guidelines, leading to concerns about antibiotic resistance from inappropriate use of broad-spectrum antibiotics and resulting treatment failure during longer or more frequent shortages. The authors also found an overall decline in antibiotic use during the shortage, suggesting greater alignment with practice guidelines for use of non-antimicrobial treatment strategies.
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Tschumper, E., Dupuis, K., McCrory, K., and Pitts, W. (2021). Evaluation of Prolonged Versus Continuous Infusions of Piperacillin/Tazobactam During Shortages of Small Volume Parenteral Solutions. (Abstract only.) Journal of Pharmacy Technology. 37(6):271-277.
This retrospective cohort study compared outcomes of patients receiving prolonged infusions of piperacillin/tazobactam to those receiving continuous infusions in a single center during a national shortage of small volume solutions. The authors found no differences in mortality, length of therapy, incidences of thrombocytopenia, acute renal failure, seizures, or 30-day readmission rates.
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Blood Culture Media

Butt, S., Kressel, A., Haines, B., et al. (2024). Rapid Implementation of a Clinical Decision-support Workflow During the National Blood Culture Bottle Shortage. Infection Prevention in Practice. 6(4).
The authors describe their hospital’s decrease of weekly average blood culture bottle use of nearly 30 percent during a nationwide shortage by implementing evidence-based blood culture restrictions in their electronic health record.
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Doern, C., Whitman, M., Doll, M., et al. (2025). Blood Culture Bottle Shortage Mitigation Efforts: Analysis of Impact on Ordering and Patient Impact. Antimicrobial Stewardship and Healthcare Epidemiology. 5(1):e6.
The authors assessed the effects of communicating blood culture guidance and implementing an electronic health record order throughout a health system during a shortage of blood culture bottles. They found these interventions reduced emergency department use by more than 40 percent and overall use by more than 35 percent.
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Humphries, R., Wright, P., Banerjee, R. et al. (2025). Rapid Implementation of Blood Culture Stewardship: Institutional Response to an Acute National Blood Culture Bottle Shortage. Clinical Infectious Diseases. 80(2):472-474.
The authors describe their health system’s significant reduction in blood culture orders during one week of a blood culture bottle shortage. Their stewardship efforts included guidance to providers in electronic health record blood culture order sets, restricting repeat blood cultures collected within 48 hours, limiting initial blood culture orders to a single set, and limiting initial blood culture orders to a single set except for patients with a Severe Sepsis and Septic Shock Management Bundle (SEP-1) alert.
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Ryder, J., Van Schooneveld, T., Diekema, D., and Fabre, V. (2024). Every Crisis is an Opportunity: Advancing Blood Culture Stewardship During a Blood Culture Bottle Shortage. Open Forum Infectious Diseases. 11(9):ofae479.
The authors share strategies for implementing blood culture stewardship using a graded approach based on supply. They include a table of step-wise mitigation strategies noting advantages, disadvantages, and estimated impact on blood culture utilization; summarize response approaches and tips for implementing stewardship interventions; and identify low-yield blood cultures to be minimized during a blood culture bottle shortage.
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Blood Products

Association for the Advancement of Blood & Biotherapies. (n.d.). Example Blood Component Shortage Notification and Contingency Plan for Hospital. (Accessed 4/11/2024.)
This hospital plan is offered as a template which can help hospitals to prepare for platelet, red blood cell, plasma, or other blood component shortages. It includes recommendations for assessments by transfusion physicians, notification strategies for blood bank leaders, and additional steps for long-term planning (e.g., creating a system to move blood products between facilities, improving blood bank notification to hospitals, and increasing community donations).
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Hermelin, D., Alcorn, K., Gammon, R., et al. (2024). Futility and Potentially Inappropriate Treatment in Massive Transfusion. Blood Bulletin. 24(2).
These considerations can help healthcare providers determine potentially inappropriate treatment in massive transfusion, particularly during severe blood shortages (e.g., during a public health emergency or mass casualty incident).
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Chelation

58. Singh, M., Kane, J., and Said, S. (2024). Pediatric Lead Chelation Managed During Critical Medication Shortages: Case Report and Literature Review. The Journal of Pediatric Pharmacology and Therapeutics. 29(5):544-549.
The authors share a case report of an infant treated with enteral succimer monotherapy following the exhaustion of a hospital’s supply of edetate calcium disodium during a national shortage. They discuss the need to identify and study alternative chelation therapy regimens and encourage efforts to mitigate treatment shortages through stockpiling in the Strategic National Stockpile.
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Chemotherapeutics/Oncology

Alpert, A. and Jacobson, M. (2019). Impact of Oncology Drug Shortages on Chemotherapy Treatment. (Abstract only.) Clinical Pharmacology and Therapeutics. 106(2):415–421.
This journal article analyzed outpatient chemotherapy use before, during, and after drug shortages for newly diagnosed patients with breast, colorectal, leukemia, lung, lymphoma, ovarian, or pancreatic cancer, using Medicare claims from Surveillance Epidemiology and End Results data. The article also highlights limitations of drug shortage reporting methods.
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American Society of Clinical Oncology. (2026). Clinical Guidance.
This webpage includes clinical guidance for the prioritization of limited supply of antineoplastic agents in addition to various disease site-specific and alternative treatment guidance documents.
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Santos, E., Oliver, T., Geisel, R., et al. (2023). Drug Shortages in Oncology: ASCO Clinical Guidelines for Alternative Treatments. JCO Oncology Practice. 20:19-32.
This journal article raises awareness, outlines strategies, and offers clinical guidance for treatment planning during antineoplastic drug shortages.
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Shuman, A. and Unguru, Y. (2020). Drug Shortages: The View Across an Ocean. The Oncologist. 25(4):274-276.
This editorial highlights the shortage of vincristine in February 2018 due to a decision of one out of two manufacturers to discontinue production. The article provides a summary of past policy strategies to address drug shortages in the U.S. and puts forth a set of additional policy recommendations to ameliorate relevant systemic issues.
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Socal, M., Acha, J, Yang, C., et al. (2025). Key Drivers and Mitigation Strategies of Oncology Drug Shortages 2023 to 2025. The Cancer Journal. 31(5):e0791.
The authors identified and studied the characteristics of recent drug shortages, categorized their causes, and described the mitigation strategies used to address them.
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Society of Gynecologic Oncology. (2026). Chemotherapy Drug Shortage Page.
This webpage includes information on chemotherapy drug shortages such as position statements, webinars, a discussion group, and links to media coverage.
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Tinajero, J., Markary, T., Chen, J., et al. (2025). Clinical Review of Substitutions or Alternatives for Critical Chemotherapy Drug Shortages in Hematologic Malignancies. (Abstract only.) American Journal of Health-System Pharmacy. 82(5):e224–e241.
This review of literature is on the antineoplastic agents used to treat hematologic malignancies that experienced a drug shortage from 2010 to 2023. Recommendations are provided for substitutions and alternative regimens during critical shortages.
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Fluids and Electrolytes: Intravenous Fluid and Electrolytes

American Society of Health-System Pharmacists. (2018). Sterile Water for Injection Shortage FAQ.
This fact sheet provides best practice recommendations to manage a shortage of sterile water for injection vials.
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American Society of Health-System Pharmacists. (2024). Small- and Large-Volume Fluid Shortages – Suggestions for Management and Conservation.
This article provides information on best practices for handling intravenous fluid shortages (e.g., sodium chloride injections, Lactated Ringers injection, sterile water, dextrose). The resource includes relevant definitions, general recommendations, as well as operational, informatics, and communication strategies.
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ASPR TRACIE. (2024). Intravenous Fluid Shortage Strategies.
During shortages of sterile fluids for intravenous (IV) injection, hospitals and healthcare providers must modify usual practices for administration to conserve product. The information in this tip sheet is derived from existing published resources, based primarily on previous shortage experiences.
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Australian Commission on Safety and Quality in Health Care. (2024). Fact Sheet – Conservation Strategies and Safety Considerations During Intravenous (IV) Fluids Supply Disruption.
This webpage provides clinicians with information on how to manage intravenous fluid supply disruptions for adults, children, and neonates. It also includes links to relevant resources.
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Gorgens, S., Alshadad, A., Malek, A., et al. (2026). The Impact on Healthcare Facilities of the 2024 IV Fluids Shortage after Hurricane Helene: A Mixed Methods Study. PLOS One. 21(4):e0344524.
The authors conducted a mixed methods study combining quantitative survey data and qualitative data from semi-structured interviews with members of the National Critical Care Task Force to characterize the severity of a nationwide intravenous fluid shortage and the challenges it posed to hospitals. They found nearly 90 percent of hospitals were affected by the shortage despite all respondents indicating they had supply shortage plans in place prior to the hurricane. The article outlines the various ways respondents allocated limited supplies, including more than 17 percent who gave some of their supply to neighboring hospitals. While the authors acknowledge the limited sample size and scope of their study, it is the first analysis of the shortage and attempt to develop a framework of solutions.
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Harris, T., Farrar, J. , Byerly, S., et al. (2024). Evaluation of a Novel Enteral Phosphorus Therapy with Enteral Nutrition during a National Intravenous Sodium Phosphate Shortage. Nutrients. 16(9):1394.
This journal article evaluates an enteral phosphorus therapy during a national shortage of intravenous sodium phosphate. The evaluation focused on the safety and efficacy of this temporary administration of a diluted solution for the treatment of hypophosphatemia in enterally fed patients with severe traumatic injuries.
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Mazer-Amirshahi, M. and Fox, E. (2018). Saline Shortages – Many Causes, No Simple Solution. (Abstract only.) The New England Journal of Medicine.378:1472-1474.
While saline is inexpensive, the authors note that keeping it sterile and suitable for intravenous injection requires careful manufacturing. This contributed to shortages after an intravenous bag production facility was affected by Hurricane Maria. The article includes a table of the history of saline shortages, and how saline and pharmaceutical shortages can affect patient care.
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Minnesota Department of Health. (2024). Recommendations for Ethical Allocation of Sterilized Fluids.
In 2024, Hurricane Helene damaged a Baxter facility that produced intravenous fluids and related products. This document provides a voluntary framework for the ethical allocation of these products until the shortage is resolved.
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Patino, A., Marsh, R., Nilles, E., et al. (2018). Facing the Shortage of IV Fluids — A Hospital-Based Oral Rehydration Strategy. The New England Journal of Medicine .
The authors describe the oral rehydration strategy developed for patients with mild dehydration seen in the Emergency Department at Brigham and Women’s Hospital in response to the ongoing shortage of intravenous (IV) fluids.
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Society for Maternal-Fetal Medicine. (2024). SHFM Alert: Intravenous Fluid Shortages.
This alert provides guidance on intravenous fluid conservation strategies.
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Society of Gynecologic Oncology. (2024). SGO Clinical Practice Advisory: Intravenous Solutions Shortage Guidelines.
This practice advisory provides preoperative, intraoperative, case specific, postoperative, chemotherapy administration, and clinical trial principles for intravenous fluid conservation.
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Visage, R., Kaiser, N., Williams, R., et al. (2019). Oral Methods of Urinary Alkalinization for High-dose Methotrexate Administration: Alternatives to Intravenous Sodium Bicarbonate During a Critical Drug Shortage. (Abstract only.) Journal of Pediatric Hematology/Oncology. 41(5):371-375.
This article describes a protocol implemented by a hospital to use oral alkalinizing agents instead of intravenous sodium bicarbonate during a shortage. A retrospective review by the authors found oral alkalinization to be an effective alternative strategy for most patients.
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Fluids and Electrolytes: Parenteral Nutrition

Holcombe, B., Mattox, T., and Plogsted, S. (2018). Drug Shortages: Effect on Parenteral Nutrition Therapy. Nutrition in Clinical Practice. 33(1):53-61.
This journal article is a review of the history and contributing factors of parenteral nutrition component shortages, prevention and mitigation efforts of the U.S. Food and Drug Administration and manufacturers, the effects of these shortages on patients, and resources and strategies to manage future shortages. This review also includes reports that monitored past drug shortages.
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Molotsky, K., Herrera, O., and Christensen, M. (2025). Use of Alternative Calcium Gluconate in Sodium Chloride Co-Infused with Parenteral Nutrition for Neonates and Infants During National Shortage. The Journal of Pediatric Pharmacology and Therapeutics. 30(1):100-105.
The authors conducted a retrospective review of the electronic health records of infants who received a co-infusion of calcium gluconate in sodium chloride and parenteral nutrition during a shortage of calcium gluconate vials. They found this substitution to be a viable alternative during a shortage, but discussed challenges including determining how the product should be ordered, the method of administration, and the need for close monitoring of patients.
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Wischmeyer, P., Klek, S., Berger, M., et al. (2024). Parenteral Nutrition in Clinical Practice: International Challenges and Strategies. American Journal of Health-System Pharmacy. 81(3):S89–S101.
This review outlines strategies to use in clinical practice to address challenges in the parenteral nutrition use process, including product shortages.
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Fluids and Electrolytes: Peritoneal Dialysis Solution

American Society of Nephrology. (2024). Interim Strategies for Conservation of Peritoneal Dialysis (PD) Solution.
This document highlights interim patient-level strategies developed by several dialysis organizations that can conserve peritoneal dialysis solutions
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American Society of Pediatric Nephrology. (2024). Interim Guidance on PD Solution Conservation During Supply Shortage.
This tip sheet offers strategies for reducing the number of peritoneal dialysis solution bags used per day, emphasizing that this is the primary step that will efficiently address supply challenges.
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ASPR TRACIE. (2024). Shortage Strategies and Resources: Peritoneal Dialysis Solution.
Medical product shortages and disaster-induced impacts from hurricanes and other extreme weather incidents can disrupt dialysis treatment and access to critical supplies. This tipsheet can help healthcare providers adapt to a shortage of peritoneal dialysis solution.
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Heparin

Benge, C. and Burka, A. (2019). Heparin Drug Shortage Conservation Strategies. Federal Practitioner. 36(10):449-454.
The authors suggest strategies to be implemented by the U.S. Department of Veterans Affairs health system to conserve supplies of unfractionated heparin during a shortage.
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Rosovsky, R., Barra, M., Roberts, R., et al. (2020). When Pigs Fly: A Multidisciplinary Approach to Navigating a Critical Heparin Shortage. The Oncologist. 25(4):334-347.
This journal article summarizes how Massachusetts General Hospital activated its Hospital Incident Command System to address the threat of a heparin drug shortage following an outbreak of African swine fever (ASF) in 2019. ASF affected China's pig population, which is where most of the crude heparin is derived, and then supplied to the U.S. The article details the operations, challenges and barriers, and process implementation of the Emergency Operations Plan.
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Intravenous Immunoglobulin (IVIG)

Belmonte, M., Albiero, A., Callewaert, F., et al. (2025). Understanding Supply Sustainability of Plasma-derived Medicinal Products: Drivers and Consequences of Shortages. Vox Sanguinis: The International Journal of Transfusion Medicine. 120(8);754-764.
The authors describe the results of a literature review on the societal and economic effects of plasma-derived medicinal products (PDMPs) including intravenous immunoglobulins (IVIgs). They identify issues that may constrain the supply of these products and suggest policy interventions to ensure sustainable use and exploring the use of alternative treatments to mitigate shortage risks and maintain access to life-saving treatments.
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Derman, B., Schlei, Z., Parsad, S., et al. (2021). Changes in Intravenous Immunoglobulin Usage for Hypogammaglobulinemia After Implementation of a Stewardship Program. JCO Oncology Practice. 17(3):e445–e453.
In response to the limited allocation of intravenous immunoglobulin (IVIG) at the University of Chicago and subsequent inability to meet demand despite the use of alternatives, an IVIG stewardship model was created. This IVIG stewardship program involved a tiered approach and analysis plan, using new recommendations for decreased IVIG administration that yielded high adherence.
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Edington, H., Sutton, K., Bennett, C., et al. (2021). Dealing with a Critical National Shortage – Approaches to Triaging Immune Globulin Supply in Pediatric Hematology and Oncology. (Abstract only.) Pediatric Blood and Cancer. 67(7):e28260.
The authors describe their pediatric hospital system’s development of best practice guidelines for use of intravenous immunoglobulin (IVIG) during a national shortage. They created a three-tier system for prioritizing receipt of IVIG for oncology and hematology/immunology.
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Moral, P., Cabenero-Navalon, M., Lopez-Leon, P., et al. (2025). Infectious Outcomes of a Standardized Subcutaneous Immunoglobulin Dose Reduction Strategy in Primary Immune Deficiencies Amid Global Shortage. Frontiers in Immunology. 15:1527514. doi: 10.3389/fimmu.2024.1527514.
This retrospective study assessed the impact of a hospital’s implementation of a contingency plan adjusting the dosage of subcutaneous immunoglobulin in humoral primary immunodeficiency patients during a pandemic. The authors found that implementation of this protocol was successfully maintained without an increase in infection and that individualized dose reduction may be a safe and cost-effective approach during times when plasma-derived products are scarce.
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Perez, E., Orange, J., Bonilla, F., et al. (2017). Update on the Use of Immunoglobulin in Human Disease: A Review of Evidence. Journal of Allergy and Clinical Immunology. 139(3S):S1-S46.
This article is an update to evidence-based guidelines on the use of immunoglobulin therapy for various indications, noting that given its limited supply, it should be used where supported by evidence and where it provides the greatest clinical benefit.
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Roth, K., Darwish, C., Keller, M., et al. (2024). Implementation of a Tier System for IVIG Indications to Address IVIG Shortage at a Tertiary Care Pediatric Medical Center. (Abstract only.) Pediatric Blood and Cancer. 71(4):e30871.
The authors discuss the establishment of a multidisciplinary task force and implementation of a tiered system for indications of use of intravenous immunoglobulin during a national shortage. During the study period, all requests for Tier 1 indications were approved and less than three percent of all requests were denied. The authors found no adverse effects from the denials and suggested that triaging for high-priority indications could be an effective strategy during drug shortages.
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Oxygen

ASPR TRACIE. (2018). Considerations for Oxygen Therapy in Disasters.
This ASPR TRACIE fact sheet provides information on the types of oxygen therapy and the types of oxygen supplies generally available as oxygen therapy was a limiting factor in many hospitals during the pandemic. It also provides information on the typical sizes and length of use of various oxygen storage methods. Conservation methods are also described.
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Blakeman, T. and Branson, R. (2012). Oxygen Supplies in Disaster Management. Respiratory Care. 58(1):173-183.
This article describes the different types of oxygen supplies available and planning to address vulnerabilities in both the hospital and the wider community.
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Botta, M., Caritg, O., van Meenen, A., et al. (2023). Oxygen Consumption with High-Flow Nasal Oxygen versus Mechanical Ventilation- An International Multicenter Observational Study in COVID-19 Patients (PROXY-COVID). The American Journal of Tropical Medicine and Hygiene. 108(5):1035-1041.
The authors compared the amount of supplemental oxygen consumed with high-flow nasal oxygen versus mechanical ventilation during the first two full days of oxygen support in the intensive care unit of patients enrolled in a larger observational study of patients with hypoxemic respiratory failure due to COVID-19. They calculated actual, hourly, and daily data on consumption to inform hospital planning for oxygen needs and conservation strategies.
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California Office of Statewide Health Planning and Development. (2021). Health Facility Medical Oxygen Systems Best Practices During COVID-19 Pandemic.
This guide shares best practices in the use and maintenance of medical oxygen systems to help health care facilities manage demand on their oxygen systems during a pandemic.
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Devereaux, A., Backer, H., Salami, A., et al. (2021). Oxygen and Ventilator Logistics During California's COVID-19 Surge: When Oxygen Becomes a Scarce Resource. Disaster Medicine and Public Health Preparedness. 17:e33. doi: 10.1017/dmp.2021.267.
This article describes how California managed demand that overwhelmed supply of oxygen during a pandemic-driven patient surge.
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Jain, R. and Sharma, C. (2021). Oxygen Supply in Hospitals: Requisites in the Current Pandemic. Anesthesia: Essays and Researches. 15(3):252-256.
This article describes the different types of oxygen supplies used in hospitals.
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Ribas-Solis, F., Diaz-De-Cerio-Paniagua, J., and Abasolo-Osinaga, E. (2024). Hospital Oxygen Supply Overwhelmed Due to COVID-19: When Demand Exceeds Supply. Respiratory Care. 69(8):937-945.
The authors conducted a retrospective study to describe oxygen supply challenges in their hospital, analyze characteristics and design criteria of the medical gas pipeline system, and suggest steps to prevent future vulnerabilities.
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Ritz, R. and Previtera, J. (2008). Oxygen Supplies During a Mass Casualty Situation. Respiratory Care. 52(2):215-225.
This article describes the compressed gas cylinders, oxygen concentrators, liquid oxygen devices, and bulk liquid oxygen systems used in health care and discusses developing a resource management plan and conservation options.
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Toner, E. (2021). Potential Solutions to the COVID-19 Oxygen Crisis in the United States. Center for Health Security.
This memoranda highlights findings from a virtual meeting held in January 2021 with frontline clinicians and public health officials from across the U.S. who discussed how they were meeting challenges associated with oxygen and supply shortages.
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World Health Organization. (2020). Oxygen Sources and Distribution for COVID-19 Treatment Centres.
The WHO developed this interim guidance to aid in quantifying demand, identifying available oxygen sources, and selecting surge oxygen sources for COVID-19 patients in low- and middle-income countries.
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Personal Protective Equipment

Centers for Disease Control and Prevention. (2024). Conserving Supplies of Personal Protective Equipment in Healthcare Facilities during Shortages.
This site has multiple links to help healthcare facilities and staff optimize their personal protective equipment (PPE), with specific guidance on the usage of gowns, masks, eye protection, and N95 respirators.
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Healthcare and Public Health Sector Joint Supply Chain Resilience Workgroup PPE Task Group. (2024). PPE Standardization Priorities for a Resilient Public Health Supply Chain.
This report summarizes findings from a multi-year program to address gaps and needs in government and voluntary standards for personal protective equipment (PPE). A Task Force reviewed literature and gathered input from experts and stakeholders to identify and understand PPE standardization gaps, then developed a plan to address the gaps. The final step was to prioritize these standards actions into the priorities covered in depth in this report.
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Radiocontrast Agents

Abdellatif, W., Vasan, V., Kay, F., et al. (2022). Know Your Way Around Acute Unenhanced CT During Global Iodinated Contrast Crisis: A Refresher to ED Radiologists. (Abstract only.) Emergency Radiology. 29(6):1019–1031.
This systematic review summarizes the American College of Radiology’s radiological diagnostic guidance based on common unenhanced CT findings in the acute emergency setting.
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Al-Azizi, K., Moubarak, G., Szerlip, M., et al. (2024). Impact of Iodinated Contrast Shortage on Contrast-Associated Acute Kidney Injury: A Single Center Experience. Proceedings (Baylor University. Medical Center). 37(2):218–226.
This retrospective study investigated the incidence, characteristics, and outcomes of contrast-associated acute kidney injury (CA-AKI) during a contrast shortage in comparison to an earlier period, at a single percutaneous coronary interventions (PCI) center. The study found that there was a scarcity of iodine contrast media for PCI procedures during the shortage, which was associated with a significant increase in the utilization of intravascular imaging and a significant reduction in CA-AKI.
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American Society of Health-System Pharmacists. (2022). Considerations for Imaging Contrast Shortage Management and Conservation.
This fact sheet describes potential actions for the health care system to consider in response to a prolonged shortage of iohexol.
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Amukotuwa, S., Jackson, D., & Bammer, R. (2022). Iodinated Contrast Media Conservation Measures During a Global Shortage: Effect on Contrast Media Use at a Large Health System. American Journal of Roentgenology. 219(6):983.
This journal article quantified the effect of iodinated contrast media conservation measures at a single health system during the global shortage of 2022.
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Amukotuwa, S., Jackson, D., and Bammer, R. (2023). Impact of Iodinated Contrast Media Conserving Interventions and Lessons for the Future. Journal of Medical Imaging and Radiation Oncology. 67(1):28–36.
This journal evaluated the effect of iodinated contrast media (ICM) conserving interventions on ordering practices and ICM consumption for computed tomography (CT). The study found that CT interventions improved patient triage to contrast-enhanced CT (CECT) and about two-thirds reduction in ICM consumption.
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Barreto, I., Grajo, J., Brock, D., et al. (2022). A Health System’s Response to the Ongoing Global Shortage of Iodinated Contrast Media. American Journal of Roentgenology, 219(6).
This journal article presents the strategies that a large U.S. health system implemented during a global shortage of iodinated contrast media. Strategies include system-level action, operational flexibility, modification of CT protocols, and close communication by clinical personnel.
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Cavallo, J. and Pahade, J. (2022). Practice Management Strategies for Imaging Facilities Facing an Acute Iodinated Contrast Media Shortage. Policy, Quality, and Practice Management. 219(4):531-687.
This clinical perspective article reviews iodinated contrast media conservation techniques depending on the severity and duration of the supply shortage.
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Davenport, M., Chu, P., Szczykutowicz, T., and Smith-Bindman, R. (2022). Comparison of Strategies to Conserve Iodinated Intravascular Contrast Media for Computed Tomography During a Shortage. JAMA. 328(5):476–478.
This study models the amount of contrast that could be conserved using computed tomographic examinations under the scenario of the global shortage of iodinated contrast media in 2022.
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Eibschutz, L. and Gholamrezanezhad, A. (2022). How Low Can We Go? Strategies and Recommendations to Combat the Iodinated Contrast Shortage. (Abstract only.) Emergency Radiology. 29(5):925–928.
This journal article outlines strategies by service in the event of an iodinated contrast shortage, along with recommendations related to alternatives and communication.
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England, A., Rawashdeh, M., Moore, N., et al. (2024). More Sustainable Use of Iodinated Contrast Media – Why? Radiography. 30(Suppl 1):74–80.
This narrative review assesses the need for and reports methods to deliver sustainable iodinated contrast media administration.
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Gertz, Z., Mitchell, B., Kontos, M., et al. (2025). Percutaneous Coronary Intervention During the Shortage of Iodinated Contrast. The Journal of Invasive Cardiology. 37(5).
This multicenter study evaluated how a contrast shortage, related to a factory shutdown during the COVID-19 pandemic, impacted percutaneous coronary interventions (PCI). Using CathPCI registry data from hospitals in the Virginia Cardiac Services Quality Initiative statewide consortium, the study found that the significant decline in contrast use during PCI did not impact patient outcomes.
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Glazer, D., Lucier, D., Sisodia, R., et al. (2023). Electronic Health Record Order Entry-Based Interventions in Response to a Global Iodinated Contrast Media Shortage: Impact on Contrast-Enhanced CT Utilization. American Journal of Roentgenology. 220(1):134–140.
This retrospective study at a large multisite health system assessed the impact of electronic health record order entry-based interventions in response to the global contrast media shortage of 2022. These two interventions were 1) an alert about shortages after any contrast-enhanced body CT orders, with recommendations for alternate imaging modalities, and 2) a requirement for referrers to enter detailed clinical information for all contrast-enhanced body CT orders. The study found that these interventions significantly reduced contrast-enhanced CT utilization by influencing ordering clinician behavior and associated clinical practice.
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Gopireddy, D., Virarkar, M., Vulasala, S., et al. (2023). Metrics-Driven Successful Strategy by Emergency and Radiology Driven Task Force to Mitigate Global CT Contrast Media Shortage in a Safety Net Hospital. Journal of Clinical Imaging Science. 13(2).
This journal article reports on a safety net hospital’s implementation of comprehensive crisis management strategies from the American College of Radiology, including a wire diagram.
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Grist, T., Canon, C., Fishman, E., et al. (2022). Short-, Mid-, and Long-term Strategies to Manage the Shortage of Iohexol. Radiology. 304(2):289–293.
This report provides short-, mid-, and long-term strategies for patient triage and imaging protocols to address contrast media (iohexol) shortages and associated supply chain issues. Short-term strategies include establishing an incident command center to direct and monitor media usage, delaying elective contrast-enhanced CT examinations, reducing contrast media dosage, and employing alternative diagnostic modalities. Mid-term strategies include repackaging contrast media, using multiuse and multiaccess methods, communicating and negotiating with payers for billing and reimbursement, and ensuring compliance through communication with ordering providers. Long-term strategies include advocating for legislation to facilitate expansion of contrast media manufacturing plants and institutional stockpiling of contrast media supplies.
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Hahn, B., Chacko, J., Mohan, M., et al. (2022). The Effect of an Iodinated Contrast Material Shortage on Ordering Patterns in the Emergency Department. Cureus. 14(12):e32846.
This retrospective, observational study sought to describe the effects of an iodinated contrast material (ICM) shortage on the ordering patterns of emergency medicine physicians. This pre-/post-test study found that emergency medicine physicians ordered more non-contrast CT scans and increased repeat imaging with ICM material during the shortage.
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Horný, M., Saindane, A., and Duszak, R. (2022). Clinical Characteristics of Most Frequent Use of Iodinated Contrast Media for CT. Policy, Quality, and Practice Management. 219(5).
This journal article used a large insurance dataset to characterize the examinations, delivery settings, and clinical indications for which contrast-enhanced CT is most commonly used to inform emerging national guidelines and institutional policies during contrast media shortages.
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Isabelle, M., Lacson, R., Johnston, H., et al. (2024). Reducing Intravenous Contrast Utilization for CT: A Health System-Wide Intervention with Sustained Impact. Journal of the American College of Radiology. 21(11):1746–1754.
This retrospective, multisite study at a large health system sought to determine the volume of intravenous iodinated contrast media used for CT before, during, and after the global iohexol shortage. The study found that standardized contrast media dosing for commonly performed CT examinations rapidly decreased contrast media utilization for over one year.
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Kaiser, D., Abdalkader, M., Berberich, A., et al. (2022). Acute Shortage of Iodinated Contrast Media: Implications and Guidance for Neurovascular Imaging and Intervention. Neuroradiology. 64(9):1715–1718.
This editorial provides strategies to minimize daily iodinated contrast media (ICM) use and to conserve resources for essential examinations.
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Koeppel, D. and Boehm, I. (2023). Shortage of Iodinated Contrast Media: Status and Possible Chances – A Systematic Review. European Journal of Radiology. 164:110853.
This systematic review explores background, interventions, and benefits of low-dose iodinated contrast media (ICM) regimens during shortage situations.
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Layer, Y., Isaak, A., Mesropyan, N., et al. (2024). Image Quality of Abdominal Photon-Counting CT with Reduced Contrast Media Dose: Evaluation of Reduced Contrast Media Protocols During the COVID19 Pandemic Supply Shortage. Heliyon. 10(6):e28142.
This journal article assessed the impact of reducing the contrast media dose (CMD) on the diagnostic quality of photon-counting detector CT (PCD-CT) and energy-integrating detector CT (EID-CT), which maintained diagnostic interpretability.
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Mossa-Basha, M., Zhu, C., Pandhi, T., et al. (2024). Deep Learning Denoising Improves CT Perfusion Image Quality in the Setting of Lower Contrast Dosing: A Feasibility Study. American Journal of Neuroradiology. 45(10):1468–1474.
This journal article compared reduced iodinated contrast media and standard dose CTP acquisitions and examined the impact of deep learning denoising on CTP image quality, which can improve image quality for low iodinated contrast media CTP protocols.
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Ranger, R., Truong, D., and Thompson, J. (2024). Decreased Portal Vein Attenuation and Liver Enhancement with Reduced Intravenous Contrast Dosage During the National Iodinated Contrast Shortage of 2022. Journal of Clinical Imaging Science. 14(13).
This journal article sought to examine differences in liver attenuation and enhancement between contrast dosages during the iodinated contrast shortage of 2022.
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Salazar, G., Mossa-Basha, M., Kohi, M., and Burke, L. (2022). Short-Term Mitigation Steps During the Iohexol Contrast Shortage: A Single Institution’s Approach. Journal of the American College of Radiology. 19(7):841-845.
This journal article presents the protocol changes for contrast conservation at a quaternary care academic medical center.
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Schuster, N., Ahadian, F., Zhao, Z., et al. (2022). Best Practices for Interventional Pain Procedures in the Setting of an Iodinated Contrast Media Shortage: A Multisociety Practice Advisory. Interventional Pain Medicine. 1(3):100122.
These guidelines are best practice recommendations for the performance of interventional pain procedures in the setting of an iodinated contrast media shortage, developed by representatives from the Spine Intervention Society and the American Academy of Pain Medicine.
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Schwartz, S. and Watts, L. (2024). Contrast Media Shortages – Medical Imaging Considerations: A Literature Review. (Abstract only.) Journal of Medical Imaging and Radiation Sciences. 55(1):97–103.
This literature review analyzes the effects of intravenous contrast media shortages and how these shortages affect patient care within computed tomography.
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Starekova, J., Chu, S., Bluemke, D., et al. (2023). MRA as the Preferred Test for Pulmonary Embolism During the Iodinated Contrast Media Shortage of 2022: A Single-Center Experience. American Journal of Roentgenology. 221(6):736–746.
This retrospective single-center study describes the University of Wisconsin–Madison Hospital and Clinics’ experience using pulmonary magnetic resonance angiography (MRA) as an alternative to computed tomography angiography (CTA) to diagnose pulmonary embolism during the iodinated contrast media shortage in 2022. The study showed that pulmonary MRA was a practical substitute for pulmonary CTA in emergency settings.
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Wang, C., Asch, D., Cavallo, J., et al. (2022). Statement from the ACR Committee on Drugs and Contrast Media on the Intravenous Iodinated Contrast Media Shortage. Journal of the American College of Radiology. 19(7):834-835.
This article provides a statement from the American College of Radiology during the contrast shortage of 2022, with recommendations on how providers can address the emergency locally.
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Wang, J., Duan, X., Mahmood, U., et al. (2024). An Adult and Pediatric Size-Based Contrast Administration Reduction Phantom Study for Single and Dual-Energy CT Through Preservation of Contrast-to-Noise Ratio. Journal of Applied Clinical Medical Physics. 25(5):e14340.
This phantom study provides a quantitative framework for a change in protocol to address the contrast shortages. This method is either lowering kV in single-energy CT (SECT) or using lower energy virtual monochromatic images (VMI) from dual-energy CT (DECT), which reduces ICM dosage while preserving the iodine contrast-to-noise ratio. The findings of this study provide a quantitative baseline for other institutions for their scanning protocols.
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Rhogam

American College of Obstetricians and Gynecologists. (2024). Rho(D) Immune Globulin Strategies.
This practice advisory offers prioritization and conservation strategies for settings experiencing shortages of human Rho(D) immune globulin (RhIg).
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Clausen, F. (2024). Antenatal RHD Screening to Guide Antenatal Anti-D Immunoprophylaxis in Non-Immunized D- Pregnant Women. (Abstract only.) Immunohematology, 40(1):15-27.
This review article highlights the strengths and challenges of antenatal RHD screening as a strategy to guide the administration of antenatal prophylaxis in non-immunized D– pregnant women and to avoid unnecessary prophylaxis.
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Grace, M., Goodhue, B., & Vora, N. (2025). Rho(D) Immune Globulin Shortage and Fetal Rh(D) Screening with Cell-Free DNA. (Abstract only.) Current Opinion in Obstetrics and Gynecology. 37(2):55-59.
The American College of Obstetricians & Gynecologists reviewed the literature and recommend cfDNA screening for fetal Rh(D) status as an approach to triage the administration of RhIg during shortage situations.
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Muscarella, S., Morgan, B., & Horvath, S. (2025). Rhesus D Immune Globulin in Early Pregnancy: A Clinical Review. (Abstract only.) Obstetrics and Gynecology Clinics of North America. 52(2):207–218.
This review article compares current national and international guidelines for RhD testing and prophylaxis during the first trimester, which are critical during worldwide shortages.
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Schwalb, A., Federspiel, J., Dotters-Katz, S., et al. (2025). Rhesus D Prophylaxis: When and Why We Give Rhesus D Immunoglobulin. (Abstract only.) Obstetrical & Gynecological Survey. 80(5):315–324.
This review article highlights the importance of RhD prophylaxis, outlines current guidelines for administration, clarifies areas of uncertainty for prophylaxis administration, and reviews key concepts for patient education and shared decision-making.
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Agencies and Organizations

American Society of Clinical Oncology.
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American Society of Health-System Pharmacists.
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IBx Connect.
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Society of Gynecologic Oncology.
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