Wide Variability in Prethrombectomy Workflow Practices in the United States: A Multicenter Survey.

BACKGROUND AND PURPOSE: Clinical outcomes in patients with acute ischemic stroke caused by large vessel occlusion depend on the speed and quality of workflows leading to mechanical thrombectomy. In the absence of universally accepted best practices for workflow, developing stroke hospitals can benefit from improved awareness of real-world workflows in effect at experienced centers. To this end, we surveyed prethrombectomy workflow practices at stroke centers throughout the United States. MATERIALS AND METHODS: E-mail and phone interviews were conducted with neurointerventional team members at 30 experienced, endovascular-capable stroke centers. Questions were chosen to reflect workflow components of triage, team activation, transport, case setup, and anesthesia. RESULTS: There is wide variation in prethrombectomy workflows. At 53% of institutions, nonphysician staff respond to stroke alerts alongside physicians. Imaging triage involves noninvasive angiography or perfusion imaging at 97% and 63% of institutions, respectively. Neurointerventional consultation is initiated before the completion of neuroimaging at 86% of institutions, and the team is activated before a final treatment decision at 59%. The neurointerventional team most commonly arrives within 30 minutes. Patients may be transported to the neuroangiography suite before team arrival at 43% of institutions. Procedural trays are set up in advance of team arrival at 13% of centers; additional thrombectomy devices are centrally stored at 54%. A power injector for angiographic runs is consistently used at 43% of institutions. Anesthesiology routinely supports thrombectomies at 67% of institutions. CONCLUSIONS: Prethrombectomy workflows vary widely between experienced centers. Improved awareness of real-world workflows and their variations may help to guide institutions in designing their own protocols of care.

The case of the high-risk safety product.

After several days of meetings, J.F. Winchester, president of MDC Industries, felt no closer to a decision. MDC, a manufacturer of wall and ceiling panels, was considering whether to exercise an option to buy a new and safer wallboard technology. The product was being touted as revolutionary, but, Winchester wondered, could MDC afford to carry the flag? According to its inventor, Robert Goerner, Smoke-Safe would be a vast improvement over standard safety-rated wallboard. With almost the same flame-retardant properties, Smoke-Safe had the advantage of giving off almost no fumes or smoke in fire tests. And, Winchester knew, most fire-related deaths are from smoke, not flames. Indeed, the numbers were grimly persuasive: 82% of fire-related injuries involving standard panels were caused by smoke inhalation. What's more, Smoke-Safe would cost about the same to manufacture as MDC's current wallboard. But MDC had several other good options for spending the $5 million Goerner was asking; building plastics was only one of its profit centers. And the prospect of launching a campaign to change building codes in order to market Smoke-Safe, which could spark a fight with competitors, was daunting. Since its current wallboard gave MDC only 18% of the wallboard market, many industry insiders speculated whether MDC had the market clout to influence major cities to revise their codes. Six experts in marketing, law, and ethics advise MDC Industries on how it can balance ethical and business imperatives in making its decision.