Why the world-renowned stroke care leader credits improved outcomes to workflow efficiencies
When a patient has a stroke, every minute matters. Dr. Mayank Goyal1, director of imaging and endovascular treatment at the Calgary Stroke Program in Alberta, Canada, knows this.
That’s why, since the early 2010s, Dr. Goyal has worked with the University of Calgary to reduce the intake-to-treatment window substantially — from a then-average of about 200 minutes to an image-to-reperfusion (of the affected brain) timeline of just an hour.2
That kind of efficiency takes a great deal of manpower, resources, and technology, but above all, it takes a keen eye on workflow optimization at every juncture of a patient’s care — from the initial 911 call to imaging, treatment, patient/caregiver education, and discharge.
It might sound daunting, but it’s doable, Dr. Goyal stresses. With a clear focus on improving outcomes, any center, anywhere, can clean up their workflow for a smooth experience for all. We caught up with the world-renowned stroke care leader (who also helped develop GE Healthcare’s FastStroke platform) to learn how.
The Calgary Stroke Program has a strong reputation for excellent acute stroke outcomes. How did you achieve such distinction?
These things grow organically. Like with everything else, what happens is that people who are motivated and share a common cause come together for the benefit of improving outcomes. Then, that creates a snowball effect and attracts other similar minds and then, from there, it keeps on growing.
What role did workflow efficiency and operations play in that growth?
It helps that we were among the early ones to realize the importance of workflow. Back in 2011, not a lot of people were talking that much about workflow, but we were really focused on it. We were working on all kinds of process changes to optimize workflow and train people. For example, one of the innovations that I created back in 2011 is what I call BRISK, brisk recanalisation ischemic stroke kit, which is a way of setting up your angio so that it's always ready to receive a stroke patient.
Did people from other centers start to take notice?
Yes, that was our intent. My colleague Michael Hill and I traveled to sites to spend time training them on all that we had learned to influence other sites as well. So not only were we trying to optimize workflow on our side; we were doing two other things, too. On one hand, we were publishing data to say why it makes sense, like our 2013 study that showed feasibility for a 60-minute imaging-to-reperfusion time.2 And secondly, we traveled to other sites within that trial to help them optimize their workflow, too.
What are all the milestones involved in shortening that window of treatment time?
One of the things we realized early was that ultimately, the faster we can open the vessel, the higher the likelihood of a good outcome. Once you realize that, then you ask: What is preventing us from opening the vessel fast, and how can we solve those challenges? If it’s spending time on imaging to do an MRI, maybe you consider replacing the MRI with a CT scan, which is much faster. Or it could be focusing on shortening the time for other things, too — like setting up the IV line, or explaining things to the family.
You focus on the various steps you can take and approach every one with a solution. And as different people come up with different ideas, you’re able to influence those changes and move them forward.
So what all does it take to make those changes happen?
There are two components to it. Obviously, you need resources and the necessary manpower. But you also need a local champion who’s going to advocate for improvement and pull everyone together, to get everyone to realize the importance of what you’re doing.
How does staffing fit into all of that?
Generally, we’re strongly in favor of having a certain level of centralization so that there is sufficient volume and everyone knows what they’re doing: the overall machinery is well-oiled. But a vital piece of that is organization at the pre-hospital level so that appropriate decisions are made in the field and the team at the hospital is notified of upcoming patients before they arrive.
And what about technology?
You need a few things. One is a centralized imaging and patient record database. Here in Alberta, we have a central database for the whole province of Alberta where every patient is in a central record. So if a patient is coming in, I can quickly get into the database and find out the past history, whether they have a cardiac disease or not, whether they've had previous strokes or not, and what kind of medications they're on. Another thing you need is communication between the primary hospital and the tertiary hospital. Neither of those things is difficult to implement because the technology already exists.
So, it’s just a question of implementing the technology we already have?
Absolutely. It's very different now compared to what it was six or seven years ago, because now we have data, policies, and good articles on how to do it. So, if someone wanted to do it, now they can put these things into play quite quickly because it's already known what all needs to be done. You don't have to reinvent the wheel.
Clinically speaking, what minimal CT scanning is needed to enable the post-processing analysis?
At the very least, a patient with suspected stroke needs to have a non-contrast CT to rule out bleed and a CTA to detect the presence of large vessel occlusion. Additional information to detect viability of affected tissue is of course desirable and important. This can be done in different ways, such as ASPECTS, collaterals or CT perfusion.
And what role does advanced imaging analytics play in enabling a rapid and accurate diagnosis?
Stroke is highly time sensitive and there is a sense of urgency for decision making. Additionally there is the issue of instantaneous availability of expertise 24/7/365. This is where stroke analytics can play a major role and make it easier to interpret and make decisions, whether it is the diagnosis of large vessel occlusion or determination of brain viability.
In what ways have you worked with GE Healthcare to develop FastStroke, and how does that platform enable faster diagnostic and treatment decisions? What was your experience in helping develop FastStroke?
I worked with the GE Healthcare team to facilitate the design of FastStroke from the earliest stages of how the product should look and behave to finally testing the final product. The beauty of the product is its user-friendly intuitive interface while at the same time maintaining flexibility based on varying practice patterns at different institutions. In addition, the interface is modular that allows the addition of features and further analytics as the field progresses.
- Mayank Goyal. The Hotchkiss Brain Institute. http://www.hbi.ucalgary.ca/profiles/dr-mayank-goyal. Accessed June 19, 2018.
- Ultrashort imaging to reperfusion time interval arrests core expansion in endovascular therapy for acute ischemic stroke. Journal of NeuroInterventional Surgery. https://www.ncbi.nlm.nih.gov/pubmed/?term=Ultrashort+imaging+to+reperfusion+time+interval+arrests+core+expansion+in+endovascular+therapy+for+acute+ischemic+stroke. Accessed June 19, 2018.