Our next talk is by Dr. Michelle Williams, a prospective multicenter study evaluating the time burden of a neurothrombectomy call on physicians. Good afternoon, everyone. My name is Michelle Williams. I'm a PGY-1 at Wake Forest. Thank you very much for the opportunity to speak with you today. I'm going to be talking to you about the burden of neurothrombectomy call. This was a multicenter prospective paper that was recently published. I'd like to start by saying thank you to all of our multiple contributors. We had a lot of people, a lot of different institutions who did very good work for us. So thank you, everyone, for your help. And nothing to disclose. So a little bit of background. As we all know, there have been many recent trials that have shown a benefit of mechanical thrombectomy for large vessel occlusive stroke, and this is compared to giving TPA. Most recently, the DAWN and DEFUSE-3 trials have kind of expanded the eligibility criteria to patients who have wake-up strokes, that is, strokes occurring within the past 24 hours. So we did a prior study that was published in 2017. It was a retrospective multicenter study that was specifically to look at the frequency and time requirements of mechanical thrombectomy procedures. At the time that this study was done, we were doing about one neurothrombectomy every five days. That was the rate kind of across all institutions. What we found was that mechanical thrombectomies are very disruptive to the provider's schedule. It was kind of a bimodal distribution here, but most of them were occurring between the hours of 8 and 9 p.m., meaning that oftentimes physicians were having to come in from home, and the ones that were occurring during normal work hours were kind of disruptive to their daily schedule. Now, by design, this study we knew was kind of underestimating the overall time burden on the physician. So this study that I'm going to be talking to you about today was a prospective multicenter trial across geographically diverse stroke centers, and this one included non-procedural consults, which are designated as false positives, meaning they ultimately did not proceed to mechanical thrombectomy. Data was collected over 30 days, so 30 consecutive 24-hour call periods, and this was around the time of spring to summer of 2017. We looked at days of the week. We looked at start times of the consult, which was the time at which the attending physician was made aware of the consult, not when the residents or fellows had seen the patient. And then end time of the consult, which was defined during work hours as when all orders were in, all the discussions were finished with the family, but did not include things like dictation of the note. And then end times during non-work hours were defined as the time that the attending physician got back home. We also looked at delays lasting 30 minutes or delays that were greater than 30 minutes, whether cross-coverage was required for any cases, and whether or not the physician had to commute in from home. So these are some of our results. This is organized by institution. As you can see, there were nine very geographically diverse centers all over the United States. We had a mixture of mostly comprehensive, but also some primary stroke centers as well, and places ranging from one to five operators, mostly about two or three operators. We had a total of 214 consults during this time period. Of that, 84 of them eventually proceeded to thrombectomy. Meaning that there were 130 false positive consults. The median time for a procedural consult was 171 minutes. For a false positive consult, it was 27 minutes. And then the overall time burden was about 69 minutes. So this is organized kind of by time of day, all the pooled neurothrombectomy procedures over the 30-day period. So organized by time of day, and the horizontal bars represent the time from initial contact until all responsibilities had been completed. And this is a similar style graph, but this is for the false positive consultations only. And you'll notice for both graphs, they're kind of skewed towards the right side. That would be more towards the evening times. There's a peak in the afternoon, but mostly towards evening and nighttime. And then this is the combined graph, showing both of those. And then this is the combined graph, showing both procedural consults and false positive consultations. Again, you can see kind of skewed more towards afternoon and evening. We found that delays occurred 30% of the time in 70% of the cases that were performed during daytime hours. Alternate operators were required in 10% of the cases. And the physician had to commute from home during 51% of non-peak hour cases. Now this graph is looking at the only neurothermectomies from the previous 2017 study, as well as this study, and combining them together. Again, organized by time of day. So there were 189 procedures in the 2017 study, and 84 in this study. They span different amounts of time. And again, even though we're doing these thermoctomy procedures at all times of the day, they tend to be grouped more towards later in the evening. And we found that from the previous study in 2017 to this current study, we'd actually increased our rate. The previous was one every five days. And during this study, we were doing approximately one neurothermectomy every three days. And keep in mind, this was before the publication of Dawn and Diffuse. So even though we haven't collected any firm data since Dawn and Diffuse have been published to say that our rates are continuing to increase, but many of our providers do feel that, you know, as their patient pool has increased, they are doing more procedures and seeing more consults, even since this most recent study was published. So in conclusion, neurothermectomy call is very burdensome and disruptive to the provider's schedule. I mean, you imagine you have providers taking call every two or three days, and they're having an hour where they're coming in at three in the morning, where they're having their scheduled cases disrupted, or even cases where, you know, they're told that you have a patient coming in from two hours away. You know, they're not able to do other things during that time. They're waiting for the patient to get there, waiting for the patient, and then the patient may not even be an intervenable candidate. But that's very disruptive to the provider's life. And this is a problem that we anticipate will continue to worsen in the future as the rate of thermectomy continues to increase. So it's going to be crucial to develop strategies to help prevent burnout, not just for the provider, you know, the attending provider, which is what these studies were looking at. But every time you do a thermectomy, you're pulling in a whole team. You have ancillary staff, you have nursing, you have residents, you have fellows in some cases. So we're going to have to look at ways to optimize our triage, optimize how we're compensating providers, and basically anything that we can do to help prevent burnout in our physician and other staff. Thank you very much. We have time for a question or two, so I'm going to take the moderator's prerogative. Did you look at all in regards to where your consults were coming from, ER versus inpatient, and then from the inpatient side, what time the attending on the consulting service rounded as to why you were getting all these last-minute afternoon and early evening consults? I bet you'd be very instructive. Yeah. No, that wasn't something that we looked at in this paper, but I'm sure that could be a future area to look at. If you want to prevent burnout, you just have to get the medicine attendings to round in the morning. To not call us, yeah. It would be much better. Any other questions from the audience? All right.

neurothrombectomy calls

physicians' schedules

mechanical thrombectomy procedures

burdensome

burnout prevention