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Abdalla RN, Ansari SA, Hurley MC, Attarian H, Fargen KM, Hirsch JA, Cantrell DR, Curl PK, Daves PR, Shaibani A. Correlation of Call Burden and Sleep Deprivation with Physician Burnout, Driving Crashes, and Medical Errors among US Neurointerventionalists. AJNR Am J Neuroradiol 2022; 43:1286-1291. [PMID: 36007952 PMCID: PMC9451637 DOI: 10.3174/ajnr.a7606] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2022] [Accepted: 06/27/2022] [Indexed: 01/26/2023]
Abstract
BACKGROUND AND PURPOSE High call frequency can lead to inadequate sleep, fatigue, and burnout, resulting in detrimental effects on physicians and patients. We aimed to assess the correlation between the frequency and burden of neurointerventional surgery calls and sleep deprivation with physician burnout, physical and driving safety, and fatigue-related medical errors. MATERIALS AND METHODS We sent an online questionnaire to the members of the 2 neurointerventional surgery societies comprising 50 questions and spanning 3 main topics: 1) overnight/weekend call burden, 2) sleeping patterns, and 3) Copenhagen Burnout Inventory. RESULTS One hundred sixty-four surveys were completed. Most (54%) neurointerventional surgeons reported burnout. Call burden of ≥1 every 3 days and being in practice >10 years were independent predictors of burnout. Thirty-nine percent reported falling asleep at the wheel, 23% reported a motor vehicle crash/near-crash, and 34% reported medical errors they considered related to call/work fatigue. On multivariate logistic regression, high call burden (called-in >3 times/week) was an independent predictor of sleeping at the wheel and motor vehicle crashes. Reporting <4 hours of uninterrupted sleep was an independent predictor of motor vehicle crashes and medical errors. Most neurointerventional surgeons recommended a maximum call frequency of once every 3 days. CONCLUSIONS Call frequency and burden, number of years in practice, and sleep deprivation are associated with burnout of neurointerventional surgeons, sleeping at the wheel, motor vehicle crashes, and fatigue-related medical errors. These findings contribute to the increasing literature on physician burnout and may guide future societal recommendations related to call burden in neurointerventional surgery.
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Affiliation(s)
- R N Abdalla
- From the Departments of Radiology (R.N.A., S.A.A., D.R.C., A.S.)
- Neurological Surgery (R.N.A., S.A.A., A.S.)
- Department of Radiology (R.N.A.), Ain Shams University, Cairo, Egypt
| | - S A Ansari
- From the Departments of Radiology (R.N.A., S.A.A., D.R.C., A.S.)
- Neurology (S.A.A.)
- Neurological Surgery (R.N.A., S.A.A., A.S.)
| | - M C Hurley
- Department of Radiology (M.C.H.), University of Chicago, Chicago, Illinois
| | - H Attarian
- Sleep Medicine (H.A.), Northwestern University, Feinberg School of Medicine, Chicago, Illinois
| | - K M Fargen
- Department of Neurosurgery (K.M.F.), Wake Forest University, Winston-Salem, North Carolina
| | - J A Hirsch
- Department of Radiology (J.A.H.), Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - D R Cantrell
- From the Departments of Radiology (R.N.A., S.A.A., D.R.C., A.S.)
| | - P K Curl
- Department of Radiology (P.K.C.), University of Washington, Seattle, Washington
| | - P R Daves
- Department of Finance (P.R.D.), University of Tennessee, Knoxville, Tennessee
| | - A Shaibani
- From the Departments of Radiology (R.N.A., S.A.A., D.R.C., A.S.)
- Neurological Surgery (R.N.A., S.A.A., A.S.)
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Yaeger KA, Rossitto CP, Marayati NF, Lara-Reyna J, Ladner T, Hardigan T, Shoirah H, Mocco J, Fifi JT. Time from image acquisition to endovascular team notification: a new target for enhancing acute stroke workflow. J Neurointerv Surg 2021; 14:237-241. [PMID: 33832969 DOI: 10.1136/neurintsurg-2021-017297] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2021] [Revised: 03/25/2021] [Accepted: 03/26/2021] [Indexed: 11/03/2022]
Abstract
OBJECTIVE To quantify the time between initial image acquisition (CT angiography (CTA)) and notification of the neuroendovascular surgery (NES) team, a potentially high yield time window to target for optimization of endovascular thrombectomy (ET) treatment times. METHODS We reviewed our multihospital database for all patients with a stroke with emergent large vessel occlusion treated with ET between January 1, 2017 and August 5, 2020. We dichotomized patients into rapid (≤20 min) and delayed (>20 min) notification times and analyzed treatment characteristics and outcomes. RESULTS Of 367 patients with ELVO undergoing ET for whom notification data were available, the median time from CTA to NES team notification was 24 min (IQR 12-47). The median total treatment time was 180 min (IQR 129-252). The median times from CTA to NES team notification for rapid (n=163) and delayed (n=204) cohorts were 11 (IQR 6-15) and 43 (IQR 30-80) min, respectively (p<0.001). The median overall times to reperfusion were 134 min (IQR 103-179) and 213 min (IQR 172-291), respectively (p<0.001). The delayed patients had a significantly lower National Institutes of Health Stroke Scale (NIHSS) score on presentation (15 (IQR 9-20) vs 16 (IQR 11-22), p=0.03), were younger (70 (IQR 60-79) vs 77 (IQR 64-85), p<0.001), and more often presented with posterior circulation occlusion (16.7% vs 7.4%, p<0.01). The group with rapid notification time had a statistically larger median improvement in NIHSS score from admission to discharge (6 (IQR 0.5-14) vs 5 (IQR 0.5-10), p=0.04). CONCLUSIONS Time delays from initial CTA acquisition to NES team notification can prevent expedient treatment with ET. Process improvements and automated stroke detection on imaging with automated notification of the NES team may ultimately improve time to reperfusion.
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Affiliation(s)
- Kurt A Yaeger
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Christina P Rossitto
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Naoum Fares Marayati
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Jacques Lara-Reyna
- Department of Neurosurgery, Mount Sinai Health System, New York, New York, USA
| | - Travis Ladner
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Trevor Hardigan
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Hazem Shoirah
- Department of Neurosurgery, Mount Sinai Health System, New York, New York, USA
| | - J Mocco
- Department of Neurosurgery, Mount Sinai Health System, New York, New York, USA
| | - Johanna T Fifi
- Department of Neurosurgery, Mount Sinai Health System, New York, New York, USA
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Almallouhi E, Debenham E, Grant C, Spiotta AM, Holmstedt CA, Al Kasab S. Increased telestroke call burden after the extended thrombectomy window trials. J Telemed Telecare 2021; 29:291-297. [PMID: 33470141 DOI: 10.1177/1357633x20982738] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
INTRODUCTION Clinical trials have proven the efficacy of mechanical thrombectomy in stroke patients with large-vessel occlusion presenting within 24 hours of symptom onset. Extending the thrombectomy window to 24 hours resulted in a higher number of thrombectomies being performed. However, little is known about the impact of the extended thrombectomy window on the telestroke call burden. METHODS We used the prospectively maintained database of a telestroke network covering a large geographic area in the Southeast USA. We included patients presenting between January 2015 and December 2019. We compared the characteristics and outcomes between patients who presented before and after the publication of the extended window thrombectomy trials. RESULTS A total of 9041 patients presented with stroke-like symptoms during the study period. Of these, 4995 presented after February 2018. There was no difference in the patient demographics in both groups. However, patients in the post extended window group had a lower National Institute of Health Stroke Scale on presentation (3 vs. 4; p < 0.001) and longer symptom-onset-to-door time (124 vs. 85 minutes; p < 0.001). The number of consults per month nearly doubled (200 vs. 103; p < 0.001) in the extended thrombectomy window era. Similarly, the number of mechanical thrombectomies performed per month increased from four to seven since extending the thrombectomy window (p < 0.001). DISCUSSION The number of telestroke consults nearly doubled after the publication of the extended thrombectomy window trials, with an increase in the number of thrombectomies performed. These findings have important operational implications for hospitals implementing telestroke call coverage.
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Affiliation(s)
- Eyad Almallouhi
- Department of Neurology, Medical University of South Carolina, USA
| | - Ellen Debenham
- Department of Neurology, Medical University of South Carolina, USA
| | - Cheryl Grant
- Department of Neurology, Medical University of South Carolina, USA
| | | | | | - Sami Al Kasab
- Department of Neurology, Medical University of South Carolina, USA.,Department of Neurosurgery, Medical University of South Carolina, USA
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Fargen KM, Leslie-Mazwi TM, Chen M, Hirsch JA. Physician, know thyself: implicit and explicit decision-making for mechanical thrombectomy in stroke. J Neurointerv Surg 2020; 12:952-956. [DOI: 10.1136/neurintsurg-2020-015973] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2020] [Revised: 03/27/2020] [Accepted: 03/30/2020] [Indexed: 01/02/2023]
Abstract
Few clinical situations in medical practice are as time-sensitive and and have such profound ramifications as selection of patients with acute stroke for mechanical thrombectomy (MT). Emergent large vessel occlusion has become a treatable disease with minimal numbers needed to treat to achieve a functional, long-term neurologic outcome. However, MT carries risk and many patients who are appropriately reperfused continue to have significant neurologic deficits and disability despite a successful procedure. The decision to offer or withhold MT can be complex. Frequently decisions must be made based on incomplete information or emergently while the physician is awoken from sleep or distracted while performing other procedures. A growing number of studies have examined cognitive errors and biases as they pertain to patient diagnosis and treatment in medicine. Dual process theory identifies two decision-making processes as system 1 ('implicit') and system 2 ('explicit') and describes the patterns through which decisions are formulated. The implicit system is the default pathway as it requires little effort or focus, uses mental short cuts, and is rapid; however, this pathway is subject to considerable bias and error. This manuscript reviews the mechanisms underlying the way in which physician decisions about MT are made, specifically highlighting prominent biases that may affect judgment, and reviews other important principles, such as confidence in decisions, aggressiveness to pursue MT, and strategies to improve decisions.
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Dalsania AK, Kansagra AP. Strategies to reduce the impact of demand for concurrent endovascular thrombectomy. J Neurointerv Surg 2020; 12:1072-1075. [PMID: 32188761 DOI: 10.1136/neurintsurg-2020-015826] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2020] [Revised: 02/23/2020] [Accepted: 02/25/2020] [Indexed: 12/20/2022]
Abstract
BACKGROUND The rise in demand for endovascular thrombectomy (EVT) has increased the possibility that multiple patients with acute ischemic stroke may present concurrently and exceed local capacity to provide timely treatment. In this work, we quantitatively compared the efficacy of various strategies to mitigate demand in excess of capacity (DEC). METHODS Strategies evaluated included a backup neurointerventional team for 3 hours, 8 hours, or 24 hours per day; a separate pre-intervention imaging team; and a 30% decrease in procedure duration. For each strategy, empirical distributions were used to probabilistically generate arrival time and case duration for 16 000 independent trials repeated across a range of annual case volumes. DEC was calculated from time series representing the number of concurrent cases at each minute of the year for each trial at each case volume. RESULTS All strategies decreased DEC compared with baseline. At a representative volume of 250 cases per year, availability of a backup team for 3 hours, 8 hours, and 24 hours per day reduced DEC by 27.0%, 60.3%, and 97.2%, respectively, compared with baseline. Similarly, availability of a pre-intervention imaging team and a 30% decrease in procedure duration reduced DEC by 26.6% and 17.7%, respectively, compared with baseline. CONCLUSIONS A backup neurointerventional team, even if available only part time, was an effective strategy for decreasing DEC for EVT. Understanding the actual quantitative benefit of each strategy can facilitate rational cost-benefit analyses underlying the development of efficient and sustainable models of care.
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Affiliation(s)
| | - Akash P Kansagra
- Mallinckrodt Institute of Radiology, Washington University School of Medicine, St Louis, Missouri, USA .,Department of Neurological Surgery, Washington University School of Medicine, St Louis, Missouri, USA.,Department of Neurology, Washington University School of Medicine, St Louis, Missouri, USA
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Kim JG, Choi JC, Kim DJ, Bae HJ, Lee SJ, Park JM, Park TH, Cho YJ, Lee KB, Lee J, Kim DE, Cha JK, Kim JT, Lee BC. Effect of the Number of Neurointerventionalists on Off-Hour Endovascular Therapy for Acute Ischemic Stroke Within 12 Hours of Symptom Onset. J Am Heart Assoc 2019; 8:e011933. [PMID: 31625423 PMCID: PMC6898823 DOI: 10.1161/jaha.119.011933] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Background Off‐hour presentation can affect treatment delay and clinical outcomes in endovascular therapy (EVT) for acute ischemic stroke. We aimed to examine the treatment delays and clinical outcomes of EVT between on‐ and off‐hour admission and to evaluate the effect of hospital procedure volume and the number of neurointerventionalists on off‐hour EVT. Methods and Results From a multicenter registry, we identified patients who were treated with EVT within 12 hours of symptom. Annual hospital procedure volume was divided as low (<30), medium (30–60), and high (>60). The effect of the number of neurointerventionalists and annual hospital procedure volume on clinical outcome was estimated by the generalized estimation equation. Of the 31 133 stroke patients, 1564 patients met the eligibility criteria (mean age: 69±12 years; median baseline National Institutes of Health stroke scale score, 15 [interquartile range, 10–19]). Of 1564 patients, 893 (57.1%) arrived during off‐hour. The off‐hour patients had greater median door‐to‐puncture time (110 versus 95 minutes; P<0.001) compared with on‐hour patients. Despite the treatment delay, the functional outcome at 3 months did not differ between off‐ and on‐hour (odds ratio with 95% CI for 3‐month modified Rankin Scale 0–2, 0.99 [0.78–1.25]; P=0.90). The presence of three neurointerventionalists was significantly associated with favorable outcomes at 3 months during on‐ and off‐hour (2.07 [1.53–2.81]; P<0.001). The association was not observed for annual hospital procedural volume and the functional outcomes. Conclusions The number of neurointerventionalists was more crucial to effective around‐the‐clock EVT for acute stroke patients than hospital procedural volume.
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Affiliation(s)
- Joong-Goo Kim
- Department of Neurology Jeju National University Hospital Jeju Korea
| | - Jay Chol Choi
- Department of Neurology Jeju National University Hospital Jeju Korea.,School of Medicine Jeju National University Jeju Korea
| | - Duk Ju Kim
- School of Medicine Jeju National University Jeju Korea
| | - Hee-Joon Bae
- Department of Neurology Seoul National University Bundang Hospital Seoul National University College of Medicine Seongnam Korea
| | - Soo-Joo Lee
- Department of Neurology Eulji University Hospital Daejeon Korea
| | - Jong-Moo Park
- Department of Neurology Nowon Eulji Medical Center Eulji University Seoul Korea
| | - Tai Hwan Park
- Department of Neurology Seoul Medical Center Seoul Korea
| | - Yong-Jin Cho
- Department of Neurology Ilsan Paik Hospital Inje University Goyang Korea
| | - Kyung Bok Lee
- Department of Neurology Soonchunhyang University College of Medicine Seoul Korea
| | - Jun Lee
- Department of Neurology Yeungnam University Hospital Daegu Korea
| | - Dong-Eog Kim
- Department of Neurology Dongguk University Ilsan Hospital Goyang Korea
| | - Jae-Kwan Cha
- Department of Neurology Dong-A University College of Medicine Busan Korea
| | - Joon-Tae Kim
- Department of Neurology Chonnam National University Hospital Gwangju Korea
| | - Byung-Chul Lee
- Department of Neurology Hallym University Sacred Heart Hospital Anyang Korea
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The pincer movement of cost and quality in neurointerventional care: resource management as an imperative. J Neurointerv Surg 2019; 11:323-325. [DOI: 10.1136/neurintsurg-2019-014871] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/21/2019] [Indexed: 11/03/2022]
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Albuquerque FC. From Spokane to McCall. J Neurointerv Surg 2018; 10:921-922. [DOI: 10.1136/neurintsurg-2018-014387] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/29/2018] [Indexed: 11/04/2022]
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Schwegel C, Rothman N, Muller K, Loria S, Raunig K, Rumsey J, Fifi J, Oxley T, Mocco J. Meeting the evolving demands of neurointervention: Implementation and utilization of nurse practitioners. Interv Neuroradiol 2018; 25:234-238. [PMID: 30269668 DOI: 10.1177/1591019918802411] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Growth in the neurointerventional field, as a result of the emergence of thrombectomy as the gold standard treatment for large vessel occlusions, has created complex challenges. In an effort to meet evolving demands and fill workflow gaps, nurse practitioners have taken on highly specialized roles. Neurointerventional care has rapidly evolved similarly to interventional cardiac care, in that nurse practitioners are successfully being incorporated as procedural assistants in catheterization laboratories. Similar utilization of nurse practitioners in interventional neuroradiology holds the capacity to decrease physician workload, mitigate stresses contributing to burn-out, and reallocate more physician time to procedures. Nurse practitioner practice faces procedural, clinical, legal and interpersonal barriers. Despite calls for expanded practice by the Institutes of Medicine, a paucity of nurse practitioner training opportunities exists. Fragmented privileging processes contribute to environments where nurse practitioners must navigate hurdles without established interventional neuroradiology-specific precedent. Increased nurse practitioner mentorship, fluoroscopy law standardization, physician support surrounding nurse practitioner autonomy, and role consistency is imperative for optimal nurse practitioner utilization. Nurse practitioners are uniquely equipped to bridge evolving gaps through the provision of safe, efficacious care, and generating revenue at lower costs. Discussion surrounding nurse practitioner use to bridge workflow gaps is an exciting opportunity for future practice development.
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Affiliation(s)
- Claire Schwegel
- 1 The Mount Sinai Health System, Cerebrovascular Center, New York, NY, USA
| | - Nicole Rothman
- 2 Columbia University Medical Center, School of Nursing, New York, NY, USA
| | - Kimberly Muller
- 2 Columbia University Medical Center, School of Nursing, New York, NY, USA
| | - Stephanie Loria
- 2 Columbia University Medical Center, School of Nursing, New York, NY, USA
| | - Katherine Raunig
- 2 Columbia University Medical Center, School of Nursing, New York, NY, USA
| | - Jamie Rumsey
- 1 The Mount Sinai Health System, Cerebrovascular Center, New York, NY, USA
| | - Johanna Fifi
- 1 The Mount Sinai Health System, Cerebrovascular Center, New York, NY, USA
| | - Thomas Oxley
- 1 The Mount Sinai Health System, Cerebrovascular Center, New York, NY, USA
| | - J Mocco
- 1 The Mount Sinai Health System, Cerebrovascular Center, New York, NY, USA
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