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Shifting bottlenecks in acute stroke treatment
  1. Mayank Goyal1,
  2. Ashutosh P Jadhav2,
  3. Alexis T Wilson1,
  4. Raul G Nogueira3,
  5. Bijoy K Menon1
  1. 1Department of Radiology and Clinical Neurosciences, Cumming School of Medicine, Calgary, Alberta, Canada
  2. 2Department of Neurology and Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
  3. 3Department of Neurology, Neurosurgery and Radiology, Emory University School of Medicine, Atlanta, Georgia, USA
  1. Correspondence to Dr Mayank Goyal, Seaman Family MR Research Centre, Foothills Medical Centre, 1403 29th St NW, Calgary, Alberta, Canada T2N 2T9; mgoyal{at}

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We know without doubt that ‘time is brain’. How do we know this? It is a combination of data, logic, biological plausibility, and experience.

Now that endovascular treatment is the standard of care,1–5 we have an obligation to focus on process improvement to maximize patient benefit. As we go down the pathway of improving these processes, it is important to understand the idea of bottlenecks.

What are bottlenecks? In any complex process, not all parts of it are flow-limiting, especially when one considers parallel processing. For instance, imagine a situation where, in a particular hospital A, all endovascular stroke cases are done under general anesthesia (GA). Also imagine that, after working hours, anesthesia is usually available within 1 h of being called. The neurointerventionist is working hard with hospital administration to ensure that the nurse and technologist can be in the laboratory within 20 min instead of the current 30 min; even if successful, this would essentially be a waste of time as the bottleneck is anesthesia availability time. In the same scenario, now imagine that they took a decision to try to perform most cases without anesthesia; in this case, the availability of the team becomes the new bottleneck. This is what is meant by shifting bottlenecks.

Human behavior is such that, if one component of the overall workflow is extremely slow, there is a tendency to not worry about a few minutes here and there since the one …

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  • Competing interests MG has received consulting fee from Medtronic for conduct and design of SWIFT PRIME trial. ESCAPE trial for partly funded by Medtronic through a grant to University of Calgary. MG has developed technologies related to improving systems of stroke diagnosis that has been subsequently licensed to GE Healthcare.

  • Provenance and peer review Not commissioned; internally peer reviewed.