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Global Stroke Ethnography

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PROBLEM

A major biotechnology firm developed a novel therapy to treat ischemic strokes. But the product team was unsure how to adapt the drug to diverse emergency departments across Europe, Asia, and America. How should the drug be packaged? Where should it be stored? Who should prepare and administer it?

These questions are pressing in the case of strokes. Each minutes is a matter of life and death. Patients have just 4.5 hours to receive a plasminogen activator (tPA) infusion that busts the clots in their arteries.

Working hypotheses shift over the course of ethnographic studies. Whereas our initial expectation was that stroke treatments would vary by regions, we instead came to find that practices diverged significantly within regions. As we reviewed our field notes and film, what came to light were the intricate and habituated practices by which stroke team members shared responsibilities and navigated hospital systems.

Stroke team members’ practices were rapid and reflexive. Retrieving supplies was often done instinctively. Our observations of nurse behavior, in particular, revealed that the hierarchies and responsibilities among nursing staff impacted the procedures involved in stroke treatments. Drawing on the behavior maps written as part of my field notes, we created journey maps to visualize the patterns among stroke team practices.

At some facilities, nurses were empowered to prepare and administer therapies; at others, nurses depended on physicians and pharmacists. Moreover, the level of responsibility impacted the devices and supplies used. For example, nurses tasked with dosing and reconstituting drugs needed immediate access to transfer devices and IV tubing. The roles afforded to nurses were central determinants of stroke teams’ needs.

We began by gathering available information about the procedures, products, and personnel involved in stroke treatments. Sources included:

 

  • American Heart Association (AHA) clinical and professional resources

  • Hospital drug delivery guidelines

  • Physician order sheets and drug formularies

 

Questionnaires were also disseminated to stroke center coordinators in an effort to collect insights about the supplies used in stroke treatments. However, we soon encountered limits. Too much went undocumented.

We wanted to get a better sense of the unspoken preferences and pain points that are part of the ingrained knowledge, corporeal practices, and deep competences at work in crisis scenarios. In which ways do finite resources, stressful collaboration, and spontaneous decision-making affect actual treatments? To uncover thick data about stroke teams’ behaviors, we traveled to hospitals.

PROCESS

DATA ANALYSIS/ INSIGHTS

In partnership with neurologists, radiologists, and emergency department directors, my team coordinated daylong site visits in nine facilities. Our days were spent conducting semi-structured interviews with stroke team members and strategically waiting near ambulance bays. When patients arrived with strokes, I followed their pathway from triage through treatment.

 

It’s not easy watching people suffering from a stroke. Nor is it always clear what takes place among stroke team members in fast-paced crisis scenarios. To capture the nuanced interactions involved in the stroke treatment journey, I wrote furiously. My field notes documenting the spaces, devices, people, practices, and timing.

 
 
 

FIELDWORK

RESULTS

The final results were design criteria for a new drug and device kit adaptable to diverse stroke center systems. We presented the criteria as a hierarchical decision chart, which enabled our client to bundle its stroke drug with modular supply sets. As a result, new markets in Japan, China, and Germany opened up to the company.

The client’s product team has begun to roll out variations of the kit to suit stroke centers’ unique demands.  

Our methods and findings were also presented at the 2019 Human Factors and Ergonomics in Health Care annual meeting.

*Certain details have been omitted in conformity with confidentiality agreements.

© 2020 by Larry S. McGrath