Impact of Telemedicine Stroke Nurse Practitioner Care on Inpatient Management in Vascular Neurologist Underserved Primary Stroke Centers.

Abstract

Background: Many primary stroke centers (PSCs) lack vascular neurologists, unnecessarily transferring thrombolysis patients to comprehensive stroke centers (CSCs). We implemented a telemedicine inpatient stroke nurse practitioner (NP) PSC service to reduce unnecessary transfers.

Methods: A prospective observational study was conducted to assess the feasibility and quality of telemedicine-delivered inpatient NP acute stroke management at CSC-affiliated PSCs. Following systemic thrombolysis treatment directed by telemedicine CSC vascular neurologists, uncomplicated patients were admitted to PSC internal medicine hospitalists; hospitalists ordered stroke consultation by either in-person community general neurologists (GNs) or a CSC stroke-trained telemedicine NP. We analyzed demographics, clinical management variables, complications, and stroke core measure compliance between patients receiving GN or NP consultation.

Results: Among 1237 patients, 720 (58.2%) were managed by GNs and 517 (41.8%) by NPs. Patient sex and admission National Institutes of Health Stroke Scale scores were similar, but NP patients were younger than GN patients (64.5 + 14 versus 69 + 13 years; P<0.001) and more racially diverse (P=0.012), with more admitted to the low socioeconomic hospital (P<0.001). NPs managed most (98.5%; P<0.001) post-tPA (tissue-type plasminogen activator) patients due to GN refusal. GN patients had higher modified Rankin Scale score prestroke disability (P=0.006) and more with left middle cerebral artery or posterior circulation (P<0.001) stroke. On multivariate analyses, National Institutes of Health Stroke Scale score documentation within 12 hours of admission was better by NPs (90.5%) than GNs (69.7%; P<0.001). NPs were also significantly more compliant than GNs (92.6% versus 41.3%; P<0.001) in documenting stroke mechanism and more compliant (83.3% versus 19.9%; P<0.001) than GNs with ordering extended external cardiac monitoring or implantable loop recorders for embolic stroke of unknown source; readmissions within 30 days of discharge for new stroke events were clinically but not statistically different (GN 34.4% versus NP 17.6%; P=ns).

Conclusions: NP telemedicine-delivered inpatient stroke care in vascular neurologist-underserved PSCs is feasible and results in improved adherence to several guideline-directed core measures for stroke center quality monitoring. These findings support expanded use with further study of the impact of telemedicine stroke NPs in PSC hospitals to prevent unnecessary patient transfers to CSCs.