NURS 718 Week 5 Case Study 3 on Evaluating a Telehealth Service Expansion Example

Case Study 3: Should the Telestroke Network Add a Remote Stroke Nurse Practitioner? Evaluating an Information System Expansion With Structure, Process and Outcome Measures

Case Summary

Six months after Shenandoah Valley Health connected its three emergency departments to a comprehensive stroke center's telestroke service, 41 patients have received a telestroke consultation and 17 have received thrombolysis. Median door-to-needle time at the two smaller hospitals fell from 74 to 58 minutes. However, 14 of the 17 thrombolysis patients were still transferred to the stroke center after treatment, mainly because no local physician felt comfortable managing them overnight. The stroke center now offers a second service: a telemedicine stroke nurse practitioner who would round remotely on admitted stroke patients each day and be available by video overnight, at an annual cost of about $180,000. The board has asked whether to add it.

Question 1: What Framework Should Guide the Evaluation?

Tan and Payton (2010) describe evaluation as a continuing part of the information system life cycle, not a single event after implementation. The model proposed by Donabedian (1988) offers a practical structure for evaluating a clinical information service by examining structure, process and outcome together.

The fourth row matters as much as the first three. Balancing measures capture what an improvement might cost elsewhere in the system, and a service that keeps patients local but exhausts the night nurse is not a success. Most process measures can be drawn from the shared electronic record and the stroke registry the regional center already submits, while workload data will need a simple log kept by charge nurses for each stroke admission. Each measure should have one owner, a definition agreed with the stroke center and a reporting interval, so that the evaluation is built into routine operations rather than assembled at the end.

Question 2: What Do the First Six Months Show?

The emergency phase appears to be working: door-to-needle time fell by 16 minutes, a clinically meaningful improvement. The data cannot yet show outcomes such as disability, because the numbers are small and follow-up is short. The high transfer rate after thrombolysis points to a gap in the inpatient phase rather than the emergency phase, which is exactly what the proposed service addresses. Seventeen patients are too few to estimate effects precisely, so any decision should be framed as a test rather than a certainty. The six months also contain useful process signals. Of the 41 consultations, the hub's logs show that most began within ten minutes of the page, which suggests the emergency workflow is stable enough to build on. What the logs cannot show is whether the 14 transfers were clinically necessary or simply the only option available overnight; a chart review of those cases by the stroke coordinator would separate the two and give the pilot a true baseline. Six months of data can show where a system is failing even when they are too few to prove what will fix it.

Question 3: What Does the Evidence Say About Telemedicine Stroke NPs?

A 2026 prospective study at primary stroke centers without vascular neurologists compared inpatient stroke consultation by a stroke-trained telemedicine nurse practitioner from a comprehensive stroke center with in-person consultation by community general neurologists across 1,237 patients (Dusenbury et al., 2026). Nurse practitioners managed nearly all post-thrombolysis patients, documented the NIH Stroke Scale within 12 hours of admission more often (90.5% versus 69.7%), documented stroke mechanism far more often (92.6% versus 41.3%) and ordered extended cardiac monitoring for embolic stroke of unknown source more often. Thirty-day readmissions for new stroke events were lower with nurse practitioners but the difference was not statistically significant. The authors concluded that the model was feasible and improved adherence to core measures. The study was observational and the groups differed in age and disability, so it supports the model's quality without proving it prevents transfers in every setting. Two features of the study fit Shenandoah Valley Health closely: the hospitals had no vascular neurologist, and the remote nurse practitioners worked from a comprehensive stroke center that also provided emergency telestroke. That arrangement mirrors the proposal, since the same hub would supply both services and the inpatient team could see the emergency consultation notes. Tan and Payton (2010) describe information systems as most valuable when they connect decisions across the stages of care, and an inpatient service linked to the emergency one extends that connection past the first hour.

Question 4: What Unintended Effects Should Be Anticipated?

Remote services often move work rather than remove it. In a real-world comparison of heart failure care, patients managed with remote monitoring had more frequent and longer consultations, mostly with specialized nurse practitioners, with no difference in cardiologist time or readmissions (Nieuwenhuys et al., 2026). A remote stroke nurse practitioner would rely on bedside nurses to present patients on video, carry out neurological checks, run swallow screens and relay orders, so local nurses' workload would rise. Telestroke also raises the possibility of treating stroke mimics, which a 2026 review notes remain common among patients evaluated and treated through telestroke, although serious bleeding after treating a mimic is uncommon (Zhang et al., 2026). Both effects should be measured. A third effect is less visible. When local physicians hand overnight decisions to a remote clinician, their own confidence with stroke patients may fall further, making the system more dependent on the contract. The pilot should therefore include joint case reviews in which the hospitalists and the remote nurse practitioner discuss each admission, so that local skill grows alongside the service rather than shrinking behind it.

Question 5: What Should the Board Decide?

The board should approve a twelve-month pilot of the telemedicine stroke nurse practitioner service at the community hospital first, with four conditions. Success criteria should be set in advance: a reduction in post-thrombolysis transfers by at least half and stable or improved core measure compliance. Bedside nurse staffing should be adjusted for stroke admissions, with workload tracked. The contract should include data sharing so outcomes can be measured. And the board should review results at six and twelve months, deciding whether to expand to the critical access hospital. The cost of $180,000 should be compared with the cost of transfers avoided and with revenue retained when patients stay local. If the community hospital avoids even a third of last year's transfers, the savings in ambulance costs and the admissions kept in the system would likely offset much of the fee, although the finance office should model this with its own figures before the board votes. The contract should also allow the system to end the service at twelve months without penalty if the success criteria are not met. Zaccagnini and White (2017) describe the DNP as a leader who translates evidence into practice and then evaluates the result; in this case, that means the DNP should chair the pilot's evaluation group and present its findings to the board.

Christian Reflection

Scripture repeatedly condemns dishonest scales, treating a false measure as a wrong against God and neighbor alike (English Standard Version Bible, 2001/2016, Proverbs 20:10). In an evaluation, the temptation is not usually fraud but selective reporting, celebrating the faster treatment times while leaving the nurses' extra hours out of the report. Measuring honestly, including the workload a new service places on nurses and the possibility of harm, is part of using an information system faithfully rather than promoting it.

Conclusion

The telestroke network has improved emergency treatment times, and its failure point now lies in inpatient care. Evidence supports remote stroke nurse practitioners as a way to deliver guideline-based inpatient care where neurologists are scarce. The board should test the service through a conditional pilot evaluated with structure, process, outcome and balancing measures.

References

Donabedian, A. (1988). The quality of care: How can it be assessed? JAMA, 260(12), 1743-1748. https://doi.org/10.1001/jama.1988.03410120089033

Dusenbury, W., Swatzell, V. M., Krishnaiah, B., Elangovan, C., Nearing, K., Alexandrov, A. V., & Alexandrov, A. W. (2026). Impact of telemedicine stroke nurse practitioner care on inpatient management in vascular neurologist underserved primary stroke centers. Stroke: Vascular and Interventional Neurology, 6(5), Article e002313. https://doi.org/10.1161/SVIN.125.002313

English Standard Version Bible. (2016). Crossway. (Original work published 2001)

Nieuwenhuys, W. W., van Leunen, M. M. C. J., van de Pol, J. A. A., Hafkamp, F. J., Spee, R. F., Tio, R. A., Funk, M., & Kemps, H. M. C. (2026). Real-world impact of remote patient management on care consumption and care time in heart failure: Retrospective cohort study. JMIR Formative Research, 10, Article e89187. https://doi.org/10.2196/89187

Tan, J. K. H., & Payton, F. C. (2010). Adaptive health management information systems: Concepts, cases, and practical applications (3rd ed.). Jones and Bartlett.

Zaccagnini, M. E., & White, K. W. (Eds.). (2017). The doctor of nursing practice essentials: A new model for advanced practice nursing (3rd ed.). Jones & Bartlett Learning.

Zhang, W., Wang, L., Ren, S., Yang, Z., Wu, G., & Gao, K. (2026). Telestroke systems and thrombolysis decisions: Diagnostic uncertainty, treatment thresholds, and stroke mimics. Frontiers in Neurology, 17, Article 1889300. https://doi.org/10.3389/fneur.2026.1889300