Advanced Practice Nurses on the Stroke Unit: A Cross-Sectional Study

Objective: To evaluate the economic and quality outcomes associated with a collaborative advanced practice nurse and hospitalist physician model of care on the in-patient Stroke Unit as compared to usual hospitalist physician-led care. Background: In the standard medical model, physicians have historically assumed responsibility for all aspects of medical decision making for hospitalized patients. Value-based reimbursement now creates a pressing need for transformative care models which promote evidence-based care while providing high quality experiences for patients and families. High functioning collaborative teams are anticipated to be essential under value-based reimbursement. Methods: The study developed from a care improvement effort implemented within a Joint Commission-designated Primary Stroke Unit at a large Midwestern private Catholic hospital.  Hospitalist nurse practitioners were assigned to the Stroke Unit in collaboration with hospitalist physicians to implement daily hospital management for patients with stroke and transient ischemic attack. To evaluate outcomes associated with the care model, a retrospective cross sectional design was used with 100 patients in the collaborative advanced practice nurse and hospitalist physician care group and 100 patients in the usual hospitalist physician-led care group. Primary outcome measures were length of stay, 30-day re-admissions, stroke core measure documentation, and patient experiences of care. Analysis of demographic characteristics assured that the samples were similar. Results: The collaborative care group performed better on one of five stroke core quality measures and on two of three patient experience of care measures. Mean length of stay and hospital re-admissions were similar between groups.  Five patients left the Stroke Unit against medical advice in the usual hospitalist physician-led care group, while there were no discharges against medical advice in the collaborative care group. Conclusion: Advanced practice nurse and hospitalist physician collaboration is a promising model for healthcare quality improvement during inpatient stroke care; results are likely generalizable to other adult medicine populations.