Medical Decision-Making and Process Measures in a Consultative Hub-and-Spoke Teleneurocritical Care Network.

backgroundTeleneurocritical care (TeleNCC) aims to project expertise to hospitals lacking dedicated neurocritical care. However, its influence on clinical care remains underexplored.

methodsWe prospectively studied two TeleNCC cohorts. Within a tertiary care medical decision-making cohort, TeleNCC consultants documented recommended changes in prespecified aspects of evaluation and management for patients at a tertiary care hospital with neurosurgery, neurology, and critical care but without dedicated neurocritical care. In a separate community process measure cohort, TeleNCC consultants documented prespecified process measures (consultation duration, transfer to tertiary care versus local patient retention, and approaches to brain death determination) for patients across ten community hospitals lacking on-site neurology support. Differences were evaluated by site and diagnosis.

resultsWithin the tertiary care medical decision-making cohort (n = 123), TeleNCC consultants recommended changes in evaluation and management for 71.8% of patients, including neuroimaging, neuromonitoring, medication initiation/adjustment, operative management, and de-escalation from critical care. TeleNCC consultations often did not require video evaluation. Within the community process measure cohort (n = 1493), consultation duration varied by site. Tertiary care transfer was rare (0-9.2% among 9 of 10 hospitals), although patients with subarachnoid hemorrhage (SAH) were transferred more frequently (38.5%; p < 0.001) than patients with toxic-metabolic/systemic encephalopathy, hypoxic-ischemic encephalopathy, or other cerebrovascular disorders. Community hospital providers evaluated 47 patients for brain death under TeleNCC guidance; 16 (61.5%) of 26 patients evaluated by clinical criteria alone met criteria, as well as 16 (76.2%) of 21 patients evaluated via additional ancillary testing.

conclusionsFor patients at a tertiary care hospital, TeleNCC consultants recommended changes in medical decision-making for the vast majority of patients, whereas community hospital patients receiving TeleNCC consultation as their initial neurologic evaluation rarely required transfer to tertiary care, despite complex conditions, including suspected brain death. These observational cohorts demonstrate the versatility and efficiency of TeleNCC across care settings, although interventional studies are needed to evaluate the impact of TeleNCC on clinical outcomes.