The Neurocritical Care Team

The Ever-evolving Role of the Advanced Practice Nurse, From Physician Extender to Midlevel Intensivist

by Veronica Moreno, ACNP-BC, neurosciences


The advanced practice nurse (APN) role was developed during a time of major healthcare reform, physician shortages, and both societal and economic need. the APN has been at the forefront of these changes and evolved as a profession into an integral part of the modern healthcare system.


Cottage Health System advanced practice nurses: Veronica Moreno, ACNP, CNRN; Emily Rorden, ACNP-BC, CNRN; Martha Serrato, ACNP-BC


Today the APN is a registered nurse with a master’s, post-master’s or doctoral degree. APNs are certified by a specialty organization after passing a national certification exam. They diagnose, treat, teach and counsel patients and most have prescriptive authority.


The four main groups of APNs are the nurse practitioner (NP), the certified nurse specialist (CNS), the certified nurse anesthetist (CRNA) and the certified nurse midwife (CNM). The focus of this article is on the development of the NP role and the changes in health care that led to the development.


Historical Context

The NP role has evolved from the early portrayal of a physician extender to a modern-day midlevel intensivist—the driving force in the modernization of medicine, healthcare reform, economic forces and the needs of society. Currently, 115,000 NPs are practicing in the United States.


In the late 1950s and early 1960s, there was an increase in physician specialization. A number of physicians left primary care, resulting in shortages especially in rural and medically underserved areas. In 1965, the Medicare and Medicaid program increased coverage and the availability of medical care for low-income women, children and the elderly. The APN’s role was developed to meet the increased need for healthcare delivery.


A nurse and a physician created the first NP training program. In 1965, Loretta Ford and Henry Silver developed the first NP program in Colorado. The focus was on health promotion, disease prevention, and the health of children and families.


During the 1970s, the APN profession was further defined and legitimized. The American Nurses’ Association (ANA) defined and published guidelines that addressed scope of practice, skills and continuing education requirements. Furthermore, there was documentation of the increased availability of primary care, and both patient and physician satisfaction elevated the profession. Studies conducted in the 1980s evaluated outcomes and the delivery of health care by APNs. One randomized trial in JAMA supported the hypothesis that primary care outcomes do not differ between NP and physician healthcare delivery.


In the late 1980s to early 1990s, the biggest change occurred that affected APN education. The American Nurses Credentialing Center (ANCC) changed the requirement to sit for a national certification exam to graduate-level education and preparation. Prior to this, APN education took place through multiple non-degree programs of varying length. A registered nurse could attend one of the certification programs as a means to enter into practice. Many HMOs dominated by physicians held certificate programs with the goal of producing low- salaried mid-level practitioners to function as physician extenders.


The Move to NP Sub-specialization

The first group of acute care nurse practitioners (ACNP) was certified in 1995. This newest subspecialty was developed during a time when teaching and academic hospitals were forced to cut back on residency hours. In 2003, the first national mandate to limit resident hours was instituted by the Accreditation Counsel for Graduate Medical Education. Then in 2011, call restrictions were implemented for first-year residents.


Following these new mandates, non-physician providers have been utilized in many healthcare systems to meet the needs of patient care. Although other NPs with a background in family medicine, pediatrics or gerontology practice in hospital settings, only ACNPs are specially trained in critical care and the management of critically ill ICU patients.


ACNP specialty areas of practice include critical care, trauma, surgery, hospitalist, neurosurgery and interventional radiology, to name a few. According to the ANCC, approximately 10,000 ACNPs are currently certified in the United States.


Today, as hospitals are forced to alter current practices and develop new models of care, the idea of an inter- professional practice approach to care has moved to the forefront. APNs are among the various practitioners who have proven they are capable of providing high-quality, cost-effective care. Hospitalized patients are sicker than in the past, and patients in intensive care have increasingly more complex conditions. Many ICU patients require teams of highly trained specialists to care for them. This is especially true for patients in the modern neurocritical care unit.


At Cottage Health System

At Santa Barbara Cottage Hospital, neurocritical care patients occupy part of the surgical intensive care unit. The multidisciplinary team of professionals who care for these patients includes NPs, pulmonologists, RNs, respiratory therapists, dietitians, and physical, occupational and speech therapists, to name a few. Caring for these complex patients would be nearly impossible without this team.


Santa Barbara Cottage Hospital has employed three ACNPs who are an integral part of the neurosciences team. Working in a collaborative practice with a dedicated group of pulmonary intensivists, the NPs guide the daily management of hospitalized acute and critically ill neuro ICU patients.


The ACNPs work 12-hour shifts, three days per week, managing an average of 15 to 18 patients daily. Most of the patients are in intensive care and among the sickest patients in the hospital.


The growth of the neuroscience services of Santa Barbara Cottage Hospital has required expansion and ongoing development of the inter-professional team that cares for these patients. The ACNPs work closely with the attending neurosurgeon and provide comprehensive patient care from admission through discharge. In addition to the day-to-day management of patients, ACNP duties include attending and presenting patients during multidisciplinary rounds, advanced procedures such as central line and arterial line placement, lumbar puncture, and specialty physician consultation.


Scope of Services

The daily management of the complex neurocritical care patient requires in-depth knowledge of critical care, pharmacology, anatomy and pathophysiology pertaining to the neurosciences. Furthermore, an understanding of general neurosurgical and neuroendovascular procedures and postoperative care is essential to patient management. The ACNP uses standardized procedures and hospital protocols in the management of acutely ill hospitalized patients. The maintenance of blood pressure, fluids, electrolytes, Fi02, Pa02, Pc02, sedation, paralytics, anticoagulation and body temperature within certain parameters is of key importance for good outcomes. The primary goal of neurocritical care is the prevention of secondary brain injury; the treatment and management of neurocritical care patients varies significantly depending on the patient’s disease process.


Historically, pulmonary critical care physicians and intensivists have cared for patients in the ICU. The Committee on Manpower for the Pulmonary and Critical Care Societies has estimated the need for intensivists will fall short of the demand by as much as 22 percent by 2020.


According to the 2010 Institute of Medicine (IOM) report, The Future of Nursing, “millions more patients are expected to access healthcare services under the federal Affordable Care Act, [and] APRNs should be prominent in providing that care.”


As we sit on the brink of yet another major healthcare reform, the APN will be vital in providing care and filling healthcare delivery gaps. The APN has evolved from simply being an extension of the physician into a mid-level provider and necessary component of the inter-professional healthcare team. The modern APN is a highly educated individual capable of managing acutely ill hospitalized patients and providing high-quality, cost- effective health care as a midlevel intensivist.


For more information about Santa Barbara Neuroscience Institute at Cottage Health System, please visit our website at


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