T h e H i s t o r y o f N e u ro c r i t i c a l

Care as a S ubspecialty
Kristi Tempro, MD, Cherylee W.J. Chang, MD,*

KEYWORDS
 History  Neurointensive care  Neurocritical care
 Subspecialty critical care medicine  Subspecialty certification

KEY POINTS
 The practice of intensive care has been integral to the treatment and recovery of critically
ill patients since the nineteenth century.
 Neurologists established their role as intensivists during the poliomyelitis epidemic. Fu-
eled by neurovascular and epilepsy advances, neurocritical care continues to evolve
particularly for those with disorders of consciousness and traumatic injury.
 Neurocritical care embraces physicians from multiple primary specialties and includes
multiprofessional teams proven to better patient outcomes.
 Recent ABMS subspecialty recognition, ACGME accreditation, efforts toward global
collaboration, and guideline standardization will continue to refine the role of neurointen-
sivists in modern health care.

INTRODUCTION

The early impetus for the development of the modern intensive care unit has been
driven in part by neurologic conditions and their impact on other body systems. Yet
the journey to recognition of neurocritical care (NCC) as a subspecialty has been
long (Fig. 1). One major driver was the development of a postoperative neurosurgery
area at the Johns Hopkins Hospital in 1923, under the aegis of neurosurgeon Walter
Dandy. Moreover, the polio epidemics in the early 1900s resulted in vast numbers
of patients with neuromuscular respiratory failure, which spurred technological ad-
vances in mechanical ventilation, tracheostomy, and endotracheal intubation. In the
ensuing years, the bedside critical care clinician has become increasingly aware of
the need to interweave growing knowledge of the nervous system, its pathobiological
states, and pharmacologic and technological advances into their practice and
research. In the United States, the coming of age of NCC has included being formally

Department of Neurology, Neurocritical Care, Duke University, 40 Duke Medicine Circle, Box
3824, Durham, NC 27710, USA
* Corresponding author.
E-mail address: Cherylee.chang@duke.edu
Twitter: @changc808 (C.W.J.C.)

Crit Care Clin 39 (2023) 1–15

https://doi.org/10.1016/j.ccc.2022.06.001 criticalcare.theclinics.com
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2 Tempro & Chang

Fig. 1. Roadmap to Subspecialization—Journey of Neurocritical Care. Legend: ABMS, Amer-

ican Board of Medical Subspecialties; ACGME, Accreditation Council for Graduate Medical
Education; CCM, Critical Care Medicine; DGNI, German Neurological Society of Neurological
Intensive Care and Emergency Medicine; MGH, Massachusetts General Hospital; NCC, Neuro-
critical care; NCS, Neurocritical Care Society; NeuroICU, Neurocritical care unit; SCCM, Soci-
ety of Critical Care Medicine; UCNS, United Council for Neurologic Subspecialties. aSome
individuals with overlapping (UCNS and ABMS) certification.

recognized as a subspecialty of medicine by the American Board of Medical Spe-

cialties (ABMS) in 2018, the international growth of NCC societies, integration of
NCC into larger critical care societies, and inclusion into their journals. This article
delves into the history of NCC, its evolving presence among critical care subspe-
cialties, and steps toward certification of individuals. A separate article will focus on
education of neurointensivists and accreditation of training programs.

HISTORICAL REVIEW
The Development of Intensive Care Medicine as a Specialty
Historically, famine and vector-borne pathogens, such as plague, were the major
cause of premature death. However, by the mid-1850s, waterborne infectious dis-
eases became a major cause of death and a subject of intense study for the prevention
and treatment through improved sanitation.1 During this Victorian era, medicine began
transforming its paradigm from tradition-based to science-based practice. It was dur-
ing this time of scientific evolution that critical care medicine (CCM) was born.
From its inception, critical care has been a multiprofessional and multidisciplinary field.
Its practice was forged in the 1850s by Florence Nightingale in British Military camps dur-
ing the Crimean War.2 She developed Nightingale Rose diagrams, which demonstrated
that mortality predominantly involved preventable deaths rather than traumatic war injury.
Improved sanitation and hygiene, and a novel practice of triaging more severely injured
soldiers to beds closest to nursing stations for closer monitoring decreased mortality.
Similar to Nightingale’s practice, Dr Walter Dandy established a 4-bed neurosurgical
intensive care unit in 1923 at the Johns Hopkins Hospital in Baltimore where continuous
specialized postcraniotomy nursing care took place close to operating rooms.3
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 History of Neurocritical Care as a Subspecialty 3

The polio epidemic of the early 1900s brought neurologists to the forefront of critical
care teams. Their involvement was integral to providing the impetus to improve tech-
niques for large-scale ventilatory care, standardization of frequent intensive moni-
toring, and skilled nursing care.4,5 In the 1920s, the first effective negative pressure
ventilator, the Drinker-Shaw iron lung, was tested on a poliomyelitis patient.6 By the
1930s, endotracheal and tracheostomy tubes advanced from rigid metal tubes and
positive pressure ventilators were developed. Intensive care was focused on airway
management, optimization of ventilation, pulmonary toileting, and maintenance of he-
modynamic stability. Additionally, nursing care addressed pressure relief by frequent
repositioning, an issue highlighting another contribution to critical care by a neurolo-
gist. Jean-Martin Charcot described the progression of Decubitus ominosus in bed-
bound patients with severe neurologic disease and inadequate nutrition in 1877.7
With the development of the polio vaccine, fewer patients with primary neurologic
disease required ventilatory support. The military conflicts of World War II, Korean
and Vietnam Wars, led to advances in resuscitation and postsurgical care. Specialized
areas of intensive care were focused on postoperative patients led by surgeons and
anesthesiologists. Because further technological advances occurred with greater un-
derstanding of pulmonary and cardiac pathophysiology, internists, chiefly pulmonolo-
gists, became involved in the care of patients in intensive care areas. Neurologists
distanced themselves from the intensive care arena until the 1970s. During this
interim, due in part to the “space race” and biotechnological needs for aerospace
medicine,8 advances in computers and telemetry with cardiac and respiratory moni-
toring led to further specialization. These changes supported the development of a
care team with specialty training including nurses and respiratory therapists, and
eventually pharmacologists, dieticians, occupational, physical, and speech therapists.
To advance the growth of this new specialty, there was a great need to develop and
harmonize training, standards of practice, units’ physical requirements, organizational
structure, and specific roles of each member of the multiprofessional critical care
team. Forward-thinking individuals including Drs Max Harry Weil, Peter Safar, William
Shoemaker, and Ake Grenvik pioneered this study.9–13 Together, with 30 other physi-
cians, they founded the Society of Critical Care Medicine (SCCM) in 1971. The chal-
lenge at the time, and as it remains today, was to define the role of CCM because it
relates to other specialties.
Throughout the next decade, in the United States, specialties continued to debate
whether to create a new specialty board of CCM through the ABMS to certify individ-
uals. The effort was not successful, and the American Board of Anesthesiology (ABA),
American Board of Internal Medicine (ABIM), American Board of Pediatrics, and Amer-
ican Board of Surgery (ABS) moved forward separately to create independent pro-
cesses for critical care subspecialty certification.13,14 Neurology and emergency
medicine did not pursue CCM as a subspecialty area at that time. In 2013, diplomates
of the American Board of Emergency Medicine (ABEM) were able to obtain formal crit-
ical care certification through the ABA.14 Involvement of the American Board of Neuro-
surgery (ABNS) will be discussed in a later discussion.

Neurologists Reemerge in the Field of Critical Care Medicine

In the United States, a small number of neurologists reentered the arena of critical care
in the early 1970s. These individuals typically were dually trained in internal medicine
or anesthesiology.15 Neurologic surgeons remained involved in the intensive care unit
(ICU) through postoperative management of their patients, including patients with
aneurysmal subarachnoid hemorrhage (aSAH), traumatic brain (TBI), and spinal
cord injuries (SCI). Early Neurointensive care units (NeuroICUs) started with combined
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4 Tempro & Chang

expertise of specialists. The Massachusetts General Hospital established a neuroICU

in 1969 under the direction of 2 neurosurgeons, Robert Ojemann and Nicholas Zervas,
MD, in close collaboration with neurologist, J. Phillip Kistler. A dedicated training pro-
gram was established there in 1978.16 Subsequent NeuroICUs and training programs
emerged during the next decades (Table 1).
With the approval of intravenous recombinant tissue plasminogen activator for
acute ischemic stroke (AIS) in 199617 and early studies in endovascular techniques,18
neurologists regained primary roles as intensivists. The detachable Guglielmi coil
began revolutionizing the endovascular treatment of aneurysms.19 Patients with AIS
and aSAH required intensive monitoring and specialized bedside neuroscience
nursing. The hourly nursing neurologic examination became recognized as an essen-
tial tool in the critical care arsenal for the early detection of potentially reversible neuro-
logic injury. The neuroscience nurse has been pivotal in creating a safe neuroICU. An
intensivist in a neuroICU not only had clinical duties but also had the added responsi-
bilities of providing education regarding the nuances of the neurologic examination
and emphasizing the implications of neglecting seemingly subtle signs and symptoms.
Demonstrating improvement in patient outcomes was essential to validate the neuro-
ICU model and secure resources to establish additional units and training programs. Ad-
ministrators needed to see the value of specially trained NCC physicians, nurses,
advanced practice providers (APPs), pharmacists, rehabilitation therapists, respiratory
therapists, and dieticians. A robust body of literature has emerged in the United States
and internationally (eg, Japan, Korea, Saudi Arabia, Switzerland, and the United
Kingdom) to make the case. The establishment of dedicated neuroICUs is associated
with decreased ICU and hospital lengths of stay, cost, and mortality, as well as improved
discharge disposition for patients with cerebrovascular disease, TBI and SCI.20–35

Table 1
Early neurocritical care units/training programs in the United States

Year
Program Established Founders Background
MGH NeuroICU 1969 Robert Ojemann, MD Neurosurgery
MGH training 1978 Nicholas Zervas, MD Neurosurgery
J. Phillip Kistler, MD Neurology
Allan Roper, MD Neurology/Internal Medicine
Sean Kennedy Anesthesiology
Johns Hopkins 1984 Daniel Hanley, MD Neurology/Internal Medicine
Hospital Cecil Borel, MD Neuroanesthesiology
Columbia U 1984 Matthew Fink, MD Neurology/Internal Medicine
UVA 1989 E. Clark Haley, MD Neurology/Internal Medicine
Thomas Bleck, MD Neurology/Internal Medicine
Wash U 1992 Michael Diringer, MD Neurology
Duke U 1993 Cecil Borel, MD Neuroanesthesiology
Joanne Hickey, PhD, ACNP Neuroscience Nursing
UCSF 1994 Darryl Gress, MD Neurology

Abbreviations: MGH, Massachusetts general hospital; NeuroICU, Neurointensive Care Unit—all

programs but MGH established training programs concomitant with the development of the crit-
ical care unit; U, University; UCSF, University of California, San Francisco; UVA, University of Vir-
ginia; Wash U, Washington, University at St. louis.
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 History of Neurocritical Care as a Subspecialty 5

Early Beginnings: Formal Organization of Neurocritical Care Professionals

In Germany, the first independent neuroICUs emerged in the 1960s in Giessen, Chem-
nitz, and the University of Hamburg. The acute management of cerebrovascular dis-
ease was also the impetus for the development of more specialized units
throughout Germany including the University of Heidelberg in 1986, Leipzig in 1991,
and 1997 in Munich, Frankfurt, Dresden, Wuerzburg, and others. Leaders such as
Werner Hacke and Karl Einhäul have been inspirational in the international field of
NCC. The German Neurological Society of Neurological Intensive Care and Emer-
gency Medicine (DGNI) were founded in 1984. In 2009, the DGNI merged with the sec-
tion of Neurocritical Care of the German Society for Neurosurgery.36,37
In the United States during the mid-1980s, neurologists interested in CCM helped
create a Critical Care and Emergency Neurology (CCEN) section within the American
Academy of Neurology (AAN). However, to embrace the unique qualities of NCC as an
international, multidisciplinary, multiprofessional field, leaders in NCC created an inde-
pendent organization that would be inclusive of all care team members. The Neurocrit-
ical Care Society (NCS) was established in 2002 as an international organization to
improve outcomes for patients with life-threatening neurologic illness. The first
meeting in 2003 had nearly 100% of its 70 members in attendance. The NCS has
now grown to more than 2800 national and international members including physi-
cians, nurses, pharmacists, APPs, trainees, and other critical care professionals. Sub-
sequently, established critical care societies have become inclusive of NCC expertise
and other international societies have been founded specifically to address the neuro-
logically critically ill.

Neurointensivists and the Critical Care Workforce Shortage

In 1998, the American College of Chest Physicians, the American Thoracic Society
and SCCM formed a Committee on Manpower for Pulmonary and Critical Care Soci-
eties. They were tasked with assessing the critical care workforce supply, based on
the current workforce and training estimates, compared with the demand, accounting
for population growth and aging. In 2000, this group projected that by 2020 there
would be a 22% shortfall in intensive care specialist hours. This shortfall was expected
to increase to 35% by 2035.38,39
The recognition that a trained intensivist adds quality and improved patient out-
comes threatened to increase this workforce gap.40 In 2000, the National Quality
Forum together with the Leapfrog Group, set out to improve the quality, equity, and
availability of health care by proposing specific regulatory guidelines to improve hos-
pital safety, quality, and cost containment. They hoped to leverage hospital compli-
ance by showcasing compliant hospitals to payors and consumers. In the critical
care area, hospitals were evaluated on whether critical care certified physicians
were present within 5-minutes, on-site or by telemedicine, to staff their ICUs.41
Four years into this initiative, it was evident the health-care system fell short, as 63%
to 90% of the estimated 4.4 million ICU admissions were still being cared for without
recommended ICU physician staffing measures. Barriers included inadequate supply
of critical care physicians and perceived increased hospital costs.42–44 A 2003 survey
found that many hospitals lacked an identified ICU director. Resistance to implement-
ing full-time intensive care presence included fear of loss of income and control by
those currently providing that care without requisite training.45
Critical care-trained neurologists could help fill this workforce gap. Discussed in
later discussion, United Council for Neurologic Subspecialty (UCNS)-certified neuro-
intensivists was recognized in 2008 by the Leapfrog Group. This lent support to the
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6 Tempro & Chang

role of a neurologically trained intensivist.46 However, the initial proposal limited neu-
rointensivists to fulfilling physician staffing requirements in a “neuroICU” because a
formalized route to prove adequate training and competency on par with other inten-
sivists was lacking.47 This nuance furthered the impetus to seek an ABMS subspe-
cialty designation for NCC through the Accreditation Council for Graduate Medical
Education (ACGME). The Leapfrog language also compelled neurosurgery to address
NCC as a subspecialty.
Given their limited workforce, NCC physicians were not the only solution. The early
2000s saw a surging interest in NCC APPs.48,49 These nonphysician providers have
significantly increased immediate bedside presence of advanced neuroscience exper-
tise. Timely bedside evaluation, alongside implementation of evidence-based proto-
cols, is key contributor to mortality benefit of an intensivist and ICU-focused teams.

Neurocritical Care Subspecialty Recognition and Certification

The first dedicated neurointensivists were trained in both neurology and internal med-
icine or were neuroanesthesiologists or neurosurgeons with embedded critical care
training. By1985, the only path to critical care certification was through an ABMS pri-
mary Board certification from the ABIM, ABS, and ABA; and in 2013, ABEM.14 In the
late 1980s, an increasing number of hospital administrators, academicians, and clini-
cians recognized the need for neurologically trained intensivists to manage post-
thrombolysis or neuroendovascular patients, support and educate specialized
neuroscience nurses and APPs, and provide administrative guidance for a NeuroICU.
Expansion of the field also led to increasing literature related to the specialty of
NCC. SCCM’s official journal, Critical Care Medicine, added a permanent section
dedicated to NCC in 1993,15 and the official journal of NCS, Neurocritical Care started
publication in 2004 with Eelco Widjicks at the helm as Editor-in-Chief.
To create a pathway for accreditation of NCC programs and certification of individ-
uals, in 2005, the NCS, with joint sponsorship from the AAN, CCEN section, and So-
ciety for Neuroscience in Anesthesiology and Critical Care (SNACC), petitioned and
received recognition as a subspecialty by the UCNS. The first subspecialty NCC cer-
tification examination was offered in 2007.
As neurointensivists integrated into nonneurological ICUs, alongside their critical
care colleagues, it became apparent that they would be better supported in privileging
and credentialing if the NCC training programs had the same rigorous standards, mile-
stones, and certification of competency as those with ACGME oversight. Additionally,
the perceived training limitations of NCC physicians potentially preventing them from
working outside a NeuroICU had been raised by Leapfrog and others.46,47 However,
when compared with other critical care training programs, NCC was similar in many
ways.50 In 2016, NCS leadership sought support from the AAN to assist its petition
to the American Board of Psychiatry and Neurology (ABPN) for recognition of NCC
as an ABMS subspecialty.
Supporting letters were provided by the AAN, American Neurological Association,
Association of University Professors of Neurology, Child Neurology Society, Profes-
sors of Child Neurology, and SNACC. Information was provided on the maturation
of NCC to support recognition as an ABMS subspecialty, including an adequate num-
ber of providers, training programs, and unique subspecialty focused literature. At the
time of the petition in 2016, there were 1241 UCNS Diplomates certified in NCC and
60 UCNS accredited NCC fellowships. From the training standpoint, all 149 neurology
and 106 neurosurgery ACGME-accredited residency programs included a NCC core
curriculum component to comply with the Review and Recognition Committee
requirements.
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 History of Neurocritical Care as a Subspecialty 7

Other evidence to support the petition included the fact that international critical
care professional societies such as the SCCM and European Society of Intensive
Care Medicine (ESICM) created neuroscience sections within their societies to allow
dialog and opportunities for collaboration for members with an interest in this area.
Additionally, in 2016 SCCM designated a seat for a neuroscience representative on
their governing Council. Specialty-focused conferences, the development of
specialty-specific guidelines, and the national and global popularity of the NCS-
sponsored Emergency Neurological Life Support enhanced the awareness of the
importance of this critical care subspecialty.
Furthermore, in 2016, the National Uniform Claim Committee (NUCC) approved a
NCC taxonomy code (2084A2900X).51 NUCC is an organization chaired by the Amer-
ican Medical Association and Centers for Medicare and Medicaid Services charged
with developing a standardized data set to transmit claim and encounter information
between institutions and third-party payers. The taxonomy code designates a pro-
vider’s classification and specialization. By achieving its own taxonomy code, NCC
was validated and supported as a “medical subspecialty devoted to the comprehen-
sive multisystem care of the critically ill neurological patient.” This helped differentiate
critical care neurologists from other neurologists. Additionally, it clarified that “like
other intensivists, the neurointensivist generally assumes the primary role for coordi-
nating the care of his or her patients in the ICU, both the neurologic and medical man-
agement of the patient.”51
In 2017, the ABPN agreed to sponsor NCC as an ABMS subspecialty and requested
cosponsors of other member Boards to maintain multidisciplinary collaboration. In
May 2018, 38 years after the first ABMS recognition of CCM as a subspecialty, the
ABMS approved the ABPN application for NCC with the initial cosponsoring boards
including the ABA, ABEM, and ABNS. In 2020, the ABIM joined as a cosponsor. Rep-
resentation from these cosponsoring member boards developed the content outline
and examination. In 2021, the ABA offered to sponsor certification for ABS diplomates.
The first ABMS NCC certification examination was administered in October 2021.
More than 1000 candidates took the examination, reflecting the growth and coming
of age of NCC as a subspecialty.

Neurosurgeons and Neurocritical Care Certification

Historically, neurologic surgery training programs have been inclusive of all areas in
which a neurosurgeon may need to practice in their community, including the critical
care management of their patients. Therefore, the ABNS does not offer subspecialty
board certification. In 1985, the ABNS applied and was endorsed by ABMS to provide
certification of special competence in CCM but chose not to develop training pro-
grams or an examination process at that time.13 Diplomates of neurosurgery have
been eligible to complete CCM training and take the written examination in an ABS
or ABA critical care program. CCM certification is awarded after the candidate also
passes the ABNS oral examination.52,53
To address the emergence of fellowship training programs in neurosurgery, the So-
ciety of Neurologic Surgeons (SNS) created the Committee for Accreditation of Sub-
specialty Training (CAST) in 1999.54 CAST became involved in NCC after UCNS began
issuing NCC certification to individuals, including neurosurgeons, and the Leapfrog
initiative recognized that the quality of care in hospital ICUs were impacted favorably
by trained intensivists. In 2013, CAST was renamed the Committee on Advanced Sub-
specialty Training and formalized fellowship review committees and began issuing in-
dividual certificates in NCC.54
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8 Tempro & Chang

In addition, the concept of a recognized focused practice (RFP) designation was

approved by ABMS in March 2017. This designation recognizes the value of the
board-certified individual who chooses to focus within a specific setting, population,
condition, or specialized procedures, Examples include hospital medicine (ie, hospi-
talists) within the ABIM or American Board of Family Medicine or bariatric surgery
within the ABS. Focused practice is an added designation to a primary board certifi-
cation. The designation is maintained by meeting clinical practice requirements for the
specified area, and as of September 2019, the ABNS has taken the RFP route for NCC
certification.55,56

Challenges Along the Way

Challenges offer opportunities. In 2005, the Brain Attack Coalition’s recommendations
for Comprehensive Stroke Centers managing stroke patients requiring “high intensity
medical and surgical care,” did not include the essential element of NCC expertise.57
This was based on the premise that there were too few neurointensivists available.
However, there was an opposing opinion that centers wishing to provide care to the
most complex stroke patients should provide the most advanced high quality of
care.58 Because the availability of neurointensivists increased and further literature
emerged demonstrating quality improvement, recommendations were adjusted.
Simultaneously, as noted above, concern for critical care workforce shortages
arose. In 2008, some proposed that subspecialty units and neurointensivists with
limited general and other subspecialty critical care exposure during training would
fragment and threaten the quality of critical care.47,59 This concern pushed for a
high level of comprehensive critical care training in UCNS NCC fellowships and pursuit
of ABMS certification and ACGME training accreditation for NCC. Harmonizing critical
care training across specialties has been a long-standing issue, and there is ongoing
interest in revisiting the concept of a common comprehensive core critical care curric-
ulum in training programs across all specialties.60
Efforts to standardize and improve the quality of NeuroICUs led to NCS publishing
standards for NeuroICUs regarding organizational structure and processes, physical
structure, personnel, equipment, and collaborative relationships to guide hospital ad-
ministrators and directors charged with establishing a successful and sustainable
NeuroICU.61 This emphasized the importance of teamwork and collaborative relation-
ships between critical care units and colleagues to ensure best practice.62

International Neurocritical Care Certification

The Competency Based Training in Intensive Care Medicine in Europe (CoBaTrICE)
was formed to evaluate the general critical care certification.63 A CoBaTrICE survey
regarding the certification process within its 41 affiliated countries revealed a lack of
standardized training and certification and demonstrated that critical care is not a
monolithic specialty but instead, quite a complex one.64 Its goal was to produce
guidelines, a comprehensive core syllabus and educational resources to ensure stan-
dardized critical care within its participating organizations/countries.65,66
The efforts of CoBaTriICE and the Multidisciplinary Joint Commission in Intensive
Care Medicine resulted in the first international critical care certification, the European
Diploma In Critical Care (EDIC). Currently, ESICM is the sole official provider of the
EDIC.65 There are routes to critical care certification in other countries such as the
Royal College of Physicians and Surgeons of Canada and the College of Intensive
Care Medicine of Australia and New Zealand. However, to date, there is no interna-
tional NCC certification. Of note, the UCNS provides an eligibility pathway for NCC
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 Table 2
Global partners of the neurocritical care society

Middle East/South African North/Central American

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College of Intensive Care
Medicine of Australia
and New Zealand (2017)
Indian Society of
Neuroanaesthesiology
(2015)
Indian Society of Critical
Care Medicine (2015)
Society of Neurocritical
Care, India (2018)
Neurocritical Care Society
International Pan Arab
Critical Care Society
(2011)
Ethiopian Neurological
Association (2022)
Canadian Neurocritical
Care Society (2018)
Neurocritical Care Society,
Guatemalan Chapter
(2011)
Colegio Mexicano de
Medicina Crı́tica A.C
(2015)
Panama Chapter of the
Caribbean and Centro-
American Societies of
Sociedad Argentina de German Society for
Terapia Intensiva (2013) Neurointensive and
Neurointensive Care Emergency
Brazilian Association Medicine (2016)
(2015) Swedish Acute Neurology
Sociedad Chilean de Society (2012)
Medicina Intensiva (2016)
Colombian Association of
Intensive and Critical
Care (2016)

History of Neurocritical Care as a Subspecialty

reservados.

of India (2020) Critical Care (2012)

The Japan Society of
Neurologic Emergencies
and Critical Care (2013)
Korean Neurocritical Care
Society (2011)
Philippine Neurocritical
Care Society (2017)
Brain R.E.S.C.U.Eb (2017)
Society of Intensive Care
Medicine, Singapore
(2018)
Nepalese Society of Critical
Care Medicine (2015)

( ) Year Partnership Established.

a
Not an official NCS regional chapter.
b
R.E.S.C.U.E: Responders and Educators to Strengthen Care for Neurologic Critical-Emergency Patients.

9
10 Tempro & Chang

certification for internationally trained candidates who are faculty in a UCNS-

accredited NCC training program.67

Global Recognition of Neurocritical Care as a Subspecialty

Despite a focus on recognition of NCC as a subspecialty in the United States, Ger-
many was well ahead in the creation of NeuroICUs and DGNI. In 2019, the European
Academy of Neurology recognized NCC as a new medical subspecialty and the
importance of a multidisciplinary “neuroscience team” in managing the spectrum of
neurologic conditions. A diverse Scientific Panel on NCC was created to provide sup-
port for related research and education in European countries.68
With the global growth of NCC, the NCS created 4 regional chapters (Asia/Oceania,
Middle East/Africa, North/Central America, and South America), each with a desig-
nated seat on the NCS Board of Directors. As of March 2022, NCS has 23 global
NCC /critical care partners (Table 2).
NCC’s global growth and recognition during the last century created opportunities
for collaborative research and knowledge sharing. In 2020, 257 sites from 47 countries
participated in a point prevalence study to gather data on organization and care pat-
terns of NCC.69,70 Similar collaboration will continue to advance NCC because it
moves through practitioner certification, training program accreditation, better under-
standing of disease processes, and development of diagnostic and prognostic indica-
tors to benefit the neurocritically ill.

SUMMARY

Since its inception in the 1920s, NCC has evolved into a unique and integral field within
CCM. With continued advancements in the field, the role of neurointensivists is crucial.
NCC teams are multiprofessional and multidisciplinary collaborations that include
physicians from multiple specialties, APPs, nurses, pharmacists, respiratory thera-
pists, dieticians, and rehabilitation services. These collaborations have shifted the
paradigm for critical care. The recent pandemic highlighted the importance of collab-
oration across critical care units and providers. This awareness has had global impact
and resulted in significant international growth within the field. Improvement of the
neurologic patient’s morbidity and mortality following consistent care by neurointen-
sivists has now been data proven. Although this is paramount, the practice of NCC
also requires an ever-present and equally important ethical and sociocultural mindful-
ness. This is due to pathophysiologic states unique to this field such as coma, unre-
sponsive wakefulness syndrome, and death by neurologic criteria. These and other
clinical conditions with emerging biotechnology can elucidate diagnostic, therapeutic,
and prognostic advances and create opportunities for further research and expansion
of NCC. With the springboard of established subspecialty recognition, growing global
presence and societal collaboration, the future of NCC is promising.

CLINICS CARE POINTS

 Dedicated neurointensive care units, staffed by those specially trained in NCC, can decrease
ICU and hospital lengths of stay, cost, and mortality; and improve the discharge disposition of
patients with TBI, SCI and cerebrovascular disease.
 Timely bedside (on-site or remote) evaluations by critical care-trained physicians and APPs
are directly linked to improved quality of care and outcomes for critically ill patients.
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 History of Neurocritical Care as a Subspecialty 11

 Critical care workforce shortages were anticipated decades ago and are a reality in the
present day especially in the face of the current pandemic. An additional labor force
founded through the subspecialty of NCC has expanded the availability of critical care
expertise.
 Through collaboration of multiple specialty Boards, there exist multiple pathways to obtain
individual certification for NCC dependent on ones’ primary board certification.

DISCLOSURE

The authors have nothing to disclose.

REFERENCES

1. Shaw-Taylor L. An introduction to the history of infectious diseases,epidemics

and the early phases of the long-run decline in mortality. Econ Hist Rev 2020;
73:E1–19.
2. Nightingale F. Notes on matters affecting the health, efficiency, and hospital
administration of the British Army. Founded chiefly on the experience of the
late War. Presented by request to the Secretary of state for war. Privately printed
for Miss Nightingale. London: Harrison and Sons; 1858.
3. Sherman IJ, Kretzer RM, Tamargo RJ. Personal recollections of Walter E. Dandy
and his brain team. J Neurosurg 2006;105:487–93.
4. Hardy AD. Poliomyelitis and the neurologists: the View from England, 1896- 1966.
Bull Hist Med 1997;71:249–72.
5. Ropper AH. Neurological intensive care. Ann Neurol 1992;32:564–9.
6. Drinker P, McKhann CF. The use of a new apparatus for the prolonged adminis-
tration of artificial respiration: a fatal case of poliomyelitis. JAMA 1929;92:
1658–60.
7. Levine JM. Historical perspective on pressure ulcers. J Am Geriatr Soc 2005;53:
1248–51.
8. Pitt JA. The human factor in long-duration manned spaceflight. In: the Human
Factor- Biomedicine in the manned space program to 1980. The NASA History
Series. Washington DC: National Aeronautics and Space Administration; 1985.
p. 52–72.
9. Weil MH, Tang W. From Intensive care to critical care medicine- a historical
perspective. Am J Respir Crit Care Med 2011;183:1451–3.
10. Weil MH. The society of critical care medicine, its history and its destiny. Crit Care
Med 1973;1:1–4.
11. [No Authors Listed]. Guidelines for organization of critical care units. JAMA 1972;
222:1532–5.
12. Grenvik A, Leonard JJ, Arens JF, et al. Critical care medicine certification as a
multidisciplinary subspecialty. Crit Care Med 1981;9:117–25.
13. Grenvik A. Subspecialty certification in critical care medicine by American spe-
cialty boards 1985;13:1001–3.
14. American Board of Medical Specialties. ABMS Board certification report 2020-
2021. Available at: https://www.abms.org/wp-content/uploads/2022/01/ABMS-
Board-Certification-Report-2020-2021.pdf. Accessed March 13, 2022.
15. Bleck TP. Historical aspects of critical care and the nervous system. Crit Care Clin
2009;25:153–64.
Descargado para Anonymous User (n/a) en National Autonomous University of Mexico de
ClinicalKey.es por Elsevier en noviembre 12, 2022. Para uso personal exclusivamente. No se
permiten otros usos sin autorización. Copyright ©2022. Elsevier Inc. Todos los derechos
reservados.
12 Tempro & Chang

16. History of neurocritical care at Mass general. Available at: https://www.

massgeneral.org/neurology/neurocritical-care/about/history. Accessed March
25, 2022.
17. National Institute of Neurological Disorders and Stroke rt-PA Stroke Study Group.
Tissue plasminogen activator for acute ischemic stroke. N Engl J Med 1995;333:
1581–7.
18. del Zoppo GJ, Higashida RT, Furlan AJ, et al. PROACT: a phase II randomized
trial of recombinant pro-urokinase by direct arterial delivery in acute middle cere-
bral artery stroke. PROACT Investigators Prolyse Acute Cereb Thromboembo-
lism. Stroke. 1998;29:4–11.
19. Viñuela F, Duckwiler G, Mawad M. Guglielmi detachable coil embolization of
acute intracranial aneurysm: perioperative anatomical and clinical outcome in
403 patients. J Neurosurg 1997;86:475–82.
20. Mirski MA, Chang CWJ, Cowan R. Impact of a neuroscience intensive care unit
on neurosurgical patient outcomes and cost of care: evidence-based support
for an intensivist-directed specialty ICU model of care. J Neurosurg Anesthesiol
2001;13:83–92.
21. Diringer MN, Edwards DF. Admission to a neurologic/neurosurgical intensive care
unit is associated with reduced mortality rate after intracerebral hemorrhage. Crit
Care Med 2001;29:635–40.
22. Suarez JI, Zaidat OO, Suri MF, et al. Length of stay and mortality in neurocritically
ill patients: impact of a specialized neurocritical care team. Crit Care Med 2004;
32:2311–7.
23. Lerch C, Yonekawa Y, Muroa C, et al. Specialized neurocritical care, severity
grade, and outcome of patients with aneurysmal subarachnoid hemorrhage.
Neurocrit Care 2006;05:85–92.
24. Varelas PN, Eastwood HJY, Spanaki MV, et al. Impact of a neurointensivist on out-
comes in patients with head trauma treated in a neurosciences intensive care
unit. J Neurosurg 2006;104:713–9.
25. Bershad EM, Feen ES, Hernandez OH, et al. Impact of a specialized neurointen-
sive care team on outcomes of critically ill acute ischemic stroke patients. Neuro-
crit Care 2008;9:287–92.
26. Varelas PN, Schultz L, Conti M, et al. The impact of a neuro-intensivist on patients
with stroke admitted to a neurosciences intensive care unit. Neurocrit Care 2008;
9:293–9.
27. Josephson SA, Douglas VC, Lawton MT, et al. Improvement in intensive care unit
outcomes in patients with subarachnoid hemorrhage after initiation of neurointen-
sivist co-management. J Neurosurg 2010;112:626–30.
28. Samuels O, Webb A, Culler S, et al. Impact of a dedicated neurocritical care team
in treating patients with aneurysmal subarachnoid hemorrhage. Neurocrit Care
2011;14:334–40.
29. Knopf L, Staff I, Gomes J, et al. Impact of a neurointensivist on outcomes in crit-
ically ill stroke patients. Neurocrit Care 2012;166:63–71.
30. Damian MS, Ben-Shlomo Y, Howard R, et al. The effect of secular trends and
specialist neurocritical care on mortality for patients with intracerebral haemor-
rhage, myasthenia gravis and Guillain-Barré syndrome admitted to critical care
: an analysis of the Intensive Care National Audit & Research Centre (ICNARC)
national United Kingdom database. Intensive Care Med 2013;39:1405–12.
31. Egawa S, Hifumi T, Kawakita K, et al. Impact of neurointensivist-managed inten-
sive care unit implementation on patient outcomes after aneurysmal subarach-
noid hemorrhage. J Crit Care 2016;32:52–5.
Descargado para Anonymous User (n/a) en National Autonomous University of Mexico de
ClinicalKey.es por Elsevier en noviembre 12, 2022. Para uso personal exclusivamente. No se
permiten otros usos sin autorización. Copyright ©2022. Elsevier Inc. Todos los derechos
reservados.
 History of Neurocritical Care as a Subspecialty 13

32. Ryu JA, Yang JH, Chung CR, et al. Impact of neurointensivst co-management on
the clinical outcomes of patients admitted to the neurosurgical intensive care unit.
J Korean Med Sci 2017;32:1024–30.
33. Soliman I, Aletreby WT, Faqihi F, et al. Improved outcomes following the establish-
ment of a neurocritical care unit in Saudi Arabia. Crit Care Res Pract
2018;2764907.
34. Jeong JH, Bang JS, Jeong WJ, et al. A dedicated neurological intensive care unit
offers improved outcomes for patients with brain and spine injuries. J Intensive
Care Med 2019;34:104–8.
35. Kim TJ, Lee JS, Yoon JS, et al. Impact of the dedicated neurointensivists on the
outcome in patients with ischemic stroke based on the linked big data for stroke
in Korea. J Korean Med Sci 2020;35:e135–43.
36. Wartenberg KE. Neurointensive care Units in Germany. ICU management & prac-
tice ICU Volume 10, Issue 2. 2010. Available at: https://healthmanagement.org/c/
icu/issuearticle/neurointensive-care-units-in-germany. Accessed March 25, 2022.
37. Kunze K. Neurologische Intensivmedizin in Deutschland. Spec Edition Neurologi-
sche Intensivmedizin aktuell 2006;1435–2966. ISSN.
38. Angus D, Kelley MA, Schmitz RJ, et al. Committee on Manpower for Pulmonary
and Critical Care Societies (COMPACCS): Caring for the critically ill patient. Cur-
rent and projected workforce requirements for care of the critically ill and patients
with pulmonary disease: can we meet the requirements of an aging population?
JAMA 2000;284:2762–70.
39. Health Resources and Services Administration (HRSA). Report to Congress—The
critical care workforce: a study of the supply and demand for critical care physi-
cians, 2006. Requested by: Senate Report 108 – 81.
40. Kelley MA, Angus D, Chalfin DB, et al. The critical care crisis in the United States:
a report from the profession. Chest 2004;125:1514–7.
41. Gasperino J. The Leapfrog initiative for intensive care unit physician staffing and
its impact on intensive care unit performance: a narrative review. Health Policy
2011;102:223–8.
42. Pronovost P, Needham D, Waters H, et al. Intensive care unit physician staffing:
financial modeling of the Leapfrog standard. Crit Care Med 2004;32:247–53.
43. National Quality Forum (NQF). Safe practice 11: intensive care Unit care. In: Safe
practices for better healthcare–2010 Update: a Consensus Report. Washington,
DC: NQF; 2010. p. 169–74.
44. Halpern NA, Pastores SM, Oropello JM, et al. Critical care medicine in the United
States: addressing the intensivist shortage and image of the specialty. Crit Care
Med 2013;41:2754–61.
45. Kahn JM, Matthews FA, Angus DC, et al. Barriers to implementing the Leapfrog
Group recommendations for intensivist physician staffing: a survey of intensive
care unit directors. J Crit Care 2007;22:97–103.
46. The Leapfrog group. Hospital survey: Factsheet: ICU physician staffing. Available
at: https://preview2021.ratings.leapfroggroup.org/sites/default/files/inline-files/
2021%20IPS%20Fact%20Sheet_3.pdf. Accessed March 22, 2022.
47. Krell K. Critical care workforce. Crit Care Med 2008;36:1350–3.
48. Caserta FM, Depew M, Moran J. Acute care nurse practitioners: the role in neuro-
science critical care. J Neurol Sci 2007;261:167–71.
49. Yeager S. The neuroscience acute care nurse practitioner: role development, im-
plementation, and improvement. Crit Care Nurs Clin North Am 2009;21:561–93.
Descargado para Anonymous User (n/a) en National Autonomous University of Mexico de
ClinicalKey.es por Elsevier en noviembre 12, 2022. Para uso personal exclusivamente. No se
permiten otros usos sin autorización. Copyright ©2022. Elsevier Inc. Todos los derechos
reservados.
14 Tempro & Chang

50. Marcolini E, Seder D, Bonomo J, et al. The present state of neurointensivist

training in the United States: a Comparison to other critical care training pro-
grams. Crit Care Med 2018;46:307–15.
51. National Uniform Claim Committee. Available at: https://www.nucc.org/index.
php/21-provider-taxonomy/229-new-7-1-2016. Accessed March 22, 2022.
52. American College for Graduate Medical Education. ACGME program require-
ments for Graduate medical education in surgical critical care. Available at:
https://www.acgme.org/globalassets/PFAssets/ProgramRequirements/442_
SurgicalCriticalCare_2020.pdf?ver52020-06-22-090711-273&ver52020-06-22-
090711-273. Accessed March 27, 2022.
53. American College for Graduate Medical Education. ACGME program require-
ments for Graduate medical education in Anesthesia critical care. Available at:
https://www.acgme.org/globalassets/pfassets/programrequirements/045_
anesthesiologycriticalcare_2021.pdf. Accessed March 27, 2022.
54. Society of Neurological Surgeons. CAST history. Available at: https://sns-cast.
org/history/. Accessed March 26, 2022.
55. American Board of Medical Specialties. Focused practice designation. Available
at: https://www.abms.org/board-certification/board-certification-requirements/
focused-practice-designation/. Accessed March 26, 2022.
56. Society of Neurological Surgeons. CAST: structure. Available at: https://sns-cast.
org/structure/. Accessed March 25, 2022.
57. Alberts MJ, Latchaw RE, Selman WR, et al. Recommendations for comprehensive
stroke centers. A consensus statement from the brain Attack Coalition. Stroke
2005;36:1597–616.
58. Hemphill JC, Bleck T, Carhuapoma JR, et al. Is neurointensive care really optional
for comprehensive stroke care. Stroke 2005;36:2344–5.
59. Chang CW, Torbey MT, Diringer MN, et al. Neurointensivists: Part of the problem
or part of the solution? Crit Care Med 2008;36:2963–4.
60. Tisherman S, Spevetz A, Blosser S, et al. A case for change in adult critical care
training for physicians in the United States: a white Paper developed by the crit-
ical care as a specialty Task Force of the society of critical care medicine. Crit
Care Med 2018;46:1577–84.
61. Moheet AM, Livesay SL, Abdelhak T, et al. Standards for neurologic critical care
Units: a statement for healthcare professionals from the neurocritical care society.
Neurocrit Care 2018;29:145–60.
62. Kaplan L, Moheet AM, Livesay SL, et al. A perspective from the neurocritical care
society and the society of critical care medicine: team-based care for neurolog-
ical critical illness. Neurocrit Care 2020;32:369–72.
63. De Lange S, Van Aken H, Burchardi H. European society of intensive care med-
icine statement: intensive care medicine in Europe—structure, organisation and
training guidelines of the multidisciplinary joint committee of intensive care med-
icine (MJCICM) of the European union of medical specialists (UEMS). Intensive
Care Med 2002;28:1505–11.
64. Barrett H, Bion JF. An international survey of training in adult intensive care med-
icine. Intensive Care Med 2005;31:553–61.
65. CoBaTrCE Collaboration The. Development of core competencies for an interna-
tional training programme in intensive care medicine. Intensive Care Med 2006;
32:1371–83.
66. European Society of Intensive Care Medicine. European diploma in intensive care
Medicine. Available at: https://www.esicm.org/education/edic2-2/. Accessed
March 25, 2022.
Descargado para Anonymous User (n/a) en National Autonomous University of Mexico de
ClinicalKey.es por Elsevier en noviembre 12, 2022. Para uso personal exclusivamente. No se
permiten otros usos sin autorización. Copyright ©2022. Elsevier Inc. Todos los derechos
reservados.
 History of Neurocritical Care as a Subspecialty 15

67. United Council of Neurologic Subspecialties. Neurocritical care certification ex-

amination eligibility criteria. Available at: https://www.ucns.org/Online/Online/
Certification/Neurocritical_Cert.aspx. Accessed March 22, 2022.
68. European Academy of Neurology. Neurocritical care. Available at: https://www.
ean.org/home/organisation/scientific-panels/neurocritical-care. Accessed March
23, 2022.
69. Suarez JI, Martin RH, Bauza C, et al. Worldwide organization of neurocritical care:
Results from the PRINCE study Part 1. Neurocrit Care 2020;32:172–9.
70. Venkatasubba Rao CP, Suarez JI, Martin RH, et al. Global survey of outcomes of
neurocritical care patients: analysis of the PRINCE study Part 2. Neurocrit Care
2020;32:88–103.

Descargado para Anonymous User (n/a) en National Autonomous University of Mexico de

ClinicalKey.es por Elsevier en noviembre 12, 2022. Para uso personal exclusivamente. No se
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