NeuroVoices: Daniel Harrison, MD, on Defining APP Competencies in Neurocritical Care Teams

Daniel Harrison, MD

Advanced practice providers (APPs), which include nurse practitioners (NPs) and physician assistants (PAs), play essential roles in neurocritical care (NCC), complementing the work of neurointensivists and other members of the care team. Their responsibilities are varied and include key roles such as patient management, procedures, monitoring and data interpretation, medication management, coordination of care, and family and patient communication, among others.

In 2024, a group of NCC APPs (n = 18) and physicians (n = 12) in the United States with experience in education scholarship or APP program leadership gathered together to define consensus entrustable professional activities (EPAs) for NCC APPs using a 3-round Delphi approach. Published in Critical Care Medicine, the steering committee generated an initial list of 61 possible EPAs. The panel proposed 30 additional EPAs, culminating in 47 unique nested EPAs retained by consensus, all encompassed within six core EPAs defined by the steering committee to address medical knowledge, procedural competencies, and communication proficiency.

Investigators concluded that these core EPAs may aid in curricular design for an EPA-based assessment of new NCC APPs and may inform the development of EPAs for APPs in other critical care subspecialties. As part of a new iteration of NeuroVoices, lead author Daniel Harrison, MD, sat down to describe the process behind choosing these EPAs and the importance of creating robust educational frameworks and curricula to address these competencies. Harrison, a neurointensivist and assistant professor of neurology at Boston Medical Center, also spoke on the value these EPAs bring to NCC divisions, the evolving role of NCC APPs, and the ways to help APPs feel comfortable in their environment without causing burnout.

NeurologyLive: What were the reasons behind gathering this expert consensus group?

Daniel Harrison, MD: Casey Albin, MD, and I have worked together on a couple of different projects in the past, and we were actually designing assessment methods for a separate education project. We were thinking about ways to evaluate the efficacy of simulation-based medical education or interventions for neurocritical care APPs, and we realized there wasn’t really an evidence-based tool for assessment in this population.

There are definitely descriptions in the literature of other educational interventions developed for this group before, but there wasn’t a didactic framework that any of these interventions were based on. So we thought, just for the purposes of evaluating the types of interventions we were thinking about creating, we could use what are called EPA-style assessments or evaluations—EPAs being entrustable professional activities. Hopefully, we’ll get to talk more about those.

But we realized that if we just stopped there and created assessments in the style of EPAs, it would only help us for this one study. If we actually took the time to do the groundwork and create a list of consensus EPAs for neurocritical care APPs themselves, it would have much wider applicability and reach. So we decided to take that extra step, and that’s how we got to where we are now.

What were some of the core EPAs you landed on and why?

I can start out by telling you how we even chose the EPAs in the first place. We used a modified Delphi process, where we built a steering committee that included myself, Casey Albin, and Erica Sigman, who’s an incredible neurology educator at Emory. Casey and I reviewed a variety of documents, including onboarding materials from our institutions, the Neurocritical Care Society’s APP onboarding course, and Emergency Neurology Life Support (ENLS). From these, we came up with a list of possible EPAs.

We took this list to an expert panel of 30 clinicians—both physicians and APPs—who had experience leading APP groups or were experienced neurocritical care educators. We asked them to vote on the EPAs we identified and allowed them to propose any we might have missed. Anything that received greater than 80% consensus as being very important for APPs to be able to do by the end of onboarding was included.

So, as the steering committee, we really let the experts decide what the EPAs should be, rather than dictating what we thought was most important. To summarize, the six core EPAs, along with their nested components, focused on:

• Taking a history and performing a neurologic exam.
• Performing specific procedures commonly done in the neuro ICU.
• Interpreting data from neuro ICU monitoring systems.
• Managing neurologic diseases
• Managing medical comorbidities
• Communication skills, which I think is super important.

Of the 6 core EPAs you settled on, was there a specific one that you wanted to emphasize more?

I’d start off by saying that it’s on us as educators to make sure the curricula we develop—whether onboarding, fellowship, or continuing education—are robust and meet the needs of new folks coming into practice. These individuals may not be as adept at identifying their own blind spots as someone with years of experience in neurocritical care.

What surprised me most about the consensus items was just how many there were. You mentioned there were 47 nested EPAs, which is incredible. That’s a lot to learn in a short time, especially since onboarding processes can range from three months to a year. For instance, managing cardiac arrest is on the list, but as a neurointensivist or APP in a neuro ICU, you might only manage one or two cases per year.

If your onboarding is just three months, you might not even encounter that scenario during training. So, the curricula we create—whether didactic or simulation-based—need to supplement those less common but equally critical scenarios.

How do we as a clinical community help APPs feel comfortable in neurocritical care settings and avoid overloading them?

Well, one of the great things about EPAs is that they have different levels of entrustment. As someone becomes more competent, they progress through these levels of supervisory needs. For example, the expert panel in this project focused on what APPs should be able to do with indirect supervision by the end of onboarding.

We’re not asking them to master or teach all 47 tasks by the end of onboarding. Instead, we’re asking them to reach a level where they can perform tasks with indirect supervision—where the supervising physician might be down the hall or elsewhere on the unit.

From there, the next step is practicing with more distant indirect supervision, which is critical for APPs working in neurocritical care, especially overnight shifts. Having this framework allows us to track incremental gains and build competence over time.

How has the role of neurocritical care evolved over the last decade?

There’s been an explosion of new interventions, especially for conditions like acute ischemic stroke. With more interventions available, we have more patients to treat, and those patients are getting older. This increased demand has highlighted the gap between the supply of neurologists and the needs of patients.

Incorporating APPs into neurocritical care is one way to address this. Over the past decade, I’ve seen more institutions do this effectively, which I think is a great step forward. I also think educational interventions and frameworks like this one will continue to support APPs and improve patient care.

From your experiences in neurocritical care, are there any recommendations for improving efficiency?

In terms of educational efficiency, now that we have this framework, it can guide curricula for APPs. By the way, there’s also a set of EPAs for neurology residents developed by Dr. Schmidt Bauer in Germany, which came out just before ours. We need to base educational initiatives on these frameworks, which have validity evidence behind them. One area we can all improve is providing formative feedback and assessments that help learners grow.

This work is the second EPA set developed for APPs, and I hope it inspires other neurology subspecialties to follow suit. Creating these frameworks will accelerate learning, improve confidence, and ultimately enhance care for patients in neurocritical care and beyond.

REFERENCE
1. Harrison DS, Sigman EJ, Chang JH, et al. A Modified Delphi Consensus Approach to Define Entrustable Professional Activities for Neurocritical Care Advanced Practice Providers. Critical Care Medicine. 2024;52(7):1032-1042. doi:10.1097/CCM.0000000000006260