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One Size Doesn’t Fit All: Variability in Neurocritical Care Coverage Models

One Size Doesnt Fit All Web

Faced with a national shortage of neurocritical care (NCC) physicians, neuroscience service lines have been forced to piece together NCC services, including relying on other intensivist specialties. Developed in the early 1980s, modern NCC is a relatively new specialty that is still gaining traction across the United States.

  • The Neurocritical Care Society was founded just 19 years ago in 2002.
  • The United Council for Neurologic Subspecialties offered the first board certifications for NCC in 2007.
  • The Accreditation Council for Graduate Medical Education approved NCC fellowship programs in 2019.

As more health systems establish neuro-ICUs, service line leaders are working to identify best practices to manage and staff NCC programs.

In 2020, ECG interviewed representatives from NCC programs across the United States to identify common themes and current practices in neuroscience service lines. The program leaders represented 10 health systems and 20 facilities throughout the regions (shown in figure 1), and the interviews focused on detailed program, coverage, and compensation statistics for NCC and stroke programs. To better aggregate results, ECG focused on four main components of NCC programs.

  • Coverage model
  • Compensation
  • Provider mix
  • Telemedicine
FIGURE 1: Interview Facilities by Region

During the interviews, ECG found a high level of variability between the NCC programs’ coverage models and provider staffing. However, compensation and telemedicine services were more consistent across health systems. Key results in the defined four categories are shown in figure 2 and described in detail below.

FIGURE 2: Interview Results

Coverage Model

Coverage models differed at each facility, but 100% of interviewees had an attending model for their NCC coverage. Of the interviewed programs, the median shift was 12 hours (at a range of 9 to 12 hours), and the yearly expected number of weeks worked per physician was 25 (at a range of 23 to 26). Night requirements varied greatly, with some facilities having 12‑hour nighttime on-site shifts and other facilities relying on call coverage and supplementing in-house support with residents, APPs, fellows, and other critical care unit physicians.


NCC physician compensation structures were consistent across all programs interviewed. All the interviewees used fixed-salary compensation plans. The compensation level was typically determined based on a blended rate of multiple surveys and specialties (e.g., neurology, neurology stroke, pulmonary critical care) due to limited data on NCC-specific physicians. Only the ECG Physician and APP Compensation Survey offers benchmarks for the NCC specialty.

Provider Mix

Program provider mix varied greatly based on available physicians, APPs, fellows, and residents. Physician specialties also differed across each interviewed facility. Although most physicians were boarded in NCC units, physicians from non-neuroscience-specific specialties, including pulmonary and anesthesia intensivists, supported the programs. Programs also depended on other critical care services to provide coverage support, with some facilities integrating all the critical care coverage responsibilities. Additionally, interviewees relied heavily on nonphysician support to help effectively run the programs:

  • 89% of programs had APP support.
  • 89% had resident/fellow support.
  • 78% had both APP and fellow/resident support.


Less than half of the programs interviewed offered telemedicine services other than telestroke. Of these, programs noted tele-ICU and telehealth emergent care as the most common solutions offered. Interviewees cited a lack of system resources and investment as the most frequent roadblock to developing a more established telemedicine portfolio. However, most programs were optimistic that changes due to COVID-19 would lead to more system-level support and a renewed sense of urgency to implement tele-NCC services.

Additional Findings

Although NCC coverage models varied based on facilities’ resources, ECG was able to identify common characteristics across most programs:

  • Most organizations relied on an attending model that included nonphysician support and compensated physicians with a fixed salary.
  • Furthermore, NCC programs did not have well-developed telemedicine services outside of telestroke but were interested in them and hopeful that their health system would pursue additional telesolutions.

Our coverage model interview findings are consistent with a similar survey from the Critical Care Medicine journal article titled “Workforce, Workload, and Burnout in Critical Care Organizations: Survey Results and Research Agenda.” The findings in that article are based on a 97-item survey completed by 23 critical care teams in the United States and Canada. Although it focused more broadly on critical care organizations, the survey is still representative of issues facing NCC programs. High-level findings included that:

  • Dedicated APPs were present in 80% of organizations.
  • Physicians worked a median of 168 shifts (equivalent to 24 seven-day weeks).
  • The median shift duration was 12 hours.
  • The median number of consecutive shifts allowed was 7.

Given the high level of variability in coverage models, ECG recommends neuroscience service lines periodically evaluate their NCC practices to identify any gaps or opportunities.

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