Question 5.1: What are the Roles and Responsibilities of the Team Providing TeleNCC?Recommendation 5.1:

The composition of the team providing TeleNCC services will vary according to the level of services required and the TeleNCC model that is adopted—at a minimum, it is a solo NCC physician, and at the other end of the spectrum, the team may comprise a combination of healthcare providers including a NCC physician, a critical care RN, a neurocritical care APP, a NCC fellow, and a pharmacist [4, 8, 14].

The roles, responsibilities, and structure of the TeleNCC team will be clearly defined ahead of time between the spoke and hub site. Regardless of their location, the hub personnel will be available for the predetermined periods of time on the basis of the care model.

Responsibilities for TeleNCC Provider:

The respective responsibilities of each provider type vary and delegation and sharing of responsibilities are also flexible in accordance with the various permutations of the TeleNCC team composition. Here we recommend the minimum expected roles and responsibilities for the various members of the TeleNCC team with additional suggestions for expanded and optional responsibilities (Table 3) [8].

Table 3 Roles and responsibilities of TeleNCC providers and collaborative staff at the hub and spoke sitesHub Teleneurointensivists:

This will be an intensivist who is board-certified or board-eligible in neurocritical care [14]. We recommend in all cases this is a telemedicine neurocritical care expert consultant advising the primary in-person admitting physician (or clinical provider) of record for the patient(s); they additionally require an in-person spoke site proceduralist partner.

At a minimum, this hub Teleneurointensivist is responsible for: obtaining history and examination with the assistance of the spoke personnel, viewing of the raw imaging, EEG, transcranial doppler (TCD), etc., and interpretation of the results, creating a treatment plan with the spoke providers and provide anticipatory guidance (e.g., what to do and when to reach back to the hub), and communicating with the patient and their family, including participation in family meetings with the in-person team to discuss neuroprognosis or goals of care. It is recommended for documentation to use a standardized template in EHR and to perform systematic handoffs (Please refer to Documentation standards in Structure Sect. 3, and Activation and Communication section for recommendations on time to activation and triage for emergent consults, Sect. 6).

The optional and expanded responsibilities include the following. First, facilitating and supervising the spoke providers’ brain death exam, but not acting as the legally responsible in-person examiner. Assisting the in-person provider’s performance of a brain death examination can be particularly helpful if the provider has less experience and in circumstances where two brain death exams are mandatory. Next, the TeleNCC provider may perform regular education and mentoring of the spoke team, and host debriefing meetings after critical events. Third, they may also participate in staff meetings, educational conferences, peer review, root cause analysis (RCA), and quality improvement (QI) activities. Finally, they may help enroll for NCC clinical trials/studies in decentralized clinical trial arrangements.

Spoke or Hub TeleNCC-Specific Advanced Practice Provider

Requirements for the spoke or hub TeleNCC APP at the minimum are: (1) NIHSS certification, (2) demonstrated training and experience necessary for eventual neurocritical care competency, and (3) appropriate institutional credentialing for practice in neurocritical care.

The provider ideally should have the opportunity to become certified in ENLS and have work experience in a dedicated in-person NCC. This learning experience should be focused on understanding triage and management of the comprehensive ICU neurological examination, management of neuroinvasive monitors and therapies, and neurocritical care emergencies for core disease pathologies. In the most optimal scenario, panelists felt that this training period in an in-person NCC should be at least 1–2 months.

The specific required minimal responsibilities are triage, initial response to NCC emergencies, obtaining history and conducting examination independently or via video with the hub provider (if physically present as the spoke APP), participating in rounds, collaborating on treatment plan, communication between spoke and hub teams for execution of plans, provide anticipatory guidance and be available for questions, family communication, documentation using a standardized template in EHR and systematic handoffs.

Optional and expanded responsibilities include completion of neurocritical care advanced practitioner fellowship, participating in peer review/RCA, QI and conferences as needed, helping patient enrollment for NCC trials/studies and, in some states, supervising the brain death exam.

Hub NCC Fellow

The TeleNCC fellow performs essentially the same functions as the board certified neurointensivist; however, fellows should receive supervision or oversight by neurocritical care faculty in compliance with the ACGME and institutional guidelines. The supervision of the fellow by the TeleNCC physician may be done on site simultaneously or via multi-presence functionality on telemedicine systems.

Hub TeleNCC Pharmacist:

Minimum requirements include: (1) a doctorate degree in pharmacy, 2) PGY1 residency or 5 years of clinical experience.

Optimal requirements: (1) board-certification in critical care pharmacotherapy (BCCCP) (2) have completed a PGY2 in Critical Care Pharmacy, and (3) certification in ENLS.

For the non-TeleNCC pharmacist at the spoke hospital, it is recommended that there is clear communication and roles as to responsibilities for primary medication management, cross-checking, and advanced monitoring when specific neurological medications are used. The pharmacist is typically working asynchronously with the TeleNCC team and is actively discussing cases on a routine daily basis.

For a full description of pharmacy roles, please refer the Pharmacy Sect. 10.

Spoke Physician and Non-TeleNCC APP:

The spoke site provider staffing will vary depending on the capabilities and resources of the spoke hospital. Some may have intensivists with or without APPs on site and need TeleNCC for consults on an ad hoc basis and for overnight coverage. Other hospitals may have a neurohospitalist or anesthesiologist staffing a smaller ICU and will be looking for dedicated TeleNCC assistance 24/7. The spoke site physician will be the attending of record.

Required Responsibilities of the Spoke Physician/APP include initiation of the TeleNCC consult for patients with NCC needs (conditions that require NCC care should ideally be identified in advance on the basis of discussions with spoke/hub), assist with history and remote examination (telepresenter role), family communication, and placing orders. This provider should develop treatment plans with the TeleNCC provider and execute these plans. They must be present on site to monitor patients, inform TeleNCC personnel of any major clinical changes or results, and perform emergent procedures. This clinician should ensure appropriate handoffs including guidance as to when to reach back to hub, adequate EHR documentation, perform brain death exams, ensure safe and smooth transfer of patients to hub, and participate in RCA/peer review, conferences, QI initiatives.

Spoke Critical Care TeleNCC Team Lead RN and Non-TeleNCC RN

The TeleNCC Team lead RN is a spoke hospital TeleNCC-focused RN, with specific interest and training in Neurocritical Care. In some institutions, this is referred to as the “Spoke Neuro RN Champion.” This role is not a requirement for the spoke TeleNCC service, but rather an optimal component in the ideal setting.

If there is such a provider fulfilling this role, to meet their responsibility and role requirements, we recommend: (1) the requisite critical care nursing experience and neurocritical care nursing experience, (2) NIHSS certification, and (3) the ability to perform a neurocritical care examination, especially the coma exam. For specific credentialing, the RN should have some sort of specialty neuroscience (e.g., SCRN, NVRN, CNRN) or critical care board certification (e.g., CCRN).

This provider RN is the rounding spoke-partner for the hub provider. They may function as a triage (or first call), be present during rounds and provide nursing support with just-in-time, anticipatory guidance, and regular education to the spoke nurses. They should also be able to actively liaise with any admission and transfer centers or hospital command centers and ensure smooth and safe transfer of patients from spoke hospital with systematic handoffs. Importantly, the RN should ensure recommendations are implemented and carried out.

Optional and expanded responsibilities include: ENLS certification, participating in peer review/RCA, QI, and staff meetings as needed.

The non-TeleNCC RN is an intensive care unit RN who works with the TeleNCC team but usually does not have formal training or experience in TeleNCC nursing. This provider at a minimum should have training in how to perform a coma exam and, optimally, a NIHSS exam.