In several studies, although not randomized to eliminate biases from selection, the care provided in the critical recruitment of nurse practitioners and medical assistants was equal to or greater than that provided by physicians and resident fellows.  These studies are limited by their inability to randomize patient selection and have been strongly criticized because the complexity of the assigned treatment generally decreases with the degree of practice. Patients cared for by acute care nurses in a neurosurgical environment for a period of six months were given a shorter period of stay in intensive care units, Decrease in rates of urinary tract infections and skin degradation compared to routine medical management  In addition, a systematic check found that patients in the care of acute care nurses were hospitalized 2,306 days less than the basic population cared for by fellows, saving $2,467,328.  The CPDA has several options for being certified national board. The American Association of Critical-Care Nurses (AACN) offers the Acute Care Nurse Practitioner-Adult/Gero (ACNPC-AG) certification.  Eligible applicants must pass an examination, have a valid RN licence and have a graduation degree from an accredited Advanced Practice Advanced Practice advanced care program. The American Nurses Credentialing Center offers approval from the Adult-Gerentology Acute Care Nurse Practitioner – Board Certified (AGACNP-BC).  This certification exam replaces the ACNP BC test to better build on the APRN consensus model, which promotes a more consistent model of admission, accreditation, certification and training of nurses.  Both registration information will continue to be used, but applicants applying after 2015 will only take the BC AGACNP exam. Applicants must hold a valid RN licence and be certified from the maintenance of an accredited program comprising at least 500 hours of clinic and specific content in pathophysiology, pharmacology, health assessment, health promotion and conservation, diagnosis and disease management.  Many health boards require nurses to be certified by a national certification body.
   In New Jersey, a common protocol is a written document prescribed by the state, which describes the prescribing guidelines for drugs and equipment for an AFN in a particular practical environment; this common protocol must be agreed and signed cooperatively by the AAP and its medical member-designate cooperating. It must be reviewed, updated and co-signed at least once a year. Although the language may vary from practice to practice in the common protocol, each common protocol must follow the project defined by the new Jersey State Board of Nursing rules at 13:37-6.3www.state.nj.us/lps/ca/nursing/nurjon.htm.