ANESTHESIOLOGY/PAIN MEDICINE CLINICAL PRIVILEGES

Transcription

1 Initial Appointment Reappointment Applicant: To request Core Privileges and/or a special procedure, place an X in the appropriate column. Applicants have the burden of producing information deemed adequate by the Hospital for a proper evaluation of current competence, current clinical activity and other qualifications, and for resolving any doubts related to qualifications for requested privileges. Qualifications for Anesthesiology: Successful completion of an ACGME or AOA-accredited residency in anesthesiology: and Current certification or active participation in the examination process leading to certification in anesthesiology by the American Board of Anesthesiology or the American Osteopathic Board of Anesthesiology. 250 hospital anesthesiology cases, reflective of the scope of privilege requested, during the past 12 months or demonstrated successful completion of an ACGME- or AOA-accredited residency within the past 12 months. ANESTHESIOLOGY CORE PRIVILEGES REQUEST Privileges to perform history and physical exam, administration of anesthesia, including general, regional, and local, and administration of all levels of sedation to [pediatric*], adolescent, and adult patients. Care includes pain relief and maintenance, or restoration, of a stable condition during and immediately following surgical, obstetrical, and diagnostic procedures. May provide care to patients in the intensive care setting in conformance with unit policies. Assess, stabilize, and determine the disposition of patients with emergent conditions consistent with medical staff policy regarding emergency and consultative call services. The core privileges in this specialty include the procedures as listed below and such other procedures that are extensions of the same techniques and skills. Assessment of, consultation for, and preparation of patients for anesthesia Clinical management and teaching of cardiac and pulmonary resuscitation Diagnosis and treatment of acute, chronic, and cancer-related pain Evaluation of respiratory function and application of respiratory therapy Image-guided procedures Management of critically ill patients Monitoring and maintenance of normal physiology during the perioperative period Relief and prevention of pain during and following surgical, obstetric, therapeutic, and diagnostic procedures using sedation/analgesia, general anesthesia, regional anesthesia Supervision and evaluation of performance of personnel, both medical and paramedical, involved in perioperative care Supervision of certified registered nurse anesthetists Treatment of patients for pain management (excluding chronic pain management) 1

2 *PEDIATRIC ANESTHESIOLOGY CRITERIA Qualifications: Successful completion of an ACGME- or AOA-accredited residency in anesthesiology, followed by successful completion of an accredited fellowship in pediatric anesthesiology. 250 hospital anesthesiology cases, reflective of the scope of privilege requested, during the past 12 months or demonstrated successful completion of an ACGME- or AOA-accredited fellowship within the past 12 months. REQUEST PEDIATRIC ANESTHESIOLOGY CORE PRIVILEGES R equested Up to 1 month of age (not applicable for SHHG) R equested 1 to 6 months of age (not applicable for SHHG) R equested 6 months to 2 years of age (not applicable for SHHG) R equested > 2 years of age Perform history and physical exam, administration of anesthesia, including general, regional, and local, and administration of all levels of sedation to pediatric patients. Includes evaluation of complex medical problems in infants and children when surgery is needed, planning and care before and after surgery, pain control, if needed after surgery, and anesthesia and sedation for procedures out of the operating room, such as an MRI, CT scan, and radiation therapy. May provide care to patients in the intensive care setting in conformance with unit policies. Assess, stabilize, and determine the disposition of patients with emergent conditions consistent with medical staff policy regarding emergency and consultative call services. The core privileges in this specialty include the procedures on the attached procedures list and such other procedures that are extensions of the same techniques and skills. R equested-tube placement only in children under 2 years of age PAIN MEDICINE CRITERIA Qualifications: Successful completion of an ACGME or AOA accredited residency in a relevant medical specialty, followed by completion of an ACGME or AOA accredited fellowship in pain medicine of at least a 12-month duration OR active participation in the examination process by the American Board of Anesthesiology, the American Board of Psychiatry and Neurology or the American Board of Physical Medicine and Rehabilitation leading to certification in pain medicine by the American Board of Pain Medicine. 50 inpatient, outpatient, or consultative pain medicine, reflective of the scope of privilege requested, during the past 12 months or demonstrated successful completion of an ACGME- or AOA-accredited pain medicine fellowship within the past 12 months. 2

3 3 PAIN MEDICINE CORE PRIVILEGES REQUEST Privileges to perform history and physical exam, evaluate, diagnose, treat, and provide consultation to patients of all ages with acute and chronic pain or pain requiring palliative care. Includes invasive pain medicine procedures beyond basic pain medicine. May provide care to patients in the intensive care setting in conformance with unit policies. Assess, stabilize, and determine the disposition of patients with emergent conditions consistent with medical staff policy regarding emergency and consultative call services. The core privileges in advanced pain medicine include the basic pain medicine core and the procedures on the attached procedures list and such other procedures that are extensions of the same techniques and skills. Behavioral modification and feedback techniques Chemical neuromuscular denervation (e.g., Botox injection) Diagnosis and treatment of chronic and cancer-related pain Discography and intradiscal/percutaneous disc treatments Epidural and intrathecal medication management Epidural, subarachnoid, or peripheral neurolysis Fluoroscopically guided facet blocks Implantation of subcutaneous, epidural, and intrathecal catheters Infusion port and pump implantation Injection of joint and bursa, including sacroiliac, hip, knee, and shoulder joint injections Management of chronic headache Modality therapy and physical therapy Neuroablation with cryo, chemical, and radiofrequency modalities Nucleoplasty Percutaneous and subcutaneous implantation of neurostimulator electrodes Peripheral, cranial, costal, plexus, and ganglion nerve blocks Prevention, recognition, and management of local anesthetic overdose, including airway management and resuscitation Recognition and management of therapies, side effects, and complications of pharmacologic agents used in the management of pain Rehabilitative and restorative therapy Stress management and relaxation techniques Spinal injections, including epidural injections, interlaminar, transforaminal, nerve root sheath injections, and zygapophysial joint injections Superficial electrical stimulation techniques (e.g., transcutaneous electrical neural stimulation) Trigger point injection Special Non-core privileges (See Specific Criteria) Non-core privileges are requested individually in addition to requesting the core. Each request for these privilege(s) must meet the specific threshold criteria. 3 SPECIAL PROCEDURES PAIN MEDICINE Procedures that may not be part of training, and/or may require proof of training and/or experience. Request Procedure Initial Criteria Reappointment Criteria Moderate Sedation *Current ACLS certification or completion of airway management skills station with an anesthesiologist; AND Same as initial criteria 3

4 *Successful completion of the hospital s moderate sedation post-test. Deep Sedation *Current ACLS certification or completion of airway management skills station with an anesthesiologist; AND *Successful completion of the hospital s moderate sedation post-test. Percutaneous Vertebroplasty *Must meet criteria for Pain Medicine Core; AND * Fellowship that included training in OR completion of a hands-on training course in percutaneous vertebroplasty. Training must include performance of at vertebroplasties in at least 5 patients as primary operator, under the supervision of a qualified physicians, and without complications. Also must have completed training in radiation safety. Same as initial criteria Demonstrated current competence and evidence of the performance of at least 5 procedures within the past 24 months based on results of ongoing professional practice evaluation and clinical outcomes. Balloon Kyphoplasty *Must meet criteria for Pain Medicine Core; AND * Fellowship that included training. Also must have completed training course in the use of the inflatable bone tamp and have been proctored for initial cases by a Kyphon representative. Must have completed training in radiation safety. Demonstrated current competence and evidence of the performance of at least 5 procedures within the past 24 months based on results of ongoing professional practice evaluation and clinical outcomes. Acknowledgment of practitioner I have requested only those privileges for which by education, training, current experience, and demonstrated performance I am qualified to perform and for which I wish to exercise at [hospital name], and I understand that: a. In exercising any clinical privileges granted, I am constrained by hospital and medical staff policies and rules applicable generally and any applicable to the particular situation. b. Any restriction on the clinical privileges granted to me is waived in an emergency situation, and in such situation my actions are governed by the applicable section of the medical staff bylaws or related documents. Signed Date Department/Clinical Service Chief recommendation I have reviewed the requested clinical privileges and supporting documentation for the above-named applicant and: Recommend all requested privileges Recommend privileges with the following conditions/modifications: Do not recommend the following requested privileges: Privilege Condition/modification/explanation 4

5 Notes: [Department chair/chief] signature Date FOR MEDICAL STAFF USE ONLY Credentials committee action Date Medical executive committee action Date System Board action Date 5