NAME: DATE: MARGARETVILLE HOSPITAL PHYSICIAN ASSITANT/NURSE PRACTITIONER ED CLINICAL PRIVILEGES

Transcription

1 SUPERVISING PHYSICIAN(s): MARGARETVILLE HOSPITAL PHYSICIAN ASSITANT/NURSE PRACTITIONER ED CLINICAL PRIVILEGES The following privileges are required to practice in the Emergency Room of Margaretville Hospital: Suturing Digital nerve block I&D abscess I&D paronychia Subungual hematoma drainage Local wound care/burn care Review patient records History and Physical exam, including rectal and pelvic and complete discharge instructions Gastric lavage Immobilization & splinting of fractures Reduce fractures/dislocations (elbow, hip, joint prosthesis require prior consultation with orthopedist) Peripheral or Intra-Osseous Access Administer intra-muscular subcutaneous injections and IV meds Insert catheters Pass nasogastric tube Draw blood/venous & arterial puncture (ABG) Perform CPR/BLS, ACLS and ATLS Protocols (requires ACLS and ATLS certifications) Anterior/Posterior Nasal Packing Eye care/flourescein stains and wood lamp exam Ear care/removal of impacted cerumen Assist in other procedures as requested by a physician Order laboratory & diagnostic testing Participate in departmental rounds & conferences as requested by Director of Service Prescribe drugs, including controlled substances Perform patient teaching and counseling on health maintenance SPECIAL CATEGORY II Superficial facial suturing. Complex lacerations require consult with MD Eye Care/Foreign Body removal within 24 hours with follow-up referral Tube Thoracostomy Joint aspiration and injections Set up and adjustment of traction Procedural Sedation (please complete privilege request form and PSA test) Ventilator Management Emergency Only Rapid Sequence Intubation (RSI) Emergency Only (please complete Privilege Req. Form and PSA/RSI Test, both attached)

2 I have requested only those privileges for which by education, training, current experience and demonstrated performance I am qualified to perform at the Margaretville Hospital. 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. I also request the ability to do any procedure in an emergency situation. Applicant s Signature: Date: I have reviewed the requested clinical privileges and supporting documentation for the above named applicant and recommend approval. Department Chair s Signature: Date: Broadway Campus

3 MARGARETVILLE HOSPITAL Allied Health Staff Physician Assistant/Nurse Practitioner Inpatient Clinical Privileges SUPERVISING PHYSICIAN(s): Allied Health PA/NP Privileges LEVEL I: Perform History and Physical examination on patients and review patient records to determine health status (Findings, conclusions and assessment of risk must be endorsed by a qualified physician and countersigned) Prepare discharge summaries Must be countersigned by supervising physician Write medical orders including controlled substances Order routine laboratory tests Writes orders for administration of blood and blood products Perform patient teaching as required Counsel patients on health maintenance and other problems, according to physician s instructions. Make rounds and write pertinent progress notes on patient s medical record and record pertinent patient data. Perform the following: Wound care and Dressings; Venipuncture and starting IV/IO; Bladder catheterization; Blood collection (venous and arterial/io); Give injections IM, SQ, IV; CPR; Pap Smear; Ear Lavage. Communicate to attending the result of laboratory data to include Blood Profile, Blood Chemistries, urinalysis, arterial blood gases, electrocardiograms and x-rays for patients. Collaborate with patient, family, and hospital services to effect early discharge. LEVEL II Initiate and participate in Cardiopulmonary Resuscitation (BLS) (with certification) Hospital wide requirement. Program and Direct Advance Cardiopulmonary Resuscitation (must be certified in ACLS). Attach Certificate. Emergency Department requirement. Administer intravenous medications Determination of Death and notify the attending physician and family members. Place IV/IO Access Draw arterial blood gas samples Obtain other samples by nonsurgical methods Reinsertion of Gastrostomy Tubes Reinsertion of Tracheostomy Tubes Endotracheal Intubation Cricothyroidotomy per ATLS training Administration of endotracheal medications per ACLS training (Attach ACLS Certificate) Removal of tracheostomy tubes Insertion of enteric suctioning tubes Assist attending in surgery Suture minor lacerations Removal of sutures and staples Assist in maintenance and removal of surgical drains if instructed by physician Assess the trauma patient Incision and drainage of an abscess Peripheral or Intra-Osseous Access Appropriate wound care to include debridements, removal of tubes, drains, sutures, staples, et cetera Control of external hemorrhage to include suturing and cautery Ventilator Management EMERGENCY ONLY Administration of Vasopressor agents LEVEL III Reduce fractures/dislocations (elbow, hip, joint prosthesis require prior consultation with orthopedist)

4 Applying splints Removing casts and splints Joint aspiration and injections Thoracostomy Tube I have requested only those privileges for which by education, training, current experience and demonstrated performance I am qualified to perform at the Margaretville Hospital. 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. I also request the ability to do any procedure in an emergency situation. Applicant s Signature: Date: I have reviewed the requested clinical privileges and supporting documentation for the above named applicant and recommend approval. Department Chair s Signature: Date:

5 MARGARETVILLE HOSPITAL/EMERGENCY DEPARTMENT RAPID SEQUENCE INTUBATION PRIVILEGE REQUEST FORM APPLICANT S PRINTED NAME: DATE: I am requesting RSI privileges on: Initial Appointment As a new privilege Minimum Training Required: 1. Required to complete a nationally approved difficult airway course within six months of the date on this request. 2. Successful completion of RSI Test 3. ATLS, ACLS and PALS Certification I agree that I will complete the required training to perform RSI at Margaretville Hospital. I also attest that I have read and I will comply with the policy on RSI. I have attached my ATLS, ACLS and PALS certifications, along with the completed RSI test. Applicant s Signature: APPROVAL The applicant has successfully demonstrated to me sufficient knowledge in Rapid Sequence Intubation. Date Chair, Department of Anesthesia

6 MARGARETVILLE HOSPITAL/EMERGENCY DEPARTMENT PROCEDURAL SEDATION AND ANALGESIA (PSA) PRIVILEGE REQUEST FORM APPLICANT S PRINTED NAME: DATE: I am requesting PSA privileges on: Initial Appointment As a new privilege Minimum Training Required: 1. Successful completion of PSA Test 2. Documentation of Training in PSA 3. ATLS, ACLS and PALS Certification I attest that I have completed required training to perform PSA at Margaretville Hospital. I also attest that I have read and I will comply with the policy on PSA. I have attached my ATLS, ACLS and PALS certifications, along with the completed PSA test. Applicant s Signature: APPROVAL The applicant has successfully demonstrated to me sufficient knowledge to administer Procedural Sedation and Analgesia. Date Chair, Department of Anesthesia