CRITICAL CARE CLINICAL PRIVILEGES St. Dominic Jackson Memorial Hospital

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1 PRINTED NAME: DATE: All new applicants must meet the following requirements as approved by the governing body, effective: 02/25/2016 INSTRUCTIONS Applicant: Check the requested box for each privilege requested. Applicants have the burden of producing information deemed adequate by the hospital for a proper evaluation of current competence, current clinic activity, and other qualifications, and for resolving any doubts related to qualifications for requested privileges. Department Chair/Chief: Check the appropriate box for recommendations on the privilege listing as well as the last page of this form. If recommended with conditions or not recommended, provide the condition or explanation. Other Requirements: Note that privileges granted may only be exercised at sites and/or settings that have sufficient space, equipment, staffing, and other resources required to support the privilege If any privileges are covered by an exclusive contract, practitioners who are not a party to the contract are not eligible to request the privilege(s), regardless of education, training, and experience. Exclusive or employment contracts are indicated by [EC]. This document is focused on defining qualifications related to competency to exercise clinical privileges. The applicant must also adhere to any additional organizational, regulatory, or accreditation requirements that the organization is obligated to meet. QUALIFICATIONS FOR CRITICAL CARE CORE PRIVILEGES Initial Applicants: To be eligible to apply for privileges in critical care, the applicant must meet the following criteria: Education For critical care medicine training undertaken July 1, 1991 and after, successful completion of an Accreditation Council for Graduate Medical Education (ACGME) or American Osteopathic Association (AOA) accredited postgraduate training program in the relevant medical specialty and successful completion of an accredited fellowship in critical care medicine. Training completed prior to July 1, 1991 must have been completed in a program associated with an Accreditation Council for Graduate Medical Education (ACGME) or American Osteopathic Association (AOA) accredited residency in internal medicine. Board Certification - Must meet the Medical Staff Bylaws requirements for board certification. Renewal of Privileges: Required Current Experience - Inpatient care to at least 30 patients in the critical care unit, reflective of the scope of privileges requested, during the past 12 months or successful completion of an ACGME- or AOA- accredited residency or clinical fellowship within the past 12 months. To be eligible to renew privileges in critical care, the applicant must meet the following criteria: Required Current Experience Current demonstrated competence and an adequate volume of experience with acceptable results, reflective of the scope of privileges requested, for the past 24 months based on results of ongoing professional practice evaluation and outcomes. Evidence of current physical and mental ability to perform privileges requested is requires of all applicants for renewal of privileges. Page 1 of 5

2 QUALIFICATIONS FOR NEURO CRITICAL CARE CORE PRIVILEGES Initial Applicants: To be eligible to apply for privileges in neuro critical care, the applicant must meet the following criteria: Must be approved for critical care core privileges. Education - For critical care medicine training undertaken July 1, 1991 and after, successful completion of an Accreditation Council for Graduate Medical Education (ACGME) or American Osteopathic Association (AOA) accredited postgraduate training program in the relevant medical specialty and successful completion of an accredited fellowship in critical care medicine. Training completed prior to July 1, 1991 must have been completed in a program associated with an Accreditation Council for Graduate Medical Education (ACGME) or American Osteopathic Association (AOA) accredited residency in internal medicine. Board Certification - Must meet the Medical Staff Bylaws requirements for board certification. Renewal of Privileges: Required Current Experience - Inpatient care to at least 30 patients in the critical care unit, reflective of the scope of privileges requested, during the past 12 months or successful completion of an ACGME- or AOA- accredited residency or clinical fellowship within the past 12 months. To be eligible to renew privileges in neuro critical care, the applicant must meet the following criteria: Must maintain critical care core privileges. Required Current Experience Current demonstrated competence and an adequate volume of experience with acceptable results, reflective of the scope of privileges requested, for the past 24 months based on results of ongoing professional practice evaluation and outcomes. Evidence of current physical and mental ability to perform privileges requested is requires of all applicants for renewal of privileges. QUALIFICATIONS FOR MODERATE/CONSCIOUS SEDATION Initial Applicants: Must complete Moderate/Conscious Sedation training module. Renewal of Privileges: Will monitor cases for ongoing competency Page 2 of 5

3 REQUESTED PRIVILEGES REQUESTED Request Privileges Below. Only request privileges for which by education, training, current experience, and demonstrated performance you are qualified to perform (please refer to qualifications outlined above) and wish to exercise at St. Dominic s. If there are privileges listed in the core procedure listing that you do not perform please strike through these items. CORE PRIVILEGES CRITICAL CARE CORE PRIVILEGES: Admit, evaluate, diagnose, and provide treatment or consultative services for patients with multiple organ dysfunction and in need of critical care for life-threatening disorders. 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 following high-risk, high-volume, problem-prone procedures, and such other procedures that are extensions of the same techniques and skills, which are commonly performed by the intensivist in the critically ill patient: Performance of history and physical exam Airway maintenance intubation, including fiberoptic bronchoscopy and laryngoscopy Arterial puncture and cannulation Intrapulmonary shunt, and alveolar arterial gradients Cardiac output determinations by thermodilution and other techniques Cardiopulmonary resuscitation Temporary cardiac pacemaker insertion and application Cardioversion and defibrillation Electrocardiography interpretation Endoscopy Evaluation of oliguria Insertion of central venous, arterial, and pulmonary artery balloon flotation catheters Insertion of hemodialysis and peritoneal dialysis catheters Interpretation of intracranial pressure monitoring Lumbar puncture Management of anaphylaxis and acute allergic reactions Management of critical illness in pregnancy Management of life-threatening disorders in intensive care units, including but not limited to shock, coma, heart failure, trauma, respiratory arrest, drug overdoses, massive bleeding, diabetic acidosis, and kidney failure Management of massive transfusions Management of the immunosuppressed patient Monitoring and assessment of metabolism and nutrition Needle and tube thoracostomy Percutaneous tracheostomy/cricothyrotomy tube placement Perform waived laboratory testing not requiring an instrument, including but not limited to fecal occult blood, urine dipstick, and vaginal ph by paper methods Pericardiocentesis Preliminary interpretation of imaging studies Thoracentesis Tracheostomy Page 3 of 5 DEPT CHAIR/ SERVICE CHIEF REC

4 Image-guided procedures Use of reservoir masks, nasal prongs/canulas, and nebulizers for delivery of supplemental oxygen and inhalants Ventilator management, including experience with various modes and continuous positive airway pressure therapies Wound care NEURO CRITICAL CARE CORE PRIVILEGES: Admit, evaluate, diagnose, and provide treatment or consultative services for patients with multiple organ dysfunction and in need of critical care for life-threatening disorders. 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 following high-risk, high-volume, problem-prone procedures, and such other procedures that are extensions of the same techniques and skills, which are commonly performed by the intensivist in the critically ill patient: Interpretation of transcranial Doppler monitoring Management of thrombolytic therapy Management of patients after peripheral and cerebral endovascular procedures Management of cerebral perfusion pressure SPECIAL PRIVILEGES: Conscious/Moderate Sedation 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 St. Dominic s, 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. Signature: Date: Page 4 of 5

5 DEPARTMENT CHAIR/SERVICE CHIEF S 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/Modificcation/Explanation Notes: Department Chair/Service Chief Signature: Date: FOR MEDICAL STAFF SERVICES DEPARTMENT USE ONLY Initial Appointment Reappointment Credentials Committee Action Medical Executive Committee Action QA/PI Committee Action Governing Board Action Effective from / / to / / Page 5 of 5