Pediatric critical care medicine

Transcription

1 Practice area 414 Clinical PRIVILEGE WHITE PAPER Pediatric critical care medicine Background Pediatric critical care medicine is the subspecialty of pediatrics that focuses on treating children, from birth to young adulthood, for illnesses or injuries that result in the child being in an unstable, critical condition. Pediatric critical care medicine specialists are often referred to as pediatric intensivists. Pediatric critical care specialists advanced training and experience prepares them to give children in pediatric ICUs (PICU) the unique medical care that they require. According to the American Academy of Pediatrics (AAP), these practitioners generally care for pediatric patients in the following manner: Diagnose unstable, life-threatening conditions Perform thorough monitoring, medication, and treatment of patients in a PICU Supervise children on respirators Provide medical treatment for severe heart and lung disease Place special catheters in the blood vessels and heart Manage medications and treatments for children with brain trauma Following medical school, pediatric critical care specialists complete a pediatric residency program that is accredited by the Accreditation Council for Graduate Medical Education (ACGME) or the American Osteopathic Association (AOA). Pediatric critical care specialists also complete a fellowship in pediatric critical care medicine (three or more years of training in pediatric critical care) to become eligible for certification in the subspecialty by the American Board of Pediatrics (ABP). Such specialized training includes the development of special competence in cardiopulmonary resuscitation; stabilization for transport; trauma; triage; ventilatory, circulatory, and neurologic support; management of renal and hepatic failure; poisoning; complicated hematological, infectious, and immune problems; continuous monitoring; and nutritional support. Alternatively, a physician who is certified in anesthesiology by the American Board of Anesthesiology (ABA) may apply for certification in pediatric critical care medicine by the ABP on the basis of completion of two years of training in pediatric critical care medicine. Effective July 1, 2013, the ABP and ABA offer a dual pathway for certification in pediatric critical care medicine and anesthesiology, which confer eligibility for certification in both disciplines after five years of training.

2 The AAP states that pediatric critical care has advanced rapidly during the past three decades, rendering it essential for practitioners in the field to possess current knowledge of the pathophysiology of life-threatening processes, as well as to have the advanced technological abilities needed to monitor and treat pediatric critical care patients. Related white papers: Pediatrics Practice area 152 Anesthesiology Practice area 125 Critical care medicine Practice area 129 Involved specialty Pediatric critical care medicine specialists Positions of specialty boards ABP The ABP grants subspecialty certification in pediatric critical care medicine to applicants who have completed training in a program accredited by the ACGME or the Royal College of Physicians and Surgeons of Canada. Applicants must meet the following criteria in order to be eligible for subspecialty certification: Be currently certified in general pediatrics and continue to maintain current general pediatrics certification Have a valid, current, unrestricted license to practice medicine in one of the states, districts, or territories of the United States or a province of Canada in which he or she practices, or have unrestricted privileges to practice medicine in the U.S. Armed Forces Provide the names of program(s) and program director(s) where fellowship training occurred Demonstrate research/academic scholarly activities undertaken during fellowship training In addition to fulfilling these general eligibility criteria, applicants must meet the following specific eligibility criteria for ABP subspecialty certification in pediatric critical care medicine: Submit a verification of competence form completed by their program director(s) verifying satisfactory completion of the required training; evaluating clinical competence, including professionalism; and providing evidence of meaningful accomplishment in research and scholarly activity Meet either the criteria stated in the Principles Regarding the Assessment of Meaningful Accomplishment in Research or those stated in the Principles 2

3 Regarding the Assessment of Scholarly Activity as described in the General Eligibility Criteria for Certification in the Pediatric Subspecialties Pass the subspecialty certifying examination A subspecialty fellow who is certified in anesthesiology by the ABA may apply for admission on the basis of completion of two years of subspecialty fellowship training in pediatric critical care medicine. Individuals who are currently training in or have completed training in anesthesiology who plan to utilize this pathway must begin training in pediatric critical care medicine by July 1, Effective July 1, 2013, physicians interested in certification in both anesthesiology and pediatric critical care medicine may enter the dual pathway for certification in both disciplines. The ABP and ABA have agreed to a pathway that includes the following stipulations: The pathway is available to those who have completed the required training for certification in general pediatrics. Both the anesthesiology and pediatric critical care medicine training must be completed in the same institution or in close geographic proximity in the same academic health system. Training in pediatric critical care medicine may precede or follow training in anesthesiology, or the training may be fully integrated. An individual in the pathway must be identified by the end of the first year of training or preferably before training begins in anesthesiology and pediatric critical care medicine. An outline of the five-year plan that details how the training requirements of the ABP, the ABA, and the ACGME will be met must be submitted to both boards for approval. Individuals will be approved for this pathway on a caseby-case basis; programs will not be approved. Although double counting of scholarly activity/research experience is allowed, all clinical training requirements must be met in each discipline and may not be double counted. Six months of the scholarly activity required for pediatric critical care medicine certification will be completed during the six months of research time allowed during the anesthesiology residency. The trainee s Scholarship Oversight Committee will oversee this training, as required by the ABP s General Eligibility Criteria for Certification in the Pediatric Subspecialties. The five years of training will not confer eligibility for certification in pediatric anesthesiology by the ABA. Trainees in the pathway will be eligible for certification in both anesthesiology and pediatric critical care medicine upon the satisfactory completion of all five years of training. Certification in one discipline is not contingent on certification in the other. 3

4 Positions of societies, academies, colleges, and associations AAP The AAP publishes the policy statement Medical Staff Appointment and Delineation of Pediatric Privileges in Hospitals. In the statement, the AAP says a major portion of the credentialing process is the delineation of clinical privileges. Through this process, the medical staff evaluates and recommends that an individual practitioner be allowed to provide specific patient care services in the hospital based on the hospital s mission and needs, as well as the individual practitioner s training, experience, and skills. Privileges may be denied to an applicant if the hospital does not have the facilities for the requested procedure (e.g., a pediatric cardiologist who requests privileges for cardiac catheterization from a hospital that does not have catheterization facilities). Departments within the hospital are responsible for defining the minimum education, training, and experience that a practitioner must possess to deliver care of varying complexity or to perform specific procedures. This may be done across departments when practitioners of various disciplines care for patients. Once criteria are established, they must be recorded in written form and applied equitably to practitioners from different specialties. Criteria for clinical privileges are based on the complexity of care needed by the patient (e.g., routine inpatient, routine newborn, subspecialty, or intensive care). According to the AAP, board certification or eligibility in pediatrics or a pediatric subspecialty, or training in a pediatric specialty, is assumed to define a basic set of skills and knowledge needed to care for sick children. Many non-pediatrician physicians can document by their training and experience that they are competent in caring for pediatric patients. Experience in procedures performed on children also should be documented. As new procedures and treatment modalities develop, guidelines for clinical privileges also must develop. New procedures and treatment modalities can be divided into major new procedures (e.g., endoscopy or laparoscopic surgery) or minor changes (e.g., a new way to perform laparoscopic surgery). Practitioners wishing to be granted privileges in a major new procedure or treatment modality must document sufficient hands-on training to be deemed competent, according to the AAP. Physicians may gain this training through supervised training programs. A practitioner also may gain provisional privileges that allow him or her to perform the procedure under the supervision of another practitioner skilled in the procedure (i.e., proctoring). Data from some new procedures have shown that the complication rate decreases significantly and competency increases significantly after a certain number of the procedures are performed. Guidelines for competency in new procedures or 4

5 treatment modalities must be developed on the basis of a review of the literature and technical aspects of the procedure. Once the practitioner successfully meets the guidelines, full privileges are granted. SCCM The AAP jointly published Guidelines and Levels of Care for Pediatric Intensive Care Units (PICU) with the Society of Critical Care Medicine (SCCM). The guidelines discuss the scope of pediatric critical care services, hospital facilities and services, personnel, drugs and equipment, quality monitoring, and training and continuing education necessary for PICUs and the healthcare personnel who staff them. According to the document, studies suggest that having a full-time pediatric intensivist in the PICU improves patient care and efficiency. Nonphysician providers must receive credentials and privileges to provide care in the PICU only under the direction of the attending physician, and the credentialing process must be made in writing and approved by the medical director. An in-house physician at the postgraduate year three level or above in pediatrics or anesthesiology is essential for all Level I PICUs. In addition, all hospitals with PICUs must have a physician in-house 24 hours a day who is available to provide bedside care to patients in the PICU. This physician must be skilled in, and have credentials to provide, emergency care to critically ill children. However, depending on the unit size and patient population, more physicians at higher training levels may be required. The guidelines further recommend that all respiratory therapy staff members for the PICU should have clinical experience managing pediatric respiratory failure and pediatric mechanical ventilators, and should have training in pediatric advanced life support or an equivalent course. Level I PICUs must have a respiratory therapist in-house 24 hours per day dedicated to the PICU, according to the AAP/SSCM guidelines, while hospitals with Level II PICUs must have respiratory therapy staff in-house at all times, although they need not be dedicated to the PICU. The SCCM, in conjunction with the American College of Critical Care Medicine (the consultative body of the SCCM), publishes Guidelines for Critical Care Medicine Training and Continuing Medical Education. The guidelines state that on completion of the subspecialty training program in critical care medicine, each physician must be able to: Identify the needs of and provide care for all critically ill adult and/or pediatric patients Provide resuscitation, including advanced techniques, to any patients sustaining a life-threatening event 5

6 Initiate critical care to stabilize and manage patients who require transport to another facility for a higher level of critical care support Initiate and manage the use of mechanical ventilators, and wean patients from mechanical ventilators using a variety of techniques Instruct other qualified caregivers and the lay public in the theory and techniques of cardiopulmonary resuscitation Treat cardiogenic, traumatic, hypovolemic, and distributive shock using conventional and state-of-the-art approaches Recognize the potential for multiple organ failure and institute measures to avoid or reverse this syndrome Identify life-threatening electrolyte and acid-base disturbances, provide treatment, and monitor the outcome Diagnose malnutrition, and use and monitor advanced nutrition support methodologies Diagnose common and uncommon poisonings and provide all necessary treatment Instruct other practitioners in the appropriate use and monitoring of conscious and deep sedation, and use advanced pain management strategies Select, place, and use appropriate invasive and noninvasive monitors for titrating therapy in any critically ill patient Prioritize complex data to support an action plan Use and help enforce advanced methods of infection control Follow medication safe practice guidelines and determine cost-effectiveness of therapeutic interventions Support and increase the skills of ICU nurses and ancillary personnel in caring for critically ill patients by acting as the ICU team leader ACGME In its Program Requirements for Graduate Medical Education in Pediatric Critical Care Medicine, the ACGME states that the purpose of an accredited program in pediatric critical care medicine is to provide fellows with an understanding of the biology of acute, life-threatening disease and injury, and the necessary cognitive and technical skills to prepare them to serve as skilled clinicians, competent educators, and physician scientists that contribute to scientific advances in the field. To achieve this, the program must emphasize the fundamentals of clinical diagnosis, patient assessment, and clinical management, including multisystem life support. According to the ACGME, pediatric subspecialty programs must provide three years of training and must be organized and conducted in a way that ensures an appropriate environment for the well-being and care of patients, in addition to providing adequate training for fellows in the diagnosis and management of subspecialty patients, including progressive clinical, technical, and consultative experiences that will enable the fellow to develop expertise as a consultant 6

7 in the subspecialty. In addition, prerequisite training for entry into a pediatric subspecialty program should include the satisfactory completion of an ACGMEaccredited pediatric residency or other training suitable to the program director. With regard to patient care, fellows must have the opportunity to acquire the knowledge and skills required to diagnose and manage patients with acute, lifethreatening problems. This must include, but not be limited to, the development of special competence in such areas as: Cardiopulmonary resuscitation Stabilization for transport Trauma Triage Ventilatory, circulatory, and neurologic support Management of renal and hepatic failure, poisoning, and complicated hematological, infectious, and immune problems Continuous monitoring Nutritional support With regard to procedural skills, fellows must become proficient in critical care procedures with patients sufficiently ill and cases sufficiently complex. These procedures include, but are not limited to: Peripheral arterial and venous catheterization Central venous catheterization Endotracheal intubation and thoracostomy tube placement Sedation of conscious patients Furthermore, the ACGME states that there should be sufficient exposure to the use of invasive and noninvasive hemodynamic and intracranial monitoring to ensure understanding of their uses and limitations. Fellows must also demonstrate competence and effective participation in teambased care of critically ill patients whose primary problem is surgical. Meeting these goals requires coordination of care and collegial relationships among pediatric surgeons, neonatologists, and critical care intensivists concerning the management of medical problems in these complex critically ill patients. Some of the fellows clinical experience may take place in other critical care settings for example, with anesthesiologists, in a medical ICU, in a burn unit, in a neonatal ICU, and/or in a surgical ICU. Electives in these units may be included in the clinical experience, but they should not replace time in the PICU. The time spent in these other critical care settings should be no more than four months. An exception to the four-month limit is made for programs in which all postoperative cardiovascular care is provided in a pediatric cardiac surgical ICU separate from the PICU. If there is a separate pediatric cardiac ICU, a maximum of six months may be spent on such rotations over the three years of training. 7

8 With regard to medical knowledge, the curriculum should include instruction in collation and critical interpretation of patient care data. Interpretation of laboratory studies essential to the care of the critically ill pediatric patient must also be included. Fellows must demonstrate their proficiency in the knowledge of: Pathophysiology of single and multiple organ dysfunction Pharmacologic principles, and the ability to apply these principles to the critically ill patient Additionally, instruction in biomedical instrumentation must be offered to familiarize fellows with current and developing technology, and fellows must participate in regularly scheduled multidisciplinary conferences such as morbidity and mortality review and case conferences. Positions of accreditation bodies CMS CMS has no formal position concerning the delineation of privileges for pediatric critical care medicine. However, the CMS Conditions of Participation (CoP) define a requirement for a criteria-based privileging process in (c)(6) stating, The bylaws must include criteria for determining the privileges to be granted to individual practitioners and a procedure for applying the criteria to individuals requesting privileges (a)(6) states, The governing body must assure that the medical staff bylaws describe the privileging process. The process articulated in the bylaws, rules or regulations must include criteria for determining the privileges that may be granted to individual practitioners and a procedure for applying the criteria to individual practitioners that considers: Individual character Individual competence Individual training Individual experience Individual judgment The governing body must ensure that the hospital s bylaws governing medical staff membership or the granting of privileges apply equally to all practitioners in each professional category of practitioners. Specific privileges must reflect activities that the majority of practitioners in that category can perform competently and that the hospital can support. Privileges are not granted for tasks, procedures, or activities that are not conducted within the hospital, regardless of the practitioner s ability to perform them. 8

9 Each practitioner must be individually evaluated for requested privileges. It cannot be assumed that every practitioner can perform every task, activity, or privilege specific to a specialty, nor can it be assumed that the practitioner should be automatically granted the full range of privileges. The individual practitioner s ability to perform each task, activity, or privilege must be individually assessed. CMS also requires that the organization have a process to ensure that practitioners granted privileges are working within the scope of those privileges. CMS CoPs include the need for a periodic appraisal of practitioners appointed to the medical staff/granted medical staff privileges ( [a][1]). In the absence of a state law that establishes a time frame for the periodic appraisal, CMS recommends that an appraisal be conducted at least every 24 months. The purpose of the periodic appraisal is to determine whether clinical privileges or membership should be continued, discontinued, revised, or otherwise changed. The Joint Commission The Joint Commission has no formal position concerning the delineation of privileges for pediatric critical care medicine. However, in its Comprehensive Accreditation Manual for Hospitals, The Joint Commission states, The hospital collects information regarding each practitioner s current license status, training, experience, competence, and ability to perform the requested privilege (MS ). In the introduction for MS , The Joint Commission states that there must be a reliable and consistent system in place to process applications and verify credentials. The organized medical staff must then review and evaluate the data collected. The resultant privilege recommendations to the governing body are based on the assessment of the data. The Joint Commission introduces MS by stating, The organized medical staff is respon sible for planning and implementing a privileging process. It goes on to state that this process typically includes: Developing and approving a procedures list Processing the application Evaluating applicant-specific information Submitting recommendations to the governing body for applicant-specific delineated privileges Notifying the applicant, relevant personnel, and, as required by law, external entities of the privileging decision Monitoring the use of privileges and quality-of-care issues MS further states, The decision to grant or deny a privilege(s) and/or to renew an existing privilege(s) is an objective, evidence-based process. 9

10 The EPs for standard MS include several requirements as follows: The need for all licensed independent practitioners who provide care, treatment, and services to have a current license, certification, or registration, as required by law and regulation Established criteria as recommended by the organized medical staff and approved by the governing body with specific evaluation of current licensure and/or certification, specific relevant training, evidence of physical ability, professional practice review data from the applicant s current organization, peer and/or faculty recommendation, and a review of the practitioner s performance within the hospital (for renewal of privileges) Consistent application of criteria A clearly defined (documented) procedure for processing clinical privilege requests that is approved by the organized medical staff Documentation and confirmation of the applicant s statement that no health problems exist that would affect his or her ability to perform privileges requested A query of the NPDB for initial privileges, renewal of privileges, and when a new privilege is requested Written peer recommendations that address the practitioner s current medical/clinical knowledge, technical and clinical skills, clinical judgment, interpersonal skills, communication skills, and professionalism A list of specific challenges or concerns that the organized medical staff must evaluate prior to recommending privileges (MS , EP 9) A process to determine whether there is sufficient clinical performance information to make a decision related to privileges A decision (action) on the completed application for privileges that occurs within the time period specified in the organization s medical staff bylaws Information regarding any changes to practitioners clinical privileges, updated as they occur The Joint Commission further states, The organized medical staff reviews and analyzes information regarding each requesting practitioner s current licensure status, training, experience, current competence, and ability to perform the requested privilege (MS ). In the EPs for standard MS , The Joint Commission states that the information review and analysis process is clearly defined and that the decision process must be timely. The organization, based on recommendations by the organized medical staff and approval by the governing body, develops criteria that will be considered in the decision to grant, limit, or deny a request for privileges. The criteria must be consistently applied and directly relate to the quality of care, treatment, and services. Ultimately, the governing body or delegated governing body has the final authority for granting, renewing, or denying clinical privileges. Privileges may not be granted for a period beyond two years. 10

11 Criteria that determine a practitioner s ability to provide patient care, treatment, and services within the scope of the privilege(s) requested are consistently evaluated. The Joint Commission further states, Ongoing professional practice evaluation information is factored into the decision to maintain existing privilege(s), to revise existing privileges, or to revoke an existing privilege prior to or at the time of renewal (MS ). In the EPs for MS , The Joint Commission says there is a clearly defined process facilitating the evaluation of each practitioner s professional practice, in which the type of information collected is determined by individual departments and approved by the organized medical staff. Information resulting from the ongoing professional practice evaluation is used to determine whether to continue, limit, or revoke any existing privilege. HFAP The Healthcare Facilities Accreditation Program (HFAP) has no formal position concerning the delineation of privileges for pediatric critical care medicine. The bylaws must include the criteria for determining the privileges to be granted to the individual practitioners and the procedure for applying the criteria to individuals requesting privileges ( ). Privileges are granted based on the medical staff s review of an individual practitioner s qualifications and its recommendation regarding that individual practitioner to the governing body. It is also required that the organization have a process to ensure that practitioners granted privileges are working within the scope of those privileges. Privileges must be granted within the capabilities of the facility. For example, if an organization is not capable of performing open-heart surgery, no physician should be granted that privilege. In the explanation for standard related to membership selection criteria, HFAP states, Basic criteria listed in the bylaws, or the credentials manual, include the items listed in this standard. (Emphasis is placed on training and competence in the requested privileges.) The bylaws also define the mechanisms by which the clinical departments, if applicable, or the medical staff as a whole establish criteria for specific privilege delineation. Periodic appraisals of the suitability for membership and clinical privileges is required to determine whether the individual practitioner s clinical privileges should be approved, continued, discontinued, revised, or otherwise changed ( ). The appraisals are to be conducted at least every 24 months. 11

12 The medical staff is accountable to the governing body for the quality of medical care provided, and quality assessment and performance improvement ( ) information must be used in the process of evaluating and acting on re-privileging and reappointment requests from members and other credentialed staff. DNV DNV has no formal position concerning the delineation of privileges for pediatric critical care medicine. MS.12 Standard Requirement (SR) #1 states, The medical staff bylaws shall include criteria for determining the privileges to be granted to individual practitioners and a procedure for applying the criteria to those individuals that request privileges. The governing body shall ensure that under no circumstances is medical staff membership or professional privileges in the organization dependent solely upon certification, fellowship, or membership in a specialty body or society. Regarding the Medical Staff Standards related to Clinical Privileges (MS.12), DNV requires specific provisions within the medical staff bylaws for: The consideration of automatic suspension of clinical privileges in the following circumstances: revocation/restriction of licensure; revocation, suspension, or probation of a DEA license; failure to maintain professional liability insurance as specified; and noncompliance with written medical record delinquency/deficiency requirements Immediate and automatic suspension of clinical privileges due to the termination or revocation of the practitioner s Medicare/Medicaid status Fair hearing and appeal The Interpretive Guidelines also state that core privileges for general surgery and surgical subspecialties are acceptable as long as the core is properly defined. DNV also requires a mechanism (outlined in the bylaws) to ensure that all individuals provide services only within the scope of privileges granted (MS.12, SR.4). Clinical privileges (and appointments or reappointments) are for a period as defined by state law or, if permitted by state law, not to exceed three years (MS.12, SR.2). Individual practitioner performance data must be measured, utilized, and evaluated as a part of the decision-making for appointment and reappointment. Although not specifically stated, this would apply to the individual practitioner s respective delineation of privilege requests. CRC draft criteria The following draft criteria are intended to serve solely as a starting point for the development of an institution s policy regarding this practice area. The core 12

13 privileges and accompanying procedure list are not meant to be all-encompassing. They define the types of activities, procedures, and privileges that the majority of practitioners in this specialty perform. In addition, it cannot be expected or required that practitioners perform every procedure listed. Instruct practitioners that they may strikethrough or delete any procedures they do not wish to request. Minimum threshold criteria for requesting privileges in pediatric critical care medicine Basic education: MD or DO Minimal formal training: Successful completion of an ACGME- or AOAaccredited residency in pediatrics, followed by successful completion of an accredited fellowship in pediatric critical care medicine and/or current subspecialty certification or active participation in the examination process (with achievement of certification within [n] years) leading to subspecialty certification in pediatric critical care medicine by the ABP. Required current experience: At least [n] 1 pediatric critical care patients, 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 [plus advanced cardiac life support, pediatric advanced life support, or advanced pediatric life support provider status]. References If the applicant is recently trained, a letter of reference should come from the director of the applicant s training program. Alternatively, a letter of reference may come from the applicable department chair and/or clinical service chief at the facility where the applicant most recently practiced. Core privileges in pediatric critical care medicine Core privileges for pediatric critical care medicine include the ability to admit, evaluate, diagnose, and provide treatment or consultative services and critical care management of life-threatening organ system failure from any cause in children from the term or near-term neonate to the adolescent, as well as support of vital physiological functions. These privileges also include providing care to patients in the intensive care setting in conformance with unit policies. Core privileges further include the ability to assess, stabilize, and determine the disposition of patients with emergent conditions consistent with medical staff policy regarding emergency and consultative call services. 1 Healthcare organizations should define the minimum case/patient volume (the [n] ) required to maintain clinical competence as recommended by the applicable department chair and the medical executive committee and subject to approval by the governing body. 13

14 The core privileges in this subspecialty include the procedures on the following procedures list and such other procedures that are extensions of the same techniques and skills. Performance of history and physical exam Evaluation and management of life-threatening disorders or injuries in ICUs, including but not limited to shock, coma, elevated intracranial pressure, seizures, infections, acute and chronic renal failure, acute endocrine electrolyte emergencies (including diabetic ketoacidosis), nonkenotic hyperosmolar coma, thyrotoxicosis, syndrome of inappropriate antidiuretic hormone, diabetes insipidus, adrenal insufficiency, systemic sepsis, heart failure, trauma, acute and chronic respiratory failure, drug overdoses, massive bleeding, central nervous system dysfunction (including cerebral resuscitation), diabetic acidosis, and kidney failure Airway maintenance intubation, including fiberoptic bronchoscopy Basic and advanced cardiopulmonary resuscitation Calculation of oxygen content, intrapulmonary shunt, and alveolar arterial gradients Cardiac output determinations by thermodilution and other techniques Cardioversion Establishment and maintenance of an open airway in nonintubated, unconscious, paralyzed patients Evaluation of oliguria Insertion and management of chest tubes Insertion of central venous, arterial, and pulmonary artery balloon flotation catheters Interpretation of antibiotic levels and sensitivities Intracranial pressure monitoring Maintenance of circulation with arterial puncture and blood sampling Management of anaphylaxis and acute allergic reactions Management of massive transfusions Management of pneumothorax (needle insertion and drainage systems) Management of renal and hepatic failure, poisoning, and complicated h ematological, infectious, and immune problems Management of the immunosuppressed patient Monitoring and assessment of metabolism and nutrition Percutaneous needle aspiration Percutaneous tracheostomy/cricothyrotomy tube placement (Seldinger technique) Pericardiocentesis or tube placement Peritoneal dialysis Peritoneal lavage Pharmacokinetics Pressure-cycled, volume-cycled, time-cycled, and flow-cycled mechanical ventilation Stabilization for transport 14

15 Thoracostomy tube placement Use of narcotics, ketamine, pentobarbital, thiopental, etomidate, and benzodiazepines to facilitate airway management, sedation, and/or conscious sedation in the ICU Use of reservoir masks and continuous positive airway pressure masks for delivery of supplemental oxygen, humidifiers, nebulizers, and incentive spirometry Ventilator management, including experience with various modes Special noncore privileges in pediatric critical care medicine If desired, noncore privileges are requested individually in addition to requesting the core. Each individual requesting noncore privileges must meet the specific threshold criteria governing the exercise of the privilege requested, including training, required previous experience, and maintenance of clinical competence. Reappointment Reappointment should be based on unbiased, objective results of care according to a hospital s quality assurance mechanism. To be eligible to renew privileges in pediatric critical care medicine, the applicant must have current demonstrated competence and an adequate volume of experience ([n] pediatric critical care patients) 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 required of all applicants for renewal of privileges. In addition, continuing education related to pediatric critical care medicine should be required. For more information Accreditation Council for Graduate Medical Education 515 North State Street, Suite 2000 Chicago, IL Telephone: Fax: Website: American Academy of Pediatrics 141 Northwest Point Boulevard Elk Grove Village, IL Telephone: Fax: Website: 15

16 American Board of Anesthesiology 4208 Six Forks Road, Suite 1500 Raleigh, NC Telephone: Fax: Website: American Board of Pediatrics 111 Silver Cedar Court Chapel Hill, NC Telephone: Fax: Website: American Osteopathic Association 142 East Ontario Street Chicago, IL Telephone: Fax: Website: Centers for Medicare & Medicaid Services 7500 Security Boulevard Baltimore, MD Telephone: Website: DNV Healthcare, Inc. 400 Techne Center Drive, Suite 100 Milford, OH Telephone: Website: Healthcare Facilities Accreditation Program 142 E. Ontario Street Chicago, IL Telephone: Website: 16

17 The Joint Commission One Renaissance Boulevard Oakbrook Terrace, IL Telephone: Fax: Website: Society of Critical Care Medicine 500 Midway Drive Mount Prospect, IL Telephone: Fax: Website: Editorial Advisory Board Clinical Privilege White Papers Product Manager, Digital Solutions Adrienne Trivers Managing Editor Mary Stevens William J. Carbone Chief Executive Officer American Board of Physician Specialties Atlanta, Ga. Darrell L. Cass, MD, FACS, FAAP Codirector, Center for Fetal Surgery Texas Children s Hospital Houston, Texas Jack Cox, MD Senior Vice President/Chief Quality Officer Hoag Memorial Hospital Presbyterian Newport Beach, Calif. Stephen H. Hochschuler, MD Cofounder and Chair Texas Back Institute Phoenix, Ariz. Bruce Lindsay, MD Professor of Medicine Director, Cardiac Electrophysiology Washington University School of Medicine St. Louis, Mo. Sally J. Pelletier, CPCS, CPMSM Director of Credentialing Services The Greeley Company, a division of HCPro, Inc. Danvers, Mass. Beverly Pybus Senior Consultant The Greeley Company, a division of HCPro, Inc. Danvers, Mass. Richard A. Sheff, MD Chair and Executive Director The Greeley Company, a division of HCPro, Inc. Danvers, Mass. The information contained in this document is general. It has been designed and is intended for use by hospitals and their credentials committees in developing their own local approaches and policies for various credentialing issues. This information, including the materials, opinions, and draft criteria set forth herein, should not be adopted for use without careful consideration, discussion, additional research by physicians and counsel in local settings, and adaptation to local needs. The Credentialing Resource Center does not provide legal or clinical advice; for such advice, the counsel of competent individuals in these fields must be obtained. Reproduction in any form outside the recipient s institution is forbidden without prior written permission. Copyright 2013 HCPro, Inc., Danvers, MA