Advanced Practice Nurse Please check applicable credential [ ] Nurse Practitioner [ ] Clinical Nurse Specialist [ ] Certified Nurse Midwife [ ] Certified Registered Nurse Anesthesist Area of focus _ *************************************************************** Minimum threshold criteria for requesting Advanced Practice Nurse Privileges: A. Licensure: Listed as indicated above on the Colorado Board of Nursing Advanced Practice Registry. B. Education: Completion of an Advanced Practice Nurse Program, and accreditation by the National League for Nursing or the Council on Collegiate Nursing Education. Waiver: The educational criteria will be waived for those Nurse Practitioners (NP) who were registered with the Advanced Practice Registry prior to July 1, 2008. (The grandfather clause does not include prescriptive authority.) C. Certification: Board certification in a population foci or sub-specialty at the advanced practice level D. Experience: For initial application, the applicant must document education and training, or provide evidence of competence, for clinical skills in their requested field of training. The applicant must have met the minimum requirement(s) for the requested privileges within the past 24 months. E. Applicant must provide documentation of the minimum requirement(s) for procedures, verified by Activity logs OR the clinical manager of the unit(s) where they manage their patients. F. Physician Collaboration: An advanced practice nurse shall practice in accordance with the standards of the appropriate national professional nursing organization and have a safe mechanism for consultation or collaboration with a physician or, when appropriate, referral to a physician. Advanced practice nursing also includes, when appropriate, referral to other health care providers. CRS 12-38-111.5 (6) All activities of APN are subject to Departmental Peer Review and on-going evaluation *************************************************************** I knowledge I have reviewed the Colorado Nurse Practice Act and am aware of its requirements and time frames. Initials Date *************************************************************** APN Management of Patient Care * Current BLS certification * Current ACLS certification if working in cardiac or critical care area * Current PALS certification if working with Pediatric patients * Current NRP certification if working with neonates. * Chart review of first 3 patients managed Page 1 of 8
APN Management of Patient Care (includes unless modified) * Review of Patient records * write/dictate admission orders * perform comprehensive assessment of patient's medical, physical and psychosocial status (H&P) * round on patients independently and record progress notes * perform routine nursing procedures * administer intradermal test * write orders for diagnostic procedures, treatments and medication in accordance with an ongoing treatment plan and within their scope of training * administer injections (intramuscular, intravenous or intradermal) * cleanse and debride wounds * administer local infiltrative anesthesia * apply dressings, bandages * provide CPR * provide pre and post operative surgical /medical care * provide patient education in maintaining health and preventing disease * triage patients to determine need for medical attention. APN Prescriptive Authority * Proof of registry with the Colorado Board of Nursing for prescriptive authority * APN must have a current DEA license in their name * Master's prepared * 60 hours of formal pharmacologic training at Master's level * 1800 hours of practicum APN Prescriptive Authority (includes unless modified) (Prescription drugs prescribed for persons requiring routine health maintenance or routine preventive care; Prescription drugs and controlled substances may be prescribed to patients requiring) * Care for an acute, self-limiting condition, A self-limiting condition is one that has a defined diagnosis, a predictable outcome and is not threatening to life or limb. * Care for a chronic condition that has been previously established; or * Terminal comfort care ----------------------------------------------------- APN Special Procedures-------------------------------------------------------------------- Moderate sedation * Review of educational material and completion of exam (passing = 8 out of 10) Reapply every appointment period. Fluoroscopy (Radiation Safety Certificate) Documented completion of the Rocky Mountain Chapter of the American Association of Physicists in Medicine (RMAAPM) online fluoroscopy training module at http://chapter.aapm.org/rockymtn/ftm/ Reapply every appointment period. Note: Physician education related to fluoroscopy radiation safety managed by the Colorado Department of Public Health and Environment effective 7/1/2010. APN SP Pediatrics, Newborns in nursery * Have APN Management of Patient Care privileges * Current PALS certification * Current NRP certification * Chart review of first 3 patients managed Page 2 of 8
APN SP - Circumcision * Documentation or attestation of the performance of at least 12 circumcisions in the last 2 years. * Direct observation of minimum of 3 procedures. 6 per year required; must provide the volume of procedures done within the past 2 years. If less than 6 procedures are done within 2 years, the applicant must be precepted for a minimum of 2 procedures. APN SP - Stress Testing (exercise) * Collaborating Cardiologist * 12 Lead EKG competency * 12 hrs Cardiac related CME (within 12 months) * Satisfactorily complete 1 hr training course * Perform 10 supervised stress tests * Provide recommendation of Director of Cardiology, or his designee * Documentation within the previous 24 months of supervision of 30 excercise stress tests 24 Exercise Stress Tests in 1 year APN SP - Stress Testing (pharmacological) * Collaborating Cardiologist * 12 Lead EKG competency * 12 hrs Cardiac related CME (within 12 months) * Satisfactorily complete 1 hr training course * Perform 10 supervised stress tests * Provide recommendation of Director of Cardiology, or his designee * Documentation within the previous 24 months of supervision of 30 pharmacologcial stress tests APN SP - Stress Testing - Restrictions: On site MD supervision by supervising cardiologist is required for patients who have one of the following: 1) ACS as evidenced by Troponin >1.4 2) Left ventricular dysfunction as evidenced by EF <30% 3) Severe aortic stenosis as evidenced by AVA <1.0cm2 4) Severe lung disease 24 Pharmacological Stress Tests in 1 year APN SP - Intrathecal Chemo Criteria for to apply for clinical privilege: * Documentation or attestation of performing a minimum of 20 procedures within the last two years * Current BLS certification * Chart review of 6 cases Page 3 of 8
APN SP - Thoracentesis. 6 thoracentesis in 1 year ** Direct observation of 6 procedures by any similarly credentialed Practitioner. is warranted, it must be completed within 12 months. APN Operating Room Assistant Criteria for to apply for clinical privilege: * Documentation of performing a minimum of 20 procedures within the last two years * Current BLS certification * Evaluation of first 3 cases by PSF Circulating Nurse APN Operating Room Assistant (includes unless modified) * Suturing - (APN may close sub-cutaneous and skin wounds, but no complex wounds or fascia may be closed without the Collaborating surgeon being scrubbed. The Physician must be readily available, i.e, physician may not provide primary care for any other patient, may not begin or become involved in another operative case and must be in the OR suite, surgeon's lounge, or the ICU until the time the patient is transported out of OR.) * Positioning of patient * Hold retractors or limbs * Minor lacerations (not involving neuro-vascular or tendon damage, joint involvement, or hands and face) * Advancement of drains * Writing pre-op orders and post-op order ----------------------------------------------------- APN OR Assist Special Procedures -------------------------------------------------------------------- APN OR SP Arterial line placement Page 4 of 8
APN OR SP Bronchoscopy APN OR SP Central line placement APN OR SP Chest Tube Insertion APN OR SP Cath assist (IABP insertion) APN OR SP Independent removal of IABP Page 5 of 8
APN OR SP Endotracheal Intubation APN OR SP Endovascular Vein Harvesting APN OR SP Femoral cutdown (include documentation described above)e) APN OR SP Swan Ganz APN Neonatal Nurse Practitioner Criteria to apply for privilege: * Meet threshold criteria for APN * Prescriptive authority and DEA (must have by 12/31/2012) * Current NRP certification Completion of annual NICU skills review Page 6 of 8
APN Neonatal Nurse Practitioner (description) Provides care for Neonates admitted to NICU. Includes the following procedures: " Intubation of Neonates " Umbilical catheter placement - venous and/or arterial " Lumbar puncture " Peripheral arterial line placement/lab draws " Thoracentesis/thoracostamy " Resuscitation of neonates " Urinary catheter placement " Transpyloric tube placement " PICC placement " LMA placement " Infant resuscitation " Venous catheter placement " Neonatal transport **************************************************************************************************** APN Certified Nurse Midwife Criteria to apply for clinical privilege 1. Documentation and completion of an ACNM accredited education program 2. Documentation of current active license as a Registered Nurse in the State of Colorado 3. Current registration in the Colorado Advanced Practice Registry as a Certified Nurse-Midwife 4. Current and continuous certification by the American College of Nurse-Midwives or their designee including the ACNM Certification Council (ACC) or the American Midwifery Certification Board (AMCB) 5. Current and continuous certification in American Heart Association/American Academy of Pediatrics Neonatal Resuscitation Program (NRP) 6. Documentation of current competence to include recent completion of a training program in Nurse-Midwifery or an active clinical practice during the past 24 months, including performance of the privileges requested 7. Documentation of continuing education including current enrollment in the ACNM Certificate Maintenance Program (CMP) which is for CNMs certified in 1996 or after or the ACNM Continuing Competency Assessment Program (CCA) which is for CNMs certified before 1996 5 cases per year ** Direct observation of 3 cases by a similarly credentialed practitioner. is warranted, it must be completed within 12 months. APN Certified Nurse Midwife (description) Inpatient nurse-midwifery care including the management of patients during the antepartum, intrapartum and post partum period in accordance with ACNM Standards ----------------------------------------------------- APN CNM Special Procedures -------------------------------------------------------------------- APN CNM SP Order Cytotec for cervical ripening after medical consult * CNM privileges 5 cases per year * Included with APN Prescriptive Authority preception Page 7 of 8
For areas of practice not specifically addressed above or if there are procedures you would like to request that are not listed, write them in the blank areas on the last page. These will be reviewed by the Credentials Committee individually. The PSF Medical Staff Office will contact you with regard to any additional documentation of training or experience that may be needed. Upon receipt of all documentation, your request will be reviewed by the Credentials Committee individually and you will be notified if it is determined to grant you this privilege and the requirements set by the Credentials Committee for preception and reappointment criteria. Clinical privilege(s) requested: Additional privilege: Additional privilege: Additional privilege: Please sign and date to request the above initialed clincial privileges. Printed Name Signature Date Page 8 of 8