SPECIALTY OF CRITICAL CARE NURSE PRACTITIONER Hspital Delineatin f Clinical Privileges (DOP) Criteria fr granting privileges: Current natinal bard certificatin as an Acute Care Nurse Practitiner r Adult-Gerntlgy Acute Care Nurse Practitiner Current, unencumbered license t practice as a Registered Nurse and as a Nurse Practitiner (APRN) in the state(s) f his/her practice. Educatin in the apprpriate specialty at the masters r dctral level Current Drug Enfrcement Agency (DEA) number Current, unencumbered Nurse Practitiners (APN) Certificate with prescriptive authrity Current Advanced Cardiac Life Supprt (ACLS) certificatin Applicants will be requested t prvide dcumentatin f practice and current clinical cmpetence as defined n the attached cmpetency grid. Applicants have the burden f prducing infrmatin deemed adequate by the hspital fr a prper evaluatin f current clinical cmpetence, and ther qualificatins and fr reslving any dubts. Current Clinical Cmpetence - MLH In additin t the required educatin, experience and/r training specified n each DOP, dcumentatin f current clinical cmpetence (CCC) is required. Current clinical cmpetence is described as having perfrmed the privilege recently and perfrmed it well. CCC is assessed prir t granting privileges initially and is reassessed when renewing privileges at reappintment. CCC may be lcatin specific (acute hspital care/surgery center) and/r age specific. This shuld nt be cnfused with Fcused Prfessinal Practice Evaluatin (FPPE). FPPE is an evaluatin f clinical cmpetence f new privileges granted and perfrmed at a licensed MLH facility (MHMH, MHOBH). This applies t privileges fr all new applicants as well as additinal privileges current members. Bth FPPE and current clinical cmpetence assessments are privilege-specific. FPPE is cnducted during the perid after granting new/additinal privileges. FPPE must ccur at the MLH facility(ies) where privileges/membership are held. Current clinical cmpetence may be evaluated frm case lgs prvided by nn-mlh facilities. Current Clinical Cmpetence Requirements fr New Applicants If applying directly frm training, r based n the training received in a frmal training prgram, prvider shuld submit case* lgs frm the prgram authenticated by the prgram directr alng with their recmmendatin attesting t the cmparable training, experience and qualificatins relative t the criteria fr the clinical privileges requested. Bard apprved: 2/21/18 1
If applying mre than 1 year after training cmpletin, submit the fllwing: Aggregate data frm acute care r surgery center facility fr the previus 12 mnth time perid, identifying the tp 10 diagnsis cdes and the number f patients per cde. Any cmplicatins/pr utcmes shuld be delineated and accmpanied by an explanatin. Prcedure list frm acute care r surgery center facility fr the previus 12 mnth time perid, identifying the tp 10 CPT/ICD cdes and the number f prcedures per cde. Any cmplicatins/pr utcmes shuld be delineated and accmpanied by an explanatin. Case lgs (see specificatins belw)any special privileges requested that meet the criteria specific fr the number f prcedures defined fr current clinical cmpetence. Current Clinical Cmpetence Maintenance f Privileges fr Current Practitiners Practitiner shuld submit the fllwing: Aggregate data frm acute care r surgery center facility fr the previus 12 mnth time perid, identifying the tp 10 diagnsis cdes and the number f patients per cde. Any cmplicatins/pr utcmes shuld be delineated and accmpanied by an explanatin. Prcedure list frm acute care r surgery center facility fr the previus 12 mnth time perid, identifying the tp 10 CPT/ICD cdes and the number f prcedures per cde. Any cmplicatins/pr utcmes shuld be delineated and accmpanied by an explanatin. Case lgs (see specificatins belw) fr any special privileges requested that meet the specific number f prcedures defined fr current clinical cmpetence. Case Lgs All required case lgs and/r prcedure lists must cntain the fllwing infrmatin at a minimum: Date, patient identifier, CPT/ICD prcedure cde, diagnsis, cmplicatins, and dispsitin, and the facility name, name/title f the persn authenticating the lg, signature, date signed, and cntact infrmatin. If the infrmatin requested is nt available, please prvide an explanatin. *A case is defined as an episde f care either cgnitive r prcedural. Fr interpretive care, a case is interpretatin f ne diagnstic study. Onging Prfessinal Perfrmance Evaluatin (OPPE) OPPE is evaluated peridically (mre frequently than annually) in the facility where membership/privileges are held. T assure OPPE requirements are satisfied, the practitiner must peridically exercise the privileges in the MLH facility(ies) where he/she has membership. OPPE must ccur regularly n patient encunters in the MLH facility(ies) where privileges/membership are held. Bard apprved: 2/21/18 2
Specialty/Prcedure Delineatin f Privilege Frm Educatin/Training Dcumentatin fr Initial Granting Initial Applicatin (Prf f current clinical cmpetence) FPPE Validatin f cmpetence after appintment and/r granting f a new r additinal privilege (T be cmpleted within ne year) Maintenance Requirements Critical Care Nurse Practitiner Cre Current natinal bard certificatin as an Acute Care Nurse Practitiner r an Adult-Gerntlgy Acute Care Nurse Practitiner by American Nurses Credentialing Center (ANCC) r Acute Care Nurse Practitiner Adult-Gerntlgy by American Assciatin f Critical Care Nurses (AACN) Current, unencumbered license t practice as a Registered Nurse and as a Nurse Practitiner (APRN) in the state(s) f his/her practice. Educatin in the apprpriate specialty at the masters r dctral level Current, unencumbered Nurse Practitiners (APN) Certificate with prescriptive authrity Current Drug Enfrcement Agency (DEA) number Current Advanced Cardiac Life Supprt (ACLS) certificatin Case lg dcumenting 10 critical care in patient encunters during the previus 12 mnths at the practitiner s primary practice facility. If case lgs are nt available an Initiatin f Practice r Return t Practice plan will be necessary. First 5 cases MLH Data will be btained fr practitiners when available. The applicant shuld supply additinal case lgs frm ther facilities HIM departments, if necessary, t meet the minimum requirements t be cnsidered fr the privilege. Aggregate data shuld include the tp 10 diagnsis cdes, with the number f inpatients per cde, and prcedure lists indicating the tp 10 CPT/ICD cdes, with the number f prcedures per cde fr the previus 12 mnths. Any cmplicatins/pr utcmes shuld be delineated and accmpanied by an explanatin. Department chair recmmendatin will be btained frm primary practice facility. Endtracheal Intubatin Dcumentatin f training in prcedure, supervising physician must 35 successfully prctred endtracheal intubatins, f which 20 may be simulatins, as evidenced by prctr evaluatin frms Case lg f 15 successful endtracheal intubatins in the past 12 mnths frm primary facility First 5 cases Case lg dcumenting 10 prcedures cmpleted during the past 24 mnths Central Line insertin Dcumentatin f training in prcedure, supervising physician must 5 successfully prctred Central Line insertins as evidenced by prctr evaluatin frms Case lg f 5 successful central line insertins in the past 12 mnths frm primary facility First 5 prcedures Case lg dcumenting 10 prcedures during the previus 24 mnths Bard apprved: 2/21/18 3
Specialty/Prcedure Delineatin f Privilege Frm Educatin/Training Dcumentatin fr Initial Granting Initial Applicatin (Prf f current clinical cmpetence) FPPE Validatin f cmpetence after appintment and/r granting f a new r additinal privilege (T be cmpleted within ne year) Maintenance Requirements Arterial Line insertin Thracentesis Chest Tube insertin Dcumentatin f training in prcedure, supervising physician must Dcumentatin f training in prcedure, supervising physician must Dcumentatin f training in prcedure, supervising physician must 5 successfully prctred arterial line insertins as evidenced by prctr evaluatin frms Case lg f 5 successful arterial line insertins in the past 12 mnths frm primary facility 5 successfully prctred thracenteses as evidenced by prctr evaluatin frms Case lg f 5 successful thracenteses in the past 12 mnths frm primary facility 5 successfully prctred chest tube insertins as evidenced by prctr evaluatin frms Case lg f 5 successful chest tube insertins in the past 12 mnths frm primary facility First 5 prcedures First 5 prcedures First 5 prcedures Case lg dcumenting 10 prcedures during the previus 24 mnths Case lg dcumenting 10 prcedures during the previus 24 mnths Case lg dcumenting 10 prcedures during the previus 24 mnths Bard apprved: 2/21/18 4
Scpe f Service and Respnsibility: Scpe f service is based upn educatin, clinical training, demnstrated skills and capacity t manage prcedurally related cmplicatins. The Nurse Practitiner will cllabrate with the supervising physician in admitting, managing care, and discharging patients frm the hspital The Nurse Practitiner shall be in cmpliance with all applicable state and hspital rules including, but nt limited t, supervisin, prtcls, patient reviews, and prescriptins. Clinical Supervisin Requirements: The supervisin f the Nurse Practitiner will be cmpliant with all applicable state rules and regulatins. Cre Critical Care Nurse Practitiner Privilege: Cnsistent with the intent f the state rules and regulatins, privileges serve the purpse t maximize the cllabrative practice f Nurse Practitiners and supervising physicians in a manner cnsistent with quality health care delivery. Therefre, written prtcls develped jintly by the supervising physician and the Nurse Practitiner will guide the nging medical management f patients and the fllwing privileges. 1. Perfrm and dcument initial and subsequent histry and physicals. Once every ten (10) business days the supervising physician shall make a persnal review f the histrical and therapeutic data and shall s certify by signature. 2. Develp wrking assessments and rder necessary diagnstic studies. 3. Draw diagnstic cnclusin. 4. Plan and prescribe diagnstic tests and treatments accrding t apprved prtcls, including but nt limited t rehabilitatin and respiratry therapy treatments/services (bth inpatient and utpatient), cmfrt measures, restrative care, further testing, fllw-up care, and patient educatin/cunseling. 5. Recrd and dcument assessments, rders, diagnstic cnclusins, and treatment plans n the medical recrd. 6. May prvide subsequent care. This is nt in lieu f daily visits by the supervising physician r ne f the physician s substitutes, if the physician is directly and primarily respnsible fr the patient s care (Refer t Medical Staff Rules and Regulatins, Cnduct f Care.) 7. The Nurse Practitiner may write prescriptins, and any prescriptin written and signed by the Nurse Practitiner under the supervisin and cntrl f a supervising physician shall be deemed t be that f the Nurse Practitiner. Cntrlled substances may be prescribed cnsistent with state rules and regulatins. 8. Cllabrate with supervising physician and ther health care prviders t prvide patient care. 9. May prepare a discharge summary, including final diagnsis and prcedures, and incrprate the physical findings, labratry reprts, and the patient s curse in the hspital. In additin the summary will indicate the instructins given the patient in reference t diet, medicatin, physical activity, and fllw-up care. The discharging physician will certify the cmpleted medical recrd. Prcess Prtcl: The Nurse Practitiner, in cllabratin with the supervising physicians, identifies the fllwing evidence-based resurces, texts, and reference dcuments that are applicable standards f care and prvide the applicable prcess prtcls fr care management: Bard apprved: 2/21/18 5
Cnsultatin: The Nurse Practitiner will be managing Primary, Secndary, and Tertiary care cnditins fr the abve described patient ppulatin. In general, cmmunicatin with a physician will be sught fr all f the fllwing situatins and any thers deemed apprpriate: Whenever situatins arise which g beynd the intent f the Prtcls r the cmpetence, scpe f practice r experience f the Nurse Practitiner Whenever patient cnditins fail t respnd t the management plan in an apprpriate time. Any rare r unstable patient cnditins. Any patient cnditins which d nt fit the cmmnly accepted diagnstic patterns fr a disease r disrder. Any unexplained physical examinatin r histrical finding. At the request f the patient, the Nurse Practitiner r the physician. All emergency situatins after initial stabilizing care has been started. Whenever a physician is cnsulted, a ntatin t that effect, including the physician s name, must be made in the medical recrd. Special Prcedures: The applicant must prvide dcumentatin f current clinical cmpetence in perfrming the prcedure cnsistent with the criteria set frth in medical staff plicies gverning the exercise f specific privileges and the appended cmpetency grid. Applicants have the burden f prducing infrmatin deemed adequate by the hspital fr a prper evaluatin f current clinical cmpetence, and ther qualificatins and fr reslving any dubts. Bard apprved: 2/21/18 6
Critical Care Nurse Practitiner Clinical Privileges Check belw the particular privileges desired as Nurse Practitiner fr each facility: Please check ( ) applicable age categries fr each privilege requested. Privilege Descriptin Age Limitatins Critical Care Nurse Practitiner Special Privileges Endtracheal Intubatin Central Line Insertin Arterial Line Insertin Thracentesis Chest Tube Insertin Methdist Healthcare Memphis Hspitals (MHMH) Germantwn, Le Bnheur Medical Center, Nrth, Suth & University, Outpatient Clinics & Diagnstic Facilities Infants (29 days 2 Years) Children & Adlescents (2-18 years) Adults & Adlescents (13 & Abve) Methdist Healthcare Olive Branch Hspital (MHOBH) Adults & Adlescents (13 & Abve) Specialty Fcus: cnditin(s), disease(s) fr the patient ppulatin (e.g. pediatric neurlgy, adult cardilgy) Clinical privileges are granted nly t the extent privileges are available at each facility. Limitatins Darkly shaded areas represent privileges nt available t any practitiner due t the service nt being ffered by the facility. Acknwledgement f practitiner I have requested nly thse privileges fr which by educatin, training, current experience and demnstrated perfrmance I am qualified t perfrm and fr which I wish t exercise at the facilities indicated abve, t the extent services are available at each facility, and I understand that: (a) in exercising any clinical privileges granted, I am cnstrained by facility and medical staff plicies and rules applicable generally and any applicable t the particular situatin (b) any restrictin n the clinical privileges granted t me is waived in an emergency situatin and in such situatin my actins are gverned by the applicable sectin f the medical staff bylaws r related dcuments Practitiner's Signature Date Printed Name Bard apprved: 2/21/18 7
Acknwledgement f spnsr I agree t abide by the clinical supervisin respnsibilities listed and the Nurse Practitiner will abide by the privileges utlined abve and the apprpriate facility Medical Staff Rules and Regulatins. Date: Signature (N Stamps) Emplying r Supervising Physician Printed Name ID # Bard apprved: 2/21/18 8