INTERNAL MEDICINE SUBSPECIALTY CARDIOLOGY

Transcription

1 KALEIDA HEALTH Name: Date: INTERNAL MEDICINE SUBSPECIALTY CARDIOLOGY PLEASE NOTE: Please check the box for each requested. Do not use an arrow or line to make selections. We will return applications that ignore this directive. Minimal requirement is successful completion of an accredited fellowship and board eligibility or certification within this specialty. *** s are required for Level II and Level III Privileges. Please attach a copy of your current Conscious Sedation training certificate. If you do not have s, please request the as listed on the Internal Medicine Delineation of Privileges. CARDIOLOGY - LEVEL I PRIVILEGES Consultation CARDIOLOGY - LEVEL II PRIVILEGES Initial request requires documentation from Chief of Service or training director confirming appropriate cognitive and technical skills. s are required and are part of the Internal Medicine Delineation of Privileges. Right heart and Swan-Ganz catheterization And hemodynamic manipulation for initial (within past 5 years) 25 Successful Annual Activity (Maintenance) Pericardiocentesis Temporary Pacemaker 5 4 Placement Cardioversion elective Intra-aortic balloon pumping - Hemodynamic manipulation 10 Initial request requires the following: Interpretation of at least 150 Contrast Cardiac CTs, with 50 where the candidate is physically present (and mentored) and involved in acquisition and interpretation of the cases, and evaluation of 50 noncontrast studies, and attendance in at least 20 hrs of devoted CCT classes. Cardiac CT Initial request requires the following: Interpretation of at least 150 Cardiac MR, with 50 where the candidate is physically present (and mentored) and involved in acquisition and interpretation of the cases, and attendance in at least 30 hrs of devoted CMR classes. Cardiac MR * * With Following With Following IM/Cardiology

2 IM-Cardiology Name: Page 2 CARDIOLOGY - LEVEL II PRIVILEGES (CON T) The following procedures are Medical Staff s that may be restricted to and/or limited by contracts with Kaleida Health. s are required and are part of the Internal Medicine Delineation of Privileges. ECG (all forms) Stress Testing (all forms) Echocardiography (transthoracic) Transesophageal echocardiography Intraoperative echocardiography Nuclear Cardiology (all forms) Holter Monitoring CARDIOLOGY - LEVEL III PRIVILEGES Requires successful completion of RRC approved Invasive Cardiology Fellowship training and NASPE credentialed for EP studies and pacemaker insertion. s are required and are part of the Internal Medicine Delineation of Privileges. Left heart catheterization and coronary angiography for initial (within past 5 years) for initial (within past 5 years) Successful Annual Activity (Maintenance) INTERVENTION* *Stent, *Balloon coronary angioplasty, *Directional atherectomy (Rotational) *Directional atherectomy (laser) Permanent pacemaker insertion to include Micra Pacemaker new 5 replacement Privileging for Endovascular Closing of Atrial Septal Defect (ASD) and Patent Foramen Ovale (PFO) Physician must be board certified in Internal Medicine; and successfully completed a fellowship in either Cardiac Intervention or Pediatric Interventional Cardiology; and board certified or board eligible in Cardiology or Pediatric Cardiology; and submit 2 letters of recommendation, one of which must be from the Director of the Catheterization Lab; and present 50% of his cases in the Cardiac Cath Conference. Initially the physician must have successfully completed 4 PFO or ASD closures under supervision of an established Cardiac Interventionalist dealing with PFO and ASD closures. Endovascular Closing of Atrial Septal Defect and Patent Foramen Ovale 4 PFO or ASD closures 4 PFO or ASD closures * * With Following With Following

3 IM-Cardiology Name: Page 3 CARDIOLOGY LEVEL III PRIVILEGES Cont d s are required and are part of the Internal Medicine Delineation of Privileges. Privileging for the following Cardiac Electrophysiological procedures requires evidence of a fellowship in Cardiac Electrophysiology. Electrophysiological studies Transvenous Placement of AICD Radio Frequency ablations to include Cryo Ablation ICD and Pacemaker extractions Privileging for Lead Extractions by Laser requires completion of an ACGME-approved Cardiac Electrophysiology Fellowship documenting the performance of a minimum of 5 cases OR if training completed prior to the offering of a Cardiac Electrophysiology fellowship, provide documentation of extensive experience in the performance of Lead Extractions, to include the performance of 5 Lead Extractions per year for the immediate past 2 years.) Documentation of at least one (1) lead extraction during the previous two years is required at reappointment. (Cases are performed in the OR with Thoracic Surgical backup.) Lead Extractions by Laser 5 1 Privileging for Aortic Valvuloplasty requires current Interventional (Coronary) s and attendance at an ACC/AHA approved symposium on Aortic Valvuloplasty or Cardiology Fellowship which includes Aortic Valvuloplasty training. Must perform two (2) cases under observation of a certified operator. Must perform three (3) cases per year for maintenance of practice. Must present ALL Valvuloplasty cases in Cath Conference. Must follow ACC/Kaleida Policy for indication of Aortic Valvuloplasty. Aortic Valvuloplasty 2 3 Privileging for Trans Catheter Aortic Valve Placement requires current Interventional (Coronary) s. Further Qualifications for Interventional Cardiologist: 1. Professional experience with 100 structural heart disease procedures lifetime; OR left-sided structural procedures per year of which 60% should be Balloon Aortic Valvuloplasty (BAV). Atrial Septal Defect and Patent Foramen Ovale Closure are not considered left sided procedures; AND 3. Device specific training as required by the manufacturer. Trans Catheter Aortic Valve Placement (Excludes vascular access. A team approach is essential for this procedure) Percutaneous Left Atrial Appendage Closure(Example: Watchman) Must be proctored for first 2 cases Percutaneous Left Atrial Appendage Closure Percutaneous Mitral Valve Repair (Example: Mitral Clips) Must be boarded in Interventional Cardiology Percutaneous Mitral Valve Repair Trans Septal Puncture Must be proctored for first 5 cases Trans Septal Punture Insertion/Removal of Vent Assist Device Must be proctored for first 3 cases Insertion/Removal of Vent Assist Device Catheter directed pulmonary thrombectomy Must be proctored for first 3 cases Catheter directed pulmonary thrombectomy

4 IM-Cardiology Name: Page 4 Privileging for peripheral vascular procedures requires evidence of a course or fellowship training in addition to the minimum number of observed procedures. Peripheral Vascular Procedures: Diagnostic 100 Interventional ** 50 ** e: Interventional is considered as a group of s because it is believed that an interventionist must have the ability to respond using any of a number of techniques. s are required for Level II and Level III Privileges. Please attach a copy of your current Conscious Sedation training certificate. If you do not have s, please request the as listed on the Internal Medicine Delineation of Privileges. 1. Providers seeking s in moderate/conscious sedation must complete either the ASA sedation course or Medsimulation course receiving a score of 85% or above. * e: Providers completing the on-line training course provided by Medsimulation from other institutions receiving a score of 85% or higher will be accepted as an equivalent measure of acceptable knowledge for sedation s. 2. Once the provider has successfully passed the course, he/she must send the certificate of course completion to the medical staff office via (medicalstaffoffice@kaleidahealth.org) or fax ( or ). 3. In addition to demonstrating medical knowledge through completion of this course, providers must also maintain airway management skills through current completed training and certification in ACLS, ATLS or PALS. 4. After a four year period of privileging the provider must repeat either the ASA sedation course or Medsimulation course and receive a score of 85% or greater or a comparable course reviewed and accepted by the Chief of Anesthesiology. They must also maintain airway management skills through completed and current training and certification in ACLS, ATLS or PALS.

5 IM-Cardiology Name: Page 5 KEY *NOT GRANTED DUE TO: Provide Details Below **WITH FOLLOWING REQUIREMENTS Provide Details Below 1) Lack of Documentation 1) With Consultation 2) Lack of Required Training/Experience 2) With Assistance 3) Lack of Current Competence (Databank Reportable) 3) With Proctoring 4) Other (Please Define) (i.e., Exclusive Contract) 4) Other (Please Define) DETAILS: National Practitioner Databank Disclaimer Statement Kaleida Health must report to the National Practitioner Data Bank when any clinical s are not granted for reasons related to professional competence or conduct. (Pursuant to the Health Care Quality Improvement Act of 1986 (42 U.S.C et seq.) / / Signature of Applicant Date Signature of Chief of Service Date APPLICANT: PLEASE RETAIN A COPY OF THIS SIGNED DELINEATION FOR YOUR RECORDS