MONROE CARRELL Jr. CHILDREN S HOSPITAL AT VANDERBILT APPLICATION FOR ADVANCED PROCEDURE PRIVILEGES

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Alexina Craig
5 years ago
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1 REQUEST FOR ADVANCED PROCEDURE PRIVILEGES Advanced Procedure Privileges: Are those approved procedural privileges requiring additional education and training and may be granted only upon evidence of initial and ongoing competency. INSTRUCTIONS 1. Privileged Professional Staff providers requesting advanced procedure privileges must do so using the appropriate request form (Adult or Pediatric). Requests with supporting documentation are submitted to Provider Support Services and thereafter reviewed by the Joint Practice Committee. 2. Supporting Documentation: Requests for advanced procedure privileges at initial appointment, reappointment and additional privilege additions must be supported by the following: Procedure notes evidencing successful completion of required number of procedures performed; and/or Simulation/animal lab certificate of completion Colposcopy and Moderate Sedation privileges require a separate request form available through Provider Support Services. 3. Special procedures will only be approved if medically necessary as an integral part of the provider s scope of practice. Required forms must be signed by supervising physician. Competency threshold numbers are minimum baselines and may be increased at the discretion of the supervising physician. All providers privileged to perform advanced procedures are subject to the mandates of focused professional practice evaluation (FPPE) and ongoing professional practice evaluation (OPPE). 1

2 PSP Name: Department: Location: Primary Supervising Physician: Providers with appropriate education, training, competency and board certification may request additional special procedural privileges as supported by the supervising physician. Procedures will only be approved if medically necessary as an integral part of the provider s scope of practice. The initial and continued competency requirements are subject to validation and attestation of competency, and requirements may be increased based on national standards or at the supervising physician s discretion. Simulation or animal model labs may serve as validation of continued competence in accordance with national standards and guidelines. b) Advanced Procedures Initial Adding Reappointment REQUEST PRIVILEGE INITIAL COMPETENCY CONTINUED COMPETENCY NEONATOLOGY Arterial access-peripheral 3 2 Chest tube, insertion 3 2 Chest tube, removal 3 2 Endotracheal intubation 3 3 Emergency evacuation air leak 3 3 Lumbar puncture 3 3 Umbilical arterial catheter, insertion 3 3 Umbilical venous catheter, insertion 3 3 PEDIATRIC CRITICAL CARE Arterial line, insertion 5 4 Central venous line, insertion 5 4 Central venous line, removal 4 3 Chest tube, insertion 5 4 Chest tube, removal 4 3 Endotracheal Intubation 10 5 Moderate Sedation-use separate request form Lumbar Puncture 5 3 Arterial sheath, removal 4 3 SPECIAL PROVISIONS 2

3 PEDIATRIC CARDIAC SURGERY Chest tube, insertion 5 4 Chest tube, removal 4 3 Epicardial pacing wire removal 5 4 Transthoracic catheter removal 5 4 PEDIATRIC DERMATOLOGY Cantherone treatments for mulluscum 3 2 Cryosurgery, skin lesions 3 2 Skin biopsies 3 2 Skin punch biopsies 3 2 Skin shave biopsies 3 2 PEDIATRIC DEVELOPMENTAL MEDICINE Intrathecal pump myleogram refill 5 4 Intrathecal pump reprogram 5 4 PEDIATRIC EMERGENCY SERVICES Cervical immobilization 4 3 Complex laceration repair 4 3 Epistaxis control 4 3 Excision of toenail or fingernail with digital blocking 4 3 Reduction of dislocations 4 3 Fracture/dislocation immobilization 4 3 Gastrostomy tube, exchange and removal 4 3 Irrigation and Drainage of 4 3 o Superficial Abscess o Paronychia o Sebaceous cyst Lumbar puncture 4 3 Nasotracheal, endotracheal intubation 10 5 Nursemaid elbow reduction 3 2 Reduction of finger and toe dislocations 4 3 Slit lamp examination with or without foreign body removal 5 4 Splinting of sprains 4 3 Suturing of minor lacerations 5 4 Tonometry 3 2 Trephination of subungual hematoma 4 3 Wound follow up and repacking 4 3 PEDIATRIC HEMATOLOGY/ONCOLOGY Bone Marrow biopsy / aspiration 5 4 Lumbar puncture 5 4 Skin punch biopsy 3 2 3

4 PEDIATRIC NEUROSURGERY Cervical collar management and removal 3 2 CSF draw from EVD, lumbar drains, externalized shunts 4 3 Drain management and removal 3 2 Instillation of antibiotics/tpa into EVD 5 4 Intrathecal baclofen trial 5 4 Intrathecal pump myleogram 5 4 Intrathecal pump myleogram refill 5 4 Intrathecal pump reprogram 5 4 Lumbar puncture 5 4 Lumbar puncture with drain insertion 5 4 Neurostimulator analyze/program 10 5 Placement, bone markers 5 4 Shuntograms 4 3 Shunt reprogramming 4 3 Shunt Tap 4 3 PEDIATRIC ORTHOPEADICS Cervical immobilization 4 3 Closed reduction (casting/splinting/traction) 4 3 Facet and other joint injections/aspirations 4 3 Fracture/dislocation immobilization 4 3 Joint aspirations 4 3 Reduction of finger and toe dislocations 4 3 Splinting of sprains 4 3 Closed/open surgical drain: management & removal 3 2 PEDIATRIC OTOLARYNGOLOGY Drainage Tube/Packing Removal 3 2 Tracheostomy decannulation 5 4 Tracheostomy downsize/upsize 4 3 PEDIATRIC TRAUMA/General Surgery Appendicostomy & Cecostomy tube & management 3 2 Bowel Irrigation 3 2 Central venous line, removal 4 3 Cervical collar management and removal 3 2 Chest tube removal 4 3 Closed/open surgical drain: management, & removal 3 2 Gastrostomy tube: sizing, exchange and removal 4 3 Tracheostomy downsize/upsize 4 3 Tracheostomy decannulation 5 4 Wound Vac dressing change & management 3 2 4

5 PEDIATRIC UROLOGY EMG uroflow 3 2 Lysis labial adhesions 3 2 Removal double J stent 5 4 Video Urodynamics 3 2 Requesting Practitioner Signature: Date: Initial Appointment Attestation: I have instructed, observed, or supervised throughout the required number of procedures for which is requesting advanced procedure privileges as delineated. I attest that he/she is competent to perform the requested procedures unsupervised, based on established practice protocols, unless otherwise noted. Reappointment Attestation: I have reviewed the procedural notes and technique for procedures which is requesting continued advanced procedure privileges as delineated. I attest that he/she is competent to perform the requested procedures unsupervised, based on established practice protocols, unless otherwise noted. Attestor: Date: Approvals Supervising Physician: Date: Department Chair: Date: 5

VANDERBILT UNIVERSITY MEDICAL CENTER APPLICATION FOR ADVANCED PROCEDURE PRIVILEGES PROFESSIONAL STAFF WITH PRIVILEGES (PSP)

VANDERBILT UNIVERSITY MEDICAL CENTER APPLICATION FOR ADVANCED PROCEDURE PRIVILEGES PROFESSIONAL STAFF WITH PRIVILEGES (PSP) APPLICATION FOR ADVANCED PROCEDURE S PROFESSIONAL STAFF WITH S (PSP) Advanced Procedure Privileges: Are those approved procedural privileges requiring additional education and training and may be granted