BAYLOR SCOTT & WHITE TEXAS SPINE & JOINT HOSPITAL

Transcription

1 BAYLOR SCOTT & WHITE TEXAS SPINE & JOINT HOSPITAL NAME: Initial Appointment / Reappointment / Update (Circle One) REQUESTED PRIVILEGE PAIN BLOCKS Blood Patch Hardware Block Epidurogram Fluoroscopy Intradural/Intrathecal Injection-At least 3mo. ACGME pain fellowship Manipulation of Spine, any level, w/sedation CERVICAL PAIN BLOCKS Discogram - Cervical Epidural Steroid Injection - Cervical Hypertonic Saline Injection - Cervical Medial Branch Block - Cervical Facet Joint - Cervical Selective Epidural - Cervical Selective Nerve Block - Cervical Suprascapular Nerve Block THORACIC PAIN BLOCKS Discogram - Thoracic Epidural Steroid Injection - Thoracic Hypertonic Saline Injection - Thoracic Medial Branch Block - Thoracic Facet Joint - Thoracic Selective Epidural - Thoracic Selective Nerve Block - Thoracic LUMBAR PAIN BLOCKS Discogram - Lumbar Epidural, Steroid Injection - Lumbar Epidural Neurolytic Block - Lumbar Injection for Lysis of adhesion - Lumbar Medial Branch Block - Lumbar Facet Joint - Lumbar Selective Epidural - Lumbar Selective Nerve Block - Lumbar Epidural, Continuous, Caudal (Sacral) Epidural, Steroid Injection - Caudal Injection for Lysis of adhesion - Caudal Sacroiliac Joint Injection Genicular NB Opturator NB Coccyx SPECIALTY PAIN BLOCKS IDET Disctrode Neucleoplasty Dekompressor Verterbralplasty or Kyphoplasty MILD / VERTOS REQUIRED >0 LESI's CRITERIA BC/BE Anesthesia only 30L, T, C* 30 L then T L then 2T L1-L & 2 S1 2-L1-L & 2 S1 w/cath w/o cath w/cath w/o cath disco's + course 0 disco's + course 0 disco's + course 0 disco's + course 0 disco's + course 0 disco's + course HAS DONE APPROVED DENIED *NOTE For those that currently have privileges for lumbar epidurals, lumbar facets and or sacroiliac joint injections you will need to do at least 0 lumbar discograms and complete a certified cadaveric course for IDETs, Disctrodes and Neucleoplasties. For those who do not currently have privileges for lumbar epidurals, lumbar facets and or sacroiliac joint injections you will need to do at least 0 lumbar discograms and complete a certified cadaveric course for IDETs, Disctrodes and Neucleoplasties.

2 *NOTE *MUST BE PROFICIENT IN LUMBAR DISCOGRAPHY BEFORE STARTING CERVICAL DISCOGRAPHY REQUESTED **NOTE For all who have completed an Anesthesia, PM&R, Radiology, Neurology or Orthopedic residencies you must complete 0 lumbar procedures before training for cervical or thoracic procedures. For those that do not meet the above criteria you must complete 00 lumbar procedures and have at least six months experience doing lumbar procedures prior to learning cervical or thoracic procedures. For all new physicians coming into Pain Management at BSWTSJH you must be board eligible or certified before privileges will be granted. IV Infusion IV Infustion-Regitine/Lidocaine PRIVILEGE REQUIRED 2 HAS DONE APPROVED DENIED Transdiscal Epidural Catheter w/ External Reservoir w/o laminectomy Lumbar Drain Neurotomy/ Rhizotomy - Lumbar Neurotomy/ Rhizotomy - Cervical Neurotomy/ Rhizotomy - Thoracic Neurotomy/ Rhizotomy - Dorsal Root Ganglion Neurotomy / Rhizotomy - Genicular RF Neurotomy / Rhizotomy - Opturator RF Neurotomy/ Rhizotomy - Trigeminal Neurotomy/ Rhizotomy - Sphenopalatine Ganglia Neurotomy/ Rhizotomy - Sympathetic - Cervical Neurotomy/ Rhizotomy - Sympathetic - Lumbar Neurotomy/ Rhizotomy - Sympathetic - Thoracic Radio-Frequency - Caudal/Stellate Ganglion/Sympathectomy Stellate Ganglion Block Sympathetic Block -Cervical Sympathetic Block -Lumbar Sympathetic Block -Thoracic Sympathetic Neurolysis - Cervical Sympathetic Neurolysis - Lumbar Sympathetic Neurolysis - Thoracic Sympathectomy - Thoracic Splanchnic Block Splanchnic Neurolysis Hypogastric Plexus Block Hypogastric Plexus Neurolysis Auxiliary Nerve Block Celiac Plexus Block Trigeminal nerve block Brachial Plexus Block Brachial Plexus Nerve Block Occipital Nerve Block Peripheral Nerve Block Plexus Block - Cervical Plexus Block - Lumbar Psoas Compartment Block Inguinal Nerve Block Intercostal Nerve Block (a.k.a. rib block) Supraclavicular Block same as idet 3 mth. Pain+ same as above LRF+ cases T-MBB+LRF CRF+C-sel trigeminal+ sphenopalatine+ symp blk + L-RF completion of L-Symp T-disco or T-sele splan. Blks + REQUESTED PRIVILEGE REQUIRED HAS DONE APPROVED DENIED Wrist Joint Block Hip Injection Shoulder Injection Knee Injection Ankle Injection Random Joint Injection

3 Elbow Injection Trigger Point Injection Bursa Injection Femoral Nerve Block Sternal Block Spinal Cord Stimulator (a.k.a. DCS:Dorsal Column Stimulator) Placement of Neuroelectrodes for Trial Analysis of Pulse Generator Analysis of Pulse Generator w/ reprogramming Catheter Replacement or Revision Injection of Substance or other than Anesthetic (Lioresal) Refilling of Pump Intrathecal Drug Delivery Pumps (BSWTSJH only) Incision & Implant Pulse Generator** Insertion Subarachnoid Catheter W / Reservoir w/o Laminectomy** and letter of competence from proctor Triggers Co-Surgeon - must have cases with proctor unless anesthesia trained Revise or Remove Stimulator Generator, Electrodes, Receiver** Insertion or Revision of Intrathecal Drug Delivery Pumps** **Indicates needs at least 3 total of any combination with a proctor 3 mth.pain+ 3 mth.pain+ 3 mth.pain+ 3 mth.pain+ 3 mth.pain+ 3 mth.pain+ MISCELLANEOUS Conscious Sedation (see attached request letter) OTHER Acknowledgment of Practitioner I am qualified to perform the privileges I have requested based on my licensure, education, training, experience and current competence. I certify that I am able to perform the privileges I have requested. Furthermore, if I am requesting privileges for procedures that I have not previously been granted at Baylor Scott & White Texas Spine & Joint Hospital I have attached education documentation, certificates, licensure, etc. for the committee to review. A minimum of 0 procedures (accrued over a 24 month period) is required for re-appointment Practitioner's Signature Date I,, am requesting privileges to perform conscious sedation at Baylor Scott & White Texas Spine & Joint Hospital. I am qualified to perform conscious sedation based on my licensure, education, training, experience and current competence

4 My current ACLS card is attached. Thank You, Practitioner's Signature Approved Denied

5 DR. CREDITIALING COUNTS PROCEDURE # OF CASES DONE # OF CASES NEEDED CERVICAL Cervical Interlaminar Cervical Transforminal Cervical Facets -AO/AA Cervical Medial Branch Cervical RF L-RF + Cervical Stellate / Symp Cervical Disco 30L, T, C* Occipital Nerve Block *MUST BE PROFICIENT WITH LUMBAR BEFORE STARTING CERVICAL THORACIC Thoracic Interlaminar Thoracic Transforminal Thoracic Facets Thoracic Medial Branch Thoracic RF TMBB + LFR #'S Thoracic Disco 30 L + T Intercostal Blocks Thoracic Sympathetic RF Thoracic Sympathetic LUMBAR Lumbar Interlaminar L1 THRU L Lumbar Transforminal 2 - S1 Lumbar Facets 2 Lumbar Medial Branch - SACRAL Lumbar RF Caudal Epiduarl w w/o cath W - W/O Lumbar Disco 30 Sacroilliac Joint 1 Hip Coccyx Injection 2 Blood Patch Sacral RF Hardware Block Ganglion Impar Lumbar Sympathetic Lumbar Sympathetic RF Splanichnic Block / RF * Celiac Plexas Block *

6 ilioinguinal NB * Saphenous NB * *waiting on peer recommendations OTHER INJECTIONS SCS Trial 3 MTS. PAIN + Baclofen Trials Morphine Pump Trial Pump Check Pump Fill Glenohumeral / shoulder Lumbar Puncture Knee Inj Geniculate nerve block Bertolotti / Assim joint injection SAME AS LUMBAR FACET above is an artificial joint created by the transverse process meeting the iliiac crest Drain / Aspiration Botox Injection Trigger Point Injection Ankle Inj Lysis of Adhesions Supraclavicular Block Bursa inj. Suprascapular NB Supraorbital NB Trigeminal RF SURGERY COUNTS PROCEDURE NUMBER DONE NUMBER NEEDED SCS IMPLANTS SCS EXPLANTS SCS REVISION LD - WOUND Pump Implant Pump Revision Battery Replacement Pump Replacement Pump Removal