CLINICAL PRIVILEGE WHITE PAPER

Transcription

1 Procedure 88 CLINICAL PRIVILEGE WHITE PAPER Liposuction Background Liposuction, also called suction lipoplasty or suction-assisted lipectomy (SAL), is a surgical technique used for the removal of unwanted areas of fat. These fatty bulges are most commonly found in the thighs, hips, abdomen, and buttocks or in facial areas such as the chin, jowls, and neck. Traditional liposuction is done by making small incisions in appropriate locations and inserting a hollow tube or cannula under the skin in the fat layer. The cannula is hooked up to a suction pump, and the fat is literally vacuumed out with high-suction pressure. This technique can cause significant bleeding, bruising, trauma, and blood loss, which limit the amount of fat that can be safely removed. Tumescent liposuction is the technique more commonly used today. The procedure involves injecting a medicated solution into fatty areas before the fat is removed. The fluid, a mixture of intravenous salt solution, lidocaine (a local anesthetic), and epinephrine (a drug that contracts blood vessels), makes fat removal easier, reduces blood loss, and provides anesthesia during and after surgery. Fluid injection also helps to reduce the amount of bruising after surgery. A newer method of removing unwanted fat is ultrasonic liposuction, also known as ultrasound-assisted lipoplasty (UAL), In UAL, a special titanium cannula transmits high-frequency ultrasound energy to the fat layer where it causes disruption of the fat cells it touches. This liquefies the fat, which is then drained or suctioned through a hollow portion of the titanium cannula with a low, gentle vacuum. Because this technique is more refined and gentle to the tissues, there is less blood loss, less bruising, less pain, and a significantly faster recovery. Liposuction should be a safe procedure, but in the past, liposuction patients have experienced serious complications, even death. These complications have involved the removal of too much fat or the improper administration of anesthesia. Frequently, such adverse events occur during office-based surgeries. As a result, eight states, including Florida and New Jersey, now regulate or are in the process of regulating office-based surgical procedures, including liposuction. Administrators who are responsible for credentialing or privileging this procedure should determine whether there are regulations they must follow. Please replace Clinical Privilege White Paper, Liposuction Procedure 88, with this updated version. A supplement to Briefings on Credentialing 781/ /01 1

2 Involved specialties Plastic surgeons, general surgeons, dermatologists, gynecologists, ophthalmologists, oral and maxillofacial surgeons, and otolaryngologists Positions of societies and academies ASPS The American Society of Plastic Surgeons (ASPS) publishes the clinical practice guideline Lipoplasty. In this guideline, the ASPS states that operating physicians should have the following qualifications: Hospital privileges for body contouring, SAL, and UAL regardless of the type of facility in which the procedure is performed Documentation of training in one of the following three ways: - Completion of SAL and/or UAL training during an accredited residency or fellowship - Completion of a training course approved for a minimum of eight hours of American Medical Association Category I continuing medical education (CME) credit - Meet the standards of the hospital where the physician has admitting privileges (for those who received training during the developmental stages of this procedure) The ASPS also publishes Plastic Surgery Briefing: Liposuction. In this briefing, the society makes the following position statement: The American Society of Plastic Surgeons (ASPS) believes that liposuction is generally safe, provided that patients are carefully selected, the operating facility is properly equipped, and the physician has basic (core) accredited surgical training with special training in body contouring. Patients should be aware that lipoplasty to remove more than five liters (5,000 cc s) of fat and fluid requires a high level of surgical skill and a provision for prolonged monitoring after the procedure. ASPS believes that UAL is an acceptable alternative to traditional liposuction in some circumstances because it offers the potential of easier removal of fat in more fibrous areas. However, because the heat generated by ultrasonic energy creates a risk for burns to treated areas, plastic surgeons should complete a CME Category I approved training program in UAL before using the technique clinically. ASPS believes that pre-injection methods (including tumes- 2 A supplement to Briefings on Credentialing 781/ /01

3 cent and super-wet techniques) usually decrease blood loss and reduce the need for transfusion. Surgeons who use these techniques to remove large volumes of fat and fluid must have a background of surgical education in the principles of fluid management. In the briefing, the ASPS makes the following statement regarding surgeon selection: Because there are no federal or state laws governing the scope or quality of specialty education a physician must attain to designate him/herself a specialist, patients should exercise care in selecting a surgeon. In particular, ASPS recommends that individuals seeking liposuction inquire whether privileges to perform liposuction have been granted to a particular surgeon at an accredited hospital because hospitals must examine credentials carefully before granting specialty privileges to staff physicians. If the procedure is to be performed outside a hospital, patients may inquire whether the surgical facility is accredited by an organization such as the American Association for Accreditation of Ambulatory Surgical Facilities. This organization requires maintenance of strict quality standards for facilities that achieve its accreditation. The ASPS further states that it does not recommend liposuction for individuals with complicated diabetes, poor circulation, significant heart or lung disease, or who ve recently undergone surgery in the region to be treated. AAD The American Academy of Dermatology s (AAD) publishes Guidelines of Care for Liposuction, which was approved by the AAD board of directors in December In these guidelines, the Academy recommends the following physician qualifications: The physician performing liposuction has completed residency training or is board-certified in a specialty recognized by the American Board of Medical Specialties, and that provides education in liposuction and training in cutaneous surgery The physician has documented liposuction training in residency or documented training and experience at the surgical table under the supervision of an appropriately trained and experienced liposuction surgeon A supplement to Briefings on Credentialing 781/ /01 3

4 In addition to the surgical technique, training includes instruction in fluid and electrolyte balance, potential complications of liposuction, and tumescent anesthesia and other forms of anesthesia employed The guidelines include the following recommendations regarding the facility in which the procedure is performed and the availability of emergency care: Liposuction can be performed safely in a physician s office surgical facility, an ambulatory surgical facility, or a hospital operating room All liposuction surgeons and designated operating room staff should have training in the management of acute cardiac emergencies Hospital privileges should not be required to perform tumescent liposuction, but a written plan for management of medical emergencies, including possible transfer, should be in place AACS, ASLSS The American Academy of Cosmetic Surgery (AACS) is the nation s largest organization representing cosmetic surgeons. The academy s membership includes practitioners of medical disciplines including dermatology, ophthalmology, otorhinolaryngology, plastic and reconstructive surgery, oral and maxillofacial surgery, general surgery, cosmetic dentistry, and others. The American Society of Liposuction Surgery (ASLSS) is a specialty subgroup of the AACS. A joint Ad Hoc Committee of the AACS and the ASLSS was formed to create the 2000 Liposuction Guidelines. These guidelines contain the following recommendations for training and education for liposuction surgery: Physicians practicing liposuction surgery should have adequate training and experience in the field. This training and experience may be obtained in residency training, cosmetic surgery fellowship training, observational training programs, CME-accredited postgraduate didactic and live surgical programs, or via proctorship with trained credentialed surgeons experienced in liposuction techniques. Postgraduate training should include completion of a didactic liposuction course and completion of a live surgical workshop on liposuction. Both courses should be certified for CME and sanctioned by the ASLSS, or another similar 4 A supplement to Briefings on Credentialing 781/ /01

5 Liposuction Procedure 88 organization. In addition, a proctorship or preceptorship, including one-on-one or observational learning should be included in the training and education of the surgeon performing liposuction. Surgeons of multiple specialties perform liposuction surgery. Qualified surgeons who practice liposuction surgery must have the necessary skills to perform the procedures and the knowledge to diagnose and manage cardiovascular, surgical, or pharmacological complications that arise. Surgeons who have received adequate training and surgical experience as either a primary surgeon or cosurgeon as part of their residency do not require attendance at didactic courses, live surgical workshop, or preceptorship. If residency experience is not adequate, the surgeon should complete the three levels of education. The guidelines also recommend the following for the privileging of liposuction surgeons: For hospital or ambulatory surgery center privileging, surgeons should follow existing requirements for obtaining privileges for any existing or new procedure. However, if there is concern about competency and experience, the standards, as outlined by the JCAHO, should be adhered to, including, but not limited by, any one of the following: training, experience, specialty, and board certification. When questions arise, the surgeon seeking privileges in liposuction must submit evidence of having attended didactic lectures, live surgery workshops, and clinical cases. If there is no evidence of clinical cases, then the surgeon may complete a proctoring or preceptorship program in which a qualified, experienced liposuction surgeon would oversee the applicant for the number of procedures necessary to determine satisfactory technique and patient management. The proctor should have current privileges at the facility (under peer review and quality assurance) to perform such procedures, and be willing to, without bias, observe and evaluate the applicant surgeon. The number of procedures required to be proctored may be determined at the individual center but should be adequate to examine the pre-, intra-, and postoperative management by the applicant. The confidential case evaluations must be provided, in writing, to the appropriate committee or board, which A supplement to Briefings on Credentialing 781/ /01 5

6 grants such privileges. Any conflict that may arise between proctor and applicant surgeon should be resolved according to appropriate regulations or bylaws of the individual center. Annually, all liposuction surgeons are encouraged to obtain CME, specifically in the field of liposuction and related surgery, through the use of current scientific publications, videotapes, scientific conferences, courses, or workshops. Positions of other interested parties ABPS ABD According to the American Board of Plastic Surgery, there are two major pathways toward obtaining acceptable graduate level training for certification in plastic surgery. They are the independent model and the integrated model. Independent model Residents must complete two to three years of concentrated plastic surgery training, with no less than 12 months of senior/ chief responsibility after successful completion of one of the following criteria: Completion of a total of 36 months of general surgery (a minimum of 18 months must be devoted to rotations in the primary and secondary components of general surgery) Completion of an accredited neurological surgery, orthopedic surgery, otolaryngology, or urology residency Completion of a residency program in oral and maxillofacial surgery approved by the American Dental Association Integrated model Residents must meet the following criteria: Training of no less than five years of clinical residency under the authority and direction of a plastic surgery program director No less than two years of this program must be concentrated plastic surgery training, and the final 12 months must entail senior clinical plastic surgery responsibility The American Board of Dermatology states that candidates for certification are required to have a total of four years of postgraduate training. The first year must consist of clinical training in one of the following types of broad-based programs: Internal medicine 6 A supplement to Briefings on Credentialing 781/ /01

7 General surgery Family practice Obstetrics and gynecology Pediatrics Emergency medicine. Then there must be three years of full-time training as a resident in a dermatology residency training program accredited by the Accreditation Council for Graduate Medical Education (ACGME) or the Royal College of Physicians and Surgeons of Canada. CRC draft criteria Minimum threshold criteria for requesting core privileges for liposuction The following draft criteria are intended to serve solely as a starting point for the development of an institution s policy regarding liposuction. Basic education: MD or DO Minimum formal training: Applicants must have completed an ACGME/American Osteopathic Association (AOA) accredited surgical residency program. If the residency program did not include liposuction training, applicants must show completion of an accredited CME liposuction training program or equivalent experience. Required previous experience: Applicants must demonstrate that they performed 50 liposuction procedures (SAL and/or UAL) in the past 12 months. Note: A letter of reference should come from the director of the applicant s surgical residency program or from the director of the applicant s CME liposuction training program. Alternatively, a letter of reference should come from the chief of surgery at the institution where the applicant most recently practiced. Reappointment Reappointment should be based on unbiased, objective results of care according to the organization s existing quality assurance mechanisms. Applicants must demonstrate their maintained competence with evidence that they performed 100 liposuction procedures (SAL and/or UAL) in the past 24 months. In addition, continuing education related to liposuction should be required. A supplement to Briefings on Credentialing 781/ /01 7

8 For more information For more information regarding this procedure, contact: American Academy of Cosmetic Surgery American Academy of Liposuction Surgery 737 N. Michigan Avenue, Suite 820 Chicago, IL Telephone: 312/ Fax: 312/ Web site: American Academy of Dermatology 930 N. Meacham Road PO Box 4014 Schaumburg, IL Telephone: 847/ Fax: 847/ Web site: American Board of Plastic Surgery Seven Penn Center, Suite Market Street Philadelphia, PA Telephone: 215/ Fax: 215/ Web site: American Board of Dermatology Henry Ford Health System 1 Ford Place Detroit, MI Telephone: 313/ Fax: 313/ Web site: American Society of Plastic Surgeons 444 East Algonquin Road Arlington Heights, IL Telephone: 847/ Fax: 847/ Web site: 8 A supplement to Briefings on Credentialing 781/ /01

9 Privilege request form Liposuction In order to be eligible to request clinical privileges for liposuction, an applicant must meet the following minimum threshold criteria: Education: MD or DO Minimum formal training: Applicants must complete an ACGME/AOA-accredited surgical residency program. If the residency program did not include liposuction training, applicants must show completion of an accredited CME liposuction training program or equivalent experience. Required previous experience: Applicants must demonstrate that they performed 50 liposuction procedures (SAL and/or UAL) in the past 12 months. References: A letter of reference should come from the director of the applicant s surgical residency program or from the director of the applicant s CME liposuction training program. Alternatively, a letter of reference should come from the chief of surgery at the institution where the applicant most recently practiced. Reappointment: Reappointment should be based on unbiased, objective results of care according to the organization s existing quality assurance mechanisms. Applicants must demonstrate their maintained competence with evidence that they performed 100 liposuction procedures (SAL and/or UAL) in the past 24 months. In addition, continuing education related to liposuction should be required. I understand that by making this request I am bound by the applicable bylaws or policies of the hospital, and hereby stipulate that I meet the minimum threshold criteria for this request. Physician s signature: Typed or printed name: Date: A supplement to Briefings on Credentialing 781/ /01 9

10 Clinical Privilege White Papers Advisory Board Publisher/Vice President: Suzanne Perney Executive Editor: Dale Seamans Managing Editor: Edwin B. Niemeyer James F. Callahan, DPA Executive vice president and CEO American Society of Addiction Medicine Chevy Chase, MD Sharon Fujikawa, PhD Clinical professor, Dept. of Neurology University of California, Irvine Medical Center Orange, CA John N. Kabalin, MD, FACS Urologist/Laser surgeon Scottsbluff Urology Associates Scottsbluff, NE John E. Krettek Jr., MD, PhD Neurological surgeon Vice president for medical affairs Missouri Baptist Medical Center St. Louis, MO Michael R. Milner, MMS, PA-C Senior physician assistant consultant Phoenix Indian Medical Center Phoenix, AZ Beverly Pybus President The Beverly Group Georgetown, MA Richard Sheff, MD Practice director Quality and credentialing The Greeley Company Marblehead, MA The information contained in this document is general. It has been designed and is intended for use by hospitals and their credentials committees in developing their own local approaches and policies for various credentialing issues. This information, including the materials, opinions, and draft criteria set forth herein, should not be adopted for use without careful consideration, discussion, additional research by physicians and counsel in local settings, and adaptation to local needs. The Credentialing Resource Center does not provide legal or clinical advice; for such advice, the counsel of competent individuals in these fields must be obtained. Reproduction in any form outside the recipient s institution is forbidden without prior written permission. Copyright 2001 Opus Communications, a division of HCPro, Marblehead, MA A supplement to Briefings on Credentialing 781/ /01