KALEIDA HEALTH Name Date DELINEATION OF PRIVILEGES - ORAL AND MAXILLOFACIAL SURGERY PLEASE NOTE: Please check the box for each privilege requested. Do not use an arrow or line to make selections. We will return applications that ignore this directive. Procedures designated with an asterisk (*) indicate that Moderate or Deep Sedation may be required. If you do not have Moderate or Deep Sedation privileges, you must invite a Kaleida Health anesthesiologist to participate in the procedure. LEVEL I (CORE) PRIVILEGES Level 1 (core) privileges are those able to be performed after successful completion of an accredited residency program in that core specialty. The removal or restriction of these privileges would require further investigation as to the individual s overall ability to practice, but there is no need to delineate these privileges individually. History and Physical for diagnosis and treatment plan Admitting Privileges Production and Interpretation of Routine Intraoral and Extraoral Radiographs Diagnosis and Management of Oral and Maxillofacial disease/pathology - uncomplicated and complicated *Dentoalveolar Surgery including: extraction of teeth, surgical endodontics, orthodontic exposure, transpositions, implantation *Preprosthetic Surgery including: soft tissue minor surgery, hard tissue minor surgery, implant placement, maxillary sinus elevation with and without graft Trauma Surgery including: *Dentoalveolar Fractures *Condylar subluxation *Mandible fractures *Maxillary fractures Malar fractures Nasoethmoid fractures Orbital fractures *Nasal fractures Frontal Sinus fractures *Repair of Lacerations *Removal of foreign body *Repair of soft tissue defects-incidental to trauma Septoplasty and septorhinoplasty- incidental to trauma Nasal Packing Oral and Maxillofacial Pathology *Biopsy/Excision - soft tissue, hard tissue Maxillary sinus surgery including: *Caldwell Luc and Antrostomy Salivary gland surgery *Biopsy/Excision *Sialodochoplasty *Sialolithectomy *Closure of Salivary Fistula
Oral and Maxillofacial Surgery Name: Page 2 LEVEL I (CORE) PRIVILEGES (CONT D) Temporomandibular Joint Surgery *Arthrocentesis Arthrotomy ofr disc plication, discectomy with or without graft, arthroplasty, eminoplasty/eminectomy *Nerve Surgery for distal segments of trigeminal and facial nerves including: neuroplasty, decompression, neurolysis, transection, avulsion or chemical destruction *Repair of Nerve Injury *Infection/Hematoma including: aspiration, incision and drainage, treatment of osteomyelitis and medical management *Orthognathic Surgery Mandible, Genioplasty, Maxilla,Forehead, Orbit, Midface Septoplasty and Septorhinoplasty in conjucntion with Orthognathic Surgery Reconstructive Surgery * Vestibuloplasty Flaps and Grafts harvesting and use *Adjacent transfer, Mucosa, Skin, Myofascial *Split thickness graft, Skin, Mucosa *Full thickness graft, Skin, Mucosa *Dermis / Adipose *Bone graft, Mandible, Maxilla, Iliac crest *Tibial plateau Calvarium Rib Graft Cartilage, Auricular, Nasal septum *Graft to facial bones, Autogenous, Allogeneic, Alloplastic, Xenograft * Scar Revision Nitrous Oxide Inhalation Sedation Cleft Palate/Alveolar Cleft Repair Arthroscopy of temporomandibular joint Total temporomandibular joint replacement Osteodistraction of maxillofacial skeleton Tracheotomy (Adult)
Oral and Maxillofacial Surgery Name: Page 3 LEVEL III PRIVILEGES Those procedures which categorically require documentation of additional training or significant experience, such as high risk or new procedures. (Volume Criteria may be applicable.) Granted Not Granted* With Following Requirements** (Provide Details) Harvesting and use of: (Documentation of 5 cases) myocutaneous flap/graft (distant) osteomyocutaneous flap/graft (distant) greater auricular nerve sural nerve Microscopic/microvascular nerve anastomosis for repair (Documentation of 5 cases and credentialing course) Laser ablation/surgery (Certification of Laser course and 6 case submission) Transmandibular staple (Completion of training course ) Pediatric Craniofacial Procedures (e.g. LeForte III osteotomy) (Completion of Craniofacial fellowship) Tracheotomy, elective (Pediatric)
Oral and Maxillofacial Surgery Name: Page 4 MODERATE/CONSCIOUS SEDATION 1. Providers seeking privileges in moderate/conscious sedation must complete either the ASA sedation course cost $199.00 (www.asahq.org/education/online-learning/safe-sedationtraining-moderate) or Medsimulation course cost $75.00 (www.medsimulation.com) receiving a score of 85% or above. * Note: 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 privileges. 2. Once the provider has successfully passed the course, he/she must send the certificate of course completion to the medical staff office via e-mail (medicalstaffoffice@kaleidahealth.org) or fax (859-5592 or 859-5593). 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. (ACLS is offered through Kaleida Health Corporate Clinical Education. Please call 716-859-5515 for information. You can also take either course online if you prefer. The following are just a few suggestions. You may be able to obtain this training somewhere else: https://promedcert.com/ $179.00, www.buffalocpr.com/aclsatubcampus.html $135.00 or www.wnyhe.com/courses/acls/ $175.00.) 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. Granted Not Granted* With Following Requirements** (Provide Details)
Oral and Maxillofacial Surgery 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 privileges are not granted for reasons related to professional competence or conduct. (Pursuant to the Health Care Quality Improvement Act of 1986 (43 U.S.C. 11101 et seq.) / Signature of Applicant Date I recommend approval of the procedures requested by the applicant: a) as requested b) as amended I have consulted with on / / who agrees to recommend approval of the requested Level II/III privileges for Pediatric care in Oral Maxillofacial Surgery. / Signature of Chief of Service Date APPLICANT: PLEASE RETAIN A COPY OF THIS SIGNED DELINEATION FOR YOUR RECORDS