LIST OF CLINICAL PRIVILEGES CARDIOTHORACIC SURGERY AUTHORITY: Title 10, U.S.C. Chapter 55, Sections 1094 and 1102. PRINCIPAL PURPOSE: To define the scope and limits of practice for individual providers. Privileges are based on evaluation of the individual s credentials and performance. ROUTINE USE: Information on this form may be released to government boards or agencies, or to professional societies or organizations, if needed to license or monitor professional standards of health care providers. It may also be released to civilian medical institutions or organizations where the provider is applying for staff privileges during or after separating from the Air Force. DISCLOSURE IS VOLUNTARY: However, failure to provide information may result in the limitation or termination of clinical privileges INSTRUCTIONS APPLICANT: In Part I, enter Code 1, 2, or 4 in each REQUESTED block for every privilege listed. This is to reflect your current capability. Sign and date the form and forward to your Clinical Supervisor CLINICAL SUPERVISOR: In Part I, using the facility master privileges list, enter Code 1, 2, or 4 in in each VERIFIED block in answer to each requested privilege. In Part II, check appropriate block either to recommend approval, to recommend approval with modification, or to recommend disapproval. Sign and date the form and forward the form to the Credentials Office. CODES: 1. Fully competent within defined scope of practice. 2. Supervision required. (Unlicensed/uncertified or lacks current relevant clinical experience. 3. Not approved due to lack of facility support. (Reference facility master Strawman. Use of this code is reserved for the Credentials Function.) 4. Not requested/not approved due to lack of expertise or proficiency, or due to physical disability or limitation. CHANGES: Any change to a verified/approved privileges list must be made in accordance with Service specific credentialing and privileging policy. NAME OF APPLICANT NAME OF MEDICAL FACILITY I Scope Requested Verified The scope of privileges in cardiothoracic surgery includes the evaluation, diagnosis, treatment and consultation for patients with congenital and acquired abnormalities of the heart and great vessels; a variety of conditions of the chest wall, lungs, and mediastinal structures; and traumatic injuries to the chest and cardiothoracic structures. CT surgeons P385568 provide non-surgical care as well as pre-, intra-, and post-operative surgical care. Cardiothoracic surgeons may admit to the facility and may provide care to patients in the intensive care setting in accordance with MTF policies. They assess, stabilize, and determine the disposition of patients with emergent conditions in accordance with medical staff policy. Diagnosis and Management (D&M) Requested Verified P390328 Pulmonary artery catheter insertion and interpretation Procedures Requested Verified P385576 P384665 P390326 P388457 P384077 P385588 P385594 P385596 P385598 P388364 P385198 P388561 P384105 P388216 P385612 P385616 P384085 Thoracic: Endoscopy Mediastinoscopy; direct, video-assisted Bronchoscopy, flexible and rigid Esophagoscopy (flexible or rigid) Laryngoscopy; direct, indirect Thoracoscopy; direct, video-assisted Minor Procedures Requested Verified Pleural biopsy; open, closed Needle biopsy, lung Esophageal bypass tube insertion Lung abscess drainage Thoracentesis Tube thoracostomy Lymph node biopsy Tracheostomy Esophageal dilatation Lungs Requested Verified Reduction pneumoplasty Sleeve lobectomy or pneumonectomy Thoracotomy 1
Lungs (Con t) Requested Verified P384087 P384089 P384091 P384093 P384095 P385618 P385620 P385622 P385624 P385630 P384097 P384099 P385632 P385636 P385638 P384103 P385640 P385644 P384121 P385646 P385650 P385658 P385662 P385666 P384107 P384119 P384109 P384111 P384113 P384115 P385668 P385670 P385672 P385674 P385676 Pleurectomy / pleurodesis Wedge, segmental, other anatomic resection Lobectomy Pneumonectomy Decortication Chest Wall and Pleura Requested Verified Resection of tumor or infection Thoracoplasty Surgical decompression for thoracic outlet syndrome - resection first rib Rib resection and drainage (Eloesser) Sternal resection (partial or complete, with primary or secondary closure, with or without pectorals muscle advancement) Repair of chest wall deformity (pectus excavatum, pectus carinatum) Chest wall resection/reconstruction with or without muscle flap Trachea Requested Verified Trachea and bronchus repair- trauma Tracheal resection for tumor, stricture, or cyst Mediastinal tracheostomy Tracheo-esophageal fistula repair Mediastinum Requested Verified Cervical/anterior mediastinotomy and drainage Pericardial window / pericardectomy Mediastinal tumor or cyst excision Esophagus Requested Verified Repair of esophageal trauma / perforation Ligation of esophageal varices Esophageal diverticulectomy (intra- or extrathoracic approach) Esophageal bypass (colon, small intestine) Closure of fistula Repair of esophageal atresia Esophageal reflux procedures (intra- or extrathoracic approach) Esophagostomy Esophagectomy Esophagogastrostomy Esophagomyotomy Diaphragm Requested Verified Repair esophageal and paraesophageal hiatal hernia (intra/extrathoracic) Congenital hernia repair Diaphragm plication, repair, resection, or reconstruction Insertion of diaphragmatic pacer Video-assisted thoracoscopic procedures Requested Verified Diagnostic biopsy or pleurodesis 2
P385678 P385680 P385682 P385684 P385686 P385688 P385692 P385696 P385698 P388154 P385700 P385702 P385704 P385706 P385708 P385710 P385712 P385714 P385716 P385718 P385720 P385722 P385724 P385726 P385728 P385730 P385734 P385736 P385738 P385835 P385837 P385839 P385841 P385851 Video-assisted thoracoscopic procedures (Con t) Requested Verified Lobectomy or pneumonectomy Mediastinal tumor or cyst resection Empyema drainage with or without decortication Esophageal procedures Thoracic sympathectomy/ sympathotomy Cardiac: Minor Procedures Requested Verified Sub-xyphoid drainage Cardioversion Sternal wire removal Sternal debridement and rewiring/plating/reconstruction Intra-aortic balloon pump placement/removal Valve surgery with cardiopulmonary bypass Requested Verified Valve replacement Commissurotomy Valve repair Homograft / autograft replacement Aortic root replacement Repair of congenital defects Requested Verified Shunting procedures Pulmonary artery banding Patent ductus division Coarctation of aorta repair Vascular ring/arch anomaly repair Septal defect repair Valvular defect repair Cardiac revascularization Requested Verified Primary revascularization with or without cardiopulmonary bypass (CPB) Coronary artery endarterectomy Ventricular aneurysmorraphy Acquired ventricular septal defect (VSD) repair Electrophysiologic cardiac surgery Requested Verified Pacemaker insertion - transvenous, epicardial Automatic Implantable Cardioverter Defibrillator (AICD) - transvenous, epicardial Arrythmia ablation procedures Great vessels Requested Verified Ascending aorta and aortic arch replacement Descending thoracic aortic replacement Thoracoabdominal aneurysmorrhaphy Surgical repair of injury (e.g., laceration, perforation) to great vessels Thoracic Endovascular Aneurysm Repair 3
P385845 P385847 P385849 P385853 P385855 P385859 P389285 P385861 P385863 P387235 P385867 P385869 P385871 P385873 P385875 P390747 P385879 Endarterectromy, repair, replacement, bypass: Requested Verified Innominate artery Carotid artery Subclavian artery Pulmonary artery and vena cava Requested Verified Pulmonary embolectomy Pulmonary thromboendarterectomy Vena cava interruption/ligation/clipping Vena cava filter placement Heart Requested Verified Resection of cardiac tumors Repair of cardiac trauma, myocardium Removal of foreign body Extracorporeal circulatory support of surgical procedures (cardiac and noncardiac) Cardiopulmonary bypass Veno-veno bypass Left atrial to descending aorta or femoral artery bypass Hypothermic circulatory arrest Insertion of left/right/biventricular assist devices (LVAD, RVAD, BiVAD) Extra corporeal life support (ECLS) Requested Verified Additional privileges Requested Verified Intraoperative use of lasers Other (Facility- or Provider-specific Privileges Only) Requested Verified SIGNATURE OF APPLICANT DATE 4
II CLINICAL SUPERVISOR S RECOMMENDATION RECOMMEND APPROVAL RECOMMEND APPROVAL WITH MODIFICATION RECOMMEND DISAPPROVAL (Specify below) (Specify below) STATEMENT: CLINICAL SUPERVISOR SIGNATURE CLINICAL SUPERVISOR PRINTED NAME OR STAMP DATE 5