Basic Education: MD or DO (Applicants must meet the following criteria) Be certified by or be currently qualified to take the board certification examination of a board recognized by the American Board of Medical Specialties; the Bureau of Osteopathic Specialists; the American Board of Podiatric Surgery; or a board or association with equivalent requirements approved by the Texas Medical Board in the specialty for which the practitioner will seek privileges and practice at the Hospital; or have completed an ACGME/AOA accredited residency training General Surgery followed by an approved residency/fellowship training program in general Thoracic and Cardiothoracic Surgery and/or a fellowship approved by the ACGME that provided complete training in the specialty for which the practitioner will seek privileges and will practice at the Hospital. Volume, Clinical Outcomes and Appropriateness: 1. Must perform at least 100 coronary artery bypass graft surgery (CABG) procedures annually and maintain acceptable clinical outcomes, OR If doesn t meet volume threshold, physicians must have all morbidities and mortalities reviewed through the peer review process, and maintain acceptable clinical outcomes. 2. Must maintain acceptable clinical outcomes: a. In-Hospital Mortality Rate < 3.0%, 100% peer review if above threshold b. In-Hospital Rate for type I neurologic events < 3.0%, 100% peer review if above threshold c. In-Hospital Rate for Mediastinitis < 2%, 100% peer review if above threshold d. In-Hospital Rate for Renal Dysfunction < 8%, 100% peer review if above threshold 3. Must have a random sample representing 10% of total procedures reviewed annually for appropriateness regarding symptomatology, lesion severity, and conduit utilization. Patients should be classified utilizing the ACC/AHA guidelines with at least 10% of patients representing class I indications. CORE (Please place your initials in the box beside the privilege you are requesting) Applicant s Initials Approved Denied Admit to CVICU with co-management by cardiologists to all units & CCU Perform H&Ps All core General Surgery privileges THORACIC Thoracentesis Bronchoscopy Chest tube placement Chest wall, rib, pleural lesions Emergency surgery, comprehensive management of Lobectomy, pulmonary Lower extremity bypasses Lymph node dissections, radical, regional, excluding: -inguinal pelvis radical neck dissection -retroperitoneal Lymph node, excision/biopsy Management of patients who may or may not require surgical intervention Median Sternotomy Mediastinoscopy Pleurectomy Pneumonectomy Page 1 of 5
Portal hypertension, management of patients who may or may not require surgical intervention Portal hypertension, shunt procedure Pulmonary resections Scalene node resection Transthoracic hiatal hernia repair Esophageal procedures Mediastinoscopy Tracheostomy Thoracoabdominal exploration Thoracotomy, open (exploratory) Thoracoscopy or Video-Assisted Thoracic Surgery (VATS) Thromboendarterectomy Tracheoplasty Tracheostomy, open technique Tracheostomy, percutaneous technique Vagotomy, selective Vagotomy, transthoracic Valvulopasty Varicosities, excision of Vascular system, comprehensive management of Vascular system, noninvasive diagnostic evaluation Visceral Artery Bypass/Reconstruction Aortic Aneurysm Cardiopulmonary bypass procedures Coronary artery bypass Cardiac valve repair Cardiac valve replacement Myocardial resection procedures Resection of cardiac tremors Pulmonary embolectomy Embolectomy, with or w/o catheter Great vessel surgical procedures Pericardial procedures, resection Pericardiocentesis, emergent Aneurysm repair (thoracic, abdominal) Carotid body, tumor, excision Carotid endarterectomy CARDIOVASCULAR Conduction system interventions (MAZE) Page 2 of 5
Hematoma, incision/drainage Pacemaker implantation Placement of arterial, central venous and pulmonary artery balloon flotation catheters Calibration and operation of hemodynamic recording systems Transvenous pacemakers Placement/operation of intra-aortic balloon pump *Documentation of training, experience, if not part of initial training. *Repair of congenital anomalies *Off-pump coronary bypass *Minimally invasive cardiac procedures *Endovascular repairs/interventions *Transesophageal echocardiography *Ventricular support procedures Ventilator management Cardiothoracic/vascular trauma SPECIAL PRIVILEGES The attached criteria must be met prior to requesting these privileges. Moderate sedation (see attached criteria) Therapeutic Hypothermia (see attached criteria) Note: Privileges granted may only be exercised at the site(s) and/or setting that have the appropriate equipment, license, beds, staff, and other support required to provide the services defined in this document. APPLICANT S SIGNATURE Applicant s Printed Name APPROVALS: Medical Director, Cardiovascular Services Chief, Surgery Department Revised 4/08, 2/09, 3/10, 02/2016 Page 3 of 5
Moderate Sedation Criteria I. Definition: As defined by the American Society of Anesthesiologists, Moderate Sedation is a drug-induced depression of consciousness during which patients respond purposefully to verbal commands, either alone or accompanied by light tactile stimulation. No interventions are required to maintain a patent airway, and spontaneous ventilation is adequate. Cardiovascular function is usually maintained. Continuum of Depth of Sedation and Definition of General Anesthesia and Levels of Sedation/Analgesia (Approved by ASA House of Delegates on October 13, 1999, and amended on October 27, 2004) Moderate Sedation should be distinguished from the following: Minimal Sedation: A drug-induced state during which patients respond normally to verbal commands. Deep Sedation: A drug-induced depression of consciousness during which patients cannot be easily aroused but respond purposefully following repeated or painful stimulation. General Anesthesia: A drug-induced loss of consciousness during which patients are not arousable, even by painful stimulation. *A licensed independent practitioner (LIP) must be present when moderate sedation is being administered. II. Eligibility: Physicians without general anesthesia privileges may obtain privileges to administer Moderate Sedation by providing evidence of: Successful training in administering Moderate Sedation either as part of an ACGME-approved residency training program or by virtue of the successful completion of the Hospital s Moderate Sedation training module consisting of moderate sedation guidelines and exam; AND Current certification in Advanced Cardiac Life Support (ACLS) or its equivalent (PALS, NRP, ATLS, FCCS) or current Board certification in Emergency Medicine or Critical Care Medicine. III. Renewal of privileges: Renewal of privileges will be dependant upon evidence that the physician competently performed Moderate Sedation during the past 24 months and current certification in ACLS or its equivalent (PALS, NRP, ATLS, FCCS) OR current Board certification in Emergency Medicine or Critical Care Medicine. Approved: BOM 6/09 Page 4 of 5
Criteria for Privileges in Therapeutic Hypothermia I. Definition: Temperature Hypothermia (TH) is the practice of transiently reducing body temperature to mitigate the effects of cerebral ischemia in selected patients. II. III. IV. Background: Cardiac arrest with resultant cerebral ischemia often leads to severe neurologic impairment. Studies of comatose survivors of out-of-hospital cardiac arrest have demonstrated favorable neurologic outcomes with initiation of therapeutic hypothermia. (1,2) The Advanced Life Support Task Force of the International Liaison Committee on Resuscitation has advised: Unconscious adult patients with return of spontaneous circulation (ROSC) after out-of-hospital arrest should be cooled to 32-34 degrees Celsius for 12-24 hours when the initial rhythm was ventricular fibrillation; such cooling may be beneficial for other rhythms or in-hospital cardiac arrest. (3) Cooling methods typically include the combined use of refrigerated intravenous fluids, externally applied ice packs and cooling mats, and endovascular cooling catheters. Potential Complications: External cooling devices: skin breakdown Endovascular cooling catheter: bleeding, thrombosis, infection Hypothermia: electrolyte imbalance, shivering Eligibility: Applicants must be credentialed in Critical Care or Emergency Medicine. Use of the endovascular cooling catheter (InnerCool device) shall require the applicant to have completed basic education including both instructional video viewing and hands-on familiarization at an in-service. V. Performance Improvement: Data on all patients treated with TH modalities at UMC will be collected and reviewed yearly. Outcomes and complications will be examined by Performance Improvement personnel from appropriate departments and recommendations forwarded to the Credentials Committee. References 1. Bernard, S., Gray, T., Buise, M., Jones, B., Silvester, M. Gutteridge, M., et al. (2002). Treatment of Comatose Survivors of Out-Of-Hospital Arrest with Induced Hypothermia. New England Journal of Medicine, 346(8), 557-563. 2. The Hypothermia after Cardiac Arrest Study Group. (2002). Mild therapeutic hypothermia to Improve neurologic outcomes after cardiac arrest. New England Journal of Medicine, 346(8), 549-556. 3. Nolan, J., Morley, P., Hoek, V., Hickey, R., (Writing Group). (2003). Therapeutic Hypothermia after cardiac arrest. An advisory statement by the Advanced Life Support Task Force of the International Liaison Committee on Resuscitation. Circulation, 108, 118-121. Page 5 of 5