KALEIDA HEALTH Name ABMS Board DELINEATION OF PRIVILEGES - REHABILITATION MEDICINE Certification: Please circle all that apply: Board Qualified: Inpatient Rehab Care: Admitting Privileges** (**e: Admitting privileges to Medical Rehab Units is restricted to physiatrists under contract with Kaleida Health.) Consult Privileges Outpatient Care: Evaluation & Treatment 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. LEVEL I (CORE) PRIVILEGES Physicians must have satisfactorily completed an ACGME approved Rehabilitation Medicine Residency Program A. He/She is qualified for adolescent and adult physiatrist management of: History and Physical for Diagnosis and Treatment Stroke Non-traumatic Brain Dysfunction Traumatic Brain Dysfunction Neurologic conditions including: multiple sclerosis, Parkinsonism, polyneuropathy, Guillain-Barre Syndrome, poliomyelitis(late effects), motor neuron disease Non-traumatic spinal cord dysfunction Traumatic spinal cord dysfunction Amputations of upper and lower extremities including prosthetic evaluation and prescription Fractures Joint Replacement Major multiple trauma Rheumatic Diseases Cardiac Rehabilitation Burns Congenital disorders including: cerebral palsy, spina bifida, myelomeningocele Debility Pressure sores Motor Unit Diseases including: neuropathies, myopathies, and muscular dystrophies Neurogenic bladder and bowel Soft tissue injuries Cervical, thoracic, and lumbar spine disorders LEVEL I (CORE) PRIVILEGES (CON T) A. He/She is qualified for adolescent and adult physiatrist management of: Peripheral vascular disorders Neuromusculoskeletal pain syndrome, acute and chronic Pulmonary rehabilitation Custom seating and wheelchair evaluation and other adaptive equipment to restore function Orthotic evaluation and prescription B. He/She may treat medical diseases routinely encountered in this practice, such as: Respiratory diseases, acute and chronic, uncomplicated Endocrine disorders, specifically diabetes mellitus, acute and chronic, uncomplicated Nervous disorders, acute and chronic, uncomplicated Gastrointestinal disorders, acute and chronic, uncomplicated Urinary tract disorders, acute and chronic, uncomplicated Hypertension and cardiac disorders, acute and chronic, uncomplicated Metabolic and allergic disorders, acute and chronic, uncomplicated C. He/She may perform: Venipuncture Arterial puncture Arthrocentesis Soft tissue injections Rehab Medicine 5/2007
Rehabilitation Medicine Name: Page 2 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. LEVEL II PRIVILEGES He/she is qualified by virtue of completion of PM&R residency and documentation of current clinical competency based on a minimum volume/year (in parentheses) and submission of 2 reports at time of credentialing for each privilege requested to perform and interpret: Diagnostic electromyography and electrodiagnosis (10) Motor and sensory nerve conduction testing (10) Somatosensory evoked potentials (5) Auditory and visual evoked potentials (5) Intraoperative monitoring (5) Intra-articular joint injections (5) Tracheostomy tube replacement (5) Intrathecal baclofen pump management (5) PEG tube removal (5) Trigger point injection (5) Visco supplementation (5) *
Rehabilitation Medicine Name: Page 3 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. * e: 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.
Rehabilitation Medicine Name: Page 4 LEVEL III PRIVILEGES Procedures- He/she is qualified by virtue of fellowship training or attendance at an approved regional or national workshop plus a minimum number of procedures under direct supervision of a credentialed MD shown in brackets and has submitted documentation of current clinical competency based on a minimum volume/year (shown in parentheses) and submission of 2 reports at time of credentialing for review. Lumbar epidural injection 10 (10) Cervical epidural injection 10 (10) Selective nerve root blocks 10 (5) Facet joint injections 10 (5) Nerve and motor point blocks 5 (5) Botox injection 5 (5) Prolotherapy 5 (5) Radiofrequency Ablation {10} (5) Spinal Cord Stimulator Insertion {10} (5) Spinal Cord Stimulator Removal {10} (5) Sacroiliac joint injection under fluoroscopic guidance need documentation of at least 5 cases or 5 cases with proctoring *
Rehabilitation Medicine Name: Page 5 LEVEL III PEDIATRIC PRIVILEGES He/she is qualified by virtue of dual BE/BC in pediatrics and PMR or PMR plus a one year fellowship in Pediatric PMR for newborn to adolescent physiatric management of: Stroke Non-traumatic brain dysfunction Traumatic brain dysfunction Neuromuscular conditions including: muscular dystrophies, myopathies, spinal muscular atrophies, hereditary sensorymotor neuropathies, and Guillain-Barre Syndrome Non-traumatic and congenital spinal cord dysfunction including dysraphism Traumatic spinal cord dysfunction Congenital and acquired amputation of the upper and lower extremities including prosthetic evaluation and prescription Fractures Major multiple trauma Rheumatic disease Burns Scoliosis Static and progressive disorders causing spasticity Pressure sores Neurogenic bladder and bowel Soft tissue injuries Neuro musculoskeletal pain syndromes, acute and chronic Custom seating and wheelchair evaluation and other adaptive equipment to restore function Cervical, thoracic, and lumbar spine disorders Developmental screening Lumbar puncture Orthotic evaluation and prescription *
Rehabilitation Medicine Name: Page 6 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 (42 U.S.C. 11101 et seq.) Signature of Applicant / / Signature of Chief of Service APPLICANT: PLEASE RETAIN A COPY OF THIS SIGNED DELINEATION FOR YOUR RECORDS