INITIAL: [ ] RENEWED: [ ] ADDITIONAL: [ ] Privileges are granted for Sutter Medical Center, Sacramento and exercise of privileges is based on the type of care, treatment and services provided at each facility. Privileges are granted for Sutter General Hospital, Sutter Memorial Hospital, Sutter Center for Psychiatry, Capital Pavilion Surgery Center, or Sutter Oaks Midtown and exercise of privileges is based on the type of care, treatment and services provided at each facility. To request Privileges, please place an X in the request column. In box, indicate the number of identified procedures performed in previous 24 months from any facility. If the condition/privilege you desire is not included on this form, please submit a separate written request along with appropriate documentation of training and/or experience. Please be prepared to supply verification of volume performance if requested. ANESTHESIA [ ] Endotracheal intubation [ ] Laryngoscopy, indirect and direct [ ] Infiltration anesthesia [ ] Peripheral and regional nerve block [ ] Deep Sedation, procedural sedation and rapid sequence intubation including privileges for but not limited to; Ketamine, Propofol, Opiates, Benzodiazepines, Etomidate, depolarizing/nondepolarizing paralytic anesthesia EYE, EAR, NOSE AND THROAT [ ] Removal of foreign bodies of nose and ear [ ] Removal of superficial corneal foreign bodies [ ] Anterior and posterior nasal pack [ ] Lateral Canthotomy (emergent) OBSTETRICS/GYNECOLOGY [ ] Culdocentesis Provisional members will be proctored for a minimum of first two shifts in the Emergency Medicine Department by one or more Senior members of the department. Proctoring shall begin immediately upon appointment to the medical Staff. Procedure proctoring in concurrent; overall care proctoring is done retrospectively. Page 1 of 6
[ ] Delivery of baby [ ] Post Mortem C Section (emergent) INTERNAL MEDICINE [ ] Diabetic ketoacidosis [ ] Diabetic coma [ ] Pulmonary edema [ ] Congestive heart failure [ ] Respiratory insufficiency [ ] Acidosis, metabolic or respiratory [ ] Alkalosis, metabolic or respiratory [ ] Toxic exposure [ ] Status epilepticus [ ] Acute hypertension [ ] Acute psychosis [ ] Cardiorespiratory arrest [ ] Coma, etiology unknown [ ] Acute myocardial infarction [ ] Cardiac arrhythmias [ ] Massive GI bleed [ ] Status asthmaticus [ ] Shock [ ] Critical electrolyte imbalance [ ] Severe cerebrovascular accident [ ] Near drowning [ ] Delirium tremens [ ] Hepatic or renal insufficiency [ ] EKG interpretation [ ] Defibrillation [ ] Cardiorespiratory resuscitation and advanced life support [ ] Thyrotoxicosis [ ] ED Ventilator Management ORTHOPEDICS [ ] Arthrocentesis [ ] Injection of tendon sheaths, ligaments, trigger points, and bursa [ ] Repair of extensor tendons Page 2 of 6
[ ] Closed reduction of dislocations and fractures [ ] Emergency splinting of fractures [ ] Rongew of bone in finger tip injury repair RADIOLOGY [ ] Emergency IVP and cystogram [ ] Ultrasound (Continued on next page) A. Training and credentialing of emergency physicians will be done on a voluntary basis. Physicians not interested in learning sonography will continue to order ultrasound studies under existing protocols. Emergency physicians who have completed training and proctoring will continue to have the option of calling a technician or radiologist to obtain studies. B. Emergency physicians may become eligible for privileges in ED ultrasound in one of four ways: 1. Successful completion of a residency in emergency medicine in a training program in which formal ultrasound training is included in the curriculum. Completion of emergency medicine residency. This typically includes training in a total of 150 ultrasound studies divided among the various procedures. A letter from the director of the training program attesting to the applicant s competence and number of studies trained should be submitted with the privilege request. 2. Previous attainment of ED ultrasound privileges at another hospital with ultrasound credentialing requirements that meet or exceed those of SMCS. 3. Successful completion of at least 24 hours of formal training in ED ultrasound, including at least 12 hours of hands on training in bedside ultrasound, in a course or courses approved by the American College of Emergency Physicians; plus 16 hours of independent study (e.g., directed readings, computer tutorial programs, attendance at conferences on ED ultrasound, time spent working with technicians or radiologists). 4. Successful completion of a 16 hour course of formal training in ED ultrasound, including at Physicians with Ultrasound Privileges before January 1, 2012 will be grandfathered in. Thereafter, during the period of provisional privileges, the ED physician must perform 10 studies with the provisional ED reading confirmed either by: 1. Review of ultrasound findings in real time by an emergency physician with full ED Ultrasound privileges. 2.A repeat study in the Medical Imaging Department. 3. Surgical confirmation of ED findings. The accuracy of the studies will be judged on whether or not the study correctly identifies the presence or absence of the ruleout diagnosis. Failure to note findings incidental to the stated goal of the study will not be considered an error on the part of the emergency physician. Likewise, it will not be considered an error if an ED physician considers his or her own scan indeterminate and obtains a definitive scan through the Medical Imaging Department. Indeterminate scans will not count, though, toward the required total of 10 scans for full privileges. If there are errors in the ED physician s interpretation of any of the initial 10 studies, then further training and/or proctoring may be required at the discretion of the Emergency Medicine Chief or EM Administrative Committee. Representative scans from all studies will be kept in the ED for a Continued medical education and proficiency Physicians who perform emergency ultrasound exams will obtain continuing medical education (CME) in ultrasound after the initial training phase. Ultrasound is a learned specialty that requires the maintenance of skill and familiarity with the technology. The amount of CME and the frequency will depend on the number of applications used and developments in emergency ultrasound. This education may include journal club, conference lectures, morbidity and mortality conferences, hands on training courses, or other CME established formats. Page 3 of 6
Ultrasound Continued least 8 hours of "hands on" training, in an period of at least one year. Scans ACEP approved course or courses; plus may be saved either as thermal performance of 10 exams in the ED proctored prints, on video, or on computer by a physician credentialed in ED Ultrasound; disk. plus 16 hours of independent study as in "3", above. C. For routes B.3 and B.4, once formal course training has been completed, the emergency physician will be granted provisional privileges in ED ultrasound. (Note: physicians who have not completed the requirements for provisional credentialing in "B.4." above, with the exception of the independent study requirements, may not use the ultrasound equipment in the ED except under the direct supervision of an ultrasound credentialed physician.) Physicians who meet provisional ultrasound credentialing requirements through methods outlined in B.3 or B.4 are expected to complete independent study requirements during their period of provisional credentialing. Studies will be performed and documented in accordance with the guidelines in the SMCS ED Ultrasound Manual. Once the ED physician has satisfactorily completed 10 studies he or she will be eligible for full (non proctored) privileges in Emergency Department Ultrasound (Continued on next page) D. During the period of provisional privileges, the ED physician must perform 10 studies with the provisional ED reading confirmed either by: 1. Review of ultrasound findings in real time by an emergency physician with full ED Ultrasound privileges. 2. A repeat study in the Medical Imaging Department. 3. Surgical confirmation of ED findings. The accuracy of the studies will be judged on whether or not the study correctly identifies the presence or absence of the rule out diagnosis. Failure to note findings incidental to the stated goal of the study will not be considered an error on the part of the emergency physician. Likewise, it will not be considered an error if an ED physician considers his or her own scan indeterminate and obtains a definitive scan through the Medical Imaging Department. Indeterminate scans will not count, though, toward the required total of 10 scans for full privileges. If there are errors in the ED physician s Page 4 of 6
Ultrasound Continued interpretation of any of the initial 10 studies, then further training and/or proctoring may be required at the discretion of the Emergency Medicine Chief or EM Administrative Committee. Representative scans from all studies will be kept in the ED for a period of at least one year. Scans may be saved either as thermal prints, on video, or on computer disk. SURGERY [ ] Cricothyrotomy [ ] Debridement, revision, repair and closure of wounds of skin, soft tissues and mucous membranes [ ] Incision and drainage of superficial abscesses and hematomas [ ] Lumbar puncture [ ] Tube thoracostomy [ ] Abdominal paracentesis [ ] Pericardiocentesis [ ] Peripheral and central vascular catheterization [ ] Vascular cutdown [ ] Intracardiac injection [ ] Open chest cardiac massage [ ] Arterial cannulation for monitoring [ ] Sigmoidoscopy UROLOGY [ ] Insertion of urethral catheters, filiforms and sounds [ ] Urinary bladder aspiration by needle or trochar OTHER [ ] Problems of a general nature in Pediatrics, OB/GYN, viral infections etc. E. Once the ED physician has satisfactorily completed 10 studies he or she will be eligible for full (nonproctored) privileges in Emergency Department Ultrasound. Page 5 of 6
Acknowledgment of Practitioner: I understand that (a) in exercising clinical privileges granted, I am constrained by Medical Staff Policies and Procedures, Rules and Regulations, and (b) any restriction on the clinical privileges granted to me is waived in an emergency situation and in such situation my actions are governed by the applicable section of the Medical Staff Bylaws. By completing and submitting this privilege delineation form, you are attesting that you have performed the stipulated number of procedures as indicated above. ********************************************************************************************************************************* COMMITTEE APPROVALS Department QI/Administrative Committee Date: Or Dept Chief (in lieu of mtg) Credentials Committee Date: Medical Executive Committee Date: Board of Directors Date: TEMPORARY PRIVILEGE APPROVAL Department Chief: Date: DOCUMENT APPROVALS Emergency Medicine Administrative Committee: Date: 10/27/2011 Credentials Committee Date: 01/10/2012 Medical Executive Committee Date: 01/24/2012 Board of Directors Date: 02/13/2012 Page 6 of 6