KALEIDA HEALTH Name Date DELINEATION OF PRIVILEGES - OPHTHALMOLOGY 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 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. Admission and Discharge privileges at Kaleida Health facilities to include hospital inpatients, ambulatory service center patients and other categories of patient admissions. History and Physical for diagnosis and treatment plan EYELIDS: Blepharotomy; drainage of eyelid abscess Xanthelasma, plastic excision and repair Excision of nevus or papilloma Lid margin lesion, benign or malignant; block excision & plastic repair with graft Blepharoplasty for redundant skin or herniation of orbital fat through orbital septum Canthoplasty Plastic restoration of eyebrow by graft Blepharorraphy, tarsorrhaphy, canthoplasty Lid lacerations, reconstruction and plastic repair Ptosis, plastic correction: Levator resection/illif or similar method Entropion or ectropion, plastic repair, muscle or tarsal resection or imbrication with graft (cicatricial) Temporal artery biopsy ORBIT: Orbitotomy; for exploration, abscess, foreign body, tumor or pseudo-tumor; fracture of orbit with repair; decompression Exenteration or evisceration of orbit Orbital injection of alcohol for pain GLOBE: Enucleation or evisceration with or without implantation Secondary implantation; plastic restoration of orbital volume Repair of perforated globe Paracentesis, treatment or diagnosis, aspiration Pterygium, excision Curettage and cautery of corneal ulcer Removal of intraocular foreign body with or without magnet Excision, lesion of iris, malignant or non-malignant Excision, lesion of ciliary body, cyclectomy Repair of iridodialysis (CON T) Cataract extraction Intraocular lens implantation and removal Repair of wound for flat anterior chamber Anterior vitrectomy (including pars plana) Muscle operation for squint Astigmatic Keratotomy CONJUNCTIVA: Suture of conjunctiva for laceration Biopsy Excision of Lesion Conjunctivoplasty: Free graft with conjunctiva Free graft with buccal mucous membrane Flap operation for ulcer, perforation of operative wound Repair of symblepharon LACRIMAL: Drainage, lacrimal gland abscess, I & D Drainage, lacrimal sac abscess Excision, lacrimal gland Excision, lacrimal sac Catheterization, nasolacrimal duct Plastic repair of severed or lacerated canaliculus Dacryocystorhinostomy Closure, punctum Dilation and/or irrigation of punctum or canaliculus Probing, nasolacrimal duct GLAUCOMA: Intraocular surgery for glaucoma, peripheral iridectomy and filtering LASER SURGERY: Iridotomy Lysis of suture Lysis of adhesions Trabeculoplasty Retinal Photocoagulation Capsulotomy Ophthalomology 5/2017
Ophthalmology Name: Page 2 LEVEL II PRIVILEGES - ADULT Muscle Transposition Antimetabolites (Glaucoma Surgery) (Two three-hour CME-approved courses on use of antimetabolites or completion of a Glaucoma Fellowship. Botulinism Injections (Oculo-Plastic Fellowhip or two three-hour CME-approved courses on the use of botulinum injections and two satisfactory cases performed under supervision of an Fascia Lata Sling for Ptosis (Oculo-Plastic Fellowship or two satisfactory cases performed under supervison of an ophthalmologist with privileges for this procedure) Epikeratophakia (Four three-hour CME-approved courses in epikeratophakia and two satisfactory cases performed under supervison of an Penetrating Keratoplasty ophthalmologist with privileges for this procedure or approval from Program Director with certified list of at least five monitored successful cases or completion of a Corneal Fellowship) Radial Keratotomy (Two four-hour CME-approved courses in radial keratotomy and two satisfactory cases performed under the supervision of an ophthalmologist with privileges for this procedure or completion of a Corneal Fellowship) Implanatation of Glaucoma Drainage Devices (Completion of a Glaucoma Fellowship or procedure specific credentialing during residency or satisfactory completion of four cases supervised by an ophthalmologist credentialed for this procedure.) Deep Anterior Lamellar Keratoplasty (DALK) Endothelial Keratoplasty (DSEK) * LEVEL III PRIVILEGES - ADULT Repair of Retinal Detachment Posterior Vitrectomy Laser Endophotocoagulation *
Ophthalmology Name: Page 3 LEVEL II PRIVILEGES - PEDIATRIC Muscle Transposition (Pediatric Fellowship or two satisfactory cases performed under supervision of an ophthalmologist with privileges for this procedure) Antimetabolites (Glaucoma Surgery) (Two three-hour CME-approved courses on use of antimetabolites or completion of a Glaucoma Fellowship or Pediatric Fellowship) Botulinism Injections (Pediatric or Oculo-Plastic Fellowhip or two three-hour CME-approved courses on the use of botulinum injections and two satisfactory cases performed under supervision of an Fascia Lata Sling for Ptosis (Pediatric or Oculo-Plastic Fellowship or two satisfactory cases performed under supervision of an ophthalmologist with privileges for this procedure) Penetrating Keratoplasty ophthalmologist with privileges for this procedure or approval from Program Director with certified list of at least five monitored successful cases or completion of a Corneal Fellowship) Implanatation of Glaucoma Drainage Devices (Completion of a Pediatric Fellowship or procedure specific credentialing during residency or satisfactory completion of four cases supervised by an ophthalmologist credentialed for this procedure.) Deep Anterior Lamellar Keratoplasty (DALK) Endothelial Keratoplasty (DSEK) * LEVEL III PRIVILEGES - PEDIATRIC Glaucoma Under Age 2 (Completion of Pediatric Ophthalmology Fellowship) Cataract Under Age 1 (Completion of Pediatric Ophthalmology Fellowship) Repair of Retinal Detachment Posterior Vitrectomy Laser Endophotocoagulation *
Ophthalmology 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. * 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. Adults Pediatrics *
Ophthalmology 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 below) 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 (1) I recommend approval of the procedures requested by the applicant. a) as requested b) as amended, (2) That I, the Chief of Service, have consulted with the Chief of the Division of Pediatric Surgical Services concerning any requests of this applicant for Level II/III privileges on patients below the age of 18. / Signature of Chief of Service Date APPLICANT: PLEASE RETAIN A COPY OF THIS SIGNED DELINEATION FOR YOUR RECORDS