APPLICATION FOR ADVANCED PROCEDURE S PROFESSIONAL STAFF WITH S (PSP) Advanced Procedure Privileges: Are those approved procedural privileges requiring additional education and training and may be granted only upon evidence of initial and ongoing competency. INSTRUCTIONS 1. Professional Staff Privileged providers requesting advanced procedure privileges must do so using this form. Requests with supporting documentation are submitted to Provider Support Services and thereafter reviewed by the Joint Practice Committee. Colposcopy, Moderate Sedation, and Nitrous Oxide administration privileges require additional forms available through Provider Support Services. 2. Supporting Documentation: Requests for advanced procedure privileges at initial appointment, reappointment and additional privilege additions must be supported by the following: Log of procedures performed indicating MR #, date, proceduralist, preceptor, and name of procedure; and/or *simulation/animal lab certificate of completion as appropriate. Current procedural protocols are on file with The Center for Advanced Practice Nursing & Allied Health (CAPNAH) Required forms must be signed by supervising physician. 3. Advanced procedures will only be approved if medically necessary as an integral part of the provider s scope of practice. 4. Competency threshold numbers are minimum baselines and may be increased at the discretion of the supervising physician. 5. All providers privileged advanced procedures are subject to the mandates of focused professional practice evaluation (FPPE) and ongoing professional practice evaluation (OPPE). 6. If a procedure is not listed below, please refer to the Application for Adding Advanced Procedures. Formal review and approval of this application by the Joint Practice Committee is necessary before a provider may be privileged the procedure. *APSC Position Statement on Simulation for Competency Requirements The Advanced Practice Standards Committee accepts simulation as a way to meet competency in procedural requirements for Advanced Practice Professionals (APP). Simulation may be used when there are insufficient opportunities to meet competency requirements within a patient population. Appropriateness of simulation for demonstration of procedural competency is at the discretion of APP Leader in collaboration with the supervising physician(s). Competency is defined as the acquisition of knowledge skills and abilities at a level of expertise sufficient to accurately perform the procedure. Simulation is a technique used to replace or amplify real experience in an interactive manner. Simulation training must include a summative assessment which includes a return demonstration. A Competency Certificate must be awarded to the Advanced Practice Provider upon completion of an approved simulation training. Standards of Competency will be determined by the AP Leader and supervising physician(s). Off-site simulation training for procedural competency must be subject to approval by the Advanced Practice Leader and supervising physicians. Qual Saf Health Care. Oct 2004; 13(Suppl 1): i2 i10. doi: 10.1136/qshc.2004.009878 Harvey, L., 2004 14, Analytic Quality Glossary, Quality Research International, http://www.qualityresearchinternational.com/glossary/ 1
APPLICATION FOR ADVANCED PROCEDURE S PROFESSIONAL STAFF WITH S (PSP) Practitioner Name: Department: Location: Primary Supervising Physician: The initial and continued competency requirements are subject to validation and attestation of competency and requirements may be increased based on national standards or at the supervising physician s discretion. Advanced Procedures Initial Adding Reappointment FOR REFERENCE ONLY: INITIAL (DOCUMENTED OVER AN APPOINTMENT ( BE OBTAINED PERIOD AND REVIEWED BY Appendicostomy & Cecostomy Tube & Management Arterial Line, Insertion Arterial Sheath, Removal Arteriotomy Closures- femoral Arthrocentesis BIOPSIES Bone Marrow biopsy / aspiration Cervical biopsy Endometrial biopsy FNA/Core/Percutaneous Needle Biopsy 10 5 2
APPLICATION FOR ADVANCED PROCEDURE S PROFESSIONAL STAFF WITH S (PSP) (DOCUMENTED INITIAL OVER AN APPOINTMENT ( BE OBTAINED PERIOD AND REVIEWED BY Prostate biopsy Shave biopsy Skin biopsy Skin punch biopsy Bone markers, insertion Bone markers, placement Bone Marrow Harvest/Assist 4 2 Botox Injections Bowel Irrigation Bronchoscopy for Lavage Cantherone Treatments for Mulluscum Blistering agent Cardiac Ventricular assist device optimization Central Venous line, insertion Cervical collar management and removal Pediatric Cervical Immobilization Chemical or Talc Pleurodesis, bedside Chemical Peel dermatology Chest Tube, insertion (for fluid or air) Chest Tube, removal Closed/open/percutaneous surgical drain: management & removal Complex laceration repair Complex wound management 3
APPLICATION FOR ADVANCED PROCEDURE S PROFESSIONAL STAFF WITH S (PSP) INITIAL (DOCUMENTED OVER AN APPOINTMENT ( BE OBTAINED PERIOD AND REVIEWED BY Cryosurgery skin lesions CSF draw from EVD, lumbar drains, externalized shunts Cystoscopy, stent removal, urethral dilation, Electrodessication and curettage superficial skin cancers EMG Uroflow Endotracheal intubation - NEONATAL 3 3 Endotracheal Intubation PEDIATRIC/ADULT 5 3 Epicardial pacing wire removal - PEDIATRIC Epicardial pacing wires, removal Epistaxis control - PEDIATRIC Escharotomy 3 3 Excision of toenail or fingernail with digital blocking - PEDIATRIC Facet and joint injections/aspiration Facet and other joint injections/aspirations - PEDIATRIC Facet and joint injections/aspiration - Image guided joint injections (Interventional radiology) Femoral arterial sheath insertion Filler injections dermatology Fracture closed reduction (casting/splinting/traction) Fracture/dislocation immobilization Gastrostomy tube, exchange and removal Hemorrhoid banding 4
APPLICATION FOR ADVANCED PROCEDURE S PROFESSIONAL STAFF WITH S (PSP) INITIAL (DOCUMENTED OVER AN ( BE OBTAINED APPOINTMENT PERIOD AND REVIEWED BY Incision and drainage of minor abscess (perirectal, breast, axillary, extremity, skin, etc.) Irrigation and Drainage of - PEDIATRIC - Superficial Abscess - Paronychia - Sebaceous cyst Incision and drainage thrombosed hemorrhoids Injection bulking agents; botox urology 5 3 Instillation of antibiotics/tpa into EVD Intense pulse light (IPL) removal benign lesions, photo-damaged skin Intraaortic balloon pump, removal Intracranial Pressure (ICP) Monitor Placement Intrathecal baclofen trial - PEDIATRIC Intrathecal pump myleogram - PEDIATRIC Intrathecal pump myleogram 5 3 Intrathecal pump myleogram refill - PEDIATRIC Intrathecal pump myleogram refill 5 3 Intrathecal pump reprogram - PEDIATRIC Intrathecal pump reprogram 5 3 Joint aspirations PEDIATRIC Joint Injections/Aspiration Joint Injection - Trochanteric hip injections Lap band adjustment Laser hair removal Laser treatment, leg veins 5
APPLICATION FOR ADVANCED PROCEDURE S PROFESSIONAL STAFF WITH S (PSP) INITIAL (DOCUMENTED OVER AN APPOINTMENT ( BE OBTAINED PERIOD AND REVIEWED BY Lumbar puncture 3 3 Lumbar puncture with drain insertion Lysis labial adhesions Nasopharyngeal endoscopy Needle Decompression 3 3 Needle Localization 10 5 Neurostimulator analyze/program 10 5 Occipital nerve block 3 3 Ommaya reservoir - access Oropharyngeal soft tissue biopsies Paracentesis 5 5 Percutaneous drain insertion - Superficial 5 5 Photodynamic therapy-dermatology Placement of LHRH agonists urology Placement of negative pressure dressing Pulmonary Artery Catheter, insertion 5 5 6
APPLICATION FOR ADVANCED PROCEDURE S PROFESSIONAL STAFF WITH S (PSP) SCOPE OF PRACTICE GUIDE: Use as reference when selecting for competency thresholds and approval PEDIATRIC NEONATAL ADULT INITIAL ( BE OBTAINED (DOCUMENTED OVER AN APPOINTMENT PERIOD AND REVIEWED BY Reduction of dislocations Reduction of finger and toe dislocations Reduction of Nursemaid elbow PEDIATRIC Removal double J stent Screening Ultrasound: scrotal, prostate, renal 10 5 Shunt reprogramming Shunt reprogramming - PEDIATRIC Shunt Tap Shunt Tap - PEDIATRIC Shuntograms Shuntograms - PEDIATRIC Slit lamp examination with or without foreign body removal Small-vein sclerotherapy dermatology Splinting of sprains Suturing simple/ minor lacerations -PEDIATRIC Suturing simple/minor lacerations TCA application anal condyloma Thoracentesis Thrombin Injection for Pseudoaneursym Tonometry Tracheostomy decannulation - PEDIATRIC 7
APPLICATION FOR ADVANCED PROCEDURE S PROFESSIONAL STAFF WITH S (PSP) SCOPE OF PRACTICE GUIDE: Use as reference when selecting for competency thresholds and approval PEDIATRIC NEONATAL ADULT INITIAL ( BE OBTAINED (DOCUMENTED OVER AN APPOINTMENT PERIOD AND REVIEWED BY Tracheostomy, decannulation Tracheostomy downsize/exchange/upsize Transthoracic catheter removal Trephination of subungual hematoma Trigger point injections 3 3 Tunneled Catheter Insertion Tunneled Catheter Removal/Repair Tunneled Catheter with Reservoir Removal Umbilical arterial catheter, insertion 3 3 Umbilical venous catheter, insertion 3 3 Vasectomy 10 5 Video Urodynamics - PEDIATRIC Video Urodynamics 5 2 8
APPLICATION FOR ADVANCED PROCEDURE S PROFESSIONAL STAFF WITH S (PSP) Initial Appointment Proctor Approval: I have instructed, observed, or supervised throughout the required number of procedures for the provider listed below who is requesting advanced procedure privileges as delineated. I attest that he/she is competent the requested procedures unsupervised, based on established practice protocols, unless otherwise noted. Reappointment Proctor Approval: I have reviewed the procedural notes and technique for procedures for the provider listed below who is requesting continued advanced procedure privileges as delineated. I attest that he/she is competent the requested procedures unsupervised, based on established practice protocols, unless otherwise noted. Proctor (Privileged APRN/PA/MD) signature: Date: Proctor printed name: Requesting Practitioner signature: Date: Requesting Practitioner printed name: Department Approvals: Supervising Physician signature: Date: Supervising Physician printed name: Department Chair/Chief of Staff signature: Date: Department Chair/Chief of Staff printed name: 9