Summary of Services and Availability (by location) Each location has sufficient space, equipment, staffing and financial resources in place or available in sufficient time as required to support each requested privilege. On an ongoing basis, the organization consistently determines the resources necessary for each requested privilege related to the facility's scope of service. Please review the following Summary of Services and Availability by Location prior to making your selections. If a facility is specifically identified below as NOT having a privilege/service available, you will NOT be considered for that privilege at that individual facility. Any request made that is identified as not available at an individual site will be considered Not Applicable for that site(s), and will be identified as such on your final approved Delineation of Privileges form. x means Privilege is Available at that location. C means contractual arrangement restricts granting this privilege. means Privilege Not Available at that location. Facility Codes: CHP= Childrens Hospital of Pittsburgh of UPMC, North Privilege Core privileges Consultation privileges HEAD AND NECK Tracheostomy ENDOCRINE Parathyroidectomy and thyroidectomy Excision thyroglossal duct cyst Adrenalectomy, including partial Retroperitoneal Lap-assisted THORA Resection/reconstruction of chest wall Thoracotomy, anterior approach to the spine BREAST Excisional and incisional breast biopsy Operations on the nipple Mastectomy (segmental including node dissections, total, modified radical, subcutaneous) Localization and retrieval of radioactive seeds SLN injection ABDOMEN AND PELVIS Groin hernia repair Ventral hernia repair
Page 2 of 5 Umbilical hernia repair Peritoneal/retroperitoneal dissection (e.g. for exposure of the spine or lymphadenectomy) Exploratory laparotomy/laparoscopy Diaphragmatic Herniorrhaphy ALIMENTARY TRACT Esophagectomy Nissen fundoplication Gastrectomy, gastroenterostomy, gastrostomy Vagotomy except highly selective Highly selective vagotomy Cholecystectomy (all techniques), cholecystostomy, common bile duct exploration Appendectomy Incision, excision, resection of intestine, including placement of enterostomy Hemorrhoidectomy, Stapled hemorrhoidectomy, sphincterotomy, fistulotomy and other techniques Transanal excision/fulguration of anorectal mass Repair enterocele/rectocele* Reconstructive perineal procedures (sphincteroplasty, repair vesico-vaginal-enteric fistula)* Colectomy (all)/colostomy Transanal TEMIS TEMS Splenectomy Abdominoperineal resection ally assisted* Restorative proctocolectomy* Adrenalectomy, including partial
Page 3 of 5 Liver resections* Pancreas resections/debridement Pancreatectomy GENITOURINARY TRACT (In conjunction with other procedures) Insertion cystostomy tube Partial cystectomy, bladder repair Nephrectomy Hysterectomy Salpingooophorectomy SKIN/SOFT TISSUE/BONE Regional lymph node dissections, partial/complete including sentinel node techniques Cervical Axillary Mediastinal Periaortic Pelvic Sentinel Node Biopsy Skin grafting, partial and full thickness Fasciotomy Amputations Biopsy peripheral nerve TRAUMA Pericardial window/pericardiocentesis Lung lobectomy Pneumonectomy Procedures on Esophagus Teletrauma ENDOSCOPY Esophagogastroduodenoscopy/biopsy Esophageal stent placement Percutaneous endoscopic gastrostomy Laryngoscopy Bronchoscopy/biopsy Anoscopy/Proctoscopy Sigmoidoscopy/Colonoscopy/Biopsy/ Polypectomy/Stents BURN SURGERY INTRAOPERATIVE ULTRASOUND ULTRASOUND Focused Abdominal Sonogram for Trauma (FAST) VIDEOMAPPING
Page 4 of 5 Videoassisted parathyroidectomy/thyroidectomy Videoassisted neuroendocrine tumor resection Intraoperative Nuclear Mapping (Gamma Probe) ROBOTICS (Certificate Required) FLUOROSCOPY (Certificate Required) LASER Nd:YAG CO2 KTP:YAG Argon Excimer- 308 nm Diode- 532 nm Diode- 630 nm Diode- 810 nm Diode (Indigo)- 832 nm Ho:YAG ANESTHESIA Moderate Sedation CRITICAL CARE Medical supervision of intensive care unit patients, emergency transport, critical illness, and multi-system organ failure Arterial catheter insertion Central venous and percutaneous dialysis catheter insertion Pulmonary artery catheter insertion Pericardiocentesis Interpretation and management of hemodynamic data Initiation and management of vasoactive and/or antiarrhythmic drug infusions Debrillation/cardioversion Transthoracic echocardiography (limited) Airway management of the non-intubated patient Endotracheal intubation (oral, nasal) Cricothyrotomy Percutaneous tracheostomy Bronchoscopy Thoracentesis Thoracostomy tube insertion/ management Mechanical ventilation initiation and management Renal replacement therapy management Nutritional management of the ICU patient Lumbar puncture Intercostal nerve block Cardiopulmonary resuscitation Abdominal paracentesis Diagnostic ultrasonography Fluoroscopy Administration of intermittent and continuous sedation,
Page 5 of 5 analgesia, and intravenous anesthetics for management of critically ill patients, as well as for moderate and deep sedation PRIVILEGES ONLY FOR PRACTITIONERS APPLYING TO CHILDRENS HOSPITAL OF PITTSBURGH OF UPMC (CHP): Privilege Core privileges- General Surgery Core privileges- Pediatric Surgery Core privileges- Pediatric Surgery Satellite Vascular Surgery Trauma Call Moderate sedation Deep sedation Laser-Argon Laser- CO2 Fluoroscopy (Certificate Required) Telemedicine Revised: 3/6/14