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1 SPECIALTY OF EMERGENCY DEPARTMENT NURSE PRACTITIONER (Pediatric Hspital Facilities) Delineatin f Clinical Privileges Criteria fr granting privileges: Current natinal bard certificatin in the apprpriate advanced practice nursing specialty Current unencumbered license t practice as a Registered Nurse and as a Nurse Practitiner (APN) in the state(s) f his/her practice. Educatin in the apprpriate specialty at the masters r dctral level Current Drug Enfrcement Agency (DEA) number and registratin in the state(s) f his/her practice, as applicable. Current unencumbered Tennessee Nurse Practitiners (APN) Certificate with prescriptive authrity Current PALS certificatin Applicants will be requested t prvide dcumentatin f practice and current clinical cmpetence as defined n the attached cmpetency grid. Applicants have the burden f prducing infrmatin deemed adequate by the hspital fr a prper evaluatin f current clinical cmpetence, and ther qualificatins and fr reslving any dubts. Current Clinical Cmpetence - MLH In additin t the required educatin, experience and/r training specified n each DOP (Delineatin f Privilege) frm, dcumentatin f current clinical cmpetence is required. TJC (The Jint Cmmissin) describes current clinical cmpetence as having perfrmed the privilege recently and perfrmed it well. Current clinical cmpetence is assessed prir t granting privileges initially and is reassessed when renewing privileges at reappintment fr maintenance f privileges. Current Clinical Cmpetence (CCC) may be lcatin specific (acute hspital care/surgery center (ASC) and/r age specific (adult, pediatric,nenatal). This shuld nt be cnfused with FPPE (Fcused Prfessinal Practice Evaluatin) FPPE: an evaluatin f clinical cmpetence f all new privileges as perfrmed at the specific licensed MLH facility (MHMH, MHOBH, Fayette, MECH) fr which they have been initially granted. This applies t privileges fr all new applicants as well as t new/additinal privileges fr current members. Bth FPPE and current clinical cmpetence assessments are privilege-specific. FPPE is cnducted during the perid after granting new/additinal privileges. FPPE must ccur at the MLH facility(ies) where privileges/membership are held. Current clinical cmpetence may be evaluated frm case lgs prvided by nn-mlh facilities. Current Clinical Cmpetence: Requirements fr New Applicants If applying directly frm training, r based n the training received in a frmal training prgram, prvider shuld submit case* lgs frm the prgram authenticated by the prgram directr alng with their recmmendatin attesting t the cmparable training, experience and qualificatins relative t the criteria fr the clinical privileges requested. 1

2 If applying mre than 1 year after training cmpletin, submit the fllwing: Aggregate data frm acute care r surgery center facility fr the previus 12 mnth time perid, identifying the tp 10 diagnsis cdes and the number f patients per cde. Any cmplicatins/pr utcmes shuld be delineated and accmpanied by an explanatin. Prcedure list frm acute care r surgery center facility fr the previus 12 mnth time perid, identifying the tp 10 CPT/ICD cdes and the number f prcedures per cde. Any cmplicatins/pr utcmes shuld be delineated and accmpanied by an explanatin. Case lgs (see specificatins belw) fr any special privileges requested that meet the criteria specific fr the number f prcedures defined fr current clinical cmpetence. Current Clinical Cmpetence: Maintenance f Privileges fr Current Practitiners Practitiner shuld submit the fllwing: Aggregate data frm acute care r surgery center facility fr the previus 12 mnth time perid, identifying the tp 10 diagnsis cdes and the number f patients per cde. Any cmplicatins/pr utcmes shuld be delineated and accmpanied by an explanatin. Prcedure list frm acute care r surgery center facility fr the previus 12 mnth time perid, identifying the tp 10 CPT/ICD cdes and the number f prcedures per cde. Any cmplicatins/pr utcmes shuld be delineated and accmpanied by an explanatin. Case lgs (see specificatins belw) fr any special privileges requested that meet the specific number f prcedures defined fr current clinical cmpetence. Case Lgs All required case lgs and/r prcedure lists must cntain the fllwing infrmatin at a minimum: Date, patient identifier, CPT/ICD prcedure cde, diagnsis, cmplicatins, and dispsitin, and the facility name, name/title f the persn authenticating the lg, signature, date signed, and cntact infrmatin. If the infrmatin requested is nt available, please prvide an explanatin. *A case is defined as an episde f care either cgnitive r prcedural. Fr interpretive care, case is interpretatin f ne diagnstic study. OPPE (Onging Prfessinal Perfrmance Evaluatin) The Jint Cmmissin (TJC) requires OPPE peridically (mre frequently than annually) in the facility where membership/privileges are held. T assure OPPE requirements are satisfied, the practitiner must peridically exercise the privileges in the MLH facility(ies) where he/she has membership. OPPE must ccur regularly n patient encunters in the MLH facility(ies) where privileges/membership are held. 2

3 Specialty/Prcedure Delineatin f Privilege Frm Educatin/Training Dcumentatin fr Initial Granting Initial Applicatin (Prf f current clinical cmpetence) FPPE Validatin f cmpetence after appintment and/r granting f a new r additinal privilege (T be cmpleted within ne year) Maintenance Requirements Nurse Practitiner Pediatric Emergency Medicine Cre Current natinal bard certificatin in the apprpriate advanced practice nursing specialty Current, unencumbered license t practice as a Registered Nurse and as a Nurse Practitiner (APN) in the state(s) f his/her practice. Educatin in the apprpriate specialty the masters r dctral level Current unencumbered Nurse Practitiners (APN) Certificate with prescriptive authrity Current Drug Enfrcement Agency (DEA) number r registratin in the state(s) f his/her practice, as applicable Current PALS certificatin Case lg dcumenting 10 utpatient encunters during the previus 12 mnths at the practitiners primary practice facility First 5 cases MLH Data will be btained fr practitiners when available, the applicant shuld supply additinal case lgs frm ther facilities HIM departments, if necessary, t meet the minimum requirement(s) t be cnsidered fr the privilege. If n activity is fund, applicant shuld supply case lgs frm ther facilities HIM departments t meet the minimum requirement(s) t be cnsidered fr the privilege. Aggregate data submitted shuld include the tp 10 diagnsis cdes, with the number f inpatients per cde, and prcedure lists indicating the tp 10 CPT/ICD cdes, with the number f prcedures per cde fr the previus 12 mnths. Any cmplicatins/pr utcmes shuld be delineated and accmpanied by an explanatin. Scpe f Service and Respnsibility: Scpe f service is based upn educatin, clinical training, demnstrated skills and capacity t manage prcedurally related cmplicatins. The Nurse Practitiner will cllabrate with the supervising physician in admitting, managing care, and discharging patients frm the hspital. The Nurse Practitiner shall be in cmpliance with all applicable state and hspital rules including, but nt limited t, supervisin, prtcls, patient reviews, and prescriptins.

4 Clinical Supervisin Requirements: The supervisin f the Nurse Practitiner will be cmpliant with all applicable state rules and regulatins and specifically as utlined in Rules f Tennessee Bard f Medical Examiners Divisin f Health Related Bards Chapter and Rules f Tennessee Bard f Nursing Chapter Cre Nurse Practitiner Privilege: The privileges shall be fr all pediatric emergency patients frm 0-18 years f age seen at the pediatric hspital facilities n an utpatient basis. Cnsistent with the intent f the state rules and regulatins, privileges serve the purpse t maximize the cllabrative practice f Nurse Practitiners and supervising physicians in a manner cnsistent with quality health care delivery. Therefre, written prtcls develped jintly by the supervising physician and the Nurse Practitiner will guide the nging medical management f patients and the fllwing privileges. 1. Perfrm and dcument initial and subsequent histry and physicals. Once every ten (10) business days the supervising physician shall make a persnal review f the histrical and therapeutic data and shall s certify by signature. 2. Develp wrking assessments and rder necessary diagnstic studies. 3. Draw diagnstic cnclusin. 4. Plan and prescribe treatment accrding t apprved prtcls, e.g. cmfrt measures, restrative care, further testing, fllw-up care, and patient educatin/cunseling. 5. Recrd and dcument assessments, rders, diagnstic cnclusins, and treatment plans n the medical recrd. 6. The Nurse Practitiner may write prescriptins, and any prescriptin written and signed by the Nurse Practitiner under the supervisin and cntrl f a supervising physician shall be deemed t be that f the Nurse Practitiner. Cntrlled substances may be prescribed cnsistent with state rules and regulatins. 7. Cllabrate with supervising physician and ther health care prviders t prvide patient care. 8. May prepare a discharge summary, including final diagnsis and prcedures, and incrprate the physical findings, labratry reprts, and the patient s curse in the hspital. In additin the summary will indicate the instructins given the patient in reference t diet, medicatin, physical activity, and fllw-up care. The discharging physician will certify the cmpleted medical recrd. Cre Prcedures: a. Apprved LeBnheur Emergency Department Treatment Prtcls b. Anesthesia tpical/lcal c. Arterial Puncture fr Labratry specimen d. Debridement f first and secnd degree burns e. Epistaxis, nasal packing f. Hernia Reductin umbilical and inguinal g. Intersseus placement h. Lumbar Puncture

5 i. MIC/GT tube replacement j. Nail remval k. Reductin f Rectal prlapse l. Splinting f Extremities m. Subungal hematma evacuatin n. Suprapubic tap. Tth reimplantatin Prcess Prtcl: The Nurse Practitiner in cllabratin with the supervising physicians identifies the fllwing evidence-based resurces, texts, and reference dcuments that are applicable standards f care and prvide the applicable prcess prtcls fr care management: Pediatric Emergency Department Patient Care Prtcls Griffith s 5 Minute Pediatric Cnsult; Schwartz Textbk f Pediatric Emergency Medicine; Fleisher and Ludwig Pediatric Primary Care fr Nurse Practitiners; Burns, Dunn et al Clinical Guidelines in Child Health; Uphld & Graham The Harriet Lane Handbk f The Jhns Hpkins Hspital published by Msby Cnsultatin: The Nurse Practitiner will be managing Primary, Secndary, and Tertiary care cnditins fr the abve described patient ppulatin. In general, cmmunicatin with a physician will be sught fr all f the fllwing situatins and any thers deemed apprpriate: Whenever situatins arise which g beynd the intent f the Prtcls r the cmpetence, scpe f practice r experience f the Nurse Practitiner Whenever patient cnditins fail t respnd t the management plan in an apprpriate time. Any rare r unstable patient cnditins. Any patient cnditins which d nt fit the cmmnly accepted diagnstic patterns fr a disease r disrder.

6 Any unexplained physical examinatin r histrical finding. At the request f the patient, the Nurse Practitiner r the physician. All emergency situatins after initial stabilizing care has been started. Whenever a physician is cnsulted, a ntatin t that effect, including the physician s name, must be made in the medical recrd. Special Prcedures: The applicant must prvide dcumentatin f current clinical cmpetence in perfrming the prcedure cnsistent with the criteria set frth in medical staff plicies gverning the exercise f specific privileges and the appended cmpetency grid. Applicants have the burden f prducing infrmatin deemed adequate by the hspital fr a prper evaluatin f current clinical cmpetence, and ther qualificatins and fr reslving any dubts.

7 Nurse Practitiner Pediatric Emergency Department Clinical Privileges Check belw the particular privileges desired as Nurse Practitiner fr each facility: Privilege Descriptin Age Limitatins Nurse Practitiner Pediatric Emergency Department Cre Nenates (0-28 days) Please check () applicable age categries fr each privilege requested. Methdist Healthcare Memphis Hspitals (MHMH) Methdist Extended Germantwn, Le Bnheur Medical Center, Care Hspital (MECH) Nrth, Suth & University, Outpatient Clinics & Diagnstic Facilities Infants (29 days 2 Years) Children & Adlescents (2-18 years) Adults & Adlescents (13 & Abve) Adults (18 & Abve) Methdist Healthcare Olive Branch Hspital (MHOBH) All Ages Specialty Fcus: cnditin(s), disease(s) fr the patient ppulatin (e.g. pediatric neurlgy, adult cardilgy) Limitatins Emergency Medicine, Pediatric Hspital Facilities Clinical privileges are granted nly t the extent privileges are available at each facility. Darkly shaded areas represent privileges nt available t any practitiner due t the privilege nt being ffered by the facility. Acknwledgement f practitiner I have requested nly thse privileges fr which by educatin, training, current experience and demnstrated perfrmance I am qualified t perfrm and fr which I wish t exercise at the facilities indicated abve, t the extent services are available at each facility, and I understand that: (a) in exercising any clinical privileges granted, I am cnstrained by facility and medical staff plicies and rules applicable generally and any applicable t the particular situatin (b) any restrictin n the clinical privileges granted t me is waived in an emergency situatin and in such situatin my actins are gverned by the applicable sectin f the medical staff bylaws r related dcuments Practitiner's Signature Date Printed Name

8 Acknwledgement f spnsr I agree t abide by the clinical supervisin respnsibilities listed and the Nurse Practitiner will abide by the privileges utlined abve and the apprpriate facility Medical Staff Rules and Regulatins. Signature (N Stamps) Emplying r Supervising Physician Date: Printed Name ID #

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