DELINEATION OF PRIVILEGES - NEUROSURGERY

Transcription

1 KALEIDA HEALTH Name Date DELINEATION OF PRIVILEGES - NEUROSURGERY 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. Procedures are separated into levels of complexity (Level I-A*, Level I, Level II, and Level III), which require increasing levels of education and experience. In general, procedures learned during residency are grouped in Level I-A or Level I and are granted upon evidence of successful completion of residency training. Level II procedures may or may not require evidence of additional training beyond residency. Documentation of additional training and/or experience is required for all Level III procedures. LEVEL I-A PRIVILEGES* These procedures generally do not involve surgery and are limited to consultations and minor procedures. Physicians must have satisfactorily completed an ACGME approved Neurosurgery Residency Program or equivalent. History and Physical for diagnosis and treatment plan Lumbar puncture Insertion of percutaneous arterial catheter Insertion of lumbar spinal drain C1-2 tap Puncture ventricular shunt Epidural injection of medication Myelography * Requirements* * 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. Physicians must have satisfactorily completed an ACGME approved Neurosurgery Residency Program or equivalent. Basic Procedures including: Admission and Follow-Up History and Physical for diagnosis and treatment plan* Vena cava (intervention) Lumbar puncture* Suture laceration Chest tube placement Endotracheal intubation Insertion of percutaneous arterial catheter* Peripheral vein/artery cut down Replacement of tracheostomy tube Swan-Ganz insertion and interpretation Tracheostomy Debride wound Additional Procedures Insertion of lumbar spinal drain* Ventricular puncture with/without drain insertion C1-2 tap* Puncture ventricular shunt* Epidural injection of medication* Myelography* External cranial fixation Halo application Biopsy, superficial, head or neck Arterial puncture, insertion of catheters, injection of dye - angiography ICP monitor insertion Determination of brain death Craniotomy/Craniectomy/Burr Hole Trauma Tumor Abscess/infection Cyst Vascular or revascularization Developmental anomaly Vascular decompression

2 Neurosurgery Name: Page 2 Neuroectomy Seizure Repair cranial or dural defect or lesion Approach and treatment of skull base lesion Insertion or revision of CSF or cyst shunt Sterotactic framed localization of lesion Sterotactic frameless localization Transsphenoidal surgery of pituitary lesion Spinal Procedures Decompression - all levels Stabilization - all levels Cervical with instrumentation Thoracolumbar with instrumentation For treatment excision or repair of: intradural and/or extradural congenital degenerative infectious traumatic neoplastic vascular Implantable pump or stimulator Rhizotomy Axial Fusion Disc Replacement Endoscopy as an Adjunct Cranial Spinal Peripheral nerve Peripheral Nerve Exploration and repair Decompression, avulsion, transposition, or anastomosis peripheral nerve Excision peripheral nerve tumor and biopsy, implantation stimulator, block Surgery of extracranial and vertebral arteries including endarterectomy and grafting procedures Biopsy Muscle CNS and peripheral nerve Vascular Dural LEVEL II PRIVILEGES - Requires documentation of additional training or experience and may require case lists and outcomes. Use intraoperative laser CO2/Yag/KTP - Requires 1.) Completion of approved training program in Laser Surgery of Center /Peripheral Nervous System that addresses: principles of operating Lasers, clinical applications, risks to patients and staff, safety procedures and care of equipment; didactic and practical training with lasers within last year. Or 2.) 4 or more unsupervised cases within last year and training program completed w/in last 3 years. (Attach documentation) Pathology specimens must be obtained as appropriate. Cortical mapping Cryosurgery Diagnostic Angiography Carotid or vertebral artery Endoscopy as primary approach brain spine peripheral transnasal Vertebroplasty Kyphoplasty Thrombolysis IV Functional/ablative rhizotomy/rhizolysis placement brain electrode cordotomy creation lesion brain or spine *

3 Neurosurgery Name: Page 3 LEVEL II PRIVILEGES Conscious Sedation (Adult) 1. Initial Request: Must have completed a Kaleida Health approved training course (documentation required) or training during ACGME Accredited Residency (verification letter from program director required.) 2. Maintenance of privilege: The course needs to be taken again every 4 years. 3. The course can be found at: * LEVEL II PRIVILEGES PEDIATRIC Requires documentation of additional pediatric training or experience. Cranial Procedures (<16 years) Ventricular puncture through burr hole or fontanelle Subdural tap through burr hole or fontanelle Craniotomy/Craniectomy for tumor, trauma, abscess, cyst, vascular lesion, Chiari malformation, or decompression Cerebrospinal fluid diversion (ventriculostomy, spinal reservoir, shunting procedure) Intracranial endoscopy Sterotactic approach for biopsy in conjunction with other procedure Frameless stereotaxy Spinal Procedure (<16 years) Application of orthotic, traction or halo device Laminectomy or laminotomy for spinal tumor, disc, trauma, abscess, cyst, decompression Excision of intervertebral disc, anterior approach, with or without fusion Repair of myelomeningocele Laminectomy for treatment of syringomyelia Lumbar spinal fluid shunt Spinal fusion, posterior Spinal fusion, anterior Insertion of epidural or intrathecal infusion pump Use of spinal stereotaxis in conjunction with any of the above Spinal endoscopy in conjunction with any of the above Peripheral Nerve Procedures (<16 years) Exploration and repair, decompression, trans- position, or anastomosis of peripheral nerve Excision of peripheral nerve Laser Procedures (<16 years) Use of laser in conjunction with any of the above listed pediatric procedures Conscious Sedation (Pediatric) 1. Initial Request: Must have completed a Kaleida Health approved training course (documentation required) or training during ACGME Accredited Residency (verification letter from program director required.) 2. Maintenance of privilege: The course needs to be taken again every 4 years. 3. The course can be found at: *

4 Neurosurgery Name: Page 4 LEVEL III PRIVILEGES ENDOVASCULAR PROCEDURES Requires documentation of endovascular experience and training including letter from Residency Program Director or Certificate from Hands On Program within the last two years. Level of initial supervision will be determined. Intracranial Angioplasty Brachiocephalic Angioplasty Brachiocephalic Stents Carotid Stent Iliac Stents Intracranial Stent Embolization of Arteriovenous Malformation Aneurysm Endovascular Occlusion Embolization of Tumor, Extracranial Embolization of Tumor, Intracranial Test Occlusion/Occlusion of Cranial Vessel Embolization/Carotid Cavernous Fistula (head,neck, spine) Spinal Angiography, Diagnostic Spinal Embolization Thrombolysis, Intraarterial, acute Stroke or Vessel Occlusion * LEVEL III PRIVILEGES PEDIATRIC - Requires documentation of additional pediatric training or minimum 6 months of clinical Pediatric Neurosurgery Fellowship, and experience, including documentation of more than 3 such procedures on children within last 18 months. Untethering of myelomeningocele Repair of untethering of closed or occult dysraphic malformation * Selective sensory rhizotomy Craniotomy for encephalocele, dermal sinus tract, or other cranial developmental malformation Craniectomy, craniotomy, or craniofacial reconstruction of craniosynostosis

5 Neurosurgery 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) 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 et seq.) Signature of Applicant / Date I recommend approval of the procedures requested by the applicant: as requested as amended I have consulted with the Pediatric Surgery COS on / / who agrees to recommend approval of the requested Level II/III privileges for Pediatric care in Neurosurgery. / Signature of Chief of Service Date APPLICANT: PLEASE RETAIN A COPY OF THIS SIGNED DELINEATION FOR YOUR RECORDS (Neurosurg/mso-Reviewed & Revised-12/2015)