CARDIOLOGY Delineation of Privileges APPLICANT: INITIAL APPOINTMENT REQUIREMENTS: BASIC EDUCATION: M.D. or D.O. from an accredited school of medicine or osteopathy. Successful completion of an ACGME or AOA accredited residency in Internal Medicine and a Fellowship in Cardiology. BOARD CERTIFICATION: Board certified in Cardiology. Applicants who are not board certified in Cardiology, but are in the board certification process, are allowed to perform core privileges provided they completed an ACGME or AOA residency program in the United States and become certified or remain eligible. GRANDFATHER CLAUSE: Exceptions to the board certification/eligibility requirement will be made for those practitioners who have held privileges at Renown Regional Medical Center prior to 7/06. CONTINUING MEDICAL EDUCATON: Provide CME in accordance with the requirements of the State of Nevada for maintenance of Nevada State Medical License. REQUIRED PREVIOUS EXPERIENCE: At least 50 cardiology patients, reflective of the scope of privileges requested, in the past 12 months OR The successful completion of an approved ACGME or AOA residency or clinical fellowship within the past 12 months. Board certification or eligibility must be continuously maintained. MENTORING/PROCTORING Each Associate Staff member will be assigned a mentor/proctor. Qualified applicants are granted privileges and must be proctored/mentored as indicated within this document by a physician with these privileges. All procedures should be performed at a Joint Commission Accredited hospital and mentored/proctored by your assigned mentor/proctor. Members are eligible to request elevation to Active Staff, consistent with the Bylaws and Credentialing Policies of the Medical Staff. For special privileges that have not previously been available at this facility and require proctoring, proctoring may be done at another facility by a proctor with said privileges and the proctoring physician will be required to produce documentation of the procedures and the Renown physician will help ensure this is completed. REAPPOINTMENT REQUIREMENTS: During reappointment all objectively generated data from the quality assurance/peer review process relevant to these privileges will be considered. Reappointment should be based on unbiased, objective results of care according to a hospital s quality assurance mechanism. To be eligible to renew privileges in cardiovascular disease (cardiology), the applicant must demonstrate current competence and an adequate volume of experience with acceptable results, reflective of the scope of privileges requested, for the past 24 months based on results of ongoing professional practice evaluation and outcomes. Evidence of current physical and mental ability to perform privileges requested is required of all applicants for renewal of privileges. 1 of 11
Meadow CARDIOLOGY CORE PRIVILEGES Core privileges for cardiovascular disease include the ability to admit, evaluate, diagnose, treat, and provide consultation to adolescent and adult patients presenting with diseases of the heart and blood vessels and management of complex cardiac conditions. The core privileges in this specialty include the following procedures and such other procedures that are extensions of the same techniques and skills: Perform historical and physical examinations Adult transthoracic performance and interpretation echocardiography Cardioversion emergent and elective EKG interpretation, including signal average EKG Exercise Treadmill Stress Testing Infusion and management of IV Gp IIb/IIIa, thrombolytic, and antithrombolytic agents Insertion & management of central venous catheters, pulmonary artery catheters, & arterial lines Noninvasive hemodynamic monitoring Pericardiocentesis Stress echocardiography (exercise and pharmacologic stress) Tilt table testing Transcutaneous external pacemaker placement Transthoracic 2-D echocardiography, Doppler and color flow Temporary Pacemaker Placement INCLUSION/ EXCLUSION (Check the privilege and identify the privilege you wish to include/exclude) CARDIOLOGY PRIVILEGES Privileges I wish to specifically exclude: SPECIAL NOTE: Please ONLY list those elective privileges for which you no longer wish to be credentialed. Privileges required by the RRMC & RSMMC Medical Staff Bylaws, Rules & Regs to provide appropriate on-call support are not eligible for exclusion. Choosing to list any such mandatory privilege will be considered a voluntary resignation from the medical staff at RRMC & RSMMC, for inability to take specialty call. Only one privilege may be listed per line. Procedures I wish to insure are part of my Privileges based on training and education: Cardiology Privilege Checklist 2 of 11
CARDIOLOGY SPECIAL PRIVILEGES Transesophageal Echocardiography, TEE 1. Must demonstrate training in a fellowship or successful completion of a TEE course 2. Must have Echocardiographic privilege Initial : 3. Three (3) TEE procedures proctored with a physician who has TEE privileges Reappointment requirement: A minimum of three (3) documented TEEs must be done in the previous 24 months. Peripheral vascular interventions, including diagnostic and therapeutic angiography, angioplasty and stenting. 1. Must have Percutaneous Transluminal Coronary Angioplasty (PTCA) privileges. 2. Must attend a recent course that is approved by Cardiology and submit a certificate of successful completion. Initial : 1. of three (3) cases to be done by a physician with this privilege. Cases must be reviewed and approved at a Cardiology Department meeting in order to be released from mentoring. Reappointment requirement: A minimum of three (3) documented peripheral vascular interventions, including diagnostic and therapeutic angiography, angioplasty and stenting must be done in the previous 24 months. Percutaneous Atrial Septal Defect/Patent Foramen Ovale Closure A minimum of five (5) documented percutaneous artial septal defect/patent foramen ovale closure in the previous 12 months. If applicant has no previous experience, they may be proctored on five (5) cases to obtain the privilege. Reappointment requirement: A minimum of five (5) documented percutaneous atrial septal defect/patent foramen ovale closure must be done in the previous 24 months. Cardiac Catheterization and Angiography 1. Documentation of training, which is to include operative reports of ten (10) cardiac catheterizations performed within the last 24 months plus two (2) letters of support. Reappointment requirements: A minimum of ten (10) documented cardiac catheterizations and angiographs must be done in the previous 24 months. IVC Filter Deployment and Retrieval 1. Three years of approved post graduate training in Cardiology and IVC Filter certification letter during Fellowship training. Or 2. Cardiology Fellowship training and completion of an IVC Filter course and three (3) mentored cases Reappointment requirements: A minimum of three (3) IVC Filter Deployment and Retrieval procedures must be done in the previous 24 months. Cardiology Privilege Checklist 3 of 11
Regional CARDIOLOGY SPECIAL PRIVILEGES Permanent Pacemaker 1. Residency training or completion of an implantation course in pacemaker insertion, and provide documentation of having inserted at least 5 pacemakers (leads and generators or 15 lead placements for lead privileges) 2. OR 3. Demonstrated previous experience of more than fifteen (15) patients at an accepted institution without the assistance of a surgeon; 4. OR 5. Attend an accredited course in pacemaker insertions, provide documentation and participate in at least fifteen (15) proctored cases. Reappointment requirements: A minimum of fifteen (15) documented permanent pacemakers must be done with the past 24 months. Intra-aortic balloon pump A minimum of three (3) documented intra-aortic balloon pump insertions in the previous 12 months. If applicant has no previous experience, they may be proctored on three (3) cases to obtain the privilege. Reappointment requirement: A minimum of three (3) documented intra-aortic balloon pump insertions in the previous 24 months. CARDIOLOGY ELECTROPHYSIOLOGY CORE PRIVILEGES Core privileges for Cardiology - Electrophysiology include the ability to admit, evaluate, treat, and provide consultation to acute and chronically ill adolescent and adult patients with heart rhythm disorders, including the performance of invasive diagnostic and therapeutic cardiac electrophysiology procedures. Physicians may also provide care to patients in the intensive care setting in conformance with unit policies. They may assess, stabilize, and determine the disposition of patients with emergent conditions consistent with medical staff policy regarding emergency and consultative call services. The core privileges in this specialty include the procedures on the attached procedures list and such other procedures that are extensions of the same techniques and skills. INCLUSION/ EXCLUSION (Check the privilege and identify the privilege you wish to include/exclude) CARDIOLOGY ELECTROPHYSIOLOGY PRIVILEGES Privileges I wish to specifically exclude: SPECIAL NOTE: Please ONLY list those elective privileges for which you no longer wish to be credentialed. Privileges required by the RRMC & RSMMC Medical Staff Bylaws, Rules & Regs to provide appropriate on-call support are not eligible for exclusion. Choosing to list any such mandatory privilege will be considered a voluntary resignation from the medical staff at RRMC & RSMMC, for inability to take specialty call. Only one privilege may be listed per line. Cardiology Privilege Checklist 4 of 11
Procedures I wish to insure are part of my Privileges based on training and education: CARDIOLOGY ELECTROPHYSIOLOGY SPECIAL PRIVILEGES Catheter Ablation Procedure 1. Fellowship trained in electrophysiological (EP) and radio frequency (RF) catheter ablation, OR 2. Has EP privileges and documentation of a course by a recognized expert in RF catheter ablation. Mentoring: 1. First three (3) cases must be mentored. Reappointment requirements: A minimum of five (5) documented catheter ablation procedures must be done in the past 24 months Implantation or extraction of cardiovascular implantable electronic devices, including pacemakers, ICDs, cardiac resynchronization devices, implantable loop recorders, and implantable cardiovascular monitors 1. Board certified or board eligible Cardiologist. 2. Privileges either active or qualifying for electrophysiolgic studies including ventricular program stimulation and induction of ventricular arrhythmias. 3. Attend a course for continuing education from the company that manufactures the implanted device (currently CPI, Inc.) or Documented previous experience with implantation of five (5) devices during a residency program, then this course is not necessary. Mentoring: 1. First three (3) cases will be mentored. Reappointment requirements: A minimum of three(3) documented cases must be done within the past 24 months. Transseptal Cardiac Catheterization TSCC 1. Board certified or board eligible cardiologists, credentialed in cardiac catheterization. 2. Successful completion of an accredited fellowship program, which includes TSCC training and documentation of ten (10) procedures performed within the past two years. 3. If applicant has no previous experience, they may be mentored on five [5] cases to obtain the privilege. Mentoring: 1. First five (5) cases must be mentored. Reappointment requirements: A minimum of five (5) documented TSCC procedures must be done in the past 24 months. Cardiology Privilege Checklist 5 of 11
CARDIOLOGY ELECTROPHYSIOLOGY SPECIAL PRIVILEGES Electrophysiological Studies A minimum of three (3) documented electrophysiological studies in the previous 12 months. If applicant has no previous experience, they may be proctored on three (3) cases to obtain the privilege. Reappointment requirement: A minimum of three (3) documented electrophysiological in the previous 24 months. External Atrial Stimulation diagnosis/treatment A minimum of three (3) documented external atrial stimulation diagnosis/treatment in the previous 12 months. If applicant has no previous experience, they may be mentored on three [3] cases to obtain the privilege. Reappointment requirement: A minimum of three (3) documented procedures in the previous 24 months. Internal Atrial Stimulation diagnosis/treatment A minimum of three (3) documented internal atrial stimulation diagnosis/treatment in the previous 12 months. If applicant has no previous experience, they may be mentored on three [3] cases to obtain the privilege. Reappointment requirement: A minimum of three (3) documented internal atrial stimulation diagnosis/treatment in the previous 24 months. HIS Bundle Electro-Cardiography A minimum of three (3) documented HIS bundle electro-cardiography in the previous 12 months. If applicant has no previous experience, they may be mentored on three (3) cases to obtain the privilege. Reappointment requirement: A minimum of three (3) documented HIS bundle electro-cardiography in the previous 24 months. Ventricular Stimulation A minimum of three (3) documented ventricular stimulation in the previous 12 months. If applicant has no previous experience, they may be mentored on three (3) cases to obtain the privilege. Reappointment requirement: A minimum of three (3) documented ventricular stimulation in the previous 24 months. Lead Extractions 1. Successful completion of an ACGME approved training program in Cardiology 2. Maintain Permanent Pacemaker privileges Initial : 1. Perform three (3) lead extractions with a physician who has demonstrated expertise in pacemaker lead and extractions. Reappointment requirements: A minimum of three (3) documented lead extractions must be done in the previous 24 months. Cardiology Privilege Checklist 6 of 11
Meadow CARDIOLOGY INTERVENTIONAL CORE PRIVILEGES Privileges in Interventional Cardiology include the ability to admit, evaluate, treat and provide consultation to adolescent and adult patients by use of specialized imaging and other diagnostic techniques to evaluate blood flow and pressure in the coronary arteries and chambers of the heart, as well as technical procedures and medications to treat abnormalities that impair the function of the cardiovascular system. Privileges also include the ability to assess, stabilize and determine the disposition of patients with emergent conditions consistent with medical staff policy regarding emergency and consultative call services. The privileges include but are not limited to the following: Endomyocardial Biopsy Femoral, brachial or radial axillary cannulation for diagnostic angiography or percutaneous coronary intervention Interpretation of coronary arteriograms, ventriculography, and hemodynamics Intracoronary foreign body retrieval Intracoronary infusion of pharmacological agents, including thrombolytics Intracoronary mechanical thrombectomy Intracoronary stents Intravascular ultrasound of coronaries Management of mechanical complications of percutaneous intervention Performance of balloon angioplasty, stents and other commonly used interventional devices Percutaneous transluminal septal myocardial ablation Use of intracoronary Doppler and flow wire Use of vasoactive agents for epicardial and mircovascular spasm INCLUSION/ EXCLUSION (Check the privilege and identify the privilege you wish to include/exclude) CARDIOLOGY INTERVENTIONAL PRIVILEGES Privileges I wish to specifically exclude: SPECIAL NOTE: Please ONLY list those elective privileges for which you no longer wish to be credentialed. Privileges required by the RRMC & RSMMC Medical Staff Bylaws, Rules & Regs to provide appropriate on-call support are not eligible for exclusion. Choosing to list any such mandatory privilege will be considered a voluntary resignation from the medical staff at RRMC & RSMMC, for inability to take specialty call. Only one privilege may be listed per line. Procedures I wish to insure are part of my Privileges based on training and education: Cardiology Privilege Checklist 7 of 11
CARDIOLOGY INTERVENTIONAL SPECIAL PRIVILEGES Percutaneous Transluminal Coronary Angioplasty (PTCA), Cardiac Catheterization and Angiography 1. Must have Cardiac Catheterization and Angiography privilege 2. Successful completion and documentation of a regional or national angioplasty course completed within the previous two (2) years or 3. Completion of an approved fellowship in angioplasty within the previous two years or 4. Documentation of 20 cases within the previous two years Initial Mentoring: 1. Mentoring of five (5) cases at Renown Regional Medical Center or other local hospital by an Active Staff member who has the privilege. Reappointment requirements: A minimum of five (5) documented PTCA, cardiac catheterizations and angiographs must be done in the previous 24 months. Temporary Percutaneous Left Ventricular Assist Device (Impella) Interventional cardiology fellowship and documentation of completion of device training required. Reappointment requirement: A minimum of three (3) documented successful insertions without complications in the previous 24 months. Balloon Valvuloplasty 1. Formal training course or demonstrated training in a fellowship and 2. Three (3) procedures performed in the prior year. OR 3. Professional experience with structural heart cases (not including Percutaneous Atrial Septal Defect/Patent Foramen Ovale Closure) cases and 4. At least three (3) left-sided structural heart cases (not including Percutaneous Atrial Septal Defect/Patent Foramen Ovale Closure) as the primary operator Initial : 1. Two (2) procedures proctored with a physican who has Balloon Valvuloplasty privileges Reappointment Requirement: A minimum of three (3) procedures performed in the prior year. Cardiology Privilege Checklist 8 of 11
Meadow Proctored Regional CARDIOLOGY INTERVENTIONAL SPECIAL PRIVILEGES TAVR Transcatheter Aortic Valve Replacement 1. Performed at least 100 structural heart procedures (lifetime) or 2. 30 left-sided structural procedures in the prior year of which 60% are balloon aortic valvuloplasty (not including Percutaneous Atrial Septal Defect/Patent Foramen Ovale Closure or 3. 20 TAVR procedures in the prior year or 4. 40 TAVR procedures in the prior 2 years OR 5. Must have a formal training course and 6. Professional experience with five (5) left-sided structural heart cases (not including Percutaneous Atrial Septal Defect/Patent Foramen Ovale Closure) cases and 7. At least three (3) left-sided structural heart cases (not including Percutaneous Atrial Septal Defect/Patent Foramen Ovale Closure) as the primary operator mentored by a mentor who has TAVR privileges Initial : 1. Four (4) procedures proctored with a physician who has TAVR privileges Reappointment requirement: A minimum of five (5) TAVR procedures in the prior year or ten (10) TAVR procedures in the prior 2 years. CARDIOLOGY IMAGING CORE PRIVILEGES Privileges in Nuclear Cardiology include the ability to admit, evaluate, treat and consult acute and chronically ill adult patients presenting with confirmed or suspected cardiovascular disease. Core procedures include: SPECT with technetium agents and thallium PET with rubidium and nitrogen agents Planar with technetium agents and thallium ECG gating of perfusion images for assessment of global and regional ventricular function (imaging protocols and stress protocols) Viability assessment, including reinjection and delayed imaging of thallium and metabolic imaging Equilibrium gated blood pool or first pass radionuclide angiography at rest and during exercise or pharmacologic stress Qualitative and quantitative methods of image display and analysis Cardiology Privilege Checklist 9 of 11
INCLUSION/ EXCLUSION (Check the privilege and identify the privilege you wish to include/exclude) CARDIOLOGY IMAGING PRIVILEGES Privileges I wish to specifically exclude: SPECIAL NOTE: Please ONLY list those elective privileges for which you no longer wish to be credentialed. Privileges required by the RRMC & RSMMC Medical Staff Bylaws, Rules & Regs to provide appropriate on-call support are not eligible for exclusion. Choosing to list any such mandatory privilege will be considered a voluntary resignation from the medical staff at RRMC & RSMMC, for inability to take specialty call. Only one privilege may be listed per line. Procedures I wish to insure are part of my Privileges based on training and education: CARDIOLOGY IMAGING SPECIAL PRIVILEGES Equilibrium radionuclide angiocardiography and/or first-pass radionuclide angiography during exercise or pharmacologic stress A minimum of three (3) documented equilibrium radionuclide angiocardiography and/or first-pass radionuclide angiography during exercise or pharmacologic stress in the previous 12 months. If applicant has no previous experience, they may be proctored on [n] cases to obtain the privilege. Reappointment requirement: A minimum of three (3) documented equilibrium radionuclide angiocardiography and/or first-pass radionuclide angiography during exercise or pharmacologic stress in the previous 24 months. MetabolicE imaging using single-photon and/or positron-emitting radionuclides A minimum of three (3) documented metabolice imaging using single-photon and/or positron-emitting radionuclides in the previous 12 months. If applicant has no previous experience, they may be proctored on three (3) cases to obtain the privilege. Reappointment requirement: A minimum of three (3) documented metabolice imaging using single-photon and/or positron-emitting radionuclides in the previous 24 months. Cardiac Nuclear Scan Interpretation & Performance A minimum of ten (10) documented cardiac nuclear scan interpretations in the previous 12 months. Reappointment requirement: A minimum of ten (10) documented cardiac nuclear scan interpretations must be done in the previous 24 months. Cardiology Privilege Checklist 10 of 11
CARDIOLOGY IMAGING SPECIAL PRIVILEGES Cardiovascular Magnetic Resonance A minimum of ten (10) documented cardiovascular magnetic resonance in the previous 12 months. Reappointment requirement: A minimum of ten (10) documented cardiovascular magnetic resonance must be done in the previous 24 months. No procedures may be written in on this list. Any procedure that you may wish to apply for that is not provided for on this list, must be submitted in writing and evaluated for appropriateness for the specialty, trained staff to support the request and equipment needed to perform the request. I hereby request privileges as indicated by my selections above and certify that I am currently competent to perform the procedures I have requested based on my training, recent experience and within the scope of my medical license. I will provide documentation, as required, to support the granting of the privileges requested. I know of no health condition or inability to perform that, without reasonable accommodation, would impair my ability to competently perform these requested privileges. I understand that in making this request I agree to abide by the applicable bylaws, rules and regulations or policies of the hospital and/or medical staff. I further stipulate that I meet the threshold criteria for each privilege request. I also agree that I will practice within the scope of my training, education and Nevada State Licensure. Applicant s Signature: Date: Approved: 7-21-2015 Cardiology Privilege Checklist 11 of 11