Delineation of Privileges

RENOWN REGIONAL MEDICAL CENTER DELINEATION of PRIVILEGES PHYSICAL MEDICINE & REHABILITATION

The Section of PM & R delineates hospital privileges in two spheres of a PM & R practice: Standard core PM & R practice and Interventional Pain management. The standard PM & R core privileges (see appendix A). The Interventional pain management privileges will remain as a separate criteria and credentialing. Practitioners must maintain privileges for the standard PM & R department prior to requesting privileges in interventional pain management.

The standard PM & R criteria:

Requirements for Delineation of Privileges for Standard PM & R Care:

1. Basic Education: MD or DO Minimal Formal Training: Completion of an ACGME accredited residency-training program in a current Board Certification/Eligibility by the American Board of Physical Medicine and Rehabilitation. 2. Hold a current and unrestricted license to practice medicine in the state of Nevada issued by the Nevada State Board of Medical Examiners. 3. Demonstrate the ability to provide continuous specialty-specific on-call coverage to appropriately treat any potential complications of treatment in the event of the practitioner’s unavailability. 4. Participation in Department of PM & R Meetings and Quality Assurance/Peer Review Process.

BOARD CERTIFICATION:

Those applicants who are not board certified at the time of application but who have completed their residency or fellowship training within the last five years shall be eligible for Medical Staff appointment. However, in order to remain eligible, those applicants must achieve board certification in their primary area of practice within five (5) years from the date of completion of their residency or fellowship training.

______Core Privileges in Standard PM & R Care: See appendix A.

Mentoring and elevation to active status:

Each new Associate Staff member will be assigned a mentor. All Physiatrists requesting elevation to Active Staff will have a minimum of twenty cases (consults and/or H & P’s) reviewed by their mentor. This includes both inpatient and outpatient consults. The charts will be provided by Medical Information Systems office to be reviewed by each mentor. Mentor reviews will be carried out in a timely manner to avoid a delay in elevation to active staff. A recommendation, based on reviewed cases, will be forwarded to the Medical Staff Services for consideration by the department for elevation to Active Staff.

Physical Medicine & Rehabilitation Requirements for Delineation of Privileges for Interventional Pain Management:

1. Basic Education: MD or DO 2. Minimal Formal Training: Completion of an ACGME accredited training program in Physical Medicine and Rehabilitation with current Board Certification/Eligibility by the ABPMR. 3. Hold a current and unrestricted license to practice medicine in the state of Nevada issued by the Nevada State Board of Medical Examiners. 4. Demonstrate the ability to provide continuous specialty-specific on-call coverage to appropriately treat any potential complications of treatment in the event of the practitioner’s unavailability. Approved MEC 11/8/05 Approved BOG 1/23/06 Revised MEC 2/14/06 Page 1 of 7 Physical Medical & Rehabilitation RENOWN REGIONAL MEDICAL CENTER DELINEATION of PRIVILEGES 5. Participation in Department of PM & R Meetings and Quality Assurance/Peer Review Process. 6. Training in advanced cardiac life support.

7. Documented successful completion of an accredited medical course providing didactic and procedural (cadaver) training for the lumbar region.

Further criteria for cervical, thoracic, and other special procedures:

8. Conscious sedation certification 9. Fellowship training in an accredited specialty program in PM & R or Anesthesia with current Board Certification/Eligibility by the ABPMR or ABA and/or proof of training in residency in the procedure category (letter from ACGME accredited program director confirming successful completion of training and demonstration of competence to perform special request) and/or Documented successful completion of an accredited medical course providing didactic and procedural (cadaver) training for the special request category with the additional documentation of 500 lumbar procedures.

Each category of interventional pain management will have the first three (3) cases proctored once threshold criteria have been met. The first three (3) cases will require proctoring by another active staff physician within the Department of PM & R holding privileges for the injection Category. The assigned proctor will evaluate patient selection, indications, and technical competence in a written format for each case. These evaluations will be reviewed at the departmental level prior to making a recommendation on granting privileges. Seven(7) additional case/chart reviews will occur via the Q/A and peer review process. If a qualified proctor is not available within the Department of PM & R, a qualified staff physician (presently credentialed for the special request) from another RRMC Department may be utilized and will report to the Department of PM & R. If a qualified proctor within the RRMC system is otherwise unavailable, special arrangements agreeable to the Department of PM & R can be made.

INTERVENTIONAL PAIN MANAGEMENT CATAGORIES (five categories):

I. LUMBAR

______1. Interlaminar, Translaminar, and caudal epidural injections

II. LUMBAR SPECIAL PROCEDURES

______1. Facet blocks; Medial branch blocks; Radiofrequency ablation; Discography

!II. CERVICAL/THORACIC WITHOUT ANESTHESIA

______1. Interlaminar epidural injections; Discography without Anesthesia

IV. CERVICAL/THORASIC WITH ANESTHESIA ______1. Transforaminal epidural injection; Radiofrequency, Facets; MBB; Discography with anesthesia

Approved MEC 11/8/05 Approved BOG 1/23/06 Revised MEC 2/14/06 Page 2 of 7 Physical Medical & Rehabilitation RENOWN REGIONAL MEDICAL CENTER DELINEATION of PRIVILEGES IV. OTHER

______1. Intrathecal Pumps and Spinal Cord Stimulators; Lumbar Sympathetic blocks; Stellate and Celiac ganglia blocks

APPENDIX A FOR STANDARD PM & R CORE PRIVILEGES

The purpose of this document is to provide a list of procedures performed by the physiatrist. This list is not meant to be all-inclusive but does include the kinds of procedure in physician medicine and rehabilitation that demand special degrees of skill and competence. This document is subject to revision from time to time as warranted by the evolution and technology of practice.

These are only suggested criteria that a hospital granting privileges in PM&R may consider when determining what criteria should be utilized in granting such privileges. All decisions relative to criteria governing the granting of privileges are individualized decisions that each hospital must make taking into account factors relevant to the specific needs of the hospital.

Physical Examination:

A. Of pain-weakness-numbness syndromes (both neuromuscular and musculoskeletal) with a diagnostic plan an/or of prescription for treatment, which may include the use of the physical agents and/or other interventions.

1. Including assessment of extent of injury and functional assessment with determination of impairment, intervention, disability and impact on quality of life. B. Including evaluation, prescription and supervision of medical and comprehensive rehabilitation goals and treatment plans for: 1. Stroke syndromes 2. CNS degenerative diseases 3. CNS demyelinating diseases 4. Cranial nerve palsies and brainstem syndromes 5. Cerebral Palsy 6. Cognitive disorders 7. Traumatic brain and/or head injury 8. Communication and swallowing disorders including dysphasia and other related disorders 9. Spinal cord injuries and syndromes 10. Spinal Bifida and/or myelomeningocoele disorders 11. Scoliotic disorders 12. Acute and chronic neuromusculosketal pain syndromes (including but not limited to acute low back, neck, and limb pain, and repetitive stress injuries) 13. Cancer related disorders, impairment and functional limitations 14. Acute and chronic pain and pain syndromes 15. Myopathies and muscular dystrophies 16. Weakness (including poor endurance) 17. Amputation (both congenital and acquired) 18. Hand and/or foot disorders 19. Disorders of the spine and extremities that interfere with an individual’s ability to function and quality of life. 20. Impairments resulting from trauma, fracture, burns and other medical and surgical illnesses and conditions Approved MEC 11/8/05 Approved BOG 1/23/06 Revised MEC 2/14/06 Page 3 of 7 Physical Medical & Rehabilitation RENOWN REGIONAL MEDICAL CENTER DELINEATION of PRIVILEGES 21. Peripheral nerve disorders 22. Pressure ulcers (decubitus) 23. Arthritis and related rheumatic conditions 24. Cardiac/circulatory diseases 25. Peripheral vascular disorders 26. Pulmonary disorders 27. Visual disorders 28. Injuries, illnesses, and undesirable symptoms requiring medical attention related to participation in sports and recreational/fitness related activities, performing arts and occupational related activities. 29. Performing and/or other arts injuries 30. Occupational injuries 31. Other non-surgically urgent disorders requiring rehabilitation

Performance of:

A. Physical medicine and rehabilitation department supervision B. Rehabilitation unit administration and medical direction including administration and medical direction of comprehensive pain and functional restoration programs C. Routine non-procedural medical care D. Routine primary care procedures E. Spinal cord rehabilitation (including neuromuscular, genito-urinary and other advanced techniques) F. Prescription of medication G. Venipuncture H. Arterial Puncture I. Basic and Advanced cardiac life support (American Heart Association) IF CERTIFIED J. Rehabilitation potential determination K. Rehabilitation placement propriety and determination of appropriate level of care to meet patient functional needs (including but not limited to, determination of qualification for comprehensive inpatient rehabilitation, sub acute rehabilitation, home rehabilitation, or outpatient rehabilitation) L. Prescription/administration/supervision of rehabilitation therapies including physical therapy, occupational therapy, speech/language pathology, massage, therapeutic exercise, (pre) vocation and habilitation services, athletic training and other restorative therapies M. Prescription of prosthetic/orthotic and durable medical equipment N. Prosthetic/orthotic and durable medical equipment checkout O. Arthrocentesis; both aspiration and injection 1. Joints (small, intermediate and major) 2. Bursae P. Manipulation /mobilization 1. peripheral 2. spinal a. direct b. indirect 3. cranial Q. Serial casting R. Soft tissue injection 1. Ligament 2. Tendon 3. Sheath 4. Muscle 5. Facial

Approved MEC 11/8/05 Approved BOG 1/23/06 Revised MEC 2/14/06 Page 4 of 7 Physical Medical & Rehabilitation RENOWN REGIONAL MEDICAL CENTER DELINEATION of PRIVILEGES 6. Myofascial trigger point 7. Prolotherapy S. Chemolysis (Paralytic and Non-Paralytic) 1. Intramuscular (motor point) 2. peripheral nerve 3. cauda eqina – [with special training] T. Anesthetic and/or motor blocks 1. peripheral nerve 2. myoneural junction 3. sympathetic chain/ganglia – with references and proctoring 4. caudal 5. facet nerve/joint (may include use of steroid) epidural (may include the use of steroid)) 6. sacroiliac joint U. Interventional pain treatment, as delineated under “Interventional Pain Management” above, including intrathecal medication administration and electrical stimulation (surface and implantable). Interventional means to treat spasticity including botulinum toxin injection and intrathecal pumps. V. Acupuncture W. Hyperbaric oxygen treatments X. Hydrology Y. Work determination status Z. Impairment and disability evaluation

AA. Work hardening and simulation program direction BB. Rehabilitation research CC. Other

Performance and Interpretation of:

A. Electrodiagnosis 1. electromyography 2. electroneurography (nerve conduction studies) 3. special procedures (i.e. repetitive stimulation, single fiber EMG, etc.) B. Somatosensory evoked potentials 1. Non-operative (standard diagnostic) C. Auditory evoked potentials D. Visual evoked potentials E. Intraoperative neurophysiologic studies 1. SSEP 2. MEP (motor evoked potentials) 3. BAEP (brainstem auditory evoked potentials) 4. VEP (visual evoked potentials) 5. EMG 6. Electroneurography (NCS) 7. EEG F. Urodynamic studies 1. cystometrograms 2. sphincter EMG 3. urethral pressure profile 4. uroflow G. Peripheral vascular testing H. Work physiology testing: treadmill and pulmonary ECG monitoring I. Muscle/muscle motor point biopsies [with references and 5 cases] J. Facet joint arthrogram [References and 3 proctored as discussed on EPI’s] K. Discography [References and 3 proctored as discussed on EPI’s] Approved MEC 11/8/05 Approved BOG 1/23/06 Revised MEC 2/14/06 Page 5 of 7 Physical Medical & Rehabilitation RENOWN REGIONAL MEDICAL CENTER DELINEATION of PRIVILEGES L. Small, intermediate or major joint arthrogram M. Gait laboratory studies N. Ergonomic studies O. Muscle strength testing P. Range of motion evaluation Q. Coordination testing R. Radiological and lab procedures, including fluoroscopy S. Dysphagia studies (performance of fiberoptic endoscopic evaluation of swallowing (FEES) T. Assessment for impairments and functional limitations caused by osteoporosis U. Other

MUSCULOSKELETAL SCOPE OF PRACTICE

In the current medical environment, establishing parameters within which a specialist may practice is very important. The following document has been developed to define the appropriate practice for physicians who specialize in Physical Medicine and Rehabilitation (PM&R).

Using skills developed in ACGME accredited training programs; PM&R specialists routinely diagnose and treat inpatients with musculoskeletal and neuromuscular disorders, emphasizing function and rehabilitation. Physical medicine and rehabilitation specialists treat patients of all ages afflicted with painful and function-limiting musculoskeletal disorders of the spine, peripheral joints, and soft tissues such as sprains; strains, disc herniations, rheumatologic conditions and athletic injuries, PM&R specialists also diagnose and treat degenerative, developmental, acquired and traumatic neuromuscular conditions of the upper and lower limbs, spinal cord and brain. It is this unique blend of orthopedic, neuromuscular, pain and rehabilitation training and experience that makes the PM&R specialist an ideal primary or secondary care physician for patients with occupational or sports-related musculoskeletal or neuromuscular injuries. This multidisciplinary training also make the &R physician the most qualified specialist to lead the team of medical specialist and rehabilitation therapists involved in the patient’s rehabilitative care.

Physical medicine and rehabilitation specialists are specially trained to prescribe therapeutic exercise and other rehabilitation modalities. They are expert in the performance and interpretation of electrodiagnostic studies including electromyography, nerve conduction studies, and evoked potentials. PM&R specialists use routine laboratory and radiographic studies, but they are also trained to the interpretation of more sophisticated diagnostic studies that evaluate a patient’s musculoskeletal and neuromuscular systems such as CT, myelography bone scan and MRI. Many physical medicine and rehabilitation specialists are skilled in manual medicine. All PM&R residents are trained to perform injection techniques such as peripheral nerve blockade, trigger point injections, joint injections and the injection of neurolytic agents and botulinum toxin. With specific training, many PM&R specialists routinely perform fluoroscopically directed spinal and large joint procedures such as interlaminar and transforaminal epidural injections, zygapophysial joint injections, radiofrequency denervation, sacroiliac joint intra-articular injections, sympathetic blockade, provocation discography, and other advance interventional pain management techniques.

The American Academy of Physical Medicine and Rehabilitation asserts that all PM&R specialists who have completed a physical medicine and rehabilitation residency have adequate training to practice in the following areas:

1. Inpatient and outpatient musculoskeletal and neuromuscular diagnosis and rehabilitation 1. Electrodiagnostic medicine 2. Medical and rehabilitative pain management 3. Injury prevention and wellness 4. Non-surgical spine medicine 5. Sports medicine including athletes with disabilities.

In addition the Academy further asserts that many physical medicine and rehabilitation specialists have the appropriate training to provide the following areas:

1. Interventional diagnostic and therapeutic spinal procedures, 2. Interventional pain management

Approved MEC 11/8/05 Approved BOG 1/23/06 Revised MEC 2/14/06 Page 6 of 7 Physical Medical & Rehabilitation RENOWN REGIONAL MEDICAL CENTER DELINEATION of PRIVILEGES In summary, physical medicine and rehabilitation is a diverse specialty allowing its member to seek and pursue special interests such as pain medicine, spine medicine, and sports medicine. Many PM&R specialists are integrally involved in university and private practice based spine centers, pain centers, and care of athletes from all levels of participation.

______Applicant Date

______Section Chief, Physical Medicine & Rehabilitation Date

______Chief, Department of Internal Medicine Date

Date of Recommendation by the Credentials & Privileges Committee: ______Date of Recommendation by the Executive Committee: ______Date of Approval by the Board of Governors: ______

Approved MEC 11/8/05 Approved BOG 1/23/06 Revised MEC 2/14/06 Page 7 of 7 Physical Medical & Rehabilitation