KALEIDA HEALTH

Name ______Date ______

DELINEATION OF PRIVILEGES - NEUROSURGERY

All members of the Department of Neurosurgery at Kaleida Health must have the following credentials: 1. Successful completion of an ACGME accredited Residency, Royal College of Physicians and Surgeons of Canada, or an ACGME equivalent Neurosurgery Residency Program. 2. Members of the clinical service of Neurosurgery must, within five (5) years of appointment to staff, achieve board certification in Neurosurgery. *Maintenance of board certification is mandatory for all providers who have achieved this status*

Level 1 (core) privileges are those able to be performed after successful completion of an accredited Neurosurgery Residency program. 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.

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. LEVEL I (CORE) PRIVILEGES Basic Procedures including: Admission and Follow-Up Repair cranial or dural defect or lesion History and Physical for diagnosis and treatment plan* Seizure Chest tube placement Sterotactic framed localization of lesion Debride wound Sterotactic frameless localization Endotracheal intubation Transsphenoidal surgery of pituitary lesion Excision of foreign body Trauma Insertion of percutaneous arterial catheter* Tumor Lumbar puncture* Vascular decompression Peripheral vein/artery cut down Vascular or revascularization Replacement of tracheostomy tube Endoscopy as an Adjunct Suture laceration Cranial Swan-Ganz insertion and interpretation Peripheral nerve Tracheostomy Spine Vena cava (intervention) Peripheral Nerve Additional Procedures Decompression, avulsion, transposition, or anastomosis peripheral Biopsy, superficial, head or neck nerve Brain death determination Exploration and repair C1-2 tap* Excision peripheral nerve tumor and biopsy, implantation Epidural injection of medication* stimulator, block External cranial fixation Surgery of extracranial and vertebral arteries including Halo application endarterectomy and grafting procedures ICP monitor insertion Spinal Procedures Insertion of lumbar spinal drain* Axial Fusion Myelography* Cervical with instrumentation Puncture ventricular shunt* Decompression - all levels Ventricular puncture with/without drain insertion For treatment excision or repair of: Biopsy congenital CNS and peripheral nerve degenerative Dural infectious Muscle intradural and/or extradural Vascular traumatic Craniotomy/Craniectomy/Burr Hole neoplastic Abscess/infection vascular Approach and treatment of skull base lesion Implantable pump or stimulator Cyst Stabilization - all levels Developmental anomaly Thoracolumbar with instrumentation Insertion or revision of CSF or cyst shunt Neurectomy Neurosurgery DOP 9-2021

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LEVEL I-A CORE 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 Insertion of lumbar spinal drain Myelography treatment plan Insertion of percutaneous arterial Puncture ventricular shunt C1-2 tap catheter Epidural injection of medication Lumbar puncture

Request Granted Not Granted Granted with following The above Core privileges are those able to be performed after requirements: successful completion of an accredited training 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.

Level I – A CORE PRIVILEGES

LEVEL II PRIVILEGES – ADULT With Following Initial Request: PHYSICIAN Not Requirements** Requires successful completion of a Neurosurgery REQUEST Granted Granted* (Provide Details) Residency/Fellowship and a letter from the program director attesting to proficiency or experience (case list from primary hospital covering past two (2) years) At Reappointment: Past two (2) years case list required. Use intraoperative laser CO2/Yag/KTP – Requires 1.) Completion of approved training program in Laser Surgery of Cent /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.) four (4) or more unsupervised cases within last year and training program completed w/in last three (3) years. (Attach documentation) Pathology specimens must be obtained as appropriate. Case list required at reappointment. Cortical mapping Cryosurgery Diagnostic Angiography of carotid or vertebral artery Disc Replacement Endoscopy as primary approach brain peripheral spine transnasal Functional/ablative - cordotomy creation lesion brain or spine placement brain electrode rhizotomy/rhizolysis Intra Arterial (IA) Thrombolysis Intravenous (IV) Thrombolysis Kyphoplasty Rhizotomy Vertebroplasty

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LEVEL II PRIVILEGES – With Following ENDOVASCULAR PROCEDURES PHYSICIAN Not Requirements** Initial Request: REQUEST Granted Granted* (Provide Details) Requires documentation of endovascular experience and training including letter from Residency or Fellowship Program Director attesting to proficiency or certificate from “Hands On” Program within the last two (2) years. Level of initial supervision will be determined. In the absence of above requirements: Letter from the Neurosurgery Chief of Service at primary hospital attesting to proficiency and case list for the past two years. At reappointment: Past two (2) years case list required. Aneurysm Endovascular Occlusion Arterial puncture, insertion of catheters Brachiocephalic Angioplasty Brachiocephalic Stents Carotid Stent Embolization of Arteriovenous Malformation Embolization of Tumor, Extracranial Embolization of Tumor, Intracranial Iliac Stents Intracranial Angioplasty Intracranial Stent Spinal Angiography, Diagnostic Spinal Embolization Test Occlusion/Occlusion of Cranial Vessel Thrombolysis, Intraarterial, acute Stroke or Vessel Occlusion Treatment of Fistula (head, neck, spine)

NEUROSURGICAL CRITICAL CARE LEVEL II CORE PRIVILEGES – for the management/treatment of life- threatening disorders and the use of Moderate/conscious sedation, Deep Sedation and Analgesia (pain management).

Initial and Reappointment requirements:

1. Successful completion of an ACGME accredited, AOA, Royal College of Physicians and Surgeons of Canada, or an ACGME equivalent Neurosurgical Critical Care fellowship program. 2. Board certification in Neuro Critical Care, if not board certified, applicant will be given two (2) years from date of initial appointment to obtain certification in this specialty. *Maintenance of Board Certification is mandatory for all providers who have achieved this status.*

(In the absence of formal training and board certification, it will be at the Chief of Service discretion to waive the aforementioned requirements based on the applicant’s experience.)

With Following Requirements PHYSICIAN GRANTED NOT GRANTED* (Provide Details) REQUEST

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LEVEL II Core PRIVILEGES – PEDIATRIC Requires successful completion of a Pediatric Fellowship training program or In the absence of above requirements: Letter from the Neurosurgery Chief of Service at primary hospital attesting to proficiency and Pediatric cases list for the past two (2) years.

Cranial Procedures (<16 years) Cerebrospinal fluid diversion Craniotomy/Craniectomy for tumor, Stereotactic approach for biopsy in (ventriculostomy, spinal reservoir, trauma, abscess, cyst, vascular lesion, conjunction with other procedure shunting procedure) Chiari malformation or decompression Subdural tap through burr hole or fontanelle Frameless stereotaxy ventricular puncture through burr hole or Intracranial endoscopy fontanelle

Peripheral Nerve Procedures (<16 years) Excision of peripheral nerve Exploration and repair, decompression, trans- position, or anastomosis of peripheral nerve

Spinal Procedures (<16 years) Application of orthotic, traction or halo Laminectomy for treatment of syringomyelia Spinal endoscopy in conjunction with any of Excision of intervertebral disc, anterior Laminectomy or laminotomy for spinal tumor, disc, these privileges approach, with or without fusion abscess, cyst, decompression Spinal infusion, anterior Insertion of epidural or intrathecal Lumbar spinal fluid shunt Spinal infusion, posterior Repair of myelomeningocele Use of spinal stereotaxis in conjunction with infusion pump any of the above

Level II Core Privileges - Pediatric Request Granted Not Granted* With Following Requirements** (provide Details)

Level II Privilege Laser Procedures (<16 years) Use of laser in conjunction with any of the above listed Level II Core Privileges - Pediatric procedures Requirements: 1.) Completion of approved training program in Laser Surgery of Cent /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.) Four (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. Case list required at reappointment. Request Granted Not Granted* With Following Requirements** (provide Details)

LEVEL III PRIVILEGES – PEDIATRIC – With Following Initial: Requires documentation of additional pediatric training PHYSICIAN Not Requirements** or minimum six (6) months of clinical Pediatric Neurosurgery REQUEST Granted Granted* (Provide Details) Fellowship, and experience, including documentation of more than three (3) such procedures on children within last 18 months. Reappointment: three (3) such procedures on children within last 18 months. Craniectomy, craniotomy, or craniofacial reconstruction of craniosynostosis Craniotomy for encephalocele, dermal sinus tract, or other cranial developmental malformation Repair of untethering of closed or occult dysraphic malformation Selective sensory rhizotomy Untethering of myelomeningocele

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Level II MODERATE/CONSCIOUS SEDATION 1. Providers seeking privileges in moderate/conscious sedation must complete either the ASA sedation course or Medsimulation course, receiving a score of 85% or above and repeat the course every 4 years (two years for those courses with a 2 year expiration date). 2. Providers must also maintain airway management skills through current completed training and certification in ACLS, ATLS or PALS.

(For details on course availability and maintenance please review the Moderate/Conscious Sedation document located on our credentialing web page.) With following Requested Granted Not Granted* requirements** (provide Details)

KEY *NOT GRANTED DUE TO: **WITH FOLLOWING REQUIREMENTS Provide Details Below 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:______

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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. 11101 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

Neurosurgery DOP 9/2021