- 1 - KALEIDA HEALTH Name: ___________________________________ Date: ____________________________ DELINEATION OF PRIVILEGES - GENERAL SURGERY 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. GENERAL STATEMENTS - Privileges in Adult Surgery are separated into the following divisions: General Surgery and Plastic Surgery. Applicants desiring procedure privileges in more than one division must complete separate forms for each. Procedures designated with an asterisk (*) indicate that Moderate or Deep Sedation may be required. If you do not have Moderate or Deep Sedation privileges, you must invite a Kaleida Health anesthesiologist to participate in the procedure. Procedures are also separated into levels of complexity (Level I-A, Level I-B, 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 Procedures which involve primarily wound care, can be done under local anesthetic and occasionally involve application of temporary skin coverage or application of agents to expedite wound healing. Can be performed by any competent surgeon. Applies to patients who are greater than or equal to 12 years old. Debridement, Non-Selective Debridement, Selective Infection, Incision & Drainage Negative Pressure Therapy Burn Excision & Debridement, Minor Debridement of Skin, Partial Debridement of Skin, Full Debridement of Skin, Subcutaneous Decubitus Ulcer Acellular Dermal Replacement Dermal Skin Substitute Allograft, Acellular Dermal LEVEL I-A PRIVILEGES With Following (includes all of the above) PHYSICIAN Not Requirements** REQUEST Granted Granted* (Provide Details) LEVEL I-B PRIVILEGES With Following PHYSICIAN Not Requirements** REQUEST Granted Granted* (Provide Details) Vascular Lab – Read and interpret carotid, venous and arterial imaging studies. General Surgery 6/2019 General Surgery DOP Name: ______________________________________ Page 2 LEVEL I (CORE) PRIVILEGES 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. LEVEL I (CORE) PRIVILEGES Procedures which involve primarily wound care, can be done under local anesthetic and occasionally involve application of temporary skin coverage or application of agents to expedite wound healing. Can be performed by any competent surgeon. Applies to patients who are greater than or equal to 12 years old. Admission and Follow-Up Thorascopic empyema drainage History and Physical for diagnosis and treatment plan Gallbladder (open & laparoscopic cholecystectomy, incision, open excision, bypass) Thyroid/Parathyroid (aspiration, biopsy, resection) Common Duct (exploration, repair, bypass) Adrenal (resection, biopsy, repair) Other Biliary (miscellaneous procedures) Tongue (biopsy, suture) Pancreas (incision, biopsy, cyst drainage, distal resection) Salivary Gland (biopsy, repair) Anoscopy Mouth and Face (drainage, biopsy, resection, repair) Colonoscopy *Trachea (open tracheostomy, endoscopy, bronchoscopy) Sigmoidoscopy (rigid, flexible) *Veins (varicose ligations & stripping) EGD *Puncture of Vessel (cutdowns, catheterization) Hernia (inguinal, femoral, umbilical, open or laparoscopic, other) *Renal dialysis shunt Other abdomen (miscellaneous procedures) *Lymphatic System (biopsies) Kidney (repair, resection) Bone Marrow & Spleen (biopsies, resections, repairs) Genitalia (excision hydrocele, repair, biopsy) Esophagus (incision, ostomy, distal resection) Testes (biopsy, resection, repair) *Gastric (incision, excision, biopsy) Cord & Epididymis (repair, resection, ligation) Highly Selective Vagotomy Penis (biopsy, circumcision [adult]) *Bowel (repair, biopsy, endoscopy, resection, anastomosis, Tubes & Ovaries (marsupialization, biopsy, resection) colostomy) Other Gastric (vagectomy, bypass, repair) Uterus (total abdominal hysterectomy) Other Intestinal (ostomies, revision, repair) Extremities (amputations, disarticulations) Appendix (open & laparoscopic appendectomy) Breast (mastectomy, biopsy, excision, repair) Rectal & Perirectal Skin and Subcutaneous (endoscopy, biopsy, excision, repair) (incision, excision, biopsy, grafts) Anal (incision, excision, biopsy, repair) Internal Injury of Chest, Abdomen, and Pelvis Liver Subcutaneous Venous Access Port (ie Mediport) (biopsy, wedge or segmental resection, repair) ACS Level I Trauma (request only if working at OCH) With Following PHYSICIAN Granted Not Requirements** Requirement: Successful completion of the ATLS at least once REQUEST Granted* (Provide Details) and for providers that have not been actively practicing in a trauma setting within the past two (2) years, recertification will be required. [email protected]. ACS Level 1 Trauma - Internal Injury of Chest, Abdomen, and Pelvis – Trauma Evaluation and Laparotomy for any age. General Surgery DOP 6/2019 General Surgery DOP Name: ______________________________________ Page 3 Requests for pediatric surgical privileges, <18 yrs, unless otherwise specifically noted on this form for level II or level III, must be submitted in writing listing the specific privileges being requested along with documentation of training and case listings from the last 2 years for each privilege requested. This will then be reviewed by the Chief of Pediatric Surgery. LEVEL II PRIVILEGES With Following Procedures listed below, including those not listed in Level I, PHYSICIAN Not Requirements** may require documentation of additional experience or REQUEST Granted Granted* (Provide Details) training. Applies to patients who are greater than or equal to 18 years old (unless otherwise noted). Laparoscopic minimally invasive pectus excavatum repair. Thymectomy Salivary gland resection Radical Neck Dissection Radical Iliac Node Dissection Radical Groin Dissection Total Esophagectomy, Bypasses Total Gastrectomy Esophagogastroplasty ERCP Related Procedures Excision Ampulla of Vater Pancreatic Duct Sphincterotomy Pancreatic Duct Sphincteroplasty Radical Sub-total Pancreatectomy Hip Disarticulation Colectomy with ileal pouch Extracorporeal Membrane Oxygenation (ECMO) Endoscopy and Endoscopic Procedures Colonoscopy with Polypectomy Percutaneous liver biopsy Esophageal manometry PH monitoring Endoscopic Control of Hemorrhage: - Variceal - Non-variceal Enteroscopy Small bowel suction/capsule Bx Small bowel enteroscopy Endoscopic ultrasound PEG Balloon tamponade (Sengstaken) for bleeding esophageal/gastric varices Vascular Applicant must document evidence of attending course and be proctored for two cases by someone who has done more than ten. Radiofrequency Ablation (VNUS) -with Perforator Technique -List other techniques: General Surgery DOP 6/2019 General Surgery DOP Name: ______________________________________ Page 4 INTERSTIM THERAPY Requires documentation of having received training during ACGME accredited Surgery residency OR (1) attending a Theory & Technique course on InterStim Therapy, observing 2 cases performed by an InterStim-credentialed physician; OR (2) completing the InterStim on-line educational program and successfully completing training with the InterStim simulator; OR (3) completing the InterStim on-line education program and observing chronic lead placement at an InterStim experience physician site. If either pathway (1) or pathway (2) or pathway (3) is selected, then the physician requesting privileges in InterStim Therapy must be proctored on his first case by an InterStim credentialed physician and the requesting physician’s performance deemed satisfactory by the proctoring physician. Interstim Therapy LEVEL III PRIVILEGES PHYSICIAN Granted Not With Following Applies to patients who are greater than or equal to 18 years REQUEST Granted* Requirements** old. (Provide Details) Procedures which categorically require documentation of additional training or significant experience, such as high risk procedures or new procedures. Hepatic Duct Enteric Anastomosis Trans-sacral Rectosigmoidectomy Anal Sphincter Repair Rectal Pouches ADVANCED MULTIPORT LAPAROSCOPIC PROCEDURES Applicant must document evidence of training in residency, or provide an attendance certificate from an approved training course. The applicant must document having served as first assistant five cases OR completion of 1 year Fellowship trained in laparoscopic surgery. Subsequent volume criteria at each reappointment is [required]. Laparoscopic gastric procedures to include: gastric fundoplication, gastric resection, gastroenterostomy, vagotomy, duodenal procedures and gastric tube placement (excluding bariatric surgery) [5] Laparoscopic solid organ procedures to include: adrenal, pancreas, kidney and liver splenectomy and spleen [5] Laparascopic intestinal procedures to include: small and large bowel resection and anastomosis, right and left colon resection, low anterior resection, abdominal perineal resection, colostomy formation, colostomy