Loma Linda University Medical Center ANESTHESIOLOGY SERVICE PRIVILEGE FORM Name:____________________________________________________________

REQUEST

CATEGORY

MEMBERSHIP CATEGORY

Provisional (Bylaws 4.3)

All initial appointees shall be placed in the Provisional Category for the duration of their initial appointment.

Administrative (Bylaws 4.7)

For practitioners who are members of the Medical Staff who have no clinical privileges, who are recommended for appointment or reappointment to the Administrative Staff by the Chief of the Clinical Service, the Credentials Committee, and the Medical Staff Executive Committee, and who MUST meet the following:

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ACTION Approved

Conditions

Denied

1. Have been a member in good standing of the Active, Courtesy, or Provisional Staff for at least one (1) year. 2. Have completed proctoring for any clinical privileges previously requested. 3. Agree to refrain from participating in any activities within the Medical Center that require clinical privileges. 4. Provide significant service to the Medical Center and the Medical Staff in the form of academic activities, quality improvement activities, or administration. 5. Be recommended for appointment or reappointment Failure to meet any of these qualifications will be adequate grounds to deny reappointment. Affiliate (Bylaws(4.9)

Practitioners who CANNOT: 1. Vote or hold office in the Medical Staff or Service. 2. Be a member of any Medical Staff Committee. 3. Be Reappointed to the Affiliate Category. Practitioners who MUST: 1. Have been a member in good standing of the Active, Courtesy or Consulting category during the immediate preceding appointment period. 2. Have completed, in a timely manner as described in the Bylaws, an application for reappointment. 3. Have been found to be qualified for reappointment, other than the volume of clinical activity.

Active (Bylaws 4.2)

Regularly care for patients in the Medical Center; have completed proctoring and the Provisional period.

Courtesy (Bylaws 4.4)

Admit or otherwise provide care for not more than twelve (12) patients in the Medical Center during each year. Have completed proctoring and the Provisional period.

Consulting (Bylaws 4.5)

Render a clinical opinion within their competence. Shall not be eligible to admit patients or to assume continuing care of patients in the Medical Center. Not eligible to vote or hold office in the Medical Staff or Clinical Service

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Loma Linda University Medical Center ANESTHESIOLOGY SERVICE PRIVILEGE FORM Name:____________________________________________________________

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CATEGORY

QUALIFICATIONS

All

Contractual arrangement with Loma Linda Anesthesiology Medical Group, Inc., who has a contractual agreement to provide anesthesiology services to Loma Linda University Medical Center; and Current demonstrated competence and an adequate volume of current experience with acceptable results in the privileges requested, for patients of all age groups, except as specifically excluded from practice; plus one of the following: Successful completion of an ACGME or AOA-accredited residency in anesthesiology, or foreign equivalent, and acceptable practice in the privileges requested. and

Initial Criteria For Core

Current certification or active participation in the examination process leading to certification in anesthesiology by the American Board of Anesthesia or the American Osteopathic Board of Anesthesia preferred or equivalent credentials as determined by the Service Chief. To meet California Children Services (CCS) requirements maintain: As stated above for Initial Criteria plus: Six months of training in pediatric/neonatal anesthesia at a hospital with an anesthesia training program approved by the ABA

Neonatal Anesthesiology

OR two or more of the following: One year experience in providing anesthesia to infants with documentation of at least ten major cases proctored by an anesthesiologist who has six months of formal training in pediatric/neonatal anesthesia; and/or Documented proficiency in anesthesia provided to infants in 25 cases within the last three years with review by an anesthesiologist who has six months of formal training in pediatric/neonatal anesthesia; and/or At least 1 year of training in pediatrics. Certification in Pediatric Anesthesiology As stated above for Initial Criteria, plus A level of formal supervised training or demonstrated competence and experience in an anesthesia subspecialty area appropriate to the privileges being requested; or

Special Privileges

Certificates of Added or Special Qualifications in Pain Management or Critical Care Medicine; or Successful completion of an approved, recognized course when such exists, or acceptable supervised training in residency, fellowship or other acceptable program and demonstration of indications for the procedure/test/therapy; or Certification in Advanced Perioperative Transesophageal Echocardiography; or Documentation of competence to obtain and retain clinical privileges as set forth in departmental policies governing the exercise of the specific privileges.

Observation Requirements

As specified in the Anesthesiology Service rules and regulations.

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Loma Linda University Medical Center ANESTHESIOLOGY SERVICE PRIVILEGE FORM Name:____________________________________________________________

MARK IF REQUESTED

CORE PRIVILEGES

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ACTION Approved

Conditions

Denied

Privileges included in the Core: • Management of patients rendered unconscious or insensible to pain and emotional stress during surgical, obstetrical and certain other medical procedures, including pre-, intra-, and postoperative evaluation and treatment • The support of life functions and vital organs under the stress of anesthetic, surgical, and other medical procedures • Management of patients with a difficult airway • Management of problems in pain relief • Cardiopulmonary resuscitation • Supervision of patients in post-anesthesia care units and critically ill patients in special care units; except for those special procedure privileges listed below. • Flexible Bronchoscopy Includes airway examination, assist tracheal intubation, removal of secretions and foreign objects, bronchial washings and bronchoalveolar lavage. • Basic Perioperative Echocardiography PATIENT CLASSIFICATION Patient status (ASA) 1 through 5E:

Adults ≥18 years of age, for all procedures involving anesthesia care Children 2-18 years of age for all procedures involving anesthesia care > 45 weeks post-conceptual age to 2 years of age scheduled for outpatient procedures involving anesthesia care. Must provide documentation of care provided to patients in this category: either 10 in prior 1 year or 25 in prior 3 years. Neonates (from birth) to 2 years of age, all procedures involving anesthesia care. Must meet criteria for Neonatal Anesthesiology Category. Must document care provided to patients in this category: either 10 in prior 1 year or 25 in prior 3 years. or Subspecialty Board Certification in Pediatric Anesthesiology

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Loma Linda University Medical Center ANESTHESIOLOGY SERVICE PRIVILEGE FORM Name:____________________________________________________________

MARK IF REQUESTED

GENERAL

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ACTION Approved

Conditions

Denied

Supervision of Allied Health Professionals (AHP) under the following circumstances: - When an AHP is granted practice privileges by the Medical Staff; - When the AHP operates under standardized procedures; - Or under other circumstances as recommended by the Interdisciplinary Practice Committee and approved by the Medical Staff. Supervision of Residents and Students Supervise Radiologic Technologists and operate Fluoroscopy Equipment. Fluoroscopy Supervisor and Operator Permit required (attach current copy).

SPECIAL PRIVILEGES See Qualifications on Page 2 Comprehensive Pain Management Management of complex acute and chronic pain, neurolytic nerve blocks, facet blocks, and dorsal column stimulation. Comprehensive Critical Care For Special Care Unit privileges please complete the Adult Intensivist/ICU Generalist privilege form Cardiac Anesthesia for Pediatrics (See Qualifications on Page 2-Special Privileges) Cardiac Anesthesia for Adults (See Qualifications on Page 2-Special Privileges) Liver transplantation anesthesia (See Qualifications on Page 2-Special Privileges) Advanced Perioperative Transesophageal echocardiography Privileges to admit patients

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Loma Linda University Medical Center ANESTHESIOLOGY SERVICE PRIVILEGE FORM Name:____________________________________________________________

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Adult Percutaneous Tracheostomy Qualifications: Satisfactory completion of the educational requirements necessary for Board certification in Medical or Surgical Critical Care Medicine; and 1. Evidence of training by attendance at a hands-on training course in the procedure of percutaneous tracheostomy. Such course should be at least of eight (8) hours duration with experience in a laboratory setting. The laboratory setting must include a minimum of three (3) hours of supervised hands-on performance of Adult Percutaneous percutaneous tracheostomy in a simulation or cadaver model. Tracheostomy 2. The physician may waive attendance in a training course (item 1 above) if Identifies the patient care he/she can demonstrate previous practical experience via an accredited critical care activities performed at fellowship program with documented completion of a minimum of ten (10) LLUMC in the Critical Care percutaneous tracheostomy cases. Unit (CCU) by physicians practicing as sub-specialists Proctoring: in Medical or Surgical 1. The physician is required to have successful completion of a minimum of ten Critical Care Medicine. (10) percutaneous tracheostomy cases under the supervision of a qualified physician with privilege in performing tracheostomy. 2. For a physician with previous experience and/or documented completion of ten (10) percutaneous tracheostomy cases, the physician is required to have additional successful completion of two (2) proctored percutaneous tracheostomy cases under the supervision of a qualified proctor with privilege in performing percutaneous tracheostomy. 3. Need for additional proctoring, if any, to be determined by the Service Chief MARK IF REQUESTED

ACTION

Special Privileges Continued Approved

Conditions

Denied

Adult Percutaneous Tracheostomy See Qualifications Above

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Loma Linda University Medical Center ANESTHESIOLOGY SERVICE PRIVILEGE FORM Name:____________________________________________________________

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Acknowledgment of Practitioner I have requested only those specific privileges for which by education, training, current experience and demonstrated performance I am qualified to perform and for which I wish to exercise at Loma Linda University Medical Center, Inc.; and I understand that: (a) In exercising any clinical privileges granted, I am constrained by any hospital and medical staff policies and rules applicable generally and any applicable to the particular situation. (b) Any restriction on the clinical privileges granted to me is waived in an emergency situation and in such situation my actions are governed by the applicable section of the Medical Staff Bylaws.

Signed:

Date: ___________________________

**** For Medical Staff use only **** Conditions/Modifications: The requested clinical privileges have been approved by the Board of Trustees with the following conditions/modifications. Code

Privilege

Condition/Modification

Chief of Service

Date

Credentials Committee

Date

Medical Staff Executive Committee

Date

Governing Board Officer

Date

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