Cardiology/Cardiac Catherization Laboratory

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  • 1. Name:_____________________________ Valley Regional Medical Center Cardiac Catherization Laboratory I request privileges for the following Medical Procedures: Privileges Full Privileges Granted with Privileges Requested Proctoring Granted Cardiac Catherization __________ __________ __________ Percutaneous Transluminal __________ __________ __________ Coronary Angioplasty (PTCA) __________ __________ __________ Transluminal Extraction Catheter __________ __________ __________ Arthrectomy (TEC) __________ __________ __________ Directional Coronary __________ __________ __________ Arthrectomy (DCA) __________ __________ __________ Percutaneous Transluminal __________ __________ __________ Coronary Rotational Arthrectomy __________ __________ __________ Coronary Stenting, Primary __________ __________ __________ Coronary Stenting, Emergency __________ __________ __________ Percutaneous Transluminal __________ __________ __________ Angioplasty of a. Common iliac, external iliac __________ __________ __________ b. Common or superficial femoral, __________ __________ __________ Popliteal arteries c. Vessels below the knee __________ __________ __________ d. Visceral __________ __________ __________ e. Renal __________ __________ __________ f. Brachiocephalic __________ __________ __________ g. Arterial or Graft total occlusions __________ __________ __________ h. Palmaz Stenting __________ __________ __________ Permanent Pacemaker Placement Balloon __________ __________ __________ Counter Pulsatin Device Insertion/Management __________ __________ __________ I understand that: (a) In exercising any clinical privileges granted. I am constrained by hospital and medical staff policies and rules applicable generally and any applicable to the particular situation. (b) All procedures will be performed in an appropriate acute care setting except in an emergency. (c) Any restriction on the clinical privileges granted to me is waived in an emergency situation and in such a situation my actions are governed by the applicable section of the medical staff bylaws or related documents. _______________________________________ ________________________________ Applicant (Signature) Date Approved By: _______________________________________ ________________________________ Chief of Service Date Approved by: _______________________________________ ________________________________ Chairman, Credentials & Ethics Date
  • 2. Assigned Proctor:______________________________
  • 3. Procedure Qualification Criteria Independent Criteria Cardiac Catherization o Board Certified or Board Eligible in o Perform 12 catherizations per Cardiology. Cardiology year o 1 Year Invasive Cardiology training o Observation by Medical Direc in a recognized training program o 3 Years Cardiology fellowship o Review Utilization and Safety o 125 Cardiac caths at 6 & 12 months Percutaneous Transluminal o Board Certified or Board Eligible in o Perform 12 catherization Coronary Angioplasty (PTCA) Cardiology procedures per year o 1 year Invasive Cardiology training o Observation by Medical Direc in a recognized training program o 3 years Cardiology Fellowship o Review Utilization and Safety o Documentation of 50 PTCA's use at 6 & 12 months. performed in a recognized training program. Transluminal Extraction Coronary o Independent PTCA privileges at o Review Utilization and Safety Artherectomy (TEC) cath lab at 6 & 12 months the first year o Attendance of a TEC Arthrectomy credentialed. course, or provide documents of training or perform 5 TEC Arthrectomies with preceptor in the cath lab. Directional Coronary o Independent PTCA privileges at o. Review Utilization and Safety Artherectory(DCA) cath lab at 6 & 12 months the first yea o Attendance of a DCA Atherectomy credentialed. course or provide documents of training or perform 5 DCA Arthrectomies in cath lab. Percutaneous Transluminal o Independent PTCA privileges at o Review Utilization and Safety Coronary Rotational cath lab. AT 6 & 12 months the first yea Artherectomy o Attendance of a coronary rotablator credentialed. course & provide documents of training or perform 3 coronary rotational Arthrectomies in cath lab with preceptor. Procedure Qualification Criteria Independent Criteria Coronary Stent Primary o Independent PTCA privileges in o Review Utilization and Safety cath lab at 6 & 12 months the first year o Completion of a Company Coronary credentialed. Stent Workshop or completion of
  • 4. 5 coronary stents at cath lab with preceptor. Coronary Stent Emergency o Independent PTCA privileges in o Review Utilization and Safety cath lab. at 6 & 12 months the first year o Completion of a Company Coronary credentialed Stent Workshop or completion of 5 coronary stents at cath lab with preceptor. Simple PTA procedure o Independent PTCA privileges or o Perform five (5) simple PTA (Common iliac, superficial Radiologist with training in procedures with a proctor and femoral external iliac popliteal percutaneous catheter interventions 10 simple PTA procedures as arteries common femoral) o Attendance at one live primary operator. demonstration PTA courses o Participation in minimum of 10 PTA procedures under direction of proctor. Complex PTA procedure o Be an approved simple PTA o Perform fifteen (15) complex (vessels below the knee, procedure operator procedures as a primary oper visceral, renal, brachiocephalic, o Assist an established PTA operator with proctor. or arterial or graft total in a minimum of 10 complex PTA occlusions, Palmaz stenting) procedures * Approved by Board of Trustees on 10/5/98