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Gastroenterology and Endoscopy Clinical Privileges


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Gastroenterology and Endoscopy Clinical Privileges

  1. 1. Gastroenterology and Endoscopy Clinical PrivilegesName: ______________________________________________________________________________ (Please Print)To be eligible to apply for core privileges in gastroenterology, the applicant must meet thefollowing qualifications: • Current certification or active participation in the examination process leading to certification in gastroenterology by the American Board of Internal Medicine or the American Osteopathic Board of Internal Medicine with Special Qualifications in Gastroenterology. Or • Successful completion of an ACGME- or AOA-accredited post-graduate training program in gastroenterology. And • Documentation of inpatient or consultative services for at least 24 patients during the past 12 months or demonstrate successful participation in a hospital-affiliated formalized residency or special clinical fellowship and the following minimal endoscopic experience: -Diagnostic EGD-100 procedures -Total colonoscopy-100 procedures -Snare polypectomy -20 procedures -Nonvariceal hemostasis (upper and lower); includes 10 active bleeders-20 procedures -Variceal hemostasis (includes 5 active bleeders)-15 procedures -Flexible sigmoidoscopy-25 procedures -PEG-10 procedures -ERCP (diagnostic)-75 procedures -ERCP (therapeutic)-25 procedures (includes 20 sphincterotomies, 5 stent placements and is in addition to the 75 diagnostic ERCP procedures) -Tumor ablation-20 procedures -Pneumatic dilation for achalasia-5 procedures -Esophageal stent placement-10 procedures • New applicants may be requested to provide documentation of the number and types of hospital cases during the past 24 months. Applicants have the burden of producing information deemed adequate by the hospital for a proper evaluation of current competence, and other qualifications and for resolving any doubts. Gastroenterology core privileges  Requested Admit, evaluate, diagnose, treat and provide consultation to patients of all ages except where specifically excluded from practice, with diseases, injuries, and disorders of the
  2. 2. Gastroenterology and Endoscopy Clinical PrivilegesName: ______________________________________________________________________________ (Please Print) digestive organs including the stomach, bowels, liver and gallbladder, and related structures such as the esophagus, and pancreas including the use of diagnostic and therapeutic procedures using endoscopes to see internal organs. The core privileges in this specialty include the procedures on the attached list and such other procedures that are extensions of the same techniques and skills.Special procedures/techniques (see Qualifications and/or specific criteria*)To be eligible to apply for a special procedure listed below, the applicant must demonstrate successfulcompletion of an approved, recognized course when such exists, or acceptable supervised training inresidency, fellowship or other acceptable experience, and provide documentation of competence inperforming that procedure consistent with the criteria set forth in medical staff policies governing theexercise of specific privileges.Use of laser  Requested [Requires: Completion of an approved eight hour minimum CME course which includes training in laser principles and safety, basic laser physics, laser tissue interaction, discussions of the clinical specialty field and hands-on experience with lasers. A letter outlining the content and successful completion of course must be submitted, or documentation of successful completion of an approved residency in a specialty or subspecialty which included training in laser principles and safety, basic laser physics, laser tissue interaction, discussions of the clinical specialty field and a minimum of six hours observation and hands-on experience with lasers.]ERCP (therapeutic)  RequestedEndoscopic ultrasound (EUS) Requested [Requires: 24 months of formal GI or surgical training or equivalent and competence instandard GI endoscopy. The ASGE (American Society for Gastrointestinal Endoscopy) recognizes thatall physicians might not wish to perform all aspects of EUS. However the trainee should havecompleted the following minimum number of procedures.]Mucosal tumors: 75Submucosal lesions only: 40Mucosal and submucosal lesions: 100Pancreaticobiliary: 75EUS- guided FNA: Non-pancreatic: 25 Pancreatic: 25 2
  3. 3. Gastroenterology and Endoscopy Clinical PrivilegesName: ______________________________________________________________________________ (Please Print)Comprehensive competence: 50 (including at least 75 Pancreaticobiliary and 50 FNA)In the event that training has occurred elsewhere, the candidate should provide a syllabus for a coursetaken, submit a formal letter from the course director to the Division Chief, and provide numbers ofpatients and the specific diagnoses observed.Administration of moderate sedation  Requested See Credentialing Policy for Sedation and Analgesia by Non-Anesthesiologists 3
  4. 4. Gastroenterology and Endoscopy Clinical PrivilegesName: ______________________________________________________________________________ (Please Print) Gastroenterology ProceduresPlease delete and initial any procedure that you are not requestingincluded in the core. ● Interpretation of percutaneous endoscopic gastrostomy ● Interpretation of gastric, pancreatic, and biliary secretory tests ● Diagnostic EGD ● Total colonoscopy ● Snare polypectomy ● Nonvariceal hemostasis ● Variceal hemostasis (upper and lower) ● Flexible sigmoidoscopy ● ERCP, diagnostic ● ERCP, therapeutic ● Esophageal stent placement ● Biliary tube/stent placement ● Therapeutic EGD ● Esophagogastroduodenoscopy ● Esophageal dilation ● Proctoscopy ● Flexible sigmoidoscopy ● Colonoscopy with polypectomy ● Percutaneous liver biopsy ● Percutaneous endoscopic gastrostomy ● Biopsy of the mucosa of esophagus, stomach, small bowel, and colon ● Gastrointestinal motility studies ● Nonvariceal hemostasis ● Variceal hemostasis ● Enteral and parental alimentation ● Liver biopsy ● Sengstaken/Minnesota tube intubation 4
  5. 5. Gastroenterology and Endoscopy Clinical PrivilegesName: ______________________________________________________________________________ (Please Print)Acknowledgement of PractitionerI have requested only those privileges for which by education, training, current experience anddemonstrated performance I am qualified to perform and for which I wish to exercise at Newark BethIsrael Medical Center, and I understand that(a) in exercising any clinical privileges granted, I am constrained by hospital and medical staff policiesand 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 insuch situation my actions are governed by the applicable section of the medical staff bylaws or relateddocumentsSigned: _____________________________________________________________________________Date: _______________________________________________________________________________Department Chair’s RecommendationI have reviewed the requested clinical privileges and supporting documentation for the above-namedapplicant and make the following recommendation(s): Recommend all requested privileges Recommend all requested privileges with the following conditions/modifications:  Do not recommend the following requested privileges:Privilege Condition/Modification/Explanation1.2.3.4.Notes:__________________________________ _________________________ Signature Division Director Date_________________________________ _________________________ Signature Department Chair Date4/08 5