Form 0917-0009-8 0917-0009-8, Anesthesia Privileges Request Form

Circular Appendix 95–16–C.5 (04/10)
Page 5 of 5

Anesthesia PRIVILEGES REQUEST FORM

INTRODUCTION

This Anesthesia Privileges Request Form must be accompanied or preceded by a completed application for medical staff appointment, including the necessary supporting documents. Most clinical privileges pertinent to the practice of anesthesia are listed below. The request for privileges must reflect both the applicant’s and facility/staff’s ability to carry out or support the various functions. Any additional privileges may be requested on the Anesthesia Privileges Request Form or may be presented in an attached list and referenced on this form under “other.”

INSTRUCTIONS FOR COMPLETING THE FORM

Applicant: With a check mark in the appropriate location, indicate for each item whether you are requesting limited or full privileges. Limited means that the applicant may function in the area of the stated clinical privileges only under the direct supervision of a provider holding full privileges. Full means that the applicant is entitled to function independently, following standards consistent with the medical community at large. Be sure to sign the request as indicated on page 6.

Discipline-specific supervisor or consultant: Indicate your recommendation for each requested clinical privilege by placing a check mark in the appropriate location for either full, limited, or not recommended (N.R.). Please explain any recommended limitations or denial of privileges on an attached sheet. Your recommendations are considered by the governing body when granting or not granting privileges.

Assignment of clinical privileges in anesthesiology must be based upon:

1. Education.

2. Clinical training.

3. Capacity to manage procedurally related complications.

THE SUGGESTED CLASSES OF CLINICAL PRIVILEGES ARE:

I. CLASS I PRIVILEGES

Such privileges are to be granted to those members of the medical staff who are permitted to perform local infiltration anesthesia, topical application, and minor nerve blocks.

II. CLASS II PRIVILEGES

This class of privileges is assigned to those members of the medical staff who are qualified to perform specific anesthetic procedures under specified conditions in addition to local infiltration, topical application, and minor nerve block class. The Anesthesia Privileges Request Form should be completed for these privileges.

III. CLASS III PRIVILEGES

Privileges granted to those individuals who by training and experience are competent in:

a. The management of procedures for rendering a patient insensible to pain and emotional stress during surgical, obstetrical, and certain medical procedures.

b. The support of life functions under the stress of anesthetic and surgical manipulations.

c. The clinical management of the patient unconscious from whatever cause.

d. The management of problems in pain relief.

e. The management of problems in cardiac and respiratory resuscitation.

f. The application of specific methods of respiratory therapy.

g. The clinical management of various fluid, electrolyte, and metabolic disturbances.

Note: When Class III privileges are granted, they should be accompanied by specific limitations where indicated. The Anesthesia Privileges Request Form should be completed for these privileges.

ANESTHESIA PRIVILEGES REQUEST FORM

I. General Anesthesia	Applicant Requests		Supervisor/ Consultant Recommends
	Ltd.	Full	N.R.	Ltd.	Full
A. Adult
B. Child
C. Inhalation agents
D. Intravenous agents

II. IV Sedation	Applicant Requests		Supervisor/ Consultant Recommends
	Ltd.	Full	N.R.	Ltd.	Full
A. Barbiturates
B. Catamenia
C. Narcotics
D. Major tranquilizers

III. Regional Anesthesia	Applicant Requests		Supervisor/ Consultant Recommends
	Ltd.	Full	N.R.	Ltd.	Full
A. Subarachnoid block
B. Lumbar epidural block
C. Brachial plexus block
D. Sciatic-femoral block
E. Ankle block
F. Cervical epidural
G. Thoracic epidural
H. Other (specify):

IV. Pain Management	Applicant Requests		Supervisor/ Consultant Recommends
	Ltd.	Full	N.R.	Ltd.	Full
A. Differential subarachnoid block
B. Lumbar sympathetic block
C. Stellate ganglion block
D. Epidural steroids
E. Epidural narcotics
F. Celiac plexus block
G. Intercostal nerve block
H. Neurolytic block

V. Subspecialty Anesthesia

A. Infants	Applicant Requests		Supervisor/ Consultant Recommends
	Ltd.	Full	N.R.	Ltd.	Full
1. Routine
2. High risk

B. Thoracic Surgery	Applicant Requests		Supervisor/ Consultant Recommends
	Ltd.	Full	N.R.	Ltd.	Full
1. Adult
2. Child
3. Infant

C. Intracranial Surgery	Applicant Requests		Supervisor/ Consultant Recommends
	Ltd.	Full	N.R.	Ltd.	Full
1. Adult
2. Child
3. Infant

	Applicant Requests		Supervisor/ Consultant Recommends
	Ltd.	Full	N.R.	Ltd.	Full
D. Major vascular surgery
E. Caesarean section

VI. Monitoring	Applicant Requests		Supervisor/ Consultant Recommends
	Ltd.	Full	N.R.	Ltd.	Full
A. Radial artery catheterization
B. Pulmonary artery catheterization

C. CVP line placement	Applicant Requests		Supervisor/ Consultant Recommends
	Ltd.	Full	N.R.	Ltd.	Full
1. Peripheral
2. Internal jugular
3. Subclavian

VII. SpeciAl Techniques	Applicant Requests		Supervisor/ Consultant Recommends
	Ltd.	Full	N.R.	Ltd.	Full
A. Deliberate hypotension
B. Deliberate hypothermia

VIII. Airway Management

A. Awake	Applicant Requests		Supervisor/ Consultant Recommends
	Ltd.	Full	N.R.	Ltd.	Full
1. Oral
2. Nasal

B. Anesthetized	Applicant Requests		Supervisor/ Consultant Recommends
	Ltd.	Full	N.R.	Ltd.	Full
1. Oral
2. Nasal

	Applicant Requests		Supervisor/ Consultant Recommends
	Ltd.	Full	N.R.	Ltd.	Full
IX. Ventilator Management
X. Interpretation of ABGs
XI. Interpretation of PFTs
XII. Interpretation of EKGs
XIII. Supervision of CRNAs

Anesthesia PRIVILEGES REQUEST FORM

1. I hereby request the clinical privileges as indicated on the forms attached.

Applicant Date

2. I hereby recommend the clinical privileges as indicated.

Supervisor/Consultant Date

3. As Chairperson of the Medical Staff Executive Committee, I hereby recommend the clinical privileges: (check one)

As noted.

With the following exceptions, deletions, additions, or conditions:

Clinical Director Date

4. I hereby recommend the applicant for clinical privileges.

Service Unit Director Date

5. Privileges are hereby granted: (check one)

As noted.

With the following exceptions, deletions, additions, or conditions:

Chairperson of the Date

Governing Body

Estimated Average Burden Time per Response

Public reporting burden for this collection of information is estimated to average 60 minutes per response including time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to: Reports Clearance Officer, Indian Health Service, 801 Thompson Avenue, TMP Suite 450, Rockville, MD 20852, ATTN: PRA (0917–0009). Please do not send this form to this address.