Privilege request form
Critical care medicine
In order to be eligible to request clinical privileges in critical care medicine, an applicant
must meet the following minimum threshold criteria:

Education: MD or DO

Minimum formal training: Applicants must complete an ACGME/AOA-accredited
residency training program in specialties or subspecialties such as internal
medicine, pulmonary medicine, cardiology, pediatrics, or family practice,
followed by completion of an accredited training program in critical care
medicine.

Required previous experience: Applicants must demonstrate that they provided
critical care inpatient or consultative services for at least 50 patients in the past
12 months.

References: A letter of reference must come from the director of the applicant’s
critical care training program. Alternatively, a letter of reference must come from
the chief of critical care medicine at the institution where the applicant most
recently practiced.

Core privileges: Core privileges for critical care medicine include the following:
- Maintenance of open airway
- Oral/nasal intubation
- Ventilator management, including experience with various modes
- Insertion and management of chest tubes
- Placement of arterial, central venous, and pulmonary artery balloon
flotation catheters
- Calibration and operation of hemodynamic recording systems

Additional considerations: Applicants should achieve ACLS and ATLS provider
status.

Reappointment: Reappointment should be based on unbiased, objective results of
care according to the organization’s existing quality assurance mechanisms.
Applicants must demonstrate their competence with evidence that they successfully
provided critical care inpatient or consultative services for at least 100 patients during
the past 24 months.
In addition, continuing education related to critical care medicine should be required.
I understand that by making this request I am bound by the applicable bylaws or policies
of the hospital, and hereby stipulate that I meet the minimum threshold criteria for this
request.
Physician’s signature: ____________________________________________
Typed or printed name: ___________________________________________
Date: __________________________________________________________