DEPARTMENT OF PEDIATRICS
REQUEST FOR SPECIFIC PRIVILEGES
GROUP 8
1.00
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HOSPITAL CARE PRIVILEGES - See Definitions Attached
Category 0 Hospital Care
Category 1 Hospital Care
Category 2 Hospital Care
Category 3 Hospital Care
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Category 4 Hospital Care
Subspecialty in Allergy
Subspecialty in Cardiology
Subspecialty in Endocrinology
Subspecialty in Hematology
Subspecialty in Neonatology
Subspecialty in Nephrology
Subspecialty in Neurology
Subspecialty in Pulmonary Diseases
Subspecialty in Critical Care
Subspecialty in Rheumatology
Subspecialty in Gastroenterology
Subspecialty in Infectious Diseases
3.01
3.02
3.03
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NEONATAL CARE PRIVILEGES - See Definitions Attached
Class A Neonatal Care
Class B Neonatal Care
Class C Neonatal Care
4.01
4.02
4.03
4.04
4.05
4.06
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MINOR SURGICAL PROCEDURES
Circumcision of Newborn
Peripheral Venous Cutdown
Myringotomy
Exchange Transfusions
Simple Fractures & Dislocations
Peritoneal Dialysis
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DIAGNOSTIC/THERAPEUTIC PROCEDURES
Subdural Puncture
Abdominal Paracentesis
Thoracentesis
Pericardiocentesis
1.01
1.02
1.03
1.04
2.00
2.01
2.02
2.03
2.04
2.05
2.06
2.07
2.08
2.09
2.10
2.11
2.12
3.00
4.00
5.00
5.01
5.02
5.03
5.04
1
5.05
5.06
5.07
5.08
5.09
5.10
5.11
5.12
5.13
5.14
5.15
5.16
5.17
5.18
5.19
5.20
5.21
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6.01
6.02
6.03
6.04
6.05
6.06
6.07
6.08
6.09
6.10
6.11
6.12
6.13
6.14
6.15
6.16
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6.17
6.18
6.19
6.20
6.21
6.22
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6.00
Bone Marrow Aspiration
Arthrocentesis
Umbilical Catheterization
Skin Biopsy
Lung Puncture
Renal Biopsy
Hepatic Biopsy
Cisternal Biopsy
Arterial Lines
CVP Lines
Ventilator Care, PICU
Muscle Biopsy
Pediatric TPN
Lumbar Puncture
Pediatric Swan-Ganz
Chest Tube Insertion
Pediatric Bronchoscopy
PEDIATRIC SUBSPECIALTY PROCEDURES
Pediatric Cardiac Catheterization
Pediatric Angiography
Pediatric Cardioversion
Pediatric Endoscopy
Pediatric Per-Oral Biopsy
Pediatric Hemodialysis
Pediatric Myelography
Pediatric Pneumonencephalography & Ventriculography
Pediatric Cerebral Angiography
Pediatric Lymphangiography
Interpretation of Pediatric EKG's
Interpretation of Pediatric Echocardiography
Intubation
Evoked Responses
Interpretation of Pediatric EEG's
Endocrinology Procedures (Dynamic Hormonal Tested
Studies)
Clinical (Medical) Genetics Consultations
Liver Biopsy
Small Bowel Biopsy
Endoscopic Variceal Sclerosis
Rubber-band Ligation, Varices
Variceal Banding
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(12)
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(12)
(12)
(12)
(12)
1.06
1.09
1.10
1.11
1.12
3.06
3.08
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(12) 3.48
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Others
Sigmoid, Flexible, Diagnostic
Colonoscopy
GI Endoscopy using General Anesthesia
Colonoscopy with Polypectomy
Sigmoid, Flexible with Biopsy & Polypectomy
Esophagoscopy
Administration of IV Anesthesia/Analgesia when loss of reflex
may occur
Percutaneous Endoscopic Gastrostomy
______________________________________________________________________________
Signature
Date
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Department:
Reviewed and recommended, as requested:_____
Reviewed and recommended, with exception:_____
Reviewed but not recommended:_____
______________________________________________________________________________
Chairperson
Date
Medical Staff Executive Committee:
Reviewed and recommended, as requested:_____
Reviewed and recommended, with exception:_____
Reviewed but not recommended:_____
Date____________________
Board of Hospital Managers:
Reviewed and approved, as requested:_____
Reviewed and approved, with exception:_____
Reviewed but not approved:_____
Date____________________
Note: If privileges are denied, limited, or granted other than as requested,
documentation must be provided.
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Hurley Medical Center
Department of Pediatrics
Definition of Pediatric Hospital Privileges
I.
Hospital Care Privileges
Category 0 - Emergency privileges
Category 1 - Illness or problem with no apparent serious threat to life. This
will require skills usually acquired during a family practice residency. When
diagnosis is in doubt or response to treatment is not apparent, consultation
must be sought.
Category 2 - Illness or problem requiring skills usually acquired only after PL1 training in pediatrics. Physicians may apply for privileges in this category if
they supply evidence that their training or experience qualifies them for these
privileges. If there is no apparent response to treatment, consultation must
be sought.
Category 3 - Complex or severe illness or problem and those with immediate
or serious threat to life, requiring skills usually achieved only during training
sufficient to attain eligibility for board certification in pediatrics. Physicians
applying for privileges in this category should provide evidence of experience
in the care of the seriously ill child.
Category 4 - Illness or problem requiring expertise or techniques usually
acquired only during pediatric subspecialty training or experience, e.g.,
Allergy, Cardiology, Critical (Intensive Care), Endocrinology, Gastroenterology,
Hematology/Oncology, Neonatology, Nephrology, Neurology, Pulmonary
Diseases, and Rheumatology.
II.
Neonatal Care Privileges
Class A - Care of normal newborn infant more than 2000 g. - physicians
eligible for Category 1 or 2 Hospital Care.
Class B - Preterm or low birth weight (less than 2000 g.) infant or any infant
with significant neonatal problem or illness, e.g., jaundice, fever, suspected
infection, mild or moderate RDS, etc. - physicians eligible for Category 3
Hospital Care.
Class C - Life threatening illness or problem including respiratory distress
probably needing ventilatory support - physicians eligible for Category 3 or 4
Hospital Care.
III.
Minor Surgical Procedures - (Excludes simple procedures such as
venipuncture, repair of superficial lacerations or I & D of superficial abscess,
which all physicians with staff privileges are automatically permitted to do).
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IV.
Diagnostic/Therapeutic Procedures - (Excludes routine procedures such as
lumbar puncture, proctoscopy, or bladder puncture, which all physicians with
staff privileges are automatically permitted to do).
V.
Pediatric Subspecialty Procedures - For example, but not confined to:
Allergy, Cardiology, Endocrinology, Gastroenterology, Hematology/Oncology,
Neonatology, Nephrology, Neurology, Pulmonary Diseases, Critical (Intensive)
Care, and Rheumatology.
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