WESTERN REGIONAL INTEGRATED HEALTH AUTHORITY
Procedures - Privilege Classification System
Discipline of Family Practice
This privilege classification system is to clearly delineate privileges for procedures to be
undertaken by family physicians and to ensure interpretation by medical, nursing, and
administrative staff.
A.
List I (core): procedures that any reasonable, prudent family physician on Active,
Associate, or Courtesy Staff may be expected to carry out in an appropriate, safe
manner in any of the applicable areas of Hospitals or Health Care Facilities within
Western Health Region. Notwithstanding List I placement for a procedure, a
physician who has had insufficient frequency of completion of any procedure
to permit his/her comfort and competence in its performance should arrange
for his/her supervision by another physician competent in that procedure.
Alternatively, the physician may arrange for the procedure to be undertaken by
another competent physician. Privileges in Obstetrics, Neonatology, and
Paediatrics are treated separately within this document.
B.
List II (advanced): More advanced or less commonly performed procedures are
allocated to list II (see below) and must be applied for specifically by Active,
Associate, or Courtesy Staff as described below under “Application”.
C.
Unlisted Procedures: Privileges for procedures not listed in List I or List
II (see below) may be applied for specifically by Active, Associate, or Courtesy
Staff as described below under “Application”.
D.
Application: When a member of the Discipline of Family Practice, being
Active, Associate, or Courtesy Staff, wishes to apply to the Regional Chief of
Family Practice for permission to carry out specific procedures listed here in List
II or procedures not found on List I or List II, he/she is required to:
1. List procedures on his/her application or annual re-application for hospital
privileges. At other times of the year, a physician may list procedures in a
letter of application to the Regional Chief of Family Practice.
2. Include evidence of competence by:
a) qualification certificate (e.g. ACLS)
b) interview
c) oral examination and/or
d) by written testimony of instruction and supervision of the procedure by:
i) a discipline member previously approved to carry out this
procedure, or
by
ii) a physician or surgeon, with Royal College certification or its
equivalent in an appropriate recognized specialty, who has been
fully trained in this procedure.
E. Annual Review: All extra privileges and approval for the List II procedures will
be reviewed early by the Regional Chief of Family Practice, or more frequently
as the need arises.
F. Notification: Physicians approved for these extra privileges will have the approval
circulated to the medical, nursing and administration staffs of the appropriate areas of
the various facilities within the Region.
G. Emergencies: notwithstanding the above in an emergency situation, where no
other more competent physician is immediately available, procedures required in an
attempt to safeguard patient life may be undertaken.
PROCEDURE CLASSIFICATION BY BODY SYSTEM
(Please indicate with a check mark the privileges for which you apply)
Gastrointestinal Systems:
List I:
1.
2.
3.
4.
5.
Rigid Sigmoidoscopy
Proctoscopy
Excision of thrombosed external hemorrhoid
Gastric lavage
Incision and drainage of perianal abscesses
List II:
1.
2.
Flexible Sigmoidoscopy
Banding of internal/external hemorrhoids
Dermatological Systems:
List I:
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
List II:1.
Skin punch biopsy
Removal of sebaceous cysts an other superficial skin
lesions
Drainage paronychial abscess
Wedge resection of nail
Total removal of nail
Partial/complete ablation of nail bed
Incision and drainage of a superficial lesion.
Surgical debridement
Destruction of warts/skin tags using chemical, cryo, or
fulguration means
Suturing of lacerations
Excision biopsy premalignant lesions
Minor skin grafting
Gynecological and Urological Systems:
List I:
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
Insertion/removal of IUCD
Cautery/cryosurgery to cervix
Diaphragm fitting
Urinalysis
Urethral catheterization
PAP smear and routine gynecologic examination
Endometrial biopsy
Forensic examination of the sexual assault victim
Incision and drainage of Bartholin’s abscess
Dilation and Curettage
a) Diagnostic
b) Incomplete/missed abortion under 12 weeks gestation
List II:
1.
2.
3.
Urethral dilation
Culdocentesis
Vasectomy
Cardiovascular System:
List I:
1.
2.
EKG with initial interpretation
Closed cardiac massage
List II:
1.
2.
3.
4.
5.
CVP/Swan-Ganz catheter placement
External cardiac pacing*
Cardioversion electronically*
Intracardiac injection*
Portacath access
* Note: If the member of the Department has valid ACLS or ATLS certification, it will
not be necessary to apply for special permission to do these procedures.
ENT System:
List I:
1.
2.
3.
4.
5.
6.
7.
Syringing cerumen from ear canals
Removal of foreign bodies from ENT systems
Nasal packing
Nasal cautery with silver nitrate
Indirect laryngoscopy
Undisplaced fractures of nasal bones
Endotracheal intubation*
List II:
1.
2.
3.
Audiogram, including interpretation
Tympanograms, including interpretation
Nasal cautery by electocautery
Musculoskeletal System:
List I:
List II:
1.
2.
3.
4.
5.
Application of casts and splints
Intra-articular steroid injections
Aspiration of joints
Closed reduction of shoulder, patella, finger and toe
dislocations
Undisplaced fractures not requiring reduction
1.
2.
Repair of lacerated tendons
Management of amputated distal phalanges
Ophthalmologic System:
List I:
1.
2.
3.
Tonometry
Removal of non-penetrating foreign body
Treatment of corneal abrasions
List II:
1.
2.
Use of slit lamp
Excision of chalazion
General Surgical Procedures:
List I:
1.
Bone marrow aspirate/biopsy
2.
Evacuation of hematoma
3.
Removal of superfical foreign bodies
4.
Thoracentesis/insertion of chest tube*
5.
Abdominal paracentesis*
List II:
1.
Cut-down IV catheterization
Injections and Intravenous Procedures:
List I:
1.
2.
3.
4.
5.
6.
7.
Venipuncture
Immunizations
Steroid injections
Blood Transfusion
Lumbar puncture
Chemotherapy injections
Arterial blood gas sampling
List II:
1.
Insertion of subclavian CVP line*
Note: Currently designation of procedures as included under List I or List II are subject
to change. Other procedures may be added.
Other Disciplines:
Internal Medicine:
All medical conditions are treated at the discretion of the attending physician in
accordance with his/her training and abilities. Cases requiring consultation (telephone or
in person), or those requiring mandatory transfer are as outlined in the Rules. (See
appendix I)
Psychiatry:
Site specific guidelines will apply regarding those cases which can be managed locally
and those which must be transferred to the nearest psychiatric admitting facility
appropriate to the nature of the case. In general, those cases certifiable under the Mental
Health Act will require transporting to the Waterford Hospital as there is not “closed”
psychiatric admitting facility in Western Health Region.
I,___________________________________(please print), apply for the Family
Practice privileges as indicated on the preceding pages.
Are you requesting a change from privileges from the previous year?
Yes____ No____
__________________________
Applicant’s signature
______________________
Date dd/mm/yy
__________________________
Reg. Chief Family practice
______________________
Date dd/mm/yy
__________________________
Medical Director
______________________
Date dd/mm/yy
Western Regional Integrated Health Authority
Family Practice Privileges in Obstetrics and Neonatal Care
Generally privileges are granted commensurate with training, experience, special
interests, and institutional needs. Mandatory consultations to and transfers to an
obstetrician are as outlined in the rules and regulations governing the medical staff of
Western Regional Integrated Health Authority. (See appendix II)
New physician applying for Family Practice obstetrical privileges will require a
complement of five satisfactory supervised deliveries before being granted the full
privileges as follows. Additional consideration in this regard will be given to physicians
transferring from an area wherein they have already had current active obstetrical
privileges. The supervision report may be filled out by a discipline member already fully
privileged in Family Practice obstetrics, or by an obstetrician with Royal College
certification or its equivalent. (see appendix III)
Routine Obstetrical Privileges:
Normal Delivery:
1.
2.
3.
4.
5.
6.
7.
8.
Normal, full term, spontaneous, cephalic, singleton, vaginal delivery.
Outlet forceps.
Vacuum extraction
Episiotomy
Fetal scalp clip application
Artificial rupture of membranes
Augmentation of spontaneous labor with syntocinon.
Repair of episiotomy or perineal tear including second degree tear.
Neonatal Care:
Neonatal care, especially in sites without a paediatrician, requires a valid neonatal
resuscitation certificate. It would be expected that all physicians providing neonatal care
should have current resuscitation certificate within one year of applying for these
privileges. All conditions are treated at the discretion of the attending physician in
accordance with his/her training and abilities. Mandatory neonatal transfers and those
cases requiring either telephone or direct neonatal consultation are as per the rules and
regulations governing medical staff for the region. (See appendix IV)
I, ___________________________(please print), apply for privileges in Family
Practice obstetrics as indicated above.
I, ___________________________(please print), apply for privileges in Family
Practice neonatal care.
Are you requesting a change in privileges from the previous year?
Yes____ No____
___________________________________
Applicant’s signature
_______________________
Date dd/mm/yy
______________________________
Reg. Chief Fam. Medicine
_______________________
Date dd/mm/yy
______________________________
Reg. Chief Obstetrics
_______________________
Date dd/mm/yy
______________________________
Reg. Chief Paediatrics
_______________________
Date dd/mm/yy
Appendix I
Western Regional Integrated Health Authority
Discipline of Family Practice
Mandatory Transfers to Internal Medicine*
Cardiovascular Disease
1.
Cardiogenic Shock.
2.
Shock from any cause.
3.
Serious arrhythmia.
4.
Pulmonary embolism.
5.
Malignant hypertension.
Respiratory Disease
1.
Respiratory failure.
2.
Status asthmaticus.
Kidney Disease
1.
Acute renal failure.
Metabolic Disease
1.
Diabetes mellitus with acidosis or coma.
2.
Thyroid storm.
3.
Adrenal crisis.
Central Nervous System
1.
Undiagnosed coma
2.
CNS bacterial infection
3.
Status epilepticus
* Notwithstanding the above, at sites outside WMRH, after discussing with the
internist on call, if transfer of the patient would cause additional peril, or if
additional medical stabilization is required, transfer may be delayed/postponed
until patient no longer in jeopardy. The reasons for delay in transfer and
circumstances around such should be documented in the patient’s chart.
Discretionary Internal Medicine Consults
Cardiovascular Disease
1.
Undiagnosed chest pain
2.
Undiagnosed heart murmurs
3.
Myocardial Infarction with Arrhythmia
4.
Congestive Heart Failure
5.
Unstable Angina Pectoris
(Specialists must accept transfers from family physicians if, after proper verbal consultation between the
family physician and the specialist, the family physician feels that the case is beyond his or her personal
competence or the local sites’ ability to manage) (Minute 01-04-116 RMAC April 18 2001)
Appendix II
Western Regional Integrated Health Authority
Mandatory Consultations to Obstetrician During Pregnancy:
Antenatal:
1. Obstetric
a)
b)
c)
d)
e)
f)
g)
h)
Antepartum hemorrhage
Vaginal birth after Caesarian (VBAC)
Intrauterine growth retardation
Polyhydramnios/oligohydramnios
Intrauterine fetal death
Multiple gestation
Breech or other abnormal presentation
Premature rupture of membranes
2. Medical
a) Pregnancy induced hypertension
b) Pre-existing diabetes or gestational diabetes
c) Rhesus isoimmunization
d) Other medical problems; thyroid disease,cong, heart disease,
etc.
3.Post-maturity and all patients requiring induction of labor.
Intrapartum:
1.
2.
Fetal distress in labor.
Preterm labor less than 36 weeks.
Postnatal:
1.
2.
3.
4.
Postpartum hemorrhage.
Removal of retained placenta.
Third degree tears.
Cervical tears.
(Specialists must accept transfers from family physicians if, after proper verbal consultation between the
family physician and the specialist, the family physician feels that the case is beyond his or her personal
competence or the local sites’ ability to manage)
(added as per RMAC January 16, 2002, Minute 02-01-10)
Western Regional Integrated Health Authority
Mandatory Transfers of Patients in Labour to Obstetrics
1.
Abnormal presentation including breech, face and brow.
2.
Twins and multiple gestations.
3.
Patients in active labor whose cervix is 4cm dilated and then does not progress
greater than 1cm/hr over the next 4 hours.
4.
All diabetics including gestational diabetics.
5.
All patients with severe pre-eclamptic toxemia requiring anticonvulsant therapy
such as a magnesium sulphate drip.
6.
All patients on tocolytic therapy.
7.
Premature labor less than 36 weeks.
N.B.- Regional policies re: induction of labor, and gestation at which deliveries can occur
at various sites in the region will supercede these guidelines.
(Specialists must accept transfers from family physicians if, after proper verbal consultation between the
family physician and the specialist, the family physician feels that the case is beyond his or her personal
competence or the local sites’ ability to manage)
(added as per RMAC January 16, 2002, Minute 02-01-10)
Western Regional Integrated Health Authority
Application for Family Practice Privileges in Paediatrics:
All paediatric conditions are treated at the discretion of the attending physician in
accordance with his/her training and abilities. Mandatory transfers to a paediatrician, and
those cases requiring either direct or telephone consultation with a paediatrician are as
outlined in the rules and regulations governing the medical staff of Western Regional
Integrated Health Authority. (See appendix V)
I
paediatrics.
(please print), apply for Family Practice privileges in
Are you requesting a change in privileges from previous year?
Yes_______No________
_________________________
Signature applicant
____________________________
Date dd/mm/yy
____________________________
Reg. Chief Fam. Medicine
____________________________
Date dd/mm/yy
_____________________________
Reg. Chief Paediatrics
____________________________
Date dd/mm/yy
Appendix 111
Western Regional Integrated Health Authority
Supervision Report for New Family Practice Obstetrical Privileges:
Physician Name: _________________________________________________________
Date temporary privileges under supervision granted_____________________________
Supervision requirements:__________________________________________________
Cases:
Patient Name
Date
Sig Supervisor*
Remarks
- Signature of supervisor indicates satisfactory performance of the above.
- A supervisor is either a discipline member already fully privileged in
Family Practice obstetrics, or Royal College certified obstetrician or
eqivalent.
___________________________
Signature Applicant physician
_____________________
Date: dd/mm/ yy
Appendix 1V
Western Regional Integrated Health Authority
Discipline of Family Practice
Mandatory Neonatal Consults* to Paediatrician
Antenatal:
1.
Infant of diabetic mother.
2.
Prematurity < 37 weeks gestation
3.
Any condition designated by the attending physician.
Intrapartum:
1.
Multiple births.
2.
Newborns delivered by emergency Caesarean section with unacceptable
“Newborn”
Criteria.
3.
Polyhydramnios/oligohydramnios.
Newborn:
1.
Low Apgar score < 6 at five minutes.
2.
Small for gestational age infants of < 2500g or less than 2SD below the mean.
3.
Large for gestational age infants of < 4500g or more than 2SD above the mean.
4.
Infants with any of the following:
hypocalcemia, hypoglycemia**, electrolyte disturbance, acid-based
disturbances, hypotonic, hypothermia, extreme jitteriness, seizure-like
activity, heart murmur, central cyanosis.
5.
Infants with respiratory distress (tachypnea> 70 breaths/ min. longer than 2 hours
associated with the indrawing, nasal flaring, or grunting.
6.
Infants with jaundice in the first 24 hours or a bilirubin level increasing >
50mmol/L in 24 hours.
7.
Infants with dysmorphic features, congenital anomalies or organomegaly.
8.
Infants with indeterminate gender. Not urgent if voiding normally.
9.
Infants of mothers with prolonged rupture of membranes > 24 hours.
10.
Neonatal feeding problems or poor weight gain.
Discretionary Consults of Paediatrician
1.
2.
3.
4.
5.
Meconium stained infants.
Infants of mothers who have toxemia.
Precipitous delivery of infants.
Infants delivered by forceps, vacuum extraction, breech, and/or malpresentation.
Infants tightly corded at birth.
* A consult may be telephoned or direct.
** Hypoglycemia is defined as blood glucose (by glucoscan or similar device).
i) In premature < 1.7 mmol/L first 72 hours; < 2.3 mmol/L after 72 hours.
ii) Term infant < 2.0 mmol/L first 72 hours; < 2.3 mmol/L after 72 hours.
Appendix V
Western Regional Integrated Health Authority
Discipline of Family Practice
Mandatory Paediatric Transfers
3.
4.
5.
1.
2.
3.
4.
5.
6.
Cardiovascular Disease
1. Cardiac failure
2. Congenital heart defect producing serious symptoms.
3. Myocarditis/pericarditis
4. Rheumatic fever.
5. Serious dysrhythmias.
Respiratory Disease
1. Acute respiratory distress, undiagnosed or not responding to treatment.
2. Croup (severe).
3. Newly diagnosed cystic fibrosis.
4. Pulmonary tuberculosis.
5. Status asthmaticus.
6. Epiglottitis.
Infectious Disease
1. Gastroenteritis with severe dehydration.
2. Meningitis.
1.
2.
Blood Diseases
1. Hematologic malignancies i.e. leukemia, lymphoma, Histiocytosis X etc.
2. Severe anemia.
1.
2.
3.
Metabolic Disease
1. Diabetes Mellitus newly diagnosed.
2. Severe electrolyte imbalance.
3. Severe failure to thrive.
Central Nervous System
1. Acute infections (meningitis, encephalitis).
2. Status epilepticus.
Urinary Tract
1. Glomerulonephritis.
2. Nephrotic syndrome.
Musculoskeletal System
1. Juvenile rheumatoid arthritis.
Digestive System
1. Ingestion of caustic agents.
2. G.I. bleeding in children.
Discretionary Paediatric Consults (direct or telephone)
Cardiovascular Disease
1. Hypertension.
1.
2.
3.
Respiratory Disease
1. Croup (moderate).
2. Pneumonia, community acquired.
3. Chronic recurrent asthma.
1.
Infectious Disease
1. Gastroenteritis with moderate dehydration.
1.
2.
3.
Blood Diseases
1. Bleeding disorders.
2. Puerpura.
3. Mild to moderate anemia.
1.
Metabolic Diseases
1. Other endocrine disorders i.e. hypo/hyperthyroidism, hyperparathyroidism etc.
1.
2.
Urinary Tract
1. Nephrolithiasis.
2. Recurrent urinary tract infection.
1.
2.
3.
Musculoskeletal System
1. Septic arthritis.
2. Muscular dystrophy.
3. Osteomyelitis.
1.
2.
3.
Digestive System
1. Chronic diarrhea.
2. Jaundice.
3. Persistent vomiting or abdominal pain.
1.
Integumentary System
1. Severe Atopic Dermatitis
Western Regional Integrated Health Authority
Discipline of Family Practice
Periodic Review Indicators for Reappointment to Medical Staff
1.
Twenty hours of C.M.E. annually or current C.C.F.P. certification. May be
comprised of pharmaceutical company sponsored C.M.E. events, journal reading,
clinical symposia, round table discussions, distance education programs, and
undergraduate/postgraduate medical teaching. Must be able to produce evidence
of attendance at same on request.
2.
Absences from discipline meetings without reason not to exceed 10% annually, as
per the bylaws.
3.
Absences from medical staff meetings without reason not to exceed 10%
annually, as per the bylaws.
4.
Chart audits satisfactory. Dictated charts satisfactory.
5.
Personnel file free of complaints requiring disciplinary action.
Please list C.M.E. Attended Below
Type CME event
Title
Location
# Hours
I,
(please print), swear that this is a true and accurate reflection
of my C.M.E. participation over the preceding 12 months. I am prepared to provide
documentation of attendance on request.
______________________________
Signature of physician
________________________
Date dd/mm/yy
______________________________
Chief of Staff (site)
________________________
Date dd/mm/yy
______________________________
Reg. Chief Family Practice
________________________
Date dd/mm/yy
______________________________
Medical Director
________________________
Date dd/mm/yy
______________________________
Chair, Board of Directors WRIHA
________________________
Date dd/mm/yy
Form # 12 - 1621