Download Cardiothoracic and Vascular Surgery

St. Dominic Hospital
DEPARTMENT OF CARDIOLOGY/CVS
Cardiothoracic/Vascular Surgery Service
CREDENTIALS GUIDELINES
Approved by Credentials Committee: October 2008
Approved by Credentials Committee: April 2012
Approved by Credentials Committee: June 2015
In order to be eligible to request clinical privileges for cardiothoracic and/or vascular
surgery, a practitioner must meet the following minimum threshold criteria:
EDUCATION: MD or DO
MINIMUM FORMAL TRAINING: The applicant must be able to demonstrate successful completion of an
approved residency training program in general surgery that was followed by an approved residency/fellowship
training program in general thoracic and cardiovascular surgery.*
REQUIRED PREVIOUS EXPERIENCE: The applicant must demonstrate that he/she has performed a
reasonable number of procedures during the past twelve (12) months, to include a demonstration of skills in
cardiothoracic/vascular surgery.
BOARD CERTIFICATION: The applicant must be certified or qualified to take the board certification
examination as outlined below by the American Board of Thoracic Surgery and/or American Board of Vascular
Surgery. The applicant must meet the Medical Staff Bylaws requirements for board certification.
*Any physician performing vascular procedures as of January 1, 2008, are grandfathered under the credentials
guidelines. Any physicians requesting privileges after this date must meet the above requirements.
“Candidates should apply for the examination within two (2) years of the satisfactory completion of their
thoracic surgery residency. Any candidates applying for the examination two (2) years or more after the
satisfactory completion of residency will be considered individually, and recommendations for additional
training will be made before they will be eligible to apply for examination.”
IF YOU MEET THE ABOVE CRITERIA, YOU MAY REQUEST CORE PRIVILEGES IN
CARDIOTHORACIC/VASCULAR SURGERY.
ST. DOMINIC HOSPITAL
CARDIOTHORACIC/VASCULAR SURGERY
PRIVILEGES FORM
Name (please print):
Date:
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Cardiothoracic Core Privileges
Admit, evaluate, diagnose, and provide consultation to
patients of all ages except as specifically excluded from practice
with illnesses, injuries and disorders within the thoracic abdominal
cavity and related structures including the chest wall. Included,
surgical cancers of the lung, esophagus and chest wall, abnormalities
of the trachea, abnormalities of the great vessels and heart valves,
congenital anomalies, tumors of the mediastinum, and diseases of
the diaphragm, management of the airway, and the ordering of
diagnostic studies and procedures related to thoracic problems. The
core privileges in this specialty include the procedures on the
attached procedure list and such other procedures that are extensions
of the same techniques and skills.
Requested
Granted
Monitored
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Vascular Surgery Core Privileges
Admit, evaluate, diagnose, provide consultation and treat patients of
all ages except as specifically excluded from practice with
diseases/disorders of the arterial, venous, and lymphatic circulatory
systems, excluding the intercranial vessels or the heart. The core
privileges in this specialty include the procedures on the attached
procedure list and such other procedures that are extensions of the
same techniques and skills.
Requested
Granted
Monitored
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Cardiothoracic/Vascular Surgery Special Requests*
Requested
Granted
Monitored
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Moderate/Conscious Sedation
Peripheral Vascular Intervention
Other
* Proof of attendance at approved course or letter verifying training by local physician certified in Cardiothoracic
Surgery or certain number of procedures (to be determined by credentialing committee) or specific mention of
training and competence by director of residency/fellowship training program. (X = procedure not available. S =
supervised privileges only.)
Signature of Applicant:
Date:
CRITERIA FOR SPECIAL PRIVILEGE REQUESTS
MODERATE/CONSCIOUS SEDATION
Must obtain the Moderate/Conscious Sedation Packet including practice guidelines, policy, assessment test,
and privilege request form.
Qualifications for Peripheral Vascular Interventions Cardiology
To be eligible to apply for core privileges in interventional cardiology, the initial applicant must be granted core
privileges in cardiovascular medicine and meet the following criteria:
Required Previous Experience: Successful completion of an accredited residency or fellowship in one of the
following specialties: general surgery, followed by accredited fellowship in vascular surgery and leading to special
certification; radiology, followed by an accredited fellowship in interventional radiology; cardiology, meeting
requirements of the American Board of Internal Medicine (ABIM); or vascular medicine, meeting the requirements
of the ABIM. Note: A full twelve (12) months of experience in the vascular laboratory during the fellowship year
(s) is required. The experience must include the performance of at least 100 diagnostic peripheral angiographic
studies during the last 24 months (50 of those of the primary operator).
Alternate Training Pathway and/or Apprenticeship Pathway
Documented successful completion of ACGME-approved Fellowship in Cardiovascular Medicine or Vascular
Surgery or Cardiothoracic Surgery or Residency in Diagnostic Radiology; documented successful performance of
100 diagnostic peripheral angiograms and 50 peripheral vascular interventions (for at least 25 of these procedures
the applicant must be primary operator), and performance of at least 5 percutaneous peripheral arterial thrombolysis
cases (all procedures must be directly supervised by a physician who has already satisfied one of the credentialing
pathways); performance of 30 cases of diagnostic peripheral angiograms (15 as primary operator) and 15 cases of
peripheral interventions (8 as primary operator); completion of at least 20 Category 1 CME hours in a didactic
setting of peripheral angiography and non-coronary endovascular interventions.
Reappointment Requirements: Satisfactory performance of at least 25 peripheral vascular interventions cases
annually (at least 50 every two years).
CARDIOTHORACIC SURGERY CLINICAL PRIVILEGES
Note: this list is a sampling of procedures included in the core. This is not intended to be an allencompassing list but rather reflective of the categories/types of procedures included in the core.
If you wish to exclude any procedures, please strike through those procedures that you do not wish to
requests, initial and date.
Core Procedure List:
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Ablative surgery for Wolff-Parkinson-White syndrome
All procedures upon the heart for the management of acquired/congenital cardiac disease, including
surgery upon the pericardium, coronary arteries, the valves, and other internal structures of the heart
and for acquired septal defects and ventricular aneurysms
Bronchoscopy
Endarterectomy of pulmonary artery
Endomyocardial biopsy
Management of congenital septal and valvular defects
Maze procedure
Minimally invasive direct coronary artery bypass (MIDCAB),
Pacemaker and/or AICD implantation and management, transvenous and transthoracic
Palliative vascular procedures (not requiring cardiopulmonary bypass) for congenital cardiac disease
Perform waived laboratory testing not requiring an instrument, including but not limited to fecal occult
blood, urine dipstick, and vaginal pH by paper methods.
Pericardiocentesis
Pulmonary embolectomy
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Surgery of patent ductus arteriosus and coarctation of the aorta
Surgery of the aortic arch and branches; descending thoracic aorta for aneurysm/trauma
Surgery of the thoracoabdominal aorta for aneurysm
Thoracentesis
Thoracotomy
Thoracoscopy
Tracheobronchial procedures, e.g., mediastinal tracheostomy, repair of rupture or laceration, resection of
stricture or tumor
Vascular access procedures for use of life support systems, such as extra corporeal oxygenation and
cardiac support
Vascular operations exclusive of thorax, e.g., caval interruption, embolectomy, endarterectomy, repair of
excision of aneurysm, vascular graft or prosthesis
Implantation of heart value (mechanical or cellular tissue)
VASCULAR SURGERY CLINICAL PRIVILEGES
Note: this list is a sampling of procedures included in the core. This is not intended to be an allencompassing list but rather reflective of the categories/types of procedures included in the core.
If you wish to exclude any procedures, please strike through those procedures that you do not wish to
requests, initial and date.
Core Procedure List:
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Amputations, upper extremity, lower extremity
Aneurysm repair, abdominal aorta and peripheral vessels emergent and elective
Angioplasty, femoral, iliac
Bypass grafting all vessels excluding coronary and intracranial vessels
Central venous access catheters and ports
Cervical, thoracic or lumbar sympathectomy
Diagnostic biopsy or other diagnostic procedures on blood vessels
Embolectomy or thrombectomy for all vessels excluding coronary and intra cranial vessels
Endarterectomy for all vessels excluding coronary and intra cranial vessels
Extra cranial carotid and vertebral artery surgery
Hemodialysis access procedures
Intraoperative angiography
Intraoperative angioplasty, balloon dilatation
Other major open peripheral vascular arterial and venous reconstructions
Perform waived laboratory testing not requiring an instrument, including but not limited to fecal occult
blood, urine dipstick, and vaginal pH by paper methods.
Reconstruction, resection, repair of major vessels with anastomosis or replacement (excluding
cardiopulmonary, intracranial)
Sclerotherapy
Temporal artery biopsy
Thoracic outlet decompression procedures including rib resection
Vein ligation and stripping
Venous reconstruction