CLINICAL PRIVILEGES- ADULT OR GERONTOLOGICAL NURSE .
UNIVERSITY HOSPITAL AND HEALTH SYSTEMUNIVERSITY OF MISSISSIPPI MEDICAL CENTER2500 North State Street, Jackson MS 39216CLINICAL PRIVILEGES- ADULT OR GERONTOLOGICAL NURSE PRACTITIONERName: Initial Appointment ReappointmentPage 1DepartmentSpecialtyAll new applicants must meet the following requirements as approved by the governing bodyeffective: 06/7/2016Applicant: Check off the “Requested” box for each privilege requested. Applicants have the burden ofproducing information deemed adequate by the Hospital for a proper evaluation of current competence,current clinical activity, and other qualifications and for resolving any doubts related to qualifications forrequested privileges.Department Chair: Check the appropriate box for recommendation on the last page of this form. Ifrecommended with conditions or not recommended, provide condition or explanation on the last page ofthis form.Other Requirements Note that privileges granted may only be exercised at the site(s) and/or setting(s) that have theappropriate equipment, license, beds, staff and other support required to provide the services definedin this document. Site-specific services may be defined in hospital and/or department policy.This document is focused on defining qualifications related to competency to exercise clinicalprivileges. The applicant must also adhere to any additional governance (MS Bylaws, Rules andRegulations) organizational, regulatory, or accreditation requirements that the organization isobligated to meet.QUALIFICATIONS FOR ADULT NURSE PRACTITIONERSTo be eligible to apply for core privileges as an adult nurse practitioner, the initial applicant mustmeet the following criteria:Current certification as a Adult Nurse Practitioner by the American Nurses Credentialing Center (ANCC),American Academy of Nurse Practitioners (AANP), or an equivalent body as required by licensure;Required Previous Experience: Applicants for initial appointment must be able to demonstrate clinicalexperience as an Adult Nurse Practitioner during the past 24 months or demonstrate successfulcompletion of an accredited Adult Nurse Practitioner program within the past 12 months.Reappointment Requirements: To be eligible to renew core privileges as an adult nurse practitioner, theapplicant must meet the following maintenance of privilege criteria:Current demonstrated competence and an adequate volume of experience, (inpatients, outpatients, orconsultations) with acceptable results, reflective of the scope of privileges requested, for the past 24months based on results of ongoing professional practice evaluation. Evidence of current ability toperform privileges requested is required of all applicants for renewal of privileges.
UNIVERSITY HOSPITAL AND HEALTH SYSTEMUNIVERSITY OF MISSISSIPPI MEDICAL CENTER2500 North State Street, Jackson MS 39216CLINICAL PRIVILEGES- ADULT OR GERONTOLOGICAL NURSE PRACTITIONERName:Page 2CORE PRIVILEGESADULT NURSE PRACTITIONER CORE PRIVILEGES RequestedAssess, evaluate, diagnose, treat and provide consultation to provide care to patients of the agesapproved by specialty certification and adult patients who present with any symptom, illness, injury orcondition and provide services necessary to ameliorate minor illnesses and/or injuries (in conjunction withcollaborating physician). Stabilize patients with major illnesses or injuries and to assess all patients todetermine if additional care is necessary. Order and interpret appropriate diagnostic tests. Performevaluations. Order appropriate referrals and consultations. Change or discontinue medical treatment plan.Prescribe, initiate, and monitor all medications which APRNs are authorized to prescribe in Mississippi.Initiate consultation for and monitor patients during special tests.The core privileges include the procedures on the attached procedure list.QUALIFICATIONS FOR GERIATRIC NURSE PRACTITIONERSTo be eligible to apply for core privileges as a gerontological nurse practitioner, the initialapplicant must meet the following criteria:Current certification as a Gerontological Nurse Practitioner by the American Nurses Credentialing Center(ANCC), American Academy of Nurse Practitioners (AANP), or an equivalent body as required bylicensure;Required Previous Experience: Applicants for initial appointment must be able to demonstrate clinicalexperience as aGerontological Nurse Practitioner during the past 24 months or demonstrate successfulcompletion of an accredited Gerontological Nurse Practitioner program within the past 12 months.Reappointment Requirements: To be eligible to renew core privileges as a gerontological nursepractitioner, the applicant must meet the following maintenance of privilege criteria:Current demonstrated competence and an adequate volume of experience, (inpatients, outpatients, orconsultations) with acceptable results, reflective of the scope of privileges requested, for the past 24months based on results of ongoing professional practice evaluation. Evidence of current ability toperform privileges requested is required of all applicants for renewal of privileges.CORE PRIVILEGESGERIATRIC NURSE PRACTITIONER CORE PRIVILEGES RequestedAssess, evaluate, diagnose, treat and provide consultation to geriatric patients or other adult patients withearly onset of gerontoligical diseases (Parkinsons’, Alzheimer’s, etc.) who present with any symptom,illness, injury or condition and provide services necessary to ameliorate minor illnesses and/or injuries (inconjunction with collaborating physician). Stabilize patients with major illnesses or injuries and to assessall patients to determine if additional care is necessary. Order and interpret appropriate diagnostic tests.Perform evaluations. Order appropriate referrals and consultations. Change or discontinue medicaltreatment plan. Prescribe, initiate, and monitor all medications which APRNs are authorized to prescribein Mississippi. Initiate consultation for and monitor patients during special tests.
UNIVERSITY HOSPITAL AND HEALTH SYSTEMUNIVERSITY OF MISSISSIPPI MEDICAL CENTER2500 North State Street, Jackson MS 39216CLINICAL PRIVILEGES- ADULT OR GERONTOLOGICAL NURSE PRACTITIONERName:Page 3The core privileges include the procedures on the attached procedure list.SPECIAL NON-CORE PRIVILEGES (SEE SPECIFIC CRITERIA)If desired, Non-Core Privileges are requested individually in addition to requesting the Core. Eachindividual requesting Non-Core Privileges must meet the specific threshold criteria governing the exerciseof the privilege requested including training, required previous experience, and/or maintenance of clinicalcompetence.Criteria: As for core, plus any non-core privileges require Mississippi Board of Nursing approval. Writtenapproval from the Mississippi Board of Nursing should be submitted to the Medical Staff Office. Forprivileges that require on-site training, there must be documentation that the Board has been notified andthe request is pending submission of on-site training. Required Previous Experience: Applicants forinitial appointment must demonstrate performance of a sufficient number of each procedure during thepast 24 months or demonstrate successful completion of an accredited Adult Nurse Practitioner programwithin the past 12 months that included training in each requested item. Additionally, applicants mustmeet any additional proctoring requirements noted with each specific privilege. If the applicant will betrained in the procedure after being privileged at UHHS, all procedures included during training must beproctored and the appropriate documents submitted to the Credentials Committee for review. (Theprovider may not perform any un-proctored procedures until the Credentials Committee, MEC and Boardhave reviewed and approved the outcomes of the FPPE or preceptorship for the privilege.) Maintenanceof Privilege: Demonstrated current competence and evidence of the successful performance of asufficient number of each requested procedure in the past 24 months based on results of ongoingprofessional practice evaluation and outcomes.Requested: Anoscopy Arterial line insertion (applicants initially requesting this privilege must be proctored for first 5procedures by a provider who currently holds the privilege, requires current ACLS certification) Baclofen Pump Management Bone marrow aspiration (applicants initially requesting this privilege must be proctored for first 5procedures by a provider who currently holds the privilege) Bone marrow biopsy (applicants initially requesting this privileges must be proctored for first 5procedures by a provider who currently holds the privilege) Botulinum toxin injection Cardiac pacing – transthoracic (temporary) (requires current ACLS certification) Cardiac pacing – transvenous (requires current ACLS certification) Cardioversion Central line insertion and/or repositioning (femoral and internal jugular access require specialprivileges for ultrasound guided central line insertion) (applicants initially requesting this privilegemust be proctored for first 5 procedures by a provider who currently holds the privilege, requirescurrent ACLS or PALS certification) Chest tube insertion (applicants initially requesting this privilege must be proctored for first 5procedures by a provider who currently holds the privilege, requires current ACLS certification) Epicardial pacing wire removal First Assist in OR (must complete education required by AORN for RNFAs) Halos, application of Hemodialysis (acute and/or chronic) Intracardiac line removal
UNIVERSITY HOSPITAL AND HEALTH SYSTEMUNIVERSITY OF MISSISSIPPI MEDICAL CENTER2500 North State Street, Jackson MS 39216CLINICAL PRIVILEGES- ADULT OR GERONTOLOGICAL NURSE PRACTITIONERName: Page 4Intrathecal medication administration, i.e. chemotherapy (applicants initially requesting this privilegemust be proctored for first 5 procedures by a provider who currently holds the privilege)Intubation, oral and/or nasal (applicants initially requesting this privilege must be proctored for first 5procedures by a provider who currently holds the privilege, requires current ACLS certification)Laryngoscopy, direct, indirect and/or fiber opticLumbar punctureNasopharyngoscopy, diagnosticParacentesis (applicants initially requesting this privilege must be proctored for first 5 procedures by aprovider who currently holds the privilege)Pericardiocentesis (applicants initially requesting this privilege must be proctored for first 5procedures by a provider who currently holds the privilege, requires current ACLS certification)Peritoneal dialysis (acute and/or chronic)PICC line placement with or without ultrasound, including repositioningProctoscopy, including rigid proctoscopyRenal replacement therapy (continuous)Repigmentation of the areola and/or nipple (tattooing)Sexual assault examination with or without colposcopyTemporary peritoneal dialysis catheter removalThoracentesis (applicants initially requesting this privilege must be proctored for first 5 procedures bya provider who currently holds the privilege)Tissue expansions (requires preceptorship only)Tracheostomy, downsize, change, and/or remove (decannulation)Tunneled dialysis catheter removalWound vac (neg pressure), application, change, and removalFor Adult or Gerontological Nurse Practitioners providing the aesthetic services listed below, certificationis required from a Mississippi Board of Nursing approved program. Chemical face peels Dermal filler injection Microdermabrasion Sclerotherapy Use of LasersCriteria:1) Completion of an acceptable laser safety course provided by the UMMC LaserSafety OfficerAND2) Successful completion of a Mississippi Board of Nursing approved certificationprogram which included training in lasersAND3) Practitioner agrees to limit practice to only the specific laser types for which theyhave documentation of training and/or experienceMaintenance of Privilege:A practitioner must document that procedures have been performed over the past 24months utilizing lasers (with acceptable outcomes) in order to maintain active privilegesfor laser use. In addition, completion of a laser safety refresher course provided by theLaser Safety Officer is required for maintenance of the privilege. Practitioner agrees to
UNIVERSITY HOSPITAL AND HEALTH SYSTEMUNIVERSITY OF MISSISSIPPI MEDICAL CENTER2500 North State Street, Jackson MS 39216CLINICAL PRIVILEGES- ADULT OR GERONTOLOGICAL NURSE PRACTITIONERName:Page 5limit practice to only the specific laser types for which they have documentation oftraining and/or experience.ADMINISTRATION OF SEDATION AND ANALGESIA RequestedSee Hospital Policy for Procedural Sedation by Non-Anesthesiologists for additionalinformation.Section One--INITIAL REQUESTS ONLY: Demonstration of prior clinical privileges to perform procedural sedation along with agood-faith estimate of at least 20 such sedations performed during the previous year(the estimate should include information about each type of procedure wheresedation was administered with a list of any adverse events related to the sedationduring those cases, including causal analysis, treatment, and outcome:-OR Successful completion (within six months of application for privileges) of a UMHCapproved procedural sedation training and examination course that includes practicaltraining and examination under simulation conditions.Section Two--INITIAL AND RE-PRIVILEGING REQUESTS: Successful completion of the UMHC web based Procedural Sedation Course/Examinitially and at least once every two years -ANDProvision of a good-faith estimate of the number of instances of each type ofprocedure where sedation is administered with a list of any adverse events related tothe sedation during those cases, including causal analysis, treatment, and outcome:–AND ACLS, PALS and/or NRP, as appropriate to the patient population. (Current)Section Three--INITIAL AND RE-PRIVILEGING REQUESTS: Controlled Substance Prescriptive Authority Schedules II – V approval from theMississippi Board of Nursing.ULTRASOUND-GUIDED CENTRAL LINE INSERTION RequestedSee Medical Staff Policy for Ultrasound-Guided Central Line Insertion for additionalinformation.Initial Privileging:
UNIVERSITY HOSPITAL AND HEALTH SYSTEMUNIVERSITY OF MISSISSIPPI MEDICAL CENTER2500 North State Street, Jackson MS 39216CLINICAL PRIVILEGES- ADULT OR GERONTOLOGICAL NURSE PRACTITIONERName:Page 6As for core privileges plus: Completion of a UMMC ultrasound-guided central line insertionHealthstream learning module; and Completion of ultrasound-guided central line insertion simulation trainingin the UMMC Simulation and Interprofessional Education Center; and Focused professional practice evaluation to include proctoring of theultrasound-guided insertion of at least 5 central lines (femoral or internaljugular) within the first 6 months of appointmentReprivileging:As for core privileges plus: Completion of a UMMC ultrasound-guided central line insertionHealthstream learning module; and Performance of at least 10 ultrasound-guided central line insertions inthe past 24 months;If volume requirements are not met, the following may substitute: Completion of ultrasound-guided central line insertion simulation trainingin the UMMC Simulation and Interprofessional Education Center; and Focused professional practice evaluation to include proctoring of theultrasound-guided insertion of at least 5 central lines (femoral or internaljugular) within the first 6 months of re-appointmentPRESCRIPTIVE AUTHORITYI have been approved for the following schedules by the Mississippi State Board of Nursing andhave attached a copy of my approved Controlled Substance Prescriptive Authority registration.II III IV VI do not have Controlled Substance Prescriptive Authority in Mississippi.
UNIVERSITY HOSPITAL AND HEALTH SYSTEMUNIVERSITY OF MISSISSIPPI MEDICAL CENTER2500 North State Street, Jackson MS 39216CLINICAL PRIVILEGES- ADULT OR GERONTOLOGICAL NURSE PRACTITIONERName:Page 7CORE PROCEDURE LISTTo the applicant: If you wish to exclude any procedures, please strike through those procedures whichyou do not wish to request, initial, and date. Procedures that are not in concert with yourcollaborating physician’s privileges should be stricken from this list. Abcess incision and drainage, including Bartholin’ s cystAnesthetic nerve blocks- local, regional, digital and dentalArterial line removalArterial punctureArthrocentesisAssist in surgeryBladder decompression and catheterization techniquesBlood component transfusion therapyBurn managementCaustic exposures, irrigation and management ofCentral line removalChest tube removalClosed fracture/severe sprain, application and/or removal of orthopedic splint/castCryotherapyDebridementPreliminary evaluation of EKGEpistaxis, management ofEye exam, including wood’s lamp exam as well as other common ophthalmic conditionsForeign body removal, including but not limited to airway, nose, eye, ear, or skinGastrostomy (PEG) tube reinsertionGI decontamination - emesis, lavage, charcoalHernia reductionHistories and physicals, performance ofIncision line closure under physician supervision while the patient is under anesthesiaJoint injections, diagnostic (bursa, tendon, sheath, trigger point) and injection therapyLaceration repairMedication administration via chest tubeNail trephine techniquesNegative pressure dressings and bandages, application, change, and removalOcular tonometryOrthopedic evaluation of common injuriesOxygen therapyParaphimosis reductionPerform waived laboratory testing not requiring an instrument, including but not limited to fecal occultblood, urine dipstick, and vaginal pH by paper methodsPICC line removalPreliminary evaluation of radiological studies (plain radiographs, CT, MRI scans)Rectal prolapse reductionRectal tube insertionReduction/Immobilization of dislocation/fractures, including splint and cast applications
UNIVERSITY HOSPITAL AND HEALTH SYSTEMUNIVERSITY OF MISSISSIPPI MEDICAL CENTER2500 North State Street, Jackson MS 39216CLINICAL PRIVILEGES- ADULT OR GERONTOLOGICAL NURSE PRACTITIONERName: Rehab service orderingRespiratory services, ordering ofRestraints, Chemical and/or physical of agitated patient in accordance with hospital policyRoutine immunizations, performance ofRoutine screening tests such as pap smears, pregnancy tests, Chlamydia testing, wet preps,gonorrhea cultures, hemoglobin test, and microscopic urinalysisSevered extremities, preservation of (digits, ear, nose, penis)Skin biopsySkin lesion excisionsSkin test interpretationSlit lamp examSpine immobilizationSpirometry interpretationSuprapubic catheter reinsertionThrombosed hemorrhoid excisionWound managementPage 8
UNIVERSITY HOSPITAL AND HEALTH SYSTEMUNIVERSITY OF MISSISSIPPI MEDICAL CENTER2500 North State Street, Jackson MS 39216CLINICAL PRIVILEGES- ADULT OR GERONTOLOGICAL NURSE PRACTITIONERName:Page 9ACKNOWLEDGEMENT OF PRACTITIONERI have requested only those privileges for which by education, training, current experience, anddemonstrated performance I am qualified to perform and for which I wish to exercise at UniversityHospital and Health System, University of Mississippi Medical Center, and I understand that:a. In exercising any clinical privileges granted, I am constrained by Hospital and Medical Staff policiesand rules applicable generally and any applicable to the particular situation.b. Any restriction on the clinical privileges granted to me is waived in an emergency situation and insuch situation my actions are governed by the applicable section of the Medical Staff Bylaws orrelated documents.SignedDateDIVISION CHIEF’S RECOMMENDATION (AS APPLICABLE)I have reviewed the requested clinical privileges and supporting documentation for the above-namedapplicant. To the best of my knowledge, this practitioner’s health status is such that he/she may fullyperform with safety the clinical activities for which he/she is being recommended. I make the followingrecommendation(s): Recommend all requested privileges. Recommend privileges with the following conditions/modifications: Do not recommend the following requested /ExplanationNotesDivision Chief SignatureDate
UNIVERSITY HOSPITAL AND HEALTH SYSTEMUNIVERSITY OF MISSISSIPPI MEDICAL CENTER2500 North State Street, Jackson MS 39216CLINICAL PRIVILEGES- ADULT OR GERONTOLOGICAL NURSE PRACTITIONERName:Page 10DEPARTMENT CHAIR'S RECOMMENDATIONI have reviewed the requested clinical privileges and supporting documentation for the above-namedapplicant. To the best of my knowledge, this practitioner’s health status is such that he/she may fullyperform with safety the clinical activities for which he/she is being recommended. I make the followingrecommendation(s): Recommend all requested privileges. Recommend privileges with the following conditions/modifications: Do not recommend the following requested /ExplanationNotesDepartment Chair SignatureDateReviewed:Revised: 10/5/2011, 12/16/2011, 11/7/2012, 4/3/2013, 5/23/2013, 05/07/2014, 4/1/2015, 6/7/2016
To be eligible to apply for core privileges as a gerontological nurse practitioner, the initial applicant must meet the following criteria: Current certification as a Gerontological Nurse Practitioner by the American Nurses Credentialing Center (ANCC), American Academy of Nurse Practitioner
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