Pain Management Criteria/Privileges - REPOST
Last Post 22 Apr 2014 06:40 PM by Andrew Miller. 0 Replies.
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22 Apr 2014 06:40 PM
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17 Jun 2013
We are in the process of developing criteria and/or privileges for Pain Management and I am looking for current documentation used at other NH hospitals. Thank you for any information you can provide.

~RE:
This is the form we use at Speare to privilege Pain Medicine Physicians.
Please note the formatting when I pasted it came over kind of funny, so if you would rather I fax you the form, just let me know.
Thanks,
Marilyn

Applicant: Check off the “Requested” box for each privilege requested. Applicants have the burden of producing information deemed adequate by the SMH for a proper evaluation of current competence, current clinical activity, and other qualifications and for resolving any doubts related to qualifications for requested privileges.
Department Chief: Check the appropriate box for recommendation on the last page of this form. If recommended with conditions or not recommended, provide condition or explanation on the last page of this form.
Other Requirements
This document is focused on defining qualifications related to competency to exercise clinical privileges. The applicant must also adhere to any additional hospital, regulatory, or accreditation requirements that SMH is obligated to meet.
QUALIFICATIONS FOR CHRONIC PAIN MEDICINE CORE PRIVILEGES
A. Initial Appointment Criteria: To be eligible to apply for core privileges in pain medicine, the initial applicant must meet the following criteria:
Successful completion of an Accreditation Council on Graduate Medical Education (ACGME)– or American Osteopathic Association (AOA)–accredited residency in a relevant medical specialty followed by successful completion of an ACGME- or AOA-accredited fellowship in pain medicine of at least 12 months duration.
WITH
Current subspecialty certification, or active participation in the examination process leading to subspecialty certification in pain medicine by; the American Board of Anesthesiology, the American Board of Psychiatry and Neurology, the American Board of Physical Medicine and Rehabilitation, or current certification or active participation in the examination process leading to certification by the American Board of Pain Medicine.
AND
Required previous experience: Applicants for initial appointment must be able to demonstrate provision of inpatient, outpatient, or consultative pain medicine services, reflective of the scope of privileges requested, for at least 50 patients during the past 12 months, or demonstrate successful completion of a hospital-affiliated accredited residency, or special clinical fellowship, within the past 12 months.
B. Reappointment Criteria: To be eligible to renew core privileges in advanced pain medicine, the applicant must meet the following maintenance of privilege criteria:
• Current demonstrated competence and an adequate volume of experience (50 inpatient, outpatient, or consultative pain medicine services) with acceptable results, reflective of the scope of privileges requested, for the past 24 months based on results of ongoing professional practice evaluation and outcomes.
• Evidence of current ability to perform privileges requested is required of all applicants for renewal of privileges. In addition, 10 hours of continuing education related to pain management is required in two years.
• Maintenance of Board Certification.
1. CHRONIC PAIN MEDICINE CORE PRIVILEGES
 Requested
Evaluate, diagnose, treat, and provide consultation to patients of all ages with acute and chronic pain that requires invasive pain medicine procedures beyond basic pain medicine. Assess, stabilize, and determine the disposition of patients with emergent conditions consistent with medical staff policy regarding emergency and consultative call services. The core privileges in advanced pain medicine include basic pain medicine core and the procedures on the attached procedure list and such other procedures that are extensions of the same techniques and skills.
CHRONIC PAIN MEDICINE CORE PROCEDURE LIST
This list is a sampling of procedures included in the core. This is not intended to be an all-encompassing list but rather reflective of the categories/types of procedures included in the core.
TO THE APPLICANT: If you wish to exclude any procedures, please strike through those procedures that you do not wish to request, initial, and date.
1. Behavioral modification and feedback techniques
2. Chemical neuromuscular denervation (e.g., Botox injection)
3. Diagnosis and treatment of chronic and cancer related pain
4. Discography
5. Epidural and subarachnoid injections
6. Epidural, subarachnoid or peripheral neurolysis
7. Fluoroscopically guided facet blocks, sacroiliac joint injections and nerve root specific
8. Implantation of subcutaneous, epidural and intrathecal catheters
9. Infusion port and pump implantation
10. Injection of joint and bursa
11. Management of chronic headache
12. Modality therapy and physical therapy
13. Neuroablation with cryo, chemical, and radiofrequency modalities
14. Nucleoplasty
15. Percutaneous implantation of neurostimulator electrodes
16. Perform history and physical exam
17. Peripheral, cranial, costal, plexus, and ganglion nerve blocks
18. Prevention, recognition, and management of local anesthetic overdose, including airway management and resuscitation
19. Recognition and management of therapies, side effects, and complications of pharmacologic agents used in management of pain
20. Rehabilitative and restorative therapy
21. Stress management and relaxation techniques
22. Subcutaneous implantation of neurostimulator
23. Superficial electrical stimulation techniques (e.g., TENS)
24. Trigger point injection
2. SPECIAL NONCORE PRIVILEGES (SEE SPECIFIC CRITERIA)
If desired, noncore privileges are requested individually in addition to requesting the core. Each individual requesting noncore privileges must meet the specific threshold criteria governing the exercise of the privilege requested including training, required previous experience, and for maintenance of clinical competence.
2a. HYPNOSIS FOR CHRONIC PAIN MANAGEMENT
 Requested
Initial Appointment Criteria: Successful completion of an accredited ACGME or AOA residency in psychiatry that included training in hypnosis or completion of a specific training program in hypnosis sponsored by an appropriate organization such as the American Psychiatric Association or the American Psychological Association, and evidence of satisfactory completion of a period of supervision in the practice of hypnosis under the supervision of a person qualified to perform hypnosis.
Required previous experience: Demonstrated current competence and evidence of the performance of hypnosis at least 10 times for pain management in the past 12 months.

Reappointment Criteria: Demonstrated current competence and evidence of the performance of hypnosis for pain management to at least 10 patients in the past 24 months based on results of ongoing professional practice evaluation and outcomes.
2b. PERCUTANEOUS VERTEBROPLASTY
 Requested
Initial Appointment Criteria: Successful completion of an ACGME- or AOA-accredited fellowship in pain medicine . Applicants must also have completed an approved training course in percutaneous vertebroplasty that included proctoring. Applicants must also have completed training in radiation safety.

Required previous experience: Demonstrated current competence and evidence of the performance of at least 5 percutaneous vertebroplasty procedures in the past 12 months

Reappointment Criteria: Demonstrated current competence and evidence of the performance of 10 vertebroplasty procedures in the past 24 months based on results of ongoing professional practice evaluation and outcomes.


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