Trauma-Surgical Critical Care - Medical Staff Services

LEHIGH VALLEY HOSPITAL AND HEALTH NETWORKCLINICAL PRIVILEGES IN TRAUMA-SURGICAL CRITICAL CAREPage 3 of 6Name______________________________________InitialRenewedEffective from ___/___/___ to ___/___/___R = Requested G = Recommended As Requested C = Recommended with Conditions N = Not RecommendedR G C N CHESTPericardiocentesis (1)Plating of ribs for fracture management (1)Pleurodesis (1)Pneumonectomy for trauma (1)Repair of cardiac injury (1)Repair of diaphragmatic injury (1)Repair of esophageal injury (1)Repair of great vessel injury secondary to trauma (1)Thoracentesis (1)Thoracotomy for trauma (1)Tube thoracostomy (1)Wedge resection of lung for trauma (1)R G C N ABDOMENAbdominal wall reconstruction (1)Damage control laparotomy (1)Diagnostic esophagogastroduodenoscopy (EGD) (1)Diagnostic laparoscopy (1)Diagnostic peritoneal lavage (1)Exploratory laparotomy (1)Management of open abdomen (1)Mobilization of omental flap for coverage of soft tissue defect (1)

LEHIGH VALLEY HOSPITAL AND HEALTH NETWORKCLINICAL PRIVILEGES IN TRAUMA-SURGICAL CRITICAL CAREPage 4 of 6Name______________________________________InitialRenewedEffective from ___/___/___ to ___/___/___R = Requested G = Recommended As Requested C = Recommended with Conditions N = Not RecommendedR G C N ABDOMEN - Liver and GallbladderHepatic lobectomy for traumatic injury (1)Hepatorrhaphy (1)Repair of injury to common bile duct (1)Repair/resection of gallbladder for traumatic injury (1)R G C N ABDOMEN - SpleenSplenectomy for traumatic injury (1)Splenorrhaphy (1)R G C N ABDOMEN - PancreasPancreatic resection for trauma (1)Pancreaticoduodenectomy for trauma (1)R G C N ABDOMEN - StomachGastrostomy, open and percutaneous (1)Repair of gastric injury (1)Resection of stomach for traumatic injury (1)R G C N ABDOMEN - DuodenumRepair of duodenal injury (1)Resection of duodenum for trauma (1)

LEHIGH VALLEY HOSPITAL AND HEALTH NETWORKCLINICAL PRIVILEGES IN TRAUMA-SURGICAL CRITICAL CAREPage 5 of 6Name______________________________________InitialRenewedEffective from ___/___/___ to ___/___/___R = Requested G = Recommended As Requested C = Recommended with Conditions N = Not RecommendedR G C N ABDOMEN - Small BowelCreation of ileostomy (1)Placement of feeding jejunostomy (1)Repair of small bowel injury (1)Resection of small bowel for traumatic injury (1)R G C N ABDOMEN - Large BowelCreation of colostomy (1)Flexible sigmoidoscopy for diagnosis (1)Rigid sigmoidoscopy for diagnosis (1)Repair of large bowel injury (1)Resection of large bowel for traumatic injury (1)R G C N ABDOMEN - BladderPlacement of suprapubic tube for urethral injury (1)Repair of injury to urinary bladder (1)R G C N RETROPERITOMEUMNephrectomy for trauma (1)Preperitoneal pelvic packing (1)Repair of injury to ureter (1)Repair of renal injury (1)Retroperitoneal exposure for repair of traumatic injury (1)

LEHIGH VALLEY HOSPITAL AND HEALTH NETWORKCLINICAL PRIVILEGES IN TRAUMA-SURGICAL CRITICAL CAREPage 6 of 6Name______________________________________InitialRenewedEffective from ___/___/___ to ___/___/___R = Requested G = Recommended As Requested C = Recommended with Conditions N = Not RecommendedR G C N RETROPERITOMEUMRetroperitoneal exposure for spine fixation (1)R G C N VASCULARInsertion of dialysis line (1)Placement of central line (1)Placement of inferior vena cava (IVC) filter (1)Placement of pulmonary artery catheter (1)Repair of arterial injury (1)Repair of venous injury (1)R G C N OTHERFluoroscopy privileges (Additional requirements as necessary as per the Medical Physicist/RadiationSafety Officer) (1,2,4)Moderate Sedation - Adult* (18 years or older)*** (1,2,3) (*Must satisfy certain credentialing criteria to beapproved)

LEHIGH VALLEY HOSPITAL AND HEALTH NETWORKCEDAR CREST & I-78 PO BOX 689ALLENTOWN, PA 18105-1556CLINICAL PRIVILEGES IN TRAUMA-SURGICAL CRITICAL CAREName_________________________________InitialRenewalEffective from___/___/___ to ___/___/___Qualifications:Required Previous Experience:Special Procedures:Observations:Reappointment Requirements:Privileges by Location:Permitted at:1 – LVH Cedar Crest2 – LVH-Muhlenberg (includes the Behavioral Health Center and Cancer Center)3 – LVH-17th & Chew (includes TSU)4 – Fairgrounds Surgical Center

LEHIGH VALLEY HOSPITAL AND HEALTH NETWORKCLINICAL AREA TRAUMA-SURGICAL CRITICAL CAREInitialRenewedName______________________________________Effective from ____/____/____ to ____/____/____Acknowledgement of PractitionerI hereby request the privileges noted.Practitioner Signature:______________________________________________Date:_____/______/______***Recommendations***I have reviewed the request for clinical privileges and supporting documentation andRecommend As RequestedRecommend with Exceptionsthe privileges requested above.EXCEPTIONSDo Not RecommendException to Privilege:Conditions/ModificationsExplanation:TitleTitleTitleTitleTitleSignatureSignatureSignatureSignatureSignature_____/______/______Date_____/______/______Date_____/______/______Date_____/______/______Date_____/______/______Date