Privileges for Anesthesia

Name: ___________________________________________________________________________________________
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MEDICAL STAFF CATEGORY REQUESTED:

Active Uses Lucile Packard Children's Hospital (LPCH) as a primary hospital and regularly admits/treats patients
at this facility or is regularly involved in medical staff function
Minimum 11 pt contacts per year
Courtesy Active member in good standing in another hospital, admits/treats fewer than ten (10) patients per
year at LPCH OR treats LPCH patients only when incident to performing clinical teaching responsibilities
Consulting only Member in good standing in another hospital, are willing to provide consulting services in a timely
manner in the care of management of patients, does not have admitting privileges.
Please indicate any teaching title you may hold with the Stanford School of Medicine:
Faculty (MCL, UTL, CE)
Adjunct Clinical Faculty
Teaching Title:

CORE PRIVILEGES
REQUESTED

PROCEDURE
Privileges included in the Core: **
Cross out & INITIAL any privilege/s you are
not applying for in this set of Core Privileges

INITIAL CRITERIA
Successful completion of an ACGME or
AOA-accredited residency in anesthesia or
foreign equivalent training.
AND

Privileges to admit patients

Management of patients rendered
unconscious or insensible to pain and
emotional stress during surgical, obstetrical
and certain other medical procedures,
including pre-, intra-, and postoperative
evaluation and treatment

The support of life functions and vital organs

under the stress of anesthetic, surgical, and
other medical procedures

Placement of invasive monitors to include

arterial catheters and central venous lines.

Management of patients with a difficult

airway

Management of problems in pain relief

Cardiopulmonary resuscitation
Supervision of patients in post-anesthesia
care units and critically ill patients in special
care units; except for those special procedure
privileges listed below.
Regional anesthesia techniques

spinal anesthesia

epidural anesthesia

peripheral nerve block

Revised 10.11

Current certification or active participation in

the examination process leading to
certification in anesthesia by the American
Board of Anesthesia or the American
Osteopathic Board of Anesthesia or foreign
equivalent training/board
AND
Management of at least 50 cases in the past 2
years required.
AND
Privileges extend to patients of all ages and
physical status except those requiring
additional privileges as delineated below
AND
Successful completion of the Anesthesia
Module End-User Competency Test on
HealthStream

RENEWAL
CRITERIA

Proctoring
Requirement

Reappointments:
please be prepared to
provide a list of cases
performed at
facilities other than
LPCH if requested.

5 chart reviews

_____ # of cases
performed (at least
50 required) in the
past two years

Lucile Packard Children's Hospital

Anesthesia Privilege Form
Page 2

SPECIAL PRIVILEGES
(MUST ALSO MEET THE CRITERIA ABOVE)
Requested

PROCEDURE

Use of fluoroscopy equipment (or supervision of

other staff using the equipment)
Newborns 6 months: ASA PS-I & II

Newborns 6 months: ASA PS-III & IV

6 months 6 years: ASA PS-III & IV

6 years 12 years: ASA PS-III & IV

Obstetric anesthesia

C-Section

labor analgesia
Liver Transplant in patients < 14 years old

Regional Pain Techniques

sympathetic nerve block = ______ # of cases

neurolytic block = _________ # of cases

acupuncture = ________ # of cases

Monitoring procedures

pulmonary artery flotation catheter*

Monitoring procedures

TEE**

SHC Anesthesiologists
Emergent and urgent anesthetic or resuscitative
care of any patient of any age, with care
transferred as soon as possible to practitioner with
full privileges for that patient's age, physical status,
and condition

ADDITIONAL CREDENTIALING
CRITERIA (if applicable)
Radiology Supervisor and Operator
Certificate or Fluoroscopy Supervisor and
Operator Permit required
Documentation of training and/or experience
as indicated under Core Privileges above and
Pediatric subspecialty training or active
practice involving at least 10 cases in the past
two years. Documentation log required.
Documentation of training and/or experience
as indicated under Core Privileges above and
Pediatric subspecialty training or active
practice involving at least 10 cases in the past
two years. Documentation log required.
Documentation of training and/or experience
as indicated under Core Privileges above and
Pediatric subspecialty training or active
practice involving at least 10 cases in the past
two years. Documentation log required.
Documentation of training and/or experience
as indicated under Core Privileges above or
active practice involving at least 10 cases in
the past two years.
Documentation of training and/or experience
as indicated under Core Privileges above and
a minimum of 10 cases in the past two years.
Documentation log required.
Documentation of training and/or experience
as indicated under Core Privileges above and
Pediatric subspecialty training.

Must have special training in pediatric pain

management, and/or belong to LPCH
Pediatric Pain Management Group AND
initially be proctored by head of that group.

Documentation of use in monitoring for

hemodynamics of at least 4 cases in the past
two years. Documentation log required.

normally performed by cardiac

anesthesiologists
Minimum of 6 cases over the past two years.
Documentation log required.

# of Cases
performed
in past 2 yrs **
Maintenance of valid
Fluoroscopy or
Radiology Certificate
_____ # of cases
performed (at least
10 required)

_____ # of cases
performed (at least
10 required)

Proctoring
Requirement

2 observations and
1 additional chart
review

2 observations and
1 additional chart
review

1 chart review
_____ # of cases
performed (at least
10 required)
1 chart review
_____ # of cases
performed (at least
10 required)
5 chart reviews
_____ # of cases
performed (at least
10 required)
_____ # of cases
performed (at least 4
required/ or 2 under
direct supervision)

2 observations plus 1
additional chart
review

5 chart reviews
_____ # of cases
performed (at least
10 required)

_____ # of cases
performed (at least
10 required)

_____ # of cases
performed (at least
10 required)

Current active privileges at SHC

_____ # of cases
performed at SHC (at
least 10 required)

1 observation plus 1
additional chart
review

2 observations plus 1
chart review for use
of TEE in patients
under 12 years of
age
2 observations and
3 chart reviews
Proctored cases from
SHC are acceptable

** On a separate sheet of paper, please describe any major, unexpected complications you have
encountered for any of the Core Privileges or Additional Privileges you are requesting

Revised 10.11

Lucile Packard Children's Hospital

Anesthesia Privilege Form
Page 3

ACKNOWLEDGMENT OF PRACTITIONER:
I have requested only those privileges for which, by education, training, current experience and demonstrated performance, I am
qualified to perform, and that I wish to exercise at Lucile Packard Children's Hospital. I also acknowledge that my professional
malpractice insurance extends to all privilege I have requested.
I understand that in exercising any clinical privileges granted, I am constrained by hospital and medical staff policies and rules
applicable generally and any applicable to the particular situation.

Applicant Signature: _______________________________________________

If sending by email, type your name in the box above.
If sending by mail, please print first and then sign.

Revised 10.11

Date_____________________