I. PRINCIPLES OF CREDENTIALING
The Society of American Gastrointestinal Endoscopic Surgeons (SAGES) recommends the following guidelines for privileging qualified surgeons in the performance of ultrasound (transabominal, laparoscopic, endoscopic, thoracoscopic surgery, and endovascular). The basic premise is that the surgeon(s) must have the judgment and training to perform ultrasonography safely and accurately interpret the findings.
Guidelines for clinical practice are intended to indicate preferable approaches to medical problems as established by experts in the field. These recommendations will be based on existing data or a consensus of expert opinion, when little or no data are available. Guidelines are applicable to all physicians who address the clinical problem(s) without regard to specialty training or interests, and are intended to indicate the preferable, but not necessarily the only, acceptable approaches due to the complexity of the healthcare environment. Guidelines are intended to be flexible. Given the wide range of specifics in any health care problem, the surgeon must always choose the course best suited to the individual patient and the variables in existence at the moment of decision.
Guidelines are developed under the auspices of the Society of American Gastrointestinal Endoscopic Surgeons and its various committees, and approved by the Board of Governors. Each clinical practice guideline has been systematically researched, reviewed and revised by the guidelines committee, and reviewed by an appropriate multidisciplinary team. The recommendations are therefore considered valid at the time of its production based on the data available. Each guideline is scheduled for periodic review to allow incorporation of pertinent new developments in medical research knowledge and practice.
The purpose of this statement is to assist hospital credentialing committees in their task of granting privileges to surgeons for the performance of ultrasonography (transabdominal, laparoscopic, endoscopic, intraoperative, thoracoscopic and endovascular) for diagnostic and therapeutic purposes. In conjunction with the standard JCAHO guidelines for granting hospital privileges, implementation of these methods should help to insure that ultrasonography performed by surgeons is performed only by individuals with appropriate competency, thus assuring optimal patient care and procedure utilization.
Ultrasound is being increasingly used as a diagnostic tool in real time and as an aid to therapeutic decisions during surgery. Wide array of uses have been well described spanning the various surgical sub-specialties. Several publications have confirmed high degree of specificity and sensitivity of ultrasound examinations, equivalent to radiologist performed ultrasound when performed by surgeons with adequate training5,6
B. UNIFORMITY OF STANDARDS
Uniform standards should be developed which are applicable to all surgeons requesting privileges to perform ultrasonography. Criteria must be established which are medically sound and take into account the skills that a surgeon already possesses as part of his/her surgical training.
C. SPECIFICITY OF PRIVILEGING FOR ULTRASONOGRAPHY
Privileges should be granted for each major category of ultrasonography separately. The ability to perform one ultrasonographic procedure does not automatically imply adequate competency to perform another. Associated skills generally considered to be an integral part of an ultrasonographic category may be required before privileges for that category can be granted. Major categories include Focused Assessment with Sonography for Trauma FAST, abdominal (staging- laparoscopic and open), vascular, thoracic, urology and gynecology.
D. RESPONSIBILITY FOR CREDENTIALING
The credentialing structure and process are the responsibility of each hospital. It should be the responsibility of the Department of Surgery, through its Chief to recommend individual surgeons for privileges in ultrasonography as for all other procedures performed by members of his/her department.
II. MINIMUM REQUIREMENTS FOR GRANTING PRIVILEGES
Part II A is mandatory, and must be accompanied by either part II B, II C, or at least one component of part II D.
A. FORMAL FELLOWSHIP OR SURGICAL RESIDENCY TRAINING
Prerequisite training must include satisfactory completion of an accredited surgical residency program, with subsequent certification by the American Board of Surgery as required by the institution. The residency program must be accredited by the Accreditation Council for Graduate Medical Education or the equivalent body if the program is based outside the United States or Canada.
B. FORMAL TRAINING IN ULTRASONOGRAPHY
For surgeons who successfully completed a residency and/or fellowship program that incorporated a structured experience in ultrasonography, the applicant’s program director, and if desired other faculty members, should supply the appropriate documentation of training.
C. NO FORMAL RESIDENCY TRAINING IN ULTRASONOGRAPHY
For those surgeons without residency and/or fellowship training, which included structured experience in ultrasonography, or without documented prior experience in these areas, a structured training curriculum is required. The curriculum should be defined by the institution, and may include a formal course. The curriculum should include an appropriate number of opportunities for the applicant to observe, assist, and serve as primary operator for the procedure for which privileges are being sought. The curriculum should include didactic sessions and hands-on experience with inanimate and/or animate models. Other teaching aids may include video review and interactive computer programs. Several fellowships and courses by relevant professional societies including SAGES and American College of surgeons are available through out the year and can be used to gain ultrasonographic skills pertaining to a particular topic.
D. PRACTICAL EXPERIENCE
- Applicant’s Experience – Documented experience that includes an appropriate volume of cases equivalent to the procedure in question in terms of complexity. The chief of surgery should determine the appropriateness of this experience.
- Experience with Preceptor and/or Proctor – The specific role and qualifications of the preceptor and/or proctor, if required, must be determined by the institution. Criteria of competency for each procedure should be established in advance, and should include evaluation of: familiarity with instrumentation and equipment, competence in their use, appropriateness of patient selection, safety, and successful completion of the procedure. The criteria should be established by the chief of surgery in conjunction with the specific specialty chief where appropriate. It is essential that proctoring be provided in an unbiased, confidential, and objective manner.
III. MAINTENANCE OF PRIVILEGES
A. PROVISIONAL PRIVILEGES
Once competence has been determined, a period of provisional privileges may be appropriate. The time frame and/or number of cases required during this period should be determined by the chief of surgery and/or the appropriate institutional committee, board, or governing body.
B. MONITORING OF ULTRASONOGRAPHIC PERFORMANCE
To assist the hospital credentialing body in the ongoing renewal of privileges, there should be a mechanism for monitoring each surgeon’s performance. This should be done through existing quality assurance mechanisms or an appropriate hospital committee. Monitoring may include ultrasound utilization, image quality, diagnostic and therapeutic benefits to patients, complications, and tissue review in accordance with previously developed criteria.
C. RENEWAL OF PRIVILEGES
For renewal of privileges an appropriate level of continuing clinical activity should be required, in addition to satisfactory performance as assessed by monitoring of procedural activity through existing quality assurance mechanisms. Continuing education related to ultrasonography should be part of the periodic renewal of privileges.
D. DENIAL OF PRIVILEGES
Institutions denying, withdrawing, or restricting privileges should have an appropriate mechanism for appeal in place. The procedural details of this should be developed by the institution, and must satisfy the institution’s bylaws and JCAHO recommendations.
- Society of American Gastrointestinal Endoscopic Surgeons: Granting of Privileges for Gastrointestinal Endoscopy by Surgeons. Los Angeles, CA, 1992.
- Society of American Gastrointestinal Endoscopic Surgeons: Framework for Post-Residency Surgical Education & Training – A SAGES Guideline. Surg Endosc 8:9 1137-1142, 1994.
- Society of American Gastrointestinal Endoscopic surgeons: SAGES guidelines for the use of laparoscopic ultrasound. Richardson W, Stefanidis D, Mittal S, Fanelli RD.Surg Endosc. 2010 Apr;24(4):745-56.
- Position statement ST 31 by American College of Surgeons Committee on Emerging Surgical Technology and Education (CESTE).(February 1998)
- Ultrasound as a diagnostic tool used by surgeons in pyloric stenosis..Boneti C, McVay MR, Kokoska ER, Jackson RJ, Smith SD. J Pediatr Surg. 2008 Jan;43(1):87-91; discussion 91.
- Surgeon performed ultrasound facilitates minimally invasive parathyroidectomy by the focused lateral mini-incision approach..Soon PS, Delbridge LW, Sywak MS, Barraclough BM, Edhouse P, Sidhu SB. World J Surg. 2008 May;32(5):766-71.
This statement was reviewed and approved by the Board of Governors of the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) on Jan 2011.
This is a revision of SAGES publication #20 printed Oct 2003, revised Jan 2011.
For more information please contact:
11300 West Olympic Blvd., Suite 600
Los Angeles, CA 90064
- (310) 437-0544
- (310) 437-0585
Guidelines for clinical practice are intended to indicate preferable approaches to medical problems as established by experts in the field. These recommendations will be based on existing data or a consensus of expert opinion when little or no data are available. Guidelines are applicable to all physicians who address the clinical problem(s) without regard to specialty training or interests, and are intended to indicate the preferable, but not necessarily the only acceptable approaches due to the complexity of the healthcare environment. Guidelines are intended to be flexible. Given the wide range of specifics in any health care problem, the surgeon must always choose the course best suited to the individual patient and the variables in existence at the moment of decision.
Guidelines are developed under the auspices of the Society of American Gastrointestinal and Endoscopic Surgeons and its various committees, and approved by the Board of Governors. Each clinical practice guideline has been systematically researched, reviewed and revised by the guidelines committee, and reviewed by an appropriate multidisciplinary team. The recommendations are therefore considered valid at the time of its production based on the data available. Each guideline is scheduled for periodic review to allow incorporation of pertinent new developments in medical research knowledge, and practice.