Cleveland and Kings Mountain Moderate Sedation Attestation

In order to be eligible to request clinical privilege for Moderate Sedation, a practitioner must meet the following minimum threshold criteria.

Initial Appointment

Education/Training:

• Successful completion of an accredited three-year residency in anesthesia.

OR

• Successful completion of a residency (with or without a subspecialty fellowship) wherein the LIP received education, training, and experience to administer and/or supervise moderate sedation and maintain the airway (this would apply to physicians other than anesthesiologist, such as emergency medicine, neurologists, pulmonologists, gastroenterologists, radiologist, surgeons, or cardiologists). Residency Director verification of residency training and competency for Moderate Sedation.

OR

• Completion of a Atrium Health approved physician moderate sedation training program, e.g. the Carolinas Medical Center (CMC) Moderate Sedation Program.

AND

Atrium Health Moderate Sedation Standard Signed documentation that the practitioner has reviewed and agrees to comply with the Atrium Health Moderate Sedation standard.

Reappointment

Required Previous Experience:

• Performance of moderate sedation for at least 8 patients over the past 12 months.

OR

• Meet one of the education requirements for initial appointment.

I have read the above requirements and hospital policy re: moderate sedation and attest to my compliance by submitting this form.