The Journey to Office Cystoscopy Privileging

Christy B. Krieg, MSN, FNP, CUNP

Disclosures

Urol Nurs. 2020;40(2):99-103. 

In This Article

Credentialing

However, when it came time for review and approval of my privileges in late 2018, it was determined that I did need to be credentialed, even for outpatient clinics. This led to a non-small sense of panic. No APP had been credentialed for flexible cystoscopy in our large, urban academic health center. How would criteria be established?

While we were figuring this out, the highly respected and meticulous clinic manager at our cancer center, which is a hospital-based clinic, asked me to avoid performing independent cystoscopy until credentialing for cystoscopy was formalized. I honored this by requesting a staff physician supervise each of my cystoscopies until I was credentialed. Fortunately, in this busy clinic, there was always a urology MD available, and no patients were rescheduled.

The Credentials Committee determined the process would be similar to a recent process for Certified Registered Nurse Anesthetists (CRNAs) and Certified Anesthesia Assistants (CAAs), whom the Academic Health Center (AHC) had recently added to the provider mix. The committee requested I submit the following:

  • Two collegiate articles in support of advanced practice nurses (APNs) performing this procedure;

  • Training/education that is required;

  • How many procedures must be proctored;

  • Any other supporting material necessary;

  • Explain why APNs are now seeking privileges for these procedures; and

  • A case log.

For the "supporting material," I wrote a letter (Appendix A) to the committee discussing criticism of our department's wait times or "access," and anticipated future shortage of urologists in general. I also utilized arguments about continuity of care and my patients' dissatisfaction with the current state. To my letter, I also attached the SUNA cystoscopy course description, my certificate of cystoscopy workshop completion, letters of attestation from my two training urologists, my case log generated from de-identified cystoscopy billings for 2018, the BAUN program description, and four scholarly articles.

To rapidly identify appropriate articles, I turned to our SUNA Online Forum, where colleagues were kind enough to direct me to important references. The first was an article by Langston and colleagues (2017), "The Expanding Role of Advanced Practice Providers in Urologic Procedural Care," published in Urology. Using Medicare claims data, the authors described an incredible growth in procedures performed by APPs between 1994 and 2012, with percent change ranging from 522% to 24,900%+. These procedures included cystoscopy, renal ultrasound, complex Foley catheter placement, urodynamics, and transrectal ultrasound.

I also included an important article by Quallich (2017) describing the need for APPs trained in specialty care to meet the general urologic care needs of the growing geriatric population. Another article by Shields (2016) described quite comprehensively the need for APNs to perform office cystoscopy specifically, and the paucity of literature and formal direction or guidelines for those of us seeking procedural skills.

Finally, an even older but still absolutely relevant article is Shultz's 2011 article, "Practical and Legal Implications of Nurse Practitioners and Physician Assistants in Cystoscopy," published in Urologic Nursing, Schultz (2011) outlines an important three-step process for NPs seeking cystoscopy skills and privileges: identify scope of practice for your state and employer; get training and be clear on how competence will be defined; and be sure you understand legal implications. Shultz (2011) reminds us that the standard of care for competence is the same for the APP performing cystoscopy as for the physician.

In January 2019, my request for diagnostic cystoscopy privileges was granted. The Credentials Committee asked for us to outline an ideal training program, but ultimately, utilized the training path to create the criteria to be used for future applicants, against our recommendations. For example, my training physicians and I suggested a process for future applicants consisting of a formal didactic program by an accredited body, 10 instructional cystoscopies, followed by 25 NP cystoscopies under direct supervision, with additional discretionary procedures if either party felt it necessary. However, the Committee left the qualification at 50 under direct supervision. They further added that the training procedures under direct supervision shall include 50% each male and female patients. They stated credentialing for more complex procedures, such as biopsy, would need to be pursued separately. They also dictated the NP must perform at least 50 cystoscopies per year to maintain competency and must submit case logs at the time of recredentialing.

Because I listed my Urologic Nurse Practitioner Certification (CUNP) as a qualification, the committee also included CUNP in the list of requirements. While I am certainly committed to certification, there is no parallel designation for physician assistants, so I suggested the committee remove CUNP as a qualification, and add it as a recommendation. However, to my knowledge, no change was made.

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