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Hyperbaric Oxygen Therapy: is this service in your department's future?

Approximately six years ago, I recommended starting a Hyperbaric Oxygen Therapy (HBOT) service to my administrator. I was director of respiratory / pulmonary services at the time and then, as now, we were always looking for ways to expand services and increase revenue. I was somewhat confident that I could develop this program because of several reasons. First, earlier in my career I performed occasional hyperbaric treatments for patients with carbon monoxide poisoning or gas gangrene. Second and most importantly, we already had an existing wound care center, which could serve as a referral source, and a medical director who supported HBOT. As a respiratory therapist, I found that I already had a background in some of the fundamentals of HBOT; oxygen, pressure and the gas laws. It took about a full year from approval to actually opening the department and today we are a successful revenue center for the hospital. So if you are someone who is looking for a new adventure in life and want to diversify your work, while broadening your knowledge base, create more job opportunities and expand scope of practice, achieve additional credentials (CHT= certified hyperbaric technologist), and implement a successful revenue center resulting in increased job security, satisfaction and a smiling CFO, then read on.

What is HBOT?

Hyperbaric Oxygen Therapy (HBOT) is the administration of 100% oxygen to a patient at greater than normal or atmospheric pressure. This can be accomplished in a one-person chamber called a "monoplace" chamber or a "multi-place" chamber holding more than one person. Monoplace chambers are the most common and also least expensive so I will focus on these for now. The monoplace chamber pressurizes using 100% oxygen up to a maximum of 3 ATA (atmospheres absolute) which covers the treatments you will be administering. You are at one atmosphere now which equates to 760 mm Hg or 14.7 PSI or 33 feet of seawater (unless your reading this in Denver, in a plane or underwater).

Hyperbaric oxygen treatments are called "dives", since pressure changes are similar to those experienced when scuba diving and much early work was in fact done by the Navy. Each type of diagnosis treated has a somewhat standard "protocol" or treatment plan that is used to guide the therapeutic regiment. These protocols typically dictate the length and number of treatments along with various other details such as pressure or depth. Individual treatments last about 2 hours and typically 30 or more treatments may be required for problem wound healing. On the other hand, If you chose to be a 24/7 emergency service and referral site for the Divers Alert Network (DAN) you may be treating a diver with the Bends for the standard 5 hour treatment.


Today Hyperbaric Oxygen Therapy (HBOT) is used primarily to treat specific types of difficult to heal wounds. I will occasionally treat someone with severe carbon monoxide poisoning or a diver who experienced decompression sickness but it is wound care that pays the bills. Operational models may consist of a combination "wound care function" with hyperbaric or two separate departments working closely together.

The Undersea & Hyperbaric Medical Society (UHMS) publishes the list of indications for HBOT. This international, nonprofit organization has the important function of reviewing the medical research and only publishes those indications for HBOT with a sound scientific basis. They have a very informative web site found at Medicare accepts most of these indications but you need to check your National and State fiscal intermediaries for proper reimbursement codes. Most private insurers require pre-certification for HBOT. Reimbursement and financial requirements are never as easy as one might hope, but that applies to everything in healthcare today. HBOT is an accepted and legitimate medical treatment with sound medical literature supporting its use with specific indications as follows.

UHMS list of Indications for HBOT

* Air or Gas Embolism

* Carbon Monoxide Poisoning complicated by cyanide poisoning

* Clostridal Myositis and Myonecrosis (gas gangrene)

* Crush Injury, Compartment Syndrome, and other acute ischemias

* Decompression Sickness (The Bends)

* Enhancement of healing in selected problem wounds

* Exceptional blood loss (Anemia)

* Intracranial Abscess

* Necrotizing Soft Tissue Infections

* Osteomyelitis (Refractory)

* Delayed Radiation Injury (Soft tissue and Bony Necrosis)

* Skin Grafts and Flaps (Compromised)

* Thermal Burns

The basis components required to start a program.

Feasibility: What is the need for HBOT in your institution and community? Do you have a wound care center? If not, you will need to have this function performed within the HBOT department. Remember the treatment of wounds is your bread and butter. A feasibility study can be performed by reviewing ICD 9 codes and payer types for your institution over the past year. Is there a competitive hyperbaric service in neighboring hospitals? This service requires a sufficient number of referable patients to be profitable. Most importantly you need a physician champion to lead the charge and get other physicians, as well, to support the program. This lead physician could be from various specialties. We have a total of 7 trained physicians in HBOT with various backgrounds, i.e.; anesthesiology, pulmonary, vascular surgery, critical care, general practitioner specializing in diabetes and wound care. You could have emergency medicine physicians, podiatrists and so on. Lastly, you will need administrative approval and support for the expenses you will be incurring.

Expenses: You will be asking for one or two monoplace chambers which cost about $130,000.00 each. You will need a source of oxygen with high flow and a room with adequate space (for two chambers, work area, dressing room, bathroom, etc. Our physical renovation to make the area suitable cost us approximately $80,000. There will be initial training costs and then ongoing operating costs, but these are nearly all salary related.

Education: Our staff, physicians and therapists, completed a training program approved by the UHMS. The chamber operators are all registered respiratory therapists and certified hyperbaric technologists (CHT), a credential given by the National Board of Diving and Hyperbaric Medical Technology (NBDHMT).

Marketing: Regional physicians need to be knowledgeable about the benefits of HBOT, therefore, an educational and marketing plan will be necessary for success. Lectures and newspaper articles are an informative way to educate physicians.

Risks: Risks are present in every new venture, lack of patients or insurance denials can hurt any service but can be minimized if managed well. Clinically, our most common problem is the equalization of ear pressure when initiating treatment but there are many ways to remedy this. Oxygen toxicity is a concern but manageable and fortunately rare. A COPD patient with air trapping requires a benefit / risk analysis and standby chest tube.

Finally, it is important to research the various resources in the field and speak to programs that are in existence. There are turnkey companies that will start your program or other companies that will even operate your entire program for you. That pathway might be best if you're short on financial and/or human capital. For more information and one of the most valuable resources about HBOT, pick up a copy of; "Hyperbaric Medicine Practice", Eric P. Kindwall, MD and Harry T. Whelan, MD, available through Best Publishing Company. So dive in, the water's fine.

by Kenneth Capek RRT, CHT, MPA
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Title Annotation:MANAGEMENT
Author:Capek, Kenneth
Publication:FOCUS: Journal for Respiratory Care & Sleep Medicine
Article Type:Medical condition overview
Date:Sep 22, 2011
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