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Nursing home wound care: The case for hyperbaric medicine

May 1, 2009
by Mary Pat Finn, BA, MHA
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Bed sores, lesions, pressure sores, and chronic wounds are a constant source of worry, not to mention infection, and are enormously problematic for nursing homes to manage. All the more frustrating is that nursing homes often are labeled as “uncaring” based on their “nosocomial rate,” the industry term for in-house acquired wounds, even though there are many reasons for non-healing wounds. Some are the result of medical conditions such as diabetes and poor circulation. Some are acquired due to constant pressure of a patient lying in one position for too long.

This nosocomial rate at times, has become a negative industry label and is a source of significant frustration to administrators, DONs, and floor nurses. As most families of nursing home residents will attest, the individuals caring for the residents are sincere, qualified and interested in delivering the best care to their residents. But despite these best interests of those tasked with infection control and good clinical care, wound management will always be a dilemma for nursing homes.
Hyperbaric oxygen chamber

Hyperbaric oxygen chamber

War on wounds

Given that wound care management is an essential element of nursing home care protocols, the industry is beginning to look to technology to assist in this constant war on wounds. One technology which is not new to healthcare but emerging as a treatment modality in nursing homes is hyperbaric oxygen therapy (HBOT), a method of administering pure oxygen at greater than atmospheric pressure. A patient is placed on a gurney and moved into a mono-place hyperbaric oxygen chamber and breathes oxygen in a pressurized environment for two hours for five days per week. This treatment regime is provided to attain a therapeutic effect that is typically administered for 20-26 treatments. This simple technology increases the level of oxygen delivered to the tissues and augments wound healing. HBOT can reduce the size of an open wound and aids in the body's development of healthy supportive tissue.

Perry Baromedical, a U.S. manufacturer of hyperbaric oxygen chambers, estimates the percentage of nursing homes in the United States with hyperbaric oxygen chambers is less than 1% in comparison with that of hospitals, which is approximately 20%. This statistic is changing. Perry Baromedical has received more inquiries from skilled nursing facilities over the last year than in its 40-year history. This interest has grown because the most common treatment location for HBOT is in hospital-based wound care clinics and it is inconvenient for nursing facilities. Currently, the Centers for Medicare & Medicaid services (CMS) provide for payment of outpatient HBOT, a treatment modality covered by CMS as a Part B (outpatient) service. So by definition a patient residing in a nursing home can receive HBOT either in a hospital-based wound care clinic or in a clinic based in the outpatient portion of a nursing facility.

From a practical point of view, the transport of a nursing home patient daily, five days per week is so fraught with logistical issues (not to mention patient comfort issues) that it is just not feasible for most HBOT-eligible patients to access treatment in this manner. A more ideal approach is for the nursing home industry to embrace HBOT as a treatment option in their facilities. In this way, patient transport issues are eliminated, the availability for those patients in need is secured, and the patient's comfort and compliance increases. Lastly, in-house HBOT provides nursing homes an opportunity to offer one of the most effective wound treatment modalities right under its own roof. Access is not restricted and the facility can see improvements in wound healing for its residents with chronic non-healing wounds.

Training/staffing for HBOT

Nursing homes, like hospitals, have the right kind of staff already available to become trained in hyperbarics. Nurses, CNAs, and respiratory therapists can be trained to operate a hyperbaric oxygen chamber. The largest training facility in the United States is operated by International ATMO in San Antonio, Texas. A weeklong certification is available 12 months a year. Most 120-bed facilities should select two RNs and three other individuals to obtain their certification. A Certified Hyperbaric Technician is an individual who completes a certification course and is charged with operating the chamber, which includes preparing the patient, obtaining glucose readings, checking blood pressures and ear passages and also operating the chamber itself. An RN can also receive a certification in hyperbarics. More staff can be trained of course, but in most HBOT locations across the country, a core group of staff is routinely used. One technician and one physician are required for either one chamber or two chambers.

Physician attendance during treatment is a requirement for hyperbaric treatment. It is recommended that a physician be readily available to assist the HBOT technician. The physician “clears” the patient for treatment and must be in the facility and available to provide assistance, guidance, and direction should the patient encounter any distress. The physician training is the same weeklong course as for the RN or HBO T Tech; however, each takes a different exam.