Nursing home wound care: The case for hyperbaric medicine

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.

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.

Physical plant requirements

HBOT can be provided in a 20 x 20 room. The room must have a patient changing area and the space for both clean linen and soiled linen storage. A patient restroom must be readily accessible. A viewing desk for the technician to sit and monitor the patient is necessary. Please note a trained individual must be present at all times while a patient is in a hyperbaric oxygen chamber and since most treatments take two hours it is prudent to equip the room with those materials which the technician needs.

Oxygen, of course, is also required to operate a hyperbaric oxygen chamber. Bulk oxygen supplied at 50-90psi to each chamber is ideal. A hyperbaric chamber hooks directly to a standard 110-volt outlet, but most facilities will need to retrofit the oxygen supply. A local oxygen company can configure the oxygen supply and prepare the appropriate plumbing for it. A hyperbaric chamber arrives on wheels that are locked in place and then it is hooked to the oxygen supply, calibrated, and plugged into the standard outlet. Installation takes six to eight hours per chamber.

Financing HBOT

Given that reimbursement is not applicable in a nursing home environment means that the nursing home industry needs to take a good hard look at the viability of delivering HBOT as a direct purchase of the equipment with a minimal charge to the patient. By directly purchasing a hyperbaric chamber, the facility can treat a wider variety of patients because it is not constrained to treat only Medicare-approved conditions.

A nursing home that purchased one hyperbaric chamber could own it for an out-of-pocket monthly expense of $1,546. HBOT units are not nearly as expensive as they once were. They now range from $80,000 to $105,000 for a typical 34 to 36 unit. Hyperbaric chambers also can be leased for five to seven years, which reduces the initial cash outlay; rentals are also available. A hyperbaric chamber has a life expectancy of 20 years. Therefore, a facility can choose to pay for its purchase up front or finance depending on how quickly they wish to pay for the equipment. In today’s market, hyperbaric chambers are typically financed. Oxygen (bulk) can be supplied for about $36 to $50 ($6 to $8 dollars per treatment is typical of oxygen usage) per day. Physicians bill their professional fee for service just as they do on monthly patient visits and the facility provides the staff. Either the facility or the employee can absorb the cost of the HBOT training.

With one chamber, four to five patients can be treated per day at 1.5 to 2 hours per patient. The facility, of course, can choose longer hours of operation; however, 8 to 10 hours per day is the industry standard. Since most patients require a 25-treatment regime, a facility can treat 48 to 58 patients in a year based on standard operating guidelines.

Clinical benefits

In a nursing facility the types of wounds that can be treated will vary. However, HBOT can be used successfully on diabetic wounds. By providing pure oxygen in a pressurized chamber, HBOT delivers 10 to 15 times more oxygen than if delivered at sea level or at normal atmospheric levels. The positive effects of HBOT are:

• Promotes new blood vessels

• Decreases swelling and inflammation

• Deactivates toxins

• Improves the rate of healing

HBOT is used to treat a wide variety of conditions. Currently, Medicare approves the treatment of 15 conditions to include diabetic wounds, radiation tissue damage, osteomyelitis refractory, skin grafts and flaps, necrotizing soft tissue infections, crush injuries, acute traumatic ischemias, air or gas embolisms, carbon monoxide poisoning, smoke inhalation, decompression sickness, severe anemia, and cyanide poisoning.

By evaluating the cost of dressing changes, more dedicated wound nurses, in-services, the regulatory issues, and the cost of not providing aggressive wound care, the case for having on-site HBOT as a treatment modality-and seeking a modest payment from those patients in need-is viable. It seems reasonable that with an out-of-pocket expense of less than $2,000 dollars per month, a nursing home can own HBOT equipment, offer a state-of-the-art treatment modality, improve healing outcomes, and dramatically improve its management of chronic non-healing wounds.

Summary

A paradigm shift needs to take place in the nursing home industry. The technology is available to make 21st-century wound care available in the long-term care setting. The purchase of HBOT equipment needs to be viewed like any other nursing home purchase such as linens, landscaping, wheelchairs, supplies for the activity department, a facility van, med carts, etc. We have to stop purchasing equipment only if it is reimbursed and look ahead to what clinical benefits can be derived from that technology and encourage the nursing homes industry to differentiate itself in the market by offering a variety of services such as HBOT.

Mary Pat Finn, BA, MHA, is Senior Vice President for Perry Baromedical and has spent more than 14 years in the wound care business both on the operations and development level. She has opened wound programs in hospitals and freestanding locations throughout the United States and Puerto Rico. Additionally, she has provided consulting on wound care billing, marketing, and operations management of wound care clinics and locations.

For more information, call (727) 424-7082, e-mail mpfinn@perryhbo.com, or visit https://www.perrybaromedical.com. To send your comments to the author and editors, e-mail finn0509@iadvanceseniorcare.com.

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At a glance…

Despite the best of intentions, wound management will always be a challenge for long-term care facilities. Technology can help. Hyperbaric oxygen therapy (HBOT), while widely used in healthcare, is being used more in long-term care facilities. HBOT is a method of administering pure oxygen at greater than atmospheric pressure. This simple technology increases the level of oxygen delivered to the tissues and augments wound healing.

Long-Term Living 2009 May;58(5):24-27