BACKGROUND

The practice of hyperbaric medicine involves the delivery of 100% oxygen intermittently at pressures in excess of normal atmospheric pressure. This is achieved by the use of a pressurized (hyperbaric) chamber. Chambers are designed to accommodate a single patient (monoplace) or several patients simultaneously (multiplace).

Exposure to hyperbaric doses of oxygen results in several therapeutic effects. They include hyper-oxygenation of poorly perfused or otherwise hypoxic tissues, selected antimicrobial activity, neovascularization, reduction/elimination of gas emboli, vasoconstriction without component hypoxia and antagonism of ischemia-reperfusion injury.

Exposure pressure, duration, frequency, and course (dose) will vary depending upon each patient’s referral condition. Carbon monoxide poisoning, for example, usually requires no more than three treatments. Radiation damaged tissue may necessitate forty (or more) treatments.

Physicians engaged in the practice of hyperbaric medicine range across the entire spectrum of clinical specialties.

UNDERSEA AND THE HYPERBARIC MEDICAL SOCIETY

The Undersea and Hyperbaric Medical Society (UHMS) serves as the principal medical and scientific body for this discipline. It is international in its scope and sets standards regarding the appropriate clinical application of hyperbaric oxygen therapy (HBOT). The UHMS also seeks to improve the scientific basis of HBOT promote evidence-based treatment protocols and best practice standards, and provide continuing education for technologists, nurses, advanced practice providers, and physicians.

The Society’s position on eligibility, training, credentialing and continuing medical education is as follows [1]:

Physician Qualification and Training

1. Must be fully licensed (MD or DO) and board certified or board eligible in a recognized clinical (medical or surgical) specialty.
2. Must complete at least 40 credit hours of a UHMS-approved hyperbaric medicine introductory training. Physicians who have undertaken at least 11 months of hyperbaric fellowship training and have been awarded a completion certificate from an academically-based clinical program are considered to have met this training requirement.
3. Are specifically privileged to practice clinical hyperbaric medicine under the process delineated by the institution’s privileging or credentialing committee.
4. Complete a period of preceptorship in which they demonstrate consistent competence in hyperbaric medicine case management, treatment procedures, and safety before working independently without supervision.
5. For reappointment, hyperbaric medicine physicians must complete a minimum of 12 credit hours of Physician category 1 AMA/AOA PRA CME in hyperbaric-related topics for each 12 months of hyperbaric practice or 24 credit hours in 2 years. If local requirements or the requirements of certification agencies exceed these standards, the CME requirements of the physician's certification and privileging agencies should be followed. 

Board Certification

The American Board of Preventive Medicine has established a procedure for subspecialty certification in undersea and hyperbaric medicine. With the exception of emergency medicine boarded physicians, all eligible physicians, regardless of specialty, must apply for board certification through the ABPM. Emergency medicine physicians apply through the American Board of Emergency Medicine. If the physician is a Doctor of Osteopathy, the pathway to certification will flow through a similar pathway of added qualifications through the American Board of Osteopathy Physical Medicine or Emergency Medicine.

At the present time, there is only one pathway to subspecialty board certification, and that is fellowship training. There are several pathways to certificates of added qualification, however, the acceptance of this training/education is not yet determined.

Joint Commission on Accreditation of Healthcare Organizations

The JCAHO has no formal position on the delineation of privileges in hyperbaric medicine. However, this organization states that the professional criteria specified in medical staff bylaws must be applied to all applicants. Further, the JCAHO states that such criteria constitute the basis for granting initial or continuing medical staff membership and for granting initial, renewed or revised clinical privileges.

Hyperbaric Medicine Initial Credentialing Criteria

1. Basic education: MD or DO
2. Applicants must have completed Accreditation Council for Graduate Medical Education or American Osteopathic Association accredited specialty-training program. (Board Certified or Board Eligible in a recognized clinical or surgical specialty).
3. Documented satisfactory completion of an Undersea and Hyperbaric Medical Society approved 40-hour introductory training program in hyperbaric medicine, within three years of the application for credentialing, unless presently practicing hyperbaric medicine elsewhere.
4. Working knowledge of the following:
1. Management of critically ill patients, including those requiring ventilator support.
2. Recognition and management of potential side effects and complications of hyperbaric oxygen therapy.
3. UHMS approved (and common investigational) indications for hyperbaric oxygen therapy.  
4. Hyperbaric chamber operation and emergency procedures.
5. Physicians applying for privileges must agree to participate equitably in the consultation call schedule.
6. Physicians will recognize the hyperbaric program’s treatment protocol guidelines as representative of best practice guidelines; and review these guidelines annually. Should dosing variances be considered necessary, the discharge summary will include a qualifying narrative and be subject to peer review.
7. Physicians will undergo peer preceptorship of their first six hyperbaric (consultation/case management) cases.  
8. Physicians will provide direct supervision of each hyperbaric treatment, and consistent with prevailing compliance criteria. These criteria are made by the institution and some by third-party payers, and/or Medicare/Medicaid.

Core Privileges

Core privileges in hyperbaric medicine will include but are not limited to the following referral indications:

• Decompression sickness
• Cerebral arterial gas embolism
• Carbon monoxide intoxication
• Gas Gangrene
• Crush Injury
• Enhancement of healing in selected problem wounds
• Necrotizing soft tissue infections
• Osteomyelitis
• Late radiation tissue injury
• Compromised skin grafts and skip flaps
• Thermal burns
• Intracranial abscesses
• Acute exceptional blood loss anemia
• Diabetic foot ulcers

Reappointment

Reappointment as a hyperbaric medicine consultant will be based on unbiased objective results of care according to the institution’s existing quality assurance mechanisms.  

Applicants must be able to demonstrate that they have maintained competence by showing evidence that they have provided inpatient and/or outpatient hyperbaric consultative and case management services for the minimum number of patients, as established by that institution.

For reappointment, hyperbaric medicine physicians must complete a minimum of 12 credit hours of Physician category 1 AMA/AOA PRA CME in hyperbaric-related topics for each 12 months of hyperbaric practice or 24 credit hours in 2 years. If local requirements or the requirements of certification agencies exceed these standards, the CME requirements of the physician's certification and privileging agencies should be followed. 

REFERENCE ORGANIZATIONS

Undersea and Hyperbaric Medical Society
10020 Southern Maryland Boulevard, Suite 20
Dunkirk, MD 20754
www.uhms.org

Joint Commission on Accreditation of Healthcare Organizations
One Renaissance Boulevard
Oakbrook Terrace, IL 60181
www.jcaho.org

American Board of Preventive Medicine
330 South Wells Street, Suite 1018
Chicago, IL 60606
www.abprevmed.org

REVIEW/REVISION OF POLICY

This policy shall be reviewed and, if necessary, revised at least every year.

Policy Effective Date:

Reviewed Date:

Revised Date: