POLICY HEADER

• Document Number: ___________________________________________
• Effective Date: _________________________________________________
• Review Date: ___________________________________________________
• Revision Date: __________________________________________________
• Policy Owner: ___________________________________________________
• Responsible Department: Hyperbaric Medicine / Wound Care
• Approved By: ___________________________________________________

SCOPE

This policy applies to all members of the multidisciplinary HBOT care team.

• Personnel: All certified/authorized healthcare clinicians addressed herein.
• Settings: Hyperbaric oxygen therapy units

Applicable Personnel and Responsibilities

• Physicians, nurses, hyperbaric technologists, and ancillary staff involved in patient preparation, treatment, and post-treatment care.

Roles and Responsibilities

1. Hyperbaric Nurse/Technologist: Perform pre- and post-treatment skin evaluation for unknown skin abnormalities, implement offloading interventions, and ensure documentation accuracy.
2. Safety Director: Review and approve all items entering the chamber to ensure they meet the fire and safety requirements set by NFPA 99 (the Health Care Facilities Code), which mandates strict standards to prevent fire hazards in oxygen-enriched environments, and align with facility safety protocols. Ensure skin assessment and PU/PI prevention risk assessment is validated in accordance with institutional policy.
3. Medical Director: Oversee the clinical appropriateness of interventions and authorize the use of items restricted from the hyperbaric chamber (i.e., any medical devices or positioning aids not explicitly on the facility’s pre-approved "Go/No-Go" safety list) when medically indicated.
4. All Staff: Maintain vigilance for early signs of pressure injury and promptly report concerns.

PURPOSE

This policy establishes a standardized, evidence-based approach to pressure injury (PI) prevention in patients receiving hyperbaric oxygen therapy (HBOT). It was developed to address a recognized gap in the field regarding consistent offloading practices and risk mitigation for patients with limited mobility or existing wounds. The goal is to ensure proactive identification of risk factors, implementation of appropriate offloading and positioning strategies, and maintenance of skin integrity throughout the HBOT process.

Rationale

1. Patients receiving HBOT are at increased risk for pressure injuries due to immobility during treatment, comorbid conditions, and prolonged supine positioning. [1]
2. Consistent offloading and skin protection are essential to prevent tissue ischemia, maintain periwound integrity, and optimize wound healing outcomes.
3. Incorporating a standardized workflow for assessment, intervention, and documentation promotes patient safety, reduces complications, and supports compliance with national standards for wound and hyperbaric care.[2]

DEFINITIONS

1. Pressure Injury: Pressure injuries/ulcers are localized damage to the skin and/or underlying tissue, usually over a bony prominences or related to a medical or other devices, resulting from prolonged pressure or pressure in combination with shear. The lesion can present below intact skin or as an open ulcer, which may be painful. Synonyms for this condition include, bedsores, decubitus ulcers, pressure sores and many more. [3]
2. Offloading: Optimal offloading refers to strategies or techniques that redistribute pressure away from pressure points to surrounding tissues, minimizing the risk of critical tissue deformation and ischemia. This includes both full body repositioning (e.g., turning the individual) and repositioning specific anatomical regions or micromovements (e.g., repositioning the limbs, repositioning the head, using a slight readjustment of the body when a full turn is not feasible, etc.). [3]
• Offloading can be achieved through patient repositioning strategies and offloading devices that reduce sustained mechanical load on the skin and underlying tissues. See topic "Pressure Ulcers/Injuries - Treatment".
3. Prohibited item risk assessment [4][5]
• “Prohibited item” is an item that is needed and may be allowed in the chamber with caution, after a careful risk assessment is completed and risk mitigation strategies are in place.
• A prohibited item risk assessment is a structured process used to evaluate the safety of external items - such as wound dressings, medical devices, or textiles - before allowing them into a hyperbaric oxygen therapy (HBOT) chamber.
4. Go/No-Go list: Refer to a facility-specific digital record used in hyperbaric medicine to identify which items are approved for use (“Go”) and which are not approved for use (“No-Go”) inside a hyperbaric chamber. It is created and maintained through the Go/No-Go Tool, which combines the NFPA Risk Assessment Algorithm and the Burman Scoring System to evaluate the safety of items such as wound dressings, devices, and textiles. See topic "Prohibited Item Risk Assessment".

SCOPE OF SUPERVISION

1. Medical Oversight: The Hyperbaric Medical Director or designee provides direct supervision for all hyperbaric oxygen treatments, ensuring all patient assessments and offloading interventions remain within established clinical protocols and patient safety standards.
2. Safety Supervision: The Hyperbaric Safety Director oversees the environment of care, ensuring all positioning aids, offloading devices, and medical items introduced into the hyperbaric environment have undergone mandatory risk assessment and authorization.
3. Clinical Scope of Practice: As permitted by their individual state’s scope of practice, licensed nursing personnel and hyperbaric technologists may independently observe for skin alterations that may be pressure related, collect data for pressure injury risk assessments, and implementation of approved offloading protocols.
4. Escalation Protocol: Any findings of concern (e.g., new skin breakdown, treatment intolerance, or offloading device failure) must be escalated immediately to the supervising Hyperbaric Provider for evaluation and adjustment of the care plan.

POLICY STATEMENT

1. All patients undergoing HBOT will receive a pre-treatment skin evaluation for unknown skin abnormalities and an individualized offloading plan to prevent any pressure-related skin injury that potentially could occur during HBOT.
2. The care team will ensure that all offloading devices and positioning aids are safe for use within the hyperbaric chamber environment.
3. No item or device will be introduced into the chamber without prior prohibited item risk assessment and written authorization from the Safety Director and Medical Director, in accordance with NFPA 99 and facility-specific “Go/No-Go” safety protocols.

PROCEDURE

1. Pre-Treatment Assessment

1. Skin evaluation for unknown skin abnormalities: Examine all skin surfaces, including under and around medical devices, catheters, tubing, and garments, prior to each HBOT session.
• Inspect high-risk areas including heels, sacrum, elbows, and other bony prominences for erythema, discoloration, or existing injury.
• Document findings in the patient’s HBOT record and communicate any skin abnormalities to the hyperbaric physician.
2. Offloading: Assess patient comfort and instruct the patient to communicate any discomfort or need for movement immediately to prevent pressure injury. 
• Implement individualized offloading interventions, which may include:
• Heels: Float heels completely off the bed using pillows under the calves, heel offloading boots, or other approved positioning devices.
• Sacrum: Apply sacral offloading devices or positioning cushions to reduce pressure in the periwound region and protect wound edges.
• Other Areas: Pad elbows, occiput, and lateral malleoli as indicated to prevent shear and friction.
• Confirm that all devices are positioned securely, do not compromise circulation, and are compatible with chamber safety requirements.
• Repositioning: Teach patient to reposition patient at least every 1-4 hours
• Reminders (e.g., alarm clocks, apps) to prompt them to reposition can be helpful. 
3. Prohibited item risk assessment: Verify that all wound dressings and offloading devices have undergone prohibited item risk assessment and are approved for chamber use.
• If any item is not listed on the facility’s approved “Go/No-Go” list, a formal risk assessment must be completed and documented before use.

2. Positioning Prior to Chamber Entry

1. Verify that all offloading devices are in place and functioning before chamber closure.
2. For patients unable to self-reposition, ensure proper body alignment and support.
3. Confirm that positioning allows for continuous pressure relief throughout the HBOT session.
4. Reassess patient comfort and alignment immediately following treatment.

3. Safety Time Out (STOP)

1. Safety Time Out (STOP): Perform a mandatory Safety Time Out (STOP) immediately prior to chamber pressurization to verify patient identity, treatment profile, and confirmation that all prohibited items have been removed. This must be completed by two staff members and documented.

4. Post-Treatment Evaluation

1. Reinspect all offloaded areas for signs of redness, blanching, or new skin breakdown.
2. Document findings and notify the provider of any changes or concerns. If any new skin breakdown, redness, or blanching is identified, document the finding in the patient's record and initiate an incident report per facility protocol. Notify the hyperbaric physician immediately.
3. Reinforce patient and staff education on the importance of offloading and skin protection for ongoing wound healing.
4. Update the care plan as needed based on reassessment findings.

DOCUMENTATION REQUIREMENTS

1. Record all assessments, interventions, and patient responses in the HBOT record.
2. Include details of offloading devices used, skin integrity findings, and any modifications to the care plan.
3. Maintain documentation of prohibited item risk assessments for all items introduced into the chamber.

QUALITY MONITORING

1. Compliance with this policy will be monitored through periodic chart audits, direct observation, and review of incident reports.
2. Findings will be incorporated into the facility’s quality and performance improvement program to ensure continuous enhancement of patient safety and outcomes.