Any podiatrists seeking better patient outcomes should consider adding hyperbaric oxygen therapy (HBOT) to their treatment options. The practice of putting patients inside a hyperbaric chamber — either a monoplace or a multi-place chamber — and having them breathe 100 percent oxygen while under increased atmospheric pressure is gaining currency, and is well documented in the scientific literature.1
Hyperbaric oxygen therapy has several proven mechanisms of action, including:
• edema reduction;
• fibroblast proliferation and collagen formation;
• angiogenesis (neovascularization);
• enhanced bacterial killing;
• toxin inhibition and inactivation;
• antibiotic synergism; and
• neutrophil reperfusion response.1
The advantages of HBOT include faster rates of wound healing through angiogenesis and anti-bactericidal properties of 100 percent oxygen, limb salvage and reduced hospital length of stay.2-4 While HBOT is not for every patient, it has been the lead author’s experience that HBOT is a powerful modality that can make all the difference in a successful clinical outcome for appropriate patients. A typical wound care program will have 15 to 20 percent of its patients as potential HBOT candidates.
Whether you are part of an established wound care program, have your own private practice or are a hospital-based podiatrist, your patients can benefit from HBOT. In order to make the best use of HBOT, it is critical to understand which medical conditions and clinical parameters will make a patient a candidate for HBOT. It is also critical to understand hyperbaric medicine’s mechanisms of action in order to begin the patient selection process for HBOT.
After identifying patients as HBOT candidates, one must perform several tests to rule out potential complications during oxygen treatment. Typically, these tests will include electrocardiography, chest X-rays, and lab tests, including a complete blood cell count with differential and chemistry. Clinicians should also obtain a solid patient history and perform a physical exam to rule out ear, nose and throat issues; cardiac and pulmonary problems, including congestive heart failure, chronic obstructive pulmonary disease, decreased ejection fraction; and renal failure. Clinicians should also determine whether there are issues with diabetic glucose control. One should determine if there is a history of seizures and carefully review the patient’s medication history.
A vascular evaluation may be required. In some cases, HBOT reimbursement is contingent on demonstrating vascular proficiency through the use of transcutaneous oximetry (TCOM or TcPO2) testing. When it comes to diabetic lower extremity wounds, the Centers for Medicare and Medicaid Services (CMS) now require a positive vascular assessment. Barring that, any claims for HBOT related to that patient will be denied. Prior to beginning HBOT, one must address, correct and verify the correction of vascular deficiencies. Limitations in podiatric scope of practice dictate that an MD or DO conduct the history and physical although a DPM can direct the TCOM testing providing that the area being tested falls within the DPM scope of practice.
Case Study One: Using HBOT For A Patient With Osteomyelitis And Gas Gangrene
A 67-year-old obese female presented to the ER with a septic wound, a white blood cell count of 23,000 and gas in the soft tissues. The patient had diabetes and hypertension. She was taking insulin and lisinopril. She initially received treatment for interdigital tinea but did not follow up with her podiatrist.
An examination revealed the patient’s vascular status was acceptable. Her treatment consisted of surgical debridement with a midfoot amputation and a flap.
The patient also received HBOT on her first postoperative day. She had hyperbaric oxygen at 2.5 ATA BID for five days and QD for 40 days. The patient later healed and was walking in an ankle-foot orthotic (AFO).
Case Study Two: Treating An Elderly Patient With Diabetes And Bilateral Forefoot Gangrene
A 90-year-old male presented with a history of bilateral forefoot gangrene due to peripheral vascular disease. He had non-insulin dependent diabetes.
His treatment consisted of a femoral-popliteal bypass followed by a proximal transmetatarsal amputation of the left foot. He also had a revisional transmetatarsal amputation of the right foot.
The patient received hyperbaric oxygen at 2.5 ATA for 40 sessions. He healed and began ambulating in an AFO and a diabetic shoe, and started exercising on a bicycle.
A Guide To Implementing HBOT At Your Facility
Private practice podiatrists can refer their patients to a local or regional hyperbaric medical facility where the patient receives treatment and the referring physician stays informed of the patient’s progress. For established wound care programs, adding hyperbaric chambers will likely enhance their program and increase the number of patients they see. For hospitals, adding hyperbaric chambers may mean the difference between reducing hospital length of stay and transferring their patients to another facility that offers HBOT on-site.
Good Samaritan Regional Medical Center’s Wound Care Institute was operational for three years before we started looking into adding hyperbaric chambers. It was an involved process from beginning to end and required the expertise of an experienced HBOT third-party service provider. In our case, we brought in the Life Support Technologies group, a New York-regional HBOT and wound care service provider, to help us with all phases of HBOT implementation, staff education, compliance and national accreditation. It took us two years from initiating the process to full hospital administration and regulatory agencies approval, and treating our first HBOT patient.
Good Samaritan Regional Medical Center has treated 160 patients with HBOT and its Wound Care Institute now sees an average of 50 to 65 podiatric patients weekly. The Wound Care Institute has become one of only a handful of facilities in the U.S. Northeast to be accredited under the nationally recognized Undersea and Hyperbaric Medical Society (UHMS) program.
When adding hyperbaric chambers to any facility’s treatment options, physicians need to consider many things, the first of which is space. Requirements include a patient intake and waiting area, ample room for the hyperbaric chambers, a patient changing area and lockers, a patient examination area and, for clinical staff, lockers for their personal things. Ideally, the hyperbaric chambers will be located adjacent to or in close proximity to the wound care program. This will make physician supervision of HBOT far more practical and will save wear and tear on physicians who may otherwise have to travel from another part of the building to examine patients or deal with any potential complications.
It is important to note that partnering with experienced HBOT practitioners makes good sense, particularly if you are just getting into the hyperbaric field. However, make sure that they will be providing comprehensive policies and procedures covering all aspects of the operation, from the provision of treatment to general safety and the management of adverse events that can occur just as they do with any modality one employs in patient care. The HBOT providers should also support you in dealing effectively with the fire marshal, your state’s department of health, engineers and the Joint Commission to create the physical space that is compliant with local and national codes, and the paperwork trail required by government regulations.
Equally important, HBOT practitioners should be providing and defining procedures and documentation critical for insurance reimbursement, and working with your facility’s billing department on procedures to avoid pitfalls and ensure that everyone gets paid for services. As changes to the healthcare system continue to emphasize cost reduction, improved patient outcomes, and other quality-of-care related activities, you will need to focus on achieving accreditation for your center. The Joint Commission recognizes the UHMS accreditation.
If you are going to work with a contract provider, part of the due diligence is ensuring the provider has a proven track record in setting up and achieving accreditation. Without that, you will end up doing the considerable amount of work yourself to achieve accreditation and will likely spend far more time and money on the effort than you would with a good, experienced partner in hyperbaric medicine.
Dr. Levine practices in Nanuet, N.Y. He is the Co-Director of the Wound and Hyperbaric Institute and the Chief of Podiatric Surgery at Good Samaritan Regional Medical Center in Suffern, N.Y.
Mr. Chowdhury has been a CHT since 2004. He is the Training Director for the Life Support Technologies Group, is part of the faculty for the Introduction to Hyperbaric Medicine course, and has helped run one of the group’s nine hyperbaric units. Mr. Chowdhury is known internationally for his top-selling, non-fiction book, The Last Dive.
1. Kindwall EP, Whelan HT (eds). Hyperbaric Medicine Practice, third edition. Best Publishing Co., Flagstaff, AZ, 2008.
2. Eisenbud DE. Oxygen in wound healing: nutrient, antibiotic, signaling molecule, and therapeutic agent. Clin Plast Surg. 2012; 39(3):293-310.
3. Warriner RA 3rd, Hopf HW. The effect of hyperbaric oxygen in the enhancement of healing in selected problem wounds. Undersea Hyperb Med. 2012; 39(5):923-35.
4. Bishop AJ, Mudge E. Diabetic foot ulcers treated with hyperbaric oxygen therapy: a review of the literature. Int Wound J. 2012 Jul 2 (epub ahead of print).