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A Message from the Safety Committee

“An ounce of prevention is worth a pound of cure.”

Not just in human health but in the life of your hyperbaric equipment, a preventative maintenance program keeps your systems running efficiently, economically, and most importantly safely.

Preventative maintenance is the act of performing regularly scheduled maintenance activities to help prevent unexpected failures in the future. When properly performed and documented according to a plan it can reduce downtime, financial costs, prevent fines, and ultimately reduce liability. If you are lucky enough to have purchased a system that came with a schedule, it may be as simple as ensuring it is being followed and documented. For many however, especially multiplace chambers that had several components that were installed separately over the years, this may require a custom schedule to be developed. This can pose quite a challenge and requires one to reference the manufacturer’s recommendations and cross reference with standards such as the NFPA, PVHO, CGA or CSA and regulations (if any) set by the local authority having jurisdiction.

If you are starting from scratch to create a new plan or updating an existing plan, knowing where to start is the first step. The Divers Alert Network (www.dan.org) has a safety & prevention section that has resources for chamber operators. There you will find under “tools” a chamber maintenance schedule which provides a good place to begin. It outlines daily, weekly, monthly, etc. checks that should be considered for preventative maintenance. This is not a complete list and will need to be modified to fit your system but is a good framework to start with. It will also be useful to have references as to what parts are required according to the manufacturer specifications, the supplier of those parts, and determine if there are long lead times to have the parts when required. Using a software app to track upcoming maintenance, parts, and suppliers is very useful to ensure the facility is keeping up to date.

first pic sherri articleIn a multiplace facility one critical area that requires regular maintenance is the fire suppression system. The NFPA requires that the system be functionally tested semi-annually to ensure the flow rate and supply pressure are adequate for the required minimum times. The fire suppression system often has multiple parts and may include, pressurized water supply reservoir, compressed gas supply, pressure reducing regulators, tracking regulators, check valves, quarter turn valves, pneumatic valves, activation systems, flame detectors, alarms, float switches on the water supply, and gauges to name some of the important items, and all these components need a maintenance plan of their own. Often these components will need more frequent maintenance than their counterparts that are found on the gas system due to the potential for rust to contaminate the system. Consideration into monthly refilling of the water reservoir may reduce some of the risk of rust entering the system.

The following section is dedicated to reviewing several of the parts within the fire suppression system individually and identifying why more frequent inspection may be warranted.

pic 2 sherri articleWater supply lines should be periodically checked, especially at elbows and T junctions for accumulation of rust. If sufficient rust is present, it may reduce the amount of water flow per minute. This should be done at various locations between the water supply and the chamber hull and include inside the chamber.

Fire suppression systems will have water supply one way check valves to avoid flow in the wrong direction. Thes valves are comprised of a spring that keeps the valve closed until enough pressure is applied to compress the spring and open the poppet allowing for flow of water. When rust accumulates on the sealing surface of the poppet leaks may occur and sealing of the one-way check valve may not be obtained. Regular inspection of the poppet head should be part of the maintenance prevention plan.

pic 3 sherri articleFor safety, all chamber penetrators including those for fire suppression should have a shut off valve as close to the penetrator as possible. If the chamber is in Canada this needs to be on both sides of the chamber hull. These are generally ¼ turn valves which are quick operating , requiring only a ¼ turn of the handle to close and easy to identify from the valve handle position if it is in the closed or open position. Inside of the valve is a ball with a hole through it, such that, when open gas/water can flow through and when closed the hole is sealed off by the sealing surfaces on either side. This surface is usually a Teflon seal. Scoring of this sealing surface by rust particles can cause these valves to leak and not be able to isolate the line in the event of a line rupture. For this reason, ¼ turn valves in a water system will need more frequent inspection.

pic 4 sherri articleAll pneumatically activated valves in the fire suppression system must have a means of manual operation should the air supply fail. This back up manual valve should be function tested and inspected on a consistent schedule.

Pressure reducing regulators to handlines can also be contaminated by rust and cause the supply pressure to not reach its designed pressure over bottom pressure. This highlights the importance of testing each handline individually as well as ensuring the regulators are inspected at regular intervals.

Should the handline have a spring activated handle to initiate the flow of water, a directional arrow to show the flow of water may be of use to ensure that in the event of emergency activation it is aimed at the flames and not at the person operating it. This will depend on the chamber design, as not all handlines are of this type and directional arrow would not be required.

pic 5 sherri articleThe water supply reservoir must be pressurized to overcome the internal pressure of the chamber. Often this supply system comes with a float switch that will shut off the water supply when the reservoir is low to avoid adding pressurized air to the chamber and causing it to increase depth. The function of this switch should be confirmed to ensure it activates prior to gas being put through the water system.

Depth gauges should be calibrated and supply pressure gauges function tested on an annual basis and replaced when indicated. These are important to ensure the supply pressure to the suppression system is accurately high enough to overcome bottom pressure and to ensure it is not too high for the system itself which could cause relief valves to fire.

pic 6 sherri articleFlame detectors and audible/visual alarms should also be added to the testing schedule. Testing should confirm that bulbs are not burnt out, wiring to audible alarms are functional, and any remote alarms need to be checked that they are not only sounding but that the correct response is being performed by those who it is reaching. Including the building security, local fire, and first responders in your testing of the system is advantageous and often provides opportunity for improvement in the overall fire and emergency response plan.

pic 7 sherri articleThe last part of the preventative maintenance is ensuring that everyone knows how the system is activated and has practiced emergency drills annually. Avoidance of a fire in the first place cannot be overlooked. All electrical systems inside the chamber should have connections and wiring inspected. Ensuring that signage for what not to bring in a chamber is visible, that everyone is checked prior to entering the chamber each time, and that all occupants not only understand what does not go into a chamber but equally importantly why.

Preventative maintenance is an imperative part of hyperbaric chamber operations. Knowing that all parts of the hyperbaric system are maintained, up to date, and safe will reduce the likelihood of downtime while the unit is repaired. Proper planning will ensure the parts needed are always on hand. With components such as the fire suppression system, ensuring that testing of the system does not bring you unexpected failure which will render your system inoperable, shutting you down until repaired, can be prevented by regularly inspecting and servicing the components that comprise the system. Thus ensuring potential contamination with rust is dealt with early or avoided all together. All of this will allow the safety director to sleep well at night knowing the system will work in the unlikely event it is ever activated.

Keeping oneself informed and up-to-date with information

UHMS is a valuable source of information for healthcare professionals.

One way this information is shared is through the UHMS website. An example of an important document that can be found on the website is the UHMS Guidelines for Credentialing, Privileging, and Supervision of Hyperbaric Oxygen Therapy in the U.S.A. (https://www.uhms.org/images/Position-Statements/UHMS_Cred_and_Priv_Guide_2022_final_Jul_2023_V4.pdf). This document was first created in 2009 and has been updated regularly since then. However, it is surprising to find that many healthcare facilities are still unaware of this document. By following this guideline, facilities can provide the best possible care to their patients. While I will not be discussing the current updates, I will highlight some of the key items that are commonly found during a survey.

A common issue we observe is physicians failing to uphold their continuing medical education (CME) obligations. Despite the updated CME requirements from a few years ago, there are still some facilities that remain unaware of the revised guidelines. As an example, please refer to page 20 and 21 of the guidelines for a noteworthy observation.

Page 20
“Continuing Medical Education (CME) for Initial UHM Credentials or Reappointment MD/DO or APP applicants seeking either initial UHM credentialing, subsequent reappointment, or are transferring from an outside health care facility must demonstrate completion of a minimum of twelve (12) hours a year or a total of twenty-four (24) hours of Physician Category 1 AMA/AOA PRA CME in hyperbaric medicine-related topics within the preceding two (2) year period. Page 21 of 22 • If the health care facility credentialing requirements or the requirements of certification agencies exceed these standards, the CME requirements of the physician’s health care facility or certification and privileging agencies should be followed.”

Page 21
Minimum Proof of Continuing Education
“Minimum of twelve (12) credit hours of Physician Category 1 AMA/AOA PRA CME in hyperbaric medicine-related topics for each twelve (12) months of hyperbaric practice or twenty-four (24) credit hours in two (2) years.”
There has been a recent trend where some facilities have appointed DPMs as Medical Directors. However, it should be noted that according to the guidelines on page 14, only MDs/DOs should hold the position of Medical Director. It’s important to stay up to date with information to ensure all necessary elements are in place. This guideline has not changed, but the trend highlights the importance of being aware of current standards.

Page 14
“Medical Directors (MD/DO only) Must meet all the qualifications required of Independent Supervisors of HBO2 and the following:

  • Current ABMS/AOA board certification in UHM (preferred)
    • Board certification in UHM supersedes the UHMS PATH program. MD/DOs who hold UHM certification through the ABMS/AOA are not required to complete the UHMS PATH program.
  • Completion of the UHMS PATH program Completion of an ABMS/AOA board certification in UHM or the UHMS PATH is mandatory after December 31, 2027. Candidates should enroll in and begin the PATH program with modules currently available. The expectation of Medical Directors is that they have attained sufficient training, education, and experience to independently attend HBO2 sessions, supervise and mentor providers attending Page 15 of 22 HBO2, create policies and procedures, and a quality improvement process consistent with the standards of the UHMS Accreditation Program.”

According to the statement, it will be mandatory for the Medical Director to have completed an ABMS/AOA board certification in UHM or the UHMS PATH after December 31, 2027. This is because the field of hyperbaric medicine is continuously improving, and there is a constant push for more education and certification. To learn more about obtaining these qualifications, visit the Education tab on the UHMS website.

The UHMS distributes numerous documents containing valuable information. To stay updated, it’s recommended to regularly check the Position Statement on their website https://www.uhms.org/resources/position-statements.html. There are many sections on the website to explore, so don’t hesitate to ask one of the UHMS staff members for guidance. We are more than happy to assist you in enhancing your hyperbaric facility to meet quality standards.

- Derall Garrett

Multicenter Hyperbaric Outcomes Registry: 2023 Q3 Update

The Multicenter Hyperbaric Outcomes Registry collects a defined set of outcome measures for all 14 UHMS-approved, and for some emerging hyperbaric oxygen treatment indications. The registry is a consortium of participating treatment centers. All participating sites use the same Research Electronic Data Capture (REDCap) template, which defines the data elements collected for every patient.

Participants complete a general symptom survey and disease-specific symptom questionnaire immediately pre- and post- treatment. Additional follow-up questionnaires are sent to patients at three months, and at one, three and five years after treatment completion to help assess long-term outcomes.

As of June, 2023 there were 27 participating centers, and approximately 5800 patient entries in the registry. That number continues to grow. Overall case mix from 2019 to present is shown below (Figure 1). Radiation injury continues to be the leading indication for treatment.

figure 1 silverman article

A relatively small number of more severe adverse events were reported, including seizures and pulmonary edema during treatment. The registry data includes treatment conditions under which those events occurred. For example, in 2022:

  • Seven seizures were reported for patients starting in 2022: one occurred at 2.0 ATA, one at 2.4 ATA, three at 2.8 and two at 3.0 ATA.
  • Approximately 7% of patients experienced claustrophobia. About half of those stopped treatment, but others were able to be managed with minimal or no treatment disruption.
  • Otic barotrauma was reported in 5% of patients. About 8% of patients had placement of one or bilateral myringotomy tubes to manage ear pain

The disease specific symptom surveys allow us to view the magnitude of positive outcomes as well. For instance, dry mouth symptoms in Head and Neck patients are shown below:

figure 2 silverman article

The registry allows us to examine standardized outcome measures across centers which may treat small numbers of patients individually, but combined hopefully will help direct and support future treatment practices.

Reflecting on a Successful ASM

Greetings from all of us here at UHMS!

In my prior note, we were in the final preparations for hosting the UHMS ASM in San Diego. We were cautiously optimistic about attendance with the pandemic in our rearview mirror and hoped that a combination of stellar content and faculty, the ASM being in San Diego, and the hotel and conference center’s location on the water would bring out our members once again.

Now we’re 60 days post-meeting, and what’s the verdict, you ask? From purely objective measures, the meeting was a success.

Attendee evaluations have been overwhelmingly positive. Below is an interim analysis of 178 respondents’ scores across all categories.

EDGraph

Financially, from a direct cost perspective, we experienced a surplus, which is also positive.

Other reasons, I believe the meeting was a resounding success.

Attendance for our pre-courses was at peak levels, while the general session attendance was on par with prior non-COVID years. An interesting and exciting statistic was that approximately 1/3 of the registrants were first-time attendees to a UHMS ASM.

We had an amazing lineup of speakers. Our Keynotes delivered moving presentations and received an outpouring of gratitude from the audience afterward. Also, the plenary speakers did not disappoint.

Great work was accomplished by the many UHMS committees who met during the meeting. The creative juices were really flowing. Several new initiatives were launched in key committees while other projects were reinvigorated.

We gave two STEM scholarships to attend the ASM tuition-free. Both awardees were students, including one, a medical student and the other, a senior in high school. Congratulations, Denise Nemeth, and Madison Gesell! On a side note, we’re excited to continue this program and hope to award up to ten scholarships next year for students interested in physiology and medicine with the support of a grant to UHMS.

I enjoyed seeing and speaking with all of you at the meeting, and if we missed connecting, please do not hesitate to reach out if I can be of assistance.

While on the topic of ASMs, we are already planning for next year in New Orleans, and the call for abstracts will be going out before September 1st.

Additionally, next year will be a big year for UHMS elections with officer and director positions coming open, including the President-Elect, Vice President, Treasurer, 2 Members-at-Large (MAL), including our MAL military active-duty, and Associate Nurse Representative-elect. Look for the call for nominations in mid-December.

Hope to see you all in New Orleans next year!

UHMS Finances
Through July, UHMS’s financial position year-to-date is stable. Income is higher than budget, but we’re also experiencing higher non-salary expenses. On a PL basis, we are seeing a modest surplus.

 Jan-Jul 2023 PL
   Actual Budget
 Income  $1,024,387  $956,611
Expense  $960,051  $875,323
Net  $64,375  $81,288

Our balance sheet remains healthy, with operating, savings, and investment accounts continuing to hover at near-all-time highs.

Certification Matters
We continue to receive questions about technician and nursing certification. The UHMS’s position is unchanged in that we believe that all team members involved in providing care to patients in hyperbaric medicine should be certified, and our position statement - The Importance & Recognition of Hyperbaric Certification for Technicians & Nurses can be found here - UHMS POSITION STATEMENT.

Congratulations to the Q3 Associate Scholarship Award winner Norbet Rodriguez Milan. He will be able to attend a UHMS-approved Introductory Course in Hyperbaric Medicine at no cost, which is required to sit for UHMS-recognized hyperbaric certification exams.

Member Benefits
As a reminder, UHMS members receive three free CE/ CME credits upon joining or renewing. This benefit represents an immediate $40 savings for Associate members and $60 for Regular members annually.

Associate Member Town Hall
Members are invited to attend the UHMS Associate Council town hall meeting on the second Thursday of every quarter, where invited speakers present on relevant topics that apply to our specialty.

Corporate Partners
If you are a UHMS Corporate Partner, please attend our monthly Corporate Partner Town Hall meeting series. These are held on the 1st Wednesday of every month at 12 PM and are intended to be an open forum for discussing the challenges and successes your businesses and practices are experiencing and to create momentum and collaboration where appropriate.

If your organization wants to educate the UHMS membership about the care provided or the goods and services offered, consider joining our Corporate Partnership Program. See https://www.uhms.org/corporate-memberships.html.

MEDFAQs
The UHMS offers its version of “ask the experts.” MEDFAQs can be found at the following URL – https://www.uhms.org/resources/medfaqs-frequently-askedquestions-faq.html and is a valuable tool for our membership.

If you are familiar with MEDFAQs, check back, as new Q&As are posted regularly.

Research
The Multicenter Registry for Hyperbaric Oxygen Therapy at Dartmouth (MRHBO2) continues seeking funds for free hospital membership. The MRHBO2 is funded entirely via grants, not by the registry’s participating hospitals. Please consider supporting this critical need to help keep the barrier to joining low - https://www.uhms.org/donate-to-themulticenter-registry-for-hyperbaric-oxygen-therapy.html.

Remember that donations made to the UHMS Funds for Research and Policy Advancement are tax-deductible. For more information, check out the UHMS website – https://www.uhms.org/funding.html.

QUARC
To better understand the field’s challenges, log in and visit the QUARC page – https://www.uhms.org/resources/quarc.html. Here, you will find impending legislation, LCD, and other relevant policies on the provision and limitations of HBO2 coverage and the UHMS’s responses and guidance.

The chairs of QUARC are requesting that any unusual denials or challenges with physicians gaining access to insurance panels for HBO2 services, let us know as soon as possible, please – jpeters@uhms.org.

UHM
If you are a UHMS member, we are happy to announce a new search feature for previous issues and articles from UHM/UBR - https://www.uhms.org/publications/uhm-journal/download-uhm-journalpdfs.html. Currently, the feature works with keywords.

If you have a suggestion or comment on how we can serve you better, please email me directly at jpeters@uhms.org or call me at 561-776-6110 extension 100. It is my pleasure to serve you, our membership, and I continue to look forward to hearing from you.

- John Peters

Remarks from Dr. Michael Strauss upon receiving the 2023 UHMS Behnke Award

June 18, 2023, San Diego, California

It is indeed a great honor to receive the premier award of the Undersea and Hyperbaric Medical Society. Dr. Behnke, although retired at the time, was a willing audience for my novel ideas about diving medicine upon my entry into the Navy 56-years ago. His inspiration motivated me to continue a 46-year affiliation with the Navy and evolve these ideas into papers and diving texts. Not only that, as a personal friend he let me use his sword to complete my military uniform for my wedding ceremony 49-years ago. Consequently, receiving this award has special significance for me and motivated me to put in writing the 3-topics I addressed in my acceptance responses.

As a customary starting point, I must give thanks to those who made this award possible: First, to Dr. Paul Cianci who nominated me for this honor and those who supported the nomination, Second, to my mentor Dr. George Hart who deserves praise beyond adequate expression for persuading me to join him in Long Beach, mentor me to become the most knowledgeable orthopaedist in hyperbaric medicine, to fully support my Navy and diving activities, and to serve as a business partner for our clinical activities. In this day and age, it is incredible to believe that we had a business arrangement based on mutual trust and devoid of any writing agreements–or even handshakes. Third, I am deeply indebted to the Navy, for the learning opportunities, training, diving, orthopaedic, and world-wide travel and friendship activities it afforded me. Fourth, I am thankful to the UHMS honoring me with this award, but even more so for allowing me to share more than 50 presentations at our meetings and articles in the Undersea and Hyperbaric Medicine Journal. And finally, but not least, to my family who are here this evening for fully supporting me on official–often times accompanying me–and not so official junkets, and helping in generating my writings. My wife, Wendy, my greatest fan, yet severest critic always managed to keep the “home fires burning” for all my diverse and away-time activities.

My next focus is about challenges facing hyperbaric medicine. First, and most concerning is the dearth of hyperbaric contributions from academic medical centers. When I first became involved with clinical applications of hyperbaric oxygen 46 years ago, there were about 40 medical centers who treated conditions requiring HBO–and most of these were for threatened loss of life or limb diagnoses with many papers generate from their experiences. Today, the numbers of facilities treating emergencies have not substantially increased although there are now an estimated 1500 centers that treat outpatient, non-emergency conditions. The reason for this is reimbursements are not provided for inpatient HBO treatments due to establishment of the DRG (Diagnostic Related Group) system where the hospital is reimbursed for a pre-determined amount for the admitting diagnosis. This becomes a “Catch-22” situation. Why would hospital administrators fund services for which they receive no reimbursements? This, to me, explains the dearth of academic medical centers’ contributions to the HBO literature. A recent orthopaedic surgery article summarized the METRC’s (Major Extremity Trauma Research Consortium’s) on-going, funded projects. Of the $150 million dollars funded and over 500 investigators participating, not one study mentioned using HBO. As Dr. Julius Jacobsen so stated in his remarkably perceptive 1984 Internal College of Hyperbaric Medicine Presidential Address, HBO will not survive unless well controlled studies are produced. At our ASM meeting this year, there was a “glimmer of hope. “Dr. Parambir Bulai demonstrated through his own perseverance and resourcefulness the value of HBO for inflammatory bowel syndromes while working at the Northwestern Medical Center in Evanston, Illinois. The bottom line, we as a society, need to convince payers that “cutouts” for emergency inpatient HBO treatments be made. The rewards are manifold with not only improving patients’ outcomes, but also for the stimulation of research to validate HBO’s usefulness and for discovering new indications—as Dr. Bulai single handedly has done.

A second concern is relying on the Wagner grading system to justify HBO treatments. It is archaic (first published 44 years ago), relays on a single observation to decide whether or not HBO treatments are justified, and has no published validating or reliable studies. It lends itself to upcoding the subjective observations to obtain reimbursements for HBO treatments. There is a great need for the UHMS endorsing an objective wound scoring system using several assessments with easily observable findings to grade each assessment. The Apgar score for determining newborn vitality is an excellent model for such a grading system.

Finally, our Undersea and Hyperbaric Medicine journal impact factors hovers around one. I propose that “Wound Care” be added to the journal title. With about a third of our ASM presentations dealing with wound care as well as publications in the Journal, adding this title to the journal has the potential for attracting more quality articles, increasing readership and improving our journal’s impact factor. A few years ago, the Aerospace Medicine journal added Aviation and Environmental Medicine to its title. Its impact factor has continued to improve.

A final, departing consideration is what are my plans for the future. First, I am fortunate to be in a position where I am able to remain a tertiary consultant and surgeon for wounds that are not healing as expected. In the process I mentor bright and motivated residents for these problems–a source of great satisfaction. Now that my Diving Science…Revisited text is in print, I am revising my MasterMinding Wounds text. Like my diving text revision, the revision is to be much different than the original version. With 46-years of working with wounds, I have developed many novel ideas and techniques that I want to share with others. Presently, I have four papers in various stages of submission for publication and many more ideas for future writings. Finally, I unequivocally offer my services to the UHMS to help with their educational and administrative programs–especially with the 3-concerns mentioned above.

In summary, I relate to Robert Frost’s poem, “The Road not Taken.” Had I taken the other road I wonder where I would be at this time. The road taken has been an enlightening, exhilarating and extraordinary opportunity and one that has allowed me to develop exceptional relationships with experts in a variety of disciplines

Third Quarter 2023

The UHMS Annual Scientific Meeting was held June 16-18 in San Diego, California and was a big success. The meeting was well attended and the feedback we have received has been mostly positive. Thank you to all of the people who worked very hard to make this event happen. Mark your calendars for ASM 2024 which will be held in New Orleans from June 13-15. The planning committee has already began preparations.

In-person courses that should be on your radar include the Medical Examiner of Divers course which will be held this year from September 21-24 in New Orleans. This course is designed to prepare medical providers to examine commercial, sport, scientific and other related public service divers and determine their fitness to dive. The Physicians Training in Diving Medicine (PTDM) course will be held from October 16-26 in San Diego. This course is designed to train physicians in the recognition and treatment of diving medical emergencies. I look forward to seeing all of the new Fellows at PTDM.

Online and virtual educational options include the UHMS Program for Advanced Training in Hyperbaric Medicine (PATH) which confers an advanced level Certification of Added Qualification (CAQ) as well as the virtual UHMS Chapter Meetings. Check the UHMS website for dates and topics with the next one being the Northeast Chapter hosting Clinical Hyperbaric Medicine on Saturday October 14, 2023.

I encourage all of you to take advantage of the myriad educational opportunities that our society offers.

- Pete Witucki