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Hyperbaric therapy: growing demand for a new service line
Hyperbarics provide a welcome diversion from unit rounding—and a new skill set for physicians



Published in the March 2008 issue of Today's Hospitalist

Editor’s note: This is the fourth in a series of profiles of hospitalist groups that have launched new services..

GROUP: Northland Hospitalists
LOCATION: North Kansas City, Mo.
NEW SERVICE: Medical supervision of hyperbaric oxygen therapy

A former hobby—and a push from hospital administrators—helped convince Greg Cummins, DO, to launch a new hospitalist service that has him serving as an onsite consultant for patients undergoing hyperbaric oxygen therapy.

Dr. Cummins was familiar with the general principles of hyperbarics from his days spent scuba diving. A hyperbaric chamber delivers oxygen at greater than atmospheric pressure
"It doesn’t take much extra time—about 15 minutes at either end—to check on these patients."

—Greg Cummins, DO
Northland Hospitalists
and treats a variety of conditions, including decompression sickness.

Like a growing number of hospitals across the country, North Kansas City Hospital, where Dr. Cummins’ eight-physician group works, is using hyperbarics to treat wounds. While ED physicians working within the wound center generally oversee the therapy, the hospital’s wound care service wanted backup coverage when the ED physicians were overbooked or on vacation.

That’s when Dr. Cummins and the hospitalist service stepped in. He and a colleague volunteered to get the necessary training and certification so they could begin providing coverage. The two hospitalists assess patients before and after each “dive” or chamber session, and they are available throughout the session.

“If we’re running all three chambers and we’re in the house already, it doesn’t take much extra time—about 15 minutes at either end—to check on these patients,” Dr. Cummins says. “In between, we’re able to round on our own patients or catch up on charting.”

How it works
The hospital uses hyperbarics to treat FDA-approved indications such as osteoradionecrosis and threatened flaps. Increasingly, hyperbarics are also used to speed the healing of wounds, particularly in patients with peripheral vascular disease and diabetic complications. There are about 600 hyperbaric programs in the country, 90%ofwhich are hospital-based.

A typical dive lasts about 90 minutes, Dr. Cummins explains. The hospital’s hyperbarics technicians call the hospitalists to let them know what schedule they need to cover. The techs also call physicians when a session is about to conclude, so hospitalists can wrap up what they’re doing and head back to the chambers.

State regulations in Missouri require physicians to be physically present at the start and completion of each dive. A physician must also be immediately available during the procedure in case medical problems arise.

Contraindications for hyperbarics include hypoglycemia, respiratory failure and uncontrolled seizure disorders, among others, while complications include oxygen-induced seizures or barotraumas. Complications are rare, Dr. Cummins points out, and most dives that are aborted are typically due to patients’ inability to clear their ears on the descent or to claustrophobia.

Right now, the hospitalists oversee dives only on weekday afternoons, which works out well for scheduling and staffing.

“We haven’t needed to change the way we work, because we’re usually only handling the afternoons,” Dr. Cummins points out, adding that the hospitalists rarely provide oversight on weekends. “Offering the service hasn’t affected our staffing at all.”

A growing list of indications
Dr. Cummins says that working in hyperbarics is professionally gratifying for several reasons.

For one, it gives the hospitalists who get the training another skill set and qualification, increasing the program’s value to the facility. The service also offers a welcome diversion from the usual unit rounding, as well as an opportunity to see chronic, problem wounds heal with the help of hyperbaric therapy.

“We see a lot of Medicare patients month after month who have mal healing wounds,” Dr. Cummins explains. A patient who needs hyperbarics to help heal wounds may come in for as many as 20 sessions.

He admits that, for the most part, the ED physicians at his facility “have a lock on the service” and that the hospitalists’ number of weekly sessions tops out at around eight.

But Dr. Cummins predicts that may soon change. More community physicians are becoming aware of the therapy’s benefits, he says, and the number of indications for hyperbarics is increasing.

A growing body of evidence suggests, for instance, that hyperbarics may be effective in a wide range of other conditions, from osteomyelitis and post-radiation tissue injury to certain heart conditions.

“There are a whole bunch of diagnoses that hyperbarics appears to work for,” Dr. Cummins says, “but it’s a matter of what the insurers will approve. I’d like to see our group do more of it.”

Reimbursement challenges
What are the downsides of covering hyperbarics? There is wide variation among insurers not only in the diagnoses for which the service is reimbursable, Dr. Cummins says, but in how much health plans are willing to pay. He notes that one large insurer pays only half of what a second leading market payer reimburses.

“It’s all over the map, literally,” he says, adding that on average his group receives about $165 per session. That’s been, he adds, a good source of supplemental income for the hospitalists.

For hospitalist groups thinking of launching the service, either as a primary provider or as ED wound-center back-up, Dr. Cummins offers the following advice.

First, find out what state laws require in terms of physician supervision. Second, assess both the needs of your hospital and of your local market to make the business case for hospitalist-managed hyperbarics. Many smaller community hospitals, Dr. Cummins notes, are beginning to install chambers, an indication that demand is growing.

And finally, Dr. Cummins urges hospitalists to opt for the best hyperbarics training available. He and his colleague completed a weeklong training course approved by the Undersea and Hyperbaric Medicine Society, which he says is among the most comprehensive in the U.S.

“There are some shorter weekend crash courses,” Dr. Cummins says, “but that’s not a good way to go. It’s worthwhile for hospitalists to go the extra step to become certified in hyperbarics if they plan to staff the service.”

Bonnie Darves is a freelance writer specializing in health care. She is based in Lake Oswego, Ore.

Getting paid
THE CENTERS FOR Medicare and Medicaid Services (CMS) pays for hyperbaric therapy for the following indications:

  • Acute carbon monoxide intoxication
  • Decompression illness
  • Gas embolism
  • Gas gangrene
  • Acute traumatic peripheral ischemia, as an adjunct treatment
  • Crush injuries and suturing of severed limbs, adjunctive treatment
  • Progressive necrotizing infections
  • Acute peripheral arterial insufficiency
  • Preparation and preservation of compromised skin grafts
  • Chronic refractory osteomyelitis, which is not responding to conventional medical and surgical management
  • Osteoradionecrosis as adjunctive treatment
  • Soft tissue radionecrosis as adjunctive treatment
  • Cyanide poisoning
  • Actinomycosis, as adjunctive therapy when disease doesn't respond to antibiotics and surgical treatment
  • Diabetic wounds of the lower extremities for patients who have type I or II diabetes and a lower extremity wound due to diabetes; have a wound classified as Wagner grade III or higher; and have failed an adequate course of standard wound therapy
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