Fitness to Work in Pressurized Settings: (2012-01) July 2012
Safety During Multiple Occupancy Monoplace Chamber Operations: (2011-02) July 2011
Portable, Fabric, Low-pressure Hyperbaric Chambers: (2011-01) April 2011
On-Line Introductory Training in Hyperbaric Medicine: (2010-02) October 2010
Physician Attendance and Supervision of Hyperbaric Oxygen Therapy: (2010-01) April 2010 (Rev. July 2013)
In-home Delivery of Hyperbaric Oxygen Therapy: (2009-05) October 2009
Intermittent Air Breathing: (2009-04) August 2009
Hyperbaric Safety Director: (2009-03) July 2009
Recognized Hyperbaric Safety Codes and Standards: (2009-02) March 2009
UHMS Facility Accreditation: (2009-01) January 2009
It is the position of the National Board of Diving & Hyperbaric Medical Technology that every individual employed as a multiplace chamber inside tender, and all those who might otherwise be required to enter the pressurized chamber, be medically cleared as fit to work in this unique environment. The precise scope and extent of such screening examinations will be consistent with both prevailing standards and any recommendations from authoritative bodies. Interval repeat screening assessments should be conducted consistent with prevailing standards and following injury or illness that might influence subsequent medical fitness. Records documenting screening assessments should be maintained within each facility’s Human Resources/Personnel files as appropriate, and for a period of time consistent with prevailing regulations.
Failure to undertake such medical fitness screening is considered by the National Board of Diving & Hyperbaric Medical Technology to represent a fundamental breach of hyperbaric operational safety.
It is the position of the National Board of Diving & Hyperbaric Medical Technology that whenever two persons occupy a Class B ‘monoplace' hyperbaric chamber, individual grounding and air breathing capabilities should be provided to both occupants.
Class B chambers are designed for single occupancy in accordance with the National Fire Protection Association - NFPA 99. From time to time, however, a hyperbaric physician may require that a particular patient be accompanied during their monoplace chamber-based treatment(s). A common example is the pediatric patient who is not being mechanically ventilated. These patients may be accompanied by either a staff member or a family member, depending upon several variables. Hyperbaric textbooks and other publications feature numerous photographic examples of this practice pattern.
It is not the intent of the National Board of Diving & Hyperbaric Medical Technology to condone this practice, or otherwise. Rather, the Board recognizes that this practice does occur and wishes to ensure that appropriate safety measures are employed.
Both occupants should be directly grounded, the manner of which should be in accordance with NFPA 99 188.8.131.52.3.2. An example photographic illustration is attached as Appendix 1. Consistent with the Board's position on intermittent air breathing (Position Statement 2009-04, August 2009), both occupants should be provided with an individualized air breathing capability. An example photographic illustration is attached as Appendix 2.
It is the position of the National Board of Diving & Hyperbaric Medical Technology that the design, fabrication and common use of portable, fabric, low-pressure (operating at pressures of no greater than 1.4 ATA) hyperbaric chambers is inconsistent with recognized and prevailing safety codes and standards.
The operational design pressure of a hyperbaric chamber that encloses a human within its pressure boundary falls within the scope of the American Society of Mechanical Engineers Pressure Vessels Human Occupancy 1 (ASME PVHO 1-2007). Portable, fabric, low-pressure chambers do not comply with this important safety code.
These chamber types are cleared by the Federal Drug Administration (FDA) only for the treatment of acute altitude (mountain) sickness and only when compressed with air. However, they are widely promoted for a large number of ‘off-label' conditions and are at further variance with the FDA's clearance in that some are used with oxygen concentrators and other sources of oxygen (‘enriched air'). It is also apparent that these chambers are not always operated in a manner consistent with the standards of the National Fire Protection Association (NFPA) 99 chapter on hyperbaric facilities.
It is the position of the National Board of Diving & Hyperbaric Medical Technology that portable, fabric, low-pressure hyperbaric chambers be limited in their use to the treatment of acute altitude sickness and that they be compressed only with air. Further, these chamber types should be designed, fabricated and operated in a manner consistent with prevailing codes and standards.
It is the position of the National Board of Diving & Hyperbaric Medical Technology that introductory training in hyperbaric medicine must be undertaken in face-to-face classroom or seminar type settings. The NBDHMT has long recognized the value of on-line education as a means of maintaining and advancing knowledge and skills. However, this recognition does not extend to the learning of an entirely new field of medicine, technology, and related safety.
Such introductory hyperbaric training courses are expected to require a minimum of 40 hours of face-to-face instruction, some of which will involve a practical 'chamber-side' environment. This NBDHMT position is entirely consistent with the education and training standards of the Undersea and Hyperbaric Medical Society.
Physician Attendance and Supervision of Hyperbaric Oxygen Therapy: (2010-01) April 2010 (Rev. July 2013)
It is the position of the National Board of Diving & Hyperbaric Medical Technology that provision of hyperbaric oxygen therapy must be directly supervised by a physician (which includes a nurse practitioner/physician assistant where permitted by prevailing credentialing and regulatory standards) who is formally (UHMS or other authoritative body) trained in hyperbaric medicine, involving a face to face classroom vs. online setting. Such supervision should extend to:
- Assessment of suitability for HBO therapy
- Determination of risk-benefit profile
- Interpretation of any related diagnostic testing
- Generation of a therapeutic dosing profile
- Evaluation of subsequent clinical course, and
- Management of any related side effects and complications
Further, the hyperbaric physician must be on the premises and immediately available to the chamber facility at all times that the chamber(s) is occupied. Immediately available would meet the intent of this Position Statement if the physician could arrive at the chamber facility within five minutes of being summoned and in doing so, would not place in jeopardy any other patient presently under their care.
It is the duty of hyperbaric nursing and technical personnel to safely implement ordered therapy and closely monitor patients during their treatments. Should a patient voice complaints or manifest signs suggesting an unanticipated change in status, considered to be hyperbaric related or otherwise, the hyperbaric physician should be immediately notified. Importantly, hyperbaric nursing and technical personnel do not assume any of the physician responsibilities noted above and cannot initiate hyperbaric treatment without patient-specific hyperbaric physician signed medical orders.
It is the position of the National Board of Diving & Hyperbaric Medical Technology that the installation and provision of in-home hyperbaric oxygen therapy is inherently unsafe and cannot be condoned. The basis for the position is concern for the well-being of all such patients involved and the safety of those in proximity to the hyperbaric oxygen therapy delivery system.
In-home provision of hyperbaric oxygen therapy is likely to result in a bypassing of otherwise mandatory federal, state, and local codes as they relate to design, construction, installation, and operations.
In-home provision of hyperbaric oxygen therapy is likely to occur without adequate physician oversight and the operational support of appropriately trained and certified hyperbaric technologists and nurses. These shortcomings serve to further erode important safety standards.
It is the position of the National Board of Diving & Hyperbaric Medical Technology that every recompression treatment facility and every clinical hyperbaric chamber, regardless of type or class, be equipped to provide intermittent air breathing. Intermittent air breathing, commonly referred to as an ‘air break', serves to prophylax against and lower the incidence of, central nervous system oxygen toxicity. Intermittent air breathing also serves to treat pre-monitory signs and symptoms of oxygen toxicity, thereby reducing the potential for symptom progression to overt seizure.
The application and sequencing of intermittent air breathing will be at the discretion of the hyperbaric physician. However, intermittent air breathing should be immediately instituted (by either the multiplace chamber tender or monoplace chamber operator) whenever an acute change in patient status occurs and is consistent with, or suggestive of, CNS oxygen toxicity.
It is the position of the National Board of Diving & Hyperbaric Medical Technology that every recompression treatment facility and every clinical hyperbaric medicine service appoint a Hyperbaric Safety Director. This position is consistent with a previous NBDHMT Position Statement regarding adherence to recognized codes and standards. It serves to emphasize what the NBDHMT considers to be a key safety aspect. The Hyperbaric Safety Director should undergo formal and comprehensive training in the safety aspects of hyperbaric medicine and related technology. They should develop, maintain and manage a safety program based upon compliance with recognized standards. The resulting program should demonstrate effective elements of hazard mitigation, while employing recognized risk management concepts.
It is recognized that some hospitals and management companies with more than one hyperbaric facility appoint corporate safety directors. In these situations, an on-site safety director should also be designated. The intent is to have this individual be a full time member of each hyperbaric facility's staff.
The term Hyperbaric Safety Director can be replaced with other titles of similar meaning and identical intent. Examples include Hyperbaric Safety Supervisor, Hyperbaric Safety Technologist, Lead Hyperbaric Safety Technologist, Hyperbaric Safety Manager, and Duty Hyperbaric Safety Technologist, and like terms. It is not the intent of the NBDHMT to assign a title. Rather, the intent of this Position Statement is to identify and emphasize the need for a trained and designated hyperbaric safety individual at each facility.
It is the position of the National Board of Diving & Hyperbaric Medical Technology that the codes and standards expressed in the American Society of Mechanical Engineers' safety Standard for Pressure Vessels for Human Occupancy (ASME PVHO-1)* and the National Fire Protection Association 99, Health care Facilities, Chapter 20, (Hyperbaric Facilities)** be rigorously adhered to.
Using only hyperbaric chambers that have been designed, fabricated, tested and stamped in accordance with ASME PVHO-1 gives the user a high level of confidence in the quality and safety of the equipment in use and is an effective risk management tool. The use of hyperbaric chambers that do not meet these codes is strongly discouraged.
The installation and operational requirements found in NFPA 99, Chapter 20 have proven themselves since they were first issued in 1968. Not only does this standard provide guidance with regard to proper installation of hyperbaric chambers, it clearly prescribes safe day-to-day safety procedures that all should adhere to.
One standard that is particularly important from a day-to-day perspective is the issue of acceptable clothing. NFPA 99 Chapter 20 mandates that only clothing, and linens, made of 100% cotton or a blend of cotton and polyester fabric is permitted inside the hyperbaric chamber. These items shall be provided by the treating facility or specifically approved for hyperbaric use by the safety director in accordance with NFPA 99, 184.108.40.206.7.
The NBDHMT adds that acceptable clothing worn inside the hyperbaric chamber must not contain pockets. The majority of hyperbaric fires over the past two decades have been the result of prohibited items (pocket warmers, cigarette lighters and cellular telephones, are examples) being taken into the chamber. Eliminating pockets will do much to eliminate the introduction of prohibited items.
* American Society of Mechanical Engineers Safety Standard for Pressure Vessels for Human Occupancy, 2002. www.asme.org
**National Fire Protection Association 99, Health Care Facilities; 2005. www.nfpacatalog.org
It is the position of the National Board of Diving & Hyperbaric Medical Technology that every clinical hyperbaric medicine program (defined here as a facility not solely available for the treatment of diving/decompression accidents) undergo the Undersea and Hyperbaric Medical Society Hyperbaric Facility Accreditation Survey.
It is the position of the NBDHMT that UHMS accreditation represents the most effective standard by which safety and effectiveness of hyperbaric medicine delivery systems can best be determined. The survey process allows each hyperbaric medicine program to be recognized for its strengths and to employ strategies to overcome its identified weaknesses.
The NBDHMT believes that a UHMS accredited hyperbaric medicine facility offers its patients, staff, and parent institution the highest assurance of safety, compliance, and therapeutic effectiveness.