Baromedical Nurses Association (BNA) Announces Release of Updated Guidelines

  • Jolene Cormier and Dana Winn
  • Volume 09 - Issue 3

Information provided by Jolene Cormier and Dana Winn, Director at Large representatives in the BNA.

The Baromedical Nurses Association (BNA) announces the release of the updated 2018 Guidelines of Nursing Care for the Patient Receiving Hyperbaric Oxygen Therapy. Find it at:

http://hyperbaricnurses.org/nursing-guidelines/

It was formerly called the Nursing Standards of Care, first published in 2007. Baromedical nursing’s origins began in 1950s Europe, quickly moving outward.

Hyperbaric Medicine

Read more: Baromedical Nurses Association (BNA) Announces Release of Updated Guidelines

Baromedical Nurses Association (BNA) Updates

  • Laura Josefsen, RN, ACHRN
  • Volume 09 - Issue 3

Information compiled by Laura Josefsen, RN, ACHRN from the BNA Website: hyperbaricnurses.org

Annette Gwilliam, president, continues to lead the Baromedical Nurses Association (BNA) to new heights and excitement. Kevin Kraft, vice president, is active in many projects of the board. Robin Ortega, as the administrative assistant and treasurer, also oversees the website hyperbaricnurses.org. This website provides an extensive amount of information, including membership, education (free CEUs for members, nominal fee for nonmembers), newsletters, BNACB updates, nursing guidelines, safety, certification, and contact information for all board members.

Hyperbaric Medicine

Read more: Baromedical Nurses Association (BNA) Updates

Press Release from Smith & Nephew:

  • Smith & Nephew
  • Volume 09 - Issue 3

UK’s NICE publishes a Medtech innovation briefing on PICO™ for the prophylactic use in surgically closed incisions to reduce surgical site complications

June 29, 2018

As follow-up to previous news, Smith and Nephew would like to announce the first and only Medtech innovation briefing (MIB) published by the UK’s National Institute for Health and Care Excellence (NICE) on a Negative Pressure Wound Therapy (NPWT) device for preventing surgical site complications (SSCs). Below is the official press release.

Smith & Nephew (LSE: SN, NYSE: SNN), the global medical technology business, announces that the UK’s National Institute for Health and Care Excellence (NICE) has issued a Medtech innovation briefing (MIB) on the use of PICO Single-Use Negative Pressure Wound Therapy (sNPWT).

The MIB reports the prophylactic use of PICO as a potentially more effective alternative to standard surgical dressings in the prevention of surgical site complications (SSCs). This is the first and only MIB published by NICE on an NPWT device for preventing SSCs.

Complications from surgical incisions are a significant economic and human burden, costing an approximate £1 billionto the NHS each year and contributing to significant morbidity and mortality in the UK and globally. A recent World Union of Wound Healing Societies consensus guidelines reports that up to 60% of surgical site infections (SSIs) are preventable2.

The prophylactic use of the PICO system is proven to be effective in reducing SSCs, including SSIs and dehiscence (wound rupturing) of the surgical incision, in patients at elevated risk of SSCs7.

The PICO dressing has a proprietary AIRLOCK™ technology that uniformly and consistently delivers NPWT across a surgical incision and the surrounding zone of injury generated naturally by the incision itself3,4. This proprietary feature is designed to help reduce the risk of wound complications by reducing postoperative fluid, swelling and associated tension around a closed surgical incision compared with standard dressings5,6. The combination of these actions helps reduce the risk of surgical wound dehiscenceand SSIs7, the 2 most common SSCs.

Evidence shows how the prophylactic use of PICO resulted in fewer complications and in earlier discharge from hospitals, reducing length of stay, on average by more than 8 days, in closed laparotomy wounds after abdominal surgery8*, which has the potential to release bed days for the NHS. In patients undergoing primary hip and knee arthroplasties, it was estimated that care with PICO enabled cost savings of more than £7,000 per high-risk patient (BMI ≥35 or ASA ≥3) compared with care with standard dressings9**.

Read more about NICE’s finding here: http://www.smith-nephew.com/PICOMIB

Ms. Pauline Whitehouse, Consultant General and Colorectal Surgeon, Worthing Hospital, said, “Following the introduction of PICO into our Trust for moderate- to high-risk incisions, we quickly noticed a significant reduction in superficial surgical site infections. We have now introduced PICO across the Trust and are seeing similar reductions in infective complications for other specialities.”

MIBs are objective information on device and diagnostic technologies to aid local decision-making by clinicians, managers and procurement professionals. They are NICE advice, designed to support NHS and social care commissioners and staff who are considering using new medical devices, and other medical or diagnostic technologies. The briefing will help avoid the need for organisations to produce similar information locally, saving staff time and resources. MIBs are commissioned by NHS England and produced in support of the NHS 5-Year Forward View, specifically as one of a number of steps that will accelerate innovation in new treatments and diagnostics.

As part of the MIB, NICE conducted a thorough review of the published and peer-reviewed data from a variety of meta-analyses and randomised controlled trials (RCTs). The effectiveness of PICO in reducing SSCs has been examined in 10 RCTs and multiple observational studies. A recently published 1,839 patient meta-analysis demonstrated the efficacy of PICO, used prophylactically, significantly reducing SSIs by 58% in closed surgical incisions compared with standard care5***.

PICO is suitable for use in both hospital and community settings, and is approved for a number of indications, including surgically closed incision sites.

“NICE MIBs are a great resource for NHS organisations and are often a reference used by healthcare systems beyond the UK. Today we are delighted to see the NICE MIB support for the prophylactic use of PICO as an effective alternative for clinicians who look to reduce their rates of surgical site complications. This will provide them with the confidence to use PICO for their at-risk patients and procedures, in support of their efforts to achieve better economic and clinical outcomes,” said Paolo Di Vincenzo, Smith & Nephew’s SVP of Advanced Wound Management. “With PICO, we are keeping Smith & Nephew at the forefront of delivering pioneering solutions that continue to improve current standards of care, by reducing the burden and delivering better clinical and economic outcomes. PICO has shown significant clinical results in reducing life-threatening infections on closed surgical incisions, which has contributed significantly to improved patient outcomes, in a cost-effective portable solution.”

Media: www.smith-nephew.com/picomib/

About Smith & Nephew

Smith & Nephew is a global medical technology business dedicated to helping healthcare professionals improve people’s lives. With leadership positions in Orthopaedic Reconstruction, Advanced Wound Management, Sports Medicine and Trauma & Extremities, Smith & Nephew has around 15,000 employees and a presence in more than 100 countries. Annual sales in 2017 were almost $4.8 billion. Smith & Nephew is a member of the FTSE100 (LSE:SN, NYSE:SNN).

For more information about Smith & Nephew, please visit our website www.smith-nephew.com, follow @SmithNephewplc on Twitter or visit SmithNephewplc on Facebook.com.

Forward-looking Statements

This document may contain forward-looking statements that may or may not prove accurate. For example, statements regarding expected revenue growth and trading margins, market trends and our product pipeline are forward-looking statements. Phrases such as “aim”, “plan”, “intend”, “anticipate”, “well-placed”, “believe”, “estimate”, “expect”, “target”, “consider” and similar expressions are generally intended to identify forward-looking statements. Forward-looking statements involve known and unknown risks, uncertainties and other important factors that could cause actual results to differ materially from what is expressed or implied by the statements. For Smith & Nephew, these factors include: economic and financial conditions in the markets we serve, especially those affecting health care providers, payers and customers; price levels for established and innovative medical devices; developments in medical technology; regulatory approvals, reimbursement decisions or other government actions; product defects or recalls or other problems with quality management systems or failure to comply with related regulations; litigation relating to patent or other claims; legal compliance risks and related investigative, remedial or enforcement actions; disruption to our supply chain or operations or those of our suppliers; competition for qualified personnel; strategic actions, including acquisitions and dispositions, our success in performing due diligence, valuing and integrating acquired businesses; disruption that may result from transactions or other changes we make in our business plans or organisation to adapt to market developments; and numerous other matters that affect us or our markets, including those of a political, economic, business, competitive or reputational nature. Please refer to the documents that Smith & Nephew has filed with the U.S. Securities and Exchange Commission under the U.S. Securities Exchange Act of 1934, as amended, including Smith & Nephew’s most recent annual report on Form 20-F, for a discussion of certain of these factors.

Any forward-looking statement is based on information available to Smith & Nephew as of the date of the statement. All written or oral forward-looking statements attributable to Smith & Nephew are qualified by this caution. Smith & Nephew does not undertake any obligation to update or revise any forward-looking statement to reflect any change in circumstances or in Smith & Nephew’s expectations.

◊ Trademark of Smith & Nephew. Certain marks registered US Patent and Trademark Office.

* 50-patient study; length of stay reduced: PICO 6.1 days; control group 14.7 days; p<0.019

** Calculations based on a 220-patient RCT

*** Meta-analysis included 10 RCT and 6 observational studies. Reduction in SSI (16 studies) included 1,839 patients (2,154 incisions); PICO 5.2%; control group 12.5%; p<0.0001. Mean reduction in hospital length of stay (8 studies included): 0.47 days; p<0.0001

References

  1. Guest J et al, Health economic burden that different wound types impose on the UK’s National Health Service. Int Wound J 2016; doi: 10.1111/iwj.12603.
  2. World Union of Wound Healing Societies (WUWHS) Consensus Document. Closed surgical incision management: understanding the role of NPWT. Wounds International, 2016.
  3. Data on File. DS/17/253/R. Project Opal PICO 7 System Stability Testing - Initial Time Point. October 2017.
  4. Malmsjö M et al. Biological effects of a disposable, canisterless Negative Pressure Wound Therapy system (invitro). Eplasty 2014; 14:e15.
  5. Selvaggi F et al., New Advances in Negative Pressure Wound Therapy (NPWT) for Surgical Wounds of Patients Affected with Crohn’s Disease. Surgical Technology International XXIV; 83- 89.
  6. Loveluck et al (2016) Biomechanical modeling of forces applied to closed incision during NPWT eplasty16e20.
  7. Strugala, V. and Martin, R. Meta-analysis of comparative trials evaluating a prophylactic single-use negative pressure wound therapy system for the prevention of surgical site complications. Surgical Infections (2017). DOI 10.1089/sur.2017.156.
  8. O’Leary, Donal Peter et al. 2017. “Prophylactic Negative Pressure Dressing Use in Closed Laparotomy Wounds Following Abdominal Operations.” Annals of Surgery. Jun 265(6): 1082-1086.
  9. Nherera LM, Trueman P, Karlakki SL. Cost-effectiveness analysis of single-use negative pressure wound therapy dressings (sNPWT) to reduce surgical site complications (SSC) in routine primary hip and knee replacements. Wound Repair Regen. April 2017. doi:10.1111/wrr.12530.

Wound Care

Diving with Disabilities - Part 3 of 3

  • Lientra Q. Lu, BS, Michael B. Strauss, MD
  • Volume 09 - Issue 3

This third article in the series on diving with disabilities is an excerpt from the extensive revision in progress of Dr. Michael Strauss and Dr. Igor Aksenov’s Diving Science textbook.

This three-part series is extracted from a chapter in the second edition of Diving Science by Michael B. Strauss, MD, et al. which covers special diving types, situations and environments. Part 3 of this series in the current issue of WCHM discusses previous medical problems of diving and provides resources for divers with handicaps.

Previous Medical Problems of Diving

Introduction  This subject has the potential to generate much discussion. The comment if “bent” (i.e. joint pain only decompression sickness) once, the second “hit” (i.e. episode of decompression sickness) will be at the same site. Data to support this comment is not known to the authors. However, there is physiological justification for decompression sickness (DCS) to target a joint that has been previously traumatized. If the trauma was severe, it is logical that scar tissue, injured muscle and healed fracture sites will have altered perfusion. This will likely influence on and offgassing during the scuba dive and make the site more vulnerable to developing gradients sufficient to cause DCS in the joint.

Residual  Disabilities and Bends Proneness If neurological disabilities remain after an episode of decompression sickness or arterial gas embolism severe enough to alter gait and/or interfere with higher brain center functions, scuba diving should not be resumed. Often times reasons for the episodes are not obvious and this raises the question, “Is the diver bends prone i.e. experienced DCS without an apparent reason?” A patent foramen ovale (see cardiovascular disabilities section of this chapter) could be considered a bends prone factor. If DCS occurs without apparent reason, disordering events, that is incidents that could have altered the offgassing of nitrogen during the dive, should be sought by a careful review of the dive history.6

Conversely, some divers appear bends resistant and do not develop symptoms of DCS even though their dives are extra-ordinary and/or exceed dive tables/dive computer guides. Coagulopathies (abnormalities of blood clotting) have not been established as a cause of DCS or conversely, a reason divers do not get “bent.” However, nitrogen bubbles in contact with endothelial surfaces (the linings of blood vessels) initiate an inflammatory reaction somewhat resembling the reperfusion injury as observed with transient interruption of the blood supply to critical organs. Hence, it is our recommendation that divers who experience decompression sickness in the 1970s, Chryssanthou proposed that smooth muscle activating factors (SMAFs) were associated with decompression sickness in laboratory animals subjected to pressurizations. He then utilized “anti” SMAFs (somewhat analogous to antiinflammatory agents), which resolved the bends symptoms. Although the information received attention and sounded enticing at the time, he was unable to obtain funding for further studies and the roles of SMAFs and anti-SMAFs “died a silent death.”18 pain only symptoms with complete resolution and an apparent deserving event is identified, should not resume scuba diving for a minimum of two weeks after the occurrence. This is the time the nitrogen bubble, endothelium inflammatory reaction would be expected to resolve. A new area of interest concerns microparticles in the blood stream which may provide a nidus for bubble enucleation.19 However, at this time, changes in ambient pressure coupled with perfusion and gradients provide the best understanding why bubbles occur in decompression sickness.20

In the 1970s, Chryssanthou proposed that smooth muscle activating factors (SMAFs) were associated with decompression sickness in laboratory animals subjected to pressurizations. He then utilized “anti” SMAFs (somewhat analogous to antiinflammatory agents), which resolved the bends symptoms. Although the information received attention and sounded enticing at the time, he was unable to obtain funding for further studies and the roles of SMAFs and anti-SMAFs “died a silent death.”18

Deserved versus Undeserved Decompression Sickness  Another consideration with regard to returning to diving is whether or not the episode of decompression was deserved (for example the diver exceeded the diving tables) or undeserved (there was no apparent violation of diving practices). If deserved and there are no residuals after hyperbaric oxygen recompression treatment, we feel it is OK to allow the diver to resume scuba diving. However, we advise the diver to wait two weeks before doing such to allow the theoretically injured endothelium from the nitrogen bubble interaction to resolve. If the DCS episode was undeserved, we hesitate to allow the patient to resume scuba diving. With the above considerations, logical advice can be made regarding return to diving or not (Table 7).

Diving with Disabilities TableTABLE 7. Return to Diving after an Episode of Decompression Sickness or Arterial Gas Embolism

Other Considerations  Injuries from marine animal encounters such as jellyfish stings and spine puncture injuries impose only temporary restrictions to diving—once the problem is resolved, the patient may return to diving. After nonfatal shark bites, motivated divers have resumed scuba diving just as surfers who experienced similar injuries have done so. The unilateral loss of hearing, especially if associated with a scuba dive, is an absolute contraindication for scuba diving as was previously discussed (see Hearing Impairments under Neuropsychiatric Disorders section ). This is because the ears are such a vulnerable structure to barotrauma associated with changes in ambient pressure. Almost all the other medical problems of diving such as nitrogen narcosis, oxygen toxicity, hypothermia, sunburn, panic and blackouts impose no or only temporary restrictions for diving once the problems are resolved.

Organizations and Agencies Dealing with Divers with Disabilities

In their goals to promote scuba diving to a broader population and demonstrate that everyone can enjoy scuba diving, many diving organizations have established programs to train and certify divers with disabilities such as paraplegia, asthma, diabetes, and epilepsy/seizures. For each type of disability, it is advisable that divers are trained and well informed about the risks in advance for their conditions. Consider the following:

Handicapped Scuba Association (HSA) has started from a research program at the University of California, Irvine in the 1970s using donated equipment from the Professional Association of Diving Instructors (PADI). Adapting curricula from both PADI and the National Association of Underwater Instructors (NAUI), HSA now has their own certification programs focusing on divers with a wide range of disabilities, including visually impaired, posttraumatic stress disorder, paraplegia, quadriplegia, and those with highfunctioning intellectual disabilities.21,22 The programs are multileveled and center on the physical challenges disabled divers must overcome under water.

Even though they did not offer suggestions for a training program for divers with asthma, the Undersea and Hyperbaric Medical Society (UHMS) created a guideline on the risks and symptoms of divers with asthma at their 1995 annual scientific meeting.23 The symposium “Are Asthmatics Fit to Dive?” concluded that divers with a history of asthma are at risk of shortness of breath, panic, arterial gas embolism and drowning. Scuba diving is OK if the asthmatic’s symptoms are intermittent, is asymptomatic at the time of the scuba dive, and does not require medications to remain such. The Divers Alert Network (DAN) reported a small increase in the risk of decompression illness but there were not enough data points to accurately assess it. Another note is that divers with active asthma (requiring medications) may be diving against medical advice but are probably doing such since their symptoms are mild.

Before 1997, people with diabetes were advised against scuba diving due to the risk of becoming hypoglycemic under water. However, with proper training and planning in advance, diabetic divers can avoid this problem. DAN has issued a diving guideline for the diabetic on their website with emphasis on the diver’s physical fitness even under hypoglycemic conditions (in which some people are prone to seizures, lack of coordination, or impaired judgment).24 PADI as well as Scuba Schools International (SSI) also include the education and preparation for people with diabetes in their normal open-water diving certificates.

It is almost uniformly agreed that patients with epilepsy not scuba dive.25,26 However, epilepsy has many presentations, and some might not adversely affect the ability to scuba dive safely. In the United Kingdom, the Sport Diving Medical Committee requires people with epilepsy to be seizure-free and off of their medications for at least 5 years before diving. In the United States, scuba diving is considered the same as driving in terms of limitations and they vary from state to state, ranging from 6 months to a year’s restriction and 5 years off of their medications according to DAN. Most of the divers also need a “sign-off” from their doctors, who should be familiar with diving medicine as well as the patients’ medical conditions.

Conclusions

Certainly, the discussion of every possible disorder that can be considered a disability for scuba diving cannot be included in this chapter. Two thousand plus pages of medical and surgical textbooks include countless disorders that contraindicate scuba diving. Common sense needs to be used in making recommendations when patients with conditions other than those mentioned in this chapter occur in patients who would like to scuba dive. On one end of the spectrum there are dermatological conditions that temporarily prevent or minimally limited restrictions for scuba diving. In the middle are conditions like celiac disease and Crohn’s disease where relative contraindications to scuba diving can usually be mitigated. At the other end of the spectrum are decompensating conditions like liver failure, end-stage kidney disease, critical limb ischemia, advanced cancers and major wounds that are incompatible with scuba diving. This chapter, we believe, includes the 99 percent of disabilities and handicaps that are likely to be encountered in those who want to engage in scuba diving activities.

Myths and Misconceptions about Scuba Diver Disabilities and Handicaps

Myth  Handicaps and disabilities are essentially the same thing

Facts  Although closely related terms, handicaps usually refer to disorders that limit a particular activity while a disability is more a legal term that the problem prevents usual and customary activities. Disabilities are often rated by percentages determined by how much the patient is incapacitated. The American Disabilities Act (ADA) specifies what accommodations employers as well as new construction must make to accommodate those patients with handicaps. Education, assistive devices and therapy are typical interventions used to mitigate handicaps.


Myth  Patients who have had heart attacks should not scuba dive

Fact  A heart attack is not an absolute contraindication for scuba diving. Considerations of how much heart damage, if any, occurred, whether or not the heart muscle has been revascularized, and the patient’s exercise potential determine if the patient has enough cardiac reserve to scuba dive without undue risk. Likewise, low demand scuba dives such as in warm water, with absence of currents, diving off of boats with descending lines, and good visibility should be selected as the diving venues for such divers.


Myth  A diabetic who has experienced a hypoglycemic episode should not scuba dive

Fact  The more important consideration is the stability of the diabetic’s blood sugars. If labile, scuba diving should not be done. However, if stable and the diver is knowledgeable about his/her disease, performs blood glucose testing immediately before and after a scuba dive, carries an emergency supply of a high sugar content item on the dive, and plans the dive to reduce energy expenditures and stresses, scuba diving without undue risks is possible.


Myth  It is unfair not to allow a patient with a history of adult-occurring seizures to scuba dive.

Fact  Fairness is not the question! The risks of seizure occurring while on a scuba dive is compounded by the stresses of increased ambient pressures, Valsalva maneuvers to clear the ears, increased oxygen partial pressures as the diver descends, and energy demands to meet emergencies. The history of seizure disorder in contrast to asthma and diabetes is the one relative common condition that essentially all diving authorities consider a contraindication to scuba diving.


Myth  The respiratory system and especially the alveoli are the ultimate “fast” tissue with respect to on and offgassing with changes in ambient pressure and correspondingly present no contraindications for scuba diving

Fact  While the first part of the myth is true, respiratory conditions that interfere with the effectiveness of gas exchange in the alveoli such as asthma, emphysema, atelectasis (collapse of lung alveoli), pulmonary fibrosis and lung cancer must be considered before allowing a patient with problems of this type to scuba dive. Some such as asthma prevent relative contraindications while a spontaneous pneumothorax is a temporary (up to 5 years) contraindication. In addition, with explosive decompressions, the offgassing of gas in the alveoli may be overwhelmed with bubble formation in these structures leading to the life and death problem of lung decompression sickness, referred to as the chokes.


Myth  Once a diver has experienced decompression sickness without violation of the dive computer or diving tables, he/she should not be allowed to scuba dive again

Fact  Several considerations must be given to this myth. First, are there residual problems such as neurological deficits that persist after the hyperbaric oxygen recompression treatment? Second, can disordering events to offgassing be identified during the ascent phase of the dive? If there are no residuals and disordering events, for example, dehydration, interference with offgassing due to keeping an extremity in the cramped position, or a patent foramen (PFO) identified, scuba diving may be resumed after the diver is educated about the problem, and in the case of the PFO, corrected.

Reference

  1. Strauss MB, Aksenov IV, Miller SS. Making the scoring of wounds objective: adding rhyme and reason to wound evaluation and management. Wound Care Hyperbaric Med. 2012;3(1):21-37.
  2. Schipke JD, Pelzer M. Effect of immersion, submersion, and scuba diving on heart rate variability. Br J Sports Med. 2001 Jun;35(3):174-80.
  3. Pollock NW, Natoli MJ. Aerobic fitness of certified divers volunteering for laboratory diving research studies. Undersea Hyperb Med. 2009; July/Aug; 303-304; abstract.
  4. Bove AA. Cardiovascular disorders and diving. In: Bove and Davis’ Diving Medicine. 2004; Elsevier Inc.:493.
  5. Moon RE, Rorem J. Patent Foramen Ovale. DiversAlertNetwork.org. Copyright March/April 1995.
  6. Strauss MB, Lu LQ, Miller SS. Gradient perfusion model part 2: substantiation of the GPM with clinical cases. UHM; 2018; 45(3):297-305.
  7. Lafay V, Trigano JA, Gardette B, Micoli C, Carre F. Effects of hyperbaric exposures on cardiac pacemakers. Br J Sports Med. 2008 Mar;42(3):212-6; discussion 216. Epub 2007 Sep 3.
  8. Pollock NW, Uguccioni DM, Dear GdeL. Diabetes and recreational diving: guidelines for the future. Diving Hyperb Med. 2006; 36(1): 29-34.
  9. Dear GL, Pollock NW, Uguccioni DM, Dovenbarger J, Feinglos MN, Moon RE. Plasma glucose response to recreational diving in divers with insulin-requiring diabetes. Undersea Hyperb Med. 2004; 31(3): 291-301).
  10. Dembert ML, Jekel JF, Mooney LW. Weight/height indices and percent body fat among U.S. Navy divers. Aviat Space Environ Med 1984 May;55(5):391-5).
  11. Davis JC (ed). The Return to Active Diving After Decompression Sickness or Arterial Gas Embolism. Proceedings of a Symposium held 28 May 1980. UHMS Publication Number 41(CW)11-13-80. Bethesda: Undersea and Hyperbaric Medical Society; 1980; 42 pages.
  12. Vezzani G, Bosco G, Camporesi EM. Hyperbaric oxygen treatment of avascular bone necrosis of the femoral head. In: Hyperbaric Oxygen Therapy, 863-880. https:\\www.NCBI.NLM.NIH.GOV\PUBMED\20637561. July 2010.
  13. Butler Jr. FK. Diving and hyperbaric ophthalmology. Surv Ophthalmol. 1995 Mar-Apr;39(5):347-66.
  14. Zizola F. Blind Scuba Divers. noorimages.com/feature/blind-scuba-divers/
  15. Kay A. Scuba Diving: A soothing adventure. Autism Parenting Magazine. June 2015. https://www.autismparentingmagazine.com/scubadiving-a-soothing-adventure/
  16. Brook K. 7 amazing benefits of overcoming PTSD with scuba diving. www.aquajunkies.com/overcome-ptsdwith-scuba-diving/
  17. Asthma PDR Medical Dictionary, 3rd Eds, Lippincott Williams & Wilkins, Baltimore, 2006, p. 170.
  18. Chryssanthou C, Teichner F, Antopol W. Studies on dysbarism. IV. Production and prevention of decompression sickness in non-susceptible” animals. 1971. Aerosp Med; 42(8):864-867.
  19. Thom, S. R., Bennett, M., Banham, N. D., Chin, W., Blake, D. F., Rosen, A., et al. (2015). Association of microparticles and neutrophil activation with decompression sickness. J. Appl. Physiol. 119, 427–434.doi: 10.1152/japplphysiol.00380.2015
  20. Strauss MB, Miller SS, Lu LQ. The gradient perfusion model part 1: why and at what sites decompression sickness can occur. UHM, 2008; 45(3):287-295.
  21. Davis C. Scuba Diving with a Disability.Deeper Blue. September 2016. www.deeperblue.com/scuba-diving-disability/
  22. Handicapped Scuba Association. https://www.hsascuba.com/
  23. De Lisle Dear G. Asthma & Diving. DiversAlert Network. Accessed February 2018.www.diversalertnetwork.org/medical/articles/Asthma_Diving
  24. Novak B. Scuba Diving with Type 1Diabetes – You can do it! Beyond Type 1.July 2015. beyondtype1.org/scuba-divingwith-type-1-diabetes-you-can-do-it/
  25. Sawatzky D. Epilepsy/Seizures and Diving.Diver Magazine. January 2012. divermag.com/epilepsyseizures-and-diving/
  26. Cronje F. Epilepsy and Diving: why it is not a good idea to combine the two. Divers Alert Network. Accessed February 2018. www.diversalertnetwork.org/medical/articles/Epilepsy_and_Diving_Why_It39s_Not_A_Good_Idea_to_Combine_the_Two

About the Authors

Michael-Strauss
Michael Strauss, M.D., an orthopaedic surgeon, is the retired medical director of the Hyperbaric Medicine Program at Long Beach Memorial Medical Center in Long Beach, California. He continues to be clinically active in the program and focuses his orthopaedic surgical practice on evaluation, management and prevention of challenging wounds. Dr. Strauss is a clinical professor of orthopaedic surgery at the University of California, Irvine, and the orthopaedic consultant for the Prevention-Amputation Veterans Everywhere (PAVE) Problem Wound Clinic at the VA Medical Center in Long Beach. He is well known to readers of WCHM from his multiple articles related to wounds and diving medicine published in previous editions of the journal. In addition, he has authored two highly acclaimed texts, Diving Science and MasterMinding Wounds. Dr. Strauss is actively studying the reliability and validity of the innovative, user-friendly Long Beach Wound Score, for which he already has authored a number of publications.
 

Lientra-Lu
LIENTRA LU is a research coordinator at the VA Medical Center in Long Beach, California, under the guidance of Dr. Ian Gordon, a vascular surgeon, and Dr. Michael Strauss. She is also an administrative assistant in the accounting department of the Southern California Institute for Research and Education (SCIRE). She received a bachelor of science degree in chemical biology at the University of California, Berkeley, in 2015 and subsequently has taken medically related courses at the University of California, Los Angeles. Miss Lu is helping with diabetic foot and venous leg ulcer studies at the VA Medical Center while also serving as an assistant in patient care at the PAVE Clinic there. She also works with the American Red Cross in her other interest, disaster preparedness.
 

Dive Medicine

Risk Management Analysis

  • Jolene E. Cormier, BSN, RN, EMT-P, CHRN, CHT
  • Volume 09 - Issue 3

Risk Management is defined by ISO 14971 as “the systematic application of management policies, procedures, and practices to the tasks of analyzing, evaluating and controlling risk” (Schmidt). The purpose of risk management is to identify risks, take steps to mitigate them, and evaluate whether the actions had the intended outcome. ISO 14971 (Schmidt) lists three steps to the risk management process:

  1. Risk analysis – identifying hazards associated with a device, a procedure, or activity.
  2. Risk evaluation – assess the probability of the hazard occurring and the severity or impact of the consequence. Probability and severity can be scored using a lowmedium-high determination. A sample matrix can be found in the NFPA 99 Handbook (2015, p.74).
  3. Risk control – methods for mitigating the risk which can include redesigning a system or process, staff training or protective measures

Redesigning a process or system (inherent safety) is considered the most effective for controlling risk, while a focus on training is considered the least. Some risks can be eliminated (adding an item to the No Go list prevents risks associated with that item); however, often risks cannot be completely eliminated. As stated by Schmidt, “safety means the freedom from unacceptable risk.”

There are two risk analysis methods, retrospective and prospective, based on whether the process is being completed proactively or reactively. If an incident has already occurred a retrospective risk analysis is used to evaluate the cause or causes of the error and try to prevent reoccurrence. A prospective risk analysis attempts to identify possible risks and tries to reduce or eliminate them before an occurrence. In a perfect world all risk analysis would be proactive: In reality both techniques are subject to biases that can affect quality or accuracy. Bias constitutes a “pre-conceived preference or inclination that has the potential to affect the impartiality of evaluations or decisions” and can result in risks being overlooked or prematurely dismissed (Peacos). Different forms of bias that can affect risk management include: 1) team assembly (individuals with a similar mindset or not including someone who is not affected by the outcome); 2) not considering risks from supporting systems; 3) resistance to change. A hospital system’s internal resources (risk management, environment of care, safety, and infection control) can qualify as team members not affected by the outcome and of a different mindset. Risk analysis expert Paul Baybutt recommends having a devil’s advocate on the assessment team to combat the effects of cognitive biases, someone willing to challenge your views to help determine their validity.

Prospective risk management techniques are often used when evaluating or modifying equipment for the hyperbaric environment; however, this process can be applied throughout the hyperbaric department. It is important to have a systematic method for completing any risk assessment so none of the items or steps that may be required are missed or forgotten. These items/steps may include: identifying the hazard, the probability and severity matrix used, infection control, fire risk, consulting external or internal resources, relevant information/literature review, training and documentation of the process.

Before I lose anyone, the key word is may; not all of these items will be necessary, depending on what is being considered or assessed, and the time commitment depends on the project and the key players (or resources) that need to be involved. An expertise in risk analysis is not necessary; literature reviews, consulting resources, and assembling a diverse team can help ensure everything addressed. Documentation may not need to be extensive but having a record trail is important, as it can serve as a template for future assessments and provide justification for the end result.

To illustrate how quickly and easily some risk assessments can be completed and documented, following are two examples of completed prospective risk analyses that resulted in a change in practice and/or policy.

PROSPECTIVE RISK ANALYSIS FOR ALCOHOL FOAM IN THE HYPERBARIC ROOM
Problem: Alcohol foam was automatically installed outside and inside the hyperbaric chamber room due to hospital policy. There were case reports of fires due to ignition of alcohol gel/foam, with increased fire risk in a hyperbaric environment. However, alcohol foams reduce the spread of health-care associated infections.
Probability: Low. Few cases have been reported, and alcohol evaporates quickly. Ignition sources are kept out of the monoplace chamber, and patient grounding is checked before each treatment.
Severity: 1. Fire in the monoplace chamber – high due to mortality rate; all previous incidences have proven fatal. 2. Spread of hospital-acquired infections – low due to the presence of an effective alternate. A sink with soap is located in the hyperbaric room.
Internal Resources: Infection control manager and environment of care (EOC) safety officer. An email was sent to the internal resources identified with copies of the case report found. Responses were sent by the end of the day, and engineering removed the alcohol foam. The change was discussed among the hyperbaric team.
 
PROSPECTIVE RISK ANALYSIS FOR DEFIBRILLATION IMMEDIATELY OUTSIDE A MONOPLACE CHAMBER
Problem: The risk of fire due to arcing during defibrillation immediately outside a monoplace environment. The patient and associated linens are oxygen-enriched after they are removed from a monoplace chamber, which is pressurized with 100% oxygen
Probability: Low. Fires have been reported during defibrillation in an oxygen-enriched atmosphere (OEA) when oxygen is flowing directly across the patient’s chest, and when paddles are used for defibrillation. Our facility has an AED, which uses pads. Also, cold oxygen is heavier than air and will fall to the floor within 30 seconds. Patient covering and scrub top/gown will need to be removed, resulting further in oxygen dissipation from around patient.
Severity: 1. Fire – high. Fire can result in patient death and staff death or injury. 2. Patient death due to cardiac arrest and delayed defibrillation – high. Immediate early defibrillation and chest compressions are shown to improve survival for patients in cardiac arrest.
Clinic Conclusion: As long as adhesive pads are used, not paddles, it is unnecessary to move the stretcher away from the chamber for defibrillation. The risk of death due to delayed defibrillation is greater than the risk of fire due to arcing in these circumstances. As long as pads are used with AED it is unnecessary to delay defibrillation in patients who have had an apparent cardiac arrest inside the monoplace chamber once they are removed from the chamber.
Internal Resources: Clinic medical director, policy committee to review changes. After being approved by the hyperbaric team and medical director, the new policy was presented to the policy committee, education provided to staff and safety drills updated to reflect the change in procedure.
REFERENCES
ECRI Institute. Fires from defibrillation during oxygen administration. Health Devices. July 1994; 23(7): 307-308.
ECRI Institute. Defibrillation in oxygen-enriched environments. Health Devices. Mar-Apr 1987; 16(3-4): 113.
Garcia JR. Management of the critically ill patient in a hyperbaric setting: nursing considerations and preventions. In LarsonLohr V. Editor, Hyperbaric Nursing and Wound Care. 2010; 83-108. Flagstaff, AZ: Best Publishing Company.
Sunde K, et al. Part 6: Defibrillation: 2010 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science with Treatment Recommendations. Resuscitation 2010; 81:e71–e85. DOI: 10.1016/j. resuscitation.2010.08.025
Theodorou AA, Gutierrez JA, Berg RA. Fire attributable to a defibrillation attempt in a neonate. Pediatrics. 2003; 112(3). Whelan HT, Kindwall EP. Hyperbaric Medicine Practice. 4th edition. 2017. North Palm Beach, FL: Best Publishing Company.

Special thanks to devil’s advocate Jane Ahlstrom, CHT.

References

Baybutt P. Cognitive biases in process hazard analysis. J Loss Prev Proc Ind. 2016; 43: 372-377.

Peacos P. Bias: The hidden danger to your risk assessment. 2016. Am Pharm Rev. Retrieved from: https://www.americanpharmaceuticalreview.com/Featured-Articles/184365-Bias-The-Hidden-Danger-to-Your-Risk-Assessment/

Schmidt B. (201). Prospective risk management. Patient Safety and Quality Healthcare. 2010. Retrieved from: https://www.psqh.com/analysis/prospective-risk-management/

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About the Author

Jolene-E-Cormier
JOLENE E. CORMIER, BSN, RN, EMT-P, CHRN, CHT is senior director at large with the BNA and a volunteer on the UHMS safety committee. The views expressed in this article are her own and not the formal opinion of either of these organizations. She can be reached at This email address is being protected from spambots. You need JavaScript enabled to view it..
 

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