Ask the Experts: What is the Current Perspective Regarding Supervision of Hyperbaric Dives by Nurse Practitioners?
Question: “I would be interested in the current perspective regarding supervision of hyperbaric dives by nurse practitioners.
- Is it safe?
- What preparation for supervision is appropriate?
- How many centers across the nation are using NPs?
- What are the pros and cons to having an NP supervise dives?
Other policy or procedure recommendations for NP supervision of dives.”
Question from Carol, BSN, RN and student of Wound Care Education Partners.
Our Experts Offer the Following Answers:
Question 1. Is it safe?
Answer. It is safe with appropriate preparation. As with other disciplines within medicine that utilize nurse practitioners and physician assistants, the provision of safe care is a function of proper training and sufficient supervision. The UHMS (Undersea and Hyperbaric Medical Society) and the National Board of Diving and Hyperbaric Medical Technology (NBDHMT) consider mid-level practitioners qualified to safely supervise Hyperbaric Oxygen Therapy (HBOT) so long as those criteria are met (see position statements below).
Question 2. What preparation for supervision is appropriate?
Answer. The UHMS position statement provides the following information:
The Non-Physician provider specific recommendations:
a) The UHMS supports the on-site supervision of hyperbaric oxygen therapy by a nurse practitioner or physician assistant if each of the following conditions is met:
i. The supervising physician meets the UHMS recommendations for physician attendance as per UHMS guidelines.
ii. The supervising physician is immediately available to the Hyperbaric Medicine Department as specified by applicable government regulations.
iii. The nurse practitioner or physician assistant has obtained appropriate specialty certification through the NBDHMT as a Certified Hyperbaric Registered Nurse (CHRN) or Certified Hyperbaric Technologist (CHT), or international equivalent.
The NBDHMT position statement provides the following information:
a) HBO must be directly supervised by a physician (or 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 face-to-face classroom versus online setting. Such supervision should extend to:
a. Assessment of suitability for HBO therapy
b. Determination of risk benefit profile
c. Interpretation of any related diagnostic testing
d. Generation of a therapeutic dosing profile
e. Evaluation of subsequent clinical course, and
f. 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 his/her 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 as 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.
Question 3. How many centers across the nation are using NPs?
Answer. At this time, there are only a few.
Question 4. What are the pros and cons to having an NP supervise dives?
Answer. As with many pro/con discussions, the determination of which elements fit into a given category hinges largely on one’s perspective. Any substantive answer must acknowledge the parties represented in this discussion, which include: patients, mid-level providers, physicians, and administration. Each group will see this topic through a unique lens and there are opinions that won’t be represented here. The points made below are not listed as pro or con for those reasons.
Patient: Some may prefer physician-level supervision, but there shouldn’t be any difference in the actual treatment provided.
There are no cost savings to the patient subsequent to having mid-levels supervise HBOT.
Mid-level: Enjoyment of engaging in hyperbaric medicine, expanded scope of practice, potential for additional income.
Physician: Potential for reduced work hours and revenue loss due to less time working in HBO, increased requirement for direct supervision of mid-levels and immediate availability. Responsibility for mid-levels requires additional work and liability which are frequently not associated with added compensation.
Administration: Potential for greater scheduling flexibility as more people can supervise treatments. Mid-levels are paid less but physician supervision and immediate access may offset these overhead reductions.
Question 5. Other policy or procedure recommendations for NP supervision of dives.
Answer. One recommendation is to include a nurse practitioner job description per NP scope of practice guidelines. In addition to broadening the scope of practice, hyperbaric specific training, experience, and competency standards are necessary for credentialing purposes within a healthcare facility. While stand alone wound care centers may not require that level of documentation, proof of training and experience is part of the UHMS and NBDHMT position statements.
References: Expert answers provided by Laura Josefsen, RN and Nick Bird, MD, MMM
This article was previously published in Wound Care & Hyperbaric Medicine magazine Volume 5 Issue 1.