Setting nursing standards in hyperbaric oxygen therapy L. Stables and J. Tarry
This articles focuses on work undertaken as part of a Standards of Care initiative in a Kegional Hyperbaric Oxygen Unit in the North of England. The historical development of Hyperbaric Oxygen Therapy, possible clinical applications, and aspects of administration are reviewed. An example of one of the series of nursing standards derived is included together with the patient information sheet and evaluation questionnaire given to patients at the conclusion of the treatment. It is concluded that writing and monitoring Standards of Care can be a very effective quality assurance strategy at unit level.
WHAT IS HYPERBARIC OXYGEN THERAPY? Hyperbaric oxygen therapy (HBO) is an intermittent non-invasive therapy involving the use of barometric pressure greater than that at sea level. The patient breathes 100% oxygen whilst in a ‘monoplace hyperbaric chamber’ pressurised to greater than normal atmospheric pressure (H yox Systems Ltd 1988) - one atmosphere = 706mmHg pressure. The therapy works by elevating the plasma oxygen level in proportion to the partial pressure of inspired oxygen (Henry’s Law). At 3 ATA the amount of oxygen in plasma is increased to approximately 6% vol. (6mls oxygen per 100mls blood.) The
(Staff nurse) L. St&k RGN, (Sister) J. Tarry SRN, RFN, SCM (Clinical Nurse Specialist), High Dependency and Regional Hyperbaric Medicine Unit, Monsall Hospital, North Manchester Health Authority, Newton Heath, Manchester Ml0 8WR (Requests for offprints to LS) Manuscript
accepted 6 November
of oxygen the same.
HISTORICAL ASPECTS Interest in hyperbaric therapy was noted in antiquity. According to Aristotle, Alexander the Great used a diving bell at the Battle of Tyre in
332 BC (Fischer, Jain, Brown & Lehrl, 1988). More recently studies carried out in the 1930s were concerned with treating decompression sickness and reducing decompression times after diving. The use of oxygen at different pressures in aviation and space travel was explored by physicians and scientists involved in the support of sub-sea and space activities in the 1950s and 1960s. Its application to modern medicine was delayed due to a lack of suitable equipment. Clinical hyperbaric oxygen therapy had its foundation in the 1950s with the work of Boerema Brummelkamp and others at the University of Amsterdam. It was complemented by the work of Illingworth and others in Glasgow. 17
There is considerable debate in scientific circles as to the efficacy of hyperbaric oxygen therapy for various medical conditions. A large descriptive study by Ellis and Mandal (1983) reported results based on 87 patients with anaerobic infections who received hyperbaric oxygen therapy. Whilst the authors considered that their findings provided evidence of the advantages of hyperbaric oxygen therapy in this patient group they acknowledged that there was a need for a large controlled study to establish scientific proof. Gabb and Kobin (1987) also commented on the need for more conclusive evidence for hyperbaric oxygen therapy, based on clinical trials. Decompression sickness is the only disorder for which the benefits of hyperbaric oxygen therapy have actually been proven scientifically (Tobin, 1989). Kesearch into this treatment is complicated by a number of factors: Firstly, as with other research involving human subjects, there is the difficulty of establishing control and experimental groups which are equally matched for all major characteristics hyperbaric oxygen (variables). Secondly, therapy is often viewed as a last resort after all other forms of treatment have failed, thus further increasing the potential number of intervening variables which may influence results. Thirdly the potential population for such studies is limited.
CLINICAL APPLICATIONS Hyperbaric oxygen therapy has been used in the treatment of decompression sickness, air and gas embolisms (actimomycosis), acute cyanide poisoning, acute smoke inhalation and carbon monoxide poisoning. (The use of HBO therapy in carbon monoxide poisoning was reported in Myers, Snyder, Linberg & Cowley, 1981.) Hyox Systems Limited (1988) cited further possible applications for hyperbaric oxygen therapy: anaerobic infections, arterial insufficiency, bone grafts, chronic osteomyelitis, osteoradiation and soft tissue necrosis, skin grafts or flaps with compromised circulation,
necrotising soft tissue infections, peripheral vascular disorders, ulcers (decubitus, diabetic, venous stasis and arterial insufficiency) and to promote wound healing. However controlled studies are necessary to establish the benefits of hyperbaric oxygen therapy for patients with these conditions (Tobin, 1989). Whilst hyperbaric oxygen therapy has been widely used in the USA and other countries for the treatment of anaerobic infections, this has not been the case in the United Kingdom (UK). Indeed surgery remains the preferred treatment for Clostridium Welchii infections in the UK (British Medical Journal 1978).
ADMINISTRATION OF HYPERBARIC OXYGEN THERAPY Organisation of treatment sessions in the Regional Hyperbaric Oxygen Therapy Unit Hyperbaric oxygen therapy sessions are administered on a sessional basis, from one session only to treat carbon monoxide poisoning or decompression sickness for example, to an extended course of therapy over many weeks. An example of patients requiring long term treatment would be those with osteoradiation necrosis. An acutely ill patient with severe tissue necrosis or gas gangrene requires intensive therapy. This entails 4 sessions in each 24 h period. The maximum time permissible in a single-person chamber is 2 h; the patient spends 4 h out of the chamber between sessions. It is during these limited periods, i.e. 4 h, that the patient is accessible for care and treatment from the multidisciplinary team. For this category of patient the average total number of hours of therapy is 14-18h (see Fig. 1).
Patient preparation and care during therapy in the regional hyperbaric oxygen therapy unit Prior to commencement of hyperbaric oxygen therapy it is essential that the patient is prepared
Diagnosis: Osteo Radiation Necrosis NAME:
John Brown l-
Fig. 1 Patient treatment
both physically and emotionally, and also informed about possible side effects of therapy. During administration of the therapy the patient is constantly supervised by a qualified nurse. Communication is made possible by the provision of an intercom system. Relatives/friends are encouraged to be in the hyperbaric treatment room with the supervising nurse whilst the patient is undergoing therapy (if the patient so wishes). Usually this helps to allay fears and anxiety. In the interests of safety the patient is provided with cotton clothing and asked to remove spectacles, dentures and jewellery, but rings can be worn if they are covered with tape. These precautions minimise the risk of damage to the chamber canopy by scratching of the surface, and reduce the risk of friction and static charges which could lead to fire (clearly this environment enriched with oxygen is a potential fire hazard). An emergency button is provided to enable
rapid access to the patient; decompression then occurs in 30 s. There is a degree of confinement due to the size of chamber (as illustrated in Fig. 2), and so it is important that the patient is comfortably positioned before entering the chamber. Claustrophobia may be a problem for some patients (Tobin, 1989).
Fig. 2 A patient receiving hyperbaric oxygen therapy
Systems Ltd ‘99 - Hyperbaric
process and outcome criteria
- keeps accurate records of care given and signs at the time.
- gives patient care based upon the assessment.
Fig. 3 An example of the nursing standards written,
Devised by L Stables & J Tarry
ensures that the patient/relatives understand the information by giving them the opportunity to have points clarified.
- discusses the HBO procedure patient and relatives.
- together with the patient, designs a care plan, based upon the assessed needs.
Fischer B. et al. 1999 - Handbook of Hyperbaric
Each patient undergoing therapy has a therapy record card and completed prescription card. Legally valid consent to treatment obtained from patient prior to procedure by Medical Officer.
- has access to: (i) relevant reference materials** (ii) existing regimes of therapy
can state the safety aspects such as: (i) pre-check of equipment before use (ii) the need for the patient to remove spectacles, false teeth and jewellery and to wear cotton clothing.
The allocated nurse: - assesses the physical and emotional needs of the patient, using a specific nursing tool.
The allocated nurse: - has knowledge of the principles of HBO - is assessed as competent by the sister in charge or her deputy, in the management of (i) patient care during HBO (ii) the equipment used - assesses the patient’s need for analgesics/ anxiolytics to help allay fear and to control any pain and reports to medical staff.
prior to the
- the patient reports that his/her discomfort and/or pain is within a range he/she can tolerate prior to commencing HBO
- the patient reports that his/her anxiety levels are within a range he/she can cope with, prior to entering treatment.
ensures that the patient/and/or relatives are able to state the main features of HBO and side effects.
- documents care given in the nursing care plan and signs at the time.
The allocated nurse: - carries out care according to the patient’s assessed physical and emotional needs, as identified in the nursing care plan.
oxygen therapy as in-patientlout-patient
Each patient undergoing Hyperbaric Oxygen Therapy (HBO) and his/her close relatives, treatment from a qualified competent nurse who is experienced in HBO
North west regional hyperbaric
of a patient for the administration
INTENSIVE AND CRITICAL CARE NURSING
The trained nursing staff want to ensure that patients are adequately Therapy. This questionnaire
prepared to undergo Hyperbaric
is designed to help us, to achieve this aim.
1. Did Your nurse introduce herself? 2. Do You feel that you and your family were given sufficient information about the chamber? 3. Did You understand the information? 4. Did you feel adequately prepared? 5. Did we help to overcome or reduce any fears that you may have had before your treatment started? 6. Did you suffer any discomfort? Were you made aware that this might happen?
PLEASE COMPLETE THIS QUESTIONNAIRE
AFTER YOUR FIRST SESSION
THANK YOU Devised by L Stables 81 J Tarry, Jan 1990 Fig. 4 Patient satisfaction questionnaire
The temperature raised
within the chamber
by the patient’s
heat, but is regulated
by the use of the cooling
in their study and this was linked with
in two patients.
In the same study Ellis and Mandal found that 43% of patients experienced
Other possible effects of hyperbaric oxygen therapy
and in 5 cases this necessitated of
During the period of compression a common problem experienced by the patient is minor, or even major, This
and/or pain in the ears.
is due to the changes
to the effects
in pressure people
this the patient
asked to follow the instructions given before therapy; to swallow hard until relief is obtained.
in 28% of
recorded by Ellis and Mandal(l983) were dyspnoea (18% of patients in the study), and neurological disturbances including Grand Ma1 seizures and other symptoms such as parasthesiae occurred in a total of 8 patients, Neurologic complications may be related to problems
toxicity (Tobin, 1989). It can be seen from the information
INTENSIVE AND CRITICAL CARE NURSING
far that it is necessary to have highly motivated and competent staff with the knowledge, technical skills and organisational ability to deliver quality care. A series of Nursing Standards have now been devised; the first on the preparation of patients for daily or twice daily therapy is included in this paper (Fig. 3). Subsequent
standards focus on the preparation of patients for the administration of intensive hyperbaric oxygen therapy, the care of patients during therapy (non-intensive therapy and intensive therapy), and post-therapy care (non-intensive and intensive therapy).
CONCLUSION When critically ill patients receive HBO which entails additional hazards, the provision of high quality nursing is vitally important. Kecognising the need to formulate and write standards of care for hyperbaric oxygen therapy patients, to aid in achieving high quality care consistently, resulted in this first attempt. Whilst the process proved to be more complex than was initially anticipated there have been a number of benefits. Through devising written standards it has been possible to agree and make explicit the care that is given in a more formal system than previously existed, (although there has always been access to technical manuals and expert medical and nursing advice and supervision). The authors would agree with Harris (1990): . . . every experienced nurse has her own internalised standards which allow her to judge whether care is satisfactory or falling short - we have always done this and indeed set ourselves high standards’. But by using written standards and tools such as the patient satisfaction questionnaire (Fig. 4) it is now possible to monitor standards of care, an important element in the present health care climate; and finally, written standards of care can be used for education purposes especially for new staff during their period of orientation to this specialised area of nursing.
Thanks to Margaret Coulter (formerly Clinical Nurse Specialist, Medical Acute Unit/Clinical Lecturer, North Manchester General Hospital and Department of Nursing, University of Manchester) for help during the draft stage of this article.
Bass B H I970 The treatment of varicose leg ulcers by hyperbaric oxygen. Postgraduate MedicalJournal. 46: 407-408 Department of Health I989 A strategy .,I for nursing.., DOH, London Donabedian A 1966 Evaluating the quality of medical care. Millbank Memorial Fund Quarterly. 44 (2): 166-206 Glassburn J K, Brady L W 1977 Treatment of necrotic wounds with hyperbaric oxygen, 6th International Coneress On Hvnerbaric Medicine. Aberdeen University Press,‘Aberdeen, pp 279-285 Hart G B, Lamb R C, Strauss M B 1983 Gas gangrene: a collective review. Journal of Trauma 23, (I I): 99lIO00 Kitson A IYSX Raising the standards. Nursing Times 84 (25): 28-32 Kitson A et al I YSY Standards of care - a framework for quality. Scutari Press, KCN London Northwest Regional Health Authority 1989 Standards for nursing services. Nursing Department Rowden R I990 Setting standards - quality of care. Nursing Times 86 (8): 29-30 Royal College of Nursing 1980 Standards of nursing care. RCN London Schofield J 1990 Practical standards. Nursing Times 86 (8): 3 l-32 Thompson H 1989 How to set standards. Nursing Standard 3 (26): 39
References BMJ 1978 Hyperbaric oxygen. British Medical Journal 6119: 1012 Ellis M E, Mandal U K 1983 Hyperbaric oxygen trealment: IO years experience of a regional infectious diseases unit. Journal of Infection 6: 17-28 Fischer B, .Jain K K, Brau E, Lehrl S 1988 Handbook of Hyperbaric Oxygen Therapy. Springer-Verlag, Berlin Gabb G, Robin E D 1987 Risk-benefit analysis in chest medicine. Hyperbaric oxygen. A therapy in search of diseases. Chest 92 (6): 1074-I 082 Harris L 1990 Quality assurance makes sense. Nursing Times 86 (6): 32-33 Hyox Systems Limited 1988 Hyperbaric oxygen therapy systems Myers R A M, Snyder S K, Linberg S, Cowley A I98 I Value of hyperbaric oxygen in suspected carbon monoxide poisoning. JAMA 246 (2 I): 2478-2480 Tobin M J 1989 Essentials of critical care medicine. Churchill Livingstone, Edinburgh.
Appendix Information sheet for hyperabric oxygen therapy patients and relatives This sheet is designed to assist in answering any questions you may have in connection with your hyperbaric oxygen therapy. You will have had an opportunity to look at the chamber and discuss its effects with a member of the nursing staff. The chamber may not have the same effects on every patient, but below are some answers which may help to allay any fears that you may have. Please discuss with the nursing staff, if you have any further questions or worries. 1. What is hyperbaric oxygen therapy? It is a means of enabling you to breathe 100% oxygen in a pressurised chamber. It assists in the treatment of certain illnesses. 2. How long has this sort of treatment been used? There has been a steady increase in the use of hyperbaric oxygen therapy since the early 1950s. 3. How does it work? Hyperbaric oxygen therapy raises oxygen delivery to the tissues of the body, which in turn assists in the control and elimination of certain infections, circulatory problems and many other conditions. 4. What kind of preparation can I expect? In the interests of safety, you will be asked to wear cotton clothing, remove spectacles, dentures and jewellery; your wedding ring can be covered with tape during your treatment. If you wish, reading material and a drink can be taken into the chamber. It is advisable that you visit the lavatory prior to your treatment.
5. What can I expect when inside the chamber? A member of the nursing staff will remain with you throughout your treatment. An intercom system is available to allow you to communicate with staff, relatives and your friends. Alternatively a radio or television can be provided. Owing to the changing pressures in the chamber, at the beginning of the session you may experience some discomfort in your ears, similar to the effects of taking off in an aeroplane. This can be relieved by swallowing hard. Because of the restricted space, you may find it rather difficult to turn over whilst in the chamber, so the nursing staff will ensure that you are comfortable prior to the trolley entering the chamber. The temperature in the chamber can also be affected by your body heat. This can be controlled by the nursing staff adjusting the temperature regulator. If you remain exceptionally warm and uncomfortable we can use an open circuit facility which cools the chamber. What happens after my session? On completion of your session it is advisable, if you are an out patient, for you to sit and r-lax for at least half an hour, during which time You will be offered a drink. We hope this information sheet has proved useful to you. If you have any further questions which you feel could be added to this sheet, please do not hesitate to inform us. This would help us when dealing with other clients. (Devised by L Stables &J Tarry, Jan 90).