Hyperbaric Competencies: BEYOND the Course
Medical skills and devices require competencies. As a new nurse, I learned core hospital competencies for bedside procedures such as foley catheter insertion, intravenous catheter (IV) insertion, and nasogastric (NG) tube placement. I never stopped completing competencies as I worked in different units and developed new skills. When I learned to work in the emergency department, I was required to complete an arrhythmia competency course, demonstrating that I could read and interpret cardiac rhythms. I had to complete more competencies before I was allowed to work in the emergency department trauma bays. When I worked in the intensive care unit, I had to complete a myriad of complex competencies for various open heart and cardiothoracic devices before I was allowed to manage those patients. All these competencies went into my hospital HR and certificate management systems. Hyperbaric oxygen therapy is no different. Class A and Class B hyperbaric oxygen therapy chambers are medical devices –proper training and competency should be required to operate a chamber with a patient inside.
Historically, in the HBO2 industry, much emphasis has been placed on completing an introductory 40-hour HBO2 training program. These courses are recognized and approved by various entities in the industry, and each entity applies its curriculum standards and review process for course recognition. Much debate also occurs around how the course should be staged (in person, virtually, or self-paced). While the course is critical for teaching hyperbaric history, theory, and clinical practice, no course can teach competency for every conceivable chamber and gas system a student may encounter when returning to their own center. Students who complete these courses often report having more questions than answers when they return to their own unit after completing an appropriate course.
There are well over one thousand hyperbaric programs in the United States, and within these programs, there are many varieties of chamber make and model. Sechrist, Perry, Pan American, and ETC are just a few companies that have produced hyperbaric chambers over the years. Each of these companies also produced various chamber models, some with additional features such as electronic interfaces. Multiplace systems can also be unique, with specific capabilities developed for the institution in which they operate.
One must also consider the endless complexity of gas systems, as understanding how to monitor and operate the affiliated gas systems is another responsibility of a hyperbaric chamber operator. Some HBO2 programs are tied directly into the hospital’s bulk oxygen system, while others may have a dedicated (smaller) bulk system for the unit or even a Dewars system. Medical air may be piped into the chamber from H tanks in the unit, in an adjacent storage area, or even a hospital medical air compressor. Some chambers can even compress oxygen or air, which adds to the complexity of learning to operate the system in one’s unit.
The need to demonstrate competency doesn’t stop with operating chambers and their affiliated gas systems. What about hyperbaric-related clinical skill sets such as tympanic membrane inspection, use of TCP02 devices (if the unit has one), or use of hyperbaric unit glucometers? Clinical competency should be demonstrated on all these items. Some competencies will only include technical items, while other competencies may include clinical theory and training around unit policies for various patient situations and emergencies.
Multiplace hyperbaric chambers can also be complicated, with even more potential for competency training related to the control panel, staff access, and staff exposure to various pressures.
When designing competencies, there’s much to consider. Should the competency document be based on a pass/fail system (competent or not competent)? Or should competency include levels of proficiency such as competent and able to train others (superuser), competent but not able to train others, and not competent?
After designing a competency, staff should also consider what to do with those competencies. Storing physical/paper competencies for all active hyperbaric staff is always a great idea. But what about software? Many hospital programs have portals and human resource software that allow for the uploading of competencies. Managers in these systems should also consider how and when they’ll audit these competencies for their staff. Once a competency program is in place, the logic follows that there needs to be enforcement and auditing around that program.
Even after a strong competency document has been designed, one must ask…how long is it good? Is the competency document recognized indefinitely, or does it expire? Should a policy be developed that requires competency to be repeated continuously? If competencies must be repeated annually, who will sign off those with expiring competencies?
Even after competencies have been designed and enforced, program managers should ask themselves whether their staff is spending enough time operating the equipment to stay competent. Full-time hyperbaric chamber operators will quickly become proficient in daily chamber operations. But what about casual staff who complete the initial training process but only cross-cover hyperbaric operations every few weeks? Are they spending enough time with the chambers to remain proficient? How should a program measure the ongoing competency of staff? Should a program enforce mandatory “practice” time for staff not operating hyperbaric equipment daily? If so, how often?
Some hospital programs may have multiple campuses that staff float between. In this case, there may be differences in chamber or gas system type between campuses. Sending staff from one campus to another without proper orientation and training at both locations can also lead to confusion and operational issues. In these situations, program managers may want to consider whether they should develop an ambiguous HBO chamber competency or whether specific competencies (for each make and model of the chamber in their system) should be developed and enforced for traveling staff.
In summary, hyperbaric oxygen therapy is a specialty that deserves adequate training and competency standards as any other. The introductory hyperbaric course should not be viewed as the end of a student’s training but only the beginning. Every hyperbaric oxygen program should have adequate competency training and documentation in addition to completing an introductory course.