The rise in specialized wound and hyperbaric centers across the United States has resulted in an increased need for physicians to administer hyperbaric oxygen therapy (HBOT). However, there are no published national standards or recommendations for credentialing physicians for this service. The American College of Hyperbaric Medicine (ACHM), established in 1985, is a 501(c)(6) professional organization founded to support the clinical applications and professional practice of HBOT and to serve the developing specialty of wound care. Members of the ACHM include physicians, nurses, technicians, and allied health professionals who are dedicated to the appropriate utilization of hyperbaric oxygen for the benefit of patients. The ACHM has advocated for the recognition of HBOT as a distinct medical specialty that understands the standards of care for the use of oxygen as a therapeutic agent. Quality assurance and improvement in the practice of hyperbaric medicine and educational activities to enhance the understanding of the scientific evidence supporting oxygen-based technologies in clinical practice are integral parts of the organization’s mission.1 The ACHM has drafted this document to guide hospital credentialing committees in the process of physician credentialing. The ACHM Consensus Statement represents the opinion of leaders in the field of hyperbaric medicine in the United States. It is important to note that although this document applies to both hospital-based and nonhospital-affiliated centers, they have separate requirements.
CREDENTIALING CHALLENGES IN HYPERBARIC MEDICINE
Before 2010, the American College of Graduate Medical Education (ACGME) through the American Board of Preventative Medicine and Emergency Medicine offered a practice tract option for subspecialty board eligibility in Undersea and Hyperbaric Medicine (UHM). As of 2013, the practice tract option closed, and board certification for allopathic physicians through the emergency medicine or preventive medicine boards now requires a 1-year fellowship.2 The majority of physicians currently practicing hyperbaric medicine have not completed a hyperbaric fellowship as recognized by the ACGME and are therefore not eligible to take the UHM subspecialty board examination. Thus, fellowship programs alone cannot meet the current physician staffing requirements. At present, there are only a few approved hyperbaric medicine fellowships. Even if sufficient fellowship positions were available, physicians in their mid to late careers who are currently practicing hyperbaric medicine would have to return to training programs in order to complete an ACGME-recognized fellowship. Thus, while completion of an ACGME-recognized fellowship represents the highest level of training in hyperbaric medicine, at this time, the ACHM Consensus Statement does not recommend that UHM subspecialty board certification be required for HBOT privileges. The change in the definition of hyperbaric physician supervision to include “other qualified healthcare professionals” has served to further complicate the issue. Podiatrists and allied health professionals (nurse practitioners, physician assistants) are not eligible for fellowship programs in hyperbaric medicine. Therefore, the ACHM Consensus Statement does not recommend that subspecialty board certification be required for HBOT privileges for podiatrists, physician assistants, or nurse practitioners. These allied health professionals should be closely supervised by an appropriately qualified physician in accordance with national and local credentialing authorities. The independent practice of hyperbaric medicine by allied health professionals is inappropriate.
It should be acknowledged that not all hyperbaric centers have the same capabilities. The capacity of a hyperbaric facility to care for a patient is determined by the training and experience of the supervising physician, the professional staff, and the nurses and hyperbaric technicians, in addition to equipment available (eg, ventilator support for critical care patients, the ability to provide “air breaks,” and so on). Thus, requirements for physician credentialing in any practice setting should be developed in conjunction with the policies of the facility and should consider the acuity level of patients to be treated, the hyperbaric diagnoses that will be managed, and the type of chamber being used at the facility (monoplace vs multiplace). Hyperbaric physician credentialing requirements should be commensurate with the level of care and scope of practice of the providers at that facility.
State medical licensure, primary board certification (American Board of Medical Specialties [ABMS]–recognized board certification in a related medical or surgical specialty), and parallel requirements for “Allied Health Personnel” consistent with Joint Commission Standards is advised.3 The ACHM Consensus Statement does recommend that the following guidelines be used judiciously to reflect the scope of practice of the individual clinical settings:
Hyperbaric Medicine Core Privileges
* Identify and diagnose patients who meet the criteria and/or would benefit from HBOT, and effectively communicate the treatment plan with the referring physician, the patient, and the family.
* Evaluate and medically assess patients to ensure the safe delivery of hyperbaric medicine.4
* Provide therapeutic management using HBOT.
* Perform consultations in hyperbaric medicine using approved documentation methods as required by The Joint Commission, and adhere to principles of quality improvement and patient safety.
* Order diagnostic procedures related to the patient’s diagnosis.
* In the case of a multiplace chamber operation, the physician must be able to properly oversee the safe work environment of inside attendants unique to the hyperbaric environment.
RECOMMENDED MINIMAL CREDENTIALING REQUIREMENTS
Hospital Outpatient Department Credentialing (Initial Application):
1. Residency and board certification requirements as outlined in the Medical Staff Credentialing Application to reflect local standards
2. Hold an unrestricted state medical license
3. Current certification in advanced cardiac life support (ACLS)
4. Completion of an ACGME-, American Osteopathic Association–, or Department of Defense–recognized fellowship in hyperbaric medicine with board eligibility or board certification in the subspecialty of UHM by the ABMS or the American Osteopathic Association
A. The ACHM Consensus Statement also recommends that hyperbaric physicians not board certified in the subspecialty of UHM obtain a Certificate of Added Qualification (CAQ) in Hyperbaric Medicine within 2 years of being granted privileges in hyperbaric medicine. Pathways to CAQ include the following:
* Physician Certification in Hyperbaric Medicine as endorsed by the ACHM and administered by the American Board of Wound Healing5
* Hyperbaric Physician CAQ endorsed and administered by the Undersea and Hyperbaric Medical Society (UHMS)6
* The American Osteopathic Conjoint Committee of UHM7
5. Complete a 40-hour introductory course in hyperbaric medicine approved by the ACHM, the UHMS, or the Department of Defense
6. Minimal Initial Educational/Training Requirements:
* The National Coverage Determination policy published by the Centers for Medicare & Medicaid Services does not outline credentialing requirements; however, many Local Coverage Determination policies require practitioners to provide documentation of an approved 40-hour introductory course in hyperbaric medicine in order to bill for their services.8,9
* The ACHM Consensus Statement suggests that all clinicians overseeing HBOT undergo the following training as a minimal initial educational requirement:
A. Education: If the physician took the course more than 2 years prior to applying but has not overseen at least 25 treatments per year, an approved 40-hour introductory course must be retaken.
B. Training: The ACHM Consensus Statement suggests that the first 25 hyperbaric treatments (not individual patients) be proctored in person by a physician credentialed in hyperbaric medicine at the facility or by an expert in the field. Face-to-face proctoring should be followed by a review of the subsequent 100 treatments. This can be accomplished through a chart review or through the center’s electronic health record, perhaps as part of an Ongoing Professional Practice Evaluation process as recommended and outlined by The Joint Commission.3
∘ The physician must demonstrate competency in chamber operation and the emergency treatment of hyperbaric-related medical conditions and complications of therapy.
∘ The proctoring requirement can be waived by the hospital credentialing committee if the physician demonstrates evidence of a history of supervising at least 50 treatments, performing 5 consultative hyperbaric cases in the last 2 years, and documentation (signed letter with primary source verification) from a training program director or director of a hyperbaric center attesting to case volume and competency.
Hospital Outpatient Department Credentialing (Reappointment Application)
1. Fifteen category 1 CME credits in hyperbaric medicine over a 24-month period
2. Must provide evidence of 25 treatments within the past year (50 treatments over 24 months) or sufficient volume to make an informed determination of competency
3. It is recommended that physicians show evidence of ongoing self-assessment of knowledge and cognitive skills in application of hyperbaric medicine (eg, publications, posters, grand rounds or podium presentations, providing proctorship, and research participation).
Nonhospital-Affiliated Center Credentialing
Hyperbaric oxygen therapy provided in the nonhospital-affiliated center reflects the same risks and challenges that are present in an outpatient hospital department that is affiliated with a hospital. To that end, very similar requirements should be met by all hyperbaric practitioners.
1. Hold an unrestricted state medical license
2. ABMS board certification to reflect the community standard
3. If not board certified in UHM, the ACHM Consensus Statement recommends that hyperbaric physicians obtain a CAQ in hyperbaric medicine. Pathways to CAQ include the Physician Certification in Hyperbaric Medicine as endorsed by the ACHM and administered by the American Board of Wound Healing, the Hyperbaric Physician CAQ endorsed and administered by the UHMS, and the American Osteopathic Conjoint Committee of UHM.
4. Successful completion of a 40-hour introductory training program that is approved by the ACHM or UHMS
5. Demonstration of experience in hyperbaric medicine as evidenced by the supervision of 100 hyperbaric treatments (proctorship is difficult in a private practice setting; however, remote supervision can be accomplished by a variety of methods as outlined above)
6. Current certification in ACLS
7. Maintenance of continuing education: 15 category 1 CME credits in hyperbaric medicine every 24 months
8. Demonstrate evidence of ongoing self-assessment of knowledge and cognitive skills in application of hyperbaric medicine (eg, publications, posters, grand rounds or podium presentations, providing proctorship, and research participation).