TL;DR: HBOT patient co-management is the shared clinical responsibility between a referring physician and a hyperbaric centre during a course of hyperbaric oxygen therapy. Effective co-management requires a structured referral package, mid-treatment status checks, coordinated adverse event protocols, and a closing handoff with a documented outcome summary. Canadian physicians who follow these six steps reduce delays, improve adherence, and capture better data for follow-up care.
HBOT patient co-management is the shared clinical responsibility between a referring physician and a hyperbaric centre during a course of hyperbaric oxygen therapy. Most Canadian referring physicians never visit the chamber their patient sits in. They write the referral, hand it over, and wait. That model leaves clinical gaps. Patients arrive at hyperbaric facilities with incomplete workups, comorbidities flare mid-course, and outcome data rarely makes it back to the referring chart. This guide outlines six practical steps Canadian physicians can use to co-manage hyperbaric oxygen therapy referrals from indication through discharge.
Canada Hyperbarics connects referring physicians with accredited hospitals and regulated facilities across the country. The coordination patterns below reflect what Canadian centres expect from referring physicians, and what referring physicians should expect back.
What is HBOT patient co-management?
HBOT patient co-management is the structured clinical partnership between the physician who refers the patient and the hyperbaric centre that delivers treatment. A typical course of hyperbaric oxygen therapy runs 20 to 40 sessions over 4 to 8 weeks. During that window, the referring physician remains the primary medical provider for the underlying condition, comorbidities, and any complications. The hyperbaric centre owns the delivery of treatment, in-chamber safety, and session-by-session response.
Co-management is not optional. The UHMS and Canadian centres expect a continuous information loop between referrer and treatment centre. Patients on insulin, anticoagulants, or chemotherapy need both teams synchronised. Without that, treatment is paused, missed sessions accumulate, and clinical outcomes drop.
How do you confirm an HBOT indication before referral?
Step 1: Confirm the indication matches an evidence-based use. Before sending any patient, verify the indication appears on the Undersea and Hyperbaric Medical Society (UHMS) Indications list, or has documented Health Canada-aligned evidence for off-label use. Health Canada recognises 14 conditions for hyperbaric chamber licensing, including non-healing diabetic foot ulcers, delayed radiation injury, compromised grafts and flaps, severe carbon monoxide poisoning, sudden sensorineural hearing loss, and necrotizing soft tissue infections.
For diabetic foot ulcers specifically, a 2024 network meta-analysis of 57 randomised controlled trials covering 4,826 patients found HBOT significantly increased the complete healing rate compared with standard of care, particularly for Wagner grade 3 and 4 wounds (OuYang et al, Frontiers in Endocrinology 2024 (PubMed)). Combination protocols with negative pressure wound therapy or platelet-rich plasma outperformed standalone treatments. Document the failed conservative care trajectory before referral: this is the evidence the centre will use to justify the protocol.
For emerging indications such as long COVID, set expectations carefully. A 2024 systematic review of 10 clinical studies found HBOT improved quality of life, fatigue, and cognition in long COVID patients, but the authors note that precise protocols and post-treatment evaluations still require larger trials (Wu et al, Life 2024 (PubMed)). Frame the referral as investigational where the evidence supports that framing.
How should you prepare a patient before HBOT referral?
Step 2: Complete the pre-treatment workup the centre will require. Most Canadian hyperbaric facilities ask for a baseline chest X-ray, ECG in patients over 50 or with cardiac history, fasting glucose or HbA1c in diabetic patients, and an ENT clearance for any patient with sinus or middle ear disease. Sending an incomplete workup means the centre will request it before the first session, delaying treatment by one to three weeks.
Counsel the patient on three practical realities before they leave your office:
- Time commitment. Each session is 90 to 120 minutes. A typical course is 20 to 40 sessions, scheduled daily on weekdays. Patients often underestimate the burden until session 5.
- Travel and access. Many Canadian patients live more than two hours from the nearest accredited centre. Some take temporary accommodation near the chamber for the duration. Confirm before referring.
- Coverage status. Confirm whether the patient is being referred to a publicly funded pathway (which varies by province) or to a private clinic where they pay out of pocket. Setting this expectation before referral prevents cancellation at intake.
What goes into a proper HBOT referral package?
Step 3: Send a structured referral package, not a one-line consult request. A referral package that hyperbaric centres can act on without follow-up calls includes the following components:
- Primary indication coded to ICD-10 with the duration of disease
- Failed prior treatments and their duration (the evidence of medical necessity)
- Complete current medication list with attention to oxygen toxicity interactions: disulfiram, bleomycin history, cisplatin, doxorubicin
- Comorbidities with active management plans, especially diabetes, cardiac disease, COPD, claustrophobia, and seizure history
- Baseline imaging and laboratory results from the prior 90 days
- Explicit contact information for the referring physician and after-hours coverage
- The clinical question being asked: salvage, healing acceleration, symptom relief, or adjunct to definitive surgery
A complete package shaves an average of 7 to 14 days off intake at most Canadian centres. It also gives the hyperbaric physician the information needed to choose an appropriate protocol, whether that is 2.0 ATA for soft tissue radiation injury or 2.4 to 2.5 ATA for delayed radiation cystitis or proctitis.
How do you coordinate care during the HBOT course?
Step 4: Establish a mid-treatment check-in protocol. Schedule one structured contact with the hyperbaric centre at the midpoint of the planned course, typically session 10 or 15. The midpoint check should answer four questions:
- Tolerance: Has the patient experienced barotrauma, oxygen toxicity, or claustrophobia requiring protocol changes?
- Adherence: How many sessions has the patient missed, and why? Missed sessions of more than 20 percent of the planned course often warrant re-evaluation.
- Early response: Are there objective markers of improvement? Wound area reduction, audiometry, visual acuity, or symptom scales depending on indication.
- Comorbidity status: Have any underlying conditions, especially blood glucose, blood pressure, or cardiac rhythm, changed during treatment?
A 2024 prospective study on retinal artery occlusion patients monitored by fluorescein angiography demonstrated that structured mid-treatment imaging guided HBOT duration decisions: patients underwent a mean of 33.9 sessions, with revascularisation observed in 87.1 percent by day 21 (Chiabo et al, British Journal of Ophthalmology 2024 (PubMed)). The study illustrates how mid-treatment objective monitoring lets the centre tailor the course rather than running a fixed protocol.
How do you manage adverse events during HBOT?
Step 5: Agree on a shared adverse event response protocol before treatment starts. Most adverse events during hyperbaric oxygen therapy are minor and managed by the centre directly. The most common are middle ear barotrauma, sinus barotrauma, and transient myopia. A 2025 multi-centre retrospective study of 1,799 HBOT sessions in 69 patients aged 75 and older reported side effects in 20.3 percent: 8.7 percent middle ear barotrauma, 4.3 percent sinus barotrauma, 4.3 percent confinement anxiety, with no life-threatening events (Cracchiolo et al, Undersea and Hyperbaric Medicine 2025 (PubMed)).
The events that require referring physician involvement are different in character. The table below summarises the typical division of responsibility:
| Event | Managed by Hyperbaric Centre | Requires Referring Physician |
|---|---|---|
| Middle ear barotrauma | Yes (myringotomy tubes if needed) | No |
| Confinement anxiety | Yes (premedication, support staff) | Consult for prescription |
| CNS oxygen toxicity (seizure) | Yes (acute management) | Yes (workup, anticonvulsant review) |
| Hypoglycaemia in diabetic patient | Yes (acute glucose, snack protocol) | Yes (medication adjustment) |
| Pneumothorax | Yes (chamber abort, oxygen) | Yes (admission, imaging, follow-up) |
| Decompensation of comorbidity | Yes (session pause) | Yes (primary management) |
Confirm in advance that the hyperbaric centre has your direct contact and the after-hours number for your covering colleague. Centres that pause treatment for a comorbidity flare lose ground quickly: a 3 to 5 day pause in a wound healing protocol can erase the gains of the prior 10 sessions.
How should you close the HBOT referral loop?
Step 6: Require a discharge summary with objective outcome data. The closing handoff is where most referring physicians lose information. Ask the hyperbaric centre for a written discharge summary at the end of the course that includes:
- Total sessions delivered and protocol used (ATA, duration, air breaks)
- Objective response measures at baseline, midpoint, and conclusion
- Adverse events encountered and how they were managed
- Recommendations for follow-up imaging or repeat assessment
- Recommendation on whether further HBOT courses are clinically warranted
For conditions where late-effect benefits are common, such as radiation injury or compromised flaps, plan a structured follow-up at 4 weeks, 3 months, and 6 months post-discharge. The centre will not typically schedule these. The referring physician owns the long-term outcome data.
Frequently asked questions about HBOT patient co-management
How long does a typical HBOT course last in Canada?
A typical HBOT course in Canada runs 20 to 40 sessions of 90 to 120 minutes each, scheduled daily on weekdays. Diabetic foot ulcer protocols average 30 to 40 sessions. Acute carbon monoxide poisoning, by contrast, uses 1 to 3 sessions. Confirm the expected course length with the receiving centre before counselling the patient.
When should a referring physician contact the hyperbaric centre directly?
Contact the centre directly at three predictable points: at referral submission to confirm receipt and discuss anticipated start date, at the midpoint check (session 10 to 15) to review tolerance and early response, and at any unscheduled adverse event involving a comorbidity you manage. Routine session-by-session updates are not the norm in Canadian centres.
Is HBOT covered by provincial health insurance for the indication I am referring?
Coverage varies by province and indication. OHIP covers the 14 Health Canada-recognised conditions at hospital programmes and select eligible Independent Health Facilities across Ontario. MSP in British Columbia funds HBOT at Vancouver General Hospital only. AHCIP in Alberta covers HBOT at the Foothills / Arthur J.E. Child Comprehensive Cancer Centre programme in Calgary (Alberta Health Services) and the Misericordia Community Hospital programme in Edmonton (operated by Covenant Health). RAMQ in Quebec covers hospital-based HBOT. MSI in Nova Scotia funds HBOT at the QEII Health Sciences Centre. Several other provinces have no confirmed public coverage for private clinics. Confirm coverage status with the receiving centre and with the patient before referral.
What are the absolute contraindications I should screen for before referral?
The single absolute contraindication is an untreated tension pneumothorax. Relative contraindications that require management before referral include uncontrolled seizure disorder, severe obstructive lung disease with bullous emphysema, recent ear surgery, untreated upper respiratory infection, active chemotherapy with bleomycin or cisplatin, and severe confinement anxiety. Discuss any of these with the hyperbaric physician before submitting the referral.
How do I document HBOT referrals for medical-legal purposes?
Document the indication, evidence base cited (UHMS Indications list reference or specific PubMed citation for off-label use), the failed conservative trajectory, the informed consent conversation about benefits, risks, and time commitment, and the patient acknowledgement that travel, coverage, and time may affect adherence. For off-label indications, document explicitly that the patient understands the investigational nature. Retain the discharge summary from the hyperbaric centre as part of the permanent record.
What happens if my patient cannot tolerate the chamber?
Approximately 4 to 6 percent of referred patients cannot complete a planned HBOT course due to confinement anxiety, persistent middle ear barotrauma despite myringotomy tubes, or new adverse events. The hyperbaric centre will typically attempt premedication, support staff accompaniment, or a switch from monoplace to multiplace chamber where available. If intolerance persists, the centre returns the patient to your care with a recommendation. There is no penalty to the patient or to your referring relationship for incomplete courses.
Where can I find a list of Canadian HBOT facilities and their referral processes?
Canada Hyperbarics maintains a directory of accredited hospitals and regulated facilities across Canada, with referral contact information and indication-specific notes. The directory is organised by province and chamber type, so referring physicians can identify the nearest centre with a protocol matching their patient indication.
Where to refer next
Strong HBOT co-management starts with the right facility match. Browse the Canada Hyperbarics facility directory to find an accredited centre near your patient. For evidence reviews on specific indications, see the research database covering more than 14,400 HBOT studies. For patient-facing FAQs you can share before referral, see the FAQ section.
This content is for informational purposes only and does not constitute medical advice. Hyperbaric oxygen therapy decisions should be made between the patient, the referring physician, and the hyperbaric medicine physician. Always follow Health Canada guidance and provincial regulatory requirements when referring patients for hyperbaric oxygen therapy.