Bill, like many Americans, poses a care challenge when faced with health problems requiring acute care intervention. Many hospitals and other healthcare organizations fail to recognize the value of preplanning in caring for this complex patient population. Failure to develop criteria-based protocols can occur for several reasons. One recent this study suggests this failure results from the complex nature of preplanning-the project is time consuming, requires a variety of disciplines, is house-wide, and becomes overwhelming and discouraging for team members.1 Regardless, clinicians from throughout the United States are having experiences similar to those described by Kramer. Bariatric beds and scales are imperative in controlling cost and improving outcomes, along with special considerations to preplanning, the physical environment, other support equipment, and education, all from an interdisciplinary perspective.
Overweight and obesity are common health conditions, and their prevalence is increasing globally. Recent estimates suggest that 2 in 3 US adults are overweight, defined by a BMI higher than 25. Of all Americans between the ages of 26 and 75 years, 10-25% are obese. This is an increase of more than 25% during the past 3 decades. Six to 10% are morbidly obese and will need special accommodation when accessing healthcare.2 These dramatic increases have occurred throughout racial and ethnic groups and include both sexes.3
Bariatrics is a term derived from the Greek word baros and refers to the practice of healthcare relating to the treatment of obesity and associated conditions. The specialty of bariatrics is increasingly important because the number of obese and overweight Americans is increasing. The implication for caregivers is that activities such as turning, lifting, and repositioning heavy patients can predispose caregivers to physical injury. Additionally, failure to provide adequate patient activity and mobility leads to issues of patient safety, such as skin injury.4
Patients who are physically dependent and obese are more likely to develop complications resulting from a long hospitalization. As Kramer describes, skin breakdown, such as pressure ulcers, rashes, dermatitis, and tape-related skin tears, are related to immobility and aggravated by obesity. Immobility also contributes to pulmonary complications, such as pneumonia, and exacerbates preexisting conditions, such as overweight hypoventilation syndrome or sleep apnea. Immobility can lead to a prolonged hospitalization, feelings of powerlessness, and subsequently depression. Mobilizing the patient early and safely can reduce some of these immobility-related complications of hospitalization.5
In addition to the safety hazards of obesity and immobility, there can be hazards to caregivers when mobilizing the patient. Even the most compassionate caregiver's intervention can be colored by his or her realistic fear of physical injury. Healthcare is becoming one of the most dangerous jobs in the United States, with physical injuries reaching epidemic levels.6 Literature reports that 89% of back injury claims filed by hospitals are related to patient handling, and the direct costs associated with these injuries exceed $15,000 per claim. It is estimated that $50 billion per year is spent on treatment of back injuries. Workers' compensation back injuries cost 255% more than non-work-related back injuries, and hospitalization is twice as likely for these individuals. Caring for the patient who is obese places the caregiver at particular risk for injury.7
It is important to recognize that the economic costs are only a portion of the real cost of occupational injuries. Injured caregivers are faced with lost time from work, emotional and physical distress, job and career changes, and role changes at home. There are also hidden costs for the organization, such as lost revenue resulting from a loss in productivity, decreased employee retention, costly orientation of new staff, diminished staff morale, and added administrative time for investigation and paperwork.8 Ms Kramer correctly identifies that proper care of the bariatric patient requires special care and intervention. Numerous strategies are available to reduce or prevent caregiver injury and promote patient safety, of which preplanning, the physical patient care environment, appropriate equipment, and education are discussed herein.
Preplanning for Care
Healthcare facilities must have a plan in place to care for the special needs of patients who are morbidly obese. Rather than attempting to make a standard size fit all, patients are best served when equipment and care are selected that are appropriate to their size and needs. Preplanning with manufacturers and vendors to provide equipment for the patient who is morbidly obese is essential. Institutional policies and procedures to obtain transportation and transfer devices, bed frames and support surfaces, wheelchairs, walkers, and commodes or furniture must be available.
When selecting oversized equipment, it is essential to consider both the weight limit and the width of the equipment. For example, a patient may not exceed weight limits for a standard bedside commode, but he or she may be unable to use a standard device because of the width of the patient's hips. Criteria-based protocols for use of specially designed equipment are designed to ensure more appropriate, timely, and cost-sensitive use of equipment. Performance improvement teams offer a resource to develop and implement appropriate policies and resources for bariatric equipment needs.
Implementing changes to better manage the unique care issues associated with patients who are morbidly obese can be challenging for caregivers. The initial cost of any change, however, is often viewed as an obstacle. Without a thorough understanding of the cost incurred in caregiver injury and the prolonged hospitalization of the patient, it may be difficult to economically justify introduction of specialized equipment, which may not be reimbursed by third-party payers. However, consider Bill and Kramer's description of cost incurred in the absence of preplanning.
Performance improvement (PI), based on the principles of CQI, seeks to make changes that improve the therapeutic, cost, and satisfaction outcomes associated with patient care. Decisions need to be made by those individuals closest to the patient that are customer-focused, and change must be ongoing. A bariatric task force could include a physical/occupational therapist (PT/OT), a WOC nurse, a risk manager, a safety specialist, an ergonomist, a front-line caregiver, and an administrator, among others. A former patient who can provide input from the experience of being cared for as a heavier patient is invaluable. Vendors are also valuable in this process because they are able to partner with hospitals that are looking for equipment that could be tailored to better meet the needs of caregivers. These quality-based efforts can be unit-based or house-wide. Regardless, they are important because they can more accurately establish the actual needs of the organizations as they seek to reduce or prevent caregiver injury.
The Physical Environment
Even patients who maintain a high level of functioning and independence at home may be compromised when entering the hospital environment.9 For example, the home environment may be modified to allow for the patient's size and mobility needs. There may be wide pathways through rooms with handrails or heavy furniture that the patient may use for balance. The patient's bed, chairs, and even bedside commode may be oversized to allow for adequate support and balance. The patient and/or caregiver may have devised routines for daily activities, such as bathing, toileting, and exercise. In the hospital, however, the patient is presented with equipment that is often too small or lightweight, preventing safe activity and mobility. Most furnishings in the hospital environment are on wheels, and this is not safe or adequate to support a large person attempting to transfer in and out of bed or chair or to ambulate around the room or restroom.10
Some restrooms are too small to accommodate the patient comfortably. Many wall-mounted commodes will not support the weight of patients who are obese. Bedside commodes, wheelchairs, and walkers are too narrow for these patients. This inappropriate equipment may give the impression of being too small to accommodate the patient's weight. The patient may be in a weakened condition with decreased balance or function resulting from illness, medication, pain, immobility, or dietary changes associated with a hospital admission.11 Turning, transferring, or ambulating the patient who is obese places the caregiver and patient at risk for injury. Often the patient is not only fearful of falling and incurring injury to self but also of falling on or otherwise causing injury to a caregiver.
Equipment
Standard hospital equipment may pose safety risks for the patient who is obese and his or her caregivers. On the other hand, equipment specially designed for overweight patients can improve their quality of care, reduce the patient's length of stay, and make it easier and safer for caregivers to perform care measures.12 For instance, placing a bedpan under a patient who is obese and cannot walk to the bathroom may be challenging for the caregiver and embarrassing for the patient. But an appropriately sized bedside commode with a walker or transfer system to assist the patient onto the commode is more likely to ensure complete emptying of the bladder, preventing a hospital-acquired urinary tract infection.
Ergonomists, PT/OT, WOC nurses, case managers, and others are often responsible for making recommendations for equipment. As Kramer identifies, specialty frames and support surfaces are an essential adjunct when caring for larger heavier patients. Additionally, wide front-wheeled walkers, wide wheelchairs, wide room chairs, wide beds that lower closer to the floor, patient lifts, transport stretchers, gowns large enough to cover the patient when out of bed, wide bedside commodes, scales to weigh the patient, bed frame trapeze, an oversized stretcher in the emergency department, and a fully functioning operating room table should be considered.13
Education
Although attention must be paid to the physical environment, equipment, and preplanning for care, education is at the heart of safe size-sensitive nursing care. Nursing education serves as a valuable tool in early recognition of patient care complications. In a recent study, nurses were asked to describe competencies essential to caring for the larger patient. The top 3 competencies were (a) safety, (b) equipment, and (c) physical assessment. Other competencies described were sensitivity training, etiologies of obesity, emotional issues, and motivation. When asked to identify the best method to teach competencies, the participants listed the following in order of frequency: (a) video, (b) train the trainer, (c) self-study, and (d) others, such as one-on-one unit-based discussion and debate.14 Education is the thread that ensures safe bariatric care by weaving together the concepts of preplanning, the physical environment, and equipment.
Conclusion
Managing the complex needs of the bariatric patient can be time consuming and costly. Solutions to this nationwide situation are not simple. The prevalence of patients who are overweight is increasing and is likely to continue. A collaborative task force is in the best position to understand the issues more fully, because each department is affected in a unique yet very important and interrelated manner. Several solutions may exist; however, preplanning, adapting the physical environment, and use of appropriate equipment is one strategy. Education is another. Every effort should be made to reduce or prevent caregiver injury. The challenge to hospitals and caregivers is that all these changes must be performed in a growing climate where profit and reductions outweigh safety. An interdisciplinary approach is likely to best serve the ever-changing needs of the patient, caregivers, and the institution.15
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