A 1-size-fits-all care model fails to meet the complex needs of bariatric patients or prevent the risk of injury to their caregivers.

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ew data related to health and heath issues reveal that obesity may not be the public health threat once imagined.¹ Although this is good news to the millions of Americans who feared for their lives and health, the reality is that when a larger, heavier patient accesses healthcare, he or she requires special, well-thought-out accommodation. Likewise, regardless of the new data, even 1 obese person can pose a patient care challenge to caregivers. This article examines the recent interpretation of obesity, the increasing need for specially designed equipment, the role of a comprehensive bariatric care plan designed to promote patient safety and prevent caregiver injury, and strategies to make changes to include equipment.

Reinterpreting Obesity

       Obesity, according to the National Institutes of Health (NIH), is simply a diagnostic category that represents a complex and multifactorial disease.² But to the two-thirds of Americans who are overweight and the 10–25% considered obese, weight-related issues mean much more.³ Obesity is costly, emotionally and economically.⁴ Americans spend close to $33 billion annually in attempts to control or lose weight, while $117 billion is spent on obesity-related health problems. Obesity is a factor in 5 of the 10 leading causes of death.⁴ And, until recently, it was considered the leading cause of preventable deaths in the US.⁵ In addition to the economic costs, obesity is associated with emotional conditions, such as depression, altered self esteem, and social isolation.⁶ Researchers argue that obese individuals are the latest targets of social discrimination.⁷ Jokes and derogatory portrayals of obese people in the popular press are common.⁸ Obese Americans neither chose to be overweight nor chose to experience widespread prejudice and discrimination.⁹ Prejudice is described as a prejudgment, where discrimination refers to an action based on this prejudgment. Overweight Americans of all ages, races, ethnicity, and economic backgrounds experience both, in addition to otherness.^10,11,12
       Otherness holds special meaning in healthcare planning. When clinicians designate the quality of otherness to a patient or patient group, healthcare clinicians may justify inadequate planning and care by blaming the patient for the numerous difficulties he or she may present.¹³ This reaction suggests that, as a culture, we need to be aware of the moral dimensions of otherness and how this concept poses barriers to care. Patients suffering with drug addiction, lung cancer, AIDS, obesity, and other chronic illnesses may be excluded or abandoned by healthcare clinicians, particularly in terms of protocols, reimbursement for treatment, or care, because these are often considered self-inflicted conditions largely preventable with lifestyle changes. Issues of difference and identity as they relate to otherness on the organizational, institutional, or social level influence practical matters of healthcare like access to specially designed equipment. Clinicians must understand these sociologic concepts, which pose barriers to making changes.¹⁴
       Like otherness, prejudice and discrimination stem from the ill-conceived notion that obesity is a problem of self discipline. There is no debate that weight gain occurs when intake, meaning food intake, exceeds output, meaning activity—the real mystery behind balancing body weight depends on a number of other factors. Genetics, gender, physiology, biochemistry, neuroscience, as well as cultural, environmental, and psychosocial factors influence weight and its regulation.¹⁰ Healthcare clinicians best serve their patients when they recognize obesity as the chronic condition that it is.
       The concern of prejudice and discrimination is that these emotions pose barriers to care regardless of practice setting or professional discipline. The overwhelming misunderstanding of obesity interferes with preplanning efforts, including resources, clinical experts, and equipment. Healthcare clinicians need to ensure a safe haven from obesity-related prejudice and discrimination and the threat of otherness.¹⁵

Comprehensive Bariatric Care Plan

       In years past, it was thought that a quick assessment of the patient would determine if specially designed equipment was needed. Later, institutions recognized widespread variability in this process. One clinician might believe special accommodation was necessary while another declined. This process subsequently became unacceptable. Today, most hospitals and healthcare organizations agree that a concerted effort comprised of equipment and resources provided to the patient based on certain patient criteria is best to ensure safe, appropriate equipment in a timely manner. However, with increasing numbers of obese patients in healthcare settings, clinicians are learning that a comprehensive bariatric care plan is essential.
       A comprehensive bariatric care plan is comprised of a bariatric task force, criteria-based protocol, competency/skill set, and outcome-measurement efforts.¹⁶
       The bariatric task force is an interdisciplinary quality-improvement effort designed to address ongoing issues and ideas. Social workers, risk managers, pharmacists, ergonomists, safety officers, physical/occupational and respiratory therapists, educators, physicians, clinical nurse specialists, wound, ostomy, and continence nurses (WOCNs), and others can be essential in planning care. Each member of the team brings a unique and important perspective.¹⁷
       Healthcare facilities must have a plan in place for the special equipment needs of larger, heavier patients. A criteria-based protocol is simply preplanning based on specifically designated patient criteria. The patient’s weight, body mass index (BMI), body width, and clinical condition serve as such criteria.¹⁸ Actual weight is important to consider, because the patient’s weight may exceed the weight limits of equipment, and therefore, breakage, failure to function properly, or patient/caregiver injury can occur. Body width is described as the patient’s body at his or her widest point, which could be at the patient’s hips, shoulders, or across the belly when side lying. Equipment must be wide enough to prevent rubbing against soft tissue of the hips, legs, feet, or shoulders when prone and the belly when side lying. Equipment must be wide enough for the patient to safely be repositioned or reposition himself or herself. And, any clinical condition that interferes with mobility, such as pain, sedation, fear, or resistance to participate in care, places the patient at risk for costly and preventable complications of immobility. Preplanning protocols should be designed to meet the actual equipment needs of the patient and caregiver, including training thereof.^18,19
       Education must be available to ensure basic skills or competencies. Members of the bariatric task force serve as a pool of experts to develop lesson plans/education addressing clinical needs that have been identified by clinicians. For example, assuming clinicians are seeking information pertaining to “use of equipment to prevent caregiver injury,” a physical/occupational therapist, nurse expert, vendor representative, risk manager, and patient member of the task force could develop a 1-hour module to teach these clinical skills.
       In order to ensure long-term success of a comprehensive bariatric program, it is essential to understand and participate in outcome studies. The aim of cost, clinical, and satisfaction research is to measure the value of an organizational improvement effort.
       Each of these steps (ie, bariatric task force, preplanning, competencies/skill set, and outcome measurement) serve to support a comprehensive effort to control costs and improve care by promoting patient safety and preventing caregiver injury, as do provisions for equipment.

Equipment

       Although all components of a comprehensive care plan are essential, equipment is an important component of preplanning for care, since it is the first-line strategy for promoting patient safety and preventing caregiver injury. A number of studies reveal the increasing incidence, cost, and number of back-injury claims associated with patient care. More than half of strains and sprains are due to manual-lifting tasks while assisting dependent patients with their mobility needs.²⁰ Injuries that result from manual lifting and transferring patients are among the most frequent causes of injury.¹⁹ Patient care becomes more difficult and dangerous as the size and weight of the patient population increase.²¹
       Rather than attempting to make standard-sized equipment fit all, patients are best served when equipment is selected that is appropriate to patients’ sizes, shapes, and needs. Institutional policies and procedures to obtain equipment must be available. Members of the clinical staff must be aware of these policies and methods for accessing equipment, regardless of the day of the week or hour of the day. Preplanning with manufacturers and vendors to provide equipment for the morbidly obese patient is essential. Clinicians and vendors must be aware of expectations for delivery policies, such as time to deliver, where to deliver, frequency and depth of equipment orientation and documentation thereof, and who should monitor equipment usage.
       When selecting oversized equipment, it is essential to consider both the weight limit and width of the equipment. For example, a patient may not exceed weight limits for a standard wheelchair but may be unable to use a standard product because of the width of his or her hips. Standard hospital equipment may pose safety risks for the obese patients and their caregivers. For instance, consider the 320 lb man transported from the med-surg unit to radiology for a test in his standard sized bed. Imagine everyone’s surprise and distress when the left-front wheel literally broke off from the bed and the patient and the bed blocked the hallway for 3 hours on a busy Wednesday afternoon. The issue was not only the patient’s embarrassment but also the limited options for transferring the patient back to his room; numerous safety issues emerged. Equipment specially designed for overweight patients can improve their quality of care, reduce the patients’ length of stay, and make it easier and safer for caregivers to perform care measures.²² For another less dramatic case, think about placing a bedpan under an obese patient who cannot walk to the bathroom; this is challenging for the caregiver and embarrassing for the patient. Many clinicians seek an oversized bedpan, which may not be a practical solution. Perhaps an appropriately sized bedside commode with a walker or transfer system is a more reasonable solution.²³ The simple act of over sizing a standard sized product is not always the best option for the larger, heavier patient. Remind colleagues to determine what the objection of care/intervention is and which tools are available to accomplish the task.
       Ergonomists, physical and occupational therapists, WOCNs, case managers, and others are often responsible for making recommendations for equipment. 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 patients when out of bed, wide bedside commodes, abdominal binders, longer tracheostomy tubes and ties, scales to weigh the patients, bed frame trapezes, an oversized stretcher in the emergency department, and a fully functioning operating room table should be considered.²⁴ Criteria-based protocols for use of specially designed equipment are helpful to ensure more appropriate, timely, and cost-sensitive introduction of equipment.²⁵

Introducing Equipment

       Making changes may be not easy for caregivers. The economic cost of any change serves an obstacle. Some clinicians choose to use conventional methods to make changes, while others choose more unconventional strategies. In order to facilitate changes, for instance, institutions must recognize the cost incurred in caregiver injury along with costs related to avoidable complications that occur because of inadequate equipment.
       Current literature offers many situations for which proper equipment has improved the quality, cost, and satisfaction of patient care. This literature can be presented to the appropriate groups/task forces/committees within the organization to begin the change process. For instance, in viewing trends and obesity, research suggests that in 2–5 years, hospital workforce injuries will be reduced by 30% due to installation of specialized equipment like lifts and hoists. These changes are thought to be especially beneficial to those providing direct patient care, because this category of worker has the highest occupational injury rates of any profession. More than one-third of nurses suffer from back-related injuries, and each year 12% leave nursing because of injury.²⁶ In the near future, nursing retention efforts will focus on reducing the risk of personal injury and overall fatigue of care for obese patients. Staff training on ergonomics and body mechanics will be ongoing, and lift teams will be formed in many facilities to safely move patients.²⁷
       Oversized abdominal binders are products that have recently gained interest in the area of bariatrics. In the event of abdominal surgery, excess body and abdominal fat can increase the tension at the wound edges.²⁷ To reduce the occurrence of abdominal wound separation, some clinicians use a surgical binder to support the area. Binders not only provide comfort to the patient but are designed to minimize the shearing forces between the abdominal wall and abdominal skin.²⁸ If the binder does not fit properly, however, it can lead to skin breakdown or failure to comply with the plan of care. The binder needs to be large enough to comfortably fit the patient, and bariatric-sized binders meet this requirement.
       Another area of growing concern is lateral transfer, as more clinicians are reporting neck and shoulder injuries. Lateral transfers are a growing threat to caregiver safety, and neck and shoulder pain is fast becoming as prevalent as back injury as an adverse outcome of moving dependent patients. Although many patients are independent in transfers, some are not and require extra personnel to transfer the patient. A hover-type, air-displacement, lateral-transfer product may ensure a safe transfer while protecting the caregiver from injury. This category of product can safely transfer a fully dependent 1,000 lb person with the assistance of 2 caregivers.
       Pressure ulcer development is not unusual in the presence of immobility. Repeated citations in the literature report pressure ulcer development with subsequent cost related to increase length of stay, direct costs of treatments, and risk of injury to clinical staff. Introduction of specialized equipment serves as an adjunct to prevent these costly and predictable consequences of care.^29,30
       Some clinicians find that approaching introduction of equipment through conventional methods is fruitless. Although the evidence is anecdotal, clinicians have been known to introduce specially designed equipment for a specific patient by simply appealing to those in decision making roles. Consider William, a 475 lb man with bilateral hip ulcers due to a bed that accommodated his weight but not his width. Ellen, the wound expert, knew she had met obstacles in introducing equipment house wide, but she felt she could make a difference in William’s outcome. So, she collected the equipment brochures of the equipment William was using and the equipment he needed, prepared a single-page sheet describing the differences in equipment, copied an academic article describing pressure ulcer formation among obese patients with a detailed section on ill-fitting equipment, and took photographs of the skin breakdown. Once she prepared the tools she felt she needed, Ellen made 15-minute appointments to speak with the materials manager, her immediate supervisor, and William’s unit supervisor. By the end of the day, she had the equipment William needed. This method is certainly unconventional and seldom useful for long-term change, but as a patient advocate, she was able to accomplish her goal. Taking this 1 step further, she could carefully monitor the patient and at a later date present the data to the performance improvement/risk manager to determine if this process should be in place for all patients meeting certain criteria.²⁰
       Performance improvement (PI), based on the principles of continuous quality improvement (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 and must be customer-focused, and change must continue to be ongoing.³¹ Ellen, the wound expert in William’s care, was in a perfect role for making changes for his care and to serve as an ad hoc member of the performance improvement effort when skin care among bariatric patients was discussed.

Conclusion

       Regardless of the recent reinterpretation of statistics pertaining to obesity, healthcare organizations need to continue to strive to manage the complex needs of obese patients. Equipment is not limited to furniture and beds, and clinicians and patients can offer input as to the many different ways healthcare institutions can provide reasonable accommodation to this underserved population. Institutions, clinicians, vendors, manufacturers, and consumers need to work collaboratively to identify opportunities for product development and availability. Clinicians best serve consumers and their respective institutions by using conventional and sometimes unconventional methods to make change.