Caring for the Obese Patient

Caring for the Obese Patient

By Kelly M. Pyrek

According to the National Center for Health Statistics of the Centers for Disease Control and Prevention (CDC), more than 60 percent of adults in the United States are overweight and 20 percent are morbidly obese. While obesity has nearly doubled in 20 years, the increase in the number of morbidly obese individuals -- those who are 100 pounds or more overweight -- represents a growing patient population that can be served in the surgical hospital environment.

According to the American College of Surgeons, morbid obesity is defined as more than 100 pounds greater than normal body weight or a body mass index (BMI) of 40 kg /m2 or more (or a BMI of 35 kg /m2 or more if associated with significant co-morbidities). It is associated with many diseases and disorders including diabetes, hypertension, heart attacks, strokes, dyslipidemia, sleep apnea, asthma, low back and disk disease, weight-bearing osteoarthritis of the hips, knees, ankles and feet, thrombophlebitis and pulmonary emboli, intertriginous dermatitis, urinary stress incontinence, gastroesophageal reflux disease, gallstones, and cirrhosis and carcinoma of the liver. In women, infertility, cancer of the uterus and cancer of the breast are also associated with morbid obesity.

Based on the prevalence of obese individuals and the surge in popularity of bariatric surgery, healthcare professionals in the surgical hospital environment can expect to encounter a growing number of obese patients. Many surgical hospitals are joining the ranks of healthcare systems that are better accommodating the special needs of this patient population -- but at a price. Studies have shown that in the last decade, obesity raised healthcare costs by an average of $395 a year, with healthcare expenditures for obese individuals totaling an estimated $117 billion annually, representing approximately 5 to 7 percent of overall healthcare costs.

The strain is showing at some hospitals. One healthcare facility has reported improvising by wiring two operating tables together to accommodate an obese patient, while another hospital has already introduced ceiling-mounted bariatric lifts above all beds. Other healthcare facilities have been installing floor-mounted toilets after some obese patients accidentally broke toilets off the walls.

Other ways healthcare facilities are coping with serving obese patients include renting an entire room from a vendor specializing in bariatric furniture and equipment that can provide walkers, commode chairs, wheelchairs, lifts and beds with a capacity of up to 1,000 pounds. The number of manufacturers of bariatric equipment is increasing rapidly as greater numbers of obese patients seek weight-loss surgical procedures or elective procedures, but their furniture, lifts and special accessories carry a significant price tag. Bariatric wheelchairs manufactured by Gendron provide 32-inch-wide seats, have a weight capacity up to 850 pounds and can cost from $680 to $4,130; the Burke Tri-Flex bed has a 1,000 pound capacity and costs $11,995; the Magnum II Bariatric Patient Care System from Hill-Rom is a bed that functions as a chair and transport vehicle that supports up to 600 pounds and costs $26,000-plus; and the UltraTwin FreeSpan lift from Liko has a capacity of 880 pounds and costs $11,000.

According to healthsafetyinfo.com, injuries caused by healthcare workers handling obese patients are increasing, and a significant number of healthcare facilities are scrambling to accommodate larger patients safely. In California, Kaiser Permanente is including several extra-large rooms for obese patients in each of the 30 new buildings it plans to build in 2003, while other facilities are considering the purchase of special lifts, scales with 800-pound capacities and operating tables able to withstand 1,000 pounds.

Facilities also are creating "lift teams," are holding inservices to teach healthcare providers about ways to safely work with obese patients and offering sensitivity training classes to office and clinical staff.

Some facilities are specializing in treating this special patient population. Many healthcare facilities view the growing popularity of bariatric surgery as a means to build their business and provide improved healthcare to the obese population in their community.

More than 500 bariatric patients are seen annually through Fresno Surgery Center's weight reduction program, according to Cheryl Miller, RN, director of clinical services and risk management for the Fresno, Calif. surgical hospital.

"Weight reduction surgery is a very serious surgery," Miller says. "Our patients have tried all other things and this is their last-ditch effort. They are very motivated because they either face total disability or a host of co-morbidities and even death. They have decided to make a significant lifestyle change."

Miller adds that the nature of the surgery demands rigorous compliance with program requirements, including the ability to walk 2 miles before they can have their surgery, as well as meeting mandatory attendance of a pre-op informational meeting and a post-op support group.

Miller says her staff members take the special considerations needed by an obese patient in stride. "They need close monitoring and observation during the first night due to sleep apnea or respiratory problems, plus you have added the component of anesthesia and pain medication. Another issue that must be handled carefully is the stress on staff because of patients' weight. They use a lot of help in the OR from the table, but we are putting them right onto their beds. We don't move them from gurney to bed because a lot of them don't even fit on the gurneys, and the gurneys have weight limits. We found it is easier to move them directly onto their beds. They also must be sure to have an adequate number of people to move the beds. As for the beds themselves, we make sure that our patients are comfortable in the beds, determining if a regular bed or a bari bed will best suit them."

Proponents of dedicated bariatric care support the concept of creating self-contained patient-care delivery rooms designed exclusively for obese patients. These rooms are equipped with mechanical ventilators, parallel bars, large bathrooms and hygiene aides, plus widened doorways and beds exceeding 60 inches in width (the standard hospital bed is 35 inches wide), as well as 36-inch wide wheelchairs and extra-large commode seats. It also may be more financially feasible than renting equipment individually, bariatric equipment manufacturers say. Demand for bariatric equipment began escalating at least a decade ago, bariatric equipment manufacturers say, with no let-up in sight.

The statistics alone support administrators' decisions to accommodate bariatric patients. The American Society for Bariatric Surgery (ASBS) estimates 57,200 such procedures were done in 2001, a 29 percent increase from 2000. In 2002, 60,000 individuals underwent weight loss surgery in the U.S., according to the ASBS. The number of surgeons specially trained in this field is growing, too; membership in the ASBS has grown about 30 percent in the last two years, for a total of 572 physicians. Some physicians are reporting bariatric surgery wait lists of up to two years.

The American College of Surgeons, recognizing the overwhelming demand for bariatric surgery, offers the following recommendations:

Create a professional team. Surgeons practicing bariatric surgery should be certified by the American Board of Surgery within five years after completion of an accredited residency program in general surgery. Bariatric surgeons also must acquire an understanding of morbid obesity as a disease and an intimate knowledge of the numerous diseases and conditions induced or aggravated by morbid obesity. They must understand there is an active collaboration with multiple patient-care disciplines including nutrition, anesthesiology, cardiology, pulmonary medicine, orthopedic surgery, psychiatry and rehabilitation medicine.

Consider patient indications and prerequisites. Not all obese individuals are candidates for bariatric surgery. The patient must be committed to the appropriate work-up for the procedure and for continuing long-term postoperative medical management, and understand and be adequately prepared for the potential complications of the procedure. Screening of the patients to ensure appropriate selection is a critical responsibility of the surgeon and the supporting healthcare team.

Evaluate healthcare facilities and personnel. In healthcare institutions recognized as accomplished in bariatric surgery, there is a demonstrated commitment to provide adequate facilities and equipment, as well as a properly trained and funded appropriate bariatric surgery support staff. Minimal standards in these areas are set by the institution and maintained under the direction of a qualified surgeon in charge of a bariatric surgery management team including experienced surgeons and physicians, skilled nurses, specialty-educated nutritionists, experienced anesthesiologists, and, as needed, cardiologists, pulmonologists, rehabilitation therapists and psychiatric staff. The operating room environment required by bariatric surgery has special operating room tables and ancillary equipment available to accommodate patients weighing up to 800 pounds or more. Appropriate bariatric retractors, staplers and long instruments must be available. Anesthesia for bariatric surgical procedures is performed by individuals specially trained in this area and regularly assigned to bariatric procedures as a member of the bariatric surgery team. Specialized OR staff familiar with the equipment, instruments, and procedures must be identified as members of the bariatric surgery team. The staff of the recovery room must be expert in the immediate postoperative care of the morbidly obese patient and their special needs, particularly for ventilatory support. The preoperative assessment of morbidly obese patients may require special radiology equipment. The perioperative care of morbidly obese patients requires special beds, chairs, and commodes. Nursing personnel are trained and skilled in giving respiratory care, assisting with ambulation and recognizing potential intravascular volume, cardiac, diabetic and vascular problems.

Advocating greater sensitivity toward obese or physically challenged patients on the behalf of healthcare providers are Syed M. Ahmed, MD, MPH, Jeanne Parr Lemkau, PhD and Sandra Lee Birt, who in an article in Family Practice Management say obese patients "often feel unwelcome in medical settings, where they encounter negative attitudes, discriminatory behavior and a challenging physical environment." The researchers further charge that these barriers to healthcare mean obese patients often skip the essential exams and tests that account for the increased health risks of obesity. A surgery center or surgical hospital's physical environment can affect the quality of an obese patient's experience, so owners/operators are encouraged to evaluate the facility in terms of its user-friendliness to an obese or physically challenged patient.

Ahmed, et al, write, "Sensitivity to the needs of obese patients may require attention to parking, office entry, furniture, medical equipment, supplies and even office reading material. You may even need to work with specialized vendors to address the many needs of this patient population. The initial cost of upgrading your practice may be offset by larger dividends in the long run as your practice becomes more accommodating to a broader range of clientele."

They suggest attention should also be paid to practice procedures, as obese patients may find it difficult to sit down and stand up repeatedly, so a limited number of "stops" during their visit can decrease the burden of mobility.

The following are modifications that can be made to accommodate obese or physically challenged patients:

Parking and practice entry

• Close parking for those with special needs
• Ramps and handrails at entrances
• Adequately sized doors and hallways

Waiting room

• Adequate number of large chairs with armrests or regular chairs without armrests and sufficient height to facilitate rising
• Patient-education materials that are friendly to obese patients and address relevant health concerns

Rest rooms

• Adequate size and number of rest rooms
• High, easy-rise toilets
• Adequate space surrounding toilets
• Handrails next to toilets
• Personal hygiene materials such as moist towelettes to facilitate cleansing

Exam rooms

• Scale with wide base and a capacity of weighing larger patients
• Larger blood pressure cuffs available