Obesity is a rapidly increasing problem in the U.S. and worldwide. An unprecedented number of obese and overweight people live in the U.S., with approximately 68% of the population affected by this chronic health issue.1 Obesity affects every organ system and is a disease associated with significant morbidity and mortality as well as reduction in quality of life.1-2 In 1991, the National Institutes of Health (NIH) issued a consensus statement in support of gastrointestinal surgery for severe obesity.3
Weight loss surgery, as a justified modality for the treatment of obesity, is substantiated by numerous studies.4-5 In fact, surgical intervention is now considered the only effective and acceptable treatment for weight loss and long-term management in the morbidly obese patient population.6 The increased demand for surgical weight loss as a treatment of obesity has resulted in an influx of patients in the healthcare setting ranging from surgical centers to long-term care facilities.
The National Health and Nutrition Examination Survey (NHANES) of 1999-2004 cited overweight and obesity among Americans 20 years and older at a distressing 66.3%. These figures included a body mass index (BMI) of overweight (BMI≥ 25.0 kg/m2), obese (BMI≥ 30.0 kg/ m2), and morbidly obese (BMI ≥40.0 kg/m2). With increased BMI comes an increased burden of disease.3 Obesity related co-morbidities include type 2 diabetes, lipid disorders, cardiovascular disease, hypertension, and arthritis and joint pain and quite often these conditions lead a patient to seek care.6 Healthcare workers cannot help but notice the increased strain obesity and related conditions has placed on our healthcare systems, the care environments, and personnel in all practice settings.
The safe patient handling movement has received significant attention in Washington over the past few years. Many hospitals and extended care facilities have voluntarily organized and implemented safe patient handling programs prior to legislative requirements mandating this. Organizations now exist to help promote safe care. The Obesity Action Coalition (OAC) is the only non-profit organization whose sole focus is representing individuals affected by obesity. OAC was founded in 2005 and remains at the forefront of the fight against obesity, advocating on Capitol Hill for access to obesity treatments, and promoting safe patient care. OAC represents the voice of all those affected by the disease of chronic illness.
Healthcare organizations should determine if their facilities can accommodate the unique requirements of the growing population of patients who are obese, as well as the increasingly overweight employees caring for this patient population.7 If an adequate environmental assessment is performed, healthcare facilities can not only reduce their risk of liability, but they can better serve the bariatric patient and define quality patient care. In today's sea of change in the healthcare market is increasingly competitive. This competition can lead to increased consumer satisfaction, efficiency, profitability, professional standing and safety. A growing number of insurance companies require healthcare facilities meet specific criteria to be considered competent to care for obese patients and maintain standards set for safety and quality care.
Many bariatric patients admitted into healthcare facilities, especially long-term care facilities, will require assistance with bathing, hygiene and toileting.8 Concern about the safety of those who provide direct patient care has been ongoing. This concern has been heightened in the past decade as the number of work related injuries has increased. With rising rates of obesity it has been estimated that a nurse or healthcare worker who provides direct patient care lifts an estimated 1.8 tons in an average workday.9Obese patients often feel unwelcome in medical settings where they often encounter challenges in the physical environment.
Physical size of people who are obese may result in numerous limitations to include mobility, positioning, environmental access (such as to bathrooms), as well as use of medical equipment designed to accommodate those patients of lower BMI. The Veteran's Administration (VA) has been instrumental in developing guidelines to protect the safety of both the patient and caregiver. The Bariatric Toolkit10, developed through the VA Patient Safety Center, include seven safe patient handling and movement algorithms to guide sensitive and appropriate care. The Toolkit is available online.
The Bariatric Toolkit facilitates staff understanding related to the unique handling needs and movement challenges related to the obese patient. Objectives of the Toolkit include: familiarizing staff with technical solutions currently available, to identify when these specialty handling tools should be utilized, how to implement the safety algorithms for equipment selection, to review features of bariatric policy, and to help with decisions on whether to buy versus rent equipment to assist in patient care. Algorithm # 7 focuses on bariatric toileting tasks.
Considerations when assisting a patient with hygiene and toileting include a thorough risk factor assessment. Potential risks include slippery or wet surfaces, uneven flooring, obstructions on floor surfaces, physical obstructions (commodes, furniture), physical spaces too small or difficult to access, doorways that are too narrow, poorly arranged furnishings, poorly designed bathing areas, poor design of chairs, and uneven work surfaces (between caregiver, bed, wheelchair and toilet).10
Best Practices for Safe Handling of the Morbidly Obese Patient were developed and published in 2007 by a safety task force formed by the National Association of Bariatric Nurses (NABN). Findings, which were summarized after a careful review of the literature, conclude that several factors impact patient and caregiver safety. The patient's ability to assist, cooperate and to bear weight are important considerations. An awareness of the patient's upper body strength is also essential. Use of appropriate assistive devices, teamwork and staff education are necessary.11 Unfortunately, the taskforce noted a lack of nursing research in this area.
The key to safe patient care and a safe clinician work environment is an ongoing analysis of the work environment and the tasks required while using an ergonomic focus. There is greater risk of both staff and patient injury in long-term care facilities and when comfortable body postures cannot be sustained. Teamwork or lift teams can alleviate some of this risk and can achieve safer more comfortable care for the patient.
Proper preparation, dissemination of knowledge, and use of an experienced interdisciplinary team are essential for safety as well as maintaining patient-sensitive quality care. Today's healthcare leaders must recognize the challenges of larger patients, use necessary algorithms and equipment, educate staff, and promote patient and staff safety all while providing quality care. The field of safe patient handling for the bariatric patient is developing at a rapid pace, and new technology will help meet the growing demands and ultimately improve safety for all involved in the healthcare environment.
1. Schroeder R, et al. Treatment of adult obesity with bariatric surgery. Am Fam Phys. 2011; 84(7): 805-814.
2. World Health Organization. Controlling the global obesity epidemic, 2008. http://www.int/nutrition/topics/obesity/en/
3. Petitpain D, et al. Preoperative vitamin D status in potential bariatric surgery patients. Bariatric Nursing and Surgical Patient Care. 2010; 5 (3), 255-260.
4. Adams TD, , et al. Long-term mortality after gastric bypass surgery. The New England Journal of Medicine. 2007; 357(8), 753-761.
5. Coupaye M, et al. Nutritional consequences of adjustable gastric banding and gastric bypass: a 1-year prospective study. Obesity Surgery. 2009; 19, 56-65.
6. Al Harakeh AB, et al. Natural history and metabolic consequences of morbid obesity for patient denied coverage for bariatric surgery. Surgery for Obesity and Related Diseases. 2010; 6, 591-596.
7. Lockton Companies, LLC. Ten safety steps to enhance bariatric patient care. January 2012. Retrieved from: http://www.lockton.com/
8. Muir M, et al. Safe patient handling of the bariatric patient: Sharing experiences and practical tips when using bariatric algorithms. Bariatric Nursing and Surgical Patient Care. 2008; 3(2), 147-158.
9. Whipple KL. Maximizing healthcare provider safety while rehabilitating the bariatric patient. Bariatric Nursing and Surgical Patient Care. 2008; 3(1), 41-45.
10. U.S. Department of Veteran's Affairs. Safe bariatric patient handling toolkit. 2012. http://www.visn8.va.gov/visn8/patientsafetycenter/safePtHandling/toolkitBariatrics.asp
11.McGinley LD, et al. Best practices for safe patient handling of the morbidly obese patient. Bariatric Nursing and Surgical Patient Care. 2008; 3(4), 255-260.
Laurie McGinley is Bariatric Program Manager, Western Bariatric Institute, Reno, Nev.