Basic Concerns in Bariatics
Most healthcare facilities are unprepared to meet the special needs of extremely obese patients in terms of facility design and equipment planning. This remains true even though hospitals not affiliated with bariatric surgical programs are affected by the sharp increase in extremely obese patients. Consider these staggering statistics:
Data collected through the CDC's Behavioral Risk Surveillance System show that, in 2005, only 4 states had obesity prevalence rates less than 20%; 17 states had prevalence rates greater than or equal to 25%, of which three states had prevalence rates of 30% or more.
The number of people classified as overweight and obese has reached an all-time record high in the United States, with 64% of adults considered overweight, and as many as 30% of these individuals classified as obese.
One-quarter of the world's population is overweight, of whom 312 million are obese, according to the International Obesity Task Force (May 2004).
Bariatric surgery skyrocketed from 16,000 cases in 1992 to 103,000 cases in 2004.
Obesity is the second leading cause of preventable death in the United States, with approximately 280,000 adult deaths per year being attributable to obesity.
“Overweight” is defined as excess body weight characterized by a body mass index (BMI) of 25 to 29.9 kg/m2. The terms “extremely obese” or “morbidly obese” are used to describe individuals with a BMI greater than or equal to 40 kg/m2, or 35 kg/m2 with comorbidities. “Extremely obese” patients can range in weight from 250 to 1,000 lbs or more, depending on their height. Obese patients often have co-morbidities, including diabetes, asthma, hypertension, sleep apnea, hyperlipidemia, joint and back disease, gout, and heart disease.
Facility design issues related to safe, respectful, high-quality care of extremely obese patients are not the concerns of older facilities alone. Many recently constructed facilities have significant design issues when it comes to meeting the special needs of extremely obese patients. Currently, neither the American Institute of Architects/Academy of Architecture for Health or the American Disabilities Act provide specific guidance on physical design associated with care of extremely obese patients. Healthcare facilities must often rely on their own experiences or the experiences of other facilities in meeting these special needs.
Among the most significant design issues involved is patient ingress and egress because doorways are often not wide enough. Inadequate doorway widths (e.g., 34 inches) may make it difficult for an ambulatory bariatric patient using a walker to access a patient bathroom, for example. This access problem is even worse for a patient transported via wheelchair, considering that a bariatric wheelchair may have an overall width of 39 inches. Ingress and egress issues are exacerbated and often impossible to address for extremely obese patients being transported via a bariatric bed or stretcher in traditionally designed facilities, as a bariatric bed may be 41 inches wide and expand to 57 inches wide when side rails are put up.
Patient rooms present another design challenge. Existing patient rooms are often too small to meet the special needs of extremely obese patients. In determining bariatric room size requirements, focus on the primary space drivers in these rooms, which include space for such specialized equipment and furnishings as bariatric beds, resident lifts, bariatric wheelchairs, or oversized chairs.
Other patient room space drivers include maneuverability needs for both the bariatric patient and for the care team who are trying to safely and ergonomically assist the patient. Bariatric patients are likely to require assistance in transferring from a bed to chair or a chair to toilet. Depending on the patient's ability to bear weight, level of cooperation, and upper body strength, two to three caregivers may be needed to assist the patient using a patient lift to safely and ergonomically transfer the patient from a bed to a chair.
The typical size of a bariatric room large enough to accommodate all this was addressed by the Bariatric Room Advisory Board, a group of clinicians, designers and equipment planners assembled by the manufacturer Hill-Rom. The Advisory Board concluded that the optimal room size for extremely obese individuals would be 14″ × 15″.
Patient bathrooms may present another design challenge. Toilets may have insufficient weight capacity, especially if they are wall-mounted. In addition, the height of the toilet and space limitations around the toilet may make it difficult for the bariatric patient to sit down or stand up. Grab bars can assist, but because grab bars typically have a maximum load capacity of 250 lbs, they are clearly insufficient for most bariatric patients. In addition, open space in bathrooms or showers may not be sufficient for caregivers to provide required assistance.
Design considerations for bariatric patient bathrooms include the need for floor-mounted toilets with increased heights to facilitate ease of sitting down and standing up and sufficient space around the toilet to allow for unrestricted movement. Reinforced grab bars are a must. The shower stall should have a sufficient opening and space for unrestricted movement by the bariatric patient and, if necessary, staff performing assists. In addition, space for adaptive equipment such as wheelchairs and lifts is essential to plan for.
Other design issues to consider include public corridors that may not be wide enough to transport a patient in a bariatric bed. Elevators along those corridors may present another challenge, as they may have inadequate door width, overall size, and weight capacity. Most hospital elevators have an average weight capacity of 2,000 to 3,000 lbs, a capacity that may be exceeded when the weight of the bariatric patient, bed, transport staff, and specialized equipment are added together. Some hospitals have resorted to using freight elevators to transport bariatric patients, which can be embarrassing and demoralizing for the patient. Determining the best and safest routes and designated elevators for transporting extremely obese patients is important during planning.
Equipment Planning Issues
Many hospitals are unprepared for meeting the special equipment needs of extremely obese patients. It's not uncommon, for example, for extremely obese patients to be weighed on a hospital's freight or laundry scale when an accurate weight is needed to calculate a medication dose. A far worse potential scenario is the possibility of a caregiver approximating the weight of an extremely obese patient only because a scale with sufficient weight capacity was unavailable.
As mentioned above, many hospitals do not have sufficient specialized equipment to assist in bariatric patient transfer and movement. The National Safety Council reports that a healthcare worker is 41% more likely than the average worker to need time off because of serious occupational injuries and illness. The potential for staff injury is most significant when a task involves heavy physical work, including when the worker is bending, twisting, or otherwise awkwardly positioned, as well as when the employee employs faulty lifting techniques or body mechanics. Implementing a manual-lift–free environment to minimize the risk of injury to patients or caregivers is extremely important. It is essential that hospitals have an adequate number of bariatric-specific patient lifts strategically placed throughout the facility in any areas that are likely to care for extremely obese patients.
Standard hospital beds may be insufficient in size and weight capacity for bariatric patients and lack features that support specialized bariatric care. Standard wheelchairs and stretchers also are inadequate for transporting most extremely obese pa
tients. Oversized bariatric wheelchairs and bariatric beds may be required for basic safety.
Basic patient room furnishings, such as chairs, may lack the size and weight capacity needed for bariatric patients. Standard chairs with arms are a particular problem in this regard, as there may not be enough space between arms for patient use. The same furniture issues apply to waiting areas, public areas, and elsewhere.
Some common equipment considerations for all hospitals include the following:
Bariatric beds. Primary considerations include weight and size capacity, ranging from 600- to 1,000-lb weight capacity, in addition to specialized features, such as in-bed scales and a mechanism to raise the head of the bed while lowering the foot of the bed, bringing the patient to a sitting position and thus better able to get in and out of the bed
Scales. Check the weight capacity of scales since many standard models will not accommodate the weight of bariatric patients. Scales suitable for extremely obese patients include those incorporated in the patient bed, as well as wheelchair-accessible scales and standing scales with built-in hand rails.
Physiologic monitors or sphygmomanometers. Extra-large blood pressure cuffs are an essential accessory for measuring the blood pressure for extremely obese patients.
Patient lifts. Patient lifts are available in portable lifts or fixed versions. Portable lifts cost less and provide greater flexibility in that they can be moved from room to room, as needed. Fixed lifts usually have an overhead track system, and may be best suited to dedicated bariatric areas. These are typically custom configured as single-track or room-covering track configurations, therefore close teamwork is essential among designers, equipment planners, and clinicians to appropriately engineer this installation.
Bariatric wheelchairs. Bariatric wheelchairs are a must for extremely obese patients' mobility needs.
Bariatric stretchers. These are available with weight capacities of up to 700 lbs. However, many facilities consider placing bariatric beds in the emergency department or postanesthesia care unit, or even as transportation devices in lieu of stretchers to reduce the need to transfer an extremely obese patient from bed to stretcher and vice versa.
Diagnostic imaging systems. Primary considerations for imaging systems for bariatric patients include bore size, table capacity, and image quality. Bore size is a critical factor when evaluating the potential use of an imaging device for extremely obese patients, as standard bore sizes may be too small. Few CT scanners are able to accommodate patients weighing more than 300 lbs. Table capacity also varies among models. Bariatric-capable systems and open MR units can often accommodate patients up to 550 lbs. In general, the weight capacities of current and future systems should be reviewed in detail.
Operating room tables. The weight and size accommodations of operating room tables must be able to accommodate the individual patient while maintaining full articulation capabilities. Bariatric operating tables are available from several manufacturers.
Furnishings. Oversized chairs should be available in public areas such as lobbies and waiting rooms. Oversized patient chairs are essential in exam rooms and other patient areas. This, of course, also requires more floor space for these areas.
ECRI recommends several strategies to effectively address the special needs of bariatric patients in terms of facility design and equipment.
Charge the design/planning team with the overarching goal of providing safe, respectful, high-quality care for extremely obese patients.
Designate a multidisciplinary team to assess bariatric-related facility design and equipment needs throughout the continuum of in-hospital care.
Consider the following essential design factors: ingress and egress requirements, optimum transport routes, space requirements (for the patient, specialized equipment, and the care team to safely and ergonomically maneuver), and the need for fixed adaptive equipment (e.g., reinforced grab bars).
Incorporate provisions meeting the special needs of extremely obese patients in all renovation/construction projects.
Consider equipment needs for each individual patient, keeping in mind that one size does not fit all. Verify that the weight and size capacity of the relevant specialized equipment or furnishings meet the special needs of the individual patient. Just because equipment has been labeled by vendors as “bariatric” doesn't mean that it will accommodate any bariatric patient. Listed capacities differ, for example.
Maintain par levels of specialized equipment in areas that frequently care for extremely obese patients (e.g., emergency department), based on anticipated utilization demands.
Consider storage availability and constraints for specialized equipment.
Considering obesity trends and the skyrocketing increase in bariatric surgical programs, hospitals should plan to address the special design and equipment needs of extremely obese patients in both their short- and long-range planning. These needs should be addressed not just in particular care areas, but throughout the healthcare continuum. HD