Room For All: Trends In Bariatric Healthcare Design
Five years ago, Mercy Health was planning a new 645,000-square-foot community hospital on the west side of Cincinnati that would offer inpatient services, ambulatory clinical needs, and an expanded cardiology program. The 250-bed facility would also incorporate three designated bariatric rooms with adjoining bariatric toilet rooms; dual-leaf, 5-foot-wide non-corridor doors; operating tables with 600-pound weight limits; a CT scanner with a bariatric table; and 600- and 1,000-pound patient lifts in ICU rooms.
“If you’re a good community hospital and you want to meet the needs of your patients, you have to recognize that your patient population is growing in size and diagnostic problems,” says Larry Bagby, Mercy Health project manager for the West Hospital.
It’s a wake-up call that’s been heard by many healthcare organizations over the last decade, as the correlation between the escalating epidemic of obesity in the U.S. and its effect on patients, staff, and facilities has become clear.
“Back in the day, you always had some toilet fixture or grab bar falling off a wall because it wasn’t anchored correctly. Whether it was a hospital or a nursing home, no one was ready for that type of population,” says Michael Zambo, principal, Bostwick Design (Cleveland). “They just dealt with it as a patient-by-patient issue.”
Today, more than one-third of U.S. adults (36 percent) and approximately 17 percent of children and adolescents ages 2-19 are obese, according to the Centers for Disease Control and Prevention (CDC). And in June, the American Medical Association (AMA) designated obesity as a disease. “The purpose of the policy is to advance obesity treatment and prevention,” AMA president Ardis Dee Hoven said in a June 25 blog post. “It issues a call for a paradigm shift in the way the medical community tackles this complicated issue.”
With the medical community poised to potentially heighten its focus on obesity, the population of patients coming into facilities could be on the rise, too, further emphasizing the need for well-designed bariatric accommodations.
Initial approaches to bariatric design centered on patient rooms and toilet facilities, according to many designers, but today focus is on the patient’s entire journey and care continuum.
“You need to look at it more holistically: How is the patient coming in? Is the door wide enough? Does your waiting room have furniture that can handle a 500-pound load?” says Henry Chao, principal, healthcare design director, HOK (New York). “All these play into the design issue.” Peter Grandine, senior medical planner, HOK (San Francisco), agrees: “If you can’t get a bariatric wheelchair in the front door, then that patient can’t be treated. You need to think about it from their arrival to their exit.”
Defining the issue
While most owners recognize the need to address spaces to better support a bariatric population, there’s no minimum weight requirement or code to follow. Further complicating matters is the lack of a standard for what defines a bariatric patient. Designers often specify products that are based on weight or design to a specific carrying capacity, while the CDC uses body mass index to define obesity. Rates of occurrence also vary around the country, making it difficult to develop requirements that would be universally appropriate (See chart in image gallery).
The Facility Guidelines Institute (FGI) was one of the first to offer some guidance when it published the 2010 edition of the Guidelines for Design and Construction of Health Care Facilities with recommendations for bariatric accommodations. These guidelines remain the most widely adopted source of information for the industry.
In the 2014 edition, which will be released early next year, most of the specific pound requirements that were included in the 2010 language were challenged and removed. For example, while the 2010 guidelines stated grab bars intended for use by bariatric patients shall be designed and installed to sustain a concentrated load of 1,000 pounds, the 2014 version will keep the standard open to interpretation and suggest that that load be determined during the design phase.
“In the process of writing minimum standards, there’s a lot of debate on what is truly a minimum weight, size, spatial need, anchoring strength for grab bars or lifts, and other criteria for accommodating the morbidly obese,” says Doug Erickson, chair, 2010 and 2014 Health Guidelines Revision Committee. “Therefore, the 2014 edition hasn’t made significant modifications to the requirements for bariatric accommodations.”
That leaves healthcare organizations to look at their patient populations and predict future needs in order to set standards, with some leaving it up to individual facilities. For example, in 2010, when Mercy Health partnered with AECOM (Los Angeles), Mic Johnson (Minneapolis), Champlin Architecture (Cincinnati), and Turner Construction Co. (New York) on its West Hospital, the team decided it wanted “to be able to meet most needs and even the episodic occasional need,” Bagby says.
Brent Oberholzer, architect of record, Champlin Architecture, says the approach starts in the ED with trauma and critical care rooms that are equipped with 1,000-pound-capacity patient lifts. The ED also houses a bariatric toilet, while throughout the facility, the decision was made to use all floor-set toilets that have a 1,000-pound carrying capacity. “For many years, the industry used wall-hung toilets for ease of cleaning,” he says. “But the floor-set [toilet] is becoming standard because it simply has a capacity to support a full range of patient sizes.”
Bostwick’s Zambo says he usually asks a facility early in the design phase about its bariatric population and if it’s a chronic problem. “If it is, we ask them to define what weight they typically see and what we should design for,” he says. “Many times in the OR and imaging suites, it’s determined by the capacity of the tables. In most cases, we’re seeing 400 to 500 pounds.”
When assessing how and where to implement bariatric design elements, owners must also consider construction costs. Experts says it’s hard to put a dollar figure on the cost difference between a standard patient room and a bariatric patient room, but note that furniture with steel reinforcements to hold a 500-pound person, for example, has a higher price tag. There are also costs associated with grab bar reinforcements or rearranging HVAC and lighting systems to install a ceiling lift. Bariatric rooms also require a larger square footage.
Opportunity despite obstacles
While these design changes better accommodate bariatric patients, there are other benefits, too. For instance, in 2009, Mercy Health introduced its Living Injury Free Together (LIFT) program into six hospitals and six long-term care facilities, installing a variety of lift devices and tools to help staff move patients. As a result, patient handling incide
nts dropped 95 percent from 2009-2012, while workers’ compensation costs were dramatically reduced. (For more on this program, see the sidebar at the end.)
Others say there’s an opportunity to create a niche in the community. “If your facility has accommodations for bariatric patients, they’re more likely to come to your facility, so you can recoup some of the initial cost from that standpoint,” says Craig Pickerel, architect at SSOE Group (Toledo, Ohio).
Pickerel has also had some clients who didn’t have the budget for full-scale bariatric design but put in the infrastructure for patient lifts to make it future-ready. “Especially with new construction, it’s best to build it in there while you’ve got everything opened up,” he says.
Designing with dignity
Whether it’s new construction or a retrofit project, there are different strategies for accommodating bariatric patients. For instance, a hospital might create a bariatric unit or add bariatric rooms to an existing wing. “From an ongoing financial perspective, the organization has to consider whether specialists will travel to a bariatric unit for a heart patient, for example, or provide bariatric accommodations on the heart unit to lessen time and cost of specialists moving between units. There are pros and cons to both scenarios,” says Debra Harris, CEO, RAD Consultants (Austin, Texas).
Travel routes also need to be considered by installing wider doorways, replacing some swing-door entrances with sliding doors, or expanding elevators and hallways to accommodate larger beds and wheelchairs, for example.
Designers say another important factor that can’t be overlooked is making bariatric design feel inclusive and part of the overall aesthetic. “You have to design it in such a way that it doesn’t stand out,” Zambo says. For example, Pickerel says that on a recent ICU project, SSOE’s design team replaced a standard walk-in shower with one that had shower equipment that could be used either mounted on the wall or hand held. For a bariatric patient, caregivers could assist the person by turning the entire bathroom into a shower room. “Flexible design can help make it look not so superficially designed for a bariatric patient,” he says.
Another idea, HOK’s Grandine says, is applying changes across the board, such as specifying larger door sizes for exam rooms. One area that’s getting easier to address is the waiting room, as more manufacturers introduce seating options with designs and upholstery styles that resemble existing furniture lines. “The larger bariatric seats look like a loveseat so the patient gravitates toward those, and then there would be several of them so it doesn’t really stand out,” he says.
Bariatric design has become a regular topic within the healthcare design community, but there’s still more to be done. “The awareness is in place,” says Champlin’s Oberholzer. “The challenge is going to be with our existing facilities and retrofitting. It’s difficult and it gets expensive.”
Many designers also point to the need for minimum design requirements (not just guidelines), similar to ADA, to help outline issues such as weight limits, door widths, accessibility, clearances, and equipment needs.
There’s also the desire for research to show if all these efforts are on the right track. “When you hear the nursing staff isn’t using the lifts because they’re hard to use or whatever it may be, then why did we make all that effort?” says Bostwick’s Zambo. “There has to be a little bit of validation to know if it’s working.”
Mercy Health gives nurses a LIFT
In 2009, Cincinnati-based Mercy Health says its nursing staff was regularly seeing 450-pound patients, so frequently that the staff moved about 88 million pounds that year without assistance from equipment or moving devices. The result was a rising rate of staff injuries and patient handling incidents.
“Our nurses racked up 2,470 restricted duty days, 239 lost time days, and a quarter of a million dollars in workers’ compensation costs, not to mention extra costs for temporary staff and lowered morale,” says Kelley Crandell, director of disability management and employee health services for Mercy Health.
There was also concern that these work injuries would be a red flag to the Occupational Safety and Health Administration and lead to a time-consuming inspection on employee safety.
After recognizing these issues, Crandell talked to management about investing almost $5 million in equipment to help nurses move patients safely. The new Living Injury Free Together (LIFT) program would provide such tools as ceiling lifts in all intensive care units, mobile passive lifts for dependent patients, non-mechanical devices to help patients to the bathroom, and maxislides/tubes for repositioning patients in bed.
Once the program was approved for Mercy Health’s six hospitals and six long-term care facilities, Crandell faced the challenge of convincing the nurses that the new program wouldn’t add time to their workload and in fact was more comfortable and dignified for both nurse and patient. “They saw work injuries as a regular job hazard,” she says.
Four years into the program, Crandell measured the results:
• Patient handling incidents dropped 95 percent, from 135 in 2009 to six in 2012
• Restricted days fell 98 percent, from 2,470 to 30
• Lost days decreased 99 percent, from 239 to two
• Workers’ compensation costs dropped 99 percent, from $286,950 to $1,849.
Source: Mercy Health
Since its inception, the program has been expanded to other health systems under Mercy’s parent company, Catholic Health Partners, including a hospital in Springfield, Ohio, and seven other long-term care facilities.
Anne DiNardo is senior editor of Healthcare Design. She can be reached at firstname.lastname@example.org.