Accommodating the bariatric patient
Obesity in the United States is epidemic. According to the Centers for Disease Control and Prevention, 30% of Americans are considered to be obese.
That's a lot of people who face daily challenges in situations that others take for granted—getting up from a chair, fitting into a movie or airline seat, or finding clothes that fit or healthcare facilities that provide medical services sensitive to their condition. Obese people are also at higher risk for several diseases, including diabetes, high blood pressure, gall bladder disease, osteoarthritis, heart disease, stroke, and several kinds of cancer. It's no wonder, then, that obesity currently is listed behind cigarette smoking as the second-leading cause of preventable death in the United States.
Obese patients impact hospitals in two ways: first, by electing to undergo surgical intervention procedures that result in weight reduction, and second, by routine use of healthcare facilities, whether they be emergency rooms, nursing units, or doctors' offices.
For these reasons, the many accommodations that are made in bariatric-specific units must find their way into all other hospital areas. Specifically, healthcare providers need to consider the bariatric population in regard to spaces, equipment and supplies, furnishings, and operations when forming their design checklist. If patients feel isolated, or that they are drawing attention to themselves or are not being accommodated, they are less likely to return to the facility. And that, of course, affects the hospital's bottom line.
Is There a Standard?
Designers do not have bariatric-specific guidelines. Therefore, additional considerations should be made for the extra support and space required for bariatric patients and those who assist them with their daily activities—not just on special bariatric units, but throughout healthcare facilities.
For example, St. Vincent Carmel Hospital in Carmel, Indiana, had been offering bariatric surgery since 1998 but did not have a dedicated bariatric unit until opening one with 28 beds in spring 2003. In this case, focusing on the bariatric unit's goals helped guide some evidence-based design decisions that led to positive results after the unit opened. The functional design parameters of St. Vincent Carmel's bariatric unit allowed the designers to better respond to the design and operational standards that should be integrated in all hospital areas to meet obese patients' needs.
Patient sensitivity is an essential consideration in designing for bariatric patients. Designers should strive to keep patients from feeling alienated or restricted as they move through spaces during testing and treatment.
Seating is one essential interior design consideration that plays to patients' sensitivity. Today, more furniture companies are coming out with bariatric-oriented lines that look like nonbariatric chairs but provide more support and reinforcement (figures 1 and 2). In the waiting room and family lounges in St. Vincent Carmel's bariatric unit, all seating accommodates obese patients and family members. Since bariatric surgery patients require endoscopies, benches that accommodate them, instead of standard chairs, are included in all endoscopy patient rooms. Bariatric seating also has been integrated into every seating area in all other hospital waiting areas.
“You never want a bariatric-specific seating section,” says Dawn McDonald, interior designer for Maregatti Interiors, the company that designed the interiors for the St. Vincent Carmel's addition. “We mix bariatric chairs in with other furnishings so they have the same look and feel.”
McDonald explains that she doesn't place the chairs “front and center” in the waiting area or tuck them away in the back of the room, isolating the patients. Instead, she often provides love seats because they are discreet yet provide the extra room and stability larger patients need. As a general rule, 15 to 20% of waiting room chairs should accommodate obese patients.
Bariatric Unit Specifics
Bariatric unit spaces must be designed so that staff can easily maneuver larger equipment. The corridors and doorways (figure 3), not to mention equipment storage areas, have to be big enough to accommodate larger patients, wheelchairs, and gurneys, as well as family members who might be obese, as well. Recessed hinges in doors allow for a maximum amount of doorway width.
Bathroom size is another important consideration. The shower must be large enough to accommodate patients yet must be configured so they can still reach railings for support (figure 4). Those railings need to be structurally supported behind the wall to handle the extra weight. Floor-mounted toilets that are higher than standard toilets are essential. Often, custom fixtures must be installed to accommodate these extra requirements. Also, let's not forget removable showerheads with flexible hoses, which are ideal for bariatric showers.
In addition to specialized bariatric beds, patients' rooms (figure 5) should include bedside amenities such as refrigerators and freezers, so patients' bariatric-program–specific dietary supplements (e.g., Popsicles and certain beverages) are within easy reach. Additional bedside amenities that improve the experience include easy access to lighting, bedside computers, and phone, television, and thermostat controls. All bariatric patient room chairs should provide adequate seating, not only for the bariatric patient but also for family members.
Within the unit, a scale recessed into the floor (figure 6), with a grab bar, provides a safe and accurate weight reading. The scale is easy to use and should be discreetly placed within the unit. In hospitals years ago, overweight patients had to stand on a loading dock to get an accurate weight because standard scales did not accommodate them.
Accommodations Throughout the Hospital
Because obese patients seek services other than bariatric surgery, it's a good idea to integrate some features of the bariatric unit into all areas of the hospital. “I would recommend to any acute care hospital that is thinking of renovating to consider the needs of caring for their patient populations and evaluate the equipment they currently have so that the patients can be cared for appropriately and staff injuries can be reduced or prevented,” says Ted Eads, MSN, RN, Director of Bariatrics at St. Vincent Carmel Hospital.
Also, a percentage of standard hospital equipment—patient beds, wheelchairs, stretchers, gurneys, etc.—should be sized to accommodate obese patients. Patients should be able to get the tests they need with adequate radiology equipment and spaces. In addition, rehabilitation, surgical, and critical care units should all provide facilities to handle obese patients, and public restrooms in the hospital must have a stall that accommodates them, as well.
At St. Vincent Carmel, culture drove several decisions about what type of equipment and supplies it purchased. This is apparent in surgery, where beds with denser mattresses were purchased to accommodate obese patients who undergo back surgery. Larger surgical instruments and tables are also available for heavier patients.
Since cardiac problems and strokes are more common in obese individuals, the emergency department should be a particular focus when tailoring hospitals to these patients. St. Vincent Carmel only purchases emergency department beds if they support more than 550 pounds. Even supplies such as blood pressure cuffs and bedpans should be larger. Imaging equipment tables are available in larger sizes that can support more weight. Diane Anderson, RTT, manager of the Cardiopulmonary and Neurodiagnostics Department at St. Vincent Carmel, can recall patients exclaiming, “I actually fit in your x-ray!”
While lifts aren't needed all the time for bariatric patients, it is better to have them in case the need arises. “You don't want to go overboard with lifts, but you need to evaluate what you have and use common sense,” says Eads.
According to Brian Gregg, public relations manager for Hill-Rom, a global provider of products and solutions for healthcare, the demand for equipment and services that accommodate the bariatric patient has been on the rise: “With obesity doubling in the past ten years or so, it's no surprise that interest in the products, programs, and services in our bariatrics line has increased significantly.”
The statistics from before and after the unit's opening in April 2003 prove that St. Vincent Carmel is meeting its goals. The 28-bed bariatric unit is designed to have half of it converted for other uses if needed, but so far the unit has filled up quickly. The hospital has seen a 16% increase in volume, from 133 surgeries a month before the unit opened to 150 surgeries a month as of June 2005. The hospital also has reduced costs by an average of $815 per inpatient visit between 2003 and 2005.
Labor savings resulted from decreasing Hours per Patient Day (HPPD), from a budgeted 11.3 to an actual 10.2. Length of stay (LOS) has also declined. From April 2002 to June 2005, average LOS was 2.70 days for laparoscopic roux gastric bypass and 5.01 days for roux gastric bypass, two common types of bariatric surgery. From April 2003 to June 2005, average LOS was 2.02 days for laparoscopic roux and 3.81 days for roux.
One of the most impressive stats is the hospital's patient satisfaction percentage, which was in the 79th percentile among competing hospitals in April 2003 and soared to the 98th percentile a year later. It has now been open more than two years, and patient satisfaction has stayed at the 95th to 98th percentile the entire time. The overall satisfaction among surgeons increased from 4.02 on a 5.0 scale in April 2003 to 4.74 in April 2004. In fact, the bariatrics unit was the highest-scoring department in the hospital's quarterly survey of employee satisfaction.
All of this illustrates why designers must take an all-encompassing approach to creating spaces to accommodate bariatric patients. HD
Monte Hoover, AIA, is Chairman of BSA LifeStructures, and Keith Smith, AIA, is a Principal for BSA LifeStructures, based in Indianapolis, with an office in Chicago. BSA LifeStructures was the architect and engineer for the St. Vincent Carmel Hospital addition.
From a Patient's Perspective
James Lewis underwent laparoscopic roux gastric bypass surgery at St. Vincent Carmel Hospital. He had the advantage of knowing neighbors who had undergone the surgery and who could attest to a positive experience at the hospital.
Lewis's own positive experience began when he entered the hospital's new lobby, which features a soft color palette and textures, as well as a soothing waterwall and piano. “When you go into the hospital, you are already nervous, so anything to calm you down is good,” he said. He also commented that the design of the facility flows well, and that he appreciated the accommodating seating. “As a larger person, you notice things like seats. A lot of thought went into their design. During the pretesting and registration at the admittance desk, I remember thinking, ‘I actually fit in this chair and am comfortable.’” Lewis also noted that the staff did a great job explaining the steps of the procedure to keep his comfort level high.
The new private unit's layout fosters interaction among patients. That interaction wasn't possible before the addition, when bariatric patients shared space with other medical or surgical patients. “It's nice to be able to talk with people who are experiencing the same thing you are,” Lewis said.
Lewis noted that walking often is encouraged just two hours after surgery, not only to get patients moving but also to prevent dangerous blood clots in the legs. To foster this, the bariatric unit was designed in a “racetrack” layout. When patients walk around the unit four times, they have walked a mile and can track their lap distances on a “Lap Leaders” wipe-off board.
Also, as anyone who has worn a hospital gown knows, coverage is important, especially when walking around. Lewis noticed right away that the gowns fit, and the staff helped make sure everything was good to go before walk time.
Since Lewis's wife also went through the surgery, he has experienced being a visitor, as well as a patient. With two family lounges, a kitchenette, and no restrictions on visiting hours, St. Vincent Carmel's bariatric unit is conducive to visitors' comfort and convenience. Family can even stay overnight if they wish.
Patients are not in the facility long. For example, Lewis had surgery on a Wednesday and was home that Friday. Patients generally go home the very next day after gastric banding (lap band) surgery. A medical office building attached to St. Vincent Carmel is convenient for patients, who can see their doctors on the same campus where they had their surgery.
—Monte Hoover, AIA, and Keith Smith, AIA