A nurse takes a report from the Emergency Department regarding Joe, a 748-pound patient with a Stage III right buttock pressure ulcer from months of bed rest and respiratory failure related to bronchitis and probable obesity hypoventilation syndrome. The patient arrives to the respiratory step-down unit on a bed that is too small to accommodate his size comfortably. His legs are extending beyond the sides of the bed, his hospital gown is too small and he is visibly uncomfortable. He is too embarrassed and fearful to ask for help. Joe is fearful because of the pain he knows he will feel with movement, but also fearful that because of his weight he may injure his care givers.
Vanessa is the nurse who takes the report from the emergency department. She is told that a bariatric bed was ordered for Joe, but it is unknown when the bed will arrive or if it will accommodate his weight. The pressure ulcer was not assessed in the ED, and the patient was incontinent upon his transfer from the ED and requires a complete bed change. The unit is short staffed and Vanessa is concerned about providing appropriate nursing care to the patient, being mindful of the patient's need for dignity and her own fears that she may injure herself without adequate staff and equipment appropriate for the patient's size.
The bariatric bed arrives minutes after the patient is brought to the floor. The staff is unfamiliar with the bed and they are not sure how to operate it. Both beds will not fit in the patient room, so the patient ends up being transferred from one bed to another out on the unit and not in the privacy of the room. The hospital has equipment available to help with safe transfers; however no one knows where the equipment is stored or how to use it. Joe is transferred to the other bed with the assistance of seven caregivers. The nurses have trouble fitting the bed into the patient room and don't realize that the bed can be deflated for easier transfers. Joe is exhausted and embarrassed by the process and asks to be left alone.
Defining the Problem
This scenario is all too common in hospitals across the United States. Often times, the complex and labor intensive care needed to adequately meet the needs of the obese patient population is deficient due to lack of resources, knowledge and sufficiently trained staff.
The epidemic of obesity has significant healthcare implications for the United States. An estimated 36.5% of U.S. adults are considered obese by definition of their BMI. 1 Obese patients spend 42% more on healthcare costs than adults who are of a healthy weight.2 This is of great consequence in the hospital setting as a preponderance of patients who are admitted are then considered overweight or obese.
Obesity complicates all aspects of healthcare especially in the hospital setting. Obese patients often require more frequent and intense health care than non-obese patients due to obesity-related conditions such as diabetes, hypertension, joint disease, gastric reflux, heart disease, incontinence, respiratory problems, sleep apnea, cancer, pressure ulcers, and soft tissue infections. 3
Addressing the Challenge
Hospital staff must then take special considerations with the admission of an obese patient. Concerns regarding equipment include the availability of appropriate size beds, commodes and chairs. Nurses must consider the feasibility of walkers, manual and electronic lifts, transfer devices, and other equipment to improve and facilitate mobility. Diagnostic equipment must be designed with the obese patient in mind, including adequately sized CT scans, blood pressure cuffs and other diagnostic equipment. Bedside nurses need to learn assessment techniques appropriate for the obese patient population and potential complications. Physical therapy, occupational therapy, dietary, respiratory therapy, pharmacy and social work must be partners in the care of this population and well-informed about their unique needs.
An evidence-based practice (EBP) review was undertaken at a 526-bed urban hospital in upstate New York in order to research best practices and improve the care of the obese patient population. The product of the EBP review was the creation of an evidence-based multidisciplinary clinical practice protocol to guide the care of the bariatric patient. The protocol details the following areas:
Pulmonary and Cardiac Considerations
Common Skin Considerations and Treatments
Selection of Appropriate Patient Equipment/Where it is located
Safe Patient Handling Guidelines
Evidence-based clinical practice protocols are useful tools if they are readily available at the point of care. The protocol was made available electronically within the health system's electronic documentation system. All nurses working within the healthcare system received education on the protocol and completed a post-test to document their understanding. In addition, during yearly hospital mandatory education, a lead physical therapist teaches all hospital staff how to use bariatric equipment needed by obese patients, such as mechanical and lateral lifting devices. This education reduced the number of injuries directly related to lifting.
Several improvements in care have been made as a result of the EBP review:
A process for ordering equipment that is appropriate for the obese patient population
A list of all lift equipment available to staff with weight capacity
Yearly education to reinforce the use of lifting devices and safe transferring techniques
Development of expert resources and consultation services
Protocol that is available electronically at the point of care
Mary was admitted to the step down unit from the intensive care unit. Mary was a 530-pound patient with respiratory failure, failure to wean requiring a trach, osteomyelitis and depression. Mary had been confined to her home for the past two years and had not stood in over a year.
The inter-professional team worked together to provide evidence-based care to the patient to meet her goal of attending her daughter's college graduation. The physical therapist and the nurse practitioner worked together to formulate a plan to help Mary to walk again with the help of assistive devices. The clinical nurse specialist educated Mary's family and the nursing staff on the mobility devices Mary would need ensured her care plan was carried out. The respiratory therapist and pulmonologist worked together to maximize Mary's pulmonary status and came up with a plan for weaning which eventually allowed her to only require oxygen. The dietician worked with Mary and her family for appropriate weight loss, and the social worker helped plan a safe discharge plan for home. Mary attended her daughter's graduation.
Mary's story illustrates that patient-first care to the bariatric population that can be provided using an inter-professional team and standardized protocol.
1. Centers for Disease Control (2016) Adult Obesity Facts. https://www.cdc.gov/obesity/data/adult.html
2. Robert Wood Johnson Foundation (2016) The State of obesity. http://stateofobesity.org/rates/
3. Galinsky, T., Hudock,S., and Streit,J. (2010) Addressing the need for research on the bariatric patient. Rehabilitation Nursing, 35(6), 242-247.
Lori Dambaug is an assistant professor of nursing and clinical nurse specialist track coordinator, Wegmans School of Nursing, St John Fisher College, Rochester, New York. Margaret M. Ecklund is an advance practice nurse working as a clinical nurse specialist with the wound, ostomy, and skin care team for Legacy Health, Portland Oregon.