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Health care community responding to obesity epidemic
Staff training, equipment, imaging techniques are changing to accommodate the increasing needs of obese patients.
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In response to the growing number of obese, morbidly obese and super obese patients, various adaptations are being made in the health care community, with changes needed at nearly every level of response — from emergency vehicles to gurneys to hospital rooms. These changes include investment in new equipment that can handle more patients who strain the limits of standard equipment, as well as revised training for staff who need to learn how to safely lift and move heavy patients.
An American Society for Metabolic and Bariatric Surgery Center of Excellence at The Ohio State University Medical Center is an example of one health care facility that is adapting to the growing epidemic, with dedicated rooms to the care of very large patients.
“In every city, you will see 25 people out of 100 that could be close to 100 lb overweight, but you may see only one to two in 1,000 who are 200 to 400 lb overweight. These patients are classified as super-super obese or mega obese. Those are the patients who need the most help. They get shunned, however, both in the public’s eye and within the industry,” said Dean J. Mikami, MD, assistant professor of surgery in the division of general and gastrointestinal surgery at The Ohio State University Medical Center.
Mikami’s hospital has taken steps to address these patient’s growing needs, with the addition of extra large beds, extra large doorways, extra large bathrooms, extra strong handlebars. Lift machines are installed in the rooms so that nurses do not have to carry or wheel an extremely obese patients from one bed to another.
“All of the furniture in those rooms is steel reinforced to hold a patient who can weigh up to 750 lb,” he told Endocrine Today.
It is one of the 310 hospitals and institutions in the country designated an ASMBS Center of Excellence, meaning it must have performed at least 125 bariatric surgeries per year collectively and that the facility has a dedicated multidisciplinary bariatric team.
Obesity rate increasing
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Photo by Jeff Bates |
According to the CDC, the prevalence of obesity has continued to grow over the past decade. More than 93 million Americans are obese, with that number expected to climb to 120 million in the next five years. More than 8 million Americans are morbidly obese, defined as weighing more than 100 lb over ideal body weight or having a BMI >40.
In 2006, only four states had a prevalence of obesity less than 20%, according to CDC data. Twenty-two states had a prevalence about 25% or greater; two of these states (Mississippi and West Virginia) had an obesity prevalence that topped 30%.
The largest increase in obesity has been in the group with a BMI that exceeds 30 — about 59 million American adults — a prevalence that has doubled since NHANES II (1976 to 1980), according to The Obesity Society. Those people, at significant health risk, may eventually require emergency care, diagnostic imaging tests, and a stay in a facility that must be able to respond to their needs.
“Roughly 65% of the population is overweight or obese, so we should be concerned about having appropriate equipment,” Stephen Rosen, MD, chief of endocrinology, Pennsylvania Hospital in Philadelphia, told Endocrine Today.
Pennsylvania Hospital and the Hospital of the University of Pennsylvania, two separate hospitals in the University of Pennsylvania Health System, are ASMBS Centers of Excellence.
“We established a bariatric center of excellence in recognition of the growing problem within the population — that roughly 75% of the population is overweight or obese and 41% are obese,” Rosen said.
Cost of care
According to a study of national costs attributed to both overweight (BMI 25 to 29.9) and obesity (BMI > 30), medical expenses accounted for 9.1% of total U.S. medical expenditures in 1998 and may have reached as high as $78.5 billion ($92.6 billion in 2002 dollars), according to data from the CDC.
Obesity-attributable medical expenditures ranged from $87 million in Wyoming to $7.7 billion in California in 2003, CDC data indicate. The cost associated with obtaining appropriate medical equipment for treating obese individuals can vary from a minor to a major expenditure.
“To adapt a blood pressure meter for larger arms is relatively inexpensive, yet special chairs can cost over $1,000 and lifts are even more expensive. The costs may be different for each health care facility,” Rosen said.
His hospital has adapted to the changing needs of patients, with special chairs, larger scales, blood pressure cuffs, larger operating room tables, larger wheelchairs and other equipment.
 Stephen Rosen |
“These people need to be treated with respect and their problems need to be dealt with,” he said.
Mikami said that his hospital has invested in special beds that have extra padding to prevent patients from damaging or killing tissue that can result from lying on one spot too long. “Our beds have special air mattresses that have extra air pumps that rotate on their own, so patients do not get pressure sores or other complications that heavier patients can face,” he said.
The hospital has also purchased longer cameras for its laparoscopic surgery on patients with a BMI greater than 70.
“We have longer ports that can be put through the abdominal wall. Instead of being 10 cm long, they are 15 cm long. Our instruments all come in extra long lengths,” Mikami said.
The Birmingham Business Journal reported in 2007 that the expense associated with extra equipment for a bariatric hospital can top $2,000 for each sling to lift patients, $10,000 for special beds, and the additional cost per square foot for larger hospital rooms.
Local communities are also finding they need to invest in additional equipment to respond effectively to all citizens. The Miami Dade Fire Rescue department recently told the Miami Herald that it had spent about $35,000 to retrofit bariatric units, including purchasing stretchers to hold larger patients and a special lift system that can help with patients who weight up to 1,100 lb.
A spokesman for American Medical Response reported recently in the New York Times that a bariatric ambulance, one able to transport patients who weigh up to 1,000 lb, can cost $100,000 to build. That compares with $70,000 for the cost of a standard size ambulance.
In-hospital staff training
Hospital staff is being trained to work with obese patients, with specially trained physical therapists on staff to handle patients who are much heavier.
Data from one study cited in a 2007 article in Bariatric Nursing and Surgical Patient Care showed that use of a walking belt and mechanical hoist reduced staff injuries from 83 to 47 per 200,000 work hours.
 Susan L. Humphreys |
Eleven friction-reducing devices made for lateral transfers were examined in one study and showed benefits over manual lifting, according to Susan L. Humphreys, RN, MS, nurse manager at The John Hopkins Hospital in Baltimore.
“The obese patient clearly presents special challenges in terms of lifting safely and resource requirements to accomplish mobility tasks,” Humphreys said in the article, adding that successful solutions to the problem must address no-lift policies, ergonomic assessments and controls, lift teams and ongoing research.
According to the article, the American Nurses Association has published a position statement calling for engineering controls, no-lift policies and additional research. “ANA believes that manual patient handling is unsafe and is directly responsible for musculoskeletal disorders suffered by nurses.”
Humphreys said that several states have undertaken efforts to legislate safe patient handling, with legislation passed in Washington and Texas and introduced in several other states.
Many nurses and researchers have talked about the “need for a paradigm shift from requiring nurses to learn body mechanics to requiring the organization to provide the safe environment through ergonomic research, no-lift policies and education. As the research continues to show the financial cost of occupational back injuries, and the shortages of nurses becomes more critical, organizations will shift to the new paradigm out of necessity,” she advised.
Medical imaging
The limitations of standard imaging equipment are another concern.
Radiology departments encounter difficulty with transporting obese patients for imaging, accommodating them on appropriate imaging equipment and acquiring desired image quality, according to an article that appeared in the American Journal of Roentgenology last year.
Raul N. Uppot, MD, assistant professor in radiology at Harvard Medical School and Massachusetts General Hospital, and colleagues examined the problems associated with imaging obese patients.
The researchers said that transporting patients for imaging should include coordinating with the transport department to schedule obese patients when larger wheelchairs and stretchers are available. Radiologists should be given advance notice about the weight and body diameter of patients referred for imaging, so that appropriate imaging protocols can be instituted, Uppot told Endocrine Today.
Industry standards exist for table weight limits and aperture diameters for imaging equipment, including fluoroscopy, CT, cylindric bore magnetic resonance imaging and vertical bore MRI. These weight and aperture limit data should be posted, and radiologists and technologists should be aware of those limits to avoid injury and/or equipment damage.
The surface areas of some obese patients may be too large to fit on a 14 in x 17 in cassette for radiography, and image quality may be compromised in sonography due to difficulty in positioning obese patients properly, according to the researchers.
Providing care
Mikami pointed to other more intangible costs associated with the obesity epidemic, the psychological burden that can be connected with morbid obesity in some people.
“The one in 1,000 people who is 400 lb overweight — those are the patients that need the most help, but unfortunately those patients can’t work.
“They are often unemployed, are usually on Medicare or Medicaid. Those are the patients who really need help, but there is not a lot of literature about them,” he said.
For some of those patients to undergo bariatric surgery, they often must lose some weight prior to the procedures.
“Those patients were never sent to surgery in the past because it was thought to be too high of a risk. But with the right type of program and the right type of care, these patients can now get help,” Mikami said. – by Christen Haigh
For more information:
- CDC Obesity Trends. Obesity Costs: http://www.cdc.gov.
- Humphreys SL. Obesity in patients and nurses increases the nurse’s risk for injury lifting patients. Bariatric Nursing and Surgical Patient Care. 2007;1:3-6.
- Obesity Action Coalition: http://www.obesityaction.org.
- Obesity Trends/Statistics, etc.: http://www.obesity.org.
- Surgical Review Corporation: http://www.surgicalreview.org.
- Uppot RN, Sahani DV, Hahn PF, et al. Impact of obesity on medical imaging and image-guided intervention. Am J Roentgenol. 2007;188:433-440.