Bariatric Patients…Weighing Up The Issues

As the number of bariatric patients continues to increase, so do the associated risks and costs.

In addition to specialist equipment, there is also a need for systems to be in place to ensure a safe environment for both patients and nursing staff.

In 2001 37 bariatric patients were admitted to Manning Base Hospital in Taree. By 2010 that number had increased almost tenfold, with 332 patients weighing between 130kg to 293kg. This included a pregnant woman weighing 194kg. Over a 10-year period the average weight of a non-ambulant patient at the hospital was 164kg and the heaviest patient was a staggering 293.4kg.

Clearly there is potential for manual handling incidents for nursing staff, and injuries to patients unless proper equipment and systems are in place to manage bariatric patients.

‘We are in a country area so if you want to fly a patient out of the north coast in a fixed-wing plane the weight capacity is 150kg. If you’re in a helicopter it’s 180kg,’ says Eddie Wood, manual handling co-ordinator at Manning Base.

‘If you take the case of the194kg woman pregnant with her first baby as an example, we have to look at the risk – in other words, what can go wrong and what is the best way to transport the mother and baby and the 32kg of equipment that has to go with them.

We rang the Sydney Helicopter Service and they put a special heavy-duty helicopter on standby. In the end we didn’t need it, but these are the things you have to have in place in case of an emergency.

‘When I visit various hospitals and nursing homes and ask staff the weight capacity of their beds and lifters, often they don’t know. If you don’t know the weight capacity of your equipment, you can’t safely put a patient on a bed or use a lifter and maintain patient and staff safety,’ says Eddie.

Developing a bariatric risk management plan

To this end Eddie has developed a bariatric risk management plan. The plan includes the use of the Red Dot Mobility System that rates a patient’s mobility on a score of one to four red dots displayed above the patient’s bed. One dot means a patient can walk unaided, and four means they are non-ambulatory.

In order to manage bariatric patients safely, hospitals need specialised equipment. ‘You’ve got to work it out from when the patient comes into ED,’ explains Eddie. ‘The patient may come in an ambulance or walk in. From the ambulance perspective, the first thing you must have is a bed you can put the patient on. The weight capacity of bariatric beds here at Manning Base goes up to 350kg. We have roughly 200 beds: 60% can take 250kg, 20% can take 200kg and the rest 350kg.

‘The second thing to consider is how you are going to weigh this patient. You can’t take them to the operating theatre unless you weigh them because the anaesthetist needs to know the weight  of the patient. So you need a bariatric electric weighing device. We have six 300kg electronic omega lifters with an electronic weighing device, one on each floor of the hospital.

‘Bariatric patients here stay on the same bed for the whole hospital stay. So they go back on to the 350kg bed and are taken to ICU, where they will be nursed and a mobility plan put in place.

‘The patient will hopefully start getting better so they’ll need a chair to sit on. And you have to take them for a shower, so you need a 350kg capacity commode chair,’ says Eddie.

Good for nurses, good for patients

Having this type of equipment is not only beneficial to patients, it can also reduce the number of manual handling incidents. Manning Base Hospital saw the number of staff injured in 2009 drop to just three, compared with 68 in 1996-1997.

‘We have 16 lifters – every single ward has a 300kg lifter and a 200kg lifter so there is no walking from one area to another to get it. They are all electric. We have standardised equipment throughout the hospital and training is done on the same equipment,’ says Eddie. ‘Staff don’t do any lifting – under no circumstances are nurses to lift patients. We position them but don’t physically lift them.’

Bariatric equipment is expensive, costing Local Health Networks (LHNs) millions of dollars. However, it is needed for safe patient care. Equipment for bariatric patients is a lot more expensive because of higher engineering requirements. For example, a bariatric bed costs $8,900 and a regular bed $3,000.

‘At Manning, we have spent $325,000 on bariatric equipment and $478,000 on electric beds,’ says Eddie.

Aside from financial costs, non-ambulatory bariatric patients also require a higher number of staff to perform basic nursing and physiotherapy. For example, a non-compliant diabetic female patient admitted to Manning Base in September 2007 who remained there until February 2008 required a total of 10,912 staff attendances over the six-month period of care. According to Eddie, this many resources would not have been used with a non-bariatric patient.

Not all hospitals are designed to cope with bariatric patients. However, thanks to pressure from the NSWNA, the Australasian Health Facility Guidelines now include the requirement for all new and renovated hospitals to have a proportion of oversized patient rooms and bathrooms that accommodate bariatric equipment.

However, the guidelines are not always effectively followed. A common problem is placing toilets too close to the wall so that bariatric equipment and patients do not fit. This is partly a problem with too rigid compliance with Australian Standards for access in bathrooms and toilets.

‘Each facility must look at the physical dimensions of the hospital before they decide what equipment they get,’ says Eddie. ‘I’ve done a risk plan for Hunter New England so we have designated hospitals where bariatric patients go. The heaviest patient we had at Manning Hospital was 293kg – too large for some of our smaller, 20-bed hospitals to provide safe care where equipment has a weight capacity of 200kg. We have clear directives so that the ambulance takes them straight to a larger hospital where they can be managed in a safe manner with staffing and bariatric equipment.

‘If you don’t know what bariatric patients are coming in to your hospital you can’t manage them so you have to have simple flagging systems for ambulances, aircraft, helicopters and hospitals.’

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Managing bariatric patients at smaller facilities

As part of the redevelopment of Orange Base Health Service, a dedicated bariatric room was installed, in which staff are able to move patients out of bed with a hoist and take them to a bariatric toilet, shower and chair.

But because the Far West and Western NSW Local Health Networks also have some very small facilities they developed a bariatric policy, which classified hospitals from A to D, with D facilities being those that could only take self-caring bariatric patients.

‘It’s not just about the equipment, it’s about the number of staff available,’ says Judy Robinson, risk manager for the Far West and Western NSW Local Health Networks.

‘If it’s outside a hospital’s available resources, the patient will be transferred to an appropriate facility to ensure the safety of both the patient and staff.

‘You must have a very clear guide for small sites to ensure they are empowered to manage the safety of both the patient and staff appropriately. Our hospitals know what their rating is and the policy states that at a D hospital you have to have basic equipment such as a bed, toilet and lifter that has the weight capacity to manage the patient weight. At an A-rated facility we need to demonstrate the ability to manage a patients who may require high-level care such as intensive care, including capacity for X-ray, CT and theatre. This includes the ability to supply extra staff to care for the bariatric patient.

‘B and C facilities are in between, so B may do high-dependency care but probably not surgery. C is probably the majority of our hospitals where patients are self-caring with not a high level of care required because a lot of our hospitals only have two staff on a shift, so you can’t have really heavy patients because even with the lifters and specialised equipment you still need several staff to help manage the situation,’ says Judy.

As the Emergency Departments at each facility replace their beds, the aim is to ensure that at least one bed is bariatric. The LHNs also have a small loan pool of equipment that they lend to small sites which is suitable for short-term and self-caring bariatric patients.

In terms of manual handling injuries, Judy says these are still common but are far less severe than in previous years. ‘Rather than disc or bone or high-level injuries where people could be medically retired, we’re seeing more soft tissue injuries and a day off or no time off. This is due to having proper equipment and training and increased awareness.’