A growing problem

The treatment of bariatric patients brings with it a unique set of risks. HRMR asks how these can be successfully addressed.

With obesity on the rise, it is increasingly important for healthcare risk managers to ensure their organizations address the specific issues relating to the care of bariatric patients. If careful planning is not in place then hazardous situations can arise once a patient has been admitted. That is the view of Lori Severson, loss control consultant for Lockton companies.

“The population in the US is increasing in weight and falling into the obese category more and more,” she says. This view is supported by statistics. The Centers for Disease Control and Prevention has reported that about one in three US adults is obese, whereas about 20 years ago it was about one in five. About 6 percent of the adult population is extremely obese today; 20 years ago that figure was 3 percent.

“We will also see the employee population becoming overweight or obese, so there’s going to be a ripple effect in the employment setting in terms of hazards for the employer to address from the employee and the patient perspectives,” says Severson.

BIGGER EXPOSURE
The extent of the problem should not be underestimated. Every day healthcare employees assist bariatric patients through the various doors, hallways and rooms and around equipment. Patients who have difficulty walking or standing rely on staff to help lever them to and from surfaces and to push and pull them from surface to surface in supine postures. Done manually, this is a very high-risk task, but it’s performed countless times each day in every institution, meaning huge exposure for both the employee and the patient.

“Healthcare risk managers really need to be addressing this so that they can design the appropriate work environment and put in place the technology and training needed to accommodate the patients their organizations are going to be facing over the next 30 years,” says Severson.

Cindy Wallace, senior risk management analyst for ECRI Institute, an independent, non-profit organization that researches the best approaches to improving patient care, agrees that the treatment of bariatric patients is a hot topic. ECRI Institute has seen a significant number of events involving equipment issues—such as a lack of bariatric beds—and issues involving a lack of preparation, such as not being ready to care for an obese patient who had to undergo a caesarean section.

In order to mitigate the risk of adverse events, Wallace says risk managers need to bring together the appropriate individuals within the facility to examine their current processes for providing care to obese patients.

“They need to look at how the facility is designed, what the infrastructure is like and what type of equipment and supplies they currently have,” she says.

Severson agrees that the infrastructure is crucial. In particular, she says it is important to address hazards caused by the architecture of the buildings; for example, if they are pre-1960 the doors may not be wide enough.

“It is necessary to understand the current architectural best practice guidelines, to ensure you have the appropriate door width, and to ensure you have the appropriate bariatric equipment—beds, wheelchairs—to be able to provide dignified care,” she says.

She adds that engineering controls are hospitals’ number one measure for ensuring safe care of bariatric patients, so patient moving and handling guidelines need to be backed up with strict adherence to guidelines that, for example, give appropriate distances or gaps around beds.

A white paper published in 2012 by Lockton emphasised the need to design to the two most common shapes of bariatric patients: pear-shaped (fat is mostly stored in the hips and thighs) and apple-shaped, also called ‘central obesity’, where fat is stored primarily around the stomach area. Each of these body shapes requires different equipment and procedures for mobility.

When you can’t engineer in safety, it says, you need to rely on administrative controls, ensuring you have the policy and the procedures in place for employees to understand the organization’s toolkit so that they can provide dignified and quality care.

DIGNITY AND CARE
Dignity is a factor that is sometimes overlooked when providing bariatric care, according to Wallace.
“Some caregivers have been found to view a person who is obese as lazy or non-compliant. Healthcare facilities really need to address those attitudes,” she says.

Severson agrees that bariatric patients sometimes have a negative experience of healthcare as a result of biases towards people who are overweight. To overcome this, she says hospitals need to examine interactions with the patient right from their first point of contact, when they come in to make an appointment, all the way through to the way they are treated once they are in a care setting. Dignity and care should be priorities throughout the process.

“They can run into difficult conversations—staff not speaking to them appropriately because perhaps they have some misconceptions of who bariatric patients are and how they and their family act; sometimes there are dynamics that can be difficult in those conversations,” she says, adding that healthcare systems need to teach staff not to have those biases and inappropriate conversations with bariatric patients and their families.
When examining how well your hospital prepares for the care of bariatric patients, Wallace recommends gathering data on the population your facility currently serves, and finding out what percentage of patients are obese or extremely obese. It is also important to review any event data involving individuals who are obese to see where there have been problems or complaints, and to examine staffing and training issues in the light of this information. It may be necessary to purchase or hire specialised equipment, and to make infrastructural changes.

“It’s also important to prepare in advance when you can,” she adds. “Some admissions to a healthcare facility are elective so you need to work with your admitting physicians to let the facility know in advance that an individual is obese.”

Severson agrees that planning is vital. “If people start accepting the bariatric patient population but it isn’t a strategic objective and isn’t designed into what they do, then after they’ve accepted this patient they have to back-pedal and get all these components in place without any quality thought and planning,” she says. 