R E V I E W S & A N A LY S E S Class III Obese Patients: Is Your Hospital Equipped to Address Their Needs? Lea Anne Gardner, PhD, RN INTRODUCTION Senior Patient Safety Analyst Pennsylvania Patient Safety Authority More than one-third (35.7%) of US adults were obese as of 2010, as well as approxi- mately 17% of children and adolescents.1 In 2011, 28.6% of Pennsylvania’s population Christine Gibbs, MSN, RN Nurse Manager was obese.2 Obesity is an increasingly prevalent problem that affects the healthcare York Memorial Hospital system as well as patients. In 2006, medical spending was $1,429 greater for an obese person than spending for a healthy-weight person, and the medical cost of obesity was estimated to have risen to $147 billion per year by 2008.3 Some of the expenditures ABSTRACT are related to medical equipment, which can cost as much as $47,808 for an operating Safely caring for class III obese patients room table or $330 for an evacuation sled.4 Providing clinical care for obese patients brings a unique set of demands to health- in the hospital setting can require extra staff, new policies and procedures, and care facilities and their staff. Class III obese special equipment.5 patients require special equipment that is Not all obese patients require special care and equipment, but class III obese patients big enough and strong enough to support have different needs. Class III obese patients are identified as having a body mass them safely while in the care of others. A index (BMI) greater than or equal to 40 or weighing 100 pounds or more than their review of five years of events reported to ideal body weight.6 From 2000 to 2005, the prevalence of individuals reporting a BMI the Pennsylvania Patient Safety Author- greater than 40 increased by 52% and the prevalence of individuals reporting a BMI ity identified 180 equipment-use event greater than 50 increased by 75%.6 Healthcare facilities need to be prepared to provide reports involving class III obese patients. In safe general medical care to class III obese patients whose size surpasses the capacity July 2012, a statewide survey was sent to of present equipment. Some hospitals are addressing these challenges by preparing Pennsylvania hospitals to determine how their facilities to better accommodate these patients.7 Evaluating patient care needs prepared they were to care for this patient from admission to discharge for class III obese patients can lead to the development of population. The survey identified that specific patient care pathways and protocols and the establishment of staffing consider- 36.5% (n = 23 of 63) of respondents indi- ations for delivering safe patient care.5,8,9 cated that their hospital does not have an evacuation plan in place for moving class ANALYSIS OF REPORTS ASSOCIATED WITH MORBID OBESITY III obese patients to a safe location in an emergency. An additional finding was that A review of the Pennsylvania Patient Safety Authority’s Pennsylvania Patient Safety more hospitals rent versus own bariatric Reporting System (PA-PSRS) database was conducted to determine the extent of adverse equipment, which may provide insight into events that class III obese patients experience in Pennsylvania healthcare facilities. why, in some of the Authority event reports, With the exception of a few event-specific requests for details about medication errors, bariatric equipment was not available or PA-PSRS event reports do not capture weight information. To identify this patient why patients had delays in care. Address- population, PA-PSRS event narratives were searched using the words “obese,” “morbidly ing equipment challenges can include obese,” and “bariatric.” To capture a representative sample, a five-year time period from tracking the number of class III obese January 1, 2007, through December 31, 2011, was selected, and 1,774 adverse event patients at the facility, educating staff reports that involved class III obese patients were identified. A comparison of the num- about the acquisition and use of bariatric ber and percentage of Incidents (i.e., near-miss events) and Serious Events (i.e., events equipment, providing sensitivity training, with harm) between PA-PSRS class III obese patient population event reports identified and updating policies and procedures and PA-PSRS general patient population event reports was performed for this five-year for class III obese patients. (Pa Patient Saf time period. An analysis of event reports identified that the Serious Event reports Advis 2013 Mar;10(1):11-8.) accounted for 24% of the adverse events, whereas in the PA-PSRS general event report population for the same five-year time period, Serious Event reports accounted for less Corresponding Author Lea Anne Gardner than 4% of the adverse events.10 Next, an examination of the event types of the class III obese patient reports compared with the PA-PSRS general population reports revealed a higher-than-expected number Scan this code with your mobile of equipment-related reports. This article will address the topics of providing safe gen- device’s QR eral medical care for class III obese patients and the use of bariatric equipment. reader to access the Authority’s Facility-Level Issues toolkit on this Of the 1,774 adverse event reports, 10% (n =180) were associated with the use of equip- topic. ment or devices or facility-level limitations when caring for class III obese patients. In Vol. 10, No. 1—March 2013 Pennsylvania Patient Safety Advisory Page 11 ©2013 Pennsylvania Patient Safety Authority R E V I E W S & A N A LY S E S comparison, the PA-PSRS general popula- assisted back to bed using the Hoyer that engage in bariatric surgery. The sur- tion equipment-related reports accounted lift. The patient complained of pain vey concentrated on facility-level issues, for 0.8% of all adverse event reports in in his right shoulder and did sustain equipment-related issues, and policies 2011.10 Only one equipment-related event a small skin tear on their right fore- and protocols that can affect the delivery occurred in an ambulatory surgical facility; arm. The patient did sustain a large of safe care for class III obese patients. the remaining events occurred in hospitals. hematoma on the right shoulder and For purposes of the survey, class III obese Seven common issues were identified in left chest area. patients were identified as patients who the reports: (1) class III obese patient hos- Class III obese patient hospital policy and weighed more than 450 pounds. The pital policies and procedures not followed, protocol issues were present in a majority survey was administered to all hospitals insufficient, or absent; (2) bariatric equip- of the event reports (69.4%, n = 125 of in Pennsylvania in July 2012 and had ment availability; (3) bariatric equipment 180). These event reports also included a 35.3% response rate (n = 85 of 241); access; (4) bariatric equipment limitations; issues with the availability and mainte- 11.9% (n = 8 of 67) of hospitals respond- (5) bariatric equipment failure; (6) inad- nance of bariatric equipment, the selection ing are designated as Bariatric Surgery equate staffing for safe patient transfers of regular versus bariatric equipment, the Centers for Excellence by the American or direct patient care; and (7) hospital not transfer of a patient to another hospi- Society for Metabolic and Bariatric Sur- completely retrofitted. The following are tal, inadequate staffing for safe patient gery.11 The number of responses for each a few examples of equipment-related transfers and care delivery, the use of question varied because not every respon- event reports. radiologic equipment, and lack of com- dent answered every survey question. The patient was scheduled for a munication among staff about patient Behavioral health hospitals and children’s MRI [magnetic resonance imaging] size and needs. Table 1 provides a sum- hospitals did not participate in the study. scan [but the exam was refused] after mary of the event reports. The Figure shows the percentage of hospi- two attempts because of the size of tal survey participants. the patient. The patient was too SURVEY OF THE READINESS large and [could] not breathe when OF PENNSYLVANIA HOSPITALS DEMOGRAPHIC REALITIES in the scanner. TO ACCOMMODATE CLASS III VERSUS FACILITY PERCEPTIONS While transferring a bariatric patient OBESE PATIENTS In the survey, respondents were asked if from the chair to the bed using the The information uncovered in the event their hospital limits care of obese patients appropriate rental patient transfer reports analysis raised questions about to the emergency department because of mat, one of the canisters supplying air how prepared Pennsylvania hospitals are safety concerns. Only 1.6% (n = 1 of 61) to the mat malfunctioned, causing a to provide general medical care safely to of respondents indicated yes, yet 23.5% loss of air. Once the mat started to class III obese patients. A 31-question (n = 12 of 51) of hospital respondents lose air, the patient’s weight shifted survey was developed based on informa- indicated that their emergency depart- to that side and the patient with tion obtained from the PA-PSRS event ment had to transfer a patient to another the mat fell to the floor between the reports analysis, a literature search, and hospital because of safety concerns related chair and the bed. The patient was conversations with Pennsylvania hospitals to the patient’s weight. Table 1. Pennsylvania Patient Safety Reporting System Morbidly Obese Patient Event Report Issues (N = 180) CATEGORY* NO. OF REPORTS† % OF REPORTS Morbidly obese patient hospital policies and procedures not followed, 125 69.4 insufficient, or absent Hospital does not have bariatric equipment 78 43.3 Needed to wait for equipment (lack of access) 51 28.3 Inadequate staffing for safe patient transfers or direct patient care 43 23.9 Bariatric equipment failed 32 17.8 Facility not completely retrofitted 10 5.6 Equipment limitations 5 2.8 * Twenty-nine reports identified the appropriate use of bariatric equipment. † Event report narratives could have indicated more than one issue. Page 12 Pennsylvania Patient Safety Advisory Vol. 10, No. 1—March 2013 ©2013 Pennsylvania Patient Safety Authority Respondents were then asked if they have own bariatric scales also indicated that care for extremely obese patients can dif- a policy in place for obtaining a baseline they use rental equipment, too. Tables fer from actual circumstances. height and weight for every patient; 2 and 3 show breakdowns of the type of Knowing the patient population demo- 97.0% (n = 64 of 66) of respondents said bariatric equipment owned and rented, graphics helps hospital leaders make yes, though only 66.7% (n = 42 of 63) of respectively. informed decisions about which patients respondents that own bariatric equipment The analysts conclude that perceptions they can safely care for, as well as the types have bariatric scales. Some of the respon- about the ability to provide safe patient of equipment, building limitations, and dents that indicated that their hospitals staff required to meet the needs of every patient.12 Conducting a needs assessment Figure. Percentage of Hospital Survey Participants (N = 85) by weighing every patient in a sampling cohort upon admission will identify 2% the number and percentage of class III Acute care (1 to 100 beds) obese patients that frequent a hospital.13 Weighing every patient upon admission 13% 14% Acute care (101 to 200 beds) also assists in determining whether a hospital has the capacity (i.e., necessary Acute care (201 to 300 beds) equipment, space, and personnel avail- 11% Acute care (301 or more beds) able) to provide safe care to this patient 18% population.13 Critical access 6% CHALLENGES ASSOCIATED WITH Long-term acute care CLASS III OBESE PATIENTS 13% Rehabilitation 23% Before addressing specific patient needs, a discussion about how much respect class III MS13060 Unknown status obese patients receive is essential, as this can impact their seeking care and report- ing health concerns.9 Weight stigma and discrimination is pervasive and not limited Table 2. Survey Response: Bariatric Equipment Owned by Hospitals (N = 63) to healthcare settings.14,15 The stigmatiza- NO. OF % OF tion of obese patients exists and has been EQUIPMENT FACILITIES FACILITIES shown to negatively impact their care.16 Wheelchairs 59 93.7 Sensitization to the plight of all obese patients, not just class III obese patients, Blood pressure cuffs 58 92.6 is essential to understanding their cir- Scales 42 66.7 cumstances and needs and can help in Beds 41 65.1 addressing their healthcare issues sooner. Stretchers 38 60.3 In the Authority survey, slightly less than Lifts (including Hoyer, sit-to-stand, air bag 11 17.5 half of respondents (47.1%, n = 33 of 70) system, portable, or ceiling-mounted lifts) stated that their hospital provides different Bedside commodes 7 11.1 types of staff education programs regarding the care of obese patients. The majority of Chairs 3 4.8 respondents (69.7%, n = 23 of 33) whose Operating room tables 2 3.2 hospitals have training programs in place Hover mats 2 3.2 provide sensitivity training. Nonjudg- mental attitudes and addressing privacy Bedside furniture 1 1.6 concerns toward class III obese patients are Procedure tables 1 1.6 essential to providing safe patient care. For Walkers 1 1.6 example, healthy-weight patients do not Shower chairs 1 1.6 want outsiders knowing what their weight Vol. 10, No. 1—March 2013 Pennsylvania Patient Safety Advisory Page 13 ©2013 Pennsylvania Patient Safety Authority R E V I E W S & A N A LY S E S is, just like a class III obese patient would Table 3. Survey Response: Bariatric Equipment Rented by Hospitals (N = 72) not want that information disseminated. NO. OF % OF Obtaining sensitive information such as EQUIPMENT FACILITIES FACILITIES the patient’s weight in a dignified, respect- Beds 56 77.7 ful, nonjudgmental manner is vital to Wheelchairs 16 22.2 securing the proper information and the Lifts 6 8.3 appropriate type of equipment.17,18 Scales 5 6.9 Stretchers 4 5.5 EQUIPMENT DECISIONS Bedside commodes 4 5.5 A study by Drake et al. (2008) revealed Shower chairs 3 4.2 that the most significant barrier for Unspecified (e.g., rent equipment when 3 4.2 nurses to providing “excellent” patient need exceeds equipment owned by facility, dependent on patient needs) care to class III obese patients was special equipment needs.19 Owning and renting Bariatric recliners 1 1.4 bariatric equipment are not mutually Chairs 1 1.4 exclusive. Some of the respondents Hover mats 1 1.4 indicated that their hospital does both. Specialty bariatric beds 1 1.4 Fewer respondents acknowledge owning Walkers 1 1.4 bariatric equipment (n = 63) compared with the number who rent (n = 72). A Table 4. ECRI Institute SELECTPlus Average Prices for Bariatric Equipment, 2011 major consideration with renting bariatric equipment is the time needed to secure EQUIPMENT TYPE PRICE PER ITEM bariatric rental equipment. The major- Operating room tables $47,808 ity of survey respondents (75%, n = 45 Beds $18,555 of 60) said that it takes one to six hours to receive rented bariatric equipment. Treadmills $9,828 Another 11.7% (n = 7) indicated that Laparoscopes $8,857 it takes more than six hours to receive Ceiling lifts $7,743 rented equipment, and 8.3% (n = 5) of Mobile lifts $7,065 respondents indicated that it takes more than 12 hours. Time to receive specialized Wheelchair mover* $6,895 equipment can impact the care class III Stretchers $6,550 obese patients receive and the staff caring Cadaver cart $5,715 for them. Knowing the costs associated with owning versus renting bariatric Commode (600-pound weight capacity) $5,220 equipment helps inform decisions about Stretcher ramp (for ambulance) $4,600 whether to purchase or rent equipment. Exam tables and chairs $4,589 Table 4 provides prices for a variety of Patient scales $2,406 bariatric equipment. Patient seating/recliners $2,154 Equipment for Vital Signs Wheelchairs $1,571 Obtaining accurate vital signs is basic and Traction frames (overbed trapeze) $992 essential to excellent, high-quality patient Shower chair $771 care. Medications, activity orders, diet, Evacuation sled $330 and other aspects of treatment rely heavily on accurate vital signs, including blood Adult thigh blood pressure cuffs † $16.47 pressure measurement. If a blood pressure Adult large blood pressure cuffs† $15.64 cuff is too small for a patient, an inac- * Motor attached to the back of a wheelchair curate reading will result.20 In the survey, † Prices from ECRI Institute PriceGuide 2012 92.1% (n = 58 of 63) of respondents Page 14 Pennsylvania Patient Safety Advisory Vol. 10, No. 1—March 2013 ©2013 Pennsylvania Patient Safety Authority reported owning bariatric blood pressure cuffs. When asked if every location in the BLOOD PRESSURE CUFF SIZES hospital where blood pressure is measured Arm circumference 22 to 26 cm—the cuff should be “small adult” size: 12 x 22 cm has cuffs of all size for obese patients, 73.6% (n = 53 of 72) of respondents said Arm circumference 27 to 34 cm—the cuff should be “adult” size: 16 x 30 cm yes, and 74.7% (n = 56 of 75) of respon- Arm circumference 35 to 44 cm—the cuff should be “large adult” size: 16 x 36 cm dents reported that their nurses were trained to properly obtain blood pressures Arm circumference 45 to 52 cm—the cuff should be “adult thigh” size: 16 x 42 cm in obese patients of different sizes. See Source: Pickering TG, Hall JE, Appel LJ, et al. Recommendations for blood pressure measure- “Blood Pressure Cuff Sizes” for suggested ment in humans and experimental animals. Part 1: blood pressure measurement in humans: a sizes based on arm circumference.20 statement for professionals from the subcommittee of professional and public education of the American Heart Association council on high blood pressure research. Circulation 2005 Feb 8; 111(5):697-716. Lift Equipment Lifts and transfer devices are necessary to prevent the friction and shear that occurs when repositioning a patient to prevent patient back to bed. Staff safety also it appropriately, including knowing the pressure ulcer development, to help needs consideration. Staff injuries* can equipment weight capacities and how to move patients who have limited mobility create staffing shortages, which can com- obtain the equipment. The survey results to prevent falls, and to protect the staff promise patient safety.23 showed that 65.5% (n = 36 of 55) of members assisting the patient. Out of 63 respondents mark their equipment with respondents who own equipment, 15.9% Daily-Use Equipment the weight capacity, 63.6% (n = 35 of 55) (n = 10) reported owning lifts, and 10.0% Larger-size equipment such as bariatric said equipment manuals are available (n = 1 of 10) of respondents who own lifts bedside commodes, wheelchairs, and to identify weight capacity, 21.8% also rent them. Only 8.3% (n = 6 of 72) beds are essential for daily use by class III (n = 12 of 55) said the weight capacity is of respondents who rent equipment rent obese patients. Even in hospitals that own not identified, and 20.0% (n = 11 of 55) lifts. Without mechanical lifts, multiple bariatric equipment, renting additional replied in the “other” category. Some staff members are often recruited to assist equipment for daily use may be neces- of the methods in the other category in moving obese patients. This situation sary if demand increases. More survey included posting lists, making information puts both the patient and staff members respondents own bedside commodes available on the system-wide intranet and at risk for injury, as illustrated in the fol- and wheelchairs than rent this type of log books, making information available lowing event report: equipment; only 9.5% (n = 6 of 63) of in departmental policies and procedures, respondents own bedside commodes and and developing systematic plans to label Patient given [diuretic] and did not 5.6% (n = 4 of 72) rent them, while 93.7% all equipment using symbols to identify use [bedside commode but] went to (n = 59 of 63) of respondents own bariat- weight limits. Creating a systematic plan the bathroom instead. [The patient] ric wheelchairs and 22.2% (n = 16 of 72) using symbols or other indicators (e.g., voided on the floor and slipped in rent them. The opposite trend was found colored tape) rather than printing weight urine. [The patient was] unable to with bariatric beds; 65.1% (n = 41 of 63) limits directly on equipment to identify get up because [the patient was] of survey respondents own bariatric beds, weight capacities on bariatric equipment obese. Security was called, and several while 77.8% (n = 56 of 72) rent them. provides a way to inform staff of the guards assisted [the patient] from the weight restrictions of the equipment while floor to the chair, and then to the bed. In-Service Training maintaining patient dignity. Hospitals The National Institute for Occupational have established multiple approaches to Safety and Health’s recommendation is The availability of specialized bariatric identifying weight capacities; however, that an assistive device should be used if equipment when caring for class III 3.6% (n = 2 of 55) of respondents did not a care provider needs to lift more than obese patients is only as good as how know if their staff were knowledgeable 35 pounds of another individual’s body well staff know how to access and use about the weight capacity of available weight.21 One leg of a 350-pound patient equipment. Development of policies can weigh as much as 62 pounds.22 This * The average direct cost of a back injury in and procedures for education and healthcare is $37,000, and indirect costs can is an important point to consider when training of all staff is necessary to ensure range from $147,000 to $300,000.22 The one- thinking about completing a dressing time expense of a lift ranges from $7,000 to the appropriate acquisition and use of change, repositioning, or assisting a $7,700.4 bariatric equipment. Vol. 10, No. 1—March 2013 Pennsylvania Patient Safety Advisory Page 15 ©2013 Pennsylvania Patient Safety Authority R E V I E W S & A N A LY S E S STRUCTURAL CONSIDERATIONS Some units may also have larger hallways example, as one paper noted, “During Class III obese patients require larger and patient rooms that may be more Hurricane Katrina, 12 staff members at spaces and equipment that supports appropriate for the patient and their a New Orleans area hospital took nearly weight loads two to three times as heavy as needed equipment. The PA-PSRS event two hours to carry a single obese patient the weight loads of equipment for healthy- reports analysis revealed that hospitals down an emergency stairwell. As a result, weight patients. Structural considerations do not always check that the bariatric many staff members were unable to assist for using bariatric equipment include not equipment will fit the existing facility with other aspects of the hurricane only patient amenities but cumulative structure and allow enough room for evacuation.”25 More recently, there was patient weight load, patient transport, and safe patient care; that the bariatric bed the evacuation of hundreds of patients emergency evacuation considerations. and other equipment fit safely through from New York University’s Bellevue Hos- the door to the patient room; and that pital Center during Hurricane Sandy, as Older hospital buildings need to take into there is enough space for the patient, the well as some of the city’s surrounding hos- account the cumulative load. The increase equipment, and the staff. Protecting not pitals prior to Hurricane Sandy. The chief in the number of class III obese patients only the class III obese patient but also all executive of Maimonides Medical Center has resulted in some hospitals choosing the patients and staff can be done with in Brooklyn, Pamela Brier, told the New to make structural changes to buildings good planning and little cost using these York Times, “As prepared as we think we to accommodate these patients. Hospital action steps. The following is an event are we’ve never had a mock disaster drill bariatric care unit building guideline spec- report that illustrates the need to address where we carried patients downstairs. I’m ifications address issues such as the size of hospital building constraints: shocked that we didn’t do that. Now we’re the room, shower stall, doorway, and wait- going to.”26 ing areas.24 These guidelines also address A rapid response team [was] called on issues of toilet placement (i.e., toilets a patient. The patient was in a bar- Being in the midst of a disaster is not need to be floor-mounted, with a specific iatric bed, which, upon attempting to the time to figure out how to safely and amount of distance from the wall in order transfer the patient to the ICU [inten- effectively evacuate patients. Class III to allow the patient room to sit comfort- sive care unit], would not fit [through] obese patients with BMIs greater than ably and to accommodate a wheelchair).24 the door. All expandable parts of the 60 might benefit most if admitted, when Another structural issue that hospitals bed were returned to their normal posi- possible, to units that are easily accessible need to consider is the building’s floor tion (not expanded) and all siderails to exits without having to travel down capacity and whether the floors can sup- were lowered in order to attempt elevators or stairs. In addition to the port these heavier cumulative weight loads to fit the bed out of the room, thus physical location of these patients, having when there are multiple class III obese compromising patient safety. The bed the appropriate equipment available to patients on the same floor. When respon- repeatedly got stuck in the doorframe move these patients will help staff evacu- dents were asked if their hospital has an and was only able to be dislodged with ate them safely and efficiently. Developing elevator that can accommodate the obese extreme force by multiple personnel. a thorough evacuation plan and having patient, the equipment used in their care, When the bed was finally dislodged, the appropriate resources will make and the staff, 78.9% (n = 60 of 76) of it was noted that there was damage evacuation safer and more efficient, thus respondents said yes, 17.1% (n = 13) said to the doorframe and the metal strip protecting the safety of all the patients. no, and 3.9% (n = 3) did not know. on the door. Most important when considering the ADDRESSING CLASS III OBESE While many hospitals may not be in a hospital’s structure is an evacuation plan. PATIENT EQUIPMENT NEEDS financial position to make structural changes, there are some actions that can Patient safety is the top priority in health- Providing safe care for class III obese be adopted in the hospital that would care. It is imperative to address class III patients can be accomplished whether or have an immediate effect in ensuring obese patients in emergency evacuation not bariatric equipment is purchased. safe care for class III obese patients. For plans. More than one-third (36.5%, n = The following strategies address example, deciding where these patients 23 of 63) of the respondents did not have equipment-related issues for class III should be admitted affects the day-to-day an evacuation plan in place for moving obese patients: care of the patient. Utilizing strategically class III obese patients to a safe location placed nursing units such as those near in the event of an emergency. Class III — Provide sensitivity training to all the ground level or those near radiological obese patients who have severe mobil- healthcare staff.13,22,27,28 departments may ease transports for ity issues will depend on staff to help — Assess whether the hospital has poli- testing and admission and discharge. them in the event of an evacuation. For cies addressing the needs of obese Page 16 Pennsylvania Patient Safety Advisory Vol. 10, No. 1—March 2013 ©2013 Pennsylvania Patient Safety Authority patients (e.g., lifting policies, rental — Evaluate the availability of smaller by the individuals filling out the event equipment policies).12,13,22 bariatric-related equipment (e.g., reports rather than the identification of — Weigh every patient upon admission blood pressure cuffs, longer tour- patients by their weight or BMI. Limita- to the hospital, including patients in niquets, larger gowns, longer wrist tions associated with the statewide survey the emergency room.13,27,29 identification bands, longer needles, include (1) a potential response bias — Measure every patient’s height upon extra-long tracheostomy tubes for the toward hospitals that care for class III admission to calculate their BMI, emergency room).13,22,27 obese patients, (2) a potential nonresponse including patients in the emergency — Evaluate elevator size and weight bias due to an underestimation of the room.13,27,29 capacity.22,27,28 number of and issues associated with class — Evaluate floor weight capacity and III obese patients, and (3) a low response — Measure patients’ abdominal girth to doorway and hall size.12,22,27 rate potentially resulting from the time the determine equipment of the appro- survey was administered. priate size.13,27,29 — Develop and test an evacuation — Assess patients’ mobility needs to plan.12,28 CONCLUSION determine if special equipment is — If emergency transport vehicles required.22 are owned by a hospital, evaluate As the prevalence of class III obese whether class III obese patients can patients increases, the issue of delivering — Trend the hospital’s obese patient be accommodated safely.27 safe care will impact many more hospitals population to help determine than those identified in the statewide the level of demand and develop — Ensure that staff know who to contact survey. This article identified some of a business case for purchasing when equipment (owned or rented) the problems that class III obese patients equipment.22,27 will be needed or require repair.22 encounter when different types of equip- — Evaluate the average daily census of — Evaluate staffing needs based on the ment (bariatric and nonbariatric) are obese patients compared with the number of class III obese patients on unavailable, malfunction, or are improp- bariatric equipment.22,27 a unit.13,22 erly used or when hospital policies and — Take inventory of bariatric equip- — Educate staff on the proper use of procedures are not followed, insufficient, ment, noting weight capacities.13,27 equipment.22 or absent. This article also provides a wide — Evaluate the type and number of range of solutions that all hospitals can equipment owned.13,27,28 LIMITATIONS institute. If priorities were assigned to the — Consider a phased-in approach to The 180 PA-PSRS event reports identi- strategies, the strategies at the top of the equipment acquisition.27 fied for this analysis related to class III list would be sensitivity training; measur- — If considering purchasing equip- obese patients underrepresent the actual ing height, weight, and abdominal girth of ment, evaluate storage capacity and a number of class III obese patients who all patients; and developing an evacuation system to track the equipment.27 experienced adverse events during hospi- plan for class III obese patients. talization. Identification of class III obese — Develop and make accessible to staff Acknowledgment patients in PA-PSRS was accomplished a system to identify the weight capac- Ramsey Dallal, MD, FACS, assistant professor of through a search of the PA-PSRS event surgery, Jefferson Healthcare, and vice chair of ity of the equipment.12,27 report narrative descriptions, which rely surgery, Einstein Healthcare Network, contributed on the subjective assessments provided to the development of the survey for this article. NOTES 1. Ogden CL, Carrol MD, Kit BK, et al. 3. Finkelstein EA, Trogdon JG, Cohen JW, 2009 Jul [cited 2013 Jan 31]. http://www. Prevalence of obesity in the United States, et al. Annual medical spending attribut- ashfordstpeters.nhs.uk/attachments/ 2009-2010 [National Center for Health able to obesity: payer- and service-specific 1205_Bariatric%20Patient%20Policy.pdf. Statistics Data Brief online]. No. 82. Jan estimates. Health Aff (Millwood) 2009 6. Sturm R. Increases in morbid obesity in 2012 [cited 2013 Jan 8]. http://www.cdc. Sep-Oct:28(5):w822-31. the USA: 2000-2005. Public Health 2007 gov/nchs/data/databriefs/db82.pdf. 4. ECRI Institute. SELECTPlus bariatric Jul;121(7):492-6. 2. Centers for Disease Control and Pre- equipment cost request. E-mail to: 7. New beds for Mercy Hospital [television vention. Overweight and obesity: adult Lea Anne Gardner. 2011 Oct 19. transcript online]. WNEP 16 News 2010 obesity facts [online]. 2012 [cited 2013 Jan 5. Ashford and St. Peter’s Hospitals NHS Sep 16 [cited 2011 Oct 12; link no longer 31]. http://www.cdc.gov/obesity/data/ Trust. Bariatric patient policy [online]. available]. adult.html. Vol. 10, No. 1—March 2013 Pennsylvania Patient Safety Advisory Page 17 ©2013 Pennsylvania Patient Safety Authority R E V I E W S & A N A LY S E S 8. Dartfod and Gravesham NHS 16. Puhl RM, Brownell KD. Bias, discrimina- [cited 2013 Jan 25]. www.nursingworld. Trust. Guidelines for the care of tion, and obesity. Obes Res 2001 Dec;9 org/MainMenuCategories/ bariatric patients [online]. 2006 (12):788-805. ANAMarketplace/ANAPeriodicals/ Jun [cited2012 Nov 8]. http://www. 17. Thomas SA, Lee-Fong M. Maintain- OJIN/TableofContents/Vol142009/ safeliftingportal.com/hottopics/ ing dignity of patients with morbid No1Jan09/Bariatric-Patient-Handling- documents/0RAPY8V7X0_Guidelines_ obesity in the hospital setting [online]. Program-.aspx. on_the_Care_of_Bariatric_Patients.pdf. Bariatric Times 2010 Apr 15 [cited 2012 23. Saracino S, Schwartz S, Pilch E. Imple- 9. Kundravi RM. Meeting the challenges Nov 9]. http://bariatrictimes.com/ menting a safe patient handling and associated with morbidly obese patients. maintaining-dignity-of-patients-with- movement program in a rehabilitation Pa Patient Saf Advis [online] Dec 2010 morbid-obesity-in-the-hospital-setting. setting. Pa Patient Saf Advis [online] 2009 [cited 2013 Jan 31]. http://patientsafety 18. Bejciy-Spring SM. R-E-S-P-E-C-T: a model Dec [cited 2013 Jan 31]. http://patient authority.org/ADVISORIES/ for the sensitive treatment of the bariatric safetyauthority.org/ADVISORIES/ AdvisoryLibrary/2010/dec7(4)/Pages/ patient. Bariatric Nurs Surg Patient Care AdvisoryLibrary/2009/Dec6(4)/ 155.aspx. 2008;3(1):47-56. Pages/126.aspx. 10. Pennsylvania Patient Safety Authority. 19. Drake DJ, Baker G, Engelke MK, et al. 24. Facilities Guidelines Institute. Guidelines 2011 annual report [online]. 2012 Challenges in caring for the morbidly for design and construction of health care facili- Apr 30 [cited 2013 Jan 25]. http:// obese: differences by practice setting ties. 2010 ed. Chicago: American Society patientsafetyauthority.org/PatientSafety [online]. South Online J Nurs Res 2008 for Healthcare Engineering: 2010. Authority/Documents/FINAL%20 Aug [cited 2012 Nov 8]. http://www. 25. Gillings J. Special needs population: 2011%20Annual%20Report.pdf. resourcenter.net/images/SNRS/Files/ emergency management of bariatric 11. American Society for Metabolic and Bar- SOJNR_articles2/Vol08Num03Art08. patients [online]. 2010 Jul [cited 2013 iatric Surgery. MBSAQIP update: a report html. Jan 31]. http://www.naccho.org/topics/ on the transition to the new ASMBS-ACS 20. Pickering TG, Hall JE, Appel LJ, et al. emergency/AHPIP/loader.cfm?cs quality program: the Metabolic and Bar- Recommendations for blood pressure Module=security/getfile&pageid=150910. iatric Surgery Accreditation and Quality measurement in humans and experi- 26. Hartocollis A, Bernstein. At Bel- Improvement Program (MBSAQIP) mental animals. Part 1: blood pressure levue, a desperate fight to ensure the [online]. [cited 2013 Jan 3]. http://asmbs. measurement in humans: a statement for patients’ safety [online]. NY Times org/2012/08/mbsaqip-update. professionals from the subcommittee of 2012 Nov 1 [2012 Nov 8]. http://www. 12. McGinley LD, Bunke J. Best practices professional and public education of the nytimes.com/2012/11/02/nyregion/ for safe handling of the morbidly obese American Heart Association council on at-bellevue-a-desperate-fight-to-ensure-the- patient. Bariatric Nurs Surg Patient Care high blood pressure research. Circulation patients-safety.html?pagewanted=all. 2008 Dec;3(4):255-60. 2005 Feb 8;111(5):697-716. Also available 27. ECRI Institute. Bariatric services: safety, 13. Arzouman J, Lacovara JE, Blackett A, at http://m.circ.ahajournals.org/ quality, and technology guide. Plymouth et al. Developing a comprehensive bar- content/111/5/697.long. Meeting (PA): ECRI Institute; 2004. iatric protocol: a template for improving 21. Collins JW. Safe patient handling and 28. ECRI Institute. Safety of extremely obese patient care. Medsurg Nurs 2006 Feb;15 lifting standards for a safer American residents and their caregivers. Contin Care (1):21-6. workforce [online]. Testimony before the Risk Manage 2005 Nov;1:Patient/ 14. Puhl RM, Heuer CA. Obesity stigma: Committee on Health, Education, Labor, resident care 8:1-19. important considerations for public and Pensions Subcommittee on Employ- 29. Wright K, Bauer C. Meeting bariatric health. Am J Pub Health. Jun 2010; ment and Workplace Safety United States patient care needs: procedures and 100(6):1019-28. Senate. 2010 May 11 [cited 2013 Jan 31]. protocol development. J Wound Ostomy 15. Puhl RM, Heuer CA. The stigma of obe- http://www.cdc.gov/washington/ Continence Nurs 2005 Nov-Dec;32 sity: a review and update [online]. Obesity testimony/2010/t20100511.htm. (6):402-6. 2009 [cited 2012 Nov 7]. http:// 22. Muir M, Archer-Heese G. Essentials of yaleruddcenter.org/resources/upload/ a bariatric patient handling program docs/what/bias/WeightBiasStudy.pdf. [online]. Online J Issues Nurs 2009 Jan Page 18 Pennsylvania Patient Safety Advisory Vol. 10, No. 1—March 2013 ©2013 Pennsylvania Patient Safety Authority PENNSYLVANIA PATIENT SAFETY ADVISORY This article is reprinted from the Pennsylvania Patient Safety Advisory, Vol. 10, No. 1—March 2013. The Advisory is a publication of the Pennsylvania Patient Safety Authority, produced by ECRI Institute and ISMP under contract to the Authority. Copyright 2013 by the Pennsylvania Patient Safety Authority. This publication may be reprinted and distributed without restriction, provided it is printed or distributed in its entirety and without alteration. Individual articles may be reprinted in their entirety and without alteration provided the source is clearly attributed. This publication is disseminated via e-mail. To subscribe, go to http://visitor.constantcontact.com/ d.jsp?m=1103390819542&p=oi. To see other articles or issues of the Advisory, visit our website at http://www.patientsafetyauthority.org. Click on “Patient Safety Advisories” in the left-hand menu bar. THE PENNSYLVANIA PATIENT SAFETY AUTHORITY AND ITS CONTRACTORS The Pennsylvania Patient Safety Authority is an independent state agency created by Act 13 of 2002, the Medical Care Availability and Reduction of Error (Mcare) Act. Consistent with Act 13, ECRI Institute, as contractor for the Authority, is issuing this publication to advise medical facilities of immediate changes that can be instituted to reduce Serious Events and Incidents. For more information about the Pennsylvania Patient Safety Authority, see the Authority’s An Independent Agency of the Commonwealth of Pennsylvania website at http://www.patientsafetyauthority.org. ECRI Institute, a nonprofit organization, dedicates itself to bringing the discipline of applied scientific research in healthcare to uncover the best approaches to improving patient care. As pioneers in this science for more than 40 years, ECRI Institute marries experience and indepen- dence with the objectivity of evidence-based research. More than 5,000 healthcare organizations worldwide rely on ECRI Institute’s expertise in patient safety improvement, risk and quality management, and healthcare processes, devices, procedures and drug technology. The Institute for Safe Medication Practices (ISMP) is an independent, nonprofit organization dedicated solely to medication error prevention and safe medication use. ISMP provides recommendations for the safe use of medications to the healthcare community including healthcare professionals, government agencies, accrediting organizations, and consumers. ISMP’s efforts are built on a nonpunitive approach and systems-based solutions. Scan this code with your mobile device’s QR reader to subscribe to receive the Advisory for free.