According to the Center for Disease Control and Prevention, more than 30% of the population is considered to be obese and more than 66% of the population is overweight.


Bariatric care is of increasing importance across the nation and here in New York.

In 1985 less than 10% of New Yorkers were considered obese.

In 1991 10%-14% of New Yorkers were considered obese.

In 1997 15%-19% of New Yorkers were considered obese.

In 2002 20%-24% of New Yorkers were considered obese.


(Based on a study from the CDC with obese defined as having a Body Mass Index greater or equal to 30.)


Designing for the Obese
As hospitals struggle to serve the growing number of overweight patients, design experts offer tips on creating bariatric-friendly healthcare spaces.

By Dave Barista, Assistant Managing Editor

November 1, 2005

Building Design and Construction

During the past 20 years, obesity among U.S. adults has increased more than 60%, according to the National Center for Health Statistics. The disease now affects more than 60 million adults, or about 30% of the U.S. adult population.

Unfortunately, the vast majority of U.S. hospitals are ill-prepared to accommodate the growing number of overweight patients. One reason is the lack of bariatric-specific design guidelines.

"Designers may think they cover obesity by adhering to ADA guidelines," said Keith Smith, AIA, principal with Indianapolis-based healthcare design specialist BSA LifeStructures. "ADA covers legal disabilities only, and obesity is not considered a legal disability."

Smith said special considerations for the overweight and obese population should be the norm on all hospital projects, not just special bariatric-care units. Design considerations include everything from wider doorways and heavy-duty beds to patient lifts and larger toilets.

BD&C talked with leading healthcare design experts for their advice on designing bariatric-friendly healthcare spaces:

Plan for larger equipment. Doorways and storage areas should be larger than normal to accommodate oversized wheelchairs, beds, and gurneys. At St. Vincent Carmel (Ind.) Hospital, the Building Team increased door widths from 36 inches to 42 inches to better accommodate larger patients and equipment, according to Smith, lead architect on the project. Smith also specified doors with recessed hinges to maximize the openings.

Some hospitals are specifying 48-inch doorways and even 60-inch double-leaf doors (composed of a combination of 24- and 36-inch doors) in bathrooms to allow sufficient clearance for two nurses to assist the patient into these tight spaces, said Dennis Gallant, director of Design Innovations and Programs with Hill-Rom, a Batesville, Ind.-based manufacturer of healthcare-related equipment.

Avoid wall-mounted toilets. Although these are popular among facility staff for their ease of maintenance, wall-mounted toilets may not stand up to constant use by obese patients. "They can pull away from the wall and potentially break from the carrier with larger patients," said Randy Regier, AIA, president of Taylor & Associates Architects, Newport Beach, Calif. Regier urges Building Teams to specify floor-mounted units that can support at least 1,000 pounds. Other considerations: floor-mounted sinks and oversized toilet seats, which can range from 16 to 19 inches in width and up to 19 inches deep.

Choose the right lift system. Whether portable or mounted, a lift system in patient rooms is a must. "Healthcare workers sustain more overexertion injuries than virtually any other type of worker," said Suzanne M. Bish, operational marketing manager with Hill-Rom. She said that aides, nurses, radiology technicians, and physical therapists all rank among the professions at greatest risk for back injury.
Portable lift systems have become more popular as hospitals look to maintain flexibility. High-end systems can lift more than 1,000 pounds off the floor. Many smaller units weight less than 100 pounds for easy mobility, while providing the ability to lift 600 or more pounds.
Where space is at a premium, a ceiling-mounted unit may be the way to go. Many of these systems provide full room coverage and are designed to allow staff members to lift, rotate, and recline or decline patients without manual assistance.

Provide plenty of room around toilets and beds. BSA LifeStructures' Smith recommends at least 24 inches of space on either side of toilets to accommodate patients and staff assisting in ambulation.
Placement of toilets is also vitally important, said Richard Dallam, principal with Seattle-based architect NBBJ. Poorly placed units will force patients to make twisting movements to position themselves on the toilet, which can be particularly detrimental to post-surgical patients. "We locate toilets so that they can be accessed by moving sideways, rather than making a 90- or 180-degree turn," said Dallam.
Similarly, allow at least five feet of clear space around three sides of the bed to provide ample room for patients in wheelchairs or with walkers. This also provides clearance for portable lifts to be maneuvered along side the bed, said Hill-Rom's Gallant.

Include heavy-duty grab bars in and around showers. Grab bars in bathrooms and showers should be structurally supported to handle at least 500 pounds of weight, said Smith. Showers should include multiple handrails, built-in seating, minimal step-up, and removable showerheads with a flexible hose to minimize movement during washing. Size is also crucial. "Showers must be large enough to accommodate patients, yet configured so patients can still reach railings for support," said Smith.
Recess weigh scales into the floor. Years ago, obese patients had to be shuttled to the loading dock to get an accurate weight reading. Most hospitals today are more sympathetic to patients' dignity, providing oversized scales in patient rooms or within bariatric departments. Smith recommends that scales be recessed into the floor with grab bars nearby to ease maneuverability.

Beds equipped with weigh scales are also becoming popular. The latest units can provide accurate readings up to 1,000 pounds. "This way patients can be admitted directly to their hospital bed instead of having to be taken to a loading dock," said Bish.

Other new technologies in hospital beds include units with built-in powered transport to minimize the number of staff members required to transport patients, and beds with powered side air bolsters that can be deflated with the touch of a button to allow for closer care or easy transport, especially during an emergency situation, said Bish.
Hill-Rom's ExcelCare bed, for instance, expands from 40 to 50 inches wide. Similarly, Camtec Products, Church Creek, Md., offers a bed that expands from 37 to 54 inches in width, allowing it to be used for both bariatric and non-bariatric patients.

In any case, bariatric beds should be rated for at least 600 pounds.
Don't forget about family members. "Obesity is truly a genetic disease," said Ken Fujioka, MD, director of the Center of Weight Management at Scripps Clinic, La Jolla, Calif. "If we have a son come in, chances are the parents will also be heavy." This means waiting areas and patient rooms should be equipped with wider chairs (30 to 40 inches wide) with reinforced arms that can support 750 pounds or more. Fujioka said bench-style seats will also do, especially for projects on a tight budget.
Avoid creating "bariatrics-only" sections in general waiting areas. "Mix bariatric chairs with the other furnishings with the same look and feel," said Dawn McDonald, IIDA, senior associate with Indianapolis-based Maregatti Interiors, lead interior designer on the St. Vincent Carmel Hospital project. "We oftentimes use loveseats because they are discreet, yet provide the extra room and stability larger people need." McDonald recommends that 15?20% of waiting room chairs accommodate obese patients.
Michael Lehman, principal with Taylor & Associates Architects, said specifying larger furniture has a ripple effect on space planning and costs. "Waiting areas must be larger or provide fewer seats to accommodate the wider chairs," said Lehman. "Also, alcoves must be bigger to store oversized furniture."

Plan for additional air-conditioning capacity. Since obese patients typically have increased sensitivity to temperature, additional air-conditioning capacity may be required to keep patients and their families comfortable. This can include everything from portable fans to beefed up HVAC systems. The bariatric patient rooms at St. Vincent Carmel Hospital, for example, feature an air exchange rate 15?20% higher than standard patient rooms to react more quickly to changes in thermostat settings.

Get a bariatric facility assessment. Several manufacturers and consultants offer assessment services that will track the pathway of obese patients through the hospital or bariatric unit. This can help the Building Team formulate a plan of action for both the initial construction and future expansion plans.

So, how are hospitals responding to the influx of obese patients?
"The response varies," said Sharon Woodworth, associate principal with Anshen+Allen, San Francisco. "Some new hospitals are designing all of their rooms with many of these features, while others are implementing some of the features?wider doors, but no lifts, for example?in some of the rooms," said Woodworth.

Of course, some hospitals have decided to do nothing at all. "Those facilities will not be able to admit bariatric patients," said Woodworth.

Bariatric care: If the sheet fits

24 May 2007

Anita Rush takes a look at a new sheet that may help reduce risk when repositioning bariatric patients in bed.

By Anita Rush, clinical nurse specialist, bariatrics, Berkshire Community Equipment Services

Caring for bariatric patients requires more nursing staff, more nursing time and presents greater safety concerns than care of the non-obese patient. In some instances, one patient may require six members of staff to undertake care and nursing tasks, while the time taken to complete these tasks could be as much as two hours, depending on the patient's mobility and body dynamics.

It has been well documented that the risk of work-related musculoskeletal disorders (WRMSDs) is further increased when handling human loads that are heavy, highly dependent and unpredictable. As more bariatric patients are present in the care environment, there is a need to address the demands on care resources and develop a realistic economical structure.

Under the Health and Safety at Work etc Act 1974 and the amended Manual Handling Operations Regulations 1992, employers have a duty to provide a safe system of work that reduces the risk of WRMSDs to service providers and patients.

Repositioning the patient in bed and inserting slings are the type of frequent tasks nurses and carers undertake as part of routine holistic care to bariatric patients. Although equipment, such as sliding sheets, is available, these tasks can be considered to be high risk if the patient has to be moved frequently.

Currently, hoist and sling manufacturers are trying to address this problem, and one firm has designed a sling that can be left under the patient to enable repositioning. Called the RepoSheet, this product was designed by Liko to facilitate the repositioning of the patient and, following a risk assessment, to reduce the number of nursing and carer staff required to undertake this task with minimal exertion.

RepoSheet evaluation

We assembled a team of bariatric specialists to evaluate the product with a bariatric patient over a whole day. The aim of the evaluation was to ensure that:

• it was fit for purpose;


• it would minimise the amount of nurse/carer exertion;


• it was comfortable for the patient;


• it was easy to use; and


• it was easy to change.

As this was a new product, there was no system of a similar nature to benchmark it against. The sheet's green colour caused some discussion at first but our bariatric patient didn?t find it uncomfortable. Our first task was to move our patient up the bed, then to turn them in bed, and finally to replace the sheet. All three tasks were achieved, with the latter taking the longest to perform.

Advantages

One of the main advantages of the RepoSheet was the ease with which you could attach it to the hoist and, when not in use, tuck it under the mattress of the bed. Working out how to change the sheet in the first instance was like mastermind but once we had worked it through, it was a simple and quick process.

The sheet can be used with other hoists that have the same working load as the sling, and are compatible with the looped system of the product. As stated on the manufacturer?s instructions, the RepoSheet facilitates repositioning of the patient with minimum physical effort, reducing the number of staff attending to the patient.

End-user feedback was also positive. Not only did the patient feel comfortable when the three tasks were being undertaken, but, having experienced the slide sheets being inserted, they also felt it was less intrusive.

From an infection control aspect, the sheet can be cleaned in a washing machine and dried in a tumble drier, while clear washing instructions are on the label of the product. From a cost perspective, we feel the product is value for money. It comes in packs of three, enabling time for turnaround if soiled.

Disadvantages

To date there is no published research to suggest that leaving the RepoSheet under the patient compromises tissue viability, although it has been tested in an intensive care unit and the patient?s skin was not compromised. Compatibility between the sheet material and dynamic mattresses, in relation to pressure damage, is not known.
While generally compatible with a four-foot hospital bed, the width of the sheet was too short for the bed. There was also some difficulty with using it on a three-foot bed.

Conclusion

Based on the evaluation day and an end-user trial in the community, which enabled a couple to turn at night, the sheet appears to be a cost-effective step forward in bariatric handling.
It reduces the number of staff required to care for patients; it reduces the risks associated with heavy patient handling; and it enables dignified care delivery to bariatric patients.
However, equipment compatibility is paramount. Therefore, both the risk assessment process and clinical judgement must consider the safest course in equipment provision. One size does not fit all.