By Jeannie Akridge

Just as so many obese patients face overwhelming issues relating to weight loss difficulties, mounting medical problems, psychological stigmas and the like, hospitals face increasingly overwhelming concerns in treating these patients.

The sheer number of overweight and obese people in the United States is alarming enough. The National Institutes of Health states that nearly two-thirds of the U.S. population is overweight or obese. About 9 million Americans are "extremely obese", with a body mass index, or BMI, over 40. "The rate of obesity in the U.S. increased by almost 60 percent in the 1990s," says Hans Sigvardsson, president of bariatrics products supplier Liko, Inc.

In comparison, hospitals are now seeing more obese and extremely obese patients entering the hospital system. A survey released in November 2003, by GPO Novation, showed that 80 percent of responding hospitals have seen more severely obese patients in the last year than ever before. And what about the financial impact on those hospitals? Survey respondents estimated the cost per facility to be between $3,500 and $500,000 annually.

When asked to estimate how much more a seriously obese patient might spend on a hospital visit versus a patient of average weight, responses ranged from $500 to $10,000 per visit. As a result, costs are increasing for non-obese patients as well. 53 percent of respondents said that the costs incurred in treating obese patients has increased the cost of care for other patients. The Centers for Disease Control estimates that care for overweight and obese patients costs an average of 37 percent more than for people of normal weight, adding an average of $732 to the annual medical bill of every American. In 2003, obesity-related medical costs in the United States reached a total of $75 billion.

Safety in dealing with numbers

With these rising numbers, come numerous complications relating to medical treatment. Besides the cost issue, healthcare employees must consider the daunting safety implications for both the patient and caregiver. The weight of the problem lies in transporting, or simply moving obese patients. Hospitals that don’t have the right type of equipment face the risk of injuring valuable nurses and other personnel. Says Sigvardsson, "incidences of back injuries from patient lifting activities are impacting hospitals and long-term care facilities through increased workers’ compensation claims, high employee turnover, and low employee morale, all of which contribute to increased operating expenses for the organization." According to the National Council of Compensation, the average cost per health care worker injury is $8,400.

Likewise, moving extremely obese patients who have been immobile for a long period of time poses its own unique batch of problems. In a presentation titled, "Transfer and Mobility of the Obese Patient" at the 2002 NAAFA convention, Dr. Michael Dionne, PT, founder of Choice Physical Therapy, Inc., explained about complications relating to muscle atrophy and anasarca, or "the congested state" in which body parts swell, resulting in the accumulation of fluid. In this case, sudden movement can prove very dangerous or even fatal. Dr. Dionne continued to explain that each obese body type must be moved in a different way, and noted that when obese people fall, they fall very differently from average-sized people, with different resulting injuries.

AmpleWear Gown from Graham

Other difficulties in turning, transferring, or ambulating patients can lead to immobility-related skin breakdown, such as pressure ulcers. Overweight hypoventilation syndrome from excess fat on the rib cage and chest can result in respiratory insufficiency. Colostomy care can be difficult due to the presence of skin folds and a large abdominal apron of fat.

Unfortunately, the nation continues to gain weight and overweight people keep getting sicker. The long list of conditions associated with excessive weight include diabetes, hypertension, heart disease, arthritis, sleep apnea, and cancers of the breast, uterus, kidney, gallbladder, colon and rectum. Obesity is also associated with high blood cholesterol, complications of pregnancy, surgical complications and dementia. What this means for hospitals is that they will continue to see more and more obese patients in all areas of the hospital. In a Washington Post article, Susan Yanovski, director of the obesity and eating disorders program at the National Institute of Diabetes and Digestive and Kidney diseases, said, "All physicians are now treating obese patients, from the pediatrician to the geriatrician."

Preparing hospitals for dealing with the obese and morbidly obese patient includes not only costly equipment purchases or rentals, but also worker education and in some cases facility renovations.

Educating healthcare employees in best treatment practices

While obese patients typically need more care than the average-sized person, research has found that they will often avoid seeking medical attention for fear of insensitive handling or even that the healthcare facility will not be able to accommodate their needs. Many believe the health system doesn’t want to deal with them or is out to humiliate them. And many others grow weary of being told they need to lose weight before their symptoms can be treated.

In the health professional’s court, we are prone to find an underlying anti-fat bias, albeit subconscious in some cases. While the bias likely stems from a variety of sources – frustration in helping obese patients to lose weight to no avail, fear of injuries, and even aggravation in completing a difficult task – the fact remains that it is the hospital’s job to care for and treat the obese patient.

In the Obesity Research journal 2001, Rebecca Puhl and Kelly D. Brownell of Yale University examined a collection of studies that suggested that doctors and nurses do harbor negative feelings about obese patients. One such study of 400 physicians showed that one-third of them included the obese among patients who cause them feelings of "discomfort, reluctance or dislike". A similar study of nurses found that nearly a third said they prefer not to care for the obese at all. In addition, other studies show that doctors often see obese people as lacking in self-control, or lazy.

So how do hospitals work to change the automatic responses displayed in their employees? Novation points to a website produced by the Rudd Institute, an organization dedicated to identifying and ameliorating bias and stigma associated with obesity, and educating the public about obesity issues, https://implicit.harvard.edu/implicit/research/obesity/www/obesity.htm. The educational site offers an online test that reveals test takers’ attitudes towards obesity. What the test often shows is that it is possible to harbor automatic associations between obese people and motivation, or lack thereof, without even realizing it.

The Rudd Institute site provides several words of advice for health professionals in dealing with obese patients including, "See the person, not the pounds." They advise that health professionals acknowledge to their patients how difficult it is to lose weight, forget about the idea of an "ideal weight", and focus on the patient’s health modification behaviors, not the number on the scale.

Another online resource, www.naafa.org, from the National Association to Advance Fat Acceptance, gives these guidelines for caring for obese:

The National Institutes of Health has issued a clinician handbook that covers a wide range of topics including how to diagnose diseases associated with obesity, how to get help for patients outside of the medical system and how to be more sensitive to obese patients.

An article from the Archives of Family Medicine, titled, "The sensitive Treatment of the Obese Patient", advises practitioners to, "avoid any display of frustration or distaste when doing a difficult examination." The article also gives recommendations about the medical interaction itself, such as how to improve office space and examination specifics.

Says Yanovksi, "More education will come through workshops by professional societies, articles in medical journals, Web-based continuing education and training for clinic staff – from the doctor to the receptionist."

Above all, she reminds us, "People who are obese crave what anybody else craves, which is just respect and dignity."

The fundamentals of bariatric equipment

The management of obese patients provides special challenges, and the best way to ensure safe patient handling is through the use of special mechanical equipment manufactured to meet the size and weight requirements of the obese patient.

Whether rentals or purchases, with the proper equipment in place, hospitals can comfortably service this market. There are essential items that every hospital with bariatric patients should consider. Then there are hundreds of specialty items, plus larger sized versions of basic medical supplies and surgical instruments to consider. Novation currently offers more than 800 of the most widely used bariatric products in its bariatric portfolio.

In the Novation survey, beds, wheelchairs, gowns, and blood pressure cuffs were among the most commonly cited bariatric items purchased. Kristin Lucido, a spokesperson for Novation, considers the following bariatric items "essential products" for treating the bariatric patient: beds, lift systems, scales, wheelchairs, bedside commodes and stretchers. "Bariatric suite" options are available with up to a 1,000 lb. load capacity, that include a bed/air mattress, lift system, wheelchair, walker, and commode/shower chair. Keep in mind that oftentimes "combination" products are offered such as beds or wheelchairs with built-in scales, or treatment tables with built-in foot stools.

Transport systems

One of the most critical areas to evaluate will be the patient transport system. Most injuries involve moving or transferring the obese patient and each patient situation should be carefully examined to determine the most appropriate transfer device. A common product is the lift or lift system, which can be obtained with weight load capacities of up to 1,000 lbs. Lift systems include overhead lifts, hydraulic and electric lifts, standing lift devices, bedside sling lifts, overhead A-frame lifts and full frame trapeze systems. There are also lift systems specifically designed for the bath or shower. For convenience, many lifts include a built-in scale. Each lift system provides unique advantages and has specific limitations; your bariatrics supplier can help you to determine the most suitable lift device for your needs. Another product that will prove useful in bariatric transfers includes the versatile reclining stretcher chair, which can be obtained with a load capacity up to 1,000 lbs. Sliding boards, transfer benches, slings and stretchers provide additional transport options, while heavy duty wheelchairs, walkers and rolling devices are among patient mobility aids.

Other essentials

Contact with the bariatric patient will begin with the waiting room. Hospitals should have several sturdy armless chairs, spaced about six to eight inches apart or specially designed bariatric chairs.

The examining area should include scales with a wide base, located in a private area. A variety of exam and surgical tables are available, plus bariatric table extension options to adapt the hospital’s existing tables. In most cases, exam tables should be bolted to the floor or wall for extra support. In addition, provide a sturdy stool to assist patients in getting on the table. Another device to consider would be an open MRI scanner which can accommodate up to 500 lbs.

Longer surgical gloves, needles and syringes, and extra-large examining gowns are just a few of the common medical items that can be found in bariatric sizes.

Finally, the facility itself needs to be examined to determine if remodeling is needed. For example, are pathways and doors wide enough for extra-wide equipment? According to the Novation survey, 17 percent of responding hospitals have remodeled physical facilities to accommodate obese patients. Keep in mind product widths and assembly options when making purchases.

While acquisitions can be expensive they are becoming more of a medically necessary expense for an increasing number of hospitals. In 2003, Novation’s KCI bariatric equipment rentals amounted to $22,307,319.

Bariatric equipment

Following is a partial listing of products available to accommodate bariatric patients.

Stretchair patient transfer systems

Bathing/Bathroom                

Patti Horton has been a registered nurse and healthcare consultant for more than 30 years.  She graduated from City University of NY and Mercy College in Westchester, NY. Patti has extensive experience in the area of education and behavioral science having worked with middle and upper management personnel in corporations such as IBM, Texaco, The New York Times and the Federal Bureau of Investigations.  She is a 15+ year member of NAAFA (National Association to Advance Fat Acceptance), an organization that helps fat people cope with everyday issues. This year Patti will be travelling with Stretchair to numerous hospital facilities, bariatric training seminars, and trade shows.