Accommodating the obese or morbidly obese patient is something no facility can afford to ignore. The obesity crisis shows no signs of slowing and members of this growing population are presenting at hospitals of all shapes and sizes everywhere.

A third annual Bariatric Supply Survey by group purchasing organization Novation of its VHA hospital members, shows that 64 percent of respondents have seen an increase in admissions of severely obese patients since 2004, according to preliminary results. Surgery and the emergency room (E.R.) were cited as the top two departments that see the most obese patients. Nearly half of respondents said that they’re seeing obese patients throughout the entire hospital.

For the most part, facilities that offer bariatric surgical services should already have the appropriate equipment on hand to cater to the obese population. But since obese and morbidly obese patients can show up at any hospital for any number of health problems – facilities everywhere need to have the proper products, equipment, policies and procedures in place to safely handle and care for the obese, and even morbidly obese patient.

So believes Joseph I. Kamelgard, MD, FACS, a gastric bypass surgeon who recently opened up a dedicated bariatric facility in New Jersey.

"The way I look at it, if you have 100 people in a room, the statistics are that 60 percent are going to be overweight, 25 percent or so are going to be obese, and 7 percent are going to be morbidly obese." To him, the bariatric equation is as simple as using current statistics to ideally accommodate bariatric patients. For example, the ratio of over-sized to normal-sized chairs available in a hospital waiting room should reflect the ratio of obese to normal-sized people in the population.

"If you’re a healthcare provider and a healthcare facility, you can’t just squeeze everybody into the same mold. You need to accommodate the average patient population," said Dr. Kamelgard.

"Some facilities don’t feel that they need to accommodate every patient," he continued. "Morbid obesity is a recognized cause of disability for many Americans; however, bigotry toward the morbidly obese is still widely practiced and tolerated, even within the medical profession. The legal interpretation of the Americans with Disabilities Act is that if an individual calls a doctor and says, ‘I want to bring my child to see you but my child is deaf and needs a sign language interpreter,’ the doctor is required to provide that sign language interpreter at his own expense even if it costs him more than he gets reimbursed for the visit. By a similar standard, healthcare facilities should be required to accomodate all disabled patients, even those disabled by obesity."

While every facility should have a bare minimum of bariatric equipment on hand (i.e. bed, wheelchair, commode, lift), being properly equipped to handle the obese patient encompasses the entire spectrum of care.

"That’s why we have over 1,000 items in our bariatric portfolio at Novation, because truly it affects everything that involves the patient," said Sandy Wise, R.N., MBA, senior director surgical services, Novation. She asks caregivers to consider the continuum of care for a normal-size patient, then apply each of those products to the bariatric patient model. These patients will need larger ID bands, patient gowns, oxygen masks, blood pressure cuffs, anti-embolism stockings, bed pans, slippers, as well as longer surgical instruments, needles and trach tubes, just to name a few, said Wise.

Team approach

With so many products to consider and so many factors involved in the sum of the bariatric equipment equation, it only makes sense to involve a multi-disciplinary team in the evaluation process. And these "bariatric teams" are popping up everywhere.

"As we talked to customers around the country, what we found was that they were creating groups within their hospitals to try to figure out what they needed to support bariatric patients – and not just those that are undergoing bariatric surgery," said Dave Jacobs, president, Medline’s Durable Medical Equipment division. "They realize they have bariatric patients throughout the whole hospital. They were forming these ad hoc committees with people from risk management and nursing and materials management and the O.R., getting together and brainstorming what kind of products do they need to have in order to support bariatric patients, and how do they mange those products?"

According to Cheryl Ann McGinnis, PT, MA, supervisor of inpatient physical therapy, Mercer Campus, Capital Health System in Trenton, NJ, "We have a bariatric committee that is made up of key players in the facility and includes nurse managers from many of the floors, bed managers, ED room, rehab services, purchasing, education and a skin care specialist. Together the group has discussed equipment needs throughout the hospital and ways in which we can improve the facility to meet the needs of the bariatric patient. Members of this group are also part of the Safe Patient Handling Committee and help to tie in equipment needs in both areas," explained McGinnis.

As director of perioperative services for Good Samaritan Hospital, Alma Gregory Baird, said her facility "organized a facility and equipment team comprised of nursing (pre/intra/post operative units), engineering, risk management, radiology and transport to assess bariatric needs.

"Put together a multidisciplinary team to ensure that proper equipment and quantity will meet all patients’ needs throughout the continuum of care," advises Baird.

In-service and trials

An important part of the bariatric equipment selection process is the trialing of equipment in-house.

"We are definitely a strong advocate of in-services because we feel it really puts the rubber to the road," said Michael Klein, vice president, TSK Products. "I think it’s a pretty important part of the whole cycle. When you’re talking about expensive equipment it’s something that has to be done."

In the event a hospital is seeking help on a single piece of equipment, TSK Products offers the opportunity for the hospital to evaluate the product at their facility for a one-to-two week trial, said Klein.

"This provides the using department the chance to put the equipment to use with real patients and see if it is what they need. There is no cost for this type of evaluation, other than, with certain equipment, the return freight cost if the hospital chooses not to purchase," said Klein.

TSK Products also offers "Mini Safety Seminars" in which they work with the hospital’s risk management or safety committee, and bring four to five selected products to a hospital for an entire day of "show and tell". TSK staff provides demonstrations of the equipment, and hospital staff nurses and nurse managers are encouraged to use the equipment to see if it is something that may be of use to them.

"Buyers should insist from their vendors that they have the opportunity to try it, especially if it’s an expensive item," added Klein.

In addition, TSK Products offers an Equipment Assessment for Bariatric & Obese Patients which provides an on-site walkthrough of the various pathways of the bariatric and obese patients throughout the facility.

Stretchair Patient Transfer Systems Inc., makers of unique, flexible, transport equipment, offers in-service through live Web casts that give nurses the flexibility to schedule at their convenience. Stretchair also offers product trials through their primary dibstributor Universal Hospital Services (UHS).

Recognizing an opportunity to help facilities with their bariatric equipment assessment needs, Medline embarked on a year-long research project. The culminating result of the research project is the introduction of the company’s new Bariatric Readiness Assessment Program designed to help facilities recognize all the areas in which a bariatric patient may need special accommodation.

Purchase decisions

Factoring into the bariatric equipment acquisition process will be the decision of whether to rent or buy.

According to Medline’s Jacobs, "in the past, people have done a lot of rentals. But that’s something that facilities are starting to move away from," he added.

"We’ve had a lot of members who have told us they are looking now to purchase more than rent," agreed Wise. According to the Novation Bariatric Products survey, beds and wheelchairs were the most commonly rented or leased equipment. Respondents considered total cost, usage patterns, availability and storage issues when choosing whether to rent or buy.

"Big equipment requires big space to store," added Wise.

There are questions surrounding not only where do you keep your bariatric equipment, but will it be accessible to staff when and where it’s needed?

Interesting to note, Medline now clearly marks all of its equipment – bariatric and standard – with a maximum weight capacity so that workers can immediately tell which product they need.

Jacobs says he’s seen a few different reasons for the upswing in rentals. For one, facilities are simply finding the need to use the equipment more often and the pay-off for a purchase can be achieved in a relatively short amount of time. And two, they are realizing that much of this bariatric equipment can be used for patients who are heavy, but may not be considered obese. In other words, by standardizing and purchasing a bedside commode that will accommodate 1,000 pounds, they’ll be prepared for any situation.

Wise noted that manufacturers are helping to make standardization on higher-weight capacity equipment easier by offering more choices. "One thing that has been really interesting that has happened this year is I am seeing that many of the suppliers have increased the [weight] capacity of the equipment that they’re manufacturing," said Wise. "For instance, Medline is our DME provider, and they’ve worked on a wheelchair that has greater capacity than they thought they would ever need."

"Most standard products only support up to 300 pounds, maybe 250. You have a lot of people who may be between 300 and 500 pounds who are very mobile and standard products won’t necessarily accomodate them," added Jacobs.

Flexible equipment

Equipment that can serve multi-purposes throughout the facility may help to ease the financial burden associated with capital equipment purchases. And there are many different types of flexible bariatric equipment.

First, there is equipment that is literally, flexible.

"Probably the most innovative thing that’s happened, is the advent of the beds and the stretchers that actually kind of telescope; the side rails will expand and contract," said Wise. "You can use the bed for normal size patients and then expand it out to accommodate an obese patient. They did that for the purposes of going through elevators and doors, for facilities that have not renovated. I know that manufacturers are looking at the fact that their equipment needs to be able to be accessible to those that haven’t done major renovations."

TSK Products offers the ExpandaCare bariatric bed that holds patients from 100 to 1,000 lbs. The siderails expand from 39 1/2" to 54" to
accommodate patients of all sizes, yet it can still fit through most standard hospital doorways and elevators.

Then, there is flexible, multi-functional bariatric equipment.

"The one single area that we continue to hear about needing multi-functional bariatric equipment is the E.R.," said Donna Horn, vice president, sales and marketing, Stretchair. "The need for multi-functional equipment in E.R. was a factor in the development of the Crosstown." The Crosstown 1200 Motorized Stretchair with riding platform is a self-contained transportation system that offers infinite positioning from seated to stretcher articulation, accommodates 1,200 pounds and has a 36" seat width. It can be used as everything from a wheelchair to a stretcher to a minor procedure table.

"The utilization of the Crosstown would eliminate any transference of a bariatric patient in the E.R. until they would be either admitted for a lengthy stay or were released," said Horn. Stretchair’s new Versatile Hygiene Chair serves as a bed-side or toilet commode, with powered sit-to-stand assist, and a rust-proof shower chair, all with 1,000-lb. weight capacity. (See New Products on page 58.)

Surgical tables provide another opportunity for standardization and cost-savings. Look for tables that allow both lift and articulation for their advertised weight limits, that allow imaging capabilities and have interchangeable accessories allowing for multiple types of surgeries.

Skytron’s Hercules 6700B surgical table provides a hefty 1,200-lb. lift & 1,000-lb. articulation, plus full body imaging capability for all types of procedures, reducing the need for multiple support accessories and optimizing ease of patient set-ups.

The new 3600B UltraSlide surgical table from Skytron provides 23" top slide with the precision positioning of an imaging table. It helps reduce patient set-up times, the need to reverse patients and/or use of time consuming special positioning devices. The UltraSlide delivers 1,000 lift and 800 lb. articulation.

Both tables provide features that make them ideal for use in bariatric surgeries, as well as accommodate general surgery procedures.

"As you know, in the U.S. the definition for bariatric patients and patient types is broadening with our growing patient size, not only for bariatric procedures, but for any and all other types of surgical procedures. Americans are getting larger across the board," said Randy Tomaszewski, R.N./BSN, MBA, vice president of marketing, Skytron.

Tomaszewski says the secret to Skytron’s success in new table options is that they are committed to "listening to our customers and delivering to them clinically significant product breakthroughs that make their jobs easier and safer, for all involved in handling not only large patients, but patients of any size."

TRUMPF’s TITAN is a mobile, modular, split-leg, fully articulating surgical table with unrestricted 1,000 lb. weight capacity, meaning it maintains its advertised weight capacity even at extreme angles such as 40-degree reverse trendelenburg.

"By meeting the demands of a wide range of surgical disciplines with a table that has an unrestricted 1,000 lb. weight capacity, TRUMPF has virtually eliminated the need for separate universal and bariatric tables," said Maik Walther, managing director, TRUMPF. "This is in part thanks to the TRUMPF Universal Coupling Point System which allows care-givers to use a wide range of easily interchangeable, computer-controlled TRUMPF components to adapt the table for virtually any surgical discipline."

STERIS Corp. gained a new versatile bariatric table offering with their acquisition of FH Surgical last March. The C-Max combines multiple positioning capabilities with radiolucence and imaging capabilities and offers 900-lb. lift and articulation.

The Amsco 3085 SP surgical table from STERIS accommodates patients up to 1,000 lbs. and allows for safe raising and lowering of larger patients in both normal and reverse orientation.

Another example of flexible equipment, TSK Products is now offering the GynoCart; a self-contained gynecologic examination cart for the ER, Radiology, OB/GYN, Outpatient Clinics, or other departments. The GynoCart is completely mobile throughout the entire hospital, and converts any hospital stretcher or bed into a full gynecologic exam table. Klein says the cart has been a big attraction with E.R.s who are often limited to just one OB/GYN stretcher for special emergency cases. It also eliminates the need to transfer patients from the stretcher or bed to the exam table.

Safe patient handling

Much of bariatric care is a safety issue, both from the healthcare worker and the patient perspective, due to the great degree of risk involved with transferring even moderately overweight patients. Patients in general are getting larger and what used to be considered a bariatric or obese patient is now much closer to an "average" patient size seen at many hospitals. In short, there are more and more patients who impose a greater degree of risk with every transfer or transport.

"From the bariatric patient’s paradigm, the fear of falling is a significant safety issue not only from the obvious potential for physical harm but also the significant loss of dignity. Nurses, on the other hand, fear being injured when handling bariatric patients while at the same time desire equipment that is simple to operate," said Horn.

"I think the surge in bariatric surgeries and the huge swing in obesity has reawakened and rejuvenated the safety committee/risk management committees in the hospitals," said TSK’s Klein. "And we have found that we’re really kind of reinventing ourselves. We still offer bariatric equipment and products but we’d like to say we offer products for staff and patient safety. I would say that probably 30 percent of our product sell is for equipment used for general staff and patient safety, not necessarily for bariatrics."

Capital Health System’s McGinnis serves as task leader for a newly formed lift process on the Mercer campus and is also spearheading the drive for the hospital to evaluate and purchase not only bariatric equipment but any equipment related to patient/staff safety.

McGinnis describes how the facility is considering a lift team. "The idea of the lift team was started by three key people in the rehab services department who have been working with the negative effects lifting has had on our staff and the establishment as a whole. Each of us has seen the need to improve how we move patients and recognized that staff was getting injured, and re-injured even though we were educating them.

"The main goal of the lift team is to create an environment of safety for the staff and the patient," she continued. "The lift team would be using equipment to transfer patients out of bed rather than manually getting patients out of bed. The members would also be taking on the responsibility of care of the equipment, something that in the past had not been managed well.

"As patients have gotten larger our standard methods of mobilizing patients needed to be reevaluated. At the 2005 Safe Patient Handling and Movement Conference, we were able to evaluate many pieces of equipment and chose a sit-to-stand assist lift that we currently use on our larger patients. We designed a guide for staff to use when assessing these larger, less mobile patients, or simply patients that require more than moderate amount of assistance from the therapist," said McGinnis.

For a look at the different types of bariatric patients and their various mobility limitations, capabilities and needs, visit ARJO’s "Bariatric Resident Gallery" on its website, www.arjo.com. ARJO offers a full range of bariatric lift and transfer equipment including sling lifts, ceiling lifts, standing and raising aids, and bariatric sliding sheets.

ARJO’s Maxi Sky 1000 offers a complete ceiling lift system specifically designed to facilitate safe and dignified transfer of non-ambulatory bariatric clients. The sophisticated and easy-to-operate system allows a single caregiver to perform transfers without stress or strain and with no manual lifting.

Liko Inc. recently launched a new public awareness "Safe Lifting Environment" campaign. By signing up on their web site, www.safeliftingenvironment.com, facilities can get free signage and educational materials to help raise awareness of safe patient lifting techniques.

A new mobility aid from Liko, the RollOn, attempts to bridge the gap between conventional rolling walkers and powered sit-to-stand lifts. The height-adjustable RollOn provides standing and transfer assistance for patients up to 350 lbs., eliminating the need for caregivers to manually support patients who may have good upper body strength and good weight bearing ability, but who are unsteady, non-ambulatory, or have problems walking.

Medline recently introduced its Bariatric Rollator, a 4-wheel rolling "walker" with a padded seat and backrest that can accommodate a 400 lb. weight capacity. The Rollator is made of lightweight aluminum and weighs only 18.9 pounds, has loop brakes for quick stopping and folds for storage.

TSK Products now provides a powered wheelchair called the Breez that was desinged to eliminate the physical exertion associated with transporting heavier patients with manual wheelchairs. A nurse can easily transport any patient weighing up to 750 lbs. with just a flip of the control lever - and the wheelchair will travel up to 22 miles on a single charge.

Another approach to safe lifting is to consider equipment that actually helps to minimize or eliminate the need to lift and/or transfer patients in the first place. "In order to maximize safety, patient handling must be minimized with the solution being the utilization of flexible, multi-functional equipment," said Stretchair’s Horn.

For example, the Crosstown Motorized Stretchair can be utilized as a gurney, wheelchair, standing/lifting aid, short term bed and for performing minor procedures and exams.

"Essentially, a patient could be placed in the Crosstown and never transferred to another piece of equipment until they are released. By minimizing patient handling, injuries to nurses can be reduced as well as the different types of equipment required," said Horn.

Another piece of equipment that can help reduce the number of patient transfers is the TRUMPF ORBIT PT (Patient Transfer) system that offers "one nurse, one button, no lifting" patient transfer for patients up to 400 lbs. The ORBIT PT is a stationary transfer unit that uses a remote controlled conveyance system to transfer the patient from hospital bed to mobile surgical table top. Following the procedure the process is simply reversed.

"As a mobile table, TRUMPF’s TITAN can be part of any patient transfer process. Mobility serves to increase patient safety by reducing the number of patient transfers and avoiding the accidental tipping that can occur with a manual table or less stable table," added Walther.

TRUMPF offers consulting on its Complete Patient Management Concept which minimizes patient transfers, reduces staff stress and improves safety. This consulting and education can help facilities better equip their staff to handle all cases including bariatric patients, said Walther.

Education will be key to ensuring that safe lifting procedures are followed consistently and correctly. Eighty-five percent of the respondents to the 2005 Novation Bariatric Supply Survey said they had offered training for their staff regarding special procedures for dealing with severely obese patients.

"I think the big issue is still healthcare worker safety," said Wise. "That’s truly what’s driving a lot of these decisions. Hospitals obviously are very interested in preserving the dignity and providing the best care for this patient population – that certainly hasn’t changed. But now there’s the added incentive of you really have to take care of your workers who care for these patients. Hospitals are realizing that they have to invest in the proper equipment to protect their workers."

"Quality products to assist in the care of bariatric patients can save thousands of dollars by preventing injuries to patients and staff," emphasized Gail McWilliams R.N.,MS,CCRN, CEN, clinical nurse specialist-ED/critical care/behavioral health for Shore Health System, Cambridge, MD. "Back injuries are rampant in healthcare workers. Lifts and devices to move patients easily are not only lifesavers but money savers."

"The cost can be high but I truly believe all you need is one patient hurting themselves in your office, because the chair collapses or the table collapses. All you need is one lawsuit, one problem, and the incremental cost of the equipment is far cheaper," said Dr. Kamelgard.

"Quality of care is foremost and safety goes hand in hand with quality. The cost of preventing injury is immeasurable. It’s not about saving money as the primary reason but providing adequate products for the patient population," said David Holland, purchasing manager, Capital Health System, Trenton, NJ.

Regardless of the cost, it seems that facilities nationwide are stepping up to the plate to serve this dynamic population of obese and morbidly obese patients.