Operating Room

Bariatric care belts loosen as fiscal belts tighten

by Jeannie Akridge

Not a single state in the nation can claim a population with obesity levels below 20 percent, finds the 2011 Edition of America’s Health Rankings¹, which has tracked the health of the nation for the past 22 years. In fact, obesity has grown an astounding 137 percent since the 1990 Edition, from 11.6 percent of the adult population then to 27.5 percent now, with nearly one in three Americans considered obese. This has been a major contributing factor to the 69 percent annual decline in health improvement since the ‘90s, concedes the report.

Three-quarters of all U.S. states are now saddled with obesity rates above 25 percent; in 15 of those states obesity levels are above 30 percent. The population especially tips the scales in Mississippi, a state that struggles with an obesity rate of 35 percent. Colorado maintains its position as harboring one of the more svelte populations in the U.S., but crept past the 20 percent mark with 21.4 percent of its population now being considered obese.

If these trends continue, warned the report, 43 percent of the population could be obese by 2018.

Across the nation, we’re loosening our belts to accommodate this increasingly heavy population. Just one example, fewer passengers are now allowed onboard the Washington State Ferry in compliance with updated Coast Guard rules based on information from the Centers for Disease Control and Prevention that puts the weight of the average citizen at 185 pounds compared to the previous 160.

As the numbers inch upward, the healthcare system is left to deal with the fallout. Heart disease, hypertension, diabetes, osteoarthritis and sleep apnea are just a few of the conditions that have been linked to obesity. By some estimates, medical care costs of obesity in the U.S. have reached $150 billion annually.

Cathy Denning, vice president, sourcing operations at Novation, noted that obesity treatments such as bariatric surgery have historically been out of reach for those who fail to qualify for Medicare or insurance reimbursement. As a consequence, untreated obesity may lead to individuals presenting at hospital emergency rooms for heart attacks, ruptured gall bladders, appendicitis or any number of obesity-related conditions. "There hasn’t necessarily been an emphasis on reimbursement for the treatment of obesity, but there is a lot of emphasis on the treatment of the co-morbidities for obesity," lamented Denning.

Novation’s 2011 Bariatric Survey² of its VHA Inc. and UHC member hospitals confirmed an increase in admissions of morbidly obese patients, along with expanded services, supplies and training to accommodate this population. According to the annual survey, 58 percent of responding facilities had seen an increase in admissions of morbidly obese patients in the past 18 months.

Nearly three-quarters of Novation survey respondents (72 percent) indicated that their emergency rooms are equipped to handle morbidly obese patients. The types of bariatric equipment available for exclusive use in the ER include durable medical equipment (85 percent), stretchers (84 percent), lifts (74 percent), transfer devices (70 percent) and beds (63 percent). "ERs are the most fully equipped from a stretcher and transport perspective," confirmed Denning.

When asked about bariatric outpatient programs in member facilities, 53 percent of the Novation survey respondents said they have a fitness program in their facilities, 61 percent have a weight loss program (another 61 percent provide special meals and supplements for morbidly obese patients) and 62 percent have a counseling program.

In a move to help reduce obesity and the chronic illnesses associated with it, in late November, the Centers for Medicare & Medicaid Services announced that Medicare was adding coverage for preventive services including screening for obesity and counseling for eligible beneficiaries by primary care providers.

"There is a high level of recidivism in people that have had any kind of weight loss," Denning maintained. "The statistics demonstrate that treating obesity as a chronic illness and providing counseling along with it is the best way to decrease recidivism and increase success for the patient. In a best practice setting, counseling is a prerequisite for bariatric surgery. In fact many people are turned down due to their pre-surgical consultation. Or they are followed more closely based on what is identified in their pre-surgical consultation. Best practice dictates that there is counseling that is associated with all bariatric surgery, both pre and post."

"Coverage for screening should do a few things that affect facilities," suggested Tom Lorick, product marketing manager, Winco Mfg. LLC. "One is that those patients that may not have been able to afford to visit in the past may now have the incentive to seek medical help. Second, it helps to reduce the negative stigma often associated with extremely obese patients allowing them to feel a little more comfortable in seeking assistance. There may not be a huge influx of patients, but the pressure will be on the facilities to be able to accommodate and in fact even seek out those patients as a revenue source and to maintain accreditation standards as they will undoubtedly shift as well."

Among current weight loss options, including lifestyle modification, diet and pharmaceutical agents, surgical intervention is proving to be the most effective treatment to date, and new minimally invasive endoscopic procedures on the horizon promise to help further improve outcomes and accessibility.

Of the 41 percent of Novation survey respondents who offer bariatric surgery programs in their facilities, (63 percent of which are certified as a Bariatric Center of Excellence) the most common type of surgery performed is gastric banding surgery (94 percent).

Sleeve gastrectomy (gastric sleeve) is among the newer bariatric procedures and is being performed in 60 percent of responding Novation member facilities. In addition, nearly 70 percent perform open gastric bypass surgeries and 72 percent offer endoscopic gastric bypass.

Associated reconstructive surgery is also rising along with the number of weight loss surgeries, with 78 percent of survey respondents seeing an increase in the number of bariatric-related reconstructive surgeries over the last 18 months.

"If you are 400 pounds and you lose weight and you’re down to 120 pounds, now cosmetic surgery is needed so people are having post weight loss cosmetic surgery," said Denning. "These are necessary cosmetic procedures," she added, noting that extra skin folds pose an infection risk.

Broader range of bariatric products

Products purchased by VHA and UHC hospitals to accommodate obese and morbidly obese patients range from DME, acute care beds, patient lifts, scales, stretchers, OR tables and air transfer devices, to blood pressure cuffs, longer urinary and IV catheters, anti-embolism stockings, pneumatic compression sleeves, incontinence products and orthopedic softgoods. Hand held dopplers that magnify sound are used to help caregivers hear the pulse of heavier patients through a thick layer of adipose tissue. The comprehensive offering of bariatric products includes even post mortem body bags such as the BioSeal sizeable, sealable containment solutions now offered on contract through Novation.

In response to the growing patient population, Winco raised the minimum weight capacity for the majority of its chairs by over 22 percent last year. "In addition we have added XL versions of most of our blood draw chairs and recliners to address even higher specific requirements," said Lorick. "Finally we have added bariatric-specific products including the Stretchair, and bariatric exam tables capable of up to 1,000 pound capacities."

Advised Lorick, "When evaluating a seating solution, it is critical to take into account the setting for use. For instance, in long term care a position lock is desirable, and drop arms make transfer to and from wheelchairs and beds easier. In dialysis and oncology settings, swing-away arms assist with the same issues, but also increase convenience for cleaning and disinfection tasks. In clinical settings, powered hi/lo/recline operations assist the caregiver in patient transfer situations and in achieving treatment positioning that is optimal for the care provider and patient. These features allow the caregiver to assist the bariatric patient while reducing their own movement activities (bend, twist and lift) that represent opportunities for injury to the caregiver. Finally, in addition to bearing higher weight capacities, the furnishings must also offer more generous seating areas, appropriate arm rest height, leg support points etc., that take into account unique bariatric patient shape requirements."

Winco’s infinite positioning Stretchair is available with up to a 1,000 pound weight capacity including hi/lo/recline operations. "This means that extremely obese patients can be safely and conveniently positioned by power for clinical procedures and transfer operations with a minimum of effort on part of the caregiver," said Lorick. "Whether drawing blood, undergoing dialysis/infusion or simply moving the patient from one area of the hospital to another, proper positioning can be achieved with one device."

"The Stretchair is cleared by the FDA as a transfer device," he added. "Because it can be used in the upright position as a chair and then power reclined to a fully flat transfer device, it offers exceptional versatility as a general purpose treatment, transfer and recovery room device in a variety of settings and applications. The powered hi/lo operation allows positioning to be optimized for the caregiver in both the seated and reclined position. The footprint of the Stretchair is smaller than a stretcher while offering the advantages of power assisted patient positioning."

A new bariatric ambulation and gait training product, Thera Extra, has recently been introduced by Ergolet, an international manufacturer of patient mobility products. The Thera Extra walking table is designed to support larger patients, up to 525 lbs in gait training or rehabilitation situations, and can be utilized in post-operative situations to encourage early patient mobility. The Thera Extra features electric drive and a widened base for extra space and stability. In addition to the Thera Extra, Ergolet offers a range of bariatric products: 1,000 pound overhead lifting solutions, 550 pound Hera Maxi hygiene chair, 700 and 1,000 pound mobile floor lifts and various 600 and 1,000 pound slings.

Training for safety

Beyond purchasing products, the majority of hospitals responding to the Novation survey (92 percent) offer training for staff regarding special procedures for dealing with morbidly obese patients. Nearly half (49 percent) have increased training for staff. Types of training offered include safe transfer of morbidly obese patients (91 percent), use of size-appropriate equipment (81 percent), as well as sensitivity training for working with morbidly obese patients (56 percent). "No lift" policies are in place at 38 percent of responding facilities.

"The survey shows there has been a lot of focus on training and investment to accommodate the morbidly obese patient. And through that training, the facilities believed that they saw better outcomes both for their staff and their patients," Denning asserted.

In a recent focus group at a VHA leadership meeting, participants spoke of the need for sensitivity training as well as using discretion when labeling and identifying "size-appropriate equipment" designed to accommodate heavier patients, Denning shared. Moreover, she said, training staff on the use of that size appropriate equipment "in a way that maintains the dignity of the patient and also the safety of the caregiver" is equally important. "It goes both ways. If you put a 90-pound patient in a chair that is designed to accommodate a 400-pound patient, you have extra width, so it causes their legs to not be appropriately centered on the chair. It’s not good for the smaller patient either to use a larger size piece of equipment on them. So all around, I think that training is imperative to ensure that all sizes of patients are cared for appropriately."

Educating caregivers on the need to consistently use transfer devices, lifts and other transport equipment to make safe patient transfers will not only ensure patient and caregiver safety but will help protect valuable human resources. "Hospitals don’t want staff out with back injuries secondary to trying to move a patient that is impossible to move without some kind of assist device. Being a nurse myself, you tend to think you’re infallible particularly when you’re younger, and then you find that you’ve done something you shouldn’t do – and it can impact your career. The last thing we need during a shortage of good, qualified personnel is to have folks out because they injured themselves when there was a perfectly good solution to taking care of that patient. There are no-lift requirements in many areas now. There are consequences in many facilities, according to the focus group, for not adhering to those procedures," she added.

References

1. United Health Foundation’s 2011 America’s Health Rankings:
http://www.americashealthrankings.org/

2. Novation Bariatric Supplies Market Research Report, November 2011. https://www.novationco.com/pressroom/industry_info/BariatricSuppliesSurvey201111.pdf