Changing the mindset: An inter-disciplinary approach to management of the bariatric patient
Article Outline
- Summary
- Introduction
- Obesity in Australia
- Care of the bariatric patient
- Managing the bariatric patient: our approach
- Conclusions
- References
- Copyright
Summary
Obesity is a major health issue throughout the world. Modern nomenclature has replaced the word obesity with bariatric-related terminology. A bariatric person is defined as one who has health limitations due to their physical size, lack of mobility and environmental access. Obese people are often characterised by society as being lazy and unattractive, and this perception is prevalent among healthcare professionals also. This paper describes an innovative approach to obesity management in a large Australian health district in Queensland.
Keywords: Bariatric, Obesity, Overweight, Inter-disciplinary, Nursing equipment
Introduction
The World Health Organization (WHO) has raised obesity as a major health issue with its cost impacting on individuals and health systems across both western and developing countries. In recent times, the term obesity has been replaced by the nomenclature of bariatric, which originated from the Greek words baros meaning heavy, and iatric relating to medical treatment. In modern terminology, this translates into the art and science of providing healthcare for overweight, obese and size-challenged people. A bariatric person can also be defined as anyone who has limitations in health due to their physical size, lack of mobility and environmental access (Bushard, 2002). Other factors to consider include characteristics such as body type or ethnic group. In this context, professional judgment is paramount, especially as some studies have shown that healthcare workers, including nurses, believe that people who are obese are lazy, unmotivated, demanding, or unattractive. Such attitudes can undermine safe and effective care for this patient group (Baugh, Zuelzer, Meador, & Blankenship, 2007).
This paper explores the issue of obesity management, and describes how healthcare workers can care for the increasing bariatric population with care, dignity and respect. In particular, it draws on the experience of a large Australian health district in Queensland. In our District we started by setting up a working group to address the issue of bariatric patient management. Our initial task was to establish a district strategy through which we initiated a ‘healthy lifestyles’ program. As our work progressed we were able to focus on the more specific aspects of bariatric patients’ needs, including the provision of appropriate equipment. By implementing an audit strategy we were able to identify key issues and implement problem-based interventions. We now have a specially designed Bariatric Kit, which contains all the necessary tools and equipment required to care for bariatric people.
Obesity in Australia
Levels of overweight and obesity within the adult population have increased rapidly throughout the world in the last few decades (Hasha & Bray, 2008). Conservative estimates indicate that at least 500 million people worldwide are overweight, as defined by a body mass index (BMI) of between 25 and 29.9, and an additional 250 million are obese with a BMI of 30 or higher (Seidell, 2000). Recent data from the United States indicate that as much as 66% of the adult population is overweight or obese (Ogden et al., 2006). In 2001, approximately nine million Australians over the age of eighteen were estimated to be overweight or obese, as judged by a BMI greater than 25, with 3.3 million in the high risk obese group with a BMI of 30 or more (Australian Bureau of Statistics, 2002). And, in its 2004–2005 National Health Survey, the Australian Bureau of Statistics (2006) reported that more Australian adults were overweight or obese than in 2001.
A 2003 study by the Australian Institute of Health and Welfare (AIHW) recognised obesity to be the number one cause of preventable death in Australia (Begg et al., 2007). Obesity and overweight affects over 60% of Australian adults (67% males and 53% females) (National Health and Medical Research Council, 1997, AIHW, 2002a) and up to 25% of children (Magary, Lynne, Daniels, & Boulton, 2001). Queensland obesity demographics were similar to the national averages in 1995 (Queensland Government, 2001) but at the time of writing they have increased, with childhood obesity rapidly escalating. The WHO (2008) estimates that by 2015, 33% of the Australian population fifteen years and over will have a BMI of more than 30.
Overweight and obesity places a large burden on the resources of the health system. It was reported that in Australia, obesity contributes to 4% of the overall burden of disease (AIHW, 2002b). At a minimum, obesity is linked to cardiovascular challenges such as hypertension and stroke, and type 2 diabetes. However, the data that is currently available is questionable, as it is contended that there has been inadequate measurement of this population.
Care of the bariatric patient
Like most other patients, the bariatric patient may present as a planned, unplanned or emergency admission or because of an ambulance transfer from another facility. However, because of their unique needs, and the needs of staff providing their care, facilities should properly plan for the full range of presentations and put appropriate admission protocols in place to assist in the timely and safe admission of bariatric patients to hospital. Obesity negatively affects virtually all body systems and increases patient risk of specific malignancies and conditions such as hypertension (WHO, 2008). In addition to physical co-morbidities, multiple psychological pathologies and stressors stem from obesity (Fulton, 2001). Psychological stressors include prejudice and discrimination from others (including healthcare staff), limited access to public conveniences and difficulty maintaining personal relationships. If left untreated, morbid obesity results in increased morbidity and mortality and a shorter life-span (Davidson & Callery, 2001). It should be noted that, in general, the current approach to health care is focused upon treatment of co-morbidities rather than the prevention of the disease.
The value of teamwork should not be overlooked, and care of the morbidly obese patient requires an interdisciplinary approach in which all members should have a good level of knowledge in this field. This is vital, in order to make an effective contribution to the physical and emotional well-being of the bariatric patient. The provision of education for the healthcare team and the implementation of strategies to prevent reduced mobility, predictable skin and wound breakdown, and other complications will increase the quality of care for morbidly obese patients. This, in turn, leads to improved clinical outcomes, control of unnecessary costs, and increased satisfaction of patients and their families.
Staff safety when managing bariatric patients is also important. It is essential to provide support to staff implementing bariatric management strategies, particularly taking into consideration the issues of the ageing workforce, and ensuring that processes are set in place to minimise workplace health and safety events (Muir & Heese, 2008). Having a safe system of work is a necessary requirement to help manage the increased risk of manual handling injuries, associated with patients’ weight, size and load complexities which predispose to low back pain in healthcare workers. Lower back pain can be a contributing factor in the attrition of health care staff.
Healthcare facilities worldwide have been taken unaware by the insidious growth of the bariatric pandemic, which seems to have caught off guard a wide range of healthcare services. As the bariatric population continues to grow, so does the demand for bariatric equipment. Whereas hospitals could once survive by occasionally hiring bariatric equipment on an ad hoc basis, this is no longer an effective strategy. This is one example of how, in the past, management of the bariatric patient has been reflexive; often occurring only when there was a patient or staff safety issue. Clearly, this approach is not conducive to effective solutions, management and care.
Generally, the bariatric patient is not contained within a single patient group. Rather, due to their many co-morbidities, they are to be found in all areas of the healthcare system. Ideally, a planned, organisational approach is needed so that healthcare provision for the bariatric patient can be delivered with dignity and respect, in a safe environment. For hospitals to achieve this goal, an inter-disciplinary team approach is required.
Managing the bariatric patient: our approach
In 2004, The Prince Charles Hospital Health Service District (TPCHHSD) in Queensland, Australia experienced increasing difficulties with unplanned, uncoordinated bariatric admissions, which then led to sub-optimal patient care and staff stress. Bariatric patients were uncomfortable and at times embarrassed by the lack of available resources to cater for their specific needs. In turn, the staff were frustrated by their incapacity to provide the best care possible.
In June 2005, in response to the increasingly obvious needs of the bariatric population, and the lack of available resources to deliver effective care, the health district established a Bariatric Working Group (BWG). The group is an inter-disciplinary team of healthcare workers, which is committed to identifying and caring for the needs of the growing bariatric population. And, in this context, the stated goal of the BWG is to ensure best practice in their care and management. Therefore, the main purpose of the group was to support staff to care for bariatric patients, predominantly by shifting the system of care from one of unprepared crisis management to an organised, planned approach.
One of our greatest achievements has been to involve and empower expert staff from a myriad of specialties. This included the director of the sleep laboratory, senior cardiologist, dieticians, occupational therapists, physiotherapists, the equipment consultant, psychologist, financial directors, staff from Aged Care and the Executive Nursing Director. This team is unique in Australia and to our knowledge there is no similar team that has been established internationally. When the BWG was established, the hospital was a specialised cardio-thoracic facility. Thus, at that time, the hospital did not employ bariatric surgeons or endocrinologists. However, such personnel could offer valuable contributions to effective bariatric management and would complement such a team, should one be set up in a general hospital. Also, given the continuing problem of childhood obesity, it is suggested that paediatricians should also be involved.
Against the backdrop of the bariatric pandemic, and the ad hoc approaches of the past, the BWG began an inter-disciplinary journey of networking with a range of healthcare organisations and individuals both within and outside the hospital in order to improve the management and care of bariatric people. Activities that were required included the re-design of equipment, active trouble-shooting at the bedside, and generally peeling away the multiple layers of issues that usually accompany this patient group.
Our first achievement was to develop a district strategy in alignment with international, national and state directions for the prevention and treatment of obesity and build upon national and state initiatives related to promotion of physical activity and nutrition improvement. Funding was obtained to establish a Lifestyle Initiatives For Everyone (LIFE) committee, which initiated a program called Lighten Up To A Healthy Lifestyle. The program format uses a group-based healthy lifestyle program. Topics discussed are behaviour changes, finding a suitable approach for weight loss, prevention of weight gain, developing a healthy attitude towards eating and physical activity. Individual screenings and six workshops are conducted and individuals are assisted to develop a support network to help them sustain their new habits.
Best practice in healthy eating for our staff was also considered. Meetings were established with personnel from the hospital cafeteria to ensure healthy food is always available for staff and patients. It was important to ensure that the message on healthy eating was a reality for our workforce, who are often seen as role models within the clinical context, and are in full view of patients.
Due to the increased profile gained through these and other strategies, the BWG was asked by the District Executive to contribute to the planned re-development of the hospital, to incorporate bariatric facilities. As a result, we were able to establish a purpose built bariatric patient room within a ward setting, with appropriate inbuilt hoist facilities as well as appropriate physical space, for the management of such patients. Selection of the correct equipment was important, as sub-optimal apparatus can break relatively easily and staff and patients may be injured. Education support was also provided. Without appropriate equipment and training, management of the bariatric patient can result in frustration, embarrassment and safety concerns for both workers and patients (Blackwood, 2004).
To ensure best practice, monitoring and evaluation of the bariatric patient and their discrete requirements was a challenge. The literature suggests that a weight limit is dependent upon the limitations of the equipment and environment in which the bariatric patient presents. However, a weight limit is not an isolated criterion. Some patients, who are not excessively heavy, but are short in stature and have large fatty deposits, may have their mobility affected significantly, finding it difficult to position themselves and unable to fit into standard equipment. Thus, the use of body weight alone can be quite misleading when interpreting a patient's requirements, and healthcare facilities must recognise that simply weighing a patient is insufficient to determine their equipment needs.
In practice, the combination of weight, BMI and waist circumference all influence the clinical management of bariatric patients. Increasingly, emphasis is put on calculation of BMI and measurement of waist circumference. In primary care, this will lead to better recognition of obesity and its co-morbidities (Wilding, 2007). We performed an audit of all hospital wards, and found that 60% of nursing staff were unsure to how to calculate BMI and 30% of wards did not have a height chart. As a consequence, calculator wheels to assist staff with BMI assessment were obtained for each ward and were located with the height measure. An annual BMI audit is now conducted in conjunction with other audits. Whilst waist circumference is now considered to be a more reliable estimate of obesity and predictor of co-morbidity than BMI, there is no consensus regarding the optimal protocol for its measurement (Ross et al., 2008). Waist circumference may be measured at the umbilicus, the mid-point, or the minimal waist. At this point, we continue to use BMI as our standard measure with bariatric patients due to the difficulty of accurately and consistently measuring this group.
In 2005, we conducted a risk management audit, to determine the availability of suitable equipment for use with the bariatric patient, with respect to their BMI. In this audit, we were astounded to learn that 52% of our acute population was overweight (BMI greater than 25) and 12% were morbidly obese (BMI greater than 40). Of significance were the findings that 24% of our routine cardiac surgical patients had a BMI greater than 30, and 84% of our sleep study patients had a BMI of greater than 25 (Humphries, 2005). The latter finding also reinforces the reason that sleep disorder units in Australia have lengthy waiting lists. In 2006, when we repeated the audit, we found that our bariatric population had increased further, in keeping with the global trend.
In our first audit, it was of concern that the equipment audit indicated there were 37 different types of chairs without known weight capacities, little equipment for hygiene care for people over 200
kg, and the maximum weight specification of our beds was 180kg (Humphries, 2005). These findings indicated clearly that we were not able to service our bariatric patient population with the correct equipment. Furthermore, most equipment was not labelled clearly with its safe working load (SWL). In response, where possible, all equipment has now been labelled with its SWL and product companies are asked to supply equipment with a clear indicator on their equipment.
Over the years, in health service delivery, there has been an evolution of equipment. For example, whereas 100kg wheelchairs were once standard, they now seem paediatric size. As a result of our audits, it became obvious that there was a need to escalate the benchmark on what was regarded as ‘normal’ size. What we once called bariatric equipment i.e. rated for people up to 200kg, now equips our standard patients.
We have now compiled a Bariatric Kit, which contains a selection of equipment that has a SWL of up to 350kg. The kit includes a bed, chairs, commodes, elbow support frames, walkers, heel wedges, blood pressure cuffs, recliners, a hoist, wheelchair, emergency trolley, air transfer device, intubation kit, and scales. To ensure that the clinicians managing the bariatric patients could present their ideas and needs in the right forum, some of this equipment was re-designed in conjunction with engineers and supportive companies. It has been quite an achievement to compile this kit as the commercial market has not yet understood the practical needs of the bariatric patient: ‘big’ does not always mean safe and functional. Gradually, equipment companies are recognising the need to adapt equipment so that it is not just big, but is also functional. This requires a team approach with input from expert clinicians. Our Bariatric Kit is now well equipped. We can now provide appropriate equipment when a bariatric patient is admitted no matter what the type of admission. Importantly, the staff now feel more confident and supported in dealing with the daily challenges of this patient group. In addition to the Bariatric Kit, we have also purchased specialised exercise equipment for the musculoskeletal physiotherapy outpatient clinic, which is suitable for use by bariatric patients.
When purchasing bariatric equipment it is important to recognise that the costs are often more than triple the cost of ‘standard’ equipment due to its specialised nature and the need for lightweight materials to enable its mobility and ease of use. Such materials are expensive. Each of our basic bariatric kits requires an initial capital cost of around Aus$ 45,000. Furthermore, continued maintenance must be budgeted for. Although bariatric equipment requires a similar level of annual maintenance as other equipment it also requires an annual inspection by engineers to check for stress fractures and wear.
Whilst we have reviewed our risks to include audits of our population, practices and equipment, it is important to note that we have also involved workers who have reviewed the psychological needs of this patient group. We feel that this has enabled our management plan to have a well-rounded view in the provision of holistic care for the bariatric patient. In some hospitals, obesity/metabolic clinics are in operation. These clinics often oversee the dietary, exercise and counselling needs of bariatric patients, and provided that the approach is a coordinated one, between all parties, they provide a valuable contribution to bariatric patient management. To achieve long-term success with the bariatric population we believe that strong links to the community and general practitioners are required. In our hospital, follow-up dietary care of bariatric patients is initiated from the dietetics clinic and follow-up care is available on a regular basis through continued contact with general practitioners.
Several significant partnerships have been established which have been critical to the success of caring for the bariatric patient. To support sustainability and integration of health services our project team linked with key stakeholders from public health and other government and non-government agencies. It was not long before we discovered that many other facilities were also floundering. We therefore established the Queensland Bariatric Interest Group (QBIG). This group meets periodically throughout the year to share with each other experiences, information and education on bariatric care. It provides a wonderful opportunity to network and learn from a large number and variety of institutions. Another useful source of information is the National Association of Bariatric Nurses (NABN, 2007), which was formed in the United States in 2004. Through this society, nurses can also undertake specialist bariatric certification thus acknowledging the growth of the specialism and requirements for professional support.
Of all the stakeholders, of course the most important are the bariatric patients themselves. We harnessed their knowledge and experience in a number of different ways, including trial and evaluation of all specialist equipment by one of our bariatric consumers, who is also a member of QBIG. His unique insights and experience were always valued and helpful.
Conclusions
Hospitals now face financial decisions regarding which and what type of expensive equipment should be purchased. To reiterate, it should be recognised that this dilemma does not just stand alone in the western world. Developing countries are experiencing sections of their population that are obese or morbidly obese (WHO, 2008).
We now know that caring for the bariatric patient has its challenges which can be overcome with careful staff training, understanding, planning, and appropriate equipment. In this regard, it is important to disseminate our developed understanding of bariatric care. We have presented our outcomes at various conferences and enhanced this by developing a bariatric poster which has assisted in disseminating the valuable lessons that we have learned. We have extended our extensive pressure ulcer program to include preventing pressure ulcers in the bariatric patient. We have also showcased our multidisciplinary course to the state by hosting a one-day course, which included a large trade display of bariatric equipment. There was a huge response to this course with staff travelling from all over the state and interstate. Staff feedback, since attending the course, is that they feel better equipped to care for the bariatric patient population. To date, the team has presented numerous workshops, including a video conference, ensuring high exposure to many rural inter-disciplinary groups, sharing input and establishing networks of commonality. This further reinforced the need to continue to network and share the lessons learned.
In progressing along this path we do not yet have all the answers, but we have departed significantly from our crisis management approach of the past, to a planned, organised system in the present. However, in terms of health outcomes, our bariatric patients comment often on the outstanding care we are now able to provide. In 2008, we received no documented complaints from bariatric patients about their care, whereas in the past we had received complaints about insulting comments by staff, related to their size. Furthermore, in 2008, we had no documented incidents or injuries to staff whilst caring for bariatric patients.
Although our work is relatively new, we are excited to have a co-ordinated, inter-disciplinary approach, fantastic networks and staff who are willing and responsive to change. Key to our success has been interdisciplinary teamwork and we fully support the belief that better teams produce better care, but it is also important to recognise that for effective outcomes teamwork is a long-term task that requires constant attention and adjustment (Firth-Cozens, 2001). In the context of bariatric patient management, there is no ‘one size fits all’ and each patient has individual needs and equipment requirements that require assessment. Bariatric patient management is a constant challenge that requires executive support, clinical champions, patient involvement, and financial investment.
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PII: S1322-7696(09)00025-0
doi:10.1016/j.colegn.2009.03.002
© 2009 Royal College of Nursing, Australia. Published by Elsevier Inc. All rights reserved.
