Criteria-Based Protocols and the Obese Patient: Pre-planning Care for a High-Risk Population
O besity is best described as the excessive accumulation of body fat. This chronic condition often manifests as a slow, steady, progressive increase in body weight. In one sense, the cause of obesity is straightforward - the state of expending less energy than the amount consumed. But in another sense, obesity is more intangible, involving the complex individual regulation of body weight, specifically body fat. This individual regulation is the unknown factor in weight management cases.1 Research suggests that the reason many patients are unclear about the cause of their excessive weight is because the etiology of obesity is complex and multifactoral. Several causes have been suggested, including genetic alterations, neurologic disorders, endocrine disease, or drugs.2 In addition, the presence of this condition has social, economic, emotional, and clinical consequences. Despite these consequences, the prevalence of obesity in the US has increased by 30% in the past decade, from 25% to 33%. Six million Americans are morbidly obese.3
In earlier literature, obesity was defined as a body weight greater than 30% of what is described as ideal body weight. More recently, body mass index (BMI), thought to be a more meaningful measurement tool,4 offers a mathematical formula (weight[kg]/height[m2]) that assigns relative risk for mortality and morbidity based on a numeric value. For example, a person with a BMI of 20 to 26 is considered healthy, while someone with a BMI greater than 40 is considered obese. From a clinical perspective, obese patients who are hospitalized reportedly are at a higher risk for certain common and predictable complications because of their body weight and size. For example, patients who weigh 100 lb or more above their ideal body weight have exponential increases in mortality and serious morbidity as compared with their non-obese counterparts.5 Additionally, due to emotional and physical causes, some obese people resist pursuing healthcare and frequently defer hospitalization until the last possible moment; therefore, obese patients are often sicker by the time they access care.6 In many cases, caring for obese patients can be more complicated and, from a practical perspective, more difficult.
Healthcare is fast becoming one of the most dangerous jobs in the US; five of the highest risk groups are healthcare professionals.7 In acute care facilities, turning, lifting, and repositioning very heavy patients can predispose caregivers to physical injury.8 Caregivers report the fear of personal injury when caring for larger, heavier patients, yet pre-planning activities to reduce risk are generally not forthcoming.
Case in Point
Criteria-based protocols offer a standardized method to ensure the process of pre-planning for care, especially among high risk, high cost, or high volume patient populations. Ms. A, a recent nursing school graduate, was proud to have responsibility for a monitored respiratory unit in a large metropolitan hospital, but she was ill-prepared for Mr. W, a 670-lb electrical engineer admitted for respiratory decompensation. Appropriate equipment and resources were not available to Ms. A and her unit, so it was impossible to turn or reposition Mr. W, and the nurses reported he was becoming weaker each day he was unable to engage in activity. Routine physical assessment, intravenous access, diagnostic exams, and pain management all were overwhelming. Every day, another challenge in caring for Mr. W remained unmet. To Ms. A's surprise and disappointment, physical therapists assisting Mr. W to the side of the bed on his fifth day of admission detected a 15 cm x 22 cm dark "bruised-looking" area over his right and left buttocks. On further examination, a 7 cm x 5 cm Stage III pressure ulcer was found in the buttock cleft. Additionally, on day 126 of hospitalization, two nurses and one radiology technician were injured caring for Mr. W to the extent that they were unable to return to work. These common and predictable complications in caring for larger immobile patients might have been prevented with education and resources provided in a timely appropriate manner.
Pre-planning is designed to promote patient safety and prevent caregiver injury. The goal of a criteria-based protocol in Mr. W's case would be early recognition of a patient who, because of weight and mobility issues, is at risk for obesity-related complications such as pressure ulcers. Additionally, timely and appropriate introduction of equipment, physical therapy, and wound care consultants might have prevented pressure ulcer development. A criteria-based protocol would have identified interventions necessary to control some of the clinical challenges inherent in caring for heavier, more complicated patients.
Barriers to Pre-planning
A number of barriers exist to any kind of change in healthcare organizations.9 The well-documented nursing shortage has posed challenges in all but the most essential performance improvement efforts because nurses are unable to leave their direct patient care responsibilities to participate in team meetings, data collection, or other activities. The financial instability of many healthcare organizations has further threatened the trend for change and subsequent improvement in some areas of patient care. Organizations are reluctant to devote resources to services that may not expeditiously produce a positive outcome because the immediate bottom line is of greatest importance. Determining how to begin to develop a criteria-based protocol is difficult, particularly when it is likely that every department in the hospital has contact with members of this patient group. For example, depending on whether the patient is admitted through the emergency department or through the admitting office, special accommodation is necessary. Failure to pre-plan can hinder patient movement from one department to another and subsequently lead to further delays in necessary diagnostic and therapeutic intervention. Because of the inherent high-risk, high-cost nature of the obese population, special clinical accommodations are unavoidable.
Getting started can be the most challenging aspect of developing a bariatric protocol,10 especially when little to no research exists that describes best practice strategies for care. Clinical experts, teamwork, and group participation are critical to embracing a project of this complexity. Administrative support is essential. Additionally, in striving for success, frontline clinical staff must be part of the process. Change requires strong leadership, active participation, empowerment, and education, making support essential on all levels. Communication between disciplines and departments is imperative11 (see "The UMCAZ-Tucson Experience").
In developing a plan of care, the value of an interdisciplinary team cannot be overlooked. Specialists such as pharmacists, physical and occupational therapists, wound care specialists, clinical experts, respiratory therapists, and others (including vendors) can offer valuable ideas in pre-planning for care. Each discipline brings unique ideas and solutions to common challenges. A team approach has become the standard of care for many organizations - for example, some organizations require interdisciplinary patient care conferences within 8 hours of admission if the patient meets certain criteria, such as a BMI greater than 50. However, the presence of a team does not necessarily ensure timely access to assessment and intervention.12 A preplanning tool, then, becomes the critical factor in caring for more complex patients.
Healthcare facilities should have a plan in place for the special needs of the morbidly obese patient. Just as the term implies, a criteria-based protocol means pre-planning based on pre-determined criteria. The patient's actual weight, BMI, body width, and clinical condition serve as criteria. Actual weight is particularly important because if equipment weight limits are exceeded, breakage, failure to function properly, or injury to the patient or caregiver could result. If the body is so wide that it restricts patient movement or creates rubbing of the soft tissue on the frame of the equipment, care can be compromised; therefore, the configuration of the body is a crucial factor to include in establishing criteria for planning care. Clinical conditions (eg, pain, sedation, or an uncooperative temperament), can interfere with the patient's ability to participate in care and subsequently place the patient at risk for complications. Each of these criteria could be useful in identifying which patients are at risk and require pre-planning for care.
Patients are best served when resources, such as equipment and care, are appropriate to the patient's size, height, weight distribution, and mobility needs. For example, throughout the organization, consideration must be made of equipment (eg, magnetic resonance scanners and OR and X-ray tables) that typically has weight limitations. Facility-wide identification of weight limits of diagnostic and treatment equipment prevents misunderstandings as to what resources are actually available to clinicians.
Pre-planning with manufacturers and vendors to provide equipment for the morbidly obese patient is essential (see "Bariatric Equipment"). Institutional policies and procedures for obtaining oversized transportation and transfer devices, bed frames, support surfaces, wheelchairs, walkers, commodes, and furniture need to be instituted.13 When selecting oversized equipment, it is essential to consider both the weight limits and the width of the equipment. For example, patients not exceeding the weight limit for a standard bedside commode may still be unable to use a standard device due to the width of their hips. Most medical equipment suppliers rent or sell extra-wide wheelchairs, walkers, and commodes that accommodate patients weighing up to 1,000 lb. Some rental companies provide a number of oversized bariatric items as a "bundle," providing a price incentive.
Although appropriate equipment is essential, other resources are equally valuable. A clinically and educationally diverse group of clinicians and hospital support personnel needs to be involved in the pre-planning process. Education is critical to planning individualized care that complements the criteria-based protocol. Competency tools can be a resource to set and maintain standards of care. Research suggests that the top three skills needed to care for larger patients are caregiver safety, use of equipment, and physical assessment of the patient.14
Skin and Wound Care
Skin care needs among obese patients can be complex, yet some contend that most are relatively common and can be met with some predictability. Pressure on soft tissue can cause ulcers in areas other than bony prominences. This can include the hip areas due to friction from the sides of chairs, wheelchairs, commodes, and other furniture. Additionally, the pressure of skin against skin in the skin fold areas can produce a pressure ulcer. Moisture on skin and between skin folds can have a damaging effect on skin. Any area of non-intact skin (eg, wounds, pressure ulcers, and procedural skin invasions such as a tracheostomies) is influenced by the negative effects of poor perfusion, tension to the wound edges, intra-abdominal pressure, inadequate oxygenation, and protein malnutrition, seriously delaying healing.12
Patients who have been identified as at-risk for skin breakdown need to be assessed at least every 12 hours and more frequently as indicated by their condition. Skin folds should be inspected every shift, washed with a mild cleanser, and carefully dried at least on a daily basis and as needed. A moisture barrier cream can be applied to areas affected by incontinence, wound drainage or excessive perspiration that can result in moisture within skin folds.15
To prevent incontinence-related skin injury, the patient may need help in moving to the bedside commode or bathroom. The patient should be cleansed post-toileting with a peri-bottle every void, then carefully dried and a moisture barrier applied as needed. Skin folds can be further protected with absorbent padding as needed to prevent damage from excessive moisture. Lamb's wool, abdominal dressings, peri-pads, a soft receiving blanket, or soft cloths placed in between skin folds to promote comfort and control moisture should be considered.
Pressure areas and all skin areas and folds should be inspected every shift and pressure adjusted by repositioning. All tubes must be checked for direct pressure on the skin - for example, chest tubes, Foley catheters, or gastrostomy tubes must be repositioned accordingly.16 Turn/lift sheets should be used appropriately. The number of people assisting must be determined to be adequate or appropriate. Using bariatric equipment and pre-planning are thought to prevent injury to patient and/or staff. Timely, appropriate use of specially designed oversized equipment such a bariatric bed, walker, and/or commode can enhance mobility and independence; thereby, preventing some of the predictable and costly skin-related complications.
Preparing for the Future
Although attempts to reduce body weight are common among Americans, the prevalence of obesity has continued to increase since the 1980s. Considering that more than two-thirds of US adults are overweight, it is likely that issues of caring for the overweight patient will continue. Not only has the percentage of adult overweight Americans increased, but also the number of overweight children has doubled, and even though some overweight people are able to lose some of their body weight, a majority regains that weight within 5 years.17
The observed increases will adversely affect healthcare delivery because obesity is strongly associated with several chronic diseases and increased complexities, and therefore, the cost of care. This may lead to costly hospitalization, especially in the absence of pre-planning. Recent estimates suggest that obesity-related morbidity currently accounts for 6.8% of US healthcare costs.18 This increasing prevalence will likely impact acute care and may influence not only the frequency of admission, but also the level of care that patients in the future will require when hospitalized. Clinicians best serve the needs of the patient and their organizations when policies and protocols are in place to guide pre-planning for the care. Continued use of interdisciplinary teams is essential to more fully understand the interdepartmental impact of caring for overweight patients in the acute care setting. Furthermore, manufacturers and vendors need clinical input in order to more fully understand the unique equipment needs of the larger patient. Research to evaluate the outcomes of care and implementation of bariatric protocols is needed.
Solutions to this industry-wide problem are not simple and are complicated by a climate in which profit and reductions outweigh caregiver safety and patient care. A sample obesity protocol has been provided (see "Obesity [Bariatric] Protocol: A Sample").
Because of its chronic nature and associated complexities, obesity is rarely considered a condition that is easily resolved. Given these realities, acute care clinicians best serve their patients by controlling the common and predictable symptoms and complications associated with caring for larger patients. Pre-planning is essential to this effort. The goal of a bariatric criteria-based protocol is to ensure more appropriate, timely, and cost-sensitive use of resources. A comprehensive patient-centered plan of care that meets the unique and individualized needs of the patient also will likely result in meeting the patient care and organizational goals of the clinician and the facility. - OWM
The authors wish to thank Rebecca Malone, PharmD; Mary Meer, RD; Corrine Jue, RD; John Hart; John Klune, RPT; Jeanne Fenn, RNC, M Ed; Rosie Holgerson, RN; Kathy Knak; Bobbie Dunson; Stella Mesa; Claire Wells, RN,; and Dona Lawson, RN