Retrofitting hospitals for obese patients

Facing an increasing number of morbidly obese patients, U.S. hospitals need to invest in architectural designs and equipment to safely and effectively serve these patients, experts say. That includes widening everything from CT scanners to toilets to waiting room chairs to hospital gowns. They say these changes are necessary not only for the patients' safety and comfort, but for the safety of hospital staff.

“The reality of it is that the whole hospital should be equipped for bariatric patients,” said Dr. David Spencer, a general and bariatric surgeon at Chesapeake Regional Medical Center in Virginia, which recently spent more than $100,000 retrofitting one of its units, including renovating bathrooms and buying new mattresses.

Newer facilities often consider measures for obese patients within their design budgets, but older medical centers are challenged with starting from scratch. A soon-to-be-released Novation survey of 125 hospitals found that only 25% had invested in physical renovations to accommodate morbidly obese patients, although 63% reported performing more surgeries on bariatric patients over the last 18 months. The median cost of the renovations was estimated at $1.2 million, the report found.

More than 700 U.S. hospitals are certified by the American Society for Metabolic and Bariatric Surgery for their accommodations for the morbidly obese. The facilities most likely to make these improvements to serve patients with an extremely high body mass index are those with bariatric surgery centers. The certified facilities offer special accommodations from their operating rooms to their cafeterias—with CT scanners and MRIs of wider circumferences, large hospital gowns and blood pressure cuffs, wider walkers, toilets that exceed the standard weight-bearing limit and armless chairs in the lunchroom. The global market for bariatric surgery devices is expected to reach $1.9 billion by 2018, according to BCC Research.

Officials at Bailey Medical Center, just outside of Tulsa, Okla., say their 73-bed hospital was built specifically to address the community's high percentage of obese residents. Completed in 2006, the center includes sturdier toilets and radiology and imaging machines with high weight capacity. The construction price tag was $57 million, a hospital spokeswoman said.

Lifting, handling and transferring large patients has always been a concern for hospital leaders. But the issue has gotten greater attention as the U.S. obesity epidemic continues. Between 2000 and 2010, the proportion of Americans with a body mass index of 40 or higher increased 70% to more than 15 million adults, or 6.6% of the population, according to a study in International Journal of Obesity. Not all obese patients require special care, but those with a BMI of 40 or more are considered class III and need specialized weight equipment.

The issue of serving morbidly obese patients has become so pressing that a section on preparing for bariatric patients in the emergency department was included in the Facility Guidelines Institute recommendations in 2010. It offers insight on the design and construction of new healthcare facilities and those undergoing major renovations. New FGI recommendations are expected to be released in the next few months.

“Hospitals are trying to make accommodations, but the report card is incomplete,” said Charles Griffin, president of the Academy of Architecture for Health, a part of the American Institute of Architects.

From full architectural redesigns to purchasing larger wheelchairs and wider door frames, Griffin said some hospitals are retrofitting their facilities, an effort that allows caregivers to safely and effectively handle large patients. But not every hospital sees large numbers of morbidly obese patients. So the challenge for hospitals is “how do you plan for an undetermined population that's going to come in randomly with varying needs?” There is no simple answer, he added.

Nevertheless, advocates and healthcare workers say it's worth the investment. “If nurses can't lift or reposition patients, it eventually leads to other economic consequences for the hospitals,” said Susan Gallagher Camden, an expert in healthcare risk management who has written about the topic for the Online Journal of Issues in Nursing.

Limited budgets and competing interests are leaving hospitals ill-prepared for dealing with larger patients, but addressing the issue may help a lot of other things fall into place, she said. “From an economic perspective, when we mismanage large patients, it's costly in terms of increased lengths of stay, injuries related to mobility issues—like falls or the development of pressure ulcers—and higher 30-day readmission rates,” Gallagher said.

Special accommodations for morbidly obese patients also are important from a staff-safety perspective. Musculoskeletal disorders are a major source of injury to healthcare workers, according to a report from the federal Occupational Safety and Health Administration. Sprains and strains in the shoulders and lower back are the most often reported injuries, compounded by the obesity epidemic. OSHA recommends patient transfer and lifting devices as key components to protecting workers.

Some observers say it will take more than voluntary guidelines to ensure patient and staff safety.

“Legislation would certainly be strong,” said Keith Wrightson, worker-safety and health advocate for Public Citizen's Congress Watch. In a report called Health Care Workers Unprotected, he looked at evidence from states that have safe patient handling laws. “The results have been overwhelming in the reduction of on-the-job injuries. Regulations work. And OSHA has failed to keep pace with the changes,” he said.

Last June, Rep. John Conyers (D-Mich.) introduced the Nurse and Health Care Worker Protection Act, a bill that would require the U.S. labor secretary to create a standard for safe patient handling and injury prevention to prevent injury to healthcare workers. Health facilities would be required to purchase an adequate number of mechanical lifting devices for their employees to transport and lift patients.

Conyers' proposal gained support from the American Nurses Association, which says only 11 states currently have “safe patient handling” laws. In 2012, the ANA convened experts from numerous disciplines to develop a set of guidelines as a foundation for establishing comprehensive safe patient handling and mobility (SPHM) programs.

But hospitals have to consider the full gamut of needs. “It's more than just about buying equipment,” said ANA spokesman Adam Sachs. “Organizations need to make safe patient handling and a culture of safety a high priority within the organization. It's an investment in higher-quality care and increased safety.”

Many hospitals opt to rent specialized equipment for morbidly obese patients when needed, but safety experts warn that unforeseen complications can arise if the planning isn't thorough. For example, a report from the Pennsylvania Patient Safety Authority looking at whether hospitals in the state were prepared to deal with class III patients documented a case where a rented bariatric bed “repeatedly got stuck in the doorframe and was only able to be dislodged with extreme force by multiple personnel” who were trying to transport a patient to the ICU. The study found that more hospitals in that state opted to rent rather than own bariatric equipment, which may have led to delays in care.

“Based on the information that we learned in Pennsylvania, although most hospitals own bariatric and blood pressure equipment, they may want to consider other items that are essential to patient care,” said Lea Anne Gardner, senior patient safety analyst who authored the report.

When planning for bariatric patients, whether in long-term care or acute-care settings, both the American Nurses Association and ECRI Institute provide lists of items all hospitals should consider, including bariatric beds, total lift systems, wheelchairs in varying widths and depths, stretchers with a 1,000 pound capacity, 42-inch toilets and scales that are wheelchair accessible.

Griffin said many of his clients have considered replacing furniture in waiting rooms, which he said is a reasonable and cost-effective first step. “The furniture choices hospitals and designers make can impact patients' comfort levels before they begin receiving treatment,” he said. “Room equipment and layout can dramatically impact the level of care and efficiency that healthcare providers deliver.”

For now, though, each medical center ultimately has to make its own determination, based on the needs of the community.

“Hospitals need to measure the nature of the risk in their facility by asking questions like 'what is the prevalence of obese patients on any one day' and 'what percentage of the population has a BMI that affects patient care,' ” Gallagher said. “Then you can determine if you need to throw economic resources into this.”

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