Are hospitals adequately prepared to meet the needs of obese patients? Consider the real-life case of an overweight man who suffered from congestive heart failure due to a lack of exercise and mobility secondary to his shortness of breath. His overweight condition was subsequently diagnosed as “morbid obesity” by his primary care provider.

Late one evening, his deteriorating medical condition required emergent care at a local hospital. His treating physician requested he be taken promptly to the local emergency department. His chief complaints at that time included worsening shortness of breath and chest pain. Upon receiving orders from the physician for a chest x-ray, the nurse asked him to “walk” to the radiology department so that the x-ray could be completed. This obese man—in obvious distress—ended up walking to the radiology department from the emergency department—because there was no bariatric wheelchair to transport him.

Why would a health care provider ask such a patient to walk to another area of the hospital? Beyond the absence of the bariatric wheelchair, the hospital was not, in fact, prepared to care for and meet the needs of obese patients.

The following day, the incident was reported to hospital administration who acknowledged the lack of medical equipment to accommodate larger patients. A short time later, the facility purchased several larger-size wheelchairs to meet these needs. Now there are a number of wheelchairs in this hospital that can accommodate the obese patient population. This situation is not unique and opportunity is there for HME providers who wish to market to hospitals.

In this particular anecdote, patient safety, self-image, quality care, and hospital liability were all at risk. All of these variables could have been improved if proper medical equipment had been available in the first place.

An Expanding problem
Today, approximately 60 million people or one third of the adult American population suffer from obesity and this trend continues to grow. The causes of obesity may be a combination of various factors including imbalances in metabolic rate, genetics, behavioral, environmental, or psychological/psychosocial state.

The term “overweight” has been defined by the US Department of Health and Human Services and the World Health Organization as a body mass index (BMI) of 25 to 29.9 kg per m2—whereas obesity is defined as a BMI of 30 kg or more per m2. A BMI calculator may be used by the health care provider or by the lay individual, and can be accessed online at the National Heart, Lung, and Blood Institute Web site. BMI classifications have been designated by the National Institutes of Health (1998) as:
            • Underweight      18.5
            • Normal         18.5 to 24.9
            • Overweight         25 to 29.9
            • Obesity (Category I)     30 to 34.9
            • Obesity (Category II) 35 to 39.9
            • Extreme Obesity     40
Obesity has become a national health issue in the United States during the last 15 years. National obesity prevalence rates range from 28% to 50% depending on sex and ethnicity. National statistics indicate that between 1976 and the year 2000, the overweight group increased from 47% to 64% in the United States.

Specialized Equipment
Health care for the obese patient has become very specialized. Chairs, beds, and even embarrassingly small hospital gowns can lead to hazards for both patients and caregivers. Therefore, the provision of health care today must take into account proper equipment, coexisting diseases, patients’ self-image, concern for emotional factors, nursing and staff members’ responses to the patients, and the physical environment of the facility.

Bed frames, mattresses, and support surfaces, including wheelchair cushions, must be rated for safe working load at or below the patient’s actual weight. Adequate sizing, ease of use/maneuverability, and staff/patient safety must always be of prime concern when heavy-duty lifts, walkers, commodes, or other bariatric equipment is used.

Diabetes and More
The obese population is at increased risk of developing Type 2 diabetes that usually requires medications and testing equipment to check blood sugar levels at prescribed intervals. Another medical condition commonly seen in the obese population is dyslipidemia, an abnormal concentration of lipids in the blood. This may be manifested by higher than normal total cholesterol levels, abnormal low- and high-density lipoprotein levels, and elevated triglyceride levels, all of which increase the risk of developing atherosclerosis and coronary heart disease.

The rate of high blood pressure is doubled in obese patients, so weight management becomes necessary and blood pressure monitoring is essential. Management of hypertension usually requires larger equipment such as scales with a higher weight capability and larger-size blood pressure cuffs.

Another medical condition frequently seen is sleep apnea, an intermittent absence of breathing while asleep, which is a potentially life-threatening condition. It is usually treated with continuous positive airway pressure (CPAP) therapy to prevent the collapse of airways.

Less commonly seen coexisting diseases include Pickwickian syndrome, a combination of symptoms that may include decreased respiratory rate, daytime sleepiness secondary to sleep apnea, and a flushed facial appearance. These symptoms may be reversible in the obese population if diagnosed and treated properly. Obesity may also place one at increased risk for prostate, kidney, gall bladder, colon, and endometrial cancer.

Self-Image Concerns
A number of recent studies have focused on the obese patient’s self-image and self-esteem. In one study, a total of 13.2% of obese women with a mean BMI of 35.2 reported that health care providers made insulting comments; 22.5% of this same group suggested that they were treated with disrespect due to their weight. The reports also indicate that women are likely to delay or cancel health care appointments due to possible weight gain. Disrobing or direct personal contact has been shown to be the reason.

There are also a number of individual and family concerns. Severely obese persons experience limited mobility, and require frequent intense medical care and hospitalization due to related medical conditions. The severity of their illness may also be at an increased stage due to the lack of medical care/treatment as a result of their weight embarrassment. There is also the increased risk of death in relationship to obesity and, therefore, a higher mortality rate.

Health care professionals should receive sensitivity training to increase awareness of and compassion for the larger patient population. Also, if health care providers receive proper ergonomic training for moving, transferring, and handling obese patients, they may feel safer and therefore exhibit increased acceptance of them.

All health care providers should receive training regarding any specialized bariatric equipment available in their facility. Medical equipment used incorrectly or inappropriately may be unsafe for the patient and health care provider. In the past 5 years, support groups for obese patients have formed across the nation. Information about these groups should be made available to the patients and to all health care personnel providing their care.

To provide quality care for obese individuals, the physical environment and facility layout must be addressed. The design of bariatric products should be as close as possible to that of normal hospital equipment. The following is a list of equipment that addresses the physical environment for the care of the overweight or obese population:
    • large, armless chairs to accommodate larger body frames
    • sturdy, wider examination tables for patient safety
    • extra-large examination gowns to promote dignity
    • large-size blood pressure cuffs to accommodate larger extremities and foster increased accuracy
    • weighing scales with weight capability greater than that of commonly used scales
    • patient assessment performed in a private, discreet location
    • large wheelchairs for safe transfers and mobility
    • heavy-duty lifts to ensure safety and “trust” with patient transfers
    • bed frames designed to accommodate the needs of the larger individual
    • support surfaces for comfort
    • support surfaces for pressure ulcer prevention and treatment
    • more space to ensure a comfortable, safe environment.

Rosalyn S. Jordan, RN, BSN, CWOCN, is a senior clinical manager and Grace M. Hukushi, RN, BSN, is a clinical applications specialist at a major health care corporation.