Getting Your Arms Around Caring Getting Your Arms Around Caring

for for Patient of SizePatient of Size

Glenn Carlson MSN, CCRNCritical Care Clinical Nurse Specialist

Bronson Methodist HospitalKalamazoo, Michigan

ConflictsConflicts

I am a on the speaker’s bureau for I am a on the speaker’s bureau for AACNAACN

I am not endorsing any product I am not endorsing any product mentioned in the talkmentioned in the talk

Program ObjectivesProgram Objectives

Statistics of patients of size in critical careStatistics of patients of size in critical care Literature Review of affects on mortality and Literature Review of affects on mortality and

morbiditymorbidity

Case study example of the challenges patients Case study example of the challenges patients of size can present in the ICUof size can present in the ICU

Key concerns expressed by staff in treating Key concerns expressed by staff in treating patients of sizepatients of size

Using technology to address the challenges of Using technology to address the challenges of patient and caregiver safetypatient and caregiver safety

Culture of sensitivityCulture of sensitivity

ClassificationClassificationBody Mass Index = Body Mass Index = Weight (kg)Weight (kg)

Height (m2)Height (m2)

UnderweightUnderweight <18.5 <18.5

NormalNormal 18.5 – 24.918.5 – 24.9

OverweightOverweight 25.0 – 29.925.0 – 29.9

ObesityObesity 30.0 – 34.9 - Class I30.0 – 34.9 - Class I

35.0 – 39.9 - 35.0 – 39.9 - Class IIClass II

Severe Obesity Severe Obesity >> 40 - Class III 40 - Class III

Economic Costs- CDCEconomic Costs- CDCTable 1, Aggregate Medical Spending, in Billions of Dollars, Attributable Table 1, Aggregate Medical Spending, in Billions of Dollars, Attributable

to Overweight and Obesity, by Insurance Status and Data Source, to Overweight and Obesity, by Insurance Status and Data Source, 1996–19981996–1998

Overweight and ObesityOverweight and Obesity ObesityObesity

MEPS (1998) NHA (1998)MEPS (1998) NHA (1998) MEPS (1998) NHA (1998)MEPS (1998) NHA (1998)

Out-of-pocketOut-of-pocket $7.1$7.1 $12.8$12.8 $3.8$3.8 $6.9$6.9

PrivatePrivate $19.8$19.8 $28.1$28.1 $9.5$9.5 $16.1$16.1

MedicaidMedicaid $3.7$3.7 $14.1$14.1 $2.7$2.7 $10.7$10.7

MedicareMedicare $20.9$20.9 $23.5$23.5 $10.8$10.8 $13.8$13.8

TotalTotal $51.5$51.5 $78.5$78.5 $26.8$26.8 $47.5 $47.5

Michigan about 2.9 billionMichigan about 2.9 billion

NoteNote: Calculations based on data from the 1998 Medical Expenditure Panel Survey merged with the 1996 : Calculations based on data from the 1998 Medical Expenditure Panel Survey merged with the 1996 and 1997 National Health Interview Surveys, and health care expenditures data from National Health and 1997 National Health Interview Surveys, and health care expenditures data from National Health Accounts (NHA). MEPS estimates do not include spending for institutionalized populations, including Accounts (NHA). MEPS estimates do not include spending for institutionalized populations, including nursing home residents.nursing home residents.SourceSource: Finkelstein, Fiebelkorn, and Wang, 2003: Finkelstein, Fiebelkorn, and Wang, 2003

What are these What are these costs related to?costs related to?Co morbid conditions are the Co morbid conditions are the likely reason for death not obesitylikely reason for death not obesity

HypertensionHypertensionType II diabetesType II diabetesOsteoarthritisOsteoarthritisGall bladder dysfunctionGall bladder dysfunctionHypertrophic obstructive Hypertrophic obstructive cardiomyopathycardiomyopathyHyperlipidemiaHyperlipidemia

Other co morbid Other co morbid conditionsconditions

Hypoventilation- Hypoventilation- obstructive sleep obstructive sleep apneaapnea

Degenerative arthritisDegenerative arthritis Psychosocial- studies Psychosocial- studies

have shown a have shown a relationship to relationship to psychiatric disorders psychiatric disorders and depression that and depression that lead to eating as a lead to eating as a coping mechanismcoping mechanism

Wellness Profiles of a midwest Wellness Profiles of a midwest hospitalhospital

0%

10%

20%

30%

40%

50%

60%

BMI<=23Ideal

BMI <=25Desired

BMI 25+Overweight

BMI 30+Obese

BMI, Women

Wellness Profiles of a Midwest Wellness Profiles of a Midwest HospitalHospital

0%

10%

20%

30%

40%

50%

60%

BMI<=23Ideal

BMI <=25Desired

BMI 25+Overweight

BMI 30+Obese

BMI, Men

Puddin' down to 297Puddin' down to 297poundspounds

GRAND RAPIDS, Mich. (WOOD) - WSNX GRAND RAPIDS, Mich. (WOOD) - WSNX radio host Puddin' is trying to become radio host Puddin' is trying to become West Michigan's "biggest loser."West Michigan's "biggest loser."

CustomersCustomers

Include “Patients of Size”Include “Patients of Size” Provider practicesProvider practices EDED SurgerySurgery Lab, radiologyLab, radiology OutpatientOutpatient Etc.Etc.

Statistics On Patients Of SizeStatistics On Patients Of SizeIn The ICUIn The ICU

Prevalence of obesity within medical-surgical ICUs Prevalence of obesity within medical-surgical ICUs ranges from 9% to 26%; morbid obesity from 1.4% to ranges from 9% to 26%; morbid obesity from 1.4% to 7%7%

Neville Neville et. al.et. al. reported that 26% of blunt trauma reported that 26% of blunt trauma patients requiring ICU care were obese. A substantial patients requiring ICU care were obese. A substantial portion of bariatric surgical patients may require portion of bariatric surgical patients may require prolonged ICU careprolonged ICU care

Nguyen Nguyen et. al.et. al. reported that 7.6% of laparoscopic reported that 7.6% of laparoscopic gastric bypass patients and 21.1% of open gastric gastric bypass patients and 21.1% of open gastric bypass patients required ICU care after surgerybypass patients required ICU care after surgery

6% to 24% of bariatric surgical patients require 24 hrs 6% to 24% of bariatric surgical patients require 24 hrs of ICU careof ICU care

Excerpt from Fredric M. Pieracci, MD; Philip S. Barie, MD, MBA, FCCM;Excerpt from Fredric M. Pieracci, MD; Philip S. Barie, MD, MBA, FCCM;Alfons Pomp, MD, Alfons Pomp, MD, Crit Care Med 2006; 34:1796–1804Crit Care Med 2006; 34:1796–1804

John Hopkins- Hogue et al John Hopkins- Hogue et al Intensive Care Medicine Intensive Care Medicine 20092009

Obesity and morbid obesity does not Obesity and morbid obesity does not adversely impact ICU mortalityadversely impact ICU mortality

Obesity may be associated with lower Obesity may be associated with lower hospital mortalityhospital mortality

No association between obestiy and No association between obestiy and duration of mechanical ventilation or duration of mechanical ventilation or ICU stayICU stay

Long tern effects of critical illness in Long tern effects of critical illness in patients of size relatively unknown.patients of size relatively unknown.

University of Virginia- University of Virginia- Surgical InfectionsSurgical Infections

No independent association of No independent association of increased BMI with mortality for increased BMI with mortality for surgical trauma ICU patient with surgical trauma ICU patient with infection.infection.

Impact of Obesity in the Critically Ill Trauma Patient: A Impact of Obesity in the Critically Ill Trauma Patient: A Prospective StudyProspective StudyBochicchio GV, Joshi M, Bochicchio K, Nehman S, Tracy JK, Scalea TMBochicchio GV, Joshi M, Bochicchio K, Nehman S, Tracy JK, Scalea TMJ Am Coll SurgJ Am Coll Surg. 2006;203:533-538. 2006;203:533-538

The authors collected prospective data on trauma The authors collected prospective data on trauma patients (N = 1167) admitted to a shock trauma center, patients (N = 1167) admitted to a shock trauma center, of whom 62 (5.3%) were obese -- defined as a body of whom 62 (5.3%) were obese -- defined as a body mass index (BMI) ≥ 30. mass index (BMI) ≥ 30.

Most of the patients (71%) in the study had sustained Most of the patients (71%) in the study had sustained blunt trauma. blunt trauma.

Although the severity of injury was about the same in Although the severity of injury was about the same in both groups, the obese patients had a significantly both groups, the obese patients had a significantly higher risk for complications. Furthermore, the risk for higher risk for complications. Furthermore, the risk for infection was increased (infection was increased (PP = .001) and the length of = .001) and the length of stay was 10 days longer (stay was 10 days longer (PP = .001); ventilator use was 8 = .001); ventilator use was 8 days longer (days longer (PP = .001); and the overall risk for in- = .001); and the overall risk for in-hospital mortality was 7-fold higher in the obese group hospital mortality was 7-fold higher in the obese group ((PP = .002). = .002).

Trauma and patient of sizeTrauma and patient of size

Neville, A.L., et al. "Obesity Is an Neville, A.L., et al. "Obesity Is an Independent Risk Factor of Independent Risk Factor of Mortality in Severely Injured Blunt Mortality in Severely Injured Blunt Trauma Patients." Trauma Patients." Archives of Archives of SurgerySurgery. September 2004, Vol. . September 2004, Vol. 139, pp. 983–987. 139, pp. 983–987.

What they did:What they did:

The researchers looked at records on The researchers looked at records on every person who came into the surgical every person who came into the surgical intensive care unit at one L.A. trauma intensive care unit at one L.A. trauma center in 2002. For each person, they center in 2002. For each person, they calculated body mass index (BMI), which calculated body mass index (BMI), which is a way to measure body weight while is a way to measure body weight while taking height into account. A BMI over 30 taking height into account. A BMI over 30 is considered obese. Most of the people is considered obese. Most of the people were injured in car accidents or were were injured in car accidents or were pedestrians hit by cars.pedestrians hit by cars.

What they found:What they found: Obese people were twice as likely to die, even Obese people were twice as likely to die, even

though obese patients and nonobese patients had though obese patients and nonobese patients had similar patterns of injuries. Nearly a third of obese similar patterns of injuries. Nearly a third of obese patients died, compared to 16 percent of patients died, compared to 16 percent of nonobese patients. The researchers don't know nonobese patients. The researchers don't know why this is—maybe the obese people who died why this is—maybe the obese people who died had other problems like high blood pressure. Or had other problems like high blood pressure. Or maybe the body's normal inflammatory response maybe the body's normal inflammatory response to injuries has a worse effect on obese people. to injuries has a worse effect on obese people. The researchers also mention that obese people The researchers also mention that obese people are just harder to work on—radiology isn't as are just harder to work on—radiology isn't as accurate, surgery is harder, and keeping airways accurate, surgery is harder, and keeping airways clear is tougher, too.clear is tougher, too.

Others have not found thisOthers have not found this

Effect of Obesity on Mortality Effect of Obesity on Mortality in Severely Injured Blunt in Severely Injured Blunt Trauma Patients Remains Trauma Patients Remains UnclearUnclearZein et al.Zein et al.Arch SurgArch Surg 2005;140:1130-1131. 2005;140:1130-1131.

Morris et al Chest 2007Morris et al Chest 2007

In a prospective cohort study of all ICU In a prospective cohort study of all ICU patients in King County, Washington, with patients in King County, Washington, with ALI in 1 year (1999 to 2000), 825 patients ALI in 1 year (1999 to 2000), 825 patients had a BMI recorded. Using multivariate had a BMI recorded. Using multivariate analysis, patients in the abnormal BMI analysis, patients in the abnormal BMI groups were compared to normal groups were compared to normal patients in the following areas: mortality, patients in the following areas: mortality, hospital length of stay (LOS), ICU LOS, hospital length of stay (LOS), ICU LOS, duration of mechanical ventilation, and duration of mechanical ventilation, and discharge disposition. discharge disposition.

Chest 2007 contChest 2007 cont There was no mortality difference in any of the There was no mortality difference in any of the

abnormal BMI groups compared to normal-weight abnormal BMI groups compared to normal-weight patients. patients.

Severely obese patients had longer hospital LOS than Severely obese patients had longer hospital LOS than normal-weight patients (mean increase, 10.5 days; 95% normal-weight patients (mean increase, 10.5 days; 95% confidence interval [CI], 4.8 to 16.2 days; p < 0.001); confidence interval [CI], 4.8 to 16.2 days; p < 0.001);

ICU LOS and duration of mechanical ventilation were ICU LOS and duration of mechanical ventilation were also longer in the severely obese group when analysis also longer in the severely obese group when analysis was restricted to survivors (mean increase, 5.6 days; was restricted to survivors (mean increase, 5.6 days; 95% CI, 1.3 to 9.8 days; p = 0.01; and mean increase, 95% CI, 1.3 to 9.8 days; p = 0.01; and mean increase, 4.1 days; 95% CI, 0.4 to 7.7 days, respectively; p = 4.1 days; 95% CI, 0.4 to 7.7 days, respectively; p = 0.03). Severely obese patients were more likely to be 0.03). Severely obese patients were more likely to be discharged to a rehabilitation or skilled nursing facility discharged to a rehabilitation or skilled nursing facility than to home. than to home.

Effect of obesity on intensive care morbidity and mortality: A Effect of obesity on intensive care morbidity and mortality: A meta-analysis *.meta-analysis *. Critical Care Medicine. 36(1):151-158, January 2008.Critical Care Medicine. 36(1):151-158, January 2008.Akinnusi, Morohunfolu E. MD; Pineda, Lilibeth A. MD; El Solh, Ali A. MD, Akinnusi, Morohunfolu E. MD; Pineda, Lilibeth A. MD; El Solh, Ali A. MD, MPHMPH

Design: Meta-analysis of studies comparing Design: Meta-analysis of studies comparing outcomes in obese (body mass index of outcomes in obese (body mass index of >=30 kg/m2) and nonobese (body mass >=30 kg/m2) and nonobese (body mass index of <30 kg/m2) critically ill patients in index of <30 kg/m2) critically ill patients in intensive care settings. intensive care settings.

Data Source: MEDLINE, BIOSIS Previews, Data Source: MEDLINE, BIOSIS Previews, PubMed, Cochrane library, citation review PubMed, Cochrane library, citation review of relevant primary and review articles, and of relevant primary and review articles, and contact with expert informants. contact with expert informants.

Setting: Not applicable. Setting: Not applicable. Patients: A total of 62,045 critically ill Patients: A total of 62,045 critically ill

subjectssubjects

Measurements and Main Measurements and Main Results:Results:

Fourteen studies met inclusion criteria, with 15,347 obese Fourteen studies met inclusion criteria, with 15,347 obese patients representing 25% of the pooled study population. patients representing 25% of the pooled study population. Data analysis revealed that obesity was not associated Data analysis revealed that obesity was not associated with an increased risk of intensive care unit mortality with an increased risk of intensive care unit mortality (relative risk, 1.00; 95% confidence interval, 0.86-1.16; p (relative risk, 1.00; 95% confidence interval, 0.86-1.16; p = .97). = .97).

However, duration of mechanical ventilation and intensive However, duration of mechanical ventilation and intensive care unit length of stay were significantly longer in the care unit length of stay were significantly longer in the obese group by 1.48 days (95% confidence interval, 0.07-obese group by 1.48 days (95% confidence interval, 0.07-2.89; p = .04) and 1.08 days (95% confidence interval, 2.89; p = .04) and 1.08 days (95% confidence interval, 0.27-1.88; p = .009), respectively, compared with the 0.27-1.88; p = .009), respectively, compared with the nonobese group.nonobese group.

In a subgroup analysis, an improved survival was In a subgroup analysis, an improved survival was observed in obese patients with body mass index ranging observed in obese patients with body mass index ranging between 30 and 39.9 kg/m2 compared with nonobese between 30 and 39.9 kg/m2 compared with nonobese patients (relative risk, 0.86; 95% confidence interval, patients (relative risk, 0.86; 95% confidence interval, 0.81-0.91; p < .001).0.81-0.91; p < .001).

Obesity 2008 Olivares and Obesity 2008 Olivares and VillamorVillamor

Meta-Analysis and systematic reviewMeta-Analysis and systematic review Decreasing trend in obese patient and Decreasing trend in obese patient and

mortality and no association between mortality mortality and no association between mortality and morbidly obeseand morbidly obese

Longer ICU stay and increased MOD Longer ICU stay and increased MOD

WhyWhy

Posit 1- Obese patients receive Posit 1- Obese patients receive better carebetter care

Posit 2- Better nutritional reserves Posit 2- Better nutritional reserves (underweight significantly (underweight significantly increased mortality)increased mortality)

Posit 3- Higher levels of leptin that Posit 3- Higher levels of leptin that may improve survival in septic may improve survival in septic patientspatients

““Barry” – A Case StudyBarry” – A Case Study

On Admission:On Admission: Patient is middle aged and morbidly obese Patient is middle aged and morbidly obese

Admitted after falling and hurting his backAdmitted after falling and hurting his back

Patient has been paralyzed since fall - lying Patient has been paralyzed since fall - lying supinesupine

History of frequent admissions to hospitals History of frequent admissions to hospitals related to co- morbidities, multiple dyspneic related to co- morbidities, multiple dyspneic episodes, coagulopathy- clots easily, hx of DVTepisodes, coagulopathy- clots easily, hx of DVT

““Barry” – A Case StudyBarry” – A Case Study

Assessment, Diagnosis & ResultsAssessment, Diagnosis & Results X-rays show fracture of a vertebraeX-rays show fracture of a vertebrae

Requires open CT/MRIRequires open CT/MRI

MRI shows spinal compression related to large MRI shows spinal compression related to large lung tumor pressing on cordlung tumor pressing on cord

Neurosurgery states not a good candidate for Neurosurgery states not a good candidate for surgerysurgery

Family and patient decide no CPR and no Family and patient decide no CPR and no intubationintubation

Patient dies Patient dies

Treating Barry Presents Many Treating Barry Presents Many challengeschallenges

Cannot sit up or turn to left because of spinal Cannot sit up or turn to left because of spinal precautionsprecautions

No bariatric intermittent compression devices, No bariatric intermittent compression devices, a question of how to dose anticoagulanta question of how to dose anticoagulant

Need to find open MRI, will not fit into CT or Need to find open MRI, will not fit into CT or MRI tubeMRI tube

Dyspnea not recognized as symptom of lung Dyspnea not recognized as symptom of lung cancer but part of morbidity of sizecancer but part of morbidity of size

CXR difficult to interpretCXR difficult to interpret Neurosurgery communicates too high of a risk Neurosurgery communicates too high of a risk

for surgeryfor surgery

Key Concerns Staff Have Regarding Key Concerns Staff Have Regarding Caring for Patients of SizeCaring for Patients of Size

Special Treatment Special Treatment NeedsNeeds

Respiratory Respiratory decompensationdecompensation

Skin problemsSkin problems

Patient & Caregiver Patient & Caregiver SafetySafety

Special Treatment Needs:Special Treatment Needs:Blood PressureBlood Pressure

Thigh cuffs are not accurate on the armThigh cuffs are not accurate on the arm

Forearm cuffs are not accurate for this groupForearm cuffs are not accurate for this group

May best be managed by noninvasive May best be managed by noninvasive continuous blood pressure measurement continuous blood pressure measurement technology that measures pressure from wrist technology that measures pressure from wrist sensor: Medwave Vasotracsensor: Medwave Vasotrac and Tensys and Tensys T- T-LineLine (T-Line (T-Line only for patients under effect of only for patients under effect of anesthesia).anesthesia).

Special Treatment Needs: Special Treatment Needs: Calculating Dosages & Administering Calculating Dosages & Administering Medication Medication

Calculating DosagesCalculating Dosages Options: Ideal, actual, adjusted body weightOptions: Ideal, actual, adjusted body weight Dose to effect: Begin with ideal and dose to Dose to effect: Begin with ideal and dose to

effecteffect ConsultConsult Pharm D for dosing when possible Pharm D for dosing when possible

AdministrationAdministration Subcutaneous & Intraveneous routes Subcutaneous & Intraveneous routes require longer than usual needlesrequire longer than usual needles VeinsVeins can be difficult to locate can be difficult to locate

Special Treatment Needs: Special Treatment Needs: DVT preventionDVT prevention

Bariatric Intermittent Pneumatic DevicesBariatric Intermittent Pneumatic Devices

Appropriate dosing of anticoagulantAppropriate dosing of anticoagulant

Early mobilizationEarly mobilization

Special Treatment Needs:Special Treatment Needs:Use Of Central LinesUse Of Central Lines

Obese patients have double the use and lines Obese patients have double the use and lines are in longer than non-obese pts because of are in longer than non-obese pts because of difficulty in placing peripheral linesdifficulty in placing peripheral lines One study suggests no difference in One study suggests no difference in

mechanical insertion complication rate mechanical insertion complication rate El-Solh A et al (2001)El-Solh A et al (2001)

Switch to PICC lines as soonSwitch to PICC lines as soon as possibleas possible

Special Treatment Needs:Special Treatment Needs:Determining Cardiac DynamicsDetermining Cardiac Dynamics

Using Using actual body weightactual body weight is inaccurateis inaccurate Lower total blood volume than non-obese Lower total blood volume than non-obese

(volume/weight)(volume/weight) OO22 and cardiac output are directly proportional to and cardiac output are directly proportional to

amount of weight over “ideal”amount of weight over “ideal” Cardiac output from exercise due to in heart rate, Cardiac output from exercise due to in heart rate,

NOT from stroke volume or ejection fractionNOT from stroke volume or ejection fraction in Oin O2 2 due to disease state not yet determineddue to disease state not yet determined

Using Using ideal body weightideal body weight is inaccurate is inaccurate OO2 2 and cardiac output are higher than in non-obeseand cardiac output are higher than in non-obese

Using Using adjusted bodyadjusted body weightweight is an effective compromise is an effective compromise [Ideal-(actual-ideal) X 0.4][Ideal-(actual-ideal) X 0.4]

Special Treatment Needs: Special Treatment Needs: Diagnostic Tools For Spinal Cord Diagnostic Tools For Spinal Cord PatientsPatients Typical diagnostic aids Typical diagnostic aids

may not be available to may not be available to patients of sizepatients of size No CT scansNo CT scans No enclosed MRINo enclosed MRI No venous dopplersNo venous dopplers Chest x-rays difficult Chest x-rays difficult

to interpretto interpret

Obesity interfered with 7 Obesity interfered with 7 of every 1,000 abdominal of every 1,000 abdominal ultrasounds in 1989. That ultrasounds in 1989. That rate more than doubled rate more than doubled (19) by 2003.(19) by 2003.

Obesity interfered with 8 Obesity interfered with 8 out of every 10,000 chest out of every 10,000 chest X-rays in 1989. By 2003, X-rays in 1989. By 2003, the rate had more than the rate had more than doubled to 19 doubled to 19

““Because radiologists can't Because radiologists can't get the images needed to get the images needed to diagnose potentially serious diagnose potentially serious problems, these patients problems, these patients incur the cost of extra incur the cost of extra diagnostic tests -- and they diagnostic tests -- and they may have to settle for may have to settle for substandard care- Spinal substandard care- Spinal cord injured patients of size cord injured patients of size of particular challenge”of particular challenge”

Uppot, R.N. Uppot, R.N. RadiologyRadiology, August 2006; vol 240: pp 435-439, August 2006; vol 240: pp 435-439

Preventing Respiratory Preventing Respiratory DecompensationDecompensation

Use patient turning and Use patient turning and early mobilizationearly mobilization

Consider Percussion Consider Percussion Use Trendenlenburg Use Trendenlenburg

position- Left lateral position- Left lateral decubitus, semi recumbentdecubitus, semi recumbent Increases tidal volumeIncreases tidal volume Avoid supine or Avoid supine or

Trendelenburg when Trendelenburg when possiblepossible

Constant assessment of Constant assessment of OSAOSA

Ready availability of airway Ready availability of airway assist teamassist team

Availability of extra long Availability of extra long tracheostomy tubestracheostomy tubes

Maintaining Skin IntegrityMaintaining Skin Integrity

No powders in skin foldsNo powders in skin folds Daily inspection of skin; frequent, scheduled Daily inspection of skin; frequent, scheduled

turningturning Pay careful attention to moisture managementPay careful attention to moisture management Float patient’s heelsFloat patient’s heels Avoid “pushing and pulling” when repositioningAvoid “pushing and pulling” when repositioning Guard against pressure, shear, and pinching Guard against pressure, shear, and pinching

when using lifts and slingswhen using lifts and slings Position tubes and Foleys over the patient’s Position tubes and Foleys over the patient’s

body and not in skin foldsbody and not in skin folds Consider rectal tube for liquid stoolsConsider rectal tube for liquid stools

Challenges To Patient & Caregiver Challenges To Patient & Caregiver SafetySafety

Patient RepositioningPatient Repositioning

TransfersTransfers

TransportTransport

MobilityMobility

Frequency & Cost of Back InjuriesFrequency & Cost of Back Injuries

Nurse’s Aides and Orderlies are Nurse’s Aides and Orderlies are the highest risk occupation the highest risk occupation category for work-related category for work-related musculoskeletal injuriesmusculoskeletal injuries11

Nurse injuries related to patient Nurse injuries related to patient handling are increasinghandling are increasing22

750,000 lost workdays annually750,000 lost workdays annually $20 Billion annually$20 Billion annually

Back pain is second only to the Back pain is second only to the common cold as the most common cold as the most frequent cause for nurse’s sick frequent cause for nurse’s sick leaveleave331. United States Department of Labor, Bureau of Statistics2. Patient Care Ergonomics Resource Guide: Safe Patient Handling and Movement, Pt. Safety Center of Inquiry, VHA and DOD, 20013. Frymoyer JW, Cats-Baril WL. An overview of the incidence and costs of low back pain. Orthop Clin North Am 1991;22:263–71.

Using Technology Can Help Address Using Technology Can Help Address Patient & Care Giver SafetyPatient & Care Giver Safety

Repositioning: Turning Repositioning: Turning SurfacesSurfaces

Transfer: Lateral Transfer: Lateral Transfer DevicesTransfer Devices

Transport: Variable Transport: Variable width beds; stretcher width beds; stretcher chairschairs

Mobility: Foot or side Mobility: Foot or side exit beds; mobility aids exit beds; mobility aids and accessoriesand accessories

Using Technology To Assist In patient Using Technology To Assist In patient carecare

Integrated design Integrated design delivers flexible, delivers flexible, individualized therapies individualized therapies in a single framein a single frame

““Built-in” features help Built-in” features help reduce the need to reduce the need to transfer complex transfer complex patients patients

Many features help Many features help minimize the potential minimize the potential risks associated with risks associated with patient handlingpatient handling

850 lb capacity

Kinetic Therapy SystemKinetic Therapy System

Moisture management (low air loss)Moisture management (low air loss) Percussion and pulsation- staff assist Percussion and pulsation- staff assist

and patient assistance with and patient assistance with secretionssecretions

Rotation important to assist staff with Rotation important to assist staff with turningturning

Cardiac chair can help in mobilization Cardiac chair can help in mobilization and aid in comfortand aid in comfort

Built in scaleBuilt in scale Order with Lift and make sure Order with Lift and make sure

whatever lift is used works with bed whatever lift is used works with bed frame.frame.

BariMaxxBariMaxx II Power Drive System II Power Drive System With MaxxAir ETSWith MaxxAir ETS MRS MRS

Expandable width of 36, 42 Expandable width of 36, 42 and 48 inchesand 48 inches

Side exit preferable for Side exit preferable for rehabilitative staff and some rehabilitative staff and some patientspatients

Turn assist aids in patient Turn assist aids in patient repositioningrepositioning

Continuous lateral rotation up Continuous lateral rotation up to 30 degreesto 30 degrees

Power drive system to assist Power drive system to assist with patient transportwith patient transport

Built in scaleBuilt in scale1000 lb capacity

Ease of patient transfer may Ease of patient transfer may require fewer caregiversrequire fewer caregivers

Air technology creates a nearly Air technology creates a nearly frictionless transfer surface helping frictionless transfer surface helping reduce risk of caregiver injuryreduce risk of caregiver injury

Pad design allows patients to Pad design allows patients to remain on the transfer pad for all remain on the transfer pad for all ancillary procedures, such as ancillary procedures, such as radiology, CT scan, radiation radiology, CT scan, radiation therapy, etc.therapy, etc.

Sani-liner provides a safe layer Sani-liner provides a safe layer between patient and mattress to between patient and mattress to help mitigate infection help mitigate infection

1,000 lb capacity

Valuable Assistance In Lateral Valuable Assistance In Lateral TransfersTransfers

Treatment of Patients Of Size Treatment of Patients Of Size Requires A Multidisciplinary EffortRequires A Multidisciplinary Effort

Hospital wide committee developmentHospital wide committee development Treatment guidelinesTreatment guidelines Mobility (no lift) algorithm - VHA websiteMobility (no lift) algorithm - VHA website BMI calculations (40+ BMI gets bariatric equipment)BMI calculations (40+ BMI gets bariatric equipment) Access to and routine use of special equipmentAccess to and routine use of special equipment Weight limit labels for all equipment listed in policy Weight limit labels for all equipment listed in policy Provision of airway assist teamsProvision of airway assist teams Cultural sensitivity trainingCultural sensitivity training Community resources- bariatric surgery programs, diet, Community resources- bariatric surgery programs, diet,

lifestyle enhancements, diagnostics (open MRI availability, lifestyle enhancements, diagnostics (open MRI availability, etc.)etc.)

Involvement of rehab departmentInvolvement of rehab department Staff safetyStaff safety Assist with mobilization and patient ROM and strengthAssist with mobilization and patient ROM and strength

What do you see?What do you see?

(Allon, 1975; Staffieri, 1967, 1972).(Allon, 1975; Staffieri, 1967, 1972).

Both normal-weight Both normal-weight and overweight and overweight children describe children describe obese silhouettes obese silhouettes as "stupid," "dirty," as "stupid," "dirty," "lazy," "sloppy," "lazy," "sloppy," "mean," "ugly," and "mean," "ugly," and "sad," among other "sad," among other pejorative labels   pejorative labels  

Crocker, J., Cornwell, B., & Major, B. (1993). The stigma of Crocker, J., Cornwell, B., & Major, B. (1993). The stigma of overweight: Affective consequences of attributional ambiguity. overweight: Affective consequences of attributional ambiguity. JOURNAL OF PERSONALITY AND SOCIAL PSYCHOLOGY. 64(1), 60-JOURNAL OF PERSONALITY AND SOCIAL PSYCHOLOGY. 64(1), 60-70.70.

"Of all the conditions for which a "Of all the conditions for which a person may be stigmatized in our person may be stigmatized in our culture, including racial or ethnic culture, including racial or ethnic group membership, religious group membership, religious affiliation, physical handicaps, and affiliation, physical handicaps, and sexual preference, the stigma of sexual preference, the stigma of being overweight may be the being overweight may be the most debilitating."most debilitating."

If the world needed any more proof that Americans are If the world needed any more proof that Americans are some fattie mcfatties, we present the French-Fry some fattie mcfatties, we present the French-Fry Holder. This $10 device fits in cup holders and holds a Holder. This $10 device fits in cup holders and holds a standard cardboard container of french fries. It even standard cardboard container of french fries. It even has a small holder for ketchup, for those fattersons that has a small holder for ketchup, for those fattersons that need to add a little more flavor (and sodium) to their need to add a little more flavor (and sodium) to their deep-fried potato sticks. A no-slip grip secures the deep-fried potato sticks. A no-slip grip secures the device in any cup-holder to prevent any wasted fries. device in any cup-holder to prevent any wasted fries. Weren't French fries designed to be the perfect food Weren't French fries designed to be the perfect food while driving? Sure, we're all about driving safety, while driving? Sure, we're all about driving safety, which this device addresses, but we wonder if the which this device addresses, but we wonder if the morbid-nature of this product outweighs its positives.morbid-nature of this product outweighs its positives.

Insensitivity Toward Patients Of SizeInsensitivity Toward Patients Of SizeIs CommonIs Common

““He has poor protoplasm and is so He has poor protoplasm and is so large he can’t even care for himself: large he can’t even care for himself: Its hopeless” Its hopeless”

““They have done it to themselves”They have done it to themselves”

““Don’t like to care for them because Don’t like to care for them because of the body odor”of the body odor”

““He is sick because all he does is sit He is sick because all he does is sit around”around”

Obesity is often described Obesity is often described as the last 'acceptable' as the last 'acceptable' form of discrimination form of discrimination based on physical based on physical appearances.appearances.

American Obesity Association

Crandall, C., & Biernat, M. (1990). The ideology of anti-fat Crandall, C., & Biernat, M. (1990). The ideology of anti-fat attitudes. JOURNAL OF APPLIED SOCIAL PSYCHOLOGY. 20(3), 227- attitudes. JOURNAL OF APPLIED SOCIAL PSYCHOLOGY. 20(3), 227- 243. 243.

"What turns these attitudes into "What turns these attitudes into prejudices is that they exist in the prejudices is that they exist in the face of mounting evidence that face of mounting evidence that one's weight is largely determined one's weight is largely determined outside of volitional control"outside of volitional control"

Genetics: Twin studies Genetics: Twin studies

Fraternal Fraternal IdenticalIdentical

Health Care ProfessionalsHealth Care Professionals An Implicit Associations Test was An Implicit Associations Test was

administered administered Found significant pro-thin anti-fat biasFound significant pro-thin anti-fat bias Found subjects endorsed stereotypes Found subjects endorsed stereotypes

of lazy, stupid and worthless.of lazy, stupid and worthless. Lower levels of bias were associated Lower levels of bias were associated

with being male, older, weighing more, with being male, older, weighing more, having a positive outlook, having obese having a positive outlook, having obese friends and understanding the friends and understanding the experience of obesity.experience of obesity.

TA Wadden, Obesity Research 2003

Are the Obese Bias against Are the Obese Bias against the Obese?the Obese?

Implicit Association Test used with explicit Implicit Association Test used with explicit measures used in 2measures used in 2ndnd group as well. group as well.

68 overweight individuals in 168 overweight individuals in 1stst and 48 and 48 overweight individuals in the 2overweight individuals in the 2ndnd group. group.

Significant anti-fat bias noted on IATSignificant anti-fat bias noted on IAT Endorsed explicit belief that fat people are Endorsed explicit belief that fat people are

lazier than thin people.lazier than thin people.

SS Wang International Journal of Obesity 2004

The problems we OverlookThe problems we Overlook From a survey of 1549 patients published in Obesity From a survey of 1549 patients published in Obesity

Surgery by Dr. DeitelSurgery by Dr. Deitel Specific problems associated with massive obesitySpecific problems associated with massive obesity

Unable to:Unable to: % of Patients% of Patients

Cut toenailsCut toenails 7373

Cross legsCross legs 8585

Buckle seat beltBuckle seat belt 2727

Fit into theatre seatFit into theatre seat 3636

Wipe selfWipe self 2121

Urinate accurately (men)Urinate accurately (men) 5252

Will Not:Will Not:

Sleep in room with S.O.Sleep in room with S.O. 8181

Undress in front of S.O.Undress in front of S.O. 7373

Preferred Terms in ObesityPreferred Terms in Obesity

167 obese women and 52 obese men 167 obese women and 52 obese men surveyedsurveyed

Terms Least desirable:Terms Least desirable: Fatness, excess fat, obesity and large sizeFatness, excess fat, obesity and large size

Terms more desirableTerms more desirable Weight, BMI, excess weight, unhealthy Weight, BMI, excess weight, unhealthy

body weight, weight problem, unhealthy body weight, weight problem, unhealthy BMI, heaviness.BMI, heaviness.

Preferred “patients of size”Preferred “patients of size”

TA Wadden, Obesity Research 2003

LiteratureLiterature

Supports the idea that healthcare providers Supports the idea that healthcare providers label obese patientslabel obese patients

Supports the fact that labeling sets up Supports the fact that labeling sets up isolationisolation

Supports the fact that the label is Supports the fact that the label is communicated to all staffcommunicated to all staff

Survey of severe obese- 80% report being Survey of severe obese- 80% report being treated disrespectfully by the medical treated disrespectfully by the medical professionprofession

Labeling may worsen diseaseLabeling may worsen disease

LabelsLabels

Falls into two Falls into two categoriescategories

•Stigmatized illnesses (bariatric)•Confused uncommunicative

Responses Responses

Exclusionary- Avoid patient at all costsExclusionary- Avoid patient at all costs Care for patient unemotionallyCare for patient unemotionally

Culture of SensitivityCulture of Sensitivity

Respectful Language:Respectful Language: Instead of morbid obesity – severe Instead of morbid obesity – severe

obesityobesity Instead of excess fat – excess Instead of excess fat – excess

weightweight Instead of obese patient – “patient Instead of obese patient – “patient

of size” or “patients with a weight of size” or “patients with a weight problem” or unhealthy BMIproblem” or unhealthy BMI

Create Culture of Create Culture of SensitivitySensitivity

1.1. Understand obesity is a disease Understand obesity is a disease not a character flawnot a character flaw

2.2. Challenge your own attitude/biasChallenge your own attitude/bias

3.3. Empathize with patient experienceEmpathize with patient experience

4.4. Use respectful languageUse respectful language

5.5. Provide equipment/furnishings Provide equipment/furnishings that fit patient needthat fit patient need

Questions/DiscussionQuestions/Discussion

Thank you!Thank you!Glenn Carlson