Size Matters
To help nurses prevent injury and safely care for obese patients, more facilities are heeding the call for specialized bariatric equipment and lift teams

By John Leighty
October 2, 2003


Jill Arzouman, MSN, RN, has helped develop hospital protocols for handling severely obese patients, but she no longer assists in moving people who weigh more than 300 pounds.

"I have a bad back, not from moving any one patient, but from doing it over a number of years," said Arzouman, an advanced practice clinical nurse specialist at the University Medical Center in Tucson, Ariz. "I just can't help lift heavy patients."

Arzouman is not alone. When it comes to risk for back injuries, nurses aides and assistants rank the highest-above construction workers-and RNs, LPNs and VPNs, health aides and physical therapists are high on the list, according to the Bureau of Labor Statistics.

The problem is that the nation's population is getting heavier, and the number of people considered morbidly obese-100 pounds or more overweight-is soaring. The added weight puts a strain on hospital systems that must install special beds, lifts, scales, wheelchairs and other equipment to accommodate the needs of the obese.

Some diagnostic facilities are not able to serve the morbidly obese, which results in a lack of preventive and imaging services available to a portion of the bariatric population-patients with a body mass index of 35 or greater.

A growing need

When more overweight patients began to show up at University Medical Center and strain staff resources, a multidisciplinary team was formed to come up with solutions. Co-chaired by Arzouman and Jane Lacovara, MSN, RN, who also share clinical duties, the panel developed a set of protocols for handling a range of issues that involve obese patients.

"Overweight patients can put employees at risk of being hurt," Lacovara said, "so it's very important when a bariatric patient is admitted that the hospital gets the proper equipment for handling them. We want to protect employees from back injuries and strains."

Lacovara said staff at the 355-bed hospital could quickly customize a "bari room," where everything is larger than normal. The room would have an oversized bed, chair, toilet and access to an overhead mechanical lift. If extra equipment is needed, the hospital contracts with an outside vendor to supply it on short notice.

The protocol includes a set of preprinted orders that can be easily followed by the hospital's 713 nurses. For example, if a patient's abdominal girth is a certain size, or if a patient has pulmonary problems, then special equipment must be obtained. "Everything is laid out for them so they don't have to memorize the procedures," Lacovara said.

In most cases, a clinical nurse specialist coordinates the patient's needs through consultations with a nutritionist, pharmacist and social services. Case management for the patient's discharge needs is set up at the time of admittance.

Heavy duty

At Kaiser Permanente, special two-person "lift teams" have been trained to handle the increase of heavy patients at the managed care organization's hospitals throughout California.

Dale Thompson, a workplace safety expert with Kaiser Permanente's Southern California region, said the teams are on duty from 5 a.m. until about 8 p.m. in order to help with weigh-ins in the morning and to make sure patients are secure for the night. The teams often handle between 30 and 35 lifts a day, using special equipment.

"If the use of lift teams can prevent two or three staff injuries, this can save a significant amount of money," Thompson said. "The equipment is expensive, but it lasts for years."

Thompson said one study of San Diego area emergency departments showed an average of one 350-pound patient visit per week. The study prompted Kaiser's San Diego facility to install a gurney in its ER that can handle a 650-pound patient and a mechanized bed for someone weighing up to 1,000 pounds.

The lift team concept and procedures for handling morbidly obese patients was developed in a labor-management partnership, and the results have been outstanding, Thompson said.

"We've seen a 46 percent reduction in nursing staff injuries in the second quarter of this year, so the lift teams have had a tremendous effect, and I think we can do much better."

SizeWise Rentals, a Kansas City, Mo., company that provides bariatric rehabilitation equipment rentals nationwide, is expanding to meet the demand for beds, lifts and wheelchairs that can handle weight capacities of up to 1,000 pounds.

Susan Gallagher, MSN, CNS, RN, a clinical nurse specialist who does educational outreach for SizeWise, said she encourages hospitals to develop protocols and competencies for handling obese patients. At the forefront should be preplanning for a bariatric patient's arrival, based on the patient's weight, degree of immobility and pain, the need for special IV procedures and other factors.

"The equipment is great because it helps prevent clinical complications and reduces injuries to nurses and other caregivers doing patient transfers," Gallagher said. "But this is just the beginning of what is needed for effective bariatric care."

Skilled nursing homes that provide long-term care can find themselves stretched thin by having a bariatric patient, said Cindy Forbis, MHA, RN, administrator of The Bluffs in Columbia, Mo.

An example is a 68-year-old woman who weighed 275 pounds when admitted to the 120-bed facility three years ago and now tips the scales at 385 pounds. She requires a private room, a full-size bed instead of the typical twin and an extra-large shower chair. An electronic lift is also needed for transfer purposes.

"We've had employees injured working with obese residents. If someone 375 pounds starts to fall, there's no way you're going to stop them. If you try, you're going to get injured, and we've had that happen." Nurses' and health aides' injuries have included back strain, shoulder strain and a foot injury when a lift tipped over.

Because most nursing home patients are Medicare recipients, reimbursement rates don't adequately cover the cost of care for most residents, let alone those who are morbidly obese, usually elderly and often immobile, Forbis said.

As a result, the admissions criteria for the facility are being revised to exclude patients who weigh more than 350 pounds, Forbis said. "This is unfortunate, but we can't pull from the resources of all the other residents. If there were better reimbursement, we could justify having bariatric patients."

Group Effort

At Providence Hospital in Southfield, Mich., emphasis is placed on treating medical conditions related to obesity-breathing problems, apnea, lung disease-and in assessing the risk of patients becoming immobile.

Nurses also are trained annually in the mechanics of moving heavy patients, said Diane Wehby, MSN, RN, director of critical care and respiratory therapy at the 459-bed hospital. Although the facility has no formal lift teams, coordination and teamwork are key in handling a patient weighing more than 250 pounds.

"There's a lot of peer pressure within the nursing group to be sure there's adequate help before moving someone," Wehby said. "One thing that's a quick career stopper is a back injury."

Before her role at Providence, Wehby had worked in weight management and helped develop a bariatric surgery program at Sinai-Grace Hospital in Detroit. She emphasizes the need to help overweight people retain their dignity and to have them move about as much as possible to prevent pneumonia, blood clots and infections from being immobile.

"We need to get patients up and moving, and we need to do that safely," Wehby said. She said the hospital has mechanized beds for those 350 pounds or heavier that will allow patients to stand up and walk directly off the beds so they don't lose their balance.

Wehby said there's a social stigma to being morbidly obese that prevents many people from seeking treatment, including bariatric surgery. She would like to see this change now that being overweight is becoming a national health crisis.

"Americans are getting bigger and bigger, and obesity will kill you or lead to premature death," Wehby said. "The tendency to get obese is one of our most important health issues."

Kay McVay, RN, president of the California Nurses Association, said the union's bargaining committees are asking for the establishment of lift teams similar to Kaiser's in every new hospital contract negotiation.

"I don't think I know of a nurse who has worked more than five years who hasn't had a shoulder, neck or back injury of some kind-it comes with the territory," McVay said. "I've worked in nursing 47 years and have had them all."

She said the CNA also is drawing attention to the need for special pressurized beds that rotate so the patient doesn't have to be physically turned and that redistribute weight to prevent skin breakdown. Mechanized beds also can move heavy patients from a prone to an upright position so they can stand up more easily.

Although some changes to accommodate obese patients are expensive in the short term, they pay off over time, McVay said.

"It takes between $40,000 and $60,000 to bring in a new nurse and get them up to par, so you don't want that nurse hurt." McVay said. "The better a hospital takes care of its RNs, the more profitable that facility will be."

Contact John Leighty at johnsan@aol.com