As health care professionals explore treatment pathways geared toward meeting the needs of obese clients, acquiring specialized equipment and providing staff training in the care of these individuals can prove beneficial for all involved. Research from Georgia’s Mercer University School of Medicine indicates that, for a number of reasons ranging from psychological to physical difficulties and mobility problems, bariatric patients tend to wait longer to seek medical care for ailments, and as a result will often remain under medical care longer than nonobese patients.
According to bariatric specialist Michael Dionne, PT, of Choice Physical Therapy Inc, Gainesville, Ga, the bariatric population requires a unique approach to mobility in order to protect the patient and reduce worker injury. Safety training programs present a methodical approach to transfer of patients of size in a clinical setting. Screening tools used by clinicians at a client’s bedside help staff make decisions on how to assist these patients in transfer and ambulation, as well as provide greater insight into decision points for transfer equipment evaluations.
Back injuries are a solid concern for physical therapists and other staff who regularly attend to larger patients. Statistics from the APTA reveal that in the last decade, 32% of physical therapists and 35% of physical therapy assistants sustained work-related musculoskeletal injuries working with clients.
Over his years of practice, Dionne has developed a series of lectures, seminars, books, and DVDs on working with obese individuals. He not only emphasizes the importance of safety and sensitivity when creating a care pathway for obese patients, but he has developed a methodology for lifting larger patients he calls the No Lift Zone. “Don’t put your spine on the line,” stresses Dionne, who promotes developing a plan that will provide safety for professionals and their clients, emphasizing a reliance on equipment to move larger patients. “Too many physical therapists have disappeared from the profession [after experiencing] back injuries.
“There’s no way to [lift these individuals] other than with specialized equipment,” says Dionne, who believes the best clinical pathway can be created by promoting awareness of the special needs of the obese to staff members of both bariatric and non-bariatric facilities.
Manon Short, RPT, an injury prevention coordinator at Tampa General Hospital, Tampa, Fla, recommends educational seminars for treating obese patients for all the hospital’s facilities.
“The day-long program at Tampa General presented mobility, safety, and skin care of larger patients,” says Short. “We also had social workers on hand to deal with the issues these patients present.”
Short, who is a member of a special task force at Tampa General that meets every couple of months to discuss the evolution of care and policies for treating the obese, says that if an obese client is to be admitted into the facility for care, the person’s case must first be discussed by the task force in preparation. For example, therapists will review the individual’s skin condition to determine care protocol, turning schedules, and the specialty bed that might be needed. Then, if necessary, the in-house lift team—which is on call 24/7—will be notified as to how to handle the patient’s arrival, and will address matters ranging from changing bed sheets to meeting an ambulance at the emergency department for larger and less mobile patients.
THE HOME PATHWAY
Michael Dionne, PT, of Choice Physical Therapy Inc, Gainesville, Ga, refers to the three equipment necessities a bariatric patient should have in their home as “The Triad.”
This combination consists of a wheelchair or mobility device, a weight-rated bed, and whatever lifting device the patient requires. In addition to the equipment, doorways might need to be widened, ramps installed, and floors might require reinforcement. (He believes the preferred location of the individual is the living room of the home.)
According to Dionne, once all of the factors are known, costs of the key items are usually negotiated among the hospital, the insurance companies, and the rental companies. Payment is not standard with insurance companies and HMOs; it depends on the policy. Medicare might pay for home modifications once they are completed if there is a letter from a physician.
For more information on Michael Dionne, PT, and Choice Physical Therapy Inc, go to www.bariatricrehab.com.
Lifts have become a crucial factor in the care of bariatric patients. Ultimately providing protection for caregivers and clients, many lifts are designed either to attach to a bed, or as freestanding units. From the portable trapeze, which is used with an assistant to help the patient change positions in bed, to freestanding electronic slings that can hold more weight and have the safety of padding that prevents skin tearing, lifts can be used to place the patient into a mobility device, or to move the patient while the bedding is changed. Lift chairs move up and back to enable the patient who cannot stand to be upright. Many new medical facilities are installing over-the-bed lifts to safely move patients from bed to stretcher for surgery or tests, without the therapists and/or caretaker putting their “spine on the line.”
It is crucial to determine a client’s capability of movement prior to treatment. For example, can the individual walk without assistance, or are they in need of help? Once this is established, an appropriate mobility device can be recommended for the individual.
Daniel J. Drake, MSN, RN, CBN, manager of bariatric programs at Pitt Memorial Hospital, Greenville, NC, and president of the National Association of Bariatric Nurses, believes most bariatric patients are better off in power-driven wheelchairs, as they may not be able to push the wheels forward in manual chairs due to the larger width of the chair.
An advocate of both safety and sensitivity issues connected to bariatric patients, Drake says, “[Power-driven] wheelchairs are easier for the patient to operate, as they not only offer a joystick control, but have safer braking systems that can help prevent accidents on ramps and uneven ground.” Drake also prefers the use of scooters by patients weighing less than 550 pounds. “The tighter turning ratio [of a scooter] can make mobility easier in small spaces,” he offers.
When looking for mobility solutions for bariatric clients, professionals have a plethora of equipment available to help individuals in need of partial assistance, as well as those who are completely incapable of self-propelling. When only a minimal amount of support is needed, there are specialty four-leg canes, crutches, forearm crutches, walkers, and safety scooters with wheels that are reinforced and have larger handles and grips. For men and women unable to self-propel, wheelchairs and motorized scooters are a prime solution. Wheelchairs and scooters have made tremendous advances in the field of bariatric medicine and are now able to accommodate individuals weighing as much as 800 pounds. (Of course, seating and positioning considerations must be made for each individual’s fit and comfort—including such modifications as special cut outs for “redundant tissue,” extralarge seat belts, and extralarge cushions to provide more substantial skin protection.)
For quick transfers, reinforced, extrawide manual wheelchairs for bariatric patients can fold up for easy transportation. In addition, portable ramps can make transfers and accessibility easier where permanent ramps do not exist.
BEDDING, BATHING, AND ACCESSORIES FOR DAILY LIVING
Since standard hospital beds are often a problem for obese individuals to negotiate, bariatric hospital beds are now available in a variety of styles and sizes (ranging up to 54 inches in width and accommodating users weighing as much as 1,000 pounds). These beds also offer an impressive array of features, including manual and fully electric controls, adjustability, trapezes, hand remote controls, rails, grips, customized mattresses for all sizes, and medical needs.
Bathing and personal care issues can also provide a challenge for bariatric patients, and must be addressed with a modicum of sensitivity and intelligent solutions to make the experience less of an ordeal-—whether in-home or in-facility care situations.
These special considerations can include introducing weight-rated, extrawide shower chairs, benches, and gurneys to bathing and shower areas. (In fact, many professional care facilities now stock extended-size bath sheets, as well as examination gowns for larger-size clientele.) Also, shower nozzles with extralong hoses can often enable an individual to self-bathe. There are also several types of long-handled sponges and scrubbers on the market to make self-care easier for bariatric patients. In addition, specialized personal grooming tools, such as long-handled clippers for toenails, can make personal care easier for a larger person.
Another necessary problem to address is toilet modification. A common solution for modifying ceramic toilets is to raise the platform by at least 3.5 inches, to provide easier seating. In addition, larger seats can be purchased for comfort. For more severe circumstances, a bedside steel frame commode, with such features as locking wheels, removable back seats, and drop arms, is available. (Plastic liners allow for easier cleaning of these commodes.) For those whose movements are confined, larger autoclavable bed pans, with low back rims for patient ease, are available.
In addition to the above-mentioned items, there are a myriad of available products to make the tasks of daily living easier for bariatric individuals, including extralong bath mats, shampoo trays that enable cleansing without bending down or dripping, footbrushes that strap to the wrist, toilet paper holders to help patients wipe, soap holders on long handles for back washing, large bariatric diapers, and reinforced step stools.
THE SENSITIVITY FACTOR
Dana Schuster, MA, rehab counselor and president of the Association for Size Diversity and Health (ASDAH), advises facility professionals and at-home caretakers not to forget the sensitivity factor when dealing with a larger clientele. “Do not make assumptions about what a large body can [or cannot] do,” says Schuster. “Know the weight limits on all the equipment used in a treatment setting, and be nonjudgmental.”
Schuster believes that with a little extra thought and effort, therapists and caretakers can provide their bariatric patients with safe, superior, and customized care, while helping them maintain their independence and preserve their dignity.
Cathy Logan is a contributing writer for Rehab Management. For more information, contact .