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CMS adds to pressure for safe patient handling
Lack of repositioning leads to pressure ulcers
One pressure ulcer can cost as much as your entire budget for new patient handling equipment. That alone is a reason to create a safe patient handling program that can accommodate patients of size, whether or not your hospital performs bariatric surgery, says Susan Gallagher Camden, PhD, RN, MA, MSN, WOCN, a Houston-based consultant on bariatric risk management, clinical advisor with the Celebration Institute in Houston, and author of The Challenges of Caring for the Obese Patient (Matrix Medical Communications, Edgemont, PA; 2005).
Don't expect any reimbursement to treat those pressure ulcers caused when employees don't have adequate equipment and are afraid of injuring themselves by turning or repositioning a morbidly obese patient, she notes. As of October 2008, the Centers for Medicaid & Medicare Services (CMS) no longer reimburses hospitals for Stages III and IV pressure ulcers that were not present upon admission.
"Those can be very large [claims] and very, very expensive," says Camden, an expert on bariatric safe patient handling who notes that a case requiring skin grafts can cost up to $100,000.
That rule change provides financial justification for an upgrade in patient handling, such as the installation of ceiling lifts, she says. "It's going to be quite an amazing opportunity for us to implement good-quality care," says Camden, who was scheduled to speak at this month's Safe Patient Handling and Movement Conference, sponsored by the Patient Safety Center of the James A. Haley VA Medical Center in Tampa, FL.
Better patient handling also will improve the patient experience, as employees become more comfortable caring for the bariatric population, says Shirley Thomas, RN, MPA, manager of the vascular/GI surgery unit and the lift team at the University of California (UC) Davis Medical Center in Sacramento. Thomas recently spoke in an audio conference titled "Prevention of Employee Injuries and Lift Teams A Comprehensive Approach," which was sponsored by AHC Media, the publisher of Hospital Employee Health.
Employees need "the right equipment at the right place at the right time," as well as better information about the causes of obesity, she says. UC Davis Medical Center provided bariatric sensitivity training to about 500 employees. "I've seen a shift in the culture of how accepting we are of patients of size," Thomas adds.
'Bariatric' patients can be in any unit
More Americans are obese than ever before. About a third of adults have a body-mass index (BMI) of 30 or greater, according to the Centers for Disease Control and Prevention. About 5% are extremely obese, with a BMI of 40 or greater, according to the National Center for Health Statistics. Those patients may exceed the weight limits of standard lift equipment.
It is a mistake to assume that special equipment for patients of size is only needed by hospitals that have a bariatric surgery program. Any hospital in the country is likely to treat patients who are extremely obese, says Camden. "If we just look at the hospital population, we know that at least one in 20 will require some kind of accommodation because of their weight," she says.
Can you handle 'patients of size'?
Assessment is key, experts say
Whether your hospital has a bariatric surgery program, you should review your patients' needs and plan for heavier patients, say experts in bariatric care. Here are some steps to take to protect both patients and caregivers from injury:
Assess the BMI of your patient population.
Conduct a point prevalence study by recording the height, weight, and BMI of every patient admitted that day. You also may want to conduct a point prevalence study of pressure ulcers that includes the patients' BMI. That will tell you where to focus your resources. One facility found that the lab was seeing many patients of size and needed larger furniture to accommodate them. When installing ceiling lifts, give priority to areas that care for more patients of size, says Susan Gallagher Camden, PhD, RN, MA, MSN, WOCN, a Houston-based consultant on bariatric risk management, clinical advisor with the Celebration Institute in Houston and author of The Challenges of Caring for the Obese Patient (Matrix Medical Communications, Edgemont, PA; 2005).
Consider patients of size when purchasing or replacing equipment or remodeling.
The University of California (UC) Davis Medical Center created a multidisciplinary bariatric care committee, which revised policies and procedures and assessed needs. "We did an inventory of bariatric waiting room chairs, floor-mounted toilets, the weight load on the railings, [and lift equipment] to see where we needed to expand our equipment and furniture to accommodate bariatric patients," says Shirley Thomas, RN, MPA, manager of the vascular/GI Surgery Unit and the lift team at the UC Davis Medical Center in Sacramento.
New ceiling track systems should be capable of accommodating patients up to 850 pounds, says Camden. Instead of slings, hospitals can purchase bands that are easy to slide under a patient and attach to the lift, she says. Rolling a heavy patient to place a sling under him or her can create a hazard, she notes.
Partner with risk managers and safety professionals.
You have some natural allies as you seek to improve care for patients while protecting employees. A pressure ulcer due to inadequate repositioning or a patient fall presents liability issues for the hospital, as well as safety concerns, says Camden. She also recommends working with skin care experts to determine their concerns.
Purchase adequate equipment.
Your equipment choices should be linked to your assessment of your patient population. For example, Camden notes that a hospital could put ceiling tracks in every room but maintain only two or three lift motors per unit. "One hospital explained to me that they rent the lifts so they only pay for the days the lift is in place," she says. Even with the ceiling lifts, hospitals will need some freestanding lifts for cases in which the patient is outside the range of the tracks, Camden notes.
UC Davis Medical Center purchased a "vehicle extraction lift" after an incident with a 500-pound patient who could not bear any weight. Employees tried to help her out of her car using a slide board but dropped her. The lift team arrived and used a lift to help the patient, who was not injured. That potential problem is now averted because of the new lift that is designed to help fully dependent patients out of a car.
Consider the needs of your own employees.
Some of your own employees may qualify as morbidly obese. You and other employee health staff may benefit from a better understanding of the causes of obesity and the health risks they may have. UC Davis Medical Center provides sensitivity training that covers the genetic, environmental, social/cultural, and emotional causes of obesity.
The proportion of morbidly obese patients may be significantly greater in some areas of the country. Obesity rates vary, with the greatest prevalence in Alabama, Mississippi, and Tennessee, according to the CDC.
At UC Davis Medical Center, every day about 12 to 22 patients out of the daily census of about 570 patients weigh 300 pounds or more. "Other hospitals I've spoken to have as many as 30%," says Thomas.
Furthermore, it may be a mistake to focus the large-capacity equipment in your bariatric surgery area, notes Camden. Patients are encouraged to walk shortly after their gastric bypass surgery.
"The weight loss surgery patient has been screened. They're pretty healthy patients other than their obesity," she says. "Some are in the hospital just 24 hours. It's really those patients in other areas that create issues for health care workers and for hospitals."
Morbidly obese patients are at greater risk for Type 2 diabetes, coronary heart disease, high blood pressure, osteoarthritis, certain cancers, sleep apnea, and respiratory problems, according to the CDC.
Even pediatric units treat the occasional patient of size. Thomas recalls an 11-year-old, 450-pound boy who was admitted as doctors sought to determine the cause of his extreme weight. He was diagnosed with a pituitary gland deficiency.
Hospital saves $1.6 million
Safe patient handling that incorporates the needs of bariatric patients pays off in dollars and in other benefits.
The hospital has implemented its ceiling lift infrastructure gradually, placing ceiling lifts in one room per unit to accommodate patients of size. All new construction of patient rooms will incorporate ceiling lifts, Thomas says.
UC Davis Medical Center has lift teams that are available 24/7; they perform about 200 lifts per day. Since January 2005, when they were implemented, through June of 2008, workers' compensation claims related to patient handling declined by $1.6 million. Previously, the claims had been increasing.
In the past two years, no nurses have suffered career-limiting injuries related to patient handling. "We've really saved people's jobs," Thomas reports. "Anecdotally, nurses will say they had a previous back injury, and [now] they go home without their backs being sore anymore."
It's a recruitment tool as well. UC Davis has a nursing vacancy rate of about 3%. And it's a cornerstone of the hospital's emphasis on a culture of safety. "We talk to nurses about putting their safety at the same level they would patient safety," says Thomas. "You don't have to injure yourself in order to protect another person's life."
[Editor's note: A copy of the audio conference, "Prevention of Employee Injuries and Lift Teams A Comprehensive Approach," is available from AHC Media by calling customer service at (800) 688-2421. The code for this program is 11T09314-7556.]