ED nurses seeing increasing numbers of obese patients: Don't put them at risk

Many EDs are not prepared for these patients

A woman reports abdominal pain after a motor vehicle collision, so a computed tomography (CT) scan is needed to determine if a liver or spleen laceration exists. It's pretty straightforward — except that the patient weighs 450 pounds. Since the maximum weight your CT scanner can hold is 350 pounds, the patient has to be transferred to another hospital, which means risky delays.

A man's knee needs immobilization, but the usual sized splints are too small for this 500-pound patient, so he is placed in an ill-fitting splint or none at all, which results in pain and risk of further injury.

These are common occurrences in EDs, as the numbers of morbidly obese patients continue to rise. "The numbers are increasing, along with the actual weights of the patients," says Mindi Huckabee, RN, CEN, director of emergency services at Trident Medical Center in Charleston, SC.

Cindy Rentsch, RN, MSN, CCRN, CEN, clinical educator of emergency services at Edward Hospital in Naperville, IL, says, "Unfortunately, we are increasingly seeing patients in the 400- to 600-pound range — two within the last month."

These patients need special equipment and interventions, says Pamela S. Rowse-Schmidt, RN, quality/risk consultant and former ED nurse manager at St. Rose Dominican Hospitals in Henderson, NV. "Many EDs are not prepared to handle these cases," she says. "We have to be ready for the issues that accompany these patients."

Even something as simple as not having the correct sized blood pressure cuff can be dangerous, warns Rowse-Schmidt. "We all know how critical an accurate blood pressure can be related to clinical intervention," she says. For example, if the blood pressure reading is higher than it actually is, the patient may be given an antihypertensive drug to prevent stroke. "If we continue to monitor the patient with the same equipment giving erroneous readings and titrating the medications based on those readings the patient could drop their hemodynamic perfusion so significantly that an untoward outcome could be the result," says Rowse-Schmidt.

New guidelines call for revamping of care of obese patients in the ED were published in the Chicago-based American Society for Healthcare Risk Management's Journal of Healthcare Risk Management.1 Here are several recommendations with tips for compliance:

• Assess equipment for weight limit, width, and length.

The equipment that needs to be assessed includes gurneys, side rail supports, gowns, blood pressure cuffs, wheelchairs, scales, walkers, wall-mounted grab bars, crutches, extension tubing for Foley catheters, and restraints, according to the guidelines.

However, buying the appropriate equipment may be cost-prohibitive for smaller departments, says Rowse-Schmidt.

Trident's ED stretchers, manufactured by Stryker in Kalamazoo, MI, have a weight limit of 375 pounds. "All of our equipment has been evaluated for use with obese patients," says Huckabee. "We also purchased wide wheelchairs for transport of these patients to and from radiology."

At St. Vincent Hospital in Green Bay, WI, the ED purchased two bariatric stretchers for $4,500, and two extra-wide chairs for the triage area at $250 each, all from Stryker, says Jennifer Gerdmann, RN, BSN, director of emergency and trauma services. "We also have adjusted some of our waiting room chairs by taking the arm rests off," she adds.

If you lack the right equipment, patients could be injured when being transferred into or out of a bed, says Rentsch. "A fall would be devastating, in that it is difficult to lift these patients from the floor as well as the injuries they could sustain from the fall," she says.

Creative solutions may be needed when all else fails, says Rentsch. "The other day, our engineering staff had to construct an apparatus for transferring a patient from the cart to a bed," she says. Another problem occurred when bariatric chairs purchased by the ED couldn't fit through the doorways of diagnostic testing areas, adds Rentsch. "We are now in the process of examining these doorways for renovation," she says.

When an ambulance brought a 750-pound patient with shortness of breath to University Medical Center's ED in Las Vegas, where Rowse-Schmidt was charge nurse, regular hospital gurneys couldn't be used because they could hold only 300 pounds. ED nurses found a solution by unloading the patient directly onto a hospital bed and rolling him into the ED, reports Rowse-Schmidt.

• Switch to weight-based protocols.

St. Vincent's ED now uses weight-based protocols for heparin because the dosages are more accurate, says Gerdmann. "Thin patients were getting too much and obese patients were getting too little," she says. Weight-based protocols also are used for narcotics, because patients with a higher body weights need higher doses to be effective, says Gerdmann. "Receiving 2 mg of morphine affects a 100-pound patient much differently than a 200-pound patient," she says. "Typically, the higher the weight, the more medication needed to be therapeutic."

• Choose the location for intramuscular injections carefully, and compress the fatty subcutaneous layer with one hand using a 1.5 inch needle.

"Nurses tend to forget that what is appropriate normally isn't going to be appropriate for our obese patients," says Rowse-Schmidt. "You have to press down if you have a large volume of subcutaneous fat, but nurses have been trained to pinch up."

Select an area covered by lower levels of adipose tissue, says Rowse-Schmidt. "Thighs are generally going to be a difficult location. However, at the point of the deltoid muscle, there may be closer access to the muscle itself," she notes.

The selection also will depend on what medication is being administered, says Rowse-Schmidt. "A million units of [penicillin G benzathine suspension] isn't going to go well with a deltoid location because of the volume and the viscosity of the drug itself," she says.

• Have an airway management plan.

"It doesn't take an extremely obese patient to create a set of circumstances where airway management is difficult, if not impossible," says Rowse-Schmidt. "The ED nurse needs to be prepared for the 'what ifs.'" For this reason, you should have "rescue" alternative airway devices readily available, she adds.

At Trident, "we utilize an airway management cart that includes devices for difficult intubations," says Huckabee. The cart contains laryngeal mask airways, fiberoptic scopes, and endotracheal tubes in larger sizes.

• You may need to assist vascular access with ultrasonography.

In the ED, obtaining intravenous access is essential to the delivery of emergent care, says Rowse-Schmidt. "You can lose the battle for patient resuscitation by the lack of an IV, and you don't have the time to wait for the radiology tech to come place a PICC [peripherally inserted central catheter] line," she says.

At St. Vincent's ED, after nurses were unable to obtain peripheral access on a critically ill obese patient, the physician attempted to obtain a central line instead, but was unable to access the vein, so medications were given down the endotracheal tube, says Gerdmann.

To address this problem, a vascular probe attachment was purchased for the ED's ultrasound machine, she says. "We have able to successfully insert central lines in patients when we are prevented from using the usual anatomical landmarks," Gerdmann says.

• Ask the patient, "What works for you?"

The primary job of the nurse is to keep patients safe, Huckabee says. For example, ask the patient the best way to help them get off a stretcher, she says. "This is a difficult task for obese patients," Huckabee says. "For an obese patient trying to ambulate, ask the patient what works best for them to avoid any falls or injuries."

Reference

  1. Abke A. Strategies for risks presented by obese patients in the ED. ASHRM Journal 2005; 25:33-35.

Sources

For more information about the care of obese patients, contact:

  • Jennifer Gerdmann, RN, BSN, Director of Emergency and Trauma Services, St. Vincent Hospital, 835 S. Van Buren St., P.O. Box 13508, Green Bay, WI 54307-3508. Telephone: (920) 433-8505. Fax: (920) 431-3093. E-mail: Jennifer.Gerdmann@stvgb.org.
  • Mindi Huckabee, RN, CEN, Director of Emergency Services, Trident Medical Center, 9330 Medical Plaza Drive, Charleston, SC 29406. Telephone: (843) 797-4104. E-mail: Mindi.Huckabee@HCAhealthcare.com.
  • Cindy Rentsch, RN, MSN, CCRN, CEN, Clinical Educator, Emergency Services, Edward Hospital, 801 S. Washington, Naperville, IL 60540. Telephone: (630) 527-7527. E-mail: CRentsch@edward.org.
  • Pamela S. Rowse-Schmidt, RN, Quality/Risk Consultant, St. Rose Dominican Hospitals-Rose de Lima Campus, 102 E. Lake Mead Drive, Henderson, NV 89015. Telephone: (702) 616-5548. Fax: (702) 898-6381. E-mail: wownurse@aol.com.