Tips for working with large patients

The American Society for Healthcare Risk Management (ASHRM) in Chicago recommends that risk managers assess their organization's readiness for treating obese patients. In addition to equipment needs and changes in policies and procedures, clinical strategies must be adequate.

ASHRM's recommendations were compiled by Ann Abke, RN, ARM, FASHRM, a loss prevention specialist providing risk management support to Catholic Healthcare West's 42 hospitals in California, Nevada and Arizona.1 These are some of the clinical risk strategies that ASHRM recommends:

  • Vascular access may need to be assisted by ultrasonography.
  • Physiologic response to analgesia and sedation may be different in the obese patient, so doses should be carefully calculated and titrated incrementally.
  • For injections to be deposited intramuscularly, the location needs to be chosen carefully and the fatty subcutaneous layer compressed with one hand when using a 1.5-inch needle.
  • Consult a pharmacist to determine whether dosing should be based on lean, ideal, or proportion of actual weight.
  • Alert staff that management of the airway can be extremely difficult and problematic in that these patients desaturate (lose oxygen carried by hemoglobin in the blood) more quickly than nonobese patients. Formulate an airway management plan when first encountering the obese patient.
  • Have "rescue" alternative airway devices readily available. Confirm endotracheal intubation by three or more methods, including caponometry or capnography.
  • Monitor the patient for fatigue of respiratory muscles — hypercapnia may be increasing.
  • Know the capacity of the facility's diagnostic radiology equipment. If unable to accommodate the patient in your facility, identify a facility in the area that has the capability. Develop a plan of action to expedite transfer to another facility for the tests if necessary and appropriate.
  • If uncertain as to how best to adapt care to a problem, the patient may be the best one to make the determination. This is considerate and affords the patient some control over the situation. Simply ask the patient, "What works for you?" or "How has this been done for you in the past?"
  • Assess equipment for weight limit, width, and length. This includes gurneys, side rail supports, gowns, linen, bedpans, commodes, blood pressure cuffs, wheelchairs, scales, walkers, bathroom doorframe, toilets, wall mounted grab bars, patient chairs, lateral transfer devices, door widths to ancillary departments, elevators (weight limits), ancillary department tables/gurneys, lifting devices, crutches, extension tubing for Foley catheters, and restraints.

Reference

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