Do you have strategies to care for obese patients?

EDs report numbers are increasing dramatically

(Editor’s note: This is the first of a two-part series on improving care of obese patients in the ED. This month’s story addresses special considerations for assessment and supplies. Next month, we’ll cover complications of surgical treatment for morbid obesity you may be seeing in your ED.)

Would you be able to manage an airway, start an intravenous (IV) line, or determine accurate medication dosages for a 300-pound patient in your ED?

"We definitely have seen a rise in the number of obese patients in our ED," reports Stephanie J. Baker, RN, BSN, CEN, MBA/HCM, director of emergency services at Paradise Valley Hospital in National City, CA. According to a recent study, the prevalence of adults who are severely obese quadrupled between 1986 and 2000.1

To improve care of obese patients in your ED, do the following:

Be ready to use alternatives to obtain an adequate airway.

Because intubation can be more difficult in obese patients, have a bag-valve mask available at all times, advises Baker. "It may be necessary to have one person bag and one hold the patient in the chin-lift or jaw-thrust position to better open the airway," she says.

In some cases, difficult airway devices or emergency airway surgical procedures may be necessary, adds Baker. "It is imperative to have these supplies and sterile trays readily available in the ED," she says.

Ensure that IV access is obtained.

Because many obese patients have no visible vein structure, ask patients if they know where they usually have blood drawn, advises Baker. "Obese patients often know what works for them, and this avoids unnecessary sticks," she says.

It may be easier to start IVs in areas over bony prominences with fewer fascias, such as the thumb, wrist, top of foot, or saphenous vein in the medial ankle, advises Baker. Placing a warm towel on the area for a few minutes may produce enough vasodilatation so you can see a vein, she adds.

You may need to consider an external jugular central line, says Jane Lashock, RN, BSN, CEN, ED nurse and bariatric nurse coordinator at Greater Hazleton (PA) Health Alliance.

"The clavicle area is generally not an area of large fat distribution, so that can be a plus," she says. "However, external jugular access can be a challenge with the stout neck."

Make patients comfortable.

Here are three simple ways to increase comfort of obese patients:

Provide appropriate linens. "We use obesity gowns that are much larger and can modestly cover a patient up to 500 pounds," says Baker.

Transfer patients to regular inpatient beds. "This will make your patient much more comfortable, prevent skin breakdown, and allow the patient to have a bed with automatic controls, thus reducing back’ work for the ED staff," Baker says.

Offer patients heavy-duty walkers instead of crutches. It is difficult for obese patients to balance their weight on the palms of the hands, and this can lead to nerve damage due to distribution of weight on the armpits, advises Lashock.

Address potential problems with medication administration.

There might be unexpected distribution or absorption of intramuscular medications that are stored in fat, says Lashock.

In addition, the average intramuscular needle is 1½ inches in length, which will generally only penetrate to the subcutaneous tissue and not the muscle in the morbidly obese, she says. Consider alternative routes for administering drugs, such as oral or IV, Lashock recommends.

In addition, you may need to administer higher amounts of weight-based medications such as atropine, says Lashock. To address this, consider making a dosage chart for obese patients as with pediatric dosages, she suggests.

Perform more X-rays at the bedside.

To avoid transporting obese patients, portable chest X-rays are given at the bedside, says Baker. "The pros are quicker results and less patient movement, and the cons are having only one view instead of two," she says.

Obese patients also are given bedside X-rays for extremities, shoulders, flat plate abdomen, and hip and pelvis, says Baker. "Again, you may give up a little in quality or number of views. But it is usually enough for you to determine a disposition or if other studies are indicated," she says.

Avoid compromising the patient’s respiratory status.

If patients are lying down on a backboard, the weight on their diaphragm and chest could be harmful to their respiratory status, says Lashock. "So we have to work quickly at clearing their cervical spine, and tilt the bed up higher while they’re still on the board, to help facilitate tidal volume," she advises.

Assess the need for special equipment.

Do a self-assessment of your ED’s equipment, such as stretchers, backboards, and cervical collars, to ensure the safety of obese patients, Lashock recommends.

"If chairs have a weight limit of 250 pounds, and a 600-pound person breaks the chair and injures himself, the hospital is liable," she warns.

Paradise Valley’s ED recently purchased six wider gurneys with stronger side rails, thicker mattresses, and an extra wheel for stability for approximately $3,000 apiece, says Baker.

When evaluating equipment, consider the width as well as the weight it will accommodate, advises Lashock. For example, the average width of a backboard is approximately 18 inches, with a weight capacity of 350 pounds. "I saw one backboard that can supposedly hold 1,000 pounds, but the width was still no better," she notes.

Reference

1. Sturm R. Increases in clinically severe obesity in the United States, 1986-2000. Arch Intern Med 2003; 163:2,146-2,148.

Sources

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

Stephanie Baker, Paradise Valley Hospital, 2400 E. Fourth St., National City, CA 91950. Phone: (619) 470-4386. E-mail: StephanieRN1@cox.net.

Jane Lashock, RN, BSN, CEN, Bariatric Nurse Coordinator, Greater Hazleton Health Alliance, 668 N. Church St., Suite 104, Hazleton, PA 18201. Phone: (570) 459-5607. Fax: (570) 459-1140. E-mail: janern@ptd.net.

The Airpal Patient Transfer system is used to transfer patients from bed to stretcher to other areas of the hospital and is designed to reduce back injuries, require fewer staff members to transfer patients, and improve patient comfort. ED patients may remain on the transfer pad for all ancillary procedures, including radiology, CT scan, radiation therapy, heart catheterization, physical therapy, labor and delivery, and surgery. Contact Airpal, 5002 Camp Meeting Road, Center Valley, PA 18034. Phone: (800) 633-4725 or (610) 866-5475. Fax: (610) 866-2634. E-mail: weyhill@aol.com. Web: www.airpal.com.

Stryker "Big Wheel" for ED gurneys make it easier to transport obese patients. Separately, the cost is $1,175. The Atlas 660 gurney has a 660-pound weight limit and includes the Big Wheel. The cost is $5,995. Contact Stryker Medical, 6300 S. Sprinkle Road, Kalamazoo, MI 49001-9799. Phone: (800) 787-9537 or (269) 329-2100. Fax: (269) 329-2213. E-mail: jscharff@med.strykercorp.com. Web: www.strykercorp.com.

The Large Body Surface (LBS) is an accessory developed for larger patients to increase cot width to 34 inches. The LBS attaches to 35-P and 93-P ProFLEXX cots. The cost is $995. Contact Ferno, 70 Weil Way, Wilmington, OH 45177. Telephone: (800) 733-3766 or (937) 382-1451. Fax: (937) 382-1191. Web: www.ferno.com.

Lift and transport systems for obese patients include "crane"-type lifts with fabric slings to put under the patient that then attach to the lift device. Disposable fabric covers are provided. Contact Arjo, 50 N. Gary Ave., Roselle, IL 60172. Phone: (800) 323-1245 or (630) 307-2756. Fax: (888) 594-2756. Web: www.ARJO.com.

An Extra Wide Walker can support up to 400 pounds, and the crossbar will not interfere with the patient’s stride. It also can be used as an over-the-toilet support. The cost is $114.80 plus $13.95 for ground shipping. Contact WisdomKing.com, Customer Service, 2410 Cades Way, Unit B, Vista, CA 92081. Phone: (877) 931-9693 or (760) 727-6471. Fax: (760) 727-6479. Web: www.wisdomking.com.