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Rehab plays integral part in obesity programs at North Carolina hospital
Quarterly course trains staff from around the region
By all accounts, obesity has reached epidemic proportions in the United States. The Centers for Disease Control and Prevention (CDC) reports that more than 44 million Americans are considered obese, with body mass index scores of 30 or greater.
That reflects an increase of 74% since 1991. The National Health and Nutrition Examination Survey 1999-2000 indicated that an estimated 64% of U.S. adults are either overweight or obese.
A recent RAND Corporation study1 found a link between the rise in obesity and a 50% rise in the number of people ages 30-49 who were disabled from 1984 to 2000.
Given those numbers, it’s unlikely that your hospital hasn’t come face to face with the challenges of providing good care for obese patients. Gastric-bypass surgeries are rising, vendors are beginning to offer a greater array of equipment for larger patients, and hospitals are searching for resources to help this patient population.
Pitt County Memorial Hospital in Greenville, NC, is setting the standard for bariatric rehabilitation.
Pitt County recently started the bariatric program, one of the results of a year-old, hospitalwide bariatric task force. Staff from nursing, rehab, wound and skin care, material services, the stock room, ergonomics and safety, operating room, and trauma department are working to set procedures in place for bariatric patients.
Obesity rates are on the rise in the area, and the hospital now performs 30-35 gastric-bypass surgeries a week, with a waiting list numbering in the hundreds.
"When we look at bariatric patients in the hospital, you might think that because of the gastric surgery program, that would increase the number of complicated patients. In all reality, those are the patients we expect not to have complications," says Daniel Drake, RN, perioperative clinical nurse specialist.
"The patients who really impact us from a rehab standpoint are patients who are medical patients with long hospital stays or who have spinal cord injuries," he says.
With a spinal cord injury, staff normally would help a patient develop upper-body strength to be able to transfer to a wheelchair. "But if you’re a bariatric patient, your upper-body strength may never be able to get to the point where you can move your weight," Drake explains.
"For those patients, we’ve had to look at other solutions like lifts. Getting the wheelchairs themselves can be difficult because of the size, and the payer issues are different, too, because the cost is sometimes more for this type of equipment," he points out.
The rehab staff have developed a program to meet the special needs of bariatric patients. "They come to us for three hours of therapy — half physical therapy and half occupational therapy — a day," says Debra Jefferson, PT. "They are treated according to an individual evaluation plan set by the team."
Adequate equipment is vital
A major thrust of the program is ensuring adequate equipment. "In our rehab center, we’re faced with the difficulties of room size, doorways, equipment," she says.
"As a rehab center and as a whole hospital, we’re working to make sure we have appropriate equipment and rooms for patients of size. We’ve also started a quarterly course to educate hospital employees and other facilities in the area about bariatric patients.
"We’re talking about things like complications for different body types. Another thing I’m trying to get across is that just because a patient weighs 400 or 500 pounds does not mean they can’t do anything," Jefferson notes.
The daylong course, "The 3 Ms of Bariatric Care: Movement, Mobility, and Machines," covers surgical issues, skin and wound care, therapy techniques such as how to safely move patients, available equipment, and sensitivity training.
Steve Randall, director of ergonomics and a facilitator for the class, says the course includes a trip to the biomechanics lab to learn how to turn patients in bed, ambulate them, and position them in beds or chairs. Class participants also travel to a local bed vendor to learn how to set up the specialty beds and use them for transporting patients.
"We had a bariatric patient in rehab who was in a specialty bed, and we had a fire alarm. It was, fortunately, just a drill, but staff did not know how to break that bed down in order to get that patient out of the room," he adds.
Another situation that underscored the need for a bariatric plan occurred when three staff members were ambulating a large patient. "She coded and took all three staff members down with her," Randall explains.
"We wound up with three event reports because they tried to hold her up. We know that is not the thing to do, that we want to get that person on a controlled descent onto the floor. There are three staff members out of work in addition to what might have happened to the patient. Our goal now is to get a better plan of action for safe bariatric patient handling and movement," he says.
The program is multifaceted
Sensitivity issues also are being addressed. "A bariatric patient is a real live human being just like you and I. They have feelings," he says.
The course has attracted participants from around the region. "My gut take is there is really a market for this kind of information," Randall adds. "We’ve found there aren’t many places where you can find this. We’ve had to put it together on our own and rely on the expertise of our staff."
More resources can be found now than just a few years ago, but the market for bariatric equipment still is immature, he notes.
"Some vendors will say it’s bariatric, but not anymore. Now we need 1,000-pound capacity. We’ve found with the bedside commodes that are supposed to be bariatric that patients have so much adipose tissue that the holes don’t line up. There is a real mismatch with the physiology of the patient and the geometry of the product," Randall adds.
Most patients who undergo gastric-bypass surgery do not need rehabilitation, but many obese patients come to rehab after becoming deconditioned in the medical units, Jefferson says.
"A lot of times, staff are really scared to help these patients move, so a lot of times they don’t get the moving in the acute part of the hospital that they need. That deconditions them even more. That’s why it makes rehab integral for them," she explains.
"People with obesity are prone to cardiac problems and respiratory problems, and if they have a lengthy hospital stay, they get deconditioned," Jefferson adds.
With obese patients, special care is taken to provide consistent therapists to build rapport. "Consistent coverage develops confidence for the staff and the patient," she says.
"If it takes two or three people to transfer a patient, everyone knows what to do. It helps develop trust because sometimes they’re afraid they’ll hurt you," Jefferson stresses.
Consistency also helps overcome staff hesitation. "There is a large staff perception that they got themselves in this fix, and a lot of people don’t want to work with these patients," she says. "You’ve got to be mindful, to respect that patient, too. A lot of these patients really didn’t put themselves there. We’re finding more and more that it’s hereditary."
Don’t assume obese are unable to move
It’s also important not to assume that a large person can’t do anything. "You can decrease the possibility of staff injury by allowing the patient to do the work," Jefferson adds.
"My goal is do not leave them in the bed. They need to get up, to get mobile, to at least be sitting in the chair. We always try walking, even though that means you may need three people to help," she adds.
Staff members have come up with creative ways to get patients to do as much on their own as possible. Some patients have so much mass in their stomach area that they have trouble reaching the rails in the wide beds, Jefferson points out.
But instead of having a staff member do the work, they might do something as simple as tying a knotted sheet to the rail so patients can pull themselves, she says.
Physical therapists also have to come up with tricks to help patients exercise because often obese patients are unable to bend their arms and legs in traditional ways.
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