Kathryn M. Pelczarski is associate director, Health Systems Group, ECRI. Pelczarski has more than 18 years experience in healthcare consulting. Her role at ECRI includes the development of new services, business development, the management of major projects related to technology assessment, strategic technology planning, patient safety, medical equipment planning, acquisition assistance and utilization studies. She can be reached at [email protected].
Adult obesity is on the rise. According to the International Obesity Task Force (May 2004), one quarter of the world’s population is overweight, 312 million of whom are obese. Obesity levels have reached all-time highs in the U.S. with 30 percent of the adult population 18 or older classified as obese.
The term “extremely obese” or morbidly obese is used to describe patients with a body mass index (BMI) greater than or equivalent to 40 kg/m2 or greater than 35 kg/m2 with co-morbidities. Extremely obese patients can range from 250 or 350 pounds to 1,000 pounds.
Ambulatory care centers are often caught unprepared when it comes to meeting the special needs of extremely obese patients. While these centers are unlikely to care for patients in the upper limits of the obese range, caring for patients in the 250-400-pound range has become a routine occurrence.
Outpatient care facilities should focus on the goal of providing safe, respectful and quality care to the obese patients in all equipment considerations. Depending on the services provided at the ambulatory care center and the weight range of patients that are seen, specific equipment requirements may vary. However, the following list of top 10 essential equipment considerations is a good starting point for any ambulatory care center:
1 Exam Tables: Primary considerations for exam tables are weight capacity, powered height adjustment and width. Standard tables have weight capacities of up to 400 pounds, and bariatric exam tables have weight capacities up to 800 pounds. The use of powered high/low exam tables should be considered for heavier patients due to their reduced mobility. Powered tables lower to as little as 18 inches from the floor, which facilitates the transition from a wheelchair to the table. Wider tables are required to comfortably and safely accommodate larger patients. Room and door size need to be reviewed when using bariatric tables to ensure the door width and room size is sufficient to accommodate the increased size of the table.
2 Scales: It’s essential to check the weight capacity of scales since many standard models will not accommodate the weight of bariatric patients. Wheelchair-accessible and standing scales, both commonly used in outpatient settings, are currently available with weight limits over 800 pounds. Scales with higher weight limits are typically electronic, which require batteries or 115V power to operate. Wheelchair-accessible scales allow the patient to sit on a chair during weighing, and have ramps to aid in the positioning of the wheelchair. If standing platform scales are used, facilities should consider selecting models with built-in hand rails to stabilize patients during weighing.
3 Physiologic Monitors or Sphygmomanometers: Extra large blood pressure cuffs are an essential accessory for measuring the blood pressure of extremely obese patients. Standard large blood pressure cuffs are typically of insufficient size for the upper arm circumference of these patients.
4 Patient Lifts: Patient lifts are available as either portable lifts or fixed lifts. In an outpatient setting, portable lifts make the best sense because they cost less and provide greater flexibility in that they can be moved from room to room, as needed. Fixed lifts usually have an overhead track system, however, the primary disadvantages for an outpatient setting are that these systems are fixed systems typically more suitable for dedicated bariatric areas and they have a higher infrastructure cost.
Portable lifts must be strategically placed throughout the ambulatory care center so they are readily accessible when needed. If they are difficult to find when needed, staff may not use them, resulting in potential patient or staff injuries associated with lifting. Portable lifts require storage room, so sufficient equipment storage area should be identified. Because sizes can vary, it is important to consider dimensions when acquiring lifts. Portable lifts are approximately 45-66 inches long by 30-42 inches wide by 52-74 inches high.
5 Bariatric Wheelchairs: Bariatric wheelchairs are a “must have” as it may be difficult for extremely obese patients to walk the distance to and from their destination in the outpatient center. Typical dimensions for bariatric wheelchairs are 35-39 inches in width by 26 inches in depth. In comparison, standard wheelchairs are typically 26 inches wide by 26 inches deep. In selecting bariatric wheelchairs, it’s important to check the ergonomics for easy movement with increased weight load. Other related considerations include the required door width for egress and the clear floor space required to accommodate the turning radius of the wheelchair. Since a bariatric wheelchair is significantly wider (e.g., 39 inches) than a standard wheelchair (e.g., 26 inches), the clear floor space requirement would need to be expanded to accommodate the increased width of the wheelchair.
6 Stretchers: Stretchers must be able to accommodate the individual patient’s weight and size. Bariatric stretchers are available with weight capacities up to 700 pounds. The use of powered hi/low stretchers may be advantageous to facilitate patient transfer and positioning. Stretchers with integrated scales should be considered for patients with poor mobility. Facilities may also want to consider self-propelled stretchers to facilitate ease of movement and support patient and staff safety during transport, since it is strenuous and difficult to maneuver a stretcher while transporting an extremely obese patient.
7 Diagnostic Imaging Systems: Primary considerations for imaging systems for bariatric patients include the bore size, table capacity and image quality.
Bore size is a critical factor when evaluating the potential use of an imaging device for extremely obese patients, as standard bore sizes may be insufficient for an extremely obese patient. Closed magnetic resonance (MR) has seen relatively few advancements in bore size of the standard system, since newer MRI scanners with an open configuration are available and better suited for extremely obese patients. Recently, manufacturers of CT systems have begun to market their larger bore systems that were developed for radiation therapy, as bariatric-capable units.
Table capacity varies between imaging modalities with 350 pounds being an average maximum load. Bariatric-capable systems and open MR units can often accommodate up to 550 pounds. The weight capacities of current and future systems should be reviewed in detail.
Image quality is a major concern for bariatric patients. More ionizing radiation is necessary to penetrate the obese patient to obtain a diagnostic image both per image and for repeat or any necessary additional views. The radiation dose necessary to obtain a good image may be too high a trade-off for the poor image quality that can be expected.
8 Operating Room Tables: The weight and size of operating room tables must be sufficient to accommodate the individual patient while still maintaining full articulation capabilities. In addition, side extenders and foot boards are recommended. Bariatric OR tables are available with weight capacities up to 1,000 pounds.
9 Toilets and Grab Bars: Floor-mounted toilets are a must. Per the American Institute of Architecture Academy of Architecture for Healthcare (AIA-AAH), wall-mounted toilets must be able to withstand a concentrated load capacity of 350 pounds, which is insufficient for many morbidly obese patients. Therefore, there is a risk of the fixtures being pulled from the wall and a potential for patient injuries.
Grab bars should be provided in the toilet area. The ADA recommends that grab bars have a minimum concentrated load capacity of 250 pounds. However, this minimum is insufficient for bariatric or morbidly obese patients and can result in fixtures being pulled from the walls and a high potential for patient injuries. Additional reinforcement is essential.
10 Furnishings: Oversized chairs should be available in public areas, such as lobbies and waiting rooms, to accommodate overweight patients and their family members. In addition, oversized patient chairs are essential in exam rooms and other patient areas, resulting in the need for more floor space. Typical oversized chair dimensions are 31-34 inches wide by 25.5 inches deep.
When addressing the special equipment needs of extremely obese patients, it’s important to remember that “one size does not fit all.” Weight and size limits vary considerably between manufacturers/models that are classified as “bariatric.” In general, facilities must assess the specifications of all equipment used throughout the continuum of outpatient care to ensure that it meets the needs of these patients. The ultimate goal should be to provide safe, respectful and quality care.