Monday
March 15, 2004
Since 1960, when height and weight statistics were first compiled, the average weight of the population has increased. In each decade, the number of overweight people has gradually grown, while the number of obese has curved upward at an accelerating rate.
Today, 127 million adults--over half the adult population--are now classified as overweight, with almost half of those considered obese, according to data compiled by the American Obesity Association. Of the obese, 9 million are classified as extremely obese.
This presents health care providers with a twofold problem: Obese people require more health care than average people, and there are increased physical problems for staff and attendants in administering that care. Additionally, a boom in gastric bypass, stomach reduction and banding operations have been bringing even larger numbers of bariatric patients to health care providers.
Bariatric patients encompass a very wide weight range--from roughly 250-300 pounds to over 1,200 pounds. Moving a bariatric patient requires special training and equipment. The most basic tasks can be very difficult for the bariatric patient. Sitting up, standing, walking, going to the bathroom, taking a shower and moving from the bed to the chair are all tasks that often require assistance.
Most facilities currently do not have dedicated units for bariatric patients. In the past, the occasional severely obese patient was handled on an ad-hoc basis with existing hospital equipment, reinforced or lashed together as needed. In existing facilities, the patient room is often not large enough to house bariatric equipment, beds and required caregivers. Vicki Tierney, head of the bariatric nursing program at Unity Hospital in Fridley, Minn., notes that often toilet rooms are too small, doors are too small, toilet fixtures are incapable of supporting bariatric patients, handrails are pulled from the wall when used by bariatric patients, and floors deform or peel-up from beds being moved.
However, increasing emphasis on consistent standards of care have led hospitals and other health care providers to purchase specialized equipment for bariatric patients and to renovate facilities to accommodate the larger dimensions.
Tierney is a member of the Bariatric Room Design Advisory Board (BRDAB), a group formed by The Hill-Rom Company, Batesville, Ind., to look into developing industry standards for the design of equipment and facilities for these patients. Headed by Kitti Johnson, RNC, manager of global clinical programs and global professional programs at Hill-Rom, the BRDAB consists of bariatric surgeons, bariatric unit nurses, medical equipment planners, nurse consultants and health care architects.
The group members set a target maximum for bariatric design at 1,000 pounds, meaning that beds, chairs, wheelchairs, toilets and other patient devices should all be designed to accommodate patients weighing up to 1,000 pounds.
As in planning for other nursing units throughout the hospital, the basic building block for a bariatric nursing unit is the patient bedroom. The scale of the room is obviously larger than that required for other units, but just how much larger is the quest of today's researchers.
At its initial meeting last August, the BRDAB developed recommendations for an optimal patient room to serve the bariatric patient. There are many factors for consideration in the shaping of a room to accommodate severely obese patients--some patently evident and others that are less obvious.
Larger beds and larger equipment will drive larger room dimensions, but planners must recognize that the main driver for more space is the need for clearances around furniture and equipment for the care team to maneuver.
Because severely obese patients--many weighing upwards of 500 pounds and some approaching 1,000 pounds--are more than one nurse can handle, there is always at least two in the care team to assist in patient transfers. There are instances when three or more caregivers are recommended for patient handling.
Safety of the patient and the care team must be factored into the design. Safety for the care team starts with the use of proper ergonomics when assisting the patient. Employing ergonomically sound transfer techniques requires having ample clearances at the bedside and in patient seating zones. Furthermore, transferring these patients often requires the use of lifts, yet another factor requiring ample clearances around the bed.
Even with the most observant and efficacious care, patients will fall. Undesired consequences when the severely obese patient falls are notably increased. Wide spacing between the bed and other obstacles will facilitate the care team's effort in uprighting the patient. Wide spacing of furniture and equipment can mitigate the circumstance of the patient striking objects during a fall.
The current American Institute of Architects (AIA) Guidelines for Design and Construction of Hospital and Health Care Facilities calls for clearances around the patient bed in a single room to be a minimum of 3 feet. The BRDAB, using a Room Builder® workshop at Hill-Rom, mocked-up full sized scenarios for the bariatric patient room.
Through the trial of pushing bariatric wheelchairs, stretchers and beds around in the mock-up, the group unanimously decided the clearance should be 5 feet on the sides and at the foot of the bed. This ensures adequate clearance for the care team to assist the patient in and out of the room or to the toilet room.
The door to the patient room needs to be congruent with the larger room clearances. A width of 60 inches is considered to be sufficient to comfortably allow passage of oversized equipment.
Sliding ICU-style doors are employed in some bariatric room settings. A sliding door that will yield a 60-inch opening requires an overall opening of between 9 and 12 feet. The BRDAB preferred a pair of unequal-leaf swinging doors--one leaf 42 inches wide, the other 18 inches--as the optimal solution. This configuration will yield the desired clear opening with the least overall width, thereby giving more wall space to supporting functions.
Because severely obese people have generally been stigmatized by society, they are often reluctant to venture out of their homes and comfort zones. Their anxiety levels are high when admitted to the hospital as they often find they are ridiculed and shunned even by hospital personnel. Consequently, their needs for family support during the stay are real and acute.
The notion of family centered care, in which family members are welcomed and encouraged to participate in the caregiving during hospitalization, becomes an invaluable tool in assuring positive outcomes for the bariatric patient.
Three distinct zones define the idealized family centered care patient room. The first, nearest the room entry, is the clinical zone. The second, focused around the bed, is the patient zone. The third zone, for family seating, is near the exterior wall. Bariatric patients commonly have severely obese family members, so the family zone will need to be sufficiently sized to accept oversized seating and mobility clearances.
Most examples of bariatric rooms currently in place are modifications to standard private or semiprivate bedrooms with a width (headwall-to-footwall dimension) of around 12 feet. The BRDAB concluded that the optimal width should be 14 feet (13 feet was felt to be the minimum), and depth be 15 feet (corridor to exterior wall).
Many severely obese people are hypersensitive to ambient temperatures. In order for bariatric patients to optimize their comfort and add to a positive outcome for their hospital stays, they should have control over their environments. This includes access to the room temperature control as well as the more commonly allowed control of lighting.
An additional enhancement to patient comfort and control is the use of a ceiling fan mounted directly over the bed. Headwall designs must recognize the wider bariatric bed--even the overbed light width must be considered. Communication and entertainment systems should be available within the room and should include easy access to hospital-based education networks and Internet connections.
Consider dialysis connections within the room, as any dialysis facilities within the institution are not likely to be able to handle the bariatric patient.
Special consideration must be given to the design of the patient toilet room, and increased size is but one design factor.
Water closets must be designed to support a patient weighing 1,000 pounds. Clearance on either side of the water closet should be allowed to place a bariatric commode seat over the water closet for the comfort of extraordinarily large patients. The water closet should be mounted with a minimum distance to a flanking wall of 21 inches.
The configuration of conventional grab bar designs does not correspond to the geometry of the severely obese patient, as they do not extend far enough from the back wall. Some nurses have suggested having a bar or similar device accessible in front of the toilet, so the patient can reach forward and use both hands to pull himself or herself up. The toilet tissue dispenser must be mounted sufficiently in front of the water closet to allow the patient ease of access.
Because many severely obese patients have difficulty cleansing themselves after toileting, the addition of a bidet into the toilet room would facilitate patient hygiene and foster patient dignity.
The sink and countertop, if used, must be structurally sufficient to resist pulling away from the wall if grabbed by a falling patient.
The shower must be configured to allow the patient to be assisted by two caregivers. Showers without curbs will allow for the care team to maneuver the patient in a wheelchair.
Some institutions are using the 30-inch by 60-inch shower as recommended by the Americans with Disabilities Act Accessibility Guidelines. The BRDAB concluded that a room of at least 45 square feet, with waterproof walls and floor, would be the ideal toilet/shower room. With strategic placement of the fixtures and sloping of the floor to a drain, the entire room becomes the shower. By not having enclosing walls around the shower and using a shower curtain instead, caregivers can offer maximum assistance. A removable showerhead and shower seat are necessary.
The door opening into the toilet/shower room must accommodate the passage of the largest bariatric wheelchairs. The BRDAB members agreed that a 60-inch opening would allow for the greatest level of accessibility and safety for caregivers to assist the patient into the toilet room.
As the population of severely obese patients is increasing, so too is the number of bariatric furniture and equipment suppliers.
Facilities and medical equipment planners need to be aware of the weight-bearing capacity of these items. Much of the selection is designed with load capacities up to the 600- to 700-pound range but, as noted, patients who are presenting to these units can weigh 1,000 pounds.
High-quality bariatric beds address the challenges inherent in bariatric care--patient comfort and mobility and mitigating the risk of injury to caregivers and patients. Such beds have built-in scales and can be converted to chair position, a configuration to facilitate patient transfer. The composite bariatric bed, for planning purposes, is 90-inches long by 44-inches wide in the normal position, and 98-inches long when extended and 61-inches wide with safety sides in place.
Lifts are essential in bariatric nursing. There was talk at the BRDAB meeting about the notion of ceiling-mounted lifts as a way of reducing the number of items on the floor in the patient room and of reducing equipment storage requirements. The idea was vetoed, however, because a mobile lift would still be needed if the patient fell in an area not in range of the ceiling-mounted one.
Hill-Rom's Johnson notes that there are two types of severely obese people--pear-shaped and apple-shaped. This is important when considering seating, as pear-shaped people cannot abide chairs with arms, whereas apple-shaped bodies will do well in seating with or without arms. Offering both types of seating would service the general population as well as the severely obese.
Johnson also notes that steel-framed seating is preferred to serve the oversized patient, as conventional hospital furniture may not withstand the additional weight.
More seating options: Powered lift chairs accommodating up to 1,000 pounds are also available to assist the bariatric patient. These reclining chairs are up to 48-inches wide. Also, built-in seating, such as window seats, should be equipped with rails to provide assistance for the patient. Finally, bariatric wheelchairs are sized by weight-limit categories. The largest models can have seat widths up to 48 inches.
Additional equipment required on the unit include walkers, commode seats, hover mats for patient transfer, step stools and overbed trapezes.
Hospitals offering bariatric surgery are creating spaces for nursing units for this specialty, or creating clusters of rooms of appropriate dimensions within a typical acute care setting. These are positive steps, but there is more to do.
Other areas of the hospital are ill-prepared to handle the severely obese patient. For example, imaging equipment is not designed to accept people in the higher size extremes; therefore, these people must go without such diagnoses. Grab rails and handrails must also be designed in accordance with increased weights.
Additionally, public spaces within the hospital must be designed to welcome oversized patients and visitors. Much like the requirements of the Americans with Disabilities Act, the entire passage through the hospital should be welcoming and accommodating.
Although hospitals have begun responding to emerging demand for bariatric care through modest renovation of nursing units, most of these instances do not achieve the size and configuration necessary to truly embrace the unique needs of the severely obese patient population.
However, continued demand for this service will likely drive the evolution of standards for the design of equipment and facilities to fill this need.
James W. Harrell, FAIA, FACHA, is president of Harrell Group, a health care facility planning and design firm in Cincinnati. He is a member of Hill-Rom's BRDAB group. He can be reached at j.Harrell@harrellgroupinc.com. Bill Miller, AIA, ACHA, is principal and director of the health care studio of Moody*Nolan, an architecture firm based in Columbus, Ohio. He is also a member of the BRDAB. He can be reached at bmiller@moodynolan.com.
Architecture + Design is a tutorial published quarterly by Health Facilities Management magazine (www.hfmmagazine.com) in partnership with the American College of Healthcare Architects (www.healtharchitects.org).