As body mass index of the Western world continues to rise inexorably, a nurse’s research provides a definitive list of action points that health authorities and professionals need to address to avoid the resulting injuries to healthcare staff
MSc, Dip RGN
Clinical nurse specialist BCES
Berkshire West NHS Primary Care
Trust, Wokingham Hospital,
E-mail: [email protected]
The proportion of males in England who are obese increased by 8.3% from 1999–2004, and the proportion of obese females by
2.1% (Health Survey for England, 2004). Individuals with a body mass index (BMI) of greater than 30 are classified as obese, and greater than 40 as morbidly obese. Bariatric comes from barros (Greek) meaning large or heavy, but the application of this term is used to include a wider population than the definition of obesity.
Waist circumference may become the primary measure of obesity and is an additional measure that can be used to indicate increased risk states. A waist circumference in excess of 102cm (42 inches) carries a four-fold risk of cardiovascular
disease development (equal to having a BMI over 30). It is possible to be overweight without being obese, bodybuilders and athletes can have a disproportionately high percentage of muscle mass.
Body shape and fat distribution differ and are grouped in four categories:
- Apple-shaped (android), with shoulders, face, neck, arms, chest and the upper abdomen often distended. Fat is more prominent around the waist area and affects the heart, liver, kidneys and lungs.
- Pear-shaped (gynoid), with the fat distribution mainly on the hips and legs. The organs affected are the kidneys, uterus, bladder and intestines.
- Bulbous gluteal has excessive buttock tissue creating a protruding shelf that affects lying and sitting.
- Anasarca (generalised oedema) is commonly associated with severe breathing difficulties.
Obesity can affect health in a number of ways (see Table 1) and can increase the risk of premature death. Bariatric patients may have a limited range of movement and most have breathing difficulties – severe in some cases – inhibiting their ability to lie down supine or prone. A question often raised is: “when do you determine a patient is bariatric”? The body mass index (BMI) combined with waist measure is the recognised tool for determining obesity therefore a person with a BMI of >40 = morbidly obese. However, in terms of health and safety, those whose mobility, size and shape increase the risk of musculoskeletal injuries to patient, family and care-giver we
define as ‘Bariatric patients’. The long-term effect of working with highly dependent heavy patients with poor staffing and inappropriate equipment is that it causes over-exertion injuries to healthcare staff who are twice as likely to show signs of
advanced disc degeneration by the time they are aged in their 50s.
Moving and handling patients is an integral part of the health and social care,6 but, when equipment is unavailable to help with the task, staff are required to increase their physical effort
when handling bariatric patients. It is not only care-givers at risk, bariatric patients may also sustaining injury through:
- Inappropriate equipment
- Environmental constraints
- Unsafe handling techniques
- Inappropriate assessments
- Staff guessing patient weight
- Lack of education.
Key challenges for care-givers are:
- Turning a patient in bed
- Lateral transfers
- Transferring from bed to chair
- Lifting a limb
To enable these tasks to be carried out in a reduced risk environment requires management of financial and human resources and implementation of policies, procedures and a
multi-service strategy – as well as education and equipment.
Assessment underpins all other elements and involves multidisciplinary agencies. The first step of the intervention process identifies goals, care packages, equipment and training needs. Legislation requires a reasonably safe system of work but risk assessment outcome will depend on the individual’s capability, perception of risk levels, and the availability of resources. It is essential that the effective application of legislation and the risk assessment process identifies resources that are cost-effective, fit for purpose and contestable. In some cases, this might require a business case.
Managing bariatric patients is complex and requires intervention strategies that will inform best practice, and reduce the inherent risks. Organisations should have holistic intervention strategies in place, that include education policies and procedures. If this is not the case, they should risk-rate the consequences of not having safe systems of work in place and add this to their risk register. An ergonomic risk-assessment tool allows care-givers to develop a process that considers intrinsic and extrinsic factors that may have potential adverse effects on care delivery.
This includes lifting, lowering, carrying, pulling, pushing, and supporting by hand or bodily force, environmental constraints and equipment provision.
The risk control measures should also include appointing or employing a bariatric champion to instigate:
- Collaborative working with all service providers;
- Patient focus;
- Process for equipment provision;
- Development of a bariatric multidisciplinary group;
- Equipment resource management;
- Education programmes that enable practitioners to – recognise, predict, prevent and communicate;
Based on research conducted in 2002, I would
recommended the following fundamental
The weight of the patient should be determined and recorded as soon as possible at admission to ensure that equipment is suitable for the patient.
The bed and hoist should be compatible and raise/lower enough to ensure smooth transfers on and off the bed. This will reduce the risk of tissue damage to the patient from shear and friction and the caregivers from pushing and pulling.
Gantry hoists are suitable for moving the patient up the bed and transfers (static and ‘H’ systems) and rehabilitation (wheeled version). If choosing mobile hoists, the environmental constraints and the amount of exertion required to manoeuvre the hoist with a bariatric patient should be considered.
Bariatric patients can have breathing difficulties and may not tolerate the walking jacket sling around their chest; lift pants can be used as an alternative.
Additional space will be needed to accommodate the equipment and staff.
Rehabilitation equipment will be needed to facilitate best clinical practice and patient mobility. This could include a bed converting to a chair and a riser/recliner chair.
Selection of sliding sheets. The patient should be measured lying down to determine the maximum width – abdomen, hips, upper body, thighs, legs. If a dynamic mattress is being used, it can be changed to static mode for repositioning.
Bariatric patient management is complex and multi-factorial and organisations have a duty of care to ensure that the working environment is as safe as reasonable practicable for caregivers, family and patients. Throughout the patient’s journey (planned pre-assessment clinics or emergency admission) a safe system of work should be provided to integrate the care tasks with equipment that is fit for purpose and documented in the care plans with manual handling risk assessments.
1. American Society of Bariatric Physicians. (2003). www.asbp.org/faq. htm. Accessed 6 December 2009.
2. Campbell IW. (2004) Obesity and men’s health. In Kirby RS, Carson C., Kirby MG, Farah RN. (eds.) Men’s Health.
(2nd Ed.) Taylor Francis: London. 55-62.
3. Gallagher S. Bariatric Nursing and Surgical Patient Care 2006;1(1): 21-30.
4. Dionne M. Int J Rehabil, March 2002. www.rehabpub.com/features/32002/1. asp. Accessed 6 December 2009.
5. Pheasant S. Back Injury in Nurses: Ergonomics and Edpidemiology, in The Guide to the Handling of Patients,
4th Edition (1997), NBPA, Teddington, Middlesex.
6. Brown Wilson C. Br J Nurs 2002;10(2): 108-14.
7. Rush A. A study to investigate Bariatric Care in the Community. Unpublished MSc dissertation, 2002. Surrey