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FGI recommendations can help you help your staff account for "patients of size"

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October 1, 2018

By Megan Headley (ecl_editors@decisionhealth.com)

The American Society for Metabolic and Bariatric Surgery notes that bariatric surgeries have steadily increased in recent years, climbing 10% (to 216,000 total surgeries) from 2015 to 2016 alone. Yet bariatric patients aren’t the only group that may present challenges with movement and transfer throughout the healthcare setting, which is one reason the Facility Guidelines Institute (FGI) made a terminology change in the 2018 edition of the FGI Guidelines.

The Guidelines now focus on safe handling for “patients of size,” a switch in terminology away from bariatrics that’s meant to account for not only a patient’s weight, but also height and distribution of weight throughout the body.

Douglas Erickson, CEO of FGI, explains that the shift “has to do with accommodating any type of patient that presents themselves as unusual as far as size is concerned. … It’s not just about body mass.” For example, an 8-foot-tall patient—or visitor or staff person, Erickson points out—may have as much of a challenge in movement and comfortable accommodations as someone who has a body mass index over 40.

Performing a risk assessment

Safely accommodating these patients improves not only patient care, but care for the healthcare worker as well. In its “Determination of Minimum Design Standards for Safe Patient Handling and Transportation,” FGI highlights that back injuries affect up to 38% of nurses. “Musculoskeletal injuries are responsible for more lost work time and permanent disability than any other reported injury in healthcare,” the report adds. So it’s important to understand the risks staff face in lifting, managing, and mobilizing patients of size.

The first step in understanding what changes may need to be made in your healthcare facilities is to take a deep dive into the demographics of your patient population: Some regions will find a more pressing case for an upgrade. As the State of Obesity project highlights, adult obesity rates now exceed 35% in five states, 30% in 25 states, and 25% in 46 states. West Virginia has the highest adult obesity rate at 37.7%, and Colorado has the lowest at 22.3%. But a demographics assessment should also include an analysis of historical data on the types of patients the organization has treated who have had accommodation challenges, as well as information on visitors and staff of size.

The next step, Erickson advises, is to conduct a safety risk assessment. FGI’s assessment has seven elements, one of which is a patient handling and movement assessment (PHAMA). He notes that the PHAMA has been around for about two code change cycles, but it now reflects the recently updated bariatrics criteria.

Help provide quality care

The PHAMA should include consideration of how to accommodate patients of size, including the main parking lot, the main entrance, and transportation throughout the building.

As Erickson puts it, “What happens when a 700- to 1,200-pound patient is brought into the emergency department, and how they are going to accommodate them from that point on? Do you have the exam room necessary? If you have to take them into imaging, is imaging able to accommodate them? If you have to go up a floor, how do you get the patient up there through the corridor and elevator? All of those transportation elements have to be considered.”

This also includes an examination of furniture, equipment, door sizes, and corridor sizes. “Maybe the standard corridor of 4 feet wide is not going to be sufficient to handle that patient of size along with staff,” Erickson adds.

You can download FGI’s PHAMA from its website (link in Resources below). The 150-page document describes the different decisions that should be made when it comes to patient handling: from the number and percentage of rooms that may need to be set up for accommodations to the transportation routes into various areas of a healthcare facility.

Erickson calls this assessment the “number one thing” healthcare facilities should be doing to understand their need for changes to accommodate patients of size. “And if they can’t [make changes], where are they going to send this patient of size when they present themselves?” Erickson adds.

Changes in bedside clearance

The 2018 FGI Guidelines also includes a change in lift clearance.

“In the bariatric unit, you have to look at the different methods of delivering the patient to transfer them from the bed to the chair, or into toileting, or to a service should they need that,” Erickson explains.

The change reflects simulations done with Hill-Rom that examined various room configurations and the difficulty of transferring a patient of size from the bed using a portable or fixed lift.

“The big change for 2018 is that transfer side of the bariatric patient bed,” Erickson explains.

Under the 2018 guidelines, portable lifts now require 7 feet of clearance on the transfer side of the bed, while fixed lifts require 5 feet of clearance on the transfer side of the bed.

“This has to do with the size of the portable piece of equipment, the legs that stick out, the angle it’s sticking out at. It’s unsafe trying to transfer a large individual in a 5-foot clearance compared to the 7-foot clearance,” Erickson explains.

Understanding the distinction between bariatrics and patients of size means recognizing that there are many ways in which patients can fall outside of standards. Given the excessive risks staff face in handling patients of all sizes, not to mention the risk to hospitals if patients of size are routinely uncomfortable throughout their stay, a risk assessment is a good place to start ensuring all staff and patients see the quality of care expected.

(This article originally appeared in HCPro’s Patient Safety & Quality Healthcare magazine.)

Resources

Facility Guidelines Institute’s Patient Handling and Movement Assessments: https://www.fgiguidelines.org/resource/patient-handling-and-movement-assessments/#

Determination of Minimum Design Standards for Safe Patient Handling and Transportation: https://www.fgiguidelines.org/wp-content/uploads/2016/04/FGI_BariatricClearances_March2016.pdf

State of Obesity project: https://stateofobesity.org/adult-obesity/




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