Sidebar to Criteria-Based Protocols and the Obese Patient: Pre-planning Care for a High-Risk Population: Obesity (Bariatric) Protocol: A Sample

   Purpose. The protocol is designed to outline the management of the bariatric patient.

   Indication. Bariatrics is the practice of medicine relating to the treatment of obesity and associated conditions. The obese patient may or may not be identified by the admitting diagnosis and/or list of problems. Any healthcare worker who identifies the bariatric patient may initiate this protocol if the BMI is > 40. The protocol is designed to address many aspects of patient care for the patient admitted to the facility.

   The bariatric patient should be identified at admission to the healthcare setting whether it is in the Emergency Department or the inpatient setting.

   This protocol is to be initiated if the BMI is 40 or greater or the patient is 100 lb overweight and a potential for the patient to have special skin care needs, respiratory issues, mobility difficulties, or additional needs exists as addressed in this protocol. A nutrition referral should be made for patients meeting the bariatric criteria.

   Definition. The BMI, which describes relative weight for height, is significantly correlated with total body fat content. The BMI should be used to assess obesity. Caution must be used when interpreting BMI in a patient with edema or ascites or in persons who are highly muscular; an elevated BMI in such cases will not accurately reflect excess adiposity in these instances. Normal BMI measurements fall in the range of 18.5 to 24.9 kg/m². Obesity is defined as a BMI of >30 kg/m². A patient with a BMI of > 25kg/m² is considered overweight. Within the obese classification are grades I, II (BMI > 35 kg/m²) and III (BMI > 40 kg/m²).

   Respiratory issues. The bariatric patient should be monitored for obesity hypoventilation syndrome (OHS). In addition, it is important to monitor the patient for obesity-related atelectasis, hypopnea, and sleep apnea. Per physician's order, pulse oximetry should be monitored, particularly at night and during sleep or naps to assess hypoxemia. Hyperoxia should be avoided; SpO₂ should be maintained in the 90% to 93% range. The patient should be assessed for snoring or other signs of a partial airway obstruction. Per physician's order, the use of continuous positive airway pressure (CPAP) or noninvasive positive pressure ventilation (NPPV) may be necessary. Nursing and respiratory staff unfamiliar with the equipment must seek assistance from peers knowledgeable in the use of these devices.

   A standard-sized endotracheal tube will usually accommodate the bariatric patient; however, a longer-than-normal tracheostomy tube may be required. The special tracheostomy tube for the obese patient may not have an inner cannula, so maintaining a patent airway is important to address. If a standard tracheostomy tube is used, the clinician should ensure that the tube is in the airway and has not been placed against the soft tissue. Tracheostomy teaching must be done early in the hospital stay if the patient will be going directly home and not another facility.

   Radiology/special procedures issues. Special equipment for transporting and for diagnostic tests of bariatric patients may be required. Radiology and Special Procedures departments must be notified as soon as the patient's physician orders are written. A minimum of at least 1 hour must be anticipated for scheduled procedures so a room appropriate for the bariatric patient can be secured. The patient's weight and girth must be measured and recorded before the scheduled test. A reference guide to identify both weight and girth restrictions for the radiology equipment has been developed.

   Psychosocial issues of the bariatric patient. It is imperative to de-emphasize the need for weight loss during an acute hospitalization; however, encouraging and praising adequate caloric and protein intake are recommended.

   The impact of the hospitalization on the bariatric patient includes a lack of privacy, loss of control, and dealing with unfamiliar surroundings. The obese patient may be reluctant to accept care, difficult to assess, and experience many issues related to a prolonged hospitalization.

   Each patient will be addressed on a case-by-case basis. Although a person may qualify as obese, he/she may or may not be affected by his/her weight. With regard to psychosocial issues, staff must look for any adverse effect of weight on the patient; events may include crying or verbalizing concern related to weight issues. The patient should be offered psychosocial support in the form of a social services or chaplain consult depending on needs. Patients and staff should realize that the family also may need support. Staff may offer support in the form of listening, discussing concerns, and offering suggestions.

   Staff will demonstrate the facility's core values in caring for the obese patient. Referring to someone by his or her weight or size is inappropriate, and it is a violation of the privacy statement to speak about a patient's size/weight with other staff members not involved in care. Staff will be aware of their own feelings/opinions about obesity and its effect on patient care.

   Mobility. Consider a private room when available. The physician team following the bariatric patient will write orders for physical and occupational therapies (PT/OT), for recommendations for Durable Medical Equipment, and discharge needs. Physical/occupational therapists will evaluate these patients for strength, functional mobility, and safety issues. All hospital staff will follow the lifting/ergonomic protocols (in progress in the authors' facility).

   The following equipment should be considered in the care of the obese patient:
   * specialty beds (39" or 48" beds)
   * wide-front wheeled walkers
   * wide wheelchairs (28 inches to 40+ inches)
   * wide room chairs
   * wide beds that lower closer to the floor
   * patient lifts
   * transport stretchers
   * gowns large enough to cover the patient when out of bed
   * wide bedside commodes
   * scales to weigh the patient (available on the specialty beds)
   * bed trapeze (appropriate for weight of patient)
   * stretcher in ED (appropriate for up to 650 lb)
   * two bariatric beds in OR (appropriate for up to 1,000 lb).

   Special equipment. The CWOCN, Clinical Nurse Specialist, Nurse Practitioner, or the Clinical Supervisor will write orders for all overlays, specialty beds, lifts, scales, and similar equipment for use by patients according to the protocol.

   Employee safety. All staff will be educated on proper techniques for moving the bariatric patient. Staff must ensure that the number of personnel assisting is adequate/appropriate for the task.

   Pediatric issues. Patients less than 18 years of age will continue to be assigned to pediatric department care areas for appropriate developmental and age specific care. When special circumstances arise, the bariatric pediatric patient should not be assigned to an adult care unit based on weight as the only criteria.

   Pharmacy. Several factors may alter the pharmacokinetics of drugs in obese individuals. These may involve changes in bodily distribution, protein binding, metabolism, and elimination of many agents. Adjusting drug dosages and taking these alterations into consideration is important in caring for obese patients. Unfortunately, the literature is relatively scant in this area. Comprehensive drug dosage guides are not available to address this issue.

   It is recommended that the on-call clinical pharmacist review the medication profile of an obese patient. Depending on the day and time the call is received, a review of the patient's medications and dosages should be done within 24 to 48 hours.

   Implications for discharge. The bariatric patient needs to be referred to a case manager or social worker for continuity of care and discharge planning, who in consultation with nursing, PT/OT and Materials, will interview the patient to assess needs, determine payor source, and inform the appropriate physicians and team members of financial resources available as they relate to continued stay, discharge, and equipment acquisition. If the patient is a candidate for rehabilitation, a referral may be made to an appropriate facility. If the referral facility does not have bariatric equipment, time should be accorded to order the needed equipment. When home health care is needed, the provider should be informed that a bariatric patient is involved. When no payment source is evident, the clinician(s) can request the help of a social worker to obtain medical assistance and try to determine if the bariatric equipment companies have a charity program.

   Nursing is responsible for providing patient/family teaching regarding skin care. Patients or their caregivers must be assessed for their ability to apply topical creams, medications, and dressings.
If the patient is to be transferred to rehabilitation, the weight of the patient must be communicated to the transporter. If the patient is going home and needs special equipment at home, the case manager/social worker can contact various DME companies or contact materials management to obtain names of bariatric equipment companies. A wound care specialist also may be able to assist in locating equipment.