Safely Caring for the Hospitalized Patient with Obesity

Paul Nagle, ARM, CPHRM, Director, Department of Patient Safety and Risk Management, and Shelley Rizzo, MSN, CPHRM, Senior Patient Safety Risk Manager, Department of Patient Safety and Risk Management

Regardless of their diagnosis or comorbidities, patients admitted to a facility deserve quality care delivered with respect and sensitivity. Increasingly, obesity is a common comorbidity. In December 2019, the New England Journal of Medicine published research predicting that by 2030 almost half of American adults—48.9 percent—will have obesity. Adults with obesity are more likely to have risk factors for cardiovascular disease, prediabetes, bone and joint problems, sleep apnea, and social and psychological problems.

Children and adolescents with obesity are at risk for developing the same comorbidities as adults. For example, children with obesity have a 46 percent increased chance of developing obstructive sleep apnea (OSA). Often, they become adults with obesity.

Obesity is viewed as a chronic health condition, and patients with obesity pose patient safety issues. Physical assessment, airway management, drug dosing, equipment management, and facility infrastructure present unique challenges for this population. Preplanning and care guidelines to address these challenges will help optimize care and enhance patient and staff safety. Consider the following as you care for patients with obesity.

Patient Satisfaction

Being in the hospital puts patients in a vulnerable position. Comments or facial expressions that suggest degrading or offensive feelings about a patient with obesity can negatively influence patient satisfaction and may also affect care. For example, patients who are treated with antipathy might not be as forthcoming about medical concerns or complaints of pain. Treatment should focus on the person, not the person’s obesity.

Obstructive Sleep Apnea

Men and women with obesity have a higher risk for respiratory difficulties due to OSA. OSA is associated with airway obstruction when soft tissue of the mouth and neck relax during sleep. Predictors of OSA include excess weight and an increased neck circumference. 

A claims review by The Doctors Company revealed a pattern of severe postoperative respiratory depression in patients with OSA. Heavy sedation also puts these patients at risk. For patients undergoing invasive procedures, screening for OSA during the preoperative evaluation is essential. (For an example, see the Stop-Bang Questionnaire.) It is estimated that more than 80 percent of adults with OSA remain undiagnosed. Take appropriate precautions both during and after the procedure. Staff training should include policies for continued monitoring of patients with known or suspected OSA and early recognition of postanesthetic and surgical complications. Include OSA precautions in handoff communications to staff on other inpatient units.

Patients should not be discharged from the recovery area (i.e., to home or an unmonitored hospital bed) until they are no longer at risk for postoperative respiratory depression. This is especially true for known or suspected OSA patients who require postoperative opioids. Educate patients about the respiratory depressant effect of pain medications and the increased risk for patients with OSA, and document the education.

Patients with suspected OSA according to screening criteria or those who exhibited signs of OSA during or after a procedure should be directed to follow up with their primary care physician.

Pressure Ulcers

Patients with obesity may be immobile or difficult for staff to turn and position. These patients are at increased risk for developing pressure ulcers. Poor circulation of oxygen to fatty tissue is also a factor that can make patients with obesity more vulnerable to pressure ulcers. Because pressure ulcers may be a hospital-acquired condition, perform a thorough skin assessment upon admission, and document any ulcers with accurate descriptions, measurements, and pictures.

Frequent repositioning using additional staff or mechanical lifting devices and using a bed with a pressure-reducing mattress may help reduce the risk. Document continued comprehensive assessments for skin breakdown, pressure ulcer risk assessments, preventive measures instituted, and the care of ulcers, if present. (For assistance, see the Agency for Healthcare Research and Quality’s [AHRQ’s] Preventing Pressure Ulcers in Hospitals: A Toolkit for Improving Quality of Care.)

Fall Precautions

Patients with obesity can be at increased risk for falls due to several difficulties: limited mobility with balance, gait, or transfer issues; current illness; medications; or associated comorbidities, such as cardiovascular, respiratory, or musculoskeletal conditions.

Institute a robust fall-prevention program at your facility that includes implementing universal fall precautions, using a standardized fall risk assessment, addressing identified risks through care planning interventions, thoroughly documenting risk assessments and measures implemented, and specifying post-fall procedures that include debriefs and root cause analysis. (For assistance, see AHRQ’s Preventing Falls in Hospitals: A Toolkit for Improving Quality of Care.)

For more on this topic, read our article “Preventing Falls in Patients With Morbid Obesity: Case Study.”

Equipment

Patient care areas require equipment designed for patients with obesity, including oversized furniture, scales, MRI machines, OR tables, beds, wheelchairs, and gurneys. Appropriately sized supplies such as blood pressure cuffs, bandages, gowns, and extra-long needles are also required.

Infrastructure changes may be needed as well. If possible, design and equip designated patient rooms to accommodate patients with morbid obesity. As examples, floor-mounted toilets typically support much more weight than wall-mounted toilets, and doorways may be enlarged to facilitate sufficient clearance for wider wheelchairs and gurneys. Check available guidelines for bariatric patient rooms when upgrading rooms in your facility.

If properly sized MRI, CT, and other diagnostic equipment are not available at your facility, maintain transfer agreements with other facilities that can perform the diagnostic studies or assume care of the patients.

Focus on Staff Safety

The Centers for Disease Control and Prevention indicates that the rate of musculoskeletal injuries from overexertion in healthcare workers is one of the highest of all U.S. industries. The most common risk factor for overexertion injuries is manual patient handling (moving, lifting, or repositioning). Patients with obesity present this challenge for staff who assist with manual patient handling and ambulation. Ensure that adequate staff is available to help move a patient or to assist a patient getting in or out of bed. In patient rooms, a ceiling-mounted or portable lift can help reduce the risk of injury to staff.

Several states have enacted safe patient handling legislation to encourage the use of lifting devices and incorporate lift teams for better patient transfer coordination. Check hospital policies and procedures for additional requirements. Review and practice proper lifting techniques to avoid pulled muscles or back injuries.

For further information about obesity’s relation to malpractice claims, read our article “Overview of Obesity-Related Malpractice Claims.”


Resources

Childhood obesity causes and consequences. Centers for Disease Control and Prevention. www.cdc.gov/obesity/childhood/causes.html

Prevalence of obstructive sleep apnea in surgical population. STOPBang. www.stopbang.ca/surgery/prevalence.php

Safe patient handling and mobility (SPHM). National Institute for Occupational Safety and Health. Centers for Disease Control and Prevention. www.cdc.gov/niosh/topics/safepatient/

Wolfe RM, Pomerantz J, Miller DE, Weiss-Coleman R, Solominides T. Obstructive sleep apnea: preoperative screening and postoperative care. J Am Board Fam Med. March 2016;29(2):263-275. www.jabfm.org/content/29/2/263.full

Worker safety in hospitals: safe patient handling. U.S. Department of Labor, Occupational Safety and Health Administration. www.osha.gov/dsg/hospitals/patient_handling.html



The guidelines suggested here are not rules, do not constitute legal advice, and do not ensure a successful outcome. The ultimate decision regarding the appropriateness of any treatment must be made by each healthcare provider considering the circumstances of the individual situation and in accordance with the laws of the jurisdiction in which the care is rendered.

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