Providing care for bariatricpatients is a concern forhealthcare facilities and staff

everywhere. Delayed patient mo-bilization due to fear of injury andlack of proper policy, knowledge,or equipment for handling thesepatients can lead to poor out-comes—and may pose legal andethical concerns. Specializedequipment, beds, patient lifts, andsurgical instruments must be made

available to help nurses and otherhealthcare professionals care forand support best practices forbariatric patients. (See Bariatricsby the numbers.)

Mobility matters When patients can’t mobilize inde-pendently, they rely on nursing andphysical therapy staff to prevent im-mobility complications—pressureulcers, contractures, deep vein

thrombosis, muscle wasting, andpneumonia. Increased patient sizeis a significant barrier to early mo-bility, as are lack of proper equip-ment to lift and move the patient. Yet providing early mobilization

for dependent patients is challeng-ing, and when they’re large, itmay seem overwhelming. Thebariatric patient may be at evengreater risk for immobility and de-conditioning during hospitalizationbecause nurses may fear they’ll in-jure themselves while providingpatient care. Manual patient mobi-lization increases the risk of muscu-loskeletal injury to caregivers. Onestudy found that although bariatricpatients accounted for less than10% of the patient census in acute-care facilities, patient-handling in-juries involving them accounted for29.8% of staff-reported injuries.Safe patient handling and liftingrequires skill and specialized prod-ucts that support early mobility, lift-ing, and ambulation.Bariatric patients may fear

falling and may be embarrassedthat it takes four or five people tolift, move, or support them duringtoileting or out-of-bed activities.They may have moderate to se-vere mobility limitations due tobody type, decreased range ofmotion at the hip and knee, gener-alized adiposity, and location andsize of the pannus (a dense layerof fatty tissue over the lower ab-dominal area).

20 Current Topics in Safe Patient Handling and Mobility September 2014 www.AmericanNurseToday.com

Prepare to care forpatients of size How to make mobilization and lifting safer forbariatric patients and staff By Dee Kumpar, MBA, BSN, RN, CSPHP

Bariatrics by the numbers In 2011, the Centers for Disease Control and Prevention reported that 69% of adults were over-weight, including 35% who were obese. Among adolescents ages 12 to 19, 18.4% were obese;among children ages 6 to 11, 18% were obese; and among children ages 2 to 5, about 12%were obese. Obesity is defined as a body mass index (BMI) of 30 to 39; morbid obesity, a BMI of40 or higher. Overweight is defined as a BMI between 25 and 29.9.

Overweight and obese persons are at increased risk for many diseases and disorders, includ-ing type 2 diabetes, hypertension, hyperlipidemia, coronary heart disease, gallbladder disease,cancer, osteoarthritis, sleep apnea, and depression.

Promoting a culture ofsafety As a nurse, you can lead the wayto creating and maintaining a cul-ture of safety by supporting andmodeling safe patient-handlingpractices on your unit. A focusedapproach to managing bariatricpatients’ mobility needs requiresthoughtful planning and knowl-edge of the technology designedto support care for these patientsthroughout their entire stay. Liftingand mobility practices can bestandardized successfully if nurseshave a voice in developing a safepatient-handling and mobility(SPHM) program and in selectingSPHM technology.

Assessing the level ofassistance needed Changing practice begins withevaluating the types of lifting andmoving tasks required. Bariatric pa-tients may need assistance withcommon activities, such as toileting,bathing, skin care, eating, sittingupright, and ambulating. To elimi-nate variations in care practices,caregivers should be clear on howto assess a patient’s mobility status.Barriers to moving independently—not the patient’s weight—should bethe main criteria for determining theneed for lift equipment. Standard categories of depend-

ency levels include:• dependent—the patient relieson the nurse or caregiver for alllifting and moving activities

• minimally to moderately de-pendent—the patient relies onthe nurse or caregiver for morethan 50% of lifting and movingactivities

• independent—the patient canperform lifting and moving ac-tivities without assistance fromthe nurse or other caregiver.

Other assessment considera-tions include:• weight-bearing capability (full,partial, or none)

• whether the patient has bilater-al upper-extremity strength

• patient’s level of cooperationand comprehension

• medications, such as vasopres-sors and paralytics

• conditions that may affectchoice of transfer technique,such as stomas, fractures, severeedema, or joint replacements.

For more information on assess-ment, read “Implementing a mobil-ity assessment tool for nurses” inthis supplement.

Patient-handlingalgorithms In 2003, the Veterans Administra-tion created algorithms to provideguidance on how to safely per-form high-risk activities related topatient handling and movement.Each algorithm specifies the sug-gested number of caregivers aswell as selection and use of ap-propriate lift equipment. To down-load these algorithms, visitwww.tampavaref.org/safe-patient-handling.htm.

Organizational guidelines Manual lifting of any patient isn’tsafe. The National Institute of Oc-cupational Safety and Health (partof the Occupational Safety andHealth Administration), recom-mends 35 lb (15 kg) as the safepatient-lifting limit for healthcareworkers. The American Nurses As-sociation (ANA) supports a policyof no manual lifting, as discussedin its 2013 book, Safe PatientHandling and Mobility: Interpro-fessional National Standards. A 2010 white paper from The

Facility Guidelines Institute, titledPatient handling and mobility as-sessment (FGI-PHAMA), providesrecommendations for the rightamount of equipment in the rightlocation based on the specificneeds of patients on each type ofunit. (The ANA publication men-tioned above cites this documentas supporting evidence on select-

ing and using lift equipment.) Forexample, we know many patientsin intensive care units (ICUs) aredependent and must rely on nursesto boost, turn, and reposition themfrequently throughout the day. FGI-PHAMA recommends 100% ceil-ing lift coverage in ICUs to ensurepatient mobilization activities canbe done without delay or injury tonurses. For medical-surgical units,FGI-PHAMA recommends 50%ceiling lift coverage, because gen-erally half the patients on theseunits depend on the nurse to lift,manage, move, and support theirambulation activities throughoutsome portion of their stay.

Challenging environments Advances currently are under wayto promote safe patient handlingin other challenging hospital ar-eas, such as the operating room(OR), emergency department, out-patient areas, and ancillary units.Preplanning for patient flow andtransfer activity to and from theseunits is essential. The care teammust communicate, coordinate,and cooperate during patienttransport, lateral transfers, and

www.AmericanNurseToday.com September 2014 Current Topics in Safe Patient Handling and Mobility 21

Barriers to moving independently—

not the patient’s weight—should

be the main criteria for determining

the need for lift equipment.

repositioning. With technologyavailable to prevent injury to bothcaregivers and patients, no de-partment should put staff at riskfor injury during transfer activities.

(For a case study on bariatricequipment use in the OR, seeCase study: Bariatric surgery us-ing the proper SPHM technology.)Bariatric patients present multi-

ple concerns for healthcare work-ers. We encourage all nurses tospeak up about safety and to support a SPHM workplace en -vironment. 8

Selected referencesAmerican Nurses Association. Safe Patient Han-dling and Mobility: Interprofessional NationalStandards. Silver Spring, MD: Author; 2013.

American Society for Metabolic and BariatricSurgery. Estimate of bariatric surgery numbers.2014. http://asmbs.org/2014/03/estimate-of-bariatric-surgery-numbers. Accessed June 24,2014.

American Society of Bariatric Surgeons. Med-ical options for treating obesity fact sheet. Up-dated May 2014. www.asbp.org/images/PDFs/Resources/Obesity-Algorithm_FactSheet.pdf. Accessed June 24, 2014.

The Facility Guidelines Institute. 2010 HealthGuidelines Revision Committee Specialty Sub-committee on Patient Movement. Patient han-dling and movement assessments: A white pa-per. April 2010. https://www.dli.mn.gov/wsc/PDF/FGI_PHAMAwhitepaper_042710.pdf. Ac-cessed June 24, 2014.

Gallagher S. Implementation Guide to the SafePatient Handling and Mobility InterprofessionalNational Standards. Silver Spring, MD: Ameri-can Nurses Association; 2013.

Gallagher S. The Challenges of Caring for theObese Patient. Edgemont, PA: Matrix MedicalCommunications; 2005.

Ogden CL, Carroll MD, Kit BK, Flegal KM.Prevalence of childhood and adult obesity in theUnited States, 2011-2012. JAMA. 2014;311(8):806-14.

Randall SB, Pories WJ, Pearson A, Drake DJ.Expanded Occupational Safety and Health Ad-ministration 300 log as metric for bariatric pa-tient-handling staff injuries. Surg Obes Relat Dis.2009;5(4);463-8.

Schallom L, Metheny NA, Stewart J, et al. Effectof frequency of manual turning on pneumonia.Am J Crit Care. 2005;14(6):476-8.

U.S. Department of Veterans Affairs. Safe pa-tient handling and movement. Reviewed/Updat-ed April 30, 2014. www.visn8.va.gov/visn8/patientsafetycenter/safePtHandling/default.asp.Accessed June 24, 2014.

Dee Kumpar is the director for Safe Patient Handling Programs at Hill-Rom in Batesville,Indiana and a member of the workgroup forANA’s Safe Patient Handling and Mobility: In-terprofessional National Standards. She is onthe board of directors of the Association of SafePatient Handling Professionals.

22 Current Topics in Safe Patient Handling and Mobility September 2014 www.AmericanNurseToday.com

Case study: Bariatric surgery using the properSPHM technology By Ronda Fritz, RN, BSN, MA

An estimated 179,000 bariatric surgeries were performed in the United States in 2013. De-mand for such surgery continues to rise. However, using safe patient handling and mobility(SPHM) technology in the operating room (OR) can be challenging because of the sterileenvironment and potential lack of knowledge about safe equipment use—especially forsuch tasks as lifting the pannus and limbs. This case study shows how one nurse was able topromote a culture of safety in the OR and how the surgeon recognized the benefits to boththe surgical team and patient. As described below, a team of experts in the hospital deter-mined how to incorporate the patient lift system to support the pannus during surgery toprotect staff from injury and enhance the surgeon’s visualization and safety.

A morbidly obese patient weighing 488 lb (221 kg) with a BMI of 70 was scheduled for apanniculectomy (pannus removal) and hernia repair. The surgeon requested use of a pa-tient lift during the procedure to lift and hold the pannus. As the patient was being preppedfor surgery, the surgeon learned that the requested Böhler Steinmann pin holders, whichwould attach to the lift to support the pannus, weren’t available. He cancelled the surgeryand rescheduled it for a later date. He said he wouldn’t perform the surgery without the pa-tient lift because he didn’t want staff to hold the pannus, which weighed more than 100 lb(45 kg), for the 3 to 5 hours the surgery would take.

The panniculectomy was rescheduled. Before the operation, the nurse worked with SPHMexperts to assess how to best handle the patient and developed a plan to incorporate thepatient lift system to support the pannus during surgery, thus protecting staff from injuryand enhancing the surgeon’s visualization and safety.

The surgery was performed with use of a portable patient lift. The patient was positionedon an OR table appropriate for his size and weight and prepped in sterile fashion. The pan-nus was suspended with two Steinmann pins attached to two Böhler Steinmann pin holdersand a Golvo® 7007 lift. The patient was draped and prepped in standard sterile fashion. AnSPHM expert positioned and operated the lift during the procedure. The panniculectomy re-moved 40 lb (18 kg) of adipose tissue. When the surgery was completed, the patient wastransferred off the OR table with an air-assisted lateral transfer device.

Benefits of using the proper equipmentUsing the proper patient-handling equipment during the panneculectomy yielded the fol-lowing benefits:• No unpredictable movement of the pannus occurred while it was attached to the lift. It

was moved only when the surgeon moved the tissue or directed the SPHM expert toreposition or lift it.

• Use of the lift during the surgery enhanced patient safety.• The patient’s adipose tissue was hiding many blood vessels. Having the pannus stabilized

by the lift helped avoid unintentional vessel dissections. Estimated blood loss was 300 mL.• Use of OR staff was improved. Although six additional staff members were assigned to

assist with holding the pannus and transferring the patient off the OR table, they weren’tneeded and were released to other duties.

• No staff members were injured during the procedure. Because the air-assisted lateraltransfer device was used, no patient or staff injuries occurred during transfer from the ORtable to the bed.

• No patient injuries occurred.

Ronda Fritz is a safe patient-handling facility champion at VA Nebraska-Western Iowa Health Care System inOmaha, Nebraska. She is on the board of directors of the Association of Safe Patient Handling Professionals.