Best Practices for Proper Care of the Morbidly Obese in Surgery Centers

January 10, 2012 | Print  |

The following article is written by Anne Dean, RN, BSN, LRM, CEO and co-founder of The ADA Group.

 

As America's waistband expands more and more, we are seeing patients who qualify for the classification of the morbidly obese being admitted to the surgery centers for their procedures. This practice will, most probably, not go away, but will become even more popular. The question emerges as to whether or not the average ambulatory surgery center is prepared to take care of such patients. From what this author has seen, unless the center performs bariatric surgery, neither the available equipment nor the staff/staffing are usually adequate to provide safe care of the patient.

 

In the past, leaders in the surgery centers designated a pound limit for admission to the center (e.g., patients over 350 pounds would not be admitted for procedures). This figure was primarily selected based upon the poundage limit of stretchers and OR tables. There was not, on the whole, a conversation about other equipment (exception being a lift) needed in order to care for this type of patient. There was an assumption that any patient weighing 350 pounds was obese; however, just as America's waistband has expanded, so has our height. We are seeing many more patients in ASCs who are 6'6" tall and taller. Those patients may not, in fact, be classified as obese. This distinction has forced us to begin evaluating a patient's level of obesity based on his body mass index. Today the designation of obesity can only be made by performing a BMI.

 

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In many centers, neither the patient's weight nor BMI is made known until the day before the procedure when the schedule is sent to the operating room supervisor. This practice does not allow adequate preparatory time to plan for a safe environment for these patients. Rather, this information must be collected at the time the patient is scheduled. Collect the patient's height and weight as a matter of course during the scheduling process, then calculate the BMI. Calculation of the BMI is accomplished by taking the weight in kilograms divided by height in millimeters squared (kg/m2). The following classifications should be followed:

 

Instruct the scheduling secretary to notify the OR supervisor of any BMI greater than 35 immediately so that proper preparatory actions and processes can be put in place.

 

For preoperative care:

 

Note: The preoperative RN should interview the patient regarding reflux/GERD and should alert anesthesia where the patient admits to this condition. Determine with the patient to what degree he is able to lay flat. Advise anesthesia of this response.

 

Intraoperative care:

 

Postoperative care:

- congestive heart failure

- deep vein thrombosis

- myocardial infarction

- pulmonary embolism

- respiratory depression

- rhabdomyolysis (deep muscle damage)

- skin breakdown

 

Care of the morbidly obese in the PACU and discharge area requires a one-on-one staffing ratio until the patient is ready for discharge. It is crucial that this patient be rigorously monitored. Deep breathing/breathing treatments and leg exercises are crucial. Getting the patient up and out of the recovery bed to a chair as quickly as his condition allows is vital to his successful recovery. Repetitive education regarding breathing and leg exercises at home is critical. Provide demonstrations and demand the patient return the demonstration. Make sure he or she applies his CPAP device properly. Solicit the patient's return explanation regarding the prevention of DVT (and the care person's explanation, too). Remember that this patient's size in of itself is an obstacle in moving his or her body to the extent needed. The nurse providing postoperative instructions must ensure the patient's level of understanding is such that the patient will "move the mountain" in order to best provide the best outcome possible for his or her care. The need to limit pain medication may further inhibit activity and limit compliance. Be firm. Explain possible complications and the degree that inadequate ventilation and exercise contribute to these even to the point of pneumonia and blood clots that could, potentially, be fatal.

 

In providing the best possible patient education, the nurse caring for these patients must be aware of the underlying emotional needs as well as the obvious physical that are present. The patient may be defensive about his or her weight. The patient may, even, be in denial of the extent of the problem. The patient may be embarrassed, but, certainly sensitive about the issue. Protect his or her privacy. Provide as much privacy during the assessment and teaching phases of his care as the physical plant restrictions allow. Plan this out prior to the patient's admission. Is there space anywhere that can be commandeered to provide these special needs? This patient needs staff support.

 

How do you provide staff support of the morbidly obese patient when literature and studies abound regarding the stigma and bigotry that exists regarding such patients? Start now with providing staff education. Have round table discussions on the subject. Contact local eating disorder clinics or bariatric centers for expert guest speakers. Given the staffing constraints that exist in most surgery centers, nevertheless, select and assign staff members carefully when planning the patient's care. Just as there are considerations in making other staffing assignments due to religious beliefs, etc., so these may exist among your staff members regarding weight and the morbidly obese. Staff members should be assessed as to whether such pre-conceived convictions can be set aside to provide the degree of support these patients need.

 

Care of the staff person must also be planned and implemented when caring for the morbidly obese. Injury is a very real hazard, whether a back injury from moving the patient or an injury sustained trying to prevent a patient from falling or working with lifting devices, etc. Determine how best to mitigate such circumstances.

 

Finally, calculate the costs of providing care to the morbidly obese patient in the ASC. If your center does not routinely provide care to bariatric patients, what are all the direct and indirect costs you will be incurring compared to the reimbursement you will be receiving?

 

Learn more about The ADA Group.


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