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Patients Of Size Nti

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patient of size presentation at NTI

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Patients Of Size Nti Patients Of Size Nti Presentation Transcript

  • Getting Your Arms Around Caring for Patient of Size Glenn Carlson MSN, CCRN Critical Care Clinical Nurse Specialist Bronson Methodist Hospital Kalamazoo, Michigan
  • Conflicts
    • I am a on the speaker’s bureau for AACN
    • I am not endorsing any product mentioned in the talk
  • Program Objectives
    • Statistics of patients of size in critical care
    • Literature Review of affects on mortality and morbidity
    • Case study example of the challenges patients of size can present in the ICU
    • Key concerns expressed by staff in treating patients of size
    • Using technology to address the challenges of patient and caregiver safety
    • Culture of sensitivity
  • Classification
    • Body Mass Index = Weight (kg)
      • Height (m2)
      • Underweight <18.5
      • Normal 18.5 – 24.9
      • Overweight 25.0 – 29.9
      • Obesity 30.0 – 34.9 - Class I
      • 35.0 – 39.9 - Class II
      • Severe Obesity > 40 - Class III
  • Economic Costs- CDC
        • Table 1, Aggregate Medical Spending, in Billions of Dollars, Attributable to Overweight and Obesity, by Insurance Status and Data Source, 1996–1998
    • Overweight and Obesity Obesity
    • MEPS (1998) NHA (1998) MEPS (1998) NHA (1998)
    • Out-of-pocket $7.1 $12.8 $3.8 $6.9
    • Private $19.8 $28.1 $9.5 $16.1
    • Medicaid $3.7 $14.1 $2.7 $10.7
    • Medicare $20.9 $23.5 $10.8 $13.8
    • Total $51.5 $78.5 $26.8 $47.5
    • Michigan about 2.9 billion
    • Note : Calculations based on data from the 1998 Medical Expenditure Panel Survey merged with the 1996 and 1997 National Health Interview Surveys, and health care expenditures data from National Health Accounts (NHA). MEPS estimates do not include spending for institutionalized populations, including nursing home residents. Source : Finkelstein, Fiebelkorn, and Wang, 2003
  • What are these costs related to?
    • Co morbid conditions are the likely reason for death not obesity
      • Hypertension
      • Type II diabetes
      • Osteoarthritis
      • Gall bladder dysfunction
      • Hypertrophic obstructive cardiomyopathy
      • Hyperlipidemia
  • Other co morbid conditions
    • Hypoventilation- obstructive sleep apnea
    • Degenerative arthritis
    • Psychosocial- studies have shown a relationship to psychiatric disorders and depression that lead to eating as a coping mechanism
  • Wellness Profiles of a midwest hospital
  • Wellness Profiles of a Midwest Hospital
    • Puddin' down to 297 pounds
    • GRAND RAPIDS, Mich. (WOOD) - WSNX radio host Puddin' is trying to become West Michigan's &quot;biggest loser.&quot;
  • Customers
    • Include “Patients of Size”
      • Provider practices
      • ED
      • Surgery
      • Lab, radiology
      • Outpatient
      • Etc.
  • Statistics On Patients Of Size In The ICU
    • Prevalence of obesity within medical-surgical ICUs ranges from 9% to 26%; morbid obesity from 1.4% to 7%
    • Neville et. al. reported that 26% of blunt trauma patients requiring ICU care were obese. A substantial portion of bariatric surgical patients may require prolonged ICU care
    • Nguyen et. al. reported that 7.6% of laparoscopic gastric bypass patients and 21.1% of open gastric bypass patients required ICU care after surgery
    • 6% to 24% of bariatric surgical patients require 24 hrs of ICU care
        • Excerpt from Fredric M. Pieracci, MD; Philip S. Barie, MD, MBA, FCCM;
        • Alfons Pomp, MD, Crit Care Med 2006; 34:1796–1804
  • John Hopkins- Hogue et al Intensive Care Medicine 2009
    • Obesity and morbid obesity does not adversely impact ICU mortality
    • Obesity may be associated with lower hospital mortality
    • No association between obestiy and duration of mechanical ventilation or ICU stay
    • Long tern effects of critical illness in patients of size relatively unknown.
  • University of Virginia- Surgical Infections
    • No independent association of increased BMI with mortality for surgical trauma ICU patient with infection.
  • Impact of Obesity in the Critically Ill Trauma Patient: A Prospective Study Bochicchio GV, Joshi M, Bochicchio K, Nehman S, Tracy JK, Scalea TM J Am Coll Surg . 2006;203:533-538
    • The authors collected prospective data on trauma patients (N = 1167) admitted to a shock trauma center, of whom 62 (5.3%) were obese -- defined as a body mass index (BMI) ≥ 30.
    • Most of the patients (71%) in the study had sustained blunt trauma.
    • Although the severity of injury was about the same in both groups, the obese patients had a significantly higher risk for complications. Furthermore, the risk for infection was increased ( P = .001) and the length of stay was 10 days longer ( P = .001); ventilator use was 8 days longer ( P = .001); and the overall risk for in-hospital mortality was 7-fold higher in the obese group ( P = .002).
  • Trauma and patient of size
    • Neville, A.L., et al. &quot;Obesity Is an Independent Risk Factor of Mortality in Severely Injured Blunt Trauma Patients.&quot; Archives of Surgery . September 2004, Vol. 139, pp. 983–987.
  • What they did:
    • The researchers looked at records on every person who came into the surgical intensive care unit at one L.A. trauma center in 2002. For each person, they calculated body mass index (BMI), which is a way to measure body weight while taking height into account. A BMI over 30 is considered obese. Most of the people were injured in car accidents or were pedestrians hit by cars.
  • What they found:
    • Obese people were twice as likely to die, even though obese patients and nonobese patients had similar patterns of injuries. Nearly a third of obese patients died, compared to 16 percent of nonobese patients. The researchers don't know why this is—maybe the obese people who died had other problems like high blood pressure. Or maybe the body's normal inflammatory response to injuries has a worse effect on obese people. The researchers also mention that obese people are just harder to work on—radiology isn't as accurate, surgery is harder, and keeping airways clear is tougher, too.
  • Others have not found this
    • Effect of Obesity on Mortality in Severely Injured Blunt Trauma Patients Remains Unclear Zein et al. Arch Surg 2005;140:1130-1131.
  • Morris et al Chest 2007
    • In a prospective cohort study of all ICU patients in King County, Washington, with ALI in 1 year (1999 to 2000), 825 patients had a BMI recorded. Using multivariate analysis, patients in the abnormal BMI groups were compared to normal patients in the following areas: mortality, hospital length of stay (LOS), ICU LOS, duration of mechanical ventilation, and discharge disposition.
  • Chest 2007 cont
    • There was no mortality difference in any of the abnormal BMI groups compared to normal-weight patients.
    • Severely obese patients had longer hospital LOS than normal-weight patients (mean increase, 10.5 days; 95% confidence interval [CI], 4.8 to 16.2 days; p < 0.001);
    • ICU LOS and duration of mechanical ventilation were also longer in the severely obese group when analysis was restricted to survivors (mean increase, 5.6 days; 95% CI, 1.3 to 9.8 days; p = 0.01; and mean increase, 4.1 days; 95% CI, 0.4 to 7.7 days, respectively; p = 0.03). Severely obese patients were more likely to be discharged to a rehabilitation or skilled nursing facility than to home.
  • Effect of obesity on intensive care morbidity and mortality: A meta-analysis *. Critical Care Medicine. 36(1):151-158, January 2008. Akinnusi, Morohunfolu E. MD; Pineda, Lilibeth A. MD; El Solh, Ali A. MD, MPH
    • Design: Meta-analysis of studies comparing outcomes in obese (body mass index of >=30 kg/m2) and nonobese (body mass index of <30 kg/m2) critically ill patients in intensive care settings.
    • Data Source: MEDLINE, BIOSIS Previews, PubMed, Cochrane library, citation review of relevant primary and review articles, and contact with expert informants.
    • Setting: Not applicable.
    • Patients: A total of 62,045 critically ill subjects
  • Measurements and Main Results:
    • Fourteen studies met inclusion criteria, with 15,347 obese patients representing 25% of the pooled study population. Data analysis revealed that obesity was not associated with an increased risk of intensive care unit mortality (relative risk, 1.00; 95% confidence interval, 0.86-1.16; p = .97).
    • However, duration of mechanical ventilation and intensive care unit length of stay were significantly longer in the obese group by 1.48 days (95% confidence interval, 0.07-2.89; p = .04) and 1.08 days (95% confidence interval, 0.27-1.88; p = .009), respectively, compared with the nonobese group.
    • In a subgroup analysis, an improved survival was observed in obese patients with body mass index ranging between 30 and 39.9 kg/m2 compared with nonobese patients (relative risk, 0.86; 95% confidence interval, 0.81-0.91; p < .001).
  • Obesity 2008 Olivares and Villamor
    • Meta-Analysis and systematic review
    • Decreasing trend in obese patient and mortality and no association between mortality and morbidly obese
    • Longer ICU stay and increased MOD
  • Why
    • Posit 1- Obese patients receive better care
    • Posit 2- Better nutritional reserves (underweight significantly increased mortality)
    • Posit 3- Higher levels of leptin that may improve survival in septic patients
  • “ Barry” – A Case Study
    • On Admission:
    • Patient is middle aged and morbidly obese
    • Admitted after falling and hurting his back
    • Patient has been paralyzed since fall - lying supine
    • History of frequent admissions to hospitals related to co- morbidities, multiple dyspneic episodes, coagulopathy- clots easily, hx of DVT
  • “ Barry” – A Case Study
    • Assessment, Diagnosis & Results
    • X-rays show fracture of a vertebrae
    • Requires open CT/MRI
    • MRI shows spinal compression related to large lung tumor pressing on cord
    • Neurosurgery states not a good candidate for surgery
    • Family and patient decide no CPR and no intubation
    • Patient dies
  • Treating Barry Presents Many challenges
    • Cannot sit up or turn to left because of spinal precautions
    • No bariatric intermittent compression devices, a question of how to dose anticoagulant
    • Need to find open MRI, will not fit into CT or MRI tube
    • Dyspnea not recognized as symptom of lung cancer but part of morbidity of size
    • CXR difficult to interpret
    • Neurosurgery communicates too high of a risk for surgery
  • Key Concerns Staff Have Regarding Caring for Patients of Size
    • Special Treatment Needs
    • Respiratory decompensation
    • Skin problems
    • Patient & Caregiver Safety
  • Special Treatment Needs: Blood Pressure
    • Thigh cuffs are not accurate on the arm
    • Forearm cuffs are not accurate for this group
    • May best be managed by noninvasive continuous blood pressure measurement technology that measures pressure from wrist sensor: Medwave Vasotrac  and Tensys  T-Line  (T-Line  only for patients under effect of anesthesia).
  • Special Treatment Needs: Calculating Dosages & Administering Medication
    • Calculating Dosages
      • Options: Ideal, actual, adjusted body weight
      • Dose to effect: Begin with ideal and dose to effect
      • Consult Pharm D for dosing when possible
    • Administration
      • Subcutaneous & Intraveneous routes
      • require longer than usual needles
      • Veins can be difficult to locate
  • Special Treatment Needs: DVT prevention
    • Bariatric Intermittent Pneumatic Devices
    • Appropriate dosing of anticoagulant
    • Early mobilization
  • Special Treatment Needs: Use Of Central Lines
    • Obese patients have double the use and lines are in longer than non-obese pts because of difficulty in placing peripheral lines
      • One study suggests no difference in mechanical insertion complication rate
            • El-Solh A et al (2001)
    • Switch to PICC lines as soon
    • as possible
  • Special Treatment Needs: Determining Cardiac Dynamics
    • Using actual body weight is inaccurate
      • Lower total blood volume than non-obese (volume/weight)
      • O 2 and cardiac output are directly proportional to amount of weight over “ideal”
      • Cardiac output from exercise due to in heart rate, NOT from stroke volume or ejection fraction
      • in O 2 due to disease state not yet determined
    • Using ideal body weight is inaccurate
      • O 2 and cardiac output are higher than in non-obese
    • Using adjusted body weight is an effective compromise
      • [Ideal-(actual-ideal) X 0.4]
  • Special Treatment Needs: Diagnostic Tools For Spinal Cord Patients
    • Typical diagnostic aids may not be available to patients of size
      • No CT scans
      • No enclosed MRI
      • No venous dopplers
      • Chest x-rays difficult to interpret
    • Obesity interfered with 7 of every 1,000 abdominal ultrasounds in 1989. That rate more than doubled (19) by 2003.
    • Obesity interfered with 8 out of every 10,000 chest X-rays in 1989. By 2003, the rate had more than doubled to 19
    • “ Because radiologists can't get the images needed to diagnose potentially serious problems, these patients incur the cost of extra diagnostic tests -- and they may have to settle for substandard care- Spinal cord injured patients of size of particular challenge”
    Uppot, R.N. Radiology , August 2006; vol 240: pp 435-439
  • Preventing Respiratory Decompensation
    • Use patient turning and early mobilization
    • Consider Percussion
    • Use Trendenlenburg position- Left lateral decubitus, semi recumbent
      • Increases tidal volume
      • Avoid supine or Trendelenburg when possible
    • Constant assessment of OSA
    • Ready availability of airway assist team
    • Availability of extra long tracheostomy tubes
  • Maintaining Skin Integrity
    • No powders in skin folds
    • Daily inspection of skin; frequent, scheduled turning
    • Pay careful attention to moisture management
    • Float patient’s heels
    • Avoid “pushing and pulling” when repositioning
    • Guard against pressure, shear, and pinching when using lifts and slings
    • Position tubes and Foleys over the patient’s body and not in skin folds
    • Consider rectal tube for liquid stools
  • Challenges To Patient & Caregiver Safety
    • Patient Repositioning
    • Transfers
    • Transport
    • Mobility
  • Frequency & Cost of Back Injuries
    • Nurse’s Aides and Orderlies are the highest risk occupation category for work-related musculoskeletal injuries 1
    • Nurse injuries related to patient handling are increasing 2
      • 750,000 lost workdays annually
      • $20 Billion annually
    • Back pain is second only to the common cold as the most frequent cause for nurse’s sick leave 3
    1. United States Department of Labor, Bureau of Statistics 2. Patient Care Ergonomics Resource Guide: Safe Patient Handling and Movement, Pt. Safety Center of Inquiry, VHA and DOD, 2001 3. Frymoyer JW, Cats-Baril WL. An overview of the incidence and costs of low back pain. Orthop Clin North Am 1991;22:263–71.
  • Using Technology Can Help Address Patient & Care Giver Safety
    • Repositioning: Turning Surfaces
    • Transfer: Lateral Transfer Devices
    • Transport: Variable width beds; stretcher chairs
    • Mobility: Foot or side exit beds; mobility aids and accessories
  • Using Technology To Assist In patient care
    • Integrated design delivers flexible, individualized therapies in a single frame
    • “ Built-in” features help reduce the need to transfer complex patients
    • Many features help minimize the potential risks associated with patient handling
    850 lb capacity
  • Kinetic Therapy System
    • Moisture management (low air loss)
    • Percussion and pulsation- staff assist and patient assistance with secretions
    • Rotation important to assist staff with turning
    • Cardiac chair can help in mobilization and aid in comfort
    • Built in scale
    • Order with Lift and make sure whatever lift is used works with bed frame.
  • BariMaxx  II Power Drive System With MaxxAir ETS  MRS
    • Expandable width of 36, 42 and 48 inches
    • Side exit preferable for rehabilitative staff and some patients
    • Turn assist aids in patient repositioning
    • Continuous lateral rotation up to 30 degrees
    • Power drive system to assist with patient transport
    • Built in scale
    1000 lb capacity
  • Valuable Assistance In Lateral Transfers
    • Ease of patient transfer may require fewer caregivers
    • Air technology creates a nearly frictionless transfer surface helping reduce risk of caregiver injury
    • Pad design allows patients to remain on the transfer pad for all ancillary procedures, such as radiology, CT scan, radiation therapy, etc.
    • Sani-liner provides a safe layer between patient and mattress to help mitigate infection
    1,000 lb capacity
  • Treatment of Patients Of Size Requires A Multidisciplinary Effort
    • Hospital wide committee development
      • Treatment guidelines
      • Mobility (no lift) algorithm - VHA website
      • BMI calculations (40+ BMI gets bariatric equipment)
      • Access to and routine use of special equipment
      • Weight limit labels for all equipment listed in policy
      • Provision of airway assist teams
      • Cultural sensitivity training
      • Community resources- bariatric surgery programs, diet, lifestyle enhancements, diagnostics (open MRI availability, etc.)
      • Involvement of rehab department
        • Staff safety
        • Assist with mobilization and patient ROM and strength
  • What do you see?
  • (Allon, 1975; Staffieri, 1967, 1972).
    • Both normal-weight and overweight children describe obese silhouettes as &quot;stupid,&quot; &quot;dirty,&quot; &quot;lazy,&quot; &quot;sloppy,&quot; &quot;mean,&quot; &quot;ugly,&quot; and &quot;sad,&quot; among other pejorative labels  
  • Crocker, J., Cornwell, B., & Major, B. (1993). The stigma of overweight: Affective consequences of attributional ambiguity. JOURNAL OF PERSONALITY AND SOCIAL PSYCHOLOGY. 64(1), 60-70.
    • &quot;Of all the conditions for which a person may be stigmatized in our culture, including racial or ethnic group membership, religious affiliation, physical handicaps, and sexual preference, the stigma of being overweight may be the most debilitating.&quot;
    • If the world needed any more proof that Americans are some fattie mcfatties, we present the French-Fry Holder. This $10 device fits in cup holders and holds a standard cardboard container of french fries. It even has a small holder for ketchup, for those fattersons that need to add a little more flavor (and sodium) to their deep-fried potato sticks. A no-slip grip secures the device in any cup-holder to prevent any wasted fries. Weren't French fries designed to be the perfect food while driving? Sure, we're all about driving safety, which this device addresses, but we wonder if the morbid-nature of this product outweighs its positives.
  • Insensitivity Toward Patients Of Size Is Common
    • “ He has poor protoplasm and is so large he can’t even care for himself: Its hopeless”
    • “ They have done it to themselves”
    • “ Don’t like to care for them because of the body odor”
    • “ He is sick because all he does is sit around”
  • Obesity is often described as the last 'acceptable' form of discrimination based on physical appearances. American Obesity Association
  • Crandall, C., & Biernat, M. (1990). The ideology of anti-fat attitudes. JOURNAL OF APPLIED SOCIAL PSYCHOLOGY. 20(3), 227- 243.
    • &quot;What turns these attitudes into prejudices is that they exist in the face of mounting evidence that one's weight is largely determined outside of volitional control&quot;
  • Genetics: Twin studies Fraternal Identical
  • Health Care Professionals
      • An Implicit Associations Test was administered
      • Found significant pro-thin anti-fat bias
      • Found subjects endorsed stereotypes of lazy, stupid and worthless.
      • Lower levels of bias were associated with being male, older, weighing more, having a positive outlook, having obese friends and understanding the experience of obesity.
    TA Wadden, Obesity Research 2003
  • Are the Obese Bias against the Obese?
    • Implicit Association Test used with explicit measures used in 2 nd group as well.
    • 68 overweight individuals in 1 st and 48 overweight individuals in the 2 nd group.
    • Significant anti-fat bias noted on IAT
    • Endorsed explicit belief that fat people are lazier than thin people.
    SS Wang International Journal of Obesity 2004
  • The problems we Overlook
    • From a survey of 1549 patients published in Obesity Surgery by Dr. Deitel
    • Specific problems associated with massive obesity
      • Unable to: % of Patients
      • Cut toenails 73
      • Cross legs 85
      • Buckle seat belt 27
      • Fit into theatre seat 36
      • Wipe self 21
      • Urinate accurately (men) 52
      • Will Not:
      • Sleep in room with S.O. 81
      • Undress in front of S.O. 73
  • Preferred Terms in Obesity
    • 167 obese women and 52 obese men surveyed
    • Terms Least desirable:
      • Fatness, excess fat, obesity and large size
    • Terms more desirable
      • Weight, BMI, excess weight, unhealthy body weight, weight problem, unhealthy BMI, heaviness.
    • Preferred “patients of size”
    TA Wadden, Obesity Research 2003
  • Literature
    • Supports the idea that healthcare providers label obese patients
    • Supports the fact that labeling sets up isolation
    • Supports the fact that the label is communicated to all staff
    • Survey of severe obese- 80% report being treated disrespectfully by the medical profession
    • Labeling may worsen disease
  • Labels
    • Falls into two categories
      • Stigmatized illnesses (bariatric)
      • Confused uncommunicative
  • Responses
    • Exclusionary- Avoid patient at all costs
    • Care for patient unemotionally
  • Culture of Sensitivity
    • Respectful Language:
    • Instead of morbid obesity – severe obesity
    • Instead of excess fat – excess weight
    • Instead of obese patient – “patient of size” or “patients with a weight problem” or unhealthy BMI
  • Create Culture of Sensitivity
    • Understand obesity is a disease not a character flaw
    • Challenge your own attitude/bias
    • Empathize with patient experience
    • Use respectful language
    • Provide equipment/furnishings that fit patient need
  • Questions/Discussion Thank you! Glenn Carlson