Only by addressing the special needs of obese and extremely obese residents will facilities be ready for the challenges posed by our nation's obesity epidemic.

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ong-term care facilities face a new challenge, as obesity levels in the United States reach an all-time high. Little more than a decade ago, the admission of a 500-pound resident was a rare occurrence. Today, with as many as 30% of adults (18 years of age and older) classified as obese, long-term care facilities must prepare for the special needs of obese and extremely obese residents.¹ Many facilities, however, are not ready.
       The prevalence of obesity among adults has more than doubled in the last 25 years. Older Americans are affected by this growing trend. Researchers predict that obesity among the elderly is the “coming epidemic.” The prevalence of obesity in adults aged 60 and older will increase from 32% in 2000 to 37.4% in 2010, the researchers say. Conversely, the prevalence of healthy weight among adults aged 60 and older will decrease from 30.6% in 2000 to 26.7% in 2010.²
       To prepare, long-term care facilities must evaluate their ability to safely address the special needs of this growing population by reexamining the physical design and layout of the facility; considering the purchase of bariatric equipment specially designed for obese individuals as well as furniture and supplies that can accommodate their weight

Table 1

and size; establishing protocols that address the care of these residents and their special physical, clinical, and psychological needs; and training staff to meet those needs safely, ergonomically, and sensitively.³
       This article addresses the special needs of extremely obese residents, providing viable approaches for long-term care facilities to mitigate the risk of harm to these residents and their caregivers (see Table 1 for key recommendations).

Terminology

       Obesity is defined in terms of an individual’s body mass index (BMI), which is calculated by dividing a person’s weight by the square of his or her height.⁴ Internationally, BMI is expressed in metric form as kilograms/meter² or kg/m². An obese person has a BMI of 30–39.9 kg/m². An extremely obese person has a BMI greater than or equal to 40 kg/m2. Given these definitions, an extremely obese resident can range in weight from 250–350 pounds, depending on the individual’s height, to 1,000 pounds or more.
       This article uses the standardized definitions for obesity and extreme obesity. The term “bariatric residents” refers more generally to the obese or extremely obese resident. The word “bariatric” is derived from the Greek word baros, meaning heavy or large, and refers to the science of providing healthcare for extremely obese individuals.

Design Issues

       Because few formal guidelines are available that address design issues related to the unique needs of extremely obese residents, facilities are often forced to rely on prior experience with these residents. Currently, neither guidelines from the American Institute of Architects/ Academy of Architecture for Health (AIA/AAH) nor requirements of the Americans with Disabilities Act (ADA) provide specific guidance on the physical design of long-term care facilities tailored to caring for obese and extremely obese residents.
       Facilities must consider modifications such as widening of doorways and corridors; use of fixed adaptive equipment (eg, reinforced grab bars) and resident transfer aids (eg, lifts) suitable for safe, humane, and efficacious care; placement of oversized furniture in resident rooms as well as activity and dining areas; and implementation of protocols for resident transfer that address lifting and handling techniques and required equipment.

Resident Rooms, Ingress and Egress

       Current AIA/AAH guidelines for nursing facilities simply state that room size (ie, area and dimensions) should be determined by analyzing the needs of the resident to move about in a wheelchair; gain access to at least one side of the bed; turn and wheel around the bed; and gain access to a window, the toilet room, the closet, night stand, chair, and dresser.⁵
       When addressing the special needs of extremely obese residents, facilities must consider the need to accommodate a bariatric bed, oversized furniture, and specialized equipment (eg, lifts and bariatric wheelchairs). In addition, the room should have sufficient open space for the maneuverability needs of the resident and for the care team to safely and ergonomically assist the resident.
       Ingress and egress are among the most significant design issues. For an extremely obese resident who is ambulatory, doorway widths (eg, 34 inches) may make access to areas such as the toilet and shower rooms difficult, if not impossible. This issue is exacerbated when extremely obese residents are being transported in a wheelchair or bed. Because the typical width of a bariatric bed is approximately 41 inches (expanding to 57 inches when the side rails are up) and the average width of a bariatric wheelchair is 39 inches, transporting residents from their rooms to various areas throughout the facility presents a critical challenge.

Public Corridors and Elevator Systems

       Corridors may present unique challenges, especially heavily used corridors cluttered with equipment and corridors with inclines. Facilities should factor in the space needed for transporting a bariatric resident as well as transport personnel, a bariatric wheelchair or bed, and ancillary medical equipment. Facilities should also identify optimum and safe routes for transport.
       Like doorways, elevators also present challenges in long-term care facilities that house extremely obese residents. The recommended minimum dimensions for hospital-type elevators in nursing facilities are five feet four inches wide by eight feet five inches deep.⁵ In addition, the elevator car doors should have a clear opening of not less than three feet eight inches.⁵ No minimum standards exist for hospital or long-term care facility elevator weight capacity, but most elevators have an average rating of 2,000–3,000 pounds. Nursing facilities need to factor the weight of an extremely obese resident, wheelchair or stretcher, transport personnel, and supportive equipment together to make sure the total does not exceed the elevator’s capacity rating. In some facilities, this problem has often forced caregivers to transport extremely obese residents in a service elevator—a situation that can be very embarrassing for the resident and devastating to his or her morale.

Resident Bathrooms

       Resident bathrooms present another challenge. Wall-mounted toilets have inadequate weight capacities for extremely obese residents. The wall-mounted units may be pulled from the walls, posing a high potential for resident injuries. The preferred toilet design for obese residents is a floor-mounted unit, which has a much higher weight capacity than wall-mounted units. While toilets placed during new construction should be floor-mounted, renovating existing space to accommodate floor-mounted toilets is complex. If it is not possible to alter the existing plumbing to accommodate floor-mounted toilets, several types of portable commode chairs designed specifically for obese residents are available. Additionally, toilets should be high enough (about 17–19 inches) to minimize an obese resident’s risk of falling when sitting down or standing up.
       Existing grab bars may also be inadequate for extremely obese residents. AIA/AAH and ADA guidelines both recommend a minimum concentrated load capacity of 250 pounds,⁵ which is insufficient for extremely obese residents. Reinforced grab bars are essential.
       Space in both toilet rooms and showers should be wide enough to allow unrestricted movement of the resident (with or without a wheelchair) to reduce the potential for both resident falls and accidental entrapment. Open space also allows enough room for caregivers to assist extremely obese residents with tasks such as bathing and ambulation.

Furnishings and Supplies

       With regard to furnishings and supplies, a few sturdy, oversized, arm-less chairs could be added to resident rooms as well as in other areas of the facility (eg, recreation/activity areas, resident lounges, and dining halls). In addition to larger beds and chairs, other purchases to consider include gowns, incontinence briefs, commodes, resident scales, resident lifts, wheelchairs and walkers, and blood pressure cuffs. When acquiring and using bariatric equipment, it is important to consider that one size does not fit all. The size and weight capacity of bariatric equipment varies among manufacturers’ models, so it is essential to verify that the weight and size capacity of the equipment are sufficient to meet the needs of an individual resident.
       Facilities should develop a system for identifying a resident who will need oversized equipment during his or her stay as early as possible (eg, upon preadmission visits) so that the resident’s equipment needs can be met as soon as possible. The greater the resident’s BMI, the greater the need for specialized equipment to protect the resident and staff from injury.
       Leasing oversized equipment may be a good option. However, the cost-effectiveness of leasing may be negated as demand increases. Long-term care facilities that lease specialized equipment must be vigilant regarding service contracts with suppliers. Among other things, contracts should address acceptable turnaround time for necessary repairs to or replacement of damaged or malfunctioning equipment. All service contracts should be reviewed by the facility’s legal counsel.

Care Issues Specific to Extremely Obese Residents

       Staff must be aware of the clinical complications that often intensify the care needs of extremely obese residents. Healthcare facilities should ensure that staff who care for these residents receive training on the following facets.^6,7
       Skin care. Extremely obese residents are at increased risk for developing pressure ulcers in areas of the body that staff may not immediately associate with this risk (eg, the sides of the feet and in places where skin folds are deep, such as breast, inguinal, and perineal areas). The presence of deep skin folds also increases a resident’s risk of developing bacterial or fungal infections on the skin and impairs wound healing. Thus, staff must remain vigilant for such complications.
       Airway management. A short, fleshy neck makes endotracheal intubation difficult, and layers of fat over the rib cage can interfere with a caregiver’s ability to detect breath sounds.⁷
       Pulmonary difficulties. Complications such as sleep apnea and airway obstruction are more common in obese residents.⁷ Limited mobility and circulatory insufficiency can increase the risk of pulmonary embolism in extremely obese residents.⁸
       Nutrition. The dietary needs of extremely obese residents must be considered. Although it may seem counterintuitive, residents may be malnourished upon admission because of poor eating habits or a history of strict dieting attempts. Careful monitoring of nutrient levels is required. Obese residents who lack essential minerals and vitamins are more prone to skin breakdown and delayed wound healing, among other complications.
       Medications. Obesity can affect the way a resident responds to certain medications because it can change the absorption, tissue distribution, metabolism, and excretion of drugs.⁹ Staff should consult with the resident’s attending physician if a dosing issue is suspected.⁸
       Intravenous access. Access to the vasculature of obese residents can be compromised because of overlying tissue, development of collateral circulation, and edema. Recommendations for easier intravenous cannulation in obese residents include application of warm compresses to the site before venipuncture, use of a vein transilluminator or bedside ultrasound device to locate deeper veins, and use of a modified angle (30–45 degrees) on approach and/or use of a longer cannula.¹⁰
       Blood pressure assessment. Even in facilities that stock blood pressure cuffs of extra-large size, caregivers may still encounter extremely obese residents who are difficult to fit with a cuff. In such a case, the caregiver should measure blood pressure by using the most appropriately sized cuff on the resident’s extremity it best fits, keeping in mind that accuracy may be compromised. Consistent use of the same extremity for blood pressure measurement is the key to obtaining the most accurate blood pressure information.⁶ The extremity and type of blood pressure cuff should be noted in the care plan.
       Psychological needs. The need for social and psychological support is a key component of care for many extremely obese residents, who often struggle with feelings of depression and anger.⁶

The Importance of Staff Sensitivity

       Unfortunately, overweight and obese persons are frequently the brunt of jokes, taunting, derision, and discrimination in the media and, on a daily basis, in their personal lives. This bias has also been shown to exist in the healthcare environment.
       Staff should be cautioned about being insensitive or careless in discussing the care and treatment of obese residents. Again, respect and concern for the resident as an individual should guide all communication. It is easy for a healthcare worker to pick up the telephone and thoughtlessly call for a lift team for “a 400-pounder.” Staff should be taught to always consider the resident’s feelings, privacy, and what someone overhearing their conversations (eg, other residents, residents’ families, other visitors, and other staff) would think.

Preventing Injuries from Resident Handling and Lifting

       Musculoskeletal back injuries are common among healthcare workers and are recognized as a known occupational hazard. The heavier the resident being moved or turned, the higher the risk of staff injury. Long-term care facilities must provide staff with the mechanical and personnel assistance and ergonomics training necessary to prevent injury from managing extremely obese residents. Reliance simply on the redesign of a task or introduction of new equipment is not only ineffective but can be dangerous and result in increased injuries to residents and staff.
       Staff should be trained to “plan the move,” making sure that all necessary personnel and equipment to move the resident are ready at both the resident’s present location and the intended destination.8 All staff involved in direct resident care must be taught safe lifting techniques, proper body mechanics, and safe operation of each piece of resident-lifting and transfer equipment, with ongoing retraining and reinforcement. Facilities may also want to consider specific policies and procedures for safe resident lifting and transfer, including the use of lift teams specifically trained to handle extremely obese residents. Caregivers should also be encouraged to turn to their colleagues to aid them in handling extremely obese residents.
       Provision of mechanical lifting devices and tools is another important measure to prevent injury. Now available are resident lifts rated to hold up to 1,000 pounds, lateral transport devices to electronically move residents from side to side, and specially designed lifts to move residents from the floor or to a bed or chair. Resident-lifting equipment must be readily available and easy to operate to gain staff acceptance, or else the equipment is likely to go unused.¹¹ Equipment that requires extensive setup or that is stored in an area requiring staff to walk any distance to retrieve it will almost certainly be underutilized. Involving the end user (ie, caregiver) of such equipment in purchase decisions can help facilities select equipment that will have a high level of acceptability among staff.
       Staff must receive appropriate training to operate all the resident lifting and transfer equipment used in a facility. At delivery or installation, many equipment manufacturers offer education and training for facility staff on the safest, most effective way to use the equipment.
       When caregivers are challenged with tasks involving moving or assisting an extremely obese resident, they should remember to partner with the resident, asking, “What works best for you?” or “How has this been done for you in the past?”⁸ This promotes resident involvement and dignity and demonstrates true consideration of the resident’s needs. Conclusion Only by addressing the special needs of obese and extremely obese residents will long-term care facilities be ready for the challenges posed by the nation’s obesity epidemic. The goal must be to create an environment that supports safe, respectful, quality care of residents while maintaining staff safety.