Weighing the cost of care: How hospitals accommodate obese patients

"It's a struggle for all hospitals. It's something we talk about nearly every day."

Before UK HealthCare in Lexington started construction on a new patient tower at the University of Kentucky Albert B. Chandler Hospital, the health system took careful effort to ensure the new facility could accommodate the needs of its patients, said Bo Cofield, DrPH, vice president and chief clinical operations officer of UK HealthCare. With Kentucky ranking as the 12th most obese state in the U.S. with a 2014 adult obesity rate of 31.6 percent, those needs require bariatric accommodations.

The 12-story pavilion, which officially opened in May 2011, has five patient floors in operation with 320 inpatient beds, along with an emergency department, surgery and operating suites, and three additional patient floors either in planning or construction phases. Every patient room is the same size and design, and each contains a ceiling-mounted lift, some of which extend into bathrooms to assist with patient transfers. Patients and family members will also find wider bariatric chairs in waiting areas throughout the facility. For equipment, UK HealthCare buys the highest rated tables its manufacturer can supply in terms of weight, in addition to larger stretchers, wider wheelchairs and CT and MRI machines with bigger entryways, said Dr. Cofield.

UK Healthcare is not alone in its effort to expand access to treatment for obese patients. "It's a struggle for all hospitals," Dr. Cofield said. "It's something we talk about nearly everyday."

There's no question America is in the midst of an obesity epidemic ­— more than 78 million people in the U.S., or about one in three adults, are obese, according to the CDC. In 2013, the American Medical Association officially designated obesity as a disease, and as of 2008, the estimated annual medical cost of obesity was $147 billion, according to the CDC.

To support an increasingly heavy patient population, hospitals across the country are making structural changes and buying new equipment to accommodate bariatric patients and their family members.

"It's really ramped up in the last 10 years or so. Every facility has to address [obesity] now because it's so incredibly common," said Joan Suchomel, AIA, president of the American Institute of Architects Academy of Architecture for Health, who holds 30 years of experience in healthcare planning and design. "It's part of doing business. [Obese] patients are going to show up, and you have to be ready for them."

While early approaches to bariatric design focused solely on patient rooms and bathrooms, health systems are now considering a patient's entire experience at the hospital from start to finish. Every doorway and hallway along a patient's path throughout the hospital must be wide enough to accommodate the patient, along with wider wheelchairs and larger hospital beds.

Most hospital equipment accommodates patients of 300 pounds or less, said Don Selzer, MD, a general and bariatric surgeon at Indiana University Health in Indianapolis. For anyone heavier, different equipment, room features and direct patient care items — like hospital gowns or blood pressure cuffs — are necessary.

"We have purchased two additional scales at our [bariatric surgery] office to accommodate obese patients," said Dr. Selzer. The standing scale, purchased 12 years ago, can hold patients up to 800 pounds and cost almost $1,000. The second scale, used to weigh patients in wheelchairs, cost approximately $3,500 and is five years old. A typical hospital scale costs about $150.

Most hospitals today have CT scanners that can accommodate patients up to 450 pounds, with some offering machines rated up to 650 pounds with an 85 centimeter opening — although these are less common, said Dr. Selzer. Since a large majority of hospitals in the U.S. have taken actions to accommodate obese patients, "it's less common to transfer patients to a different hospital because of their weight, with the exception of patients with exceptionally high body mass index values," he said.

While direct patient care equipment for obese patients is crucial, accommodations must be considered for patients and family alike. "When you have a bariatric patient, there's a good chance their family members are obese," said Ms. Suchomel.

In general waiting areas, 10-20 percent of seating should be offered in bariatric sizes for patients and their family members. That number goes up to 50 percent for cardiac and bariatric units, according to AIA guidelines. Normal waiting room chairs are about 20 inches wide and cost $50 to $200. Bariatric chairs measure about 30-40 inches wide and contain arms to offer easier movement, according to Ms. Suchomel. They usually cost anywhere from $200 to $1,000.

"The core goal of bariatric care revolves around maintaining patient dignity," said Ms. Suchomel. Bariatric waiting room chairs are designed to look like love-seat versions of pre-existing chairs and scattered throughout the room to avoid the creation of "obesity-only" sections. Every renovation, retrofit and equipment accommodation aims to prevent a bariatric patient from feeling marginalized or treated differently because of their condition, said Suchomel.

An inpatient room for bariatric patients also entails specific requirements, outlined by the Facility Guidelines Institute, a nonprofit organization that offers guidance on the planning, design, and construction of medical facilities in the U.S. A typical hospital bed, which usually costs up to $2,000, is about 35.5 inches wide and requires three feet of open space on all sides. A bariatric bed, ranging in price from $2,000 to $5,000, can expand to 40 or 50 inches wide and needs five feet of open space. A normal doorway has a 45.5 inch opening, which can prove difficult for fitting a larger bariatric bed through. At VA hospitals, all bariatric rooms have doors with double leafs that can open up to make more room for patients and equipment, said Ms. Suchomel.

Patient bathrooms usually contain a wall-mounted toilet that makes it easier for hospital staff to clean underneath. However, these have a tendency to break off the wall if bearing excessive weight, so bariatric rooms are typically equipped with floor mounted toilets, some of which withstand up to 1,000 pounds, said Ms. Suchomel, although some wall mounted toilets do exist for heavier patients. To retrofit a bathroom for obese patients, a post must be installed under the toilet to provide extra support. Showers include larger grab bars and a hand-held showerhead so staff can help patients bathe, if need be.

"Probably the biggest decision surrounding bariatric accommodation is the type and amount of lifts hospitals should install," said Ms. Suchomel. The first question to answer when discussing lifts is portable or ceiling? Portable lifts require 7 by 10.5 feet of space to operate, costing less than $500 for a manual lift and at least $2,000 for motorized portable lifts. Permanent ceiling lifts only need 5 by 10.5 feet, yet cost upwards of $5,000.

While some hospitals hesitate to buy the costlier ceiling lifts, they can save valuable square footage in the construction of new bariatric rooms. If hospitals are looking to retrofit a room to accommodate obese patients, the process is more difficult and costly, says Ms. Suchomel. To install a permanent lift, the room's ceiling must be taken out and rebuilt to include the equipment.

Nurses lift approximately 1.8 tons during an eight hour shift and 52 percent of them complain about chronic back pain. Since patients are getting heavier and heavier, lifts are more important than ever. Oakland, Calif.-based Kaiser Permanente recently completed a project that put lifts in every single patient room in the intensive care units at all of its 381 hospital locations, said Ms. Suchomel.

While both retrofitting and construction can rack up a hefty price tag, Ms. Suchomel said strategies exist to navigate a tight budget. For example, transverse lifts on rails can be installed in rooms, and the motors used to power them can be moved from room to room as necessary to save money by not purchasing all the motors all at once.


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