Bariatric Times

SEP 2017

A peer-reviewed, evidence-based journal that promotes clinical development and metabolic insights in total bariatric patient care for the healthcare professional

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13 Review and Case Study Bariatric Times • September 2017 a cting as catalyst to a global awareness that individuals, communities, states, nations, and international organizations have an opportunity to better understand t he complexities of excess weight and weight maldistribution. As groups are seeking ways to meet these challenges, many are recognizing that progressive change o ften begins with a single successful idea or practice that supports a specific process. This idea or practice transforms into a facility, system, national or global b est-practice model. This has happened in the United States in areas such as child abduction (Amber's Law), newborn surrender (Safe Haven Law), and public a ccess to sexual offenders' registration (Megan's Law). CASE STUDY This case study features an e xample of care of bariatric patient care that incorporated a bariatric care team (BCT [Figure 1]). This innovative idea/practice served as a first step toward a generalized facility-wide best practice model for care of the individual with morbid obesity. The patient was a Samoan Maori man who was 29 years old and weighed 320 kg. He lived in Hamilton, New Zealand with his parents and was independently mobile in his home up to 60 feet, and even though he didn't use mobility aids at home he did use stationary furniture to assist in mobility. At time of presentation, he had type 2 diabetes mellitus (T2DM). In May 2015, he was admitted into Waikato Hospital, Hamilton, New Zealand, with a diagnosis of lower leg cellulitis and sepsis associated with Group A streptococcus. His admitting blood pressure was 115/65. He was further diagnosed with rhabdomyolysis, which was thought to be related to laying on the floor before transport to the acute care facility. His immediate treatment included invasive monitoring, local wound treatment, intravenous (IV) fluids, diuretic, and antibiotics. On Day 4, he had developed friction- related blisters on his shoulder and hip. At the time of the patient's first admission, the BCT had not yet been put in place. In-bed repositioning, sitting, standing, and walking were performed per policy; however, the frequency of mobility and activity was a nurse-driven decision. Like many organizations, a plan for addressing the need for additional training or handling equipment was not in place. Neither was criteria to access additional training or equipment, especially size-appropriate equipment. Mobilization was not attempted until Day 8 at which time it was assessed the bed was too high for safe egress, so the physiotherapist f acilitated the provision of a floor based lift/hoist to aid the patient. Delays in access to mobility equipment, combined with the transfer of care from the high d ependency unit to a ward environment resulted in a delay in the first lift/transfer from bed-to- chair, which did not occur until Day 15. He was deemed medically ready for discharge on Day 21 but required an additional 58 days in an in-patient rehabilitation unit to overcome physical deconditioning and immobility. He was discharged home on Day 79. In December 2016, the patient was admitted for a second time. Like many individuals who have endured a prolonged hospitalization, he delayed admission as long as possible. Subsequently, when he was admitted on December 11, 2016, he was much sicker and required far more intense intervention as compared to the May 2015 admission. He was admitted with left lower leg cellulitis, severe septic shock with a blood pressure reading at 60/40, and multisystem failure. Treatment included IV fluid administration, intravenous immunoglobulin (IVIM), and several IV antibiotics. Noradrenalin (norepinephrine) was given for hypotension and shock. Invasive renal support was provided by way of continuous veno-venous hemofiltration, which is a short- term treatment for patients in the intensive care unit (ICU) with kidney dysfunction accompanied by low blood pressure and who are too unstable for standard dialysis therapy. Even though the BCT was in its infancy, team members became involved with the patient's care. The team recognized that his weight and general deconditioning precluded the use of standard hospital procedures. The BCT was contacted to address his mobility as this had been the factor in the extended admission the previous year. On Day 1, the physiotherapist performed a comprehensive evaluation. The evaluation determined that the critical nature of the patient's condition prevented e ven the most basic mobility or activity. On Day 3, it was decided that his condition would allow in- bed activities/exercises, such as passive range of motion and f requent repositioning. An assessment was performed that matched his mobility needs with size- and weight-appropriate handling equipment, such as a walker, bedside commode, and floor-based lift and transfer system. On Day 4, the equipment arrived. Using the equipment, he was able to stand away from the bed, walk 90 feet with a walker, and shower with assistance. Both the nurse and patient agreed that without this specially designed equipment, mobility was unachievable. On Day 5, he was transferred from ICU to the general medical ward where mobility activities continued several times a day. Although he was admitted in far more serious condition, he was discharged home on Day 11. This trend toward early progressive mobility has emerged as a strategy to reduce ICU length of stay, general hospital length of stay, and immobility-related consequences of care among patients without obesity. 4 5 However, large studies have not been done to determine if this approach, and the approach of the BCT herein, have an impact on the care of individuals with morbid obesity. Despite the outcome described in thhis case study, it is important to note that this the case of a single patient case study and does not necessarily prove that all of the success associated with size- appropriate progressive mobility can be attributed to the BCT. Yet, this study suggests there may be a role for pre-planning when addressing complex patients whose weight interferes with delivery of standard practice. MEANING OF PREPLANNING Many of the complexities of bariatric care are left unaddressed because of misunderstandings in terms of clinical differences. Preplanning for care serves to manage common comorbid conditions as well as expedite early a nd ongoing mobility. Both lead to measurable improvement in economic and clinical outcomes (Figure 2). Preplanning for equipment has b een thought to be the first step for intervention. 46 Although this is an important step, it is simply not enough on its own. A comprehensive, interprofessional clinical approach is necessary and should include the following: 1) bariatric task force; 2) a criteria- based protocol, which includes preplanning for size-appropriate care and treatment, including equipment; 3) competencies/skill sets; and 4) outcome measurement efforts. 4 7 A criteria-based protocol is simply a preplanning tool based on specifically designated criteria. This protocol could replicate the processes put in place at the time of the patient's second admission in the case study descirbed. These criteria can include the patient's weight, BMI, body width, mobility level, and/or clinical condition. Actual weight is an important consideration as it pertains to equipment; if the weight limit for equipment is exceeded, then breakage, failure to function properly, or patient/worker injury can occur. Body width is another consideration and is described as the patient's body at its widest point, which could be at the patient's hips, shoulders, or across the belly when side-lying. If the abdominal panniculus displaces the feet and legs laterally, the feet may be the widest point of reference. A third criteria could include the patient's unique clinical condition or any clinical condition that interferes with mobility, such as pain, sedation, fear, or resistance to participate in care. Criteria-based protocols should be designed to meet the needs of the patient by ensuring access to resources, such as special equipment and clinical experts. 48 As part of a preplanning tool, this can be accomplished in a timely, cost-effective manner. Some authors believe the risk of falling and fall-related injury seems to be more related to dynamic, rather than static elements. 34,35 This could be explained by the fact that there is no real reason that people with obesity should encounter a balance disadvantage, as long as the center of gravity remains within the base of support, which is usually the case in a static situation. However, once the center of gravity falls outside of the base of support, recovering balance may become more difficult than for individuals without obesity because of the greater body weight to be moved. 36

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