**[Special Handling and Movement Challenges Related to
Bariatrics]{.smallcaps}**

-   **Objectives:**

1)  To understand what technological solutions are commercially
    available in the use of patient handling for bariatric patients

2)  To identify when to use specialized patient handling technology

3)  To understand how to implement the algorithms in equipment selection
    when caring for bariatric patients

4)  To list important features of a bariatric policy

5)  To list four factors affecting the decision to buy versus rent
    bariatric equipment

    List of Abbreviations:

    EC = expanded capacity

    BMI[^1] = Body mass index \[patient weight (kg)/ by height squared
    (m^2^)\]

    EMS = Emergency Management Services

    ICU = Intensive Care Unit

These guidelines were designed to offer various technological solutions
that can greatly assist in the care of obese patients, also called
bariatric patients. Weight, combined with atypical body mass,
contributes to an increased risk of injury to the caregiver and patient
during patient handling and movement tasks. It is evident that there is
a lack of knowledge across the healthcare environment about how to
safely manage the unique needs of bariatric patients. Managing obese
patients provides special challenges to healthcare professionals, e.g.,
turning and repositioning a patient in bed, transferring in/out of bed,
holding a limb while performing patient care tasks, and other activities
of daily living. Additionally, environmental concerns, such as doorway
clearance, weight capacity of scales, etc., must be addressed.

-   **Defining Obesity**

Defining the term "bariatric" poses a challenge, as there are many
classification systems. Internationally, bariatrics is defined as a body
mass index (BMI) greater than 30. The BMI is calculated by dividing
patient weight (kg) by height squared (m^2^).[^2] This classification
system is internationally accepted:

**Table 1. Definition of Bariatrics by BMI**

+-----------------------------------------------+-----------------------+
| #### International Standards                  | #### BMI              |
+-----------------------------------------------+-----------------------+
| Underweight                                   | \<18.5                |
+-----------------------------------------------+-----------------------+
| Normal                                        | 18.5-24.9             |
+-----------------------------------------------+-----------------------+
| Overweight                                    | 25-29.9               |
+-----------------------------------------------+-----------------------+
| Obese (1)                                     | 30-34.9               |
+-----------------------------------------------+-----------------------+
| Obese (2)                                     | 35-39.9               |
+-----------------------------------------------+-----------------------+
| Obese (3)                                     | \>40                  |
+-----------------------------------------------+-----------------------+

For our purposes, we have defined a bariatric patient as anyone who has
limitations in health due to physical size, health, mobility and
environmental access (Bushard, 2002). For the purpose of using our
assessment form and bariatric algorithms, we defined bariatric as
individuals exceeding standard capacity equipment (300 lbs) with a BMI
of 50.

Most standard equipment is rated to approximately 250-300 lbs and any
individual who exceeds this capacity is a candidate for using
specialized equipment. One method of assisting in the selection of
equipment while caring for a bariatric person is to use an assessment
form which guides the use of bariatric algorithms. This is a
standardized tool and will only work provided the included equipment is
procured. Prior to using these algorithms is the completion of the
assessment form which captures important information about the patient
(Refer to Appendix A: Assessment form).

-   **Bariatric Algorithms**

    This section provides assessment criteria to assist healthcare
    providers in planning the safe handling and movement of bariatric
    patients. The following algorithms should be used as guides when
    planning patient transfer and repositioning tasks. These algorithms
    are targeted for registered nurses, licensed practical nurses,
    nursing assistants, orderlies, physical/ occupational therapists,
    radiology technicians, patient care technicians, as well as
    caregivers in the home.

The algorithms are designed to assist healthcare caregivers in selecting
the safest equipment and techniques based on specific patient
characteristics. These guidelines are prepared based on the scientific
and professional information available in January 2003. We recommend
that users of this guideline periodically review the material to ensure
guidelines are consistent with current, reasonable clinical practice. As
with any guideline, this content provides general direction, and
professional judgment is needed to assure safety of patients and
caregivers.

Refer Appendix B for Algorithms

-   **Bariatric Algorithm #1:**\
    Bariatric Transfer to and from: Bed to Chair, Chair to Toilet, or
    Chair to Chair

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```
-   **Bariatric Algorithm #2:**\
    Bariatric Lateral Transfer to and from: Bed to Stretcher or Trolley

-   **Bariatric Algorithm #3:**\
    Bariatric Reposition in Bed: Side-to-Side, Up in Bed

-   **Bariatric Algorithm #4:**\
    Bariatric Reposition in Chair: Wheelchair, Chair, or Dependency
    Chair

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```
-   **Bariatric Algorithm #5:**\
    Patient Handling Tasks Requiring Sustained Holding of a Limb to
    Access Body Parts

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-   **Bariatric Algorithm #6:**\
    Bariatric Transporting (Stretcher, Wheelchair, Walker)

-   **Bariatric Algorithm #7:\
    **Bariatric Toileting Tasks

Let's discuss a case study using Algorithm #4 to practice.

Mrs. Smith needs to be repositioned in a chair. The first question asked
should be whether she can assist fully or partially. If Mrs. Smith is
capable of partially assisting, then the next question is whether she is
cooperative. If she is fully cooperative, then use either a bariatric
ceiling lift with seated sling, floor based lift, repositioning device
or friction reducing device with two caregivers. If Mrs. Smith is not
fully cooperative, then she should use the same equipment options
mentioned but three caregivers should assist for safety.

**Figure 1.** Bariatric Algorithm 4

![](media/image1.wmf){width="6.497222222222222in"
height="8.413194444444445in"}

-   **Bariatric Equipment**

There is a common misconception that bariatric patients can be
accommodated by simply asking for equipment designed for a "large size."
Most of the attention focuses on a bed and lift to accommodate the
patient. In fact, there are many aspects related to equipment that need
to be considered. Knowing the weight capacity of existing equipment is
critical for safety. Bariatric equipment may be indicated by using a
label indicating "EC" (expanded capacity) and weight limits. In addition
to patient handling/movement equipment, the weight capacity of bedside
recliner chairs or toilets must be considered. A standard commode, in
most hospitals, is limited to 350 pounds. Key categories of equipment
that need to be evaluated and available for bariatric patients are
outlined below. A checklist may be useful in evaluating your need of
equipment (refer to Appendix C: Safety Checklist).

-   **Bariatric Equipment Options**

These guidelines provide information on existing bariatric technologies
and manufacturers. However, they do not include bariatric accessories
(such as blood pressure cuffs, scales, surgical tables, linen/gowns, and
abdominal binders). Refer to the website for a complete listing of
equipment. This section will highlight a few new technologies and
explain how they can be helpful in caring for the obese patient.

The following categories of equipment are included in the website:
www.patientsafetycenter.com

-   Ambulation/Mobility Aids

-   Bathing Equipment

-   Beds/Mattresses/Transportation

-   Ceiling Lifts

-   Commode/Shower Chairs

-   Lateral Transfer Aids

-   Multi-Use/Portable Lifts

-   Powered Lifts

-   Stand Assist Aids

-   Transfer/Geri Chairs and Cushions

-   Wheelchairs

-   Transport Devices

Three types of equipment that may prove beneficial in saving time and
reducing caregiver injury are specialized bariatric bed systems, patient
transport devices and bariatric turning and repositioning slings.

**Bed Systems**

New beds are designed to multi-task and accommodate larger weight
capacities up to 1000 lbs. Special features offered are turn assist up
to 20 degrees to aid in patient positioning, percussion therapy,
pulsating air suspension therapy, pressure relief therapy and cardiac
chair positioning. Along with newly designed bed frames, low air loss
mattresses greatly assist in the prevention of pressure sores and
improve patient outcomes, comfort and safety.

An example of such a bed is shown below:

![](media/image2.jpeg){width="2.0833333333333335in"
height="1.6666666666666667in"}

**Figure 2.** Bariatric Bed

**Patient Transport Devices**

There are two types of patient transport technologies available. The
first type is a stand alone, detachable or independent device which
attaches to either a bed, linen cart or trolley. It works by two
batteries which power the unit to propel the device forward or backward
by operating a lever, similar to that of a scooter. Battery life ranges
and is dependent on usage time. Many of these devices can be found in
our Technology Resource Guide for Bariatric Patients (found in this
toolkit).

The second type of transport technology is one which is built into the
bed and powers it by simply pressing two buttons, unplugging the bed and
releasing the brakes. There is minimal force exerted to initiate
movement of the bed. Use of powered transport devices such as bed and
wheelchair movers and powered stretchers is becoming a popular choice as
it reduces the risk of caregiver injury by reducing the push/pull forces
involved, making patient transport a safer task for caregivers. This is
especially important in bariatric patient care where the mass of the
patient, in addition to the weight of the bed is excessive, thus
demanding higher push or pull forces during patient transport.

![](media/image3.wmf){width="3.3055555555555554in"
height="2.0555555555555554in"}![](media/image4.jpeg){width="1.417361111111111in"
height="1.9159722222222222in"}

**Figure 3.** Wheelchair mover **Figure 4.** Bed with Integrated Power

![](media/image5.jpeg){width="1.7777777777777777in"
height="1.8743055555555554in"}

**Figure 5.** Independent Bed Mover

**Turning and Repositioning Slings**

> Two tasks which prove very challenging and place caregivers at a high
> risk for injury include insertion of patient care slings under
> bariatric patients and repositioning a patient up in bed or turning to
> the side. Currently, manufacturers are working on designing slings
> that can be left under patients who have to be moved frequently. The
> advantages to this would be less strain on the caregivers to turn the
> patient to the side or log roll them to insert the sling, less time
> taken to perform the task of repositioning because the sling would
> already be there and most important, less risk and exposure to injury.
> Although there is no evidence or literature on leaving slings under
> patients and patient outcomes, this decision should be carefully
> weighed. Questions for consideration could be:

1)  Is the patients' skin compromised?

2)  How breathable is the sling?

3)  Does the sling present rough uneven edges which can cause pressure
    points if left underneath?

4)  Can the sling be left under the sheet and tucked into mattress when
    not in use?

> Leaving a sling under a bariatric patient can be advantageous to
> caregiver safety but may be detrimental to the patient and clinical
> judgment should be used to determine the safest course of action. More
> research needs to be done in this area.

-   **Helpful Hints in Selecting Bariatric Equipment**

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-   Empower staff nurses to lease or procure necessary equipment as soon
    as possible either prior to or immediately after patient admission.
    This option needs to be available twenty-four hours a day/ seven
    days a week. Delays in accessing appropriate equipment could result
    in patient discomfort and serious injury to the patient or
    caregiver. For units with bariatric patient services, equipment may
    be purchased; for others, leasing may be a better option.

-   Contact vendors that offer bariatric equipment (a list of vendors is
    in the Technology Resource Guide for Bariatric Patients provided in
    this toolkit).

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-   Know and mark weight capacities on existing equipment to assure
    appropriate use. This should be done in an unobtrusive manner, such
    as delineating "expanded capacity." This protects the dignity of the
    patient. Use of terms such as "big boy beds" or the "lift for huge
    people" provide unnecessary dignity assaults to the patient and
    their family.

-   Body dimension is critical for determining the bed width needed.
    Patients experience discomfort and increased risk for skin lesions
    when the bed is too *narrow.* Staff injuries increase when the bed
    is too *wide*, necessitating staff to reach excessively when
    providing patient care. Several bariatric beds have the capability
    to contract to allow the bed to go through a doorframe. Appropriate
    width beds also make it easier for the patient to assist in their
    own care. Height can also be a key factor in selecting a bed. If the
    patient's height exceeds 6'5", a longer-than-usual-bed will be
    required for comfort and skin protection.

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-   The right equipment can facilitate patient function and independence
    and eliminate some high-risk nursing tasks.

-   Position equipment at a height appropriate to the caregiver when
    providing care.

-   Consider motorized transportation assistance devices.

-   Consider dimensions of elevator doors and size of equipment.

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-   **Decision to Buy or Rent Bariatric Equipment**

> Specialized equipment is required to move, transport, and care for the
> bariatric patient. As facilities deal with bariatric patients on a
> more frequent basis, determinations about how to acquire the necessary
> equipment will be a common task for many caregivers. Each facility
> will need to decide whether to purchase or rent necessary equipment.
> The following are factors that may be considered when purchasing or
> renting bariatric equipment:

1.  Number and frequency of bariatric admissions

2.  Equipment purchase cost

3.  Rental cost

4.  Space demands: including fit through doorways/hallways, etc.

5.  Patient care needs: bedroom, bathroom

6.  Equipment storage needs

7.  Length of stay

8.  Equipment cleaning and maintenance needs

**Summary**

With the increase in bariatric patients and comorbidities, there is an
apparent need for a proactive approach to caring for such a population
with special needs. As caregivers are working longer at an older age,
their exposure rate increases in caring for these patients, which
translates into an increased risk of injury. Implementing an admission
process, a bariatric policy educating staff on how to care for bariatric
patients in a sensitive way prior to admission will benefit both
caregiver and patient safety (refer to Policy Template, Appendix D).
Procuring the proper equipment and fostering a culture of safety is key
to maintaining a positive environment for caring of bariatric patients.

Staff needs to be knowledgeable of available technology that could
greatly assist in patient care. This can be achieved via a bariatric
resource person who communicates with vendors of bariatric technology
and conducts equipment trials for staff to trial assistive devices.
Inservices and just in time training must be conducted to ensure all
staff is proficient with proper use of technology in patient care (refer
to Bariatric CD online). Promotion of dignified care can be accomplished
by using generic terms on equipment to indicate "use for patients
exceeding regular capacity. This could be indicated by using "EC" which
would mean "expanded capacity" on equipment.

Use of algorithms can assist in the decision making process as to type
of equipment used and the number of caregivers required to safely
transfer patients. It should be noted that although these provide
general direction, clinical and professional judgment should be used to
assure patient and staff safety.

Information provided in this chapter, although useful, may not be
adequate in assisting caregivers decision making in real life
situations. To better assist application and translation of the
information, a case scenario is presented and questions for
consideration are offered.

**[Case Scenarios:]{.underline}**

1)  Mr. Jones is 550 lbs and is unable to weight bear at all. He needs
    to go to X-Ray and currently is in Intensive Care Unit (ICU). Which
    method would be most efficient and safe to accomplish this task?

    a.  Transfer Mr. Jones with an air-assisted lateral transfer device
        to a stretcher and manually push the stretcher to X-Ray
        department

    b.  Transfer Mr. Jones to a converta chair and push the chair to
        X-Ray department

    c.  Leave Mr. Jones in the bed and use the powered feature of the
        bed to transport him

    d.  Use a sit to stand lift and transfer Mr. Jones to an expanded
        capacity wheelchair

Let's discuss each of these options.

**First Option:** Use an air assisted lateral transfer device and
stretcher.

> **Questions that you may want to consider are the following:**

1)  How difficult is it to insert the lateral transfer aid under Mr.
    Jones?

2)  Is Mr. Jones able to turn to his side to assist in inserting the
    device?

3)  Is the air assisted lateral transfer device wide enough to use for
    Mr. Jones?

4)  Can the stretcher safely support 550lbs?

5)  How many caregivers will it take to push Mr. Jones on the stretcher,
    assuming it can support 550 lbs ?

> 6\) Can the X-Ray be taken while he is on the stretcher or will
> another transfer have to be done in X-Ray?

**Second Option:** Transferring Mr. Jones to a converta chair, and then
manually push the chair to transport him to X-Ray

> **Questions that you may want to consider are the following:**

1)  What equipment and method will be used to transfer Mr. Jones to a
    converta chair-ceiling lift, floor based lift or lateral transfer
    aid ? How will you insert the sling if using a lift?

2)  Is Mr. Jones able to turn to his side to assist in inserting the
    device?

3)  Is the air assisted lateral transfer device wide enough to use for
    Mr. Jones?

4)  The converta chair provides a flat surface for the transfer then can
    be changed into a seated position for transport. A seated posture
    may be preferable for Mr. Jones especially if he has breathing
    difficulty.

5)  How many caregivers will it take to push Mr. Jones on the chair
    assuming it can support 550 lbs ? Is it easier to push this chair or
    push a stretcher?

6)  Can the X-Ray be taken while he is on the converta chair or will
    another transfer have to be done in X-Ray?

**Third Option:** Leave Mr. Jones in the bed and use the powered feature
of the bed for transport.

> **Questions that you may want to consider are the following:**

1)  Is a powered transport device available?

2)  If the bed that Mr. Jones is using has a powered feature built in,
    what is involved in activating this feature?

3)  Is Mr. Jones cooperative?

4)  Is Mr. Jones lying on a low air loss mattress?

5)  By unplugging the bed to transport him, does this deflate the low
    air loss mattress and negate the pressure relief features?

6)  How much force is required to use powered bed versus push the
    occupied converta chair or stretcher?

7)  How many caregivers are needed to push/steer bed?

8)  On arrival to X-Ray, can the X-Ray be done while Mr. Jones is in bed
    or is a transfer required?

**Fourth Option:** Use a sit to stand lift and transfer Mr. Jones to an
expanded capacity wheelchair

> **Questions that you may want to consider are the following:**

1)  Can Mr. Jones use a sit-stand lift?

-   No he cannot weight bear, therefore this is not an option

**Task Analysis:**

The decision as to which option you choose should be based on many
factors, such as resources available in the facility (in-house and
rental equipment), recruitment of caregivers, medical stability and
sitting tolerance of the patient, weight capacity of equipment, route
from bedroom to X-Ray department, size of elevator/doors, flooring
(carpet vs tile), but most importantly, how much force is required for
the caregiver to perform the essential tasks. Some of the transfers can
be eliminated which reduces the stress on the caregivers and elimination
of non-essential transfers should be the first option when possible.
Essential tasks should be given first priority from non-essential tasks
as this can minimize effort exerted, thus reducing exposure to risk of
injury.

**Directions for the Future:**

While caregivers are learning to depend more on expanded capacity
equipment to move and transfer bariatric patients, there are many areas
which need further research and evaluation.

Getting a patient out of a car and transport from the home to ambulance
remains a high risk activity for EMS workers. Options for migration
currently include sliding boards, air assisted devices or car lifts,
similar to that of floor based lifts. Sliding boards used for bariatric
patients do not typically work well due to the high friction caused from
the excessive mass of the patient. Therefore, there needs to be better
technological solutions available to minimize the friction between the
patient and device. Use of friction reducing devices in conjunction with
slide boards may prove useful.

Another challenging task for caregivers is getting a bariatric patient
up off the floor.

One product that may assist is called the ELK, which is an air bladder.
It is inserted under the patient, then inflated to raise the patient up
(see Figure 6). Two air bladders can be used with a sliding board to
maintain the patient in a supine position if necessary or one air
bladder should be used if patients' balance and sitting tolerance is
satisfactory.

![](media/image6.jpeg){width="1.1388888888888888in"
height="1.7083333333333333in"}

**Figure 6.** ELK/Patient Booster

**Related Links**

There are many useful tools that can be found on our website. To acquire
these, simply go to http://www.visn8.med.va.gov/patientsafetycenter/,
click on the resource guide link, then choose the guide of your choice.
The following reference items may be used to assist in the safe care of
bariatric patients:

1)  Assessment Form & Bariatric Algorithms

2)  Educational CD

3)  Admission Process

4)  Policy Template

5)  Bariatric Safety Equipment Checklist

6)  Reference List

**REFERENCES:**

1.  Bushard, S. (2002). Trauma in patients who are morbidly obese. AORN
    Journal, 76, 585-589.

2.  Nelson, A. (1996). Identification of patient handling tasks that
    contribute to musculoskeletal injuries in SCI nursing practice.
    JAHVAH Study.

3.  Nelson, A., Gross, C., & Lloyd, J. (1997). Preventing
    musculoskeletal injuries in nurses: Directions for future research.
    [SCI Journal]{.underline}, [14]{.underline}(2), 45-52.

4.  Royal Wolverhampton Hospitals NHS Trust. (1996). Health and safety:
    Manual handling. Policy ref: HS 11.

5.  United Kingdom Health and Safety Executive. (1992). Manual handling
    operations regulations.

6.  Veterans Health Administration and Department of Defense, Patient
    Safety center of Inquiry, Tampa, Florida. Patient Care Ergonomics
    Resource Guide: Safe Patient Handling & Movement (2001).
    Accessibility verified 5/3/05 from
    [www.patientsafetycenter.com](http://www.patientsafetycenter.com/).

7.  Barr, J., and Cunneen, J., 2001, "Understanding the Bariatric Client
    and Providing a Safe Hospital Environment," *Clinical Nurse
    Specialist*, Vol .15 No.5.

8.  *Merriam Webster New Collegiate Dictionary*. 1999. Springfield,
    Massachusetts: G. & C. Merriam.

9.  Allison, D.B., and Saunders, S.E.. 2000. "Obesity in North America:
    An overview."

10. Medical Clinics of North America, 84(2), 305-332.

11. Centers for Disease Control (CDC), 2002. "Fact Sheet on Obesity In
    1999 Among American Adults."
    [[www.cdc.gov/nccdphp/dnpa/press/archive/obesity]{.underline}](http://www.cdc.gov/nccdphp/dnpa/press/archive/obesity).

12. Youngkin, E.Q.; Sawin, K.J.; Kissinger, J.F.; Israel, D.S. 1999.
    "Pharmacotherapeutics: A Primary Care Clinical Guide." Stanford,
    Connecticut: Appleton & Lange, 731-746.

13. Must, A.; Spadano, J.; Coakley, E.H.; et al. 1999. "The Diagnostic
    Burden Associated With Overweight and Obesity." *Journal of the
    American Medical Association*, 282, 1523.

14. Kuczmarski, R., and Flegal, K. 2000. "Criteria for Definition of
    Overweight in Transition: Background and Recommendations for the
    United States*.*" *American Journal of Clinical Nutrition*,
    72:1074-81.

**Appendix A.** Assessment Criteria and Care Plan for Safe Patient
Handling and Movement

**I. Patient's Level of Assistance:**

> \_\_\_\_\_ Independent--- Patient performs task safely, with or
> without staff assistance, with or without assistive devices.
>
> \_\_\_\_\_ Partial Assist---Patient requires no more help than
> stand-by, cueing, or coaxing, or caregiver is required to lift no more
> than 35 lbs. of
>
> a patient's weight.
>
> \_\_\_\_\_ Dependent---Patient requires nurse to lift more than 35
> lbs. of the patient's weight, or is unpredictable in the amount of
> assistance
>
> offered. In this case assistive devices should be used.

*An assessment should be made prior to each task if the patient has
varying level of ability to assist due to medical reasons, fatigue,
medications, etc. When in doubt, assume the patient cannot assist with
the transfer/repositioning.*

**II. Weight Bearing Capability III. Bi-Lateral Upper Extremity
Strength**

\_\_\_\_\_ Full \_\_\_\_\_ Yes

\_\_\_\_\_ Partial \_\_\_\_\_ No

\_\_\_\_\_ None

**IV. Patient's level of cooperation and comprehension:**

> \_\_\_\_\_ Cooperative --- may need prompting; able to follow simple
> commands.
>
> \_\_\_\_\_ Unpredictable or varies (patient whose behavior changes
> frequently should be considered as "unpredictable"), not cooperative,
> or
>
> unable to follow simple commands.

**V. Weight: \_\_\_\_\_\_\_\_\_ Height: \_\_\_\_\_\_\_\_\_\_\_**

**Body Mass Index (BMI) \[needed if patient's weight is over
300\]¹:\_\_\_\_\_\_\_\_\_\_\_**

***If BMI exceeds 50, institute Bariatric Algorithms***

*The presence of the following conditions are likely to affect the
transfer/repositioning process and should be considered when identifying
equipment and technique needed to move the patient.*

**VI. Check applicable conditions likely to affect
transfer/repositioning techniques.**

\_\_\_\_\_ Hip/Knee Replacements \_\_\_\_\_ Respiratory/Cardiac
Compromise \_\_\_\_\_ Fractures

\_\_\_\_\_ History of Falls \_\_\_\_\_ Wounds Affecting
Transfer/Positioning \_\_\_\_\_ Splints/Traction

\_\_\_\_\_ Paralysis/Paresis \_\_\_\_\_ Amputation \_\_\_\_\_ Severe
Osteoporosis

\_\_\_\_\_ Unstable Spine \_\_\_\_\_ Urinary/Fecal Stoma \_\_\_\_\_
Severe Pain/Discomfort

\_\_\_\_\_ Severe Edema \_\_\_\_\_ Contractures/Spasms \_\_\_\_\_
Postural Hypotension

\_\_\_\_\_ Very Fragile Skin \_\_\_\_\_ Tubes (IV, Chest, etc.)

**Comments:\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_**

  --------------- ----------------------------------------------- -------------- ---------
  **VII. Care                                                                    
  Plan:**                                                                        

  **Algorithm**   **Task**                                        **Equipment/   **\#
                                                                  Assistive      Staff**
                                                                  Device**       

  **1**           Transfer To and From: Bed to Chair, Chair To                   
                  Toilet, Chair to Chair, or Car to Chair                        

  **2**           Lateral Transfer To and From: Bed to Stretcher,                
                  Trolley                                                        

  **3**           Transfer To and From: Chair to Stretcher, or                   
                  Chair to Exam Table                                            

  **4**           Reposition in Bed: Side-to-Side, Up in Bed                     

  **5**           Reposition in Chair: Wheelchair and Dependency                 
                  Chair                                                          

  **6**           Transfer Patient Up from the Floor                             

  **Bariatric 1** Bariatric Transfer To and From: Bed to Chair,                  
                  Chair to Toilet, or Chair to Chair                             

  **Bariatric 2** Bariatric Lateral Transfer To and From: Bed to                 
                  Stretcher or Trolley                                           

  **Bariatric 3** Bariatric Reposition in Bed: Side-to-Side, Up                  
                  in Bed                                                         

  **Bariatric 4** Bariatric Reposition in Chair: Wheelchair,                     
                  Chair or Dependency Chair                                      

  **Bariatric 5** Patient Handling Tasks Requiring Access to Body                
                  Parts (Limb, Abdominal Mass, Gluteal Area)                     

  **Bariatric 6** Bariatric Transporting (Stretcher)                             

  **Bariatric 7** Bariatric Toileting Tasks                                      
  --------------- ----------------------------------------------- -------------- ---------

**Sling Type:** Seated\_\_\_\_\_ Seated (Amputation)\_\_\_\_\_
Standing\_\_\_\_\_ Supine\_\_\_\_\_ Ambulation\_\_\_\_\_ Limb
Support\_\_\_\_\_

**Sling Size:** \_\_\_\_\_\_\_\_\_\_\_\_\_

**Signature:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Date: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_**

If patient's weight is over 300 pounds, the BMI is needed. For Online
BMI table and calculator see:
<http://www.nhlbi.nih.gov/guidelines/obesity/bmi_tbl.htm>

**Appendix B.** Bariatric Algorithms

![](media/image7.wmf){width="6.502777777777778in"
height="8.752777777777778in"}

![](media/image8.wmf){width="6.496527777777778in"
height="8.397916666666667in"}

![](media/image9.wmf){width="6.501388888888889in"
height="8.689583333333333in"}

![](media/image1.wmf){width="6.497222222222222in"
height="8.413194444444445in"}

![](media/image10.wmf){width="6.497916666666667in" height="7.5125in"}

**Appendix C.** Bariatric Equipment Safety Checklist

**HOSPITAL BED**

-   Weight limit \_\_\_\_\_\_ lbs.

-   Side rail support \_\_\_\_\_\_ lbs.

-   Bed Scale?\
    Yes \_\_\_\_ if yes, weight limit \_\_\_\_ lbs.\
    No \_\_\_\_

-   Width of bed \_\_\_\_\_\_ inches.

-   Bed adjustable for patient height?\
    Yes\_\_\_\_ No\_\_\_\_

-   Mattress type:\
    Pressure relief\_\_\_\_\
    Pressure reduction \_\_\_\_ Alternating\_\_\_\_\
    Rotational \_\_\_\_

-   Other\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**WHEELCHAIR**

-   Weight limit \_\_\_\_ lbs.

-   Width \_\_\_\_ inches

-   Seat height \_\_\_\_ inches

-   Handle width \_\_\_\_ inches

-   Powered? Yes \_\_\_\_ No \_\_\_\_

**STRETCHER**

-   Weight limit \_\_\_\_ lbs.

-   Width \_\_\_\_ inches

-   Length \_\_\_\_ inches

-   Side rail support \_\_\_\_ lbs.

-   Powered? Yes \_\_\_\_ No \_\_\_\_

**BEDSIDE COMMODE/SHOWER CHAIR**

-   Weight limit \_\_\_\_ lbs.

-   Seat width \_\_\_\_ inches

-   Adjustable height? Yes \_\_\_\_ No \_\_\_\_

**SCALES**

-   Weight limit \_\_\_\_ lbs.

-   Width \_\_\_\_ inches

**WALKER**

-   Weight limit \_\_\_\_ lbs.

-   Width \_\_\_\_ inches

**BATHROOM**

-   Doorframe width \_\_\_\_ inches

-   Shower door width \_\_\_\_ inches

-   Toilet weight bearing limit \_\_\_\_ lbs.

-   Wall mounted grab bars\
    weight limit \_\_\_\_ lbs.

**PATIENT CARE ENVIRONMENT**

-   Patient care weight limit \_\_\_\_ lbs. (basic seating chair not
    Geri/Cardiac chair)

-   Patient chair width \_\_\_\_ inches

-   Geri/Cardiac chair weight limit \_\_\_\_ lbs.

-   Geri/Cardiac chair width \_\_\_\_ inches

-   Geri/Cardiac seat height \_\_\_\_ inches

-   Step stool weight limit \_\_\_\_ lbs.

**TRANSFER DEVICES**

-   Lateral transfer devices weight limit \_\_\_\_ lbs.

-   Lateral transfer devices width \_\_\_ inches

-   Powered? Yes \_\_\_\_ No \_\_\_\_

-   Full Body (sling) weight limit \_\_\_\_ lbs.

-   Powered? Yes \_\_\_\_ No. \_\_\_\_

-   Full Body (sling) goes to the floor? Yes\_\_\_ No \_\_\_

-   Sit to stand devices weight limit \_\_\_ lbs/

-   Sit to stand devices width \_\_\_\_ inches

-   Powered? Yes. \_\_\_\_ No. \_\_\_\_

**ANCILLARY DEPARTMENTS**

-   Door widths \_\_\_\_ inches

-   X-ray table weight limit \_\_\_\_ lbs.\
    width \_\_\_\_ inches

-   CT Scan weight limit \_\_\_\_ lbs,\
    width \_\_\_\_ inches

-   OR table limit \_\_\_ lbs., width \_\_\_ inches

-   ER equipment weight limit \_\_\_\_ lbs.\
    width \_\_\_\_ inches

-   Exam room table weight limit \_\_\_\_ lbs.\
    weight \_\_\_\_ inches

**Appendix D.** Policy Template

**BARIATRIC SAFE PATIENT HANDLING AND MOVEMENT POLICY**

1.  **PURPOSE:** To ensure that caregivers assisting bariatric patients
    are protected from patient handling injuries while bariatric
    patients are cared for safely, this policy describes ways to ensure
    that employees use safe patient handling and movement techniques and
    equipment specific for bariatric patients. As well, this policy is
    set forth to provide the bariatric patient an environment of dignity
    and respect in a supportive caring culture.

2.  **POLICY:** \_\_\_\_\_\_\_\_\_\_\_\_\_ (Facility Name) wants to
    ensure that its bariatric patients/residents are cared for safely,
    while maintaining a safe work environment for employees. To
    accomplish this, a comprehensive bariatric program will be
    implemented to ensure appropriate and adequate provisions are
    identified and made for bariatric patient handling equipment,
    training and resources in keeping with an effective "Culture of
    Safety" in the work environment. Identified bariatric patient
    handling techniques and guidelines will be followed at all times.
    Additionally, mechanical lifting equipment and/or other approved
    patient handling aids will be used to prevent the manual lifting and
    handling of bariatric patients/residents. It is also the policy of
    this hospital to provide a supporting and respectful environment of
    care for all patients.

3.  **DEFINITIONS:**

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a.  **Bariatric Patient:** Can be defined as anyone who has limitations
    in health due to physical size, health, mobility, and environmental
    access (Bushard, 2002). For the purpose of using our assessment form
    and bariatric algorithms, we defined bariatric as individuals
    exceeding standard capacity equipment (300 lbs) with a BMI of 50.

b.  **Patient Handling:** Refers to the repositioning, lifting, turning,
    transferring, transporting and assisting in ambulation provided by
    health care workers to patients that need assistance.

c.  **High Risk Patient Handling Tasks:** Patient handling tasks that
    have a high risk of musculoskeletal injury for staff performing the
    tasks. These include but are not limited to transferring tasks,
    lifting tasks, repositioning tasks, bathing patients in bed, making
    occupied beds, dressing patients, turning patients in bed, tasks
    with long duration and those involving bariatric patients.

d.  **High Risk Patient/Resident Care Areas:** Inpatient hospital wards
    with a high proportion of dependent patients, requiring full
    assistance with patient handling tasks and activities of daily
    living and who are frequently moved in and out of bed. Designation
    is based on analysis of facility injury data. These units have the
    highest incidence and severity of injuries due to patient handling
    tasks. These areas include Spinal Cord Injury Units, Nursing Home
    Care Units, and other specified areas.

e.  **Manual Lifting:** Lifting, transferring, repositioning, and moving
    patients using a caregiver's body strength without the use of
    lifting equipment/aids that reduce forces on the worker's
    musculoskeletal structure.

f.  **Mechanical Patient Lifting Equipment:** Equipment used to
    mechanically lift, transfer, reposition, and move patients. Examples
    include floor based, sit to stand and ceiling track lifts and
    mechanized lateral transfer aids.

g.  Patient Handling Aids: Equipment used to assist in the lift or
    transfer process. Examples include gait belts with handles, stand
    assist aids, sliding board and friction-reducing devices.

h.  **Culture of Safety:** Describes the collective attitude of
    employees taking shared responsibility for safety in a work
    environment and by doing so, providing a safe environment of care
    for themselves, co-workers and patients.

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4.  **PROCEDURES:**

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a.  **Compliance:** It is the duty of employees to take reasonable care
    of their own health and safety, as well as that of their co-workers
    and their patients during patient handling activities.
    Non-compliance will indicate a need for retraining.

b.  **Assessments Prior to Program Implementation:**

> Prior to performing procedures set forth in this policy, it is
> mandatory that two assessments must be completed: Bariatric Needs
> Assessment and Bariatric Risk Assessment. These facilitate development
> of individualized processes and facility plans and help guide
> management to allocate resources appropriately to prepare for
> bariatric patient care and admissions.

1.  **Bariatric Needs Assessment:** To identify and prevent potential
    barriers encountered in the admission and care processes and
    complete a bariatric needs assessment. This includes collection of
    data, identifying medical conditions, patient characteristics,
    weight, height, equipment use and location trends (units).

2.  **Bariatric Risk Assessment:** This assessment identifies patient
    and staff safety issues and risk factors for bariatric patient care.
    These include risks from patient transfers, patient transport,
    compatibility with transport equipment, room sizes, door widths,
    elevator size, etc. Please refer to Attachment C, Bariatric
    Equipment Safety Checklist. Additionally, capture information on the
    bariatric equipment availability/ effectiveness and maintenance
    support. This information will help in the decision to purchase or
    rent bariatric equipment.

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c.  **Training:**

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1.  Staff will complete and document Bariatric Safe Patient Handling and
    Movement training initially, annually, and as required to correct
    improper use/understanding of safe patient handling and movement.
    Supervisors should maintain training records for three (3) years.

2.  Staff will complete and document safe patient handling and movement
    equipment training initially and as required to correct improper
    use/understanding of safe patient handling and movement. Supervisors
    should maintain training records for three (3) years.

3.  Annual competencies will assess ability to provide appropriate
    bariatric patient care.

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d.  **Bariatric Patient Handling Assessment:**

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1.  The Bariatric Patient Handling Assessment, Care Plan and Algorithms
    can be accessed \_\_\_\_\_\_\_\_\_\_\_\_\_(say where) and completed
    by anyone preparing to handle or transfer a bariatric patient
    (Attachment B).

2.  Use expanded capacity/bariatric mechanical lifting devices and other
    approved patient handling aids in accordance with instructions and
    training for bariatric patient handling

3.  Facility will list persons responsible for training and provide
    appropriate resources and manuals. Contact
    \_\_\_\_\_\_\_\_\_\_\_\_\_for this information.

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e.  **Bariatric Equipment:**

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1.  Expanded capacity/bariatric mechanical lifting devices and other
    equipment/aids will be accessible to staff. See Attachment A for a
    listing of such equipment. Depending on facility and unit needs,
    other equipment may be added to this list.

2.  Equipment provisions should be varied and sufficient to care for
    multiple patients of various sizes and medical conditions. Choose
    equipment carefully based on patients' shape, size and medical
    conditions (see Attachment B for Algorithms and Assessment form).

3.  Bariatric equipment may be leased or purchased. The decision to
    purchase or rent equipment should be determined by considering the
    following factors:

-   Number and frequency of bariatric admissions

-   Equipment purchase cost

-   Rental cost

-   Space demands: including fit through doorways/hallways, etc.

-   Patient care needs: bedroom, bathroom

-   Equipment storage needs

-   Length of stay

-   Equipment cleaning and maintenance needs

4.  \_\_\_\_\_\_\_\_ will ensure that all expanded capacity/bariatric
    equipment will be labeled as such using the following: "EC --
    \_\_\_\_ (weight)". This will identify such equipment and their
    associated weight capacities. The weight capacity will be clearly
    visible.

5.  \_\_\_\_\_\_\_\_will also maintain, clean and check equipment in
    need of servicing or repair. \_\_\_\_\_\_\_\_will store expanded
    capacity/bariatric mechanical lifting devices and other
    equipment/aids conveniently and safely.

6.  \_\_\_\_\_\_\_ will also be responsible for returning rental
    equipment.

7.  The nurse manager will arrange for patient's own equipment to be
    inspected and a safety check will be performed by the appropriate
    department prior to patient use.

8.  Equipment may be procured by \_\_\_\_\_\_\_\_\_\_\_\_\_\_(facility
    must outline procedure for accessing or renting equipment).

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f.  **Bariatric Patient Supplies:**

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1.  Appropriately-sized patient care items, such as gowns, slippers,
    robes, ID bracelets, blood pressure cuffs, linens, slings, needles,
    etc., shall be readily available and stored for easy accessibility.
    These items can be accessed by contacting the charge nurse on the
    specific unit.

2.  A system will be implemented that distinguishes different sizes of
    patient care items without stigmatizing bariatric patients.

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g.  **Admissions Procedures:**

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1.  For elective admission, \_\_\_\_\_\_\_\_\_\_\_\_\_ shall communicate
    the impending need for bariatric patient accommodations.

2.  For emergency admission, \_\_\_\_\_\_\_\_\_\_\_\_ shall communicate
    the immediate need for bariatric patient accommodation.

3.  The \_\_\_\_\_\_\_\_\_\_ shall assign the appropriate space to
    accommodate equipment for the bariatric patient (as directed by the
    \_\_\_\_\_\_\_\_\_\_\_ on the admitting unit). This may include
    blocking a space to provide a double space for a single patient.

4.  If a bariatric suite is not available, \_\_\_\_\_\_\_\_\_ must
    initiate preparation, including delivery and placement of the bed
    and other equipment in the room.

5.  The Bariatric Patient Handling Specialist or Team
    \_\_\_\_\_\_\_\_\_\_(identify who) will be notified of elective or
    emergency bariatric patient admission.

6.  Patient must be weighed as soon as possible upon entry to the
    facility in order to confirm weight and identify appropriate
    equipment.

7.  Consult specialist if needed (eg. wound care nurse, nurse educator).

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h.  **Patient Transport:**

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1.  To assist in patient transport, use a powered bed/stretcher, bed
    mover, or powered wheelchair mover. If powered equipment is not
    available, then choose the least physically demanding transport
    vehicle.

2.  Prior to transporting a patient

-   Map out the route

-   Make sure the bed fits through doorways and into elevators

-   Make sure the transport device/bed is easy to maneuver

-   Make sure an adequate number of staff are available to assist

-   Determine how many transfers are required to accomplish the task and
    minimize if possible

-   Ensure patient is medically stable

-   Calculate the weight of patient plus bed to ensure elevator weight
    and other capacities are not exceeded

i.  **Ensuring Patient Comfort and Dignity:**

> Bariatric patients have the same rights to be treated with the same
> comfort, dignity, respect and privacy as other residents. Health Care
> workers shall acknowledge the patient as a unique individual and treat
> them with compassion, seeing past a person's weight and size. They
> shall ensure that dignity and self-worth are maintained by appropriate
> and professional treatment.

5.  **DELEGATION OF AUTHORITY AND RESPONSIBILITY:**

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a.  **FACILITY DIRECTOR** shall:

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1.  Support the implementation of this policy.

2.  Support a "Culture of Safety" within this medical center.

3.  Furnish sufficient expanded capacity/bariatric lifting
    equipment/aids to ensure safe patient handling and movement of
    bariatric patients.

4.  Furnish acceptable storage locations for expanded capacity/bariatric
    equipment/aids.

5.  Provide staffing levels sufficient to support safe patient handling
    and movement of bariatric patients.

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b.  **NURSE MANAGERS** shall:

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1.  Ensure all bariatric patient handling tasks are assessed prior to
    completion and are completed safely, using appropriate mechanical
    lifting devices and other approved patient handling aids and
    appropriate techniques.

2.  Ensure appropriate and adequate numbers of expanded
    capacity/bariatric equipment are available either through rental
    agreements or through facility purchase.

3.  Ensure expanded capacity/bariatric mechanical lifting devices and
    other equipment/aids maintained regularly, in proper working order,
    and stored conveniently and safely.

4.  Ensure employees complete initial and annual bariatric patient
    training and additional training as required if employees show
    non-compliance with safe patient handling and movement or equipment
    use.

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c.  **EMPLOYEES** shall:

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1.  Comply with all parameters of this policy.

2.  Use proper techniques, mechanical lifting devices, and other
    approved equipment/aids during performance of bariatric patient
    handling tasks.

3.  Notify supervisor of any injury sustained while performing patient
    handling tasks.

4.  Notify supervisor of need for re-training in use of expanded
    capacity/bariatric mechanical lifting devices, other equipment/aids
    and lifting/moving techniques.

5.  Provide care in a manner that acknowledges the patient as a unique
    individual, treating them with compassion and respect. They shall
    ensure that dignity and self-worth are maintained by appropriate and
    professional treatment. Workers should not display negative or
    judgmental feelings and should attempt to see the person not the
    weight.

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d.  **BARIATRIC PATIENT HANDLING SPECIALIST OR TEAM** shall:

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1.  Acknowledge notification of elective or emergency bariatric patient
    admissions, and respond in a timely manner.

2.  Act as a resource and provide ergonomic consultation and support to
    staff when bariatric patients are admitted.

3.  Assist in monitoring effectiveness of equipment and identification
    of bariatric equipment needs for individual patients.

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e.  **UNION** shall: support bariatric program and policy in partnership
    with administration.

[^1]: For online calculators, see:

    http:www.kci1.com/body_mass_index_calculator.html or

    http:www.sizewiserentals.com/bmicalculator.htm

    http://www.nhlbisupport.com/bmi/bmicalc.htm

[^2]: For Online calculators, see:
    http:www.kci1.com/body_mass_index_calculator.html or

    http:www.sizewiserentals.com/bmicalculator.htm or
    http://www.nhlbisupport.com/bmi/bmicalc.htm