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Bariatric policy (care of the bariatric patient)

Contents

1 Introduction

A bariatric patient (larger person) can be defined as anyone regardless of age, who has limitations in health and social care due to their weight, physical size, shape, width, health, mobility (WHO 2000).

They may have a body mass index (BMI) greater than 40 kg per m² and or are 40kg above ideal weight for height (NICE 2014). Their size may exceed the working load limit (WLL) and dimensions of the support surface such as a bed, chair, wheelchair, couch, trolley, toilet, or mattress.

If a patient’s weight is unknown, the hip circumference of the patient needs to be measured for the patient to be able to sit or lie or use mobility equipment.

Patients may present with different body shapes with a hip width of more than 400mm for short stature.

Some people may not completely fit the above definition due to individual variations but have similar problems and needs that will require a similar approach to their care.

It is of importance, that all staff caring for such patients remain sensitive to their specific needs and always seek to preserve their dignity.

Local organisations need to work together and communicate manual handling risk assessment and care needs effectively in order to safely meet the needs of the bariatric patient, particularly where their care involves a transition between hospital and community services.

Manual handling is defined as “Any transporting or supporting of a load (including the lifting, putting down, pushing, pulling, carrying or moving thereof) by hand or bodily force” MHOR 92.

The application of ergonomic principles and structured organisational arrangements can effectively reduce the existing level of personal injury arising from manual handling activities at work. Therefore, if tasks are not assessed and modified as necessary to reduce the risk, the incidence of injury and cumulative trauma is likely to continue. Every piece of equipment such as beds, trolleys, chairs, hoists and slings have a safe working load (SWL). It is imperative that the SWL is checked and not exceeded as it will affect the stability and mechanism of the equipment. All bariatric equipment should be identified by a yellow label with black script stating the designation SWL and as required the storage location of the equipment.

2 Purpose

To minimise associated manual handling risks to both the bariatric patient and clinical staff members by providing clear guidance.

This policy will provide clinical staff with the necessary information to make arrangements that will ensure safe systems of work are in place, and to ensure high quality care can be delivered to the bariatric patient through means of thorough risk assessment, care planning and specialist equipment.

3 Scope

This policy is an integral part of the trusts overall risk management approach and should be read alongside other health and safety polices. The policy applies to all clinical staff providing care for the bariatric patient.

4 Responsibilities, accountabilities and duties

  • To provide Leadership on inclusion of patients with special resources for bariatric handling and care.
  • To ensure that staff receive the appropriate resources through the training needs analysis and risk assessments.

4.1 Senior managers

The modern matrons or service managers within the trust are responsible for the safety of both staff and patients within their clinical area. To fulfil this responsibility in relation to this policy they will:

  • identify the environment within which the patient should receive care
  • identify funding for the hire of specialist equipment and transport if required
  • organise the hiring of any identified equipment
  • make any clinical staff they manage aware of this policy
  • release staff to attend any training, which is provided in relation to this policy
  • identify any additional training needs in relation to this policy to the trust Manual Handling team

4.2 Modern matrons or service managers

The ward or department manager will liaise with the modern matron or service manager regarding the following:

  • identify any specialist equipment or transport, which is required and may need to be hired
  • make any clinical staff they manage aware of this policy
  • where required, identify and allow time for staff members to be trained on the safe use of equipment in relation to this policy
  • report any non-compliance with the contents of this policy by writing to the manual handling team, rdash.manualhandlingteam@nhs.net
  • monitor that all the necessary risk assessments are completed in line with this policy
  • allocate an appropriate environment which meets the needs of the individual whilst still promoting their privacy and dignity
  • ensure any loaned equipment is decontaminated prior to use

4.3 Ward or department managers

Care Co-ordinators will:

  • advise inpatient staff of any specific weight and measurement issues for patients, prior to admission to hospital
  • complete manual handling risk assessment documentation which can be found under questionnaire’s on SystmOne

4.4 Care co-ordinators

Care co-ordinators will:

  • advise inpatient staff of any specific weight and measurement issues for patients, prior to admission to hospital
  • complete manual handling risk assessment documentation which can be found under questionnaire’s on SystmOne

4.5 Ward staff or named nurse

Ward staff or named nurse will:

  • complete assessment documentation
  • obtain the functional independence measure score (FIM) and weight of the patient or waist circumference
  • liaise with the ward manager over the obtaining of any specialist equipment
  • contact specialist advisors for advice and support (see section 5.13)
  • initiate admission and discharge procedures in conjunction with the care co-ordinator

4.6 Manual handling team

The Manual Handling team will:

  • advise on equipment
  • be involved in the audit of this policy
  • oversee the provision of any training in relation to this policy
  • in conjunction with the health and safety lead, risk assesses the patients transport from trust premises to other premises
  • advise the ward staff in relation to the assessment of any Ligature risk posed by any prescribed beds or equipment
  • incident and trend analysis
  • monitor referrals
  • review confirmation from staff when a bariatric patient is in the trust

4.7 Ward manual handling patient key trainers

Each ward has a trained patient manual handling key trainer who will be responsible for:

  • the staff in their area working to safe manual handling procedures
  • providing manual handling training to the staff within their area of work
  • liaising with the Manual Handling team in relation to any staff training needs they are unable to meet

4.8 Dietician

5 Procedure or implementation

Staff within dietetic services play a significant role in advising on the nutritional needs of patients. It is essential that if a patient wishes to address their weight, they must show some level of motivation and agree to dietetic input before referral.

For patients who can attend an outpatient clinic, request a referral from the general practitioner (GP) to the local dietetic service. For housebound patients (Doncaster) a referral can be made to the RDaSH (Doncaster) dietetic service by trust staff using the appropriate referral form.

5.1 Bariatric patient admission procedure

Community staff with existing input into the bariatric patient’s care should complete a risk assessment (located under questionnaire’s on SystmOne on the data entry template RDaSH patient moving or manual handling assessment). This should detail any specialised equipment already in use and the patient’s level of mobility.

If the patient has complex needs which cannot be safely met, alternative arrangements such as nursing the patient in their own home should be considered (equipment and extra staffing would be essential to meet this criteria).

On admission, ward staff will liaise with their manual handling key trainer, Physiotherapy staff and, or the Manual Handling team to complete a detailed manual handling risk assessment for the period of their admission in the new environment. The completed patient moving and handling risk assessment or plan must accompany the patient at all times and information regarding handling activities must be communicated to all health care staff involved; porters, radiographers, occupational therapists, physiotherapists, doctors, nurses, ambulance personnel etc. involved in their care.

The flowchart below sets out the procedure for the admission of a bariatric patient.

5.2 Flow chart for procedure

5.2.1 Community staff

Completed by community staff for all non-urgent admissions (and wherever possible for urgent admissions) of suspected bariatric needs.

  1. Referral to the RDaSH services.
  2. Weight (and if possible, hip circumference) ascertained FIM score 5 or below.
  3. Below 160kg non bariatric, arrange admission.
  4. Inform proposed admitting ward of patient’s weight plus any obvious manual handling issues. N.B. where possible, and if training has occurred complete trust moving and handling assessment form Follow the necessary equipment identified via ‘steppingstones’ assessment.
  5. Ward environment’s suitability assessed for use of equipment identified (plus toilet facilities, bed space, etc.)

5.2.2 In-patient staff

To be completed by admitting ward staff for all suspected or confirmed bariatric patients Also, to be completed prior to any proposed transfers by intended receiving wards staff.

  1. Inform proposed admitting ward of patient’s weight plus any obvious manual handling issues. N.B. where possible, and if training has occurred complete trust moving and handling assessment form Follow the necessary equipment identified via ‘steppingstones’ assessment.
  2. Ward environment’s suitability assessed for use of equipment identified (plus toilet facilities, bed space, etc.)
  3. Ward environment suitable or ward environment unsuitable?
  4. Is necessary permission obtained to hire required equipment?
    • Permission refused, community staff to contact alternative admission wards. If no alternatives available, contact G.P. (or crisis service medic).
  5. Permission obtained, Obtain equipment identified and ensure cascading of training is initiated.
  6. Physical examination according to trust’s agreed minimum standards for inpatient admissions.
  7. Ensure needs identified from moving and handling assessment and physical examination are addressed by the MDT through care planning and (CPA) review processes, and referral has been made to physiotherapy if mobility and, or functional assessment is required.

5.3 Patients attending outpatient clinics

Where possible information on the patients weight or BMI should be provided on referral.

Equipment for example, chairs for waiting rooms, bariatric couches should be available in clinics (however these resources may be minimal). A moving and handling risk assessment must be completed, and a copy sent to rdash.manualhandlingteam@nhs.net.

5.4 Patients being treated within the community

Staff should complete a risk assessment (located under questionnaire’s on SystmOne on the data entry template RDaSH patient moving or manual handling assessment).

This will identify the number of handlers required for each visit or task. Staff treating patients within their own home must work within safe measures in order to minimise the risk of injury to themselves.

5.5 Specialised equipment

Specialist equipment will be required for the larger patient, which may include:

  • a ‘heavy duty’ electric profiling bed, pressure relieving mattress, chair, commode, wheelchair, hoist and slings, walking aids, shower seating, weighing facilities for independent and dependent service users
  • if the equipment is not available locally, it will need to be made available through a rental scheme, staff can contact specialist advisors for advice and support (see section 5.13)
  • once the equipment has been approved the staff member should arrange to a have a requisition or purchase order raised via the integra system
  • the order will include equipment details, delivery address and when delivery is required, rental period (if applicable) and invoices address
  • the order will then be sent to the supplier as per the trusts procedures
  • please refer to appendix A for more information
  • equipment should be obtained before the patient is admitted or transferred and decontaminated prior to use

5.6 Ergonomic risk factors

5.6.1 Patient Factors

Patient factors contribute to manual handling risks. The manual handling of loads presents very different risks to inanimate loads, for example, weight, shape and size of the patient, co-operation, privacy and dignity.

5.6.2 Equipment

To include:

  • weighting scales
  • bariatric mobile hoist
  • bariatric overhead gantry hoist (optional)
  • bariatric sling
  • bariatric PAT slide
  • bariatric slide sheets
  • Mangar ELK cushion
  • bariatric stand aid
  • bariatric armchair
  • bariatric bed and appropriate mattress
  • bariatric commode

5.6.3 Communication

Early planning will be vital in ensuring equipment is in place, transport has been arranged (where needed) and all needs are met.

5.6.4 Organisational and staff issues

It is the responsibility of each care group service to ensure they have the necessary equipment and staffing levels.

When undertaking an ergonomic risk assessment, the following must also be considered:

  • the safe working load of the floor
  • the type of floor covering
  • accessibility of any doors on the wards
  • the load weight of any lifts
  • the available space within the patient’s bedroom
  • the positioning of furniture within the patient’s bedroom, as there must be adequate room for staff to move around all sides of the bed

5.7 Manual handling, moving the patient

Encourage the patient to move independently whenever possible and to participate to their full capacity if assistance with movement is required.

There may be additional risks when moving the extremely heavy patient, therefore before moving the patient:

  • ensure staff members are up to date with their moving and handling training
  • staff to seek the patients consent before any restrictive equipment is used including hoists, if the patient lacks capacity to consent a decision should be made under The Mental Capacity Act (2005)
  • ensure that any specialist equipment required is available, patients should not be manually lifted
  • prepare the environment ensuring enough space to move
  • adjust the height of the bed to ensure comfort and safety for the handlers
  • ensure a full explanation is given to the patient prior to moving so they can assist where possible
  • ensure a full explanation is given to all the handlers involved in movement of the patient, so that they are aware of what they will be required to do (especially if help is enlisted from other areas)
  • apply brakes to moveable equipment (except the appropriate hoist which is being used)
  • if the patient cannot be transferred into a chair, then they must remain in bed with the appropriate pressure relieving support surface. Under no circumstances should the patient be lifted into a chair or onto a commode etc
  • bathing should be by bed bath

5.8 Postural issues

It is important when moving the bariatric patient to consider the comfort and dignity of the patient on the patient risk assessment.

Staff involved with bariatric patients need to be aware that assisting the whole person to move may be hazardous. This may also take a great deal of physical effort. In addition, their individual limbs can also be very heavy and that there is risk of injury to staff when performing personal care and nursing interventions. As part of the moving and handling assessment staff should consider the working postures they have to adopt whilst performing these tasks.

Wherever possible height adjustable equipment should be used for example, high-low beds. Working at floor level should be avoided whenever possible. If possible, the person should be encouraged to move or support the limb independently. Taking the weight of the person’s limb may also be avoided by using slide sheets, leg lifters and mechanical aids such as an inflatable lifting cushion (Mangar ELK).

Details of the risk reduction measures to be used when moving or supporting limbs should also be documented in the moving and handling assessment. Knowledge of postures assessed by evidence based rapid entire body assessment (REBA) is an advantage. Further advice on how to reduce risks in relation to working postures is also available from the organisation’s Manual Handling team.

5.9 Resuscitation of a bariatric or larger patient

The current resuscitation council (UK) Guidelines for basic and advanced life support still apply to bariatric patients; however staff will need to be aware that some basic skills may be more difficult than when dealing with a person of average body weight.

Staff must be aware of the increased effort involved to perform chest compressions on the patient who has a larger than average body mass. The girth of the chest, size of arms etc. may necessitate a change in posture during chest compressions leading to the rescuer becoming fatigued quicker. In these situations, staff should not perform compressions for longer than one minute if possible. The current resuscitation council (UK) guidelines should be followed but may need the following adjustments.

5.9.1 Depth of compression

Current guidelines state 5 to 6 cm, however it may be more appropriate to compress to a third of the depth of the chest in a person with a larger than average body mass.

5.9.2 Airway

In a person with larger than average body mass there maybe difficulties sealing a bag-valve-mask due to the amount of excess skin and body fat around the jaw line and neck.

If this is the case switching to another method such as the use of a pocket mask may be effective.

5.9.3 Choking

In a person whose abdominal girth makes abdominal thrusts impossible for the rescuer, chest thrusts should be utilised if possible.

Five back blows must always be used in the first instance followed by chest thrusts, use the heels of both hands on the sternum and perform a quick inward thrust.

5.9.4 999 calls

When speaking with call handlers, staff should inform them that the patient is larger or bariatric so that the appropriate transport is used.

Further guidance can be sought by contacting the resuscitation service (see section 5.13, specialist advisors)

5.10 Action in the event of a patient’s death

Due to the special circumstances, staff may wish to discuss sensitively with relatives, arrangements for the transfer of the deceased to the identified funeral home.

The number of undertakers able to provide these services for the patient may be limited.

5.11 Emergency evacuation

The evacuation procedure for bariatric patients is no different from the evacuation procedures for non-bariatric patients in accordance with the trusts fire safety policy.

  • initial risk assessment and personal emergency evacuation plan (PEEP) should be completed and can be found here
  • are the premises suitable to allow the evacuation of a bariatric bed?
  • the Fire Safety Advisor and Health and Safety team should always be consulted (see section 5.13)
  • what additional numbers of staff would be required for moving and handling in an emergency?
  • only one bariatric patient should occupy a single fire compartment
  • bariatric patients should only occupy the ground floor area of a multistorey building

5.12 Handling in reduced restrictive intervention

As with all RRI techniques prone restraint should be avoided, team to keep as close into the patient as possible, no restraint on the bed and correct team management principles should be adhered to as demonstrated in trust PMVA training.

Further guidance can be sought by contacting the Prevention and Management of Violence and Aggression (PMVA) team (see section 5.13, specialist advisors).

5.13 Directory of specialist advisors

5.13.1 Manual handling and equipment

5.13.2 Tissue viability

5.13.2 Wheelchair and special seating services

5.13.3 Lead physiotherapist

5.13.4 Rotherham clinical commissioning group tissue viability specialist nurse

5.13.5 Resuscitation service

5.13.6 PMVA team

5.13.7 Rental or purchasing advice

5.13.8 Health and Safety team fire safety adviser

6 Training implications

6.1 Manual handling team

  • How often should this be undertaken: Annually.
  • Length of training: 1 hour.
  • Delivery method: The contents of this policy will be included as part of the key trainers training.
  • Training delivered by whom: Manual Handling team.
  • Where are the records of attendance held: Electronic staff record system (ESR).

6.2 Manual handling key trainers

  • How often should this be undertaken: Annually.
  • Length of training: 1 hour.
  • Delivery method: The contents of this policy will be included as part of the key trainers training.
  • Training delivered by whom: Manual Handling team.
  • Where are the records of attendance held: Electronic staff record system (ESR).

6.3 All clinical staff

  • How often should this be undertaken: Annually.
  • Length of training: 30 minutes.
  • Delivery method: Contents of this policy to be included in the workplace sessions which are delivered to staff.
  • Training delivered by whom: Key trainers.
  • Where are the records of attendance held: Electronic staff record system (ESR).

As part of their training the key trainers will cover the following:

  • how to deliver training to staff in the use of the specialist equipment
  • handling the bariatric patient
  • the origins and history of the study of Bariatrics and the psychological aspects of bariatric care

7 Monitoring arrangements

7.1 Compliance with the following having been completed at, or as soon as possible following admission of the patient:

  • documented weight on admission
  • a completed manual handling assessment
  • a manual handling care plan was formulated

Also documented evidence that:

  • the manual handling care plan was reassessed on a regular basis
  • any suitable specialist equipment was obtained
  • How: Review through on-going referral information
  • Who by: Manual Handling team
  • Reported to: Health, Safety and Security forum
  • Frequency: Annually

7.2 Staffs awareness of the procedure protocols and adherence to them

  • How: Review of any complaints or concerns received which relate to the care of a bariatric patient.
  • Who by: PALS, modern matrons or service managers
  • Reported to: Patient Safety and Investigations team.
  • Frequency: As and when they arise

8 Equality impact assessment screening

To download the equality impact assessment for this policy, please follow this link: Bariatric policy EIA.

8.1 Privacy, dignity and respect

The NHS Constitution states that all patients should feel that their privacy and dignity are respected while they are in hospital. High Quality Care for All (2008), Lord Darzi’s review of the NHS, identifies the need to organise care around the individual, ‘not just clinically but in terms of dignity and respect’.

As a consequence the trust is required to articulate its intent to deliver care with privacy and dignity that treats all service users with respect. Therefore, all procedural documents will be considered, if relevant, to reflect the requirement to treat everyone with privacy, dignity and respect, (when appropriate this should also include how same sex accommodation is provided).

8.1.1 How this will be met

Privacy, dignity and respect of the patient will be considered at all times. Sensitivity to the patient’s needs will also be addressed.

8.2 Mental Capacity Act

Central to any aspect of care delivered to adults and young people aged 16 years or over will be the consideration of the individuals capacity to participate in the decision making process. Consequently, no intervention should be carried out without either the individual’s informed consent, or the powers included in a legal framework, or by order of the court.

Therefore, the trust is required to make sure that all staff working with individuals who use our service are familiar with the provisions within the Mental Capacity Act (2005). For this reason all procedural documents will be considered, if relevant to reflect the provisions of the Mental Capacity Act (2005) to ensure that the rights of individual are protected and they are supported to make their own decisions where possible and that any decisions made on their behalf when they lack capacity are made in their best interests and least restrictive of their rights and freedoms.

8.2.1 How this will be met

All individuals involved in the implementation of this policy should do so in accordance with the guiding principles of the Mental Capacity Act (2005) (section 1).

9 Links to any other associated documents

10 References

11 Appendices

11.1 Appendix A Medical devices rental flow chart

  1. Patient Assessment to establish criteria for use of medical device
  2. Is the medical device available within the service or department?
    • Yes, end process.
  3. No, Full discussion with clinical lead outlining criteria for use of specific medical device.
  4. Funding sought for rental if medical device not available within any clinical team in the care group. Requisition or purchase order Raised.
  5. Medical device delivered to patient area.
  6. Medical device used with specific patient and reviewed as appropriate.
  7. When appropriate, medical device removed from specific patient and either:
    • if trust owned, returned to service following decontamination
    • if on rental from external supplier, returned to supplier following decontamination, supplier contacted via telephone to cancel rental agreement ,reference number obtained from supplier and recorded, please ensure equipment collected in a timely manner by supplier

Document control

  • Version: 5.
  • Unique reference number: 356.
  • Approved by: Clinical policies review and approval group.
  • Date approved: 2 March 2021.
  • Name of originator or author: Rachel Benton.
  • Name of responsible individual: Clinical quality group.
  • Date Issued: 23 April 2021.
  • Review date: March 2024.
  • Target audience: All clinical staff.

Page last reviewed: February 20, 2024
Next review due: February 20, 2025

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