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Extreme obesity is typically defined as a body mass index (BMI) equal to or greater than 40kg/m[[2]]. In 2021, approximately 5.9% of adults in Aotearoa New Zealand were identified as extremely obese, with this statistic disproportionately represented amongst structurally marginalised groups, including Māori (13.0%), Pasifika peoples (24.5%) and those living in areas of high deprivation (11.9%).[[1]] Bariatric service delivery refers to the care received by those with additional needs due to extreme obesity; this includes appropriate spatial facility design, equipment uses, and collection of information needed to inform high quality services. It does not explicitly relate to specialist care for weight loss management (i.e., bariatric surgery).

The prevalence of patients admitted to hospitals with extreme obesity is unknown, although the prevalence is likely to be higher than the general population with estimates as high as 16% in North American studies of general medical patients.[[2,3]] Hospitalised patients with extreme obesity have poorer healthcare outcomes than normal-weight patients,[[4–7]] including longer lengths of stay, higher likelihoods of intensive care admission, increased risk of pressure injuries, falls, and readmission within 28 days of discharge.[[4–7]] Despite the plethora of literature highlighting the importance of appropriate bariatric service delivery,[[5,8,9]] health services in Aotearoa New Zealand do not meet the care needs of this patient population, as care is often fragmented and specialised equipment is frequently unavailable, missing or too small.[[10–12]] Currently there is a lack of robust evidence regarding variation of service provision for patients with extreme obesity by Te Whatu Ora districts.

In 2016, Capital & Coast District Health Board (CCDHB) introduced bariatric care bundles (defined as a package of wider beds, mobilisation and hygiene equipment) into the bariatric care pathway to address equipment concerns. Subsequently, this approach to bariatric service provision has been introduced into four other DHBs (Auckland, Waitematā, Canterbury, and Hutt Valley) based on a research and industry-led initiative.[[13,14]] The utilisation of these bundles as a part of the bariatric care service remains unaudited at CCDHB, and the adherence to and application of current bariatric policies remain unexplored. Additionally, the prevalence of patients admitted to CCDHB requiring bariatric care is currently unknown, limiting the ability of service providers to plan service delivery needs for this population.

Whilst moving and handling training is mandatory for all staff at CCDHB, 28 reportable events between April and September 2021 identified patients’ weight as a contributing factor leading to staff injuries, and equipment issues. The Accident Compensation Corporation (ACC) Moving and Handling Guidelines report healthcare workers have one of the highest rates of musculoskeletal disorders among all occupational groups.[[15]] In 2019, healthcare work-related entitlement claims were around 6%. Of those, soft tissue injury accounted for 64%.[[16]] To approach this concern, regular examining of safe patient handling practices may serve as a strategy in controlling unnecessary costs and improving staff and patient outcomes.[[5]]

Aim and objectives

This clinical audit aims to benchmark the quality of bariatric service delivery against moving and handling and patient care best-practice standards and determine the prevalence of hospitalised patients admitted to Wellington Regional Hospital (WRH) requiring bariatric level care. Researchers will identify areas of improvement in service delivery and provide recommendations relevant to CCDHB policies.

Criteria and standards

The audit framework was developed using ACC Moving and Handling Guidelines for bariatric patients[[15]] and relevant CCDHB policies (Appendices, Tables S1–10). The ACC guidelines were originally developed in 2003 and updated in 2012 following review of international research, consultation with healthcare stakeholders and international peer review. The purpose of ACC guidelines is to reduce manual and patient handling injuries.[[15]] The recommendations listed in the guidelines reflect evidence-informed practices consistent with international standards for safe patient handling and processes that should be considered in care planning for hospitalised patients requiring bariatric services.[[15]] These processes include admission planning, client assessment, communication, room preparation, mobilisation plan, equipment needs, space and facility design considerations and planning for discharge.[[15]] Additionally, relevant CCDHB policies and procedures were used to structure the audit framework and include: “Patient Admission to Discharge Plan”;[[17]] “Bariatric Equipment”;[[18]] “Moving and Handling”;[[19]] “Moving and Handling Patients and Objects”;[[20]] “Malnutrition in Adult Inpatients;”[[21]] “Prevention and Management of Patient Falls”;[[22]] “Health and Safety”;[[23]] “Admission to Transit Lounge”;[[24]] “Pressure Injury Prevention and Management”;[[25]] and “Adverse Event and Incident Management”.[[26]]

Method

This baseline clinical audit consisted of retrospective and cross-sectional components to identify patients requiring bariatric services admitted to WRH. Patients were identified as bariatric if they had a BMI equal to or greater than 40kg/m[[2]]; weighed ≥150kg, or had large physical dimensions requiring bariatric equipment.

Cross-sectional survey

All adult inpatients aged 18 years and over on one of nine adult inpatient wards were included in the point prevalence survey. Paediatric and delivery/postnatal wards were excluded due to different requirements and service decision-making processes. Three researchers conducted the survey (BY, EB, CH) on two occasions: 15 December 2021 and 19 January 2022. The clinical team did not calculate a sample size a priori, as the audit was limited in time and resources and only conducted on two single days. A post hoc sample size analysis with 95% confidence interval (CI) was conducted.

Patients requiring bariatric level care were identified from the clinical notes. Where no data was available, patients were asked their height and weight. The audit team calculated BMI to affirm the patient’s bariatric status. If a patient was eligible for clinical audit, researchers assessed the spatial design considerations and equipment suitability as per the criteria and standards framework (Appendices, Tables S1–10). Patients were asked to complete a hospital patient satisfaction survey about their care experiences.

Retrospective case-note review

All adult patients aged 18 years and over identified as requiring bariatric level care admitted to WRH between 1 August and 30 September 2021 were included in the case-note review. Pregnant women were excluded due to the difficulty of using BMI to determine bariatric status. The case-note review was completed to benchmark the quality of documented care against the bariatric service delivery standards framework. Researchers identified eligible patients through a bariatric equipment hire database and electronic medical records coding system. Data collection was conducted by two researchers (BY, EB).

Collected data was stored and managed using RedCap. The information collected included seven areas of moving and handling and patient satisfaction (Table 1). Data analysis was conducted using Microsoft Excel. Descriptive statistics of absolute differences and percentages of documented care that did or did not meet practice standards were analysed and presented.

Ethical approval was not required. However, the audit was conducted within an ethical framework, which included maintaining patient confidentiality, not collecting unnecessary data, anonymising all data at the time of data collection, and using the hospital secure data management software system. The clinical audit was approved by the CCDHB Clinical Audit Committee in December 2021 (Audit Approval Number: 2021/73).

Results

Cross-sectional point prevalence survey

A total of 548 patients were included in the point prevalence survey (Table 2). Of those, 6.4% of patients (n=35) were identified as bariatric. A post hoc sample size analysis shows that given a sample of 548 people, the precision of our estimate of extreme obesity is reasonable (95% CI=4.6–8.8).

Most patients requiring bariatric services were admitted as an emergency admission (80.0%) and had some level of mobility (71.4%). Of those patients identified as bariatric, 22.9% were Māori (n=8), 25.7% were Pasifika peoples (n=9), 45.7% were New Zealand (NZ) European (n=16) and 5.7% identified as other ethnicity (n=2); indicating that Māori and Pasifika peoples are overrepresented in this patient population. The clinical team identified two thirds of patients requiring bariatric services (65.7%), with the remaining (34.3%) detected by the audit team (n=12).

Five bariatric patients included in the point prevalence survey did not complete the clinical audit of facility design, space and equipment. Reasons included: that health conditions excluded the ability to be assessed, refusal to participate, or that they were absent from the ward area at the time of data collection.

Only bed spaces(33.3%) where patients were independently mobile met the standard for accommodating all equipment required to manage bariatric care and mobilise comfortably from bed to chair or commode (Table 3). Only 29.5% of all equipment used during patient care had sufficient, safe working loads to prevent actual and potential injury to patients and staff. Whilst some items had a sufficient working load, the dimensions of the equipment were not suitable to fit the patient’s size and shape. Most ward areas did not meet the standard of a safe environment; 80.0% of bed spaces and 83.3% of bathroom spaces failed to achieve the standard. Despite this, 53.3% of facilities for bariatric patients were designed to support safe moving and handling assistance. The patient satisfaction survey demonstrated an overall positive report of patients’ experience of the service received at WRH.

Retrospective case-note review

A total of 26 patients requiring bariatric services were included in the retrospective case-note review during the two-month period (see Table 4). Of those patients identified, 34.6% were Māori (n=9), 19.2% were Pasifika peoples (n=5) and 46.2% were NZ European (n=12); indicating that Māori and Pasifika peoples are overrepresented in this patient population. Most patients requiring bariatric service delivery were admitted as an emergency admission (84.6%). Five patients were excluded from the retrospective case-note review as they did not meet the bariatric inclusion criteria (incomplete data, pregnancy during admission and age (adult <18 years)).

Over two thirds of patients (69.2%) had a weight documented on or within 24 hours of admission (see Table 5). Of those patients requiring any equipment or other resources needed for moving and handling, 25% was documented as ordered. Only one bariatric bundle had been requested and was reported to have arrived within one hour, meeting the standard. The standard that all issues, patient experiences and discussions relative to bariatric care with patient and family/whānau should be documented was not achieved at all for any patient.

Most bariatric patients (92.3%) had documentation of the number of staff needed for moving and handling as per their care plan (Table 5). Additionally, 88.5% of patients had identification and assessment of moving and handling hazards documented as they appeared throughout care. Despite the evaluation of patient handling risks being documented, the LITE (Load, Individual, Task, Environment) assessment was not documented at all. Nursing staff had completed the documentation of 61.3% of patients’ risk assessments (mobility, Braden Scale, and nutrition) and 36.4% of patients who were eligible for delirium screens. Of those, the majority of risk assessments were completed within 8–16 hours of admission. Of the 25 patients, 56% of cases had written care plans by nursing staff within 8–16 hours of admission. The standard of health professionals providing education relative to bariatric needs was not achieved at all.

Most patients (73.1%) had mobility plans documented (Table 5), with daily updates completed approximately one third (36.8%) of the time. Despite mobility plans being documented, the standard that patients and families/whānau were involved in the mobility assessment process was not achieved at all.

Three quarters of patients were documented as having the appropriate equipment to be managed and maintained safely. However, 37.5% of patients did not meet this standard. This result does not equate to 100%, as a single patient could have more than one piece of equipment for their care. Additionally, 20% of patients had the appropriateness of rooms assessed by Nurse in Charge and/or Duty Nurse Manager documented.

A documented discharge plan listed within the Patient Admission to Discharge Plan (PADP) achieved standard 26.1% of the time. One third of patients had appropriate equipment documented at discharge. Additionally, all patients had a recorded discharge time noted within the Medical Application Portal (MAP). However, this is an automatic management tool and therefore does not reflect the sufficiency of documentation in the workplace.

Two patients (7.7%) had reportable events documented. In both cases “weight” was identified as a contributing factor. Both reportable events attributed to staff and patient did achieve all applicable standards for report processing (Table 4).

View Tables 1–5.

Discussion

This audit aimed to benchmark the quality of bariatric service delivery against moving and handling and patient care best practice standards. One critical finding of this audit was the lack of identification by the clinical teams that a patient met the criteria for bariatric service support. This significant issue can contribute to missed care opportunities to provide high quality care, and increases the risk of injury to staff and patients if inappropriate equipment is used. Missed care refers to delayed or omitted care (in part or whole) of any aspect required in a patient’s care plan.[[28]] Failure to appropriately provide care has been recognised as contributing to adverse events and lowering the overall quality of care.[[29]] This problem globally affects patient outcomes, including extended lengths of stay, increased risk of pressure ulcers, and hospital-acquired infections.[[30]] Failure to identify patients requiring bariatric services consequently impacts the communication of appropriate care between clinical teams. Of those requiring moving and handling assistance, only 28.6% of patient handling risks were communicated to other wards at handover.

Findings from the audit showed little consideration was given to the spatial and facility design for those patients with extreme obesity. Our results demonstrated 80% of bed spaces did not meet ACC’s standards for a safe environment.[[15]] Predominantly, bed spaces failed on the premise that the foot of the bed did not have 1,200mm of clear space to allow the safe transferring of a patient. Additionally, most bathroom spaces did not meet the standards. This was due to the bathroom space not having a minimum of 450mm from the toilet bowl centre to the wall or door openings failing to have a minimum of 1,200mm clear width. These findings are consistent with previous healthcare literature;[[11,31]] a study conducted by Hales et al. found the physical environment of the hospital created mobilisation difficulties for all participants in several care situations.[[11]] Hales et al. indicated space was a significant factor that impacted largely on the participant’s ability to mobilise independently or with equipment assistance.[[11]] Failure to create a safe environment for moving and handling will compel clinical teams to exhibit unsafe patient handling to complete a task. This will contribute to a higher likelihood of adverse events caused to staff and patients.

There were frequent issues with availability and suitability of bariatric equipment. Whilst CCDHB has “within-the-hour” access to all bariatric equipment necessary for patient care needs, its use in patient care was dependent on staff request. Safe working loads and inappropriate equipment dimensions to fit the size and shape of the patient were of most concern and related most often to shower stools and chairs. Researchers identified that most shower supplies could maintain a person’s weight with extreme obesity. However, it was not deemed appropriate due to the equipment frame not being able to fit the size and shape of the individual or the uncomfortableness while doing so. Additionally, researchers discovered that at the time of the point prevalence, the clinical team ordered a bariatric bed for one patient, but it was not delivered. The clinical team failed to follow up on this issue due to time pressures. This reinforces the issue of missed care opportunities for patients with bariatric needs, often resulting in inequities and inconsistencies in delivering high quality healthcare. Failure to provide timely and appropriate equipment suitable for patients with bariatric level support can result in continued discomfort, slower recovery and preventable reportable events caused to staff and patients.

The majority of patients in this audit had documented assessment of moving and handling hazards as they appeared throughout care. However, documentation of the LITE assessment did not achieve standard. This is a significant concern as the moving and handling of bariatric patients can carry a serious risk. The LITE principles are a method to remember key risk factors that should be considered when preparing safe patient handling tasks.[[32]] Clinical teams must consider all four principles before starting a handling technique and organising any equipment. Failure to provide documentation of LITE assessments leaves staff and patients at risk of injuries.

There was poor adherence with documenting discharge plans within the PADP. Discharge planning is crucial to improving the efficiency and quality of healthcare delivery.[[33]] A Cochrane Review identified that individualised discharge planning reduces the length of hospital stay and readmission rates for adults.[[34]] The effectiveness of individualised discharge planning does not differ for elective and emergency admissions.[[33]] Failure to provide discharge planning will cause further missed care opportunities and a higher risk of re-admission for a patient requiring bariatric services.

There was a noticeable discrepancy between patient satisfaction and standards of service delivery. This suggests service users are not aware of what they might expect during their care. From this audit it is not possible to determine if this discrepancy is specific to patients requiring bariatric level support or the population in general, due to the stigma of obesity.

Our audit has several limitations. Researchers relied on a clinical team report for the cross-sectional point prevalence if a patient was not present (i.e., not in ward at the time of data collection). Additionally, researchers entrusted patients’ estimation of weight and height if not independently measured by the clinical team. The cross-sectional audit result could potentially be affected by  the difference in seasonal effects on admissions of people with extreme obesity, as it was only conducted in the summer, and the absence of COVID-19 hospitalisations during the period of data collection. Undertaking this type of audit at different time points across the year will assist in determining a more accurate hospital prevalence. The exclusion of pregnant women with extreme obesity means the assessment of standards of care within the maternity service was not established leading to an under-estimation of overall hospital bariatric need. Researchers could not assess the duration of time from ordering equipment to delivery due to confidentiality reasons. However, researchers acknowledge 80–90% of equipment deliveries via Essential (a partnership agency providing bariatric, fall prevention and pressure relief equipment to CCDHB), are delivered within an hour of request based on company reporting. In the case-note review, there were no means to assess if actual equipment ordered met the needs and physical size requirements of the patient. Therefore, equipment reported as ordered was deemed appropriate. Although most standards were achieved for patients receiving bariatric services, the audit is unable to determine if care was culturally safe as there were no benchmarks for cultural safety within the ACC recommendations or CCDHB policies. A final limitation to the audit is the currency of the ACC moving and handling standards used to inform the clinical audit. A review and update of the evidence is required.

This clinical audit highlights the need for further consideration of how clinical teams correctly identify patients who require bariatric level support. Better processes need to be developed to improve communication and documents in the decision-making of care practices and equipment needs; supported by moving and handling education. The inclusion of bariatric experts on the redesign of hospitals and retrofitting of clinical areas is vital to ensure future care facilities appropriately meet safe environmental standards.

Conclusion

Current identification measures for patients with extreme obesity are not always practiced at CCDHB, contributing to missed care opportunities and adverse effects for patients and clinical teams. Developing and improving policy adherence will assist in addressing shortcomings in the standard of providing a safe environment for bariatric patients to support a high quality care.

View Appendices.

Summary

Abstract

Aim

To benchmark the quality of bariatric service delivery against moving and handling and patient care best practice standards, and determine the prevalence of hospitalised patients admitted to Wellington Regional Hospital requiring bariatric level care.

Method

A clinical audit consisting of retrospective case-note review and cross-sectional survey was conducted and benchmarked against Accident Compensation Corporation (ACC) national standards. Information recorded included patient demographics, admission planning, patient anthropometric and risk assessments, provider communication, room preparation, mobilisation plan, equipment needs, space and facility design considerations, discharge planning and reportable events.

Results

A total of 574 patients were included. The prevalence of hospitalised patients requiring bariatric services was 6.4%. One third of patients (34.3%) were not identified by clinical teams as requiring bariatric support. Most bed (80%) and bathroom (83%) spaces failed to achieve the facility design standard. The majority of patient focused moving and handling hazards were documented whereas environmental hazards or equipment limitations were poorly reported. Only 26.1% of patients had a documented discharge plan.

Conclusion

Inadequate identification of patients requiring bariatric support and insufficient documentation of bariatric service delivery were identified. Improving policy adherence will address shortcomings in the provision of a safe environment and high quality care for bariatric patients.

Author Information

Bailey Yee: Summer Scholarship Student, Faculty of Health, Te Herenga Waka – Victoria University of Wellington, Wellington, New Zealand. Eleanor Barrett: Moving and Handling Specialist, Centre of Clinical Excellence, Capital & Coast, and Hutt Valley Districts, New Zealand. Dr Mona Jeffreys: Senior Research Fellow, Health Services Research Centre, Te Herenga Waka – Victoria University of Wellington, Wellington, New Zealand. Dr Anne Haase: Associate Professor, School of Health, Te Herenga Waka – Victoria University of Wellington, Wellington, New Zealand. Dr Caz Hales: Senior Lecturer, Registered Nurse, School of Nursing, Midwifery and Health Practice, Te Herenga Waka – Victoria University of Wellington. Wellington, New Zealand.

Acknowledgements

We would like to thank the following staff at CCDHB who provided guidance and support for the audit: Anne Pedersen, Group Manager, Centre of Clinical Excellence; Marina Dzhelali, Research Office Manager; Kristy Macdonald, Clinical Audit and Certification Coordinator, Centre of Clinical Excellence. At the time of the clinical audit, Wellington Regional Hospital and Kenepuru Hospital were part of Capital & Coast District Health Board.

Correspondence

Caz Hales: School of Nursing, Midwifery and Health Practice, Te Herenga Waka – Victoria University of Wellington, PO Box 600. Wellington, New Zealand. Ph: 04 463 6135

Correspondence Email

Caz.hales@vuw.ac.nz

Competing Interests

Nil.

Ministry of Health. Annual data explorer 2020/2021: New Zealand health Survey [Internet]. 2021 [cited 2022 Feb 17]. Available from: https://minhealthnz.shinyapps.io/nz-health-survey-2020-21-annual-data-explorer/_w_fd3f3f1c/#!/explore-indicators.

2) Hossain MA, Amin A, Paul A, Qaisar H, Akula M, Amirpour A, et al. Recognizing Obesity in Adult Hospitalized Patients: A Retrospective Cohort Study Assessing Rates of Documentation and Prevalence of Obesity. J Clin Med. 2018 Aug 7;7(8):203.

3) Howe E, Wright S, Landis R, Kisuule F. Addressing Obesity in the Hospitalized Patient: A Needs Assessment. South Am Assoc. 2010;103(6):500-3.

4) Fusco K, Robertson H, Galindo H, Hakendorf P, Thompson C. Clinical outcomes for the obese hospital inpatient: An observational study. SAGE Open Med. 2017 Jan 1;5:2050312117700065.

5) Gallagher S. A practical guide to bariatric safe patient handling and mobility. Sarasota, Florida: Vision Publishing; 2015.

6) Hauck K, Hollingsworth B. The Impact of Severe Obesity on Hospital Length of Stay. Med Care. 2010;48(4):335-40.

7) Ness SJ, Hickling DF, Bell JJ, Collins PF. The pressures of obesity: The relationship between obesity, malnutrition and pressure injuries in hospital inpatients. Clin Nutr [Internet]. 2017 Aug 19 [cited 2018 Jul 24]; Available from: http://www.sciencedirect.com/science/article/pii/S0261561417302972.

8) Hales C, deVries K, Coombs M. The challenges in caring for morbidly obese patients in Intensive Care: A focused ethnographic study. Aust Crit Care. 2018;31(1):37-41.

9) Rose MA, Drake DJ, Baker G, Watkins FRJ, Waters W, Pokorny M. Caring for morbidly obese patients: Safety considerations for nurse administrators. Nurs Manag (Harrow). 2008 Nov;39(11):47-50.

10) Hales C. Misfits: An ethnographic study of extremely fat patients in intensive care [Internet] [PhD]. Victoria University, Wellington; 2015 [cited 2018 Jul 24]. Available from: http://researcharchive.vuw.ac.nz/handle/10063/4155.

11) Hales C, Curran N, deVries K. Morbidly obese patients’ experiences of mobility during hospitalisation and rehabilitation: A qualitative descriptive study. Nurs Prax N Z. 2018;3(1):20-31.

12) Vanderwolf V. Does one size fit all? Factors associated with prolonged length of stay among patients who have bariatric needs in a New Zealand hospital: A retrospective chart review [Master of Nursing]. [New Zealand]: University of Auckland; 2018.

13) Cassie F. The big and small of caring for the very large. New Zealand Nursing Review. 2016 Jul 1;1-8.

14) McMillan V. Sizing up care that will fit the larger patients of today and tomorrow. NZ Doctor. 2016 Feb 24;1-2.

15) Accident Compensation Corporation. Moving and handling people: Bariatric clients [Internet]. Wellington; 2012:387-406. Available from: https://www.acc.co.nz/assets/provider/acc6075-moving-guide-bariatric.pdf.

16) Stats NZ. Injury statistics – work-related claims: 2020 | Stats NZ [Internet]. 2020 [cited 2022 Feb 24]. Available from: https://www.stats.govt.nz/information-releases/injury-statistics-work-related-claims-2020.

17) Capital & Coast District Health Board. Patient admission to discharge plan (PADP) [1.1415]. Capital & Coast District Health Board; 2019.

18) Capital & Coast District Health Board. Bariatric Equipment [1.102666]. Capital & Coast District Health Board; 2018.

19) Capital & Coast District Health Board. Moving and Handling [1.1709]. Capital & Coast District Health Board; 2018.

20) Capital & Coast District Health Board. Moving and Handling Patients and Objects (Draft) [1.1709]. Capital & Coast District Health Board; 2021.

21) Capital & Coast District Health Board. Malnutrition in adult inpatients [1.102212]. Capital & Coast District Health Board; 2019.

22) Capital & Coast District Health Board. Prevention and Management of Patient Falls [1.551]. Capital & Coast District Health Board; 2021.

23) Capital & Coast District Health Board. Health and Safety [1.3116]. Capital & Coast District Health Board; 2017.

24) Capital & Coast District Health Board. Admission to Transit Lounge [1.3141]. Capital & Coast District Health Board; 2021.

25) Capital & Coast District Health Board. Pressure Injury Prevention and Management [1.58]. Capital & Coast District Health Board; 2019.

26) Capital & Coast District Health Board. Adverse Event and Incident Management [1.8723]. Capital & Coast District Health Board; 2019.

27) Population of Capital & Coast DHB [Internet]. Ministry of Health NZ. [cited 2022 Apr 11]. Available from: https://www.health.govt.nz/new-zealand-health-system/my-dhb/capital-coast-dhb/population-capital-coast-dhb.

28) Wakefield BJ. Facing up to the reality of missed care. BMJ Qual Saf. 2014 Feb;23(2):92-4.

29) Gustafsson N, Leino-Kilpi H, Prga I, Suhonen R, Stolt M, RANCARE consortium COST Action – CA15208. Missed Care from the Patient’s Perspective - A Scoping Review. Patient Prefer Adherence. 2020;14:383-400.

30) Scruth EA, Pugh D. Omission of Nursing Care: An International Perspective. Clin Nurse Spec CNS. 2018 Aug;32(4):172-4.

31) Hales C, Amankwaa I, Gray L, Rook H. Providing care for older adults with extreme obesity in aged residential care facilities: An environmental scan. Nurs Prax N Z. 2020 Nov;36(3):24-36.

32) Worksafe New Zealand. Moving and handling people in the healthcare industry [Internet]. Worksafe; 2018 [cited 2022 Feb 17]. Available from: https://www.worksafe.govt.nz/topic-and-industry/health-and-safety-in-healthcare/moving-and-handling-people-in-the-healthcare-industry/.

33) Henke RM, Karaca Z, Jackson P, Marder WD, Wong HS. Discharge Planning and Hospital Readmissions. Med Care Res Rev MCRR. 2017 Jun;74(3):345-68.

34) Shepperd S, Lannin NA, Clemson LM, McCluskey A, Cameron ID, Barras SL. Discharge planning from hospital to home. Cochrane Database Syst Rev. 2013 Jan 31;(1):CD000313.

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Extreme obesity is typically defined as a body mass index (BMI) equal to or greater than 40kg/m[[2]]. In 2021, approximately 5.9% of adults in Aotearoa New Zealand were identified as extremely obese, with this statistic disproportionately represented amongst structurally marginalised groups, including Māori (13.0%), Pasifika peoples (24.5%) and those living in areas of high deprivation (11.9%).[[1]] Bariatric service delivery refers to the care received by those with additional needs due to extreme obesity; this includes appropriate spatial facility design, equipment uses, and collection of information needed to inform high quality services. It does not explicitly relate to specialist care for weight loss management (i.e., bariatric surgery).

The prevalence of patients admitted to hospitals with extreme obesity is unknown, although the prevalence is likely to be higher than the general population with estimates as high as 16% in North American studies of general medical patients.[[2,3]] Hospitalised patients with extreme obesity have poorer healthcare outcomes than normal-weight patients,[[4–7]] including longer lengths of stay, higher likelihoods of intensive care admission, increased risk of pressure injuries, falls, and readmission within 28 days of discharge.[[4–7]] Despite the plethora of literature highlighting the importance of appropriate bariatric service delivery,[[5,8,9]] health services in Aotearoa New Zealand do not meet the care needs of this patient population, as care is often fragmented and specialised equipment is frequently unavailable, missing or too small.[[10–12]] Currently there is a lack of robust evidence regarding variation of service provision for patients with extreme obesity by Te Whatu Ora districts.

In 2016, Capital & Coast District Health Board (CCDHB) introduced bariatric care bundles (defined as a package of wider beds, mobilisation and hygiene equipment) into the bariatric care pathway to address equipment concerns. Subsequently, this approach to bariatric service provision has been introduced into four other DHBs (Auckland, Waitematā, Canterbury, and Hutt Valley) based on a research and industry-led initiative.[[13,14]] The utilisation of these bundles as a part of the bariatric care service remains unaudited at CCDHB, and the adherence to and application of current bariatric policies remain unexplored. Additionally, the prevalence of patients admitted to CCDHB requiring bariatric care is currently unknown, limiting the ability of service providers to plan service delivery needs for this population.

Whilst moving and handling training is mandatory for all staff at CCDHB, 28 reportable events between April and September 2021 identified patients’ weight as a contributing factor leading to staff injuries, and equipment issues. The Accident Compensation Corporation (ACC) Moving and Handling Guidelines report healthcare workers have one of the highest rates of musculoskeletal disorders among all occupational groups.[[15]] In 2019, healthcare work-related entitlement claims were around 6%. Of those, soft tissue injury accounted for 64%.[[16]] To approach this concern, regular examining of safe patient handling practices may serve as a strategy in controlling unnecessary costs and improving staff and patient outcomes.[[5]]

Aim and objectives

This clinical audit aims to benchmark the quality of bariatric service delivery against moving and handling and patient care best-practice standards and determine the prevalence of hospitalised patients admitted to Wellington Regional Hospital (WRH) requiring bariatric level care. Researchers will identify areas of improvement in service delivery and provide recommendations relevant to CCDHB policies.

Criteria and standards

The audit framework was developed using ACC Moving and Handling Guidelines for bariatric patients[[15]] and relevant CCDHB policies (Appendices, Tables S1–10). The ACC guidelines were originally developed in 2003 and updated in 2012 following review of international research, consultation with healthcare stakeholders and international peer review. The purpose of ACC guidelines is to reduce manual and patient handling injuries.[[15]] The recommendations listed in the guidelines reflect evidence-informed practices consistent with international standards for safe patient handling and processes that should be considered in care planning for hospitalised patients requiring bariatric services.[[15]] These processes include admission planning, client assessment, communication, room preparation, mobilisation plan, equipment needs, space and facility design considerations and planning for discharge.[[15]] Additionally, relevant CCDHB policies and procedures were used to structure the audit framework and include: “Patient Admission to Discharge Plan”;[[17]] “Bariatric Equipment”;[[18]] “Moving and Handling”;[[19]] “Moving and Handling Patients and Objects”;[[20]] “Malnutrition in Adult Inpatients;”[[21]] “Prevention and Management of Patient Falls”;[[22]] “Health and Safety”;[[23]] “Admission to Transit Lounge”;[[24]] “Pressure Injury Prevention and Management”;[[25]] and “Adverse Event and Incident Management”.[[26]]

Method

This baseline clinical audit consisted of retrospective and cross-sectional components to identify patients requiring bariatric services admitted to WRH. Patients were identified as bariatric if they had a BMI equal to or greater than 40kg/m[[2]]; weighed ≥150kg, or had large physical dimensions requiring bariatric equipment.

Cross-sectional survey

All adult inpatients aged 18 years and over on one of nine adult inpatient wards were included in the point prevalence survey. Paediatric and delivery/postnatal wards were excluded due to different requirements and service decision-making processes. Three researchers conducted the survey (BY, EB, CH) on two occasions: 15 December 2021 and 19 January 2022. The clinical team did not calculate a sample size a priori, as the audit was limited in time and resources and only conducted on two single days. A post hoc sample size analysis with 95% confidence interval (CI) was conducted.

Patients requiring bariatric level care were identified from the clinical notes. Where no data was available, patients were asked their height and weight. The audit team calculated BMI to affirm the patient’s bariatric status. If a patient was eligible for clinical audit, researchers assessed the spatial design considerations and equipment suitability as per the criteria and standards framework (Appendices, Tables S1–10). Patients were asked to complete a hospital patient satisfaction survey about their care experiences.

Retrospective case-note review

All adult patients aged 18 years and over identified as requiring bariatric level care admitted to WRH between 1 August and 30 September 2021 were included in the case-note review. Pregnant women were excluded due to the difficulty of using BMI to determine bariatric status. The case-note review was completed to benchmark the quality of documented care against the bariatric service delivery standards framework. Researchers identified eligible patients through a bariatric equipment hire database and electronic medical records coding system. Data collection was conducted by two researchers (BY, EB).

Collected data was stored and managed using RedCap. The information collected included seven areas of moving and handling and patient satisfaction (Table 1). Data analysis was conducted using Microsoft Excel. Descriptive statistics of absolute differences and percentages of documented care that did or did not meet practice standards were analysed and presented.

Ethical approval was not required. However, the audit was conducted within an ethical framework, which included maintaining patient confidentiality, not collecting unnecessary data, anonymising all data at the time of data collection, and using the hospital secure data management software system. The clinical audit was approved by the CCDHB Clinical Audit Committee in December 2021 (Audit Approval Number: 2021/73).

Results

Cross-sectional point prevalence survey

A total of 548 patients were included in the point prevalence survey (Table 2). Of those, 6.4% of patients (n=35) were identified as bariatric. A post hoc sample size analysis shows that given a sample of 548 people, the precision of our estimate of extreme obesity is reasonable (95% CI=4.6–8.8).

Most patients requiring bariatric services were admitted as an emergency admission (80.0%) and had some level of mobility (71.4%). Of those patients identified as bariatric, 22.9% were Māori (n=8), 25.7% were Pasifika peoples (n=9), 45.7% were New Zealand (NZ) European (n=16) and 5.7% identified as other ethnicity (n=2); indicating that Māori and Pasifika peoples are overrepresented in this patient population. The clinical team identified two thirds of patients requiring bariatric services (65.7%), with the remaining (34.3%) detected by the audit team (n=12).

Five bariatric patients included in the point prevalence survey did not complete the clinical audit of facility design, space and equipment. Reasons included: that health conditions excluded the ability to be assessed, refusal to participate, or that they were absent from the ward area at the time of data collection.

Only bed spaces(33.3%) where patients were independently mobile met the standard for accommodating all equipment required to manage bariatric care and mobilise comfortably from bed to chair or commode (Table 3). Only 29.5% of all equipment used during patient care had sufficient, safe working loads to prevent actual and potential injury to patients and staff. Whilst some items had a sufficient working load, the dimensions of the equipment were not suitable to fit the patient’s size and shape. Most ward areas did not meet the standard of a safe environment; 80.0% of bed spaces and 83.3% of bathroom spaces failed to achieve the standard. Despite this, 53.3% of facilities for bariatric patients were designed to support safe moving and handling assistance. The patient satisfaction survey demonstrated an overall positive report of patients’ experience of the service received at WRH.

Retrospective case-note review

A total of 26 patients requiring bariatric services were included in the retrospective case-note review during the two-month period (see Table 4). Of those patients identified, 34.6% were Māori (n=9), 19.2% were Pasifika peoples (n=5) and 46.2% were NZ European (n=12); indicating that Māori and Pasifika peoples are overrepresented in this patient population. Most patients requiring bariatric service delivery were admitted as an emergency admission (84.6%). Five patients were excluded from the retrospective case-note review as they did not meet the bariatric inclusion criteria (incomplete data, pregnancy during admission and age (adult <18 years)).

Over two thirds of patients (69.2%) had a weight documented on or within 24 hours of admission (see Table 5). Of those patients requiring any equipment or other resources needed for moving and handling, 25% was documented as ordered. Only one bariatric bundle had been requested and was reported to have arrived within one hour, meeting the standard. The standard that all issues, patient experiences and discussions relative to bariatric care with patient and family/whānau should be documented was not achieved at all for any patient.

Most bariatric patients (92.3%) had documentation of the number of staff needed for moving and handling as per their care plan (Table 5). Additionally, 88.5% of patients had identification and assessment of moving and handling hazards documented as they appeared throughout care. Despite the evaluation of patient handling risks being documented, the LITE (Load, Individual, Task, Environment) assessment was not documented at all. Nursing staff had completed the documentation of 61.3% of patients’ risk assessments (mobility, Braden Scale, and nutrition) and 36.4% of patients who were eligible for delirium screens. Of those, the majority of risk assessments were completed within 8–16 hours of admission. Of the 25 patients, 56% of cases had written care plans by nursing staff within 8–16 hours of admission. The standard of health professionals providing education relative to bariatric needs was not achieved at all.

Most patients (73.1%) had mobility plans documented (Table 5), with daily updates completed approximately one third (36.8%) of the time. Despite mobility plans being documented, the standard that patients and families/whānau were involved in the mobility assessment process was not achieved at all.

Three quarters of patients were documented as having the appropriate equipment to be managed and maintained safely. However, 37.5% of patients did not meet this standard. This result does not equate to 100%, as a single patient could have more than one piece of equipment for their care. Additionally, 20% of patients had the appropriateness of rooms assessed by Nurse in Charge and/or Duty Nurse Manager documented.

A documented discharge plan listed within the Patient Admission to Discharge Plan (PADP) achieved standard 26.1% of the time. One third of patients had appropriate equipment documented at discharge. Additionally, all patients had a recorded discharge time noted within the Medical Application Portal (MAP). However, this is an automatic management tool and therefore does not reflect the sufficiency of documentation in the workplace.

Two patients (7.7%) had reportable events documented. In both cases “weight” was identified as a contributing factor. Both reportable events attributed to staff and patient did achieve all applicable standards for report processing (Table 4).

View Tables 1–5.

Discussion

This audit aimed to benchmark the quality of bariatric service delivery against moving and handling and patient care best practice standards. One critical finding of this audit was the lack of identification by the clinical teams that a patient met the criteria for bariatric service support. This significant issue can contribute to missed care opportunities to provide high quality care, and increases the risk of injury to staff and patients if inappropriate equipment is used. Missed care refers to delayed or omitted care (in part or whole) of any aspect required in a patient’s care plan.[[28]] Failure to appropriately provide care has been recognised as contributing to adverse events and lowering the overall quality of care.[[29]] This problem globally affects patient outcomes, including extended lengths of stay, increased risk of pressure ulcers, and hospital-acquired infections.[[30]] Failure to identify patients requiring bariatric services consequently impacts the communication of appropriate care between clinical teams. Of those requiring moving and handling assistance, only 28.6% of patient handling risks were communicated to other wards at handover.

Findings from the audit showed little consideration was given to the spatial and facility design for those patients with extreme obesity. Our results demonstrated 80% of bed spaces did not meet ACC’s standards for a safe environment.[[15]] Predominantly, bed spaces failed on the premise that the foot of the bed did not have 1,200mm of clear space to allow the safe transferring of a patient. Additionally, most bathroom spaces did not meet the standards. This was due to the bathroom space not having a minimum of 450mm from the toilet bowl centre to the wall or door openings failing to have a minimum of 1,200mm clear width. These findings are consistent with previous healthcare literature;[[11,31]] a study conducted by Hales et al. found the physical environment of the hospital created mobilisation difficulties for all participants in several care situations.[[11]] Hales et al. indicated space was a significant factor that impacted largely on the participant’s ability to mobilise independently or with equipment assistance.[[11]] Failure to create a safe environment for moving and handling will compel clinical teams to exhibit unsafe patient handling to complete a task. This will contribute to a higher likelihood of adverse events caused to staff and patients.

There were frequent issues with availability and suitability of bariatric equipment. Whilst CCDHB has “within-the-hour” access to all bariatric equipment necessary for patient care needs, its use in patient care was dependent on staff request. Safe working loads and inappropriate equipment dimensions to fit the size and shape of the patient were of most concern and related most often to shower stools and chairs. Researchers identified that most shower supplies could maintain a person’s weight with extreme obesity. However, it was not deemed appropriate due to the equipment frame not being able to fit the size and shape of the individual or the uncomfortableness while doing so. Additionally, researchers discovered that at the time of the point prevalence, the clinical team ordered a bariatric bed for one patient, but it was not delivered. The clinical team failed to follow up on this issue due to time pressures. This reinforces the issue of missed care opportunities for patients with bariatric needs, often resulting in inequities and inconsistencies in delivering high quality healthcare. Failure to provide timely and appropriate equipment suitable for patients with bariatric level support can result in continued discomfort, slower recovery and preventable reportable events caused to staff and patients.

The majority of patients in this audit had documented assessment of moving and handling hazards as they appeared throughout care. However, documentation of the LITE assessment did not achieve standard. This is a significant concern as the moving and handling of bariatric patients can carry a serious risk. The LITE principles are a method to remember key risk factors that should be considered when preparing safe patient handling tasks.[[32]] Clinical teams must consider all four principles before starting a handling technique and organising any equipment. Failure to provide documentation of LITE assessments leaves staff and patients at risk of injuries.

There was poor adherence with documenting discharge plans within the PADP. Discharge planning is crucial to improving the efficiency and quality of healthcare delivery.[[33]] A Cochrane Review identified that individualised discharge planning reduces the length of hospital stay and readmission rates for adults.[[34]] The effectiveness of individualised discharge planning does not differ for elective and emergency admissions.[[33]] Failure to provide discharge planning will cause further missed care opportunities and a higher risk of re-admission for a patient requiring bariatric services.

There was a noticeable discrepancy between patient satisfaction and standards of service delivery. This suggests service users are not aware of what they might expect during their care. From this audit it is not possible to determine if this discrepancy is specific to patients requiring bariatric level support or the population in general, due to the stigma of obesity.

Our audit has several limitations. Researchers relied on a clinical team report for the cross-sectional point prevalence if a patient was not present (i.e., not in ward at the time of data collection). Additionally, researchers entrusted patients’ estimation of weight and height if not independently measured by the clinical team. The cross-sectional audit result could potentially be affected by  the difference in seasonal effects on admissions of people with extreme obesity, as it was only conducted in the summer, and the absence of COVID-19 hospitalisations during the period of data collection. Undertaking this type of audit at different time points across the year will assist in determining a more accurate hospital prevalence. The exclusion of pregnant women with extreme obesity means the assessment of standards of care within the maternity service was not established leading to an under-estimation of overall hospital bariatric need. Researchers could not assess the duration of time from ordering equipment to delivery due to confidentiality reasons. However, researchers acknowledge 80–90% of equipment deliveries via Essential (a partnership agency providing bariatric, fall prevention and pressure relief equipment to CCDHB), are delivered within an hour of request based on company reporting. In the case-note review, there were no means to assess if actual equipment ordered met the needs and physical size requirements of the patient. Therefore, equipment reported as ordered was deemed appropriate. Although most standards were achieved for patients receiving bariatric services, the audit is unable to determine if care was culturally safe as there were no benchmarks for cultural safety within the ACC recommendations or CCDHB policies. A final limitation to the audit is the currency of the ACC moving and handling standards used to inform the clinical audit. A review and update of the evidence is required.

This clinical audit highlights the need for further consideration of how clinical teams correctly identify patients who require bariatric level support. Better processes need to be developed to improve communication and documents in the decision-making of care practices and equipment needs; supported by moving and handling education. The inclusion of bariatric experts on the redesign of hospitals and retrofitting of clinical areas is vital to ensure future care facilities appropriately meet safe environmental standards.

Conclusion

Current identification measures for patients with extreme obesity are not always practiced at CCDHB, contributing to missed care opportunities and adverse effects for patients and clinical teams. Developing and improving policy adherence will assist in addressing shortcomings in the standard of providing a safe environment for bariatric patients to support a high quality care.

View Appendices.

Summary

Abstract

Aim

To benchmark the quality of bariatric service delivery against moving and handling and patient care best practice standards, and determine the prevalence of hospitalised patients admitted to Wellington Regional Hospital requiring bariatric level care.

Method

A clinical audit consisting of retrospective case-note review and cross-sectional survey was conducted and benchmarked against Accident Compensation Corporation (ACC) national standards. Information recorded included patient demographics, admission planning, patient anthropometric and risk assessments, provider communication, room preparation, mobilisation plan, equipment needs, space and facility design considerations, discharge planning and reportable events.

Results

A total of 574 patients were included. The prevalence of hospitalised patients requiring bariatric services was 6.4%. One third of patients (34.3%) were not identified by clinical teams as requiring bariatric support. Most bed (80%) and bathroom (83%) spaces failed to achieve the facility design standard. The majority of patient focused moving and handling hazards were documented whereas environmental hazards or equipment limitations were poorly reported. Only 26.1% of patients had a documented discharge plan.

Conclusion

Inadequate identification of patients requiring bariatric support and insufficient documentation of bariatric service delivery were identified. Improving policy adherence will address shortcomings in the provision of a safe environment and high quality care for bariatric patients.

Author Information

Bailey Yee: Summer Scholarship Student, Faculty of Health, Te Herenga Waka – Victoria University of Wellington, Wellington, New Zealand. Eleanor Barrett: Moving and Handling Specialist, Centre of Clinical Excellence, Capital & Coast, and Hutt Valley Districts, New Zealand. Dr Mona Jeffreys: Senior Research Fellow, Health Services Research Centre, Te Herenga Waka – Victoria University of Wellington, Wellington, New Zealand. Dr Anne Haase: Associate Professor, School of Health, Te Herenga Waka – Victoria University of Wellington, Wellington, New Zealand. Dr Caz Hales: Senior Lecturer, Registered Nurse, School of Nursing, Midwifery and Health Practice, Te Herenga Waka – Victoria University of Wellington. Wellington, New Zealand.

Acknowledgements

We would like to thank the following staff at CCDHB who provided guidance and support for the audit: Anne Pedersen, Group Manager, Centre of Clinical Excellence; Marina Dzhelali, Research Office Manager; Kristy Macdonald, Clinical Audit and Certification Coordinator, Centre of Clinical Excellence. At the time of the clinical audit, Wellington Regional Hospital and Kenepuru Hospital were part of Capital & Coast District Health Board.

Correspondence

Caz Hales: School of Nursing, Midwifery and Health Practice, Te Herenga Waka – Victoria University of Wellington, PO Box 600. Wellington, New Zealand. Ph: 04 463 6135

Correspondence Email

Caz.hales@vuw.ac.nz

Competing Interests

Nil.

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2) Hossain MA, Amin A, Paul A, Qaisar H, Akula M, Amirpour A, et al. Recognizing Obesity in Adult Hospitalized Patients: A Retrospective Cohort Study Assessing Rates of Documentation and Prevalence of Obesity. J Clin Med. 2018 Aug 7;7(8):203.

3) Howe E, Wright S, Landis R, Kisuule F. Addressing Obesity in the Hospitalized Patient: A Needs Assessment. South Am Assoc. 2010;103(6):500-3.

4) Fusco K, Robertson H, Galindo H, Hakendorf P, Thompson C. Clinical outcomes for the obese hospital inpatient: An observational study. SAGE Open Med. 2017 Jan 1;5:2050312117700065.

5) Gallagher S. A practical guide to bariatric safe patient handling and mobility. Sarasota, Florida: Vision Publishing; 2015.

6) Hauck K, Hollingsworth B. The Impact of Severe Obesity on Hospital Length of Stay. Med Care. 2010;48(4):335-40.

7) Ness SJ, Hickling DF, Bell JJ, Collins PF. The pressures of obesity: The relationship between obesity, malnutrition and pressure injuries in hospital inpatients. Clin Nutr [Internet]. 2017 Aug 19 [cited 2018 Jul 24]; Available from: http://www.sciencedirect.com/science/article/pii/S0261561417302972.

8) Hales C, deVries K, Coombs M. The challenges in caring for morbidly obese patients in Intensive Care: A focused ethnographic study. Aust Crit Care. 2018;31(1):37-41.

9) Rose MA, Drake DJ, Baker G, Watkins FRJ, Waters W, Pokorny M. Caring for morbidly obese patients: Safety considerations for nurse administrators. Nurs Manag (Harrow). 2008 Nov;39(11):47-50.

10) Hales C. Misfits: An ethnographic study of extremely fat patients in intensive care [Internet] [PhD]. Victoria University, Wellington; 2015 [cited 2018 Jul 24]. Available from: http://researcharchive.vuw.ac.nz/handle/10063/4155.

11) Hales C, Curran N, deVries K. Morbidly obese patients’ experiences of mobility during hospitalisation and rehabilitation: A qualitative descriptive study. Nurs Prax N Z. 2018;3(1):20-31.

12) Vanderwolf V. Does one size fit all? Factors associated with prolonged length of stay among patients who have bariatric needs in a New Zealand hospital: A retrospective chart review [Master of Nursing]. [New Zealand]: University of Auckland; 2018.

13) Cassie F. The big and small of caring for the very large. New Zealand Nursing Review. 2016 Jul 1;1-8.

14) McMillan V. Sizing up care that will fit the larger patients of today and tomorrow. NZ Doctor. 2016 Feb 24;1-2.

15) Accident Compensation Corporation. Moving and handling people: Bariatric clients [Internet]. Wellington; 2012:387-406. Available from: https://www.acc.co.nz/assets/provider/acc6075-moving-guide-bariatric.pdf.

16) Stats NZ. Injury statistics – work-related claims: 2020 | Stats NZ [Internet]. 2020 [cited 2022 Feb 24]. Available from: https://www.stats.govt.nz/information-releases/injury-statistics-work-related-claims-2020.

17) Capital & Coast District Health Board. Patient admission to discharge plan (PADP) [1.1415]. Capital & Coast District Health Board; 2019.

18) Capital & Coast District Health Board. Bariatric Equipment [1.102666]. Capital & Coast District Health Board; 2018.

19) Capital & Coast District Health Board. Moving and Handling [1.1709]. Capital & Coast District Health Board; 2018.

20) Capital & Coast District Health Board. Moving and Handling Patients and Objects (Draft) [1.1709]. Capital & Coast District Health Board; 2021.

21) Capital & Coast District Health Board. Malnutrition in adult inpatients [1.102212]. Capital & Coast District Health Board; 2019.

22) Capital & Coast District Health Board. Prevention and Management of Patient Falls [1.551]. Capital & Coast District Health Board; 2021.

23) Capital & Coast District Health Board. Health and Safety [1.3116]. Capital & Coast District Health Board; 2017.

24) Capital & Coast District Health Board. Admission to Transit Lounge [1.3141]. Capital & Coast District Health Board; 2021.

25) Capital & Coast District Health Board. Pressure Injury Prevention and Management [1.58]. Capital & Coast District Health Board; 2019.

26) Capital & Coast District Health Board. Adverse Event and Incident Management [1.8723]. Capital & Coast District Health Board; 2019.

27) Population of Capital & Coast DHB [Internet]. Ministry of Health NZ. [cited 2022 Apr 11]. Available from: https://www.health.govt.nz/new-zealand-health-system/my-dhb/capital-coast-dhb/population-capital-coast-dhb.

28) Wakefield BJ. Facing up to the reality of missed care. BMJ Qual Saf. 2014 Feb;23(2):92-4.

29) Gustafsson N, Leino-Kilpi H, Prga I, Suhonen R, Stolt M, RANCARE consortium COST Action – CA15208. Missed Care from the Patient’s Perspective - A Scoping Review. Patient Prefer Adherence. 2020;14:383-400.

30) Scruth EA, Pugh D. Omission of Nursing Care: An International Perspective. Clin Nurse Spec CNS. 2018 Aug;32(4):172-4.

31) Hales C, Amankwaa I, Gray L, Rook H. Providing care for older adults with extreme obesity in aged residential care facilities: An environmental scan. Nurs Prax N Z. 2020 Nov;36(3):24-36.

32) Worksafe New Zealand. Moving and handling people in the healthcare industry [Internet]. Worksafe; 2018 [cited 2022 Feb 17]. Available from: https://www.worksafe.govt.nz/topic-and-industry/health-and-safety-in-healthcare/moving-and-handling-people-in-the-healthcare-industry/.

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34) Shepperd S, Lannin NA, Clemson LM, McCluskey A, Cameron ID, Barras SL. Discharge planning from hospital to home. Cochrane Database Syst Rev. 2013 Jan 31;(1):CD000313.

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Extreme obesity is typically defined as a body mass index (BMI) equal to or greater than 40kg/m[[2]]. In 2021, approximately 5.9% of adults in Aotearoa New Zealand were identified as extremely obese, with this statistic disproportionately represented amongst structurally marginalised groups, including Māori (13.0%), Pasifika peoples (24.5%) and those living in areas of high deprivation (11.9%).[[1]] Bariatric service delivery refers to the care received by those with additional needs due to extreme obesity; this includes appropriate spatial facility design, equipment uses, and collection of information needed to inform high quality services. It does not explicitly relate to specialist care for weight loss management (i.e., bariatric surgery).

The prevalence of patients admitted to hospitals with extreme obesity is unknown, although the prevalence is likely to be higher than the general population with estimates as high as 16% in North American studies of general medical patients.[[2,3]] Hospitalised patients with extreme obesity have poorer healthcare outcomes than normal-weight patients,[[4–7]] including longer lengths of stay, higher likelihoods of intensive care admission, increased risk of pressure injuries, falls, and readmission within 28 days of discharge.[[4–7]] Despite the plethora of literature highlighting the importance of appropriate bariatric service delivery,[[5,8,9]] health services in Aotearoa New Zealand do not meet the care needs of this patient population, as care is often fragmented and specialised equipment is frequently unavailable, missing or too small.[[10–12]] Currently there is a lack of robust evidence regarding variation of service provision for patients with extreme obesity by Te Whatu Ora districts.

In 2016, Capital & Coast District Health Board (CCDHB) introduced bariatric care bundles (defined as a package of wider beds, mobilisation and hygiene equipment) into the bariatric care pathway to address equipment concerns. Subsequently, this approach to bariatric service provision has been introduced into four other DHBs (Auckland, Waitematā, Canterbury, and Hutt Valley) based on a research and industry-led initiative.[[13,14]] The utilisation of these bundles as a part of the bariatric care service remains unaudited at CCDHB, and the adherence to and application of current bariatric policies remain unexplored. Additionally, the prevalence of patients admitted to CCDHB requiring bariatric care is currently unknown, limiting the ability of service providers to plan service delivery needs for this population.

Whilst moving and handling training is mandatory for all staff at CCDHB, 28 reportable events between April and September 2021 identified patients’ weight as a contributing factor leading to staff injuries, and equipment issues. The Accident Compensation Corporation (ACC) Moving and Handling Guidelines report healthcare workers have one of the highest rates of musculoskeletal disorders among all occupational groups.[[15]] In 2019, healthcare work-related entitlement claims were around 6%. Of those, soft tissue injury accounted for 64%.[[16]] To approach this concern, regular examining of safe patient handling practices may serve as a strategy in controlling unnecessary costs and improving staff and patient outcomes.[[5]]

Aim and objectives

This clinical audit aims to benchmark the quality of bariatric service delivery against moving and handling and patient care best-practice standards and determine the prevalence of hospitalised patients admitted to Wellington Regional Hospital (WRH) requiring bariatric level care. Researchers will identify areas of improvement in service delivery and provide recommendations relevant to CCDHB policies.

Criteria and standards

The audit framework was developed using ACC Moving and Handling Guidelines for bariatric patients[[15]] and relevant CCDHB policies (Appendices, Tables S1–10). The ACC guidelines were originally developed in 2003 and updated in 2012 following review of international research, consultation with healthcare stakeholders and international peer review. The purpose of ACC guidelines is to reduce manual and patient handling injuries.[[15]] The recommendations listed in the guidelines reflect evidence-informed practices consistent with international standards for safe patient handling and processes that should be considered in care planning for hospitalised patients requiring bariatric services.[[15]] These processes include admission planning, client assessment, communication, room preparation, mobilisation plan, equipment needs, space and facility design considerations and planning for discharge.[[15]] Additionally, relevant CCDHB policies and procedures were used to structure the audit framework and include: “Patient Admission to Discharge Plan”;[[17]] “Bariatric Equipment”;[[18]] “Moving and Handling”;[[19]] “Moving and Handling Patients and Objects”;[[20]] “Malnutrition in Adult Inpatients;”[[21]] “Prevention and Management of Patient Falls”;[[22]] “Health and Safety”;[[23]] “Admission to Transit Lounge”;[[24]] “Pressure Injury Prevention and Management”;[[25]] and “Adverse Event and Incident Management”.[[26]]

Method

This baseline clinical audit consisted of retrospective and cross-sectional components to identify patients requiring bariatric services admitted to WRH. Patients were identified as bariatric if they had a BMI equal to or greater than 40kg/m[[2]]; weighed ≥150kg, or had large physical dimensions requiring bariatric equipment.

Cross-sectional survey

All adult inpatients aged 18 years and over on one of nine adult inpatient wards were included in the point prevalence survey. Paediatric and delivery/postnatal wards were excluded due to different requirements and service decision-making processes. Three researchers conducted the survey (BY, EB, CH) on two occasions: 15 December 2021 and 19 January 2022. The clinical team did not calculate a sample size a priori, as the audit was limited in time and resources and only conducted on two single days. A post hoc sample size analysis with 95% confidence interval (CI) was conducted.

Patients requiring bariatric level care were identified from the clinical notes. Where no data was available, patients were asked their height and weight. The audit team calculated BMI to affirm the patient’s bariatric status. If a patient was eligible for clinical audit, researchers assessed the spatial design considerations and equipment suitability as per the criteria and standards framework (Appendices, Tables S1–10). Patients were asked to complete a hospital patient satisfaction survey about their care experiences.

Retrospective case-note review

All adult patients aged 18 years and over identified as requiring bariatric level care admitted to WRH between 1 August and 30 September 2021 were included in the case-note review. Pregnant women were excluded due to the difficulty of using BMI to determine bariatric status. The case-note review was completed to benchmark the quality of documented care against the bariatric service delivery standards framework. Researchers identified eligible patients through a bariatric equipment hire database and electronic medical records coding system. Data collection was conducted by two researchers (BY, EB).

Collected data was stored and managed using RedCap. The information collected included seven areas of moving and handling and patient satisfaction (Table 1). Data analysis was conducted using Microsoft Excel. Descriptive statistics of absolute differences and percentages of documented care that did or did not meet practice standards were analysed and presented.

Ethical approval was not required. However, the audit was conducted within an ethical framework, which included maintaining patient confidentiality, not collecting unnecessary data, anonymising all data at the time of data collection, and using the hospital secure data management software system. The clinical audit was approved by the CCDHB Clinical Audit Committee in December 2021 (Audit Approval Number: 2021/73).

Results

Cross-sectional point prevalence survey

A total of 548 patients were included in the point prevalence survey (Table 2). Of those, 6.4% of patients (n=35) were identified as bariatric. A post hoc sample size analysis shows that given a sample of 548 people, the precision of our estimate of extreme obesity is reasonable (95% CI=4.6–8.8).

Most patients requiring bariatric services were admitted as an emergency admission (80.0%) and had some level of mobility (71.4%). Of those patients identified as bariatric, 22.9% were Māori (n=8), 25.7% were Pasifika peoples (n=9), 45.7% were New Zealand (NZ) European (n=16) and 5.7% identified as other ethnicity (n=2); indicating that Māori and Pasifika peoples are overrepresented in this patient population. The clinical team identified two thirds of patients requiring bariatric services (65.7%), with the remaining (34.3%) detected by the audit team (n=12).

Five bariatric patients included in the point prevalence survey did not complete the clinical audit of facility design, space and equipment. Reasons included: that health conditions excluded the ability to be assessed, refusal to participate, or that they were absent from the ward area at the time of data collection.

Only bed spaces(33.3%) where patients were independently mobile met the standard for accommodating all equipment required to manage bariatric care and mobilise comfortably from bed to chair or commode (Table 3). Only 29.5% of all equipment used during patient care had sufficient, safe working loads to prevent actual and potential injury to patients and staff. Whilst some items had a sufficient working load, the dimensions of the equipment were not suitable to fit the patient’s size and shape. Most ward areas did not meet the standard of a safe environment; 80.0% of bed spaces and 83.3% of bathroom spaces failed to achieve the standard. Despite this, 53.3% of facilities for bariatric patients were designed to support safe moving and handling assistance. The patient satisfaction survey demonstrated an overall positive report of patients’ experience of the service received at WRH.

Retrospective case-note review

A total of 26 patients requiring bariatric services were included in the retrospective case-note review during the two-month period (see Table 4). Of those patients identified, 34.6% were Māori (n=9), 19.2% were Pasifika peoples (n=5) and 46.2% were NZ European (n=12); indicating that Māori and Pasifika peoples are overrepresented in this patient population. Most patients requiring bariatric service delivery were admitted as an emergency admission (84.6%). Five patients were excluded from the retrospective case-note review as they did not meet the bariatric inclusion criteria (incomplete data, pregnancy during admission and age (adult <18 years)).

Over two thirds of patients (69.2%) had a weight documented on or within 24 hours of admission (see Table 5). Of those patients requiring any equipment or other resources needed for moving and handling, 25% was documented as ordered. Only one bariatric bundle had been requested and was reported to have arrived within one hour, meeting the standard. The standard that all issues, patient experiences and discussions relative to bariatric care with patient and family/whānau should be documented was not achieved at all for any patient.

Most bariatric patients (92.3%) had documentation of the number of staff needed for moving and handling as per their care plan (Table 5). Additionally, 88.5% of patients had identification and assessment of moving and handling hazards documented as they appeared throughout care. Despite the evaluation of patient handling risks being documented, the LITE (Load, Individual, Task, Environment) assessment was not documented at all. Nursing staff had completed the documentation of 61.3% of patients’ risk assessments (mobility, Braden Scale, and nutrition) and 36.4% of patients who were eligible for delirium screens. Of those, the majority of risk assessments were completed within 8–16 hours of admission. Of the 25 patients, 56% of cases had written care plans by nursing staff within 8–16 hours of admission. The standard of health professionals providing education relative to bariatric needs was not achieved at all.

Most patients (73.1%) had mobility plans documented (Table 5), with daily updates completed approximately one third (36.8%) of the time. Despite mobility plans being documented, the standard that patients and families/whānau were involved in the mobility assessment process was not achieved at all.

Three quarters of patients were documented as having the appropriate equipment to be managed and maintained safely. However, 37.5% of patients did not meet this standard. This result does not equate to 100%, as a single patient could have more than one piece of equipment for their care. Additionally, 20% of patients had the appropriateness of rooms assessed by Nurse in Charge and/or Duty Nurse Manager documented.

A documented discharge plan listed within the Patient Admission to Discharge Plan (PADP) achieved standard 26.1% of the time. One third of patients had appropriate equipment documented at discharge. Additionally, all patients had a recorded discharge time noted within the Medical Application Portal (MAP). However, this is an automatic management tool and therefore does not reflect the sufficiency of documentation in the workplace.

Two patients (7.7%) had reportable events documented. In both cases “weight” was identified as a contributing factor. Both reportable events attributed to staff and patient did achieve all applicable standards for report processing (Table 4).

View Tables 1–5.

Discussion

This audit aimed to benchmark the quality of bariatric service delivery against moving and handling and patient care best practice standards. One critical finding of this audit was the lack of identification by the clinical teams that a patient met the criteria for bariatric service support. This significant issue can contribute to missed care opportunities to provide high quality care, and increases the risk of injury to staff and patients if inappropriate equipment is used. Missed care refers to delayed or omitted care (in part or whole) of any aspect required in a patient’s care plan.[[28]] Failure to appropriately provide care has been recognised as contributing to adverse events and lowering the overall quality of care.[[29]] This problem globally affects patient outcomes, including extended lengths of stay, increased risk of pressure ulcers, and hospital-acquired infections.[[30]] Failure to identify patients requiring bariatric services consequently impacts the communication of appropriate care between clinical teams. Of those requiring moving and handling assistance, only 28.6% of patient handling risks were communicated to other wards at handover.

Findings from the audit showed little consideration was given to the spatial and facility design for those patients with extreme obesity. Our results demonstrated 80% of bed spaces did not meet ACC’s standards for a safe environment.[[15]] Predominantly, bed spaces failed on the premise that the foot of the bed did not have 1,200mm of clear space to allow the safe transferring of a patient. Additionally, most bathroom spaces did not meet the standards. This was due to the bathroom space not having a minimum of 450mm from the toilet bowl centre to the wall or door openings failing to have a minimum of 1,200mm clear width. These findings are consistent with previous healthcare literature;[[11,31]] a study conducted by Hales et al. found the physical environment of the hospital created mobilisation difficulties for all participants in several care situations.[[11]] Hales et al. indicated space was a significant factor that impacted largely on the participant’s ability to mobilise independently or with equipment assistance.[[11]] Failure to create a safe environment for moving and handling will compel clinical teams to exhibit unsafe patient handling to complete a task. This will contribute to a higher likelihood of adverse events caused to staff and patients.

There were frequent issues with availability and suitability of bariatric equipment. Whilst CCDHB has “within-the-hour” access to all bariatric equipment necessary for patient care needs, its use in patient care was dependent on staff request. Safe working loads and inappropriate equipment dimensions to fit the size and shape of the patient were of most concern and related most often to shower stools and chairs. Researchers identified that most shower supplies could maintain a person’s weight with extreme obesity. However, it was not deemed appropriate due to the equipment frame not being able to fit the size and shape of the individual or the uncomfortableness while doing so. Additionally, researchers discovered that at the time of the point prevalence, the clinical team ordered a bariatric bed for one patient, but it was not delivered. The clinical team failed to follow up on this issue due to time pressures. This reinforces the issue of missed care opportunities for patients with bariatric needs, often resulting in inequities and inconsistencies in delivering high quality healthcare. Failure to provide timely and appropriate equipment suitable for patients with bariatric level support can result in continued discomfort, slower recovery and preventable reportable events caused to staff and patients.

The majority of patients in this audit had documented assessment of moving and handling hazards as they appeared throughout care. However, documentation of the LITE assessment did not achieve standard. This is a significant concern as the moving and handling of bariatric patients can carry a serious risk. The LITE principles are a method to remember key risk factors that should be considered when preparing safe patient handling tasks.[[32]] Clinical teams must consider all four principles before starting a handling technique and organising any equipment. Failure to provide documentation of LITE assessments leaves staff and patients at risk of injuries.

There was poor adherence with documenting discharge plans within the PADP. Discharge planning is crucial to improving the efficiency and quality of healthcare delivery.[[33]] A Cochrane Review identified that individualised discharge planning reduces the length of hospital stay and readmission rates for adults.[[34]] The effectiveness of individualised discharge planning does not differ for elective and emergency admissions.[[33]] Failure to provide discharge planning will cause further missed care opportunities and a higher risk of re-admission for a patient requiring bariatric services.

There was a noticeable discrepancy between patient satisfaction and standards of service delivery. This suggests service users are not aware of what they might expect during their care. From this audit it is not possible to determine if this discrepancy is specific to patients requiring bariatric level support or the population in general, due to the stigma of obesity.

Our audit has several limitations. Researchers relied on a clinical team report for the cross-sectional point prevalence if a patient was not present (i.e., not in ward at the time of data collection). Additionally, researchers entrusted patients’ estimation of weight and height if not independently measured by the clinical team. The cross-sectional audit result could potentially be affected by  the difference in seasonal effects on admissions of people with extreme obesity, as it was only conducted in the summer, and the absence of COVID-19 hospitalisations during the period of data collection. Undertaking this type of audit at different time points across the year will assist in determining a more accurate hospital prevalence. The exclusion of pregnant women with extreme obesity means the assessment of standards of care within the maternity service was not established leading to an under-estimation of overall hospital bariatric need. Researchers could not assess the duration of time from ordering equipment to delivery due to confidentiality reasons. However, researchers acknowledge 80–90% of equipment deliveries via Essential (a partnership agency providing bariatric, fall prevention and pressure relief equipment to CCDHB), are delivered within an hour of request based on company reporting. In the case-note review, there were no means to assess if actual equipment ordered met the needs and physical size requirements of the patient. Therefore, equipment reported as ordered was deemed appropriate. Although most standards were achieved for patients receiving bariatric services, the audit is unable to determine if care was culturally safe as there were no benchmarks for cultural safety within the ACC recommendations or CCDHB policies. A final limitation to the audit is the currency of the ACC moving and handling standards used to inform the clinical audit. A review and update of the evidence is required.

This clinical audit highlights the need for further consideration of how clinical teams correctly identify patients who require bariatric level support. Better processes need to be developed to improve communication and documents in the decision-making of care practices and equipment needs; supported by moving and handling education. The inclusion of bariatric experts on the redesign of hospitals and retrofitting of clinical areas is vital to ensure future care facilities appropriately meet safe environmental standards.

Conclusion

Current identification measures for patients with extreme obesity are not always practiced at CCDHB, contributing to missed care opportunities and adverse effects for patients and clinical teams. Developing and improving policy adherence will assist in addressing shortcomings in the standard of providing a safe environment for bariatric patients to support a high quality care.

View Appendices.

Summary

Abstract

Aim

To benchmark the quality of bariatric service delivery against moving and handling and patient care best practice standards, and determine the prevalence of hospitalised patients admitted to Wellington Regional Hospital requiring bariatric level care.

Method

A clinical audit consisting of retrospective case-note review and cross-sectional survey was conducted and benchmarked against Accident Compensation Corporation (ACC) national standards. Information recorded included patient demographics, admission planning, patient anthropometric and risk assessments, provider communication, room preparation, mobilisation plan, equipment needs, space and facility design considerations, discharge planning and reportable events.

Results

A total of 574 patients were included. The prevalence of hospitalised patients requiring bariatric services was 6.4%. One third of patients (34.3%) were not identified by clinical teams as requiring bariatric support. Most bed (80%) and bathroom (83%) spaces failed to achieve the facility design standard. The majority of patient focused moving and handling hazards were documented whereas environmental hazards or equipment limitations were poorly reported. Only 26.1% of patients had a documented discharge plan.

Conclusion

Inadequate identification of patients requiring bariatric support and insufficient documentation of bariatric service delivery were identified. Improving policy adherence will address shortcomings in the provision of a safe environment and high quality care for bariatric patients.

Author Information

Bailey Yee: Summer Scholarship Student, Faculty of Health, Te Herenga Waka – Victoria University of Wellington, Wellington, New Zealand. Eleanor Barrett: Moving and Handling Specialist, Centre of Clinical Excellence, Capital & Coast, and Hutt Valley Districts, New Zealand. Dr Mona Jeffreys: Senior Research Fellow, Health Services Research Centre, Te Herenga Waka – Victoria University of Wellington, Wellington, New Zealand. Dr Anne Haase: Associate Professor, School of Health, Te Herenga Waka – Victoria University of Wellington, Wellington, New Zealand. Dr Caz Hales: Senior Lecturer, Registered Nurse, School of Nursing, Midwifery and Health Practice, Te Herenga Waka – Victoria University of Wellington. Wellington, New Zealand.

Acknowledgements

We would like to thank the following staff at CCDHB who provided guidance and support for the audit: Anne Pedersen, Group Manager, Centre of Clinical Excellence; Marina Dzhelali, Research Office Manager; Kristy Macdonald, Clinical Audit and Certification Coordinator, Centre of Clinical Excellence. At the time of the clinical audit, Wellington Regional Hospital and Kenepuru Hospital were part of Capital & Coast District Health Board.

Correspondence

Caz Hales: School of Nursing, Midwifery and Health Practice, Te Herenga Waka – Victoria University of Wellington, PO Box 600. Wellington, New Zealand. Ph: 04 463 6135

Correspondence Email

Caz.hales@vuw.ac.nz

Competing Interests

Nil.

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