Pediatric Bariatrics: Trends in Mobility,Safety,Risk,and Ethics

Introduction

Sixty-seven percent of Americans are considered overweight, while as many as 40% are obese as defined by a body mass index (BMI) of 30 or greater. ¹ Obesity is a major concern for many adults, but more importantly, it is thought to be the most common health problem facing U.S. children today. Conditions associated with excess adiposity are serious and lead to a wide range of debilitating and life-threatening circumstances. In healthcare settings, many pediatric patients who are obese become immobile simply because of their body weight, postural instability, and weight maldistribution. This poses clinical challenges, especially for nurses charged with preventing injury or planning for care. Pediatric nurses often are presented with the difficulty of assessment, planning, and evaluation of size-appropriate care, for which many are largely ill prepared. Both patient safety and caregiver injury are fast becoming serious considerations in managing the clinical care of children who are obese. This article explores and identifies some of the challenges in mobilizing larger children, with an eye to preventing caregiver injury. Safety, risk, and ethical concerns are discussed within this context.

Safety imperative

Several studies reveal the increasing incidence, cost, and number of back injury claims associated with patient care. ² More than half of strains and sprains can be attributed to manual lifting tasks while assisting dependent patients with their mobility needs. Injuries that result from manual lifting and transferring of patients are among the most frequent causes of nursing-related injuries. Patient care becomes more difficult for nurses as the size, balance, and weight of the pediatric population increases. Standard hospital equipment, such as chairs or bed frames, may pose safety risks for children who are obese and their caregivers. On the other hand, processes specially designed for children who are overweight can improve quality of care, reduce the child's length of stay, and make it easier and safer for caregivers to perform basic care. For instance, placing a bedpan under a child who can't walk to the bathroom may be challenging for the caregiver and embarrassing for the child and family members. But with an appropriately sized lift, walker, or bedside commode, the child is likely to become more independent in moving into a position to empty his or her bladder more fully, preventing a hospital-acquired urinary tract infection or hygiene challenges. Heavy-duty walkers, for example, that accommodate both the patient's width and weight make it easier to safely assist in ambulating heavy, weak, or deconditioned children. Beds, support surfaces, and wheelchairs that support up to 1000 pounds (454 kg) also are available. In addition, a number of lift designs are available to mobilize the very large child or the child with a significantly distorted habitus, such as portable floor lifts and ceiling lifts as well as specialized slings and bands. Specially trained mobility teams have been integrated into patient care teams with a high degree of success. ³ Providing processes and equipment specially designed for the larger child is important for reducing work-related back injuries among caregivers and lowering the risk of immobility-related patient safety issues. ⁴

Incorporating the services of the hospital's department of facilities to “re-engineer” otherwise dangerous environmental hazards is a good first step. For example, consider the risks of wall-mounted toilets, where a simple floor-to-commode adapter solves the inherent risk. When selecting oversized equipment, considering the weight limit, height, and width of the equipment is essential. For example, a child may not exceed weight limits for a standard bedside commode, but may be unable to use a standard device because of the width of his or her hips. Many children do not have the height to safely side or foot egress from a bariatric frame. Consider a “low-bed” type frame, typically used for fall prevention, as a tool for ensuring the frame can lower safely to provide proper side egress.

Healthcare facilities must have a plan in place to care for the special needs of the morbidly obese patient. ⁵ Rather than attempting to make standard processes fit all, patients are best served when care is appropriately designed to their size and needs. Criteria-based protocols in place for use with specially designed equipment are created to ensure more appropriate, timely, and cost-sensitive use of equipment. Standardized measurement and definition are a universal criteria wherein to make changes and develop policies.

Reimbursement, clinical guidelines, and criteria-based protocols ought to be available based on weight, height, width at the widest point, and factors such as pain, immobility, sedation, or lack of cooperation, and other factors pose challenges to nursing care. A policy that mandates physical therapy, nurse experts, pharmacy, specialty equipment, or other resources based on patient criteria should be developed to prevent complications and, therefore, improve clinical, cost, and satisfaction outcomes. For example, a child might be provided with an extra-wide bed, heavy-duty walker, mobility team, physical therapy consultation, wound ostomy continence nurse assessment, and clinical social worker evaluation simply based on the child's weight of 320 pounds (145 kg), hip width of 25 inches (64 cm), and shortness of breath on ambulation. The needs of each child will vary, yet the protocol must be written in such a way as to recognize the needs of the child before an adverse outcome develops.

Both equipment and appropriate preplanning are important, yet not enough to protect a child from the common, predictable, and costly complications related to immobility. Nursing education serves as a valuable tool in early recognition of patient care complications. In a recent study, nurses were asked to describe competencies essential to caring for the larger patient. The top three competencies were (a) safety, (b) equipment, and (c) physical assessment. Other competencies described were sensitivity training, etiologies of obesity, emotional issues, and motivation. When asked to identify the best method to teach competencies, the participants listed the following in order of frequency: (a) video, (b) train the trainer, and (c) self-study. ⁶ Preparing for the care of the child who is obese might vary from organization to organization. Regardless, education, preplanning, and equipment are thought to provide frontline tools necessary in safely providing care to the child and protecting caregivers from injury.

Recognizing Risk

Although legal mandates designed to protect patients are in place and used nationwide for all types of negligence, the courts have always had a compelling interest to protect children. Therefore, it is in the best interests of any organization caring for the child who is obese to recognize and understand the legal aspects of negligence when providing service to this high- risk patient population. This is especially true of surgery centers providing metabolic surgery to the under 18-year-old population. From a legal perspective, larger Americans seldom bring attention to themselves. Many individuals of size feel they are responsible for inadequate care because of their weight. However, in the past few years, size and weight acceptance advocates are asserting their legal rights to reasonable accommodation. This is especially true for children; even though children are unable to advocate for themselves, there is increasing interest by the courts, attorneys, size and weight acceptance groups, healthcare organizations, and parents to protect children through reasonable accommodation in the pediatric setting.

Briefly, negligence is a legal theory that applies to many medical malpractice cases. To win a negligence suit, the plaintiff's attorney must prove that four legal elements exist: (a) duty, (b) breach of duty, (c) damages, and (d) causation. Suits can be filed for a number of reasons. Some authors contend that misunderstanding is sometimes at the heart of claims: the patient held an expectation that was not met by the healthcare facility or the nurse(s), and an adverse outcome occurred. However, the occurrence of an adverse outcome does not prove negligence. Negligence must be proven using the four legal elements. Regardless, defending against a lawsuit can be economically and emotionally overwhelming; therefore, avoiding lawsuits is a meaningful objective. If the medical record suggests there is lack of communication between nurses and other members of the healthcare team, attorneys tend to investigate further. This is considered a “red flag.” Clinicians on all levels must communicate, not only with each other, but with the child and family. In the face of intervention that holds special risks, it is important to discuss this with the responsible party and document the discussion.

Attorneys and other experts look to the health record to determine the story of the child's patient care experience, whether it is in the hospital, clinic, or home. In the event that there are questions about what should be documented or how to document a special event, it may be in the nurse's best interest to speak to his or her risk manager. This is especially true in situations where there are issues of compliance. Caring for larger children is certainly more complex even without any co-existing diagnoses or pre-admission mobility issues. Children, their parents, and caregivers are asked to perform tasks that they may be ill equipped to accomplish. Sometimes the inability to carry out activities is because of patient-related fear, apprehension, or misunderstanding. It is important to explore communication and the threat of miscommunication to insensitivity and therefore risk. ⁷

Ethical Concerns

Implementing changes to better manage the unique care issues for the child who is morbidly obese can pose a dilemma for caregivers. The ethical principle of justice may serve as a point of discussion herein. Justice, as it relates to the healthcare setting, generally refers to the just distribution of healthcare goods and services in the face of scarce resources. ⁸ Who gets what?

From an organizational perspective, the initial cost of any change is perceived as an economic liability. Without a meaningful understanding of the cost incurred in caregiver injury and risks of an immobility-related significant event, it may be difficult to economically justify introduction of specialized patient processes, which very well may not be reimbursed by third party payers. In the face of the increasing prevalence of obesity among all age groups, it is expected that pediatric nurses will assume more responsibility for not only understanding pathophysiology, but specialty surgeries, nursing competencies and skills, policies and procedures, emotional and social components of size, or equipment needs in managing the unique needs of the pediatric patient who is obese. This raises the question of allocation of scarce resources and how these resources are distributed fairly among this vulnerable population and others.

Summary

It is well established that the child who is obese presents numerous care challenges, and it is in the interest of health care organizations to meet these challenges in a clinically and ethically sound manner. Comprehensive education, preplanning, proper equipment, and awareness of liability risks serve to improve clinical satisfaction and cost outcomes in caring for children who are obese.