Retrofitting Healthcare Facilities for Bariatric Patients: A Cost Analysis Study in a Public Sector Hospital of a Developing Country

Abstract

Background:

The rising trend of obesity and morbid obesity around the world emphasizes the need for designing healthcare facilities that fit the needs of these patients. Keeping in view the safety of morbidly obese patients and also the staff handling them, it was thought pertinent to study and analyze the structural, manpower, and financial aspects that need consideration while planning a bariatric facility.

Materials and Methods:

This study was carried out in an apex tertiary care hospital in India through review of literature and in-depth interviews of stakeholders providing care and facilities as well as from the market to determine the spacing needs and cost of retrofitting a 10-bedded bariatric facility in an existing hospital. Traditional method of cost analysis was used to arrive at the cost estimates for the financial year 2016–2017.

Results:

An estimated cost of U.S. $39,139 (INR 2,616,500) per bed has been projected in retrofitting the setting of this study with a 10-bedded bariatric facility with an existing manpower pool for the same. For a retrofitting facility requiring additional manpower, an estimated cost of U.S. $90,496 (INR 6,049,700) per bed has been projected in this study setting.

Conclusion:

Given the growth of bariatric population both worldwide and in India, it is need of the hour to consider retrofitting existing healthcare facilities for bariatric patients. Although hospitals would incur an initial cost in such retro-fittings, in the long run, they would overrun their value in terms of patient needs and satisfaction, which indeed is the ultimate goal in healthcare.

Introduction

In the past few years, there has been a dramatic rise in the number of overweight and obese population reporting to hospitals because of their clinical condition. In 2014, the World Health Organization estimated 13% of the global population to be overweight and obese. It has been stated that >50% of the obese population in the world live in 10 countries with the United States, China, and India accounting for nearly 28% of them.¹ A multicentric study carried out in India has reflected the prevalence of overweight to be 33.5% and obesity to be 6.8%.² The United States also incurs a direct aggregate cost of $113.9 billion on obesity and overweight residents.³ An Indian study among urban married women estimated an average monthly expenditure of U.S. $1.97 (INR 132) in overweight, U.S. $2.14 (INR 143) in obese, and U.S. $3.35 (INR 224) in morbidly obese women compared with only 1.02 U.S. $ (INR 68) in normal weight women, accounting for 2–3% more expenditure on health to the total household expenditure.⁴

In the past 20 years there has been an increase in the number of admissions of bariatric patients to healthcare facilities.⁵ This increase in number presents a challenge to the healthcare facilities and other service providers in terms of providing care that is effective and safe for both the patient and the healthcare provider. These patients have special physical and emotional needs^6,7 that must be addressed by the healthcare facility to make them comfortable and exempt them from having any feeling of discrimination or neglect. The hospital administrator is also duty bound to safeguard the health of his employees from any occupation-related injury and therefore, the need to cater to bariatric patients with special facilities and protocols. They pose increased risk to the providers because of their physical structure causing injury and difficulty in maintaining hygiene. In addition, many patients suffer from chronic diseases such as diabetes, osteoarthritis, cancer, hyperventilation, sleep apnea, cardiovascular, and hepatobiliary complications, and so on, and their complications lead to longer hospital stay.^8–10 Intravenous cannulation and cardiopulmonary resuscitation are relatively challenging in bariatric patients compared with nonbariatric patients. Majority of the government hospitals including teaching institutions have not recognized the special needs of bariatric patients in terms of facility design and care protocol. Therefore, given this scenario, this study aimed to specify the facility requirements and cost analysis for retrofitting/converting an existing facility into a 10-bedded bariatric facility of a tertiary care hospital to meet the requirements of bariatric patients.

Methodology

This study was carried out at the All India Institute of Medical Sciences (AIIMS), New Delhi, an apex tertiary care hospital, as a project to study and develop a plan for care of bariatric patients reporting to the hospital to seek medical and surgical care and also estimate the cost of setting up such a facility in an existing hospital. For preparation of the plan, literature was reviewed from bibliographic databases such as PubMed and Google Scholar, and in-depth interviews were carried out with different stakeholders. In-depth discussions were held with the specialist surgeon performing bariatric surgeries, nurses, and hospital attendants providing care to bariatric patients in the existing facility and thematic analysis was carried out to understand the issues and challenges faced by them in rendering care to bariatric patients. Traditional method of cost analysis was used to arrive at the cost estimates for the financial year 2016–2017. The cost of setting up a 10-bedded facility into an existing hospital infrastructure was calculated after acquiring the costs for various equipments from different vendors/suppliers in the market. In addition, costs were attributed to various other cost centers such as manpower. Manpower costs were determined by taking into consideration the current pay packages being drawn by the personnel working in similar positions at AIIMS, New Delhi. Land costs and costs for support services have not been considered as the hospital is already constructed and is functional. However, costs of renovation have been considered after due deliberations and in-depth analysis of the costs incurred by the Engineering Service Division at the hospital under study.

Results

The institute is an over 2000-bedded tertiary care teaching institute situated in North India and has been receiving >150 morbidly obese patients annually for treatment at their facility. Among these >100 patients are admitted annually for various bariatric care procedures. The safety of these patients and the staff deployed to take care of them make it imperative for the authors to look into this aspect.

Visit to any health facility is warranted because of either a routine health problem or an emergency condition; hence, healthcare facilities should be planned accordingly to accept a bariatric patient in both the conditions. The design considerations should reflect both at the emergency department and in the different inpatient care areas. As regards the provision of special equipment and other arrangements, facility may be provided according to the availability of resources and number of visits by such patients. Planning facilities for bariatric patients need to be performed in a stepwise manner with broad vision. This article presents a plan of such facility in four major dimensions:

Infrastructure and facility plan in terms of space.

Planning of equipments.

Planning for manpower.

Estimation of cost and financial implications.

Infrastructure and facility plan in terms of space

Architects and designers need to consider many things when designing to accommodate obese patients, from wider doorways, heavy-duty beds, adequate-sized toilets, to overhead patient lifts. The American Institute of Architects have recommended some guidelines that need to be taken into account when planning a bariatric facility.^5,11–13

Building entries: Buildings should have entry points with comfortable ramps and hand rails with a minimum door width of 0.97 m. The building entries should be facilitated with adequate-sized wheel chairs, waiting areas, and public toilets.

Treatment and procedure rooms: Procedure and treatment rooms need to be adjusted to accommodate the bariatric clients and facilitate the entry of bariatric beds/trolleys and wheel chairs. The bariatric beds are ∼1.01 m wide along with side bars and 2.7 m in length compared with a normal bed of 2.6 m. Bariatric wheel chairs are sized at 0.9 m width. Therefore, entry to the treatment room should be such as to accommodate the same with 1.8 m turning radius. Doors of examination rooms should be at least 1.2 m wide with possibly sliding features.

Patient rooms and toilets: In general, it has been recommended that the patient room should have an additional space of 9.29 m². It is also to be considered that bariatric patients are likely to have obese family members and care givers and therefore the furnishings should be adequately sized. An equipment manufacturer recommends that the bariatric room be at least 25.26 m² compared with the average private room size of 16.35 m². This allows for 1524 mm of clear space around three sides of the patient's bed to provide ample room for wheelchairs (including an 1828.8 mm turning radius), walkers, and portable patient lifts. Doors, seating space for attendants, washrooms, and so on in the facility structure need due consideration.

Toilets need to have a wider door width of 1.09 m and adequate space for two caregivers to assist a patient with preferably centrally located commode seat. Walls should have extra-strength blocking to accommodate grab bars that support up to 363 kg and sinks that are capable of supporting additional weight.

Planning of equipment

Bariatric wheel chairs: Typical dimensions for bariatric wheelchairs are 0.88–0.99 m in width by 0.66 m in depth in comparison with the standard wheelchairs that are typically 0.66 m in width by 0.66 m in depth. In selecting bariatric wheelchairs, it is important to check the ergonomics for easy movement with increased weight load.

Stretchers: Bariatric stretchers with integrated scales are available with weight capacities up to 318 kg. The use of powered high/low stretchers may be advantageous to facilitate patient transfer and positioning.

Examination table: Examination tables with weight capacity of 363 kg should be used instead of standard tables having weight capacity of 182 kg. Powered tables that are capable of lowering to as little as 0.45 m from the floor should be used to facilitate the transition from a wheelchair onto the examination table.

Air mattresses: Theses mattresses enable air-assisted safe patient lateral transfers, thereby minimizing the risk of injury to the patient and to the care provider. They also prevent any skin shearing and bruising. The mattresses available in the market are also radiolucent and magnetic resonance imaging compatible for artifact-free imaging.

Weighing scales: Special bariatric weighing scales have weight capacity of ∼363 kg. Scales with higher weight limits are typically electronic that require batteries or 115 V power to operate and wheelchair-accessible scales with additional features such as body mass index and body fat percentage calculators.

Physiologic monitors and sphygmomanometers: Sphygmomanometers and monitors need to be supplied with extra-large cuff sizes so that they may fit bariatric patients and accurate readings may be obtained.

Diagnostic imaging system: Primary considerations for imaging systems for bariatric patients include the bore size, table capacity, and image quality. Bore size is a critical factor when evaluating the potential use of an imaging device for extremely obese patients, as standard bore sizes may be insufficient for an extremely obese patient. The weight-bearing capacity of the system and the image quality need to be considered.

Operating room tables: Bariatric operating room tables are available with weight-bearing capacities of up to 454 kg with additional side extenders and foot boards.

Overhead lifts/slings/hoists: To minimize injuries and ensure safety of patient and hospital staff, three types of hoists with appropriate safe working load may be used: electric mobile hoists, hydraulic mobile hoists, and gantry hoists that are available in different sizes.

Deep vein thrombosis (DVT) pumps: Special emphasis may be laid on provision of DVT pumps in these facilities because the condition of DVT in these patients, although rare, is a preventable complication.

Although the list is exhaustive, the above-mentioned list gives a fair idea of the equipments and facility plan to be considered for a bariatric healthcare facility.

Planning for manpower

Planning of manpower for a bariatric facility may be looked upon in two different scenarios:

Inan existing healthcare facility to be retrofitted for the provision of bariatric care. Here, some staff including specialists (if available), resident doctors, nurses, and hospital attendants who are already working in the current setting may be deployed in the retrofitted facility and the focus then should be onto redefine their job responsibilities to an extent to match the requirements of such a facility. Because, in this case, the area retrofitted for such special care would be carved out from an existing functional area of the hospital, the staff previously working there may be employed for the care of bariatric patients with some amount of training. Here, new hospital staff may be minimal and less cost is incurred on manpower.

In a stand-alone bariatric care facility that is not associated or part of the existing healthcare facility. Here, the requirement for trained manpower comes into place and needs to be planned accordingly as all the staff required for operationalizing the center may have to be appointed. Table 1 gives the manpower requirement for bariatric facility.

In addition to the projected staff, there are certain cadres as given hereunder that individual healthcare organization may consider recruiting depending on their individual needs:

Specialized nursing staff.

Secretarial staff.

Data entry operators.

Table 1.

Manpower Requirement for a 10-Bedded Bariatric Facility^14–16

Manpower	Number required	Norms followed
Professor	1	Medical Council of India: Norms for faculty in teaching hospitals
Assistant Professor	2	Medical Council of India: Norms for faculty in teaching hospitals
Residents	8	Medical Council of India: Norms for faculty in teaching hospitals. In addition, practical considerations were also considered
Nurses	18	SIU Norms
Technicians	6	No norms are available. Number was determined as per the workload in the hospital under study
Group D staff	12	No norms are available. Number was determined as per the workload in the hospital under study

“Staffing in Nursing Units” 2010; Medical Council of India 1999; Clinical Establishment Act Standards for Hospital (LEVEL 2) 2010.

SIU, Staff Inspection Unit.

Cost estimate and financial implications

Table 2 gives an overview of the expenditure incurred in retrofitting an existing healthcare facility while making structural adjustment and allied health staffing that is necessary for a facility to accommodate and safely handle bariatric patients for inpatient care. Estimating total costs for a construction project that will take 2–4 years to complete is an art that involves knowing the subtleties contained in a project. The costs given hereunder include the cost of the specialized equipment required in addition to the trained manpower required to successfully operationalize these facilities. Cost was determined after consulting various equipment manufacturers and distributors. Manpower costs were determined by taking into consideration the current pay packages being drawn by the personnel working in similar positions at AIIMS, New Delhi. Land costs and costs for support services have not been considered as the hospital is already constructed and is functional. However, costs of renovation have been considered. The total cost determined to set up a 10-bedded bariatric facility in an existing hospital is approximately U.S. $904,960 (INR 60,497,000). The cost as estimated is U.S. $90,496 (INR 6,049,700) per bed. In healthcare settings/institutions where specialized manpower already exists, the cost for retrofitting such a facility will be U.S. $391,395 (INR 26,165,000) amounting to U.S. $39,139 (INR 2,616,500) per bed (Table 2).

Table 2.

Cost Estimate for Setting Up a 10-Bedded Bariatric Facility

Equipment (A)	Cost per unit ^a	Number required	Total cost ^a
Bariatric beds	U.S. $5,235.6 (INR 350,000)	10	U.S. $52,356 (INR 3,500,000)
Bariatric wheelchairs	U.S. $748 (INR 50,000)	3	U.S. $2,244 (INR 150,000)
Patient shifting trolleys	U.S. $3,365.74 (INR 225,000)	3	U.S. $10,097 (INR 675,000)
Weighing scales	U.S. $748 (INR 50,000)	2	U.S. $1,496 (INR 100,000)
Commode	U.S. $1,795 (INR 120,000)	12	U.S. $21,540 (INR 1,440,000)
Bed stands	U.S. $374 (INR 25,000)	12	U.S. $4,488 (INR 300,000)
Other furniture			U.S. $74,794 (INR 5,000,000)
Total (A)			U.S. $167,015 (INR 11,165,000)

Manpower (B)	Financial implications per annum ^a	Number required	Total ^a
Professor	U.S. $35,901 (INR 2,400,000)	1	U.S. $35,901 (INR 2,400,000)
Assistant professor	U.S. $26,028 (INR 1,740,000)	3	U.S. $78,084 (INR 5,220,000)
Residents	U.S. $16,694 (INR 1,116,000)	8	U.S. $133,552 (INR 8,928,000)
Nurses	U.S. $10,770 (INR 720,000)	18	U.S. $193,860 (INR 12,960,000)
Technicians	U.S. $8,078 (INR 540,000)	6	U.S. $48,468 (INR 3,240,000)
Group D staff	U.S. $1,975 (INR 132,000)	12	U.S. $23,700 (INR 1,584,000)
Total (B)			U.S. $513,565 (INR 34,332,000)
Renovation cost (C)	U.S. $22,438 (INR 1,500,000)	10	U.S. $224,380 (INR 15,000,000)
Total (A+B+C)			U.S. $90,4960 (INR 60,497,000)

Currency converted as per rate on September 15, 2016 (1 U.S. $ = 66.85 INR).

Discussion

As evident, the world is facing an increase in the number of morbidly obese patients across the world. In addition to the increasing weight of the general patient population, a boom in bariatric surgical procedures, such as gastric bypass, stomach reductions, and banding operations, are bringing an ever-increasing number of obese patients to healthcare providers. The daunting rise has created a need for hospitals to invest in architectural designs and equipment to effectively serve these patients. A need to develop the niche to help cater to the needs of these patients has arisen and in fact the whole hospital should be equipped to cater to their needs. Healthcare today is focused on patient and employee safety.

As per the American College of Surgeons and the American Society of Metabolic and Bariatric Surgeons, accommodations for the obese person should be included in every part of the hospital, including outpatient clinics, radiology, the operating room, and the nursing floors.¹⁷ Need-based assessments after taking into consideration the prevalence of obese patients in their community before deciding the size of the facility should be carried out. If the facility is yet in the planning and designing phase, measures for obese patients should be incorporated within their design budgets.

Given the space constraints and high resource required to set up newer facilities, it is pertinent for the healthcare planners to renovate the existing facilities to make them obese friendly. In the United States, a recent survey concluded that among the hospitals that participated in the survey only 25% had invested in physical renovations to accommodate morbidly obese patients, although 63% reported performing more surgeries on bariatric patients over the past 18 months. The report further found that the estimated median cost of the renovations is $1.2 million. Hospitals across the west have spent >$100,000 in retrofitting its units to suit the needs of bariatric patients.¹⁸ A survey was carried out by an organization to know from directors of materials management and directors of surgical services regarding how hospitals are responding to increased need for equipments, facilities, and supplies for the care of obese patients. The most common new supplies cited by respondents included wheelchairs, beds, lifts, and commodes, at a mean estimated cost of $43,015 per room. The most common new product categories included furniture, surgical supplies, including lifting and transfer equipment. In fact, 55% of respondents said their organizations have purchased special equipment to help turn, raise, and lower patients.^11,19 Our study however, reported a cost of U.S. $39,040.33 per bed in retrofitting an existing healthcare facility with preexisting manpower pool and a cost of U.S. $90,266.48 per bed while considering additional manpower for the same.

The need for retrofitting varies from complete architectural overhauls to just procuring and installing a few minor transport equipments such as larger patient trolleys and wheelchairs. Not every hospital caters to a large numbers of morbidly obese patients. So the challenge for the top management is “how do you plan for an undetermined population that's going to come in randomly with varying needs?”

Staffing is another aspect that needs to be considered while calculating costs involved in setting up a bariatric facility. Bariatric care requires a team of experienced and committed surgeons, anesthesiologists, nurses, and nutritionists. In addition, trained and experienced staff is required in the recovery room and patient floors. This staff is required to be trained to handle nasogastric and abdominal wall drainage tubes and ambulation of morbidly obese patients. Knowledge of common perioperative complications and ability to recognize intravascular volume, cardiac, diabetic, and vascular problems are required.

Hospitals have to consider the full gamut of needs. Accommodating all the needs of such patients is a costly affair. Making changes to accommodate obese patients can be expensive because bariatric equipment and supplies cost 25–30% more than traditionally sized items.²⁰ In addition, obese patients often require longer hospital stays, more clinical staff, and costlier interventions than patients who are not obese. Obesity-related conditions such as sleep apnea and diabetes also increase the cost of care.

Conclusion

Healthcare executives and administrators are recognizing the growing relation of design of their facilities and their ability to adequately cater to all patients with care, safety, and dignity. Design is a critical tool in improving long-term clinical outcomes for bariatric patients. Three significant contributors to a well-designed bariatric facility management are adequate spacing and functional design, appropriate equipments and furnishings, and adequate staff training. Keeping in view the statistical projections of growth of bariatric population both worldwide and in India, it is the urgent need of the hour to consider retrofitting existing healthcare facilities for bariatric clients. Although hospitals would incur an initial cost in such retrofittings, in the long run, they would overrun their value in terms of patient needs and satisfaction, which indeed is the ultimate goal in healthcare.

Footnotes

Acknowledgments

The authors of the study sincerely acknowledge the Engineering Services Department at All India Institute of Medical Sciences for all the information related to construction and renovation cost shared by them. We also acknowledge the vendors and suppliers contacted during market survey to estimate the cost of equipments required for a bariatric facility.

Author Disclosure Statement

No competing financial interests exist.

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