The dramatic increase in obesity in the general population is accompanied by a concomitant increase in bariatric surgical programs. Gastrointestinal endoscopy has an important role in patient evaluation, postoperative management, and emerging endoscopic bariatric therapies. Endoscopy units must address special design and equipment needs of obese patients in short- and long-range planning. Obese people require more health care resources than nonobese people, with increased physical challenges for staff in administering that care. This article details endoscopy unit considerations pertaining to the bariatric patient, which may apply to pretreatment endoscopic evaluation, managing postoperative bariatric surgical complications, and emerging endoluminal bariatric therapies.
The prevalence of class III obesity (body mass index >40 kg/m 2 ) has increased dramatically. As such, bariatric surgery procedures have increased, with surgery becoming widely accepted as the most effective method of weight loss for severe obesity. Gastrointestinal endoscopy has a role in preoperative patient assessment, management of postoperative complications, and as a potential initial bariatric treatment with emerging endoscopic bariatric therapies. Endoscopy units should address the unique design and equipment needs of obese patients in both their short-range and long-range planning. Obese patients require more health care resources than nonobese patients, and there are greater physical challenges for staff and attendants administering care to obese individuals. Basic patient transfer is one such example. Bariatric patients encompass a wide weight range, from roughly 250 to 300 lbs (113–136 kg) to more than 1200 lbs (544 kg). Transferring bariatric patients of these different weight ranges may require special techniques, equipment, and training to assure safety of both the patients and the health care professionals.
Safe and effective performance of gastrointestinal endoscopy has the following requirements ( Table 1 ):
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An adequately trained and credentialed endoscopist to perform specific gastrointestinal endoscopic procedures
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Properly trained nursing and ancillary personnel
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Operational, well-maintained equipment
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Adequately designed and equipped space for patient preparation, performance of procedures, and patient recovery
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Trained personnel and appropriate equipment to perform cardiopulmonary resuscitation.
| All Endoscopy Facilities | Facilities Catering to Obese Patients |
|---|---|
| A properly trained endoscopist with appropriate privileges to perform specific gastrointestinal endoscopic procedures | The facility should comply with the standards of the Americans with Disabilities Act |
| Properly trained nursing and ancillary personnel | Staff must be experienced with and sensitive to the special needs of bariatric patients, and protected against ergonomic and lifting injuries Staffing must be sufficient to safely care for the bariatric patient |
| Operational, well-maintained equipment | Specially rated procedure tables (stretchers) for patients with morbid and supermorbid obesity Carbon dioxide insufflation should be available for endoscopic retrograde cholangiopancreatography and deep enteroscopy procedures |
| Adequately designed and equipped space for patient preparation, performance of procedures, and patient recovery | Facility sized for passage of large-capacity rolling stretchers and wheelchairs through doorways and passages Generously appointed common areas (waiting room, bathroom, etc), with appropriately sized furniture and reinforced commodes, should be available for bariatric patients and their family members |
| Trained personnel and appropriate equipment to perform cardiopulmonary resuscitation | Access to anesthesia providers is desirable Ambulances servicing free-standing endoscopy centers must be equipped to safely care for bariatric patients |
Moreover, for bariatric patients, the following additional considerations apply:
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Facility compliance with the standards of the Americans with Disabilities Act
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A generously appointed waiting room to accommodate bariatric patients and their family members
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Appropriately sized endoscopy unit for passage of large-capacity rolling stretchers and wheelchairs through doorways and passages
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Specially rated procedure tables (stretchers) for patients with severe obesity
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Staff experienced with and sensitive to the special needs of bariatric patients, and protected against ergonomic and lifting injuries.
This article details endoscopy unit considerations pertaining to the bariatric patient, which may apply to pretreatment endoscopic evaluation, postoperative management of bariatric surgical complications, and emerging endoluminal bariatric therapies.
Type of facility
Endoscopy facilities vary, and include hospital-based endoscopy units, single-specialty or multispecialty ambulatory surgery centers (ASCs), and office-based endoscopy suites. Each model has its unique set of advantages, disadvantages, and regulatory issues. The hospital and ASC environments are highly regulated by state and federal agencies and third-party accreditation bodies. In the United States these include the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), the Accreditation Association for Ambulatory Healthcare (AAAHC), and the American Association for Accreditation of Ambulatory Surgery Facilities (AAAASF). Private payers sometimes impose their own specific requirements. Office endoscopy suites, previously less regulated, have been subject to more control by state and federal agencies in recent years.
The institutional needs of a bariatric program extend across outpatient and inpatient environments. The American Society for Metabolic and Bariatric Surgery (ASMBS) has established a Bariatric Surgery Centers of Excellence program. Education and guidance documents are managed by the independent Surgical Review Corporation (SRC). The Bariatric Surgery Review Committee (BSRC) reviews the information, determines whether the guidelines are met, and grants or denies the designation. Many of these principles may be applied to endoscopy units serving the needs of bariatric patients, and in particular for units being developed to perform emerging endoluminal bariatric procedures. Provisional Status requires evidence of an institutional commitment to excellence in the care of bariatric patients, as demonstrated by infrastructure investment and ongoing in-service education programs in the management of bariatric patients.
Hospitals with established bariatric surgery programs are expected to have these provisions in place, at least within dedicated auspices. When performing endoscopic procedures on hospitalized bariatric patients it is desirable to make use of existing provisions; this may mean performing endoscopic procedures in existing bariatric operating room space, and may be the best course of action for managing the superobese and acutely ill patients in the perioperative period. In the former group, facilities and staff dedicated to their management may prove necessary. In most other circumstances, existing endoscopic facilities should be modified and new facilities developed to accommodate bariatric patients, at least within a component of their functionality.
General considerations
Endoscopy units caring for bariatric patients should be expected to maintain a full line of equipment and instruments for the care of such patients. Radiologic tables and facilities for fluoroscopic imaging of obese patients are also desirable. These requirements apply to management of postoperative strictures, leaks and fistulas, and postoperative pancreaticobiliary endoscopy. In addition, these technologies are apt to play roles in emerging endoluminal bariatric procedures.
Most programs currently do not have separate endoscopy units for bariatric patients. In the past, the occasional severely obese patient was handled on an ad hoc basis with existing equipment. Endoscopy programs should have access to equipment and instruments for the care of patients who undergo bariatric surgery. Such equipment may include bariatric procedure tables, lifts, accessories (eg, clips, stents, fibrin glue), and fluoroscopy apparatus to accommodate class III obesity. Radiology equipment with a weight capacity of more than 450 lbs (200 kg) has only recently become available. In addition, chairs, beds, scales, floor-mounted or supported toilets, wheelchairs, and stretchers/litters that are strong enough and wide enough to accommodate the severely obese are required. Furniture and equipment should be able to accommodate patients who are within the anticipated patient weight limits established by the program. Weight capacities should be documented by the manufacturer’s specifications, and this information should be available to relevant staff.
In accordance with provisional status designation by the SRC, appropriate patient movement/transfer systems must also be located wherever bariatric surgery patients receive care. Personnel must be trained to use the equipment and, most importantly, be capable of moving these individuals without injury to the patient or themselves. That said, hospital-based and ambulatory endoscopy units do not need to change all of the equipment, furniture, and instruments throughout the entire facility. This requirement only applies to those areas where patients undergoing bariatric surgery receive care. For some programs, then, this is a dedicated bariatric patient care area. Endoscopic outcomes may well be enhanced when conducted by endoscopists and in endoscopy units with a particular interest, investment, and higher volume of bariatric and related endoscopy.
Reception Area
Severe obesity is associated with social stigma and discrimination. Therefore, obese individuals are often reluctant to venture out of their homes and comfort zones. There are many factors for consideration in the shaping of a space to accommodate severely obese patients—some patently evident, and others that are less obvious. It is important to have furniture, clothing, doorways, bathrooms, and wheelchairs that are appropriate and comfortable for patients with severe obesity and for their families. Families of obese patients tend to be large-sized also, and accommodations for accompanying family members must also be considered ( Fig. 1 ).
Preparation/Recovery Area
Larger beds and larger equipment necessitate larger room dimensions, but planners must recognize that the main determinant of more space is the need for clearance around furniture and equipment to allow the care team to maneuver.
Because severely obese patients, many weighing upwards of 500 lbs (227 kg) and some approaching 1000 lbs (454 kg) are more than one nurse can handle, there must always be at least 2 in the care team to assist in patient transfers and positioning. There are instances when 3 or more caregivers are recommended for patient handling. In addition, extra-large blood pressure cuffs are an essential accessory for monitoring extremely obese patients.
Patient and staff safety should be factored into endoscopy unit design. Employing proper ergonomic techniques is critical to ensuring safety for the care team when assisting the patient. Ergonomically sound transfer techniques require ample clearance at the bedside and in patient seating zones. Furthermore, transferring these patients often requires the use of lifts, yet another reason for ample clearance around the bed.
Even with the most observant and cautious care, patients may fall. Undesired consequences when the severely obese patient falls are notably increased. Wide spacing between the bed and other obstacles will facilitate the care team’s effort in up righting the patient. Wide spacing of furniture and equipment can mitigate the probability of the patient striking objects during a fall.
According to Pelczarski, among the most significant facility design flaws are inadequate doorway widths. Doorways that are too narrow (eg, 34 in [864 mm]) may be problematic for ambulatory bariatric patients using an assistive device such as a walker. Narrow doorways may also be problematic for nonambulatory bariatric patients. Bariatric wheelchairs can be up to 39 inches (991 mm) wide while bariatric beds and stretchers may expand to 57 inches (1448 cm) wide with the side rails up.
The Guidelines for Design and Construction of Hospital and Health Care Facilities set forth by the American Institute of Architects (AIA) mandate a minimum of 3 ft (915 mm) for clearances around the patient bed in a single room. Through a trial of pushing bariatric wheelchairs, stretchers, and beds around in a mock-up room, one group of experts recommended a 5-ft (1524 mm) clearance on the sides and at the foot of the bed. This ensures adequate clearance for the care team to assist the patient in and out of the room or to the bathroom. To accommodate a patient with a bariatric walker and allow passage for other foot traffic, a minimum of 5 ft (60 in or 1524 mm) is required for the width of a corridor ( Fig. 2 ).
Related posts:
Obesity Overview: Epidemiology, Health and Financial Impact, and Guidelines for Qualification for Surgical Therapy
Medical Therapy for Obesity
Presurgical Evaluation and Postoperative Care for the Bariatric Patient
Management of Acute Postoperative Hemorrhage in the Bariatric Patient
Accessing the Pancreatobiliary Limb and ERCP in the Bariatric Patient
Management of Postsurgical Leaks in the Bariatric Patient
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