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Interprofessional Collaboration in Developing Best Practices for Bariatric Patient Care
GTA Rehab Best Practices Day May 1, 2015
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Credit Valley Hospital 2200 Eglinton Avenue West, Mississauga
Mississauga Hospital 100 Queensway West, Mississauga
Queensway Health Centre 150 Sherway Drive, Toronto
In the next 8 minutes we will:
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• Demonstrate lessons learned in the rehabilitation setting regarding care of the Bariatric patient
• Demonstrate the close interprofessional connections required to achieve patient and team goals
Credit Valley Hospital 2200 Eglinton Avenue West, Mississauga
Mississauga Hospital 100 Queensway West, Mississauga
Queensway Health Centre 150 Sherway Drive, Toronto
Clinical Objectives
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• To restore function through interprofessional collaboration, clinical expertise, environmental and equipment modification, and partnership with the Bariatric patient
• To develop new THP Bariatric Care Standards to reflect interprofessional collaboration
Credit Valley Hospital 2200 Eglinton Avenue West, Mississauga
Mississauga Hospital 100 Queensway West, Mississauga
Queensway Health Centre 150 Sherway Drive, Toronto
Clinical Priorities
• Wound healing
• Optimizing nutritional status & knowledge
• Restoring functional mobility
• Restoring self-care independence
• Mitigating injury risk to patient & staff during
patient care, handling and mobility
Goal:
Successful transition from hospital to home
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Interprofessional Team
Patient & Family
MRP
RD
RN
OT PT
OTA/PTA
PSW
RPN
Physiatrist
Vendors
Med. Psych OT
Wound Care RN
Ergonomic OT Employee Health
Manager
Educator
IPAC
Pharmacist
Clinical Leader
MD Consultants RT
CCAC
Clergy
Corporate Services
Compassion ∙ Excellence ∙ Courage
Credit Valley Hospital 2200 Eglinton Avenue West, Mississauga
Mississauga Hospital 100 Queensway West, Mississauga
Queensway Health Centre 150 Sherway Drive, Toronto
Interprofessional Approach to Wound Care
Concerns: • Chronic non-healing wounds
• Moisture and lymphedema management
• Mobility and nutrition
• Compliance with treatment
Solutions: • Coordinate scheduling for wound
dressing changes
• Implement collaborative care routines to maximize recovery, prevent further injury
• Problem solving for dressing application process and equipment needs
• Establish funding needs for additional staff, materials and equipment
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Patient & Family
RN MRP MD Consultants
RD
Clinical Leader
Manager Physiatrist
PSW
OT PT
RPN
OTA/PTA
Wound care RN
IPAC
Ergonomic OT Employee Health
Credit Valley Hospital 2200 Eglinton Avenue West, Mississauga
Mississauga Hospital 100 Queensway West, Mississauga
Queensway Health Centre 150 Sherway Drive, Toronto
Wound Care Impact
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0
0.5
1
1.5
2
2.5
3
3.5
4
4.5
Week 1 Week 3 Week 5 Week 9 Week 12 Week 18
Venous Ulcer Progression Timeline
Venous ulcer timeline
4 = Local colonization/infection
3 = Maintenance
2 = Healing
1= Healed
Credit Valley Hospital 2200 Eglinton Avenue West, Mississauga
Mississauga Hospital 100 Queensway West, Mississauga
Queensway Health Centre 150 Sherway Drive, Toronto
Interprofessional Approach to Self-Care
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Pre-requisites accomplished: • Wound healing to manageable
stage • Ensure nutritional intake, medical
stability • Develop core strength, sitting &
standing tolerance • On-site bariatric equipment
(Ergonomics, vendors)
• Safe transfers & mobility • Ensure adequate staffing In therapy: • Identify anxiety as barrier • Develop self-confidence • Collaborate scheduling • Modify mobility targets • Transition self-care to patient • Develop & implement daily
routines for home
MRP RN
Manager
OT PT RPN
PSW
Wound care RN
Ergonomic OT Employee Health
Med. Psych OT
Patient & Family
IPAC
Physiatrist
Clinical Leader OTA/PTA
CCAC
RD
Vendors
Corporate Services
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Essential Therapy Equipment
Mechanical lift & walk sling Bariatric walker & wheelchair
Ergometer Standing pole
Parallel bars
Credit Valley Hospital 2200 Eglinton Avenue West, Mississauga
Mississauga Hospital 100 Queensway West, Mississauga
Queensway Health Centre 150 Sherway Drive, Toronto
Impact FIM
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Credit Valley Hospital 2200 Eglinton Avenue West, Mississauga
Mississauga Hospital 100 Queensway West, Mississauga
Queensway Health Centre 150 Sherway Drive, Toronto
Interprofessional Approach to Mitigating Injury Risk
Concerns:
• Patient weight + poor mobility status significant safety risk for patient & staff
• Risk of infection transmission (MRSA)
Solutions:
• Involve THP specialist consultants – (Ergonomics, IPAC, Wound care )
• Use of specialized equipment (e.g. Limb slings for dressing changes)
• Partner with vendors to modify equipment
• Work with management re additional staffing needs (PSW)
• Cluster care (wound/self) & therapy sessions (creative scheduling)
• Listen to patient (re: abilities, methods)
• Staff education on equipment/ safe handling
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Vendors
Patient & Family
RN
RPN Manager
Clinical Leader
Ergonomic OT Employee Health
OT PT
OTA/PTA
PSW
IPAC RD
Wound care RN
MD Consultants MRP
Corporate Services
Educator
Credit Valley Hospital 2200 Eglinton Avenue West, Mississauga
Mississauga Hospital 100 Queensway West, Mississauga
Queensway Health Centre 150 Sherway Drive, Toronto
Mitigating Injury Risk Impact
• No injuries to staff or patient (WSIB cost avoidance permits investment in new equipment)
• Less staff fearfulness & stigma
• Reduced stress to wounds through equipment modification
• Timed collaborative interventions and specialized equipment optimized wound healing
• No MRSA transmission
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Credit Valley Hospital 2200 Eglinton Avenue West, Mississauga
Mississauga Hospital 100 Queensway West, Mississauga
Queensway Health Centre 150 Sherway Drive, Toronto
Functional Impact
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Admission Discharge
Wound care: Chronic bilateral venous leg ulcers
Venous ulcers healed Chronic (17 yr.) ulcer healed
Leg circumference: Left: 78 cm Right : 90cm
Leg circumference: Left : 70cm Right: 84 cm
Nutrition: BMI 60.8 Weight: 178.3 kg (393 lbs.)
BMI 41.4 31.9 % weight loss Weight: 138.3 kg (304 lbs.)
Mobility: Mechanical lift transfer Non-ambulatory
Modified Independent transfer Modified Independent with rollator
BADL’s : Total Assist bathing and dressing
Minimum Assist bathing Modified Independent dressing
Psychosocial: Anxiety and fear limiting participation
Completion of self-efficacy scale Improved confidence; self-report
Credit Valley Hospital 2200 Eglinton Avenue West, Mississauga
Mississauga Hospital 100 Queensway West, Mississauga
Queensway Health Centre 150 Sherway Drive, Toronto
Our Next Steps
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• Develop new Interprofessional THP Bariatric Care Plan • Standardize Rehab Bariatric Equipment available (ceiling lift in gym)
• Standardize Rehab Bariatric Treatment Protocols
• Education and Training across THP rehab units
• Collaborate with THP management re anticipated costs for
implementation and care of Bariatric patient
Credit Valley Hospital 2200 Eglinton Avenue West, Mississauga
Mississauga Hospital 100 Queensway West, Mississauga
Queensway Health Centre 150 Sherway Drive, Toronto
Key Messages
• Safety first – for patient & staff
• Specialized equipment & supplies
• Value the patient’s experience
• Creative interprofessional problem solving
• Psychosocial issues impact goal success
• Expect greater LOS, staffing requirement, supply budget – financial implications
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Presenters: Lynn Roberti, Occupational Therapist
Lynn.Roberti@trilliumhealthpartners.ca &
Allison Kirke, RN Wound Care Specialist Allison.Kirke@trilliumhealthpartners.ca
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Authors: Lynn Roberti OT Reg. (Ont.), Allison Kirke RN, BSc N, WOC Jennifer Brown BA, OTA/PTA, Carol Hennigar OT Reg. (Ont.), Janet Suchanek OT Reg. (Ont.), Leslie Howell BSc. PT, Rebekah Joseph RD, Devika Singh-Siripaul RN, BSc N, Educator Anne-Marie Lynch RN, CL Nadia Woloshyn OT Reg. (Ont.) Manager 4J
References
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“Bariatric patients: nursing care and specialist equipment.” The Lamp68(5): 41. Blackett, A. et. al. (2011). Caring for persons with bariatric health care issues. Journal of Wound, Ostomy and Continence Nursing. 38(2) pp 133-138. Boza, J. et. al, (2011). Skin manifestations of obesity: a comparative study. Journal of European Academy of Dermatology and Venereology. (12) pp 1220-1223. Camden, S.G. (2006). Nursing Care of the Bariatric Patient. Bariatric Nursing and Surgical Patient Care 1(1), 21-30. Donini, M., Savina, C., Castellaneta, E., Coletti, C., Paolini, M., Scavone, L., Civale, C., Ceccarelli, P., Zaninotto, S., Tineri, M., Grossi, G., De Felice, M.R., & Cannella, C., (2009) Multidisciplinary approach to obesity. Eat Weight Disorder, 14(1), 23-32. Nelson, A.L., Motacki, K., & Menzel N., (2009) The Illustrated Guide to Safe Patient Handling and Movement. New York: Springer. Nowicki, T., Burns, C., Fulbrook, P., & Jones, J., (2009) Changing the mindset: An inter-disciplinary approach to management of the bariatric patient. ScienceDirect, (16), 171-175. Pokorny, M. et. al. (2014). The relationship between pressure ulcer prevalence, body mass index, and braden scales and subscales: a further analysis. Advances in Skin & Wound Care. 27(1). Pp 26-30. Public Services Health & Safety Association Rush, A. & Muir, M. (2012).Maintaining skin integrity in bariatric patients. British Journal of Community Nursing . 17(4). Pp 154-159. Waters, T.R. (2007). When is it safe to manually lift a patient? The Revised NIOSH Lifting Equation provides support for recommended weight limits. American Journal of Nursing 107(8), 53-59. WHO (2000) Obesity: Preventing and Managing the Global Epidemic: Report of a WHO Consultation on Obesity (HEALTH CANADA) www.worksafebc.com/publications/health_and_safety/by_topic/assets/pdf/handling_patients_bk97.pdf www.washingtonsafepatienthandling.org/images/best_practices/SPH_BPGuide_Chpt5.pdf www.visn8.va.gov/visn8/patientsafetycenter/safePtHandling/toolkitBariatrics.asp
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