Safe ‘‘Handoffs’’ for the Morbidly Obese

Elaine S. Scott, PhD, RN, NE-BC,1 Marie E. Pokorny, PhD, RN,1

Mary Ann Rose, EdD,1 and Frank Watkins, BSN2

Abstract

The safety movement has brought awareness to the critical events that occur in the handoff of patients fromone point of care to another. The purpose of this study was to learn more about the nursing care and safetymanagement needs of morbidly obese patients transitioned to the community with home healthcare.Findings related to adequacy of equipment, staffing, and resources for morbidly obese patients are re-ported from a survey of home health nurses. The study highlights the accommodations home care agenciesmake to assure safe care of this population of patients and provides insight into the care transitioning thatneeds to occur between agencies. Additionally, personal injury and safety issues faced by nurses andnursing assistants working with the morbidly obese in home health are explored.

Background

Although research on best practices inthe care of morbidly obese and bariatric

patients is increasing, it remains at an infancystage.1 Most of the research to date has beenundertaken in hospital environments, whereadequate equipment, manpower, and resourcesare more readily available for the managementof the morbidly obese. Care of these clients inthe community poses a particular challenge toemergency medical services and home health-care agencies where the assurance of adequatestaff and resources is less dependable.2,3

To address these inconsistencies, the safetymovement has increased awareness about theneed to assure proper care of patients acrosshealthcare organizations.4 Transitions or ‘‘hand-offs’’ in care are now considered to be one of thecritical dimensions of assuring patient safety.5

Assuring a successful transition is particularlyrelevant for the morbidly obese patient whousually has many chronic conditions and co-morbidities.1 Safety concerns in acute care havebeen previously reported, yet little research

exists about the needs of these patients afterdischarge from an acute care facility.6,7

It is expected that transitions from acute careto home health will continue to increase as thepopulation ages and lives longer with chronicconditions.8 Because the morbidly obese haveconsiderable challenges in maintaining health,it can be assumed that they too will need homehealthcare more often. In 2006 the Agency forHealthcare Research and Quality (AHRQ) is-sued a report demonstrating a 53% increase,between the years of 1997 and 2006, in patientsbeing transitioned from the hospital into homecare. This same report noted that 9% of allhospitalizations result in a need for homehealthcare.9 The purpose of this study was tolearn more about the nursing care and safetymanagement of morbidly obese patients tran-sitioned to the community with home health-care. The study builds on a previous study thatassessed how families of morbidly obese pa-tients manage the activities of daily living.7

This study focuses on the accommodationshome care agencies make to assure safe care ofthis population of patients. Additionally, safety

1East Carolina University College of Nursing, Greenville, North Carolina.2Pitt County Memorial Hospital, Greenville, North Carolina.

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issues faced by nurses and nursing assistantsworking with the morbidly obese are explored.

Materials and Methods

Using a survey designed by investigatorsand approved by the University Medical Cen-ter and Institutional Review Board, a descrip-tive study was undertaken to query homehealthcare staff about their experiences in caringfor the morbidly obese. The survey was com-posed of 32 questions aimed at understandingthe frequency of encountering this population,staffing and equipment accommodations forsafe care, patient and nurse safety concerns,and nursing attitudes toward care of the mor-bidly obese. This survey paralleled a similar toolused to query nurses about in-patient care of themorbidly obese.10

Home care staff that attended the Associa-tion for Home and Hospice Care of NorthCarolina were given the survey at the annualconvention held in April 2008. Completion ofthe survey was considered consent and 27participants were recruited. Survey responseswere entered into Statiscal Package for theSocial Sciences 6.0 (SPSS 6.0) and analyzed forfrequencies and comparative means. Qualita-tive responses were manually reviewed.

Results

The sample of participants ranged in agefrom 28 to 63 years old with a mean age of45 years. Eighty-five percent of the nurses wereCaucasian, and 15% were minorities. Forty-twopercent of the nurses had either a diploma orassociate degree, 29% held a baccalaureate de-gree, 1% were licensed practical nurses, and theremaining percent did not complete their de-gree status on the survey. Survey participantshad practiced nursing from 8 to 35 years, witha mean of 19.2 years, and had been employedin home care for an average of 8.6 years.

In an average month 70% of the participantshad taken care of more than six morbidly obesepatients. When caring for these patients, only33% reported always having the special equip-ment they needed to safely manage care.Equipment most reported as needed was aHoyer lift and a wheelchair that would accom-modate the patient. Bariatric beds and walkerswere also frequently noted as essential for care

of these patients. Over 50% of the nurses sur-veyed reported that no special staffing accom-modations were made by the home care agencyto take care of morbidly obese patients. Instead,to support the added manpower needed tomanage these patients, 63% of the nurses statedthey coordinated the time of care delivery withanother team member such as a home healthaide or physical therapist. Those nurses whoworked for agencies that made special staffingarrangements on morbidly obese patients mostoften reported the use of same time schedulingof personnel as the means for managing careand avoiding injuries. Nurses also noted the useof family members to assist with patient man-agement as well as fire and emergency medicalsupport team members in the community.

Only one participant noted that a morbidlyobese patient had been injured while providingcare, but 15% reported a near miss event. Theseevents primarily occurred during transfers andinvolved falls or almost falls that were mini-mized by physically lowering the patient to thebed, chair, or floor. One incident of a lift mal-function was also reported. Twenty-six percentof the nurses reported having had pain or dis-comfort from caring for an obese patient. Backand shoulder pain were the discomfort thatoccurred most often. When asked what couldhave prevented injury to self or the patient,nurses suggested the availability of properequipment and additional staff. When askedwhat safety issue posed the most risk, nursesalso noted getting the patient out of the homein case of an emergency as a critical concern.

Attitudes about caring for the morbidlyobese were also explored using the survey.Only 22% of the nurses felt that the morbidlyobese patient had control over their weightand were responsible for their health issues.Yet, most nurses (67%) did not feel that some-one in the home enabled the behaviors thatcontributed to the patient’s weight. Only 14%of the nurses felt that morbidly obese patientswere more demanding; most nurses (81%) ac-knowledged that morbidly obese patient arejust like other patients needing nursing care.

Discussion

Many home health employees enter a newpatient’s home to discover inadequate equip-

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ment and resources to manage care.11 Whenthat patient is morbidly obese, the need to haveproper lifting equipment and staff is critical tothe delivery of safe, effective patient care and tothe prevention of injury to the caregiver.2 Thisresearch demonstrates that having inadequatelifting and assistive devices is a frequent chal-lenge in home health. Only 33% of the homehealth nurses reported having the equipmentthey needed to care for these patients. This isslightly more than a previous study noted whereonly 22.5% had the resources they needed.4

Essential for the handoff between hospitals andhome health is adequate discharge planningthat assures the home environment is safe forthe transition. Nursing staff coordinating thedischarge of the morbidly obese need to ask thepatient about resources in the home or requesta home evaluation be done by the home healthagency prior to transition.

Carr5 offers a list of essential skills that casemanagers and discharge nurses should considerfor an effective care transition. These includeassessing the patient’s self-care abilities andcommunicating the ‘‘patient’s essential clinicaland functional status information to the receiv-ing team.’’ With the morbidly obese patient thisis even more critical because procuring the spe-cialty sized beds, wheelchairs, walkers, bloodpressure cuffs, and lifts might take time andrequire an examination of the patient’s healthinsurance or ability to pay for these devices.Additionally, making accommodations in thepatient’s home for a bariatric bed, lift, or otherequipment may not be readily possible. Craibet al. note that often home care patients residein houses in a state of disrepair, with smallrooms and no family support.12

Both the receiving and sending organizationsare responsible for the safe handoff of patients.4

Dailey suggests that ‘‘every nurse in acute caremust be cognizant of how they can contributeto transition zone safety, just as every homecare nurse must facilitate transition coordina-tion.’’13 The HMO Workgroup on Care Man-agement has listed core functions for meetingthe needs of patients in transition.14 First theycall for nursing staff to change from an orien-tation of patient discharge to one of patienttransition. This assures a continuum of careacross organizations. The workgroup has alsoenumerated the responsibilities of the sending

healthcare team and the receiving healthcareteam. One of these is to confirm that the receiv-ing team is capable of and prepared to meet thepatient’s needs. If a morbidly obese patient istransitioned without the essential equipmentfor patient safety, then this goal has not beenmet. Doran et al.15 have developed a four-dimension assessment for home patient-safetyrisk factors. One of the client characteristicsthat increases risk is morbid obesity, and one ofthe client living situations is unsafe housing.Clearly, the need to communicate betweensender and receiver about these two factors is acritical part of handoff safety in this population.

This research evidenced another method formeeting the challenges of caring for the mor-bidly obese, the use of creative scheduling. Bycoordinating visits to be at the same time, homecare staff could increase the safety in transfer-ring and caring for these individuals. Whilethis is an innovative strategy, it does not assurethat these patients can be manually transferred.Waters16 reviews the National Institute forOccupational Safety and Health standards forlifting and reports that patient-handling tasksshould be limited to 35–55 lbs per person. Ifyou consider that the weight of the leg of a250-lb patient is about 39 lbs, it becomes clearthat transitioning a morbidly obese patient tothe home without equipment and adequatestaffing creates a major safety concern for boththe patient and the nursing staff.17 Accordingto Hospital Employee Health, the risk of backand shoulder injury is about the same for homehealth and hospital staff; however, the severityof injury is much greater in home health. Pastresearch shows that low back and shoulderinjury on the job during patient handling inhome health is the most common worker’scompensation event, and this was found to betrue in this study as well.18

Conclusions

The risk of injury for both patients and nur-ses is a real concern when caring for the mor-bidly obese patient. A lack of equipment andadequate staff to meet the needs of these pa-tients is often the reality in home healthcare.McGinley and Bunke have completed a studyof safety principles essential for working withthe morbidly obese patient.1 Factors identified

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that influence the safety of patients and care-givers included: 1) patient’s ability to assist, 2)patient’s level of cooperation, 3) patient’s co-morbidities, 4) patient’s ability to weight bear,5) patient’s ability to assist in making bodyparts accessible, 6) patient’s level of respiratorycompromise, 7) patient’s upper extremitystrength, and 8) availability of proper equip-ment. Adopting a transitioning protocol formorbidly obese patients that makes communi-cating about these factors a best practice is akey strategy for reducing worker injury and pro-moting patient safety in the home. By workingtogether, hospitals and home care agencies canassure a protected transition that includeshaving the essential equipment and resourcesready when the patient arrives home.

Disclosure Statement

No competing financial interests exist.

References

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15. Doran D, Hirdes J, Blais R, Baker G, Pickard J, JantziM. The nature of safety problems among Canadianhomecare clients: evidence from the RAI-HC report-ing system. J Nurs Manag 2009;17:165–174.

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Address reprint requests to:Elaine S. Scott, PhD, RN, NE-BC

3138 Health Sciences BuildingEast Carolina University College of Nursing

Greenville, NC 27858

E-mail: scottel@ecu.edu

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