WEIGHING HEAVILY Facilities everywhere are struggling to deal with larger and larger patients.

Outpatient facilities everywhere are caught in a bind. As patients get larger, their potential client bases get smaller. At least, that is, if facilities adhere to the traditional dictate that treating morbidly obese patients in an outpatient setting is likely to be too risky.

What's a surgical facility to do? Many have chosen what they see as the only viable option. If they'd set limits in the past — based either on BMI or on weight — they've adjusted those limits upward. In a recent Outpatient Surgery survey, 47% of respondents said they'd raised — or been forced to raise — BMI or weight limits for certain procedures in the last 5, 10 or 15 years.

"Five years ago our cutoff was 35," says the clinical manager of a Pennsylvania endoscopy center, "but we found with the ever-increasing BMI numbers that we were canceling a lot of cases. So we reevaluated our policy and increased our limit to 45." "We used to have a weight limit," says an ASC administrator from Ohio. "But we constantly ran into patients that exceeded those numbers." They, too, have raised their limit, she says.

How common is the issue? Aside from readily available and somewhat alarming statistics — the most recent CDC estimates suggest that nearly 2 of every 5 adults are obese and that teenage obesity is also on the rise — our respondents say they've seen it with their own eyes. A whopping 93% say the weight of their patients seems to have increased in recent years. Fifty-eight percent say it's increased "by quite a bit."

"It's a trend we're seeing across the board," says Lisa Waters, RN, BSN, director of perioperative services at the Vivere Dallas (Texas) Surgery Center. "Patients are much heavier, much larger. Especially in the last 5 years or so."

And it's weighing heavily on those who feel caught between competing interests. "Because the population is getting so large, and reimbursements have dwindled down to nothing," says Ms. Waters, "there's a push with investors to slide that person in, to say, 'It'll be OK.'"

At Ms. Waters's facility, the BMI limit is now 50, which, among our respondents, is not especially unusual. One in 5 have set the same limit, and others say they'll go even higher under certain circumstances. That's concerning, says Ms. Waters. "Our anesthesia providers would like to decrease our limit to 30, 35, or 40 max, but we meet a lot of resistance from those who want the money to be generated."

Who decides?
Rather than set hard-and-fast limits, slightly more than 40% of our respondents say they make decisions on a case-by-case basis. Some also use sliding, incremental criteria. "Our absolute cutoff is 50," says Cindy Beauvais, RN, BSN, MBA, CAPA, clinical director of the (Savannah) Georgia Eye Institute Surgery Center. "(But) patients with a BMI of 40 to 49 are reviewed by the anesthesiologist for appropriateness to have surgery in an ambulatory setting."

When a patient seems like a close call and a tough decision has to be made, who shoulders that responsibility? More than 60% of our respondents say their anesthesia providers have the final word.

That's as it should be, says anesthesiologist Ashish Sinha, MD, PhD, MBA, from the Drexel University College of Medicine in Philadelphia, Pa., a nationally recognized expert in the handling of obese and morbidly obese patients. "The risk is best assessed by the anesthesiologist," says Dr. Sinha, adding that in cases where the surgeon decides (about 20% of our respondents), there should be ample input from the anesthesiologist.

Beyond the safety of patients, many facility managers are concerned about the safety of their employees when it comes to dealing with extremely heavy patients. The limit for patients at the Digestive Disease Associates Endoscopy Suite in Branford, Conn., for example, is a relatively modest 300 pounds. And "it isn't as much about the patients, as it is a safety concern for the staff," says nurse manager Carol Dynderski, RN, ADN. Heavier patients are a problem, she says, "because we don't have anything except our own backs. We're a very small facility. We don't have Hoyer Lifts or other tools to lift patients. It's just us. We have to do what we can do safely for us."

UPPING THE ANTE Nearly half of our respondents say they've had to raise their BMI or weight limits in recent years.

Equipment challenges
"Our table weight limit is the limiting factor," says an Anchorage, Alaska facility leader, echoing a sentiment expressed by numerous respondents. The nurse director of a North Carolina eye clinic says they decide on a case-by-case basis, adding that they "now have an OR table that will accommodate up to 450 pounds."

Others say they've acquired tables that are built to accommodate as much as 600 or 700 pounds. A few say they can go as high as 1,000, if necessary.

At the Summit Orthopaedic Surgery Center in Newnan, Ga., patients are reviewed on a case-by-case basis, says nurse administrator Heather Atkinson, RN, and tables can accommodate up to 1,000 pounds. But they make sure "extra staff, including anesthesia, and a video laryngoscope are always available for difficult airway management."

Though it's well established that heavier patients often have challenging airways, and are more prone to respiratory issues, only about one-fourth of our respondents say they make sure to have extra anesthesia providers and/or extra anesthesia equipment on hand when treating morbidly obese patients. While that number may be deceptive — many say they simply don't treat morbidly obese patients — it does raise concerns. "We follow anesthesia recommendations and have both an airway cart and an extra practitioner in the room for intubation and extubation, if needed," says Melissa Weibel, BSN, CEO of the (Tamuning) Guam Surgicenter.

That's important, says Dr. Sinha. "When things don't go according to plan, an extra person may be able to see options the first person may not think of." And the time to critical desaturation may be shorter, because heavier patients tend to have smaller functional reserve capacity and higher metabolic demand.

Longer recoveries
A significant number of respondents say they're trying to avoid or decrease the use of opioids with patients in general, and especially with obese patients. That, too, is important, says Dr. Sinha. "People need to be aware of the interaction between obesity and narcotics, and sleep apnea, especially," he says. "Opioids suppress the respiratory drive not just when patients are in our care, but also after they leave our care. We may be asked why we would let somebody with sleep apnea get narcotics after they leave our care."

On a related point, Dr. Sinha strongly recommends implementing stricter discharge criteria for morbidly obese patients who've been given any kind of opioid or sedative — something only a small fraction of our respondents say they've done. "You need to be able to show that any potential respiratory depressive effects have worn off and that it's OK for that patient to be taken off the monitor and go home," says Dr. Sinha. For heavier patients, that may require extra time in the PACU, he acknowledges, which can be a sticking point. The answer? "Maybe instead of having them in a bed, put them in a chair," he suggests. "That way they're a little more awake. Maybe have them go to the restroom, so they ambulate a little bit. You want to make sure they don't desaturate or show any symptoms of suboptimal respiratory drive." Even if that requires extra recovery time.

Empathy matters
The Harford County Ambulatory Surgery Center in Edgewood, Md., recently raised its BMI limit from 43 to 45, as long as no other significant comorbidities are present, but many patients still end up over the limit, says nurse administrator Kim Merrill, RN, BSN. Even if they don't start out that way.

"We do a lot of workers' compensation orthopedic cases, and it sometimes takes months and months to get authorizations," says Ms. Merrill. "So patients are sitting at home because they got injured at work 10 months ago. They might have underlying health issues, and they can't exercise, because they hurt their shoulder or whatever." Meanwhile, the numbers staring up from the scale are getting larger and larger.

"It really presents a challenge to us to try to get them healthy enough for surgery, and they need the surgery so they can go back to work," she says. "We just had a woman come in that we've been trying to get on the (surgery) schedule for 10 months. But she can't get her diabetes under control because she can't afford her medicine. And because she doesn't work, she's going to get evicted from her apartment. It's very sad."

It's also a vivid illustration of the kinds of obesity-related issues that go beyond what some would reflexively characterize as a lack of self-discipline. Dr. Sinha strongly suggests providing sensitivity training that's focused on dealing with obese patients — something that only a quarter of our respondents say they provide.

"It would behoove them to do it for 2 reasons," he says. "One is the moral aspect of not wanting somebody to get insulted. But there's also the financial angle. What happens if your facility gets a bad reputation? If something goes wrong and someone sues you, the question may be asked: What have you done to address this."

Training doesn't have to be elaborate, he says. "When you sit everyone down in the morning with coffee and bagels, you can have someone talk to them for 45 minutes. It can be something online, or something to talk about when things are slow. If you're going to take care of large patients routinely, it probably should be a focus. It's a low-cost, high-yield initiative."

And insensitivity is pervasive. "Even a Miss Universe gets accused of being a fat slob," says Dr. Sinha. "If Donald Trump had had some sensitivity training, he might not have said that."

Ms. Waters agrees that empathy is key. "I've discussed this with my staff and I try to lead by example," she says. "Often, very heavy patients are very self-conscious and their self-esteem is low. They're very introverted. It's almost disheartening. They'll say things like, 'Thank you, and I'm sorry I weigh so much.' I make it a point to say: 'That's OK. You would do the same for me, wouldn't you?' They're usually taken aback at first. But they say, 'Yeah, I would.' That helps break down barriers and lets them know they're no different than me, my neighbor, or anybody else. We all come in different shapes and sizes and should be treated as equals."

FEEL THEIR PAIN Most facilities don't provide sensitivity training regarding obese patients. They should, say experts.

Many factors
"In the last 30 years, the average American has gotten about 21 pounds heavier," says Dr. Sinha, who has studied the phenomenon extensively.

Ask 5 people why, and you may get 5 different answers. "Our portion control in this country is way out of control," says Ms. Dynderski. "The average meal here in any restaurant could feed 2 people. It's the way we're raised. We live to eat. In other countries, they eat to live."

"With computers and technology, I think people are more apt to play on their phones and sit at their desks than exert any type of physical activity," says Ms. Waters.

"We're always looking for diets, and trying to eat right," adds Ms. Merrill. "But from a financial point of view, the burger deal at McDonalds is a lot cheaper than trying to buy spinach and kale and make salad, or buying berries at $5.99 a pound."

They're all right, says Dr. Sinha. "It's multi-factorial," he says. Thanks to machinery and technology, we aren't nearly as active as we were 40 or 50 years ago. "Even the act of getting up to change your TV channel is a foreign idea," he points out. "And to get up and answer the phone is no longer necessary."

For an extra quarter, we're "super-sizing," he says. "We've created a belief that bigger is better value for money. Watch anybody at a buffet line. How many times do they go back? They're trying to get value for money. And because you're eating so fast, your brain doesn't have a chance to get the signal from the stomach that you're full. You come out overstuffed. You realize it later, but by that time you've consumed the calories."

It's a trend that could get much worse before it gets better — if it gets better at all — and one that healthcare providers need to come to grips with. They need to know how to safely — and sensitively — treat their super-sized patients. OSM