A Weighty Problem

In turning away patients who are above a certain BMI, is your cutoff a sliding scale that edges outward as the obesity epidemic worsens? You're hardly alone if what started as a BMI limit of 35 has creeped up to 40, to 45 and even ballooned to 50. You're under more pressure to accommodate overweight patients, but the stakes in accepting them are high. Let's examine 10 keys to doing so safely.

BMI cutoffs can range from 35 to 50, with some facilities balancing BMI with the presence of one or more comorbidities, and others requiring discretionary approval of patients above certain BMIs by directors, surgeons and anesthesia providers.

Confounding matters is that there aren't any absolute cutoff standards for accepting obese patients for surgery at outpatient facilities. A frequently-cited November 2013 paper in Anesthesia & Analgesia, "Selection of obese patients undergoing ambulatory surgery: a systematic review of the literature" (osmag.net/p9qHQR), concludes that "the literature lacks adequate information to make strong recommendations regarding appropriate selection of the obese patients scheduled for ambulatory surgery." As a result, policies vary from facility to facility, and from industry organization to industry organization. It's truly all over the place, but a BMI over 45 appears to push the envelope. Consider:

• An Outpatient Surgery reader poll on BMI cutoff offered no clear consensus: 35 (13%), 40 (30%), 45 (18%) and 50 (19%). Perhaps most alarming is that 20% didn't know their facility's BMI limit.
• July 2012 guidelines from Kaiser Permanente (osmag.net/D4HkFy) advise that outpatient procedures "are appropriate in an ASC setting when patient weighs less than 400 pounds with BMI no greater than 45."
• A July 2017 selection criteria policy from Associated Anesthesiologists, an anesthesia group in Minnesota, says that patients with a BMI greater than 45 "are not candidates for an anesthetic" at an ASC (osmag.net/2CUWdh).
• In a 2016 presentation to the Wisconsin Society of Anesthesiologists, James Hoell, MD, of the Aurora Sheboygan (Wis.) Memorial Medical Center, recommended that patients with a BMI between 40 and 50 with known or presumed obstructive sleep apnea (OSA) follow the Society for Ambulatory Anesthesia (SAMBA) OSA guidelines, and that patients with a BMI of 50 or greater are not suitable for surgery (osmag.net/U6AqaM).

Pre-op examinations sometimes lead to disagreements among surgeons, anesthesiologists and nurses about whether it's safe to operate. "Let's say you're an orthopedic surgeon, and you bring in a patient who weighs 300 pounds," says Ashish C. Sinha, MD, PhD, DABA, MBA, professor and vice chairman of the department of anesthesiology at Temple University Lewis Katz School of Medicine in Philadelphia, Pa. "And you tell your team that, 'Hey, this is our first guest for the day.' And the team goes, 'Wait a minute, this patient's 300 pounds, we can't do this at an outpatient surgery center.' And the surgeon goes, 'Why not?' And the team says, 'Because it's risky.' And he says, 'Well, why is it risky? Last week, we did somebody who was 295 pounds, and we didn't have any problems. How is this patient actually different other than the 5-pound weight increase?' That's a very hard argument to counter."

Explicit policies and procedures can help eliminate these arguments, but, again, there are no standards to reference. The American Society of Anesthesiologists and American Association of Nurse Anesthetists haven't set hard guidelines for these situations, but they point to recommendations that center on comorbidities rather than weight.

"I could be a 250-pound person, and you could be a 300-pound person, and you could be healthier than me," says Dr. Sinha. "You could be an NFL player, for example. So weight cannot be the be-all and end-all for drawing a line in the sand."

Because of their special needs, obese patients often require more time in the OR. If your schedule doesn't account for this, you could end up falling behind, and requiring overtime from staff. In some cases, you might not even be aware of the patient's weight or BMI until just before the procedure is supposed to take place, so it's important to find out that information before scheduling the patient, especially if your center isn't equipped to handle a person of that size.

The cleanliness of any patient going into the OR is key to prevent SSIs. But obese patients have a more difficult time cleaning themselves thoroughly than average patients do. Rolls, folds and other difficult-to-reach places can collect contaminants, such as bacteria, over time.

"You need to pay extra attention to clean obese patients really well before surgery," says Lynn Barker, RN, BSN, CNOR, general surgery specialty coordinator at Cone Health in Greensboro, N.C.

Premature attempts at laryngoscopy before the patient is anesthesized is the No. 1 cause of aspiration in the OR.

Many facilities must turn away obese patients because their equipment simply cannot accommodate their weight or girth. OR tables, gurneys, C-arms, beds, waiting area chairs and other equipment that aren't designed to handle bodies above certain weights and widths could break and injure the patient or staff, as well as cause embarrassment for the patient. You'll also need special instruments like longer needles and larger blood pressure cuffs.

In the OR, AORN recommends that padding and positioning devices maintain a normal capillary interface pressure at or below 32 mm Hg to reduce the risk of pressure ulcers. In addition, Robert B. Dybec, RN, MS, CPSN, CNOR, in a July 2004 paper, "Intraoperative Positioning and Care of the Obese Patient," writes that "appropriate instrumentation, such as larger retractors, long staplers and long instruments, must be available." OR table attachments and safety restraints might be necessary as well.

High-capacity equipment usually costs more — in some cases, much more — than traditional equipment, but it's vital to safe and humane handling of an obese patient. For some facilities, this issue can extend to the physical plant itself. Architectural features like hallways, bathrooms, recovery areas and door frames must be built or retrofitted to accommodate larger patients.

As anyone in a hospital or surgical center knows, back injuries are too often suffered by staff when transporting patients. In fact, according to a June 2017 report on hospital worker injuries by the U.S. Department of Labor's Bureau of Labor Statistics (osmag.net/Xa3QzK), the most common event leading to injuries in 2015 was overexertion and bodily reaction, which includes injuries from lifting or moving patients. It stands to reason that the heavier the patient, the more likely an injury could occur, so it's vital that staff are equipped and trained properly to lift and move obese patients.

Enough staff should be on hand at all times to safely transport the obese patient; no one needs to be a hero and overexert themselves. Lifts — portable, ceiling or both — are becoming standard features of facilities that handle obese patients.

As with the other equipment, it's expensive to integrate lifts into a facility. But contrast those expenditures with the potential costs of workers' compensation, broken equipment, lost business and lawsuits, and they're likely to be a wise investment.

In general society, "fat-shaming" is prevalent. In the medical world, however, it's also depressingly widespread.

"Make sure the staff understands how it feels to be an obese patient, recognizing the stigma that's involved and how patients oftentimes shy away from medical staff," says Ms. Williams-James. "A lot of doctors and other professionals aren't very sensitive to that stigma issue with patients. They might speak to them in an insulting way or blame them for the state of their bodies. We do extensive education on this. You have to be very conscious of these patients you're taking care of, through all aspects — from the moment a patient walks through the door till the moment they're discharged, even after they get home."

Obese patients' airways are frequently described as "difficult," so anesthesia providers must take precautions and extra care in the OR. OSA, which is common in obese people, is of particular concern. According to a May 2012 report by the American Society for Metabolic and Bariatric Surgery (ASMBS), "Peri-Operative Management of Obstructive Sleep Apnea" (osmag.net/xRUzG6), obese surgical patients with OSA are at high risk for pulmonary complications, and increased risk for venous thromboembolic complications. ASMBS recommends that obese patients with moderate to severe OSA be treated with CPAP before and after surgery.

A big problem when diagnosing OSA, however, is that a patient who lives alone might not know he has it. Dr. Sinha recommends an overnight sleep study in such cases. At the very least, administer the STOP-Bang test developed by Toronto Western Hospital (stopbang.ca) before surgery.

Be careful about positioning the patient in the OR. The supine position is particularly dangerous for obese patients, as it leads to a greater decrease in functional residual capacity (FRC), total respiratory system and pulmonary compliance, and a larger ventilation/perfusion mismatch than in a normal weight patient, writes Jay B. Brodsky, MD, a founding member of the International Society for the Peri-operative Care of the Obese Patient (ISPCOP), in "Positioning the Morbidly Obese Patient for Surgery" (osmag.net/qqN2NF).

Never let spontaneously breathing, extremely obese patients lie completely flat, writes Dr. Brodsky, recommending that you tilt the operating table or place a wedge under the patient, and that you place the patient in a head-up position before induction of general anesthesia.

The Trendelenburg position and prone position are "not well tolerated" by obese patients, writes Mr. Dybec. He says they are best suited to the lateral position.

Once the obese patient is out of the OR, complications could arise. One area of particular concern during recovery is airway management and respiratory support, writes Mr. Dybec. Another is reddened skin areas that might indicate pressure injuries. There's a higher risk of readmission with obese patients, too, which could result in penalties to your facility under changing health policy regulations, according to a March 2014 report, (osmag.net/C3tQtN) in PeerJ, an open-access peer-reviewed journal.

Obesity is likely to continue to rise in America. It's worth the time and effort to develop explicit standards, processes and protocols that address the care and accommodation of obese patients. At the very least, perform a self-audit to ensure you're handling obese patients safely and humanely, in every way possible. OSM