Growing levels of obesity in many westernised countries are having a direct impact on health care systems. The impact is felt to a high degree among primary carers and emergency services personnel.
In the past 20 years obesity prevalence has increased by half in the United Kingdom and the United States and more than doubled in Australia and New Zealand. Some 20–24% of adults in the United Kingdom and Ireland and Australia are obese (Organisation for Economic Co-operation and Development, 2011).
A proportion of the obese population become morbidly obese (bariatric), i.e. have a body mass index (BMI) 40 kg/m2 or more. Between 1993 and 2011, the prevalence of morbid obesity in England was consistently higher among women (increasing from 1.4% in 1993 to 3.2% in 2011) than among men (increasing from 0.2% in 1993 to 1.7% in 2011) and the prevalence of morbid obesity in England is predicted to rise over the next 20–30 years (Public Health England, 2013). In South Eastern Australia, the prevalence of morbid obesity among women increased from 2.5% to 4.2% during the decade between 1993–7 and 2004–8 (Pasco et al, 2013) and Australia is now ranked as one of the fattest developed nations (Government of Australia, 2009).
Bariatric patients are increasingly over-represented in the use of healthcare services (WorkCover NSW 2006; Fife et al, 2007; Hignett et al, 2007; Muir et al, 2007; Cook, 2013) and their access to in-patient and out-patient treatment is a journey that frequently commences with transport from the patient's home by ambulance. On arrival at the hospital as an out-patient the journey continues through to locations of specialist departments such as radiography, or as an in-patient through to a ward and subsequently to specialist departments or potentially to theatre. On completion of treatment, the journey often resumes with the transfer by ambulance to home or another institution (Hignett et al, 2007; Cowley and Leggett, 2010a; 2010b). If treatment is unsuccessful, deceased clients are transported via the mortuary to a funeral home and finally to the funeral ceremony (Cowley and Leggett, 2011). At the commencement of the journey, and at other times when patient handling problems arise, it is not uncommon for fire service personnel to be called to assist. At each point in this journey the movement of a client presents challenges for the carer (Boatright, 2002; Grant and Newcombe, 2004); however, ambulance and fire personnel are often exposed to elevated levels of risk. The risk of injury to carers is increased when they respond reactively to situations (Gallagher, 2005; Nelson and Baptiste, 2006; Hignett et al, 2007; Humphreys, 2007).
The risks to bariatric patient carers are compounded by complications associated with patient weight, shape and cooperation. Limited mobility and decreased lung capacity reduces the patient's ability to assist in movement (Fife et al, 2007). Other factors associated with the bariatric patient's clinical condition and treatment that potentially increase the manual handling risk to carers include levels of comfort or pain, the need for privacy, and concern for dignity (Pellatt, 2005; Baptiste, 2007; Hignett et al, 2007; Humphreys, 2007; Bachman, 2008).
Morbid obesity has been variously defined, and while it is considered by some to be the point at which a person's Body Mass Index (BMI) exceeds 30 kg/m2 (World Health Organization, 2003; Nelson, 2006; Humphreys, 2007), other authors report it to be the point at which a person's BMI exceeds 40 kg/m2 (Green and Gillett, 1998; Fife et al, 2007; Byard and Bellis, 2008). Alternatively, some researchers have referred to weight alone to indicate whether or not patients can be defined as morbidly obese and have suggested that the level of morbid obesity has been reached when patients surpass their ideal weight by more than 45 kg (Boatright, 2002). The criteria used by healthcare organisations vary.
Risks to emergency service first repsonders
The manual handling risks to paramedics and fire service first responders in Australia are significant but are not quantifiable; anecdotally there are injuries associated with incidents involving bariatric patient movement but these are difficult to isolate from incidents and injuries associated with general patient movement (Cowley and Leggett, 2011).
In general the risk to workers is influenced by the design of environments within which work is undertaken; the equipment available and used; the provision of education and training; and the quality and use of written procedures. These elements are all interlinked and are usually controlled through an occupational health and safety management system (Borys, 2000), and they provide a useful framework for the analysis of risk to ambulance paramedics and fire service first responders.
Work environment
The exposure of paramedics to risk is significantly influenced by the uncontrolled environments in which they work (Lipperman and Preira, 2002; Hignett et al, 2007; Thomas and Rickabaugh, 2008), owing to the limited opportunities for the use of mechanical lifting aids. In regard to bariatric patient handling, those environments are generally residential dwellings designed for ambulant people and room size, corridor width, stair width, gradient and safe working loads can limit the use of equipment and present considerable manual handling problems. One paramedic has reported:
‘Ambulant people are mostly catered for in a domestic dwelling. In townhouses you can't get equipment in. Once you add the bariatric patient's complexities it's hard to get all your equipment close so you use the fire service to help move the patient’ (Cowley and Leggett, 2010b).
Some bariatric patients are attracted to country areas where the cost of housing is lower and where ‘supported housing’ may be available. In Australia, these properties are not only limited in size but are also remote to population centres, where facilities to assist with health care and patient movement may be available. The distribution and quantity of furniture and personal effects present further obstacles to handling equipment use. Fire fighters assisting ambulance paramedics have reported:
‘We experience manual handling shifting patients to do CPR, getting people off the bed and onto the floor, and handling here doesn't allow much space. Sometimes people are in the toilet and stop breathing and slide between the toilet and the door. Getting into the toilet and getting people out is hard, (Cowley and Leggett, 2010b).
The additional staff needed to assist with care and movement of bariatric patients are not readily available or easily accommodated within the confines of the dwelling. Removal of the patient can require the removal of doors and windows and sometimes the use of powered equipment such as cranes. Environmental factors associated with surroundings of the dwelling can limit close access by ambulances and wheeled equipment. Ideally the ambulance will be positioned as close to the dwelling as possible but access may be limited by topography, fences and other obstacles.
At the hospital, ambulance paramedics have limited control over the environments they encounter; an example proffered to these authors by a paramedic referred to an ambulance bay where for drainage purposes the surface was sloped and included ridges.
Equipment
Equipment for patient transport has in the recent past been a significant issue for emergency services. Not only are vehicle weight capacities limited, but equipment such as stretchers have limited weight capacity, and the combined weight of the stretcher and the patient may exceed the capacity of restraints in emergency vehicles in the event of sudden deceleration. To overcome some of these difficulties, on occasions alternative transport is arranged. An ambulance paramedic reported:
‘Several years ago we had no equipment but needed to move patients to go to the local hospital. We had to get a furniture removal van with a lifter on the back and remove door frames and bricks from the unit and use two crews from the fire service…we almost dragged the patient out’(Cowley and Leggett, 2010b).
Now each of the ambulance services in the six states in Australia have dedicated and fully equipped bariatric transport vehicles. However, the cost of these in some cases prohibits the deployment of resources in locations other than major centres which can be several hours away. Thus, availability in rural and regional areas is generally limited to planned rather than emergency transportation. In South Australia paramedics have identified:
‘We've had to think about roll-out [of new equipment and approaches] into the country. We're seeing an exodus to the country due to low-cost housing. This is a sparse state where accessibility is a problem and small country hospitals have no facilities.’
and:
‘We've needed to place equipment north and south of the city but it is the remote and rural areas that are difficult because the hospitals can't take the patients and they can't fly with RFDS [Rural Flying Doctor Service] because the weight limit is 145 kg plus a 60 kg stretcher. You would have to leave the medical staff behind’ (Cowley and Leggett, 2010b).
Transport by air from regional locations is limited by load capacity. On one occasion reported, the combined weight of the stretcher, patient and ancillary equipment meant that attending staff would have exceeded the capacity of the aircraft and they were left behind (Cowley and Leggett, 2010b). The Victorian ambulance service stipulates that their Complex Patient Ambulance Vehicle (CPAV) will be crewed by two staff that have been trained in the use of the specialised equipment. However, the procedures state, ‘where the patient weight is equal to or exceeds 350 kg, crewing requirement must reduce to accommodate increased patient weight’ (Ambulance Victoria 2012b).
The South Australian Bariatric Response Vehicle (BRV) has a load capacity of 500 kg. Use has increased from approximately 10 times per annum in 1998 when first introduced to about 200 times a year in 2010. The BRV collects morbidly obese people all over the state, with its heaviest patient to 2010 weighing 347 kg (Allen, 2010).
The ambulance services operating dedicated vehicles have equipped them with specialised equipment. In Victoria, the CPAV carries: a tailgate loader rated to 500 kg to accommodate stretcher, equipment and personnel simultaneously; a Ferno Powerflex stretcher that can accommodate 318 kg in its full height position or 450 kg in its lowest (trundle) position; a Hoverjack (inflatable airbed to raise a person from the floor); Hovermatt (inflatable hover bed to manoeuvre patient from bed or floor to Hoverjack or stretcher); Quickie wheelchair that can accommodate up to 295 kg; EZ Glide stair chair having a weight capacity of 227 kg and track system that allows chair to glide down stairs without lifting and carrying; and double transport seat for ambulant bariatric patient use or multiple escorts (Ambulance Victoria, 2012c).
A limitation of some of this equipment, such as the Hovermatt, is that the required power source is not always available at the point of patient collection. The size and congestion of domestic dwellings can also prevent the use of equipment. In this regard a paramedic commented:
‘We always look to use non-physical means [of client movement] but power facilities are required for equipment…for our powered devices and sometimes power failures occur no matter how well things are planned’ (Cowley and Leggett, 2010b).
Paramedics and hospital workers have commented that equipment is often designed to handle patients that tend towards the rectangular shape rather than the more typical square shape of a bariatric person (Cowley and Leggett, 2011). Within the square shape, the patient's weight is often distributed unevenly and generally falls into one of a number of categories (Rush, 2005) including: severe generalised oedema, a high upper body weight with either a rigid abdomen or an abdomen that hangs to the floor, weight carried below the waist with either significant tissue between the knees or on the outside of the thighs, or excessive buttock tissue creating a protruding shelf. This uneven distribution of weight can not only negatively affect the stability of equipment but also its structural integrity.
The findings regarding the limitations of equipment are supported by reports from other countries (Boatright, 2002; Jung, 2004; Pellatt, 2005; Baptiste, 2007; Hignett et al, 2007; Byard and Bellis, 2008). However, it seems that the problem is acute in Australia, where much of the equipment in use is manufactured in the USA. Typically this equipment is labelled in US pounds rather than metric units, and has been designed for US vehicles and hospital systems. Compatibility problems are therefore encountered when used with vehicles and other equipment in Australia. Occasionally differences in equipment used by services in different regions of Australia limit the cross-border exchange of equipment during transfers.
The relatively small population size in Australia limits the market for bariatric equipment and thus the range that is imported and made available.
It also limits the degree of design influence that may be brought to bear on manufacturers. The somewhat insular nature of the Australian states reduces the opportunity for collective influences.
Commentators from other countries have suggested that the barriers to the use of equipment for bariatric patient movement generally fall into three categories associated with the equipment, the carer and the patient. In regard to the equipment: insufficient items, instability, weight limitations, difficult operation, storage issues, convenience of location, poor maintenance and cleaning, space restrictions to control equipment, and incompatibility of equipment are cited. Fire fighters who have supported paramedics have commented:
‘Our ability to carry large equipment is really limited, the ergos help with [manual handling] techniques for moving people in confined spaces. Slings and slide sheets would be a possibility to have. Rescue equipment could be adapted but this is really designed to get to people in a rescue,’
and:
‘We deal with whatever [environments] we encounter because we must affect a rescue. If we need to rescue, the job is to get in and get the person out—it's time critical—you can't put in place lifting equipment and you don't know it's a rescue until you get there. There was one example where the person was in an upstairs bedroom and was transported to hospital by ambulance. They were under 150 kg but we had to take them down a spiral staircase in a vertical position, we needed more hands in, but extra people created a hazard’ (Cowley and Leggett, 2010b).
In regard to the carer: lack of training, lack of staff awareness, a perception that equipment is cumbersome or otherwise inconvenient, inability to locate the equipment, and time constraints are cited. In regard to the patient: aversion to the equipment, loss of a sense of control, feelings of insecurity, and discomfort have been identified (Nelson and Baptiste, 2004; Rush, 2004; Baptiste, 2007; Hignett et al, 2007; Whipple, 2008). One paramedic reported:
‘There are the psychological sides of why people become obese to bariatric, it's like cigarette addiction but the attitude is if you want to eat that much get out. The patients are generally nice and perceptive and hospital curtains are not sound proof to comments like “oh my God that is so big!” There is also nothing worse than seeing industrial cranes and pallet lifters coming toward you. The equipment is stainless steel and industrial looking, not a standard piece of [medical] equipment’ (Cowley and Leggett, 2011).
Rules and procedures
It is increasingly accepted that comprehensive programs using mechanical equipment and having a written safe patient handling policy can significantly reduce the risk of musculoskeletal injuries. With regard to this, in Australia one of the significantly limiting factors in controlling risk is the variety of definitions of ‘bariatric’ found between hospitals and between the ambulance services in different states. Some healthcare organisations rely on BMI but the BMI value used to identify bariatric patients often varies. Others rely on weights, although neither BMI nor weights account for patient shape and weight distribution. Inconsistencies in the definitions affect purchasing policies as well as procedures that inform decisions about calls for further staff to assist with manual handling tasks. Pre-hospital admission assessments are an important element of the bariatric journey and permit the planning of care and preparation of appropriate equipment prior to hospital arrival: however, the absence of consistent definitions means that triggers may not be being activated.
In New South Wales, ambulance paramedics are required to undertake a risk assessment on each occasion a bariatric patient is transported.
In the underpinning policy ‘bariatric’ refers to ‘any person whose weight or physical dimensions exceed the capability of standard equipment in use by the Ambulance Service of NSW’ (Ambulance Service of New South Wales, 2012). However, this policy cross references a NSW Health Department procedure which states that: ‘For the purposes of aeromedical transfer, an obese patient is defined as a patient weighing 110 kg or more. For road transfers, an obese patient is defined as a patient weighing 160 kg or more’ (Department of Health, 2010). Measurements of patient width and girth are required in addition to actual weight and paramedics are cautioned, ‘estimates of patients’ weights are generally underestimated and should be verified by the patient or patient's treating medical officer.
Be aware that patients may underestimate their own weight.’ Ambulance paramedics comment that weighing patients before movement is rarely possible and estimates are difficult.
In Ambulance Victoria, the CPAV is used when the patient's body weight or dimensions, as well as any equipment, is estimated to be in excess of the physical capacity of the attending crew to safely undertake the transfer, or when standard equipment or manual handling equipment options cannot assist with moving the patient. Associated manual handling policies require operational staff to perform dynamic risk assessments, i.e. manage risk in uncontrolled environments taking into account the specific variables of each situation. Thus the approach to bariatric patients is risk-based rather than being led by specific quantitative criteria. In Victoria, if CPAV is unavailable, staff determine and request other equipment and resources to assist with patient transfer or extended patient treatment at the scene (Ambulance Victoria, 2012a; 2012b). Independent third party patient transfer services may be used when the service's own vehicles are unavailable. Paramedics report, however, that procedures such as these can become unworkable when attending an emergency case in rural or remote locations.
Further complications can arise in regional and rural areas where the choice of hospitals that are adequately equipped for bariatric patient care is often limited. In Victoria, the ambulance service has compiled a list of hospitals that are equipped for bariatric patient handling such that crews may be appropriately directed with patients requiring specialised assistance. A paramedic reported:
‘The bariatric ambulance has an itinerary of what equipment each hospital has or can hire in to see if they can take a specific patient to a specific hospital. It also has a set of scales in the back so the hospital will know ahead of time if the equipment will be suitable for the patient's weight’ (Cowley and Leggett, 2010b).
Representatives of one service reported that every effort is made to obtain information about patient weight when a call is received. If it is established that the patient weight might exceed 170 kg, a second crew is dispatched to the call location. However, it was reported that, in general, patient weight is unknown at the time that a call is received. A representative of one fire service commented:
‘We're beginning to know [which jobs will involve bariatric clients] and caller id information can add information about a certain site, for example the frequency of calls from a particular site’ (Cowley and Leggett, 2010b).
‘No lift’ policies are reducing manual handling injuries in the healthcare sector (Martin et al, 2004), and when correctly implemented have the capacity to satisfactorily assist with the management of bariatric patients. In institutions where ‘No Lifting’ policies have not been correctly implemented or where personnel have not received adequate training in its operation, it was found that the risk is to some extent being transferred to ambulance and fire services which are being called to move patients. One fire service is implementing procedures that will limit and ideally prevent the manual handling of any people in situations that are not life threatening. Service representatives described a process whereby calls for assistance are filtered through an operations commander who will make a decision on whether or not to dispatch a crew to undertake the manual handling tasks, based on the circumstances of the particular case as described to them by the call centre. Caller identification information helps the operations commander make informed decisions about a response to the call. Concern for patient dignity and the welfare of colleagues in other services can compromise the application of the policy in practice.
Dignity is a major issue and the attention of neighbours and even media can influence the strategies that are used in patient movement. It has been reported that consideration for patient dignity as well as clinical needs will frequently override consideration of the crew's safety.
Training and education
The dynamic environments within which paramedics operate, with patients’ varying needs and circumstances, requires training that equips staff with the knowledge and skills to quickly and effectively assess manual handling risks and to move independently to appropriate control measures. Where bariatric equipment is in use, attempts are made to train paramedic staff in their application. However, the low availability of the equipment and the low frequency of use mean that experience is limited. A fire fighter commented:
‘We get training in the basics of safe lifting in recruits and this training is evolving because of new work methods, making jobs easier, but it is not specific for large patients, whereas ambulance staff do get that training and have engaged physios to demonstrate. It would be good to have a dummy that is similar to a bariatric person to assist our training’ (Cowley and Leggett, 2010b).
A further limitation to the application of the knowledge and skills in practice is the overriding concern for dignity of the patient or the deceased. Staff will generally place patient care and dignity above their own safety. This was confirmed by the following comments:
‘When we started bringing bariatric people into hospital they were a novelty. Now they are seen as a waste of time…a waste of resources…similar to drug users. This group of people are perceptive, not in touch about their ‘real’ weight but they say: “I know about the looks I get when I go down the street.” We push to our team leaders to push to their people that the patient comes first. Patient dignity comes first’(Cowley and Leggett, 2011).
‘A lot is the environment; there is also a human factor, a need for dignity and respect. You can't toss them around like they're a piece of material.’
‘Our people are “can do” people but sometimes people feel a particular commitment there even when it is not our responsibility and we not geared to do it.’
‘We had a 305 kg patient to transport who was short and very wide, they had respiratory and multi-system failure and eventually died, but in this case there was a loss of dignity for the patient because the neighbours were out and the media was out’ (Cowley and Leggett, 2010b).
Conclusions
There is an increasing awareness of the escalating bariatric problem in the community and the risks that carers face during the patient's journey through the health care system. However, in Australia there appears to be limited understanding of the entire bariatric journey among representatives of the individual parts or stages. Individuals understand their own role and, to some extent, that of the agencies they interact with in the preceding or subsequent stage in the journey, but the totality of the journey is unclear and there is some misperception that the journey is linear. Less attention seems to be given to the stages of the journey outside the hospital.
Whether the patient movement is undertaken in the uncontrolled environment of the home or the cemetery, or the controlled environment of the hospital, design features generally limit the use of equipment and the application of safe handling procedures.
Ambulance and fire services are increasingly developing policies and procedures that address the movement of bariatric patients and the purchase and use of equipment. Yet the efficacy of these procedures is hampered by the absence of a standard definition of the term ‘bariatric’ and the gaps in information flow during the bariatric patient journey. Various definitions of ‘bariatric’ are applied in different sectors and risk-based approaches rather than those based on weight, body dimensions or BMI may be more useful.
Improvements in manual handling risk control for carers requires greater inter and intra-industry collaboration. This will not only improve the information flow during the bariatric patient journey but also provide opportunities for the industries to apply collective influence on equipment designers and suppliers.
Substantially more work is required to inform the development of intervention strategies that will lead to significant and sustained risk reduction. Further work is also needed to quantify the frequency of bariatric patient movement within the emergency services across Australia. A clear representation of the journey and the interfaces between the agencies and carers and their respective roles would assist with the defining the problem and understanding the solutions.