bariatric sphm: understanding ethical and outcome opportunities susan gallagher phd...
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Bariatric SPHM: Understanding Ethical and Outcome Opportunities
Susan Gallagher PhD [email protected]
Disclaimer Statement
• Susan Gallagher (planner/presenter) has not declared any conflicts of interest regarding this presentation.
• All participants are required to be present for the full webinar and complete the associated evaluation to receive the designated contact hour for this activity.
Bariatrics
A term derived from the Greek word baros, and refers to the practice of healthcare relating to the treatment of obesity and associated conditions…
Bariatrics
…the implication for caregivers is that activities such as turning, lifting, and repositioning can predispose caregivers to physical injury…
Bariatrics
…additionally, failure to provide adequate patient activity and mobility leads to issues of patient safety.
Demographics
74.1% overweight40% obese (Category I and II)6.2% morbidly obese (Category III)Over 65-year-olds40% teens are overweightChildren
Costly
EconomicallyEmotionally
What’s happening in the USA?
Obesity Trends* Among U.S. AdultsBRFSS, 1985
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data <10% 10%–14%
Obesity Trends* Among U.S. AdultsBRFSS, 1986
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data <10% 10%–14%
Obesity Trends* Among U.S. AdultsBRFSS, 1987
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data <10% 10%–14%
Obesity Trends* Among U.S. AdultsBRFSS, 1988
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data <10% 10%–14%
Obesity Trends* Among U.S. AdultsBRFSS, 1989
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data <10% 10%–14%
Obesity Trends* Among U.S. AdultsBRFSS, 1990
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data <10% 10%–14%
Obesity Trends* Among U.S. AdultsBRFSS, 1991
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data <10% 10%–14% 15%–19%
Obesity Trends* Among U.S. AdultsBRFSS, 1992
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data <10% 10%–14% 15%–19%
Obesity Trends* Among U.S. AdultsBRFSS, 1993
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data <10% 10%–14% 15%–19%
Obesity Trends* Among U.S. AdultsBRFSS, 1994
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data <10% 10%–14% 15%–19%
Obesity Trends* Among U.S. AdultsBRFSS, 1995
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data <10% 10%–14% 15%–19%
Obesity Trends* Among U.S. AdultsBRFSS, 1996
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data <10% 10%–14% 15%–19%
Obesity Trends* Among U.S. AdultsBRFSS, 1997
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data <10% 10%–14% 15%–19% ≥20%
Obesity Trends* Among U.S. AdultsBRFSS, 1998
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data <10% 10%–14% 15%–19% ≥20%
Obesity Trends* Among U.S. AdultsBRFSS, 1999
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data <10% 10%–14% 15%–19% ≥20%
Obesity Trends* Among U.S. AdultsBRFSS, 2000
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data <10% 10%–14% 15%–19% ≥20%
Obesity Trends* Among U.S. AdultsBRFSS, 2001
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data <10% 10%–14% 15%–19% 20%–24% ≥25%
Obesity Trends* Among U.S. AdultsBRFSS, 2003
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data <10% 10%–14% 15%–19% 20%–24% ≥25%
Obesity Trends* Among U.S. AdultsBRFSS, 2004
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data <10% 10%–14% 15%–19% 20%–24% ≥25%
Obesity Trends* Among U.S. AdultsBRFSS, 2005
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%
Obesity Trends* Among U.S. AdultsBRFSS, 2006
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%
Obesity Trends* Among U.S. AdultsBRFSS, 2007
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%
Obesity Trends* Among U.S. AdultsBRFSS, 2008
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%
Obesity Trends* Among U.S. AdultsBRFSS, 2009
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%
Obesity Trends* Among U.S. AdultsBRFSS, 2010
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%
Purpose
Define the term ethical dilemma. Identify three ethical dilemmas that
emerge from SPHM practice. Describe outcome opportunities
associated with bariatric safe patient handling and mobility.
Ethical dilemma occurs when there are two or more equally unacceptable choices and a decision must be made
Impact in the PLWO
Complex nature of careInadequate policies and proceduresLack of size-appropriate technology and resourcesComplex nature of the individual Weight bias
Common dilemmas
Refusal – is this a communication issueVulnerabilityDignityAccess
Ethical principles
BeneficenceNonmaleficenceAutonomyJustice
Beneficence - doing good for the individual, who may be a patient, family member, caregiver or other stakeholder. Beneficience refers to seeking the greatest benefit as balanced against risk.
“Above all, do no harm”
Nonmaleficience - active prevention of harm to the individual
Autonomy - freedom of personal decision making
Justice – just distribution of healthcare goods and services
Power as a factor Moral courageSilence
Balancing principles: autonomy and beneficence
Seven Step Model
Power as a factor Moral courageSilence
Balancing principles: autonomy and beneficence
Seven Step Model
Power as a factor
1)To what extent do healthcare workers have a right to adequate SPHM resources necessary to provide safe care to the person who is obese?2)To what extent do frontline caregivers have a responsibility to identify and report unsafe size-sensitive patient care situations to the leadership team? 3)What is the responsibility of the leadership team to ensure a safe environment for patients and caregivers
Power: One step further
Social danger – threat to social statusConfirmation bias - a phenomenon wherein decision makers seek out and assign more weight to evidence that confirms their hypothesis, and ignore evidence that could disconfirm their hypothesis
The threat of Paternalism
Balance between autonomy and beneficenceCase study:
Patient/residentOrganizational
Rights and responsibilities1)To what extent should healthcare facilities provide SPHM technology, training, policies and support in caring for certain vulnerable patient populations?2)What is the responsibility of caregivers to gain skill and knowledge pertaining to size-sensitive SPHM technology and policies?3)What is the responsibility of patients and their families to participate in assessment-driven, technology-assisted mobility when it becomes available?4)What is the right of patients to expect safe handling, activity, and mobility?
Does SPHM make a difference?
Outcome Management
Evidence-based practice“I really feel that we have had fewer fall-related injuries since using the lifts to mobilize our larger patients”
Historical review
NightingaleDeming Diagnosis related groupsPerformance Payment System (PPS)Accountable Care Organizations (ACO)
Let’s take a step back
“Standardized processes are designed to promote reproducible outcomes and therefore consistent safe, quality care...measurable and manageable care.”
Bariatric SPHM outcome opportunities
Critical careFall-related injuryHAPU preventionDVT preventionEarly progressive mobilityWorker safety
Critical care opportunities
Social construction of obesityReality of biasRecognize the challengeRisk of physical injury
Healthcare opportunities
Worker health and well-beingPatient health and well-beingOrganizational health and well-being
Worker health and well-being
Bariatric SPHM studyRetention and recruitmentPatient handling injuryReplacement costs
Bariatric SPHM
“Patients with a BMI greater than 35 comprised only ten percent of the patient population, however handling patients with a BMI greater than 35 was associated with 29.8% of injuries, 27.9% of lost time, and 37.2% of restricted time. In this study lifting, turning and repositioning was usually performed using biomechanics and not equipment. Therefore, with increasing body weight and weight maldistribution of both patients and their caregivers, challenges inherent in lifting, moving and repositioning the larger, heavier patient lends to hazards of immobility.”
Randall SB, Porie WJ, Pearson A, Drake DJ. Expanded Occupational Safety and Health Administration 300 log as metric for bariatric patient-handling staff injuries. Surg Obes Related Disease. 2009;5(4): 463-468.
Worker health and well-being
Bariatric SPHM studyRetention and recruitmentPatient handling injury
Frequency and severityLost and restricted daysReturn to workReplacement cost
Patient health and well-being
HAPUFallsSatisfaction/experienceReferrals
Kaminisky study
Suggests that the better prepared and equipped to manage obese patients…the greater degree of empathy or compassion
How can I safely treat the wound care patient without a fall??
Consider the treatment that requires the fewest transfers!
Tools and resources
Organizational health and well-being
Time in activitiesRose
Readmission within 30 daysLength of stayLitigation (aggravating factor)
Pressure ulcersFall-related injuryPain
Miss Smith
21-year-old, 500-pound marginally independent woman living at home with her working family reports incontinence dermatitis, itching under her breasts and arms, right hip ulcer, and lower leg ulcers.
Miss Smith
What are Miss Smith’s immediate needs?
Does she require hospitalization? Or not? What safety considerations will she
need in the hospital? At home? How about caregivers? Could preplanning assist in care?
Outcome opportunities
Time to appropriate set-upTime to appropriate EPM
PTNursing
PreventPHIFall-related injuryHAPU
Length of staySatisfaction
Case study
29-year-old, 630 pound male admitted for open Roux-en-Y Gastric Bypass. Extended surgical time, extended critical care. Pressure ulcer discovered on day 33, treatment begun on day 35.
Case study
What are the ethical considerations?What are the legal consequences?What are the cost outcomes?What are the OUTCOME OPPORTUNITIES?
Recognizing empathy…
…Kaminsky
Summary
Align with your quality/safety initiativesIncreasing prevalenceRecognize patient, worker and organizational outcomesChange begins with all of us!