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Guidelines for the Care ofHospitalized Patients withBariatric Care NeedsStandardizing and Improvingthe Care of Adult Patients with Obesityin Alberta HospitalsDeveloped by:Diabetes, Obesity and Nutrition Strategic Clinical NetworkAlberta Health ServicesandBariatric Care and Rehabilitation Research Group,Faculty of Rehabilitation Medicine, University of Albertain collaboration withObesity CanadaVersion 1.4March 8, 2022
This work is licensed under a Creative Commons AttributionNon-commercial-Share Alike 4.0International license. To view a copy of this licence, .0/. You are free to copy, distribute and adaptthe work for non-commercial purposes, as long as you attribute the work to Alberta HealthServices and abide by the other licence terms. If you alter, transform, or build upon this work,you may distribute the resulting work only under the same, similar, or compatible licence. Thelicence does not apply to AHS trademarks, logos or content for which Alberta Health Services isnot the copyright owner.Provincial Guidelines for the Care of Hospitalized Patients with Bariatric Care NeedsMarch 8, 20222
ContentsIntroduction / Background . 5Guiding Framework . 7Understanding Obesity. 8Why is Obesity a Chronic Disease? . 9Weight Bias and Obesity Stigma .11Check Your Attitude .12Educational Resources to Decrease Weight Bias.12People-first Language .13Use of Appropriate Images .13Identifying Patients with Bariatric Care Needs .14Body Shape / Weight Distribution .15Equipment Needs.16Mobility Equipment .17Injury Prevention: Safe Patient Handling .18Functional Assessments and Precautions .18It’s Your Move Safe Patient Handling Bariatric Specific Resources .18When a Patient with Bariatric Care Needs Falls .19Care Considerations for Patients with Bariatric Care Needs / Co-morbid Conditions .20Maintaining Privacy .20Assessment .21Weight .21Blood Pressure .21Pain .21Co-morbid Conditions and Care Considerations.22Cardiovascular System .22Respiratory System and Airway Management .23Obesity Related Atelectasis or Pneumonia .23Obstructive Sleep Apnea .23Obesity Hypoventilation Syndrome .24Gastrointestinal (GI) Considerations.25Genitourinary Considerations .25Catheterization .25Lymphatic System .26Musculoskeletal System .26Osteoarthritis .26Endocrine System .26Skin and Skin Integrity.27Skin Fold Management.28Hygiene .29Odour Control .29Pressure Injury Prevention .29Wound Considerations .30Complications.30Infection .30Dehiscence .30Hematoma and Seroma Formation .30Nutrition.31Intravenous (IV) Access .31Provincial Guidelines for the Care of Hospitalized Patients with Bariatric Care NeedsMarch 8, 20223
Intramuscular Injections .31Medication Absorption and Other Pharmacological Considerations.31Importance of Mobilizing .32Transitions between Care Areas within the Hospital .32Discharge Planning or Transition to a Different Program .33Inter-facility Transfers via Emergency Medical Services .34Special Populations or Circumstances .35Radiology / Diagnostic Imaging .35Surgery and Peri-operative Considerations .35Emergency Situations / Cardiac Arrest .36Perinatal .37Pediatric Population .40Ideal Hospital Design and Room Set Up .41Appendix 1: Algorithm for Determining Bariatric Care Needs .47Appendix 2: Summary of Care Requirements.48Appendix 3: Causes and Contributing Factors for Obesity .52Appendix 4: Terminology/ Glossary .55Appendix 5: Functional Transfer Record .58Appendix 6: Braden Scale for Predicting Pressure Injury Risk .60Appendix 7: AHS Emergency Medical Service Bariatric Patient Measurement Job Aid .62References .63Acknowlegements .67Provincial Guidelines for the Care of Hospitalized Patients with Bariatric Care NeedsMarch 8, 20224
Introduction / BackgroundThe continuing rise in obesity is a global health issue. Nearly three out of five Albertans over theage of 18 have a BMI that would classify as overweight or obese (1). As of 2017, 29% of adultsin Alberta have obesity (2). Obesity was classified as a chronic disease by the CanadianMedical Association in 2015.Patients with obesity in a health care settings are at a higher risk for complications and injurydue to inadequate facility design and equipment. Many health care providers lack knowledge ofthe complex nature and causes of obesity; and believe that if a person simply exercises moreand eats less, they can lose weight (which is not true). (3) (4)Weight bias generally refers to negative attitudes toward a person because they have obesity,and can be manifested in different ways, leading to prejudice and discrimination. Patients livingwith obesity who are admitted to hospital have reported being treated with disrespect by healthcare practitioners. Weight bias can prevent healthcare providers from delivering optimal care,and negatively impacts the patient’s experience in the hospital. It also impacts the patient’sability to build a trusting relationship with health care providers. Weight bias increases patientrisk for psychological distress and delays patients in seeking future medical treatment.The Diabetes, Obesity and Nutrition Strategic Clinical Network (DON SCN) is leading aprovincial initiative to improve and standardize the care of patients with obesity when they comeinto Alberta hospitals. The Bariatric Friendly Hospital Initiative is focused on implementingstandards and guidelines to create a bariatric friendly environment within Alberta hospitals,This initiative supports health care providers to become more knowledgeable about obesity andits impact on quality care, develop competencies in the unique care needs of patients withobesity, and work effectively and compassionately with patients with obesity. It also focuses onsafe patient handling to help prevent patient and provider injury.Medicine Hat Regional Hospital was the pilot site for this initiative, and in January 2019implemented standards and guidelines to improve the care and experience of patients withobesity. Evaluation of the pilot site demonstrated an improvement in staff attitudes and beliefstowards persons with obesity, increased access to bariatric equipment, and staff who agreedbariatric care had improved in their area.The Bariatric Friendly Hospital initiative is not focused on treatment interventions for obesity, buton the safe and competent care of patients with obesity, and therefore details in regards toproviding weight loss interventions will not be part of these guidelines.Regardless of the limitations of a physical care setting, there are several modifications that canensure quality care for patients with bariatric care needs.Provincial Guidelines for the Care of Hospitalized Patients with Bariatric Care NeedsMarch 8, 20225
Purpose of the GuidelinesThe purpose of these guidelines is to provide staff, students, physicians and administrators whowork in Alberta hospitals key resources and recommendations to assess and plan safe andsensitive care for patients with obesity who have bariatric care needs.For the purpose of these guidelines, bariatric care needs should be assessed for all patientswho have a body weight of 113kg (250lbs) or more. The reason for this weight cut-off is thatsome equipment / furniture in the hospital environment has a maximum weight capacity of113kg (250lbs).Note: some patients may have a body weight of less than 113 kg, and may require assessmentfor bariatric care needs because of their body shape or stature.Key Objectives Meet the bariatric care needs of patients who are hospitalizedPromote safety for patients and staffPromote quality care free of weight bias and stigmaFacilitate transitions in care within the hospital, as well as transitions to other caresettingsTarget Audience All health care providers involved in direct patient care including but not limited toNurses, Healthcare Aides, Registered Dietitians, Pharmacists, Physiotherapists,Occupational Therapists, Therapy Assistants, Respiratory Therapists, patient transporttechnicians, diagnostic and treatment technologistsHospital AdministratorsPhysicians responsible for direct patient careAll those who influence workplace safetyProvincial Guidelines for the Care of Hospitalized Patients with Bariatric Care NeedsMarch 8, 20226
Guiding FrameworkThe R-E-S-P-E-C-T model was applied in the development of this guideline (Bejciy-Spring2008). The RESPECT model for sensitive treatment of patients with obesity provides aframework for healthcare professionals to provide patient and family centred care. At the core ofthis model is a belief that a patient with bariatric care needs has the right to care that meets theirindividual needs and is provided by healthcare professionals that are competent and attentive toproviding quality care that is appropriate, safe, and dignified. Seven core concepts are includedin the model that are summarized in Table 1.R-E-S-P-E-C-T Model and defining principles adapted for use in this guideline (5)Core ConceptRapportDescriptionInterpersonal relationship with a patient and their family that includesconnection, empathy and understanding that together create afoundation of trust. Take time to get to know your patient and take care not to makeassumptions about them based on their size.Environment /Provision of adequate space and equipment (including furniture) toEquipmentimprove the quality of care, enable participation in care, and promotemobility and autonomy. Create an accessible and safe environment with equipment that isappropriately sized, such as exam tables, stretchers andwheelchairs. Have a selection of chairs in patient, exam and waiting rooms. Ensure there are appropriate sized gowns, blood pressure cuffs andany other items that might be required. Ensure patient has easy access to toilet/commode in private area.SafetyA focus on critical safety considerations including weight capacity ofequipment, safe patient handling techniques, knowledge on theoperation of equipment.PrivacyProtecting all aspects of privacy for patients with bariatric care needsincluding adequate coverage of the body. Not all hospital rooms or patient care areas are an ideal size orlayout. You may need to be creative in the way you ensure yourpatient’s privacy. If taking your patient’s weight, do so in a private area and withoutjudgmental commentary.EncouragementTaking the time to meet the needs of patients with bariatric care needsand provide opportunities to promote independent self-care andmobility where appropriate.Caring /Commitment to actions that contribute to the dignity and comfort of aCompassionpatient with bariatric care needs. If unable to use bathroom in room, a private discrete area fortoileting is provided.TactInteractions with patients with bariatric care needs, their familymembers and the healthcare team are respectful and free of weightbias. Be aware of nonverbal signals and terms of reference such as “fat”that may be offensive to a patient living with obesity. Use people-first language such as “patient with obesity” instead ofobese patient.Provincial Guidelines for the Care of Hospitalized Patients with Bariatric Care NeedsMarch 8, 20227
Understanding ObesityIt is important for clinicians caring for patients with obesity tounderstand that is it is a complex and chronic disease.Obesity has multiple causes and factors and is not as simpleas eating too much and not exercising enough.Simply eating less andexercising more will notcure a person’s obesity.DefinitionObesity is achronicdisease.Obesity is defined as abnormal or excessive adipose tissue thatimpairs health and wellbeing (6). Obesity is a complex disease withmany causes and factors (7). Once established, obesity becomes alife-long chronic disease.Body Mass IndexBody mass index (BMI) is a screening tool used to classify weight in adults. It is calculated bydividing a person's weight in kilograms by their height in meters squared (kg/m2). BMI onlyprovides information about body size. It is not useful to identify bariatric care needs or the healthstatus of individual patients. When used in combination with waist circumference, it can indicaterisk for obesity related illness such as diabetes, hypertension and cardiovascular disease.BMI Category(for Adults)BMI Range(Kg/m2)*Disease Risk with Waist CircumferenceMen 102 cm (40 in)or lessMen greater than102 cm (40 in)Women 88 cm (35 in)or lessWomen greater than88 cm (35 in)Underweight besity Class I30-34.9HighVery HighObesity Class II35-39.9Very HighVery HighObesity Class III 40Extremely HighExtremely High*Disease risk for Type II diabetes, hypertension and cardiovascular disease(8) (9)Note: Research is still ongoing to determine if traditional BMI cut offs are appropriate for allethnicities. For example a lower BMI cut off may be more appropriate in some Asianpopulations. For persons 65 years and older the 'normal' range may begin slightly above BMI18.5 and extend into the 'overweight' range (10).Provincial Guidelines for the Care of Hospitalized Patients with Bariatric Care NeedsMarch 8, 20228
Causes of ObesityThere are many factors that can lead to weight gain including (11): Environmental / socioeconomic Genetics Age Hormones Mental health Medications OtherThe causes and contributing factors of obesity are many and it is not just as simple as eatingtoo much and not exercising enough.For more information and details about causes or contributing factors for obesity; please seeAppendix 3.Why is Obesity a Chronic Disease?The World Health Organization, Canadian Medical Association, American Medical Associationalong with other national and international scientific societies recognize obesity as a complexchronic disease with genetic, environmental, and behavioraldeterminants (12) (3). The characteristics of obesity are the samePeople withas other chronic diseases:obesity have tried complex causesto lose weight but modifiable risk factorsthe weight often long latency periodscomes back.(time between onset of the illness and feeling its effects) long durationBodies will fight to functional impairment or disability.regain their no curehighest weight.With the exception of pregnancy, once an individual gains weighttheir body will protect this extra weight (13). It doesn’t matter how orwhy they gained the weight. As a result, when an individual tries to lose weight the body putsmechanisms in place to defend the weight and put the weight back on. These mechanismsinclude: an increase in appetite a reduction in metabolic rate a reduction in activity thermogenesis (the body reduces its fuel consumption)These mechanisms are all the body’s efforts to try and protect its body weight and promoteweight regain. This is why when people lose weight they often end up putting it all back on.Provincial Guidelines for the Care of Hospitalized Patients with Bariatric Care NeedsMarch 8, 20229
Individuals canmaintain goodhealth at a widerange of bodyweights.This has significance for how health care professionals think aboutobesity and how they manage it clinically. They need to approachobesity using all of the principles of chronic disease that are usedfor other conditions like diabetes and hypertension. Treating,controlling and managing obesity is a lifelong process. There is nosimple cure for obesity and simply losing weight does not solvethe problem. (14)Obesity Treatment OptionsThis section is a brief overview of treatment options to provide acomprehensive understanding of obesity. As mentionedpreviously, these guidelines are not focused on treatment ofobesity.Obesity in adults is a chronic disease that requires long term, lifelong management. The three treatment options are: behaviourmodification, medication and bariatric surgery. Medication andbariatric surgery options work best when combined withbehaviour modification. There is currently no cure for obesity andwhen treatment is stopped, the disease returns (13).Behaviour ModificationThe goal of behaviour modification is to improve healthy habitsand change other habits, and then maintain these changes. Bestresults are achieved when patients work with an interdisciplinaryteam. Behavioural changes that support weight loss include selfmonitoring (keeping a food and activity record), healthy eating,being active, improving sleep quality, and learning to bettermanage stress and emotions.There is no cure forobesity.Once treatmentstops the diseasereturns.Obesity treatment isabout improvinghealth and wellbeing, and notsimply reducingnumbers on thescale.Success is differentfor every individual.MedicationAs of 2022, there are four prescription medications that are approved to assist with weightmanagement in Canada. When a person loses weight, appetite increases; the most effectivemedications work by decreasing appetite. Medication works best when coupled with behaviourmodifications, as described above. Medications help patients lose more weight than is possiblewith behaviour modification alone, and help them to keep the weight off. (15)Bariatric SurgeryBariatric surgery is a treatment used to help individuals with obesity manage their health andweight. It is currently the most effective treatment for obesity, and it works best when it iscoupled with behaviour modification. The most common bariatric surgeries performed in Albertaare: Sleeve Gastrectomy Gastric BypassBoth surgeries create a smaller stomach which will help an individual feel full after smallamount of food. Both surgeries also change the gut hormones that impact hunger, satiety andblood sugar. The one difference is with the gastric bypass, a portion of the small intestine isbypassed causing less absorption of calories and nutrients.Provincial Guidelines for the Care of Hospitalized Patients with Bariatric Care NeedsMarch 8, 202210
Most surgeries are performed laparoscopically with hospital admissions being between 1-3days. To be assessed for bariatric surgery, patients must be referred to one of five bariatricspecialty clinics in Alberta by their primary care practitioner.For more information about Obesity Treatment options, refer to 2020 Canadian Adult ObesityClinical Practice Guidelines.Weight Bias and Obesity StigmaWeight Bias is thenegativestereotyping ofindividuals livingwith excess weightor obesity.It often leads toprejudice anddiscrimination.Weight bias is defined as negative attitudes, beliefs orassumptions towards individuals who are living with beingoverweight or have obesity (16). Weight bias is prevalent in societyand individuals with obesity are often stereotyped as lazy,unintelligent, noncompliant, and sloppy.Unlike other chronic diseases, excess body weight associated withobesity is a visible characteristic. Weight bias remains sociallyacceptable and is rarely challenged when it happens. Individualswith obesity are often seen as responsible for their weight.Obesity stigma involves actions against people with obesity thatcan cause exclusion and marginalization, and lead to inequities.Weight Bias in HealthcareWeight bias is prevalent in healthcare. Negative attitudes about patients with obesity have beenreported by physicians, nurses, dietitians, psychologists and medical students (17). Researchhas shown that even healthcare professionals who specialize in the treatment of obesity canhold negative attitudes. When health care providers have weight bias, the quality of care apatient with obesity receives can be decreased. (18) (19)Weight Bias Impact on PatientsPatients who have experienced weight bias are at an increased risk for anxiety, depression, lowself-esteem and poor body image. Experiencing weight bias and stigma can also increasestress hormones and may put patients at increased risk for heartdisease and stroke. (20)Patients with obesity are more likely to cancel or avoid healthcare,put off preventative routine screening and may present with moreadvanced disease or illness (19).Patients with obesity often report that they are made to feel thattheir obesity is the cause of their presenting problem, concern orillness when that may not be the case at all (19). It is important forhealthcare professionals to assess a patients presenting concernand not make assumptions that a patients current health concern isdue to their weight.Patients reportthat they are madeto feel that theirobesity is thecause of theirpresentingproblem.Provincial Guidelines for the Care of Hospitalized Patients with Bariatric Care NeedsMarch 8, 202211
Factors that Decrease Weight BiasOne of the most important strategies to reduce weight bias is self-awareness. Individuals shouldidentify and address their own personal assumptions and attitudes about weight. One might askthemselves: How do I feel when I care for patients with obesity? What stereotypes do I have about persons with obesity? Do I make assumptions regarding a person’s character, intelligence, abilities, healthstatus or behaviours based on their size?Check Your AttitudeTesting assumptions is an important first step. The questions listed in the table below can helppeople become more aware of their attitudes and beliefs about weight and obesity. (21)QuestionDo you assume a patients’health, characteristics,behaviours and abilities arebased on their body size, weightand shape? Yes/NoFact / Supporting EvidencePeople come in difference sizes and shapes. Body size,weight and shape are not directly associated with apersons’ health, work ethic, willpower, intelligence or skills.Do you think that every patientwith a larger body size or ahigher BMI has obesity andneeds to lose weight? Yes/NoObesity is a chronic disease defined as excess orabnormal weight that impairs health. BMI is an indicator ofsize, not health. Not everyone with a large body size orhigh BMI has obesity. (eg. an athlete with a large amountof muscle bulk, as muscle is more dense and weighs morethan adipose tissue)Do you believe patients withobesity are personallyresponsible for their condition?Yes/NoMany people think obesity can be controlled by simplyeating healthier and being more active. But more than 300factors contribute to obesity ranging from physiologicaland psychological factors to genetic, social andenvironmental factors. Many of these are beyond anindividuals’ control.Do you let negative commentsabout a patient who has a largerbody size or has obesity gounchallenged? Yes/NoCalling attention to inappropriate, blaming or shamingjokes, comments or conversations about people withobesity or a larger body size are important to reduce suchbehaviour.The above ‘Check Your Attitude’ questions are also available online if you would like to sharewith others.Educational Resources to Decrease Weight BiasThere are a number of online modules and webinars that provide education for healthcarepractitioners for the purpose of eliminating weight bias and weight based discrimination.Some are:Diabetes Obesity and Nutrition Strategic Clinical Network Weight Bias Education ModuleProvincial Guidelines for the Care of Hospitalized Patients with Bariatric Care NeedsMarch 8, 202212
This brief 20 minutes online course is the second in a series of 3 developed for the staff ofAlberta Health Services. The goal of this course is to increase professional competency, andsupport staff to work effectively and compassionately with patients with obesity. This brief onlinecourse will support health care providers to become more knowledgeable about weight bias,and it’s impact on quality care. It will also support them to build weight sensitivity. The other twoonline learning modules are: Understanding Obesity Supporting the Care Needs of your Patient with ObesityBalanced View, British Columbia Provincial Health Services AuthorityBalanced View is a more in-depth online learning resource designed to raise awareness aboutweight bias and stigma in health
towards persons with obesity, increased access to bariatric equipment, and staff who agreed bariatric care had improved in their area. The Bariatric Friendly Hospital initiative is not focused on treatment interventions for obesity, but on the safe and competent care of patients with obesity, and therefore details in regards to
