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Interprofessional Collaboration in Developing Best Practices for Bariatric Patient Care

GTA Rehab Best Practices Day May 1, 2015

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Credit Valley Hospital 2200 Eglinton Avenue West, Mississauga

Mississauga Hospital 100 Queensway West, Mississauga

Queensway Health Centre 150 Sherway Drive, Toronto

In the next 8 minutes we will:

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• Demonstrate lessons learned in the rehabilitation setting regarding care of the Bariatric patient

• Demonstrate the close interprofessional connections required to achieve patient and team goals




Clinical Objectives

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• To restore function through interprofessional collaboration, clinical expertise, environmental and equipment modification, and partnership with the Bariatric patient

• To develop new THP Bariatric Care Standards to reflect interprofessional collaboration




Clinical Priorities

• Wound healing

• Optimizing nutritional status & knowledge

• Restoring functional mobility

• Restoring self-care independence

• Mitigating injury risk to patient & staff during

patient care, handling and mobility

Goal:

Successful transition from hospital to home

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5

Interprofessional Team

Patient & Family

MRP

RD

RN

OT PT

OTA/PTA

PSW

RPN

Physiatrist

Vendors

Med. Psych OT

Wound Care RN

Ergonomic OT Employee Health

Manager

Educator

IPAC

Pharmacist

Clinical Leader

MD Consultants RT

CCAC

Clergy

Corporate Services

Compassion ∙ Excellence ∙ Courage




Interprofessional Approach to Wound Care

Concerns: • Chronic non-healing wounds

• Moisture and lymphedema management

• Mobility and nutrition

• Compliance with treatment

Solutions: • Coordinate scheduling for wound

dressing changes

• Implement collaborative care routines to maximize recovery, prevent further injury

• Problem solving for dressing application process and equipment needs

• Establish funding needs for additional staff, materials and equipment

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Patient & Family

RN MRP MD Consultants

RD

Clinical Leader

Manager Physiatrist

PSW

OT PT

RPN

OTA/PTA

Wound care RN

IPAC





Wound Care Impact

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0

0.5

1

1.5

2

2.5

3

3.5

4

4.5

Week 1 Week 3 Week 5 Week 9 Week 12 Week 18

Venous Ulcer Progression Timeline

Venous ulcer timeline

4 = Local colonization/infection

3 = Maintenance

2 = Healing

1= Healed




Interprofessional Approach to Self-Care

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Pre-requisites accomplished: • Wound healing to manageable

stage • Ensure nutritional intake, medical

stability • Develop core strength, sitting &

standing tolerance • On-site bariatric equipment

(Ergonomics, vendors)

• Safe transfers & mobility • Ensure adequate staffing In therapy: • Identify anxiety as barrier • Develop self-confidence • Collaborate scheduling • Modify mobility targets • Transition self-care to patient • Develop & implement daily

routines for home

MRP RN

Manager

OT PT RPN

PSW

Wound care RN


Med. Psych OT

Patient & Family

IPAC

Physiatrist

Clinical Leader OTA/PTA

CCAC

RD

Vendors

Corporate Services

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Essential Therapy Equipment

Mechanical lift & walk sling Bariatric walker & wheelchair

Ergometer Standing pole

Parallel bars




Impact FIM

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Interprofessional Approach to Mitigating Injury Risk

Concerns:

• Patient weight + poor mobility status significant safety risk for patient & staff

• Risk of infection transmission (MRSA)

Solutions:

• Involve THP specialist consultants – (Ergonomics, IPAC, Wound care )

• Use of specialized equipment (e.g. Limb slings for dressing changes)

• Partner with vendors to modify equipment

• Work with management re additional staffing needs (PSW)

• Cluster care (wound/self) & therapy sessions (creative scheduling)

• Listen to patient (re: abilities, methods)

• Staff education on equipment/ safe handling

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Vendors

Patient & Family

RN

RPN Manager

Clinical Leader


OT PT

OTA/PTA

PSW

IPAC RD

Wound care RN

MD Consultants MRP

Corporate Services

Educator




Mitigating Injury Risk Impact

• No injuries to staff or patient (WSIB cost avoidance permits investment in new equipment)

• Less staff fearfulness & stigma

• Reduced stress to wounds through equipment modification

• Timed collaborative interventions and specialized equipment optimized wound healing

• No MRSA transmission

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Functional Impact

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Admission Discharge

Wound care: Chronic bilateral venous leg ulcers

Venous ulcers healed Chronic (17 yr.) ulcer healed

Leg circumference: Left: 78 cm Right : 90cm

Leg circumference: Left : 70cm Right: 84 cm

Nutrition: BMI 60.8 Weight: 178.3 kg (393 lbs.)

BMI 41.4 31.9 % weight loss Weight: 138.3 kg (304 lbs.)

Mobility: Mechanical lift transfer Non-ambulatory

Modified Independent transfer Modified Independent with rollator

BADL’s : Total Assist bathing and dressing

Minimum Assist bathing Modified Independent dressing

Psychosocial: Anxiety and fear limiting participation

Completion of self-efficacy scale Improved confidence; self-report




Our Next Steps

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• Develop new Interprofessional THP Bariatric Care Plan • Standardize Rehab Bariatric Equipment available (ceiling lift in gym)

• Standardize Rehab Bariatric Treatment Protocols

• Education and Training across THP rehab units

• Collaborate with THP management re anticipated costs for

implementation and care of Bariatric patient




Key Messages

• Safety first – for patient & staff

• Specialized equipment & supplies

• Value the patient’s experience

• Creative interprofessional problem solving

• Psychosocial issues impact goal success

• Expect greater LOS, staffing requirement, supply budget – financial implications

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Presenters: Lynn Roberti, Occupational Therapist

[email protected] &

Allison Kirke, RN Wound Care Specialist [email protected]

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Authors: Lynn Roberti OT Reg. (Ont.), Allison Kirke RN, BSc N, WOC Jennifer Brown BA, OTA/PTA, Carol Hennigar OT Reg. (Ont.), Janet Suchanek OT Reg. (Ont.), Leslie Howell BSc. PT, Rebekah Joseph RD, Devika Singh-Siripaul RN, BSc N, Educator Anne-Marie Lynch RN, CL Nadia Woloshyn OT Reg. (Ont.) Manager 4J

References

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“Bariatric patients: nursing care and specialist equipment.” The Lamp68(5): 41. Blackett, A. et. al. (2011). Caring for persons with bariatric health care issues. Journal of Wound, Ostomy and Continence Nursing. 38(2) pp 133-138. Boza, J. et. al, (2011). Skin manifestations of obesity: a comparative study. Journal of European Academy of Dermatology and Venereology. (12) pp 1220-1223. Camden, S.G. (2006). Nursing Care of the Bariatric Patient. Bariatric Nursing and Surgical Patient Care 1(1), 21-30. Donini, M., Savina, C., Castellaneta, E., Coletti, C., Paolini, M., Scavone, L., Civale, C., Ceccarelli, P., Zaninotto, S., Tineri, M., Grossi, G., De Felice, M.R., & Cannella, C., (2009) Multidisciplinary approach to obesity. Eat Weight Disorder, 14(1), 23-32. Nelson, A.L., Motacki, K., & Menzel N., (2009) The Illustrated Guide to Safe Patient Handling and Movement. New York: Springer. Nowicki, T., Burns, C., Fulbrook, P., & Jones, J., (2009) Changing the mindset: An inter-disciplinary approach to management of the bariatric patient. ScienceDirect, (16), 171-175. Pokorny, M. et. al. (2014). The relationship between pressure ulcer prevalence, body mass index, and braden scales and subscales: a further analysis. Advances in Skin & Wound Care. 27(1). Pp 26-30. Public Services Health & Safety Association Rush, A. & Muir, M. (2012).Maintaining skin integrity in bariatric patients. British Journal of Community Nursing . 17(4). Pp 154-159. Waters, T.R. (2007). When is it safe to manually lift a patient? The Revised NIOSH Lifting Equation provides support for recommended weight limits. American Journal of Nursing 107(8), 53-59. WHO (2000) Obesity: Preventing and Managing the Global Epidemic: Report of a WHO Consultation on Obesity (HEALTH CANADA) www.worksafebc.com/publications/health_and_safety/by_topic/assets/pdf/handling_patients_bk97.pdf www.washingtonsafepatienthandling.org/images/best_practices/SPH_BPGuide_Chpt5.pdf www.visn8.va.gov/visn8/patientsafetycenter/safePtHandling/toolkitBariatrics.asp

http://www.visn8.va.gov/visn8/patientsafetycenter/safePtHandling/toolkitBariatrics.asp

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