In the mid 1980s, I was introduced to my first patient of very significant size. The client demonstrated a body weight that had exceeded 1,000 pounds. At that time, no equipment options were available to manage a patient of significant size.

Many facilities accomplished management through traditional improvised fabrication and manual techniques. Transfers were often a combination of known manual lifting techniques, body mechanics, and improvised techniques to reduce overall frictional resistance. Such techniques included placement of plastic bags under the patient's draw sheet, thereby reducing frictional resistance during the side glide transfers. Few options existed for the selection of an appropriate target surface. For most facilities, beds, wheelchairs, gurneys, and bathtub benches of the day had load limitations restricted to a total capacity of about 350 pounds.

Improvised fabrications and techniques for the more sizeable patients often resulted in fractured bed frames, motor failures, failed wheelchair prescriptions, increased workers' compensation claims, and patient injuries. Inadequate equipment prescription contributed to failed attempts at mobilization and the overall cost by prolonging the patient's length of stay. Since that time, a revolution in appropriate weight-rated equipment has resulted in safe and more cost-effective work environments.

When considering equipment purchase, a facility must prioritize needs and examine equipment that would maximize cost-effectiveness and implementation. To compose a Bariatric Shopping List, I would refer facilities to a concept I created called the Bariatric Triad.¹ The Bariatric Triad refers to the minimally necessary equipment required to safely manage the dependent patient of size.

The Bariatric Triad

1. A weight-rated expandable support surface bed,
2. A weight-rated target wheelchair;
3. And a weight-rated bedside lift with scale.

This triad reflects the minimally necessary equipment to transition the patient through the health care system in a cost-effective manner. The great benefit of this concept is that the equipment would have a high degree of portability and follow the patient, but it could also achieve upright positioning of the patient to maximize discharge potential. Many secondary facilities will not accept a patient that has not achieved a sitting posture. Thus, in a Bariatric Shopping List, the Bariatric Triad dominates the first three spots.

Ceiling Lifts: Ceiling lifts are an absolute must over any bed in which a high frequency of dependent patients occur. The only drawback related to the ceiling lift is its lack of portability. The bedside lift can follow the patient all the way home if needed.

4. Gurneys: Gurneys are vital to accomplish safe patient transport to and from diagnostics and preoperative/postoperative environments. Patients with dependency must be transported to these environments on a gurney.
5. Side Glide Devices: While sling loading devices can complete transfer to gurneys, the side glide devices are very efficient and safe means of mobilization of the dependent patient between surfaces. Patients with dependency should not be transported to operative and diagnostic environments, since the personnel do not have the expertise to define levels of assist.
6. Walkers: Bariatric walkers are a must for clinicians to avoid placing professionals in the indefensible position of walking someone with underrated equipment. While a patient can be discharged with the Bariatric Triad, the discharge clearly can be achieved faster if the patient is up and walking.
7. Commodes: Weight-rated bedpans or commodes that are portable are first on the list of this category, followed by floor-mounted, wide-load bariatric bathroom commodes. The former devices can follow the patient, because the latter floor-mounted commode typically is mounted in a Bariatric Suite.
8. Furniture (bedside, waiting room, lobby, floor-mounted commodes): Once basic transfer and conveyance issues are resolved, facilities need to examine general environment changes for their facilities. This would include bench seating in lobbies and corridors and bariatric-capacity chairs in the rehab environments and patient rooms.
9. Walkers, Crutches, and Canes: Rollator walkers, crutches, and assorted canes are necessary for rehabilitation and progression of the patient.
10. Shower Commode Chairs: These items would be moved up in long-term care environments. For many patients, these items are the first chance at adequate personal hygiene in a long time.
11. Stretcher, High-Low Chairs: These are wonderful devices. However, I place them lower on the list, since they are not required to achieve adequate upright positioning. The Bariatric Triad can accomplish this task in the face of a very limited budget. I do like this category of equipment. However, any clinician who has had to run past one of these devices to find a wheelchair understands the need to prioritize positioning device for effective discharge.

Additional Items for the Rehab Shopping List

12. Therapy Mats and Parallel Bars: Too often a neglected area of service is the rehabilitation gym. In today's health care system, few acute care patients are ever transported to a therapy gym. The therapy mats and parallel bars should be able to accommodate both the patient and the caregiver in the rehabilitation environment.
13. Standing Frames (Powered Transporters, Frame Lifts, Pneumatic Risers): Perhaps the greatest challenge I have had to improvise in the clinic is standing sizeable patients. New innovations make these devices a powerful addition for the rehabilitation gym. I envision that every rehabilitation environment should have adequate therapy mats and standing frames.
14. Other Devices: I view these remaining devices as nice to have, but accessory on my Bariatric Shopping List. Many of these items simply lack portability; or in terms of cost-effectiveness, they can be replaced by one of the above items.

The successful Bariatric Shopping List will effectively prioritize versatility and cost of each product type. The products must match the environment. An effective list will maximize safety for all involved and promote effective care of the patients.

Michael Dionne, PT, is president of Choice Physical Therapy Inc, Gainesville, Ga, and founder of www.bariatricrehab.com. He is internationally recognized for his work in safe patient management of the patient of size. He can be reached at .

Reference

1. Dionne M. Among Giants. Morrisville, NC: Lulu; 2006.