R E V I E W S & A N A LY S E S Class III Obese Patients: The Effect of Gait and Immobility on Patient Falls Lea Anne Gardner, PhD, RN INTRODUCTION Senior Patient Safety Analyst Class III obese patients are identified as having a body mass index (BMI) greater than Pennsylvania Patient Safety Authority or equal to 401 or weighing 100 pounds or greater than their ideal body weight.2 The Maryann Pagano, MSN, RN, CMS extra body mass limits flexibility, slows down movement, and affects gait. Gait is a Course Coordinator Dixon School of Nursing combination of the person’s balance, control of the body’s trunk and limbs, and physi- Abington Memorial Hospital cal ability to respond to changes in the environment.3,4 People with BMIs greater than or equal to 40 have been shown to have multiple physical changes in their gait as a result of the location and distribution of the additional weight.5 When compared with ABSTRACT people whose BMI is between 20 and 25, class III obese people have been identified as Gait disturbances and immobility are having a distinctly different pattern of walking.3,4 The gait variation observed and mea- risk factors that are highly correlated sured in people with class III obesity closely resembles gait variations found in people with a patient’s risk for a fall. A query who have Parkinson’s disease or strokes, namely shorter stride length, wider stance, and of five years of event reports to the decreased cadence (i.e., steps per minute) and velocity.3,4 Alterations in gait, coupled Pennsylvania Patient Safety Authority’s with immobility, predispose class III obese patients to loss of muscle strength, which Pennsylvania Patient Safety Reporting heightens the propensity to fall and can make ambulation a perilous activity.6 System (PA-PSRS) found that of the class In addition, certain comorbid conditions that class III obese people are at risk of III obese patients who had mobility developing, such as venous insufficiency and venous ulcers, can also impede their gait.7 issues and fell, 7% of these falls were Finally, the increased risk of falling is exacerbated when there is an overestimation of harmful enough to be classified as Seri- functional mobility and capabilities coupled with an underestimation of the degree of ous Events (compared with 3% in the imbalance and muscle weakness.8 overall PA-PSRS population in 2011). Gait disturbances were identified in CLASS III OBESE PATIENT FALLS EVENT REPORTS AND SURVEY 68% of the reports of class III obese RESULTS patients who fell. Subsequent need for A query of five years of reports, from January 1, 2007, through December 31, 2011, to lift teams or lift equipment use following the Pennsylvania Patient Safety Authority’s Pennsylvania Patient Safety Reporting Sys- a fall was reported in 64% of the reports tem (PA-PSRS) database identified that 20% (n = 357 of 1,774) of class III obese patient of class III obese patients who fell. reports were falls event reports. This percentage of falls event reports is higher than the Targeted falls risk assessment, imple- percentage of falls event reports (16%, n = 35,640 of 228,835) in the overall PA-PSRS mentation of falls prevention strategies, population for 2011.9 Class III obese patients were identified through a query of PA- and lift teams and lift equipment are PSRS narrative descriptions using the terms “obese,” “morbidly obese,” or “bariatric.” essential items to assist in keeping class III obese patients safe when transferring, A detailed analysis was performed on the falls event report narrative descriptions to turning, or ambulating. (Pa Patient Saf determine how many falls reports identified immobility as a contributing factor. Immo- Advis 2013 Sep;10[3]:96-8.) bility was identified when the PA-PSRS narratives stated that patients needed moderate or maximum assistance when turning, transferring, or ambulating or when patients Corresponding Author Lea Anne Gardner were on bed rest or had conditions indicative of immobility (e.g., ventilator depen- dency, recent surgery, limb infections, leg amputations). This subset of class III obese patient falls-related PA-PSRS event reports in which immobility was identified had a total of 329 falls reported. A further analysis of the Serious Event (i.e., an adverse event resulting in patient harm) reports was explored after identifying a study that showed class III obese patients as being at lower risk for an injury with a fall.8 Of the class III obese patients who had mobility issues and fell, 7% of these falls were harmful enough to be classified as Serious Events; this is more than twice the percentage of falls-related Scan this code Serious Events in the overall PA-PSRS population in 2011 (3%).9 with your mobile PA-PSRS falls event reports revealed three different circumstances that were present in device’s QR cases in which class III obese patients fell: weight distribution issues, gait disturbance, reader to access and overestimation of functional status by the patient. “Weight distribution” was the the Authority’s term used to identify patients who had an excess amount of weight and a distribution toolkit on this of excess body mass that could negatively impact the patient’s ability to move (i.e., shifts topic. in the center of gravity that can “throw” the patient off balance), regardless of whether Page 96 Pennsylvania Patient Safety Advisory Vol. 10, No. 3—September 2013 ©2013 Pennsylvania Patient Safety Authority the patient was stationary or ambulatory. the bedside commode. The patient’s Falls Prevention Strategies Weight distribution issues were present knees buckled, and the staff lowered When considering the implementation of in all 329 falls event reports. “Gait distur- the patient to the floor. The patient falls prevention strategies, a multifaceted bance” focused on the patient’s stance, was placed back into bed utilizing a approach that includes care processes speed of walking, muscle strength, and patient lift. The patient had a total (e.g., identification bracelets, medication agility and was identified in 68% (n = 225) right hip replacement [previously and] review, patient education), technology of the falls event reports. Overestimation complained of right hip pain [after (e.g., call buttons, lifts), and the physical of function by patients was identified in the fall]. An x-ray revealed a [hip] environment (e.g., installation of bariatric 57% (n = 186) of the falls event reports. dislocation. equipment such as grab bars and lifts, size The following are PA-PSRS narratives that In July 2012, the Authority conducted of the room) has demonstrated results in illustrate these issues. a hospital statewide survey to identify minimizing falls and injuries from falls.16-18 [An obese patient was] admitted hospital preparedness to provide general When selecting targeted falls prevention through the emergency department medical care to class III obese patients. strategies, align the strategies with the for increased shortness of breath. The survey was administered to all hospi- specific type of risk factors, such as gait [The nurse and respiratory therapist] tals in Pennsylvania, and the response rate instability and lower-extremity weakness, had just left the patient’s room was 35.3% (n = 85 of 241).10 Several of the that may have been identified during the minutes prior to the fall. The patient survey questions asked respondents about falls risk assessment. requested nothing when asked [if the the types of educational programs, patient patient needed anything]. The patient care policies, and care plans that were Lift Teams and Equipment decided to get out of bed to [use the] developed for the care of class III obese Transferring, lifting, or assisting class III bedside commode on his own because patients. The statewide survey respondents obese patients to ambulate safely requires he felt stronger and [the commode] identified that the majority of hospitals good planning that starts prior to the was only one step away from the bed. that provide educational programs (93.9%, patient’s arrival to the hospital. The first The patient stated that the wheels n = 31 of 33) address body mechanics and step in planning can begin with the devel- went out from under the patient lifting techniques; however, only 6.0% opment of lifting policies that take into on the bedside commode, and [the (n = 4 of 67) of respondents indicated that account criteria such as setting a 35-pound patient] fell. The patient ripped the their hospital had lift teams. manual lifting weight limit for staff mem- top portion of the left middle finger bers who are expected to lift patients who off during the fall. WAYS TO PREVENT FALLS OF are very heavy and dependent.19 Other lift An obese postoperative patient was CLASS III OBESE PATIENTS policy considerations include the avail- sitting on an elevated toilet seat in ability, acquisition, and use of bariatric Falls Risk Assessment lift equipment, the establishment of lift the patient’s bathroom. The patient A focused falls risk assessment and teams, and the implementation of a safe stated they leaned over too far to periodic reassessment is the first step to patient handling program.20,21 When iden- wipe themself and slid off the seat identifying patients who are at risk for a tifying lift team members, planning can and fell to the floor. The patient was fall.11 Gait instability, lower-extremity weak- include the identification of a lift team [being] assisted back to bed when a ness, and assistance for toileting are three for each shift and having additional lift small amount of blood was noticed of six risk factors that are highly correlated team members when needed or on call. on the dressing. [When the] dressing with a risk to fall12-14 and are more likely Protocols on special handling and move- was removed to check the wound, it to be seen in the class III obese patient ment challenges related to class III obese was found to be dehisced. population.6,15 Targeted questions and patients are currently available and address It was also noted that 64% (n = 211 of assessment related to these risk factors transfers, handling, and repositioning 329) of the falls event reports indicated should be included in the falls risk assess- patients.15 For example, the development the need for a mechanical lift or addi- ment for class III obese patients. Assessing of an algorithm on transferring class III tional personnel to help lift the patient to functional status prior to admission can obese patients from a bed to a chair or a safe location after a fall. establish a baseline level of mobility and from a chair to a toilet or an algorithm The patient sustained a hip disloca- reduce the chance of unrealistic expecta- on repositioning patients while in bed are tion while being lowered to the floor. tions of both the staff and the patient protocols that can help staff keep patients Three staff members utilized a gait during the patient’s hospital stay. and the healthcare team safe from a fall belt to assist the obese patient off event and/or injury.15 Vol. 10, No. 3—September 2013 Pennsylvania Patient Safety Advisory Page 97 ©2013 Pennsylvania Patient Safety Authority R E V I E W S & A N A LY S E S LIMITATIONS Another limitation is in the identification CONCLUSION The 329 PA-PSRS class III obese patient of a patient’s mobility status. Mobility Gait disturbances and immobility issues falls event reports identified for this issues were identified by subjective assess- in class III obese patients place these analysis underrepresent the actual ments of patients needing moderate to patients at an increased risk for a fall. number of class III obese patients who maximum assistance. Standardizing terms Some ways to mitigate this safety risk are experienced a fall event during hospital- such as “moderate” and “maximum” assis- through falls risk assessment and reassess- ization. Identification of class III obese tance might produce different results. In ment as well as careful planning of class patients in PA-PSRS was accomplished addition, limitations associated with the III obese patient policies and protocols. through a query of the event report nar- statewide survey include (1) a potential Developing class III obese patient policies rative descriptions, which relies on the response bias toward hospitals that care for and protocols that focus on lift teams, lift subjective assessments provided by the class III obese patients, (2) a potential non- equipment, and algorithms to safely move individuals completing the event reports response bias due to an underestimation class III obese patients is a way to proac- rather than the identification of patients of the number of and issues associated tively plan for the challenges presented by their weight or BMI. with class III obese patients, and (3) a low when caring for this patient population. response rate potentially resulting from the time the survey was administered. NOTES 1. National Institutes of Health National Apr 30 [cited 2013 Mar 28]. http:// environment, the care process and tech- Heart Lung and Blood Institute. Clinical patientsafetyauthority.org/PatientSafety nology: a systematic review. J Adv Nurs guidelines on the identification, evalu- Authority/Documents/FINAL%20 2011 Dec;67(12):2501-24. ation, and treatment of overweight and 2011%20Annual%20Report.pdf 17. Muir M, Archer-Heese G. Essentials of obesity in adults: the evidence report 10. Gardner L, Gibbs C. Class III obese a bariatric patient handling program [online]. NIH pub. no. 98-4083. 1998 Sep patients: is your hospital equipped [online]. Online J Issues Nurs 2009 Jan [cited 2013 Apr 5]. http://www.nhlbi.nih. to address their needs? Pa Patient Saf [cited 2013 Jan 25]. www.nursingworld. gov/guidelines/obesity/ob_gdlns.pdf Advis [online] 2013 Mar [cited 2013 Apr org/MainMenuCategories/ANA 2. Strum R. Increases in morbid obesity in 19]. http://patientsafetyauthority.org/ Marketplace/ANAPeriodicals/OJIN/ the USA: 2000-2005. Public Health 2007 ADVISORIES/AdvisoryLibrary/2013/ TableofContents/Vol142009/No1Jan09/ Jul;121(7):492-6. Mar;10(1)/Pages/11.aspx Bariatric-Patient-Handling-Program-.aspx 3. Ling C, Kelechi R, Mueller M, et al. Gait 11. Feil M, Gardner L. Falls risk assessment: 18. Arzouman J, Lacovara JE, Blackett A, et and function in class III obesity [online]. a foundational element of falls prevention al. Developing a comprehensive bariatric J Obes 2011 Nov 26 [cited 2013 Apr 3]. programs. Pa Patient Saf Advis [online] protocol: a template for improving patient http://www.hindawi.com/journals/ 2012 Sep [cited 2013 Apr 19]. http:// care. Medsurg Nurs 2006 Feb;15(1):21-6. jobes/2012/257468 patientsafetyauthority.org/ 19. Collins JW. Safe patient handling and 4. Ling CG, Brotherton SS, Smith SO. ADVISORIES/AdvisoryLibrary/ lifting standards for a safer American Review of the literature regarding gait and 2012/Sep;9(3)/Pages/73.aspx workforce [online]. Testimony before the class III obesity [online]. J Exerc Physiol 12. Oliver D, Daly F, Martin FC, et al. Risk Committee on Health, Education, Labor, Online 2009 Oct [cited 2013 Feb 1]. factors and risk assessment tools for falls and Pensions Subcommittee on Employ- http://www.asep.org/asep/asep/ in hospital inpatients: a systematic review. ment and Workplace Safety United States JEPonlineOctober2009.html Age Aging 2004 Mar 33(2):122-30. Senate. 2010 May 11 [cited 2013 Jan 31]. 5. Fabris de Souza SA, Faintuch J, Valezi 13. Shimada H, Kim H, Yoshida H, et al. Rela- http://www.cdc.gov/washington/ AC, et al. Postural changes in mor- tionship between age-associated changes testimony/2010/t20100511.htm bidly obese patients. Obes Surg 2005 of gait and falls and life-space in elderly 20. American Nurses Association. Safe Aug;15(7):1013-6. people. J Phys Ther Sci 2010;22(4):419-24. patient handling and mobility [online]. 6. Del Porto HC, Pechak CM, Smith DR, 14. Ganz DA, Bao Y, Shekelle PG. Will my 2013 [cited 2013 Feb 11]. http:// et al. Biomechanical effects of obesity on patient fall? JAMA 2007 Jan 3;297(1): nursingworld.org/MainMenuCategories/ balance. Int J Exerc Sci 2012;5(4):301-20. 77-86. WorkplaceSafety/SafePatient 7. Yosipovitch G, DeVore A, Dawn A. 15. United States Department of Veterans 21. Saracino S, Schwartz S, Pilch E. Imple- Obesity and the skin: skin physiology and Affairs. Safe bariatric patient handling menting a safe patient handling and skin manifestations of obesity. J Am Acad toolkit [online]. 2012 Dec [cited 2013 movement program in a rehabilitation Dermatol 2007 Jun;56(6):901-16. Feb 10]. http://www.visn8.va.gov/visn8/ setting. Pa Patient Saf Advis [online] patientsafetycenter/safePtHandling/ 2009 Dec [cited 2013 Apr 19]. http:// 8. Himes CL, Reynolds SL. Effect of obesity toolkitBariatrics.asp patientsafetyauthority.org/ on falls, injury, and disability. J Am Geriatr ADVISORIES/AdvisoryLibrary/ Soc 2012 Jan;60(1):124-9. 16. Choi YS, Lawler E, Boenecke CA, et al. 2009/Dec6(4)/Pages/126.aspx 9. Pennsylvania Patient Safety Authority. Developing a multi-systemic fall preven- 2011 annual report [online]. 2012 tion model, incorporating the physical Page 98 Pennsylvania Patient Safety Advisory Vol. 10, No. 3—September 2013 ©2013 Pennsylvania Patient Safety Authority PENNSYLVANIA PATIENT SAFETY ADVISORY This article is reprinted from the Pennsylvania Patient Safety Advisory, Vol. 10, No. 3—September 2013. The Advisory is a publication of the Pennsylvania Patient Safety Authority, produced by ECRI Institute and ISMP under contract to the Authority. Copyright 2013 by the Pennsylvania Patient Safety Authority. This publication may be reprinted and distributed without restriction, provided it is printed or distributed in its entirety and without alteration. Individual articles may be reprinted in their entirety and without alteration provided the source is clearly attributed. This publication is disseminated via e-mail. To subscribe, go to http://visitor.constantcontact.com/ d.jsp?m=1103390819542&p=oi. To see other articles or issues of the Advisory, visit our website at http://www.patientsafetyauthority.org. Click on “Patient Safety Advisories” in the left-hand menu bar. THE PENNSYLVANIA PATIENT SAFETY AUTHORITY AND ITS CONTRACTORS The Pennsylvania Patient Safety Authority is an independent state agency created by Act 13 of 2002, the Medical Care Availability and Reduction of Error (Mcare) Act. Consistent with Act 13, ECRI Institute, as contractor for the Authority, is issuing this publication to advise medical facilities of immediate changes that can be instituted to reduce Serious Events and Incidents. For more information about the Pennsylvania Patient Safety Authority, see the Authority’s An Independent Agency of the Commonwealth of Pennsylvania website at http://www.patientsafetyauthority.org. ECRI Institute, a nonprofit organization, dedicates itself to bringing the discipline of applied scientific research in healthcare to uncover the best approaches to improving patient care. As pioneers in this science for more than 40 years, ECRI Institute marries experience and indepen- dence with the objectivity of evidence-based research. More than 5,000 healthcare organizations worldwide rely on ECRI Institute’s expertise in patient safety improvement, risk and quality management, and healthcare processes, devices, procedures and drug technology. The Institute for Safe Medication Practices (ISMP) is an independent, nonprofit organization dedicated solely to medication error prevention and safe medication use. ISMP provides recommendations for the safe use of medications to the healthcare community including healthcare professionals, government agencies, accrediting organizations, and consumers. ISMP’s efforts are built on a nonpunitive approach and systems-based solutions. Scan this code with your mobile device’s QR reader to subscribe to receive the Advisory for free.