In this article...

• Transfer to hospital
• Arrival at hospital
• Specialist equipment
• Clinical care
• Conclusion

It is estimated that the percentage of obese men in the UK will be 25% by 2010 and 33% by 2020. The health risks associated with obesity, including hypertension, coronary heart disease and Type 2 diabetes, are all well known and well recognised.

But is it also recognised that obesity poses distinct patient safety issues?

Transfer to hospital

Now that “obesity ambulances” are available at a cost of £90,000 each, should an Ambulance Trust purchase at least one of these vehicles and would it be negligent to fail to do so? Is it acceptable to continue to rely instead on the assistance of the Fire Service? If an obese patient dies whilst staff are deliberating on how to move her, would her widower have a claim against the Ambulance Trust if earlier transfer to hospital would have saved her?

Arrival at hospital

The obese patient’s first point of arrival at hospital is frequently the accident and emergency department. If the patient safety aspects of obesity have not been comprehensively addressed, it may only then become evident that the facility does not have the requisite equipment or trained staff to move or care for him. What if an acutely ill obese patient deteriorates or dies whilst specialist equipment is being sourced from elsewhere or hired? It has been suggested that equipment should now be commissioned on the same ratio as obese patients, i.e. 1 “super sized” to every 3 “normal” items of equipment.

Specialist equipment

Some items of equipment designed for the care of obese patients will entail significant capital outlay and smaller items of equipment will also have a significant cumulative value. But if a facility baulks at the cost of purchasing this equipment, staff will be at risk of injury and the patient’s care may be compromised.

If you do not have scales with a capacity to weigh up to 800 lbs, large stable platforms and handrails, is it acceptable to weigh an obese patient on a freight or laundry scale? Are these alternatives sufficiently accurate to calculate the correct medication dose or will staff estimate (quite possibly very inaccurately) the patient’s weight with implications for manual handling and drugs dosage?

What about scanning modalities? The number of inconclusive scans “limited by body habitus” has increased dramatically with the rise in obese patients. Abdominal ultrasound is compromised by layers of abdominal fat as vital organs are beyond the depth of the ultrasound waves. Now that ultrasound scanners capable of greater depth penetration for the “technically difficult patient” are available, is it acceptable not to have a scanner with this capability? As MRI image acquisition is technically less challenged by obesity, is it negligent if a facility fails to invest in a new “open” scanner with a reinforced table?

If an obese patient has lower abdominal pain, it could be a benign fibroid, ovarian cancer or appendicitis. If a conventional CT scan or an ultrasound is ineffective, the choices facing the doctor are to wait and see if the pain resolves or to operate. Both options carry risks, and neither option would be appropriate if the patient were slimmer. Exploratory surgery has all but been abandoned since scanning modalities were introduced. Is it acceptable to revert to outdated treatment modes simply because the patient is obese?

Surgery on obese patients is technically more challenging. Operating tables must be reinforced and capable of being lowered so that the surgeon can operate safely. Longer and stronger surgical instruments are needed to resist breakage in the face of the added torque. Post-operative complications are more common. Wound infection, slow healing and sepsis lead to longer stays. Immobility leads to increased risk of bed sores and, in the presence of infection, risks hospital acquired infections.

Other oversized items include large size ID bands (to avoid mix ups), oxygen masks (obese patients de-saturate quickly), blood pressure cuffs (to avoid the misdiagnosis of hypertension in patients with fat but short arms), anti embolism stockings (to avoid DVTs), etc. These items are used as part of the care continuum by every patient, but the absence of larger sized versions leads to very specific safety issues in the case of obese patients.

Clinical care

The Royal College of Physicians has suggested that many recently qualified doctors have an inadequate knowledge of the management of obesity. Obesity can co-exist with malnutrition. This is a training issue, but is there also active discrimination against morbidly obese patients? Are surgeons less willing to operate for the same indications as in slimmer patients? Is it a breach of the Human Rights Act to decline surgery on the grounds of weight? In the UK, several Trusts have refused hip and knee replacements to obese patients. Is this clinically justified or financially motivated?

Is it acceptable practice if an obese woman is not seen in pregnancy by a Consultant or could it be negligent? What about fetal anomaly scans where fat mass makes it difficult to see the chambers of the heart or the fetal brain, or to diagnose congenital defects or intra uterine growth retardation?

Conclusion

There are very real patient safety and best practice problems associated with the treatment and handling of obese patients within a healthcare environment. Although the costs involved are a concern, unless addressed now there will be an increase in adverse incidents.

Although many of these questions are unresolved by the Courts at present, the writer’s experience of clinical negligence cases involving obese patients is that the impact of obesity on their clinical care, however serious, will not provide the clinician with a defence to suboptimal care when judged by the standard of care that would have been offered to a slimmer patient. The clinician must take the patient’s obesity into account and then make extra efforts to reach a diagnosis or offer appropriate treatment, regardless of those difficulties. It is the responsibility of the healthcare organisation to provide the clinicians with the necessary equipment to allow them to offer this standard of care to the 25% of the population who need it. A Trust that fails to take the impact of this into account when preparing their risk assessment policies, training their staff, commissioning new equipment and supplies and even designing their facilities, will find that they have no defence to the claims that will inevitably follow. The impact of obesity on patient safety and on claims must be addressed now to avoid claims in the future.

And finally, is there potential for claims by obese patients who allege that obesity is a disease with a genetic basis and that failure by the NHS to treat it, whether with drugs or with weight reduction surgery, is in itself negligent, resulting in the development of the avoidable medical conditions associated with obesity?