Designing Space for the Bariatric Resident

Long-term care facilities need to rethink the space required to provide quality care for bariatric residents because of the high risk of injury to both residents and staff during these residents' care. Most existing architectural designs, furnishings, and equipment can accommodate residents weighing as much as 350 pounds, but for larger residents, as well as for the staff who care for them, standard-size resident rooms are a barrier to care and safety. This article focuses on the space and equipment requirements for providing care to residents weighing 350 to 1,000 pounds.

Planning Care
Process mapping is an effective care-planning tool for facilities providing care for bariatric residents. By mapping a resident's care needs from admission through discharge or death, and by considering each part of the facility that might be used during the resident's stay, the planner can identify space and capacity problems that may be encountered.

Potential problems include insufficient door widths to allow the bariatric resident access into the building, inadequate space for turning a stretcher (if needed) in the halls, and lack of access to or inadequate space within the resident room and bathroom, the shower/bathing room, the activities room or lounge, elevators, the facility van, etc.

Staff will need written protocols for handling the bariatric resident through each phase of the process. In addition, the facility will need to coordinate with the local hospital to ensure that it can provide care for the facility's bariatric residents requiring hospitalization.

Planning to ensure adequate space for bariatric residents can have a positive effect on their care. The following cascade of events occurs when residents have enough space in which to be properly cared for and mobilized:

• Heart/lung capacity and blood circulation increase when residents are up and moving; their hearts beat faster, increasing the amount of oxygen that reaches their tissues and organs.
• The risk of pneumonia, thrombosis, and other illnesses is reduced as a result of the increased heart/lung capacity and blood circulation.
• Residents' quality of life is improved.

For providing care to bariatric residents, having adequate space and equipment means:

• Reduced need to assist residents;
• Fewer strain-related injuries and increased staff productivity;
• Lower staff turnover rates;
• Reduced costs of delivering care; and
• Enhanced quality of nursing care.

Special Needs
If room furnishings are not large enough or if caregivers cannot get appropriately sized equipment into the resident's room and/or gain adequate access to the resident's bed, then care suffers. The facility may also be in jeopardy of regulatory noncompliance.

Care needs. Care may be provided to residents:

• Within the confines of bed (for those with virtually no mobility). This includes lifting, turning, boosting, and feeding them, as well as applying dressings and assisting with hygiene.
• Around the bed and beyond, into other areas of the facility (for residents who are mobile with assistance and who range from being only somewhat independent to somewhat dependent). In bariatric resident rooms, there needs to be enough space to accommodate several pieces of equipment and up to six healthcare workers simultaneously for resident handling and various care tasks.

Care may also include assisting the resident with mobility tasks such as:

• Transfers from bed to chair/wheelchair/commode/stretcher and back;
• Transfers from bed to shower chair or stretcher and back;
• Transfers from bed to toilet and back; and
• Ambulation assistance-i.e., helping with sitting, standing, or walking.

The appropriate equipment and methods used for transfers depend upon:

• Resident's weight and height;
• Resident's ability to bear weight and assist;
• Resident's trunk and upper-extremity strength;
• Whether resident has an infectious disease that might require isolation;
• Resident's cognition level or presence of dementia;
• Resident's cooperativeness; and
• Medical complications that might affect resident's mobility-e.g., the presence of various tubes, the existence of pressure ulcers, whether the resident has undergone amputations, etc.

Furniture needs. The type of furniture needed in the resident's room is the basic facility-provided or resident-owned furniture, albeit larger and with an increased weight capacity. The absolute minimum space designed to meet these needs adds an additional 5 feet to the width of the standard room. Additional space may be needed depending upon the resident's personal effects and furniture.

Bariatric chairs have expanded widths-up to 36 inches-as do other pieces of bariatric furniture and equipment. The beds available for bariatric residents range up to 54 inches wide and 88 inches long when overhead bars are included (because the bars are attached to the outside surface of the headboard). Obviously, adequate space must be allowed to accommodate these items.

The minimum width for doors should be 60 inches, because the doorway into the room must accommodate the bed width and the widest piece of equipment. A split door that can be expanded to that width should be considered.

Equipment needs. The table provides a list of equipment/furnishings that are needed for the bariatric resident.

Essential equipment for mobility includes an extra-capacity ceiling lift and/or a floor lift, in addition to an extra-capacity SARA, depending upon the resident's mobility.

There is increasing interest in ceiling-track systems that can save space and increase safety for both bariatric residents and their caregivers. All facilities being newly constructed or with resident rooms that are being significantly renovated should seriously consider ceiling lifts, because the expense of installing tracks in the ceiling is often less during construction than when retrofitting a room after construction is complete.

Some facilities have beds that convert to chairs. These may reduce the amount of space required, by eliminating the task of transferring a resident from the bed to a separate chair. Physical loads for caregivers transporting residents to a chair or to the bathroom are sometimes prohibitive, but a powered commode chair or a powered mobile lift (the latter is in development) could make this activity possible in the future.

Space needs. Most residents of long-term care facilities need some type of assistance. From the caregiver's perspective, the space provided in resident rooms designed for bariatric residents must allow for proper ergonomic postures during nursing care activities to minimize musculoskeletal injuries. Therefore, the room should be at least 13 feet, 3 inches wide by 15 feet long.

Mobility tasks for the bariatric resident, with varying space requirements, will usually be performed with equipment and three to four caregivers, depending on the resident's ability to assist. Options for transferring bariatric residents are:

• Independent transfer with or without aids, such as a mobile walking device, cane, or other device;
• Transfer with limited assistance from one healthcare provider and a mobile walking device, cane, or other device; or
• Transfer with three or more caregivers, using a mechanical transfer device such as a standing and raising aid (SARA), a sling or ceiling lift, or a bed/stretcher that converts to a chair or repositioning aid.

Example of space needs. The care plan for a 600-pound, non-weight-bearing resident includes the need to perform a lateral transfer from the bed to a stretcher for showering, either with a ceiling lift and three caregivers or with a friction-reducing sheet and six caregivers. To turn lift equipment 360 degrees requires a 5-foot radius of floor space between the equipment and the walls. Ideally, there should also be 5 feet of space on either side of the bed, although a minimum of 39 inches is required to allow nurses to position their stance and move safely and ergonomically during resident-handling maneuvers.

An individual is considered to meet the bariatric criteria if he or she is overweight by more than 100 pounds, has a BMI of 40 or greater, or weighs more than 300 pounds (137 kg).^3,4

• Transporting a resident to the bathroom by wheelchair;
• Transporting the resident to the bathroom by commode chair;
• Residents ambulating by pushing or using an assistive walking device;
• Transporting residents with a sit/stand, ceiling, or floor lift; or
• Transferring residents to the toilet from a wheelchair using a walker, sit/stand aid, or lift device.

Which method should be used depends upon the resident's ability to assist and ambulate. If it is determined that caregivers can safely transport the resident (with assistance), then the resident will be able to access the bathroom facility. If the resident cannot assist or the caregivers cannot safely transport the resident without risk of injury to the resident or themselves, then the resident may be toileted at the bedside using a commode chair.

Most toilets are not designed to accommodate the bariatric resident. Toilets that are floor mounted are preferable to those that are wall mounted, because they are more sturdy, but even they have their limits. If an oversized toilet is available then it should be purchased. However, if the toilet cannot accommodate the resident's size and weight, then an extra-capacity commode chair will need to be used over the toilet or at the bedside.

There also must be space for folding support handles used to assist the resident in standing, without impeding the access of mobility equipment. Additional space is also needed so that the caregiver can assist the resident with hygiene care after the resident uses the toilet. The space we recommend is 31 inches on either side of a floor-mounted toilet. This will allow enough space from the walls to accommodate an oversize commode chair.

The toilet should be placed 8 inches from the wall. Since hygiene care in this small area is difficult, a built-in shower hose and wet area built into the design would be extremely helpful for those residents who are able to stand. This design currently needs to be studied and problems identified before be-ing adopted, but it appears promising.

The ideal room configuration has a bathroom attached to the bedroom area.

Showering Facilities
Bariatric residents often find hygiene tasks difficult because they cannot reach all of the areas requiring care. Therefore, they usually need assistance. Caregivers also find it difficult to provide good hygiene for bariatric residents because of body folds and corresponding skin-integrity issues. In long-term care facilities, hygiene assistance is sometimes provided in private bathrooms, but usually it takes place in private or all-facility shower/tub rooms.

Depending on the size and weight of bariatric residents and their general health and mobility, it is possible that, for some, bathing in a tub would be unsafe or inappropriate. Currently available tubs are not designed to accommodate a resident who weighs more than 500 pounds; therefore, showering may be a safer and more acceptable practice. Shower chairs are currently being designed to accommodate the bariatric resident and should be available soon. An ideal design would allow the resident to recline in a comfortable position and be safely transported to the shower area by two caregivers.

For residents who do not meet the weight-limit criteria of shower chairs, reclining bariatric shower stretchers or plastic-covered bariatric transport stretchers should be considered. These residents cannot tolerate lying on their backs, so the reclining feature is important. Otherwise, they should only be showered while lying on one side with their head slightly propped up, if this position can be tolerated. Residents showered while lying on their side should not be turned during this procedure, because of the narrow width of most stretchers.

The shower stretcher is managed in the shower room by two to three caregivers. The shower area must be large enough to allow the caregivers to circulate around the entire stretcher while using the shower hose.

Our recommendation for the combined bathroom and shower area is 106 inches by 177 inches, and the length of the shower hose should be at least 98 inches. This type of bathing, with two or three caregivers, allows access to most body creases and difficult-to-reach areas. The shower door must be wide enough to allow the stretcher to pass through along with the caregivers.

Other Considerations
In addition to space requirements for resident rooms and care areas, other issues must be considered by facilities planning to care for bariatric residents. For example, elevators must have the appropriate space and weight capacities. Also, planning what to do in the event of a bariatric resident's death is important in facilities that will need to transport and temporarily house the body.

• Extra-capacity floor and/or ceiling lift
  
• Appropriately designed and sized slings (1x, 2x, 3x)
  
• Wheelchairs in various widths (26", 28", and larger)
  
• Extra-wide stretcher with 1,000 lb (455 kg) capacity
  
• Extra-capacity and extra-width walkers
  
• Armchair or stretcher-chair up to 32" (105 cm) wide
  
• Step stool with extra size and weight capacity
  
• Commode up to 42" (105 cm) wide
  
• Extra-wide bedpans
  
• Extra-capacity shower chair or shower stretcher
  
• Extra-capacity standing and raising aids (SARAs)
  
• Beds expandable up to 54" (135 cm) wide
  
• Bariatric-size pressure-reduction mattresses
  
• Trapeze bar system for over the bed
  
• Powered "tug" for pushing bed, stretcher, or wheelchair
  
• Bariatric-size friction-reducing devices (air-powered or slide sheets)
  
• Extra-capacity clothing, slippers, and incontinence pads/briefs
  
• Appropriately scaled tape measures for measuring special medical supplies-e.g., longer needles, larger blood pressure cuffs, etc.

References
1. Mokdad AH, Serdula MK, Dietz WH, et al. The spread of the obesity epidemic in the United States, 1991-1998. JAMA 1999;282:1519-22.
2. Mokdad AH, Bowman BA, Ford ES, et al. The continuing epidemics of obesity and diabetes in the United States. JAMA 2001;286:1195-1200.
3.World Health Organization. Global strategy on diet, physical activity and health. Accessible at www.who.int/dietphysicalactivity/en.
4.World Health Organization. Controlling the global obesity epidemic. Accessible at www.who.int/nut/obs.htm.