Designing for the Obese
During the past 20 years, obesity among U.S. adults has increased more than 60%, according to the National Center for Health Statistics. The disease now affects more than 60 million adults, or about 30% of the U.S. adult population.
Unfortunately, the vast majority of U.S. hospitals are ill-prepared to accommodate the growing number of overweight patients. One reason is the lack of bariatric-specific design guidelines.
"Designers may think they cover obesity by adhering to ADA guidelines," said Keith Smith, AIA, principal with Indianapolis-based healthcare design specialist BSA LifeStructures. "ADA covers legal disabilities only, and obesity is not considered a legal disability."
Smith said special considerations for the overweight and obese population should be the norm on all hospital projects, not just special bariatric-care units. Design considerations include everything from wider doorways and heavy-duty beds to patient lifts and larger toilets.
BD&C talked with leading healthcare design experts for their advice on designing bariatric-friendly healthcare spaces:
Plan for larger equipment. Doorways and storage areas should be larger than normal to accommodate oversized wheelchairs, beds, and gurneys. At St. Vincent Carmel (Ind.) Hospital, the Building Team increased door widths from 36 inches to 42 inches to better accommodate larger patients and equipment, according to Smith, lead architect on the project. Smith also specified doors with recessed hinges to maximize the openings.
Some hospitals are specifying 48-inch doorways and even 60-inch double-leaf doors (composed of a combination of 24- and 36-inch doors) in bathrooms to allow sufficient clearance for two nurses to assist the patient into these tight spaces, said Dennis Gallant, director of Design Innovations and Programs with Hill-Rom, a Batesville, Ind.-based manufacturer of healthcare-related equipment.
Avoid wall-mounted toilets. Although these are popular among facility staff for their ease of maintenance, wall-mounted toilets may not stand up to constant use by obese patients. "They can pull away from the wall and potentially break from the carrier with larger patients," said Randy Regier, AIA, president of Taylor & Associates Architects, Newport Beach, Calif. Regier urges Building Teams to specify floor-mounted units that can support at least 1,000 pounds. Other considerations: floor-mounted sinks and oversized toilet seats, which can range from 16 to 19 inches in width and up to 19 inches deep.
Choose the right lift system. Whether portable or mounted, a lift system in patient rooms is a must. "Healthcare workers sustain more overexertion injuries than virtually any other type of worker," said Suzanne M. Bish, operational marketing manager with Hill-Rom. She said that aides, nurses, radiology technicians, and physical therapists all rank among the professions at greatest risk for back injury.
Portable lift systems have become more popular as hospitals look to maintain flexibility. High-end systems can lift more than 1,000 pounds off the floor. Many smaller units weight less than 100 pounds for easy mobility, while providing the ability to lift 600 or more pounds.
Where space is at a premium, a ceiling-mounted unit may be the way to go. Many of these systems provide full room coverage and are designed to allow staff members to lift, rotate, and recline or decline patients without manual assistance.
Provide plenty of room around toilets and beds. BSA LifeStructures' Smith recommends at least 24 inches of space on either side of toilets to accommodate patients and staff assisting in ambulation.
Placement of toilets is also vitally important, said Richard Dallam, principal with Seattle-based architect NBBJ. Poorly placed units will force patients to make twisting movements to position themselves on the toilet, which can be particularly detrimental to post-surgical patients. "We locate toilets so that they can be accessed by moving sideways, rather than making a 90- or 180-degree turn," said Dallam.
Similarly, allow at least five feet of clear space around three sides of the bed to provide ample room for patients in wheelchairs or with walkers. This also provides clearance for portable lifts to be maneuvered along side the bed, said Hill-Rom's Gallant.
Include heavy-duty grab bars in and around showers. Grab bars in bathrooms and showers should be structurally supported to handle at least 500 pounds of weight, said Smith. Showers should include multiple handrails, built-in seating, minimal step-up, and removable showerheads with a flexible hose to minimize movement during washing. Size is also crucial. "Showers must be large enough to accommodate patients, yet configured so patients can still reach railings for support," said Smith.
Recess weigh scales into the floor. Years ago, obese patients had to be shuttled to the loading dock to get an accurate weight reading. Most hospitals today are more sympathetic to patients' dignity, providing oversized scales in patient rooms or within bariatric departments. Smith recommends that scales be recessed into the floor with grab bars nearby to ease maneuverability.
Beds equipped with weigh scales are also becoming popular. The latest units can provide accurate readings up to 1,000 pounds. "This way patients can be admitted directly to their hospital bed instead of having to be taken to a loading dock," said Bish.
Other new technologies in hospital beds include units with built-in powered transport to minimize the number of staff members required to transport patients, and beds with powered side air bolsters that can be deflated with the touch of a button to allow for closer care or easy transport, especially during an emergency situation, said Bish.
Hill-Rom's ExcelCare bed, for instance, expands from 40 to 50 inches wide. Similarly, Camtec Products, Church Creek, Md., offers a bed that expands from 37 to 54 inches in width, allowing it to be used for both bariatric and non-bariatric patients.
In any case, bariatric beds should be rated for at least 600 pounds.
Don't forget about family members. "Obesity is truly a genetic disease," said Ken Fujioka, MD, director of the Center of Weight Management at Scripps Clinic, La Jolla, Calif. "If we have a son come in, chances are the parents will also be heavy." This means waiting areas and patient rooms should be equipped with wider chairs (30 to 40 inches wide) with reinforced arms that can support 750 pounds or more. Fujioka said bench-style seats will also do, especially for projects on a tight budget.
Avoid creating "bariatrics-only" sections in general waiting areas. "Mix bariatric chairs with the other furnishings with the same look and feel," said Dawn McDonald, IIDA, senior associate with Indianapolis-based Maregatti Interiors, lead interior designer on the St. Vincent Carmel Hospital project. "We oftentimes use loveseats because they are discreet, yet provide the extra room and stability larger people need." McDonald recommends that 15–20% of waiting room chairs accommodate obese patients.
Michael Lehman, principal with Taylor & Associates Architects, said specifying larger furniture has a ripple effect on space planning and costs. "Waiting areas must be larger or provide fewer seats to accommodate the wider chairs," said Lehman. "Also, alcoves must be bigger to store oversized furniture."
Plan for additional air-conditioning capacity. Since obese patients typically have increased sensitivity to temperature, additional air-conditioning capacity may be required to keep patients and their families comfortable. This can include everything from portable fans to beefed up HVAC systems. The bariatric patient rooms at St. Vincent Carmel Hospital, for example, feature an air exchange rate 15–20% higher than standard patient rooms to react more quickly to changes in thermostat settings.
Get a bariatric facility assessment. Several manufacturers and consultants offer assessment services that will track the pathway of obese patients through the hospital or bariatric unit. This can help the Building Team formulate a plan of action for both the initial construction and future expansion plans.
So, how are hospitals responding to the influx of obese patients?
"The response varies," said Sharon Woodworth, associate principal with Anshen+Allen, San Francisco. "Some new hospitals are designing all of their rooms with many of these features, while others are implementing some of the features—wider doors, but no lifts, for example—in some of the rooms," said Woodworth.
Of course, some hospitals have decided to do nothing at all. "Those facilities will not be able to admit bariatric patients," said Woodworth.