Elizabeth White had always considered herself one of the stronger nurses in the intensive care unit of the hospital in San Bernardino County, California. So early one December morning in 2003, when an unconscious, 374-pound patient had gradually slid toward the foot of his bed, she pulled him back up with the help of just one other person.
An hour later, White, who lifted weights and did sit-ups to stay fit, was in “horrible pain,” she recalled. Still, she pushed through the next few hours until her overnight shift ended at 7 a.m. Later, an MRI revealed stretched ligaments between two of the lumbar vertebrae in her lower back, plus severe degeneration in all of her lumbar discs. Her 15 years of working as a nurse, of awkwardly adjusting and turning and lifting people in hospital beds, had taken their toll.
In the United States, where two-thirds of adults are classified as overweight or obese, larger patients are increasingly the norm, and the healthcare industry has evolved in many ways to accommodate them, from developing sturdier medical equipment to building heavier-duty hospital beds. The sector has been much slower, however, to tackle other, subtler ways obesity weighs on the healthcare system, such as the tolls of physically handling larger patients, despite the vast medical and financial benefits of doing so, nurses and other medical experts say.
“It’s those little things that add up,” said Robert Cima, a colorectal surgeon at the Mayo Clinic in Rochester, Minnesota. Many hospitals have neither the equipment nor the resources to move their patients efficiently, he said, even though they long ago began buying parallel sets of surgical equipment for operating on larger patients. Now, “the real issue is caring for them on the floor. That cost is huge, relative to the operating room,” Cima said.
In 2014, the U.S. spent $3 trillion, or 17.5 percent of its GDP, on healthcare. Obesity-related medical costs constitute a burgeoning share of such spending, from 6.5 percent in 1998 to 9.1 percent in 2006, the same year the CDC estimated medical care for an obese person cost $1,429 more than for someone who was not obese. Overall, estimates of annual obesity-related medical spending in the U.S. range from $147 billion to $190 billion.
If the act of moving a bedridden patient sounds mundane or insignificant, it’s neither. Adjusting patients regularly is vital for their health not only by preventing bedsores, which can become infected, but also by stopping fluid from pooling in the lungs and causing pneumonia.
Lifting and moving patients are not easy tasks. Even turning a 100-pound patient on her side puts about 1,000 pounds of pressure on the mover’s back, said White, 60, who has started a company that sells a machine called ErgoNurse that lifts and moves patients in hospital beds. No matter how small the patient, she emphasized, given the mechanics of the operation, nurses have no way of moving a person in a bed without risking injury to themselves.
Meanwhile, patients are ever larger, White said. When she started out as a nurse in 1988, a 250-pound patient was a rarity. By the time she quit, in 2004, two out of the 16 patients in her unit consistently weighed at least 400 pounds, she estimated.
Obesity rates in the United States have doubled for adults since the 1970s and tripled among children. By 2014, nearly 29 percent of adults were classified as obese, meaning they had a body mass index (a proportion calculated using weight and height) of more than 30. Nearly 17 percent of children ages 2 to 19 years were defined as obese from 2011 to 2012.
Carrying extra pounds has been linked with diabetes and other chronic diseases that are costly and debilitating. But these diseases are not solely to blame for higher healthcare costs. Statistically, heavier people have higher rates of hospital-acquired infections. They spend more time in the hospital and have higher rates of admissions to intensive care units. To nurses and their advocates, what’s increasingly apparent is the mounting toll of these pounds on hospital staff.
In 2011, the Bureau of Labor Statistics said hospital workers had twice the average rate of on-the-job injuries from overexerting themselves, citing lifting, moving and repositioning patients as the top risk factor. The CDC has directly cited “rising obesity rates in the United States” as “increas[ing] the physical demands on caregivers.”
Emily Gardner, a worker health and safety advocate at Public Citizen, a Washington nonprofit organization that in July published a report on safe patient handling, echoed the CDC’s point. Yet only 3 percent to 25 percent of hospitals and other healthcare facilities in the U.S. have contraptions such as ceiling lifts or other machinery to ease the strain on nurses, she said, and places that do own equipment don’t always train workers to use it.
Many nurses will spend decades manually lifting patients, Gardner said. Then, a single incident, often a larger patient who needed to be moved, causes a sudden injury.
“Hospitals know that it’s a problem,” Gardner said. “But there are so many other issues they’re facing that they haven’t prioritized this as they should.”
To date, 11 states have instituted Safe Patient Handling laws, which call for healthcare facilities to have patient lifting equipment and training to use it. Massachusetts, whose public health department attributes at least 21,500 days, or nearly 59 years, of lost work every year to patient-lifting injuries, is currently considering such legislation. Experts also pointed out these laws benefit patients by preventing injuries and preserving dignity.
For Vicki Gonzalez, a nurse at the Jackson Memorial Hospital in Miami, the turning point for her hospital came in 2013, when an obese patient fell down on her way back from the bathroom. The dozen nurses and other aides in the vicinity could barely help her back up.
“It became very difficult for us to get her off the floor,” Gonzalez said, because the hospital lacked the equipment to lift larger patients. Eventually they were able to use an inflatable device to get the patient safely back into her bed.
Gonzalez is now the head of the Safe Patient Handling project at the Jackson Health System, which is installing 220 ceiling lifts and training nurses to use them. The initiative is slated to save the hospital $9 million to $13 million annually.
Some doctors warn that for smaller hospitals or those with less funding, buying equipment like bigger beds and wheelchairs, not to mention ceiling lifts — a permanent one can cost $16,000, while mobile ones are an average of $6,000 — might be prohibitive. They “are just not going to be able to retrofit and have all the expertise they need to care for these really morbidly obese patients,” Mayo’s Cima said.
But proponents of these programs argue the initial expense is one of the savviest investments a hospital can make.
“There is an upfront cost,” Mary Jo Assi, director of nursing practice and work environment at the American Nurses Association, allowed. More important, however, was “the return on investment” — for the sake of nurses, patients and the entire U.S. healthcare system.
Without these changes, White, the ErgoNurse designer, predicted people, particularly the women who currently constitute 80 percent of the nursing force, will be driven from the profession.
“Women have so many more opportunities these days,” White said. “It’s becoming less of an attraction for people to go into nursing. They don’t have to go into something that is so challenging, where they can be hurt.”