Transcript Everything`s bigger in Texas…and getting bigger. Obesity in the ED

A GROWING PROBLEM EVERYTHING’S BIGGER IN
TEXAS…AND GETTING BIGGER.
OBESITY IN THE ED
Kimberly Leeson, MD
Texas A&M CHRISTUS Spohn
Emergency Medicine Residency
Obesity in Emergency Medicine
• Introduction
• Peds
• H&P
• Satisfaction
• Equipment,
Testing &
Treatment
• Costs/LOS
• A, B, Cs
• Trauma
• Summary
Definitions
• Body Mass Index (BMI)
= weight (kg)/ height
(m2)
• Overweight = BMI ≥ 25
(≥ 85%tile for age and
sex)
• Obesity = BMI ≥ 30 (≥
the 95%tile)
• Morbid or extreme
obesity = BMI ≥ 40
25
30
40
Obesity Trends* Among U.S. Adults
BRFSS, 1990, 2000, 2010
(*BMI ≥30, or about 30 lbs. overweight for 5’4” person)
2000
1990
2010
No Data
<10%
20%–24%
10%–14%
25%–29%
15%–19%
≥30%
Texas obesity rank compared to
other states …
15th
https://www.dshs.state.tx.us/topicrelatedcontent.aspx?itemsid=909
Trust for America’s Health and Robert Wood Johnson Foundation. The State of Obesity 2014. Wash,
D.C. 2014.
History & Physical Exam
• Depression
• Hirsuitism
• Snoring
• Cold intolerance
• Daytime somnolence
• Polydipsia
• Constipation
• Reflux
• Abdominal pain
• Menstrual
irregularities
• Joint pain
• Skin rashes/lesions
• Headaches
• Developmental delay
Challenges of physical exam:
• Rolling patient
• Visualizing all surfaces
• Rectal or genital exams
• Foley catheters
Equipment, Testing and
Treatment
Equipment, Testing & Treatment
• More:
• IV attempts
• LFTs
• Cardiac enzyme tests
• abdominal x-rays
• No significant difference in ED treatment
Ngui B, McDonald Taylor D, Shill J.Effects of obesity on patient experience in the emergency department. Emerg Med Australas. 2013
Jun;25(3):227-32.
Platts-Mills TF, Burg MD, Snowden B. Obese patients with abdominal pain
presenting to the emergency department do not require more time or
resources for evaluation than non-obese patients. Acad Emerg Med. 2005
Aug;12(8):778-81.
• Obese patients were similar to nonobese patients in regard to:
• LOS (457 vs. 486 minutes)
• Laboratory studies (3.2 vs. 2.9 tests)
• Abd/pelvic CT scans (30% vs. 31%)
• Abdominal US (16% vs. 13%)
• Rates of consultations (27% vs. 31%)
• Operations (14% vs. 12%)
• Admissions (18% vs. 24%)
Kam J; Taylor DM, Obesity significantly increases the
difficulty of patient management in the emergency
department. [Emerg Med Australas], 2010 Aug; Vol. 22
(4), pp. 316-23.
• Anatomical Landmarks
• Blood Pressure
• Patient positioning and procedures
• IVs
• Phlebotomy
Medication Administration
• Consider altered
pharmacokinetics because of:
• Volume of distribution
changes
• Renal clearance
• Hepatic metabolism
• Abnormal protein binding
• Underlying disease
• Unpredictable responses to
medications
Dargin J, Medzon R. Emergency Department Management of
the Airway in Obese Adults. Annals of Emergency Medicine.
Volume 56,
No 2 : August 2010.
Roe JL, Fuentes JM, Mullins ME.Underdosing of
common antibiotics for obese patients in the ED.
Am J Emerg Med. 2012 Sep;30(7):1212-4.
• Underdose antibiotics
• treatment failure
• antibiotic resistance
Lee DH; Jung KY; Choi YH; Cheon YJ, Body mass
index as a prognostic factor in organophosphatepoisoned patients.[Am J Emerg Med], 2014 Jul; Vol. 32
(7), pp. 693-6.
• N = 112 organophosphate poisoned patients
• 40 were obese
• Obese organophosphate poisoned patients had
longer use of:
• mechanical ventilation
• ICU care
• total LOS
A,B,C S
Airway
• Faster desaturation in
morbidly obese patients
• Increased aspiration risk
• BVM ventilation is more
difficult
• Larger volume of gastric fluid
• Reduced pulmonary
compliance
• Increased intra-abdominal
pressure
• Increased chest wall
resistance
• Increased airway resistance
• Abnormal diaphragmatic
position
• Increased upper airway
resistance
• Higher incidence of GERD
and hiatal hernia
Breathing
• Lung capacity
• Vital capacity
• V-Q mismatch
• Hypopnea and hypercapnea
• Rapid desaturation
Dargin J; Medzon R, Emergency department management of the airway in obese adults. Annals Of
Emergency Medicine, 2010 Aug; Vol. 56 (2), pp. 95-104.
Circulation
• Underestimate dehydration and EBL
• Difficulty palpating pulses
• Mortality 24.4% vs 16.6%
Nelson J et al.Obese trauma patients are at increased risk of early hypovolemic shock: a
retrospective cohort analysis of 1,084 severely injured patients. Crit Care. 2012 May 8;16(3):R77.
TRAUMA
Trauma-Injury Patterns
• More rib and pelvic fractures
Pomerantz WJ, Timm NL, Gittelman MA.Injury patterns in obese versus nonobese children
presenting to a pediatric emergency department. Pediatrics. 2010 Apr;125(4):681-5.
• More lower extremity fractures (OR 1.71)
• Less head and face injuries
Type of Trauma
• Falls - Obesity is
protective, lower
mortality
• MVC- Longer LOS, less
likely to be discharged
but fewer head injuries
Osborne Z, Rowitz B, Moore H, Oliphant U, Butler
J, Olson M, Aucar J. Obesity in trauma: outcomes
and disposition trends. Am J Surg. 2014
Mar;207(3):387-92.
Complications
Mulcahey MK, Appleyard DV, Schiller JR, Born CT. Obesity and the
orthopedic trauma patient: a review of the risks and challenges in
medical and surgical management. Hosp Pract (1995). 2011
Feb;39(1):146-52.
• Higher incidence of comorbidities
• DM
• HTN
• Cardiopulmonary disease
Serrano PE, Khuder SA, Fath JJ Obesity as a risk
factor for nosocomial infections in trauma patients.
J Am Coll Surg. 2010 Jul;211(1):61-7.
• Longer LOS with same ISS, number of vent
days and ICU LOS
• Obesity was an independent risk factor for
nosocomial infection after trauma
Am Surg. 2013 Mar;79(3):247-52.
Obesity does not increase morbidity and mortality after laparotomy
for trauma. Livingston DH1, Lavery RF, N'kanza A, Anjaria D, Sifri
ZC, Mohr AM, Mosenthal AC.
• more respiratory failure and renal failure
• more bacteremia +/- septic shock
• abdominal wound dehiscence
• prolonged hospital stay
Impact of obesity in damage control laparotomy
patients.
Duchesne JC et al. J Trauma. 2009
Jul;67(1):108‐12; discussion 112‐4
• No difference in mortality among obese (15%)
and non-obese (9%) patients (P = .39)
• Obese children did have more complications
(41% vs 22%, P =0.04).
• obese patients required longer ICU stays (8+/-9
vs 6+/-6 days, P=0.05) after severe trauma
Liu T; Chen JJ; Bai XJ; Zheng GS; Gao W, The
effect of obesity on outcomes in trauma patients: a
meta-analysis.[Injury], 2013 Sep; Vol. 44 (9), pp.
1145-52.
• Objective: This study aims to assess the effect of obesity on injury severity
score (ISS), mortality and course of hospital stay among trauma patients.
• Method: A systematic review of the literature was conducted by Internet
search. Data were extracted from included studies and analysed using a
random-effects model to compare outcomes in the obese (body mass index
(BMI)≥30kgm(-2)) with the non-obese (BMI<30kgm(-2)) group.
• Result: Eventually, 18 studies met our inclusion criteria with 7751 obese
patients representing 17% of the pooled study population. The data revealed
that obesity was associated with increased risk of mortality, longer stay in the
intensive care unit and higher rates of complication. Additionally, obese
patients seemed to have longer duration of mechanical ventilation and hospital
length of stay but it did not reach statistical significance. No difference was
observed in ISS between the two groups.
• Conclusion: Evidence strongly supports the correlation of obesity with worse
prognosis in trauma patients and further studies should target this kind of
population for therapy and prevention.
Christmas et al. Morbid obesity impacts
mortality in blunt trauma. Am Surg. 2007
Nov;73(11):1122‐5.
• Multiorgan injury experienced a significantly
longer hospital length of stay
• Fourfold increase in mortality
Brown CV, Neville AL, Salim A, Rhee P, Cologne K,
Demetriades D. The impact of obesity on severely
injured children and adolescents. J Pediatr Surg. 2006
Jan;41(1):88‐91
• No difference in mortality among obese (15%)
and nonobese(9%) patients (P = .39)
• More complications (41% vs 22%, P =0.04).
• Longer ICU stays (8 +/‐ 9 vs 6 +/‐ 6days, P =
.05) after severe trauma.
Bottom Line
• More complications - YES
• More mortality?
PEDIATRICS
Ginde AA; Santillan AA; Clark S; Camargo CA Jr . Body mass index and
acute asthma severity among children presenting to the emergency
department., Pediatric Allergy And Immunology: Official Publication Of
The European Society Of Pediatric Allergy And Immunology 2010 May;
Vol. 21 (3), pp. 480-8.
• Obesity prevalence higher for ED asthma
exacerbation visits
• No association with severity or admission
likelihood
SATISFACTION
Ngui B, McDonald Taylor D, Shill J. Effects of
obesity on patient experience in the emergency
department. Emerg Med Australas. 2013
Jun;25(3):227-32.
• There were no differences between the groups
in time to be seen, monitoring, other
procedures, assistance required, place of
disposition or ED length of stay (P > 0.05).
• Obese patients had a lower death rate in the
ED or hospital than non-obese patients (1.6%
vs 7.5%, P < 0.01).
Gudzune KA, Bleich SN, Richards TM, Weiner JP, Hodges K, Clark
JM. Doctor shopping by overweight and obese patients is
associated with increased healthcare utilization. Obesity (Silver
Spring). 2013 Jul;21(7):1328-34.
• Negative interactions with healthcare providers may lead patients
to switch physicians or "doctor shop." We hypothesized that
overweight and obese patients would be more likely to doctor
shop, and as a result, have increased rates of emergency
department (ED) visits and hospitalizations as compared to
normal weight nonshoppers.
• As compared to normal weight beneficiaries, overweight
beneficiaries had 23% greater adjusted odds of doctor shopping
(OR 1.23, 95%CI 1.04-1.46) and obese beneficiaries had 52%
greater adjusted odds of doctor shopping (OR 1.52, 95%CI 1.261.82). As compared to normal weight non-shoppers, overweight
and obese shoppers had higher rates of ED visits (IRR 1.85,
95%CI 1.37-2.45; IRR 1.83, 95%CI 1.34-2.50, respectively),
which persisted during within weight group comparisons
(Overweight IRR 1.50, 95%CI 1.10-2.03; Obese IRR 1.54, 95%CI
1.12-2.11).
Chen EH, Shofer FS, et al. Emergency physicians do not use more
resources to evaluate obese patients with acute abdominal pain. Am J
Emerg Med. 2007 Oct;25(8):925-30.
Platts-Mills TF, Burg MD, Snowden B. Obese patients with abdominal
pain presenting to the emergency department do not require more time
or resources for evaluation than nonobese patients. Acad Emerg Med.
• Refute the idea2005
of increased
use of resources
Aug;12(8):778-81.
in obese patients in the ED.
• Both specific to abdominal pain, but state that
obese patients did not experience longer
disposition times, diagnostic testing, length of
stay, or final diagnosis.
• Obese patient did not require increased
resources.
Bertakis KD, Azari R. Obesity and the use of health
care services. Obes Res. 2005 Feb;13(2):372-9.
Gordon B, Afek A, Livshits S. The Association of Body
Mass Index and Increased Utilization of Health Care
Services- A Retrospective Cohort Study of 51521
Young Adult Males. Endocr Pract. 2014 Jul
1;20(7):638-45.
• Outside of the ED, other studies state that the
obese population had significantly more doctor
visits as well as increased use of resources.
Baskerville JR, Moore RK. Morbidly obese patients receive
delayed ED care: body mass index greater than 40 kg/m2
have longer disposition times. Am J Emerg Med. 2012
Jun;30(5):737-40.
• Morbidly obese patients take significantly longer to
disposition than normal or mildly obese patients
(difference, 101 minutes [95% CI, 55-146];
P<.0001).
• The mean length of stay for patients with BMI less
than 35 kg/m2 was 287 minutes in contrast to 388
minutes for patients with BMI greater than 40
kg/m2. Computed tomography use was
significantly less likely in the BMI class 0 and 1
groups compared with the BMI class 3 group (0.41
[79/195] vs 0.56 [57/102]; difference, 0.15 [95% CI,
0.03-0.27]; P=.012).
Medical Costs
increased
P Value
Cost
overwt
22%
0.077
obese
28%
0.020
morbid
obese
44%
0.015
WHAT CAN WE DO ABOUT
THIS GROWING PROBLEM?
How can we make a difference in
the ED?
• Don’t ignore or overlook overweight/obesity in
the ED setting - many docs don’t mention it!
• Recognize and identify signs of obesity-related
complications:
• HTN, dyslipidemia, hyperinsulinemia, and
obstructive sleep apnea, etc
• Consider PCP/dietitian referral for long-term f/u
• Ensure that appropriate equipment is available
to evaluated and care for obese patients
• Establish protocols for managing larger patients
• Teach parents and children
about the importance of
maintaining a healthy
lifestyle
• Give families concrete
suggestions to help with
weight reduction
• Encourage portion control
• Provide healthy food
suggestions
• Get unhealthy snacks out of
the house
Home
Set aside time for healthy
meals
Physical activity
Limit television viewing
Summary
• People are fat and are getting fatter
• You will be impacted by obesity in your Emergency
Department
• Know what complications can arise from obesity
• Help your patients identify weight related problems
• Teach your patients how to combat obesity• Education
• Referral
References
• Baskerville JR, Moore RK. Morbidly obese patients receive delayed ED care: body
mass index greater than 40 kg/m2 have longer disposition times. Am J Emerg Med.
2012 Jun;30(5):737-40.
• Bertakis KD, Azari R. Obesity and the use of health care services. Obes Res. 2005
Feb;13(2):372-9.
• Bottone FG, Musich S, Wang SS. Obese older adults report high satisfaction and
positive experiences with care. BMC Health Serv Res. 2014 May 16;14:220.
• Dargin J; Medzon R, Emergency department management of the airway in obese
adults. Annals Of Emergency Medicine, 2010 Aug; Vol. 56 (2), pp. 95-104.
• Ferrada P; Anand RJ; Malhotra A; Aboutanos M. Obesity does not increase mortality
after emergency surgery, [J Obes], Vol. 2014, pp. 492127
• Ginde AA; Santillan AA; Clark S; Camargo CA Jr . Body mass index and acute asthma
severity among children presenting to the emergency department., Pediatric Allergy
And Immunology: Official Publication Of The European Society Of Pediatric Allergy
And Immunology 2010 May; Vol. 21 (3), pp. 480-8.
• Gordon B, Afek A, Livshits S. The Association of Body Mass Index and Increased
Utilization of Health Care Services- A Retrospective Cohort Study of 51521 Young
Adult Males. Endocr Pract. 2014 Jul 1;20(7):638-45.
• Gudzune KA, Bleich SN, Richards TM, Weiner JP, Hodges K, Clark JM. Doctor
shopping by overweight and obese patients is associated with increased healthcare
• Jain, A. What works for obesity? A summary of the research behind obesity interventions.
Clinical Evidence, BMJ Publishing Group, April 2004
• Kam J; Taylor DM, Obesity significantly increases the difficulty of patient management in
the emergency department. [Emerg Med Australas], 2010 Aug; Vol. 22 (4), pp. 316-23.
• Lazar MA; Plocher EK; Egol KA, Obesity and its relationship with pelvic and lowerextremity orthopedic trauma. American Journal Of Orthopedics 2010 Apr; Vol. 39 (4), pp.
175-82.
• Lee DH; Jung KY; Choi YH; Cheon YJ, Body mass index as a prognostic factor in
organophosphate-poisoned patients. The American Journal Of Emergency Medicine [Am
J Emerg Med], 2014 Jul; Vol. 32 (7), pp. 693-6.
• Liu T; Chen JJ; Bai XJ; Zheng GS; Gao W, The effect of obesity on outcomes in trauma
patients: a meta-analysis [Injury], 2013 Sep; Vol. 44 (9), pp. 1145-52.
• Arch Intern Med. 2011 Feb 28;171(4):316-21.The influence of physician acknowledgment
of patients' weight status on patient perceptions of overweight and obesity in the United
States.
• Post RE1, Mainous AG 3rd, Gregorie SH, Knoll ME, Diaz VA, Saxena SK.Mulcahey MK;
Appleyard DV; Schiller JR; Born CT Obesity and the orthopedic trauma patient: a review
of the risks and challenges in medical and surgical management, Hospital Practice (1995)
2011 Feb; Vol. 39 (1), pp. 146-52.
• Ngui B; McDonald Taylor D; Shill J,Effects of obesity on patient experience in the
emergency department. [Emerg Med Australas], 2013 Jun; Vol. 25 (3), pp. 227-32.
• Obesity Prevalence Maps http://www.cdc.gov/obesity/data/prevalence-maps.html
• Osborne Z; Rowitz B; Moore H; Oliphant U; Butler J; Olson M; Aucar J, Obesity in trauma:
outcomes and disposition trends. [Am J Surg], 2014 Mar; Vol. 207 (3), pp. 387-92;
discussion 391-2.
• Peitz GW; Troyer J; Jones AE; Shapiro NI; Nelson RD; Hernandez J; Kline JA Association
of body mass index with increased cost of care and length of stay for emergency
department patients with chest pain and dyspnea. [Circ Cardiovasc Qual Outcomes], 2014
Mar; Vol. 7 (2), pp. 292-8
• Pomerantz WJ; Timm NL; Gittelman MA, Injury patterns in obese versus nonobese
children presenting to a pediatric emergency department. [Pediatrics], ISSN: 1098-4275,
2010 Apr; Vol. 125 (4), pp. 681-5.
• Post RE1, Mainous AG 3rd, Gregorie SH, Knoll ME, Diaz VA, Saxena SK. The influence
of physician acknowledgment of patients' weight status on patient perceptions of
overweight and obesity in the United States.Arch Intern Med. 2011 Feb 28;171(4):316-21.
• Roe JL; Fuentes JM; Mullins ME, Underdosing of common antibiotics for obese patients in
the ED, [Am J Emerg Med], 2012 Sep; Vol. 30 (7), pp. 1212-4.
• The State of Obesity in Texas http://stateofobesity.org/states/tx/
• Trust for America's Health and Robert Wood Johnson Foundation. The State of Obesity
2014 [PDF]. Washington, D.C.: 2014.
• Twaij A; Sodergren MH; Pucher PH; Batrick N; Purkayastha S., A growing problem:
implications of obesity on the provision of trauma care, [Obes Surg], 2013 Dec; Vol. 23
(12), pp. 2113-20.
QUESTIONS?