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Guidance and considerations in toileting provision for bariatrics

 In the UK today, some 8 million adults are classed as obese, based on Body Mass Index (BMI) – almost 25% of the population. Approximately a third of children are overweight.

Increased body mass has a big impact on daily life, even before associated health issues are taken into account.

Everyone, regardless of size, goes to the toilet on average eight times a day. Adaptations in ‘the smallest room’ therefore need to be applied to optimise effective personal hygiene, with optimum independence and dignity.Everyone, regardless of size, goes to the toilet on average eight times a day. Adaptations in ‘the smallest room’ therefore need to be applied to optimise effective personal hygiene, with optimum independence and dignity.

Guidelines recommend that in a bariatric care environment, considerations should be given to provide a wider and higher toilet seat, minimum turning radius of 1.8m/6ft to accommodate larger wheelchairs, and ensure adequate distance between toilet and sink to allow the person to rise without using the sink for support.Guidelines recommend that in a bariatric care environment, considerations should be given to provide a wider and higher toilet seat, minimum turning radius of 1.8m/6ft to accommodate larger wheelchairs, and ensure adequate distance between toilet and sink to allow the person to rise without using the sink for support.

Using the toilet

Before an obese person can ‘go to the loo’ they need to be able to get onBefore an obese person can ‘go to the loo’ they need to be able to get onand off it. Their weight, and corresponding size, can impinge on mobility and agility.

Toilet support systems

If people need support to lower or raise themselves, the basin is often usedIf people need support to lower or raise themselves, the basin is often usedas a support system. Because of the bariatric user’s bigger size, a separatesupport system would be required, rather than reliance on the basin (whichmay not withstand the downforce load), or one integrated into the WC.

Toilet lift

If the person can stand and walk unaided, or with minimal help, a toilet liftIf the person can stand and walk unaided, or with minimal help, a toilet liftwould provide appropriate support.

A toilet lift is fitted over the WC, and replicates automatically the naturalA toilet lift is fitted over the WC, and replicates automatically the naturalmovement of standing and sitting. They help people with limited mobility geton and off the toilet with little or no carer assistance, keeping their feet on the floor and maintain their centre of gravity to ensure balance. The seating area is up to 480mm/18ins wide, against 450mm/17ins for a conventional WC seat.

Standard toilet lifts accommodate a weight loading up to 150kg/24stone.Standard toilet lifts accommodate a weight loading up to 150kg/24stone.A bariatric version is available, which will withstand up to 250kg/37 stone.

Aerolet Technical Image

Shower chair 

A shower chair has an appropriately-positioned opening in the padded seatA shower chair has an appropriately-positioned opening in the padded seatto enable access to the toilet pan without the user having to transfer on tothe toilet from the chair.

Hoist

If the person cannot stand and walk easily, a hoist may be required –If the person cannot stand and walk easily, a hoist may be required –addressing manual handling considerations of safety and weight loadings.

Variants include wheeled frames and ceiling track. Choice is influenced byVariants include wheeled frames and ceiling track. Choice is influenced bybudget, and whether it is for:

  • A single or multi-user environment
  • A single or multi-user environment
  • For use in one room or beyond
  • The layout of the room i.e. whether ceilings and walls are robust enoughto bear the necessary load, and the positioning, and style/protuberance offixtures and fittings.

The transfer requirement is also a major factor – be it moving someone fromThe transfer requirement is also a major factor – be it moving someone fromwheelchair to toilet (at similar height), or a requirement for height-adjustability e.g. from wheelchair to changing table. (line drawing of hoist system).

Hoist Technical Image 1Hoist Technical Image 2

The toilet

Whereas the user will most likely have a conventional WC, a wash and drytoilet may often be a more appropriate solution to achieving effectivecleanliness to a consistent standard.

There are two main influencing factors – weight loading and body mass.

Weight loading:

The toilet itself needs to withstand the weight load. The seat and brackets The toilet itself needs to withstand the weight load. The seat and brackets similarly need to be robust. Conventional WCs and most wash/drytoilets bear up to 127kg/20 stone. Most bariatric aids will withstand upto 346.5kg/55st. The Closomat Palma Vita Bariatric wash and dry toiletaccommodates 362kg/57 stone.

Body mass:

The user needs to be able to sit securely on the WC, and in the rightposition over/on the seat and pan. They, or their carer, need to be able toreach their bottom to wipe clean.

The user must be sat comfortably, with their back supported against thecistern, and their torso and legs forming a 90° angle.

Shower Toilet Image 1

Buttocks need to be supported but slightly parted to enable effectiveButtocks need to be supported but slightly parted to enable effective bowel evacuation. 

Shower Toilet Image 2

A larger body can often cause the user to be sat too far forward, so theirA larger body can often cause the user to be sat too far forward, so their bottom does not cover the seat opening. The user can feel perched on the toilet, and unstable.

Their flesh impacts on their – or their carer’s – ability to reach and wipeclean. In such instances, a wash/dry toilet is a more hygienic and dignified solution.

Wash and dry automatic shower toilet

A wash and dry toilet eliminates the requirement for comprehensive intimatecare. It combines a toilet, bidet and drier in one unit. The toilet cleansand dries the user after use, removing the need for manual cleansing withtoilet tissue, and all the associated hygiene and contamination issues. It also enhances the user’s independence and self-care skills. Cleaning with toilet tissue requires manual, mental and physical dexterity, flexibility, and balance. It requires intimate hand: body contact, either by the user or their carer. Cleaning with a shower requires only the ability to sit in the right place, and trigger a mechanism.

Selection of a wash and dry unit will be influenced by need, budget, locationand length of need. The cost is not just that of whichever unit is chosen,but what adaptation – if any – will be required to accommodate the unit,and ensure it works, and the length of time it is envisaged the toilet will be needed. There is also the associated reduction in care cost/time. As the wash and dry toilet effectively washes the anal area, it eliminates the potential for faecal smearing and/or cross-contamination under fingernails etc.

Flush Wash Dry Image

Toilet seating 

The size of the seat needs to be larger, to accommodate increased bodymass. A bariatric seat tends to be deeper – (60mm/2.5ins) and wider –480mm/19ins compared to 410mm/16ins. Versions exist which will safelybear up to 363kg/57st. For larger-bodied people, a bariatric (or monk’s)bench may be more comfortable. A padded standard toilet or horse-shoe seat mounted on a steel frame, the bench is positioned over the top of thetoilet. Flat-topped versions and ones with armrests are available. A bench will bear up to 349kg/55st as standard.

Douching

The positioning of the douche can be set in most cases to user requirements,to achieve the fundamental aim of washing the user’s anal area. Once set,it is not likely to be adjusted unless the user or his/her needs change.The positioning, and angle, of the douche within the pan is set at point-of manufacture, and varies from make to make.

Ensure there is adequate clearance between the douche and the bottom of the seat for effective cleaning, and any possible avoidance of potential douche/body contact (potentially an issue with bariatric users).

The douche position and extension is key to effective washing. A standard douche will achieve good cleansing for most people who can attain a normal seating position. If a ‘normal’ seating position cannot be achieved, anextended douche arm may be specified.

The douche spray pattern also varies, and needs to be wide enough to cleanse effectively.

The amount of water also varies: the more water that passes into the douche, the more efficient the clean. Some units use as little as 2l/minute, others 8l/min.

Operation

The user has to be able to easily operate the toilet. Some units have theircontrols positioned behind and/or to the side of the unit, and/or featuresmall push buttons. Where bolt-on units are used, conventional flush is tobe employed before/after the douching process, which may even require theuser getting off the toilet, turning round to flush, then manoeuvring back onto the toilet.

The bulk of a bariatric user may make conventional operation difficult,requiring specification of alternative operating tools.

Further reading: Guide to specification of an automatic wash/dry toilet.

Closomat

The UK’s first, and still biggest-selling, supplier of wash and dry (automatic shower) toilets, the Closomat automatic wash and dry toilet has sold over 55,000 units since it was introduced some 55 years ago, many of which are still in daily use 30 years after first being installed.The UK’s first, and still biggest-selling, supplier of wash and dry (automatic shower) toilets, the Closomat automatic wash and dry toilet has sold over 55,000 units since it was introduced some 55 years ago, many of which are still in daily use 30 years after first being installed.

Today the Closomat Palma Vita floor-standing automatic toilet is the industry benchmark, being the only one of its kind developed specifically forToday the Closomat Palma Vita floor-standing automatic toilet is the industry benchmark, being the only one of its kind developed specifically fordisabled people.

The Palma Vita is the only unit of its kind to achieve Medical Device Class 1The Palma Vita is the only unit of its kind to achieve Medical Device Class 1 certification.

Closomat has extended its expertise to now offer a range of accessibletoilet, bathroom and wetroom equipment, including shower chairs, Apres Shower body driers, and the Aerolet range of toilet lifters.

As a result, the company is unique in delivering in house design advice,supply, installation, commissioning and aftercare service & maintenancethrough its own dedicated team of engineers.

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