Bariatric Service Line

– Lessons Learned

Tracy M. Morris, BSN, RN, BC, CLIN. IV,

Clinical Educator Rucker 4

Overview

• Introduction to Bariatrics

• Analysis of Educational Needs

• Educational/Competency Strategies for

Preparation

• Thoroughness of Readiness

• Obstacles/Barriers

• Success of Preparation

• Lessons Learned & Unexpected Outcomes

Intro

Michael Trahan, MD,

Bariatric Surgeon – joined

Martha Jefferson Surgical

Associates after 6 years as a

surgeon & assistant

professor of surgery at the

Center for Weight

Management, University of

Texas Medical Branch in

Galveston, TX.

Bariatric Surgical Types

Two Types of Procedures:

Restrictive Procedure = Gastric Banding (―lapband‖)

Restrictive & Malaborptive = Gastric Bypass (Roux-en-Y)

Candidates for bariatric surgery

• BMI >/= 40 kg/m2 or BMI >/= 35 kg/m2 with

significant co morbidities

• Attempted and failed non-operative control

• Favorable risk: benefit ratio

• Psychological stability

• No substance abuse including tobacco

• Realistic outlook on necessary lifestyle

modifications

Gastrointestinal Surgery for Severe Obesity: National Institutes of Health

Consensus Development Conference Statement. Am J Clin Nutr 1992; 55(2):

615-619.

Dr. Trahan’s Texas Experience

*Of nearly 300 patients

238 Bypasses & 60 Bands

Average weight = 280 lbs (BMI 47)

~90% female

All but 2 were laparoscopic

Hospital stay for Bypass: 2.26 days

Hospital stay for Bands: 0.98 days

No deaths

One leak, one PE, one DVT

3 patients spend time in the ICU

Dr. Trahan’s In-service to Rucker 4: ―Introduction to Bariatrics-The Basics‖ (2007)

Analysis of Educational Needs

Conducted through

several group

meetings with Dr.

Trahan - starting in

July of 2007

(multidisciplinary) for

organizational needs

as a whole R4

identified as ―Bariatric

Unit‖ identified

educational needs of

nursing staff.

What was Analyzed/Identified?

• Staff educational needs:

– Bariatric surgical population’s unique care needs

• Introduction to new line of service

• Complications post-operatively

– Emphasis on Respiratory Assessment

– Equipment Needs

• Awareness Training

– All bariatric surgical pts. must be monitored (tele &

Spo2)

• Remote monitoring/lead placement training

Educational/Competency Strategies for

Preparation

• Dr. Trahan voiced desire to educate the staff –

presented two in-services:

• Part I: ―Introduction to Bariatrics‖

• Part II: ―Complications‖

• Dr. Trahan arranged for Ethicon Rep. to in-

service staff on:

• Part III: ―Awareness Training‖

Educational/Competency Strategies for

Preparation

• Remote monitoring education/training (tele &

Spo2)

– Robert Christy, RT, provided in-service/on-

hands training for: ―Respiratory Assessment

in the Bariatric Pt.‖

– Philips Rep./R4 Clin. Educator provided

training on monitoring equipment/lead

placement.

Thoroughness of Readiness

• Required a team effort from

the very start!

• Championed by Dr. Trahan

• Presented from the start as

a positive opportunity for

MJH.

Foundation – supports entire

structure (Phase I)

Living space ( Phase II

- hospitalization)

The highest point/summit (Phase

III: discharge/recovery) –

providing pt. with needed

tools/knowledge – *prevention of

damage to structure

Obstacles / Barriers

• Stigma (preconceived ideas about obesity)

• Limitations of facility: equipment/space

– Lack of bariatric equipment (ex: Day

Surgery with pull down wall toilets, X-ray

table limitation, etc.)

– Limited environmental considerations for

bariatric pts. and visitors (furniture

accommodations)

Obstacles / Barriers

• Education (limited understanding of the

biological/emotional impact of obesity)

• Experience (limited experience with bariatric

equipment/supplies/population)

• R4 Budget (budget planned back in May

2007) – money for needed equipment and

supplemental staffing (r/t monitoring and

ambulation needs)

Success of Preparation

**Anticipated first

patient not until

January of 2008

Emphasis placed on

educational needs

early on First case

arrived on Dec. 19th,

2007**

Success of Preparation

• Identified/hand-picked staff to

provide care in advance

• Ensured adequate staffing

• Planned registration process to be

completed ahead of time on R4

• Planned to admit pt. pre-op to R4

Success of Preparation

• Clin. Educator arranged to work with staff

nurse to admit pt. and receive pt. post-

operatively

• Coordination with all departments

involved prior to admission

• All appropriate equipment in place prior to

pt.’s arrival (planned case-by-case)

Lessons Learned & Unexpected Outcomes

*First bariatric surgical patient:

Type: Lap Banding Procedure

37 y.o. female, 280 lbs. BMI 41.79

PSH: none

PMH: morbid obesity with lifelong problem with weight – unable to control weight using diet / exercise / behavior modification

As off 1/14 (4 week

post-op) pt. down

260 lbs.)

Lessons Learned & Unexpected Outcomes

*Admission of bariatric medical/surgical patient to

R4

Type: Ventral Hernia Repair

Female, 400+lbs

PSH: Failed Gastric Bypass w/complications

PMH: OSA, severe morbid obesity, chronic pain

(methadone), mobility limitations, etc.

Lessons Learned & Unexpected Outcomes

*First bariatric surgical patient case:

Lack of Nutrional Offerings

Pts are to receive sugar-free and non-

carbonated liquids (bariatric clear liqs) –

Lacked choices for after cafeteria hours /

dietary staff not knowledgeable about diet

<>Have worked with cafeteria to have other

choices available (stock on unit)<>

Lessons Learned & Unexpected Outcomes

*Second med/surg bariatric case:

Failure in Communication (multiple units affected) Day Surgery not aware of pt.’s weight upon admission

(limited space & equipment)

R4 not aware of pt.’s admission until pt. in PACU. Not aware of special needs until on the unit.

Proper equipment not in place increase in pt.’s anxiety, emotional & physical pain, loss of human dignity, risk for pt. and staff injury—equipment provided several hours later by company in Richmond—not local company (could not promise delivery) <>Elevated toilet sets placed in bariatric rooms<>

Pain Management Issue

Lessons Learned & Unexpected Outcomes

Lack of Bariatric Equipment

BSC not able to be obtained from any other units in

the hospital = Is our organization as a whole ready to

provide care for this population which is increasing in

numbers?

Remote Monitoring Alarms Disabled

Pt. cont’d to take O2 mask off, causing drop in Spo2

below 92% activate alarm, CMT turned alarm off

nurse caring for pt. noticed drop in Spo2 at nurses’

station CMT notified to inquire why unit not notified

<>Spoke with CMT. Midas report completed<>

Concerns

• Lack of equipment / staff trained to

use equipment

• Lack of furnishings for visitors

• R4 to be viewed as unit for ALL

bariatric pts. to be admitted

• Physicians taking advantage of

remote monitoring capabilities

• Staffing / budgetary constraints

(FTEs)

Current Initiatives for Improvement

• Looking to purchase

futon type chair for

bariatric rooms

• Purchasing large wheel

chair for unit

• Establish relationship

with new KCI rep. for

future planning for

equipment needs/training

What is on the Radar?

• First Gastric Bypass is

scheduled for Feb. 12th

• Dr. Trahan’s Pt. Seminars are

offered the second Wednesday

of every month (excellent

attendance!)

• Goal: 3 pts. every week

Conclusion

Vince Lombardi who left his mark on teambuilding in the NFL stated: ―Individual commitment to a group effort--that is what makes team work, a company work, a society work, a civilization work.‖

Thanks!