Facility works to ensure safety in bariatric program

Most complications are preventable, experts say

Robert Wood Johnson University Hospital Hamilton (RWJ Hamilton), a recipient of the 2004 Malcolm Baldrige National Quality Award, has just begun offering a new bariatric (weight loss) program; but long before it took its first case, it has been making preparations to ensure the highest possible quality of care.

This is particularly important at a time when the complications of bariatric surgery are grabbing headlines, but Earl L. Noyen, MD, medical director for the program, insists those concerns may be a bit overblown.

"We have probably had over 150,000 of these cases done last year — of all types — and even more worldwide," says Noyen. "The death rate reported from gastric bypass at the American Society of Bariatric Surgery consensus conference in 2004 was less than 1%. And, from the gastric banded procedure [laparoscopic adjustable gastric banding — a minimally invasive procedure that places an adjustable band around the top portion of the stomach] it is minimal — like 0.1%."

The latter procedure, like gastric bypass, also restricts food intake, but without bypassing any of the small intestines. This surgical option can be reversed if needed.

As for complications, says Noyen, the overall complication rate is about 10%; these complications can range from infection to blood clots, or pulmonary embolism. "Still, it’s significantly less than other surgeries we do on a routine basis," he notes.

However, many candidates for the surgery present with a significant amount of risk to begin with, he says. "It’s not like taking a 17-year-old with a good history, on no meds, and operating," he says. "These patients are usually in their 40s, mainly female, with one or two problems. And when they get over 50, you see significant problems related to obesity like heart disease or sleep apnea. In addition, most if not all are diabetic, they may have had previous surgeries, and they are on meds for chronic diseases. In any setting, the risk is significant — and on top of that you have morbid obesity."

Lowering the risks

What RWJ Hamilton has done, says Noyen, is to minimize those risks. To begin with, the bariatric surgery program is comprehensive and embraces a team approach; candidates are evaluated and pre-existing conditions are evaluated. Patients receive education on procedure options, risks, outcomes, potential side effects, and lifestyle modifications. Progress is monitored and strict dietary and exercise regimens are instituted. Patients are paired with clinical professionals, exercise specialists, nutritionists, and support staff to provide a full continuum of services and counseling.

"These should be integral parts of any weight loss program; you need such a comprehensive program — outpatient care as well," Noyen observes. In fact, he says, the facility has established a separate Center for Health and Wellness where the patients can be seen for nutrition and diet classes, as well as other educational programs, and fitness trainers also are available.

The bottom line, he asserts, is that "Most complications are preventable." For example, in terms of the bypass surgery itself, the biggest worry is a leak, but the team at RWJ is working proactively to minimize the risk of a leak occurring, "When we reconfigure, there is always that risk," he observes. "To make it less likely, we do several things in the operating room."

For example, apart from sutures and staples, the team applies Tissel — a binding polymer that allows in-growth of tissue to help with the healing process. "On the day following surgery, we all go to radiology, where the patient swallows some dye and we proactively check for leaks," adds Noyen. "If there is one, we have the option to go back to the OR in 24 hours and repair it. If there is no leak, we start feeding the patient."

With that protocol, he says, the team may still miss a small percentage of leaks, but the staff are trained to be vigilant, and nurses regularly check vitals. "If the heart rate is over a certain level, the team is alerted and we may still go back laproscopically," he notes.

In addition, with minimally invasive surgery there is no big wound, so patients are able to ambulate even on the day of surgery. "One of the biggest steps you can take to cut back on blood clots is to get up and move, and the nursing staff helps patients do this," he says. "With the smaller incision, patients can breathe better, and there are fewer cases of pneumonia."

In the past, with more invasive surgery, up to 30% of patients developed incisional hernias; now, that is less than 1%. "We have put all the things in place needed to reduce our risk, and hopefully we have a benchmark program," he says.

Special equipment, training implemented

Other aspects of the program geared to enhance safety include the ordering of special equipment and specialized staff education. "We met with different ancillary folks at the hospital looking at equipment that would enhance safety," says Noyen. "That includes larger tables to accommodate obese patients in the OR, the purchase of added padding for beds, and having larger commodes. Even something like larger gowns are important. We did all of that even before our first case."

Education has been facilitated by Summerville, NJ-based Ethicon, a company from which the facility purchased a disposable surgical product. "They provide inservices for physicians, scrub staff, and the RN staff," says Barbara Lee, RN, CNOR, director of surgical services. "In fact, 80% of our staff went to an all-day session with them."

The program included techniques of surgery, complications, and sensitivity training for staff so they would be better able to deal with obese patients. "We wanted to make sure the staff was aware of what the patients were feeling, learned how to help them maintain their privacy and prevent embarrassing situations, such as not having the appropriate chair because they couldn’t fit into what was available," Lee explains. "We have discreetly taken care of much of that by providing appropriate chairs, larger gowns, and so forth." The nurses will have everything prepared and waiting for each particular patient, she adds.

Some of the education was also geared to the particular type of staff involved, she continues. "For example, Ethicon brought four of our scrub staff and nurses to their lab and covered hands-on aspects of the procedure with the physicians," she explains.

Lee adds that a steering team continues to meet regularly to talk about the program. Input is solicited from "any department or unit where patients go in their entire spectrum of care," she explains. "They each know what works best in their own area."

As a result of these ongoing discussions, a good deal of the equipment considered was standardized, rather than purchasing a variety of products. "Everyone is required to learn the entire process the patient will go through," Lee adds. "This way, if issues come up anywhere along the continuum of care, they know who to contact."

For more information, contact:

Earl L. Noyen, MD, Program Director, Barbara Lee, RN, CNOR, Director of Surgical Services, Robert Wood Johnson University Hospital Hamilton, One Hamilton Health Place, Hamilton, NJ 08690. Phone: (609)586-7900.