Same-Day Surgery kicks off 35th anniversary year

This month’s issue marks the 35th anniversary issue of Same-Day Surgery. We are honored to have been with you since the beginning. As you have changed, so have we. We’re now on twitter (@SameDaySurgery) and send out information weekly via e-mail. (Sign up at

We kick off this 35th anniversary celebration by marking a growing trend: patients with increasingly higher body mass indexes (BMIs). We tell you about recently released guidelines from a national group that can help providers better care. During our anniversary year, we’ll explore other the new thresholds that outpatient providers are crossing including surgery on an increasingly elderly population. We’ll also examine how you can use new trends, such as social media, to your benefit. We’ll discuss how transparency is changing your job. In this month’s issue, we include our annual salary survey results.

We look forward to serving you for the next 35 years!

Are you prepared for high BMI patients or just focused on their gown sizes?

The answer spells the difference between never events and good care

As the num ber of people in the general population with high body mass index (BMI) rises, outpatient surgery providers are seeing growing numbers of these patients. The question arises, are providers treating them appropriately? No, according to the National Association to Advance Fat Acceptance (NAAFA).

"In the midst of our nation's frenzy to fight fat, there is an alarming increase in bias against fat patients among healthcare providers," the NAAFA said recently in a release announcing "Guidelines for Healthcare Providers who Treat Fat Patients." (See excerpt, below. The full guidelines are available at

Pat Lyons, RN, MA, who worked with the NAAFA to develop the guidelines, says, "Standard medical practice often operates from the basic assumption that high weight causes all medical problems and that no problem can be successfully treated without focusing on weight loss." Lyons also previously served as the female project director of the WomanCare Plus Research Project at the University of California, Berkeley, which collected data from African American and white women on barriers to gynecological cancer screening related to BMI.

"Many assume they are not doing their job if they don't counsel fat people to lose weight, so after a lifetime of this kind of medical treatment, fat patients may be even more frightened about surgery than other people," Lyons says. These patients might need extra support and reassurance, she says. "They may not believe surgeons really know what they are doing with big bodies," Lyons says.

Such concerns might be understandable. One of the major co-morbidities associated with obesity is obstructive sleep apnea (OSA). In addition to respiratory support, obese patients might have unique positioning needs. The special needs of obese patients came to the attention of one California hospital after it experienced two sentinel events within six months involving patients with a high body mass index (BMI). (See story, below.)

Lyons suggest you ask yourself, "Are the surgeons well-trained and experienced in doing procedures on patients of all sizes of large, and I mean above 300 pounds too?"

Managers need to ensure that members of their staff aren't discriminating against patients based on their size. Michigan prohibits discrimination against overweight persons, and several cities, including Washington, DC, and San Francisco, have enacted anti-discrimination ordinances.

The newly released guidelines offer assistance. For example, they suggest providers "engage in health-centered, non-weight focused language (i.e., avoid the term obese.)"

This advice is seconded by Rebecca Puhl, PhD, director of research at the Rudd Center for Food Policy & Obesity at Yale University, New Haven, CT. "There are many straightforward strategies that providers can use to reduce weight bias toward their obese patients," Puhl says. "This can start with challenging one's own assumptions and stereotypes about body weight, and using sensitive language with patients in patient-provider communication to ensure that they are not blaming or stigmatizing their patients."

The NAAFA guidelines also suggest it might be necessary to provide size diversity training to your staff. (See Resource at end of this article.) "Weight bias toward obese patients can occur in a number of ways, ranging from stigmatizing or prejudiced comments from providers, fat jokes made by medical staff, and denial of treatment or medical services or procedures," Puhl says.

She points to a recent column in a surgery publication, "meant to be humorous," that included derogatory fat jokes toward overweight patients. It included such statements as "You should worry about performing surgery on the super-sized if there is a comma in your patient's body weight," and doctors should worry about operating on patients "who have more chins than a Chinese phone book."

Puhl said, "It made national headlines. He [the author] later apologized, but this is a clear example of how socially acceptable weight bias has become, even among health providers whose job it is to care for obese patients." (For more on the article, go to

Your surgery staff, lab technicians, and other staff need to be well-trained that X-ray equipment might not be adequate, Lyons says. When that situation occurs, staff members should use non-judgmental language and attitudes, she advises. Lyons offers this example: "I'm sorry, our X-ray machine is too small to meet your needs," rather than, "You are too big for our equipment."

In addition to your staff, ensure your facility is prepared. "Once someone gets to outpatient, be sure gowns, BP cuffs, wheelchairs, gurneys, or other transport equipment is substantial for both safety and comfort," Lyons advises. Also consider weight capacity and width of patient chairs, special support for wall-mounted toilets, the weight and lift capacity of OR/procedure tables, and patient safety straps on OR tables and gurneys, experts suggest.

Address at-home support, Lyons suggests. Wound care issues might arise if a person can't see or reach the surgical site, she explains. They might need bathing aids or other support.

Lyons says the attitude starts with your surgeons. She says to ask yourself, "To what extent are they focused on the whole patient, versus only the specific body part needing surgery, and addressing any special needs related to weight in a non-judgmental way?"


"Guidelines for Healthcare Providers Who Treat Fat Patients" (Excerpt)

Medical Procedures

• Ensure your patients have access to durable medical equipment (DME) that meets their size needs.
• Have several sizes of blood pressure cuffs readily available. Using a small blood pressure cuff on a bigger arm can produce false readings.
• Have longer needles and tourniquets available in order to draw blood from your patients.
• Utilize appropriate equipment for OB/GYN exams (i.e., longer specula).
• Your lavatory should have a seat that is split in front, to enable patients to more easily hold urine specimen cups in place. A urine specimen collection device with a handle or a "hat" is preferable.
• Closely monitor breathing with sedation if there is increases incidence of sleep apnea and airway problems.


• Provide several sturdy armless chairs, couches, or benches in your waiting room. Chairs with arms often cannot accommodate a fat patient.
• There should be 6 to 8 inches of space between chairs.
• Sofas should be firm and high enough to ensure that your patients can rise with ease. Exceptionally low and soft sofas can be difficult.
• Be mindful of the information you provide in your waiting rooms and on the walls. Ensure it reflects diversity, including size, to promote a safe and inclusive environment for all your patients.

Source: National Association to Advance Fat Acceptance, Foster City, CA. Web:

BMI questionnaire may avoid never event

As obesity rates climb in the United States, perioperative professionals must be prepared to care for patients with a high body mass index (BMI) and to prevent the surgery-related complications seen in this patient population. High-BMI protocols, including strategies centered on interdepartmental communication, respiratory care, equipment, and staff education can reduce the risk of surgical complications for obese patients, according to a report in a recent issue of AORN Journal.1

The effects of a high BMI on perioperative safety were brought to the forefront at John Muir Medical Center in Concord, CA, when two sentinel events occurred during a six-month period. At the time these sentinel events occurred, perioperative administrators did not have a mechanism for advance notification when elective, nonbariatric surgical procedures were scheduled for patients who were obese. The bariatric patients already had a clinical nurse specialist attending to their needs.

"The problem was with patients not having bariatric surgery who may have an equal or exceeding BMI, but they fell out of the oversight," says Diane Graham, MS, RN, CNS, CNOR, clinical nurse specialist in surgical services at John Muir. For nonbariatric patients, additional preparations for respiratory support and positioning needs were required on short notice, Graham says.

In the article, Graham and colleagues describe the work of a High BMI Task Force to create and implement a system that would improve surgical results for obese patients. The hospital implemented revised checklists noting the patient's BMI. When a patient appears for preop education and has a BMI above 35, a High BMI Questionnaire is now used.

"It's directed at determining whether a patient might have difficulty breathing postop," Graham says. "They might have a sleep apnea problem. If they have that, in postop recovery area, they will be needing a positive pressure machine or ventilator." [A copy of that questionnaire is included with the online version of Same-Day Surgery at Select "Access your newsletters." If you need assistance, contact customer service at (800) 688-2421 or]

Chart audit results confirmed the quality improvement project, was successful; 92% of 50 charts showed inclusion of the BMI on the surgery schedule, and 94% showed inclusion of the BMI on the preoperative checklist. No serious positioning incidents or intubation emergencies have occurred in patients with a high BMI since Jan. 1, 2009, Graham says.

A first step is to assess your patient population to determine how many of your patients have a high BMI, Graham suggested in an interview with Same-Day Surgery. "Given the fact that we know nationally that the BMI of patients is increasing… regardless of your population, you can be pretty assured you will be getting these patients more frequently."

The bottom line is to "be proactive to protect your patients in the positioning and respiratory sense, so you're not taken unaware when you have those patients come in," Graham says. "It's better to be proactive, rather than respond to injuries."

She points to the two sentinel events at her facility. "I don't want other people to have that kind of occurrence to discover they have deficits in their positioning or respiratory care of the patient," Graham says. (See story about white paper on the potential role of endoscopic bariatric therapies in treating obesity and obesity-related diseases, below.)


  1. Graham D, Faggionato E, Timberlake A. Preventing perioperative complications in the patient with a high body mass index. AORN J 2011; 94:334-344. Doi: 10.1016/j.aorn.2011.05.017.

Societies explore role of endoscopy for obesity

The American Society for Gastrointestinal Endoscopy (ASGE) and the American Society for Metabolic & Bariatric Surgery (ASMBS) have issued a white paper on the potential role of endoscopic bariatric therapies (EBTs) in treating obesity and obesity-related diseases like Type 2 diabetes.

The white paper titled, "A Pathway to Endoscopic Bariatric Therapies," appears in the November issue of GIE: Gastrointestinal Endoscopy, the peer-reviewed scientific journal of the ASGE.

"The two societies formed a joint task force to identify opportunities where endoscopic treatments may play a role in improving patient outcomes and reducing costs," said Gregory G. Ginsberg, MD, FASGE, ASGE president and chair of the ASGE/ASMBS Task Force on EBT. "The white paper establishes the criteria for success as new technologies and procedures are developed."

According to the white paper, several EBTs are in different stages of development and include a wide variety of methods to induce weight loss and reduce obesity-related diseases and conditions. EBTs are performed entirely through the gastrointestinal tract using thin flexible endoscopes and might offer patients an outpatient alternative to bariatric procedures including laparoscopic gastric bypass, adjustable gastric banding, and sleeve gastrectomy.

Bipan Chand, MD, chairman of the ASMBS Emerging Technology and Procedure Committee and co-chair of the ASGE/ASMBS Task Force, says, "Endoscopic therapy has the potential to be applied across the continuum of obesity and metabolic disease. However, it is generally expected that endoscopic modalities achieve weight loss superior to that produced by medical and intensive lifestyle interventions, have a favorable risk/benefit profile, and have scientific evidence to support its use."

The white paper addresses endoscopic bariatric therapy treatment classification, potential indications, and efficacy including: primary efficacy endpoints such as weight loss, definitions for weight loss, comparison of weight loss between therapies, threshold for weight loss, and study design. It also addresses secondary efficacy endpoints such as reduction in obesity-related co-morbidities, changes in quality of life, safety, durability, repeatability, adoption of EBTs in the context of global patient care, endoscopy unit considerations, training and credentialing, cost effectiveness, and government and industry relations.

According to the Centers for Disease Control and Prevention (CDC), about one-third of U.S. adults (33.8%) are obese. Medical costs associated with obesity are about $147 billion or 10% of all medical spending, double what it was a decade ago.1 The ASMBS estimates there are 17 million people in the United States with morbid obesity (BMI of 40 or more, or a BMI of 35 or more with an obesity-related disease).

Obesity is a disease that contributes to more than 30 other obesity related diseases and conditions that include Type 2 diabetes, hypertension, heart disease, sleep apnea and certain cancers.

Bariatric surgery has been shown to be the most effective and long lasting treatment for obesity and many related conditions.2 Studies have shown patients might lose 30 to 50% of their excess weight six months after surgery and 77% of their excess weight as early as one year after surgery.3 The Agency for Healthcare Research and Quality (AHRQ) reported significant improvements in the safety of bariatric surgery over the last several years due in large part to improved laparoscopic techniques and the advent of bariatric surgical centers of excellence. The overall risk of death from bariatric surgery is about 0.1%4 and the risk of major complications is about 4%.5


  1. Finkelstein EA, Trogdon JG, Cohen JW, et al. Annual medical spending attributable to obesity: payer-and service-specific estimates. Health Affairs 2009. 29:w822-w831. Accessed at
  2. Weiner RA. Indications and principles of metabolic surgery. U.S. National Library of Medicine 2010; 81:379-394.
  3. Wittgrove AC et al. Laparoscopic gastric bypass, Roux-en-Y: Technique and results in 75 patients with 3-30 months follow-up. Obesity Surgery 1996. 6:500-504.
  4. Agency for Healthcare Research and Quality (AHRQ). Statistical Brief No. 23. Bariatric Surgery Utilization and Outcomes in 1998 and 2004. January 2007.
  5. Flum DR, Belle SH, King WC, et al. Perioperative safety in the longitudinal assessment of bariatric surgery. NEJM 2009 361:445-454. Accessed at