1. Bariatric Service Line
– Lessons Learned
Tracy M. Morris, BSN, RN, BC, CLIN. IV,
Clinical Educator Rucker 4

2. 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

3. 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.

4. Bariatric Surgical Types
Two Types of
Procedures:
Restrictive Procedure
= Gastric Banding
(―lapband‖)
Restrictive &
Malaborptive =
Gastric Bypass
(Roux-en-Y)

5. 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.

6. 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)

7. 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.

8. 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

9. 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‖

10. 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.

11. 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.

13. The highest point/summit (Phase
III: discharge/recovery) –
providing pt. with needed
tools/knowledge – *prevention of
damage to structure
Living space ( Phase II
- hospitalization)
Foundation – supports entire
structure (Phase I)

14. 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)

15. 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)

16. 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**

17. 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

18. 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)

19. Lessons Learned & Unexpected Outcomes
*First bariatric surgical patient:
As off 1/14 (4 week
post-op) pt. down
Type: Lap Banding Procedure 260 lbs.)
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

20. 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.

21. 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)<>

22. 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

23. 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<>

24. 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)

25. 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

26. 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

27. 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!