Bariatric Service Line – Lessons LearnedTracy 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
IntroMichael Trahan, MD,Bariatric Surgeon – joinedMartha Jefferson SurgicalAssociates after 6 years as asurgeon & assistantprofessor of surgery at theCenter for WeightManagement, University ofTexas Medical Branch inGalveston, TX.
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 modificationsGastrointestinal Surgery for Severe Obesity: National Institutes of HealthConsensus 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 ICUDr. 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.
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 entirestructure (Phase I)
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: As off 1/14 (4 week post-op) pt. downType: Lap Banding Procedure 260 lbs.)37 y.o. female, 280 lbs. BMI 41.79PSH: nonePMH: morbid obesity with lifelong problem with weight – unable to control weight using diet / exercise / behavior modification
Lessons Learned & Unexpected Outcomes*Admission of bariatric medical/surgical patient to R4Type: Ventral Hernia RepairFemale, 400+lbsPSH: Failed Gastric Bypass w/complicationsPMH: 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 OutcomesLack 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
ConclusionVince Lombardi who lefthis mark onteambuilding in the NFLstated: ―Individualcommitment to a groupeffort--that is whatmakes team work, acompany work, asociety work, acivilization work.‖ Thanks!