Bariatric Center Spotlight: Centennial Center for the Treatment of Obesity

| April 30, 2007

Centennial Center for the Treatment of Obesity is in Nashville, Tennessee.

TELL US ABOUT THE ROLES AND RESPONSIBILITIES OF THE LEAD STAFF AT YOUR FACILITY.
The primary role of the program management team is to serve as a guide for patients seeking information and qualification for bariatric surgery. We also serve as primary liaisons for the surgeons and hospital. The primary roles of the surgical team are to provide a safe, comfortable environment, cutting edge technology, and trained, experienced personnel for our patients. The primary goals of the nursing team are patient assessment, medication administration, monitoring the patients postoperatively for complications, educating patients from admission through discharge, and educating patients and their family members.

WHAT IS THE SIZE OF YOUR FACILITY? WHAT DOES IT PHYSICALLY ENCOMPASS?
Our facility has 613 beds, and it expands over 37 acres, including satellite offices in surrounding counties.

Please describe your staff.
Dr. Douglas Olsen is our medical director and has 17 years of experience as sa urgeon and six years of experience as a bariatric surgeon. Dr. Olsen attended Rush Medical College in Chicago, Illinois, and is a member of the ASBS, ABS, and SAGES.
Dr. David Dyer has 16 years of experience as a surgeon, and six years of experience as a bariatric surgeon. He attended University of Tennessee, Memphis College of Medicine and is a member of ASBS, ABS, SAGES, and ACS.
Dr. Hugh Houston has five years of experience as a surgeon, and four years of experience in bariatric surgery. He attended University of Louisville School of Medicine in Louisville, Kentucky, and trained in the Laparoscopic Bariatric Fellowship. He is a member of ASBS, ABS, and SAGES.
In addition to our surgeons, we have a team of highly trained medical professionals, including receptionists, medical assistants/schedulers, nurses, exercise physiologists, dietitians, financial counselors, program managers, and clinical resource coordinators—all of whom help to provide our patients with a safe, comfortable environment.

What is the number of patients treated on an annual basis at your facility? What are the patient demographics?
We treat annually over 400 bariatric patients who range in age from teenagers to people in their 70s. Ninety-four percent of our patients are from Tennessee and Kentucky.

How is your facility managed and by whom?
Our program is managed by our administrative team and Joann Ettien, Administrator of Centennial Women’s Hospital, and Douglas Olsen, MD, Medical Director. We also have a management team on site at the clinic. Eloise Bray is the Program Manager; Kathy Hungerford, RN, is the Assistant Program Manager, and Debbie Thompson, RN, is the Clinical Resource Coordinator.

Does your center have one particular area of expertise?
An area of expertise in our program is laparoscopic gastric bypass surgery; however, we have expanded our program to include other surgical treatments along with medical weight loss.

GIVE A GENERAL SYNOPSIS OF HOW YOUR PATIENTS ARE TREATED WHILE UNDER THE CARE OF YOUR CENTER.
From the moment a patient walks into our lobby, it is obvious that all aspects of our center, including the furniture and layout, are designed with the needs of the morbidly obese patient in mind. The care of our patients begins with the informational seminar and continues through follow-up visits after surgery. The patient is cared for by trained, qualified, sensitive staff who are trained in HIPAA-mandated standards and COE philosophies. Many of the staff members are bariatric patients themselves who want to “give back” to others seeking this life-saving surgery.

WHAT ARE SOME OF THE NEW EQUIPMENT, DEVICES, AND PRODUCTS INTRODUCED AT YOUR FACILITY LATELY?

The nursing floor recently purchased bariatric beds manufactured by Hill-Rom. These beds are a wonderful addition to our program because they are equipped with air mattresses that inflate on the sides to provide comfort for patients of various sizes. All of the beds are equipped with a trapeze to assist the patient with bed mobility and transfers in and out of bed, while also providing digital readouts of the patient’s weight if desired. Our patients report to the staff that the beds are very comfortable.

Each patient room is also equipped with a bench seat. The seats will accommodate patients weighing up to 1000 pounds and are wide enough to accommodate the larger patient. Each room is also equipped with an over-the-commode seat riser. It accommodates a patient’s weight up to 1000 pounds and provides a higher seat for the patient when he or she is sitting or rising from the commode. It can also be utilized as a shower chair.

The unit is also equipped with walkers for patients weighing up to 750 pounds. They are used for patient safety when a patient needs a little extra assistance with ambulation.

We also now offer cutting-edge, laparoscopic-specific operating room suites that are much larger than standard operating rooms, with state-of-the-art equipment.
We are currently introducing a system to centrally monitor pulse oximetry on our standard postoperative floor. This will allow a larger portion of postoperative bariatric patients to be able to recover immediately after surgery in a regular hospital room and avoid an evening in the intensive care unit to simply monitor oxygen saturations.

Finally, we recently added a cart caddy that was specially designed to assist in transport. It can tow a bed or stretcher up to 1600 pounds. We also provide the staff with transfer mats to ensure patient and staff safety during the transfer.

WHO HANDLES THE PROCEDURE SCHEDULING? DO YOU USE A PARTICULAR SOFTWARE PACKAGE?
Our centralized scheduling department utilizes the software, Meditech, to schedule surgery. Each physician office handles the scheduling of their patients’ surgeries and follow-up appointments. Each surgeon performs surgery at the beginning of the week and reserves Thursday and Friday for follow-up appointments in the office to keep the “office time” on track.

HOW IS INVENTORY MANAGED IN YOUR FACILITY? WHO HANDLES THE PURCHASING OF EQUIPMENT?

Each physician office coordinates the purchase of their supplies needed in the office. Otherwise, the hospital operating room director works with the surgeons to review new products and use of current instruments.

HAS YOUR FACILITY RECENTLY EXPANDED IN SIZE AND PATIENT VOLUME? WILL IT BE EXPANDING IN THE NEAR FUTURE?
We have added a medical management weight loss program, which is directed by a primary care physician and offers nonsurgical options of weight loss for those patients who do not qualify for or do not want surgery. We are also considering the addition of an adolescent bariatric program, which would provide not only weight loss surgery to adolescent patients who qualify but also provide a strong psychological focus to address the unique needs of these patients.

HOW HAS MANAGED CARE AFFECTED YOUR FACILITY AND THE CARE THAT IT PROVIDES TO PATIENTS?
Managed care has taken the predetermination process to a new level. Most patients are required to provide medically managed weight loss documentation for 6 to 18 months, which keeps a large number of our patients in the “holding” area of the approval process. We have four financial counselors who work with patients to gather the documentation needed, but insurance companies tend to change the requirements without warning, leading to the need for additional staff to work each and every account individually.

Our surgeons, anesthesiologists, and other members of our facility worked together to implement a reduced fee schedule to assist patients in paying for the surgery themselves.

What measures has your facility implemented in order to cut or contain costs and improve efficiency?
We continuously evaluate and compare different products. We also provide our staff and patients with proper lifting equipment and beds designed for bariatric patients. This decreases staff and patient injuries caused by improper lifting and transfers, which in turn decreases costs.
Furthermore, we are part of the larger corporation, HCA, and therefore we have access to the shared knowledge and resources of the corporation. This helps us become more efficient by streamlining clinical pathways, utilizing the patient registration system, accessing the internet, and utilizing paperless charts, which are all a part of the larger corporation.

DOES YOUR FACILITY HAVE AN OUTPATIENT PROGRAM?
We currently offer a weight loss program, which is directed by our registered dietitians. They usually see the patients through a 12-week program, but the length of the program is usually dictated by insurance criteria. This program evolved due to insurance requirements of a documented weight loss attempt. We require that the patients see their primary care physicians monthly and sign the necessary documents with our staff.

HOW DOES YOUR FACILITY DEAL WITH THE ISSUE OF PATIENT SAFETY AND STAFF SAFETY?
In the operating room, appropriate bariatric equipment and a minimum of four staff members are used when moving or transferring patients. The nursing unit is equipped with a patient lift that is used as needed. If a patient needs assistance with transferring, a minimum of two staff members are required to assist while using proper body mechanics. Patients are encouraged to utilize the trapeze as much as possible for bed mobility and to assist themselves with getting in and out of bed.

Another way to improve patient safety is through the use of eMAR bar code technology, which assists with proper medication administration. The system ensures accuracy of the five R’s of medication administration: The Right patient, the Right medication, the Right dose, the Right time, and the Right route of administration.

We also provide our staff with educational in-services throughout the year to address safety concerns.

HOW ARE EMPLOYEES ORIENTED AND TRAINED AT YOUR FACILITY?

New staff nurses are trained under an extended orientation process working with a preceptor. They begin by reading our bariatric handbook, which was developed by our nursing staff with input from the surgeons and covers the care of the postoperative bariatric patient. The standing orders are provided to review and study.

We have a list of required skills and competencies that must be performed by new staff members throughout their orientation phase and are monitored by the preceptor. All new staff members are required to attend an informative bariatric seminar, hosted by the surgeons and attended by prospective patients. New staff orientation can take anywhere from 6 to 12 weeks, depending on the previous experience of the nurse. The hospital financial staff have to attend a mandatory one-day orientation and also attend one of the bariatric seminars.

WHAT ARE YOUR STRATEGIES FOR RETAINING AND MOTIVATING STAFF? WHAT CONTINUING EDUCATION OPPORTUNITIES ARE PROVIDED TO STAFF MEMBERS?

Maintaining a positive attitude and promoting team spirit on the unit are key elements for retaining our staff.

Our staff is motivated by the positive results they see in their patients’ progress. It is gratifying to our nurses to watch a patient progress from the immediate postoperative phase to discharge. Many of our patients return to our floor for visits when they are at the facility for their postoperative follow-up visits with their surgeons. It is an inspiration to the nurses to hear and see the weight loss success of our patients after surgery.

The financial counselors also develop ongoing relationships with the patients. These counselor were the patients’ first cheerleaders, and it is rewarding for them to see the direct effects of their work.

The hospital also hosts an annual reunion for the patients. The nurses are invited to reunite with the patients for which they cared. It is a positive experience for both the patient and the nursing staff.

The surgeons offer educational in-services at least quarterly, which the nursing staff is required to attend. The nursing staff is also required to attend sensitivity training annually. Continuing education is offered on a continuous basis at the facility.

HOW IS STAFF COMPETENCY EVALUATED?
Our facility uses a program called HealthStream to track education credits. We also have skills labs to evaluate clinical skills competency, and yearly evaluations are conducted on the staff.

PLEASE DESCRIBE YOUR PATIENT EDUCATION PROGRAM.
Each patient is required, first, to attend our free three-hour, informational bariatric seminar offered approximately four times a month. There, the attendee receives a folder of information, including a nine-page registration form, a letter to his or her PCP outlining the recommendation letter needed for bariatric surgery, and information that outlines the pathway to surgery. At these educational seminars, one of our surgeons explains the weight loss surgery options (LapBand® and gastric bypass Roux-en-Y). The prospective patients then have the opportunity to ask the surgeons individual questions. During the second part of this seminar, one of our nurses and one of our financial counselors review pre- and postoperative issues, including the pathway to surgery and insurance information.

Once a patient is entered into the program, he or she will participate in a one-on-one consultation with his or her surgeon prior to surgery, as well as meet with a registered dietitian so he or she may learn about the postoperative diet in detail before surgery. Each patient is also provided with an “owner’s manual” following his or her first preoperative visit.

WHAT TYPE OF PATIENT SUPPORT PROGRAMS ARE OFFERED AT YOUR FACILITY?
Each month, our center nurses moderate a support group at our facility with guest speakers that cover topics of interest (e.g., plastic surgery, vitamin updates, surgeon’s advice, image consultants). Our nurses also work with postoperative patients to provide satellite support groups in surrounding counties closer to patients’ home. Twice a year, our center works with the leaders of these training sessions to ensure current information. The satellite sites are visited annually to continue the relationship with the center.

We also provide psychological support groups that meet approximately 11 times a month (10 small group sessions similar to a support group and one large session that is conducted “lecture style” to cover topics of interest). Our preoperative patients are asked to attend at least one support group meeting and one psychological support group meeting prior to surgery, and our postoperative patients are required to attend a support group meeting at least monthly to stay on track with their new lifestyles. At least once a year, our center offers a “Back on Track” session to motivate patients that have “derailed.”

WHAT LONG-TERM FOLLOW-UP MEASURES ARE PRACTICED AT YOUR FACILITY?
Postoperative patients are followed for life at no charge unless other complications arise. Our patients are patients for life—not only from the surgeons’ stand point, but in all aspects of our after-care program. We expect our patients to continually consult with the dietitians and exercise physiologists through the entire postoperative stages, as well as attend the support groups and psychological coaching programs we have in place. Our aftercare program is focused on the lifelong needs of the patient.

DOES YOUR FACILITY USE ANY ALTERNATIVE THERAPIES?
We have a very aggressive psychological program for our patients postoperatively. We feel like this is the most important therapy they can receive after surgery. We also are not afraid to offer patients appetite suppressants postoperatively if they are struggling with their weight loss. We understand this is a lifelong struggle, and surgery is not the only answer.

Patients seeking surgery do not always meet the NIH criteria for surgery, but still need to lose a significant amount of weight. We have implemented a full-service weight loss program that includes nonsurgical options for multiple groups of patients: Those not ready for surgery, those not meeting NIH criteria, or those patients that need to lose weight prior to surgery.

Through our “Back on Track” program for patients who have derailed, guest speakers and psychological coaching helps to encourage a desire to re-establish a follow up program.

Just as morbid obesity is a multifactorial disease, the treatment of morbid obesity is likewise dependent on multiple treatment strategies. Anyone who thinks that morbid obesity can be treated by surgery alone is mistaken. Our program is set up to address this multifaceted approach, combining both the surgical aspects of care along with the psychological, behavioral, and dietary treatments that often are considered “alternative” therapies.

WHAT QUALITY CONTROL ASSURANCE MEASURES ARE PRACTICED IN YOUR FACILITY?
Our facility uses EMAR, an electronic administration program, to administer medications. The nurse scans the barcode on the medication and on the patient’s armband prior to administration. This program provides a safer process for medication administration.

Also, our dietitians maintain quality statistics on all postoperative patients in order to monitor their adherence of taking supplements.

In addition, the surgeons and bariatric program require 100-percent review of all bariatric cases. The outcomes are reviewed by the bariatric team on a quarterly basis.

WHAT TRENDS DO YOU SEE EMERGING?
We see a trend toward less invasive approaches for treating morbid obesity, such as endoscopy, drug therapy, and gene therapy. Bariatric surgeons must be aware of these trends and be able to adapt to these changes in order to maintain their practices.

There is also a trend of insurance companies going back to offering coverage, but with very strict requirements (e.g., asking patients to document diet attempts for 6 or 12 months with a physician). Another trend is that many patients pay for surgery out of their own pockets rather than going through their insurance companies. Patients are also more educated than ever before not only on their insurance coverage but on working with the human resources departments at their places of employment to add weight loss surgery coverage or remove exclusions.

Another trend we see is treating patients who suffer from severe obesity at an earlier stage in their disease process. This includes the adolescent patient, the patient who meets the weight criteria but has not yet developed the health issues associated with morbid obesity, and even the patient who does not meet the NIH criteria for surgery. With newer, less morbid surgical procedures, a surgical solution to a weight problem can be offered to patients who traditionally would not have been considered surgical candidates.

Are there new technologies or equipment you would like to see utilized in your facility?

We are in the process of improving our pulse-oximetry monitoring by purchasing and installing a central monitor at the nursing station.

We are also looking into the role of endoscopy for the management of postoperative complications, like gastrogastric fistula, stomal dilatation, and contained leaks.

Its role as a primary intervention for morbid obesity is less appealing at this time.

We are also considering the possibility of offering gastric pacing. The concept of gastric pacing for weight management is a promising new development that might have great application for patients who do not qualify for other bariatric procedures but still need to lose a significant amount of weight.

WHAT TECHNOLOGIES OR EQUIPMENT DO YOU WORK WITH THAT HAVE HELPED YOUR PROGRAM?
Using a database (Exemplo Medical) designed to track our patients from beginning to end ensures efficiency and work flow.

What efforts do you make to maintain HIPAA compliance?
Any document that contains patient information is dropped into a locked shredding bin if it is not going to be part of the patient’s permanent medical record. We also adhere to our company-wide HIPAA policies.

What makes your facility unique?
There are a number of things that make our facility unique. Our program is known for the all-inclusive aftercare program that is free for the rest of a patient’s life. Not only do the surgeons see the patients free of charge for routine follow-up visits, our center houses the psychological aftercare program, “Coaching for Victory,” which patients have the opportunity to attend up to 11 times per month. Dietary and exercise counseling is available by phone or in person with our center team at the patient’s convenience.

Our nursing staff is well trained and competent to care for the post-surgical bariatric patient with equipment that is designed for the bariatric patient. The staff is caring and compassionate with a desire to help their patients succeed and meet their weight loss goals. The dietitian and clinical pharmacist also provide patient education for all of our patients.

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Category: Bariatric Center Spotlight, Past Articles

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