Center for Surgical Weight Loss at Stamford Hospital

| December 27, 2013

Center for Surgical Weight Loss at Stamford Hospital
Stamford, Connecticut  

by Dory Roedel Ferraro, MS, APRN-CS, CBN

Bariatric Times. 2013;10(12):28–31.

Welcome to the Center for Surgical Weight Loss at Stamford Hospital
The Center for Surgical Weight Loss is a hospital-owned private practice located in the Physician Office Building adjacent to Stamford Hospital, a 305-bed, not-for-profit, teaching, acute care hospital located in lower Fairfield County, Connecticut. It is accredited by the Joint Commission and maintains an affiliation with NewYork-Presbyterian Hospital/Columbia University Medical Center. Stamford Hospital is a Planetree organization, where patient-centered care is provided utilizing a holistic approach, encouraging healing of mind, body, and spirit.

Our Staff
The staff of the Center for Surgical Weight Loss comprises of an interprofessional team that includes a bariatric surgeon, nurse practitioner, registered dietitian, and clinical health psychologist, along with our support staff that includes an office manager, a receptionist, a patient navigator, and a financial specialist. All professional staff members are on-site, which provides a truly comprehensive approach to patient management.
Surgeon. Dr. Daniel Davis is the Chief of Bariatric Surgery at Stamford Hospital and the Surgical Director of the Center for Surgical Weight Loss. Dr. Davis most recently served as the Director of Bariatric Surgery at Lawrence Hospital in Bronxville, New York, and Valley Hospital in Ridgewood, New Jersey. He maintains an appointment as Assistant Clinical Professor of Surgery at Columbia University. His practice is primarily dedicated to bariatric surgery. He also specializes in advanced laparoscopic surgery of the foregut. Dr. Davis performs Roux-en-Y gastric bypass (RYGB), sleeve gastrectomy (SG), adjustable gastric banding (AGB), and duodenal switch (DS) utilizing a laparoscopic approach. He also specializes in revisional procedures, such as band to bypass.

Dr. Davis has been involved in many clinical studies and has an interest in research. He currently serves as co-investigator in The National Institutes of Health (NIH) ongoing clinical study, Longitudinal Assessment of Bariatric Surgery (LABS). He was co-investigator in a United States Food and Drug Administration (FDA) randomized trial for endoluminal effectiveness in the treatment of morbid obesity and he is actively involved with ongoing studies in emerging technology.

Nurse practitioner. Dory Ferraro, DNP, APRN-CS, CBN, is the Clinical Director of Bariatric Services at Stamford Hospital and Nurse Practitioner (NP) at the Center for Surgical Weight Loss. Ferraro is responsible for both administrative and clinical duties in the practice. She was instrumental in the development of the bariatric surgery program at Stamford Hospital, including policy development, in-service training sessions for hospital staff, and selection of the interprofessional office staff. She oversees both inpatient and outpatient care and works closely with hospital staff to ensure that patients are receiving high-quality, patient-centered care. Ferraro brings a wealth of experience to the Center for Surgical Weight Loss, having specialized in the field of bariatric surgery for two decades. She was a Clinical Coordinator for the Lap-Band FDA clinical trial and is nationally recognized for her expertise in the field of bariatric surgery. She has been published in peer-reviewed journals and recently completed her doctoral studies at Columbia University.

Ferraro sees patients for their initial consultation, during which candidacy for surgery is established; a thorough medical, weight, and family history are taken; a physical examination is performed; and a comprehensive treatment plan is formulated. Preoperative diagnostics are based on individual patients, and in addition to baseline laboratory screening panels, might include polysomnography, preoperative cardiac risk assessment, and referrals to other specialties where indicated.

Registered dietitian. Jane Conway, RD, CDN, LCSW, is the registered dietitian (RD) for the Center for Surgical Weight Loss. She provides preoperative and postoperative nutrition assessment and counseling for this specialized patient population. She creates customized meal plans, assesses the ongoing nutritional status for each patient, and provides behavioral objectives to assist patients in their weight loss goals. Conway is also licensed as a clinical social worker and facilitates biweekly bariatric support groups. Concepts from Mindfulnesss Based Eating Awareness Training (MB-EAT) are included in the support group curriculum to provide a comprehensive food management approach.

Clinical health psychologist. Dr. Christine Megan is a licensed clinical health psychologist (CHP) who specializes in cognitive behavioral therapy (CBT) and behavioral medicine. Her areas of clinical expertise include the use of evidence-based approaches in the treatment of eating and weight disorders, mood and anxiety disorders, addictive behaviors, and other health-related issues. Dr. Megan is the newest member of the interprofessional team at the Center for Surgical Weight Loss. She performs preoperative psychological evaluations and provides postoperative monitoring with periodic assessments throughout the first postoperative year. She also provides psychotherapy, both pre- and postoperatively, for patients who are in need of treatment for psychiatric comorbidities.

Patient navigator/medical assistant. Karen Heck is the medical assistant and patient navigator for the Center for Surgical Weight Loss. She organizes patient flow, takes patients’ vital signs and weight, and aids the clinicians in the educational process regarding bariatric surgery. Heck assists patients in navigating the preoperative process by facilitating access to quality medical care by scheduling tests, obtaining documents, arranging consultations and appointments, and providing support and guidance wherever needed.

Our facility
Our office facility. Our office, which is adjacent to Stamford Hospital’s main campus, was recently remodeled and outfitted to accommodate the needs of our bariatric population. Our waiting, examination, and consultation rooms are beautifully decorated, spacious, and furnished with comfortable and appropriately sized chairs and equipment.

Our hospital facility. Stamford Hospital’s surgical floor was recently renovated and a block of rooms was constructed specifically to accommodate the needs of our bariatric patients. The rooms are all single occupancy with ample room for an overnight guest. As a Planetree organization, the hospital offers a myriad of programs to patients, including patient-directed visitation; complimentary and integrative therapies, such as massage, Reiki, and acupuncture; at-your-request room service, laptop, DVD, and book lending; and health information on the TV Care Channel.

Our operating room. Stamford Hospital has eight operating rooms, each of which can accommodate patients with morbid obesity. We have a dedicated operating room team that includes a scrub technician and circulating nurse. All of our anesthesiologists are trained and experienced in the management of the bariatric patient population. Specialized equipment available includes the following: a cart for difficult intubation, a videolaryngoscope (GlideScope®, Verathon Inc., Bothell, Washington, United States), Berchtold® table (Berchtold Corporation, Charleston, SC, United States [weight capacity 750Lbs.]), intraoperative endoscopy, powered endostaplers, robotics, high-definition cameras, and a full range of bariatric laparoscopic instruments. In preparation for the procedures, patients are carefully padded and secured on an operating table that is outfitted with a pressure-limiting mattress. A bariatric slider board or hover mat is used to transfer patients from the operating room table directly into their beds.

Achieving Accreditation Designation
Since the program’s inception in June 2010, achieving designation as a Center of Excellence in Bariatric Surgery has been a goal for Stamford Hospital and for the Center for Surgical Weight Loss. Early on, Stamford Hospital formed a committee comprising representatives from each department in the hospital to understand and prepare for the accreditation process. In June 2011, the Hospital was granted provisional status by the Surgical Review Corporation (SRC). All requirements have been satisfied with the exception of volume. We perform approximately 100 bariatric cases annually. Our patients are primarily caucasian (79%) and female (67%) with a mean body mass index (BMI) of 42.9kg/m2, mean weight of 270 pounds, and mean age of 45.7 years. We have experienced significant challenges in meeting the volume requirement of 125 cases in 12 months, due, in part, to the economic downturn. We are finding a higher percentage of patients with healthcare insurance who do not currently have coverage for bariatric surgery. We are now pursuing accreditation by the American Society for Metabolic and Bariatric Surgery (ASMBS) and American College of Surgeons (ACS) unified Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP).

Managed Care
Managed care has placed additional criteria on patients before they can be eligible for bariatric surgery—a requirement that is not backed by scientific evidence. Patients are often required to participate in medically supervised weight loss for a period of 3 to 6 months prior to being deemed eligible for bariatric surgery. We find that this creates barriers in access to care, and sometimes discourages patients from pursuing surgery.
We also find that many employers do not offer benefits for bariatric surgery to their employees, which can force individuals to pay for procedures out-of-pocket. For this reason, we hope to work with major corporations in our area to develop a program that will assist surgery candidates with the expense of the procedure.

Patient Care
All prospective new patients are required to either attend an information session or view an online seminar that can be accessed on our website before they are scheduled for their initial consultation. During this 90-minute presentation, our surgeon, nurse practitioner, and registered dietitian discuss surgical options, risks and benefits of surgery, need for lifelong lifestyle changes, and the surgical preparatory process. The team outlines realistic expectations for postoperative outcomes, including expected weight loss and improvement in comorbid conditions and quality of life. At the live seminar, patients are given an opportunity to ask the staff questions.
Once the patient has satisfied the seminar requirement, he or she is scheduled to meet with each member of the Center’s team. The NP then completes a comprehensive medical history and physical examination. The RD performs dietary assessment and counseling. Patients are evaluated by our clinical health psychologist. Preoperative diagnostic evaluation is individualized and tailored to patients’ individual health history, family history, and review of systems. During each of these meetings, patients are provided with the necessary knowledge and skills to assist them in modifying their dietary and activity behaviors. This information is reinforced and built upon at each subsequent visit.

Our practice prides itself on always strictly adhering to all HIPPA (The Health Insurance Portability and Accountability Act of 1996) compliance guidelines.

Patient Adherence and Long-term Follow up
We are always seeking to improve patient adherence and strive to provide resources that will inspire and support success. Our interprofessional team works directly with each patient to develop a personalized plan that includes behavior modification, dietary guidelines, food logs, mindfulness-based eating, and recommendations for exercise. All strategies are aimed at helping patients reach attainable goals that have been set and agreed upon. A predetermined schedule of follow-up visits helps to keep patients on track with their recovery. Each patient is asked to sign a follow-up care agreement, which details his or her postoperative plan of care and the rationale behind it. Should a patient miss an appointment, we are alerted through our electronic medical record and that patient is personally contacted.

Post-surgery exercise and activity plans are supported by a complimentary 90-day membership to Stamford Hospital’s Health and Fitness Institute (HFI), an innovative wellness facility offering medically supervised fitness and lifestyle change programs. An on-staff exercise physiologist specializes in working with our bariatric patients. Personal training and group fitness programs available at HFI include aquatic exercise classes, yoga, Pilates, cycling, stretching, and meditation.

Access to regular support groups also helps us to connect with our patients and allows us to provide counsel in a comfortable and private environment. We make bi-weekly personal phone calls to each patient to invite him or her to attend support groups. We also strive to take a creative approach to motivating our patients, and host fun events, such as cooking and dance classes.

We find that patients typically lose 50 percent or more of their excess weight during the first year following surgery. In addition to tracking weight loss, we monitor their physical and psychological well-being. As often is the case, many patients experience improvement or complete resolution of their comorbid conditions, and medications they required before surgery can be titrated down or discontinued. We work closely with the patient’s primary care provider to ensure continuity of patient care.

Our patients are scheduled for two-, four-, eight-, and 12-week follow-up appointments prior to undergoing surgery. Follow-up at our center has been excellent; we have one-year follow-up data on 90 percent of our patients. We find that our most significant challenge to providing follow-up monitoring and support is missed appointments. We attempt to minimize this by confirming all scheduled appointments 24 to 48 hours prior to the patient’s scheduled visit, contacting patients who do not keep their appointments to reschedule them for a different time or day, and sending certified letters to patients when all else fails. Our office staff is well aware of the potential consequences of losing patients to follow-up and is actively involved in keeping patients engaged in the postoperative process.

It has been well-documented in the literature that lack of adherence to dietary and supplement guidelines is not without consequence. Patients are informed prior to surgery that their success following surgery is dependent on their willingness and ability to make lifelong lifestyle changes, which includes adherence to postoperative guidelines. Vomiting, discomfort, and inadequate weight loss are all potential risks patients take by straying from recommended eating guidelines. We make every effort to educate patients on the consequences and take every opportunity to reinforce this information. Knowledge is powerful.

Our Equipment and New Technologies
Our center currently uses all of the latest technology available to bariatric surgery patients. In addition to housing a comprehensive program led by an expert team of weight management specialists, we are equipped to perform all of our procedures (RYGB, AGB, SG, and DS) laparoscopically or robotically.

Recently, the use of web conferencing was introduced to connect the dietitian with individual patients to deliver medical nutrition therapy (MNT). We decided to incorporate telenutrition into our practice in an effort to improve patient access to MNT, augment clinician-patient interaction between office visits, increase patient satisfaction, and improve patient adherence to prescribed treatment plans, thereby optimizing both short- and long-term outcomes following bariatric surgery.

Dr. Davis has the ability to utilize the minimally invasive da Vinci robot (Intuitive Surgical, Sunnyvale, California, United States) to assist with laparoscopic surgery. This allows him to operate through a few small incisions with greater vision, precision, dexterity and control than traditional laparoscopy. We have found that this method also provides many benefits to patients, including fewer complications, less trauma to the body, optimal surgical precision, lower rates of infection, and a shorter length of stay. The da Vinci robot also gives patients with a higher BMI an option for minimally invasive surgery when they may not have otherwise been a good candidate.

Universal Medical Inc. (Norwood, Massachusetts, United States) manufactures an excellent product called the Slide Board Patient Transfer Sheet that our staff uses regularly. The smooth board is placed under a patient to slide him or her on and off the operating room table in the sitting or supine position. This board helps keep our patients safe during necessary transfers and allows our staff to complete the task without risk of bodily injury.
We utilize eClinicalWorks (eCW [Westborough, Massachusetts, United States]) for our electronic medical record (EMR). eCW interfaces with the hospital’s laboratory and radiology departments. Test requests and results are transmitted electronically between eCW and these two departments allowing timely and accurate reporting and follow-up of test results. Our EMR provides us with the tools necessary to handle scheduling, track follow-up appointments, maintain accurate patient records, run reports, and complete billing procedures. The technology has improved and streamlined our workflow. Not only are many features of the system customizable, but eCW makes it simple to send and receive information. Whether that information is a message to a colleague down the hall or a specialist across town, the program simplifies communication channels. This software encompasses the functionality and support our practice requires to provide the most comprehensive medical care.

Cost and Efficiency
The Center for Surgical Weight Loss and Stamford Hospital have worked diligently and relentlessly to improve the quality of patient care delivered through the implementation of evidence-based clinical pathways, quality improvement programs, and patient-centered care initiatives. This has resulted in a decrease in length of stay, fewer hospital readmissions, and an increase in patient satisfaction.

Scheduling and Inventory
All of scheduling is handled by Donna Navarro, Financial Specialist/Scheduler. Navarro works to coordinate surgical procedures and all related activities directly with the patients and the operating room.
Our inventory is closely monitored. Danielle Pimpinella, our office manager, and Karen Heck, our patient navigator/medical assistant, handles the ordering of any and all supplies needed to keep our facility fully stocked. They ensure our consultation and exam rooms are always prepared.

Patient Assessment
All of our patients must meet the NIH criteria for bariatric surgery in order to be considered for the procedure. Patients must have a body mass index (BMI) of 40kg/m2 or above, or have a BMI of 35kg/m2 or above with a life-threatening comorbid condition, such as diabetes, hypertension, or sleep apnea; have a history of obesity; have demonstrated previous efforts at weight loss in the past; and be willing and able to make the required lifelong behavioral changes recommended by our team.

The first step in the process is verifying the patient’s insurance benefits. It is important for the patient’s peace of mind and for the effective utilization of resources in the office to contact the patient’s insurer to determine coverage benefits and any specific qualifiers or determining factors. Our office’s financial specialist contacts the insurance company to verify benefits and then communicates any special requirements to both the patient and office clinicians.

The next step is assessing the patient’s medical and psychological health to identify any factors that may be a contraindication to bariatric surgery. Once the individual has consulted our surgeon, NP, RD, and CHP, their case is presented at a team conference.

Our team holds bi-weekly conferences to discuss individual cases for surgery. We also work closely with each patient’s primary care provider (PCP) to ensure the patient is medically optimized prior to surgery. We require a letter of medical necessity from the PCP prior to evaluating a patient for surgery. Once it has been determined that a patient is an acceptable candidate, we work with his or her PCP to optimize the patient medically prior to his or her surgical procedure.

Patient and Staff Safety
At the program’s inception, a needs assessment was conducted by a committee comprising the executive staff, bariatric team, and department heads within the hospital. The unit located at Main 2 North, was designated as the bariatric surgical step-down unit, and the unit was renovated and outfitted to accommodate bariatric patients. Any departments where a bariatric patient might be cared for were equipped accordingly. These areas included patient registration, radiology, emergency department, laboratory, endoscopy services, nuclear medicine, pulmonology, cardiology, day surgery, post-anesthesia care unit, and the operating room. Medical equipment, including the computed tomography (CT) scanner, magnetic resonance imaging (MRI), fluoroscopy, and other radiology equipment; operating room tables, stretchers, beds, commodes, and wheelchairs that can accommodate a weight limit well beyond 400 pounds are available throughout the hospital. A team of dedicated and specially trained nurses and physicians care for patients, and are able to meet their needs. Our emergency and operating rooms, as well as the entire surgical floor, have specialty boards that allow for easy and safe transfer of a patient to and from a bed.

Hospital rooms are outfitted with products and equipment to assist patients during their recovery. Toilets feature extra support with a discreet mount allowing weight to be distributed evenly. A safety bar located in the bathroom offers assistance and balance support. Beds are reinforced and can hold up to 500 pounds. Patients are also provided with mobility aids to assist them in moving around. Each room has also been redesigned to provide a comfortable and private space for the patient to recover, as well as accommodate an overnight visitor.

Staff Training
All Stamford Hospital employees are required to attend a sensitivity training session and repeat this training every two years. Nursing Grand Rounds and General Surgery nursing competencies each have bariatric training components. Our Hospital’s three-day New Employee Orientation program also includes training procedures specific to bariatric patients, and covers topics such as HIPPA regulations, infection control, pastoral care, and accountability, as well as the hospital’s values and mission and the Planetree philosophy.

As a hospital-owned practice, the Center for Surgical Wight Loss requires staff members who care for patients to complete additional types of training that will not only keep them safe, but also ensure the safety of our patients. Each staff member is taught how to lift and transfer bariatric patients and how to recognize complications and signs of potential complications, (i.e., a fever, pain, vomiting, or tachycardia).

The Center’s staff has extensive experience in the field of bariatrics. The professional staff has advanced education, specialized training, certifications, and expertise.

Emerging Trends
We find that many patients opt to have laparoscopic sleeve gastrectomy (LSG) procedures when considering their options for weight loss surgery. In our experience, LSG procedures seem to have a better safety profile, and, at the same time, offer many of the same benefits of RYGB.

We are always open to researching and reviewing new technologies, medications, therapies, and procedures that will further improve the treatment methods for obesity. Currently, we are involved with ongoing research into new techniques, including “incision-less” surgery and endoluminal therapies for obesity.

Patient Cases
Case 1. A 46-year-old female patient presented to our facility for LAGB with a 20-year history of bipolar II disorder with psychotic features and panic disorder. The patient had a long-term history of adherence with her psychiatric treatment team and medication regime. She was adherent to the pre-operative dietary regime and smoking cessation requirements. After her surgery, the patient began to complain of nausea and regurgitation after meals. Within several weeks of surgery she reported poor dietary adherence: eating fried and breaded foods, eating large portions, indulging in high-carbohydrate snacks, and rapid eating. She also increased coffee consumption to eight cups per day and decreased water consumption. She reported engaging in over-eating when she was feeling stressed, sad, or overwhelmed.

In order to take steps to toward a healthier eating regimen, the patient entered into weekly CBT sessions with the staff psychologist. Her treatment focused on engaging in mindful eating practices, utilizing alternative coping mechanisms when dealing with current life issues, and supportive therapy regarding current marital and family conflicts. Within a few months of treatment, the patient did not experience regurgitation or nausea, was adherent with her dietary regimen, and was engaging in mindful eating skills. She remained in treatment for a period of seven months and developed improved coping skills when dealing with life stressors. She also decreased her coffee consumption to two cups per day.

The patient has lost a total of 22 pounds post-surgery and continues follow-up with both her psychiatric treatment team and her bariatric treatment team at the Center for Surgical Weight Loss.

Case 2. Our most challenging case was a 37-year-old female patient who was referred to us for surgical intervention as a last effort to save her life. She presented with a very complicated medical history that included a longstanding history of severe migraine headaches, adrenal insufficiency, and type 2 diabetes mellitus (T2DM) as a result of chronic steroid use, cardiomegaly, depression, pulmonary hypertension, and obstructive sleep apnea (OSA). She was a longstanding cigarette smoker and had never followed through with treatment for her OSA. Our interprofessional team worked with a team of specialists in sleep medicine, cardiology, pulmonology, and endocrinology to optimize her health prior to surgery. We were successful in assisting her to quit smoking and to begin treatment for her OSA with continuous positive airway pressure (CPAP). After one year of preparation and optimization, she underwent LSG. Her procedure was without complications and she was extubated in the operating room immediately following surgery. Because of the complexity of her case, she was monitored in the critical care unit postoperatively. Her hospital course was uncomplicated and she was discharged to home. She did well postoperatively, and has been following up regularly with the bariatric team. Her exercise tolerance has improved; she no longer requires supplemental oxygen and her quality of life continues to improve as her weight decreases.

A Unique Facility
The Center for Surgical Weight Loss at Stamford Hospital offers a comprehensive program of care for every patient, providing support before, during, and long after a life-enhancing bariatric procedure. We coordinate an extraordinary breadth of expertise across many medical and support disciplines and pride ourselves on our “concierge” approach to care, which provides patients with access to the full range of holistic services they need. We support our patients across the continuum of care and understand that bariatric surgery is not the only cure for obesity. Along with medical nutrition therapy and psychological support, we offer patients adjuvant therapy with very low-calorie liquid diets and pharmacotherapy where appropriate.

Having our interprofessional and support staff in one location is very beneficial to our patients. At any time, our patients have unlimited access to our team of experts.

Our patient-centered approach to care, coupled with our onsite team of experts, supported by our robust array of treatment modalities, has allowed the Center for Surgical Weight Loss at Stamford Hospital to emerge as a “best practice” in the field of bariatric surgery.

Funding: No funding was provided.

Disclosure: The author reports no conflicts of interest relevant to the content of this article.

Author affiliations: Dory Roedel Ferraro, MS, APRN-CS, CBN is the Clinical Director of Bariatric Services at the Center for Surgical Weight Loss at Stamford Hospital

Category: Bariatric Center Spotlight, Past Articles

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