Memorial Hermann Memorial City Medical Center

| November 21, 2011

Houston, Texas

by Trudy L. Ivins, RN, CBN
Trudy Ivins, RN, CBN, is the Bariatric Program Director for Memorial Hermann Memorial City Medical Center located in Houston, Texas.

Bariatric Times. 2011;8(11):22–26

Welcome to Memorial Hermann Memorial City Medical Center
Memorial Hermann Memorial City (MHMC) Medical Center is one of 11 Memorial Hermann hospitals serving the greater Houston area, which has a vast network of affiliated physicians and numerous specialty programs and services. Based in Houston, Texas, Memorial Hermann is the largest nonprofit healthcare system in Texas. MHMC’s surgical weight loss program is one of four Memorial Hermann programs that currently meets the criteria for consolidation under the new systemwide brand NewStart®. NewStart is comprehensive, patient-centered program. The NewStart team is with the patient every step of the way, from assistance with insurance approvals to presurgical counseling, to post-surgical recovery and support. We know one surgery does not fit all. The NewStart team works together to provide the best weight loss solution for the patient. The program goal of NewStart is to help our patients achieve and maintain a healthy weight for the rest of their life.

To be included in NewStart, bariatric surgery programs must be accredited by the American Society for Metabolic and Bariatric Surgery (ASMBS) or the American College of Surgeons (ACS) and offer fully comprehensive programs that include informational seminars, psychological assessment and counseling, nutritional assessment and counseling, varied surgical options, and physical therapy and exercise programs, as well as support groups. MHMC is one of two programs among the existing four in the Memorial Hermann System that are established ASMBS Centers of Excellence (COE). ASMBS designation recognizes surgical programs with a demonstrated track record of favorable patient outcomes in bariatric surgery. While complications are possible in any surgery, the rate of complications from surgery performed at our center is low. MHMC offers all available bariatric procedures and is known for performing a high volume of successful bariatric revisions.

MHMC delivers exceptional care in the following eight service lines: bariatrics, general surgery, heart and vascular, neuroscience, oncology, orthopedics, pediatrics, and women’s services. Carving out bariatrics as a service line independent of general surgery has afforded us an opportunity to engage in highly detailed strategic planning for our surgical weight loss program.

Our staff
Our multidisciplinary bariatric surgery team includes the following:
Chief executive officer. Keith Alexander serves as our medical center’s chief executive officer. Mr. Alexander also oversees the bariatric service line at a system level. The Memorial Hermann Healthcare System has four acute care hospitals with active bariatric programs. The system’s bariatric surgeons, coordinators, and hospital leadership meet quarterly to discuss and implement policies and procedures for all four programs. Recently, they created a “leveling” document that designates the components each hospital must have in place to operate a bariatric program. All programs must be working toward obtaining the ASMBS COE designation.

Bariatric program director. Garth Davis, MD, provides guidance, leadership, oversight, and quality assurance for the practice of bariatric surgery at MHMC.

Bariatric program director/bariatric service-line leader. Trudy L. Ivins, RN, CBN, is responsible for all aspects of the program. She works closely with administration and develops strategic plans as they relate to the direction of the program. She is responsible for surgeon recruitment, marketing, quality monitoring, data reporting, patient satisfaction, cost containment, and maintaining all COE requirements, including staff education and support groups.

Bariatric dietitian. Melissa Jorge, LD, RD, is key to our patients’ long-term success in weight loss. In addition to managing evaluations, she makes herself available to our pre- and postoperative bariatric patients by participating in all support groups. She visits each postoperative patient during their hospital stay. She is also available for private consultation and participates actively in our online support group, answering nutritional questions that arise for patients after their return to their activities.

Bariatric psychologist. Monica Agosta, PsyD, has counseled bariatric patients pre- and postoperatively for the last eight years. She helps bariatric patients succeed in weight loss following surgery. A significant portion of her work is with the patients’ family members, helping them adjust emotionally to the changes that will occur in the family structure post surgery.

Director of the bariatric postoperative floor. Barbara Thomas, RN, oversees the postoperative care of our bariatric patients, ensuring quality care specific to the postoperative needs of each patient. She orients and educates all staff on our standard of care and patient sensitivity issues that are unique to the bariatric population.

Bariatric operating room coordinator. Anjie Bryant, RN, CBN, recently joined the ranks of our nurses certified in bariatrics. She plays a key role in the management of operating room flow. Scheduling more than 800 cases annually, MHMC requires a dedicated person to ensure a smooth process for patients and surgeons. The operating room coordinator is responsible for patient flow, patient safety, surgical instrumentation, operating room turnover, and surgeons’ preference cards and supplies, as well as rotating and monitoring all the bariatric procedures in the operating room daily.

Lead bariatric program assistant. Semecki (Sam) Cooke, AA, provides daily support for the bariatric surgery program. She assists with educational seminars, handles patient insurance questions and, most importantly, ensures that our patients’ experience during their hospital stay is personalized and exceptional.

Dedicated nursing staff. Several members of our nursing staff are certified in bariatrics. Debbie Cook RN, CBN, Suzanne Hovis RN, CBN  Laura Moreno RN, CBN, have recently received their certification in bariatric nursing.

Committed subspecialists. A multidisciplinary team of subspecialists is available to consult and provide support to affiliated surgeons as needed for specific patient medical issues.

Key surgeons. Several highly talented surgeons choose our facility for their bariatric patients based on the high level of care we provide. See sidebar “Meet the Key Surgeons” for names and biographies of the key surgeons at MHMC.

Our Facility
MHMC has a depth and breadth of clinical expertise that ensures our patients receive expert medical care in a safe, convenient setting. A one-of-a-kind medical center, MHMC combines a state-of-the-art hospital complex with an exclusive hotel and retail shops, all on a single, integrated campus. Patients have convenient access to nearly 1,000 physicians, more than 1,600 employees, and 300 volunteers, all of whom provide exceptional patient care and are committed to outstanding outcomes.

Our physicians and staff are patient centered. To us, that means respecting individual and family values, preferences, and needs; effective communication and patient education; and a focus on physical comfort, emotional support, and the involvement of family and friends in the healing process.

MHMC has 11 state-of-the-art inpatient operating suites, two cardiac catheterization labs, an endoscopy suite, pulmonary medicine, sleep center suites, diagnostic imaging laboratory, and other ancillary services.
All areas of our hospital are bariatric friendly and accessible. We have strategically placed bariatric furniture throughout all the waiting and testing areas. Our cafeteria is equipped with floor-mounted benches that have an unlimited weight limit. Our postoperative rooms have walk-in showers and bariatric seating. Bariatric shower chairs and bedside commodes are also available.

Patient Demographics
MHMC has seen significant bariatric surgery growth over the last two years. In fiscal year 2009, we performed 422 cases; that number jumped to 740 cases in fiscal year 2010—a 75-percent increase. By the close of 2011 fiscal year in June 2011, our case volume rose to 857.

The following is a breakdown of procedures performed in fiscal year 2011:

•    446 Roux-en-Y gastric bypass (RYGB) procedures
•    205 revisional surgeries
•    29 laparoscopic adjustable gastric banding (LAGB) procedures
•    168 sleeve gastrectomy (SG) procedures
•    Nine biliopancreatic diversion with duodenal switch (BPD/DS) operations.

Demographically, the MHMC bariatric patient population consists of the following:

•    Average body mass index (BMI): 43.8kg/m2
•    Average age: 44 years
•    Gender: 662 women, 195 men
•    Insurance—managed care: 83 percent; Medicare: seven percent; self pay: 10 percent.

An American Society of Metabolic and Bariatric Surgery Center of Excellence
MHMC has been designated an ASMBS COE facility since 2006. In February 2010, we successfully completed the renewal process for COE accreditation, which we found in some ways to be more thorough than the initial inspection. The inspection was a positive experience for our hospital and a confirmation that we are achieving our goal of maintaining a superior bariatric program. The site inspector commended us on our pathways and postoperative patient support and on our nursing staff’s knowledge.

Patient Adherence and Long-Term Follow Up
Prior to surgery, patients are required to attend an educational seminar hosted by the hospital and presented by our surgeons on a rotating basis. The seminar consists of a presentation given by the surgeon concerning all aspects of weight loss and all types of bariatric surgery. An open question-and-answer session follows the presentation. Patients are given educational materials to review at home. We assist patients with insurance verification at this time if they indicate that they would like to pursue the surgical option. For the convenience of our patients, our surgeons host a live webinar that can be accessed at home via the internet. All webinars are archived for later viewing. Each patient and family member or friend providing support also has the opportunity to view a bariatric seminar.

Patients who choose to move forward with surgery are evaluated by the surgeon to determine their candidacy. The evaluation, which includes a review of medical history and physical examination, takes place in the surgeon’s office. Patients then complete a nutritional and psychological consultation and evaluation. At this time, additional testing is ordered as needed and we work with the patient to ensure that all insurance requirements are met. We strongly encourage our patients to attend our support group and join our online support group prior to surgery.

Once cleared by the surgeon, a surgery date is set. One week prior to surgery, the patient undergoes preoperative testing at the hospital. The patient has the opportunity to meet with the anesthesiologist for evaluation and review any questions or concerns he or she may have.

On the day of surgery, the patient reports to the preoperative holding area and is prepped for surgery. The bariatric operating room team meets the patient and family prior to surgery to answer any questions the patient or family members may have. The anesthesiologist and surgeon meet with the patient to answer any questions and complete pre-surgical identification. Following surgery, the patient remains in recovery for one hour.

Once stable, the patient is transported to our designated bariatric floor, 5 East, for a zero- to two-night stay, depending on surgery type and recovery. All rooms at MHMC are private, and we encourage family members to stay with the patient to provide support. The surgeon and a weight loss surgery program representative see the patient daily and a dietitian meets with the patient before discharge.

Followup occurs at the surgeon’s office at Week 1, Months 1, 3, 6, and 9 and then annually.

Technologies, Equipment, Devices, and Products
MHMC opened in 1971. As our bariatric program developed into one of the largest programs in Texas, capital purchases have been made and new processes instituted throughout the hospital to improve safety and performance for our bariatric patients.

Medications. All medications are dispensed through the Pyxis MedStation™ system (CareFusion, San Diego, California), which enables real-time verification of patient allergies and medication interactions by scanning a barcode on the patient’s armband.

Operating rooms. State-of-the-art operating suites are equipped with Skytron Hercules 6700B operating room tables (Skytron, Grand Rapids, Michigan) that can safely support 1,200 pounds. Tables have infrared remote wireless control and 210-degree top rotation. The Image 1® high-definition video equipment and monitors (Karl Storz, Düsseldorf, Germany) provide previously unavailable detail and clarity.

Instrumentation/ endomechanicals. The Echelon Flex™ Endopath® endoscopic stapler (Ethicon Endo-surgery, Cincinnati, Ohio) enables uniform, consistent staple formation for hemostatis in a range of tissue thicknesses.

Radiology. Our technology includes a General Electric Lightspeed VCT 64 (Waukesha, Wisconsin) computed tomograpy (CT) scanner with a weight capacity of 500 pounds; a Philips Omni 100448 Easy (Andover, Massachusetts) with a weight capacity of 400 pounds; and Philips Bucky 460 height adjustable table with a weight capacity of 496 pounds.

Lift and transfer equipment. The HoverMatt® Air Transfer System (HoverTech International, Bethlehem, Pennsylvania) enables us to safely manage a patient transfer. Our Hill-Rom Liftem model Mark IV patient lift and transfer system (Batesville, Indiana) has a 700-pound capacity.

Clinical equipment. Equipment used includes a blood draw chair that has a 1,000-pound weight capacity; Stryker emergency stretchers with Zoom Motorized Drive System (Kalamazoo, Michigan) that have a 500-pound capacity; Stryker beds with 500-pound capacity; Hill-Rom Total Care beds with a 460-pound capacity; wheel chairs with 700-pound capacity; and walkers, shower chairs, and foot stools ranging from 500- to 700-pound capacity.

Scales. Within our facility we have several Detecto CN20/6855 scales (Webb City, Missouri) with a 600-pound weight capacity, two Health o meter ProPlus™ wheelchair ramp scales (Sunbeam Products, Inc., a susidary of Jarden Corp., Rye, New York) with a capacity of 800 pounds and one Health o meter ProPlus with 1,000-pound weight capacity.

Furniture. Bariatric seating options, including chairs and loveseats throughout the hospital, have 500-pound-plus weight capacity. For patient and family comfort we offer room service on demand, complimentary wireless internet, valet parking, and flat-screen cable television.

Procedure Scheduling and Inventory Management

The surgeons schedule all cases through our Surgery Scheduling department, which uses Surgical Care 4 software (Cerner, North Kansas City, Missouri). We utilize this product for scheduling preoperatively, intraoperatively and postoperatively. Our preference cards are maintained in Surgical Care 4, and they are surgeon/procedure specific.

Our inventory is managed by our Pyxis system and by manual par levels that are audited by usage and turnaround of product. The operating room has its own supply management team for surgery-specific products. The operating room director, central processing department (CPD) manager, operating room financial analyst, operating room materials management team, and operating room team leads control, management, and purchase of all supplies. Equipment requests are made by the department as needed. They go through a hospital capital review committee for prioritization and are purchased as funds become available.

Managed Care
The surgeon makes the ultimate decision of patient determination for surgery. We follow National Institutes of Health (NIH) guidelines as a first step in determining whether a patient qualifies for surgery.
Managed care has brought recent changes to how coverage applies to bariatric surgery patients. In our service area, we have seen an increase in coverage among our self-insured employers, a very positive sign that they are recognizing the long-term benefits of bariatric surgery. We are, however, also seeing an increase in “capped” plans. Capped plan policies typically cover a maximum of $10,000 in a lifetime, which does not even cover the cost of the initial surgery, much less care down the road. We are developing an educational plan to inform employers of how these limitations will eliminate the long-term benefits a company can gain by ensuring that their insurance plans support bariatric surgery with low out-of-pocket costs.

Cost and Efficiency
Our vendor-management program limits the number of vendors we use for big-ticket items, ensuring economy-of-scale contracts. A system-wide team reviews supply requests before new items are purchased. We do quarterly reviews of financials by physician. If we discover outliers, we meet one-on-one to review costs and look for opportunities to decrease them. We have staff teams that review processes to look at turnaround times and first case starts, as well as other performance improvement projects. We also use Lean Six Sigma to review processes and look for gains in efficiency.

Patient/Caregiver Safety and Education

All nursing staff, whether they are dedicated to the bariatric unit or not, receive a bariatric orientation after hiring and at the annual review held for all clinical staff. We educate our clinical staff about our commitment to helping those with the disease of obesity, the types of surgeries we offer, and how they are performed. Most importantly, we provide education on patient sensitivity issues. We want our staff to understand the emotions and thought processes that many patients with obesity have when they enter a hospital setting.

Emerging Trends
Advances in the treatment of obesity are emerging, including natural orifice transluminal surgery (NOTES) procedures. More patients are requesting incisionless procedures, such as the gastric balloon, endo barrier, and gastric imbrication. Although these procedures have not gained much ground in Texas over laparoscopic procedures, we continue to be interested and watch for more evidenced-based information to be reported. In preparation, we recently expanded the endoscopic role of our bariatric surgeons outside the operating room, allowing bariatric surgeons to use our gastrointestinal (GI) suites to evaluate their own patients as well as prepare the GI department to handle future endoscopic weight loss procedures. Our bariatric surgeons can now gain privileges in diagnostic and therapeutic endoscopy if a patient requires a stent or dilatation.

A Unique Facility
We have seen tremendous growth in our program in the last two years. All departments in our hospital felt the impact of this increase. The adjustment has been smooth as a result of detailed clinical pathways and standardization of the process flow of the patients. MHMC offers patients the “whole package,” which inclues the following offerings:
•    Affiliated physicians (some recognizable from “Big Medicine”) that are closely aligned with the hospital, perform a high volume of good quality procedures
•    Great quality outcomes
•    A facility that is fully equipped to handle the bariatric patient;
•    A staff that is sensitive to the needs of the bariatric patient
•    All surgical options including the most difficult revisions and reversals
•    A comprehensive continuum of care including nutritional and psychological support, insurance verification, and support groups
•    The desired certifications, such as ASMBS COE, Aetna Institutes of Quality® Bariatric Surgery Facility, Cigna Three Star Quality Bariatric Center, OptumHealth (United Healthcare) Bariatric COE
•    Memorial Hermann LifeFlight® access to our System’s Level I Trauma Center (though bariatric patients tend not to need it; any emergency situation can be taken care of here at Memorial Hermann Memorial City).

Additionally, we work closely with the other Memorial Hermann bariatric programs to “systemize” the service line so that we all learn and share among our counterparts.

References
1.    Davis G. The Expert’s Guide to Weight Loss Surgery. New York: Hudson Street Press.; 2009.

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Category: Bariatric Center Spotlight, Past Articles

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