by Kerrie Warne, Director, NewStart, St. Alexius Hospital
Acknowledgment: The author would like to thank Ms. Stephanie Stemmler, media liason for St. Alexius Hospital, for her assistance with the preparation of this article.
Welcome to the Newstart Surgical Weight Management Program at St. Alexius Hospital
St. Alexius Hospital, founded in 1869, is located in south St. Louis, Missouri. It offers an array of hospital-based services, including emergency care 24 hours a day, seven days a week, intensive care, cardiology and therapy programs, laboratory and pharmacy services, and comprehensive psychiatric services. St. Alexius is accredited by The Joint Commission of Healthcare Organizations (TJC) and is named a Bariatric Surgery Center of Excellence (COE) by the American Society for Metabolic and Bariatric Surgery (ASMBS). In addition, the hospital operates the Lutheran School of Nursing, a 28-month hospital-based diploma nursing program that includes both a registered nursing track and a licensed registered nurse (LPN)-to-registered nurse (RN) bridge track.
St. Alexius’ NewStart Surgical Weight Management program is one of the largest bariatric surgery programs in the Midwest, performing nearly 600 bariatric surgeries annually. Established in 1996, the NewStart program has been a certified COE since 2006. The hospital has been performing bariatric surgery for more than 20 years.
Three board-certified physicians oversee all care, and all hospital staff are regularly trained to care for and understand the concerns of bariatric surgery patients. The St. Alexius NewStart Surgical Weight Management Program has a dedicated staff comprising the following:
1. Four board-certified physicians specializing in bariatric surgery. Dr. Richard Follwell, Dr. Kumaran Chinnappan, Dr. Van Wagner, and Dr. Gregg Ginsburg
2. One full-time program director. Oversees entire program as well as marketing
3. One full-time RN program coordinator. Oversees clinical pathways, chart reviews, COE accreditation and compliance; also serves as program liaison to other hospital departments involved in bariatric program services (e.g. radiology)
4. One full-time assistant director. Maintains all data needed for COE accreditation and compliance
5. Four full-time patient advocates. Assigns prospective patients and assists them beginning with initial inquiry into the program through the insurance-approval process
6. One full-time scheduler. Handles all procedures related to actual scheduling of surgery cases
7. One full-time insurance verifier. Evaluates and processes information needed for insurance verification and approval
8. One full-time medical office coordinator. Runs the bariatric clinic
9. One full-time and one PRN nurse. Ensures overall quality of care for both preoperative and postoperative patients
10. Two full-time dietitians. Responsible for preoperative nutrition and lifestyle counseling; individual patient consultations; group nutrition classes; and development of supervised, customized diets; dietiticians are also responsible for five-year follow-up postsurgery as well as lifetime nutrition counseling services.
In addition, professional, licensed psychologists lead some of the support groups as do our dietitians.
Inpatient care is provided in a dedicated bariatric surgery unit that is equipped with specialized furniture and patient safety lifts. As a certified Bariatric Surgery COE, the NewStart program at St. Alexius has a comprehensive array of facilities and equipment that meet guidelines for bariatric care. These include specialized furniture in clinic areas, the dedicated bariatric surgery hospital unit, all waiting rooms, the intensive care unit (ICU), and radiology. Patient safety lifts are in the emergency room, operating room, all patient rooms, and in radiology. Operating rooms are also equipped with surgical tables that meet bariatric weight specifications. The entire hospital, whether a bariatric patient needs to go for care, counseling or follow up, or for preoperative and postoperative visits, is equipped with bariatric-specific furniture and equipment, including wheelchairs.
Patients come from throughout the region as well as from other states. Patients range from 18 to 72 years of age and are cleared preoperatively to ensure they can undergo the rigors of weight loss surgery and understand the lifestyle changes necessary for successful weight loss management. Eighty-eight percent of the program participants are women. In identifying motivating factors, NewStart staff note that men are primarily motivated by serious health considerations when considering weight loss surgery, while women are motivated by both health concerns and appearance.
In offering information about the success of our program, patients are always interested in overall patient outcomes. The NewStart program consistently beats the national averages in terms of overall mortality and complication rates. For example, our 2010 statistics show the following:
• Zero percent mortality rate for all of 2010
• 0.6 percent reoperation rate at the 30-day post-surgery mark
• 2.9 percent readmission rate at the 30-day post-surgery mark
• 2.0 percent complication rate at the 30-day post-surgery mark.
An American Society of Metabolic and Bariatric Surgery Center of Excellence
The NewStart program was one of the first in the region to be certified as a Bariatric Surgery COE when it was first certified in 2006. We earned our recertification in 2010. Because the program is more than 20 years old and has long demonstrated successful and long-term patient outcomes, patients usually come to us after hearing about the program through word of mouth or from former patients. The majority of our surgical team and operating room nursing staff have been together for more than a decade. Hospital-wide training programs on caring for and understanding bariatric surgery patients create an organization-wide culture of compassion and expertise in the care of patients with obesity that is recognized and appreciated throughout the community. Certification is usually the “icing on the cake” that specifically points to the quality and safety of our overall program and shows patients that we have been independently evaluated for excellence. Our reputation is typically the first thing that patients discuss with us; certification is second because more and more patients realize that many insurance companies will not reimburse them for bariatric surgery unless the procedure is performed at a designated COE. Patients also equate safety and quality with a certified program.
The process to obtain certification was, indeed, challenging. The documentation needed was rigorous. Because we obtained our certification years ago, we had to work closely with the evaluation team to determine both the data needed and the format required. In some cases, the requested format was different from our processes, so we had to work through that. Now that specific parameters have been established, it is easier to track quality initiatives, processes, and outcomes. The recertification process was easier than the initial certification because we were more familiar with the ASBMS requirements.
The internal advantage of going through the certification and recertification process is that it keeps our team focused on continuous quality improvement and data analysis. There is always room for improvement, and we regularly monitor results and seek feedback from patients and staff to determine innovative steps that would make our program even better.
Patient Adherence and Long-term Follow up
Long-term follow up and support is critical to successful bariatric surgery outcomes. Because everyone recognizes the pivotal role of follow up, the entire team is dedicated to monitoring patients and encouraging success. The St. Alexius NewStart team follows all bariatric surgery patients for a minimum of five years after surgery. The key to follow up is watching for signals that might indicate poor patient adherence to necessary lifestyle changes, including failure to show up for follow-up medical appointments, not communicating regularly, or not being forthcoming about current weight. If patients do not show up for a medical, clinical, nutrition, or counseling appointment, our program sends out letters and makes phone calls to patients asking about their overall well being and reminding them of free dietary services and lifetime counseling services available. The team also offers patient support groups, no matter how many years postsurgery they are. By doing this, we provide a continuous link to medical and nutrition counseling professionals that can be a patient’s champions and guides for continued weight-loss management.
We find that a patient’s lack of commitment or a misunderstanding of the lifestyle changes necessary following bariatric surgery impacts the long-term outcome for successfully maintaining significant weight loss. Because the NewStart staff serve as true partners in a patient’s weight loss journey, there are set processes in place to encourage patients to maintain connections to our program through phone calls, letters, the alumni support group, and dietary counseling services.
As one of the Midwest’s largest bariatric surgery centers, St. Alexius NewStart believes that all patients should be treated with professionalism and compassion. To fully understand the needs of bariatric surgery patients and their challenges, St. Alexius holds four bariatric-focused employee education programs annually. One focuses solely on sensitivity while the other three programs tackle patient safety, surgical needs, and pre- and post-surgical care. We understand that by the time a patient typically makes the call to inquire about bariatric surgery, it is likely that he or she has already tried to diet and failed for a significant period of time. Surgery is typically considered as a last resort to failed dieting and failing health.
When a patient first enters the NewStart program, he or she is assigned a patient advocate. This person is his or her go-to person for the entire time the patient is moved through screening and evaluation. A patient advocate can be a cheerleader, a secretary, and/or an insurance compliance officer—all roles that are vital to helping a patient go through the pre-surgical process. Once the patient undergoes surgery, he or she has an experienced bariatric surgical team and specialty trained nursing staff. To ensure The Health Insurance Portability and Accountability Act (HIPAA) privacy is upheld, we offer private patient consult rooms.
Technologies, Equipment, Devices, and Products
Dr. Van Wagner, Medical Director of The St. Alexius NewStart program, has trademarked an outpatient, single-site laparoscopic procedure called peri-umbilical laparoscopic surgery (PULS). This procedure requires only a single incision through the belly button instead of the 4 to 6 incisions typically needed for laparoscopic surgeries. By going in through the belly button, the scar shrinks over time until it is barely noticeable. Dr. Wagner notes that there is less post-surgical pain and a better recovery with this minimally invasive procedure. Because Dr. Wagner’s surgical skill is renowned and he is able to perform the PULS gastric banding procedure in as little as an hour, he has been retained by Ethicon Endo Surgery to train other surgeons to perform the procedure.
Dr. Kumaran Chinnapan, a bariatric surgeon at St. Alexius, is trained on and has used the Applied Gel Port™, a United States Food and Drug Administration (FDA)-approved device that offers surgeons easier access during laparoscopic procedures. For bariatric surgery, the device allows Dr. Chinnapan to make a single incision in the abdominal wall and use the port to safely insert 3 to 4 instruments. He believes the Gel Port allows for more control of the surgical area and more flexibility for movement of instruments in the abdominal area, while still enabling patients to recover rapidly from laparoscopic procedures.
Since arriving at St. Alexius in summer 2010, Dr. Chinnappan has advocated for the use of the Applied Gel Port for select bariatric patients. He said he believes it gives him better access and more maneuverability within the abdominal cavity. The port is ideal, especially when dealing with patients with extreme morbid obesity. The heavier a patient, the bigger the liver, and the more visceral fat around the stomach and the intestines, all of which give the surgeon less room to operate. Dr. Chinnappan states that the port enables him to have only a single, smaller incision but still have the ability to insert 3 to 4 instruments to perform weight loss procedures.
Dr. Ginsburg, a new addition to The St. Alexius New Start staff currently the only performs LapBand surgery. He will perform his first case at St. Alexius on May 12, 2011. We are very excited to have him on the team.
St. Alexius was the first hospital in the St. Louis region to use the Reletex® neuromodulation device as a treatment for post-operative nausea. Reletex, made by Neurowave Medical Technologies, is worn on the wrist and generates electrical impulses that stimulate the neurons on the median nerve. In the 6 to 8 months that St. Alexius has added Reletex to its post-operative care practices, nurses have noticed anecdotally that it has reduced the amount of intravenous (IV) medications necessary to treat nausea and vomiting in patients recovering from bariatric surgery. It has also received very positive feedback from patients.
Procedure Scheduling and Inventory Management
NewStart currently is working with BariAnalytics to build a custom database that will handle scheduling, billing, and patient tracking. That software system will be on line by mid-2011. The hospital has a specific purchasing department that works directly with the physicians and the operating room team to track inventory and order supplies.
The patient advocates compile information related to medical history and primary care physician and/or specialist referral/contact information. They arrange for psychiatric evaluation (to make sure patients understand fully the elective procedure they are seeking and the lifestyle changes needed as a result). A nutritional evaluation and routine pre-operative tests (blood and lab work) are also conducted. Chest x-rays are scheduled and, in some cases, an upper gastrointestinal (GI) imaging test is ordered. General guidelines for acceptance into the program include the following:
• Patients with a body mass index (BMI) of 40kg/m2 or more
• Patients with a BMI of 35kg/m2 or more if they have comorbidities (e.g. diabetes, high blood pressure, sleep apnea, or musculoskeletal issues)
• Patients determined to be 100 pounds over their ideal body weight.
It is important to note that the FDA recently lowered BMI levels for LapBand (Allergan, Irvine, California) surgeries to 35kg/m2 or more, and to 30kg/m2 or more for patients with comorbidities, which allows even more patients with obesity to undergo bariatric surgery.
Many insurance companies are now requiring six-month medically supervised diets prior to bariatric surgery. This step could be a huge hurdle for patients with morbid obesity. For example, not every primary care physician will record detailed notes about a six-month diet and education program, and a patient coming to St. Alexius may be frustrated if that requirement has not been met. We estimate that up to 30 percent of our patients are required to have had a supervised diet. We do talk with every patient, however, and in some cases, there are instances where documentation for a medically supervised diet is not needed, including The St. Alexius Newstart. We have to continually be on top of any changes in regulations governing bariatric surgery.
Cost and Efficiency
Quality improvements are ongoing within our program. We look at our patient outcomes, our overall costs, and how we deliver care to our patients. St. Alexius NewStart has a Bariatric Committee meeting every month where all hospital departments come together to discuss processes and any concerns. For example, we noticed that on Tuesdays, we had a backup of patients waiting for preoperative testing in radiology and in the labs. We determined that the same-day surgery department also had a significant number of patients on Tuesday. So, we moved preoperative testing to Fridays, and it now flows more smoothly. Physicians also attend these meetings each month, so we hear of any concerns they have and address them immediately.
Staff and Patient Safety
Throughout the hospital, there are strict clinical pathways that we follow to ensure patient safety as well as staff safety. All new employees are required to go through employee education programs, which have a defined section directly related to care and understanding of bariatric patients. The facility is also equipped with patient safety lifts that not only keep the patients safe while being transported, but also minimize any injuries that might occur to staff members. Clinical pathways address everything from proper procedures related to lab testing and pre-operative visits to inpatient care and post-surgery follow up.
All employees undergo annual training sessions related to the care and understanding of bariatric patients. Specific information related to NewStart patients is provided in every new employee orientation, and nurses go through periodic competency check lists to ensure they are fully trained to handle the special needs of bariatric patients.
NewStart offers three types of bariatric procedures, all of which are laparoscopic. They include Roux-en-Y gastric bypass (RYGB), sleeve gastrectomy, and laparoscopic adjustable gastric banding (LAGB). While gastric bypass typically shows the best results with rapid weight loss and a long track record of safety and effectiveness, it is a permanent procedure that requires both surgical cutting and reattachment, and, therefore, has the higher risk of complications. The sleeve gastrectomy procedure has become more popular since more insurance companies are approving coverage. Sleeve gastrectomy is also considered a permanent procedure, with surgical removal of a portion of the patient’s stomach. Because there is no reattachment, which increases the potential for leaks, there is less risk of complications with sleeve gastrectomy compared to gastric bypass.
LAGB procedures also are popular, primarily because of the ability to either adjust or remove the band. However, band procedures typically have slower weight loss and require regular and frequent follow up to ensure that the band does not slip or erode into the stomach. Frequent monitoring is also necessary to check for post-surgery site infections or strictures. In 2010, because of our expertise in offering outpatient, single-site gastric banding, and an increase in awareness of adjustable banding, we saw a marked increase in patients undergoing band procedures.
We have seen an increase in the number of patients who request and continue with long-term nutritional counseling. In our practice and in others across the country, we have found that patients who follow up long term (i.e., >5 years) have a much better success rate with weight loss surgery. Follow up includes maintaining regular physician appointments, attendance at lifestyle and nutrition classes, and ongoing postoperative education.
One of the exciting trends is the change in criteria for eligible bariatric surgery patients. Early in 2010, the BMI threshold was lowered to 30kg/m2 or more for LapBand surgery, which enables those who are under 100 pounds overweight to consider weight loss surgery. We anticipate that this change will have a positive impact our program over time. In particular, Dr. Chinnappan believes that patients who travel to other countries, such as Mexico, for weight loss procedures because they did not meet the old criteria, will now elect to undergo those procedures in the United States, where it will be safer and easier for long-term follow up. He believes that while many insurance companies have not revised their reimbursement criteria to cover the reduced BMI criteria-eligible patients, it is only a matter of time before they do.
We had a patient who was referred to us after a previous gastric bypass. She had developed scar tissue and stricture. Because her stomach was partially obstructed, she could not eat and kept vomiting. Strictures are usually dealt with through endoscopy and balloon dilation, but her condition did not get better. We inserted an endoscopic stent, but she had little to no relief even after that procedure. We decided that she required additional surgery, and we found an extensive amount of scar tissue in her stomach. It was a technically demanding procedure to excise the scar tissue and revise her surgery. Today, she is doing great and continues to lose weight.
According to Dr. Richard Follwell, some of the more recent difficult cases occur when patients cannot break the dangerous habit of smoking before and after surgery. Smoking minimizes blood flow to the heart in the bypass patient, which can cause vasoconstriction, severely limiting blood supply to the new stomach. Smokers have a 40-fold increase of developing an ulcer or vascular problems. In Dr. Follwell’s practice, he has actually cancelled surgeries on the day of surgery because nicotine tests showed that the patients were smoking despite his requirement that they quit. In one particular case, a patient had stopped smoking prior to gastric bypass, but then began smoking again shortly after. The patient developed an ulcer and a perforation, and ended up on a feeding tube for a short period of time. Dr. Follwell’s office scheduled additional surgeries to repair the damage. Unfortunately, the patient began smoking again and had to have a second operation. This clearly shows the struggle of a nicotine addiction patients may experience, as wel as its negative effects on surgery and outcomes. Today, that patient has quit smoking and maintained the weight loss. Dr. Follwell states that he does not believe all patients really understand the seriousness of the surgery and following all orders until the risk of death becomes apparent. He recalled his exact words to one patient in recovery: “If you do not stop smoking, you are going to die.”
A Unique Facility
There are a number of things that we point out to patients that set our program apart from others. First and foremost is our expertise. We have one of the largest bariatric programs in the Midwest and we have excellent patient outcomes. Our long-time staff members are skilled in caring for and understanding bariatric patients, and we have surgeons who are recognized leaders in bariatric surgery. Second, we truly believe in forming a partnership with all of our patients so that together we can make the journey to healthy living. We offer them lifetime nutrition counseling and educate them on proper food and nutrition issues. It is not just about offering bariatric surgery options, it is about caring for the patient, and providing the tools for successful long-term weight loss.
For more information about St. Alexius, visit www.stalexiushospital.com or call (314)-865-7000. For more information about St. Alexius’ NewStart program, call (314)-268-6108 or visit www.stalexiusnewstart.com
Category: Bariatric Center Spotlight