One of the FIRST Centers of Excellence in the United Kingdom

| September 23, 2009

The Imperial Weight Centre at Charing Cross Hospital, London, United Kingdom

Bariatric Times interviews Ahmed R. Ahmed on his facility being one of the first to achieve Center of Excellence status in the United Kingdom.

Tell us about the roles and responsibilities of the lead staff at your facility.
The Imperial Weight Centre at Charing Cross Hospital, is a university hospital-based practice functioning purely in the United Kingdom’s (UK) public health sector—National Health Service (NHS). Our objective is to improve the health of people whose weight poses a serious health risk. Apart from bariatric surgery, our unit also offers both lifestyle and pharmacotherapy approaches to weight loss. Our team consists of 15 key office staff members in addition to managerial, nursing, and scrub staff dedicated to our bariatric patients care.

We have three bariatric surgeons (I am one of only two US Fellowship trained bariatric surgeons in the UK), two bariatric physicians (including Dr. Carel le Roux who is world renowned for his work on gut peptides), four bariatric anesthesiologists (including Dr. John Cousins, the cofounder and vice president of the UK’s society of bariatric anesthesiologists), our specialist nurse practitioner Karen O’Donnell, two dietitians, one psychiatrist, one psychologist, one coordinator, one administrator, three research fellows, and one clinical fellow.

The roles of our staff are as follows:
Bariatric surgeons: preoperative surgical assessment, postoperative surgical management, education of patients/relatives/staff/general public, and research
Bariatric physicians: preoperative work up for surgery, postoperative management of metabolic complications, education of patients/relatives/staff/general public, and research
Bariatric anesthetist: preoperative anesthetic assessment, postoperative pain management, education of patients/relatives/staff/general public, and research
Bariatric nurse specialist: development of a patient-focused structured pathway; specialist advice, support, and information pre- and postoperative; gastric band adjustments; facilitate investigation, sensitivity training, and patient advocacy; education of patients/relatives/staff/general public; and research
• Psychiatrist: preoperative psychiatric assessment, postpsychiatric complication management, education of patients/relatives/staff/general public, and research
Psychologist: preoperative psychological screening, education of patients/relatives/staff/general public, and research
Dietitians: preoperative and postoperative assessment, diet management, advice and support, education of patients/relatives/staff/ general public, and research
Bariatric coordinator: facilitates the patient journey starting with scheduling appointments, operating room slots as well as entering data into the UK national bariatric surgery registry. Also acts as liaison with patients, GPs, and other hospitals
Bariatric administrator: answer patient phone calls, direct queries to appropriate persons, answer patient letters, and handle general office duties.

Describe your bariatric facility.
Our unit is located at Charing Cross hospital where the infrastructure was developed in order to safely provide a bariatric service. Some of the changes include the following:
• Designated bariatric clinic with bariatric scales, chairs, couches, and blood pressure monitoring equipment
• Designated bariatric operating room with bariatric Hovermat to help with patient transfers on and off the operating table
• Ring-fenced bariatric beds—physical beds and patient rooms specifically reserved for elective bariatric surgery patients from Monday to Friday on the surgical floor

What are the number and demographics of patients treated on an annual basis at your facility?
We perform 275 to 300 procedures per year. Eighty percent of our patients are female with median age 37. The average body mass index (BMI) of our patients is 49.

Did you find it difficult going through the process of attaining the Center of Excellence certification designation?
We found this to be a very detailed and rigorous process. We had all the information available; it was more a matter of putting it all together then formatting it correctly. The process was a useful team exercise and highlighted the number of protocols and policies available and the level of work done by the team. It also allowed us to identify what we do well along with areas that needed improving.

How do you handle patient adherence? How do you measure long-term follow up?
All of our patients are counseled about the importance of coming to follow-up appointments, which is included on our informed consent contract. Planned patient follow up occurs at 10 days, then three months, six months, and yearly thereafter. Patients who do not attend are contacted by phone. We routinely audit patient attendance at follow up so we know who is not attending follow-up appointments.

What is/are the biggest complication(s) in terms of patient adherence?
Some patients fail to follow pre- and postoperative advice, which can lead to difficulties and even cancellation of surgeries. Occasionally, patients do not contact the team when experiencing problems, as they do not want to bother the team. This is probably the most dangerous factor because,  as every bariatric surgeon knows, “delay is dangerous; denial may be lethal.”

Please give a general synopsis of how your patients are treated while under the care of your center, including patient education and HIPAA compliance.
The patient pathway at Imperial Weight Centre begins when we receive a referral letter or e-mail from a primary care physician (PCP). The majority of our referrals come from PCPs. Within a week, an appointment is scheduled. Educational material is also sent out to the patient for our weekly obesity seminar, where between 25 and 30 patients who are pre-intervention assemble and interact with one another. The dietitian, bariatric physician, and surgeon each give a 20-minute long presentation on lifestyle, pharmacotherapy, and surgical interventions for weight loss, respectively. Immediately after this, some of our existing patients (randomly selected) join the group for the next  hour to discuss firsthand their own experiences after the various interventions. This ‘support’ group is monitored and kept in check by our psychologist who encourages a lively debate between the attendees. Following this, patients are asked to choose between lifestyle, pharmacotherapy, and surgery. Those who choose surgery are asked to indicate a preference for a particular operation. Those who choose lifestyle or pharmacotherapy are entered into an appropriate six-month program where the average weight loss can be between 5 and 10 percent of total body weight. Those patients who choose surgery are invited back to the hospital a week or so later for one-on-one appointments with the bariatric physician for medical work-up and optimization, the psychiatrist for preoperative evaluation, and  dietitian for preoperative diet assessment, diet education, and advice (for both the preoperative liver diet as well as the postoperative diets) management and support. The bariatric multidisciplinary team (MDT), consisting of surgeons, physicians, psychiatrist, dietitian, and specialist nurse, meets every week to discuss all the patients referred to the unit.  Here, the decision is made as to who will progress to surgery based on the National Institute for Clinical Excellence (N.I.C.E.) (UK equivalent of N.I.H. criteria). The next two hospital appointments are with the surgeon to discuss the surgery the patient has chosen and to consent the patient and lastly with the anesthesiologist for a final presurgical check before surgery, which usually occurs 2 to 3 months postreferral. Our coordinator ensures that all patients are kept informed of their progress through our patient pathway as well as entering appropriate information into the UK national bariatric surgery registry.

What are some of the new technologies, equipment, devices, and products introduced at your facility that have been beneficial to your practice?
The Hovermat device manufactured by CJ Medical has been very useful for transferring patients from the operating room table onto the floor beds and ensures both patient and staff safety by minimizing the physical effort necessary for sliding patients off the operating table.

Who handles your procedure scheduling?

Procedures are scheduled by the coordinator per the surgeon’s request. This is done via an electronic calendar with waiting times, which are standard performance management within the NHS, being monitored centrally by the hospital and daily/weekly reports being produced from our patient administration system (ICHIS). NHS waiting times, at all times, have to be monitored to make sure we do not breach our government target of 18 weeks from PCP referral to first treatment.

How is inventory managed in your facility? Who handles the purchasing of equipment and supplies?
O.R. budgets have just been devolved locally; therefore, control of stock and equipment are by the lead clinicians for each service. Ward and outpatient equipment is purchased and managed by the individual managers of that area.

How do you perform patient assessment to determine who is appropriate for surgery?
• Patients are initially assessed, and if necessary optimized, by a bariatric physician.
• Patients are assessed by either a psychologist or psychiatrist to ensure that they are mentally prepared for surgery.
• Patients are assessed by a dietitian to verify they have have tried six months of dieting previously and they have a sound knowledge of both preoperative (liver shrinking) diet and postoperative diet progression.
• Patients are assessed by the surgeon to ensure they understand their chosen procedure and are surgically fit.
• Finally, an anesthetic preassessment service is conducted by our nurse specialist and bariatric anesthetisiologist, which assesses fitness for surgery two weeks in advance of the operation date to allow for any interventions that may be needed.

What measures has your facility implemented in order to cut or contain costs and improve efficiency?
Work has been done with one of our industry partners, Ethicon Endo-Surgery, to review all costs. Specific data have been collected in relation to both outpatient and inpatient costings. This has been used to reduce waste, improve patient pathways, and increase efficiencies in all aspects of the patients’ journeys.

How does your facility deal with the issue of patient safety and staff safety?
All clinical staff attend manual handling courses. Furthermore, each department in our hospital has access to our protocols

How are employees oriented and trained for working with the bariatric patient?
Staff are invited to attend sensitivity training, which occurs every month. Furthermore, we are incorporating bariatric sensitivity training into all resident and nursing staff induction courses.

What trends do you see emerging—including new technologies and what patients seem to be looking for?
More patients would like to access online forums and online and phone consultations to reduce the amount of time spent coming to hospital for clinic appointments. The advent of single-incision laparoscopic surgery and NOTES (natural orifice transendolumenal surgery) offers an exciting new field if these techniques can be shown to improve patient satisfaction and outcomes. Lastly, using bariatric surgery to treat type 2 diabetes in patients without morbid obesity is certainly of interest to many patients, but once again benefit would need to be proven in the setting of a randomized, controlled trial before it could be offered to the population at large.

Are there new technologies or equipment you would like to see utilized in your facility?
• The Doctor Foster PET (Patient Experience Tracker) is a PDA-based patient satisfaction survey. Questions and data analysis can be tailored to a particular service. Also, the survey is completed in real time, not retrospectively.
• The REALIZE mySUCCESS® web-based product will soon be available in the UK and its usage will surely improve patient adherence.

Describe one of your most interesting patient cases.
Refeeding syndrome after bariatric surgery. The patient previously underwent gastric banding. Two milliliters of fluid was removed from her gastric band because she was pregnant. This resulted in her becoming very hungry and turning from a catabolic state into an anabolic state. The excess insulin produced in the anabolic state most likely caused peripheral edema through a mechanism directly on the kidney.

Describe one of your most difficult patient cases.
The patient was status postlaparoscopic gastric bypass and did very well initially with good resolution of his type 2 diabetes and good weight loss. He then developed abdominal pain after eating. He was fully investigated with numerous endoscopies, imaging, laparoscopies, and second opinions but with no clear source of his pain. At his last surgery, his gallbladder was removed and a feeding gastrostomy inserted. He is now fed by gastrostomy tube and consequently is back on insulin! However, his pain appears to be less severe when he is fed via the gastrostomy tube than if he was eating by mouth. His symptoms remain a mystery.

What makes your facility unique?
We are the first international center of excellence recognized by the Surgical Review Corporation. We are also part of the UK’s first academic health science center. We are recognized as a designated specialist center for bariatric surgery receiving referrals from all around the UK. We offer not just bariatric surgery but also lifestyle and pharmacotherapy treatments to bariatric patients.

Come visit us on your next trip to London!

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Category: Bariatric Center Spotlight, Past Articles

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