One Healthcare System, Three Distinct Sites
by William B. Inabnet III, MD, FACS
William B. Inabnet III, MD, FACS, is Chairman, Department of Surgery, Mount Sinai Beth Israel, Eugene W Friedman Professor of Surgery, Icahn School of Medicine Mount Sinai, New York, New York
Bariatric Times. 2016;13(1):25–29.
Welcome to the Mount Sinai Health System Bariatric Surgery Collaborative
Surgery for severe obesity has been performed at The Mount Sinai Health System hospitals for almost 40 years. This experience provides the foundation on which our bariatric program was built. Our hospitals have a long tradition of quality and innovation in bariatric surgery. We have been performing laparoscopic, or minimally invasive surgery for obesity since 1998. Our surgeons have accomplished many “firsts,” including the development of the technique for laparoscopic duodenal switch; moreover, the first laparoscopic sleeve gastrectomy was performed at Mount Sinai in 2000.
In 2013, Mount Sinai merged its three bariatric centers to form one program dedicated to the care of patients with obesity and metabolic disease. The Mount Sinai Health System has one of the largest and busiest bariatric surgery programs in the United States. In 2015, over 1,200 bariatric surgery cases were performed among The Mount Sinai Health System Bariatric Surgery Collaborative, which includes 1) The Mount Sinai Hospital, 2) Mount Sinai St. Luke’s, and 3) Mount Sinai Beth Israel. Our teams across the system consistently work together to make this collective program into one of the most prolific bariatric surgery sites in the country.
The Mount Sinai Hospital. Located just steps from Central Park on the Upper East Side of Manhattan, The Mount Sinai Hospital location is ideally located to serve our patients.
Mount Sinai St. Lukes. This site is located near Columbia University on the Upper West Side and serves a large and diverse patient population.
Mount Sinai Beth Israel. Our Mount Sinai Beth Israel location is situated at the “cross roads” of New York City near Union Square. It is the anchor of the Mount Sinai Health System in lower Manhattan. Mount Sinai Beth Israel is uniquely located, close to a transportation hub, and able to provide service to an area that includes Midtown and Downtown Manhattan and Brooklyn.
We have a full complement of staff geared to providing care for patients seeking weight loss surgery. Staffing throughout the three sites are structured to meet requirements for the Center of Excellence Standards as defined by the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP), the nationwide accreditation and quality improvement program for metabolic and bariatric surgery, jointly sponsored by the American College of Surgeons (ACS) and the American Society for Metabolic and Bariatric Surgery (ASMBS).
Our Surgeons. The Mount Sinai Hospital. Surgeons at this site include the following: Drs. William Inabnet III, Daniel M. Herron, Linda P. Zhang, Gustavo Fernandez-Ranvier, Eric Edwards, Subhash U. Kini, Edward Chin, Scott Nguyen, and Brian Jacob.
Mount Sinai St. Lukes. Surgeons at this site include the following: Drs. James McGinty, Ninan Koshy, John Harvey, Koji Park, and Scott Belsley.
Mount Sinai Beth Israel. Surgeons at this site include the following: Drs. Paul Thodiyil, Yulia Zak, Jerome Taylor, Burton Surick, Richard Friedman, Michael Leitman. Dr. Inabnet is available at both Mount Sinai Beth Israel and the Mount Sinai Hospital.
Dr. Inabnet is Chairman of the Department of Surgery at Mount Sinai Beth Israel and provides oversight to the growth and development of The Mount Sinai Health System Bariatric Surgery Collaborative.
Dr. Thodiyil, as Director of the Bariatric Surgery Program at Mount Sinai Beth Israel, is responsible for expanding its reach and accessibility while developing the service to a standard required for MBSAQIP accreditation.
Integrated Health. Our nurse practitioners work closely with patients and surgeons in collecting clinical information and reviewing laboratory results. They guide the patient through the preoperative process, coordinate their care with multiple specialties, triage and respond to clinical enquiries and participate in patient education. They are involved in the patient’s lifelong follow up, including participation in patient support groups.
Our registered dietitians undertake each patient’s initial nutrition evaluation, determines if the patient is an appropriate candidate for surgery from a nutritional standpoint, instructs the patient on diet and exercise for weight loss and educates the patient about post-operative diet and supplement. They organize and conduct a preoperative class for patients in the month prior to surgery, reviewing preoperative and postoperative diet and supplement guidelines. In conjunction with the surgeons, the dietitians review pre- and postoperative nutritional laboratory results and recommend changes to the patient’s supplement regimen as appropriate. They provide a continuity of care, seeing patients during their hospital stay and thereafter in their life-long follow up through office visits and support group meetings.
During the patient’s hospital stay, they are cared for by the same team of registered nurses who are experienced in looking after patients undergoing weight loss surgery. They are sensitive to the needs of the patients and are educated on their postoperative care, including awareness of early signs of complications.
The financial counselors work with patients from their earliest contact, clarifying the insurance process, determining eligibility and coverage for bariatric surgery. They further inform the patient about fees for which they may be responsible. The counselors request prior authorization for the planned procedure and communicate the outcome to the patient and the hospital.
Our office receptionists welcome patients during their office visits and work on registering patients into the electronic medical records (EMR) system. They triage phone calls and patient inquiries.
The clinical staff is supported by administrative assistants who schedule patient visits and surgeries. They field phone calls and act as liaison between patients and the various clinical staff.
The practice supervisors orchestrate the smooth operation of the program, ensuring that the entire team works in concert to create a positive experience for the patient.
Bariatric surgery coordinators and clinical reviewers work closely with the program director in obtaining and maintaining MBSAQIP accreditation. The coordinators assist in program development and in maintaining compliance, with a focus on patient safety and quality improvement. The clinical reviewer extracts patient data from the medical records and reports them to MBSAQIP.
All office and hospital waiting areas are equipped with bariatric size chairs, blood pressure cuffs, weight scales, and wheelchairs. The bathrooms are wheelchair accessible, and the toilets are mounted on the ground. The exam rooms are large and the exam tables are specific to bariatric size patients.
The design of the clinical space at each site ensures adequate sized doorways to accommodate bariatric wheelchairs and walkers. The waiting rooms have wide corridors to allow for bariatric patients and their families.
Procedure Statistics and Patient Demographics
The current annual operative volume of the program exceeds 1,200 cases; with continued projected growth and the addition of the MSBI campus to the program, the annual case volume should increase to 1,500 cases, making The Mount Sinai Health System Bariatric Surgery Collaborative one of the largest in the country. This strategic growth initiative will transform our collective programs into one of the most prolific bariatric surgery sites in the country.
Achieving Accreditation Designation
Having just launched the program in May 2015, Mount Sinai Beth Israel is in the process of applying for accreditation and has already exceeded the minimum case threshold of 50 stapled cases to be designated a Comprehensive Center. With appropriate staffing in place, institutional support, and excellent patient outcomes to date, we do not anticipate any difficulty in completing the process of accreditation as a Comprehensive Center.
Dr. Inabnet is a member of the MBSAQIP Standards Committee, which created and wrote the national standards for the MBSAQIP program. Furthermore, Dr. Inabnet was Co-Chair of the ASMBS Quality and Standards Committee, which oversaw the initial transition from the Center of Excellence to MBSAQIP. MBSAQIP promotes quality in bariatric surgery by following all laparoscopic or open primary procedures in sleeve gastrectomy, gastric bypass, biliopancreatic diversion with duodenal switch, and adjustable gastric banding, as well as all revisions to previous bariatric procedures. An additional feature of MBSAQIP is the conferral of recognition to bariatric surgery centers that meet or exceed a set of rigorous peer-reviewed quality standards. This voluntary review is conducted at more than 400 participating sites across North America and Canada.
Since 2011, The Mount Sinai Hospital has been recognized as a an MBSAQIP Accredited Center—Comprehensive. The Department of Surgery at The Mount Sinai Hospital has earned this distinction by demonstrating use of a high level of resources in bariatric surgery in order to accommodate all patients, including those with complex health histories or specific needs.
Under MBSAQIP, the division aims to meet or exceed the following quality improvement benchmarks for bariatric surgery: 1) An overall 30-day morbidity rate less than the national average; 2) rate of readmissions below the national average; and 3) a 30-day re-operation rate of zero for leak, gastrointestinal perforation, and intestinal obstruction.
Mount Sinai St. Luke’s has been an accredited center since 2008. The most recent semi-annual report demonstrates that they are in the top decimal for morbidity and mortality rates. Furthermore, Mount Sinai St. Luke’s reports some of the lowest complication rates for gastric bypass surgery, which accounts for 50 percent of their surgical case volume.
Medical assistants measure patients’ accurate height and weight. to calculate body mass index (BMI). Patients with BMIs of 40kg/m2 or more are considered appropriate candidates for bariatric surgery. Patients with BMIs between 35 and 40kg/m2 require additional diagnostic testing to determine if they are appropriate candidates. Patients with type 2 diabetes mellitus (T2DM) with BMIs between 30 and 35kg/m2 also meet criteria for weight loss surgery. Patients undergo cardiac and pulmonary testing to determine fitness for surgery; psychological evaluation to assess for untreated psychiatric disorders or substance abuse and evaluate capacity to understand and follow postoperative instructions. They also have a number of blood tests to look for any underlying endocrine causes of obesity.
Patient Adherence and Follow Up
We schedule follow up visits at one week postoperatuve and then at three, six, nine, 12, and 18 months and thereafter annually. The administrative assistants place calls to patients 24 hours prior to their scheduled appointments to improve adherence to follow up. Follow-up data are tracked in the MBSAQIP database that allows generation and reporting of follow-up metrics. Patients that fail to attend three consecutive appointments are sent a return receipt letter with a follow up reminder.
Patients in the New York metropolitan area tend to move with some frequency, so it is often challenging to follow our patients when they change their home address and contact phone numbers. Rising out-of-pocket expenditure through insurance deductables and co-insurance may also contribute to poor follow up.
The preoperative patient goes through a clinical pathway designed to optimize surgery and ensure adherence with National Institute of Health (NIH) criteria for weight loss surgery. The records are documented in an electronic medical records system that is compliant with the Health Information Technology for Economic and Clinical Health (HITECH) Act. The data generated at external physician offices and diagnostic facilities are received via secure fax lines and HIPAA-compliant encrypted e-mail. Once the checklist of preoperative testing is complete, the patient is seen for a final preoperative visit. At this time the patients receive a review of the procedure, answers to any questions they might have prior to their procedure, and a date for surgery. Two weeks prior to surgery, patients are started on a low-calorie (800 kcal) diet. He or she is then sent for anesthesia pre-surgical testing.
After scheduling a surgical date, our patients are brought back to the office for a half day during which they undergo a pre-operative class that reviews the surgery techniques, what to expect in the hospital and immediate postoperative period, diet and exercise guidelines, multivitamin and protein supplementation, and signs and symptoms of complications.
Our Equipment and New Technologies
Our EMR system (Epic, Verona, Wisconsin) has allowed us to handle the large volume of clinical communications in a much more manageable fashion. It facilitates two-way communication through a secure and HIPAA-compliant pathway. Patients who do not have internet access at home are encouraged to use the computer we keep in our waiting room to access their electronic records. At present Epic is available only at The Mount Sinai Hospital; Epic integration at the other sites will occur in 2016, thereby further facilitating collaboration.
Recently, we have embraced the capabilities of mobile technology. Using an app called Epic Haiku, providers can access our EMR system. Through this app, we have secure access to clinic schedules, hospital patient lists, health summaries, test results, and notes. Although the app is available on multiple mobile devices, some find that devices with larger screens make for better viewing of lab results, imaging results, and inpatient vital signs and documentation. It is important to note that all of our sites have campus-wide secure WiFi network provided by our hospital system, which make it possible for us to utilize the benefits of mobile technology.
We have experimented with some mobile-based billing applications, but have been somewhat hindered by the high costs of these packages. We continue to research new equipment and technologies that may be beneficial to our practices.
Once patients have completed their preparation process, administrative assistants schedule them for surgery. Our current EMR system allows us to access a patient’s chart and print necessary paperwork for scheduling procedures.
The practice supervisors keep track of the inventory for the practice and all necessary supplies are ordered by our nurse directors. We make sure that we have all necessary supplies ready for use.
Operating room tables all meet specifications to accommodate the largest bariatric patients. Long instruments, scopes, and staplers are available as needed.
Managed care has not affected our ability to provide excellent service to our patients; however, rising out-of-pocket expenditure through insurance deductibles and co-insurance may contribute to poor patient adherence to postoperative follow up.
Cost and Efficiency
In order for us to help our patients through the process efficiently, we participate with almost all major insurance plans. Most of our patients have very limited out-of-pocket budgets, and most of the time it’s based on their in-network benefits.
We do not ask our patients to contribute to any “program fees,” although we ask for a small payment for nutritionist visits, which are generally not covered by insurance. These fees can be waived for special situations.
Patient and Staff Training
Across The Mount Sinai Health System, an obesity care map has been implemented. One criteria of this plan is that two attending anesthesiologists be present for the induction of anesthesia in patients with a BMI greater than 40kg/m2.
Our anesthesiologists minimize postoperative somnolence so that patients can move themselves from the operating room table to the gurney. We believe patient mobilization is important to early recovery and we encourage patients to ambulate starting the night of surgery. In patients with impaired mobility, we use standard transfer aids such as air transfer systems and low-friction slide boards in the operating room.
The single most enabling technology for both patients and providers has been the near-ubiquitous emergence of cell phones and high-speed network access. Patients use their phones to improve communication with our team at every level.
Laparoscopic instrumentation has remained fairly stable over the past few years. We would like to see improved display technology in the form of 4K cameras and monitors. Robotic surgery is gaining increasing ground in surgery of the gastro-intestinal tract, and we would like to cautiously explore its application in bariatric surgery.
An Interesting Case
Diagnosed with liver failure and three months to live, patient undergoes life saving bariatric surgery. Ms. R was a 48-year-old mother, resident of Puerto Rico, and owner of a catering business, received news during a routine doctor appointment that her liver was failing. She weighed 309 lbs, struggled with T2DM for 12 years, and was receiving 180 units of insulin a day. Struck with panic and fear that she would die from liver failure, she reached out for help. Her sister, who lived in New York, relayed that the family’s primary physician recommended The Mount Sinai Hospital.
Ms. R flew out to New York for an appointment on December 20th. She met with the transplant team who told her that, at this point, there was nothing they could do. They said she would not survive the surgery at her current weight and that her only option was to try bariatric surgery first. The team referred her to Dr. Subhash Kini, Associate Professor of Surgery and Minimally Invasive Bariatric surgeon at The Mount Sinai Hospital. Dr. Kini explained this was a very high risk surgery. He also mentioned that if gastric varices were found within the abdomen upon the operation, he would not be able to continue with surgery. He advised that Ms. R immediately start exercising and begin a very strict diet to lose as much weight as possible before surgery, which was tentatively scheduled for the following April. Ms. R, with support from her family, made the effort to change her lifestyle and lost 40 pounds.
Finally, the day arrived. After the four-hour surgery was completed, Dr. Kini said everything went well. Ms. R was walking that same day and was released on Postoperative Day 1. During surgery, Dr. Kini noticed that Ms. R’s liver appeared seriously diseased. One month later, she met with the transplant team again. They said that her lifestyle changes and surgery helped to improve her liver functions.
Ms. R continues to follow up with both the bariatric surgery and transplant teams. Due to her transformation, doctors predict that she may not need to have a liver transplant. Ms. R reports that she is happy with her life transformation and notes that little tasks no longer tire her, such as crossing her legs and walking up inclines. She is also proud to say that she can now shop anywhere for clothes that fit.
Ms. R expressed sincere gratitude to the bariatric team at The Mount Sinai Hospital, especially to Dr. Kini who she calls her superhero. “A superhero’s mission is to save people, and that’s exactly what he did. He saved me,” she said.
A Unique Facility
The Bariatric Surgery program at the Mount Sinai Health System has several transformational initiatives. First, our goal is to expand bariatric surgery services across the System. We continue to standardize clinical pathways and recruit new faculty to accommodate the strategic expansion.
The Mount Sinai Health System Bariatric Surgery Collaborative convenes a system-wide meeting every six months to discuss outcomes, refine clinical pathways, vet research protocols and enhance collegiality. Each site hosts the meeting on a rotating basis. Monthly meetings occur on a regular basis at each site.
To learn more about The Mount Sinai Health System Bariatric Surgery Collaborative, visit our new website http://weightloss.surgerymountsinai.org/.
FUNDING: No funding was provided.
DISCLOSURES: The author reports no conflicts of interest relevant to the content of this article.