Integrated Health Clinical Issues and Guidelines Committee Develops Upcoming Gastric Band Adjustment Credentialing Guidelines for Physician Extenders

Hot Topics in Integrated Health

Column Editor: Karen Schulz, RN, APN, President of the Integrated Health Section of the ASMBS; Clinical Nurse Specialist, University Hospitals of Cleveland, Cleveland, Ohio.

This month’s column by Lisa West-Smith, PhD, LCSW, and Pam Davis, RN, CBN

Lisa West-Smith, is Co-Chair, ASMBS Integrated Health Clinical Issues and Guidelines Committee. She is from the Bariatric Center at Georgetown Community Hospital/Lifepoint Hospitals, Inc., Georgetown, Kentucky. Pam Davis is Chair, ASMBS Integrated Health Clinical Issues and Guidelines Committee. She is from the Bariatric Program at TriStar Centennial Medical Center in Nashville, Tennessee.

Funding: No funding was provided in the preparation of this manuscript.

Financial disclosures: The authors reports no conflicts of interest relevant to the content of this article.

ABSTRACT
Background: Exponential growth of aftercare visits in most bariatric surgery practices makes it difficult to have gastric band adjustments performed by bariatric surgeons. Little has been published to inform development of training programs or credentialing guidelines for other clinicians who perform gastric band adjustments. Methods: An invitation to participate in an internet-based survey (via SurveyMonkey™) was e-mailed to 101 bariatric surgeons. The survey instrument, developed by an American Society for Metabolic and Bariatric Surgery Integrated Health Clinical Issues and Guidelines Committee expert panel, included items on provider types utilized; the existence of training, credentialing, or supervisory requirements; and free text items. Results: Responses were obtained from 63 bariatric surgeons. A total of 73 percent (n=46) reported utilization of physicians, physician assistants and nurse practitioners to perform band adjustments; 34 percent (n=14) also reported utilizing registered nurses. No specific training requirements existed in 32 of 41 (78%) of respondent facilities. Specific credentialing requirements were established in 9 of 41 (22%) surgeon facilities. Approximately 50 percent of respondents reported no direct supervision requirements. The mean number (n=17) of physician-supervised band adjustments recommended as a threshold for adequate training was 24 (range 10–100). Free text responses addressed skills including, port access, determining need for adjustment, and identifying problems requiring x-ray or surgeon intervention. Conclusion: A set of credentialing guidelines based on review of relevant literature, results of the present survey, and deliberation by the American Society for Metabolic and Bariatric Surgery Integrated Health Clinical Issues and Guidelines Ad Hoc Committee are forthcoming in the journal Surgery for Obesity and Related Diseases.

Introduction
While it is generally agreed in clinical forums that the exponential growth of aftercare visits in most bariatric surgery practices makes it impractical if not impossible to have gastric band adjustments performed by bariatric surgeons, to date there has been very little data published to inform the development of training programs or credentialing guidelines for the other clinicians who perform them. In order to address this important issue, the American Society for Metabolic and Bariatric Surgery (ASMBS) Executive Council charged the Integrated Health Clinical Issues and Guidelines Committee (IHCIGC) with the task of developing gastric band adjustment credentialing guidelines for physician extenders.

Background
A few published reports generally suggest that performing adjustments to the gastric band in the office setting is both safe and feasible,[1–3] and actual techniques for performing band adjustments are recommended by industry manufacturers.[4,5] Various state boards[6,7] and professional organizations[8–10] have published statements that help to delineate scope of practice and best practices for their constituents. However, determination of appropriate scope of practice and sufficient training and experience to competently perform band adjustments is less clearly defined.

For example, anecdotal reports suggest that in addition to advanced practice clinicians, such as nurse practitioners (NPs) and physician assistants (PAs), many bariatric surgery practices successfully and routinely utilize registered nurses (RNs) to perform band adjustments. This might well be considered the equivalent of an RN accessing a port for chemotherapy; it could also be argued that the decision to perform a gastric band adjustment requires diagnosis, which lies outside of the RN scope of practice. In this installment of “Hot Topics in Integrated Health,” we briefly summarize the results of an ASMBS survey that was conducted by the IHCIG Committee to establish credentialing guidelines applicable to the variety of clinicians who are likely to perform them.

Methods
In October 2011, the ASMBS IHCIGC assembled an expert panel to serve as an ad hoc committee to develop gastric band adjustment credentialing guidelines for physician extenders. All members of the panel were experienced clinicians from the disciplines of surgery, medicine, behavioral health, and nursing, including advanced practice. A survey instrument was developed to query surgical practices on provider types performing gastric band adjustments in their programs; the existence of any training, credentialing, or supervisory requirements for these clinicians; and free text items to obtain surgeon feedback on other areas of concern related to a guideline statement. The instrument was utilized in an internet-based survey (via SurveyMonkey™). In late November, 2011, an invitation to participate was e-mailed to a convenience sample of 101 ASMBS surgeon members.

Results
A total of 63 bariatric surgeons responded to the survey, with 73 percent (n=46) reporting utilization of physician extenders to perform band adjustments. Annual gastric banding surgical volume was reported by 41 respondents, with 68 percent (n=28) performing more than 100 cases per year. Monthly gastric band adjustment procedure volume was reported by 41 respondents, with 47 percent (n=20) performing more than 100 adjustments per month. While the majority of respondents reported using MDs, PAs, and NPs for gastric band adjustments, approximately 34 percent (n=14) also reported utilizing RNs to perform the procedure.

In 32 of 41 (78%) of respondent facilities no specific training requirements existed for physician extenders who perform gastric band adjustments. In-house training by the supervising physician and attendance at an industry course were the training methods reported by those who had them. Training requirements for physician extenders to utilize fluoroscopy in band adjustments were required by 53.7 percent (n=22) of surgeons who responded to this item. For practices utilizing physician extenders to perform band adjustments, a supervisory requirement of a surgeon present in the office or building was reported by 13 of 29 (45%) respondents who utilize PAs; 10 of 22 (45%) who utilize NPs; and 6 of 11 (55%) who utilize RNs. Approximately 50 percent of all respondents reported no direct supervision requirements.
The existence of specific facility credentialing requirements was reported by only 9 of 41 (22%) surgeon respondents; most commonly cited were completion of on-the-job physician training and attendance at an industry course. The mean number (n=17) of physician-supervised band adjustments recommended as a threshold for adequate training was 24 (range 10–100). In free text items, the most commonly cited issue for the supervision of gastric band adjustments for a new physician extender was not only the ability to access the port, but also how to address the patient interaction that determines the need for the adjustment and the identification of problems that would require x-ray or surgeon intervention.

Conclusion
A set of credentialing guidelines based on review of relevant literature, the results of this survey, and deliberation by the ASMBS IHCIG Ad Hoc Committee expert panel have been developed. The guidelines are scheduled to be published in the November/December 2012 issue of Surgery for Obesity and Related Diseases. The recommendations are based on expert opinion and are offered only as guidelines, and specifically not intended to establish a local, regional, or national standard of care for any gastric band adjustment procedure. The intent of the guideline statement is to provide recommendations for appropriate training and competency recognition for the valuable clinicians who provide these needed services.

Acknowledgment
The authors wish to thank the following ad hoc members of the ASMBS Clinical Issues and Guidelines Committee for their substantive contributions in the development of this survey and the forthcoming guidelines: Laura L. Baldwin, RN; Karen M. Flanders, NP CBN; Lisa Rae Gergen, MSN FNP CBN; Melissa M. Davis, MSN APRN BC CNS RNFA; Paula R. Kilgore, RN CBN; Terry L. McKenzie, RN CBN; Debra A. Proulx, RN; ASMBS Executive Council Liaisons Jaime Ponce, MD and Emma J. Patterson, MD; and ASMBS Staff Liaison, Barbara Peck.

References
1.    Dugay G, Ren CJ. Laparoscopic adjustable gastric band (Lap-Band) adjustments in the office is reasonable—the first 200 cases. Obes Surg. 2003;13:537.
2.    Shen R, Dugay G, Rajaram K, et al. Impact of patient follow-up on weight loss after bariatric surgery. Obes Surg. 2004;14:515–519.
3.    Watkins BM, Montgomery KF, Ahroni JH. Laparoscopic adjustable gastric banding: early experience in 400 consecutive patients in the USA. Obes Surg. 2005;15:82–87.
4.    Realize. Cincinnati: Ethicon Endo-Surgery, Inc.; 2007–2012. About Band Fills. http://www.realize.com/band-fills-adjustments.htm/. Accessed October 3, 2012.
5.    LapBandCentral. Irvine: Allergan, Inc.; c2007–2011. The art of adjustments with the Lap-Band AP system. http://www.lapbandcentral.com/local/files/documentlibrary/AP_ART_OF_ADJUSTMENT_Guide.pdf. Accessed October 3, 2012.
6.    Ohio Board of Nursing; Nursing Practice Interpretive Guidelines. Guidelines for registered nurse filling and unfilling a client’s gastric band. http://www.nursing.ohio.gov/PDFS/Practice/IG_gastricband052012.pdf. Accessed November 2, 2012.
7.    Arizona State Board of Nursing; Advisory Opinion: Laparoscopic Adjustable Gastric (LAGB) Fill. http://www.azbn.gov/documents/advisory_opinion/AO%20LAPARASCOPIC%20ADJUSTABLE%20GASTRIC%20BAND%20LAGB%20FILL%20Mar%202010.pdf. Accessed October 3, 2012.
8.    Association of Perioperative Registered Nurses (AORN). Position Statement on RN First Assistants. http://staging.aorn.org/WorkArea/DownloadAsset.aspx?id=21931. Accessed October 3, 2012.
9.    American Society for Metabolic and Bariatric Surgery Guidelines for Granting Privileges in Bariatric Surgery. http://asmbs.org/2012/06/granting-privileges-in-bariatric-surgery/. Accessed October 3, 2012.
10.    Gould J, Ellsmere J, Fanelli R, et al. Panel report: best practices for the surgical treatment of obesity. Surg Endosc. 2011;25:1730–1740.

Category: Hot Topics in Integrated Health, Past Articles