Beaumont Hospital Bariatric Surgery Program: Royal Oak, Michigan

TELL US ABOUT THE ROLES AND RESPONSIBILITIES OF THE LEAD STAFF AT YOUR FACILITY.
Beaumont Hospital in Royal Oak, Michigan, is a 1,061-bed, major academic and referral center. The yearly surgical volume is routinely in the top two in the nation. Ninety-one medical and surgical specialties are represented on Beaumont’s medical staff of more than 3,100 physicians.

Kevin Krause, MD, FACS, is the medical director of bariatric surgery. He started the bariatric program at Beaumont Hospital in 2001 after completing a fellowship in advanced laparoscopic surgery. David Chengelis, MD, joined the bariatric team in 2004 after completing special training in bariatric surgery. He has a general surgery practice with a special focus on laparoscopic surgery and interventional endoscopy. Together, our surgeons have performed more than 1,900 primary and revisional bariatric operations, more than 98 percent laparoscopically.

Patients have an opportunity to choose from two comprehensive weight control centers for their preoperative and postoperative care. At the Beaumont Weight Control Center, Peter McCullough, MD, is a cardiologist and the Chief of Nutrition and Preventive Medicine. He is joined by Kerstyn Zalesin, MD, an internist with a practice focused primarily on bariatric patient care. Michael Doyle, MD, is the Medical Director of Unasource Comprehensive Weight Loss Clinic. Together with their weight control staff, these physicians provide patient education, complete medical evaluations, and treat medical conditions associated with obesity.

Deborah Gibbs, RN, is the program administrator and Karen Duty, LPN, is the bariatric coordinator for the Beaumont Weight Control Center. They help streamline the process of preoperative teaching and education and organize the postoperative long-term support structure.
Program psychologists are Jacqueline Odom, PhD, and Daniel Stettner, PhD. They perform preoperative screening exams and help patients cope with changes associated with weight loss. They both participate in support group sessions to address psychological issues and barriers.

Catherine Welemirov, RD, is the hospital-based bariatric dietitian. Silvia Veri, RD, is the head dietitian at the Beaumont Weight Control Center. Nanette Cameron, RD, is the head dietitian at the Unasource Health Center. Program dietitians will address the specific pre/postoperative individual dietary needs, acknowledging the type of weight loss operation, for individual bariatric patients.

Shelli Bergeron, RN, Carrie Callahan, RN, and Kimberly Wesley, RN, are general surgical nurse clinicians at the hospital who work with the surgeons. They coordinate postoperative care and provide discharge education while patients recover in the
hospital.

Kathy Schumacher is the director of quality, safety, standards, and outcomes. She has worked extensively with organizing outcomes research and patient safety iniatives. Michele High, RN, is the bariatric outcomes nurse responsible for collecting and maintaining our bariatric outcomes. Together, they helped to coordinate the effort for the American College of Surgeons Bariatric Center of Excellence designation and track the prospective outcomes database for bariatric patients.

Describe your bariatric facility.
At the weight control centers and surgeons’ offices, the furniture in the exam rooms, waiting rooms, and labs are designed for the comfort and safety of the bariatric patients. There are private exam rooms to examine bariatric patients and scales that will accommodate larger weight capacities. There are conference rooms for education, a small library, and a demonstration kitchen.

The hospital has a designated operating room team that specializes in bariatric procedures. State-of-the-art operative instruments, Steris large-capacity tables, and patient transfer technologies are currently utilized. The AirPal patient transfer system is used to glide patients from the operative table to the hospital bed to avoid injury. In addition, the anesthesia team is trained to care for bariatric patients with difficult airways and has specialty equipment, such as a glide scope and a fiber optic bronchoscope, for intubation.

Lisa Jones, RN, is the administrative manager of our 64-bed surgical unit. All postoperative bariatric patients are admitted to this floor. Bariatric patients are provided specialized equipment, including beds, chairs, commodes, and clothing to accommodate their needs based on individualized nursing assessment..

How many patients do you treat annually?
Our bariatric surgery program averages 250-300 surgical patients annually. This includes both laproscopic gastric bypass and lap band patients. Our average hospital length of stay for open Roux-en-y gastric bypass is 3.0 days, our laproscopic Roux-en-y length of stay is 2.0 days. Our average length of stay for laproscopic bands is 1.0 day. Our average age of our patients is 46, with an average BMI of 47.

Did you find it difficult going through the process of attaining the ACS Bariatric Surgery Center Network certification designation?
Attaining the American College of Surgeons Level 1A accreditation took many hours of multidisciplinary team work. While the bariatric program was already established and successful, the process helped to expand efforts in data collection and outcomes research. Several meetings were required and helped to coordinate efforts by administrators, nurses, doctors, and various support staff. Patient volume did increase after certification, particularly the Medicare population. Patients frequently inquire about the program’s accreditation and center of excellence certification.

How do you handle patient compliance and measure long-term follow-up?
The bariatric surgical patient joining the program has full access to a multidisciplinary program, which includes support groups, nutrition classes, cooking classes, dietitian sessions, exercise physiologist, and an exercise facility. The weight centers offer an intensive program for bariatric surgery patients who are experiencing difficulties, such as insufficient weight loss, weight regain, challenges with lifestyle changes, need for additional support, or problems with choosing a healthful diet. The patient’s close relationship with the multidisciplinary team from the beginning of the bariatric surgery qualification process and postoperative care encourages patients to continue long-term follow- up care. In addition, special support for bariatric surgical patients facing challenges with lifestyle changes after surgery and weight regain reinforces continued compliance.

Measurement of long-term follow-up care incorporates the support of the bariatric surgeons, the respective weight control centers, and the hospital-based outcomes nurse. These disciplines participate with the American College of Surgeons, National Surgical Quality Improvement Program, and the Bariatric Surgery Center Network. In addition to these national databases, the program participates in the Michigan Bariatric Surgery Collaborative, which is a statewide prospective study on bariatric outcomes sponsored by Blue Cross/Blue Shield of Michigan.

Please give a general synopsis of how your patients are treated while under the care of your center, including patient education and HIPAA compliance.
Prospective patients attend a free informational seminar and are given written educational materials. Patient education continues individually when the patient meets with the medical doctor, the psychologist, and the dietitian. The bariatric surgical candidate will then be referred to the bariatric surgeon. The bariatric surgeon will meet with the patient for consultation prior to the surgery. The patient receives an explanation guide, which reviews topics the surgeon covers. The surgeon reviews all pertinent aspects of the guide with the patient. The surgeon reviews modifiable risk factors and makes recommendations for preoperative weight loss and stabilization of medical issues.

Once the patient is boarded for surgery, an additional preoperative instructional guide is sent to the patient, which is an overview of the bariatric program at our hospital. Focus of the booklet is on prevention of postoperative complications and the discharge process. The long-term educational follow-up is provided at the respective weight control centers. The centers provide medical, nutritional, psychological, and exercise support for the postoperative bariatric surgical patients. The bariatric surgical patients can attend either group or individual sessions with all disciplines.

Beaumont Hospitals and all members of its workforce (employees, volunteers, students, and on-site agency employees under the direct control of a Beaumont employee) recognize and respect the privacy of patient’s Protected Health Information (PHI). PHI will only be used or disclosed to the extent allowed by the Health Insurance Portability and Accountability Act (HIPAA), Privacy Rule, other federal, state, or applicable case law and regulations. The patient has the right to confidential treatment of PHI regardless of format (e.g., fiche, paper, film, computerized, verbal). Employees are prohibited from accessing, releasing, reading, copying, or reproducing any patient PHI without the patient’s prior written authorization or as required for performance of job responsibilities.

What are some of the new technologies, equipment, devices, and products used at your facility that have been really beneficial to your practice?
Beaumont Hospital’s Weight Control Center offers a new product line from Bariatric Advantage. Bariatric Advantage provides a complete line of nutritional supplements that have been specifically formulated to meet the unique demands of both the preoperative as well as postoperative bariatric surgical patient. The Beaumont Weight Control Center also has replaced its traditional exam tables with the Hill Adjustable Power Exam Chair, which is designed for the safety and comfort of the bariatric patient.

The Marcia and Eugene Applebaum Surgical Learning Center opened at our hospital in May 2006 and was designed to change the way healthcare professionals learn and train. The learning center is a virtual reality lab equipped with full-scale model operating rooms, patient physiologic simulators, a tissue lab, and a distance learning-equipped classroom. In addition, the surgical learning center fosters an environment where surgeons, nurses, anesthetists, technologists, and other operating room staff can train as a team. Moreover, the center is one of the most advanced medical simulation facilities in North America.

The da Vinci Surgical System, housed at the learning center, allows surgeons to perform operations from a remote console, with robotic instruments inserted via small incisions. The robot translates a doctor’s hand movement into corresponding micro-movements of the instrument. The benefits of minimally invasive robotic surgery include reduced blood loss, lower risk of infection, and less pain with faster recovery. Thus, new surgeons can test their skills using the da Vinci Surgical System before ever stepping into an operating room, and experienced surgeons can refine their skills and increase capabilities with it.
Hence, our hospital’s investment in robotic surgical technology and commitment to continued exploration of these technologies encourages enhancement of patient safety and improves the surgical patient’s outcomes. One future goal for our hospital will be to utilize the Surgical Learning Center for Bariatric Surgical Team Training.

The operating room uses an advanced video system for laparoscopic procedures, Olympus HD (High Definition) Endo Eyes. Surgeons use a new generation DST Covidien EEA made by Covidien for the gastrojejunostomy, which is longer in length and has a shorter staple height. This allows for decreased bleeding and decreases the need for additional staple reinforcement at the anastamosis. The second generation Lap Band AP system has replaced the older version. The new system has been easier to place surgically and may provide better overall results.

Who handles your procedure scheduling? What software do you use?
The hospital uses Surgical Information Systems for scheduling all procedures. The surgeon’s office staff contacts the hospital and coordinates a surgical date. The hospital will reserve the proper bariatric equipment for the operation and reserve the appropriate time slot.

How is inventory managed in your facility? Who handles the purchasing of equipment and supplies?
Our hospital uses a centralized purchasing system. All equipment is distributed by the Inventory Control Department. Requests for bariatric equipment and supplies are generated to this department. The Persons of Size committee will evaluate all equipment requests and investigate new equipment technology to meet the needs of our bariatric patients.

How do you perform patient assessment to determine who is appropriate for surgery?
Preoperative care begins at our respective weight control centers. The patient is evaluated by a board-certified internist with a focus on preventative medicine and nutrition, psychologist, dietitian, and exercise physiologist. The prospective patient will fill out a questionnaire and undergo a complete history and physical exam. The patient then undergoes blood work, urine testing, cardiopulmonary testing, and other diagnostic tests as indicated in order to assess the appropriateness, readiness, and potential risk for bariatric surgery. Comorbidities are evaluated by the internist and a treatment plan will be implemented before the patient is considered for bariatric surgery. The multidisciplinary team will conduct a case conference on each bariatric patient-candidate and decide as a group if the patient will benefit from bariatric surgery. A validated, multivariate model is used to predict the risk of death, myocardial infarction, and heart failure for each patient, and this projected probability is listed on the referral form to the bariatric surgeon.

The surgeon will review the patient’s initial evaluation and clearance from the respective weight control centers. Ultimately, the final decision to proceed is made by the surgeon after review of the above patient recommendations and examination of the bariatric patient-candidate.

What measures has your facility implemented in order to cut or contain costs and improve efficiency?
We have decreased length of stay over time by incorporating early preoperative education of patients and their families about the bariatric surgical procedure and the recovery process. Early education helps patients and family members to become active members of the bariatric healthcare team. As members of the bariatric healthcare team, the patient and family work together with staff and support efforts to facilitate a timely recovery.

The bariatric surgeons work in partnership with the radiologist for a more streamlined process for those bariatric patients who need an upper gastrointestinal (GI) evaluation. The patient is taken early in the morning for the studies and if the study is satisfactory, the surgeons are notified with an instant read. The patient can then be started on a diet more quickly. Once the patient shows tolerance to the diet, he or she can be discharged the same day.
The hospital by virtue of its large surgical volume also receives rebates and discounts on some products as an incentive for purchasing and using them for procedures.

How does your facility deal with the issue of patient and staff safety?
In terms of patient and staff safety, our facility has gait belts, sliding boards, mechanical lifts, and appropriate bariatric equipment or furniture to meet the needs of the patient as well as the staff member to prevent back injuries and patient falls. Staff has been in-serviced regarding transferring patients in their orientation as well as in previous yearly mandatory training provided. Our facility has a Persons of Size Committee that promotes and develops protocols for standardized care and safe transfer techniques for healthcare staff and persons of size. In the operating room, the AirPal inflatable transfer mat assists personnel in safely transferring the patient from the operating room table directly to the hospital bed. This system helps prevent transfer injuries for both the patient and staff.

How are employees oriented and trained for working with the bariatric patient?
Employees are educated through a one-week central orientation process upon hire. Topics related to bariatric surgical patient care include types of equipment, purpose of Persons of Size Committee and physical therapy, and occupational therapy lectures and demonstrations regarding appropriate lifting techniques to prevent back injuries.

Anne Prouty, RN, MSA is our clincal nurse specialist dedicated to our bariatric unit. Anne provides our orientees on the unit with information pertaining to the various bariatric surgeries performed at the hospital. Information on relevant signs and symptoms and complications of bariatric surgeries are also contained in the reference folder. Throughout the orientation on the unit, the orientees are educated on working with the bariatric patient by the preceptor.

All healthcare staff on this unit are trained on how to order and utilize appropriate equipment, including clothing, chairs, commodes, beds, wheelchairs, lifts, blood pressure cuffs, scales, and sequential compression devices. The bariatric surgeons provide in-services to all staff on the floor at least biannually and on an as needed basis.

What trends do you see emerging—including new technologies as well as what patients seem to be looking for?
Patients will continue to seek minimally invasive surgery and quicker recovery times. Patients are becoming increasingly educated and do research to find centers of excellence with the best overall results. Lap Band is generating more interest from the public and likely will continue to increase market share. As more patients undergo bariatric surgery, the demand for revisional procedures will continue to increase.

Describe one of your most interesting patient cases.
A 49-year-old female, who lived out of state, had been told she was too high risk for gastric bypass surgery related to underlying medical illness. She attended a lecture in her hometown by Dr. McCullough from the Beaumont Weight Control Center and became interested in our program. At the time she came to our program, she was 5’7” and weighed 259 pounds, corresponding to a BMI of 41. Additionally, the patient had associated medical conditions, including hypertension, obstructive sleep apnea, psoriatic arthritis, and gastroesophageal reflux disease. Ultimately, the patient underwent laparoscopic gastric bypass. She achieved a 125-pound weight loss at 1.5 years and her weight-related medical problems have resolved.

Describe one of your most difficult patient cases.
A 52-year-old female who underwent open gastric bypass surgery seven years ago at another hospital came to our program with complaints of weight regain and gastroesohageal reflux symptoms. At the time of her first surgery, she was 5’0” and weighed 250 pounds, corresponding to a BMI of 48. She successfully lost almost 100 pounds with her initial surgery; however, she had regained all of her lost weight. An upper GI series and EGD demonstrated a large gastrogastric fistula. The patient came to our hospital and a laparoscopic revision of gastric bypass, and lysis of adhesions was performed. The surgery was challenging related to the extensive scar tissue from prior open abdominal surgeries. The patient recovered uneventfully and has achieved a 65-pound weight loss at one year and complete resolution of her gastroesophageal reflux symptoms.

What makes your facility unique?
The bariatric program at our facility has focused specifically on minimally invasive surgery since its inception in 2001. More than 1,900 almost exclusively laparoscopic procedures have been performed with very low major complication rates versus national standards. At Beaumont Hospital, we are positioned to provide the highest level of care through our trained multidisciplinary staff caring for the bariatric patient. The hospital has committed to the educational background and equipment necessary for the care of this challenging group of patients. We have a creative and active multidisciplinary approach to program development and care delivery standardization via our very active Persons of Size Committee. We have committed to the selection and support of outstanding bariatric surgeons, nurses, care managers, and support staff as well as continue our quest to increase our case volumes with demonstrated stellar outcomes.

How does your bariatric program collect data to measure and improve the quality of surgical care?
The ACS National Surgical Quality Improvement Program (ACS NSQIP) is the first nationally validated, risk-adjusted, outcomes-based program to measure and improve the quality of surgical care. The program employs a prospective, peer-controlled, validated database to quantify 30-day, risk-adjusted surgical outcomes, which allows valid comparison of outcomes among all hospitals in the program. Participating hospitals and their surgical staff are provided with the tools, reports, analysis, and support necessary to make informed decisions about improving quality of care.

As a requirement for being a Bariatric Center of Excellence through the ACS, we participate in the Bariatric Surgical Center Network program. The network will look at bariatric surgical patient outcomes at 30 days, six months, one year, and annually.

Beaumont Hospital has joined other hospitals in Michigan to form the Michigan Bariatric Surgical Collaborative (MBSC). This group is a regional, voluntary consortium of hospitals and surgeons who perform weight loss surgery. The MBSC has organized a prospective database to study bariatric surgery outcomes in the state. The goal of the project is to improve the quality of care for patients by identifying practice patterns associated with better outcomes.

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