Penn Metabolic and Bariatric Surgery Program at the Hospital of the University of Pennsylvania Philadelphia, Pennsylvania

| July 22, 2011 | 0 Comments

by Jim Henry, RD, LD/N, and Noel N. Williams, MD, FRCSI
Jim Henry is the Bariatric Program Coordinator, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania. Dr. Williams is a surgeon at the Hospital of the University of Pennsylvania.

Bariatric Times. 2011;8(7):16–18

Welcome to the Penn Metabolic and Bariatric surgery program at the hospital of the university of pennsylvania
With more than 20 years of experience in weight loss surgery, the Penn Metabolic and Bariatric Surgery Program offers individuals with severe obesity the latest surgical procedures as tools to achieve a healthy lifestyle. Penn’s multidisciplinary teams of specialists include surgeons, bariatricians, nutritionists, nurses, and psychologists who are leaders in the field of obesity treatment. Working in collaboration with experts in cardiology, endocrinology, anesthesiology, and sleep medicine, this team provides candidates for weight loss surgery with exceptional care before and after surgery.
Our Staff
Our program at the Hospital of the University of Pennsylvania has three surgeons on staff: Noel N. Williams, MD, FRCSI, Director, Penn Metabolic and Bariatric Surgery; Kristoffel R. Dumon, MD, FACS; and Steven E. Raper, MD, FACS.
Other staff members include the following:

1.    One program coordinator. The program coordinator provides continuity in the clinical and administrative care of bariatric surgery patients. Responsibilities include expediting the admissions process for physicians, individualizing patient and family education, coordinating the delivery of services to the patient by planning with the multidisciplinary team, ensuring current and accurate communication with the physician and other healthcare providers, and coordinating the development of processes to optimize patient outcomes.

2.    Two outpatient nurse practitioners (NPs). The outpatient NPs function as advanced practice, professional consultants to the physician to assure the best possible patient care is provided. They review all preoperative medical clearances, perform routine history and physicals, and order necessary medical clearances and medications as needed. They conduct their own postoperative nursing office hours in conjunction with our registered dietitians to ensure our patients have long-range follow up and medical care. NPs at Penn conduct monthly bariatric support groups and act as co-leaders with our dietitian staff.

3.    Two inpatient NPs. The main responsibility of the inpatient NPs is acute care of bariatric patients immediately after their surgery. This involves daily patient rounds, patient education, and discharge planning. Our inpatient NPs liaise with our outpatient NPs to identify any potential patient issues that may cross over from the out-patient arena to the in-patient side and vice versa. In addition, our inpatient NPs perform our adjustments during our adjustable gastric band clinic.

4.    One outpatient registered nurse. This nurse triages our patient phone calls, schedules patient’s adjustment visits for our adjustable gastric band population, and is involved with seeing patients during our pre- and postoperative office hours.

5.    Four outpatient registered dietitians (RDs). These RDs function as advanced practice, professional consultants to the physician to assure cost-effective, high-quality, and current nutrition practices for this specialized patient population. They perform nutrition assessments, develop specialized nutrition care plans, and perform ongoing reassessments of nutritional status and nutrition interventions. In conjunction with our medical providers, the RDs run the pre-operative medical weight management program for our patients and teach group nutrition classes on a weekly basis. In addition, they conduct monthly bariatric support groups and act as co-leaders with our out-patient nursing staff.

6.    Five outpatient clinical psychologists. All of our patients receive their preoperative psychological clearance with our team from the Penn Medicine Center for Weight and Eating Disorders. This group of specialists assesses the causes of a patient’s weight problem, determines its medical and psychological consequences, and then plans a personalized program to help him or her reach his or her postoperative goals. They also remain available for our postoperative population for continued therapy and emotional support.

7.    One database coordinator. The database coordinator is responsible for all Bariatric Outcomes Longitudinal Database (BOLD) entry and compliance in coordination with the Surgical Review Corporation (SRC) requirements.

Our Facility
Recently, we opened our new bariatric office space in the Perelman Center for Advanced Medicine in Philadelphia, Pennsylvania. Our new office space contains 16 bariatric-friendly exam rooms, all equipped with bariatric-grade chairs, exam tables, gowns, and medical equipment. We conduct all of our bariatric information sessions and two out of three support groups in this office space. We share a floor with Penn Rodebaugh Diabetes Center, and our clinical psychologists from the Penn Medicine Center for Weight and Eating Disorders see all bariatric patients in our new office. Having these two important specialists located within close proximity makes it easy for our patients to maneuver through their medical care.

In the hospital, we have bariatric-designated operating rooms as well as an anesthesia team. We also have a designated bariatric patient floor on Rhoads Pavilion, 4th floor Hospital of the University of Pennsylvania, where all of our postoperative patients receive care. The nursing staff on four Rhoads is specifically trained to care for the bariatric population, which, as a result, helps speed patients recovery time and reduces the length of stay. Four Rhoads also has bariatric-grade beds, reclining and upright chairs, gowns, medical equipment, and ceiling-mounted lifts.

Patient Demographics
Each year, our facility performs roughly 700 consultations for surgery and performs roughly 400 primary bariatric cases. Approximately 50 percent of cases performed are laparoscopic Roux-en-Y gastric bypass (RYGB), 25 percent are adjustable gastric bands, and 25 percent are laparoscopic vertical sleeve gastrectomy (SG). Approximately 77 percent of our patient population are women and the remaining 23 percent are men. The average patient has a body mass index (BMI) of 46kg/m2 and is 46 years old.

An American Society of Metabolic and Bariatric Surgery Center of Excellence
The Penn Metabolic and Baiatric Surgery Program is a designated American Society of Metabolic and Bariatric Surgery (ASMBS) Center of Excellence (COE). Recently, we went through the process of recertifying our center. This was a daunting task, but it was very rewarding as well. Preparing for COE recertification allowed us to internally evaluate our program and gave us the insight on areas of program improvement. We have an interdisciplinary committee that meets routinely and whose mission is to continually improve our program and maintain our focus on patient care and successful outcomes.
It is rare that a patient will ask about the ASMBS certification; however, patients will ask whether we are a COE or center of distinction as designated by their health insurance carrier.

Patient Adherence and Long-term Follow Up
To help ensure patient adherence, we try to make the preopeative process as smooth as possible. We try to schedule patients medical clearances for them and we make every effort to group appointments so patients have to take less time off from work. Our preoperative medical weight management program not only prepares patients for the nutritional aspects of surgery, it also allows us to have face time with patients to make sure they are not having any difficulties in completing their preoperative medical clearances.

Postoperatively, we have a rigid pathway for patients to follow. Our patients are seen 7 to 10 days after surgery, then at six weeks, three months, six months, one year, and annually following surgery or as needed. Patients who undergo adjustable gastric banding are instructed to come back to the office or at least call every six weeks to check their nutritional status and discuss their current state of restriction with the band.

We conduct monthly adjustable gastric band support groups, general support groups, and graduate support groups. These groups are conducted in the evening or on Saturday mornings. We also direct patients to our website,
bariatric, for additional information and conduct a weekly web blog with our patients at

Patient adherence. Our biggest complication with patient adherence seems to be within the patient population who undergoes adjustable gastric banding.  We make every effort to stay in contact with this patient population so they can receive proper care and adjustments of their bands; however, some patients do not participate in their postoperative care diligently enough to see proper weight loss results. In addition, we have observed that the further patients are from surgery, roughly 3 to 4 years postoperative, the more difficult it becomes to reach them for annual visits.

Technologies, Equipment, Devices, and Products
Currently, we use Epic electronic medical record software (Epic Systems Corporation, Inc., Verona, Wisconsin) in our practice and across our health system. This electronic medical record (EMR) system has helped speed up the medical clearance process for our patients because as soon as a patient completes his or her consultation with a specialist in our health system, we have immediate access to the medical documentation. In addition, all telephone and written communication with patients and physicians is accessible in the patients’ EMR charts for the entire medical staff to utilize. As a result, communication between the medical staff and with patients is more transparent. However, access to the patients’ EMR charts is only granted to those practitioners and medical staff who are directly involved with the patients’ care to maintain compliance to Health Insurance Portability and Accountability Act (HIPPA) at all times.

Procedure Scheduling and Inventory Management
The bariatric surgery scheduler handles our direct coordination of procedure scheduling. To help organize and track a patient’s progress, we have a detailed Microsoft Access database that was developed by our database coordinator. Our medical assistant is responsible for ordering all bariatric office equipment, gowns, and adjustment needles required for the adjustable gastric banding procedures.

Managed Care
Every patient’s initial consultation for bariatric surgery consists of seeing 1) a registered dietitian who evaluates the patient’s current diet and knowledge of nutrition, 2) a nurse practitioner who completes a history and physical exam, and 3) the surgeon who discusses the best surgical option, risks, and benefits of surgery. After each detailed consultation, the bariatric team devises the best preoperative path for each individual patient to follow. As patients complete their pre-operative medical clearances, high-risk patients are identified and recommended for further medical work-up. Our high-risk patients are then presented at our monthly Bariatric Review Board meeting, which is attended by our bariatric surgeons, NPs, program coordinator, anesthesiologists, cardiologists, and psychologists. We present the patient’s medical history, surgical history, physical examination findings, consultation reports, weight history, and current physical status to the Board. The Board then makes a recommendation as to whether or not the patient should proceed with surgery.

Cost and Efficiency
In the fall of 2010, we consolidated all outpatient bariatric surgery across the health systemcare to our new facility in the Perelman Center for Advanced Medicine. Now bariatric patients from our sister hospitals, Pennsylvania Hospital and Penn Presbyterian Medical Center, cohort their outpatient care in the bariatric suite at the Perelman Center for Advanced Medicine. As a result, the standard of care is consistent regardless of where the patient has surgery within the health system. In addition, staffing resources are focused in the Perelman Center and not spread across three hospital campuses.

Patient/Caregiver Safety and Education
The Penn Medicine Health System has a Safe Patient Handling Committee that examines all aspects of safe patient handling both inpatient and outpatient. The Safe Patient Handling Committee is responsible for installing ceiling-mounted lifts in every patient room at the Hospital of the University of Pennsylvania. In addition, this committee works with nursing leadership to educate the nursing staff on proper patient movement techniques and equipment use.

All new employees are assigned to shadow a staff member with similar duties or qualifications during their entire orientation process to become comfortable with the daily work flow. New employees observe every stage of the process though which a patient goes through in order to have surgery. We also conduct quarterly in-service education for the out-patient, operating room, and inpatient staff. Employees are also encouraged to attend at least two bariatric-related conferences each year.

Emerging Trends
The biggest trend we see emerging from observation at our facility is the popularity among patients wanting and receiving a laparoscopic vertical SG. Many patients view the vertical SG as a safer alternative to the RYGB. They are also attracted to the fact that vertical SG requires less postoperative visits compared to required routine adjustments with the adjustable gastric band.

A Unique Facility
Penn is committed to delivering comprehensive care and providing every patient with the tools for long-term success. Penn bariatric teams ensure that patients receive treatment designed to help achieve their weight loss goals and improve their overall health. In keeping with that commitment, Penn’s physicians, dietitians, and nurses develop personalized care and education plans and provide ongoing support services. This combined expertise enables the Penn Metabolic and Bariatric Surgery Program to offer patients the best chance for long-term weight loss success.

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Category: Bariatric Center Spotlight, Past Articles

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