A Physician Assistant’s Role in Development of the Bariatric Surgery Clinical Care Pathway at Southern Maine Health Care

| June 1, 2022

by Jillian Marden, PA-C

Mrs. Marden is with Southern Maine Health Care in Biddeford, Maine.

Funding: No funding was provided for this article.

Disclosures: The authors report no conflicts of interest relevant to the content of this article.

Bariatric Times. 2022;19(6):8


The prevalence of obesity is increasing in the United States (US) and worldwide. According to the Centers for Disease Control and Prevention (CDC), in 2020, 31 percent of adults living in Maine had obesity.1 Bariatric surgery is a well-established treatment for obesity and its related metabolic comorbidities. With advances in technology and improvement in long-term success, there has been a marked increase in the demand for bariatric surgical procedures.2 The most commonly performed bariatric surgeries today are the sleeve gastrectomy and Roux-en-Y gastric bypass.3 From 2019 to 2021, the number of these surgeries performed at Southern Maine Health Care increased four-fold.

In the late 1980s, clinical care pathways were developed to improve healthcare delivery and quality and to minimize healthcare costs.4 Although no single definition for a clinical care pathway exists, five criteria have been suggested:

  1. Is a multidisciplinary plan of care
  2. Translates guideline or evidence into local structures
  3. Uses a plan, pathway, algorithm, guideline, protocol, or other “inventory or actions;”
  4. Has timeframe or criteria-based progression
  5. Standardizes care for a specific clinical program, procedure, or episode of healthcare in a specific populations.5 

Early adoption of these principles was seen in colorectal surgery with the initiation of enhanced recovery after surgery (ERAS) protocols. ERAS protocols are multimodal clinical care pathways with the common goal to standardize perioperative care and decrease length of hospital stay and morbidity.3 Over time, these protocols have been implemented in many different surgical disciplines. In 2016, the ERAS Society published evidence-based guidelines for the perioperative care of patients undergoing bariatric surgery.2 The value of clinical care pathways for standardizing care is now well recognized in bariatric surgery. The Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) requires adherence to and maintenance of clinical care pathways for program accreditation.4 

From early on, the bariatric program at Southern Maine Health Care has followed recommendations from the American Society for Metabolic and Bariatric Surgery (ASMBS) and the American College of Surgeons (ACS). With inclusion of ERAS principles, as well as clinical care pathways established by MBSAQIP, our program goals are focused on improving patient outcomes, specifically reducing surgical complications, morbidity, and hospital length of stay, while enhancing the quality of patient care and reducing healthcare costs. 

Despite clearly defining our program goals, it was evident that variations in clinical performance remained. This is where I will insert myself, a physician assistant (PA) in the bariatric program at Southern Maine Health Care, into the narrative. In addition to assisting our surgeons in the operating room, I am responsible for managing our patient’s postoperative care. This includes entering postoperative orders. I found numerous versions of a postoperative order set available for use within our electronic medical records (EMR). Fortunately, I discovered that most of my colleagues were using the same order set. However, within this order set, individual providers were selecting different orders for “standard” postoperative care. For example, one provider ordered enoxaparin sodium for postoperative deep vein thrombosis (DVT) prophylaxis, while another ordered heparin. Similarly, some patients were ordered oral acetaminophen immediately following surgery, while others were ordered two doses of intravenous (IV) acetaminophen prior to administration of oral acetaminophen. Although these patients were receiving care in accordance to our program goals, clinical performance variations were present. 

To address these concerns, our team came together to discuss these performance variations. We were able to successfully agree on standard orders that would be applicable to the majority of our postoperative patients. Once finalized, I worked with the EMR development team at Southern Maine Health Care to create a new order set reflecting these standardized orders for postoperative care. As part of this process, we removed the other order sets available within our EMR. When the order set was finalized, we put it to use. This standardized order set drastically reduced the number of order selections available, therefore significantly decreasing performance variation between providers. Shortly after implementation, I received feedback from one of the medical-surgical nurses. She recognized fewer care discrepancies between patients. She also felt that her patient care had improved, as she was better able to determine when a patient was not following the standard postoperative course. With this positive feedback, our team moved forward to standardize our preoperative laboratory and discharge order sets.   

In an effort to further reduce clinical performance variation, we are digitizing the clinical care pathway for bariatric surgery at Southern Maine Health Care. This electronic clinical care pathway will integrate our standardized order sets with quality metrics and patient outcomes. When it is established that a patient is ready for surgery, a member of our team will open the bariatric surgery clinical pathway within the individual’s EMR. Then, the patient will complete the necessary pre-, peri-, and postoperative orders within the respective order set. The defined quality metrics and patient outcomes will be preselected based on the surgery to be performed. Orders will be released during the appropriate phase of care as the patient progresses through the clinical care pathway. 

To start this initiative, I worked with our team to define patient outcomes and quality metrics within each phase of care. Once obtained, I compiled details outlining where these data are found within the EMR. This information was shared with the EMR development team at Southern Maine Health Care. At this time, the standardized order sets have been combined with patient outcomes and quality metrics within the EMR. It is currently under review. We are hopeful that this electronic clinical care pathway will help us better meet our program goals by improving our healthcare delivery and quality while minimizing healthcare costs.

There are many ways for advanced practice providers to get more involved in bariatric surgery. This experience has been challenging but rewarding. It has allowed me to embrace my leadership skills in project management. It has also helped me to develop better time management in a busy bariatric surgery practice. I am excited to see where this project goes and am very optimistic that it will improve our patient care here at Southern Maine Health Care.

References

  1. Centers for Disease Control and Prevention. Adult obesity prevalence maps. https://www.cdc.gov/obesity/data/prevalence-maps.html#overall. Updated 27 Sep 2021. Accessed 21 Feb 2022. 
  2. Stenberg E, Fernando dos Reis Falcao L, O’Kane M, et al. Guidelines for perioperative care in bariatric surgery: enhanced recovery after surgery (ERAS) society recommendations: a 2021 update. World J Surg. 2022;46(4):752. 
  3. Malczak P, Pisarska M, Piotr M, et al. Enhanced recovery after bariatric surgery: systematic review and meta-analysis. Obes Surg. 2017;27(1):226–235. 
  4. Telem D, Majid S, Powers K, et al. Assessing national provision of care: variability in bariatric clinical care pathways. Surg Obes Relat Dis. 2017;13(2):281–286.  
  5. Ronellenfitsch U, Schwarzbach M, Kring A, et al. The effect of clinical pathways for bariatric surgery on perioperative quality of care. Obes Surg. 2012;22(5):732–739.

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