Relocation of the Postoperative Bariatric Surgery Patient

Column Editor: Laura Boyer, RN, CBN
President of the Integrated Health Section of the  ASMBS; Director of Clinical Systems for The Surgical Specialists of Louisiana in Covington, Louisiana

This column is dedicated to covering a variety of topics relevant to the multidisciplinary care of the bariatric surgical patient.

This month’s column by Karen Schulz, RN, CNS, CBN

Ms. Schulz is from University Hospitals Case Medical Center, Cleveland, Ohio; and is President Elect of the ASMBS Integrated Health Section.

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

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

Bariatric Times. 2011;9(2):26–27

ABSTRACT
In this article, the authors provide guidelines for bariatric practices on transferring postoperative patients to other healthcare providers, such as other bariatric centers and primary care physicians, after a patient has moved to another location. They discuss considerations in transferring relocated patients postoperatively including, education, nutrition management, procedure-specific risks, emergency care, and communication between the patient and his/or her past and present healthcare providers.

Introduction
In 2010, 37.5 million people changed residences in the United States.[1] Of those, 29 percent moved to another county or state.[1] Our transient United States population makes it likely that each year bariatric surgery programs will lose and acquire several patients. With the increasing number of bariatric procedures done each year in the United States and abroad, it is helpful to have a plan in place for how to handle patient transfers.

It is well established in the bariatric literature that the collaboration between a multidisciplinary team of nurses, nutritionists, physicians, psychologists, exercise specialists, and support group facilitators is important for the long-term safety and success of the bariatric surgical patient.[2–4] Some patients understand the importance of adherence to a bariatric program for safe surgical outcomes and weight loss, while other may not consider life-long care in the case that they move to another location.

In order to protect both the clinician and the patient, it is important to include and document lifetime follow-up recommendations. The components of the lifetime follow-up program should be specifically documented with a copy provided to the patient preoperatively and again at the time of transfer to a new facility.

In this first installment of “Hot Topics in Integrated Health,” we list and discuss potential items the clinician might want to consider in a plan for transferring bariatric patients to other healthcare providers.

Patient education. Patients should understand that management is best provided by an individual or group knowledgeable in the field of bariatric surgery.  This care is best provided by a nationally certified bariatric center or primary care physician (PCP) with specialized education in bariatric surgery. In October 2001, The American Academy of Family Physicians published an article on post-obesity surgery patient care. The authors stated, “post surgical medical management with nutrition and exercise support are valuable roles for the family physician”[5]

Nutrition management. In addition to following the prescribed postoperative bariatric surgical diet, specific vitamin recommendations and routine laboratory markers are considered crucial items for management.[3] Although a new provider may make alterations in monitoring based on the medical condition of each patient, patients transferring out of a practice should leave with a list of the recommended daily vitamins and a schedule for laboratory testing. It is also helpful to have documentation that patients attended the preoperative nutrition education classes and received a written plan for nutrition and behavior modification from the facility they are leaving. At the time of transfer, patients should be offered another copy of written instructions.

Women of childbearing age should be advised preoperatively that pregnancy is not recommended for 18 months to two years post surgery when weight loss has stabilized. Women of childbearing potential should also be advised that in the event of future pregnancy, it is important to notify their obstetrician/gynecologist (OB/GYN) of their bariatric surgery as there is a need for increased vitamin and calorie intake that can be potentially challenging.

Procedure-specific risks. When transferring care of the bariatric surgery patient, it is also important to communicate any procedure-specific recommendations. For example, providers caring for patients who have undergone gastric bypass should know that anti-inflammatory medications should not be taken without a proton pump inhibitor as there is increased risk of anastomotic ulcer. Care providers should also understand the new anatomy and how it may affect future diagnostic procedures. Physicians should also be informed of the potential risk for internal hernia after laparoscopic gastric bypass.

Gastric band patients should be transferred with a copy of their operative note, last esophagogastroduodenoscopy (EGD) or esophagram, and record of band fills.  New care providers should understand potential risks for gastric band slippage, erosion, or device failures.

Emergency care. Patients who are educated about the importance of locating a care provider during transfer should also be counseled to identify the nearest medical facility with a designated bariatric surgery program. To avoid errors in diagnosis and treatment, bariatric surgical patients should know that future episodes of difficulty eating or epigastric or abdominal pain are best evaluated in facilities that are familiar with bariatric surgery.[6]

In some instances, patients have reported that physicians have been hesitant to treat bariatric patients from other programs, especially in emergency situations. The Federal Emergency Medical Treatment and Active Labor Act (EMTALA) was enacted by Congress in response to hospitals who refused to care for patients who could not afford to pay, but does not require physicians render care to patients they feel are outside the physician’s area of expertise.[7] A recent discussion with Robin Blackstone MD, FACS, president of The American Society for Metabolic and Bariatric Surgery (ASMBS), regarding emergency care of bariatric patient revealed that the ASMBS is currently working on a program to educate nonbariatric physicians. When interviewed for this article, Dr. Blackstone had the following comments:

“The Society supports the education of nonbariatric general surgeons in bariatric emergencies, and these courses are being planned for the SAGES and ACS meetings this year. Most patients will be able to be stabilized and sent to a hospital with a bariatric program; however, all general surgeons should be able to intervene in an acute, unstable patient in consultation with a bariatric surgeon. It is important for hospital emergency departments to establish relationships with a higher level of bariatric care when expert help is needed. This should be done in advance of an emergent case so that the process is smooth and optimal for the safety of the patient.”

The method of documentation for bariatric surgery recommendations can be in a variety of formats. In addition to our surgical consent form at University Hospitals Case Medical Center, we give patients a written quiz documenting their comprehension of the education program. Patients are also given a wallet card with their procedure, surgeon’s name, and contact phone number in case of emergency. It is also prudent to document the patient receipt of educational materials that include dietary and behavioral recommendations.

Summary
Comprehensive lifetime care is essential for optimal bariatric surgery outcomes. When relocating a distance from the originating bariatric program, it is important patients are provided with a transfer plan. The plan should be well documented and communicated both verbally and in writing to the patients. Patients should understand it is essential to locate a physician and hospital with expertise in the management of the bariatric surgery patient. Establishing communication with the downstream healthcare provider is also important for data collection purposes. The new primary care provider should be informed that long-term data is needed on their patient for the national bariatric database. Any assistance the bariatric team can give patients in locating a competent facility will improve chances for success and quality long-term follow-up care.

References
1.    Census Bureau Reports Housing is Top Reason People Moved Between 2009 and 2010. http://www.census.gov/newsroom/releases/archives/mobility_of_the_population/cb11-91.html. Accessed January 12, 2012.
2.    Mulligan A, McNamara A, Boulton H, et al. Best Practice Updates for Nursing Care in Weight Loss Surgery. Obesity. 2009;15(5):895–900.
3.    Allied Health Sciences Section Ad Hoc Nutrition Committee. Aills L, Blankenship J, Buffington C, et al. ASMBS Allied Health Nutritional Guidelines for the Surgical Weight Loss Patient. Surg Obes Relat Dis. 2008;4(5 Suppl):S73–108.
4.    McMahon M, Sarr M, Clark M, et al. Clinical management after bariatric surgery: value of a multidisciplinary approach. Mayo Clin Proc. 2006;81(10 Suppl):S34–45.
5.    Johnson NS, Schroeder R, Garrison JM. Treatment of adult obesity with bariatric surgery. Am Fam Physician. 2011;84(7):805–814.
6.    Clinical Issues Committee of the American Society for Metabolic and Bariatric Surgery. ASMBS position statement. American Society for Metabolic and Bariatric Surgery Position Statement on emergency Care of Patients with Complications Related to Bariatric Surgery. Surg Obes Relat Dis. 2010;6(2):115–117.
7.    Katz L, Paul M. When a physician may refuse to treat a patient. Physician’s News Digest. February 2002. www.physiciansnews.com/law/202.html. Accessed January 24, 2012.

Category: Hot Topics in Integrated Health, Past Articles