Tobey Hospital Bariatric Center: Wareham, Massachusetts

TELL US ABOUT THE ROLES AND RESPONSIBILITIES OF THE LEAD STAFF AT YOUR FACILITY.
Rayford Kruger, MD, FACS, is the lead gastric bypass surgeon and program director for the Tobey Hospital program located in Wareham, Massachusetts. Dr. Kruger began the program in January, 2004. He has performed more than 475 Roux-en-Y gastric bypass procedures to date. Thomas Streeter, MD, FACS, also performs gastric bypass surgery at Tobey Hospital. He has assisted in over 250 bariatric surgical cases since the program’s inception. Amy Olsen, MD, FACS, is a board-certified general surgeon who has special expertise in endoscopic surgery, including laparoscopic gastric bypass surgery, minimally invasive colon surgery, and surgical procedures to treat acid reflux and other esophageal problems. Emmet Eby, MD, FCCP, is the medical director of the Tobey Hospital bariatric surgery program. Dr. Eby provides medical clearance for all bariatric patients. Michelle A. Croft, RN, BSN, CBN, is the bariatric nurse coordinator. A member of the American Society for Metabolic and Bariatric Surgery (ASMBS), she became a certified bariatric nurse last June. Her responsibilities include patient education, nursing education, quality of patient care, team coordination, liaison between patients and surgeons, tracking and monitoring patient progress within the program, monitoring patient follow-up, and tracking patient outcomes.

Marjorie Borden, RN, is the case coordinator for bariatric surgery. She is a member of the Massachusetts Nurses Association. Her responsibilities include quality outcomes management, care management from pre-operative to post discharge, tracking and monitoring patient progress within the program, and serving as liaison between patient, family, and multidisciplinary team providing guidance, information, and resources for care. Natia Corsi, RD, Alex Carlin, RD, and Stacey Cordiero, RD, are clinical dietitians who provide nutritional consultation, evaluation, and education to all bariatric patients. All have undergone specialized training and education in nutrition education and counseling for the bariatric patient.

Anne Harris, PhD, is the bariatric program psychologist who has been in private practice treating couples and families and has specialized training in dealing with the psychological issues of bariatric surgery patients.

Suzanne Gokavi, MSW, LICSW, has a private practice as a psychotherapist with specialties in women’s issues, medical issues, and grief work, and has received specialized training for the behavioral health components of bariatric surgery patients. She runs preoperative behavioral workshops, and postoperative support groups, as well as provides psychological evaluations for bariatric surgery.

Maria Cruz, MSW, LICSW, has received specialized training in dealing with the psychological issues of bariatric surgery patients and provides psychological evaluations, preoperative behavioral workshops, and postoperative support groups.

Allen Johnson, MSW, LICSW, has specialized training in psychiatric care and substance abuse. He conducts preoperative evaluations and specializes in postoperative support groups for laparoscopic adjustable gastric band (LAGB) patients.

The operating room staff consists of a nurse manager, registered nurses, scrub technicians, health unit coordinators, and perioperative materials coordinator.

Tobey Hospital has a unit dedicated to the bariatric surgery patient. The bariatric floor staff consists of the nurse manager, registered nurses, nursing assistants, health unit coordinators, and nursing educator.

WHAT IS THE SIZE OF YOUR FACILITY? WHAT DOES IT PHYSICALLY ENCOMPASS?
Tobey Hospital is the Wareham site of Southcoast Hospitals Group, which is located in Southeastern Massachusetts. A 74-bed community hospital, Tobey opened its doors in 1940, and today offers area residents expanded medical specialties, state-of-the-art technology, and personalized patient care.

At Tobey, patients have access to sophisticated diagnostic testing and a 24-hour emergency room staffed by physicians who have specialized training in emergency medicine. Tobey’s medical staff includes specialists in cardiology, oncology, rheumatology, endocrinology, orthopedics, vascular surgery, pediatrics, obstetrical care and others.

In 2004, Tobey Hospital completed a $12 million renovation and construction project that complimented the launch of its bariatric surgery program. The Tobey Hospital project included three major components—a new surgical wing and highly sophisticated intensive care and post-anesthesia care units.

The new surgical wing also features two operating rooms called “I-suites” that are fully equipped with the latest high-tech instruments activated by voice as well as touch and computers that sit at the operating table and instantly show a patient’s lab tests or x-rays.

As part of Southcoast Hospitals Group, Tobey is linked to the region’s leader in healthcare services and offers a wide range of free, community health education and wellness programs, which includes a mobile health van.

How many patients are treated annually at your facility?
As our community grows, so does the demand for medical services. Last year Tobey had more than 4,000 discharges, 475 births, and 26,500 emergency room visits. Tobey has approximately 550 employees and 125 physicians on staff.

Since the creation of Southcoast Health System in 1996, surgical procedures at Tobey Hospital have increased by more than 20 percent, outpatient procedures have also risen by 20 percent, and significant growth is expected in both areas in the coming years.

Also contributing to growth is that many people have decided to seek their care locally rather than traveling to the nearest city, Boston. From general surgery to joint surgery to vascular surgery, Tobey is the perfect place for the most advanced medical procedures, without having to travel 45 minutes to an hour.

The close proximity of Southcoast Hospitals’ extensive network of local support services helps speed the rehabilitation and recovery process for surgical patients.

The Tobey Hospital bariatric surgery program has performed 212 Roux-en-Y gastric bypasses in 2007 and 481 since its inception. In December 2007, Tobey began offering laparoscopic adjustable gastric banding (LAGB).

The program’s bariatric patient population consists of the following:
• Surgery type: 481 Roux-en-Y gastric bypass
• Average BMI: 42
• Average age: 41
• Gender: 85% female, 15% male.

How is your facility managed and by whom?
Tobey Hospital, a not-for-profit charitable community hospital, is part of Southcoast Hospitals Group in Massachusetts. A full-asset merger, Southcoast Hospitals Group was formed in 1996 from the merger of Charlton Memorial Hospital in Fall River, St. Luke’s Hospital in New Bedford and Tobey Hospital in Wareham. Southcoast has one leadership team and a board of trustees. Southcoast Hospitals Group is part of Southcoast Health System, a community-based health delivery system with 40 access points, offering an integrated continuum of health services throughout Southeastern Massachusetts and East Bay, Rhode Island.

Our management structure at Tobey consists of a vice president and site administrator, a director of patient care services, who reports to the senior vice president and chief nursing officer for Southcoast Hospitals Group, and a nurse manger for each clinical area: perioperative services, obstetrics, emergency department and pediatrics, medical-surgical, and intensive care unit. The units have resource nurses who coordinate the care of patients and staffing for their individual units. Southcoast Hospitals Group has one president & CEO, chief operations officer, chief financial officer and chief medical officer for the three hospitals.

WHAT ARE SOME OF THE NEW EQUIPMENT, DEVICES, AND PRODUCTS INTRODUCED AT YOUR FACILITY LATELY?
Tobey Hospital’s newly built surgical wing features two operating room I-suites, which include state-of-the-art technology that includes 1188 Stryker digital cameras and an updated high-definition video system. The systems are activated by voice as well as touch and computers that sit at the operating table and instantly show a patient’s lab tests or x-rays.

Tobey also recently installed ceiling lifts as part of our hospital-wide rollout for the safe patient handling initiative. We also utilize the Hovermatt by Hovertech International in our operating rooms and patient units to transfer patients with ease. We have improved nursing documentation by recently beginning computerized documentation using the Meditech system. We have introduced wireless technology with portable laptops on wheels and PDAs, and we are also currently looking at interfacing our monitoring equipment.

How is procedure scheduling handled?
The staff in the surgeon’s office schedules the surgery with the operating room scheduler utilizing the Medical Systems Management , Inc. (MSM) software system. The MSM software averages the last 10 cases performed, dropping the low and high to determine the length of time for the case.

Please give a general synopsis of how your patients are treated while under the care of your center.
Bariatric surgery patients are treated with the utmost professionalism and respect as part of the Tobey Hospital program. The Tobey Hospital bariatric surgery program closely monitors its patients by embracing them pre-, inter-, and postoperatively. It is important that the patient is fully invested, educated, and screened before he or she undertakes surgery. Bariatric surgery at Tobey is not only a “commitment for life” for the patient, but for the bariatric surgery team as well, who is dedicated to all aspects of the patient’s care.

Preoperative. Usually patients become part of our program by word of mouth or by calling our surgical office looking for more information on having gastric bypass surgery.
Our office staff will direct our potential clients to attend a free informational seminar presented by one of our surgeons three times per month. Patients are offered material to review and are given the opportunity to ask the surgeons questions after the informational session. Interested patients are then guided to use our web-based registration process. Once they are registered, our office staff schedules a surgical consult. After meeting with the patient in person and conducting an exam, the surgeon will determine if the patient is a surgical candidate for the Tobey Hospital program.

The patient will then begin a series of mandatory consultations with our dietitians, psychologists, and licensed social workers.

Our registered dietitians start the patient on a weight loss program and review their post-surgical diet and eating behaviors. They also have two one-hour psychological evaluation appointments.

The patients then attend pre-operative behavioral workshops for approximately three months. These sessions are run by our psychology team and are limited to eight patients. Once the patient is in a workshop, he or she will see our pulmonologist for medical clearance.

At this point, if the patient is found to need any further tests, the pulmonologist will order them. They will also have an appointment with the nurse for a one-hour, one-on-one meeting to review the risks and benefits of surgery, learn what to expect during their hospital stay, take a quiz, sign a contract, review the handouts, and answer questions if needed. We encourage all patients to bring a family member to this visit.

Surgery. The patients arrive on the day of their surgery and are welcomed by a surgical day nurse. These nurses have made contact with the patient by phone a few days prior to the surgery date to review and update the health history in the patient’s chart. The surgeon, anesthesiologist, and OR nurse also meet with the patient. After surgery, our patients will go to our dedicated unit for gastric bypass patients and will be monitored closely overnight. Our nurses have clear physician order parameters and frequent education to maintain superb quality of care to our patients. Our nursing staff is complimented repeatedly by our patients regarding the quality of care they receive as inpatients, and this is reflected in our patient satisfaction surveys.

The patients advance to a full liquid diet on Day 2, and then they are discharged in the late afternoon.

Postoperative. The patients have contracted to follow-up with their surgeon one week, six weeks, three, six, nine, 12, 18, and 24 months and then annually for five years. Fortunately, being a small community-based hospital program it is easier for the patient to commit to the visits because it is so close to home.

The patients are also strongly advised to attend monthly postoperative support group meetings. Two meetings a month are run by our dietitians and five psychological support groups are run by our psychology staff. These meetings are free and are strongly encouraged.

HOW IS INVENTORY MANAGED IN YOUR FACILITY?
Southcoast Hospitals Group operates under one hospital license. Its materials management and purchasing department works with the perioperative materials coordinator on inventory management. Supplies are monitored and twice-a-week the inventory is checked and supplies are ordered as needed. An online scan system is utilized to issue purchase orders to the buyer in purchasing. The two methods of inventory management that are used are the perpetual inventory method and the just-in-time stockless process.

Has your facility recently expanded in size and patient volume?
With the introduction of a third surgeon and the introduction of laparoscopic adjustable gastric banding (LAGB) in December, 2007, we anticipate an increase in volume. Plans include relocating the bariatric unit to a renovated surgical floor with private rooms available in late 2008 or early 2009.

What measures has your facility implemented in order to cut or contain costs and improve efficiency?
As mentioned, Southcoast Hospitals Group operates under one hospital license. This in itself helps to cut costs, ensure efficiencies, and monitor overall quality and safety initiatives.

Cost containment while providing quality care is necessary in healthcare today. To cut costs, our facility has purchased more bariatric beds rather than renting, and to improve efficiency we have a designated floor for bariatric surgery patients where we utilize a critical pathway. The average length of stay for bariatric surgery in fiscal year 2007 was 2.25 days. Our overall inpatient hospital stay at the facility for fiscal year 07 was 2.8 days.

Does your facility have an outpatient program?
No, but we do offer outpatient nutritional and psychological support along with support groups.

How are new employees oriented and trained at your facility?
Our hospital orientation begins with a three-day system orientation program, including human resources orientation, nursing core orientation, and computer training. An additional day of system orientation and site-specific orientation is also provided. The educator also meets with the orientees to review the program and provide sensitivity training. Nurses on the bariatric floor are required to take a 12-hour basic arrhythmia class.

New employees are placed with a preceptor for up to 12 weeks of orientation. The orientation is competency-based. The orientee is given an orientation packet with a unit competency-based skills checklist, gastric bypass competency check list, education record, pertinent unit-specific competencies, and post-tests. The patient is also given a bariatric surgery packet, which is reviewed and contains information on the clinical pathway, diet, nursing care, sensitivity, and statistics and results from the program. Patients are also given the opportunity to schedule time in the operating room to observe a gastric bypass surgical case. Staff is also encouraged to attend support group meetings.

What are your strategies for retaining and motivating staff, and what continuing education opportunities are provided to staff members?
Strategies consist of providing annual education updates and results from the program to nursing staff. Annual education updates are provided by the surgeon, bariatric nurse coordinator, registered dietitian, and educator. Any new information or changes to existing policies, procedures, documentation, and protocols are reviewed with nursing staff. Another strategy for motivating staff was the formation of a bariatric care team to look at the environment, including physical layout and furniture throughout the hospital, equipment, safe patient handling, and patient sensitivity. Additional members of the bariatric care team include nursing, respiratory, lab, purchasing, radiology, pharmacy, maintenance, and admitting. This has been a great motivator for staff throughout the hospital to participate not only in caring for bariatric surgical patients, but bariatric medical patients as well.

Another educational opportunity we have provided for several years is sending members of the nursing staff to the annual Bariatric Summit for the comprehensive management of severe obesity, located on Amelia Island, Florida. At this annual three-day conference, the nursing staff is joined by the surgeons, registered dietitians, bariatric nurse coordinator, psychologist, and social workers. This is not only a great educational experience, but also helps to promote teamwork. The hospital has fully supported this educational program.

How is staff competency evaluated?
The preceptors on the unit evaluate staff competency. Along with the unit’s competency-based skills checklist, a bariatric surgery competency skills checklist is utilized. The skills required to care for the gastric bypass and band patient are defined and include diet, prevention, and identification of postoperative complications, pain management, activity, drain removal, wound care, special equipment, and documentation. We utilize direct observation, verbal explanation, record review, peer review, and testing to accomplish this. Annual competency is assessed at our unit skills day held each fall.

Please describe your patient education program.
Patient education is based on the team approach of our program and is one of our top priorities. It begins with free informational sessions given by the surgeon. This detailed presentation outlines the pros and cons of having surgery, along with a video that is shown explaining bypass and band procedures.

Patients are then evaluated and educated by the dietitian with two 90- minute preoperative visits. The dietitian will schedule more visits if needed. Psychological evaluation comes next with two one-hour visits. The patients then attend preoperative behavioral workshops, which consist of four classes in one month.

Each class is designed for the patient to explore his or her relationship with food, help to design goals, explore new coping skills, and discuss long-term success. During the workshop, the group leaders reinforce the guidelines and commitment to our program and what we expect their roles to be as our patients. The patient will meet with the registered nurse and review hospital stay, risks (early and late), benefits, diet, medications, supplements, and paperwork and handouts. Our surgeons see our patients every 4 to 6 weeks preoperatively. This allows patients to ask questions frequently and to develop optimal communication between the surgeons and themselves.

Our bariatric inpatient nursing staff continues patient education during their hospital stay. The nurses are able to reinforce diet, wound care, activity level, signs and symptoms to report, and supplementation. The nurses are given resources and education to help ensure quality of care. Nurses are also offered to attend conferences yearly.

Post-surgery patient follow-up is an essential part of the program and is strongly encouraged. We firmly believe that our patients will have better long-term success with support. We offer five postoperative support groupsand two dietary support groups per month. We discuss and encourage attendance of these meetings from the first day we meet with our patients. Our psychologist facilitates the groups, which are well attended, and has planned topics for each session. They also incorporate guest speakers and take home materials.

Another key message for our patients is that “The nurse is a telephone call away.” We try to encourage our patients to call with any questions or concerns to maintain a connection and feeling of being truly cared about. We also recommend dietitian visits as needed postoperative along with one-on-one psychological visits if needed.

What long-term follow-up measures are practiced at your facility?
Tobey Hospital utilizes the Exemplo database. The online system is used by all of our team members. A database assistant, along with office staff, physicians, psychologists, dietitians, and OR nurses will enter patient information and updates as appropriate. This system helps identify what actions for what patient may be needed. We also systematically review our postoperative patients’ records and actively seek them out if they are overdue for follow-up visits or if there are physician or team concerns. Dr. Kruger also has presented to the primary care physicians in the surrounding areas to assist in educating them of possible later complications, nutritional deficiencies, and the follow-up protocol of our program.

Does your facility utilize any alternative therapies?
The hospital has a policy in place that all nurses practicing accepted complimentary therapies must be employed by us and credentialed prior to being allowed to apply any of the therapies in direct patient care. Therapies include therapeutic touch, reiki, massage therapy, aromatherapy, guided imagery, and meditation.

What quality control assurance measures are practiced in your facility?
All complications, including infections, returns to surgery, leaks, deep vein thromboses, pneumonias, unplanned readmits within 30 days, and mortalities are presented on a monthly basis at the department of surgery, as well as at our quality and utilization committee. This information is also shared with our board quality committee. (Board of Trustees members are on this committee.) We utilize the Exemplo bariatric database to track patient data.

What trends do you see emerging?
We expect to see an increase in the number of restrictive procedures with LAGB. We also expect to see an increase in patient volume.

What makes your facility unique?
Tobey Hospital’s bariatric surgery program has created a dynamic team approach to which health promotion, changing behaviors, surgical treatment, and continued outreach achieves optimal outcomes and long-term patient satisfaction.

Our support groups have an extremely high rate of attendance and are held several times a month by a psychologist and a team of social workers. We have three registered dietitians who also follow patients closely. The nurses on the unit receive special education along with observation of the Roux-en-Y gastric bypass procedure in our operating room. We are helping people through a life challenge with incredible benefits. Our patients are close to home and they feel they are part of a growing family. Because we are a community-based program, we are able to offer highly personal, individualized care to our patients. In addition, in December, 2006, Southcoast Hospitals was designated a Center of Excellence by the American Society for Metabolic and Bariatric Surgery.

Tags: Bariatric Center Spotlight

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