Unity Hospital Bariatric Center: Fridley, Minnesota

TELL US ABOUT THE ROLES AND RESPONSIBILITIES OF THE LEAD STAFF AT YOUR FACILITY.
The Unity Hospital Bariatric Center has three dedicated bariatric surgeons, specially trained bariatric nurse clinicians, bariatric dietitians, a bariatric exercise specialist, and multiple support groups. The center was started in July, 1996, when Dr. Daniel R. Baker submitted a proposal for a model program development initiative in cooperation with Unity Hospital. He wanted to serve the unique needs of individuals whose genes and/or lifestyle made them morbidly obese—and who would benefit from gastric restrictive surgery. Early on, Dr. Baker recognized that along with preoperative evaluations and care, there was a need for these patients to have short-term and long-term postoperative services that assured successful recovery, weight loss success, and long-term wellbeing.

Our primary team consists of the following:
• Team leader and bariatric surgeon: Dr. Daniel Baker
• Program manager: Janet Rudlong, RN
• Medical director and surgeon: Dr. Fredrick Johnson
• Bariatric surgeon: Dr. Jeffrey Baker
• Five bariatric nurse clinicians
• One bariatric physician assistant
• Bariatric exercise coordinator.

Ancillary team/support members consist of the following:
• Preoperative case manager
• Postoperative case manager
• Pharmacists
• Dietitians
• Smoking intervention liaison
• Surgery support group facilitators
• Psychologist
• Home healthcare professionals
• Ambulatory care professionals.

WHAT IS THE SIZE OF YOUR FACILITY?
Our center’s clinic space, located on the medical campus of Unity Hospital, is approximately 5,230 square feet. Our services are also provided in the surgery suites of Unity Hospital, the radiology and lab departments, and a special bariatric hospital unit with 17 beds and in classrooms.

Unity Hospital is part of Allina Hospitals & Clinics, a not-for-profit family of hospitals, clinics, and other care services dedicated to meeting the lifelong healthcare needs of communities throughout Minnesota and western Wisconsin. The Unity Hospital Bariatric Center uses a large athletic and exercise facility at another nearby Allina hospital: Mercy Hospital. In addition, our support groups are provided in a variety of convenient community locations throughout the state.

How many patients are treated annually at your facility?
Our highest volume year was 2004, when we completed 848 bariatric surgeries. Since then, there have been several Minnesota-specific payer programs that have impacted our volumes. In 2005, we performed 611 bariatric surgeries; in 2006, we performed 491. The estimated total for 2007 is approximately 500 weight loss surgeries (for all types of procedures). Women make up 88.6 percent of our total patients. The average age for all patients is 45.6 years. The average BMI is 46.6. We have an excellent “leak rate;” from 1996 to 2006, the rate is 0.6 percent. While the national mortality rate for bariatric patients is 6.8 deaths for every 2,000 operations, our rate is one death for every 2,350 operations. The average length of stay for the open Roux-en-Y gastric bypass procedure is 2.12 days. For the laparoscopic Roux-en-Y gastric bypass surgeries, the average length of stay is 1.52 days. For the laparoscopic adjustable gastric banding (LAGB) procedure, patients are hospitalized approximately 1.15 days. Our patients’ average percentage of excess weight loss (EWL) at five years postoperative is 73.5 percent; the average weight loss at five years is 87.4 pounds.

HOW ARE YOUR PATIENTS TREATED WHILE UNDER THE CARE OF YOUR CENTER?
At Unity Hospital Bariatric Center, we embrace an environment that is conducive to promoting our patients’ sense of wellbeing. Our staff is multidisciplined and able to meet the individual needs of a diverse patient population. We know that weight loss is a journey of self discovery and providing a caring and safe environment is essential. We support the goal of lifelong management of obesity as a chronic disease and provide appropriate resources to that end. Patients trust the staff with their intimate life experiences and the many emotions that their obesity has pushed to the surface. It is a privilege and an honor to be a part of this special journey with our patients, and one that we take very seriously.

WHAT ARE SOME OF THE NEW EQUIPMENT, DEVICES, AND PRODUCTS INTRODUCED AT YOUR FACILITY LATELY?
We perform laparoscopic gastric bypass procedures using Stryker HD camera, monitors, and scopes. The variety of lengths for our equipment accommodates all sizes of patients. We use regular length and extra-long trocars, as well as irrigator tips, scissors, cautry tips, graspers, retractors and any other equipment required for the best possible surgical outcome; dependent upon surgeon preference and type of surgery, the equipment is made by Ethicon, US Surgical, Stryker, and Wolf. Our Stryker HD surgery tables can hold a patient who is up to 850 pounds. In addition, we have motorized Stryker beds for transporting patients from surgery to their medical unit.

HOW IS PROCEDURE SCHEDULING HANDLED?
Our operating room schedulers schedule bariatric surgical procedures. The surgeons have specific blocks of time during the week to perform their cases. Scheduling is completed using our Excellian software, which is also our electronic medical record software. This program averages the surgeons’ times using the last 10 cases and then recommends the appropriate start or end times for upcoming surgeries. Our surgeons are very prompt and keep a tight schedule; this greatly reduces problems associated with timeliness.

HOW IS INVENTORY MANAGED IN YOUR FACILITY?
Surgery equipment and supply inventory levels are managed by the Unity Hospital surgery buyer in conjunction with the bariatric service leaders. New equipment purchases are researched by the bariatric service leaders, who consult with the physicians and nurse managers to ensure that we have the proper equipment for the best price. We hold in-service equipment presentations for the staff members on a regular basis.

HOW HAS MANAGED CARE AFFECTED YOUR FACILITY AND CARE?
Our program management works closely with many of our managed care providers and, in Minnesota, most of our major carriers cover weight loss surgery. We are required to report yearly outcome data to our major payers, which is time-consuming. We had hoped that by becoming a Center of Excellence, our managed care partners would understand that best practices for patient care are in place and that time spent on reports would be better spent with our patients. Our biggest frustration with managed care is that patient criteria for bariatric surgery changes frequently—and our patients become frustrated as well. For example, one of our larger carriers changed its criteria three times in four months. Ideally, we would have one set of criteria for all insurance carriers in Minnesota—or the nation.

Has your facility recently expanded in size and patient volume?
Our bariatric surgery facility has expanded to include one room with built-in monitors, insufflators, cautry, and light sources. Another additional room is in the works. In addition, our center will be expanding in other ways during the next year. Recently, one of our surgeons began performing laparoscopic bypass surgeries in addition to open bypass surgeries he performs. Our center currently has three surgeons performing bariatric procedures; one surgeon completes all open bypasses and the two others perform open, LAGB, and Roux-en-Y procedures. One other surgeon is currently in training on newer procedures. Our patient volume is sustained by widespread marketing, as well as our patients referring their family members and friends.

HOW DOES YOUR FACILITY DEAL WITH THE ISSUE OF PATIENT SAFETY AND STAFF SAFETY?
Unity Hospital takes patient safety and staff safety very seriously. Our facility has a quality and safety department, with a certified safety officer as its director. We employ a safety specialist who helps manage staff safety issues. As a hospital, we have implemented all of the National Patient Safety Goals as set forth by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO).

Unity has staff members who participate on the Allina Risk Management Council, the Allina Quality Council, and the Safe Patient Moving Committee. Our Safe Patient Moving Committee consists of safety professionals from across the system who explore options for moving patients that include bariatric Air Pals and bariatric beds as well as other important concerns around the bariatric patient population. Our Falls Prevention Team has been instrumental in developing and implementing improved fall prevention policies, including standardized use of the Hendrich II fall risk assessment tool, a fall alert magnet with designation on the patient passport, red grip socks, and a fall checklist for staff members. Our facility participates in hourly rounding of inpatient units consisting of scheduled toilet use, pain assessment, and positioning.

Unity Hospital has a detailed patient handling and movement policy in place to reduce the hazards of injury for both our patients and staff. All staff members are trained on these policies upon hire and then annually. Education sessions are held when new equipment, procedures, or patient types are incorporated into our facility. We are currently in the planning stages for installing patient ceiling lifts on units that have a higher incident rate of injuries related to lifting—including bariatric patients.

HOW ARE EMPLOYEES ORIENTED AND TRAINED AT YOUR FACILITY?
All new team members receive a broad orientation to the facility and ancillary departments. At this time they are also orientated to organization policies, HIPAA practices, patient sensitivity requirements, our organization’s mission/vision, and values. New team members also attend the patient informational class (for those in the community considering weight loss surgery) and receive one-on-one peer mentoring in the bariatric center. The qualifications for becoming a bariatric nurse clinician for our program require a BSN or BA degree, an RN license, previous experience working with weight loss surgical patients, and a strong knowledge of obesity, its comorbidities, and the various bariatric surgeries. The orientation is complete in 4 to 6 weeks. We encourage staff to view actual surgical operations. In addition, we have specific criteria to be a core nurse in our OR as well as on our postoperative surgical unit. These core nurses, during their orientation, will shadow a bariatric program nurse for eight hours to understand and learn about all the education and preparation our patients go through prior to their surgery.

WHAT ARE YOUR STRATEGIES FOR RETAINING AND MOTIVATING STAFF?
There are few instances in healthcare where a provider can watch an individual’s journey to better health in such a dramatic and profound way. The Unity Hospital Bariatric Center program staff members continually express how much they love their jobs. They are very motivated, and part of their enthusiasm comes from continuous learning about bariatrics. We send one person (two, if budget will allow it) to the annual ASMBS conference and have since 1996. In addition, each nurse receives $300 per year for seminars. Employee satisfaction is surveyed annually, and the hospital president and vice president of our area meet with staff to discuss the results. A new program, Uncommon Caring, is an employee recognition program designed to celebrate the great work of our employees.

PLEASE DESCRIBE YOUR PATIENT EDUCATION PROGRAM.
Our patient education is ongoing throughout the patient’s journey with weight loss surgery and beyond. Our patients are invited to attend a free informational session that includes the history of the surgery, risk factors, medical complications, and economic and social/psychological implications of morbid obesity. The different types of surgical procedures and their risks are also explained. When a patient decides to proceed with surgery, an appointment is made with one of five bariatric nurse clinicians who review the patient’s health history form and provide a guide (or handbook) for surgery. Patients are referred to a psychologist who will discuss the behavioral changes that are necessary for weight loss success.

Patients meet with a dietitian to discuss a presurgical weight loss plan, as well as the diet that will be maintained after surgery. When the patient is ready to schedule surgery, all of this information is reviewed in a one-on-one teaching session between the patient and a bariatric nurse clinician. The patient then meets with the surgeon for a presurgical consult, a review of the surgery process, and an opportunity for questions.

After surgery, our patients are followed closely. They come back to the center at one week, five weeks, three months, six months, and nine months following surgery. After the first year, patients return on an annual basis. Each of the post-surgery visits includes medication and comorbidity updates and a diet/exercise review. We also include a psychosocial review. Our patients are encouraged to attend support groups to continue their education process.

For patients who are struggling with their post-surgery guidelines, we have a program called Find Your Weigh. The program outlines the basic guidelines of successful recovery and how to make the most of their surgeries. This program meets weekly for a weigh-in and educational/motivational session.

WHAT TYPE OF PATIENT SUPPORT PROGRAMS ARE OFFERED AT YOUR FACILITY?
The Unity Hospital Bariatric Center has a variety of support groups for our patients. Seven of the 14 groups meet in greater Minnesota so that they are convenient for our patients who live farther from our hospital. Our specialty support groups are designed to provide an opportunity for a tailored group experience. These include the Men’s Group, Graduate Group (for those whose surgery was at least one year ago), and Back-on-Track, which helps patients who have strayed from the surgical guidelines. Other groups include:
• Find Your Weigh—A weekly check-in and optional weigh-in time that includes an educational series.
• Lap-Band® Support Group—Led by our staff dietitians who present nutritional information.
• Exercise Support Group—For patients to actually exercise. This group meets weekly in a cardiac rehabilitation center with exercise equipment that is bariatric patient-friendly.
• Nia Fitness—A mind/body/spirit movement form that allows for the expression of feelings.
• Message Board—Our own home-grown online support system for patients who have had or plan to have surgery.
• Online Virtual Support Group—This one is still in the planning stages, but would allow our clinic staff to reach a larger group of patients, keeping them informed about the latest bariatric information and innovations.

WHAT LONG-TERM FOLLOW-UP MEASURES ARE PRACTICED AT YOUR FACILITY?
The postoperative follow-up protocol for our bariatric surgical patients includes the following:
• Follow-up telephone call 24 to 48 hours after discharge from the hospital.
• 24-hour access to the patients’ personal bariatric surgeon via the surgeon’s pager.
• Follow-up appointment at the physician’s office one week post-surgery.
• For our Roux-en-Y patients, an appointment with a bariatric nurse clinician occurs at five weeks, and also at three, six, nine, and 12 months, and then annually. They can consult with the nurse as often as they need and those consultations are free of charge.
• For our LAGB patients, appointments are scheduled every four weeks post-surgery for routine “fills” until they reach their feeling-full “sweet spot.” They meet with a bariatric dietitian at three months and see their physicians annually; they can also make appointments any time as needed.
• All patients receive anniversary letters that remind them to come in for blood tests and to see their surgeons.

WHAT QUALITY CONTROL ASSURANCE MEASURES ARE PRACTICED IN YOUR FACILITY?
From safety/security to infection control practices, and from safe handling of patients to innovations in better care for patients, our hospital is constantly striving for and implementing best practices. We have been recognized and won awards for patient safety, patient care innovations, and patient education. We work to meet or exceed the level of quality and care that our patients and their families expect every day, unfailing.

WHAT TRENDS DO YOU SEE EMERGING?
The emerging trends in the ever-changing world of bariatrics are sometimes exciting and sometimes frustrating. Innovations in surgical procedures, like LAGB, and in medications to fight weight regain are encouraging. We continue to fight the battles around these surgeries being considered elective—as well as the payers’ inconsistencies with criteria and coverage. The most promising trends we’re seeing include the acceptance of obesity as a disease and more primary physicians openly discussing weight management with their patients.

Does your facility utilize any alternative therapies?
Alternative therapies are beginning to be offered throughout the hospital and within our program to a greater extent. Therapies like healing touch and massage were mostly for cancer patients, but now those are being expanded to include other patients. Nurses use healing touch, imagery, and visualization with their patients; music therapy is provided by talented volunteers who help us in creating a soothing and calming environment. A new Healing Environment Committee is working to facilitate the integration of alternative therapies into our daily care of patients.

Are there new technologies you would like to see utilized in your facility?
We are researching the purchase of newer high-definition Stryker cameras and monitors. In addition, we are planning to develop an online Virtual Support Group. We want to make support for our patients as convenient and yet as comprehensive as
possible.

What efforts do you make to maintain HIPAA compliance?
Our patients entrust us daily with intimate information and details of their lives and experiences. All new employees receive HIPAA education as part of the orientation process. Bariatric team members are required to complete an annual online HIPAA compliance review program, and our patients are asked to review and sign specific HIPAA forms that are provided by our registration staff members. In addition, our patient charts are kept in a locked room away from patient view. Computers have special screens designed to obstruct indirect views of sensitive information, and they are password-protected to prevent unauthorized access to electronic patient information.

What makes your facility unique?
• Having a comprehensive center for more than 11 years is very unique. We have performed approximately 4,700 bariatric surgeries.
• We provide a personalized, patient-centered team approach to patient care—from preoperative education, patient surgery preparation, and postoperative support.
• Our surgeons are on call 24/7 and all patients receive their physician’s pager numbers so that they can call at any time.
• Surgeons make their rounds in the hospital twice a day to visit with all postoperative patients.
• Our surgeons’ practice is almost 100-percent bariatric surgery.
• We have a special postoperative medical/surgical unit in the hospital for our bariatric patients.
• We have a core bariatric staff of caregivers in the OR and postoperative surgery unit. The staff on the surgery unit is composed of registered nurses and certified nursing assistants who have been specifically trained in the care of the complex bariatric patient.
• This summer one of our nurses became a certified bariatric nurse (CBN).
• We offer a variety of tailored support groups for our patients.
• We created a postoperative video on dietary information so that our patients can view it at their convenience (as opposed to having a dietitian stop in when a patient was too groggy or not up to listening to diet and nutrition information).
• All patients sign a contract about their responsibilities after surgery.
• We created patient handbooks about bariatric surgery, and patients are given a quiz to test their knowledge of what was covered in the
handbooks.
• The Unity Hospital pharmacy carries a full inventory of the supplements our patients will need and will ship them to our patients free of charge.
• Patients receive a special gift box after surgery that includes books, lotions, a journal, photo album, and other treasured “treats.”
• Our program managers and surgeons frequently do outreach “lunch-n-learn” sessions with other medical clinics in the state. We provide free CMEs or CEUs.
• We also host educational classes for payers and companies, and at community health fairs.
• Our electronic medical records system (Excellian) provides a specially designed bariatric navigator.

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