Welcome to Physicians’ Specialty Hospital

Fayetteville, Arkansas

by Rachelle Younce, Director of Marketing at Physicians’ Specialty Hospital, Fayetteville, Arkansas

Bariatric Times. 2014;11(11):22–25.

FUNDING: No funding was provided.
DISCLOSURES: The author reports no conflicts of interest relevant to the content of this article.

Welcome to Physicians’ Specialty Hospital
Physicians’ Specialty Hospital (PSH) is a 21-bed, physician-owned, multi-specialty hospital located on North Parkview Drive in Fayetteville, Arkansas. PSH is the only physician-owned specialty hospital and also the only American Society for Metabolic and Bariatric Surgery (ASMBS) Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) Bariatric Surgery Center of Excellence in Northwest Arkansas. Since 2010, our bariatric surgical program has successfully completed over 1,000 bariatric surgeries comprising laparoscopic adjustable gastric banding (LAGB), Roux-en-Y gastric bypass (RYGB), and laparoscopic sleeve gastrectomy (LSG). The complication rate remains below one percent with no deaths at our facility. PSH is part of a state employee pilot program, which allows state employees insurance coverage for bariatric surgery for a four-year period. During the four years’ outcome measures, overall insurance costs associated with comorbid conditions, employee attendance, and job satisfaction will be tracked. The program concludes in 2016. PSH focuses on podiatric, orthopedic, spine, interventional pain, and bariatric specialized holistic care. PSH is an official provider of the Arkansas Razorbacks. We are also the home of the official orthopedic and sports medicine providers for the Razorbacks. Dr. Josh Roller, PSH Bariatric Medical Director, is also the official general surgeon of the Arkansas Razorbacks.

Our Staff
PSH has a 24-hour emergency room staffed with qualified physicians, nurses, and ancillary staff to meet any patient’s needs. The primary source of patient encounters is through the surgical services department. Most surgeries at PSH are considered minimally invasive, including spinal fusions, arthroscopic joint surgery, advanced laparoscopic general surgery, bariatric surgery, and interventional pain management. The surgeons at PSH are board certified and fellowship trained in their specialty. The bariatric surgeons and bariatric team leaders, Dr. Josh Roller and Dr. Yong Kwon, are board certified and fellowship trained in both advanced laparoscopic general and bariatric surgery. Most of the hospital’s administration team, including the chief nursing officer, the chief information officer, and the chief people officer are registered nurses.

PSH has a dedicated bariatric team under the direction of the Dr. Josh Roller. The facility has a full-time bariatric nurse coordinator and a MBSAQIP bariatric clinical reviewer. The coordinator gets involved with the bariatric surgery patient as early as possible and stays in touch with the patient throughout his or her weight loss journey. All patients at PSH receive a bariatric surgery informational flyer upon admission to the facility. The flyer has future seminar dates and the bariatric coordinator’s phone number. Patients are encouraged to attend a seminar. The other unique program our hospital recently implemented is the screening of all patients undergoing general anesthesia for obstructive sleep apnea (OSA). If the patient is deemed high risk for OSA and has a body mass index (BMI) greater than 35kg/m2, the patient is given information about weight loss surgery and offered free weight loss surgery seminar. All patients interested in weight loss surgery must attend an informational seminar prior to starting the weight loss surgery program.

PSH has a team of 30 members that are experts in caring for patients with morbid obesity. Team members come from multiple medical disciplines, including nutrition, emergency department, pre-admission testing, imaging services, pre-operative services, recovery, endoscopy, laboratory, surgical services, financial services, admissions, bariatric care unit, administration, marketing, case management, and quality assurance. Each team member is required to attend a weight loss surgery seminar and go through a specialized training program. Most nurses on the team have a critical care background and past experience with the treatment of morbidly obese surgical patients. The team meets as a group once per month to discuss ways to improve the program. PSH also has two certified bariatric nurses on staff with plans to add an additional 2 to 4 nurses in the near future.

The team at PSH complements the dedicated team at Roller Weight Loss and Advanced Surgery (RWLI). After attending an informational seminar, patients sign up to start the weight loss surgery program. Insurance companies have different guidelines that must be followed for the insurance to pay for the procedure. Some patients must have six consecutive months of physician-supervised diet and exercise prior to surgery. RWLI has a team of psychologists, registered dieticians, advanced practice nurses, medical doctors, laboratory personnel, insurance specialists, and medical assistants that have been trained in bariatric medicine. Dr. Kristin Roller, the wife of Dr. Josh Roller, evaluates every patient upon admission to the weight loss program. Dr. Kristin Roller is board certified in bariatric medicine. She assesses each patient and is responsible for recommending the best weight loss surgery plan of care that is individualized to treat a patient’s comorbid conditions. Dr. Kristen Roller also reviews all test results, physician documentation, and patient progress prior to the patient’s weight loss surgery. All team members and staff from PSH and RWLI are required to attend bariatric sensitivity training every year. Additionally, all new employees are educated on bariatric sensitivity at new hire orientation.

Our Facility
Our office facility. PSH and RWLI are fully equipped to care for patients up to 600 pounds. The hospital has a computed tomography (CT) scanner that is fully equipped to care for patients up to 450 pounds and a magnetic resonance imaging (MRI) that will accommodate patients up to 500 pounds. The operating room tables will accommodate 1,000 pounds and are equipped with special transfer devices to minimize the risk of injury to the staff and/or patient. The emergency department has a specialized lab draw chair and stretcher that can accommodate over 500 pounds. There are several chairs in the waiting room and patient rooms that will accommodate up to 500 pounds. Additionally, all of the toilets in the hospital are floor-mounted. Walkers, bedside commodes, and shower benches are available and can accommodate up to 500 pounds. A patient lift is available for immobile patients weighting up to 1,000 pounds. The hospital has several wheelchairs that will accommodate 400 pounds. The anesthesia department is equipped with difficult airway items, such as a GlideScope (Verathon, Inc., Bothell, Washington, USA), transport ventilator, and a biphasic positive airway pressure machine. Any patient undergoing weight loss surgery with a known diagnosis of OSA is required to bring their continuous positive airway pressure (CPAP) or BiPAP equipment the day of their surgery. Each piece of equipment is checked by biomedical engineering for electrical safety and labeled with the weight limit. For example, if the sticker reads “B50,” it means that the equipment will accommodate 500 pounds. Staff members receive education on the weight limit labeling during new hire orientation.

Procedure Statistics and Patient Demographics
Dr. Josh Roller and Dr. Kwon performed a total of 372 bariatric surgery cases at PSH in 2013. In fact, the bariatric team celebrated performing the one thousandth case at PSH in January 2014. Dr. Josh Roller and Dr. Kwon received a crown and the staff celebrated with a cake. The celebration was posted on the PSH Weight Loss Surgery Facebook page. The largest insurance payer was Blue Cross and Blue Shield at 38 percent of all insured cases for 2013. More women than men had bariatric surgery at PSH (76% and 24%, respectively). The average age is 50.8 years old. Complication and re-admission rate at PSH is less than one percent. The average BMI of our bariatric patients is 43.6kg/m2.

Achieving Accreditation Designation
PSH and RWLI were certified in 2010 as an American Society of Metabolic and Bariatric Surgery Center of Excellence. Overall, the transition to the MBSAQIP program was not difficult; MBSAQIP required us to send in a renewal application and a detailed questionnaire. The only difficult part was the data entry into the MBSAQIP database. Previously, data had to be entered into Bariatric Outcomes Longitudinal Database (BOLD) by the physician practice. Currently, MBSAQIP requires the new database be maintained by the hospital. This poses some difficulty because after the surgery, PSH has little contact with the patient. RWLI requires lifetime follow up be conducted on all postoperative bariatric patients. The MBSAQIP database requires all follow-up and patient outcome data be entered for the patient’s lifetime. PSH hired a full-time clinical reviewer to help with the process and RWLI had to provide electronic health record (EHR) access to the clinical reviewer. PSH is also recognized by The Surgical Review Corporation (SRC) as a Center of Excellence (COE). SRC continues to require patient outcome information to be entered into the BOLD database. Because there are two programs, PSH and RWLI, the hospital has twice the data to enter. Patients are very aware that PSH is a COE. Several insurance companies in Arkansas, including the State Benefit Pilot Program, require bariatric surgery to be done at a COE. Unfortunately, Medicare and Medicaid elected to forego this requirement. In our opinion, this is unfortunate because patients may put their lives in danger by electing to have weight loss surgery at a program that is not a COE.
managed care

Long-term follow up is a way of life for the postoperative bariatric surgery patient. All potential patients are told at the informational seminar that they will be required to follow up with RWLI at least yearly and for the rest of their lives. The follow-up schedule has been developed by RWLI and contributes to the low complication rate. Postoperative patients are required to follow up at two weeks, one month, three months, six months, 12 months, 18 months, 24 months, and then yearly for the remainder of their lives. Patient progress is logged into the EHR and then required data is transferred to both the MBSAQIP and into BOLD databases. Patients who miss appointments receive a reminder in the mail, an e-mail, and at least one phone call. Patient adherence is around 85 percent.

Patient Adherence
In our experience, the biggest complication to patient adherence is related to smoking. All patients are required to stop smoking prior to surgery. Patients with a known nicotine addiction are required to pass a urine nicotine screen prior to being scheduled for surgery. Smoking causes marginal ulcers in postoperative bariatric surgery patients.[1] Drs. Roller and Kwon have a no-tolerance approach to not only patient smoking, but also exposure to second hand smoke. Dr. Roller has reversed a RYGB on a patient that refused to quit smoking. Focus on smoking cessation starts during the first pre-operative visit. Support groups, pharmacological treatment, and counseling are all available to patients in the program. Unfortunately, some patients disregard the pre-surgery warnings and resume smoking after surgery. Smoking can lead to a life-threatening complication in the postoperative bariatric surgery patient.[2]

Patient Care
Patients are treated like royalty at both RWLI and PSH. Weight loss surgery patients follow the same HIPPA guidelines as any other patient. Our Marketing Director visits each patient and delivers a rose to our female patients and an Arkansas Razorbacks hat to our make patients the day after surgery. Our Marketing Director spends time getting to know the patient and listens for any way to improve patient care. The bariatric coordinator also visits with the patient and his or her family at least once after surgery and more often if needed. She also provides each patient with her cell phone number so they can contact her at any time.

Our Equipment and New Technologies
Drs. Roller and Kwon use a combination of surgical products to achieve the best patient outcomes. They use Endo GIA™ Universal XL (Covidien, New Haven, Connecticut, USA) stapling system, the Enseal product portfolio (Ethicon, Cincinnati, Ohio, USA), Covidien Endo Clip 5mm appliers, and trocars from Applied Medical (Rancho Santa Margarita, California).
cost and efficiency.

RWLI calls the scheduling coordinator at PSH and schedules any pre-procedure testing, such as an esophagogastroduodenoscopy (EGD) or chest x-ray. She also schedules the pre-admission testing appointment and the surgery itself. PSH is an alpha site for our new EHR produced by SourceMedical (Wallingford, Connecticut, USA). The product is called Vision Specialty Hospital. (Vision SH). Vision SH has a strong reporting module, which allows the bariatric coordinator to audit case costing, bariatric surgery block utilization, and patient demographics, such as insurance, age, BMI, and gender. Vision SH also provides information on case time, The American Society of Anesthesiologists (ASA) Physical Status class, and length of stay.

There are two designated teams in the surgical services department dedicated to bariatric surgery. Each team comprises an RN and two certified scrub technologists (CST). The teams are labelled Team 1 and Team 2. A CST has also been appointed to inventory supplies and equipment. Additionally, the Surgical Services Coordinator is responsible for holding weekly planning meetings with the bariatric coordinator. During the planning meetings, room assignments are made for the upcoming week, supply and equipment needs are discussed, and any patient condition needing specialized equipment or staffing is identified. After the planning meeting, the Surgical Services Coordinator places an order with the surgical services materials manager. Supplies are ordered for all scheduled cases for a two-week period plus 30 percent. The bariatric team has a designated area in the supply room for bariatric supplies and equipment; the area has a checklist identifying all supplies in that area with an pre-established required level. Any member of the team can use the checklist to order supplies.

Physicians’ Specialty Hospital’s mission and value statement include the motto “A Matter of Excellence.” Despite the restraint managed care and the Medicare funding cuts government has imposed on the healthcare providers of the nation, PSH will not settle for anything less than excellence for our patients. PSH and RWLI have worked together to reduce supply costs and minimize length of stay without compromising safety and quality. By reducing supply cost and minimizing length of stay the cost of bariatric surgery has decreased. This decrease in cost has helped offset the devastating reduction in reimbursement. PSH has a 98-percent overall patient satisfaction score from our bariatric surgery patients. That percentage speaks to the excellence in which each team member prides themselves.

The bariatric coordinator and members of the bariatric team meet as a group on a monthly basis. During these meetings, the tea, discusses and analyzes cases and costs. Drs. Roller and Kwon have changed from disposable trocars, which resulted in a 50-percent cost savings. Additionally, the surgeons are currently trialing disposable scissors by Applied Medical as a potential replacement for the reusable scissors that require frequent sharpening and a clip applier by Applied Medical as a potential replacement for a more costly brand. If the clip applier and scissors are selected after the evaluation period, an additional 50 percent will be saved on these items. The average cut to close time for Drs. Roller and Kwon is 74 minutes and the average room turn over time (wheels in to wheels out) is 10 minutes. The key factor in fast turnovers is having designated turn over help and enough instrumentation and equipment. The anesthesia provider is also an essential member of the team; Physicians’ Specialty Hospital’s anesthesia providers are some of the best in Northwest Arkansas. The addition of intravenous (IV) Tylenol has proven to save money and promote faster ambulation for our bariatric surgery patients. A quality assurance study3 was conducted on patients receiving IV Tylenol pre-operatively versus not receiving IV Tylenol pre-operatively. The results showed that patients receiving IV Tylenol did not use as much IV narcotics or antiemetic medications postoperatively. The decrease in pain and nausea resulted in quicker ambulation and also decreased the length of stay for our patients.

Patient Assessment
The patient assessment and determination of who is appropriate for surgery is handled by RWLI. As previously mentioned, each patient has an initial assessment that is performed by Dr. Kristin Roller, who is board certified in bariatric medicine. If there is an undiagnosed or unstable medical condition identified, Dr. Kristin Roller will work with a specialist, such as a cardiologist, to stabilize and treat the medical condition. Once the patient has been treated and stabilized, Dr. Kristin Roller will re-evaluate the patient and clear them for surgery if it is safe to do so. Some patients will be in the program for up to one year getting healthier prior to surgery. Dr. Kristin does an amazing job with these individuals; she truly treats them as if they were a member of her own family.

Patient and Staff Safety
All members of the bariatric team are trained on the safe transfer of patients with morbid obesity. Transfer protocols are available in each department and are a permanent part of the bariatric patient care manual, which is located on each unit. Transfer devices, such as Airpal mattresses and Hoyer lifts (Patterson Medical, Warrenville, Illinois) are also available for use. The protocol mandates all patients undergoing general anesthesia with a BMI of 35kg/m2 or greater are to be placed on an Airpal mattress. Staff members are oriented to the use of transfer devices during new hire department orientation and also at their yearly competency evaluation. PSH has not had a worker’s compensation claim related to lifting a bariatric surgery patient since opening in 2009.

Staff Training
All employees, including bariatric team members, receive bariatric sensitivity training upon hire and annually. The bariatric team members receive monthly departmental bariatric patient specific in-services. The bariatric team members also attend a RWLI patient seminar or support group at least annually. Each team member has access to the bariatric coordinator on a daily basis as an educational resource. Additionally, Drs. Roller and Kwon provide education on a quarterly basis.

Emerging Trends
In our experience, the latest trend in bariatric surgery is returning to the RYGB as the preferred surgery over LAGB and LSG. RYGB has proven long-term weight loss.[4] The RYGB is now a recognized cure for type 2 diabetes mellitus (T2DM) by Medicare. Patients are becoming more educated about weight loss surgery and insurance companies are starting to provide coverage. In the future, it is predicted that insurance companies will recognize the cost savings of bariatric surgery for patients with comorbid conditions. Since the RYGB improves and has the potential to resolve T2DM, the insurance companies will save millions of dollars that they otherwise would have spent on treating end-stage diabetes organ damage and associated medical and medication costs.

The program at PSH in collaboration with Drs. Roller and Kwon utilize the latest laparoscopic equipment on the market. Dr. Roller is a national instructor for the LSG procedure and has instructed surgeons from all over the United States on this procedure.

Patient Cases
An interesting case. One of the most interesting bariatric surgical cases from PSH was RYGB performed on a pair of sisters. The sisters blogged their weight loss surgery experiences, family support, exercise journey, and life-changing experiences. The public posting of the journey gave encouragement to members of the bariatric team, post bariatric surgery patients, and future bariatric surgery patients. It was incredibly inspiring to watch the progress these sisters made; they posted challenges, successes, and words of wisdom for everyone to see.
A difficult case. One of the most difficult cases at PSH involved a 34-year-old man who had a RYGB in 2012. He has done extremely well with diet and exercise; he lost 130 pounds and has kept his weight off. He is married and has a young child. What makes his case unique is that he had three of the most common postoperative complications over the past two years. He had his gallbladder removed after a testing determined a non-functional gallbladder and he also had an incarcerated hernia, which had to be emergently repaired. Prior to surgery, patients are educated on all the potential, but rare, postoperative complications. Most recently, the same patient presented to clinic with epigastric pain. Dr. Roller did a diagnostic EGD and found a marginal ulcer. Dr. Roller then prescribed a proton pump inhibitor (PPI) and misoprostol, which is a synthetic prostaglandin E 1 (PGE 1) analog used to prevent ulcers. The patient was compliant with the treatment plan and denied tobacco or alcohol use. Two weeks after the EGD and treatment, the patient presented to the emergency department with severe abdominal pain. The CT scan showed free air. The patient was taken emergently to surgery to repair a perforated ulcer. The bariatric team reviewed this case as a case study; nothing was identified as a contributing factor as to why this patient experienced all three complications. All of the surgical procedures were performed using laparoscopic techniques. This patient was able to return to work quickly and experienced minimal postoperative pain.

A Unique Facility
PSH is unique because it is one of the last physician-owned specialty hospitals the government allowed to open. Currently, the Affordable Care Act prevents physician-owned hospitals from opening or expanding in size. The patient satisfaction score at PSH is 98 percent overall and our infection rate is less than one percent.  The average length of stay for our postoperative bariatric patients is 26.5 hours and the overall complication rate for postoperative bariatric surgery patients is one percent. PSH is the only COE in Northwest Arkansas and one of only two COE’s in the state of Arkansas. PSH has received multiple quality awards and is one of the very few hospitals in Arkansas that received an increase in Medicare funding this year. PSH has a dedicated bariatric surgery unit and a dedicated bariatric surgery team. Additionally, PSH maintains a dedicated Facebook page for our Bariatric Center of Excellence. We post support group information, highlight a patient of the week, and post helpful information for our fans. PSH’s Bariatric Surgery Program partnered with RWLI to deliver “A Matter of Excellence” in bariatric surgery to our population with morbid obesity.

References
1.    Racu C, Mehran A. Marginal ulcers after Roux-en-Y gastric bypass: Pain for the patient…pain for the surgeon. Bariatric Times. 2010:7(1):23-25
2.    Smoking and bariatric surgery—why you should quit. Consumer Guide to Bariatric Surgery. www.yourbariatricsurgeryguide.
com. Accessed October 1, 2014.
3.    Viscusi ER, Singla N, Gonzalez A, Saad N, Stephanian J. IV Acetaminophen improves pain management and reduces opioid requirements in surgical patients: A review of the clinical data and case-based presentations. Anesthesiology News. 2012;38:4. www.anesthesiologynews.com
/download/SR122_WM.pdf. Accessed October 1, 2014.
4.    Blackburn GL. Solutions in weight control: lessons from gastric surgery. Am J Clin Nutr. 2005 82: 248S–252S.

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