Bariatric procedures are more often being done in the ambulatory surgery setting. The most common procedure in ASCs is gastric banding, which experts estimate makes up 90 percent of bariatric procedures performed in ASCs. Bariatric surgery represents a business opportunity for ASCs because payors, including Medicare, are increasingly reimbursing surgery centers for appropriate patients.
But treating bariatric patients, who are often extremely overweight, presents unique challenges for a surgery center, from ensuring the furniture is appropriate to making sure the staff handles sensitive issues with aplomb.
Dr. Scott Cunneen, director of bariatric surgery at Cedars-Sinai Medical Center in Los Angeles and author of Weighty Issues: Getting the Skinny on Weight Loss Surgery, and Dr. Peter LePort, medical director of the MemorialCare Center for Obesity at Orange Coast Memorial Medical Center in Fountain Valley, Calif., provide a seven-item checklist for accommodating bariatric patients in a surgery center.
1. Equipment is rated for extra weight and larger size. Dr. LePort says that one of the most important pieces of equipment a surgery center needs to accommodate overweight patients is a wheelchair specifically for bariatric patients. Standard wheelchairs are often only rated up to 350-400 pounds, but bariatric wheelchairs can be rated up to 850 pounds. The chairs are often wider as well to accommodate larger patients. Dr. Cunneen reminds centers to make sure that the doors are big enough for the larger wheelchairs. Another essential piece of equipment is the operating table itself.
"The operating table needs to have the capacity to support heavier patients since many times, you're tilting it," Dr. Cunneen says. "You need to make sure it doesn't get stuck."
Other equipment needs include gurneys, preoperative and postoperative beds, extra large gowns, extra large abdominal binders, longer tubing, larger retractors and other surgical equipment. Special surgical equipment is easy to order as long as long as a center administrator knows what to ask for, Dr. LePort says.
2. Waiting area is furnished with larger furniture. The waiting area is the patient's first impression of a surgery center, and not being able to fit comfortably in the furniture will not leave a great impression.
"If they can only fit one cheek in the chair, that's not going to be met with a lot of welcoming remarks when the patient leaves," Dr. Cunneen says.
Dr. LePort says although buying bigger furniture might seem like a small thing, it's important to patients not have to worry whether or not they can fit in the chair.
3. Bathrooms fixtures are floor mounted. Another safety issue that arises is whether or not the bathrooms are appropriately constructed for handling heavier patients, Dr. LePort says. Usually, toilets and sinks are bolted to the wall, but when a 400-pound patient puts his or her weight on that sink, it might pull right out of the wall. Both toilets and sinks need to be floor mounted to support the extra weight.
4. Staff has done sensitivity training. Dr. LePort says it's important for everyone at the center — even the staff who clean the rooms — to go through sensitivity training.
"A lot of these people have some interaction with the patient or the patient's families," he says. "Even peripherally, just by sweeping the floor, they have contact."
Oftentimes, the training involves making staff aware that their actions and words can be interpreted by a patient as inappropriate or hurtful. One example is laughter, Dr. LePort says.
"If something is funny that has nothing to do with the patient, patients assume they're being laughed at," he says. "We try to make sure that people are aware that that could happen. We don't want people in the surgery center to be stone-faced; they need to be able to react. If they know the patients might interpret it that way, they can walk a little closer to them while they're doing it so the patients can hear what's funny."
Dr. Cunneen says sensitivity training extends to the use of terms such as fat, obese and morbidly obese. His staff is generally told to use words such as large or other euphemisms because patients don't like to be reminded of their weight. On that same point, he makes sure staff gives patients the correct size gowns because handing a size 30 patient a size 10 gown is embarrassing for both parties, he says.
"That shows that [staff members] aren't sensitive to their size," he says. "How's that going to make that patient feel? Most patients don't like to go to the doctor. They don't want to have something thrown back in their face that reminds them that they're large."
Like Dr. LePort, Dr. Cunneen says his sensitivity training program focuses on helping staff better understand overweight patients.
"The training is really just to reinforce the fact that for these people, it's very serious," Dr. Cunneen says. "We have a tendency to put too much comedy on someone's disease of being overweight. Even though the stereotype is the jolly fat person, that's generally not true. They don't want to hear jokes about them being fat. Most people don't get that."
5. Staff members who deal directly with patients have received professional training. In addition to sensitivity training, staff members who interact directly with the patients need specialized training, Dr. LePort says. This includes the best way to get a patient in and out of bed, roll a patient over in bed, get them in and out of a wheelchair and walk them down the hall.
"They need to be trained, otherwise the patient is going to fall and hurt themselves or the staff member might get injured if they use their own body as they normally would," he says.
For example, if a patient needs to get out of bed, the best way is for the patient to be rolled and then to sit up because it's difficult for them to just sit up outright, Dr. LePort says.
6. Anesthesiologists are comfortable with overweight patients. Having an anesthesiologist comfortable working on overweight patients — who tend to have more breathing problems and more difficult airways to intubate — is essential, Dr. Cunneen says.
"One of the more dangerous things about these procedures is the anesthesia," he says.
Anesthesiologists should have special tools such as advanced anesthesia intubating tools to help them intubate a difficult patient, he says.
7. The center has an agreement with an inpatient facility experienced in handling bariatric patients. Both physicians agree that having an agreement with an in-patient facility is important — and having an agreement with a facility familiar with treating obese patients is even better. Dr. LePort says even the smallest complications during surgery can necessitate a transfer to a hospital. Dr. Cunneen says it's essential that this arrangement be made ahead of time.
"If it's clear that this patient needs to go to a hospital, have that arranged beforehand so you're not calling 911 or having a fire drill to figure out where to go," he says.
Related Articles on Bariatric Surgery:
7 Points on Natural Orifice Bariatric Surgery in the ASC From Dr. Todd McCarty of Lakewood Weight Loss & Wellness Clinic
Study: Bypass Better Than Gastric Banding for Weight Loss
Study: Bariatric Surgery Not as Effective for Diabetes Remission as Previously Thought
But treating bariatric patients, who are often extremely overweight, presents unique challenges for a surgery center, from ensuring the furniture is appropriate to making sure the staff handles sensitive issues with aplomb.
Dr. Scott Cunneen, director of bariatric surgery at Cedars-Sinai Medical Center in Los Angeles and author of Weighty Issues: Getting the Skinny on Weight Loss Surgery, and Dr. Peter LePort, medical director of the MemorialCare Center for Obesity at Orange Coast Memorial Medical Center in Fountain Valley, Calif., provide a seven-item checklist for accommodating bariatric patients in a surgery center.
1. Equipment is rated for extra weight and larger size. Dr. LePort says that one of the most important pieces of equipment a surgery center needs to accommodate overweight patients is a wheelchair specifically for bariatric patients. Standard wheelchairs are often only rated up to 350-400 pounds, but bariatric wheelchairs can be rated up to 850 pounds. The chairs are often wider as well to accommodate larger patients. Dr. Cunneen reminds centers to make sure that the doors are big enough for the larger wheelchairs. Another essential piece of equipment is the operating table itself.
"The operating table needs to have the capacity to support heavier patients since many times, you're tilting it," Dr. Cunneen says. "You need to make sure it doesn't get stuck."
Other equipment needs include gurneys, preoperative and postoperative beds, extra large gowns, extra large abdominal binders, longer tubing, larger retractors and other surgical equipment. Special surgical equipment is easy to order as long as long as a center administrator knows what to ask for, Dr. LePort says.
2. Waiting area is furnished with larger furniture. The waiting area is the patient's first impression of a surgery center, and not being able to fit comfortably in the furniture will not leave a great impression.
"If they can only fit one cheek in the chair, that's not going to be met with a lot of welcoming remarks when the patient leaves," Dr. Cunneen says.
Dr. LePort says although buying bigger furniture might seem like a small thing, it's important to patients not have to worry whether or not they can fit in the chair.
3. Bathrooms fixtures are floor mounted. Another safety issue that arises is whether or not the bathrooms are appropriately constructed for handling heavier patients, Dr. LePort says. Usually, toilets and sinks are bolted to the wall, but when a 400-pound patient puts his or her weight on that sink, it might pull right out of the wall. Both toilets and sinks need to be floor mounted to support the extra weight.
4. Staff has done sensitivity training. Dr. LePort says it's important for everyone at the center — even the staff who clean the rooms — to go through sensitivity training.
"A lot of these people have some interaction with the patient or the patient's families," he says. "Even peripherally, just by sweeping the floor, they have contact."
Oftentimes, the training involves making staff aware that their actions and words can be interpreted by a patient as inappropriate or hurtful. One example is laughter, Dr. LePort says.
"If something is funny that has nothing to do with the patient, patients assume they're being laughed at," he says. "We try to make sure that people are aware that that could happen. We don't want people in the surgery center to be stone-faced; they need to be able to react. If they know the patients might interpret it that way, they can walk a little closer to them while they're doing it so the patients can hear what's funny."
Dr. Cunneen says sensitivity training extends to the use of terms such as fat, obese and morbidly obese. His staff is generally told to use words such as large or other euphemisms because patients don't like to be reminded of their weight. On that same point, he makes sure staff gives patients the correct size gowns because handing a size 30 patient a size 10 gown is embarrassing for both parties, he says.
"That shows that [staff members] aren't sensitive to their size," he says. "How's that going to make that patient feel? Most patients don't like to go to the doctor. They don't want to have something thrown back in their face that reminds them that they're large."
Like Dr. LePort, Dr. Cunneen says his sensitivity training program focuses on helping staff better understand overweight patients.
"The training is really just to reinforce the fact that for these people, it's very serious," Dr. Cunneen says. "We have a tendency to put too much comedy on someone's disease of being overweight. Even though the stereotype is the jolly fat person, that's generally not true. They don't want to hear jokes about them being fat. Most people don't get that."
5. Staff members who deal directly with patients have received professional training. In addition to sensitivity training, staff members who interact directly with the patients need specialized training, Dr. LePort says. This includes the best way to get a patient in and out of bed, roll a patient over in bed, get them in and out of a wheelchair and walk them down the hall.
"They need to be trained, otherwise the patient is going to fall and hurt themselves or the staff member might get injured if they use their own body as they normally would," he says.
For example, if a patient needs to get out of bed, the best way is for the patient to be rolled and then to sit up because it's difficult for them to just sit up outright, Dr. LePort says.
6. Anesthesiologists are comfortable with overweight patients. Having an anesthesiologist comfortable working on overweight patients — who tend to have more breathing problems and more difficult airways to intubate — is essential, Dr. Cunneen says.
"One of the more dangerous things about these procedures is the anesthesia," he says.
Anesthesiologists should have special tools such as advanced anesthesia intubating tools to help them intubate a difficult patient, he says.
7. The center has an agreement with an inpatient facility experienced in handling bariatric patients. Both physicians agree that having an agreement with an in-patient facility is important — and having an agreement with a facility familiar with treating obese patients is even better. Dr. LePort says even the smallest complications during surgery can necessitate a transfer to a hospital. Dr. Cunneen says it's essential that this arrangement be made ahead of time.
"If it's clear that this patient needs to go to a hospital, have that arranged beforehand so you're not calling 911 or having a fire drill to figure out where to go," he says.
Related Articles on Bariatric Surgery:
7 Points on Natural Orifice Bariatric Surgery in the ASC From Dr. Todd McCarty of Lakewood Weight Loss & Wellness Clinic
Study: Bypass Better Than Gastric Banding for Weight Loss
Study: Bariatric Surgery Not as Effective for Diabetes Remission as Previously Thought