Introduction

The escalating prevalence of severe obesity is bringing the unique challenges of caring for severely obese weight loss surgery (WLS)¹ patients to growing numbers of facilities (1). Between 1990 and 1997, the annual rate of WLS in the United States more than doubled (2). Last year, surgeons performed 104,000 WLS procedures (3); this year, that number is expected to rise to an estimated 144,000 WLS operations (3,4).

The prevalence of clinically severe obesity is increasing much faster than that of obesity or overweight. Widely published reports on the rapidly growing prevalence of severe obesity underestimate the consequences of the trend for physician practices, hospitals, and healthcare centers. WLS puts severely obese patients at risk for complications and death—from the medical problems associated with obesity and from the surgery itself (3). Comorbidities and resulting service use are much higher among severely obese individuals than among those who are overweight or obese (5).

Care of severely obese patients requires special precautions and appropriate equipment. With treatment of WLS patients no longer a rare event, all healthcare providers must have procedures and protocols (6) in place to achieve good outcomes (7). This report describes the personnel, equipment, and physical accommodations required to reduce medical errors, enhance patient safety, and create an optimal environment for best practice treatment of WLS patients.

Research Methods and Procedures

We examined MEDLINE (Ovid and PubMed) and the Cumulative Index of Nursing and Allied Health Literature for articles on facilities resources for care of WLS patients published in English between January 1980 and March 2004. We queried several web sites for appropriate references; these included the Agency for Healthcare Research and Quality (AHRQ) and the American College of Surgeons (ACS). The majority of reference material was descriptive (Category D) and not specific to facilities resources for WLS patients.

We identified a substantial body of literature on the general subject of patient safety. Two meta-analyses (Categories A or B)—one on the efficacy of computerized order entry with decision support (8), the other on automated medication-dispensing devices (9)—were used to develop recommendations related to medical error reduction, as was a descriptive study of bar code technology (10) (Category C) (Table 2). All other recommendations are based on 11 expert opinion reports (Category D) (Table 1). Recommendations focus on patient safety, medical error reduction, systems improvement, credentialing requirements, and future research. Table 3 lists recommendations considered essential; Table 4 lists those considered optional.

Table 2. - Category A or B studies.

Full table

Table 1. - Expert opinion studies.

Full table

Table 3. - Essential recommendations.

Full table

Table 4. - Optional recommendations.

Full table

Results

Patient Safety

Severely obese patients often have special health needs, such as lower extremity edema or respiratory insufficiency, that require targeted evaluation and treatment (11). Holland et al. (12) have described a team approach to treatment based on guidelines developed specifically for the care of severely obese patients. The guidelines emphasize the importance of having necessary resources available and the need for multidisciplinary and creative team care. According to the ACS (7), an appropriate WLS treatment team should include experienced surgeons and physicians, skilled nurses, specialty-educated nutritionists, experienced anesthesiologists, and, as needed, cardiologists, pulmonologists, and rehabilitation therapists. The team should include properly trained and funded WLS support staff (7).

Recommendations: Multidisciplinary Care

• All medical staff must be adequately trained and credentialed as specified in recommendations from the surgical care, anesthesia perioperative care, and nursing perioperative care task groups (7,12).
• A team of designated medical subspecialists, fully aware of the problems and sensitivities of patients with severe obesity, should be readily available.
• A dedicated hospital administrator should be identified to provide consistent support and oversight (6).
• All personnel who interact with WLS patients should attend obesity-specific education programs focused on sensitivity training.

Equipment

Management of severely obese patients involves special precautions and appropriate procedures (6). Davidson et al. (11,13,14) have reported that even routine treatment of WLS patients requires environment-of-care modifications to a wide range of equipment, e.g., commodes, wheelchairs, and blood pressure (BP) cuffs. Sarr et al. (6) have cited the need for appropriate equipment to protect the health of WLS patients and staff. ACS recommendations also specify alterations in facilities, supplies, and equipment (e.g., operating room tables, surgical supplies, diagnostic equipment, beds) (7).

Operating Room Recommendations.

Specially-equipped operating room and ancillary equipment should be available to support patients with severe obesity, including:

• An automated extra-wide operating table with appropriate weight capacity;
• Extra-long abdominal instrument sets;
• Appropriately sized retractors; and
• 43- to 46-cm laparoscopes.

Ancillary equipment should include:

• Wide wheelchairs, stretchers, and walkers;
• Wide BP cuffs;
• Biphasic defibrillators;
• Sequential compression devices;
• Emergency airway equipment;
• Wide examinations tables bolted to the floor; and
• Scales of appropriate size and capacity.

Diagnostic and Interventional Equipment Recommendation:

Special diagnostic and interventional equipment is required to both support and accommodate WLS patients. Such equipment should include:

• X-ray and ultrasound, computerized tomography (CT), magnetic resonance imaging (MRI), fluoroscopy;
• Interventional facilities; and
• Longer needles (16).

Physical Plant Recommendations:

• Dedicated beds and specially trained personnel should be available in both post-anesthesia and intensive care units (ICUs).
• A minimum of two designated floors are required to provide intermittent relief for nurses and attendants who care for WLS patients.
• Patient rooms must have sufficiently wide entrances and bathroom doors and bathroom facilities with floor-mounted toilets and wide shower stalls.
• Patient transport elevators must have sufficiently wide doors and weight capacity to accommodate patients with severe obesity.

Strategies for Medical Error Reduction

Federal initiatives emphasize that hospitals should institute compliance programs and reporting systems to encourage all employees to report failures to deliver safe patient care (16). Advocated conditions stipulate confidentiality and a policy of nonretaliation for reports made in good faith (17). The Institute of Medicine has called for redesigned patient care systems and nonpunitive approaches to error identification. Those changes are consistent with data from other studies (18,19).

Frankel et al. (20) have found that a blame-free environment is conducive to adverse event reporting and reduction of medical errors. Studies suggest that transforming blaming behaviors to those of support will most likely increase error reporting and systems improvement initiatives (17,19,21). Two methods—executive walkrounds and sentinel event reporting systems—seem to facilitate the development of a blame-free environment in which concerns can be safely reported and appropriately addressed.

Recommendations: Management and Technology

• Implement executive walkrounds to encourage face-to-face communication between executives with decision-making authority and front-line caregivers.
• A web-based incident reporting system should be established to provide staff with a fast, easy, and blame-free way to report actionable information.

Reducing Medication Errors

Recent reports and studies of errors in the medication process have raised awareness of the threat to public health. Data show that use of barcode technology within a closed loop system (i.e., one that includes actual administration of drugs to patients) facilitates correct administration of medications (21). Matched scans of barcodes on patient wristbands and vials or drug packets prevent improper delivery of medications. Automatic entry of both scans into computerized logs at bedside have been found to ensure accountability, immediate documentation, and accurate inventory tracking. Barcode technology has also been used for specimen collection and processing to minimize misidentification during collection, transport, and laboratory processing (10).

Barcode technology is one option among other technologies applied to the various steps required for medication administration. Other applications found to reduce errors include computerized order entry with decision support, automated dispensing devices, and electronic medication administration (8,9,10). Data suggest that computerized order entry provides a 50% reduction in medication errors caused by transcription errors resulting from illegible handwriting, similar brand names, or misplaced decimal points. Embedded decision support systems have been shown to reduce errors by providing pertinent prompts to ordering physicians, including prompts on: allergies; dosing errors; frequency or route of administration; potential adverse drug-drug interactions; and the presence of hepatic, renal, or other pathology with an adverse effect on the action or metabolism of the particular medication (9).

Chan (22) has reported that implementation of Six-Sigma quality improvement methodology achieved breakthrough results in quality, cost, and patient safety. Automated, electronically controlled pharmacy management devices that dispense medications from a centrally stocked pharmacy supply have been found to increase throughput and accuracy. Data show that medications are supplied at the prescribed times in prepackaged patient-specific units and that smart infusion pumps can be tightly programmed to provide automated, continuous delivery of parenteral medication (9).

Recommendation: Institutional Pharmacy and Therapeutics Committee

• This task group recommends that an Institutional Pharmacy and Therapeutics Committee be empowered to establish and disseminate appropriate weight-based dosing of commonly used drugs for WLS patients, including: analgesics, epidural regimens, patient-controlled analgesia, anxiolytics, and deep vein thrombosis prophylaxis (low-molecular weight heparin).

Recommendation: Tracking and Management

• Effective tracking and management of medication dispensing requires computerized order entry with decision support, automated medication dispensing devices, or electronic medication administration that incorporates barcode technology (Categories A, B, and C).

Systems Improvements

In healthcare institutions recognized as accomplished in WLS, minimum standards for facilities, equipment, and surgery support staff are set by the institution and maintained under the direction of a qualified surgeon in charge of a WLS management team (7). To optimize quality of care, facilities have successfully applied the define-measure-analyze-improve-control methodology of Six Sigma (23,24,25,26,27). Healthcare organizations using this model proceed from the lower levels of quality performance to the highest level, in which the process is nearly error-free (27).

Recommendation: Personnel

• Strategies to implement and monitor systems improvements must include the appointment of a WLS program medical director to work closely with a designated hospital administrator.

Recommendation: Information

• A state-wide risk-adjusted WLS Data Registry needs to be established and maintained in an accessible (28) outcome tracking system (29).

Recommendation: Quality Assurance

• Critical pathways should be developed, implemented, and monitored for adherence.
• A quality assurance program specific to WLS should be established.

Credentialing Needs

Education and credentialing requirements for the personnel who care for WLS patients are included in reports from three Task Groups: Surgical Care, Anesthetic and Perioperative Pain; and Nursing Perioperative Care.

In addition to the above criteria, we recommend:

• The organization of a subcommittee of the Medical Staff Credentialing Committee to develop criteria for staff seeking credentialing for emerging technology.

Future Research

A shared WLS database will facilitate system improvements, improve clinical care, and enhance future research. Toward those ends, we recommend:

• A collaborative effort with third party payers to standardize outcome criteria and databases in concert with the recommended statewide WLS registry (29);
• Collaboration with industry to enable development of equipment specifically designed to meet the needs of WLS patients (in particular, appropriately sized imaging equipment); and
• Increased simulation training to WLS caregivers to address unique situations encountered in WLS, e.g., techniques for intravascular line insertion, complex airway management, and protocol for cardiorespiratory catastrophes.

Discussion

Severely obese patients have altered airway, circulation, and breathing mechanisms, which can make assessment and treatment difficult (28). Attitudes, interventions, and equipment must be evaluated and enhanced to provide the best possible care (30). The delivery of optimal care presents challenges in critical thinking, planning, and teamwork (15). Many of the WLS patients, afflicted with serious comorbidities in addition to the burdens of excessive weight, present with increased surgical risk.

Psychosocial challenges and uncontrolled complications of severe obesity require highly competent and compassionate support. Furniture, hospital equipment, instruments, and imaging resources must be suitable to deal with patients who often exceed their ideal body weight by 400 pounds. A well-trained staff, capable of dealing with the physical and emotional demands of severely overweight patients, is especially important (31). The optimal environment for achieving good outcomes includes a well-prepared and committed surgeon, an established and experienced team of health professionals, appropriate institutional resources and equipment, and a system for patient evaluation and follow-up (7).

Notes

¹ Nonstandard abbreviations: WLS, weight loss surgery; AHRQ, Agency for Healthcare Research and Quality; ACS, American College of Surgeons; BP, blood pressure; CT, computerized tomography; MRI, magnetic resonance imaging; ICU, intensive care unit.

References

1. McTigue, K. M., Harris, R., Hemphill, B., et al (2003) Screening and interventions for obesity in adults: summary of the evidence of the U.S. Peventive Services Task Force. Ann Intern Med. 139: 933–949. | PubMed | ISI |
2. Pope, G. D., Birkmeyer, J. D., Finlayson, S. R. (2002) National trends in utilization and in-hospital outcomes of bariatric surgery. J Gastrointest Surg. 6: 855–860. | Article | PubMed | ISI |
3. Steinbrook, R. (2004) Surgery for severe obesity. N Engl J Med. 350: 1075–1079. | Article | PubMed | ISI | ChemPort |
4. Charatan, F. (2000) Obesity surgery grows in popularity in the US. BMJ 321: 980
5. Sturm, R. (2003) Increases in clinically severe obesity in the United States, 1986-2000. Arch Intern Med. 163: 2146–2148. | Article | PubMed | ISI |
6. Sarr, M. G., Felty, C. L., Hilmer, D. M., et al (1995) Technical and practical considerations involved in operations on patients weighing more than 270 kg. Arch Surg. 130: 102–105. | PubMed | ISI | ChemPort |
7. ACS (2000) [ST-34] Recommendations for facilities performing bariatric surgery. Bull Am Coll Sur. 9: 20–23.
8. Kaushal, R. Bates, D. W. eds.(2001) Chapter 6: computerized physician order entry (CPOE) with clinical decision support systems (CDSSs) . Making Health Care Safer: A Critical Analysis of Patient Safety Practices: Evidence Report/Technology Assessment: Number 43: AHRQ Publication No. 01-E058 AHRQ Rockville, MD.
9. Murray, M. D. (2001) Automated medication dispensing devices. Making Health Care Safer: A Critical Analysis of Patient Safety Practices: Evidence Report/Technology Assessment: Number 43: AHRQ Publication No. 01-E058. Vol 2004 AHRQ Rockville, MD.
10. Wald, H., Shojania, K. (2001) Prevention of misidentifications. Making Health Care Safer: A Critical Analysis of Patient Safety Practices: Evidence Report/Technology Assessment: Number 43. Vol AHRQ Publication No. 01-E058 AHRQ Rockville, MD.
11. National Task Force on the Prevention and Treatment of Obesity (2002) Medical care for obese patients: advice for health care professionals. Am Fam Physician. 65: 81–88. | ISI |
12. Holland, D. E., Krulish, Y. A., Reich, H. K., Roche, J. D. (2001) How to creatively meet care needs of the morbidly obese. Nurs Manage. 32: 39–41.
13. Davidson, J. E., Kruse, M. W., Cox, D. H., Duncan, R. (2003) Critical care of the morbidly obese. Crit Care Nurs Q. 26: 105–116.
14. Barr, J., Cunneen, J. (2001) Understanding the bariatric client and providing a safe hospital environment. Clin Nurse Spec. 15: 219–223.
15. Hurst, S., Blanco, K., Boyle, D., Douglass, L., Wikas, A. (2004) Bariatric implications of critical care nursing. Dimens Crit Care Nurs. 23: 76–83.
16. Dowell, M. A., Russell, A. G., Gordon, J. H. (2001) Developing mechanisms for reporting compliance violations. Healthc Financ Manage. 55: 50–55.
17. Wolf, Z. R., Serembus, J. F. (2004) Medication errors: ending the blame-game. Nurs Manage. 35: 41–2,44,47–8.
18. Smetzer, J. L. (1998) Lesson from Colorado: beyond blaming individuals. Nurs Manage. 29: 49–51.
19. Yopp, M. (1998) Killing providers with criminal prosecution. Tenn Nurse. 61: 15–19.
20. Frankel, A., Graydon-Baker, E., Neppl, C., Simmonds, T., Gustafson, M., Gandhi, T. (2003) Patient safety leadership walkrounds: Joint Commission. Qual Saf Health Care 29: 16–26.
21. Lenderink, B. W., Egberts, T. C. (2004) Closing the loop of the medication use process using electronic medication administration registration. Pharm World Sci. 26: 185–190.
22. Chan, A. L. (2003) Use of Six Sigma to improve pharmacist dispensing errors at an outpatient clinic. Am J Med Qual. 19: 128–131.
23. (2004) Six Sigma success: 100% compliance in 3 months. Healthcare Benchmarks Qual Improv. 11: 52–5.
24. Staker, L. V. (2003) Teaching performance improvement: an opportunity for continuing medical education. J Contin Educ Health Prof. 23: S34–S52.
25. (2003) New York hospital looks to Six Sigma for culture change. Perform Improv Advis. 7: 141–3.;,.
26. (2004) Six Sigma improves care, reduces hospitals' costs. Hosp Case Manag. 12: 85–6.;,.
27. Lenaz, M. P. (2004) Added value in health care with six sigma. Manag Care Interface. 17: 50–1,54.
28. Bushard, S. (2002) Trauma in patients who are morbidly obese. AORN J. 76: 585–589.
29. Hutter, M. M., Crane, M., Keenan, M., Snow, R. L., Schneider, B. E., Cella, R. J. (2005) Data collection systems for weight loss surgery: an evidence-based assessment. Obes Res 13: 301–305.
30. Clementson, J. A. (2003) Improving rehabilitation of severely obese patients. Rehabil Nurs. 28: 171–191.
31. Surgical Review Corporation SRC. http://www.surgicalreview.org/ (accessed October 3, 2004).
32. Fulton, J. (2001) Care considerations for the client who is obese. Clin Nurse Spec. 15: 217–218.
33. Hahler, B. (2002) Morbid obesity: a nursing care challenge. Medsurg Nursing. 11: 85–90.
34. Gianos, J. (2003) Special equipment for bariatric patients. Crit Care Nurs Q. 26: 66
35. National Association to Advance Fat Acceptance Guidelines for health care providers guidelines for health workers in dealing with fat patients http://www.naafa.org/documents/brochures/healthguides.html (accessed April 22, 2004).

Acknowledgments

We thank Frank Hu and George Blackburn for manuscript preparation, Barbara Ainsley for administrative assistance, and Rita Buckley for editorial services. Preparation of this manuscript was supported in part by the Center for Healthy Living at Harvard Medical School and by the Boston Obesity Nutrition Research Center Grant P30DK46200. This report on WLS was prepared for the Betsy Lehman Center for Patient Safety and Medical Error Reduction (Department of Public Health, Boston, MA).