“The hospital was doing weight-loss procedures, and some of the staff shuttled back and forth between the [hospital and ASC], so some staff had experience with bariatric surgery,” he says. “It’s not that different from a lap chole on a procedure basis – one hour in the OR and same equipment, for the most part.”
Mr. Wilkinson estimates South Sound Surgery Center spent about $10,000 on longer laparoscopic instruments and other surgical supplies especially for obese patients, and about $800 apiece for a couple heavier-weight recliners (the older ones were only suited for up to 250 lbs.). The ASC already had OR tables that supported weights up to 500 pounds and motorized stretchers that supported up to 300 pounds.
“We’d already had a patient-exclusion criteria of up to 300 pounds, so we didn’t need to change our criteria. Most of our patients are actually young and healthy with the exception of their weight,” says Mr. Wilkinson. “Our surgeon, if he’s got an especially sick patient or one who weighs over the limit, he just does them elsewhere. He self-selects which cases to do here, and knows which are going to do well. Selection is a key.”
Here are five more keys to patient safety and a successful program, according to Mr. Wilkinson.
1. Anesthesia on board. The anesthesia team that serves South Sound has worked with the bariatric surgeon to develop specialized protocols for the procedures, and has embraced the challenges, such as airway management and , posed by obese patients. “We have a team of 20 anesthesiologists who cover our ASC, and they had been doing these cases at the hospital, so it’s not much of an adjustment for them,” he says.
2. Developing patient expectations. The vast majority of patients are up and out of the center about three hours post-op. How can you improve your chances of that happening? Have the surgeon tell patients to expect such a length of stay, and have pre-op and post-op staff reinforce it. “When they’re in the office, they’re told they’re not going to feel 100 percent, but they’re going to feel well enough to go home a few hours post-op,” says Mr. Wilkinson. “They spend about an hour in surgery, 45 minutes in PACU and another two hours in stage two recovery. You’ll always have some who stay longer or shorter, but when you gear them toward that short stay, they’re motivated to get out of there.”
It helps that patients aren’t slowed by heavy pain meds post-op: They are given liquid Lortab while in the facility and a prescription for the same to go home with.
“Patients just do better when they’re able to relax at home in their own beds or on their own couches,” says Mr. Wilkinson, noting that the system has led to excellent patient satisfaction scores – consistently 4.9 on a 5-point scale. “The ASC atmosphere appeals especially to our younger patient group.”
3. Attention to staff and patient safety. Moving and transferring patients can pose an injury risk to both nurses and patients. Patients aren’t pre-sedated (“unless there’s a good reason,” says Mr. Wilkinson), so they walk to the OR and get onto the operating table themselves. When patients are sedated post-op, a hover-pad is used to transfer them to a stretcher.
“That does help, when you consider that even a 250-lb. patient doubles the weight of some of our nurses,” he says. “We also have two stretchers that are electronic, they move on their own, which prevents injuries from pushing the stretchers.”
4. Guarantee the surgeon OR time. When you have a surgeon who’s committed to his bariatric program and organized and motivated, reward him with proper block time. South Sound has two surgeons who perform weight-loss procedures, but one does the majority of them; in fact, it’s all his practice consists of.
“We have five ORs, so we gave him a block once a week, and he typically does four cases in that block,” says Mr. Wilkinson. “We’ve done five before, but that means the last patient might not be out of here till 5 or 6, so we try to keep it to four maximum. And doing that has added about 125 cases this year to a relatively new center.”
5. Figure out finances in advance. Mr. Wilkinson says that, because he knew the costs of doing a lap chole in terms of staff, supplies and OR time, it was easy to determine the cost for laparoscopic banding and to charge accordingly.
“I added in the $10,000 in equipment costs and the per-case cost of disposables he requested and the laparoscopic band, and came up with a figure. The surgeon and I negotiated and came up with a fair market value payment,” says Mr. Wilkinson. All patients are self-pay, so the surgeon collects the fee up front from patients, then pays South Sound Surgery Center and anesthesia out of that fee. “He pays cash up front, so we’re happy. And he’s happy because it’s less than at the hospital.”
