Dr. Seidl: Bariatric surgery has been recognized as an effective treatment for obesity, and as the prevalence of obesity has increased, so have bariatric surgery rates. While surgery has resulted in positive weight loss outcomes with relatively low complication rates, it is recognized that inadequate participation in or adherence to follow-up care regimens is associated with lower weight loss, and in some cases more complications. During a breakout session at the most recent NABN conference, members discussed some of the strategies used to assist patients maintain compliance with the post-hospitalization postoperative plan of care. At that time, several members suggested that a roundtable discussion focused on helping patients stay on track after surgery would be helpful. To that end, we are here today to discuss tips and strategies for keeping patients on track and engaged throughout their weight loss journey. I would like to start this discussion by asking each of the panel members to introduce herself.
Ms. Rochin: My name is Elizabeth Rochin. I am a Clinical Manager for an inpatient bariatric surgical unit at Rex Healthcare in Raleigh, North Carolina. I am also a doctoral student at East Carolina University, and my primary research interest is the follow-up experiences of bariatric surgical patients, and how to increase adherence to lifestyle changes after surgery.
Ms. Wright: My name is Rebecca Wright. I am a registered dietitian at Murray Calloway County Hospital in Murray, Kentucky. I primarily provide outpatient medical nutrition therapy, and I am also the registered dietitian that works with the bariatric patients in our program, Bariatric Solutions.
Ms. Cowart: I am Karianne Cowart. I am currently the nurse clinician for an inpatient surgical/bariatric unit at Northside Hospital in Atlanta, GA. For the past four and one-half years, I have been a staff nurse caring for the bariatric patient postoperatively.
Dr. Seidl: Thank you. We are very happy to have the three of you here today. To start us off and to give readers some background, would you briefly describe your postoperative follow-up program? How long is the follow-up period? What is the frequency of visits? What team members participate in the follow-up sessions?
Ms. Wright: Lap band patients meet with the surgeon and nurse practitioner 1 week postoperatively and again 1 month postoperatively. At the 1 month visit, patients have the opportunity to receive the first lap band adjustment. The patient is then scheduled to return monthly to see the surgeon or the nurse practitioner for adjustments and follow-up care. After 1 year, the patient can decide whether or not to meet with the physician or the nurse practitioner every 3 months; there is no end date. Our lap band patients also meet with the registered dietitian in office visits at postoperative days one and two, and when needed per physician referral.
It is a little different for our sleeve gastrectomy patients. With sleeve gastrectomy, the patients are scheduled to see the registered dietitian seven times in the first year. They meet with the surgeon 1 week and 1 month postoperatively; then they see the surgeon or the nurse practitioner every 1–3 months, or as needed.
Ms. Cowart: Follow-up at our facility is conducted by the individual surgeons. The patients typically follow up 2 to 4 weeks postoperatively. Depending on the type of surgery, patients will follow up with the surgeon for 6 months, and then yearly for life. The information gathered by the surgeon is then provided to the bariatric specialist for our facility, which is entered into the data program for the American College of Surgeons (ACS). We are presently designated a Center of Excellence by ACS. In order to monitor these patients further, our facility also compiles information related to readmissions and revisions as well.
Ms. Rochin: Similar to the others who have shared their experiences with frequency, our surgeons see the postoperative gastric bypass patients at around 1 week postoperatively and then again 1 month, 3 months, 6 months, and 12 months postoperatively. We have seven bariatric surgeons that we work with, and each group has some variation, but that is approximately the schedule we follow.
Band adjustments are based on a different set of criteria. Those visits are not necessarily as frequent, but depend upon negotiation between the patient and surgeon for desired weight loss milestones. Meaning that if they are starting to consume a little bit too much food, the band may not be restrictive enough, or if they are not seeing the weight loss that they expected, then they schedule a visit with their surgeon to explore a band adjustment.
Dr. Seidl: Do any of you have data, whether it is exact numbers or just a rough estimate, about what percentage of your patients actually complete your follow-up program? Has your practice identified any common barriers or risk factors for not adhering to the postoperative follow-up schedule?
Ms. Wright: Approximately 95%–100% of our sleeve gastrectomy patients meet with the registered dietitian, the surgeon, and the nurse practitioner for the first two postoperative consults. However, in the first year, only 12% of those patients completed all seven visits with the registered dietitian, and 72% followed the aftercare protocol with the surgeon and nurse practitioner.
Almost 100% of patients having lap band placement met with the registered dietitian, the surgeon, and the nurse practitioner for the first two postoperative consults; and approximately 75% of the patients returned per our follow-up protocol to have a band adjustment done. So the lap band patient population has been slightly more compliant with aftercare.
Ms. Cowart: Our patients demonstrate 99% compliance with the first year of the follow-up program. However, it drops to less than 50% at the five-year mark. The most common barriers that we have identified are distance to the physician office, finances, and embarrassment for not achieving weight loss goals.
Ms. Rochin: For us, it is a little bit more difficult to follow, simply because the nursing unit does not follow the patients postoperatively; it is the physicians' offices that are following them. We are certified through Surgical Review Corporation (SRC) as a bariatric center of excellence, as well as a center of distinction through Blue Cross Blue Shield of North Carolina, and there are very specific follow-up criteria that need to be met in order to maintain those designations.
I would say the average follow-up care percentage that is reported to us from our surgeons' offices is about 74%, with a range of 71%–79%. This includes gastric banding, gastric bypass, and sleeve gastrectomy. Some specific surgeons' offices may be higher or lower.
Dr. Seidl: It sounds like between the three institutions there is variation in participation. Some of you have very high adherence rates; but in Rebecca's group, it sounds like there is fairly good adherence with the physician and nurse practitioner component of follow-up care, but less adherence with the dietitian visits. Did I hear that correctly?
Ms. Wright: Yes, and I was surprised by that. The sleeve gastrectomy patients were very compliant for the first two visits. However, compliance with the remaining five visits varied. We have several patients driving to our facility from a distance of 100–200 miles, and I have found that a common barrier with these patients has been socioeconomic status. They have told me that they do not have the money for gas, or that mass transit will not pick them up and bring them. So that has been a huge barrier to compliance with postop consults.
Another possible reason for noncompliance with follow-up could be more psychosocial in nature. We have many patients that keep their surgery a secret from their friends or their family, with many not even wanting to be seen in the lobby of the bariatric office. Also patients have reported that they just do not really feel like they need to come in for follow-up care, since they believe that the surgery fixed the problem. Moreover, for those who believe that the surgery may not have been successful, they oftentimes stop coming in for appointments, change their phone number, and we cannot even reach them in order to attempt to get them back in for follow-up care. So we do have some very difficult barriers to contend with for our patients.
Dr. Seidl: Liz and Karianne, are regular postoperative visits with the dietitian also part of the postoperative plan at your institutions? Do you know how patients are adhering to that component of the postoperative plan of care? Perhaps Rebecca knows this information in such detail because she is a dietitian and is very aware of this component of follow-up care, but I am curious about how her experience might compare to your experience.
Ms. Cowart: The dietitian sees each bariatric patient while the patient is still an inpatient. The surgeons have an independent dietitian that assists with their individual program.
Ms. Rochin: Very similarly, each of our bariatric surgical groups has their own dietitian or dietitian group that they work with. During their immediate postoperative stay, our surgeons typically schedule a nutrition consult with a dietitian prior to discharge, and that dietitian is very familiar with the standards of each physician group and works to ensure that the education that was initiated prior to surgery is reinforced.
It is pretty surprising to me, and certainly this does not apply to all patients, but a number of patients do not seem to have read the information they were given preoperatively and do not seem to know what is expected of them after surgery. The number is pretty startling among the patients that I round with. They ask a lot of questions while they are inpatients, and we will ask them, “Did you read the information your surgeon gave you?” They will be honest and tell us that they did not. So to me, it seems as if many patients are not really engaged, and are not demonstrating that assertive nature that says “I need to learn this. This is not going to be a quick fix, so I need to learn this. I need to take an active role in my care.” I think for some patients, they are surprised that we expect them to come to the hospital informed of what their role in the postoperative process is.
Dr. Seidl: I hear you saying that you routinely give people information preoperatively about what is going to be required postoperatively, only to have them tell you that they are not aware of the postoperative regimen. As a result of this, have you changed any strategies in terms of how you approach the preoperative education component?
Ms. Rochin: That is correct. Our bariatric coordinator is going to begin preoperative classes for our weight loss surgery patients in January 2012. Although this is a process under development, we are hopeful that it will help our patients understand their role in their journey. These classes will review how to prepare for surgery, what to expect in the hospital, and then what to expect in the immediate postoperative period.
Truly, the current preoperative teaching is preparing them to come into the hospital. But what patients really need, however, is to be dialoging with their surgeon about the long-term care for themselves so that they are able to be successful with their weight loss. I am sure there is structured education within the offices prior to their scheduled surgery. But once again, it depends on how engaged the patient is and whether or not they take it upon themselves to go in for that teaching, and how involved they are with their preoperative care.
Ms. Cowart: Our facility has a similar experience. The patient meets with the surgeon, perhaps several times prior to surgery. The surgeon presents the patient with a standard packet of information and a standard education program about the surgery. Before surgery, the patient will come to the hospital and meet with the bariatric specialist. This visit includes what to expect at the hospital before and after surgery. The bariatric specialist will also review the patient's understanding of the surgery and postoperative diet, as well as strategies for success. However, when the staff nurse reviews the plan of care with the patient, such as walking frequency and limiting the amount of fluid intake, the patient either does not remember receiving this information prior to surgery or confesses that they have not read the packet of information. Many patients do not seem to understand the changes required of the postoperative diet.
Ms. Wright: At our facility, we do require a preoperative day of education, and that has been the protocol since 2008 when we began offering bariatric surgery. They arrive at 8:00 AM and are usually in our office until 3:00 PM or 4:00 PM. During that period of time, they are given an education binder, and spend a full hour with the registered dietitian, reviewing the entire dietary components associated with surgery. Some of this information is repetitive because many patients are required by their insurance to meet with me monthly for 3 to 6 months before the surgery is approved. This is not new information, but I educate patients on the dietary interventions to shrink their liver for surgery. I discuss the transition of the diet after surgery, give them the suggested eating and drinking schedule, and educate them on protein requirements that are needed postoperatively.
The bariatric coordinator and nurse practitioner educate the patients about their hospital stay and early postoperative care, and take the patients' “before” picture. Our patients also meet with our exercise specialist. A benefit of having the surgery at our facility is access to our Center for Health and Wellness. Patients are given a free month to use the indoor swimming pool and exercise equipment in addition to a prescribed exercise plan specifically tailored to them. Preanesthesia testing is also completed that day. Our patients do receive a lot of education prior to the surgery.
But just as Liz said, often our patients cannot recall some information that they received. I do not really understand how that can be, since they have met with me monthly, and then they come in for this full day of education. It may just be that there is so much information and that they are overwhelmed by it, and they just cannot absorb it all.
Dr. Seidl: In terms of the educational information that is provided, is it all delivered in one format, such as all written or all verbal, or is it multimodal? Are there different teaching strategies that are used based on individual learning styles? Have you ever considered assessing preferred learning styles? In fact, in 2012 the Joint Commission standards for patient-centered education will require a documented assessment of learning styles at the first encounter, whether that encounter be in an office or in the hospital as part of the admission process. Since each of you expressed a similar theme of patients not remembering information, I am wondering if any of you have formally evaluated the education materials and the manner in which you are delivering the education.
Ms. Wright: At our facility, we do pre-education testing. I have a questionnaire that I give to patients before the teaching sessions to see if everybody in that particular class is at the same level, and to assess whether or not they retained any of the information that they previously received from me during the medical nutrition therapy sessions. The patients' responses to the questionnaire becomes the jumping-off point for our discussion that day. After we finish the hour of education, the patients are given a posttest.
During the educational session, everything that I discuss is also provided in written form. I demonstrate how to mix the protein supplement, and then I offer taste testing of the product. I use food models and measuring cups and spoons to teach portion sizes. It is very interactive. My patients are scoring 80%–100% on their posttests, indicating to me that they really understand the material. However, when it comes time to apply it, some patients will ask, “Oh, you mean I cannot drink with my meal? Did you ever tell me that before?” “Yes, I have told you that seven times,” but for some reason, they are not retaining that information.
Ms. Rochin: On my unit, the other nurses and I have been interested in conducting a research study to evaluate which mode of education is most effective for bariatric surgery patients, whether it be video, an interactive CD, or written material. We are curious about what mode of education will allow patients the best opportunity to utilize the information provided preoperatively in order to assist with their postoperative experience and care.
It is pretty remarkable just to see the differences, the different levels of engagement that we have with patients. Some are very gung-ho. Others are obviously looking for somebody to help them with losing weight. It is unfortunate, because the retention rate seems to be much higher in individuals who recognize that this is something that they alone are going to have to do—meaning, the lap band, the sleeve, or the gastric bypass is simply a weight loss tool. The rest of this process really belongs to the patient, and the patients that understand that and are very engaged seem to have a much higher rate of retention and ability to comprehend what is going on than those who are not as engaged. Those who are not as engaged are quick to say, “Why am I not losing weight so fast?” when they are back to a regular diet in 30 days.
Dr. Seidl: Are you saying that you think some of the patient's ability or inability to retain information might be related to the education process and some of it may be related to engagement more than education?
Ms. Rochin: Yes, absolutely, yes.
Ms. Cowart: We have similar experiences. It would be very interesting to determine if it is a factor of education or patient engagement. We have patients who see bariatric surgery as a “tool in the toolbox” and recognize the commitment necessary for success. Then other patients seem disengaged and unable to retain the necessary information for success.
Dr. Seidl: So have your practices implemented any type of program or examined different techniques to get people more engaged?
Ms. Wright: We started asking our postoperative patients if they would like to attend our community seminar to tell their story. We found that this has been so beneficial for our successful lap band or sleeve gastrectomy patients to speak at the seminar. It is very important for a postoperative patient to come in and talk about expectations and explain that bariatric surgery is just a tool. To make the point, we have one patient that brings in a hammer, a piece of wood, and a nail. He often uses the example of, “This hammer is just a tool, but if I do not pick it up and use it according to the way that I have been taught to use it, that nail is never going into that piece of wood.” He goes on to say that “It is the same thing with my lap band. I would not have been able to lose 100% of my excess body weight if I had not used the education that the bariatric team taught me. It is just a piece of silicone. It does not do anything by itself. It is just a tool.”
When our patients speak at the seminar, expectations are discussed. They share with the attendees the dialogue that we had with them at their initial consultation, saying, “This is what we expect of you. We expect you to come to your appointments, to participate thoroughly with everything that is taught, comply with our suggestions. We are here to love you and support you through the whole process. However, you have to do the work. You have to change your lifestyle, and this is just a tool that is going to help you do that.”
I think that in the last 6 to 9 months, our patients have complied with postoperative care and support group attendance better than ever before. They are coming in for their appointments, and their weight loss has been on track. They are so thrilled with the outcome, not just with weight, but with how they are feeling. And they are proud of themselves. So I think discussing expectations at the seminar has been really helpful for our patients.
Dr. Seidl: Thank you, Rebecca. Are there any other comments about education or engagement? If not, then we will move to a different topic. One other issue that I heard—and I think, Karianne, it was you who talked about this, and Rebecca also said they had a similar experience—that sometimes the reasons for not following up are due to distance, transportation, and other financial or socioeconomic factors. In today's environment where there are different technologies and various types of social media available, have any of you ever considered other ways to conduct follow-up appointments that are not necessarily in person?
Ms. Cowart: Our facility is actively working on implementing the use of social media as a means to increase connection with the patient. We have many patients who travel quite a distance to have surgery. Presently, we offer several support groups that meet in areas located 2–3 hours from Atlanta, but we are in the process of developing our program to include social media.
Ms. Wright: We have designed a website, and we do have monthly newsletters, which are very informative and fun, that we send out to all of our patients. We have not done anything else as of yet, but we would like to look into utilizing social media. I think that it would be really important for those patients who live far away. They need that personal contact and to know that we care and understand about how the downturn in the economy is impacting their lives—how really tough it might be for them to be able to afford to drive in for the appointment. So that is a great idea, Karianne, about maybe going to another county and having a support group somewhere outside of our county. We had not thought about that, so I am going to discuss that with our coordinator.
Ms. Rochin: The idea of social media is a very good one. I think that you can reach a lot of people that way. Formats such as Facebook reminders or even sessions conducted over Skype could be a real benefit for patients. To be able to have a conversation with a patient who lives a long distance away may increase engagement and promote a better understanding about their part in the process. What exists right now, unfortunately, is that many insurance carriers require that the patient go to the bariatric surgeon's office only and they do not consider a visit with a primary care provider or a phone conversation as meeting that requirement. This is unfortunate, because I think that there are types of media that can help, especially for patients that live a long distance away.
I think that when you are in the moment, when you are getting ready for a life-changing surgery, you do not mind driving 3 hours to see someone for a preoperative visit. But as time goes on, those 3 hours become very long. If you think about it, that is 6 hours in your car, at least, during the day, and that is a long time. Certainly, distance and transportation to follow-up visits needs to be discussed during the preoperative period and must be considered. So I think that there is a lot that we can do with accelerating technologies, such as social media, and also with the telemedicine opportunities that now exist for us. But accrediting agencies and insurance carriers have to be willing to look at those strategies and allow them to mix with patient and physician collaboration, getting them together to really help bridge those gaps.
Dr. Seidl: I think that is an excellent point. Do you find that distance is more of a barrier to follow-up for one patient type or another? If I put myself in the shoes of a patient for whom the postoperative course is going as anticipated and I am losing weight, maintaining my diet, and not having any problems, I can see myself saying, “I do not really need to drive 6 hours, because everything is going fine.” I can also see it from the standpoint of the patient where perhaps things are not going well and there is embarrassment or maybe even some degree of disappointment or shame, and now the 6-hour drive is an excuse not to make it to the follow-up visit. Have you had any experiences such as this?
Ms. Wright: Yes, I have. The patients who have been compliant and are engaging fully with me are doing very well. They will send me an e-mail or they will leave me a voice mail message and say something such as, “I know I need to see you seven times this year, but I am doing so darn good. I just do not really think I need to come in this month, so I will catch up with you in three months.” They will even send me their weight or their body mass index or their waist circumference. They are so pleased and they want to share their results, just not in person. Then on the flip side, like you said, some people are embarrassed. They do not want to come in because they met with me face to face for 6 months prior to the surgery. They know that I know that they should be knowledgeable and compliant, and it just has not worked out the way they thought it would. It was not as easy as they thought, and perhaps they did not put enough effort into it, and they have not been successful. These patients are embarrassed, and they do not want to see me, the nurse practitioner, or the surgeon. They are disappointed in themselves, so they do not come in.
Dr. Seidl: When it comes to following through with the postoperative regimen, what different ways or different strategies do you use to try and pull these two different groups back in? I would think there would be different strategies for these different types of people.
Ms. Wright: Well, with the lap band, our surgeon decided he would not do a band adjustment on a patient if they did not attend the support group at least once every 6 months. We started that about a year ago, and believe me, our support group meetings are now well attended. When patients come in, they get a “golden ticket”; it is a unique slip of paper that we developed that includes the speaker topic, our signature, and the date of attendance. After the support group session, we distribute the golden tickets to the patients, and the patients can then turn the golden ticket into the physician's office. They cannot wait to come in and turn in their ticket so they can have a band adjustment.
With the sleeve gastrectomy, it is a little different situation, since they are not being adjusted. For this group, we give the patients a unique, colorful, wallet-size card that serves as proof that they had the surgery. The patient can show this card to waitresses or to restaurant managers, and in some restaurants, they will get a discount on food or the card allows them to order a smaller portion. The card lists the surgeon's name, the date of surgery, and our phone number. We put an expiration date on the card, so patients need to attend at least one support group meeting every 6 months in order to get a new card. This strategy has helped to get patients back in a little bit more frequently. We had that brainstorm one day over lunch, and it has worked fairly well.
Ms. Rochin: One of the strategies we have implemented is targeted toward communication. Our bariatric coordinator works very hard to ensure that she has the ability to meet with patients prior to discharge, and establish a plan for communication with patients after discharge, whether that be by phone or by e-mail. E-mail is quickly becoming the preferred way of communication for many patients. Many of our patients now carry some sort of smart phone device that basically allows their e-mail to go to their phone, and therefore it has become a preferred method of communication for many of our patients.
Once we know the preferred method of communication, we send either an e-mail and/or a reminder card to their home saying, for example, “Congratulations on achieving six months postoperatively. Here is the name of your surgeon and his contact information. Please call to make sure that you are scheduling a follow-up visit.” We started this very recently, so I can't tell you how effective it has been yet, but it will be interesting to see if it has an impact on the likelihood that patients will come back for their follow-up visits after they leave the hospital environment.
Ms. Cowart: Since the patient follow-up is done in the surgeon's office, there is no formal hospital follow-up program. The surgeon's office will reach out to patients if an appointment is missed. Otherwise, the connection with the patient postoperatively is patient driven. We encourage patients to keep in touch, for example by sending us before and after photos.
Dr. Seidl: Rebecca, you mentioned support groups, and I have not heard support groups mentioned from Karianne or Liz yet. Does your practice utilize support groups? If they do, are the voluntary or mandatory? It sounds like, Rebecca, you said your support groups are “voluntarily mandatory”—correct?
Ms. Wright: That is right. We offer two during the daytime on the lunch hour, and then we offer two in the evening, so patients have four opportunities a month to come to a support group. One staff member is in charge of all four monthly meetings, and we rotate through the staff. So I might moderate all four of them in the month of December on a nutrition-related topic. The next month it may be our exercise specialist speaking to all four groups on the importance of resistance training.
One of our best speakers has been our hospital chaplain. He speaks about change and how this is particularly difficult for the patient's family and their friends and co-workers. He discusses how to adapt to all the changes one goes through when one has weight loss surgery. This meeting is always well attended. We try to bring the chaplain in to speak every 3 months.
We do really push the support group meetings. I think they are imperative for patient success. We also invite patients who are preparing for surgery to come to the support group meetings. Preoperative patients learn a lot about what is ahead, and they get to talk to actual patients who have had the surgery. I think it has been really valuable.
Ms. Cowart: We do have three different hospital-sponsored support groups. There are two general support groups offered at two different campuses. We invite those considering bariatric surgery to attend the support groups. We have a third support group that applies to patients that are 1 year post surgery. There is a direct relationship between those who attend and participate in the support group and those who succeed in achieving their goals.
Ms. Rochin: Yes, we do currently have a support group in place. It is run by our bariatric coordinator. It meets once a month, twice in one day. We are a relatively young support group, so hopefully soon we will be able to build upon that and offer it more times during each month.
One of the things that we have done that has proved to be very helpful to a number of people is that we have involved the staff nurses into the support groups who care for patients after surgery. That has been a really great connection between the patients who are coming back postoperatively and the nurses being able to see their success postoperatively. The reason I say that is because the nurses who work on the floor see the patients immediately after surgery, and before they go home, or they see them at the time of readmission for a complication or for something that has gone wrong. The staff nurses do not get to see the evolution and end result of a patient who has had successful weight loss, so we are trying to change that. We want to make sure that the nurses can see the long-term impact that they have on patient care, and the impact that they can have even for someone who is in their care for only 48 hours post procedure.
We had a number of patients that have really embraced that aspect and have connected to these nurses that cared for them. Just this past week, we had our first yearly celebration. Basically, we sent an invitation to all the patients that have had surgery within the past year, and we had about 120 people attend. We had portion-controlled food, namely proteins. We had a professional photographer. We had department stores come for makeovers, we offered wellness tips, and it was very, very well received. One of the best things we did, once again, was to invite back many of the staff nurses who had taken care of these patients to assist with this event. It really made an impact on the patients because many times the nurses would not remember, or not even recognize, the patients. But I can absolutely assure you that the patients remembered those nurses. For the nursing staff, that was such an impact to them, and they have already signed up for next year.
Ms. Wright: Wow, Liz that is such a great idea. At the NABN conference this year, someone in my discussion group talked about how important it was to involve the floor nurses, and I brought that nugget of information back to our staff. I think that is an outstanding idea. We need to consider implementing that into our program.
Ms. Cowart: For the past 3 years, our hospital foundation has hosted a similar event. This annual bariatric reunion has been a tremendous experience for everyone involved. There is a professional photographer present with people wearing evening gowns and tuxedos for dinner and dancing. The staff nurses look forward to seeing patients outside of the hospital setting and celebrating their success.
Dr. Seidl: Excellent, what a great model. I am looking at the time, and there is about 5 minutes left on our scheduled call, so I am wondering if there is any tip or strategy that you have in terms of keeping people on track and helping them maintain adherence postoperatively. I would like to give you the opportunity to share anything about your program that you think is unique or particularly remarkable.
Ms. Rochin: Very quickly, one of the things that we touched on a little bit, but I think needs some refinement in the future, is the idea of really involving the support people who are going to be working with that patient to also work with their families. I think that sometimes the family members and those directly around the patient involved really do not understand or appreciate the dramatic change that will occur in their own home. I think that that is an area that is lacking in greater understanding.
Ms. Cowart: I agree.
Ms. Wright: I agree, too.
Dr. Seidl: So, Liz, you mentioned earlier in the conversation that you are developing a new preoperative class for your patients. Are you including support people in that class?
Ms. Rochin: Well, after I just made that comment, I am going to e-mail my bariatric coordinator and say, “Make sure the families come with them.” I think it is very true that if you do not have the right support in your home, somebody can very easily say, “Oh, honey, this little peanut butter cup is not going to hurt you. Just have a little bite.” Whereas you need somebody to say, “Do not eat that peanut butter cup. You know better, your surgeon said you could not eat that.” So the right support and the right environment is needed in order for the patient to be successful, and I think in many cases it does not exist.
Ms. Wright: I agree. We invite our family members to attend preop day education and postop office visits. Their success really is determined according to who they are surrounded by. We have had the opportunity to have many couples have the surgery together, or a mother and her son, or a father and the daughter, or two sisters come in together, and it is really nice. Yesterday in our office we had a husband and wife who both had the surgery, and they keep each other accountable, and I think that is so great.
One thing that I want to share is the specific strategies we use for patients who are failing therapy, need another operation, or are regaining their weight. In our facility, when a patient is unsuccessful with weight loss, they meet with the surgeon for another consult to talk. If that intervention isn't successful, then the nurse practitioner will meet with the patient to address their lifestyle choices and provide more education. If the patient continues to fail, a referral to the registered dietitian is made. Patients are instructed to keep a detailed food diary, and the registered dietitian evaluates current eating behavior and dietary intake and then develops an action plan.
We usually check the patient's resting energy expenditure on the indirect calorimeter in our office to see how many calories a day that they are actually burning, and if they are eating enough to feed their metabolism. Often they are not eating enough, which is a surprise to them. So we have to adjust and educate them about that, and get them back into the support group again.
If they really want to have another surgery, then the surgeon will do some testing to see why and what may have happened. He will evaluate to see if there has been some kind of equipment failure, or if something else might be going on. We had two patients who had lap band changed to sleeve gastrectomy. Usually after they meet with the professional staff, they can get back on track, and we do not have to reoperate.
Dr. Seidl: So if a patient is failing, regaining weight, or not losing enough weight, your practice has a process where the patient is placed on a fairly strict follow-up program, you attempt to diagnose any problems or barriers, and then you create a plan to get the patient back on track.
Ms. Wright: Yes. When they get really discouraged because their weight did not change but they are working out for an hour a day, 5 days a week, our surgeon will say, “Okay, pull out your tape measure. Let us measure your waist, and let us look at inches lost.” When they are losing body fat and regaining muscle mass, sometimes that number does not change on the scale, and they get very discouraged. We pull the tricks out of our bag to help build the patients back up again and remind them not to lose hope, because they are really trying hard and we want them to leave satisfied with the outcome because they are making such great changes. That number really discourages, and it is so much more than a number on the scale. We try to have them look past their body weight and look at other positive outcomes, such as improvement in [hemoglobin] A1C, or reduction in medication use, or increase in mobility. Some patients initially came to see us 2 years ago in a wheelchair, and now they are walking in the door. We really try to refocus and let them look at the other positive outcomes. They might not have gotten down to 150 pounds, but look how far they have come.
Ms. Rochin: Today's roundtable has focused on a very important topic that needs to be addressed. We are speaking with colleagues today from Georgia, from Kentucky, from North Carolina, and it is obvious that the topic of postoperative adherence and follow-up is something that is touching caregivers throughout the nation. Follow-up care and successful lifestyle changes are very important issues within bariatric surgery and ones that we are really glad to see on the forefront of the agenda. So we appreciate the opportunity to have this discussion.
Dr. Seidl: I think you are right, Liz, and I think this is a great example of a discussion topic that developed from networking at the annual conference. I know there is some research about predictors of nonadherence, but to my knowledge, there is not yet much research, or even experiential information, about what strategies might work to improve adherence. I hope that this roundtable discussion helps our bariatric surgery colleagues rethink old strategies and develop new strategies.
Ms. Rochin: There are some strategies that have been published in the medical literature, but there is not a whole lot in the nursing literature. This is an area of patient care where nursing can be at the forefront and really take the lead, which is great. We have an opportunity to contribute substantially to nursing knowledge. There are strategies that we can implement in the hospital that can really set the stage for patients being successful. That is important, because, obviously, patients need to be sent back to their homes on the right foot, and if we have the opportunity to do that, then we should support and embrace that opportunity.
Dr. Seidl: Well said, Liz. I think that is a perfect place to end this roundtable discussion. Thank you to all of our participants.
