Abstracts from The National Association of Bariatric Nurses 7 th Annual Meeting and Conference September 29–October 1,2010 Norfolk,Virginia

1. Prospective, Randomized, Pilot Study Evaluating the Effect of Ice Chip Administration Versus None on the Bitterness of Crushed Medications in Post Operative Bariatric Patients

Background: Administration of crushed medications to post-operative bariatric patients is challenging for both the nurse and the patient. Bedside bariatric nurses routinely experience negative reaction from their patients when taking crushed medications. From an evidence-based practice perspective, research is warranted to improve patient perception of crushed medication bitterness and/or taste.

Study Purpose: The purpose of this study was to test whether a nursing intervention of administering ice chips to post-operative bariatric patients' tongues before and after administering crushed medications resulted in an improved bitterness and/or taste rating by the patient.

Methods and Study Procedures: In this pilot prospective study, 100 adult subjects were randomized on their first day after bariatric surgery to either an intervention group (ice chips intervention) or a control group (no ice). For the intervention group, pre and post-ice intervention scores for bitterness and taste were rated by subjects on a validated 5 point categorical scale (bitterness: 1 = least bitter; 2 = less bitter; 3 = neutral; 4 = more bitter; 5 = most bitter; and taste: 1 = least unpleasant; 2 = less unpleasant; 3 = neutral; 4 = most unpleasant; 5 = most unpleasant). The control group provided ratings after medication administration only. The Institutional Review Board approved this study; all subjects provided informed consent.

Results: Fifty subjects were in each study group, and the majority was female Caucasians. In the intervention group, there was a 1.16 point mean improvement in bitterness (3.66 to 2.62; t-stat = 5.32 p < 0.0001) and 1.04 in taste (3.86 to 2.70; t-stat = 4.72 p < 0.0001). Control group ratings were similar to the baseline intervention group ratings.

Conclusion: The hypothesis of this study was met since the ice chips intervention significantly improved patients' bitterness and taste perception ratings. Nurses can easily implement the ice chips intervention to improve bariatric patient experiences with crushed medication administration.

2. Bariatric Patients with Wounds: A Nursing Challenge

This informational presentation explores the nursing challenge of providing optimal care for bariatric patients with wounds. The focus is on treating and preventing wounds in patients with a body mass index greater than 40 who may or may not be seeking bariatric surgery. Patients dealing with morbid obesity are part of every facility's patient population and are at risk for development of hospital acquired pressure ulcers, surgical site infections and post-operative complications. Nurses need to be prepared to provide care for these patients with the goals of wound healing, patient safety, and preserving patient dignity.

After this presentation, attendees will be able to 1.) review causes, trends and risk to health associated with obesity/morbid obesity; 2.) describe how to calculate body mass index; 3.) review perioperative risks for bariatric patients; 4.) discuss the assessment, prevention and treatment of hospital acquired pressure ulcers (HAPU) in the bariatric patient population; 5.) and list types of skin and wound problems often affecting bariatric patients including surgical site infections, intertrigo and lipedema. Several case studies are used to illustrate the treatment of complex wounds in morbidly obese patients.

3. I've Got a Secret: Nondisclosure in Persons Who Undergo Bariatric Surgery

Bariatric surgery is a highly effective treatment for the morbidly obese population and is becoming increasingly popular. From a clinical perspective, most healthcare providers are well versed in the knowledge that conditions such as coronary artery disease, diabetes mellitus, dyslipidemia, and certain types of cancers are more prevalent in this population. However, the profound influence that severe obesity has on the individual and their identity as a member of society is less well understood. The purpose of this research was to explore, using qualitative research methods, the experience of 14 women who underwent bariatric surgery. This presentation will explore one major theme that was identified from the research; that being “secrecy” or purposeful nondisclosure. Secrecy or nondisclosure has been reported in the literature among persons of socially stigmatized groups. Robinson and McGrail report that the most common reason persons fail to fully disclose information is due to a concern about receiving a negative response from others. In this study a qualitative approach was used to explore meaning in the individual experiences and choices of the participants as it relates to bariatric surgery. The sample consisted of 14 females. As the data collection evolved, the phenomena of secrecy emerged as a commonly shared experience. The decision to limit disclosure regarding the decision to pursue bariatric surgery was a consistent theme. The three following sub-themes were identified that illuminated the common attribute of secrecy surrounding the participants' decisions to pursue surgery: “the lonely decision,” “looking for approval,” and “not telling.” The emotional burdens that confront obese persons are confounded by a societal stigma related to obesity. Fabricator and Wadden report that obesity stigma is a socially acceptable form of prejudice that frequently leads to depression, isolation, and poor self esteem. As a result of this stigma, obese persons report they have experienced discriminatory behaviors in multiple aspects of their personal and professional lives that have negatively affected their attitudes and beliefs in themselves. This internalization of the societal weight stigma may have contributed to the individual decision to maintain some degree of secrecy or limited disclosure among participants in this study.

4. A Program to Increase Bariatric Surgery Referrals Through Clinical Practice Guidelines

Background: Clear clinical practice guidelines are available that address identification, evaluation, and treatment of overweight and obese adults. Although there has been a consistent increase in the number of bariatric surgeries being performed, the numbers are still low compared to the number of obese Americans. Despite clinical practice guidelines and data on the efficacy, safety and technical advances of bariatric surgery the overall attitude of patients and providers toward bariatric surgery is negative. Studies show that approximately half of bariatric surgery referrals are patient initiated. Literature suggests that provider education and clinical reminders may improve attitudes and referrals to bariatric surgeons.

Purpose: The purpose of the project was to develop a program for local primary care providers on the clinical practice guidelines for the identification, evaluation, and treatment of overweight and obese adults including bariatric surgery.

Methods: PCPs from an existing database were surveyed to develop a list of items to include in the program. Sixty PCPs were emailed and sixteen providers responded to the internet survey. The majority of the providers selected six of the eleven items to be included in the program. The program was developed based on these recommendations. The program was piloted in two practices. The program was advertised to the providers by email and in a print advertisement.

Results: Seven providers attended the program. All of the participants felt the program would improve how they cared for their obese patients and believed they were more likely to adhere to the obesity clinical practice guidelines. Six of seven of the participants felt that the program improved their opinion of bariatric surgery. In addition, all of the participants felt that they were more likely to refer their obese patients to a bariatric surgeon.

Conclusion: Use of current clinical practice guidelines, simple tools and face-to-face meeting with PCPs may improve the care of obese patients. This program will be replicated at other practices. Future data collection would be helpful to evaluate if the program does improve the care of obese patients, increase the use of clinical practice guidelines and increase appropriate referrals to bariatric surgeons.

1. Bariatric Joint Practice Committee—Keeping the Dialogue Open

Purpose: This poster presentation describes the Bariatric Joint Practice Committee's interdisciplinary team members, their roles and how open communication has created a more effective and cohesive environment. Monthly meetings are designed for problem solving, follow up, teaching and program planning.

Objectives are:

Identify key team members for a Bariatric Joint Practice Committee (BJPC).

Significance: To describe one model of BJPC it's ongoing success. To provide information for a model of communication that has enhanced and improved patient care at UC Davis Health System.

Methodology: This is a process of meeting with the attending physician, fellows, nurse practitioners, psychologist, dieticians, bariatric nurse coordinator, manager of the Vascular/GI Surgery Unit and bariatric consultant, assistant nurse managers and staff nurses. We have been meeting monthly since 2006. We share updates, do a regular needs assessment for training and inservices, coordinate and plan for COE survey and dialogue and problem solve concerns and patient care issues.

Findings: The process of having a BJPC improves communication, builds trust and relationships with committee members and patients get discharged on time.

Implications: BJPC should be considered a requirement that augments the care of bariatric surgical patients to improve communication and in addressing issues and concerns.

2. Health-Related Quality of Life Following a Surgical Weight Loss Intervention

Nursing is concerned with the well-being of the whole person; therefore, understanding the patient's perspective of the impact of a surgical weight loss intervention (SWLI) is essential. The purpose of this study was to examine the self-reported health-related quality of life of individuals after a SWLI. A convenience sample of participants in a post-SWLI support group completed the SF-12v2, a demographic form and a global quality of life measure. Findings indicate that although overall quality of life was rated excellent or very good, self-report of health-related quality on social functioning, vitality, and mental health was less positive. The findings of this pilot study indicate the need for research regarding the understanding of the meaning of psychosocial and physiological well-being to the person who undergoes a SWLI and a need for a more holistic support focus inclusive of psychosocial development strategies. As nurses committed to the wholeness of individuals, it is critical that we recognize the social and emotional needs of this emerging group of patients and implement strategies to enhance individual wholeness and well-being after SWLI.

3. The Morbidly Obese Patient Moving from Hospital to Home or Nursing Home: What Are the Problems?

The challenges of providing care to hospitalized obese patients have been documented and include the need for assistive equipment, increased staff members, and specialized nursing techniques (Drake, Engelke, McAuliffe, Dutton, & Rose, 2005; Drake, et al., 2008). Additional problems arise when case managers prepare for discharge of these patients to home or nursing home. The home situation may be deemed inadequate for the care due to factors such as lack of caregiver support or inappropriate physical facilities. Similarly, nursing home placement may be difficult due to the inability or unwillingness of many nursing homes to accommodate the morbidly obese. It is quite possible that the patient becomes “stranded in hospital” with subsequent deterioration of vigor as well as increased cost.

There is little exploration of these problems in the literature. Most related studies focus on issues associated with hospital lengths of stay for obese individuals and on issues associated with the care of obese individuals in nursing homes, indicating potential limitations in access.

The purpose of this exploratory descriptive study was to identify the challenges or obstacles that hospital case managers, home care agency directors, and nursing home directors encounter when the morbidly obese patient is ready for transfer out of hospital to these types of facilities.

Case managers from licensed hospitals in the state of North Carolina as well as directors of Medicare-certified home health agencies and nursing directors from licensed long-term care facilities were surveyed to identify the problems or challenges they have experienced in discharge and receipt of morbidly obese patients. Survey questions were devised by the research group, and the survey instrument was mailed to each participant.

The data was analyzed to detect major themes. This presentation describes the themes identified. The information will be useful in bringing these problems to light and proposing solutions to enhance the quality of care for morbidly obese patients, regardless of care setting.

4. Stepping Out on the Right Foot Post Bariatric Surgery: Flipping Through Patient Goals

The 42 bed Surgical Unit at Inova Fair Oaks Hospital was recently re-designated as a Bariatric Center of Excellence. It is our continued mission to provide excellent care to our bariatric patients, both preoperatively and postoperatively, through education and support. Our goal is to not only meet desired outcomes, but to surpass them. With this in mind, we created a tool that reinforces daily achievements to meet optimum outcomes postoperatively, beginning on the day of surgery and continuing through the day of discharge.

Each patient's room has a surgery-specific flip chart listing goals to focus on for that particular day. These flip charts are easily accessible to the nurses and clinical support staff, and can be changed from patient to patient to support their particular procedure. Goals focus on early ambulation, pain control, education, incentive spirometry, hydration/diets, and any post operative testing that is ordered. Provided procedures include: laparoscopic gastric bypass, open gastric bypass, laparoscopic adjustable banding, and sleeve gastrectomy.

The flip charts were created with simplicity in mind, to ensure they could be easily understood by a diverse community within the broader population. They are printed clearly and hung visibly for easy reference, so that not only are patients aware of their care, the goals keep them informed of expectations and encourage participation in their recovery.

“Successful patient education is dependent on a well-designed plan that includes a clear statement of the goals and objectives of the educational process. Goals are the desired outcomes of learning, while objectives detail the behaviors that will be performed to achieve the goal (Rankin & Duffy, 1996; Redman, 2004).” (BNET, 05/2010)

An optimal patient outcome is part of the excellent care we aim to provide. The Surgical Unit at Inova Fair Oaks Hospital strives to present patient education in a written format that can be easily understood and practiced. The flip charts are a written tool that supports our nursing staff as they continue to verbally educate patients, their families, and the people who support them.

5. Midline Catheters in the Bariatric Surgery Patient

The obese patient has veins that are often deeply buried beneath the skin surface under a dense layer of adipose tissue making peripheral IV access very difficult (Gallagher, 2005). Our experience with Bariatric Surgery patients demonstrates this to be true.

As a result, in effort to reduce the number of venipunctures, increase patient comfort and satisfaction while providing reliable intravenous access, we place a midline catheter under ultrasound guidance in the immediate preoperative period. It is thought that use of a midline catheter will result in fewer venipunctures and fewer IV therapy complications for the Bariatric surgery patient.

Review of literature reveals that no previous research has been done on the use of midline intravenous catheters in Bariatric Surgery Patients. It is unclear if they are associated with fewer venipuncture and fewer IV therapy complications. Thus, the purpose of this study is to describe the use of midlines in the Bariatric Surgery population.

The goal of this study is to examine characteristics of the bariatric surgery patient receiving midline catheters (demographics), as well as information related to the use of the catheter (number of venipuncture attempts, catheter life, success of blood draw from midline, catheter duration, infusates), and any related complications (thrombosis, phlebitis, infection, infiltration).

6. Five Simple Goals that Make the Difference

St. Joseph Health Center is a member of Humility of Mary Health Partners. This Magnet hospital has been awarded Center of Excellence by the American Society for Bariatric Surgery. The hospital serves Trumbull and Ashtabula Counties in Northeast Ohio. In the past few decades, St Joseph's saw an increase in the number of morbidly obese inpatients.

To better serve this population, the entire hospital has adapted the protocol utilized for care of patients admitted for bariatric surgery. As a result, the hospital is now more capable in delivering better care for this specific population. Today, all morbidly obese patients are treated as bariatric patients.

To achieve high degree of care, the facility emphasizes greater awareness of the challenges faced by morbidly obese patients and has conducted environmental changes that have benefited patients and visitors. The most important factor has been to train employees to become more culturally sensitive to the needs of these specific patients. Our main focus is centered on of the five goals for great bariatric care: Caring, Compassion, Knowledge, Safety, and Sensitivity. Although most facilities that deal with morbidly obese populations have similar goals, we have received a great amount of positive feedback and high patient “satisfaction” scores. The facility strives to delivery care based on our core values and follows our goals of great care, and which is especially true for our bariatric program and is embraced by all employees.

7. Adolescent Bariatric Surgery Patients: A Rewarding Case Management Endeavor

Reducing the number of obese children and adolescents in the United States has made little progress. Obesity in children is often carried over into adolescence. Adolescent obesity is commonly accompanied by severe co-morbid health conditions. The continued progression of serious co-morbidities has made bariatric surgery a treatment option for the morbidly obese adolescent; and more bariatric surgery programs have recently implemented programs for adolescents. The adolescent has unique issues that influence the management of their health care. Texas Children's Hospital has had a multi-disciplinary adolescent bariatric surgery program since June 2004. The comprehensive care necessary for adolescent bariatric patients is outlined in this presentation; concentrating on the essential elements necessary to meet the needs of adolescents preparing and undergoing bariatric surgery.

8. Utilizing a Bariatric Sensitivity Module to Decrease Weight Based Stigmatization in Healthcare Professionals: A Web-Based Format

Problem: Obesity is reaching endemic levels in the United States. Consequently, the number of obese individuals presenting to our healthcare facilities has increased dramatically. Unfortunately, many individuals who are obese, report the pervasiveness of weight bias and stigmatization from their healthcare professionals (HCP). These negative attitudes and behaviors may increase the reluctance of obese individuals to access healthcare, which is a significant health issue in a population at increased risk for morbidity and mortality. Bias and stigmatization by HCPs can also adversely affect the quality of healthcare provided to obese individuals. The purpose of this study was twofold; first to evaluate the effectiveness of a Bariatric Sensitivity Module in decreasing stigmatization in HCPs, and then to utilize the module for future web-based education.

Method: A Bariatric Sensitivity Module was designed to educate HCPs on the multitude of causes for obesity as well as the common biases and stereotypes that many obese individuals face. The study was a pre-post test with a non-randomized sample in a large academic healthcare center in the Midwestern U.S. This study in a written format was conducted for validity and reliability. Study materials included a demographic form, pre-test, and the Bariatric Sensitivity Module. The post-test was conducted approximately one month after the completion of the Bariatric Sensitivity Module.

Results: Registered Nurses comprised 80% of the sample with an average of 8.2 years in the healthcare field. The nurses practiced in a variety of healthcare settings from the operating room to the post-intensive care rehabilitation unit. Descriptive and inferential statistics were utilized to analyze the study results. The Bariatric Sensitivity Module was found to be statistically significant in decreasing stigmatization with HCPs in the study sample. Subsequently, the module was placed into our web-based education system and has been completed by over 700 healthcare professionals.

Implications: An online Bariatric Sensitivity Module is a timely and effective method of providing essential education to healthcare professionals.