Abstracts The National Association of Bariatric Nurses 8 th Annual Meeting and Conference September 28–30,2011 Nashville,Tennessee

1. Health Care Reform and Bariatrics: Differences in Hospital Experience of Bariatric Patients and its Impact on Patient Satisfaction

The concept of value-based health care purchasing is that buyers should hold providers of health care accountable for both cost and quality of care. Value-based purchasing brings together information on the quality of health care, including patient outcomes and health status, with data on the dollar outlays going towards health (Agency for Healthcare Research and Quality, 2011). With the initiation of value based purchasing in 2013, it is essential that care providers understand the patient satisfaction aspects that will be a critical component of reimbursement. Patient experience has become an increasingly significant part of the healthcare agenda, one that promotes service and loyalty. Bariatric patients provide unique challenges and opportunities to healthcare enterprises, and may perceive care differently than other patients within the same organization. Patient satisfaction data will be presented from a unit that cares for a variety of patients, including bariatric surgical care. This data reveals distinct differences within certain realms of patient perception between bariatric and non-bariatric patients, including bedside care, education and communication, despite the same care team members. Significant differences of patient perception are experienced upon implementation of a program as well as during peak census periods. Strategies for the improvement of bariatric patient experience will be presented and discussed.

2. Incorporating Obesity Education into Adult Primary and Acute Care Nurse Practitioner Programs

Abstract: Epidemic levels of obesity in the United States have created a ripple effect throughout healthcare, and healthcare organizations have taken great strides to address obesity-related issues such as sensitivity training and adjustments to the environment of care (e.g., bariatric equipment).

Although studies suggest that nurses, physicians and their respective students need additional obesity education and training (Avidor et al., 2007; Balduf & Farrell, 2008; Perlman et al., 2007; Sansone et al., 2007; Schuster et al., 2006; Thuan & Avignon, 2005; Miller, Alpert & Cross, 2008), there are no national guidelines regarding specific obesity content that should be included in nursing curricula, and few recommendations have been made regarding how to incorporate obesity content into Advanced Practice Education.

Rather than being addressed as a disease state, obesity is typically incorporated within other disease state content (e.g., impact of obesity on weight-based medications or interventions). Additionally, obesity content is seldom incorporated into pathophysiology, pharmacology or physical assessment coursework, making it more challenging for NP students to consider in subsequent diagnostic and management courses.

The University of Maryland School of Nursing faculty evaluated curricula for both the Adult Primary and Acute Care NP programs to ensure that obesity content was not only infused throughout each respective program, but that it was also considered as a separate disease entity requiring unique diagnostic and management considerations. A review of the current obesity literature along with a review of the respective curricula and NP competencies (e.g., Adult Primary and Acute Care) provided a foundation. Obesity-related physiologic alterations and physical examination concerns were identified as key content areas. Treatment adjustments, specifically in regards to ventilatory assistance, pharmacotherapy, nutritional support and psychosocial issues, were also identified as key content areas.

Teaching strategies that target the adult learner (e.g., virtual patients, high-fidelity simulators, and objective structured clinical examinations) can be used to incorporate obesity content into the curriculum. These strategies allow NP students the opportunity to engage and apply psychosocial skills (e.g., difficult conversations, counseling techniques), psychomotor skills (e.g., central line insertion), and critical thinking skills (e.g., ventilatory management) in a non-threatening, safe environment. Utilizing these unique teaching strategies, NP students can obtain an extensive understanding of the complex and challenging needs of patients with obesity.

3. Implementation of an Educational Program to Improve Smith Island, Maryland Residents' Knowledge and Attitudes of Healthier Eating Practices and Benefits of Physical Activity

Introduction: Obesity rates in the United States have drastically increased over the past twenty years. According to the Centers for Disease Control and Prevention, the obesity rate for adults has nearly doubled since 1990, reaching as high as 32.2 percent among adult men and 35.5 percent among adult women (Flegal, 2010). Obesity is associated with increased health risks for many health related conditions which include diabetes, cardiovascular disease, stroke, cancer, sleep apnea, and a modestly elevated risk for all cause mortality. Educating the community on healthy eating and exercise practices is one strategy to develop skills which can then be used to facilitate behavioral changes. One rural community with increased obesity rates is Smith Island, Maryland. This community has special challenges to obtain a healthy lifestyle including a unique aspect of cultural sensitivity and need to be given the opportunity for obesity prevention in an isolated environment.

Purpose: The objective of this capstone project was to determine if a cultural sensitive educational program increases the knowledge of healthy eating practices and benefits of physical activity.

Design: A one-group, pre-test post-test, pre-experimental design was used to compare knowledge scores of Smith Island residents before and after an educational program on healthier eating and benefits of physical activity.

Sample: A convenience sample of 25 residents living on Smith Island was recruited to participate in the program.

Data Sources: The subjects completed a pretest prior to participating in a culturally modified educational program based on Dietary Guidelines for Adult Americans. Participants completed a post-test after the program had been completed.

Results: A dependent t-test was used to determine if there is a difference between pre-test and post-test attitudes and scores following the educational intervention. Overall, participants scored higher on the post-test as compared to the pre-test (t=‒.28, p<0.001).

Conclusions/Implications: There was an increase in knowledge of healthy eating practices and benefits of physical activity in a rural community through the use of culturally sensitive educational tools. Thus, the implications of the study demonstrate the need for culturally appropriate educational tools that focus on improving healthier eating and benefits of physical activity.

1. Evaluation of Bariatric Pre-Operative Teaching Program

Abstract: Obesity is one of the leading concerns for medical providers. It is considered a national epidemic in the United States. Obesity is one of the most damaging diseases known in the United States today. Secondary to the prevalence and the co-morbidities that accompany obesity, bariatric surgery is an increasingly used intervention in the treatment for this disease. There are requirements to become a Center of Excellence in Bariatric Surgery and there is also a need for more in-depth patient education. This now creates numerous nursing implications for the education of the patients and their families. A systematic literature review has been completed. An evaluation of a bariatric pre-operative teaching program is proposed. Lewin's Change Theory is used as a frame work for the educational process and preparation of the patients in this evidence based bariatric pre-operative teaching program. Process versus Product Evaluation model will be used to assess and evaluate the program. Limitations and recommendations related to program and evaluation also discussed.

The bariatric pre-operative teaching program that is under evaluation has been continuously revised and updated since 2001. Bariatric operations have been performed at one major teaching facility in New England for more than 40 years. The first operations for weight loss to be done at this facility were in the 1970s. During the time period of August 2000 thru April 2011, there were over 2,200 bariatric surgery cases performed. Today, three surgeons now perform approximately 200 bariatric operations a year. This facility has three surgeons doing bariatric procedures so there is a need for relative and corresponding education for the patients.

In this paper, Lewin's Theory of Change is proposed as the framework, to educate, inform and prepare patients in an evidence-based bariatric patient pre-operative teaching program. The evaluation model “Process versus Product” will be used to evaluate the bariatric pre-operative teaching program. Bariatric surgery patient satisfaction scores from 2007, 2008, 2009 and 2010, as well as patient evaluation surveys specifically pertaining to the bariatric pre-operative teaching class from 2008 thru 2011 will be used in the evaluation of the program.

2. Multidisciplinary Approach to the Care of the Bariatric Surgery Patient—Building and Maintaining Relationships is Key

Purpose: This poster presentation purpose is to describe how the multidisciplinary approach to care of the bariatic surgery patient is key to building and maintaining relationships amongst care providers. The Bariatric Joint Practice Committee is a cohesive group that fosters teamwork and open communication resulting in better outcomes for the patients. The committee meets regularly and has developed protocols and guidelines for these patients from initial orientation to the Bariatric program to the follow up appointments after discharge. The multidisciplinary meetings give the group a way to discuss problems that may arise and plans to improve the care provided for the bariatric surgery patients. The team also was instrumental in achieving our Center of Excellence.

Significance: To identify the success of the BJPC and the multidisciplinary approach for the care of the bariatric surgery patients. To describe how the building and maintaining of relationships through open communication is key to improving patient care in the UC Davis Medical Center.

Methodology: This is a process of having the multidisciplinary group that includes the attending physicians, fellows, psychologist, dieticians, nurse practitioners, bariatric nurse coordinator, manager of the Vascular/GI Surgery unit, assistant nurse managers and staff nurses meet on monthly. The meetings identifying educational needs of staff, developing pathways and bariatric protocols, developing and updating Electronic Medical Record order sets and discussing problems that many arise.

Findings: The process of having this multidisciplinary approach to care through the BJPC builds and maintains close relationships between all of the team members and is essential in improving patient care. The success of the committee is seen with the positive outcomes of the patients, which includes decreasing time of discharge, streamlining processes, creating less patient care issues and less frequent hospital returns for complications.

Discussion of implications: Committees such as the BJPC are important to any organization that provides care to patients. This multidisciplinary committee is key to building and maintaining relationships and fosters open communication and successful problem solving resulting in a higher level of care for our patients.

3. Issues in Bariatric Patients

Abstract: Let's think about it, Bariatric patients usually have skin, incontinence and mobility issues when they arrive to Rehab. Bariatric patients are already stereotyped because of their size. In this poster presentation, I will focus on patients of size admitted with skin issues, incontinence issues and mobility issues over a three month observation period. The result of the three month observation period will be revealed in the findings. Just because a patient is of size it does not always mean that they have skin, incontinence and mobility issues. Bariatric patients should not be judged. Educating patients is so important and can actually alleviate and prevent some of these issues.

4. A Multidisciplinary Approach to Mobilizing the Bariatric Patient

Purpose: The purpose of this poster is to illustrate how involving the multidisciplinary team can lead to the successful mobilization of a bariatric patient. We present a case study involving a male patient with a BMI of 61mg/m who refused to get out of bed for 4 weeks. His story depicts how the multidisciplinary approach addresses patient safety, comfort and dignity.

Significance: Pressure ulcers, DVTs and inability to bear weight are some of the many complications associated with prolonged bed rest. Mobilization is an important aspect of standard care for all patients; however, mobilizing the bariatric patient has its own set of obstacles that can often make the process intimidating. To ensure the safety of the staff and the safety, comfort and dignity of the patient it is essential to consult multiple disciplines to create and implement a successful plan.

Methodology: This poster uses a case study to illustrate how a multidisciplinary approach was used to successfully mobilize a bariatric patient.

Findings: With the appropriate use of a multidisciplinary team, a bariatric patient can be mobilized safely and with dignity. In this case study the patient, nurse, lift team, physical therapy, bariatric consultant and MD were involved in the development of the mobilization plan. This led to a stress-free process for the patient, motivating him to agree to be mobilized again in the future.

Discussion of implications: When the nurse works together with the entire health care team and considers the needs of the bariatric patient, successful mobilization of the patient can occur in a safe and dignified manner. Sharing this case study can help others better plan for the challenges faced when mobilizing the bariatric patient and increase the quality of care for bariatric patients.

5. Maintaining Dignity of Patients with Morbid Obesity in the Hospital Setting

Purpose: This poster presentation purpose is to describe the importance of and a strategy for maintaining dignity of morbidly obese patient during mobility, transfers and lifts in the hospital setting. The bariatric population has its own unique set of needs and the healthcare professional has to be aware and educated about these needs to ensure dignity in the treatment of these patients. Maintaining dignity can be achieved by requiring proper caregiver education and training; fostering respectful communication; developing bariatric protocols; providing size-appropriate furnishings, equipment, supplies and instruments; and having the right equipment at the right place and right time. In addition, the development of a bariatric team of experts to consult on mobility and care issues for these patients is paramount in promoting patient and staff safety and ensuring the best possible dignified care for patients with morbid obesity.

Significance: To educate healthcare professionals on the bariatric patients special set of needs. To describe the different equipment types, communication tools and protocols developed to care for this population.

Methodology: This poster is based on a comprehensive literature search and a description of a case study of a morbidly obese patient.

Findings: When the dignity, privacy, bariatric equipment and protocols are incorporated into the plan of care for the bariatric patients these patients are more likely to seek out care and the outcomes are better for the patient and the healthcare professional.

Discussion of implications: When the healthcare professional is aware of the bariatric patients specific set of needs it is more likely the bariatric patient will be treated with dignity.

6. Pilot Testing the Augmentech Body Position Sensor on the Morbidly Obese Patient

Purpose: The purpose of the study was to investigate the feasibility of the Augmentech Body Position Sensor (ABPS) for detecting the frequency of body position changes in non-dependent morbidly obese subjects.

Significance: Prevention of pressure ulcers in the hospitalized patient is a major responsibility of nursing. Turning and repositioning of dependent patients are important preventative measures for pressure ulcers and are generally carried out every two hours. What is unknown is the optimum positioning schedule for morbidly obese patients.

Methodology: Using a descriptive design with purposive sampling, 10 adult obese subjects in a University Sleep Center in south eastern United States were observed, data recorded and compared to readings from the ABPS. The ABPS was affixed to the patient's right thigh approximately 3 inches above the knee in the midline using paper tape. Turning and body position (prone, supine, turned to left or right side) was recorded starting at midnight and recorded the subjects position at one second intervals for approximately 4 hours. After the ABPS was removed from the subject its recordings were compared to the data documented by the researchers during the polysomnogram to determine whether there was a correlation.

Discussion: Little technology is available to monitor physical caregiving. Without a means to monitor the timeliness and reliability of caregiving, clinical management is impaired in its ability to correct care process deficiencies and to reward those who are most conscientious in their work. Clearly identifying those morbidly obese patients at risk for pressure ulcers and identifying their degree of mobility would help determine the appropriate repositioning schedule to keep them safe and make judicious use of staffing time.

7. Placement of Nasogastric Tubes by Registered Nurses in Post-Bariatric or Anatomy—Altering (Upper Gastrointestinal Tract or Stomach) Surgical Patients Guidelines

Abstract: In February 2010, a practice question was posed by Joni Tiller, Chief Nursing Officer and Vice President of Patient Care Services at INTEGRIS Baptist Medical Center, to the Oklahoma Board of Nursing staff: “Is it within the scope of practice for a Registered Nurse to place a nasogastric tube (NGT) in a patient who has undergone bariatric or other anatomy-altering surgery of the upper gastrointestinal tract or stomach?” The question arose with discussion regarding who the appropriate professionals were to place nasogastric tubes (NGT) in patients who have undergone surgery that alters their upper intestinal anatomy. It was agreed upon that those tubes should not be placed blindly by ANY health care professional, but either with visualization by fluoroscopy or a method of direct visualization. All agreed that nurses have the greatest experience placing NGTs and that this training is centered on the use of landmarks for determining the depth to which the tubes should be inserted. Anatomy altering surgery effectively eliminates these landmarks and handicaps the nurse or other healthcare professionals placing the patient at risk of substantial harm or possibly death from complications.

Based on a review of the practice issue by the Oklahoma Board of Nursing Practice committee and a task force includingcontent experts,including Sarah Kitchen RN, BSN, and Russell Gornichec, MD, INTEGRIS Bariatric Program the Oklahoma Board of Nursing has approved the Placement of Nasogastric Tubes by Registered Nurses in Post Bariatric or Anatomy Altering (Upper Gastrointestinal Tract or Stomach) Surgical Patients Guidelines. The purpose of the guidelines maintains that, while the placement of NGTs is included in treatments allowed by registered nurses when consistent with educational preparation and when not in conflict with the provision of the Oklahoma Nursing Practice Act. The technical complexity of bariatric surgery and resulting proximal anastomoses requires registered nurses to expand practice beyond the basic educational preparation through continuing education and training. According to the guidelines, it is within the scope of practice of a registered nurse, in a hospital setting only; to place nasogastric tubes in patientswho have undergone post-bariatric or anatomy-altering surgery of the upper gastrointestinal tract or stomach provided specific criteria are met including:

• The nurse has received additional training addressing the risks and safety procedures required for this procedure and meets all specified qualifications identified in the guidelines.

It is the intention of INTEGRIS Baptist Medical Center to work with other healthcare organizations to increase awareness of healthcare professionals regarding the risk of nasogastric tube placement in patients who have undergone bariatric surgery or other anatomy-altering procedures of the upper gastrointestinal tract or stomach; the need for collecting such history from patients at the point of entry into health care facility; and the need for developing, implementing, documenting, and managing a continuing competency program specific to the nursing act.

8. New Graduate Nurses Explore the Process of Completing a Research Study Focused on Bariatric Patients

Purpose: To educate new graduate RN's aboue the steps of the research process. Nursing school provided the basics of conducting a research study, but we discovered that sometimes theory and implementation do not perfectly line up. Through this poster we hope to share our experiences with other new nurses so they will be better prepared and confident in completing their own research projects. We will go through the steps of this process including: 1) Forming an idea, 2) Completing the necessary training, 3) Writing and submitting a proposal for IRB approval, 4) Conducting the research study, 5) Evaluating the results and submitting for publication.

Significance: As new grads at a teaching hospital we were able to take advantage of our nursing research department to help guide us through the steps to complete our project. Not all hospitals have this resource; we present our experiences here so other new grad nurses can benefit from what we have learned.

Methodology: A case study presenting our experiences in formulating, designing and implementing a research study involving bariatric patients.

Findings: Initially we discovered that there exists an increasing line of oversight and approval the more a study involves people (or HIPPA protected information). We used an established and validated questionnaire for our study; this saved us time by eliminating the need for creating questions and then testing their validity. Google Documents is awesome. It allowed us to share a project folder where we uploaded our review of the literature and collaborated on the same document(s) in real time from different locations. When preparing for IRB approval check, recheck and double check the written proposal.

Discussion of implications: Nursing is ever moving forward in establishing itself as an evidenced-based practice. This abstract will increase awareness of the research process and may help empower new nurses in advancing the profession. New graduate nurses will be better prepared to conduct their own research, find available resources and realize research study does not need to be a full-time job, can be a fun experience and may ultimately help provide better care for our patients.

9. The Braden Scale: An Easy Approach to the Assessment of the Bariatric Patient

Abstract: The Braden Scale is a universally accepted assessment tool used to determine the at-risk status of patients for the development of skin breakdown issues, primarily pressure ulcers. Often the nurse approaches this task as one more “thing” to add to the list of daily duties. The Braden Scale is actually the accumulation of collected data which we as nurses process every day. The scale merely helps us to put into numbers our ongoing observations.

The scale assesses six basic areas of concern or subscales. The clinician is guided by a set of questions which allows us to assign a point value to the subscale. Once all responses are completed and the values compiled, the final total indicates the at-risk level of the patient. Initially, interventions were based on the total score. More recently emphasis has been placed on applying prevention and treatment measures based on the identified area of need. However, when assessing the bariatric patient, the clinician may need more specific information than that obtained by using the standard observations as outlined in the traditional Braden Scale. Armed with the appropriate list of questions, the clinician can obtain a more accurate evaluation of the at-risk status of the bariatric patient and implement the most appropriate interventions for the prevention and/or treatment of pressure ulcers in this patient population.

When we learn to incorporate our routine observations based on information from simple questions, we will understand how the Braden Scale is not only a useful tool, but is an invaluable and simple method for the prevention of pressure ulcers. We will no longer regard the Braden Scale as an arduous task but a source of information about the skin risk status of our patients and the appropriate interventions to insure healthy, intact skin. We will be better equipped to provide the highest level of nursing care in our bariatric patient population.

10. Primary Nursing: Improving Bariatric Patient Outcomes Through Therapeutic Relationships

Purpose: The purpose of this poster presentation is to demonstrate how we chose to implement the Primary Nursing care delivery system developed by Marie Manthey, MNA, FRCN.

Significance: Providing quality, consistent, and supportive bedside care is extremely challenging and important to positive patient outcomes. Primary Nursing is based on the nurse-patient relationship that strengthens accountability of care and allows for greater patient involvement in care. By building trust through a therapeutic relationship the nurse is able to promote patients strengths and set mutual health directed goals.

Methodology: A unit-based Primary Nursing Council consisting of Registered Nurses developed our Primary Nursing care delivery system. We based our model of care on Marie Mantheys' book titled “The Practice of Primary Nursing”. A nurse is assigned to the patient at admission and follows the patient throughout their stay, and subsequent hospital admissions to our floor. Communication to other members of the team is sustained through the Primary Nursing section in the electronic medical record. Once established the nurse-patient relationship is known to the patient, family, and other members of the health care team. A Primary Nursing informational handout is given to each patient at admission and the name of the primary nurse written on the patients' whiteboard at the bedside.

Findings: A therapeutic nurse-patient relationship established at admission has allowed us to identify the unique care needs of an obese patient and establish an individualized plan of care in collaboration with other members of the healthcare team. The patients report satisfaction with better continuity of care; and the nursing staff report satisfaction with a larger role in the patients' hospitalization. After implementing Primary Nursing our patient satisfaction ratings have increased, and this year we were awarded with a 5-Star Patient Perception award from Professional Research Consultants (PRC).

Discussion of implications: The Primary Nursing model of care has allowed our staff to provide a more holistic way of caring. We have seen better compliance and outcomes for our patients and a higher level of job satisfaction for our nursing staff.

11. Keeping Bariatric Patients Safe: Partnership with Industry for Quality Improvement

Purpose: The purpose of this pilot project was to offer industry resources, including education to an academic medical center in California on the appropriate use of Bariatric equipment to promote patient and staff safety.

Significance: While there is an ongoing national obesity epidemic, more Bariatric patients are being admitted to hospitals, not only for elective weight loss surgery but for trauma and medical reasons as well. There is little evidence available on the use of clinical practice guidelines for this population. What has been identified in this unique population is a need for specialized or adapted equipment in the hospital setting. Equipment specially designed for the Bariatric population is often safety rated for up to one thousand pounds.

Methods: The industry representative rounds weekly with the hospital's Bariatric Consultant. The EMR produces a daily census of morbidly obese inpatients which includes their height, weight and BMI. With this information, each patient on the list is visited by the industry representative and Bariatric Consultant. They get input from the patient and assess the patient's equipment needs and include the patient's primary nurse in the discussion. Based on the patient's clinical information and the nurse's clinical judgment, the correct bed frame, mattress, and lift equipment are ordered. Other mobility devices and ancillary equipment are ordered as needed as the patient's clinical condition warrants. The representative also does education on the equipment for the patient, their family and the nursing staff.

Findings: The patients report satisfaction with using equipment that meets their needs; the nursing staff reported satisfaction with having the right equipment readily available to care for their patients. The nurses also appreciate the representative's ability to identify which patients would benefit from using Bariatric equipment.

Discussion of implications: Partnering with industry to quickly identify patients that are in need of Bariatric equipment removes one more task for nursing. The nurse knows that the right equipment will be ordered the first time and it prevents delays using specialty equipment that is needed to safely care for the Bariatric patient thereby reducing the potential for patient and staff injury.

12. What New Graduate Nurses Need to Know about Caring for Bariatric Patients

Purpose: Over the past two years, UC Davis Medical Center has hired 16 new graduate Registered Nurses to their Vascular/Gastrointestinal Surgery Telemetry Unit. The purpose of this poster is to describe what new graduate nurses need to know about caring for bariatric patients and to provide a template for a resource binder.

Significance: We are providing information that will be useful in orienting new graduate nurses in caring for bariatric patients. We are also providing a template for a resource binder based on input from a group of 16 new graduate nurses. There was a consensus among these nurses that while in nursing school, there lacked a focus on caring for obese patients. An article entitled “Obesity Education-Time for a Change?” conveyed this same theme.

Methodology: These new graduate nurses and their managers attended a workshop called “The Rising Stars” in February 2011. The purpose of this workshop among others was to obtain valuable input regarding what these new nurses needed during their orientation. A survey was also taken to gather information regarding the key elements to bariatric patient care.

Findings: The fruits of this meeting included the development of a Bariatric Surgery Resource Binder and an in-service given by the bariatric coordinator. The outcome was an increase in the new graduate nurse's basic knowledge and understanding of the care of bariatric patients which resulted in elevating the level of care on this unit. It also sparked our interest in attending the NABN conference, where four new graduate nurses are submitting abstracts. These nurses now know the key elements to bariatric nursing care like obesity sensitivity, per-operative complications, post-operative care, discharge criteria, patient teaching and information about the care of a patient who may return to the hospital with a history of bariatric surgery.

Discussion of implications: Now equipped with a clear understanding in providing this specialized care, the nurses on this unit were able to help earn the recognition of #1 in patient satisfaction at UCDMC and the unit also ranked in the top 10% in the nation for 2010 for overall patient satisfaction. These nurses hope to mentor this care as more new graduate nurses enter the field of Bariatric Nursing.