HRA Improves Surgical Outcomes for Obese Patients in NYC

Challenge

Obesity increases the rates of morbidity in patients undergoing non-bariatric elective surgery. Obese patients face more significant risks in surgery, no matter what precautions are taken, including increased risk of breathing complications during anesthesia and postoperative complications like heart attack and wound infection. 

Best practice guidelines exist for treating morbidly obese patients undergoing surgery, but these are seldom followed outside bariatric surgery environments. Bariatric surgeons are experts in the precautionary measures needed to complete bariatric surgeries safely, including specialized tables and instruments. These surgeons also invest significant time in extensive up-front communication with surgery patients about risks and potential complications.

David L. Feldman, MD, MBA, FACS, Senior Vice President of Healthcare Risk Advisors (HRA) and Chief Medical Officer of TDC Group, enlisted four major New York City teaching hospitals in a study to discover whether bariatric best practices could be adopted across all operatively treated obese patients.

Response

Central to the HRA team’s action plan was their belief that obese patients have a right to know about their increased risks and to make informed choices. They implemented a best-practices combination of special precautions and up-front conversations with obese patients about their increased risks. This revolved around a supplemental informed consent form that called for physicians to discuss with patients their risk for events such as difficulty in breathing or cardiac arrest following the administration of narcotic medications to help relieve post-op pain. This was designed to reduce the odds of an adverse event in the first place, but should a lawsuit occur, make the care provided much more defensible. 

Then the HRA team went a step further and created a perioperative care map for surgical obese patients with standardized special precautions for the pre-op, intra-op, and post-op phases of the patient's care journey. The team educated roughly 1,000 physicians across these four teaching hospitals on how the use of this perioperative care map would help their institutions follow best practices.

Pre-op precautions began with a nursing admission assessment to address nutrition, mobility, and skin care, followed by the crucial step of completing supplemental informed consent. This form—and importantly, the discussion accompanying it—reviewed patients’ higher risk for surgical complications, both from surgery and during recovery. It also addressed risks specific to DVT prophylaxis and other measures taken to counteract the risks associated with high BMI. In addition, pre-op precautions called for anesthesia assessment for patients rated ASA 3 or higher in the American Society of Anesthesiologists Physical Status Classification System, which included sleep apnea assessment and a plan for intra-op and post-op anesthesia management. 

Intra-op precautions included intubation in the presence of two anesthesia providers and planning for a suitable physical environment, including appropriately sized operating room tables, gurneys, blood pressure cuffs, and long instruments.

Post-op precautions included an assessment by the attending anesthesiologist before leaving the post-anesthesia care unit, a pain management protocol specific to these obese patients, and education from the nursing staff regarding mobilization, nutrition, and skin care.

Resolution

A chart audit of 170 cases across the four participating hospitals found that providers were compliant with best practices in 98 percent of those cases. Compliance was defined as completing at least 70 percent of the care map elements.

When participating surgeons and anesthesiologists reported individually on their management of morbidly obese patients, the HRA team could see statistically significant improvements in compliance with best practices. For instance, compliance with preoperative best practices shifted from below 60 percent to nearly 90 percent.

The increasing success of HRA’s care map initiative with participating hospitals shows that an educational intervention can influence physicians’ care. A simple intervention can strongly alter physician awareness of best practices, positively impacting patient health and mitigating provider risks.