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INSIDE THE CURRENT ISSUE

January 2009

Infection Connection

Outpatient Connection

Post-bariatric surgery pain management

Appropriate pain management is important following any surgical procedure, including bariatric surgery. Until recently, alternatives for treating post-surgical pain were limited to powerful narcotics, which may suppress the immune system and can have other undesirable side effects. These medications carry risks and may aggravate co-morbidities such as obstructive sleep apnea, causing dangerous outcomes. In addition the common and well-known narcotic side-effects like nausea, vomiting and constipation worsen the ability of patients to cope with pain. Furthermore, the heavy use of narcotics may impair the ability of patients to regain mobility and return to normal activities, which is especially important for bariatric patients. This can result in an increased risk of atelectasis, deep venous thrombosis and pulmonary embolism.

ON-Q PainBuster from I-Flow Corporation is a portable and patient-friendly elastomeric pain relief pump that administers an automatic and continuous, regulated flow of local anesthetic through a specially designed ON-Q SilverSoaker catheter directly to the surgical site area in the days following surgery. The pump significantly reduces narcotic use and provides significantly better pain relief than narcotics alone. A continuous infusion means there are fewer breakthrough episodes of pain.1 The device is simple to use and is worn in a pouch around the waist, over the shoulder or around the neck for up to five days after surgery. Early mobility can lessen the development of blood clots and pneumonia. Patients get back on their feet faster and have quicker return of bowel function.2 A faster recovery may mean patients can be released from the hospital sooner and return to normal activities more quickly. Typical Length of Stay (LOS) after bariatric surgery varies with the institution and the patient, but some facilities have been able to discharge their patients within 23 hours, converting the procedure from inpatient to outpatient.3

ON-Q SilverSoaker Catheters are available in a range of sizes to best fit the anatomy of the patient, and the surgeon prescribes drugs based on patient’s clinical status (such as age, body weight and disease state of patient).

References:

1. Liu SS, Richman JM, Thirlby RC, Wu CL. Efficacy of continuous wound catheters delivering local anesthetic for postoperative analgesia: a quantitative and qualitative systematic review of randomized clinical trials. J Am Coll Surg. 2006;203:914-932.

2. Beaussier H, El’Ayoubi H, Schiffer E, et al. Continuous preperitoneal infusion of ropivacaine provides effective analgesia and accelerates recovery after colorectal surgery: a randomized, double-blind, placebo-controlled study. Anesthesiology. 2007; 107:461-468.

3. Zimberg SE. Reducing pain and costs with innovative postoperative pain management. Manag Care Q. 2003;11:34-36.

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VHA
Hospitals loosening budget belts for bariatric products, equipment

by Jeannie Akridge

There’s no denying the epidemic – more than one in four Americans is considered obese, with a Body Mass Index (BMI) above 30; as much as 63 percent are overweight (BMI above 25) – and with childhood obesity in the U.S. more than tripled in the past two decades, the potential future implications are staggering. It’s no wonder healthcare facilities are feeling the strain.

Obesity cost businesses in the state of Texas alone $3.3 billion in 2005 – including the cost of healthcare, absenteeism, decreased productivity and disability. And those costs are expected to rise to as much as $15 billion by 2025. Partnering with Virgin HealthMiles, a developer of employee wellness programs that reward individuals for getting healthy, Texas governor Rick Perry has invited governors across the U.S. to participate in the Capitol Steps Challenge. Starting this month, the Challenge marks the kick-off of a year-long initiative by Virgin HealthMiles during which it pledges over $6.3 million in donations towards states’ childhood obesity awareness programs. CEO Chris Boyce noted that hospitals have become interested in the Virgin HealthMiles reward program as a way to take a proactive stance against obesity, lead by example and send a positive message to employees and the community at large. "We have become obese as communities, and we’ve become fit and thinner as communities as well," said Boyce.

Winco’s Transfer Cliner (left) and Stretchair infinite positioning transport chairs are available through TSK Products.

Diseases that are associated with obesity such as diabetes, congestive heart failure and hypertension, just to name a few, are a huge challenge for the healthcare system today. The U.S. Surgeon General estimates that 300,000 people die each year from obesity-related complications.

According to the 5th annual bariatric survey of VHA Inc. and University HealthSystem Consortium (UHC) hospitals released in April 2008 by healthcare contracting services company Novation, costs to treat obese patients jumped nearly $50,000 from 2007 to 2008, for a median cost of $83,000. Twenty percent of respondents saw a significant increase in admissions of obese patients, while 52 percent saw a slight increase.

Both healthcare providers and suppliers are responding with products and equipment designed to accommodate heavier patients throughout the facility. Michael Klein, vice president of TSK Products Inc., noted that buyers now pay close attention to weight capacity and width when making equipment upgrades, something that previously may have been an afterthought. "Can it accommodate a larger, heavier patient? – that’s on the checklist now," said Klein. "What’s also on the checklist is, ‘Can the caregiver handle this patient without putting him/herself in the compromising position of getting hurt or injured?’ The equipment needs of the bariatric program have folded in under the umbrella of safe patient handling," continued Klein, adding that equipment that was initially being bought exclusively for bariatric programs or to serve obese patients has "re-energized the awareness of safe patient handling issues system-wide."

Judy Teitelman, PT, senior associate product manager, rehabilitation for AliMed Inc., has seen hospitals purchase higher weight-capacity and wider wheelchairs. "Instead of buying an 18-inch wheelchair to transport patients to various departments, what they’re doing is buying 20 or 22-inch wheelchairs in some facilities," she said.

At TSK Products, Klein and his brother Eric apply their backgrounds in engineering to the facility assessments they perform in which they follow the potential pathway of the bariatric and obese patient checking for details such as doorway access and proper toilet supports. Whether it’s helping a facility to prepare for Bariatric Surgery Center of Excellence certification, outfitting a dialysis or oncology center with the right mix of treatment recliners, or helping an emergency department tackle bottlenecks, TSK takes into account the facility’s treatment flow, patient profile and space considerations and then recommends solutions based on that unique criteria.

Opting for multi-functional equipment can lead to high utilization and a bigger return on investment, suggested Klein. "The more often the equipment can be used the more valuable it becomes." For example, a transport chair that features infinite positioning capability allows it to act as a wheelchair, recliner and/or stretcher, thereby eliminating the need for three separate pieces of equipment. TSK offers the Stretchair, a powered, infinite positioning transport device available with 300-lb. and 675-lb. capacity and a 1,000-lb. capacity model soon to be released; as well as the 400-lb. capacity Transfer Cliner with infinite positioning capabilities.  

"An ideal application for the Transfer Cliner or Stretchair is in a Fast Track area in the ER where space is always at a premium. The ER is much better off if they can put in one Transfer Cliner rather than a stretcher and then have to get a wheelchair or gurney to transfer the patient," suggested Klein. The chairs can also be placed in supine position to perform minor procedures.

Devices that get bariatric patients moving on their own can help improve outcomes. "It’s really important to get any patient moving because if people stay in bed too long they’re apt to get pneumonia," said Teitelman. "And any time people stay in bed for long periods they quickly lose muscle mass. So especially for bariatric patients, it’s important to get them up to make sure they maintain their strength."

The TSK1954 bedpan

Among AliMed’s extensive line of over 1,000 bariatric products and equipment is a full range of mobility aids to accommodate the unique ambulatory needs of obese patients – from a standard straight cane with a 500-lb. capacity to high-weight-capacity rollators. AliMed’s Stella Stand-Assist lift with up to a 600-lb. capacity provides support while still allowing patients to use their own muscles to stand up. "It gets them into the practice of standing up on their own with some assistance," said Teitelman. "And it doesn’t require the clinician to injure themselves in order to do that."

The 600-lb. capacity Bariatric MerryWalker offered by AliMed features a conveniently located seat that allows the patient to safely step back and sit down whenever they’re fatigued, as opposed to other rollators that require the patient to turn around 180 degrees in order to sit down.

Another trend in bariatric patient care, remarked Teitelman, "there’s a lot of interest in dignity and comfort for the patients." For example, hygiene products such as self-wiping aids and over-sized bed pans that can accommodate the special needs of obese patients are popular. "Typically bed pans that are out there are designed for people who weigh less than 250 lbs. and they’re pretty narrow," she said. "So that could be a lot of pressure on the one area of those larger patients. The bed pan that we carry allows them to be much more comfortable."

Klein noted an increase in sales for TSK’s 2-quart capacity, large-sized bariatric bedpan. "Nurses love it because it’s so easy to get underneath the patient. The patient’s very comfortable, because it’s made of a very flexible material. That could make a huge difference for an obese patient who’s bedridden," he said.

Longer hospital stays by obese patients with co-morbidities have helped accentuate the need for products designed to make them feel more comfortable, observed Klein. "That could be a mattress overlay to prevent skin issues. It could be the right type of gown. It could be the right type of bariatric brief, sock or bedpan – all of these types of things that are really going to matter over the long-term."

Surgical tables offer strong, flexible support

Last year 205,000 people underwent a Bariatric surgical procedure, with the most popular being Gastric Bypass, followed by Laparoscopic Banding, noted John Ambrose, surgical table product manager for Skytron. And even if a facility does not have a dedicated bariatric surgery program, patients in general are getting heavier, and these heavier patients are likely to have a host of health issues that may send them to the operating room. "The complications for the morbidly obese include degeneration of weight bearing joints, cardiovascular and vascular disease, diabetes, depression, hypertension, and gastro-esophageal reflux at the top of the list, as well sleep apnea due to the effects of obesity," said Ambrose.

Skytron 6701 Hercules

Can you depend on your surgical tables to safely accomodate even morbidly obese patients? "Two important features to look for in any Bariatric surgical table application are patient-rated lift and articulation capability," said Ambrose. The 6701 Hercules table from Skytron has 1,200-lb. lift combined with a 1,000-lb. articulation capacity. Additional important table features helpful in reducing set up and patient positioning times are removable leg and back sections, 210-degree top rotation, Auto Beach Chair positioning, 23-inch low table height and 30-degree Trendelenburg/reverse-Trendelenburg and lateral tilt, providing an ultimately versatile surgical platform.

"The other half of the equation is an extensive compliment of accessories to accommodate the surgical staff in patient positioning and patient comfort," said Ambrose. "Skytron has a fully developed line of surgical table accessories that will optimize positioning for all Bariatric and general surgery procedures. When positioning Bariatric patients, safety for patient and staff are critical. The surgical table set-up needs must also be easy to perform and are time sensitive. Tables with low height can help in aligning the patient transport device with the surgical table. Accessories that address the extra weight associated with obese patients such as the Skytron table width extensions and Sof pads, Heavy Duty stirrups, arm boards, patient safety straps, carbon fiber back/leg extensions, power shoulder arthroscopy positioner, specialty arm, leg and body positioning accessories are vital to the success for surgical interventions of the Bariatric patient and Bariatric surgical programs."

How much weight should the table hold? "A great rule of thumb is twice what you need, if you feel the largest patient that will be accommodated is 300 lbs., than a table with a minimum lift and articulate window should be 600 lbs. This thought process will allow all end users the peace of mind that the table will perform well today and well into tomorrow," said Ambrose, adding, "any dedicated Bariatric program should consider a table with 1,200-lb. lift and 1,000-lb. articulation. It is also important to point out that some surgical table ratings vary greatly from lift and articulation ratings. Some will lift 800 or 1,000 lbs. but only articulate or manipulate half of the rating. It is critical that the table articulate in fully functional positions close to the lift rating. Articulation is of critical importance, not just lift. It is rare that a table will remain perfectly flat during any surgical procedure."


Bariatric product focus

Bariatric Vendor chart


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