Implementation of a Standardized Bariatric Quality of Care Program in Ontario, Canada

R Nenshi, BA MD MSc FRCSC, S A Glazer, MD FRCPC FCCP, J Patel, RN MScN CNN, Q Huynh, MD FRCS, L Klein, MD MSc FRCS, J Hagen, MD FRCS. Humber River Regional Hospital, Toronto, Ontario

Introduction:
The first comprehensive bariatric program in Ontario was established in Feb 2007 at Humber River Regional Hospital. Over a four year period, case volumes increased from 48 cases per year to approximately 450 cases per year and are completed by 5 surgeons. In April of 2011, a series of unexpected mortalities occurred at our site over a 6 month period. Active support was provided by senior hospital administration and a comprehensive internal and external review of the program was undertaken. This led to the creation of standardized pre-operative and post-operative pathways designed to improve the quality of care. This paper describes the programmatic changes made and the effect it has had on outcomes. We also describe pre and post implementation compliance to pre-established program measures via chart audits.

Methods:
Directed by a literature review and expert opinion, our group prioritized several areas of improvement. In the realm of pre-operative care this included: Mandatory consultation with an internist prior to surgery, final collaborative chart sign-off by Nursing, Medical and Surgical Directors prior to bariatric procedures, and the creation of standardized pre-printed order sets and prescriptions including extended VTE and reflux prophylaxis and lab work. During the operative course, we implemented guidelines including: complex bariatric patients to have 2 bariatric surgeons involved in the OR, post-operative tachycardia to be reported to bariatric surgeon on-call immediately, twice daily rounds on all bariatric patients (at least once daily by bariatric dedicated internist) and all bariatric patients to be placed on continuous post-operative pulse oximetry for 48 hours with vitals every 2 hours for the first 8 hours post-procedure. Predischarge medication reconciliation was undertaken as well as predischarge dietary reassessment. Following discharge, patients were contacted within 48-72 hours by phone by a nurse from the bariatric team and all bariatric patients presenting to our emergency department were designated as direct patient to the bariatric surgeon on call. The pre-program period was April 2009 – March 2010. During this time, 457 bariatric procedures were completed. Post-implementation (April 2010 – March 2011), 506 cases were completed. To perform our audit, we retrospectively reviewed a random sample of charts before and after implementation of our program.

Results:
Our programs overall mortality rate is 0.4%. Pre-program annual mortality was 1% and post-program annual mortality was 0% (P=0.024). Our 30-day morbidity rates also decreased from 18.44% pre-program to 14.25% following implementation, Readmission rates also decreased from 7.25% to 5.4%. Compliance to our program parameters are summarized in Table 1.

Conclusions:
We have successfully implemented a standardized bariatric quality of care program at our centre. Pre and post implementation mortality and morbidity rates show a significant improvement. We report ≥80% compliance with our program measures.

 Table 1:

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