Facility staffing, accommodations, and accreditation for care of the bariatric surgical patient

INTRODUCTION — Defined as body mass index >30 kg/m², obesity is increasing in prevalence in the United States, Canada, and worldwide [1-4]. The Centers for Disease Control and Prevention estimates that 42.4 percent of the United States population has obesity [5]. The American Society for Metabolic and Bariatric Surgery (ASMBS) reports that the number of bariatric surgeries performed annually continues to rise in the United States [6]. (See "Obesity in adults: Prevalence, screening, and evaluation", section on 'Screening'.)

This topic review will focus on the structural adjustments, appropriate physician and allied health staffing, and training that are necessary for a facility to properly accommodate bariatric surgical patients. It also discusses the criteria of becoming an accredited center in bariatric care within the United States and Canada.

The general approach to the management of obesity and a description of the operations, indications and preoperative preparation, and outcomes are discussed elsewhere.

●(See "Obesity in adults: Overview of management".)

●(See "Bariatric surgery for management of obesity: Indications and preoperative preparation".)

●(See "Bariatric procedures for the management of severe obesity: Descriptions".)

●(See "Outcomes of bariatric surgery".)

STAFFING — It is the responsibility of the metabolic and bariatric center to have adequate clinical staff to provide care for patients undergoing bariatric surgery. Depending on the acuity of the patients, the clinical staff includes not only bariatric surgeons who perform the procedures, but also other specialists such as critical care providers and medical subspecialty consultants who may be called upon to treat potential complications. Allied health staff such as nurses and dieticians are also an integral part of metabolic and bariatric surgical care.

Surgeons and physicians

Surgeons and case volume — Although credentialling requirements for bariatric surgeons vary between countries, states, and individual facilities, most facilities in the United States participate in the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP), which mandates the following criteria set forth by the American College of Surgeons (ACS) and the American Society for Metabolic and Bariatric Surgery (ASMBS) [7] (see 'Accreditation' below):

●The surgeon must be board certified or in the process of becoming board certified by the American Board of Surgery (ABS; or equivalent).

●The surgeon must have performed a minimum of 100 lifetime stapling procedures (may include up to 75 stapling procedures from fellowship).

●The surgeon must perform, at minimum, an average of 25 stapling procedures per year during the triennial reaccreditation cycle. For adolescent centers, the minimum is 15 stapling procedures per year.

●In centers that only perform nonstapling procedures, the same numerical goals above will apply to nonstapling procedures.

●In addition, the surgeons must participate in the MBSAQIP, attend at least two quality meetings and obtain at least eight metabolic and bariatric-specific continuing medical education credits per year.

Call coverage — It is expected that MBSAQIP-accredited hospitals will provide call coverage 24 hours per day, seven days per week by a bariatric surgeon for any bariatric patient who presents to its facility, even if that center or surgeon did not perform the principal bariatric procedure.

If a bariatric surgeon is not available at a local hospital where bariatric surgery is performed, that accredited center is required to provide coverage through another hospital. General surgeons can be used in lieu of or in conjunction with bariatric surgeons if they are credentialed with general surgery privileges and they undergo training so they are familiar with the bariatric procedures performed at their center, the signs and symptoms of postoperative complications, and the center's clinical care pathways.

Other physician services — An obesity medicine specialist (ie, bariatrician) should be an integral part of the weight management center who prescribes medical therapy for obesity and closely collaborates with the surgical team to provide optimal care to those who undergo bariatric surgery.

Bariatric surgical centers must also have providers who are certified in advanced cardiovascular life support to care for potentially ill patients. Such centers should also have critical care and intensive care services, as well as anesthesia, endoscopic and diagnostic/interventional radiology services. Other physician services such as pulmonology, cardiology, and nephrology consultation may also be required. For patients who may exceed these capabilities, such centers must have the ability to stabilize these patients with transfer agreements in place.

Allied health care personnel — Allied health care personnel are vital members of the multidisciplinary team that provides optimal care of the bariatric patient. The multidisciplinary team role is included in preoperative, in-hospital, and long-term education and management.

Nursing — The ASMBS has developed a certification program for Clinical Bariatric Nurse Specialists. In addition, the ASMBS, the Association of Operating Room Nurses (AORN), and the Betsy Lehman Center for Patient Safety and Medical Error Reduction publish bariatric surgical nursing guidelines to address nursing education, practices, and certification goals in an effort to improve care and reduce nursing apprehension about bariatric care [8-10].

Nutrition — Registered dietitians (RDs) are essential for the appropriate inpatient care and long-term follow-up of bariatric patients. RDs should work with the hospital food service department to develop post-bariatric surgery meals that are high in protein and low in carbohydrates and fat in the appropriate portion sizes, ensuring that if a "regular" diet is ordered for a post-bariatric patient, a proper diet is delivered. Bariatric-specific diets can be especially helpful in the immediate postoperative period when the recommendations are for clear liquids and full liquids, ensuring that the meals are augmented with protein drinks to ensure adequate protein intake. RDs can help prepare bariatric patients for the postoperative diet changes by educating patients on portion control and maintenance of adequate nutrition. Without such education, patients may eat more fat and calories than they realize. Specifics of diet information and supplementation after bariatric surgical procedures are detailed elsewhere. (See "Bariatric surgery: Postoperative nutritional management".)

Pharmacy — The pharmacy staff should be consulted about weight-based dosing for bariatric surgical patients, medications to avoid, and appropriate medication formulation. Bariatric patients can potentially have problems with medications that are not easily absorbed or are contraindicated after a malabsorptive procedure. In a study of 133 hospital admissions for patients after bariatric procedures, almost 62 percent of patients were given inappropriate medications [11]. In addition, some medications such as nonsteroidal anti-inflammatory drugs are contraindicated after gastric bypass [12]. (See "Intensive care unit management of patients with obesity", section on 'Drug therapies'.)

Physical therapy — Physical therapists can help enable bariatric surgery patients to improve functional status after bariatric surgery and reach an appropriate level of activity to correspond with their dietary intake [13-15]. As an example, for patients with high protein consumption, moderate levels of exercise are more appropriate because a high-protein diet lowers the respiratory quotient, while strenuous exercise demands a high respiratory quotient [16]. (See "Exercise physiology" and "Obesity in adults: Role of physical activity and exercise".)

Psychology/social work services — The mental and emotional aspects of obesity, weight loss, and weight loss surgery are an important consideration in the care of bariatric patients. While 20 to 60 percent of bariatric patients have a psychiatric disorder noted preoperatively [17], some psychiatric disorders are diagnosed postoperatively [18,19]. In addition, while some psychiatric conditions are improved with weight loss, others are made worse or become apparent with weight loss. (See "Outcomes of bariatric surgery", section on 'Psychosocial impact'.)

Adequate time and attention should be provided for preoperative assessment of and support for psychological disorders. Psychiatric evaluation can assist with recognition and management of disorders that can lead to obesity like binge eating, nighttime eating, post-traumatic stress disorder, depression, substance abuse, and even personality disorders. (See "Bariatric surgery for management of obesity: Indications and preoperative preparation", section on 'Psychosocial assessment'.)

In addition, higher rates of suicide, substance abuse, and divorce after bariatric surgery have been documented when compared with the general population [19,20]. While none of these are a contraindication to surgery, these disorders should be controlled prior to undergoing surgical weight loss in an effort to reduce recidivism and produce greater sustained weight loss [17]. Even patients who are doing well physiologically and seemingly emotionally after bariatric surgery should be screened for adjustment disorders, substance abuse, and depression. (See "Eating disorders: Overview of epidemiology, clinical features, and diagnosis" and "Posttraumatic stress disorder in adults: Epidemiology, pathophysiology, clinical features, assessment, and diagnosis" and "Unipolar depression in adults: Assessment and diagnosis" and "Substance use disorders: Clinical assessment" and "Suicidal ideation and behavior in adults".)

ACCOMMODATIONS — Appropriate adjustments for patients with obesity should be made in all areas where patient care is given, including outpatient clinics, radiology, the operating room, and the nursing floors. Thus, new guidelines for the design and construction of health care facilities now include bariatric-specific design considerations [21].

The following are guidelines for the essential requirements for most bariatric patients. For the rare patient whose body mass index is over 60 kg/m², a protocol should be in place regarding where to rent or lease equipment [22]. Hospitals that are performing bariatric surgery should ensure that all of the minimum recommendations are followed [23].

Nursing floors and space — Structural changes may require major reconstruction to make sure that all areas of the hospital can accommodate the larger stretchers and wheelchairs used to transport patients [24]. The Facility Guidelines Institute (FGI) recommends the following dimensions for hospitals that care for bariatric patients [21]:

●Building entry points should have door widths with a minimum of 3 ft 2 in.

●Ample-sized wheelchairs should be available at the front door of the hospital.

●Public toilets as well as waiting rooms should be constructed for the needs of patients.

●Clearance of 5 ft should be provided on both sides of each bed and at the foot of the bed between patient beds to allow for staff assistance.

●Bathroom doors should be at least 3 ft 9 in wide.

●Patient room doors should be at least 4 ft 4 in wide to allow for the passage of stretchers.

●Corridor hallways should be 5 ft wide.

Operating rooms — A bariatric operating room (OR) should be 600 square ft. According to the Association of Operating Room Nurses (AORN) bariatric surgery guidelines, OR bariatric beds should have the capacity to hold 1000 lbs, with 600 lbs tilt capacity [8]. The OR tables should also have side extenders, footboards, sufficient arm holders, and foam padding available for the arms, heels, and feet to prevent falls and pressure injuries [8]. Because bariatric patients are not likely to be able to transfer themselves after recently having had general anesthesia, lifts or other appropriate moving devices, like an air mattress, should be utilized to facilitate easy transfer [8]. The use of such devices can enable the OR staff to transfer extremely large patients with little risk to themselves or the patients.

Long laparoscopic equipment (defined as 43 to 46 cm) should be available, as well as long open surgical instruments and deep and wide retractors, in case conversion to an open laparotomy is required [25]. In addition, specially designed endotracheal tubes should be available. (See "Anesthesia for the patient with obesity" and "Airway management in the morbidly obese patient for emergency medicine and critical care".)

Radiologic facilities — Because bariatric patients may need to undergo radiologic procedures, a facility must have radiology equipment that can accommodate these patients within 60 minutes [25]. To evaluate for leak, most bariatric surgeons will opt for a fluoroscopic upper gastrointestinal series or a computed tomography (CT) scan with oral contrast. Bariatric patients should not be asked to ingest several hundred milliliters of contrast. Most studies can be effectively done with 100 milliliters taken just prior to lying down for the studies. Most CT scanners have a weight limit of 400 lbs, which should be enough for most bariatric patients, although scanners with a weight capacity of 600 lbs are available [25]. However, standard fluoroscopic units usually have a weight limit of 300 to 350 lbs and have only 45 to 50 cm of clearance between the tabletop and the image intensifier, and 70 cm is recommended for bariatric patients [25]. Large, round hoops can be employed to measure the patient before transport to ensure that the patient will fit in the imaging apparatus [26]. If the facilities for the CT scan or fluoroscopy cannot accommodate the patient, then the best option to effectively rule out a leak is a laparoscopy or laparotomy. (See "Imaging studies after bariatric surgery" and "Bariatric operations: Early (fewer than 30 days) morbidity and mortality".)

Other equipment and supplies

●Beds – Most regular hospitals beds can handle patients up to 440 lbs; however, these beds are probably too narrow at 35 to 36 in, making it difficult for bariatric patients to reach the adjustment buttons or operate the side rails [25]. Bariatric beds should be at least 44 in wide and support up to 1000 lbs. The mattresses should be the low air loss type so patients will not tend to sink in their beds [27]. The low air loss mattresses make it easier for patients to get out of bed and thus assist with preventing skin breakdown. It is optimal if the beds can be automatically adjusted into a chair position so patients can walk out of their beds from the seated position [27].

●Toilets – Floor-mounted toilets help prevent patient falls and damage to the facilities. Floor-mounted bariatric toilets can support up to 1000 lbs (453 kg), while most standard wall-mounted commodes have a 250 lb weight limit [28]. Toilets should have enough room to allow a person on each side of the commode to assist with the transfer of a bariatric patient on and off the toilet. In addition, handrails should be placed on the walls so that patients can lift themselves onto and up from the toilet. Often these toilets need to be set 24 in off a wall with handrails, which is 6 in further than the Americans with Disabilities (ADA) act requirements. Patients who weigh over 500 lbs cannot sit comfortably on a standard toilet because it is too close to the wall. Appropriately sized bedside commodes are also necessary for patients who cannot ambulate safely to the bathroom.

●Showers – To accommodate bariatric patients, shower stalls should be 4 x 5 ft (1.2 m x 1.5 m) rather than the standard 3 x 3 ft (0.9 m x 0.9 m), and handheld nozzles should be mounted on the sidewalls of the shower rather than the back so they are easier to reach and use.

●Patient transport – Patient lifts are essential for moving bariatric patients and need to be ceiling mounted. Most standard lifts can accommodate up to 600 lbs, while the bariatric ones can handle up to 1000 lbs [27]. The use of proper lifting equipment protects staff from injury and is safer for patients [29].

Bariatric wheelchairs should be 30 to 39 in wide and be able to accommodate up to 800 lbs. Walkers should be at least 28 in wide and support up to 750 lbs. Appropriately sized bariatric gowns and robes, recliners, and stretchers must be available for patients with obesity.

●Monitoring and safety devices – Immediate postoperative bariatric patients should be placed in a monitored setting because tachycardia and respiratory distress are two of the most sensitive symptoms of a gastrointestinal leak [30] and other complications. Extra-wide blood pressure cuffs, appropriately sized sequential compression devices, biphasic defibrillators, and emergency airway equipment should be readily available [25]. Because obstructive sleep apnea is often diagnosed in this population, continuous positive airway pressure devices (CPAP) should be available [31]. (See "Postoperative management of adults with obstructive sleep apnea".)

ACCREDITATION — The American College of Surgeons (ACS) and the American Society for Metabolic and Bariatric Surgery (ASMBS) have combined their recommendations and criteria for bariatric centers into the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) in order to provide a single resource of the best practices for obesity care for providers and hospitals [32].

The accreditation process includes credentialing surgeons, creating a national data registry of 100 percent of cases done by the accredited facilities, and performing center site visits. The criteria also include establishing a national collaborative network to include outreach to payers and patients centered on safety [7].

In 2024, there are 935 accredited centers in the United States and three in Canada. The Canadian programs adhere to the same standards and metrics as do United States ones. International centers can apply to become data collection centers.

Center designations

Comprehensive centers — Hospitals that meet all the accreditation criteria and perform at least 50 stapling procedures annually are considered comprehensive centers. If a hospital also provides adolescent bariatric surgery and/or obesity medicine services, it can gain additional adolescent and/or obesity medicine qualifications.

Lower acuity centers and ambulatory surgery centers — These hospitals will do at least 25 procedures annually on lower acuity patients in adults with the following criteria:

●Age 18 to 65

●Body mass index <55 for males and <60 for females

●Patients will not have organ failure, significant cardiac or pulmonary impairment, an organ transplant, or be on the transplant list

●Patients must be able to ambulate

Emergency cases are allowed as needed.

Adolescent centers — Such centers perform a minimum of 15 stapling procedures annually in the adolescent age group.

Personnel — MBSAQIP-designated centers must have a metabolic and bariatric surgery committee consisting of director, coordinator, clinical reviewer, administrative representation, and all providers who perform procedures treating metabolic or obesity-related diseases. (See 'Staffing' above.)

Training — All appropriate personnel caring for metabolic and bariatric patients are required to complete the following training sessions:

Sensitivity training — While severe obesity is present in over 30 percent of our population today, there is still a prejudice against these patients, which may negatively affect patient care [33]. In one survey, 48 percent of nurses responded that they felt "uncomfortable caring for obese patients" [33]. Accordingly, all health care personnel should undergo sensitivity training to promote awareness of bias against patients with obesity [34]. It is unclear if such training has improved nurses' attitudes [35], and most clinicians still feel that obesity is a lifestyle choice instead of a disease [36].

Patient transfer and mobilization — Nurses working with bariatric surgical patients benefit from education regarding the proper use of bariatric equipment and lifting techniques to help prevent injuries [26]. It may require two nurses instead of one to help a patient bathe or get out of bed to a chair. Caring for bariatric patients without appropriate staffing or equipment can result in injury to the provider, lost days of work, and loss of income for the hospital and the worker. Musculoskeletal injuries are the leading category of occupational injury in health care [29,37]. (See "Occupational low back pain: Evaluation and management" and "Disability assessment and determination in the United States".)

Clinical care pathways — The concept of this tenet is to provide standardized pathways of care so that patients and providers are all aware of what care is provided and where along the pathway the patient is. The pathways are put into written protocols. These protocols include preoperative, intraoperative, and lifelong postoperative care [38-40].

Risk assessment and complication recognition — Appropriate nursing care for bariatric patients requires inspection and cleansing of skin folds every shift to avoid skin irritation and fungal infections. Nursing staff should also be trained in medication administration after bariatric surgery [34] and the recognition of common complications in the postoperative period (eg, pulmonary embolus, anastomotic leak, infection, bowel obstruction) [34,41]. (See "Bariatric operations: Early (fewer than 30 days) morbidity and mortality".)

Quality improvement — A major benefit of MBSAQIP is the ability to collect and analyze data to improve patient safety and outcomes on a national level. (See 'Benefits of accreditation' below.)

Data collection — A data manager is required for a bariatric surgical program because the results and complications for weight loss surgery must be reported into specific computerized databases, according to criteria for an accredited center in bariatric surgery [42]. This allows the team to identify areas of care that need improvement and compare results with other facilities [24]. With the implementation of the MBSAQIP database, 100 percent of bariatric surgery outcomes from all accredited centers will be tracked for at least two years.

Continuous quality improvement — The hospital's metabolic bariatric surgery Committee is responsible for assessment of their program and implementing areas where they can improve. The database review of their MBSAQIP data is very helpful in finding areas for improvement. The review will also address any adverse events and ways they can be prevented.

Cost — Making changes to accommodate patients with obesity can be expensive because bariatric equipment and supplies cost 25 to 30 percent more than traditionally sized items [43]. In addition, patients with obesity often require longer hospital stays, more clinical staff, and more costly interventions than patients who do not have obesity. Obesity-related conditions such as sleep apnea and diabetes also increase the cost of care. (See "Overweight and obesity in adults: Health consequences", section on 'Health care costs of obesity'.)

BENEFITS OF ACCREDITATION — The criteria for accreditation discussed above represent the best practices for bariatric surgical care, which are consistent with guidelines from the American College of Surgeons (ACS) and the American Society for Metabolic and Bariatric Surgery (ASMBS) [7]. For hospitals that perform bariatric surgery in North America, accreditation by Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) is the best approach to ensure adherence to these criteria, which are associated with improved patient outcomes compared with nonaccreditation [44].

●Outcomes – A 2016 systematic review identified 13 studies that examined the impact of bariatric accreditation on surgical outcomes in over 1.5 million patients [45]. Overall, 10 of 13 studies reported benefit associated with achieving accreditation. A mortality benefit for accredited over nonaccredited facilities was reported by six of eight studies, with odds ratios ranging from 2.26 to 3.57. Similarly, morbidity benefit was reported by 8 of 11 studies, with odds ratios ranging from 1.09 to 1.39. Other studies also suggest that accredited centers continue to have better outcomes and lower mortality rates than do nonaccredited centers [46]. (See "Bariatric procedures for the management of severe obesity: Descriptions".)

●Volume – In a retrospective review of 277,760 laparoscopic stapling bariatric surgical procedures performed between 2006 and 2010, the in-hospital mortality rate was significantly higher in low-volume centers (<50 stapling cases/year) compared with high-volume centers (0.17 versus 0.07 percent, respectively) [47]. In addition, the in-hospital mortality rate was significantly lower in the accredited high-volume centers compared with nonaccredited high-volume centers (0.06 versus 0.22 percent, respectively). The mortality rates between nonaccredited high-volume centers and low-volume centers were equivalent; hence, the impact of accreditation may be more substantial than volume alone.

●Access – The United States Centers for Medicare and Medicaid Services has decided not to require accreditation for hospitals that perform bariatric surgery for Medicare patients [48]. This decision was made, at least in part, to ensure that Medicare patients would not have limited access to bariatric surgical care. However, the concern that accreditation would limit access to bariatric surgical care is unfounded. There is no documented evidence that Medicare patients are denied access to accredited centers. Since the initial requirement for hospital accreditation, the number of procedures for Medicare beneficiaries has increased [49,50]. The literature does not support the notion that hospital accreditation limits access for patients [51].

●Safety – Adhering to the standards for the best practices outlined by the ACS and the ASMBS is more important than the official designation as an accredited facility. If there is an institutional commitment to these practices, then, most likely, outcomes will be equivalent to those of the accredited hospitals. However, the accreditation process is the best approach to determine if an individual hospital adheres to the best practice guidelines; it is also the best approach for monitoring individual institutional performance and patient outcomes with the added benefit of comparison to national standards and outcomes data.

The MBSAQIP collects and analyzes data to improve patient safety and outcomes on a national level. Without the accreditation process, access to data on this large scale would be extremely difficult. With higher volumes, the patient safety concern is that bariatric operations performed at nonaccredited hospitals will continue to have higher mortality rates as well as higher reoperation rates and higher costs. In addition, Medicare and privately insured patients may not have access to allied health care professionals who provide nutritional, lifestyle, and psychologic counseling and postoperative follow-up that are standard of care in accredited centers. (See 'Allied health care personnel' above.)

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Bariatric surgery".)

SUMMARY AND RECOMMENDATIONS

●Staffing – It is the responsibility of the metabolic and bariatric center to have adequate clinical staff to provide care for patients undergoing bariatric surgery. Depending on the acuity of the patients, the clinical staff includes not only bariatric surgeons who perform the procedures, but also other specialists such as obesity medicine specialists, critical care providers, and medical subspecialty consultants who may be called upon to treat potential complications. (See 'Staffing' above.)

Allied health care personnel, including nurses, dieticians, pharmacists, physical therapists, psychologists, and social workers, are an integral component of the preoperative and postoperative education and management of bariatric patients.

●Accommodations – Appropriate adjustments for patients with obesity should be made in all areas where patient care is given, including outpatient clinics, radiology, the operating room (OR), and the nursing floors. Thus, new guidelines for the design and construction of health care facilities now include bariatric-specific design considerations. (See 'Accommodations' above.)

●Accreditation – The American College of Surgeons (ACS) and the American Society for Metabolic and Bariatric Surgery (ASMBS) have combined their recommendations and criteria for accredited bariatric centers into the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) in order to provide a single resource for the best practices for obesity care for providers and hospitals. (See 'Accreditation' above.)

Centers may be designated as comprehensive (>50 stapling procedures), low acuity (>25 stapling procedures), or adolescent (>15 stapling procedures) based on volume and patient acuity. However, the commitment to training and continuous quality improvement based on data collection and analysis prevails in all accredited centers. (See 'Center designations' above.)

●Benefits of accreditation – Pursuing accreditation by the MBSAQIP is the best approach for determining if a hospital adheres to best practices in bariatric surgery. Accredited hospitals have a lower mortality rate and lower reoperation rate when compared with nonaccredited high-volume and low-volume centers. (See 'Benefits of accreditation' above.)