OR Manager - November 2019 - 30

AMBULATORY
SURGERY CENTERS
Are obese patients good candidates for the outpatient setting?
In 2018, the American Society for
O
besity rates and, consequently,
obstructive sleep apnea (OSA)
are on the rise in the US, and
an increasing number of obese patients
are undergoing surgical procedures at
ambulatory surgery centers (ASCs).
Healthcare providers at such facilities
are adding procedures and taking steps
to ensure the safety of patients whose
body mass index (BMI) exceeds 40 kg/
m2, says Girish P. Joshi, MD, professor
of anesthesiology and pain management,
and Gaganpreet Grewal, MD, assistant
professor, both at UT (University
of Texas) Southwestern Medical Center
in Dallas.
Girish P.
Joshi, MD
Recent data show that
BMI and OSA in isolation
aren't necessarily
accurate indicators of
patient selection for
ASCs, says Dr Joshi.
OR Manager spoke
with both experts, who
emphasized that comorbidities
are more important than
weight in gauging an obese patient's
readiness to have surgery in an ASC.
Lifting the 'hard and fast' cutoff
Obesity prevalence in US adults rose
from 30.5% in 1999 to 39.8% in 20152016,
according to recent data from
the Centers for Disease Control and
Prevention's National Center for Health
Statistics. In youths, prevalence has increased
from 13.9% to 18.5% over the
last two decades.
Metabolic and Bariatric Surgery reported
a rise in US bariatric procedures from
216,000 in 2016 to 228,000 in 2017.
With extra weight putting pressure on
their joints, obese people are also seeking
orthopedic procedures in an ASC.
Some freestanding ASCs may turn
away morbidly obese patients because
of liability concerns or lack of equipment,
but the trend now is to welcome
and accommodate these patients in
outpatient settings, Dr Grewal says.
" As we developed more experience
with ambulatory surgery, we realized
that many obese patients can do well
with surgery, " Dr Grewal adds. Many
facilities have lifted their hard and fast
BMI cutoffs, taking steps to closely examine
any patient with a BMI between
30 and 35 kg/m2, assess his or her
health, and determine what the patient
may need during surgery.
The one rule that hasn't changed in
ASCs is the absolute weight limit, " just
because OR beds and other equipment
can only handle so much weight, " Dr
Grewal notes. Limits vary depending
on what equipment
is involved and
which manufacturer supplies the equipment.
" A particular OR table, for example,
may only be rated to handle 350
pounds, " she explains.
Time management problems
Some of the biggest challenges relating
to obese patients involve anesthesia
prep and procedure length. " A simple
thing such as starting an IV can be
a problem, " Dr Joshi says. If the anesthesiologist
has trouble locating a
vein, surgery may be delayed, causing
distress to the patient. Surgical procedures
may take longer than for nonobese
patients, mainly because of surgical
challenges. Obese patients may
also need additional staff to move them
from the gurney to the operating table
prior to surgery and from the table to a
gurney postoperatively.
A busy ASC needs to account for
these problems to keep things running
on time, Dr Joshi says, noting that these
factors are primarily management issues
rather than patient safety issues.
Don't just rely on BMI
As with any patient, obese patients
need to be assessed on the basis of
comorbidities and their potential impact
on outcomes.
Dr Joshi emphasizes that OR managers
should not fixate on BMI or OSA to
assess risk in obese patients. The majority
of current data, including analyses
of the American College of Surgeons
database, show that BMI and OSA in
isolation are not associated with increased
complications. " These patients
have more comorbid conditions that
are associated with bad outcomes, " Dr
Joshi acknowledges. Obese and OSA
patients often have respiratory, cardiac,
or endocrine problems such as diabetes,
which can lead to postdischarge
problems. However, if these conditions
AMBULATORY SURGERY ADVISORY BOARD
Jennifer Dickman, DNP, RN, CPN, Director, North Surgery Center,
UPMC Children's Hospital of Pittsburgh, Sewickley, PA
Claire Everson, RN, CNOR, CCAP, Clinical Educator and Consultant,
Bloomfield Hills, MI
Tracy Hoeft-Hoffman, MSN, MBA, RN, CASC,
Administrator, Heartland Surgery Center, Kearney, NE
30
OR Manager | November 2019
Beverly Kirchner, BSN, RN, CNOR, CASC, Chief Compliance Officer,
SurgeryDirect, Highland Village, TX
Mary Jo Steiert, BSN, RN, Administrator, Director of Nurses,
Lowry Surgery Center, Denver, CO
www.ormanager.com
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OR Manager - November 2019

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