Laparoscopic Adjustable Gastric Banding STANDARD

Transcription

1 Laparscpic Adjustable Gastric Banding STANDARD Yu may dwnlad, print r make a cpy f this material fr yur nncmmercial persnal use. Any ther reprductin in the whle r part requires written permissin frm the Cllege f Physicians and Surgens f British Clumbia and the material must be credited t the Cllege. In part, the fllwing infrmatin has been adapted with permissin frm dcuments develped by the Cllege f Physicians and Surgens f Ontari and Alberta. Updated:, March 2013, January 2012, Nvember 2010, July 2010 Apprved: July 2009 Originating cmmittee: Nn-Hspital Medical and Surgical Facilities Prgram Cmmittee

2 Cntents Preamble... 2 Cllege s Psitin... 2 Definitins Pertaining t All Cllege Guidelines... 2 Definitins fr LAGB... 3 Bariatric Prgram Standards... 6 I. Medical directr and facility requirements... 6 II. Practitiners qualificatins... 7 III. Staffing requirements... 8 a. Operating rm... 8 b. Pst-anesthesia recvery unit... 9 c. Overnight stay unit IV. Practice guidelines a. Medical recrds b. Patient selectin and screening c. Patient admissin d. Operating theatres and equipment e. Pst-anesthesia recvery unit f. Patient discharge g. Emergency prtcls h. Medicatin management i. Safety j. Physical space k. Infectin preventin and cntrl management l. Sterile prcessing management m. Quality imprvement prgram n. Manuals Appendix A Appendix B Appendix C Appendix D Appendix E Appendix F References Revisin Histry Laparscpic Adjustable Gastric Banding Standard i

3 Preamble This dcument is intended fr nn-hspital medical/surgical facilities t ensure that best practices are incrprated int facility plicies and prcedures fr the purpse f a bariatric surgery prgram acceptable t and apprved by the Cllege f Physicians and Surgens f BC. Laparscpic adjustable gastric banding (LAGB) is the nly qualifying bariatric prcedure apprved fr restricted Class 1 nnhspital facilities as specified by the Cllege. This dcument is reviewed annually and revised peridically. Infrmatin in this dcument is cnsistent with, r exceeds, hspital practice and recmmendatins frm prvincial health authrities, regulatry clleges, the American Cllege f Surgens Bariatric Surgery Center Netwrk Accreditatin Prgram, the Canadian Anesthesilgists Sciety, American Institute f Architecture (AIA), Operating Rm Nurses Assciatin f Canada and the Canadian Standards Assciatin. Cllege s Psitin The Cllege recgnizes the need fr access t bariatric surgery (i.e. LAGB) and that high quality surgical care requires dcumentatin with reliable measurements f utcmes. Laparscpic adjustable gastric banding must nly be perfrmed in nn-hspital facilities apprved and accredited by the Cllege f Physicians and Surgens f BC, and nly in facilities where the necessary persnnel, physical resurces, clinical standards, surgen credentialing standards, data reprting standards and quality assurance prgram are in place. The purpse f this standard is t allw qualified physicians and ther qualified regulated health-care prfessinals t administer a bariatric prgram in its entirety in the nn-hspital medical/surgical facility setting and t prvide patients with the benefits f the laparscpic adjustable gastric banding prcedure while minimizing the assciated risks. The Cllege s guidance f nn-hspital facilities is t ensure the safety, quality, and cnsistency f patient care and is nt meant t replace the prfessinal judgment f physicians and ther health-care prfessinals but rather incrprate current evidence-based r cnsensus-based clinical infrmatin int a framewrk fr reasnable and acceptable patient care that prmtes the best pssible patient utcmes. The decisin t recmmend surgery fr bese patients requires multidisciplinary input t evaluate the indicatins fr peratin and t define and manage cmrbidities. Facilities must assure cmmitment, rganizatin, leadership, persnnel and physical surces t prvide ptimal care. Physicians, ther regulated health-care prfessinals and supprt persnnel, must demnstrate the requisite training, skills, and experience t administer a cmprehensive bariatric prgram. Nn-hspital surgical facilities apprved t perfrm LAGB are required t have a designated inpatient hspital t which patients can be transferred if the need arises. Facilities must be lcated within a 10- minute drive f a hspital in case f emergency transfer. Definitins Pertaining t All Cllege Guidelines Mandatry: Recmmendatin: Required by authrity; bligatry, cmpulsry. A cmpulsry descriptr identified in NHMSF standards. Unfulfilled mandatry descriptrs will result in immediate requirements with specified time frames fr fllwup. Expressin f an actin which is advisry in nature. Laparscpic Adjustable Gastric Banding Standard 2

4 Requirement: Shall r Must: Expressin f an actin which is essential r mandatry. Indicates mandatry requirement and best practice, i.e. the minimum standard. Definitins fr LAGB Abbreviatins ACLS: BCLS: BMI: ASA: CAS: CLPNBC: CRNBC: CSA: LAGB: LPN: NHMSFs: PACU: OR: OSA: RN: VTE: Advanced Cardiac Life Supprt Basic Cardiac Life Supprt (CPR Level Health Prfessinal) Bdy Mass Index (weight in kilgrams divided by the square f the height in metres) American Sciety f Anesthesilgy. Patient s anesthesia physical status classificatins accrding t risk (Appendix B) Canadian Anesthesilgists Sciety Cllege f Licensed Practical Nurses f BC Cllege f Registered Nurses f BC Canadian Standards Assciatin Laparscpic Adjustable Gastric Banding Licensed Practical Nurse Nn-Hspital Medical/Surgical Facilities Pst-anesthesia care unit Operating rm Obstructive Sleep Apnea Registered Nurse Venus thrmbemblism Glssary f terms adult: Aldrete Scale: anesthesilgist: Persns 19 years f age r lder. Cnfirms the rights f adults t make their wn health-care decisin, either independently r with supprt frm family and friends. Adults can be given health care nly with their cnsent (BC s Adult Guardianship Laws: Supprting self-determinatin fr adults in British Clumbia). Clinical scale used as criteria fr patient discharge frm PACU. The Aldrete scale scres the patient n mbility, respiratry status, circulatin, cnsciusness, and pulse ximetry. All licensed medical practitiners with privileges t administer anesthetics. The nly rute t specialist recgnitin in anesthesia in Canada is thrugh the Ryal Cllege f Physicians and Surgens f Laparscpic Adjustable Gastric Banding Standard 3

5 apprpriateness: bariatric: best practice: child: class 1 facility: cllege: cmmittee: cmrbidity: cmpetence: cnsent: guideline(s): Canada s certificatin prcess. Physicians may be required t prvide anesthesia services. CAS guidelines are intended t apply t all anesthesilgists in Canada. In the NHMSF setting nly Ryal Cllege certified anesthesilgists may prvide anesthesia services. The degree t which service is cnsistent with requirements and current best practice. The field f medicine specializing in the treatment f besity. An apprach that has been shwn t prduce superir results, selected by a systematic prcess, and judged as exemplary, r demnstrated as successful. A best practice is a technique r methdlgy that, thrugh experience, research and expert pinin has prven t reliably lead t a desired result. A patient 14 years f age r less. Prvides general anesthesia services. Prfessinal regulatry bdy. vernight stay: Refer t Appendix E. practitiner: plicy: prtcl: qualified: Nn-Hspital Medical and Surgical Facilities Prgram Cmmittee. Tw r mre cexisting medical cnditins r disease prcesses that are additinal t an initial diagnsis. Guarantee that an individual s training, knwledge and skill are apprpriate t the service prvided and assurance that the training, knwledge and skill levels are regularly evaluated. Refer t BC s Health Care (Cnsent) and Care Facility (Admissin) Act: /freeside/00_96181_01 An instructinal guide r reference t indicate a curse f actin r apprpriate ptins. They incrprate the mst current evidence-based r cnsensus-based clinical infrmatin int a framewrk that prmtes the best patient utcmes. They d nt define a standard f care, but may infrm the standard f care. They are nt intended t replace the prfessinal judgment f physicians. An individual wh practices a learned prfessin and supplies healthcare services (e.g. physician, registered nurse). A principle r guideline that gverns activities in a facility that emplyees are expected t fllw. Descriptin f the steps t be taken in a prcedure. Frmal ideas, written plans and expectatins cncerning the actins f thse invlved in patient care. Having the educatin, abilities, qualities, training, r certificatin t perfrm a particular jb r duties. Laparscpic Adjustable Gastric Banding Standard 4

6 regulated healthcare prfessinal: standard: surgen: Applies t a health-care prfessinal wh is licensed and in gd standing with their regulatry Cllege. That which is established by authrity as a mdel, criterin, r rule and serves as a basis fr cmparisn. Authritative statements that describe the respnsibilities fr which individuals are accuntable. Reflect the values and pririties f the prfessin. An achievable level f perfrmance against which actual perfrmance is cmpared. A specialist certified by the Ryal Cllege f Physicians and Surgens f Canada in a relevant surgical discipline. Laparscpic Adjustable Gastric Banding Standard 5

7 Bariatric Prgram Standards I. Medical directr and facility requirements The medical directr must make applicatin in writing t the Cllege fr apprval t administer a bariatric prgram fr LAGB prcedures. Apprval is cntingent n the cmpletin f an n-site visit and cnfirmatin f the fllwing requirements: The medical directr must make applicatin in writing t the Cllege fr apprval t administer a bariatric prgram fr LAGB prcedures. Apprval is cntingent n the cmpletin f an n-site visit and cnfirmatin f the fllwing requirements: 1. meet physical space and design requirements as determined by the Canadian Standards Assciatin (CSA Z8000 and Z317.2) and the American Institute f Architects (Design Guidelines fr Facilities with Bariatric Patients) 2. review surgery utcme data t cnfirm patient safety and satisfactry lng term patient utcmes: a. mnthly fr the first six mnths f a new LAGB prgram and frequently thereafter b. mnthly fr the first six mnths with the additin f any new bariatric surgen and frequently thereafter c. as part f the surgen s re-applicatin fr privileges 3. ensure the surgen and facility cntinue t meet all requirements at time f annual reappintment fr privileges, including review f the surgen s surgical utcme data (dcumentatin f cntinuing medical educatin related t bariatric surgery is recmmended) 4. prvide key staffing and/r referral requirements: a. ne qualified bariatric surgen wh is designated as directr f the bariatric prgram and wh can prvide (represents the credentialing requirements as dcumented in the guidelines frm the American Sciety f Metablic and Bariatric Surgens (ASMBS) Glbal credentialing requirements in bariatric surgery): dcumentatin that they are wrking with an integrated prgram fr the care f the mrbidly bese patient that prvides ancillary service such as specialized nursing care, dietary instructin, band filling, cunselling, supprt grups, exercise training, and psychlgical assistance as needed dcumentatin that there is a prgram in place t prevent, mnitr and manage shrt-term and lng-term cmplicatin including defective bands dcumentatin that there is a system in place t prvide and encurage fllwup fr all patients fllw-up visits shuld either be directly supervised by the bariatric surgen f recrd r ther health-care prfessinals wh are apprpriately trained in periperative management f bariatric patients and part f an integrated prgram Laparscpic Adjustable Gastric Banding Standard 6

8 b. ne physician surgical assist while applicants can nt guarantee patient cmpliance with fllw-up recmmendatins, they shuld demnstrate evidence f adequate patient educatin regarding the imprtance f fllw-up as well as adequate access t fllw-up c. tw qualified anesthesilgists secnd anesthesilgist must be n-site during LABG surgery (e.g. prviding anesthesia in secnd OR and readily available t assist as necessary) d. periperative and pst-anesthesia recvery nursing staff wh are qualified and experienced in bariatric prcedures e. all facilities apprved t perfrm LAGB prcedures must nly perfrm LAGB when a secnd rm is perating in the facility t ensure additinal persnnel are available t assist as necessary f. bariatric prgram crdinatr (e.g. registered nurse reprting t directr f bariatric surgery) t prvide cmprehensive management f LAGB prgram, crdinatin f multidisciplinary teams (dietician, psychlgical assessment/supprt) and cmmitted lng-term medical management and fllw-up t patients including lap-band fills g. dietician experienced in bariatric medicine and LAGB prcedure h. psychlgist experienced in the assessment f mrbidly bese patients i. administrative supprt staff II. Practitiners qualificatins All general surgens wh perfrm LAGB in a NHMSF must: be certified by the Ryal Cllege f Physicians and Surgens f Canada and be licensed and in gd standing with the Cllege f Physicians and Surgens f BC hld privileges in a facility apprved by the Cllege submit t the Cllege an applicatin fr apprval specific t LAGB prcedure hld surgical hspital privileges and pssess the requisite experience and skills t perfrm advanced gastrintestinal and biliary laparscpic surgery: have perfrmed at least 100 laparscpic prcedures (chlecystectmy, nissen fundplicatin, bwel resectin, hernia repair, appendectmy) peratins ver previus 24 mnths r have a Fellwship in Bariatric Surgery and, have experience perfrming laparscpic adjustable gastric banding prcedures acceptable t the Cmmittee r have cmpleted a prctrship training in LAGB surgery which is acceptable t the Cmmittee (e.g. dcumented 10 cases with satisfactry utcmes under the supervisin f an experienced bariatric surgen) have privileges and cverage available 24/7/365 at designated in-patient hspital t manage laparscpic gastric band cmplicatins Laparscpic Adjustable Gastric Banding Standard 7

9 ensure tw qualified surgens are present during LAGB prcedures (i.e. ne bariatric general surgen and ne general surgen assisting wh is experienced in laparscpic prcedures) All anesthesilgists wh prvide anesthesia fr LAGB prcedures must: be certified by the Ryal Cllege f Physicians and Surgens f Canada and be licensed and in gd standing with the Cllege f Physicians and Surgens f BC hld privileges in a facility apprved by the Cllege pssess requisite experience in managing mrbidly bese patients and cmplex airway issues hld active hspital privileges in the practice f anesthesia r hld current ACLS training and have cmpleted an airway management curse acceptable t the Cllege if they have nt regularly practiced anesthesia in a hspital setting within three years adhere t the practice and dcumentatin/charting f anesthesia as recmmended by the Canadian Anesthesilgists Sciety participate in emergency mck drills at least every six mnths which shuld include but are nt limited t cardiac arrest, difficult airway management, anaphylaxis, hypvlemia, unrespnsiveness, acute strke and seizure Qualified and regulated health-care prfessinals (e.g. registered nurses) must: be licensed and be in gd standing with their prfessinal regulatry agency (e.g. Cllege f Registered Nurses f BC) pssess periperative certificatin and/r have the equivalent in training and experience t wrk in the perating rm r pst-anesthesia/critical care certificatin and/r have the equivalent in training and experience t wrk in the pst-anesthesia recvery unit hld current BCLS training participate in emergency mck drills at least every six mnths which shuld include, but are nt limited t cardiac arrest, difficult airway management, anaphylaxis, hypvlemia, unrespnsiveness, acute strke and seizure III. Staffing requirements In all areas f patient care delivery, the facility must ensure sufficient persnnel are available t assist with patient transferring and/r ambulatin as necessary. a. Operating rm During LAGB prcedures the fllwing staffing requirements must be met: 1. A minimum f tw periperative registered nurses wh are dedicated t the perating rm frm the start t the finish f every LAGB prcedure. One nurse is assigned t the scrub rle and the secnd is assigned t the circulating rle. Bth nurses must hld periperative certificatin and/r pssess the equivalent in training and experience t perfrm their expected duties. Laparscpic Adjustable Gastric Banding Standard 8

10 -and- 2. A third periperative registered nurse r ther regulated health-care prfessinal wh is dedicated t assist at the start and end f every case and immediately available during the case t assist as necessary. b. Pst-anesthesia recvery unit During LAGB pst-anesthesia recvery phase the fllwing staffing requirements and ratis must be met: i. Phase 1 level f care Tw registered nurses wh are pst-anesthesia recvery/critical care certified and/r have the equivalent in training and experience must be present in the same rm at all times where a patient is receiving phase 1 PAR care. One registered nurse t ne patient: at the time f admissin, until the critical elements are met: patient has a patent airway withut assistance initial assessment is cmplete patient is hemdynamically stable a secnd nurse must be available t assist as necessary One registered nurse t tw patients: tw patients are cnscius and free f cmplicatins ii. Phase 2 level f care Tw registered nurses, ne f whm is PARR/critical care certified and/r has the equivalent in training and experience, must be present in the same rm at all times where a patient is receiving phase 2 PAR care. One registered nurse t ne patient: patient f any age wh becme unstable and require transfer t a higher level f care e.g. hspital a secnd nurse must be available t assist as necessary One registered nurse t tw patients: initial admissin f the patient int pst-anesthesia phase 2 iii. Blended levels f care Perianesthesia units may prvide Phase 1 and/r Phase 2 levels f care within the same envirnment. This may require the blending f patients and staffing patterns. The perianesthesia registered nurse uses prudent judgment based n patient acuity, nursing bservatins and required interventins t determine staffing needs. Laparscpic Adjustable Gastric Banding Standard 9

11 c. Overnight stay unit Facilities shuld cnsider first the interests, well-being and safety f their patients and avid any situatin that may put patients r staff at risk. The fllwing guidelines shuld assist facilities in meeting the requirements fr vernight stay f a LAGB surgical patient: 1. The Cllege must be ntified immediately if a patient is required t stay beynd an vernight stay (i.e. 24 hurs past end f surgery). 2. There shall be written plicy defining the chain f cmmand and facility expectatins in the event f an emergency. 3. There must be a dcumented call rta fr anesthesia service and the surgical specialty f any vernight admissin. 4. Call must nt be transferred t anther surgen wh was nt invlved in the LAGB prcedure perfrmed. 5. All LABG vernight stay patients shall be 19 years r ver. 6. The vernight stay area must meet the same standards as established fr the PAR unit. In additin, the vernight stay area must meet the applicable AIA bariatric design guidelines (see Appendix D) and must als receive the necessary apprval f city/municipal and fire authrities. 7. Frmalized pst-perative care plans, discharge criteria, emergency prtcls and hspital transfer prtcls must be develped fr LAGB patients kept in the vernight stay area. Cpies must be included in the plicy and prcedure manual f the facility, and prvided t the Cllege prir t prgram apprval. During LAGB vernight stay the fllwing staffing requirements must be met: 1. The minimum cmpliment f nursing staff is: 1-5 patients 1 registered nurse in charge + 1 registered nurse r 1 licensed practical nurse. Ttal: 2 Nurses The decisin f assigning the secnd nurse as a registered r licensed practical nurse shuld depend n patient acuity and the facility s administratr and charge nurse s determinatin f staffing needs t prvide safe patient care. 2. The medical directr must ensure that nursing persnnel pssess cmpetence apprpriate t the patient ppulatin. 3. Registered nurse qualificatins must include critical care r pst-anesthesia recvery certificatin and/r the equivalent in experience and training. 4. At least ne registered nurse with current training in advanced cardiac life supprt and all ther members f the nursing staff with current training in cardipulmnary resuscitatin must be n duty at all times when patients are in the facility. The expected level f ACLS interventin must be clearly defined in the facility s plicy manual. IV. Practice guidelines a. Medical recrds A permanent recrd f all LAGB prcedures will be maintained and must include at a minimum: Laparscpic Adjustable Gastric Banding Standard 10

12 name and address f patient names f physicians and ther health-care prfessinals directly invlved in patient care prcedure perfrmed infrmed cnsent preperative histry and physical cnsultatins as indicated preadmissin anesthetic recrd recrd f allergies and medicatins labratry and/r diagnstic testing as indicated by the patient s medical status, drug therapy r nature f the prcedure anesthetic recrd perative reprt perative nursing recrd pst-anesthesia recvery recrd discharge recrd b. Patient selectin and screening Inapprpriate patients fr LAGB surgery in a NHMSF: ASA > 3 BMI > 50 and/r patients > 400 lbs patients with persnal r significant family histry f malignant hyperthermia patient with n respnsible escrt t drive them hme and stay with them vernight untreated cagulpathy untreated severe OSA and/r patients wh are nn-cmpliant with CPAP significant cardiac cmrbidity (e.g. recent MI, CHF, significant valve disease, ischemic heart disease, valve replacement, significant arrhythmia requiring pst-p mnitring) significant pulmnary cmrbidity (e.g. severe COPD/emphysema, severe restrictive lung disease, prly cntrlled asthma) cmplicated cases such as gastric prlapsed, ersins and patients wh have had previus bariatric surgery prly cntrlled diabetes prtal hypertensin impaired mbility (wheelchair r walker) patients with cnfunding psychiatric issues (e.g. active psychsis, current mderatesevere untreated depressin) Laparscpic Adjustable Gastric Banding Standard 11

13 patients with cnfunding psychscial factrs (e.g. recent r current substance/alchl abuse, disturbed eating habits, limited scial supprt, unrealistic expectatins f surgery) Apprpriate patients fr LAGB surgery in a NHMSF: nly ASA 1 and 2 patients and selected ASA 3 patients with n significant cardiac r pulmnary cmrbidities age between 19 and 65 years BMI > 30 and < 35 with at least ne severe cmrbidity related t their besity (e.g. heart disease, diabetes) BMI > 35 and < 50 (maximum weight f 400 lbs) patient has been verweight fr at least five years mild untreated OSA requiring lw dse ral piids pst-p mild t mderate treated OSA requiring lw dse ral piids pst-p selected severe OSA apprpriately treated and cmpliant with CPAP patient must be ambulatry Each patient must be carefully screened and the fllwing criteria reviewed prir t surgery by the designated directr f the bariatric prgram and the bariatric nurse crdinatr: 1. Indicatins fr surgery, cntraindicatins fr surgery, cmrbidities and perative risks. 2. Histry and physical examinatin must be perfrmed within 90 days f the prcedure by a registered physician and shuld include: utcme f previus weight lss attempts; cmrbidities; current diet habit; medicatins; allergies; previus surgery; previus hspital admissins; family physician infrmatin and assessment; next f kin infrmatin; smking habit; alchl use; ccupatin; family histry f diabetes; heart disease and cancer; current and maximum weight and BMI calculatin; and symptms f bstructive sleep apnea (OSA patients t be instructed t bring CPAP machines t facility day f surgery). Histry must be dcumented, dated and signed and be part f the patient s clinical recrd preperatively. Examinatin must be updated if necessary within tw weeks f the prcedure. 3. ASA physical classificatin must be assigned by an anesthesilgist and be recrded fr each patient (see Appendix B). 4. Anesthesia cnsult fr every LAGB patient. Anesthetic cnsults must be carried ut, dcumented, dated and signed nt mre than tw weeks befre surgery and at minimum, ne day prir t surgery. The pre-anesthesia assessment must include: review f the patient s clinical recrd a medical interview with the patient a physical examinatin relative t anesthetic aspects f care and review f previus anesthesia recrds recrd f bld pressure, heart rate, respiratin status and quality, xygen saturatin and temperature Laparscpic Adjustable Gastric Banding Standard 12

14 a review and rdering f diagnstic tests ECG, CBC, electrlytes, liver functin tests are mandatry bld gases, pulmnary functin tests, sleep study reprt as indicated 5. Cardi pulmnary (i.e. presence f sleep apnea and upper GI studies t rule ut hiatus hernia as indicated). 6. Psychlgical screening assessment, cmpleted by a psychlgist r registered cunselr experienced in the assessment f the mrbidly bese, t ascertain the patient s suitability fr the LAGB prcedure and t evaluate the patient s ability t cmply with the pst-perative recmmendatins. 7. Psychiatric evaluatin n individual basis as indicated. 8. Dietary educatinal screening, by a registered dietician, t discuss pre- and pst-surgery dietary requirements/recmmendatins and the patient s cmmitment t dietary mdificatin bth after and prir t surgery (e.g. patients t fllw a lw fat/lw carbhydrate diet 2 3 weeks prir t surgery). 9. Medical cnsultatin n individual basis as indicated (e.g. MIBI scans, internal medicine r cardilgy cnsultatin). 10. The patient r guardian will be infrmed f risks and benefits f the prcedure and written infrmed cnsent fr laparscpic adjustable gastric banding is btained and dcumented. Refer t BC s Health Care (Cnsent) and Care Facility (Admissin) Act: c. Patient admissin The regulated health-care prfessinals managing the patient care must: cnfirm and dcument that the patient has a respnsible adult t accmpany them hme and remain with patient 24 hurs pst-perative (i.e. if the patient des nt stay first 24 hurs vernight at the facility); if a respnsible adult is nt available t accmpany the patient hme pst-prcedure, the planned prcedure will be cancelled review and dcument patient pre-prcedure health evaluatin including NPO status, allergies, ASA, height, weight, BMI, and any previus medical, anesthesia and surgical prblems btain and dcument baseline data including heart rate and rhythm, respiratry rate and status, bld pressure, pulse ximetry, glucmeter reading as indicated, temperature, mental status, ability t ambulate, and pain level cnfirm as indicated VTE and antibitic prphylactic administratin cnfirm as indicated discntinuatin f anticagulant/antiplatelet/anti-inflammatry medicatins ne week prir t surgery ensure apprpriate bariatric specific fasting guidelines have been fllwed preperatively prvide patient with the apprpriate infrmatin regarding prcedure, nature f medicatins and pst-prcedure care Laparscpic Adjustable Gastric Banding Standard 13

15 review patient chart fr cmpleteness (e.g. cnsent, histry and physical, diagnstic testing, etc.) ensure surgical site verificatin/marking ensure that patient has CPAP machine as indicated sme d nt allw fr supplemental xygen delivery and this must be identified and crrected befre surgery d. Operating theatres and equipment The regulated health-care prfessinals managing the patient care must ensure: OR theatres are large enugh t accmmdate easy access fr staff, equipment and patient OR theatres are fully equipped with all apprpriate equipment and supplies apprpriate t the mrbidly bese patient OR table must accmmdate up t 400 lbs and have sufficient accessries t safely anesthetize, psitin and restrain the patient psitining devices must include but are nt limited t arm bards, bed extensins, table ft and/r leg attachments, safety straps, transfer bard r ceiling lift device, pillws, sandbags tw cmplete sterile LAGB laparscpic sets are available fr each LAGB case (ne as back-up) with apprpriate retractrs, lng surgical instruments, lng trcars and sheaths as indicated *flash sterilizatin is nt acceptable practice due t lack f inventry tw insufflatrs, tw light surces, tw cameras and tw light crds are available fr each case (ne fr back-up) tw LAGB bands are available fr each case a cmplete sterile lapartmy set is available in case f need t pen with apprpriate retractrs and all ther necessary supplies in rder t deal with prblems f (e.g. intraabdminal bleeding, bwel injury r ther intra-abdminal prblems) that may arise OR theatre drs are kept clsed during surgery heating ventilatin and air cnditining systems meet CSA standards and dcumentatin is prvided t the Cllege standard OR lights, suctin and temperature cntrls are in place emergency pwer and lighting is available fr minimum f fur hurs and tested weekly that emergency cart and difficult intubatin equipment is immediately available adequate electrical utlets are available nn-flammable medical gas piping system cmplies with BC building cdes and is serviced annually all equipment is CSA apprved and checked annually by a bimedical engineer that OR theatre is adequately staffed frm the start t finish f each case Laparscpic Adjustable Gastric Banding Standard 14

16 that surgical safety checklist (briefing, timeut and debriefing) is cmpleted and recrded n OR recrd that all intraperative charting and surgical cunts are cmpleted and signed by the apprpriate health-care prfessinals that all surgens cmplete a detailed perative reprt e. Pst-anesthesia recvery unit The regulated health-care prfessinals managing the patient care must ensure: there is adequate number f patient statins equipped with mnitring equipment which includes: ECG mnitr suctin xygen surce with mask and/r nasal cannula bag-valve-mask device intravenus supplies medicatins and narctics emergency light surce bdy warming device adequate space exists t allw fr free mvement f staff and emergency equipment access n bth sides f the patient stretcher during the patient recvery phase a registered nurse qualified and trained in recvery rm prcedures remains in cntinuus attendance t the patient there is nging patient assessment and dcumentatin f every patient which includes: respiratin rate and airway patency heart rate evaluatin bld pressure xygen saturatin by pulse ximetry clur level f cnsciusness activity hand-washing statin and/r alchl rub dispensers are easily accessible t ensure hand washing between patients f. Patient discharge 1. Discharge criteria must be met prir t discharge frm the patient frm the Facility e.g. mdified Aldrete scre (see Appendix C). Laparscpic Adjustable Gastric Banding Standard 15

17 2. The patient and/r guardian/respnsible adult will be instructed in the after care f the patient. Verbal and written discharge instructins will be given t the patient and/r respnsible adult and must include: when t resume taking medicatins taken befre prcedure new prescriptins wund care diet and activity restrictins, additive effects f alchl and ther sedative drugs n driving r perating dangerus machinery fr at least 24 hurs fllw-up care, telephne cntact numbers respnsible adult t remain with patient fr 24 hurs written materials applicable t prcedure 3. The anesthesilgist r ther cmpetent physician must remain n the premises until the patient meets predetermined recvery criteria. Discharge frm the PACU is the respnsibility f the anesthesilgist. *Pst-anesthesia recvery unit and vernight stay equipment must accmmdate mrbidly bese patients up t 400 lbs: stretchers t accmmdate bth weight and width f patient transfer r lifting devices cmmde wheelchair g. Emergency prtcls 1. Overview bathrm sinks and tilets In facilities ding LAGB there may be emergencies that relate t the airway, cardiac functin and t the management f unexpected findings during the laparscpy r intra-abdminal injuries that ensue during the prcedure. The facility must have apprpriately trained persnnel t deal with these emergencies and have the apprpriate equipment t perfrm life-saving prcedures. 2. Emergency patient care Prtcls fr the cntact f EMS and patient transfer t a hspital must be published, psted and regularly reviewed. 3. Difficult airway management Facility must be capable f and apprpriately equipped t safely and effectively deal with difficult airway prblems. The equipment necessary includes flexible brnchscpe with suctin capabilities, glide scpe and a difficult intubatin tray. 4. Emergency equipment and supplies cardiac mnitr with display Laparscpic Adjustable Gastric Banding Standard 16

18 defibrillatr means t mnitr bdy temperature emergency and resuscitative medicatin as per Cllege guidelines fr Class 1 facility (see Appendix F) tw functining laryngscpes apprpriate fr bese patients endtracheal tubes, laryngeal masks, stylets, airways and facemasks in a selectin f sizes apprpriate t the patient 100% xygen surce (tw E tanks available) and supplies psitive-pressure breathing device prtable suctin and suctin catheters (tnsil and deep) cricthyrtmy kit pulse ximeter with audible mnitr CO 2 mnitr stethscpe CPR backbard emergency recrd dcument cardiac algrithms IV fluids and supplies supply f plasma vlume expanders Magill frceps h. Medicatin management Cntrlled substances/narctics shall be managed in a manner that permits full auditing f the substances frm acquisitin thrugh t patient administratin and wastage. i. Safety 1. All equipment and supplies must be apprpriate, CSA apprved and calibrated accrding t the manufacturer s recmmended standards. 2. All equipment must underg annual inspectin and maintenance by qualified persnnel i.e. bimedical engineer. Recrds indicating cnfrmity t regulatins and inspectin and maintenance must be retained by the facility. 3. Emergency mck drills must be perfrmed at least every six mnths which shuld include, but are nt limited t, cardiac arrest, difficult airway management, anaphylaxis, hypvlemia, unrespnsiveness, acute strke and seizure. All staff must participate in mck drills with attendance and specified drills practised dcumented. j. Physical space Facilities must meet AIA bariatric design guidelines (see Appendix D) which include: Laparscpic Adjustable Gastric Banding Standard 17

19 crridr widths drway widths bathrm tilets and sinks adequate space in facility fr the health team t deliver safe, private and efficient patient care in all patient areas mandatry access t facility by emergency medical services and fire department k. Infectin preventin and cntrl management rutine practices shall be emplyed in the handling f all patients, care items and medical devices sufficient hand-washing sinks shall be available and hand-washing prtcl psted as a visible reminder f the imprtance fr staff t wash their hands apprpriate persnal prtective devices shall be emplyed by all staff sterile technique shall apply as apprpriate t prcedure perfrmed all sharps devices must be handled apprpriately and dispsed f in a dedicated bihazard puncture resistant cntainer (see WrksafeBC Guideline at Reference OSHR 6.36(1)) single-use medical devices (e.g. syringes) must nt be reused ensure that ptentially infectius materials r agents are nt transferred frm ne patient t anther; special attentin shall be given t syringes, infusin pump administratin sets and multi-dse medicatin vials l. Sterile prcessing management Facilities are required t verify the fllwing: 1. The Ministry f Health dcument (Dec 2011), Best practice guidelines fr cleaning, disinfectin and sterilizatin f critical and semi-critical medical devices in BC health authrities is incrprated int facility plicy and fllwed: 2. Sufficient LAGB instrument inventry is available and n-site. 3. Medical devices must nt be flashed n a rutine basis. Flash sterilizatin may nly be used in an emergency situatin when there is insufficient time t prcess by the preferred wrapped r cntainer methd. Flash sterilizatin must nt be used as a substitute fr insufficient instrument inventry. Manufacturer s sterilizatin recmmendatins shuld be fllwed prir t flash sterilizatin f any medical device. 4. All medical devices are apprpriately wrapped, placed in steri-peel r metal strage cntainers prir t full-cycle steam sterilizatin. 5. All sterile prcessing staff are apprpriately qualified and trained t perfrm expected duties. Laparscpic Adjustable Gastric Banding Standard 18

20 m. Quality imprvement prgram Nn-hspital facilities apprved t perfrm LAGB must have a quality imprvement prgram in place which includes prmtin and dcumentatin f the use f best practices and measuring utcmes: lng-term pst-perative fllw-up must be established fr all patients pst-perative rehabilitatin supprt shuld include dietary cunseling, exercise cunseling and psychlgical cunselling patients must be encuraged t participate in nging supprt grups imprvement in besity related c-mrbidities shuld be mnitred and dcumented fllw-up visits must ccur frequently, e.g. tw weeks pst-peratively, fur six weeks pst-peratively, three mnths, six mnths, ne year and every year thereafter a patient may be deemed lst t fllw-up if at least three cnsecutive and different cntact effrts have been dcumented including: phne call t patient letter t patient letter t patient s family physician/general practitiner Dcumentatin f the quality imprvement prgram is reviewed during the applicatin prcess fr establishing a LAGB prgram and at time f accreditatin. n. Manuals 1. Plicies and prcedures pertaining t bariatric medicine and LAGB surgery, including clinical pathways/care algrithms, shall be current, cmplete and available fr staff review. 2. Educatin materials relevant t the services prvided at the facility. Laparscpic Adjustable Gastric Banding Standard 19

21 APPENDICES Laparscpic Adjustable Gastric Banding Standard 20

22 Appendix A Specific prtcls have been develped by surgens experienced in perating n mrbidly bese patients, alng with anesthetists t ensure patient safety. These prtcls are utlined belw and these are the prtcls that we fllw. i. Sleep apnea All patients wuld be screened fr sleep apnea and thse with a STOP-Bang scre f 3 wuld 1, 2, 6 be sent fr a sleep apnea study. If a patient has sleep apnea (including thse with mderate t severe sleep apnea), s/he is instructed t bring their cntinuus psitive airway pressure (CPAP) machine with them t the facility fr use after the prcedure. Additinal measures t ensure patient safety include: minimizing anesthesia time (nte: LAGB usually takes less than ne hur) using nn-narctics t cntrl pain pst-peratively extubating when the patient is fully awake and in a semi-upright psitin In utpatient facilities fllwing this prtcl, cmplicatins resulting frm sleep apnea have nt ccurred, nt even in thse patients with mderate t severe sleep apnea and are super bese (BMI 50). 2, 3, 4 The study by Watkins et al. invlved 2,411 patients and the study by Mntgmery et al. invlved 320 super-bese patients. ii. Preventing nausea and vmiting and minimizing pst-perative pain t allw rapid ambulatin T minimize pst-perative nausea and vmiting, a scplamine patch is applied just prir t surgery and during surgery anti-nausea medicatins are administered intravenusly. T minimize pain pst-peratively, a nn-narctic is used during and pst-surgery (if needed). Laparscpic Adjustable Gastric Banding Standard 21

23 iii. iv. Preventing deep vein thrmbsis (DVT) and pulmnary emblism (PE) The fllwing steps are taken t prevent DVTs r PEs: requiring patients t stp estrgen-cntaining medicatins ne mnth befre surgery administering 4,000 U f lw mlecular heparin subcutaneusly ne hur prir t anesthesia inductin placing pneumatic cmpressin devices n the lwer extremities f the patients during surgery allwing fr rapid ambulatin pst-surgery by minimizing pst-perative nausea, vmiting and pain thrugh the administratin f apprpriate medicatins, as mentined earlier These measures have been shwn t greatly reduce risk. 2, 3 Anesthesia management Shrt-acting anesthetics are used and extubatin ccurs nce the patient can lift his/her head, respnds t cmmands and has apprpriate vital capacity. Fllwing extubatin, the patient is maintained in a 45-degree heads-up psitin. This imprves the expiratry reserve vlume and the functinal residual capacity. 5 By fllwing these guidelines, patients can typically becme mbile and leave the clinic as early as tw hurs after the prcedure. 2, 4 v. Patient supprt pst-prcedure All patients must be accmpanied by an adult cmpanin fr the first 24 hurs after the prcedure. If an adult cmpanin is nt available, the surgen must arrange fr a nurse t stay with the patient fr the first 24 hurs. Out-f-twn patients are asked t stay clse t the clinic fr tw t three days pstprcedure and must be seen by either the surgen r a nurse at the clinic befre they travel hme. All patients are called the fllwing day and their first appintment is bked within fur t six weeks. Patients are prvided with a telephne number s they can reach the surgen 24 hurs per day, seven days a week. Laparscpic Adjustable Gastric Banding Standard 22

24 References 1. Dixn JB, Schacter LM, O Brien PE. Predicting sleep apnea and excessive day sleepiness in the severely bese. Chest. 2003;123: Watkins BM, Ahrni JH, Michaelsn R, Mntgmery KF, Abrams RE, Erlitz MD, Scurlck JE. Laparscpic adjustable gastric banding in an ambulatry surgery centre. Surgery fr Obesity and Related Diseases May-Jun;4(3 Suppl):S Mntgmery KF, Watkins BM, Ahrni J. Outpatient laparscpic adjustable gastric banding in super-bese patients. Obesity Surgery. 2007;17; Watkins BM, Mntgmery KF, Ahrni JH, Erlitz MD, Abrams RE, Scurlck JE. Adjustable gastric banding in an ambulatry surgery centre. Obesity Surgery. 2005;15: Packer L. Anesthesilgy perspective: utpatient bariatric surgery: Ananesthesilgist s perspective. Bariatric Times. 2006;3(1): Chung F, Subramanyam R, Lia P, Sasaki E, Shapir C, Sun Y. High STOP-Bang scre indicates a high prbability f bstructive sleep apnea. British Jurnal f Anaesthesia May;108(5): Laparscpic Adjustable Gastric Banding Standard 23

25 Appendix B American Sciety f Anesthesilgists (ASA) Physical Status Classificatin System Only patients at Categries 1 and 2 risk level as defined by the American Sciety f Anesthesilgists shuld nrmally be accepted in the facility. Hwever, risk level Categry 3 patients may be treated there if the patient s disease is nt expected t be affected by the anesthetic. ASA 1 A nrmal healthy patient e.g. Healthy patient withut any systemic medical prblems ther than surgical. ASA 2 A patient with mild systemic disease e.g. Patient wh smkes and has hypertensin, which is well cntrlled. ASA 3 A patient with severe systemic disease e.g. Patient with diabetes and angina. Takes medicatins, including insulin. angina fairly stable. ASA 4 A patient with severe systemic disease that is a cnstant threat t life e.g. Patient with diabetes, angina and cngestive heart failure. Patient has dyspnea n mild exertin and chest pain. Laparscpic Adjustable Gastric Banding Standard 24

26 Appendix C I. Phase I recvery t phase II recvery discharge criteria: A. Mdified Aldrete scring system A minimum scre f 9/10 (and/r return t similar prep status) is achieved prir t transferring the patient t a Phase II recvery area. Table One: Mdified Aldrete scring ystem Categry Scre = 2 Scre = 1 Scre = 0 Respiratins Breathes, cughs freely Dyspnea Apnea O 2 Saturatin SpO 2 > 94% n R/A Supplemental O 2 SpO 2 < 94% n O 2 Circulatin BP +/- 20 mmhg pre-p value BP +/ mmhg prep value BP +/- 50 mmhg pre-p value LOC Awake and riented Wakens with stimulatin Nn-respnsive Mvement Mves 4 limbs spntaneusly Mves 2 limbs spntaneusly Mves 0 limbs spntaneusly B. Pst-anesthetic discharge scring system (PADSS): A minimum scre f 9/10 (and/r return t similar prep status) is achieved prir t transferring the patient t a Phase III recvery area r hme. Table Tw: Pst-anesthetic discharge scring system (PADSS) Categry Vital Signs Respiratry Status Nausea & Vmiting Descriptin f Status Within 20% range f pre-p value 20 40% range f pre-p value > 40% range f pre-p value O 2 saturatin > 94% n rm air O 2 saturatin > 94% n nasal 4 LPM r less O 2 saturatin > 94% n 10 LPM r less Minimal, treated with p medicatins Mderate, treated with parenteral medicatins Cntinues after repeated treatments PADSS Scre Laparscpic Adjustable Gastric Banding Standard 25

27 Categry Descriptin f Status PADSS Scre Pain Surgical Bleeding Acceptable t patient (with p medicatins) Pain smewhat acceptable t patient Pain nt acceptable t patient Minimal: n dressing changes required Mderate bleeding: 1 2 dressing changes Severe bleeding: interventin required II. Phase II t Phase III recvery/extended bservatin (r hme) discharge criteria: A minimum scre f 9/10 (and/r return t similar pre-p status) is achieved prir t transferring the patient t a Phase III recvery area r hme. Table Three: Pst-anesthetic discharge scring system (PADSS) fr ambulatry surgical patients Categry Vital Signs Ambulatin Nausea & Vmiting Pain Surgical Bleeding Descriptin f Status Within 20% range f pre-p value 20 40% range f pre-p value > 40% range f pre-p value Steady gait/n dizziness Ambulates with assistance Nt ambulating/dizziness Minimal, treated with p medicatins Mderate, treated with parenteral medicatins Cntinues after repeated treatments Acceptable t patient (p medicatins) Pain nt acceptable t patient Minimal, n dressing changes required Mderate bleeding Severe bleeding PADSS Scre Pst-perative viding is nt always required. See the Natinal Assciatin f PeriAnesthesia Nurses f Canada Standards fr Practice fr further infrmatin. Laparscpic Adjustable Gastric Banding Standard 26

28 Appendix D Design guidelines fr facilities with bariatric patients The design f health-care facilities has a direct impact n bth wrker safety and the quality f patient care. With an increasing number f bariatric patients (patients 100 lbs r mre ver their ideal bdy weight r having a Bdy Mass Index f 40 r mre), designing r re-designing facilities is an emerging tpic. The fllwing guidelines are sme basic numbers based n research by the American Institute f Architecture Academy fr Health. It is imprtant t nte when applying these numbers int a design that there are many ther cnsideratins that need t be taken int accunt, such as: a descriptin f the patient ppulatin physical and mental capacities, medical cnditins; the types f prcedures being perfrmed and what equipment is required hw and where patients are transprted (patient flw) dimensins and strage f equipment Crridr widths In rder t accmmdate a patient with a bariatric walker and allw passage fr ther ft traffic, a minimum f 5 ft (60 r 1,520 mm) is required fr the width f a crridr. Laparscpic Adjustable Gastric Banding Standard 27

29 Drway widths T accmmdate bariatric wheelchairs 45 (1,140 mm) drway penings are required. Where the passage f bariatric stretchers is needed, drways shuld be a minimum f 52 (1,320 mm). Rm size In rder t accmmdate the larger equipment needed fr bariatric patients, the design shall prvide a minimum f 80 ft 2 (7.43 m 2 ) fr each patient bed, and fr clearance f at least 5 ft (60 r 1,520 mm) between patient beds and 4 ft (48 r 1,220 mm) at the ft f the bed. Laparscpic Adjustable Gastric Banding Standard 28

30 Tilet rms Prvide flr-munted tilets with a drp weight rating f 700 lbs (t accmmdate an impact factr f 1.4 fr a 500 lb patient) and a clearance f 5 ft (60 r 1,520 mm). Allw fr staff assistance n tw sides f the tilet r shwer. Prvide wall-munted sinks with a rating f 300 lbs (flr-munted sinks interfere with wheelchairs). Opt fr pen shwers with a flr drain t allw fr easier staff assistance and prvide wall-munted grab bars. Ensure any wall with a wall-munted fixture is re-enfrced t meet r exceed the rating. Surce: The American Institute f Architects. (2004). Planning and Design Guidelines fr Bariatric Healthcare Facilities. Fund nline at: Laparscpic Adjustable Gastric Banding Standard 29

31 Appendix E See Overnight Stay Guideline at Laparscpic Adjustable Gastric Banding Standard 30

32 Appendix F See the fllwing dcuments: Emergency Cart Medicatin and Equipment Class 1 AS-Emergency-Cart-Class-1.pdf Malignant Hyperthermia Standard Laparscpic Adjustable Gastric Banding Standard 31

33 References Allergan Inc. Allergan s training prgram and n-ging prfessinal educatin and supprt manual LAP- BAND system. Santa Barbara, CA: Allergan, p. American Cllege f Surgens, Bariatric Surgery Center Netwrk Accreditatin Prgram. Bariatric accreditatin prgram manual. Versin V [Internet]. Chicag, IL: American Cllege f Surgens; [cited 2012 Jan 17]. 39 p. Available frm: American Institute f Architects. Design guidelines fr facilities with bariatric patients. [Internet]. Washingtn, DC: American Institute f Architects; 2004 [cited 2009 Jun 19]. 2 p. Available frm: American Operating Rm Nurses. Periperative standards and recmmended practices ed. Denver, CO: American Operating Rm Nurses, AORN bariatric guideline; p American Sciety f Anesthesilgists; Task Frce n Sedatin and Analgesia by Nn-Anesthesilgists. Practice guidelines fr sedatin and analgesia by nn-anesthesilgists. Anesthesilgy 2002;96(4): American Sciety f PeriAnesthesia Nurses (ASPAN). Standards f Perianesthesia nursing standards and practice recmmendatins Cherry Hill, NJ : ASPAN; Practice recmmendatin 1, Patient classificatin/recmmended staffing guidelines; p Amsn B, Tang B. Laparscpic adjustable gastric banding in a nn-hspital surgical facility. Vancuver, BC: Amsn & Tang, p. Presentatin t: Cllege f Physicians and Surgens f BC, Nn-Hspital Medical/Surgical Facilities Cmmittee; 2009 Jan 8; Vancuver, BC. British Clumbia Ministry f Health. Best practice guidelines fr cleaning, disinfectin and sterilizatin f critical and semi-critical medical devices in BC health authrities [Internet]. Victria, BC: Ministry f Health, [cited 2012 Jan 25]. 136 p. Available frm: Canadian Anesthesilgists Sciety. Guidelines t the practice f anesthesia. Rev. ed. Can J Anesthesia [Internet] [cited 2012 Jan 17]; 59(1); p Available frm: Canadian Standards Assciatin. Canadian health care facilities [Internet]. Mississauga, ON: Canadian Standards Assciatin; 2011 [cited 2012 Mar 21]. 416 p. CSA Standard N.: Z8000. Available thrugh subscriptin frm: Canadian Standards Assciatin. Decntaminatin f reusable medical devices [Internet]. Mississauga, ON: Canadian Standards Assciatin; 2008 [cited 2009 Jun 19]. 87 p. CSA Standard N.: Z Available thrugh subscriptin frm: Laparscpic Adjustable Gastric Banding Standard 32

34 Canadian Standards Assciatin. Effective sterilizatin in health care facilities by the steam prcess [Internet]. Mississauga, ON: Canadian Standards Assciatin; 2009 [cited 2009 Jun 19]. 122 p. CSA Standard N.: Z Available thrugh subscriptin frm: Canadian Standards Assciatin. Special requirements fr heating, ventilatin, and air cnditining (HVAC) systems in health care facilities [Internet]. Mississauga, ON: Canadian Standards Assciatin; 2010 [cited 2012 Jan 17]. 70 p. CSA Standard N.: Z Available thrugh subscriptin frm: Chi J, Digirgi M, Milne L, Schrpe B, Olivera-Rivera L, Daud A, [et al]. Outcmes f laparscpic adjustable gastric banding in patients with lw bdy mass index. Surg Obes Relat Dis Jul- Aug;6(4): Cllege f Physicians and Surgens f Alberta, Nn-Hspital Surgical Facility. Applicatin fr privileges: General surgery apprved prcedures [Internet]. Edmntn, AB: Cllege f Physicians and Surgens f Alberta; 2007 [cited 2012 Mar 27]. 1 p. Available frm: Hspital/General_Surgery.sflb.ashx Cllege f Physicians and Surgens f Ontari. Independent health facilities clinical practice parameters and facility standards laparscpic gastric band surgery. 1 st ed. [Internet]. Trnt, ON: Cllege f Physicians and Surgens f Ontari; 2009 [cited 2009 Jun 19]. 67 p. Available frm: Lau DC, Duketis JD, Mrrisn KM, Hramiak IM, Sharma AM, Ur E.; Obesity Canada Clinical Practice Guidelines Expert Panel Canadian clinical practice guidelines n the management and preventin f besity in adults and children. CMAJ [Internet] Jan [cited 2009 Jun 19];176(8); Suppl: Available frm: Maples Surgical Centre. Gastric lap band surgery prgram. Winnipeg, MB: Maples Surgical Centre, p. Presentatin t: Cllege f Physicians and Surgens f BC, Nn-Hspital Medical/Surgical Facilities Cmmittee; 2009 Jan 8; Vancuver, BC. Maskarinec G, Grandinetti A, Matsuura G, Sharma S, Mau M, Hendersn BE, [et al]. Diabetes prevalence and bdy mass index differ by ethnicity: the Multiethnic Chrt. Ethn Dis Winter;19(1): Nagelhut JJ, Plaus KL. Nurse anesthesia. 4th ed. St. Luis, MO: Saunders Elsevier, Table 38-4, Pstanesthesia discharge scring system (PADS) fr determining hme readiness; p Natinal Assciatin f PeriAnesthesia Nurses f Canada (NAPAN). Standards fr practice. 1 st ed. Pembrke, ON: Pappin Cmmunicatins; p. Natinal Assciatin f PeriAnesthesia Nurses f Canada (NAPAN). Standards fr practice. 2nd ed. Oakville, ON: NAPAN; Appendix B, Aldrete discharge scring system; p Appendix C, Pst anesthetic discharge scring system (PADSS); p Appendix F, Mdified Aldrete; p Operating Rm Nurses Assciatin f Canada (ORNAC). Recmmended standards, guidelines, and psitin statements fr periperative registered nursing practice. 7 th ed. [place unknwn]: ORNAC; Laparscpic Adjustable Gastric Banding Standard 33

35 Parikh M, Duncmbe J, Fielding GA. Laparscpic adjustable gastric banding fr patients with bdy mass index f <r=35 kg/m2. Surg Obes Relat Dis Sep-Oct;2(5): Laparscpic Adjustable Gastric Banding Standard 34

36 Revisin Histry Versin N. Versin Date Summary f Change Updated Medical Directr and Facility Requirements, item 4b frm secnd qualified general surgen assisting wh is experienced in laparscpic surgery t ne physician surgical assist Dcument title change, cver page Edits t preamble and Cllege s psitin Updated medical directr and facility requirements: minimum number f prcedures in 12-mnth perid requirement deleted, revised review f surgery utcme data t cnfirm patient safety Updated patient selectin criteria inapprpriate patients: psychiatric issues, psychlgical factrs Updated patient screening and review: review f indicatins fr surgery, cntraindicatins, cmrbidities and perative risk; psychlgical screening; dietary screening Updated Quality Imprvement Prgram Edits t Manuals Updated Appendix A: STOP-Bang screening tl Updated references Edits t physical space requirements t include CSA Z8000, page 5 Edits t pints 3 and 4 under Apprpriate patients fr LABG surgery in a NHMSF, page 11 Edits t Operating Theatres and Equipment requirements, page 14 Changed Emergency Airway Management t Difficult Airway Management, page 17 Remved intrductry paragraph under Sterile Prcessing Management, page 19 Updated link t Ministry f Health dcument, page 19 Remved ASA 5 in Appendix B ASA Physical Status Classificatin System, page 25 Edits t Appendix C Mdified Aldrete Scring System, page 26 Appendix E (hyperlink), page 32 Update t Appendix F, page 33 Edits t References, pages Edits t pint 3 f screening criteria, page 12 (as directed by the NHMSFP Cmmittee) Edits t last sentence, pint 5 f screening criteria, page Initial final versin Laparscpic Adjustable Gastric Banding Standard 35