Reduced Length of Stay by Implementation of a

Clinical Pathway for Bariatric Surgery in an

Academic Health Care Center
SERGIO HUERTA, M.D., DAVID HEBER, M.D., PH.D., MARK P. SAWICKI, M.D., CARSON D. LIU, M.D.,
DENICE ARTHUR, R.N., M.H.A., PAM ALEXANDER, R.N., IAN YIP, M.D., ZHAO-PING LI, M.D., PH.D.,
E.H. LIVINGSTON, M.D.

From the Department of Surgery, VA Greater Los Angeles Health Care System and the UCLA Center for
Human Nutrition, Los Angeles, California

Bariatric surgery is being performed in increasing numbers in an era when reimbursements are
being reduced. Academic health centers bear the responsibility for training surgeons to perform
these operations yet must keep costs to a minimum and retain high quality. The UCLA Bariatric
Surgery Program developed a clinical pathway for the pre- and postoperative management for
gastric bypass patients to achieve these goals. Medical records for 182 consecutive gastric bypass
patients were retrospectively reviewed before implementation of the pathway (Group I) during
the fiscal year of 1998/1999. Data on average length of stay, average intensive care unit length of
stay, average standard variable cost, percentage readmission rate, and percentage return to the
operating room were collected. This information was compared with the data collected prospec-
tively from 182 patients after implementation of the pathway in July of 1999 (Group II) during the
fiscal year of 1999/2000. Hospital cost per admission was reduced by 40 per cent in Group II
compared with Group I (P < 0.02). The average length of stay was reduced from 4.05 days in Group
I to 3.17 days in Group II (P < 0.033). Overall readmission rate was decreased from 4.2 per cent in
Group I to 3.2 per cent in Group II (P < 0.05). There were no differences in morbidities between
both groups. The pathway reduced costs by reducing the hospital length of stay, intensive care
unit utilization, and readmission rates. Quality was maintained as evidenced by a similar pattern
of postoperative morbidities yet readmission rates were reduced. Our results indicate that imple-
mentation of a clinical pathway for bariatric surgery reduces cost and improves quality of care in
an academic institution.

obesity is rapidly increasing in the
T HE INCIDENCE OF
United States. Current estimates indicate that
1
about 58 million Americans are obese. Obesity re-
sults in a variety of medical complications such as
hypertension, osteoarthritis, sleep apnea, diabetes, and
hypercholesterolemia resulting in markedly reduced
life expectancy.2, 3 The costs for treating these medical
complications resulting from obesity are enormous.4–7
Nonsurgical treatments are in a majority of cases un-
able to help patients maintain a significantly reduced
body weight for a long-term period.8 Thus far surgery
Presented at the Annual Meeting of the Southern California
Chapter of the American College of Surgeons, January 19–21,
2001, Santa Barbara, California.
Address correspondence and reprint requests to Edward H. Liv-
ingston, M.D., Chief, Department of Surgery (10H2), VA Greater
Los Angeles Health Care System, 11301 Wilshire Boulevard, Los
Angeles, CA 90073.
is the only modality resulting in sustained weight loss
for clinically severely obese individuals [body mass
index (BMI) ⱖ40]. The BMI is calculated by dividing
the weight in kilograms by the square of the height in
meters. Surgery results in amelioration or cure of co-
morbidities associated with obesity.9–12 In 1991 the
National Institutes of Health convened a consensus
development conference to establish criteria for selec-
tion of patients for surgical treatment of clinically se-
vere obesity. The panel provided guidelines for selec-
tion of patients for surgical treatment. The criteria
include a BMI greater than 40 kg/m2 or BMI greater
than 35 kg/m2 accompanied by obesity-related comor-
bid conditions.9 In evaluating the currently available
obesity surgery literature the panel concluded that the
two operations advisable for the treatment of morbid
obesity were the vertical-banded gastroplasty (VBG)
and the Roux-en-Y gastric bypass (RYGB). This rec-
ommendation resulted in greater acceptance of bariat-
ric operations. Accordingly there has been a substan-

1128
No. 12 CLINICAL PATHWAY FOR BARIATRIC SURGERY
tial increase in the number of obesity operations
performed since 1991.
With an increased demand in the community for
bariatric operations academic institutions are faced
with a greater responsibility for training surgical resi-
dents to perform these procedures. The UCLA bariat-
ric surgery program was established in 1993. Parallel
to the rise in obesity surgery in the community we
observed an increased surgery volume at our academic
medical center. Because of their size and comorbid
medical conditions obese patients pose a higher op-
erative risk than nonobese individuals. Additionally
the referrals to academic medical centers tend to be the
higher-risk patients. Thus we were faced with a high-
risk population in a teaching environment. Parallel to
the increased case volume was a significantly in-
creased market penetration of managed care in our
region resulting in pressures to minimize cost. We
developed a clinical pathway to standardize patient
management in this high-volume academic setting
with the intent of minimizing cost without compro-
mising quality.
In this paper we present a detailed description of the
UCLA bariatric surgery clinical pathway and examine
the effect on hospital cost and patient length of stay
(LOS) after its implementation.
Methods
The UCLA bariatric surgery database consists of
more than 1000 patients who have undergone RYGB
between 1993 and 2000. Of these the medical charts of
364 patients contained complete information regarding
hospital charges, LOS, outcomes, and readmission
rate. All complete charts were analyzed in our data-
base regarding all of these variables. The bariatric sur-
gery clinical pathway was implemented in July of
1999. The clinical pathway delineates pre-, intra-, and
postoperative care as well as patient outcomes. Expec-
tations regarding preoperative visits, preoperative
tests, admission orders, postoperative care, and ex-
pected date of discharge are outlined for each preop-
erative and postoperative day respectively.
To assess the efficacy of our clinical pathway the
medical records of 182 patients were reviewed before
implementation of the pathway (Group I) during the
fiscal year 1998/1999. This baseline information was
compared with the data collected prospectively from
182 patients after implementation of the pathway
(Group II) during the first three quarters of fiscal year
1999/2000.
All RYGB operations were performed by one of
three bariatric surgeons who specialize in this type of
operation with senior residents as first assistants. Data
on average LOS, average intensive care unit (ICU)
⭈ Huerta et al. 1129
LOS, average standard variable direct cost, percentage
readmission rate (defined as readmission within 30
days after surgery), and percentage return to the oper-
ating room were collected. The average standard vari-
able direct cost is defined as the average cost for hos-
pital utilization for a given day in the hospital or ICU
and cost per procedure in the operating room indexed
to the operation’s complexity. Comparisons were
made regarding all of the variables analyzed between
Groups I and II.
LOS was defined as discharge day minus admit day
(discharge day is not counted), except in a one-day
stay, in which case LOS is equal to one. Average
length of ICU stay was the actual number of days
spent in the ICU. Total hospital cost was obtained
from the UCLA Medical Center’s performance im-
provement database. Morbidity was defined as any
complication that prolonged hospital stay or affected
outcome. The percentage difference in morbidity was
compared between Groups I and II by Chi-squared
analysis.
Data were analyzed with the SPSS statistical pro-
gram (SPSS Inc., Chicago, IL). Differences in length
of hospital stay, hospital cost, and morbidities and
mortalities were assessed by the Student’s t test and
readmission rate was assessed by Chi-squared analy-
sis. All data are expressed as percentage or mean. Sta-
tistical significance was considered when P < 0.05.
UCLA Gastric Bypass Pathway (Fig. 1)
Preoperative Assessment
Patients were seen and evaluated by both the sur-
geon and a nutritional internist to assess their candi-
dacy for surgical intervention. All patients underwent
a full physical examination and body composition
evaluation by bioelectric impedance analysis. Patients
were informed of the risks of surgery, the possible
postoperative complications, the estimated LOS in the
hospital, the diet they would require, and the vitamin
requirements after surgery. Surgical candidates were
selected on the basis of the National Institutes of
Health guidelines.9 Briefly our criteria are that patients
must have a BMI ⱖ40 kg/m2 or ⱖ35 kg/m2 with co-
morbid conditions, and they must have attempted to
lose weight with several other modalities including
diet, exercise, and pharmacotherapy with which they
have been unsuccessful maintaining weight loss.
If deemed appropriate candidates patients were
scheduled for surgery and seen by the anesthesiologist
at least one month before the operation. All patients
received an at-home bowel preparation and were ad-
mitted the day of surgery. No special tests were re-
quired unless patients were super-obese (over 400
 1130
THE AMERICAN SURGEON
December 2001

FIG. 1. The UCLA clinical pathway. The clinical pathway delineates pre- and postoperative care. Expectations regarding preoperative visits, preoperative tests,
admission orders, postoperative care and expected date of discharge are outlined for each preoperative and postoperative day respectively. Preprinted orders are
designed for the preoperative and postoperative periods to facilitate and standardize patient management.
Vol. 67
No. 12 CLINICAL PATHWAY FOR BARIATRIC SURGERY ⭈ Huerta et al. 1131

pounds or BMI ⱖ50), in which case they required an
echocardiogram. Echocardiogram was also indicated
in patients with clinical signs of heart failure or sleep
apnea. Patients with pulmonary disease underwent
pulmonary clearance before surgery. If a patient was
suspected of having pulmonary hypertension he or she
was admitted the day before surgery for placement of
a pulmonary artery catheter.
Intraoperative Management
We performed standard RYGB at UCLA as several
studies have shown RYGB to be superior to
VBG.13–15 Briefly this procedure was performed by
firing an ETHICON (Somerville, NJ) TA-60 heavy
wire stapler horizontally across the stomach creating a
30-cm3 proximal gastric pouch. The jejunum is di-
vided 30 cm distal to the ligament of Treitz and the
first arcade of mesenteric vessels divided with a vas-
cular gastrointestinal anastomosis stapler. The distal
cut end of the jejunum was then tunneled through the
transverse mesocolon to lie anterior to the stomach. It
was anastomosed to the pouch side-to-side with a
single layer of 3-0 Maxon™ suture over a 32-F bougie
catheter, which created a one-centimeter anastomosis.
The procedure was completed by performing a side-
to-side jejunojejunostomy 40 cm distal to the gastro-
jejunostomy. The abdomen was closed with either in-
terrupted no. 1 Maxon™ or a running no. 0 looped
Maxon™ suture. The skin was closed with 4-0
Monocryl™ in a subcuticular running fashion.
Postoperative Management
Postoperative nasogastric decompression was not
used in our patient population. We divide the postop-
erative diet into stages (from I to VI) as described
below (Table 1 and Fig. 2). Sleep apnea patients were
placed on a bi-level positive airway pressure (BI-PAP)
machine immediately postoperatively. Most patients
were discharged within 3 days of the operation. While
in house they were followed by both the surgical and
nutritional teams. They received clear instructions re-
garding their diet before discharge. They were seen by
a surgeon and a nutritionist 2 weeks postoperatively
and thereafter at least five more times by the nutri-
tional internist who guided the diet and assessed pro-
tein and vitamin deficiencies. All patients were placed
on multivitamin supplements, calcium, and vitamin
B12 injections throughout life. They were also encour-
aged to engage in routine exercise.
There was a bimonthly support meeting in which
internists, nutritionists, surgeons, psychiatrists, and
nurses were available to answer the questions and con-
cerns of all patients. There was also an on-line support
group for UCLA patients.

TABLE 1. Postoperative Diet Divided into Stages from I to VI; Postoperative Day and Food Examples Are Given
Postoperative
Stage Period Food Examples
Stage I POD 1 Small amounts of water
Stage II Four hours after Less than 3 oz of fluid per hour
water is tolerated • Diluted clear juices (½ juice, ½ water)—apple, grape, or cranberry juices
• Broth—vegetable, chicken broth
• Decarbonated (“flat”) diet soda
• Sugar-Free Jell-O
Stage III At home (after Up to 8 oz of fluid per hour has tolerated
discharge through • Stage II diet plus:
week 2 postsurgery) • Meal replacements as tolerated*
Stage IV Weeks 3–5 Stage III plus:
Sugar-free Popsicles (less than 25 calories)
Tomato or V8 Juice
Crystal Light™ or other sugar free, noncarbonated beverage
Sugar-free cocoa
Decarbonated (“flat”) diet soda
Bouillon or broth
Diluted unsweetened fruit juices
Stage V Weeks 6 and 7 Stage IV diet plus soft or pureed high protein foods and fluids
Meet protein requirements about 0.8 to 1.0 g of protein per
kilogram of body weight per day
Flinstones chewable multivitamins and Tums
Stage VI Week 8 Stage VI diet plus small portions of food low in fat
throughout life and carbohydrate content
Patients are encouraged to develop a list of those food
that they can eat and those that they are unable to tolerate
Patients continue to take multivitamin supplements,
calcium and vitamin B12
POD, postoperative day.
1132 THE AMERICAN SURGEON
FIG. 2. Sample of a 1200-kcal typical Stage VI postoperative diet.
Results
Length of Stay
Before implementation of the pathway the average
LOS in Group I was 4.05 days for the first three quar-
ters of the fiscal year 1998/1999. After implementa-
tion of the pathway the length of stay for Group II was
reduced to 3.17 days for the first three quarters of
the fiscal year 1999/2000. The LOS is presented in
Fig. 3. Implementation of the pathway resulted in a
decrease in LOS by one day between Groups I and II
in all three quarters of fiscal year 1999/2000 compared
with the first three quarters of the fiscal year 1998/
2000 (P < 0.033). ICU LOS was also significantly
reduced from 0.37 days in Group I to 0.07 in Group II
(P < 0.04) (Fig. 4).
Hospital Cost
The hospital cost per admission was reduced by 40
per cent in Group II compared with Group I (P < 0.02).
December 2001 Vol. 67
Readmissions
The readmission rate is presented in Fig. 5. Overall
readmission rate was decreased from 4.2 per cent in
Group I to 3.2 per cent in Group II (P < 0.05).
Morbidities
Overall morbidities were assessed and reported in
terms of percentage. There were no differences in
morbidity between Groups I and II. The overall mor-
bidity rate for group I was 25 per cent and for Group
II 24.8 per cent (Fig. 6). Most morbidities in both
groups were in the minor to moderate category ranging
from inability to tolerate oral intake by the expected
time of discharge to wound infection requiring antibi-
otic administration. Major complications occurred
more often in Group I compared with group II. There
were more ICU admissions resulting from sepsis or
anastomotic leaks in Group I.
No. 12 CLINICAL PATHWAY FOR BARIATRIC SURGERY
FIG. 3. Average LOS in days for the prepathway period
(Group I) and the postpathway period (Group II) is depicted for the
fiscal year 1998/1999.
FIG. 4. Average percentage ICU LOS is shown. There was a
significant decrease between prepathway (Group I) and postpath-
way.
Discussion
With the advent of managed care academic institu-
tions face the overwhelming demands of minimizing
hospital cost while upholding a mission with high
commitment to excellent medical care and teaching. It
is difficult to establish a balance between these goals.
Thus clinical pathways are currently emerging as a
powerful technique to accomplish this seemingly im-
possible task.
Simultaneous to the establishment of the bariatric
program at UCLA there was a major shift in the spec-
trum of health-insurance coverage in the greater Los
Angeles area. When the program was established ap-
proximately 40 per cent of patients presented with
managed care plans. Currently 95 per cent of patients
have managed care insurance at our medical center.
These changes culminated in significantly decreased
reimbursements compelling a need to control hospital
costs for surgical patients.
⭈ Huerta et al. 1133
FIG. 5. Readmission rate is depicted for Groups I and II.
FIG. 6. Morbidity rates between Groups I and II.
Our center had to minimize cost while maintaining
our academic mission. In our bariatric program as in
any academic medical center surgical residents play a
major role in patient management. Although super-
vised they often make decisions regarding administra-
tion of medicines, admission to the ICU, studies need-
ing to be ordered, and patient discharge from the
hospital. Often the least experienced members are the
ones who write orders for surgical patients. Conse-
quently their approach to management might differ
from that of more experienced faculty members. Per-
haps the most challenging aspect of the academic in-
stitution is the frequent rotation of residents and fel-
lows caring for patients resulting in significant
variability in the delivery of care compared with that
in a community hospital. These factors contribute to
high patient care costs in academic medical centers
relative to the community.16, 17 These costs emanate in
part from the inexperience of trainees in the manage-
ment of patients.18–20 Although physician autonomy
and the effect on teaching are of major concern to an
academic institution, if a hospital is not efficient suf-
1134 THE AMERICAN SURGEON
TABLE 2. Pathways Developed by the Southwestern
Surgical Congress and Southeastern Surgical Congress
in 199521
1. Uncomplicated appendectomy
2. Complicated appendectomy
(ruptured appendectomy)
3. Laparoscopic chlolecystectomy
4. Open cholecystectomy
5. Inguinal hernia
6. Ventral hernia
7. Colectomy for diverticulitis
8. Colectomy for cancer
9. Breast biopsy
10. Modified radical mastectomy
11. Thyroidectomy
ficient funds may not be available for research, teach-
ing students, and training residents.21 Thus autonomy
must be well balanced with delivering quality care and
controlling costs.
One approach to achieving this balance is the de-
velopment of clinical pathways. Clinical pathways are
particularly valuable in large teaching hospitals where
the residents and fellows assist in patient care.22 Clini-
cal pathways were created to standardize patient care
and improve quality while reducing cost. They dictate
what will occur as a patient progresses through the
pre- and postoperative processes.
To meet the rigorous financial constraints and to
maintain our commitment to education the UCLA bar-
iatric surgery program established a clinical pathway
in July 1999. The pathway was developed by a com-
mittee of nurses, attending surgeons, internists, inten-
sive care physicians, nutritionists, quality assurance
specialists, and administrators to develop a uniformly
agreed-upon approach to managing bariatric patients.
During the postoperative period standard preprinted
orders were generated to facilitate patient manage-
ment. Although residents may lose some autonomy in
managing bariatric patients they benefit from observ-
ing how the most experienced members of the team
approach problems. This in itself is a valuable learning
exercise. There is the added benefit that resident work-
load is reduced in an era in which resident working
hours are carefully regulated. The mundane task of
writing postoperative orders is greatly facilitated by
standardized orders. The use of standardized orders
also reduces the risk of errors in patient management.
In 1995 the Southwestern Surgical Congress and
Southeastern Surgical Congress developed 11 path-
ways for the most common surgical interventions per-
formed by general surgeons (Table 2).21 These path-
ways were evaluated and found to reduce significant
cost and deliver high-quality care. The high efficacy of
clinical pathways was quickly recognized. The treat-
ment of congestive heart failure is an early example
demonstrating the efficacy of a clinical pathway in
December 2001 Vol. 67
significant reduction in cost while improving patient
management.23 As a result many organizations devel-
oped a number of guidelines for the delivery of care.
These were termed: practice standards, practice pa-
rameters, practice policies, protocols, algorithms, criti-
cal pathways, and clinical pathways.21 However, a
clinical pathway must be distinguished from other
similar terms such as practice guidelines. A clinical
pathway involves all medical personnel involved in
the care of a patient from the preoperative interview to
the follow-up. Practice guidelines are diagnostic and
treatment guides such as algorithms developed by ex-
perts in specific fields.21
In our institution we have developed a clinical path-
way for gastric bypass in the treatment of morbid obe-
sity. Our pathway delineates pre-, intra-, and postop-
erative care. In the analysis presented in this paper we
show that standardization of preoperative and postop-
erative patient management results in reduced cost and
better patient management in an academic institution.
An important element in the success of our bariatric
surgery pathway stems from the multidisciplinary ap-
proach involving the surgeon, internist, critical care
physician, and nutritionist to meet the needs of our
patient population. The follow-up is closely monitored
by the internists in clinic and by phone. They maintain
close communication with the surgeon. In this way
patient satisfaction has increased significantly as pa-
tients have clear guidance in their diets postopera-
tively. In addition the development of support groups
has resulted in patient communication and satisfaction.
In our academic medical center surgical residents
benefit from the rotation in our program in several
ways. Although the clinical pathway mandates certain
decisions regarding postoperative care the residents
learn because the pathway pursues a care pattern they
might not have tried. In addition having a standardized
pathway allows for more time spent in the operating
room learning the technical aspects of the operation.
By developing a clinical pathway the UCLA bariatric
surgery program has been able to contain cost while
maintaining high quality of care and commitment to
the training of surgical residents.
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