Pediatric & Adolescent Bariatric Center of Excellence
In partnership with key opinion leaders and industry professionals, SRC developed the Center of Excellence in Pediatric and Adolescent Bariatric Surgery (PACE) program. The PACE program identifies surgeons, facilities and patient care teams that provide excellent pediatric and adolescent bariatric surgical care and are dedicated to continuously improving healthcare quality and patient safety to their specific patient population.
The PACE program addresses issues facing the specialty, including:
- Ensuring the entire patient care team is involved in addressing the needs of pediatric and adolescent bariatric surgery patients
- Difficulty in identifying excellence for patients and referring physicians
- The need to control care provider costs and outcomes (including reimbursement and malpractice rates)
- Use of outdated procedures
- The need to establish universal standards to measure program performance
- Lack of a central outcomes database
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1. Institutional Commitment to Excellence
The applicant demonstrates a commitment to excellence in the care and management of overweight, obese and morbidly obese pediatric and adolescent surgical patients and their families “PACE Patients”.
The applicant is committed to providing PACE Patients with a medically-supervised weight loss management program that includes or is capable of supporting bariatric surgery as an intensive treatment option.
This commitment includes credentialing and privileging guidelines for bariatric surgery that are separate from general surgery guidelines.
2. Surgical Experience
Each applicant surgeon has performed at least 125 qualifying bariatric surgery procedures in his or her lifetime, with at least 100 cases performed in the preceding 12 months.
Each applicant facility and surgeon meets surgical outcomes benchmarks for mortalities, complications, readmissions and reoperations.
The following procedures, whether open or laparoscopic, are the only primary procedures that qualify:
- Gastric bypass: short- or long-limbed, transected or not transected, banded or not banded
- Gastric banding: includes procedures in which the Allergan LAP-BAND® is used in patients with Class I obesity (BMI of 30-35) and at least one comorbidity
- Duodenal switch
- Biliopancreatic diversion
- Sleeve gastrectomy
The following procedures, whether open or laparoscopic, also qualify when performed on bariatric surgery patients:
- Conversion to a primary procedure listed above
- Removal of a slipped or eroded gastric band
- Replacement of a slipped or eroded gastric band
- Gastric band repositioning
- Gastrojejunostomy repair/revision
- Enteroenterostomy repair/revision
- Altering the length of the common channel
- Altering the length of the Roux limb
- Gastric pouch revision
- Reversal of gastric bypass, vertical banded gastroplasty, intestinal bypass, biliopancreatic diversion and duodenal switch procedures
- Re-sleeving for weight gain or sleeve dilation
- Removal of a Fobi/Capella band
- Revision or repair of a perforated marginal gastrojejunalulcer
Procedures that do not qualify include:
- Gastric band port revisions, including port/tubing removal, replacement and repositioning
- Removal of a gastric band for reasons other than slippage or erosion
- Gastric stoma plication
- Repairs of inguinal, incisional, hiatal, umbilical and port-site hernias: colonic mesentery: Petersen’s hernias; and hernias forming around an adhesion
- Therapeutic endoscopic procedures used to dilate the esophagus
- Diagnostic procedures
Applicant facilities and surgeons are required to meet the following outcomes benchmarks, which were established using the BOLDTM outcomes database and validated through a review of the metrics used in payer-based quality programs:
- Overall mortality for all bariatric surgery procedures performed at the applicant facility: ≤2% at 90 days
- Overall mortality for all bariatric surgery procedures performed by each applicant surgeon:
- Mortality for the primary procedure performed at the facility (based on volume):
- Gastric bypass: <6% at 90 days
- Sleeve gastrectomy: <4% at 90 days
- Gastric banding: <2% at 90 days
- Mortality for the primary procedure performed by each applicant surgeon (based on volume):
- Gastric bypass: <6% at 90 days
- Sleeve gastrectomy: <4% at 90 days
- Gastric banding: <2% at 90 days
- Complications: < 10% at 90 days
- Readmissions: < 8% at 90 days
If a facility or surgeon does not meet one or more of the required outcomes benchmarks, they may be eligible for a conditional one-year designation approval.
3. Program Directors and Interdisciplinary Team
The applicant maintains two program Co-Directors for the program, a Pediatrician Medical Director and a Surgical Director, that both have program oversight. At least one of the directors must have significant expertise in the care of PACE Patients and at least one must participate in the relevant decision-making administrative meetings of the facility. The Co-Directors must have been officially appointed through the facility’s standard administrative process. The Surgical Director must be designated, or in the process of becoming designated, as a Center and/or Surgeon of Excellence in Metabolic and Bariatric Surgery.
The Pediatrician Medical Director must spend a significant portion of their efforts in caring for overweight, obese and morbidly obese pediatric and adolescent patients and their families. They should be a Board Certified Pediatrician with documented experience with medically-assisted weight loss programs.
The Co-Directors hold interdisciplinary team meetings at least quarterly to ensure that decisions related to bariatric surgery are addressed in a comprehensive manner. The Directors should be primarily responsible for coordinating the interdisciplinary services and care of PACE Patients.
4. Consultative Services
The applicant facility includes a full complement of the various consultative services required for the care of overweight, obese and morbidly obese pediatric or adolescent surgical patients including the immediate availability of critical care services in addition to an age-appropriate intensive care unit.
- During surgery and until discharge from the post-anesthesia care unit (PACU)
- Anesthesiologist or Certified Registered Nurse Anesthetist (CRNA) who supervises anesthesia delivery on all bariatric surgery patients and is physically present until the patient is discharged from the Following PACU discharge, the anesthesiologist or CRNA is available on-site within 30 minutes if needed.
- On-site at all times when patients are present
- Physician certified in Advanced Cardiovascular Life Support (ACLS) or equivalent, or an acute response team, at least one of which is ACLS-certified, available on-site at all times when patients are present, with an established protocol to follow in the event of a sudden respiratory or cardiac
- On-site within 30 minutes of request
- Physician capable of performing endoscopies to diagnose complications
- Interventional radiologist or other physician capable of performing inferior vena cava filter placement and percutaneous drainage of intra-abdominal abscess
- Physician with critical care credentials to manage complications (critical care physician/intensivist, hospitalist, cardiologist or pulmonologist)
The facility is also able to identify the following consultative staff:
- Psychiatrist/mental health provider
- Infectious disease specialist
- Nursing program manager
5. Equipment and Instruments
The applicant has a full line of equipment and surgical instruments to provide appropriate perioperative care for PACE Patients, including operating room tables, radiologic capabilities, surgical instruments, beds, floor-mounted or floor-supported toilets, furniture, wheelchairs, blood pressure cuffs and examination gowns. Personnel are trained in the safe operation of this equipment and capable of moving patients without injury to the patient or themselves.
6. Surgeon Dedication and Qualified Call Coverage
The applicant surgeon spends a significant portion of his or her efforts in the field of bariatric surgery and completes continuing medical education. The applicant surgeon is board-certified or an active candidate for board certification as a general surgeon by the highest certifying authority available. The applicant surgeon has privileges as both a bariatric and general surgeon at the applicant facility.
The Pediatrician Program Director must have qualified coverage and support in caring for overweight, obese or morbidly obese pediatric and adolescent patients.
The applicant facility has policies in place that require all bariatric surgeons to have qualified call coverage, and the applicant surgeon certifies that each covering surgeon is capable of identifying and treating bariatric surgery complications. Each covering surgeon is board-certified or an active candidate for board certification as a general surgeon by the highest certifying authority available.
All covering surgeons must be available on-site within 30 minutes.
Applicant and covering surgeons who are not board-certified or an active candidate may be eligible for a board certification waiver based on experience, demonstration of good standing, licensing and fellowship.
7. Clinical Pathways and Standardized Operating Procedures
The applicant formally adopts and implements clinical pathways that facilitate the standardization of weight management program admission, appropriate plans of care and perioperative care for the relevant procedure:
- Anesthesia, including monitoring and airway management
- Perioperative care, including monitoring and airway management
- Deep vein thrombosis (DVT) prevention
- Identification and evaluation of early warning signs of complications
- Preoperative multidisciplinary evaluation, education, preparation, admission workup/evaluation and informed consent of the bariatric surgery candidate and family
- Preoperative, postoperative and long-term nutrition regimen
- Pain management
The first three pathways will be deemed satisfied if the facility has accreditation from The Joint Commission (formerly known as JCAHO).
The applicant surgeon performs each bariatric surgery procedure in a standardized manner as allowed by variations in operative circumstances.
8. Weight Management, Surgical and Support Staff
The applicant has nurses and/or physician extenders who provide education and care to PACE Patients as well as a bariatric program coordinator who supervise program development, patient and staff education, interdisciplinary team meetings, and ongoing program compliance.
The applicant maintains an interdisciplinary Pediatric and Adolescent Bariatric Committee. This committee will have regular discussions and review each patient in the program. Surgical candidates will be given special consideration in consultation with appropriate surgical staff. At a minimum, programs should document the regular involvement of the program’s Pediatric Medical Director, Surgical Director, bariatric surgeon, physician extender, program coordinator, psychiatrist/psychologist, physical activity specialist and registered dietician. This team should also be in regular contact with the patient’s own pediatrician or primary care physician, if the patient has one, beyond the scope of the PACE program.
9. Patient Support Groups
The applicant provides organized and supervised support groups for all patients and their families who may undergo or have undergone bariatric surgery.
10. Long-Term Patient Follow-Up and Outcomes Data
Applicant must collect prospective outcomes data on all patients who undergo a qualifying surgical procedure in SRC’s Database (or a similar qualifying database) in a manner consistent with applicable patient privacy and confidentiality regulations. This de-identified data must be available to SRC for initial and renewal site inspections or upon request.
Facility Application Fee: $3,975 USD
Surgeon Application Fee: $650 USD
Initial Site Inspection: $1,850 USD
- Application fees must be paid prior to application submission. Provisional status is granted after applications are submitted.
- Site Inspection fee covers a one-day inspection with one site inspector. If the inspection requires more than one day and/or more than one inspector, additional charges will be incurred.
- For site inspections outside of the United States, surcharges will apply for airfare and other travel expenses.
- The applicant facility is responsible for arranging and paying for the site inspector’s hotel, ground transportation and, if needed, an interpreter/translator. These items are not included in the standard site inspection fee.
Facility Annual Fee: $3,975 USD
Surgeon Annual Fee: $650 USD
Renewal Site Inspection: $1,850 USD (every three years)
- Annual participation fees are billed one year after applicants achieve provisional status and each year thereafter.
- Renewal inspections will occur every three years after the initial site inspection.
Fees are subject to change without notice and are not refundable. Payment of required fees does not guarantee that you will achieve designation.