1. Patient Safety Improvement Red Bag Program
Thank you
Nancy M. Strange, RDN, CNSC, CD
Clinical Nutrition Specialist
University Hospital
Indianapolis, IN
9/11/2018

2. Disclosures
No financial relationships to disclose
9/11/2018

3. Perioperative Wellness Enhanced Rapid Recovery POWERR – aka the Red Bag Program
Challenge
Relationship
Vision(s)
The/Our challenge:
Wake up call: Overage of 86,000 surgical LOS days with new Medicare payment changes looming
85% of UH patients are federally funded insurance or no insurance
Readmissions > national standards/average
University Hospital PSI National ranking 103/
We knew we needed to do better. WE NEEDED AN EASY BUTTON!!!
What was my goal for the surgery clinic? (wound healing expertise, chasing post op wounds, I knew we could do better, just had to get to them before surgery. I did not understand the bigger needs at that time.
Evidenced based literature said we could do better –
MD View: ERAS –– involves expensive equipment/culture change/slower to implement in a complex med center: Daunting
RDN View– Nutrition screening – NEEDED TO IDENTIFY HIGH RISK PATIENTS (>30%)/immunonutrition – reduction in infections and LOS with immunonutrition 40% to 60% reductions
Relationship and vision challenge --- how we bridged
Vision – takes a village – our village needed to come to a more unified vision
9/11/2018

4. Perioperative Wellness Enhanced Rapid Recovery POWERR – aka Red Bag Program
Engagement
Logistics
Vision(s)
Engagement – started in one outpatient general surgery clinic
Grassroots program initiation with immunonutrition – perioperative Medical Director driving the vision
LOGISTICS:
Pre-admission testing clinics developing as a pre-operative medical clearance and education process for patients
Implementation of nutrition Screening in the outpatient surgery clinic.
Had to make the components of the red bag available – before the red bag existed
Patient had to be able to purchase the immunonutrition
– staff would purchase for the patients who could not afford.
As results were demonstrated:
9/11/2018

5. Red Bag Program - Tool Kit
Initial results
Decreased LOS
Decreased appointment load on surgery clinics
Wound healing rates significantly increased
More MDs were asking for the immunonutrition and the preop package
Vision of a “Red Bag” began to develop
Real results or placebo?
Participating surgeons were seeing excellent results.
Reduction in treating post op wounds began to happen
More staff time spent on preop education
MD comment: I have never had someone heal this well and “it is not so much what I see, it is more what I don’t see – prolonged intubations, wound infections, readmissions.”.
RDN comment: WOW
9/11/2018

6. Perioperative Wellness Enhanced Rapid Recovery POWERR – aka Red Bag Program
Engagement
Logistics
Vision(s)
Engagement – Engaged intraoperative and post operative staff to implement process with a goal of ERAS/immunonutrition utilization.
Needed to engage executive level staff to support EMR and staff support
Logistics: Multi-disciplinary committee at AHC to begin to develop a single vision/culture change in how to care for surgical patients and begin ERAS program development
9/11/2018

7. Perioperative Wellness Enhanced Rapid Recovery POWERR – aka Red Bag Program
Engagement
Education
Culture change
Vision Excitement
Engagement – Executive team decided to fully fund the program for an initial 18 months for all surgery patients * those being admitted to the hospital after surgery. MDs had to remember to order the process before. Now the standard of care was this process and the MD had to order to NOT have it.
Education process began intensively – MDs, RNs, RDNs, Management/CNS,
Patient education process ramped up.
Visions were now becoming more united – Multidisciplinary team working together. Excitement level
The vision of the new culture change took hold.
Staff coming up with ways for providing patient care more efficiently within the process.
Lot of boots on the ground people engaged in the program.
9/11/2018

8. Our Current State Wellness Program
Kit includes:
5 day supply of immunonutrition supplements
2 doses of CHG Pre-operative Bathing Solution
1 Tube of Antibiotic Ointment
Education materials

9. EASY BUTTON: Red Bag Tool Kit
Why nutrition screening and Immunonutrition?
Increased Complications and LOS
Identification of high risk nutrition patients: Significant increased rate of infections/los/wound issues that can be decreased with preoperative nutrition interventions; Rate of malnutrition: 30-55%; Complications have been shown to drop by 50%
Identification of malnutrition and MD diagnosis of malnutrition – significantly increases reimbursement from Medicare, along with increasing severity ranking.
Specialized drink with specialized proteins/fat to support immune system/wound healing and increase blood flow to the tissues
90 published studies that show decreased infection rates and LOS
Easy button for implementation. Can get good results quickly while the rest of the ERAS program is implemented.
End program should include immunonutrition, even with a full ERAS implementation.
Patient satisfier. This is their sacred ground and something they feel like they can control.
9/11/2018

10. Our Easy Button Results
With 60-65% compliance rate and 50-60% implementation:
Decreased LOS – excess patient days down by 91%
PSI national ranking: 4/134
Decreased infection rates
Wound vac use decreased
Return to the OR events decreased
Patient satisfaction scores improving
Staff engagement in the program remains strong
The ERAS program is progressing to full implementation
Discharge planning team needed to restructure work flow – patient’s medically ready for discharge 2 days earlier than usual. Long term plan:
SSI infection rates dropped by 57% - this is enough to pay for the entire cost of the red bag program for 2 years.
All other infections also showed significant drops in rates
Unintended Costs: will decrease – including excessive use of ATB.
Excess patient days down by 91%
Expect further improvements in the numbers as the program matures
Going state wide
Staff engagement remains very high .
We offer the immunonutrition for the staff to purchase for family members not having surgery at IU Health.
Malnutrition diagnosis parallel initiative is also resulting in increased reimbursement rates.
VA and Eskanasi are implementing the same program Red Bag to ERAS to better outcomes.
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