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

Disclosures No financial relationships to disclose 9/11/2018

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 103/122- 2013 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

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

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

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

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

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

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

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. 9/11/2018

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