Indiana University (IU) Health is reducing hospital stays by providing patients with a bag of items before surgery that help them “tune up” their health and position them better to ward off hospital-acquired infections (HAIs).
The pre-op wellness kits address a perennial challenge when providing high-quality healthcare, says William Wooden, MD, FACS, the James E. Bennett professor of plastic surgery and director of hospital operative services at IU Health. By improving the preoperative health of a patient, hospitals can shorten length of stay (LOS) and lower the rate of HAIs, which in turn refines outcomes and lowers costs, he says.
“We have discovered that prerehabilitation, especially when you’re coming for specialty care, can make a dramatic amount of difference. We recognize the power and importance of population health and preventive care with primary care physicians. But when someone becomes ill and needs surgery, we have to dig deeper into that patient’s healthcare status and identify things that have been unidentified,” Wooden says. “Now that the patient has the stress of surgery coming up, what are the things we can do to improve their outcome? We normally think of rehabilitation after the fact, but we thought there was an opportunity to address these problems before the surgical intervention.”
Wooden and colleagues studied the common risk factors affecting a patient’s outcome throughout a hospital stay. They identified about 75% of patients coming to IU Health arrived with three or more risk factors for a complication during hospitalization. Historically, clinical teams would try to ensure patients were taking their medications before surgery but did not do much proactively to optimize the patient’s condition before surgery, Wooden says.
“We recognized that if we actively worked to improve their pulmonary function and their physical function, actively worked to get them off tobacco, actively worked to improve their nutrition and hydration, we could drive outcomes and reduce complications,” Wooden explains. “We linked it closely to our pre-anesthetic testing center where patients go to get an ECG and lab work before surgery.”
IU Health developed a program that identifies a patient’s individual risk factors and ways to optimize the patient’s health before surgery — in days, not weeks or months. That led to the creation of the Pre-Operative Wellness, Enhanced Rapid Recovery (POWERR) program, known as the Red Bag program, in 2015.
Patients at the pre-anesthetic testing center received a red roller bag that includes a five-day supply of an immunonutrition drink with vitamins and nutrients that can bolster the immune system and improve healing. The kit includes two doses of a preoperative bathing solution, soap that can help prevent MRSA and other infections, topical mupirocin for the nostrils, an incentive spirometer to help strengthen the lungs, educational materials about smoking cessation, and an instruction sheet on how to use the contents of the bag.
Improved Nutrition Before Surgery
The IU Health team explains to patients that using the items in the bag can significantly reduce infections and other complications from surgery. The Red Bag support can shorten hospital stays by an average of two days and reduce re-admission by half.
Patients usually start consuming the nutrition drink five days before surgery and continue it for five days after, Wooden explains. The instructions urge patients to consume sports drinks until three hours before the surgery.
That recommendation contradicts the standard instruction for surgical patients to avoid any liquids in the hours before the procedure, but Wooden says research has shown patients perform better when they consume liquid calories instead of going to surgery dehydrated and with no nutrition.
“We were amazed at how far we have gotten with this program,” Wooden says. “We were able to address major surgical site infections — CAUTIs, CLABSI, C. difficile — and length of stay, with dramatic reductions — about 60% across the board.”1
About half of IU Health physicians have adopted the program, and IU Health has provided the bags to more than 70,000 patients. Between 60% and 70% of patients report using the items before surgery.
LOS was shorter, with excess patient days down by 91%. The Red Bag program also reduced the direct costs per case, with costs for major surgical cases such as cardiovascular surgery decreasing about $5,500 per case. For minor procedures and those that already were streamlined for cost effectiveness, like a total joint replacement, the program still reduced costs by about $1,300 to $1,500 per case.
A report on a cohort of 12,396 patients using the Red Bag program showed dramatic reductions in HAIs. Compliance with each element was high, with researchers reporting 80% for mupirocin, 72% for immunonutrition, 71% for chlorhexidine bath, and 67% for spirometer.1
Dramatic Effect on Outcomes
Wooden says the IU Health team is convinced pre-op wellness kits should become standard for all surgery patients. “This has been a dramatic revelation to us that collaboration between administration and providers can be so effective, especially when you focus it in a prehabilitation format like we did with the red bags,” he says. “This has been revolutionary for us at IU Health, and we hope it can work across the healthcare system at the national level.”
Patient feedback has been entirely positive, Wooden says. Some patients who underwent surgery before the Red Bag program and then again after the program’s implementation said they would not undergo another procedure without access to such tools. Implementing the Red Bag program began with the IU Health team convincing themselves the program was worthwhile. They relied on research showing the benefits of immunonutrition and other components, but it still was a leap of faith.
“No one else was doing it, so we didn’t have anyone else to look at and evaluate their outcomes,” he says. “We did some initial pilot work, and the timing was right culturally at IU Health. We had adopted Lean transformation and Six Sigma only a few years earlier. We were actively challenging ourselves to look at things more clearly and more rationally, with data-driven decision-making and pulling the right groups of people together.”
The IU Health team realized that although they were operating according to national guidelines and best practices, they were not making enough headway in quality improvement, Wooden says. Leaders started looking at the risk factors for infections, readmissions, and longer LOS.
“With something like a knee replacement, I can take weeks or months to optimize my health and address my diet, my diabetes, my pulmonary condition before I go for surgery,” Wooden says. “But if someone has cancer, we can’t wait that long. We needed a process we could execute quickly, and this is one we can do in about six days.”
Nutrition a Key Component
Immunonutrition is a key component of the Red Bag program. Wooden says the IU Health team decided to use a specific product that has produced positive effects on the immune system in other trials. To test the effectiveness, IU Health provided the product to one of its sickest patient populations: those underdoing liver and pancreas resections.
Before this study, those patients’ LOS was about 20 days and their readmission rate was about 20%, both well within national norms. After five days of immunonutrition, both the LOS and readmission rates were cut in half, Wooden reports.
“That was an ‘oh wow’ moment, showing us that this is real. A lot of people don’t believe immunonutrition is real, but if you have the right product it is absolutely valid and helpful to patients,” Wooden says. “If you recognize that nutrition is a key element of health, driving that nutrition component becomes a cornerstone of getting people through any surgery or hospitalization in a better way.”
A 2019 report revealed preoperative immunonutrition “exhibited favorable effects on the complication rate and consequently reduced the length of hospital stay” for patients undergoing salvage surgery for recurrent head and neck squamous cell carcinoma. Those patients are at high risk of complications due to the adverse effects of radiotherapy on wound healing, the authors wrote.2
The percentage of patients suffering any complications was significantly lower in the group receiving immunonutrition (35% vs. 58% in the control group).
Wooden notes IU Health occasionally sees patients with scurvy, a disease brought on by nutritional deficiency but generally thought to be a thing of the past.
“Many of our patients have very poor diets, and some have health problems that prevent them from absorbing micronutrients. They will present with scurvy, beriberi, or pellagra,” he says. “These diseases can go undiagnosed because physicians think they are dead diseases, but they are here with us, and they have a serious detrimental effect on patient outcomes. We are changing our education to teach physicians and nurses about the importance of recognizing these diseases and optimizing those patients so they can have better outcomes.”
- Kelley KE, Fajardo AD, Strange NM, et al. Impact of a novel preoperative patient-centered surgical wellness program. Ann Surg 2018;268:650-656.
- Mueller SA, Mayer C, Bojaxhiu B, et al. Effect of preoperative immunonutrition on complications after salvage surgery in head and neck cancer. J Otolaryngol Head Neck Surg 2019;48:25.
- William Wooden, MD, FACS, James E. Bennett Professor of Plastic Surgery, Director of Hospital Operative Services, Indiana University Health, Indianapolis. Phone: (317) 274-0770.