IU Health Makes Pre-op Patient Wellness a Package Deal

Development of the “red bag” at IU Health required a multidisciplinary team over several years. At IU Health University Hospital, contributors included (from left) Betsy Norton, RN; Alyssa Fajardo, M.D., a colorectal surgeon; Maureen Colin, ambulatory nurse manager; and Nancy Strange, a registered dietitian.

Visit an Indiana University (IU) Health hospital and you’re likely to see patients towing small, wheeled red bags to their cars.

The red bags bearing the IU Health logo are part of an innovative effort by Indiana’s largest hospital system to tune up patients’ health before scheduled surgeries so they can quickly get back on their feet.

Dubbed red bags for their branded color, IU Health’s program puts the hospital system and its patients on the forefront of an industry movement called enhanced recovery. The program aims to use preoperative wellness kits and similar practices to improve patient surgical outcomes.

Inside IU Health’s red bags patients find the ingredients for what might be called hospital-acquired wellness. The bags include an immunonutrition drink packed with vitamins and nutrients that support the immune system and wound healing, antibiotic ointment and soap to ward off MRSA and other infections and a breathing apparatus to strengthen the lungs.

The message to patients who are handed the bags: Using the ingredients as instructed will greatly reduce infections and other complications from surgery, trim hospital stays by an average of two days and reduce by half the potential for readmission to the hospital to treat post-operative issues.

Since launching the red bag program in 2015 at its academic health center that includes IU Health Methodist and University hospitals, IU Health has seen dramatic positive results.

William Wooden, M.D., director of operative services at IU Health and the James E. Bennett professor of surgery at IU School of Medicine, credits use of the red bags for reducing patient hospital stays at IU Health by a total of 87,000 days.

“This is one of the strongest tools we have to save hundreds of millions of dollars across the health care system,” said Wooden of the red bags and similar pre-op wellness programs at other hospitals. “This should be the new standard of care. We want to make it the easy button for the surgeons. Great surgery is not enough.”

The poor health status of many of today’s patients makes wellness programs like the red bags vital. Wooden said about 75 percent of his patients entering surgery have at least three major risk factors, such as obesity or hypertension. Malnutrition also is surprisingly prevalent.

“We see patients with major malnutrition that has gone unrecognized by anyone,” said Wooden. “We’re seeing about five cases a week of scurvy (a vitamin deficiency that prevents wounds from healing).”

“You name a nutrient, we’ve seen the deficiency,” including patients with beriberi and iodine deficiency, said Maureen Colin, ambulatory nurse manager at IU Health University Hospital, who also was on the team that helped create the red bag program.

The immunonutrition drink works to bolster patients’ immune systems and nutritional levels and improve metabolism so patients can better endure the trauma of surgery, Wooden said.

Patients typically start consuming the nutrition drink five days before surgery and continue it for five days post-surgery. IU Health’s research also showed benefits from being well-hydrated for surgery, so patients are told to also drink sports drinks such as Gatorade up until about three hours before surgery.

Wooden, who has focused on patient quality programs during his medical career, helped lead a diverse team of professionals at IU Health Methodist and University hospitals who developed the red bag program starting around 2010.

“I have never before seen the level of interdisciplinary collaboration and enthusiasm in a hospital that I’ve seen with this program,” said Nancy Strange, a registered dietitian at IU Health University Hospital, who has 39 years of experience as a dietitian.

She credits the clear benefits of using the pre-op wellness kits for the buy-in from physicians, pharmacists, physical therapists, social workers and others who care for patients. “Once they see patient results,” Strange said, “they are more willing to participate.”

Strange saw immediate benefits when IU Health began giving patients the immunonutrition drink.

“I was seeing a great number of post-operative wounds that just weren’t healing,” she said. But with the immunonutrition drink, non-healing wounds became rare. In fact, with fewer hard-to-heal wounds, there’s less need to use costly negative-pressure wound therapy, known as wound vacs, on patients, Strange said.

IU Health colorectal physician Alyssa Fajardo, M.D., who also contributed to developing the red bag program, said, “We were used to seeing patients one month after surgery and they were still recovering. Now, with the red bags, they are back to their baseline health in one month. When you see them in clinic they just look better. This is going to be a new standard of care in the future.”

Jani Glenn, a retired schoolteacher from Winchester, said she has no doubt the red bags sped up her recovery from two surgeries at IU Health earlier this year for appendix cancer.

Before Glenn’s major surgery, which lasted 10 hours, her doctor told her she’d need three days’ recovery time in the intensive care unit and another 10 days in a general hospital bed. Instead, Glenn was out of the ICU in 1 1/2 days and released from the hospital six days later.

“My recovery time was probably half of what my doctor expected,” she said. “I do feel the red bag program did help. You are getting the nutrition you need to help you get through the surgery. I was very impressed with the red bags. I would hate to go through another surgery now without them.”

Last year, IU Health provided 4,000 red bags without charge to patients at IU Health Methodist and University hospitals. Use of the red bags is being expanded to IU Health’s entire 15-hospital system.

IU Health Executive Vice President and Chief Medical Officer Jonathan Gottlieb, M.D., said the red bag development team drew on existing research to create a program that works.

“Evidence existed that optimizing the patient’s preoperative condition resulted in improved outcomes for patients and better use of health system resources,” Gottlieb said. “Borrowing an approach to preoperative optimization as published in medical journals, we ‘packaged’ this approach in a kit that was attractive to patients and caregivers.”

Wooden said he’d like to see the federal Centers for Medicare & Medicaid Services and major commercial insurers promote preoperative wellness programs nationally. “We’ve got to keep stoking the fire. This is one of the strongest tools we have to better the health of patients and save hundreds of millions of dollars in health care costs,” he said.

The number of patients who’ve benefited from the red bags at IU Health now numbers in the thousands. Strange said she still appreciates the sight of a patient leaving the hospital, red bag in tow.

“This is something they can do that allows them to prepare for surgery and know it is going to help. When I see a patient walking out with a red bag, I know they’re going to be OK.”


Wooden offers the following advice to hospital leaders considering a formal pre-op wellness program:

  • Get primary care physicians, surgeons and internists working together on pre-op wellness.
  • Find doctor, dietitian and nurse in-house champions.
  • Use the pre-op program in conjunction with comprehensive health checks, including nutritional assessments, for patients before surgery.
  • Make the pre-op wellness program a standard of care for scheduled surgeries.
  • Establish a budget to pay for the kits (the ingredients in IU Health’s red bag cost under $60 per kit).