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Surgical Pause Implementation (SAGE QUERI)

The Surgical Pause, winner of the 2023 John M. Eisenberg Patient Safety and Quality Award in the National Innovation in Patient Safety and Quality category from the Joint Commission and National Quality Forum, facilitates assessment of surgical frailty by screening Veterans before surgery using a 14-item Risk Analysis Index (RAI) embedded in the computerized patient record system (CPRS) template developed by Daniel E. Hall, MD, MDiv, MHSc, a VA surgeon and investigator with HSR’s Center for Health Equity Research & Promotion (CHERP), and colleagues. The RAI screens for frailty in approximately 30 seconds, reliably identifying Veterans who are at high risk of post-operative complications, loss of independence, and mortality. The “pause” enables further evaluation and optimization of treatment plans. The Surgical Pause originated in the field, at the Omaha VA Medical Center. Dr. Hall continued to develop the science inside and outside VA, and in 2019, the Surgical Pause earned Gold Status from VA’s Diffusion of Excellence.

Surgical Pause research is continuing through an ongoing HSR PAUSE trial led by Shipra Arya, MD, of HSR’s Center for Innovation to Implementation (Ci2i), and Dr. Hall’s IIR collaboration with VA’s Geriatrics & Extended Care Data & Analysis Center (GECDAC) to define and predict trajectories of long-term recovery and dependence after surgery.

Optimizing safety and quality of care for older Veterans

The Surgical Pause is being implemented by the Safer Aging through Geriatrics-Informed Evidence-based Practices (SAGE) QUERI Program for scale-up and spread across all five VISN 4 medical centers credentialed by the National Surgery Office for intermediate or complex surgery. Within VISN 4, patients identified as potentially frail are referred for a structured consultation aimed at clarifying overarching life goals and ensuring that the proposed surgery aligns with those goals.

Implementing four synergistic practices across VISN 4

SAGE QUERI is partnering with VA’s Office of Geriatrics and Extended Care, National Surgery Office, and VISN 4 to scale up and spread four synergistic effective practices across nine VA medical centers and 45 outpatient clinics, developing evidence-based tools and resources for implementation beyond VISN 4, and building sustained operational networks. Each of the four implemented practices addresses one of the Age-Friendly Health System practices, known as the “Four M’s,” which address common quality gaps (e.g., patient goals, medication harms) in older adult care. By triggering structured goal clarification prior to surgery, the Surgical Pause ensures that surgical treatment addresses “What Matters” to older patients, the first of the “Four M’s,” and this complements SAGE QUERI’s implementation of three other practices across VISN 4 aimed at enhancing mobilization, preserving mentation, and reducing medication harms.

In addition, SAGE QUERI partnered with VISN 8 surgical leadership for the Evaluating the Surgical Frailty Screen Rapid Response Team (RRT). After evaluating the multiple surgical screeners being used in VISN 8, the RRT consolidated the tools to the single frailty screening tool used in the Surgical Pause. The team also created an audit and feedback dashboard that was used in the VISN to monitor implementation. The team found that implementation was already widespread, with more than 15,000 screenings among 13,844 Veterans, Veteran family members, and caregivers. After feasibility was proven in VISN 8, the Surgical Pause Dashboard was adopted in February 2024 by the National Surgery Office for use at any VA medical center implementing the Surgical Pause.

A Cyberseminar on The Surgical Pause: Measuring Frailty and Doing Something About It will be held on May 23, 2024 from 12:00–1:00 p.m.