The US population is aging, and most seniors would like to be mobile and have good cardiovascular, neurologic, and orthopaedic health in their retirement years. However, an increasing number of seniors who have multiple preexisting conditions and are at extremely high risk for postsurgical complications are seeking out complex surgical procedures.
It’s important that both patients and their surgeons recognize that procedures performed on senior, frail patients are very different from similar procedures performed on healthy young patients. This is supported by the mortality rates for frail patients—all frail patients face significant risk from surgery, and about one in three very frail patients may die within 6 months of a “low-stress” surgery.1
A study of 432,828 unique patients found that 8.5% of patients identified as frail had a mortality rate of 1.55% at 30 days after undergoing what is considered very low-stress surgeries. This 30-day rate increased to 22.26% after high-stress surgeries were performed on very frail patients, who comprised 2.1% of the sample. For both frail and very frail patients, mortality rates continued to increase at 90 and 180 days, reaching a high of 43.0% at 180 days for very frail patients after moderate-stress surgical procedures.1
These mortality rates clearly show the need to evaluate the frailty of patients prior to surgery. High-risk frail patients require a different approach in order to have the best possible outcomes. With this in mind, surgeon and researcher Daniel E. Hall, MD, MDiv, MHSc, FACS, from the Veterans Health Administration (VHA) devised and implemented a 30-second screening tool that flags the 5%–10% of surgical patients identifiable as frail who are at risk for postoperative complications, loss of independence, and mortality.
Surgical Pause Starts with 12-Item Risk Analysis Index
Called the Surgical Pause, Dr. Hall’s screening tool consists of a 12-item Risk Analysis Index (RAI) that identifies at-risk patients. These patients then are evaluated further using an interdisciplinary approach that may include prehabilitation and a structured conversation designed to clarify the patient’s goals and expectations prior to surgical decision-making. In addition, operative teams implementing the Surgical Pause may use narcotic-sparing regional anesthetics during surgery and implement a systematic delirium assessment during recovery.2,3
The prehabilitation may include preoperative exercise to improve physical condition and respiratory function, as well as nutritional supplementation. These prehabilitative interventions shift the focus to increasing physiologic reserve and mitigating the risk of potential complications before they happen rather than relying only on rescuing patients after they experience postoperative complications that may result in long-term hospitalizations, readmissions, long-term institutionalization, or death.4,5
The goal clarification goes beyond informed consent, framing a conversation about surgery within the context of the patient’s life and goals. Surgeons and their staff can lead patients through this discussion by using lay language to describe the possible outcomes of surgery versus nonoperative management under the best, worst, and most likely scenarios. This discussion of options can be supplemented by visual aids given to patients and can be placed in the medical record.3,6-8
Six-Month Mortality Rates Reduced from 25% to 8%
After being implemented at the Omaha VA Medical Center in Nebraska, the Surgical Pause reduced 6-month mortality rates among frail patients from 25% to 8%.2,9 Later efforts at Pittsburgh VA Medical Center and the University of Pittsburgh Medical Center, both in Pennsylvania, and Malcom Randall VA Medical Center in Gainesville, Florida, replicated this improvement.10
As a result of this success, the Surgical Pause has been implemented at more than 50 medical centers across the VHA and the private sector; this tool also has been adopted as a national practice by the VHA’s National Surgery Office and by a growing number of private sector institutions.
The US Department of Veterans Affairs (VA) also developed a national CPRS (computerized patient record system) template to facilitate frailty assessment with the RAI.2
Surgical teams can implement the Surgical Pause by dedicating 5–10 hours a week for the first 3 months to establish the program. Afterward, only a few hours a week are required to review frail cases and generate periodic reports of process and outcomes measures. An implementation guide outlines a proposed timeline for implementation over 12 months and is publicly available on VA Diffusion Marketplace.11
Winner of Eisenberg Patient Safety and Quality Award
The VHA received a 2023 John M. Eisenberg Patient Safety and Quality Award from The Joint Commission and National Quality Forum for the development of this tool, which screens patients quickly, simply, and effectively. The panel also noted that Surgical Pause’s methodological approach and implementation strategy make it accessible and replicable within a variety of settings and facilities.
