The Surgical Pause
Last updated
Share PrintData demonstrate there is no such thing as low risk surgery in high risk, frail patients; in fact, 1 in 3 frail Veterans will die within 6 months of even “small surgery”. Historically, there was no reliable and quick way to identify the highest risk patients at the point of care before committing to a surgical plan. Recognized as a Promising Practice by the VHA Innovation Ecosystem’s Diffusion of Excellence, the Surgical Pause utilizes the simple yet sophisticated Risk Analysis Index (RAI) to screen Veterans for frailty in 30 seconds, effectively flagging high risk Veterans so that the surgical team can ensure that the proposed treatment plans both mitigate known risks and align with the Veterans’ overarching life goals. Transparent communication about the risks of protracted recovery or loss of independence after surgery empowers patients to consider non-operative management strategies. And for those who nonetheless elect surgical intervention, preoperative exercise training for as little as 3-6 weeks before surgery may improve outcomes by increasing physiologic reserve. By bringing additional resources to such frail patients, the Surgical Pause improves outcomes and adds value.
Origin:
July 2011, Omaha VA Medical Center (Omaha, Nebraska)
Adoptions:
42 successful, 33 in-progress
Awards and Recognition:
Part of SAGE QUERI Program (VISN 4) , Focus of the PAUSE Trial (HSR&D funded multi-site study), Diffusion of Excellence Promising Practice, Aligned with 4- Year HSR&D Funded Merit ... Part of SAGE QUERI Program (VISN 4) , Focus of the PAUSE Trial (HSR&D funded multi-site study), Diffusion of Excellence Promising Practice, Aligned with 4- Year HSR&D Funded Merit Review Project aimed at Improving Surgical Decision Making by Measuring and Predicting Long-Term Loss of Independence after Surgery, QUERI Partnered Evaluation Initiative
Partners:
Diffusion of Excellence, Health Services Research & Development, Quality Enhancement Research Initiative
Recent Updates
Overview
The problem
Images
Above:
There is no such thing as a low risk surgery for frail patients
Videos
Above:
Watch Dr. Hall’s iEX Talk about the Surgical Pause at the 2021 VHA Innovation Experience
The solution
Step 2: Prehabilitate the frail. It isn’t enough to just identify frailty. Something must be done. And there are a variety of options. Interdisciplinary review boards can pool the wisdom of multiple specialists to optimize the care plan. Palliative care clinicians can assist surgeons and primary care doctors in clarifying the patients' goals and ensuring that surgery is consistent with their values. Exercise training can improve functional performance in clinically significant ways that likely improve outcomes. See more
The results
Images
Above:
Interrupted Time Sequence analysis with segmented Poisson regression among 28,786 surgical patients (14,127 before frailty screening; 5402 after). 1-year mortality decreased 0.2% per month following RAI Implementation (p=0.02) Rat of improvement increased to 0.87% per month after implementing Best Practice Alerts (BPAs) for frail patients.
Metrics
- Length of Stay
- Post-Operative Complications
- Post-Operative Readmission
- Decision Regret
- Patient Centeredness of Care
- Cost
- Post-Operative Mortality
Diffusion tracker
Does not include Clinical Resource Hubs (CRH)
Implementation
Timeline
-
1-2 months
Process Buildout-Identify pilot service line(s)-Train personnel to administer RAI-Locate RAI Template in CPRS and review the overview PowerPoint.-Engage with local leadership and stakeholders to gain buy-in-Reach out to VHASurgicalPause@va.gov for additional support in this phase if needed. -
1-2 months
Implement RAI screening in clinic(s) -
3-6 months
Validate RAI in local population to garner clinical support -
3-6 months
Select appropriate interventions (e.g. interdisciplinary review, preoperative palliative care, or exercise) and build consensus -
6-9 months
Begin interventions for patients identified as potentially "frail" -
9-12 months
Program evaluation/measure outcomes -
9-12 months
Bring on additional service/sections
Departments
- Anesthesia
- Geriatrics
- Nursing services
- Palliative and hospice care
- Physical medicine and rehabilitation
- Primary care
- Surgery
Core Resources
| Resource type | Resource description |
|---|---|
PEOPLE |
|
PROCESSES |
|
TOOLS |
|
Files
- Comprehensive implementation guide for sites seeking to implement the Surgical Pause Surgical Pause Implementation Guide
- RAI Handout for patients to complete RAI Handout
- National Surgery Office Memorandum supporting use of the Surgical Pause NSO Endorsement of Surgical Pause
- VHA Program Guide 1200.21 Operations Activities that May Constitute Research VHA Operations Guide
- A guide for using the Risk Analysis Index within Epic Medical Record Platforms Screening for Frailty in Pre-Op Patients (EPIC)
- Instructions for using the new PowerApps Calculator (replacing REDCap) CPRS RAI Frailty Tool Updates - March 2022
- How-To Guide on using the RAI Frailty Tool in CPRS Using the RAI Frailty Tool in CPRS
Links
- Videotaped presentation (38 minute) providing provider-focused overview of The Surgical Pause: Preoperative Frailty Screening and Prehabilitation
- Videotaped presentation (13 minutes) focused on to implement the RAI as part of the outpatient clinic for Pre-Operative Frailty Screening and Prehabilitation
- VA PowerApps RAI Frailty Tool/Calculator (No PII/PHI) RAI PowerApps Frailty Calculator
Optional Resources
| Resource type | Resource description |
|---|---|
PEOPLE |
|
Files
- Presenter Slides from Day 1 of the Surgical Pause Symposium Surgical Pause Symposium June 2023 - Day 1
- Presenter Slides from Day 2 of the Surgical Pause Symposium Surgical Pause Symposium June 2023 - Day 2
Support Resources
| Resource type | Resource description |
|---|---|
TOOLS |
|
Files
- (2020 Annals of Surgery) Clinical Utility of the Risk Analysis Index as a Prospective Frailty (2020 Annals of Surgery) Clinical Utility of the Risk Analysis Index as a Prospective Frailty
- (2020 Annals of Surgery) Recalibration and External Validation of the RAI (2020 Annals of Surgery) Recalibration and External Validation of the RAI
- (2023 Journal of Surgical Oncology) Interpreting the risk analysis index of frailty in the context of surgical oncology (2023 Journal of Surgical Oncology) Interpreting the risk analysis index of frailty in the context of surgical oncology
Links
- Association Between Patient Frailty and Postoperative (2020 JAMA) Association Between Patient Frailty and Postoperative
- (2020 JAMA Network) Association of Preoperative Frailty and Operative Stress With Mortality (2020 JAMA Network) Association of Preoperative Frailty and Operative Stress With Mortality
- (2020 Annals of Surgery) Recalibration and External Validation of the RAI (2020 Annals of Surgery) Recalibration and External Validation of the RAI
- (2019 JAMA Surgery) Association of Preoperative Patient Frailty and Operative Stress (2019 JAMA Surgery) Association of Preoperative Patient Frailty and Operative Stress
- (2018 American College of Surgeons) Taking Control of Your Surgery- Impact of a prehabilitation program on major abdominal surgery (2018 American College of Surgeons) Taking Control of Your Surgery- Impact of a prehabilitation program on major abdominal surgery
- (2017 JAMA Surgery) Association of frailty screening (2017 JAMA Surgery) Association of frailty screening
- (2017 PNAS) On the promotion of human flourishing (2017 PNAS) On the promotion of human flourishing
- (2014 JAMA Surgery) Summary of the Panel Session at the 38th Annual Surgical (2014 JAMA Surgery) Summary of the Panel Session at the 38th Annual Surgical
- (2014 JAMA Surgery) Surgical Palliative Care Consultations Over Time (2014 JAMA Surgery) Surgical Palliative Care Consultations Over Time
- (2011 Annals of Family Medicine) Measuring Patients’ Perceptions of Patient Centered Care - A Systematic Review of Tools for Family Medicine (2011 Annals of Family Medicine) Measuring Patients’ Perceptions of Patient Centered Care - A Systematic Review of Tools for Family Medicine
- (2003 Medical Decision Making) Validation of a Decision Regret Scale (2003 Medical Decision Making) Validation of a Decision Regret Scale
Risks and mitigations
| Risk | Mitigation |
|---|---|
| Not using the RAI (Risk Analysis Index) tool consistently. | Make it part of new training and create leadership in asking for it everytime. |
| Slightly increased burden on nurses during clinic inpatient procedures. | Use CPRS RAI Template to reduce burden and adjust other clinical duties as needed. |
| Implementing RAI too late in the journey to the operating room; it is hard to change plans after surgery is scheduled. | Ensure that the RAI is measured before scheduling surgery, ideally on initial presentation to the surgery clinic and before meeting the surgeon. |
Contact
Comment
Comments and replies are disabled for retired innovations and non-VA users.
Email vhaco.national.surgery.office@va.gov with questions about this innovation.
About
Origin story
Original team
Daniel Hall
Surgeon
Jason Johanning
Chief of Surgery
Shipra Arya
Surgeon
Myrick Shinall
Surgeon
Nader Massarweh
Surgeon
Thomas Lynch
Surgeon
Thomas Edes
Director, Comprehensive Geriatrics & Palliative Care
Scott Shreve
National Director of Hospice Palliative Care
Mark Wilson
Chief of Surgery, VA Pittsburgh Healthcare System
Do you have the RAI questions (toolkit) for others to use?
Is there a way I can print this out in PDF format?
Hi Lisa, Ctrl + P should do it and then you can save as a PDF :)
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This is such a great tool and the Implementation guide is wonderful.
Thank you for your feedback, Anne! We are so glad Gainesville has found the tool and implementation guide helpful.