Daniel E. Hall MD, MDiv, MHSc, FACS (is Professor of Surgery and Anesthesiology & Perioperative Medicine, University of Pittsburgh, and Medical Director, High Risk Populations and Outcomes, University of Pittsburgh Medical Center (UPMC), and Core Investigator, Center for Health Equity Research and Promotion, US Department of Veterans Affairs (VA) Pittsburgh Healthcare System.), Danielle Hagan MSA (is Management and Program Analyst and Diffusion Specialist, US Department of Veterans Affairs.), LauraEllen Ashcraft PhD, MSW (is Assistant Professor, Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, and Implementation Scientist, US Department of Veterans Affairs.), Mark Wilson MD, PhD (is Executive Director, National Surgery Office, Veterans Health Administration.), Shipra Arya MD (is Professor, Department of Surgery, Stanford University School of Medicine, and Section Chief of Vascular Surgery, VA Palo Alto Healthcare System.), Jason M. Johanning MD, MS, FACS (is Professor, Department of Surgery, University of Nebraska Medical Center, and Chief Surgical Consultant, Nebraska-Western Iowa VA Medical Center. Please address correspondence to Daniel E. Hall)
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Abstract
Conceptual Framework
The Surgical Pause is a rapid, scalable strategy for health care systems to optimize perioperative outcomes for high-risk, frail patients considering elective surgery. The first and most important step is to screen for frailty, thereby identifying the 5% to 10% of patients at most risk for postoperative complications, loss of independence, institutionalization, and mortality. The second step is to take action to improve outcomes. Action may include clarifying perioperative goals, optimizing perioperative decision-making, and mitigating frailty-associated risks through prehabilitation.
History of Dissemination
Initially implemented at the Omaha Veterans Affairs (VA) Medical Center in 2012, the Surgical Pause was associated with a nearly three-fold survival advantage among the frail. The program was subsequently replicated at more than 50 VA and private sector hospitals with similarly robust results, leading the Veterans Health Administration (VHA) National Surgery Office to formally adopt the program in January 2024. The Joint Commission and the National Quality Forum recognized the program with the Eisenberg Award for Patient Safety and Quality at the National Level.
Lessons Learned
Successful dissemination grew from simultaneous real-world quality projects paralleled by rigorous, high-quality, peer reviewed publications demonstrating the need for and impact of the Surgical Pause. Adoption was facilitated in an iterative process to streamline feasibility and leverage existing resources. Success was accelerated by national infrastructure catalyzing a community of practice.
Conclusion
The Surgical Pause is changing surgical culture by proactively identifying frail patients, aligning treatment plans with patient-defined goals, optimizing perioperative decisions, and mitigating frailty-associated risks to deliver both quality and value.
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