Talk to the Veterans Crisis Line now
U.S. flag
An official website of the United States government

VA Health Systems Research

Go to the VA ORD website
Go to the QUERI website

The Surgical Pause Practice is Saving Veterans’ Lives

September 22, 2021

Takeaway: Dr. Daniel Hall and colleagues have developed and executed a national diffusion agreement for the Surgical Pause Practice, which screens frail Veterans before surgery so that the care plan can be optimized. They also developed a national CPRS (computerized patient record system) template to facilitate frailty assessment with the Risk Analysis Index (RAI). In addition, pilot testing is underway at 11 VAMCs with a national release date of September 22, 2021.

The Risk Analysis Index or RAI is a 14-item instrument used to measure surgical frailty. The RAI is the most thoroughly validated measure of surgical frailty prospectively tested in more than 450,000 surgical patients (including national samples of Veterans).

Frailty is a global syndrome of decreased physiological reserve accurately measured by the Risk Analysis Index (RAI). Surgical stress can exhaust frail patients’ limited reserve, which has important implications for the surgical patient because a diagnosis of frailty is associated with markedly increased risks for post-operative mortality and morbidity. Many surgical procedures are considered so minor that surgeons spend little time considering if patients can endure the stress of surgery; however, when a patient is very frail, as many as 1 in 3 die within 6 months of surgery – even after “minor” surgery.

Daniel Hall, MD, MDiv, MHSc – a VA surgeon and core investigator with HSR&D’s Center for Health Equity Research & Promotion (CHERP) and former HSR&D Career Development Awardee – developed a highly effective RAI clinical tool to screen frail elderly Veterans before they have surgery. The Surgical Pause Practice, utilizing the RAI, screens for frailty in approximately 30 seconds, reliably identifying the highest risk patients at the point-of-care. Patients at highest risk are referred for further evaluation, often using an interdisciplinary approach that can include both preoperative goal clarification and prehabilitation. At the Omaha VA Medical Center, the Surgical Pause triggered administrative review of frail patients considering surgery, and mortality rates among frail Veterans scheduled for surgery dropped from 25% to 8%. The screening tool has subsequently been implemented at VA Medical Centers (VAMCs) in Pittsburgh, Phoenix, Atlanta, and Palo Alto. In each case, the screening tool elicited a “pause” for frail patients during which a variety of interventions are deployed – all aimed at improving care. The Surgical Pause practice was then awarded Gold Status by VA’s Diffusion of Excellence.

Part of the VHA Innovation Ecosystem, the Diffusion of Excellence identifies, tests, and diffuses innovative, promising practices across the VA healthcare system through a repeatable process for scaling innovation.

This is a chance for all our employees – out there doing incredible work through the Innovation Ecosystem – to demonstrate innovation in action, and, ultimately, how VHA is changing and saving Veterans’ lives. Dr. Ryan Vega, Director, VHA Innovation Ecosystem


Working with Danielle L. Hagan, MSA, VHA Innovation Ecosystem, Diffusion of Excellence, Diffusion Specialist, Dr. Hall and colleagues have developed and executed a national diffusion agreement, as well as a national CPRS (computerized patient record system) template that facilitates frailty assessment with the RAI. After pilot testing at 11 VAMCs, the RAI Frailty Tool was released nationally on September 13, 2021. It should be available for use in every instance of CPRS by October 13, 2021. RAI values recorded with this template will be recorded in VA’s Corporate Data Warehouse (CDW) as a health factor, facilitating process and quality measurement. The Diffusion Agreement aims to implement the Surgical Pause in 55 VAMCs across all 18 VISNs by the end of September 2023. To date, 7 sites are fully implemented, 15 sites are ramping up, and 18 other sites have expressed interest and are organizing for implementation. See Surgical Pause, Diffusion Marketplace.

As of June 2021, the Risk Analysis Index developed and validated by Daniel Hall, MD, MHS, MDiv and colleagues – with support from the VISN4 Competitive Pilot Project Fund, and subsequently used in research supported by VA HSR&D and RR&D – is now available worldwide in Epic as a Clinical Program. It was also released as a national template in CPRS across the VA healthcare system in September 2021. 


Dr. Hall and his team are working with the VHA Innovation Ecosystem, Diffusion of Excellence, VA’s National Surgery Office and VHA Physical Medicine and Rehabilitation Services. The Surgical Pause is also being tested in two-step wedge randomized trials: The SAGE QUERI (Quality Enhancement Research Initiative) is using the surgical pause to trigger formal goal clarification prior to surgery as one of four “Age Friendly” healthcare practices, and the PAUSE Trial at the Palo Alto, Houston, and Nashville VAMCs will use the RAI to trigger consultation of a multidisciplinary clinic to optimize the perioperative planning for frail Veterans considering surgery.


Arya S, Varley P, Youk A, Borrebach J, Perez S, Massarweh N, Johanning J, and Hall D. Recalibration and external validation of the risk analysis index: A surgical frailty assessment tool. Annals of Surgery. December 2020;272(6):996-1005.

George E, Hall D, Youk A, et al. Association between patient frailty and postoperative mortality across multiple noncardiac surgical specialties. JAMA Surgery. January 1, 2021;156(1):e205152.

Hall D, Arya S, Schmid K, et al. Association of a frailty screening initiative with postoperative survival at 30, 180, and 365 days. JAMA Surgery. March 1, 2017;152(3):233-240.

Hall D, Arya S, Schmid K, et al. Development and initial validation of the risk analysis index for measuring fraility in surgical populations. JAMA Surgery. 2017;152(2):175-182.

Shinall M, Arya S, Youk A, Varley P, Shah R, Massarweh N, Shireman P, Johanning J, and Hall D for the OSS (Operative Stress Score) Study Group. Association of preoperative patient frailty and operative stress with postoperative mortality. JAMA Surgery. 2020;155(1):e194620

Questions about the HSR website? Email the Web Team

Any health information on this website is strictly for informational purposes and is not intended as medical advice. It should not be used to diagnose or treat any condition.