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The Surgical Pause Practice Adopted as National Program

August 3, 2023

Takeaway: Dr. Daniel Hall and colleagues developed the Surgical Pause Practice, which screens frail Veterans before surgery so that their care plan can be optimized. The VA National Surgery Office announced that it will support transition of the Surgical Pause Practice to an operational program. Further, the Joint Commission and National Quality Forum recently announced that the Surgical Pause received the 2023 John M. Eisenberg Patient Safety and Quality Award for National Level Innovation in Patient Safety and Quality.

With more than 4 million Veterans aged 65 and older, VA is working to optimize care for Veterans as they age, including managing their risk for surgery. 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 one in three die within six months of surgery – even after “minor” surgery. The VA National Surgery Office (NSO) (VA network access only) provides operational oversight and establishes policy for the delivery of surgical services by VA’s Surgical Programs. Recently, the NSO announced that the Surgical Pause Practice, which screens frail Veterans before surgery so that their care can be optimized, will be supported as a national program within the NSO.

This did not happen overnight.

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 the highly effective Risk Analysis Index (RAI) to quantify the risk of frailty among 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.

Frailty is a global syndrome of decreased physiological reserve accurately measured by the Risk Analysis Index (RAI). The 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 750,000 surgical patients, including national samples of Veterans.

Patients at highest risk are referred for further evaluation, often using an interdisciplinary approach that can include both preoperative goal clarification and pre-habilitation. The goal is to bring additional resources to the Veterans most likely to benefit. 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 was subsequently 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 were 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’s mission is to identify, replicate and scale emerging Promising Practices across the VA healthcare system.

It’s important for surgeons to assess their patients in a systematic way to see if there are risks, determine whether they can be lessened, and ensure that patient expectations are realistic and aligned with their goals. —Daniel Hall, MD, MDiv, MHSc, VA surgeon and core investigator with CHERP


The Surgical Pause Team, led by Dr. Hall, has worked closely with the VHA Diffusion of Excellence to replicate this promising practice in more than 50 VA medical centers (VAMC) with positive results. This led to recognition by the Joint Commission and National Quality Forum, which recently announced that the Surgical Pause received the 2023 John M. Eisenberg Patient Safety and Quality Award for National Level Innovation in Patient Safety and Quality.


Dr. Hall and his team continue to work with the Diffusion of Excellence, VA’s National Surgery Office, VA Geriatrics and Extended Care (GEC), and VHA Physical Medicine and Rehabilitation Services. The Surgical Pause is also being tested in two- randomized trials: The SAGE QUERI (Quality Enhancement Research Initiative) uses 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 uses 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.

Hall D, Youk A, Allsup K, et al. Preoperative rehabilitation is feasible in the weeks prior to surgery and significantly improves functional performance. Journal of Frailty & Aging; May 31, 2022. Open access.

Oyekan A, Lee J, Hodges J, et al., and Hall D. Increasing quality and frequency of goals-of-care documentation in the highest-risk surgical candidates: One-year results of the Surgical Pause Program. JB JS Open Access. April 24, 2023;(8):e22.00107.

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

Varley P, Borrebach J, Arya S, et al. Clinical utility of the risk analysis index as a prospective frailty screening tool within a multi-practice, multi-hospital integrated healthcare system. JAMA Surgery. 2023;158(5):475-483.

Varley P, Buchanan D, Bilderback A, et al. Association of routine preoperative frailty assessment with 1-year postoperative mortality. JAMA Surgery. 2023;158(5):475-483.

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