American College of Surgeons creates new standards for geriatric surgery: 5 Qs with a physician behind the framework

The American College of Surgeons' Coalition for Quality in Geriatric Surgery plans to release an updated set of care standards in July at the ACS Quality and Safety Conference in Washington, D.C.

The 30 new standards aim to improve surgical care for older patients and represent the culmination of four years of research and planning. 

Ronnie Rosenthal, MD, co-principal investigator of the CQGS project and professor of surgery and geriatrics at Yale University School of Medicine in New Haven, Conn., oversaw development of the national standards. 

Here, Dr. Rosenthal discusses how the standards address issues in geriatric surgical care and long-term goals for improving geriatric surgery nationwide.

Editor's note: Responses have been lightly edited for style and clarity.

Question: The U.S. population is rapidly aging. How will the new standards help address the growing demand for geriatric surgical care?

Dr. Ronnie Rosenthal: It's true that the U.S. population is aging at a faster rate than previous decades. Roughly 10,000 people in the U.S. turn 65 every day, and the U.S. Census Bureau projects the number of older adults will grow by 55 percent from 2010 to 2050 to make up an estimated 21 percent of the U.S. population.

As the population ages, surgeons need strategies to maintain high-quality and patient-centered care even with an increased workload. That's why the ACS, with support from the John A. Hartford Foundation, led a coalition of over 50 stakeholders in the development of the new Geriatric Surgery Verification Program. This program, which launches at the ACS Quality and Safety Conference in July, provides hospitals with a validated list of feasible, patient-centered standards for surgical care in older adults that can be implemented to continuously optimize care for this vulnerable population. The standards define the resources that hospitals need to have in place to perform operations in older adults effectively, efficiently and safely, and they reflect the best evidence and expert opinion as to how to improve surgical care and outcomes for this population. 

Q: Over 4,500 hospitals in the country perform geriatric surgery, and the Geriatric Surgery Verification Program aims for 100 participating hospitals in its program’s first year. What is your long-term goal for the program? 

RR: The long-term goal of the GSV Program is to systematically improve surgical care and outcomes for older adults. This program consists of 30 standards for surgical care in older adults that were refined and rigorously piloted over four years. Hospitals who participated in the pilot programs noted that their utilization of the GSV Program would better standardize care for older adult patients across all departments and surgical subspecialties. Our hope is that other hospitals who enroll in the GSV Program will see a similar impact and can apply key learnings and best practices from the quality program to each of their departments. 

Peer-reviewed studies of ACS' other quality improvement programs have shown that participating hospitals saw declines in surgical complications across specialties year after year, along with shortened lengths of hospital stays and lower risks of death, among other benefits. Hospitals that have enrolled in other ACS quality improvement programs have also seen their surgical teams work together more effectively and draw attention to certain issues before, during and after operation that may have previously gone unnoticed. 

Q: If a hospital fails to meet certain standards, does the program have any measures in place to help it improve?

RR: Through the GSV Program, ACS can evaluate a hospital's adherence to the latest standards of surgical care for older adults and help guide a hospital through the necessary processes for meeting the standards and ensuring continuous improvement. It's important to note that the GSV Program was developed and rigorously piloted to ensure the standards for verification are meaningful without being so burdensome that hospitals would find it difficult to implement them. The program aims to directly answer the critical need for safe, high-quality, patient-centered surgical care for older adults. Some of the program standards relate to managing medications, screening for cognitive, nutrition and mobility decline, and ensuring proper staffing is in place. The program isn't necessarily about changing the surgical techniques for procedures with older patients, but rather setting protocol for better communication to patients and their families, as well as better communication between the entire multidisciplinary healthcare team. 

Q: An article in The New York Times mentions communication as a key issue addressed by the standards. What type of communications issues are present in geriatric care, and how will the new standards address them?

RR: One of the biggest communication issues in geriatric surgical care is the lack of discussion between providers and their patients regarding patients' goals for their operation. The goal of any surgical procedure is to improve or maintain the patient's quality of life, and it is the healthcare team's responsibility to be cognizant of a patient's needs and individual goals.

Studies have shown that older adult patients may more often prioritize quality of life over quantity of life, so there's a need for surgeons to proactively initiate discussions about patients' treatment goals and whether an operation will help achieve them. Younger patients may choose to undergo a procedure with the goal of having a longer lifespan. However, an older patient may be more focused on maintaining their independence after an operation. That older patient would require a different approach to the procedure or may even choose to forgo an operation altogether if it doesn't align with his or her needs and goals. The GSV Program's standards emphasize the importance of having these provider-patient discussions and create a framework for healthcare practitioners to initiate these conversations consistently. 

Q: What do you see as the single most important aspect of the new standards for improving patient experience and care quality?

RR: The lack of communication between patients and their healthcare team in some cases can be incredibly detrimental to the care process for older adults. There is also a misconception that surgery is the same for all adults. But just as we wouldn't clinically treat a 2-year-old the same way as a 20-year-old, we clinicians need to recognize that an 80-year-old has different surgical needs and goals than a 50-year-old and requires a specialized approach to care.

The GSV Program also calls for the creation of a hospital environment that is equipped to handle the unique care needs of older Americans. The program maintains the framework for hospitals to implement a geriatric director or nurse champion role on staff, someone who is responsible for understanding and providing the necessary resources to improve patients' surgical care and recovery. 

The final 30 standards of the GSV Program will be revealed at the ACS Quality and Safety Conference this July 19-22 in Washington, D.C., and hospitals can officially apply for the program in October 2019. Hospitals that want to learn more about the program or its enrollment process can contact the ACS at geriatricsurgery@facs.org, or connect with any of the contacts here.   

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