CHICAGO: A national pilot program designed to improve outcomes for elderly surgical patients is scalable and can be implemented in a wide range of hospital types—from community hospitals to urban academic medical centers, according to a study published this week in the Journal of the American College of Surgeons (JACS).
The study evaluated the implementation of standards developed by the American College of Surgeons (ACS) Coalition for Quality in Geriatric Surgery (CQGS), a collective of 58 organizations across a variety of medical disciplines, including surgery, geriatrics, nursing, and pharmacy. This Coalition, funded by The John A. Hartford Foundation, led to the development of the ACS Geriatric Surgery Verification Program (GSV), launched in July 2019.
“We were able to demonstrate the feasibility of implementing these geriatric standards in eight different hospitals across the country that had variable sizes and geographic backgrounds and resources,” said corresponding author Xane Peters, MD, a clinical scholar in the Division of Research and Optimal Patient Care with the ACS Geriatric Surgery Verification Program and a general surgery resident at Loyola University Medical Center in Maywood, Illinois. “This study highlights the value of a geriatric-oriented surgery quality program. The number of older adults in the United States is growing every year and a program like this is valuable because it targets a part of the population that’s treated in the vast majority of hospitals across the U.S.”
The hospitals selected for the study ranged in size from about 160 beds to more than 1,000 beds. They represented every region of the U.S., and included university-associated programs, community hospitals, and government-affiliated centers.
“Our goal was to bring together a diverse group of stakeholders that were interested in optimizing care for older adults,” said senior author Marcia M. Russell, MD, FACS, vice chair of the ACS Committee on Geriatric Surgery and an associate professor of surgery at the David Geffen School of Medicine at UCLA. “The end goal was to identify the optimal standards for these patients and use those to develop a quality improvement program.”
In 2016, CQGS drafted 308 preliminary standards for geriatric surgery, winnowing that to 30 final standards for implementation at the pilot sites. In this study, researchers aimed to determine how well the selected standards could be implemented in pilot sites and to identify barriers and best practices in their implementation so that the standards could be further refined if needed.
“Virtually every hospital will have to address how it cares for the growing older population in its community. The GSV program gives hospitals a roadmap about how to deliver the best surgical care for older patients to achieve their care goal,” said Clifford Y. Ko, MD, MS, MSHS, FACS, FASCRS, Director of the ACS Division of Research and Optimal Patient Care. “This study shows that it is feasible for all hospitals to implement this program whether they are big or small, urban or rural. The GSV program not only leads to better outcomes for patients, but it also helps hospitals deliver optimal care more cost-effectively.”
Study Details and Results
The study grouped the 30 standards into six different “chapters,” or broad categories, and rated them in terms of compliance level at each hospital. The categories with the highest compliance were:
- Program Management
- Immediate Preoperative and Intraoperative Care
- Postoperative Clinical Care
The categories with the lowest compliance were:
- Goals and Decision-Making
- Preoperative Optimization (practices for preparing patients for surgery)
- Transitions of Care
The study identified barriers and challenges to the implementation of the quality standards, which helped in the development of the tools and resources available to hospitals participating in the ACS GSV Program to overcome these barriers.
The most commonly cited barriers were workflow and staffing limitations, which the authors note may have become more challenging since the COVID-19 pandemic. “The ACS GSV program offers a lot of educational resources and best practices, some of which are shared between hospitals, so that institutions that are interested in implementing these programs can make use of things that have been done by other similar institutions so they’re not reinventing the wheel,” Dr. Peters said.
Other barriers relate to educating providers about caring for geriatric patients, which led the CQGS to develop educational materials. “There are not enough geriatricians in the U.S. to care for all older adults,” Dr. Russell said. “Our program identifies some ways to adapt. If you don’t have a geriatrician at your hospital, you can still put these standards into place.”
“These findings provide evidence of real-life implementation by these eight very different hospitals and demonstrate that hospitals can put these geriatric standards into play,” Dr. Russell added. “Hospitals were able to implement the standards in about six months, which is a pretty rapid timeline, and they had high levels of both full and partial compliance.”
Study co-authors are Meixi Ma, MD, MS; Lindsey M. Zhang, MD, MS; Kataryna Christensen, BS; and Clifford Y. Ko, MD, MS, MSHS, FACS, FASCRS, with the American College of Surgeons, Division of Research and Optimal Patient Care, Chicago; Melissa Hornor, MD, MS, of Loyola University Medical Center, Department of Surgery; JoAnn Coleman, DNP, ANP, ACNP, AOCN, and Mark Katlic, MD, MMM, FACS, of Sinai Hospital, Sinai Center for Geriatric Surgery, Baltimore; Emily Finlayson, MD, MS, University of California San Francisco (UCSF), Department of Surgery; Kellie L. Flood, MD, of the University of Alabama at Birmingham Medical Center (UABMC), Department of Medicine, Division of Geriatrics, Hospice and Palliative Care; Sandhya Lagoo-Deenadayalan, MD, PhD, FACS, of Duke University, Department of Surgery, Durham, N.C.; Thomas N. Robinson, MD, MS, FACS, University of Colorado, Department of Surgery, Aurora; Ronnie A. Rosenthal, MD, MS, FACS, of Yale University, Department of Surgery, New Haven, Conn.; and Victoria L. Tang, MD, MAS, of the UCSF, Division of Geriatrics, Department of Medicine. Dr. Ma is also with UABMC, Department of Surgery; Dr. Zhang is also with the University of Chicago Medical Center, Department of Surgery. Dr. Ko is also with UCLA, Department of Surgery.
The study was supported by a grant from the John A. Hartford Foundation. Drs. Peters, Ma and Zhang were supported with funding from the foundation. The remaining authors have no relevant disclosures to report.
This article is published as an article in press on the JACS website.
Citation: Multi-Site Implementation of an American College of Surgeons Geriatric Surgery Quality Improvement Initiative. Journal of American College of Surgeons. DOI: 10.1097/XCS.0000000000000723.
