Geriatric Surgery Research Articles

Ensuring goal-aligned care in a busy surgical practice

The US population is aging. Accordingly, older adults with multiple comorbidities and geriatric syndromes will present in increasing numbers for surgical consultation. Incorporating patient goals into surgical treatment decisions is recommended by a joint guideline from the American Geriatrics Society and American College of Surgeons, the American Society of Colon and Rectal Surgeons, the Geriatric Surgery Verification program, and the Institute for Healthcare Improvement as part of building Age-Friendly Health Systems, however uptake has been slow. The aim of this review is to provide a framework for how patient goals can be elicited and used in real-world surgical practices to achieve goal-aligned care.

Priority areas for outcomes improvement among older adults undergoing inpatient general surgery inclusive of geriatric-pertinent complications.

Comprehensive studies on priority areas for improving geriatric surgery outcomes, inclusive of geriatric-pertinent data, are limited. The ACS NSQIP geriatric database (2014-2018) was used to abstract older adults (≥65years) undergoing inpatient general surgery procedures. Thirty-day complication, functional decline, and mortality rates were analyzed, with a focus on two geriatric-pertinent complications: delirium and new/worsening pressure ulcers. There were 9062 patients; 41.9% were ≥75years. Mean age was 73.9years. The majority of patients were female (54.0%), White (77.7%), and had independent functional status before surgery (94.0%). Overall 30-day complication, functional decline, and mortality rates were 33.6%, 34.5%, and 3.5%, respectively; failure to the rescue rate was 9.7%. Including geriatric-pertinent complications increased the overall complication rate by 20.4%. Delirium emerged as the leading complication (11.9%), followed by bleeding (11.1%), and wound-related complications (10.1%); these three accounted for 53.7% of complications. Delirium and pressure ulcers were associated with a >50% rate of postoperative functional decline (52.0% and 71.4%, respectively); pressure ulcers were also notable for a 25.5% failure to the rescue rate. Both were also among complications most likely to occur following the 3 most common procedures (colorectal surgery, pancreatic resections, and exploratory laparotomy), which overall accounted for approximately 79.6% of complications, 73.4% of patients experiencing functional decline, and 82.3% of mortality. Delirium is the leading complication among older adults undergoing inpatient surgery. Overall, a small number of complications and procedure groups account for most surgical morbidity and mortality among older adults and thus constitute priority areas for outcomes improvement.

Meta-Research in Geriatric Surgery: Improving the Quality of Surgical Evidence for Older Persons in a Multidimensional-Scale Research Field.

The world is facing a significant demographic transition, with a substantial increase in the proportion of older persons, as well as long-lived persons (especially nonagenarians and centenarians). One of the popular beliefs is that old age is synonymous with disease and disability. However, the successful aging hypothesis suggests that those older persons with advanced chronological age who maintain their functional capacity derive from it a delay in biological aging, enhancing the quality of organic aging and regulation. Therefore, regardless of chronological age, even in cases of extreme longevity, those older adults with a successful aging phenotype and favorable functional capacity would be expected to have satisfactory post-surgical recovery with a low risk of morbidity and mortality. Currently, there is a significant gap between the availability of high-certainty surgical evidence that allows for evidence-based interventions applicable to the long-lived population-taking into account the actual conditioning factors of the health phenotype in older persons-and, above all, predictors of satisfactory post-surgical evolution. The application of meta-research to geriatric surgery emerges as a fundamental tool to address this knowledge gap and reveals opportunities and limitations that need to be resolved in the near future to establish evidence-based surgical care for older persons. The aim of this manuscript was to present a real and globally relevant scenario related to surgical care, addressing the longevity, the availability, and the quality of surgical evidence applicable to this population, and also to present variables to consider in analysis and future perspectives in research and meta-research in geriatric surgery.

Octogenarians unable to return home by postoperative-day 30

BackgroundFor older adults undergoing surgery, returning home is instrumental for functional independence. We quantified octogenarians unable to return home by POD-30, assessed geriatric factors in a predictive model, and identified risk factors to inform decision-making and quality improvement. MethodsThis retrospective cohort study examined patients ≥80 years old from the ACS NSQIP Geriatric Surgery Pilot, using sequential logistic regression modelling. The primary outcome was non-home living location at POD-30. ResultsOf 4946 patients, 19.8 ​% lived in non-home facilities at POD-30. Increased odds of non-home living location were seen in patients with preoperative fall history (OR 2.92, 95%CI 2.06–4.14) and new postoperative pressure ulcer (OR 2.66, 95%CI 1.50–4.71) Other significant geriatric-specific risk factors included mobility aid use, surrogate-signed consent, and postoperative delirium, with odds ratios ranging from 1.42 (1.19–1.68) to 1.97 (1.53–2.53). ConclusionsThese geriatric-specific risk factors highlight the importance of preoperative vulnerability screening and intervention to inform surgical decision-making.

Development and implementation of a geriatric nursing program at an academic medical center

Brigham and Women's Hospital, a leader in geriatric surgery, was awarded Geriatric Surgery Verification by the American College of Surgeons. This award demonstrates its expertise in meeting the specialized needs of older adults in the perioperative period to optimize their surgical outcomes and experience. Among the program's standards is implementing the geriatric nurse champion role and education in alignment with the Nurses Improving Care for Healthsystem Elders (NICHE) practice model. In this month's NICHE column, nurse leaders from Brigham and Women's Hospital describe its path to achieving Geriatric Surgery Verification and implementing the NICHE practice model in the perioperative setting.

Chinese expert consensus on perioperative nutritional support for elderly surgical patients (2024)

The increasing aging population in China leads to an increase in the number of elderly patients undergoing surgical procedures. Elderly patients are characterized with conditions such as multiple comorbidities, high nutritional risk, frailty, decreased organ function, etc. Nutritional support is one of the most significant elements in the perioperative period of elderly surgical patients. Currently, there is a lack of guidelines or expert consensus on nutritional support. To promote the standardized development of clinical work in this field, the Geriatric Surgery Professional Committee of the Chinese Research Hospital Association gathered experts and formulated relevant recommendations for perioperative nutritional therapy for elderly surgical patients based on existing research evidence. This consensus included several parts: preoperative nutritional assessment, indications, goals, ingredients and approaches of perioperative nutritional support, nutritional complications and management, nutritional intervention for surgical complications, and nutritional follow-up. It is expected to provide valuable suggestions for standardizing nutritional support for elderly surgical patients.

The impact of geriatric-specific variables on long-term outcomes in patients with hepatopancreatobiliary and colorectal cancer selected for resection

BackgroundPreoperative geriatric-specific variables (GSV) influence short-term morbidity in surgical patients, but their impact on long-term survival in elderly patients with cancer remains undefined. Study designThis observational cohort study included patients ≥65 years who underwent hepatopancreatobiliary or colorectal operations for malignancy between 2014 and 2020. Individual patient data included merged ACS NSQIP data, Procedure Targeted, and Geriatric Surgery Research variables. Patients were stratified by age: 65–74, 75–84, and ≥85 and presence of these GSVs: mobility aid, preoperative falls, surrogate signed consent, and living alone. Bivariable and multivariable analyses were used to evaluate 1-year mortality and postoperative discharge to facility. Results577 patients were included: 62.6 % were 65–74 years old, 31.7 % 75–84, and 5.7 % ≥ 85. 96 patients were discharged to a facility with frequency increasing with age group (11.4 % vs 22.4 % vs 42.4 %, respectively, p < 0.001). 73 patients (12.7 %) died during 1-year follow-up, 32.9 % from cancer recurrence. One-year mortality was associated with undergoing hepatopancreatobiliary operations (p = 0.017), discharge to a facility (p = 0.047), and a surrogate signing consent (p = 0.035). Increasing age (p < 0.001), hepatopancreatobiliary resection (p = 0.002), living home alone (p < 0.001), and mobility aid use (p < 0.001) were associated with discharge to a facility. ConclusionGeriatric-specific variables, living alone and use of a mobility aid, were associated with discharge to a facility. A surrogate signing consent and discharge to a facility were associated with 1-year mortality. These findings underscore the importance of preoperative patient selection and optimization, efficacious discharge planning, and informed decision-making in the care of elderly cancer patients.

Implementation of a Multidisciplinary Team to Improve the Quality of Care for Older Surgical Patients at a Rural Academic Medical Center.

For the first time in history, people age older than 65 years make up >20% of the non-metro population, compared with 16% of the metro population. From 2010 to 2020 the nonmetro population age older than 65 years grew by 22%, while the working-age population declined by 4.9%, and the population aged under 18 years declined by 5.7%.1,2 Multidisciplinary geriatric surgical programs are an increasingly recognized approach to the care of older surgical patients and preliminary data suggest they can reduce length of stay. Although rural areas have the greatest proportion of patients age older than 65 years, implementation of such programs faces special challenges in rural settings with limited resources. Dartmouth-Hitchcock Medical Center is one of the most rural academic centers in the United States. Challenges include a shortage of geriatric-trained providers, long distances to access primary care and subspecialists, and extremely limited postacute care options and skilled nursing facility beds. To address the unique needs of our provider and patient population we began with a development period where we conducted stakeholder interviews. Using these data, we mapped out a workflow and developed pilot projects to address different portions of the workflow, such as preoperative screening for frailty and cognitive impairment, interdisciplinary weekly case conferences, proactive case management, delirium and geriatric surgery postoperative pathway order sets, and a variety of tools for reorientation and delirium management. Herein we describe the process of development and pragmatic clinical implementation of geriatric-focused care for older surgical patients in our rural tertiary center, including some of the main challenges we faced and the strategies we undertook to overcome them, and some of our early patient centered and clinical outcomes. This information may assist other institutions as they design geriatric-focused surgical programs to address the growing population of older adults and the need for compliance with state legislation. The clinical program described is not a research study, and the outcome data we report is for the purpose of description, and should not be interpreted as a rigorous research investigation of the effect of our intervention.

Preoperative Risk Factors for Discharge to Facility After Surgery in Geriatric Patients.

The Geriatric Surgery Verification Program (GSV) was developed to address perioperative care for patients ≥75 years, with a goal of improving outcomes and functional abilities after surgery. We sought to evaluate preoperative factors that place patients at risk for inability to return home (ie, discharge to a facility). Retrospective review of patients ≥75 years old who underwent inpatient surgery from January 2018 to December 2022 at a referral Veterans Administration Medical Center enrolled in the GSV program. Preoperative factors included fall history, mobility aids, housing status, function, cognition, and nutritional status. Postoperative outcomes were discharge designations as home and home with services compared to a facility (skilled nursing facility and acute rehab). Exclusion criteria included preoperative facility residence, cardiac surgery, hospital transfer, postoperative complications, hospice discharge, or in-hospital mortality. 605 patients met inclusion criteria and 173 (29%) excluded as above. Of the remaining 432 patients, mean age was 79 ± 5 and the majority were male, 426 (99%). The majority of patients were discharged home, 388 (90%), compared to a facility, 44 (10%). Patients with a fall history (OR: 2.95, 95% CI: 1.56, 5.57), utilizing a mobility aid (OR: 6.0, 95% CI: 2.8, 12.83), were partial or totally dependent (OR: 4.83, 95% CI: 2.29, 10.17), or who lived alone (OR: 2.57, 95% CI: 1.08, 6.07) had higher rates of discharge to a facility. Preoperative mobility compromise and functional dependence are associated with higher rates of discharge to a facility. These preoperative factors are possibly modifiable with multidisciplinary care teams to decrease risks of facility placement.

Making a Financial Case for the Geriatric Surgery Verification Program.

Mini abstract The financial benefits of instituting the American College of Surgeons Geriatric Surgery Verification Program far exceed the costs, with the added benefits of enhanced patient satisfaction and improved staff morale.

Clin-STAR corner: Practice-changing advances at the interface of surgery and geriatrics.

Older adults who undergo major operations are at high risk for complications, disability, and death. The physio-social compromises unique to older adults are not routinely assessed and managed in the perioperative setting. Currently, the most practice-changing topic nationally in geriatric surgery is the implementation of comprehensive, multidisciplinary geriatric care pathways to provide age-friendly care for older adults throughout their perioperative course. This review presents three recently published articles focused on defining evidence-based outcomes associated with implementation of a comprehensive geriatric surgery program for older adults undergoing major inpatient operations. These studies serve as the initial evidence evaluating the efficacy and effectiveness of comprehensive perioperative geriatric surgery programs. Each study was chosen due to their high potential for meaningful impact for both clinicians and healthcare systems looking to improve their surgical care of older adults.

Association of risk analysis index with 90-day failure to rescue following major abdominal surgery in geriatric patients

Failure to rescue (FTR) is a quality metric defined as mortality after potentially preventable complications after surgery. Predicting patients who are at the highest risk of mortality after a complication may aid in preventing deaths. Thirty-day follow-up period inadequately captures postoperative deaths; alternatively, a 90-day follow-up period has been advocated. This study aimed to examine the association of a validated frailty metric, the risk analysis index (RAI), with 90-day FTR (FTR-90). Patients aged ≥65 years who underwent a major abdominal operation between 2014 and 2020 at a quaternary care center were abstracted. Institutional data were merged with the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) and Geriatric Surgery Research File variables. The association between RAI and FTR-90 was evaluated using multivariable logistic regression. A total of 398 patients with postoperative complications were included. Fifty-two patients (13.1%) died during the 90-day follow-up. The FTR-90 group was older (median age: 76 vs 73 years, respectively; P=.002), had a greater preoperative American Society of Anesthesiologists classification score (P<.001), and had a higher ACS NSQIP estimated risk of morbidity (0.33% vs 0.20%, P<.001) and mortality (0.067% vs 0.012%, P<.001). The FTR-90 group had a greater median RAI score (23 vs 19; P=.002). The RAI score was independently associated with FTR-90 (odds ratio, 1.04; 95% CI, 1.0042-1.0770; P=.028) but not with FTR-30 (P=.13). Preoperative frailty, as defined by RAI, is independently associated with FTR at 90-day follow-up. FTR-90 captured nearly 60% more deaths than did FTR-30. Frailty has major implications beyond the typical 30-day follow-up period, and a longer follow-up period must be considered.

Assessing performance of Geriatric Surgery Verification Program preoperative communication standards in spine surgery.

To assess performance of the American College of Surgeons Geriatric Surgery Verification (GSV) Program preoperative communication standards in older patients undergoing high risk spine surgery. We performed an external validation of a natural language processing (NLP) method for identifying documentation meeting GSV communication standards. We then applied this method to a retrospective cohort of patients aged 65 and older who underwent spinal fusion procedures between January 2018-December 2020 in a large healthcare system in Massachusetts. Our primary outcome of interest was fulfillment of GSV communication domains: overall health goals, treatment goals, and patient-centered outcomes. Factors associated with the fulfillment of at least one domain were assessed using Poisson regression to adjust for confounding. External validation of the NLP method had a sensitivity of 88.6% and specificity of 99.0%. Our study population included 1294 patients, of whom only 0.8% (n = 10) patients contained documentation of all three GSV domains, and 33.7% (n = 436) had documentation fulfilling at least one GSV domain. The GSV domain with lowest frequency of documentation was overall health goals, with only 35 (2.7%) of patients meeting this requirement. Adjusted analysis suggested that patients with a Charlson comorbidity score of one or more had higher fulfillment of GSV criteria (CCI 1-3: prevalence rate ratio (PRR) 1.8, 95% confidence interval (CI) 1.5-2.1; CCI >3: PRR 1.5, 95% CI 1.2-1.9). A paucity of geriatric patients undergoing spine surgery had preoperative documentation consistent with GSV standards. Given that spine surgery is one of the highest risk surgeries in older adults and GSV standards are relevant to all surgical specialties, wider promulgation of these standards is warranted.

44 A Case Study of Non-Alcoholic Wernicke’s Encephalopathy in a Young Man with Intractable Vomiting

Objective:Wernicke’s encephalopathy (WE) is an acute neurological condition caused by thiamine deficiency. The typical presentation is characterized by a triad of oculomotor abnormalities, gait ataxia, and altered mental status, though patients rarely present with all three symptoms. WE is a serious medical condition that is associated with high rates of morbidity and mortality if left untreated. It is most commonly seen in patients with severe alcohol use disorder; however, it has also been found in patients with thiamine deficiency due to other causes of malnutrition such as prolonged starvation, hyperemesis, dialysis, cancer, and geriatric surgery. Despite growing research demonstrating WE in non-alcoholic populations, it is frequently misdiagnosed in patients without an extensive alcohol-use history, particularly when they do not present with the typical clinical triad of symptoms. Thus, more knowledge about non-alcoholic WE is needed to improve diagnostic accuracy.Participants and Methods:We present a case of a 26-year-old male with an unremarkable alcohol use history, who was diagnosed with WE following a 6-week period of excessive nausea and vomiting of unclear etiology. He presented to the ED three times prior to his diagnosis, and was treated with intravenous hydration, Zofran, and Pepcid. He presented to the ED for the fourth time with altered mental status and gait ataxia and was diagnosed with WE based on MRI findings. He was admitted and treated with high doses of IV thiamine and folate. His clinical course was tracked over time via outpatient neurology examinations, and his cognitive functioning was assessed with an outpatient neuropsychological evaluation approximately six months post-discharge. Record review, including clinical notes, lab tests, and imaging results supplement his outpatient neuropsychological evaluation performance.Results:Data from a comprehensive outpatient neuropsychological evaluation approximately six months after WE diagnosis is presented. His cognitive profile was characterized by impaired performance on measures of verbal fluency and memory, including encoding and retention of verbal and visual information (with minimal benefit from cueing). Given these impairments and continued functional declines related to cognitive deficits, he met criteria for a Major Neurocognitive Disorder. These results demonstrate persistent cognitive deficits beyond the acute WE period.Conclusions:WE is a serious neurological condition that can have lasting cognitive effects if left untreated. This case demonstrates persistent cognitive impairments six months after WE diagnosis in a young patient with an unremarkable alcohol history. These findings highlight the necessity of increased diagnostic efficiency of WE in non-alcoholic patients, as immediate thiamine treatment is essential to the recovery process. Neuropsychological functioning at a longer interval will be useful in further elucidating cognitive prognosis as well as providing quality of life recommendations.

New Onset Geriatric Syndromes and One-year Outcomes Following Elective Gastrointestinal Cancer Surgery.

To assess whether older adults who develop geriatric syndromes following elective gastrointestinal surgery have poorer 1-year outcomes. Within 10 years, 70% of all cancers will occur in older adults ≥65 years old. The rise in older adults requiring major surgery has brought attention to age-related complications termed geriatric syndromes. However, whether postoperative geriatric syndromes are associated with long-term outcomes is unclear. A population-based retrospective cohort study using the New York State Cancer Registry and the Statewide Planning and Research Cooperative System was performed including patients >55 years with pathologic stage I-III esophageal, gastric, pancreatic, colon, or rectal cancer who underwent elective resection between 2004 and 2018. Those aged 55 to 64 served as the reference group. The exposure of interest was a geriatric syndrome [fracture, fall, delirium, pressure ulcer, depression, malnutrition, failure to thrive, dehydration, or incontinence (urinary/fecal)] during the surgical admission. Patients with any geriatric syndrome within 1 year of surgery were excluded. Outcomes included incident geriatric syndrome, 1-year days alive and out of the hospital, and 1-year all-cause mortality. In this study, 37,998 patients with a median age of 71 years without a prior geriatric syndrome were included. Of those 65 years or more, 6.4% developed a geriatric syndrome. Factors associated with an incident geriatric syndrome were age, alcohol/tobacco use, comorbidities, neoadjuvant therapy, ostomies, open surgery, and upper gastrointestinal cancers. An incident geriatric syndrome was associated with a 43% higher risk of 1-year mortality (hazard ratio, 1.43; 95% confidence interval, 1.27-1.60). For those aged 65+ discharged alive and not to hospice, a geriatric syndrome was associated with significantly fewer days alive and out of hospital (322 vs 346 days, P < 0.0001). There was an indirect relationship between the number of geriatric syndromes and 1-year mortality and days alive and out of the hospital after adjusting for surgical complications. Given the increase in older adults requiring major surgical intervention, and the establishment of geriatric surgery accreditation programs, these data suggest that morbidity and mortality metrics should be adjusted to accommodate the independent relationship between geriatric syndromes and long-term outcomes.

Preoperative Code Status Discussion Workflows: Targets for Improvement in Multidisciplinary Pathways.

Discussion of perioperative code status is an important element of preoperative care and a component of the American College of Surgeons' Geriatric Surgery Verification (GSV) program. Evidence suggests code status discussions (CSDs) are not routinely performed and are inconsistently documented. Because preoperative decision making is a complex process spanning multiple providers, this study aims to utilize process mapping to highlight challenges associated with CSDs and inform efforts to improve workflows and implement elements of the GSV program. Using process mapping, we detailed workflows relating to (CSDs) for patients undergoing thoracic surgery and a possible workflow for implementing GSV standards for goals and decision-making. We generated process maps for outpatient and day-of-surgery workflows relating to CSDs. In addition, we generated a process map for a potential workflow to address limitations and integrate GSV Standards for Goals and Decision Making. Process mapping highlighted challenges associated with the implementation of multidisciplinary care pathways and indicated a need for centralization and consolidation of perioperative code status documentation.

Shared Decision Making in the Geriatric Surgery Verification Program: Assessing Baseline Performance.

As part of the launch of the Geriatric Surgery Verification program in 2019, the American College of Surgeons issued care standards for older patients, including requirements for preoperative documentation of patients' goals. Hospital performance on these standards prior to the Geriatric Surgery Verification program is unknown. To assess baseline performance of the Geriatric Surgery Verification (GSV) standard for documentation of preoperative goals for older patients, and to determine factors associated with standard adherence. Using natural language processing, this study examines the electronic health records of patients aged 65 years or older who underwent coronary artery bypass grafts (CABG) or colectomies in 2017 or 2018 at three hospitals. The primary outcome was adherence to at least one of the three components of GSV Standard 5.1, which requires preoperative documentation of overall health goals, treatment goals, and patient-centered outcomes. A total of 2630 operations and 2563 patients were included. At least one component of the standard was met in 307 (11.7%) operations and all three components were met in 5 (0.2%). Higher likelihood of meeting the standard was demonstrated for patients who were female (odds ratio [OR] 1.30; 95% CI 1.00-1.68), undergoing colectomy (OR 2.82; 95% CI 2.15-3.72), or with more comorbidities (Charlson scores >3 [OR 1.55; 95% CI 1.14-2.09]). Before GSV program implementation, clinicians for two major operations almost never met the GSV standard for preoperative discussion of patient goals. Interdisciplinary teams will need to adjust clinical practice to meet best-practice communication standards for older patients.

Implementation of a Multispecialty Geriatric Surgery Pathway Reduces Inpatient Cost for Frail Patients.

The objective of this study was to evaluate the effect of geriatric surgical pathway (GSP) implementation on inpatient cost of care. Achieving high-value care for older patients is the goal of the American College of Surgeons Geriatric Verification Program (ACS-GSV). We have previously shown that implementation of our geriatric surgery pathway, which aligns with the ACS-GSV standards, resulted in a reduction in loss of independence and complications. Patients ≥65 years who underwent an inpatient elective surgical procedure included in the American College of Surgeons National Quality Improvement Program (ACS NSQIP) registry from July 2016 through December 2017 were compared with those patients from February 2018 to December 2019 who were cared for on our GSP. An amalgamation of Clinformatics DataMart, the electronic health record, and the ACS NSQIP registry produced the analytical dataset. We compared mean total and direct costs of care for the entire cohort as well as through propensity matching of frail surgical patients to account for differences in clinical characteristics. The total mean cost of health care services during hospitalization was significantly lower in the cohort on our GSP ($23,361±$1110) as compared with the precohort ($25,452±$1723), P <0.001. On propensity-matched analysis, cost savings was more evident in our frail geriatric surgery patients. This study shows that high-value care can be achieved with the implementation of a GSP that aligns with the ACS-GSV program.

Multi-Site Implementation of an American College of Surgeons Geriatric Surgery Quality Improvement Initiative.

The American College of Surgeons (ACS) Coalition for Quality in Geriatric Surgery (CQGS) identified standards of surgical care for the growing, vulnerable population of aging adults in the United States. The aims of this study were to 1) determine implementation feasibility for 30 selected standards, 2) identify barriers and best practices in their implementation, and 3) further refine these geriatric standards and verification process. The CQGS requested participation from hospitals involved in the ACS National Surgical Quality Improvement Project (NSQIP) Geriatric Surgery Pilot Project, prior CQGS feasibility analyses, and hospitals affiliated with a core development team member. 30 standards were selected for implementation. Following implementation, site visits were conducted, and post-visit surveys were distributed. Eight hospitals were chosen to participate. Program management (55%), immediate preoperative and intraoperative clinical care (62.5%), and postoperative clinical care (58%) had the highest mean percentage of "Fully Compliant" standards. Goals and decision making (30%), preoperative optimization (28%), and transitions of care (12.5%) had the lowest mean percentage of "Fully Compliant" standards. Best practices and barriers to implementation were identified across 13 of the 30 standards. Over 80% of the institutions reported that participation changed the surgical care provided for older adults. This study represents the first national implementation assessment undertaken by the ACS for one of its quality programs. The CQGS pilot testing was able to demonstrate implementation feasibility for 30 standards, identify challenges and best practices, and further inform dissemination of the ACS Geriatric Surgery Verification Program.

Frailty, Meeting Challenges, and Beyond in Geriatric Surgery—10 Years' Experience From Singapore's First Geriatric Surgical Service

This article gives an overview of the 10 years' experience of the first dedicated geriatric surgery service in Khoo Teck Puat Hospital, Singapore. Frailty and its adverse impact on emergency and elective surgical procedures are elaborated and strategies to optimize outcomes explained. Via transdisciplinary transinstitutional collaboration, geriatric surgery service instituted trimodal intervention of prehabilitation, nutrition, and psychological support for frail patients, achieved consistent perioperative results, shortened length of hospital stay, and restored baseline function for patients undergoing major elective oncological surgery. Efforts are made to teach transdisciplinary collaboration to the next generation of doctors to meet the challenges of the Era of Geriatric Surgery.