Let It Rain: The American College of Surgeons Geriatric Surgery Verification Program Article Swipe

As our hospital has been building its Geriatric Surgery Verification (GSV) Program, the newest standards-and-verification quality program of the American College of Surgeons,1, 2 I have repeatedly noticed the same phenomenon: Just beneath the surface, maybe not even overtly recognized, we have been hungry for these changes in the way that we care for older adults. It is as if we were a field in the time of drought, a field appearing to be barren but, with the arrival of rain, becomes profuse with wildflowers, with new life (Figure 1). So, let it rain. Just beneath the surface is the feeling that, although we are caring well for our older adult patients, we are not caring optimally, we could be doing more. I have recognized this in nurses, respiratory therapists, physicians, and others on the front line of care. The pandemic probably made us all more sensitive to this feeling as our older adults were disproportionately affected by hospitalization and severe visitor restrictions. There is excitement around the GSV as it seems to have provided the push needed to bring about even better care, to make standard some processes that were being done occasionally, to nourish the Geriatrics experts who have sometimes felt like voices in the wilderness. Among the 30 GSV standards (Table 1), for example, is the mandate for a life-sustaining treatment discussion for patients with planned intensive care unit (ICU) admission; this must be documented in the medical record and revisited at least every 3 days. Our ICU providers and nurses, stating that they have wanted this for years but just needed a push, have already instituted this. Standard 5.10 states that there must be a process that guarantees safe storage and return of personal sensory equipment (eyeglasses, hearing aids, dentures), items usually removed at the most frightening time for the older adult, just when he or she is about to be rolled to the operating room (OR), effectively blind and deaf. Our process, incorporating watertight plastic boxes that can be kept with the patient at all times, will allow individuals to wear these items until they are on the operating room table and sedated and then promptly put back on when they arrive in the recovery room. Although some standards, such as vulnerability screens for cognition and frailty and more, will be used principally in the age 75 and older group, many of the standards will be immediately rolled out to the entire hospital population. A goals-of-care discussion will become standard for all patients offered an operation, twice-daily confusion assessment method screening will affect medical and surgical patients, and palliative care consultation will become more common. These changes will be welcomed by geriatricians, who will now have a large group of surgeons on their side, surgeons who have seen the light and "get it." Patients and families will applaud the leave-no-stone-unturned compulsive multidisciplinary care. No one was consciously ignoring these issues. Many just needed a small push, a little pressure from a few respected surgeons, a blueprint for implementation (the standards book is a free download from the American College of Surgeons website, facs.org/geriatrics). Our hospital president became an enthusiast after one meeting, welcoming the improvements in patient care and believing that the institution of this low-tech/high-touch program stands to improve the morale of all staff, needed even more in a pandemic world. The cost of the program is less than that of one episode of postoperative delirium. I have built a number of programs in the 35 years since my residency, but none has generated the devotion that the GSV has. Nurses volunteered to be champions on their units, Information Technology prioritized the construction of an electronic health record infrastructure, staff deliberated about potential community outreach projects, and small groups brainstormed about imaginative ways to meet certain standards. I give a suggestion now and then, but the energy is spontaneous; I am not even our program Director. So, geriatricians and others: Find a surgeon champion in your hospital, teach him or her what you have known your entire career, and let it rain. Dr Katlic is Chair of the Standards and Verification Committee of the American College of Surgeons Geriatric Surgery Verification Program and was part of the program's Core Development Group. The author is solely responsible for the content of this editorial. The opinions expressed are his own. The John A. Hartford Foundation generously supported development of the GSV program nationally. There is no sponsor for the program at Sinai Hospital or for this editorial.