Key Takeaways
A new study provides evidence for a seven-component perioperative protocol designed specifically for patients aged 65 and older.
The protocol includes delirium prevention and screening, minimization of high-risk medications, fall prevention, aspiration precautions, frequent use of incentive spirometry to expand the lungs and prevent pneumonia, and a bowel regimen to prevent constipation.
Implementing these steps is associated with better outcomes, including reduced complications and shorter hospital stays.
CHICAGO — When care teams screen older adults undergoing surgery for risk factors such as falls and delirium, they are able to improve the care and outcomes of this rapidly growing and uniquely vulnerable patient population, according to findings published in the Journal of the American College of Surgeons (JACS).
The components addressed in the study form the basis of the American College of Surgeons (ACS) Geriatric Surgery Verification (GSV) Program's older adult enhanced recovery protocol, which focuses on preventing common complications like delirium , falls, and pneumonia. By addressing these risks, the protocol can help older patients recover safely and return to their daily lives as quickly as possible.
"Surgery can be a challenging experience at any age, but older adults often face a higher risk of complications such as delirium, falls, or a prolonged recovery," said Sarah Remer, MD, lead author of the study, Clinical Scholar at the American College of Surgeons, and a general surgery resident at Loyola University Medical Center. "Our review suggests that when hospitals take proactive, targeted steps, such as routinely screening for delirium and carefully reviewing medication, we can make a real difference in helping our older patients get back to what matters most to them."
The seven components of the GSV protocol are:
Delirium prevention
Routine delirium screening
Minimization of potentially inappropriate medications
Fall prevention
Aspiration precautions
Frequent use of incentive spirometry , which is a simple breathing exercise using a handheld device to keep the lungs clear and prevent pneumonia.
Bowel regimen, which is a proactive plan using diet, fluids, and sometimes medications to prevent post-surgical constipation
Study Results
Researchers analyzed 67 studies on seven key components of older adult surgical care.
Fall prevention had the strongest evidence. Programs that proactively address risk factors have been shown to reduce fall rates, shorten hospital stays, and result in significant cost savings.
Delirium prevention and screening also have strong evidence. Using standardized tools to identify and manage confusion early, especially when combined with prevention strategies, is associated with better outcomes.
Aspiration precautions and the frequent use of incentive spirometry are associated with reductions in hospital-acquired pneumonia. Bowel regimens were associated with lower rates of gastrointestinal complications.
"This isn't just about checking boxes," Dr. Remer said. "This is about recognizing that older adults have unique perioperative needs. Valid and feasible steps such as making sure eyeglasses and hearing aids are available or starting a simple bowel regimen can prevent complications and improve recovery in older adult surgical patients"
Building on a Strong Foundation of Evidence
The findings build upon a growing body of research demonstrating the value of the ACS GSV Program. The program requires hospitals to implement standards that address the specific needs of older adults.
"This comprehensive review validates what we've seen in practice: the ACS Geriatric Surgery Verification Program provides a standardized, evidence-based approach that transforms outcomes," said Clifford Y. Ko, MD, MS, MSHS, FACS, Senior Vice President, Division of Research and Optimal Patient Care at the American College of Surgeons. "By distilling a vast body of research into a practical protocol, we give hospitals a powerful tool to address the specific vulnerabilities of older adults, leading directly to safer care and shorter recoveries. The ACS also offers a free Geriatric Surgery Patient Checklist to help guide conversations with surgical teams and ensure high-quality, personalized care."
To help hospitals put this evidence into practice on the frontlines, the ACS also offers the EPoSSI tool, the Early Planning of Small-Scale Surgical Improvement framework, which provides surgical teams with a proven, step-by-step method to implement better care.
Previous studies have shown that implementing GSV standards leads to better outcomes for older surgical patients:
Shorter hospital stays and lower rates of postoperative delirium during a beta test of the GSV program at a Veterans Affairs hospital.
Higher rates of patients maintaining their independence and shorter hospital stays after major cancer surgery after implementation of the GSV program at a community hospital.
A 50% reduction in postoperative death rates , along with improved documentation of patient care preferences reported by hospitals participating in the GSV program.
One fewer day in the hospital on average and a 50% lower risk of complications such as respiratory failure and sepsis with a dedicated geriatric surgical pathway with GSV-aligned practices.
Co-authors are Caroline Smolkin, MD; Ronnie Rosenthal, MD; Clifford Y. Ko, MD, MSHS, MS; and Marcia M. Russell, MD.
This study is published as an article in press on the JACS website.
Disclosures: Dr. Remer and Dr. Smolkin were supported in part by The John A. Hartford Foundation.
Citation: Remer S, Smolkin C, Rosenthal R, Ko C, Russell M. Scoping Review for the American College of Surgeons Geriatric Surgery Verification Program Perioperative Older Adult Enhanced Recovery Program. Journal of the American College of Surgeons, 2026. DOI: 10.1097/XCS.0000000000001942
