Newswise — CHICAGO (November 29, 2018): Surgical teams now have four new tools to help them improve outcomes for their patients in the form of screening checklists from the American College of Surgeons (ACS) Strong for Surgery program (S4S). The four common risk areas targeted in the new checklists address these issues:   

The recognition and treatment of delirium is critically important because postoperative delirium is associated with poor outcomes including functional decline, longer hospitalization, institutionalization, greater costs, and higher mortality. Studies have shown that age, alcohol abuse, poor cognitive and physical functioning, and abnormal laboratory values have been associated with delirium. High-risk patients identified for exhibiting some of the risk criteria can be candidates for interventions designed to prevent or reduce the impact of postoperative delirium.

Cognitive, gait, balance, and nutritional and functional impairments place patients at higher risk of perioperative and postoperative complications. Prehabilitation is an opportunity to help patients return quickly to the highest level of functioning possible after operation, thereby reducing surgery‚Äźrelated morbidity and/or mortality, decreasing the length of stay in hospital and rehabilitation, and reducing readmissions.

Pain Management
Unrelieved pain can result in longer hospital stays, increased rate of readmission, increased outpatient visits, and decreased ability to function fully. To ensure safe, effective pain management after the surgical procedure, it is recommended that patients receive counseling prior to their operations about pain management options. Presurgery counseling with patients that involves expectation setting, potential adverse effects, and the use of non-prescribed medication for pain relief can help patients set realistic goals for recovery.

Patient Directives
An important aspect of patient safety is patient education. Patient education before surgery helps minimize presurgery anxiety related to the operation itself. During this time, discussion referencing the financial burden, post-procedure pain, surgical risks and the necessity of the procedure are also important. The patient should feel supported in the preoperative period and should be encouraged to express his or her feelings about the surgical experience.


Checklists, which are the cornerstone of S4S, are integrated into the preoperative phase of clinical practice for elective operations by surgeons and surgical staff. By screening patients for potential risk factors that can lead to surgical complications, these checklists open the door for appropriate interventions to ensure better outcomes for patients. Global research has shown that use of a checklist improves patient optimization for an operation and helps ensure that important aspects of care are followed for each case.

S4S was originally developed by surgeons across Washington State under the leadership of Thomas K. Varghese, Jr., MD, FACS.  In 2017 it became a public health initiative offered by ACS that applies these evidence-based practices to educate patients about steps they may take to help improve their surgical outcomes, and thus, reduce complications.

“Strong for Surgery brings a well-researched presurgery checklist to surgeons' offices to help with patient education, communication, and standardization of best practices to improve clinical outcomes.  A patient’s risk of negative outcomes from an operation can be improved by using best practices to prepare them for an operation, and we’re starting to see study results where these checklists have helped to do just that,” said Dr. Varghese, head of the section of general thoracic surgery, division of cardiothoracic surgery at the University of Utah.

For the last few years, these checklists have targeted four areas known to be highly influential determinants of surgical outcomes: nutrition, glycemic control, medication management, and smoking cessation. The new checklists represent a much-anticipated expansion of the program. 

“These new checklists expand the tools of quality improvement for surgical teams working to optimize patient care before operations.  These tools have been added to the S4S toolkit to ensure that four more important aspects of surgical care are addressed for patients,” said Clifford Y. Ko, MD, FACS, Director of the ACS Division of Research and Optimal Patient Care, which administers the Strong for Surgery Program.  “Based on improved outcomes we’ve seen in hospitals using the first four checklists, we think that the benefits to patients will continue to be apparent.”

For further information on participating in Strong for Surgery visit:


About the American College of Surgeons The American College of Surgeons is a scientific and educational organization of surgeons that was founded in 1913 to raise the standards of surgical practice and improve the quality of care for all surgical patients.  The College is dedicated to the ethical and competent practice of surgery.  Its achievements have significantly influenced the course of scientific surgery in America and have established it as an important advocate for all surgical patients.  The College has more than 80,000 members and is the largest organization of surgeons in the world.  For more information, visit