Overlapping Surgery: Safety Data and Ongoing Concerns

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Excerpt

Surgeons can perform procedures in which the beginning of one operation overlaps with the conclusion of another and such procedures are defined as concurrent operations when the critical portions of both procedures occur at the same time and as overlapping when they do not. This practice can improve efficiency, access to surgical care, and improve surgical training by exposing trainees to opportunities to develop their skills and knowledge in the clinical setting.1,2
The Boston Globe, in October 2015, questioned these practices and described a case in which a patient experienced an adverse outcome after undergoing an operation that was performed by a surgeon who was involved in another procedure at the same time. They suggested that patients often are not informed that their operation may occur at the same time as another procedure.3 Some raised concerns that the primary motivation for a surgeon to conduct concurrent surgery was financial.
The Senate Finance Committee having jurisdiction over Medicare and Medicaid started a staff evaluation of these issues and sought the advice of the American College of Surgeons (ACS) while evaluating several hospitals current practice. The ACS reviewed its policies and procedures and updated the guidelines on perioperative patient care to create greater clarity around this issue.4,5 All of organized surgery, The Joint Commission, the American Hospital Association, and the Senate Finance Committee Staff have been supportive of these efforts.
The use of a team to perform staggered procedures has been a common and accepted practice in high-complexity surgery for many years. Internal analysis at hospitals has demonstrated no increased rate of complications and has, in fact, been studied for cardiothoracic surgery with no increase in operative duration or negative effect on patient outcomes.6
The best study to date is the present study conducted by researchers at the Mayo Clinic, Rochester, MN. They evaluated outcomes for overlapping operations using mortality and length of stay data from the UHC Consortium and ACS National Surgical Quality Improvement Program. They sought to measure real outcome differences using validated databases to determine the safety of this practice. This is the largest and most comprehensive study to date and the authors are to be congratulated for taking this on.7
Based on the evaluation of more than 10,000 cases, the study found that overlapping and nonoverlapping operations had comparable mortality rates and lengths of stay. These results are very important in that they demonstrate that overlapping surgery does not have negative consequences for patients. The findings are consistent with the general feeling of many surgeons who have been performing these operations for a long time but are now validated with a large study.
Although this study involves one institution the Mayo Clinic's experience with high-volume operating rooms, complex procedures and overlapping procedures clearly establishes the safety of this practice.
Little information is available to suggest how commonly overlapping and concurrent operations are performed, but recent assessment indicates that overlap occurs in anywhere from 1% to 33%. It is the responsibility of a hospital to identify when overlapping or concurrent surgery occurs through use of schedules or audits of surgeons’ practices.
Some critical questions remain based on the recent Senate Finance Staff Report: Concurrent and Overlapping Surgery: Additional Measures Warranted published in December 2016. They found variability in several areas where hospitals need to improve their policies and procedures include the following8:
Defining Concurrent and Overlapping Surgery: Most hospitals use a definition that is similar to the College's, but some hospitals define overlapping surgery more loosely. This leads to the appearance that the definitions are not adequately specific.
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