A recent Boston Globe article series focused attention on concurrent or overlapping surgeries, and emphasized the significance of informing patients that their surgical procedures might be part of a simultaneous or overlapping surgical schedule. Although addressed previously by the American College of Surgeons (ACS), this latest interest prompted the ACS to revisit the issue and update its guidelines.
Consequently, the issue of concurrent or overlapping surgeries warrants a fresh review at the institutional level to ensure that the updated ACS guidelines continue to be met and that patients continue to be appropriately informed.
Concurrent vs. overlapping surgery
Concurrent surgery is deemed to occur when critical or key parts of operations on two different patients are happening simultaneously. As noted in the ACS guidelines: “A primary attending surgeon’s involvement in the critical elements of concurrent or simultaneous surgeries on two different patients in two different rooms is not appropriate.” This is not a new guideline. Simply put, except for rare and extraordinary circumstances, a surgeon should not practice in this manner.
On the other hand, when performing overlapping surgeries, a primary surgeon completes the key or critical elements of the first operation before moving to a second surgery. The ACS guidelines state that the overlapping of two distinct operations by the primary attending surgeon may occur, but two requirements should be met.
First, if there is a qualified practitioner to perform the non-critical components of the first surgery (e.g., wound closure, application of dressings, etc.), the primary surgeon may begin a second operation. Also, if the primary surgeon begins key parts of the second surgery, he or she must ensure that another attending surgeon is immediately available if needed in the first procedure.
In contrast to the risks associated with concurrent surgeries, overlapping procedures actually offer some distinct benefits. For instance, by enhancing efficiencies in surgical scheduling, overlapping procedures can provide greater patient access to surgeons. This is especially valuable in complex scenarios that require unique surgical expertise; such expanded access often results in faster and better scheduling options for patients needing such care.
In addition, patients may also benefit from shorter wait times on the day of their scheduled procedures. A second patient can be prepped for his or her surgery while another surgeon is finishing with a first patient’s surgery.
Overlapping surgeries also offer another benefit: By expanding institutional surgical volume, surgical residents and other trainees can take advantage of increased exposure to surgical practice. Whether observing, assisting or conducting a surgery under supervision, trainees become more proficient as they gain more experience in the OR.
Four best practices to inform surgical teams and patients
Since overlapping surgeries are acceptable as long as certain conditions are met, providers must ensure clear communication with both the surgical team and the patient. These best practices can help support ongoing communication:
- Review policies and definitions at the institutional level. Evaluate the nature of facility conditions, patient populations, ancillary services and training within your organization--all of which dictate the nature of the surgeries performed and the need for specifics. For example, a hospital’s policy on overlapping surgery needs to define exactly what “immediate availability” means for any given OR suite.
- Assign a team leader to coordinate OR communication. The ACS standards state that “the performance of overlapping procedures should not negatively impact the seamless and timely flow of either procedure.” To be sure everyone in the OR understands the intended flow of patients and procedures, have a team leader coordinate communication. This could be a nurse, anesthesiologist or other provider supported by technology that assists with consent discussions, scheduling and documenting the execution of overlapping procedures.
- Follow CMS guidelines for a “well-designed” informed consent process. Patients should know whether physicians other than the primary surgeon will perform aspects of their surgery. The Centers for Medicare & Medicaid Services Hospital Interpretive Guidelines also state that a thorough consent process should indicate if residents and/or any other qualified assistive medical personnel will be involved, and should define their specific roles.
- Leverage automated tools to document informed consent discussions. Keep in mind that an optimal consent process must go beyond merely signing a consent form. Automated tools not only enhance a patient’s comprehension, but can create actual documentation of the informed consent discussions that have occurred. In addition, such consent tools can ensure inclusion of language describing both the primary surgeon’s direct and indirect involvement in the planned procedure.
Overlapping surgeries are performed regularly and effectively at most hospitals, especially teaching hospitals and trauma centers. They improve OR efficiency, patient care and resource utilization while also providing hands-on training for future surgeons. However, they must be done with an eye on patient safety and a strong communication process. Organizations must have policies in place to ensure that patients are clearly informed about the specific procedures they will undergo, the surgical processes they will experience and the personnel involved in their care.
Aaron Fink, M.D., professor emeritus of surgery at Emory University, received a doctor of medicine from Johns Hopkins University and completed clinical fellowships at the University of Western Ontario and Middlesex Hospital, London. In 1989, he assumed directorship of the surgical endoscopy program at the University of Cincinnati and from 1993 to 2009 served as chief of the surgical service in the Atlanta VA Medical Center. Until 2011, he served as chief surgical consultant for the VA Southeast Network. A past governor in the American College of Surgeons and past president of the Association of VA Surgeons, Dr. Finkhas published more than 120 research papers, review articles and book chapters.