Commentary: How Should Hospitals Respond to Surgeons’ Requests to Schedule Overlapping Surgeries?

Commentary: How Should Hospitals Respond to Surgeons’ Requests to Schedule Overlapping Surgeries? Concurrent, Operations, Overlapping, Parallel, Surgery ABBREVIATIONS ABBREVIATIONS ACS American College of Surgeons CMS Centers for Medicaid and Medicare Services OR operating room PA physician assistant PACU postanesthesia care unit The operating room (OR) director at a US academic medical center receives a request from a neurosurgeon to run 2 rooms. The rationale provided is high patient demand and a desire to increase case volume and improve patient access. How should the OR director respond? This surgeon's request taps into an ongoing national conversation about the acceptability of overlapping surgery. Longstanding surgical scheduling practices have recently come under scrutiny, sparked by an investigation by the Boston Globe in October 2015 suggesting that they endanger patients.1 More investigations have followed, including one by the US Senate Finance Committee, which regulates the Medicare program.2 Although both that Committee's report and statements from the American College of Surgeons (ACS) and neurosurgical societies have provided some guidance, individual hospitals are still vested with considerable discretion in deciding what type of scheduling overlaps to permit.3,4 It is important to note that overlapping surgery applies to not only neurosurgery, but also a wide range of surgical specialties. In this article, we present a framework for evaluating requests for overlapping surgery and a summary of the evidence bearing on the critical factors in these decisions. We focus on overlaps that exclude the “critical portions” of operations but include some overlapping operative time (Figure 1). This scenario is distinct from situations sometimes referred to as “flipping rooms” (scenario 1), in which overlap is confined to turnover time (time between first patient out of room to next patient in room within a single OR) or confined to induction or emergence from anesthesia (scenario 2). It is also different from “concurrent surgery,” in which the overlap includes some or all of the critical portions. Whereas there is broad agreement that scenarios 1 and 2 are usually acceptable, overlapping surgery (scenario 3) requires the greatest management and monitoring. Concurrent surgery (scenario 4) is unacceptable for an individual surgeon.4 FIGURE 1. View largeDownload slide Parallel room scenarios and definitions. The scenarios illustrate possibilities, but in daily practice an OR day's cases may not fit perfectly into 1 of the 4 scenarios. For example, even with best intentions because some surgeries are unpredictable, there may be risk for concurrent parts. For example, a room can drift from scenario 2 to 3 to 4 and then back to 3 to 2. FIGURE 1. View largeDownload slide Parallel room scenarios and definitions. The scenarios illustrate possibilities, but in daily practice an OR day's cases may not fit perfectly into 1 of the 4 scenarios. For example, even with best intentions because some surgeries are unpredictable, there may be risk for concurrent parts. For example, a room can drift from scenario 2 to 3 to 4 and then back to 3 to 2. FACTORS TO ASSESS IN EVALUATING REQUESTS FOR RUNNING 2 PARALLEL ROOMS How should the OR director go about evaluating the neurosurgeon's request for overlapping scheduling? Four types of considerations should be assessed and weighed: patient safety, informed consent, operational/cost factors, and regulatory compliance. Patient Safety Patient safety must be the foremost priority in surgical scheduling decisions. Therefore, it is important to understand the current evidence regarding the relationship between overlapping surgical scheduling and patient outcomes. This evidence base is currently small, but growing. The 8 peer-reviewed studies published to date do not suggest that overlapping surgeries (as opposed to concurrent surgeries) involve a heightened risk of adverse outcomes (Table).5-12 However, the ability to act with confidence based on this evidence is circumscribed by methodological limitations of the available studies. TABLE. Peer-Reviewed Studies of the Effect of Overlapping Scheduling on Surgical Outcomes as of June 2017 Authors  Data  No significant differences found for:  Significant differences found for:  Guan et al, 201610  1018 nonemergent surgeries performed by 5 neurosurgeons at an academic medical center  • Any complications •Serious complications  –  Hyder et al, 20175  Diverse surgeries at an academic medical center (2 samples, n = 26 725 and n = 9349)  • 30-d mortality • Length of stay (in one sample)  • Length of stay (longer for overlapping cases, in one sample) • Inpatient mortality (better for overlapping cases) • Procedure time (longer for overlapping cases)  Liu et al, 201712  12 010 “concurrent” surgeries from ACS’s National Surgical Quality Improvement Program  • Death and serious morbidity • Reoperation • Readmission  –  Sweeney et al, 201711  1315 microvascular free flap surgeries for head and neck defects at 2 tertiary care institutions  • Mean duration of hospitalization • 30-d complication rates (minor/major surgical or medical) • Overall survival rate of free tissue transfers  • Procedure time (longer for overlapping cases)  Zhang et al, 20169  3640 sports medicine, hand, foot, and ankle surgeries performed by 4 primary surgeons at an ambulatory surgery center  • Procedure time • 30-d complications  –  Zygourakis et al, 20176  1219 surgeries performed by 1 vascular neurosurgeon at an academic medical center  • 30-d readmissions • Acute respiratory failure • Postoperative stroke • Sepsis • Intraoperative aneurysm rupture • Estimated blood loss • Length of stay • Discharge status  • 30-d mortality (better for overlapping cases) • 30-d return to OR (better for overlapping cases) • Procedure time (longer for overlapping cases)  Zygourakis et al, 20178  7358 surgeries performed by 9 neurosurgeons at an academic medical center  • 30-d readmissions • 30-d return to OR • 30-d mortality • Acute respiratory failure • Sepsis • Estimated blood loss • Length of stay • Discharge status  • Procedure time (longer for overlapping cases)  Zygourakis et al, 20177  2319 spine surgeries performed by 3 neurosurgeons at an academic medical center  • 30-d readmissions • 30-d return to OR • 30-d mortality • Estimated blood loss • Length of stay • Total costs  • Discharge status (worse for overlapping cases) • Procedure time (longer for overlapping cases)  Authors  Data  No significant differences found for:  Significant differences found for:  Guan et al, 201610  1018 nonemergent surgeries performed by 5 neurosurgeons at an academic medical center  • Any complications •Serious complications  –  Hyder et al, 20175  Diverse surgeries at an academic medical center (2 samples, n = 26 725 and n = 9349)  • 30-d mortality • Length of stay (in one sample)  • Length of stay (longer for overlapping cases, in one sample) • Inpatient mortality (better for overlapping cases) • Procedure time (longer for overlapping cases)  Liu et al, 201712  12 010 “concurrent” surgeries from ACS’s National Surgical Quality Improvement Program  • Death and serious morbidity • Reoperation • Readmission  –  Sweeney et al, 201711  1315 microvascular free flap surgeries for head and neck defects at 2 tertiary care institutions  • Mean duration of hospitalization • 30-d complication rates (minor/major surgical or medical) • Overall survival rate of free tissue transfers  • Procedure time (longer for overlapping cases)  Zhang et al, 20169  3640 sports medicine, hand, foot, and ankle surgeries performed by 4 primary surgeons at an ambulatory surgery center  • Procedure time • 30-d complications  –  Zygourakis et al, 20176  1219 surgeries performed by 1 vascular neurosurgeon at an academic medical center  • 30-d readmissions • Acute respiratory failure • Postoperative stroke • Sepsis • Intraoperative aneurysm rupture • Estimated blood loss • Length of stay • Discharge status  • 30-d mortality (better for overlapping cases) • 30-d return to OR (better for overlapping cases) • Procedure time (longer for overlapping cases)  Zygourakis et al, 20178  7358 surgeries performed by 9 neurosurgeons at an academic medical center  • 30-d readmissions • 30-d return to OR • 30-d mortality • Acute respiratory failure • Sepsis • Estimated blood loss • Length of stay • Discharge status  • Procedure time (longer for overlapping cases)  Zygourakis et al, 20177  2319 spine surgeries performed by 3 neurosurgeons at an academic medical center  • 30-d readmissions • 30-d return to OR • 30-d mortality • Estimated blood loss • Length of stay • Total costs  • Discharge status (worse for overlapping cases) • Procedure time (longer for overlapping cases)  View Large In perhaps the strongest study, Hyder et al5 examined a large, diverse sample of cases and surgeons at the Mayo Clinic, matching overlapping and nonoverlapping cases by procedure type. They reported separately on samples of cases drawn from University Health System Consortium data (inpatient, elective, nontransplant surgeries) and the ACS-National Surgical Quality Improvement Program data (inpatient and outpatient noncardiac, nontransplant surgeries). Cases involving overlap during the critical portions of operations were excluded. The complex results did not indicate increased risk overall (Table). One curious finding was that overlapping cases had lower inpatient mortality, but the difference disappeared when the cases with greatest overlap (more than 50% of the procedure time or 60 min) were examined. Three studies have been published from the University of California, San Francisco. The first (Zygourakis et al6) retrospectively reviewed 1219 procedures performed by a single vascular neurosurgeon. The authors used the terms “overlapping” and “concurrent” interchangeably, defining them as cases in which procedure time overlapped by at least 1 s. They used mixed-effects regression models controlling for patient demographics, health status, and procedure type. They found no difference in complication rates, and more favorable 30-d mortality and return to the OR outcomes for the overlapping group compared to the nonoverlapping group. However, overlapping scheduling was associated with longer procedure time. Given the low incidence of some of the outcomes measured, the study may have been underpowered for some outcomes (power was not reported). Zygourakis et al7 performed a follow-up, retrospective study of 2319 spine cases by 3 neurosurgery attendings using the same modeling approach and definition of overlapping as the earlier study. Interestingly, unlike their previous study from the same institution, this study found no differences in rates of unplanned return to the OR and 30-d mortality. Zygourakis et al (2017)8 analyzed 7358 neurosurgeries by 9 attending surgeons at the same hospital, again using the same methods. This analysis yielded results similar to the spine cases study: on most measures, there were no differences between overlapping and nonoverlapping cases. Zhang et al9 reviewed 3640 sports medicine, hand, elbow, foot, and ankle surgeries from 4 surgeons at an ambulatory orthopedic surgery center. In contrast to other studies, this sample of cases involved relatively low-risk surgeries. Cases were designated overlapping if the surgeon had another case with an overlapping OR time. The study was adequately powered, but most outcomes were examined using bivariate analysis, raising concern about the adequacy of controls for differences between groups. The researchers found no significant differences in procedure or anesthesia time or 30-d complication rates between overlapping and nonoverlapping cases. The complication rate also bore no statistically significant relationship to the number of minutes of overlap. Guan et al10 reviewed 1018 neurosurgeries performed by 5 attending surgeons at the University of Utah, excluding emergent cases. Overlapping cases were defined as surgeries in which 2 patients were under anesthesia at the same time. Unlike most other studies, the authors used chart review to extract detailed data on patient risk factors rather than relying on administrative databases. Using multivariate regression, they found that overlapping cases were not associated with significantly higher rates of any complication. The results did not change when they used overlapping time percentage as the exposure variable rather than a binary indicator of overlap. Sweeney et al11 reviewed 1135 microvascular free flap surgeries for head and neck defects at 2 tertiary care institutions. Overlapping surgeries were defined as a second operation beginning 1 h prior to the first operation finishing, and attending surgeons ensured that concurrency did not occur. Authors found that overlapping surgeries were not associated with higher rates of minor or major surgical or medical complications within 30 d. Finally, Liu et al12 used ACS National Surgical Quality and Improvement Program data to review concurrent surgeries. Surgeries were considered concurrent if they overlapped by at least 60 min, and in this study the decision was made to utilize time as a proxy for concurrence as defined by the ACS since the critical portions are determined by surgeons’ judgment. After propensity score matching and risk adjustment, there was no significant association of concurrence with death or major morbidity, reoperation, or readmission. Inferences must be drawn from these studies with caution due to methodological limitations.13 All studies identified are nonrandomized with known differences between the overlapping and nonoverlapping surgeries, for which the analyses may not have fully controlled. Most studies sampled a narrow group of procedure types or surgeons, limiting the applicability of the results to the general population. Some may have been underpowered. The definition of overlap included cases with as little as 1 s of overlap, which may account for the many null findings when the groups were compared. In summary, based on quantity and quality of evidence available, conclusions about the safety of overlapping surgery cannot be drawn with high confidence. The majority of articles rely on neurosurgery studies. Outcome data on other types of surgeries are needed to grow the evidence base for safety of overlapping surgery. Hospital governing bodies should actively monitor this active field of research for additional findings and consider tracking and analyzing outcomes for their own patients. Informed Consent Both the Senate Finance Committee report and the statements by the professional societies stress that informed consent practices must include explicit discussion of the primary surgeon's role in the patient's operation. Thus, a critical consideration for hospitals deciding about overlapping surgery policies is whether the institution is prepared to commit to fully disclosing their scheduling practices to patients. A recent survey of 1454 American adults revealed that only 3.9% were aware of the practice of overlapping surgery, only 31% supported this practice, and 94.7% thought that it should be discussed before surgery.14 Only a slim majority (57.5%) were willing to see a surgeon who performs overlapping surgery, and most (77.9%) would accept a longer waiting period for elective surgery if overlapping surgery could be avoided. These findings suggest that a reasonable patient would consider information about overlapping scheduling material to their decisions about having surgery—the legal standard that would be applied in a lawsuit alleging breach of informed consent.15 It is worth adding, though, that in the study the distinctions between scenarios 1 through 4 (Figure 1) may not have been clear to patients, which may affect patient perception of the practice. The Senate Finance Committee in 2016 found that among 17 teaching hospitals that supplied policies on overlapping surgery, 7 had adequate informed consent guidelines that clearly stated whether surgery was scheduled to overlap, 7 used vague language stating surgeries might overlap, and 3 were unclear.2 Its report suggested the following language was exemplary: “My surgeon has informed me that my surgery is scheduled to overlap with another procedure she/he is scheduled to perform.” Of note, ambiguity still exists whether this is referring to any of the 4 scenarios depicted in Figure 1, but most likely scenario 3 applies. It also emphasized that consent should be timed early enough that patients have sufficient time to make decisions about surgery based on the information. These considerations suggest that hospitals that decide to permit overlapping surgery should include detailed informed consent guidelines in their policies. Informed consent forms must be adapted accordingly, with clear language that conveys what the patient will likely encounter in terms of scheduling and what the patient's options are if the proposed scheduling is unacceptable.13 Hospitals should only proceed if their attending surgeons are willing to adhere to what may be quite a substantial change in consent practices. Operational/Cost Factors When deciding to permit overlapping surgery, an OR director is also faced with considerations that are operational or business-oriented, such as the extent to which overlapping scheduling improves or detracts from OR efficiency and surgical revenue. Before considering the operational factors that determine efficiency gains, it is worth noting that different stakeholders will have different perspectives on the meaning of “efficiency.” For the surgeon, overlapping scheduling always means greater efficiency: having multiple rooms and decreased personal waiting time during nonoperative periods such as turnover and anesthesia-controlled time means completing more cases in a day and earning more professional fee reimbursement. Other OR staff may or may not see higher reimbursement, depending on how they are compensated. Procedure time is likely to increase if the team must wait for the attending surgeon to appear or return from a second operation, but reimbursement for the extra minutes may be lower than what team members such as the anesthesiologist would receive from starting a new case. From the hospital's perspective, whether efficiency and profit increase depends on the opportunity cost of giving the second OR to that surgeon. Would it displace another operation by a different surgeon, generating economic loss as well as possible political problems, or would the OR otherwise lie empty? If it does displace another surgery, which surgery returns more profit to the hospital? Would the overlapping second room increase or decrease staff premium pay evening hours? It is evident that the economic interests of the various providers may or may not be aligned. An OR director must determine whether overlapping surgery makes business sense not only for the surgeon but also for the hospital. Finally, it is important to bear in mind that from the patient's perspective, efficiency on the day of surgery is not increased if overlapping scheduling results in longer waiting times, especially if the patient is under anesthesia. Still, overlapping surgery, managed correctly, can decrease the waiting time for a patient to have a surgery scheduled and can result in getting the case started earlier on the day of surgery. Turning to the hospital's cost-benefit weighing, in addition to assessing OR excess capacity and opportunity cost, several additional operational factors should be evaluated (Figure 2). The first step is an evaluation of supply and demand; namely, is there sufficient patient demand for a specific surgeon to warrant overlapping scheduling and is there adequate supply of OR space, staff, and equipment to allocate 2 rooms to a single surgeon (Figure 2, steps 1-3)? FIGURE 2. View largeDownload slide Decision-making framework for overlapping surgery. FIGURE 2. View largeDownload slide Decision-making framework for overlapping surgery. Facilities should carefully consider the qualifications and experience of those who will assist the primary surgeon when he or she is not in the OR. For example, there is a difference between running 2 rooms with the help of surgical technicians vs doing it with physician assistants (PAs) vs being supported by 2 surgical fellows. Surgical and OR leaders need to determine what surgical care the support personnel are able to provide based on their training, licensure, and hospital privileges. Whether PAs are subject to the same rules of supervision and “immediate availability” of the attending surgeon as medical trainees depends on state law. California's relatively restrictive law, for example, allows PAs to operate outside the presence of a supervising physician only if the procedure is performed under local anesthesia or the supervising physician is immediately available to return to the OR at the PA’s request.16 In contrast in Arkansas, PAs may perform services in any setting authorized by the supervising physician in accordance with any applicable facility policy.17 It is also worth reflecting on the educational needs of trainees. On the one hand, overlapping surgeries can give trainees access to more cases and potentially a larger role in cases, providing crucial exposure to the breadth and depth of surgical pathology and skills. The challenge for hospitals is to provide adequate opportunities for tomorrow's surgical workforce to acquire necessary experience while ensuring that surgical scheduling decisions are made responsibly. On the other hand, one could argue that overlapping surgery interferes with resident education. While an attending surgeon is under a time constraint to run to a parallel room, residents are delegated technician tasks of opening and closing skin without as much teaching from the attending. Finally, referring back to the precise implications of different parallel room scenarios, whether the surgeon is proposing flipping rooms or true overlapping surgery has different impacts from a management perspective (Figure 2, step 4). The flipping rooms scenario, for example, runs the risk of accruing OR idle time, so an estimation of OR idle time costs needs to be made. Previous research suggest that favorable parameters to reduce OR idle time in the second room include a cut-to-close time of less than 120 min and ratio of nonoperative to operative time of approximately 1 or greater.18-21 Furthermore, the benefits of overlapping surgery increase as the amount of time that can occur in parallel in the 2 parallel rooms increases.22 In general, shorter cases allow for more turnovers to occur and as a result have more opportunities for a surgeon to start in a second room while nonoperative events, such as turnover and anesthesia-controlled time, are occurring in the first room. Additional factors worth considering that have also been studied include process bottlenecks. One study found that in a postanesthesia care unit (PACU)-constrained environment, 3 parallel-processing ORs with a fourth OR converted to a 3-bed, mini-PACU would optimize patient throughput and PACU workload better than 4 traditional ORs or 4 parallel processing ORs.23 Similarly, sterile processing and decontamination can become a bottleneck. These units’ ability to cope with high volumes of rapid turnover sets, such as ear tubes or total joint replacements, requires assessment. In one study of parallel induction rooms, one-to-one anesthesia coverage in the parallel induction actually increased anesthesia staffing cost per case 21% above the standard, linear-processing OR.24 To summarize, because of facility-specific operational factors overlapping scheduling will lead to variation in the economic benefits hospitals can expect. These benefits should be calculated as precisely as possible and reassessed periodically. Regulatory Compliance Finally, OR directors must ensure that any decisions made about overlapping scheduling are consistent with applicable rules and regulations. The Centers for Medicaid and Medicare Services (CMS) requires that teaching hospitals adhere to 2 key standards when billing Medicare or Medicaid for an operation that overlaps with another surgery. First, “the teaching surgeon must be present during all critical or key portions of both operations.” Thus, the critical portions of 2 or more surgeries performed by the same teaching physician may not take place at the same time. Second, when absent during other parts of the operation, the teaching surgeon “must arrange for another qualified surgeon to immediately assist the resident in the other case should the need arise.”25 Worth mentioning, these regulations apply directly to academic medical centers with resident or fellow trainees because CMS does not want to pay for critical parts unless critical parts are performed by the attending surgeon. Therefore, nonteaching hospitals may not be subject to the same regulatory constraints. However, the Senate Finance Committee Report reaches considerations to both teaching and nonteaching hospitals.2 These rules, which were designed around billing, set a regulatory floor for hospital policies on surgical scheduling. The guidelines issued by the ACS and neurosurgical societies extend these recommendations.3,4 These guidelines, which are quite similar to one another, state unequivocally that the practice of concurrent surgery by the same surgeon is never appropriate, but overlapping surgery is acceptable under many circumstances. The attending surgeon can initiate an operation in a second room as long as the practitioner who is finishing noncritical portions of the operation in the first room is qualified. However, if the attending surgeon were to begin critical portions of the operation in the second room, then “immediate availability” for the first room must be assigned to another attending surgeon. The guidelines also offer definitions of key terms in the CMS rules, including “concurrent” and “overlapping,” “critical portions,” “immediately available,” and “qualified practitioner.” Notably, they state that individual hospital policy should articulate what “immediately available” means, and that individual surgeons define what the “critical portions” of an operation are. Importantly, it may be difficult in practice to specifically define what constitutes “critical portions” of each surgery because what may be “critical” to one surgeon may not be critical to another. The question remains as to who gets to decide, ie surgeons, departments, hospitals, committees, national societies, the government, payers, or patients. Hospitals that choose to permit overlapping scheduling can help to ensure compliance with regulations and guidelines. First, they should consider adopting a formal policy setting forth the hospital's rules and expectations. Second, they could require primary attending surgeons not merely to attest that they were present during the critical portions, as CMS requires. Documenting their entry and exit from the OR and which parts of the procedure they personally perform has been suggested.13 Institutions have started using time stamps to monitor surgeon presence in the OR. Third, they should consider monitoring compliance with regulations and the hospital's policy through active surveillance of OR records (Figure 2, steps 5-6). Additional federal oversight of concurrent and overlapping surgeries is likely to occur in the wake of the Senate Finance Committee Report, including greater use of audits and closer looks during Joint Commission inspections. Having a policy prohibiting concurrent surgeries was specifically addressed by the Joint Commission as a site visit deliverable. Facilities need to work proactively to prepare for this environment by adopting appropriate policies and procedures and ensuring that staff are familiar with them and accountable for adhering to them. CONCLUSION Making decisions about overlapping surgery involves scrutiny and balancing of multiple legal, ethical, and operational considerations, as well as regulatory and political pressures within the hospital. From the surgeon's perspective, the rationale to run 2 rooms is efficiency in his or her personal time management: more cases can be done in a day if the surgeon can be operating during what otherwise might be turnover time or anesthesia controlled time. Every request to run 2 rooms is unique because of local unique characteristics of the surgeon, their cases, the hospital, and state regulations on duties different providers are able to perform in an OR. Currently, the decision is often based primarily on patient demand for a specific surgeon and available OR capacity. For the benefits of increased throughput to be realized and the risks minimized, other factors may need to be considered. The considerations that should inform decisions about overlapping scheduling include patient safety, informed consent, operational/cost factors, and regulatory compliance. Evidence of the safety of overlapping surgery does not presently suggest heightened risk, but more studies are needed. Several groups have recommended including the possibility of overlapping surgery in the informed consent process. Operational and cost considerations, including case mix, OR capacity, staffing, and process bottlenecks, affect the potential efficiency gains from overlapping scheduling. Federal regulations impose some constraints but allow overlapping scheduling within certain limits. Documentation is key to establishing compliance. Two procedural considerations should also be borne in mind. First, decision-making should include individuals who are not under direct pressure to maximize surgical revenue. Second, being precise about what is meant by “overlapping” surgery will aid management efforts in mitigating OR idle time and disclosing overlapping surgery to patients. In summary, the extent to which overlapping surgery offers patients shorter queues and offers hospitals economic benefits depends on multiple hospital-specific factors. Economic benefits may be offset by medicolegal risks or lessened overall efficiency if overlapping surgeries are not managed appropriately. Disclosure Author views do not reflect those of their respective departments or institutions. The authors have no personal, financial, or institutional interest in any of the drugs, materials, or devices described in this article. REFERENCES 1. Abelson J, Saltzman J, Kowalczyk L, Allen S. Clash in the name of care—A Boston Globe Spotlight Team Report. Curr Opin Anaesthesiol . 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Curr Opin Anaesthesiol . 2006; 19( 2): 185- 191. Google Scholar CrossRef Search ADS PubMed  25. Clm104c12. Medicare Claims Processing Manual.  Available at: https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/clm104c12.pdf. Accessed June 13, 2017. Acknowledgments The authors would like to acknowledge Michelle B. Bass from the Stanford Lane Medical Library and Nora A. Richardson from the Stanford Graduate School of Business Library. COMMENTS The authors review the literature (such as it is, although it is probably more than you would expect) on outcomes after overlapping surgeries. Overall, and unsurprisingly, these papers published by surgeons who advocate overlapping surgery find that this practice does not lead to worse results. Given the absence of evidence to support or end the practice, the authors suggest (again unsurprisingly) that hospitals and individuals should examine their needs and resources and make a decision whether to permit/perform overlapping surgery or not. They stress (of course) that ethical principles of patient care must remain paramount, and that resident education should not be compromised with either decision (and a case for this can indeed be made for both). What should you, the neurosurgeon, do? The answer is simple. What would you want for yourself or your family? If you would not want care by a surgeon “running 2 rooms” at any point of a case, you should not do it. If you as a patient are comfortable with the practice, especially if you believe it gives you access to a surgeon with particular expertise, then you should feel free to do so and to advocate for this policy at your hospital. This is an application of the Golden Rule, a principle ubiquitous in all human civilization. Michael Schulder Lake Success, New York The primary thesis introduced in this commentary is that the “surgeon” requests scheduling for overlapping surgery and the “OR supervisor” is ceded with the responsibility of “rules interpretation” and “regulation”. This, of course, is ill conceived; OR scheduling is “collaborative” and the operating surgeon holds ultimate accountability for patient informed consent and regulatory compliance. The focus of this commentary should be the imperative for the surgeon to have a deep understanding of the complex and interrelated factors necessary for optimal decision making. Nearly exclusively, this issue is in the academic environment; which involves training of Residents and Fellows. The Faculty Surgeon's commitment, and obligation, to provide an appropriate graduated learning and independent decision-making experience is a very important aspect of this discussion. In fact, a central element of Resident training competencies is a demonstration of independent decision making and technical surgical skills. This fact is often disregarded and must be included in the overall debate. Holistically, a movement to graduate surgical trainees with lesser experience in independent decision making or surgical skills may expose the population to a higher degree of risk. The authors correctly point out that a “patient safety” risk has not been conclusively demonstrated in the currently available literature. Nonetheless; anecdotal cases in the lay press are quite troubling and this issue should be carefully, and continually, considered by the operating surgeon. Current recommendations by the major professional surgical societies emphasize this point. I agree that the economic implications of concurrent surgery are extremely complex. However, the discussion presented in this commentary is so convoluted that the logic is hard to follow. It is well documented that the surgical “pace” in academic environments is, by nature, slower and represents a financial drag on the hospital in a diagnostic capitated payment environments (DRGs). Although, many may argue that an Academic surgeon using concurrent rooms may benefit financially because the seeming ability to “do more cases”. That same surgeon may in fact “do more cases” independently in a non-academic environment. The issue of concurrent surgery continues to be very visible, both professionally and in the lay press. I believe the proper guideposts for the Academic surgeon will always be quality of care, patient safety, and appropriately training the next generation of surgeons to do the same. Stephen M. Papadopoulos Phoenix, Arizona Copyright © 2018 by the Congress of Neurological Surgeons http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Neurosurgery Oxford University Press

Commentary: How Should Hospitals Respond to Surgeons’ Requests to Schedule Overlapping Surgeries?

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Congress of Neurological Surgeons
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Copyright © 2018 by the Congress of Neurological Surgeons
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0148-396X
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10.1093/neuros/nyx627
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Abstract

Concurrent, Operations, Overlapping, Parallel, Surgery ABBREVIATIONS ABBREVIATIONS ACS American College of Surgeons CMS Centers for Medicaid and Medicare Services OR operating room PA physician assistant PACU postanesthesia care unit The operating room (OR) director at a US academic medical center receives a request from a neurosurgeon to run 2 rooms. The rationale provided is high patient demand and a desire to increase case volume and improve patient access. How should the OR director respond? This surgeon's request taps into an ongoing national conversation about the acceptability of overlapping surgery. Longstanding surgical scheduling practices have recently come under scrutiny, sparked by an investigation by the Boston Globe in October 2015 suggesting that they endanger patients.1 More investigations have followed, including one by the US Senate Finance Committee, which regulates the Medicare program.2 Although both that Committee's report and statements from the American College of Surgeons (ACS) and neurosurgical societies have provided some guidance, individual hospitals are still vested with considerable discretion in deciding what type of scheduling overlaps to permit.3,4 It is important to note that overlapping surgery applies to not only neurosurgery, but also a wide range of surgical specialties. In this article, we present a framework for evaluating requests for overlapping surgery and a summary of the evidence bearing on the critical factors in these decisions. We focus on overlaps that exclude the “critical portions” of operations but include some overlapping operative time (Figure 1). This scenario is distinct from situations sometimes referred to as “flipping rooms” (scenario 1), in which overlap is confined to turnover time (time between first patient out of room to next patient in room within a single OR) or confined to induction or emergence from anesthesia (scenario 2). It is also different from “concurrent surgery,” in which the overlap includes some or all of the critical portions. Whereas there is broad agreement that scenarios 1 and 2 are usually acceptable, overlapping surgery (scenario 3) requires the greatest management and monitoring. Concurrent surgery (scenario 4) is unacceptable for an individual surgeon.4 FIGURE 1. View largeDownload slide Parallel room scenarios and definitions. The scenarios illustrate possibilities, but in daily practice an OR day's cases may not fit perfectly into 1 of the 4 scenarios. For example, even with best intentions because some surgeries are unpredictable, there may be risk for concurrent parts. For example, a room can drift from scenario 2 to 3 to 4 and then back to 3 to 2. FIGURE 1. View largeDownload slide Parallel room scenarios and definitions. The scenarios illustrate possibilities, but in daily practice an OR day's cases may not fit perfectly into 1 of the 4 scenarios. For example, even with best intentions because some surgeries are unpredictable, there may be risk for concurrent parts. For example, a room can drift from scenario 2 to 3 to 4 and then back to 3 to 2. FACTORS TO ASSESS IN EVALUATING REQUESTS FOR RUNNING 2 PARALLEL ROOMS How should the OR director go about evaluating the neurosurgeon's request for overlapping scheduling? Four types of considerations should be assessed and weighed: patient safety, informed consent, operational/cost factors, and regulatory compliance. Patient Safety Patient safety must be the foremost priority in surgical scheduling decisions. Therefore, it is important to understand the current evidence regarding the relationship between overlapping surgical scheduling and patient outcomes. This evidence base is currently small, but growing. The 8 peer-reviewed studies published to date do not suggest that overlapping surgeries (as opposed to concurrent surgeries) involve a heightened risk of adverse outcomes (Table).5-12 However, the ability to act with confidence based on this evidence is circumscribed by methodological limitations of the available studies. TABLE. Peer-Reviewed Studies of the Effect of Overlapping Scheduling on Surgical Outcomes as of June 2017 Authors  Data  No significant differences found for:  Significant differences found for:  Guan et al, 201610  1018 nonemergent surgeries performed by 5 neurosurgeons at an academic medical center  • Any complications •Serious complications  –  Hyder et al, 20175  Diverse surgeries at an academic medical center (2 samples, n = 26 725 and n = 9349)  • 30-d mortality • Length of stay (in one sample)  • Length of stay (longer for overlapping cases, in one sample) • Inpatient mortality (better for overlapping cases) • Procedure time (longer for overlapping cases)  Liu et al, 201712  12 010 “concurrent” surgeries from ACS’s National Surgical Quality Improvement Program  • Death and serious morbidity • Reoperation • Readmission  –  Sweeney et al, 201711  1315 microvascular free flap surgeries for head and neck defects at 2 tertiary care institutions  • Mean duration of hospitalization • 30-d complication rates (minor/major surgical or medical) • Overall survival rate of free tissue transfers  • Procedure time (longer for overlapping cases)  Zhang et al, 20169  3640 sports medicine, hand, foot, and ankle surgeries performed by 4 primary surgeons at an ambulatory surgery center  • Procedure time • 30-d complications  –  Zygourakis et al, 20176  1219 surgeries performed by 1 vascular neurosurgeon at an academic medical center  • 30-d readmissions • Acute respiratory failure • Postoperative stroke • Sepsis • Intraoperative aneurysm rupture • Estimated blood loss • Length of stay • Discharge status  • 30-d mortality (better for overlapping cases) • 30-d return to OR (better for overlapping cases) • Procedure time (longer for overlapping cases)  Zygourakis et al, 20178  7358 surgeries performed by 9 neurosurgeons at an academic medical center  • 30-d readmissions • 30-d return to OR • 30-d mortality • Acute respiratory failure • Sepsis • Estimated blood loss • Length of stay • Discharge status  • Procedure time (longer for overlapping cases)  Zygourakis et al, 20177  2319 spine surgeries performed by 3 neurosurgeons at an academic medical center  • 30-d readmissions • 30-d return to OR • 30-d mortality • Estimated blood loss • Length of stay • Total costs  • Discharge status (worse for overlapping cases) • Procedure time (longer for overlapping cases)  Authors  Data  No significant differences found for:  Significant differences found for:  Guan et al, 201610  1018 nonemergent surgeries performed by 5 neurosurgeons at an academic medical center  • Any complications •Serious complications  –  Hyder et al, 20175  Diverse surgeries at an academic medical center (2 samples, n = 26 725 and n = 9349)  • 30-d mortality • Length of stay (in one sample)  • Length of stay (longer for overlapping cases, in one sample) • Inpatient mortality (better for overlapping cases) • Procedure time (longer for overlapping cases)  Liu et al, 201712  12 010 “concurrent” surgeries from ACS’s National Surgical Quality Improvement Program  • Death and serious morbidity • Reoperation • Readmission  –  Sweeney et al, 201711  1315 microvascular free flap surgeries for head and neck defects at 2 tertiary care institutions  • Mean duration of hospitalization • 30-d complication rates (minor/major surgical or medical) • Overall survival rate of free tissue transfers  • Procedure time (longer for overlapping cases)  Zhang et al, 20169  3640 sports medicine, hand, foot, and ankle surgeries performed by 4 primary surgeons at an ambulatory surgery center  • Procedure time • 30-d complications  –  Zygourakis et al, 20176  1219 surgeries performed by 1 vascular neurosurgeon at an academic medical center  • 30-d readmissions • Acute respiratory failure • Postoperative stroke • Sepsis • Intraoperative aneurysm rupture • Estimated blood loss • Length of stay • Discharge status  • 30-d mortality (better for overlapping cases) • 30-d return to OR (better for overlapping cases) • Procedure time (longer for overlapping cases)  Zygourakis et al, 20178  7358 surgeries performed by 9 neurosurgeons at an academic medical center  • 30-d readmissions • 30-d return to OR • 30-d mortality • Acute respiratory failure • Sepsis • Estimated blood loss • Length of stay • Discharge status  • Procedure time (longer for overlapping cases)  Zygourakis et al, 20177  2319 spine surgeries performed by 3 neurosurgeons at an academic medical center  • 30-d readmissions • 30-d return to OR • 30-d mortality • Estimated blood loss • Length of stay • Total costs  • Discharge status (worse for overlapping cases) • Procedure time (longer for overlapping cases)  View Large In perhaps the strongest study, Hyder et al5 examined a large, diverse sample of cases and surgeons at the Mayo Clinic, matching overlapping and nonoverlapping cases by procedure type. They reported separately on samples of cases drawn from University Health System Consortium data (inpatient, elective, nontransplant surgeries) and the ACS-National Surgical Quality Improvement Program data (inpatient and outpatient noncardiac, nontransplant surgeries). Cases involving overlap during the critical portions of operations were excluded. The complex results did not indicate increased risk overall (Table). One curious finding was that overlapping cases had lower inpatient mortality, but the difference disappeared when the cases with greatest overlap (more than 50% of the procedure time or 60 min) were examined. Three studies have been published from the University of California, San Francisco. The first (Zygourakis et al6) retrospectively reviewed 1219 procedures performed by a single vascular neurosurgeon. The authors used the terms “overlapping” and “concurrent” interchangeably, defining them as cases in which procedure time overlapped by at least 1 s. They used mixed-effects regression models controlling for patient demographics, health status, and procedure type. They found no difference in complication rates, and more favorable 30-d mortality and return to the OR outcomes for the overlapping group compared to the nonoverlapping group. However, overlapping scheduling was associated with longer procedure time. Given the low incidence of some of the outcomes measured, the study may have been underpowered for some outcomes (power was not reported). Zygourakis et al7 performed a follow-up, retrospective study of 2319 spine cases by 3 neurosurgery attendings using the same modeling approach and definition of overlapping as the earlier study. Interestingly, unlike their previous study from the same institution, this study found no differences in rates of unplanned return to the OR and 30-d mortality. Zygourakis et al (2017)8 analyzed 7358 neurosurgeries by 9 attending surgeons at the same hospital, again using the same methods. This analysis yielded results similar to the spine cases study: on most measures, there were no differences between overlapping and nonoverlapping cases. Zhang et al9 reviewed 3640 sports medicine, hand, elbow, foot, and ankle surgeries from 4 surgeons at an ambulatory orthopedic surgery center. In contrast to other studies, this sample of cases involved relatively low-risk surgeries. Cases were designated overlapping if the surgeon had another case with an overlapping OR time. The study was adequately powered, but most outcomes were examined using bivariate analysis, raising concern about the adequacy of controls for differences between groups. The researchers found no significant differences in procedure or anesthesia time or 30-d complication rates between overlapping and nonoverlapping cases. The complication rate also bore no statistically significant relationship to the number of minutes of overlap. Guan et al10 reviewed 1018 neurosurgeries performed by 5 attending surgeons at the University of Utah, excluding emergent cases. Overlapping cases were defined as surgeries in which 2 patients were under anesthesia at the same time. Unlike most other studies, the authors used chart review to extract detailed data on patient risk factors rather than relying on administrative databases. Using multivariate regression, they found that overlapping cases were not associated with significantly higher rates of any complication. The results did not change when they used overlapping time percentage as the exposure variable rather than a binary indicator of overlap. Sweeney et al11 reviewed 1135 microvascular free flap surgeries for head and neck defects at 2 tertiary care institutions. Overlapping surgeries were defined as a second operation beginning 1 h prior to the first operation finishing, and attending surgeons ensured that concurrency did not occur. Authors found that overlapping surgeries were not associated with higher rates of minor or major surgical or medical complications within 30 d. Finally, Liu et al12 used ACS National Surgical Quality and Improvement Program data to review concurrent surgeries. Surgeries were considered concurrent if they overlapped by at least 60 min, and in this study the decision was made to utilize time as a proxy for concurrence as defined by the ACS since the critical portions are determined by surgeons’ judgment. After propensity score matching and risk adjustment, there was no significant association of concurrence with death or major morbidity, reoperation, or readmission. Inferences must be drawn from these studies with caution due to methodological limitations.13 All studies identified are nonrandomized with known differences between the overlapping and nonoverlapping surgeries, for which the analyses may not have fully controlled. Most studies sampled a narrow group of procedure types or surgeons, limiting the applicability of the results to the general population. Some may have been underpowered. The definition of overlap included cases with as little as 1 s of overlap, which may account for the many null findings when the groups were compared. In summary, based on quantity and quality of evidence available, conclusions about the safety of overlapping surgery cannot be drawn with high confidence. The majority of articles rely on neurosurgery studies. Outcome data on other types of surgeries are needed to grow the evidence base for safety of overlapping surgery. Hospital governing bodies should actively monitor this active field of research for additional findings and consider tracking and analyzing outcomes for their own patients. Informed Consent Both the Senate Finance Committee report and the statements by the professional societies stress that informed consent practices must include explicit discussion of the primary surgeon's role in the patient's operation. Thus, a critical consideration for hospitals deciding about overlapping surgery policies is whether the institution is prepared to commit to fully disclosing their scheduling practices to patients. A recent survey of 1454 American adults revealed that only 3.9% were aware of the practice of overlapping surgery, only 31% supported this practice, and 94.7% thought that it should be discussed before surgery.14 Only a slim majority (57.5%) were willing to see a surgeon who performs overlapping surgery, and most (77.9%) would accept a longer waiting period for elective surgery if overlapping surgery could be avoided. These findings suggest that a reasonable patient would consider information about overlapping scheduling material to their decisions about having surgery—the legal standard that would be applied in a lawsuit alleging breach of informed consent.15 It is worth adding, though, that in the study the distinctions between scenarios 1 through 4 (Figure 1) may not have been clear to patients, which may affect patient perception of the practice. The Senate Finance Committee in 2016 found that among 17 teaching hospitals that supplied policies on overlapping surgery, 7 had adequate informed consent guidelines that clearly stated whether surgery was scheduled to overlap, 7 used vague language stating surgeries might overlap, and 3 were unclear.2 Its report suggested the following language was exemplary: “My surgeon has informed me that my surgery is scheduled to overlap with another procedure she/he is scheduled to perform.” Of note, ambiguity still exists whether this is referring to any of the 4 scenarios depicted in Figure 1, but most likely scenario 3 applies. It also emphasized that consent should be timed early enough that patients have sufficient time to make decisions about surgery based on the information. These considerations suggest that hospitals that decide to permit overlapping surgery should include detailed informed consent guidelines in their policies. Informed consent forms must be adapted accordingly, with clear language that conveys what the patient will likely encounter in terms of scheduling and what the patient's options are if the proposed scheduling is unacceptable.13 Hospitals should only proceed if their attending surgeons are willing to adhere to what may be quite a substantial change in consent practices. Operational/Cost Factors When deciding to permit overlapping surgery, an OR director is also faced with considerations that are operational or business-oriented, such as the extent to which overlapping scheduling improves or detracts from OR efficiency and surgical revenue. Before considering the operational factors that determine efficiency gains, it is worth noting that different stakeholders will have different perspectives on the meaning of “efficiency.” For the surgeon, overlapping scheduling always means greater efficiency: having multiple rooms and decreased personal waiting time during nonoperative periods such as turnover and anesthesia-controlled time means completing more cases in a day and earning more professional fee reimbursement. Other OR staff may or may not see higher reimbursement, depending on how they are compensated. Procedure time is likely to increase if the team must wait for the attending surgeon to appear or return from a second operation, but reimbursement for the extra minutes may be lower than what team members such as the anesthesiologist would receive from starting a new case. From the hospital's perspective, whether efficiency and profit increase depends on the opportunity cost of giving the second OR to that surgeon. Would it displace another operation by a different surgeon, generating economic loss as well as possible political problems, or would the OR otherwise lie empty? If it does displace another surgery, which surgery returns more profit to the hospital? Would the overlapping second room increase or decrease staff premium pay evening hours? It is evident that the economic interests of the various providers may or may not be aligned. An OR director must determine whether overlapping surgery makes business sense not only for the surgeon but also for the hospital. Finally, it is important to bear in mind that from the patient's perspective, efficiency on the day of surgery is not increased if overlapping scheduling results in longer waiting times, especially if the patient is under anesthesia. Still, overlapping surgery, managed correctly, can decrease the waiting time for a patient to have a surgery scheduled and can result in getting the case started earlier on the day of surgery. Turning to the hospital's cost-benefit weighing, in addition to assessing OR excess capacity and opportunity cost, several additional operational factors should be evaluated (Figure 2). The first step is an evaluation of supply and demand; namely, is there sufficient patient demand for a specific surgeon to warrant overlapping scheduling and is there adequate supply of OR space, staff, and equipment to allocate 2 rooms to a single surgeon (Figure 2, steps 1-3)? FIGURE 2. View largeDownload slide Decision-making framework for overlapping surgery. FIGURE 2. View largeDownload slide Decision-making framework for overlapping surgery. Facilities should carefully consider the qualifications and experience of those who will assist the primary surgeon when he or she is not in the OR. For example, there is a difference between running 2 rooms with the help of surgical technicians vs doing it with physician assistants (PAs) vs being supported by 2 surgical fellows. Surgical and OR leaders need to determine what surgical care the support personnel are able to provide based on their training, licensure, and hospital privileges. Whether PAs are subject to the same rules of supervision and “immediate availability” of the attending surgeon as medical trainees depends on state law. California's relatively restrictive law, for example, allows PAs to operate outside the presence of a supervising physician only if the procedure is performed under local anesthesia or the supervising physician is immediately available to return to the OR at the PA’s request.16 In contrast in Arkansas, PAs may perform services in any setting authorized by the supervising physician in accordance with any applicable facility policy.17 It is also worth reflecting on the educational needs of trainees. On the one hand, overlapping surgeries can give trainees access to more cases and potentially a larger role in cases, providing crucial exposure to the breadth and depth of surgical pathology and skills. The challenge for hospitals is to provide adequate opportunities for tomorrow's surgical workforce to acquire necessary experience while ensuring that surgical scheduling decisions are made responsibly. On the other hand, one could argue that overlapping surgery interferes with resident education. While an attending surgeon is under a time constraint to run to a parallel room, residents are delegated technician tasks of opening and closing skin without as much teaching from the attending. Finally, referring back to the precise implications of different parallel room scenarios, whether the surgeon is proposing flipping rooms or true overlapping surgery has different impacts from a management perspective (Figure 2, step 4). The flipping rooms scenario, for example, runs the risk of accruing OR idle time, so an estimation of OR idle time costs needs to be made. Previous research suggest that favorable parameters to reduce OR idle time in the second room include a cut-to-close time of less than 120 min and ratio of nonoperative to operative time of approximately 1 or greater.18-21 Furthermore, the benefits of overlapping surgery increase as the amount of time that can occur in parallel in the 2 parallel rooms increases.22 In general, shorter cases allow for more turnovers to occur and as a result have more opportunities for a surgeon to start in a second room while nonoperative events, such as turnover and anesthesia-controlled time, are occurring in the first room. Additional factors worth considering that have also been studied include process bottlenecks. One study found that in a postanesthesia care unit (PACU)-constrained environment, 3 parallel-processing ORs with a fourth OR converted to a 3-bed, mini-PACU would optimize patient throughput and PACU workload better than 4 traditional ORs or 4 parallel processing ORs.23 Similarly, sterile processing and decontamination can become a bottleneck. These units’ ability to cope with high volumes of rapid turnover sets, such as ear tubes or total joint replacements, requires assessment. In one study of parallel induction rooms, one-to-one anesthesia coverage in the parallel induction actually increased anesthesia staffing cost per case 21% above the standard, linear-processing OR.24 To summarize, because of facility-specific operational factors overlapping scheduling will lead to variation in the economic benefits hospitals can expect. These benefits should be calculated as precisely as possible and reassessed periodically. Regulatory Compliance Finally, OR directors must ensure that any decisions made about overlapping scheduling are consistent with applicable rules and regulations. The Centers for Medicaid and Medicare Services (CMS) requires that teaching hospitals adhere to 2 key standards when billing Medicare or Medicaid for an operation that overlaps with another surgery. First, “the teaching surgeon must be present during all critical or key portions of both operations.” Thus, the critical portions of 2 or more surgeries performed by the same teaching physician may not take place at the same time. Second, when absent during other parts of the operation, the teaching surgeon “must arrange for another qualified surgeon to immediately assist the resident in the other case should the need arise.”25 Worth mentioning, these regulations apply directly to academic medical centers with resident or fellow trainees because CMS does not want to pay for critical parts unless critical parts are performed by the attending surgeon. Therefore, nonteaching hospitals may not be subject to the same regulatory constraints. However, the Senate Finance Committee Report reaches considerations to both teaching and nonteaching hospitals.2 These rules, which were designed around billing, set a regulatory floor for hospital policies on surgical scheduling. The guidelines issued by the ACS and neurosurgical societies extend these recommendations.3,4 These guidelines, which are quite similar to one another, state unequivocally that the practice of concurrent surgery by the same surgeon is never appropriate, but overlapping surgery is acceptable under many circumstances. The attending surgeon can initiate an operation in a second room as long as the practitioner who is finishing noncritical portions of the operation in the first room is qualified. However, if the attending surgeon were to begin critical portions of the operation in the second room, then “immediate availability” for the first room must be assigned to another attending surgeon. The guidelines also offer definitions of key terms in the CMS rules, including “concurrent” and “overlapping,” “critical portions,” “immediately available,” and “qualified practitioner.” Notably, they state that individual hospital policy should articulate what “immediately available” means, and that individual surgeons define what the “critical portions” of an operation are. Importantly, it may be difficult in practice to specifically define what constitutes “critical portions” of each surgery because what may be “critical” to one surgeon may not be critical to another. The question remains as to who gets to decide, ie surgeons, departments, hospitals, committees, national societies, the government, payers, or patients. Hospitals that choose to permit overlapping scheduling can help to ensure compliance with regulations and guidelines. First, they should consider adopting a formal policy setting forth the hospital's rules and expectations. Second, they could require primary attending surgeons not merely to attest that they were present during the critical portions, as CMS requires. Documenting their entry and exit from the OR and which parts of the procedure they personally perform has been suggested.13 Institutions have started using time stamps to monitor surgeon presence in the OR. Third, they should consider monitoring compliance with regulations and the hospital's policy through active surveillance of OR records (Figure 2, steps 5-6). Additional federal oversight of concurrent and overlapping surgeries is likely to occur in the wake of the Senate Finance Committee Report, including greater use of audits and closer looks during Joint Commission inspections. Having a policy prohibiting concurrent surgeries was specifically addressed by the Joint Commission as a site visit deliverable. Facilities need to work proactively to prepare for this environment by adopting appropriate policies and procedures and ensuring that staff are familiar with them and accountable for adhering to them. CONCLUSION Making decisions about overlapping surgery involves scrutiny and balancing of multiple legal, ethical, and operational considerations, as well as regulatory and political pressures within the hospital. From the surgeon's perspective, the rationale to run 2 rooms is efficiency in his or her personal time management: more cases can be done in a day if the surgeon can be operating during what otherwise might be turnover time or anesthesia controlled time. Every request to run 2 rooms is unique because of local unique characteristics of the surgeon, their cases, the hospital, and state regulations on duties different providers are able to perform in an OR. Currently, the decision is often based primarily on patient demand for a specific surgeon and available OR capacity. For the benefits of increased throughput to be realized and the risks minimized, other factors may need to be considered. The considerations that should inform decisions about overlapping scheduling include patient safety, informed consent, operational/cost factors, and regulatory compliance. Evidence of the safety of overlapping surgery does not presently suggest heightened risk, but more studies are needed. Several groups have recommended including the possibility of overlapping surgery in the informed consent process. Operational and cost considerations, including case mix, OR capacity, staffing, and process bottlenecks, affect the potential efficiency gains from overlapping scheduling. Federal regulations impose some constraints but allow overlapping scheduling within certain limits. Documentation is key to establishing compliance. Two procedural considerations should also be borne in mind. First, decision-making should include individuals who are not under direct pressure to maximize surgical revenue. Second, being precise about what is meant by “overlapping” surgery will aid management efforts in mitigating OR idle time and disclosing overlapping surgery to patients. In summary, the extent to which overlapping surgery offers patients shorter queues and offers hospitals economic benefits depends on multiple hospital-specific factors. Economic benefits may be offset by medicolegal risks or lessened overall efficiency if overlapping surgeries are not managed appropriately. Disclosure Author views do not reflect those of their respective departments or institutions. The authors have no personal, financial, or institutional interest in any of the drugs, materials, or devices described in this article. REFERENCES 1. Abelson J, Saltzman J, Kowalczyk L, Allen S. Clash in the name of care—A Boston Globe Spotlight Team Report. Curr Opin Anaesthesiol . 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Marjamaa RA, Torkki PM, Hirvensalo EJ, Kirvela OA. What is the best workflow for an operating room? A simulation study of five scenarios. Health Care Manag Sci . 2009; 12( 2): 142- 146. Google Scholar CrossRef Search ADS PubMed  21. Stahl JE, Sandberg WS, Daily B et al.   Reorganizing patient care and workflow in the operating room: a cost-effectiveness study. Surgery . 2006; 139( 6): 717- 728. Google Scholar CrossRef Search ADS PubMed  22. Batun S, Denton BT, Huschka TR, Schaefer AJ. Operating room pooling and parallel surgery processing under uncertainty. INFORMS J Comput . 2011; 23( 2): 220- 237. Google Scholar CrossRef Search ADS   23. Sokal SM, Craft DL, Chang Y, Sandberg WS, Berger DL. Maximizing operating room and recovery room capacity in an era of constrained resources. Arch Surg . 2006; 141( 4): 389- 395. Google Scholar CrossRef Search ADS PubMed  24. Krupka DC, Sandberg WS. Operating room design and its impact on operating room economics. Curr Opin Anaesthesiol . 2006; 19( 2): 185- 191. Google Scholar CrossRef Search ADS PubMed  25. Clm104c12. Medicare Claims Processing Manual.  Available at: https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/clm104c12.pdf. Accessed June 13, 2017. Acknowledgments The authors would like to acknowledge Michelle B. Bass from the Stanford Lane Medical Library and Nora A. Richardson from the Stanford Graduate School of Business Library. COMMENTS The authors review the literature (such as it is, although it is probably more than you would expect) on outcomes after overlapping surgeries. Overall, and unsurprisingly, these papers published by surgeons who advocate overlapping surgery find that this practice does not lead to worse results. Given the absence of evidence to support or end the practice, the authors suggest (again unsurprisingly) that hospitals and individuals should examine their needs and resources and make a decision whether to permit/perform overlapping surgery or not. They stress (of course) that ethical principles of patient care must remain paramount, and that resident education should not be compromised with either decision (and a case for this can indeed be made for both). What should you, the neurosurgeon, do? The answer is simple. What would you want for yourself or your family? If you would not want care by a surgeon “running 2 rooms” at any point of a case, you should not do it. If you as a patient are comfortable with the practice, especially if you believe it gives you access to a surgeon with particular expertise, then you should feel free to do so and to advocate for this policy at your hospital. This is an application of the Golden Rule, a principle ubiquitous in all human civilization. Michael Schulder Lake Success, New York The primary thesis introduced in this commentary is that the “surgeon” requests scheduling for overlapping surgery and the “OR supervisor” is ceded with the responsibility of “rules interpretation” and “regulation”. This, of course, is ill conceived; OR scheduling is “collaborative” and the operating surgeon holds ultimate accountability for patient informed consent and regulatory compliance. The focus of this commentary should be the imperative for the surgeon to have a deep understanding of the complex and interrelated factors necessary for optimal decision making. Nearly exclusively, this issue is in the academic environment; which involves training of Residents and Fellows. The Faculty Surgeon's commitment, and obligation, to provide an appropriate graduated learning and independent decision-making experience is a very important aspect of this discussion. In fact, a central element of Resident training competencies is a demonstration of independent decision making and technical surgical skills. This fact is often disregarded and must be included in the overall debate. Holistically, a movement to graduate surgical trainees with lesser experience in independent decision making or surgical skills may expose the population to a higher degree of risk. The authors correctly point out that a “patient safety” risk has not been conclusively demonstrated in the currently available literature. Nonetheless; anecdotal cases in the lay press are quite troubling and this issue should be carefully, and continually, considered by the operating surgeon. Current recommendations by the major professional surgical societies emphasize this point. I agree that the economic implications of concurrent surgery are extremely complex. However, the discussion presented in this commentary is so convoluted that the logic is hard to follow. It is well documented that the surgical “pace” in academic environments is, by nature, slower and represents a financial drag on the hospital in a diagnostic capitated payment environments (DRGs). Although, many may argue that an Academic surgeon using concurrent rooms may benefit financially because the seeming ability to “do more cases”. That same surgeon may in fact “do more cases” independently in a non-academic environment. The issue of concurrent surgery continues to be very visible, both professionally and in the lay press. I believe the proper guideposts for the Academic surgeon will always be quality of care, patient safety, and appropriately training the next generation of surgeons to do the same. Stephen M. Papadopoulos Phoenix, Arizona Copyright © 2018 by the Congress of Neurological Surgeons

Journal

NeurosurgeryOxford University Press

Published: Apr 1, 2018

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