Commentary

Overlapping and staggered surgeries: Is it a major problem or sign of efficiency?

Events at a major academic medical center in Boston that involved overlapping surgeries have been the focus of several recent investigative news stories. This situation has drawn attention to the reality that residents and fellows perform portions of surgeries under close supervision by the attending surgeon. But even in non-academic environments, nurses, surgical techs and trained first assistants perform many of these same non-critical portions of the surgical procedure.

With the increased focus on the association of higher volume surgeons with better quality and safety, as well as a more conscious effort to best utilize health care resources, certain surgeons in specific subspecialties have gravitated toward the practice of overlapping and staggered surgeries. Orthopedics Today Chief Medical Editor Anthony A. Romeo, MD, summarized these issues in his commentary Concurrent surgery: No evidence care is compromised in the January 2016 issue of Orthopedics Today. I would like to expand on his comments here, with an added focus on spine surgery.

Scott D. Boden

First, it is important to understand surgical procedures technically begin when the awake patient first enters the OR. There are many preparatory steps taken by nurses, nurse anesthetists and anesthesiologists before the skin incision is even ready to be made. This is especially true in spinal procedures, which may involve connecting electrodes for spinal cord monitoring, turning the patient into the prone position and other tasks typically performed by people other than the attending surgeon. Then there is the actual surgical procedure, which lasts from the time the skin incision is made until the incision is completely closed.

Defining overlapping, staggered OR

It is important to understand two key concepts. Overlapping surgery implies any portion of an operation occurs simultaneously in two ORs. One example is a long deformity case that is expected to last 6 hours. It may get underway in one OR with its extensive presurgical preparations, while a short case, such as a discectomy that is expected to last 60 minutes, is begun in a second room. In this case, the surgeon can easily complete the discectomy procedure before the deformity case incision is made, and certainly well before the critical portion of the deformity case begins.

Staggered surgery implies the surgeon alternates between two rooms to eliminate the room clean-up and set-up time, but is present for the majority of the operative procedure that takes place in each OR. This pattern, in which the surgeon alternates between two ORs to eliminate the clean-up and set-up and reduces the empty room time that inevitably occurs between cases, is typically used when there are multiple cases to complete that are expected to take a similar short amount of time.

Another important factor to consider is the motivation that leads surgeons to perform overlapping or staggered surgeries. This practice requires considerable planning, organization and technical excellence, and usually is attempted only by surgeons who have demonstrated the ability to do this safely at their institutions. Moreover, surgeons who adopt these practices are often those who are most in-demand by patients. When the resources an OR requires are used more efficiently, there is better access to these surgeons and improved value and lower overall cost of health care may result.

Address complications

However, noble motivations do not justify safety risks. In fact, complications can occur in the presence or absence of the attending surgeon and they may not be related to the technical performance of surgical tasks. Sometimes things do just happen. Even in the Boston example, the hospital and surgeons deny the complication was in any way related to the fact the surgery was done as part of an overlapping surgery situation. Moreover, there is good evidence that patients treated by higher volume surgeons have fewer complications and higher success rates. This is fostered by the practice of overlapping and staggered surgeries. Ultimately, examination of actual data can help determine if surgeons with overlapping and staggered surgical schedules have more, less or the same rate of complications as surgeons who operate in a single room. But data, not speculation by the media about a single spine surgery case, should drive that conclusion.

In the meantime, I have the following recommendations for spine surgeons. Make sure the hospital has a policy in place about overlapping and staggered surgeries. In addition, make sure to provide adequate transparency to patients about the reality that, even in single-room surgeries, not every task is performed by the attending surgeon, even though the surgeon accepts full responsibility for the surgery as “captain of the ship.”

Levels of transparency

The challenge is some patients want complete transparency with detail and other patients would rather not know those details. For example, as passengers on commercial airliners, everyone knows the less experienced co-pilot is going to perform some landings. Do we want to know prior to a landing whether it is the pilot or co-pilot who will perform the landing? I would think many people do not want to know that at the time they are flying.

I think the same is true for some patients when it comes to who is doing what during their surgical procedure. For some, too much information will create undue stress. I think we should consider an addition to the surgical informed consent form that clearly states various trained personnel will help the attending surgeon perform many non-critical aspects of the procedure. Patients can then be invited to discuss this in further detail with their surgeon, if they wish.

This issue is important and requires a balance of quality and safety issues, and access to resources in health care. At present, we should focus on appropriate transparency with patients and their families, which are customized to the level they desire. Running overlapping or staggered ORs safely is only a problem if patients are not made aware of this practice as a possibility or if they do not understand its rationale. They need to be informed of the careful thought and organization behind the use of overlapping and staggered ORs.

Disclosure: Boden reports no relevant financial disclosures.

Events at a major academic medical center in Boston that involved overlapping surgeries have been the focus of several recent investigative news stories. This situation has drawn attention to the reality that residents and fellows perform portions of surgeries under close supervision by the attending surgeon. But even in non-academic environments, nurses, surgical techs and trained first assistants perform many of these same non-critical portions of the surgical procedure.

With the increased focus on the association of higher volume surgeons with better quality and safety, as well as a more conscious effort to best utilize health care resources, certain surgeons in specific subspecialties have gravitated toward the practice of overlapping and staggered surgeries. Orthopedics Today Chief Medical Editor Anthony A. Romeo, MD, summarized these issues in his commentary Concurrent surgery: No evidence care is compromised in the January 2016 issue of Orthopedics Today. I would like to expand on his comments here, with an added focus on spine surgery.

Scott D. Boden

First, it is important to understand surgical procedures technically begin when the awake patient first enters the OR. There are many preparatory steps taken by nurses, nurse anesthetists and anesthesiologists before the skin incision is even ready to be made. This is especially true in spinal procedures, which may involve connecting electrodes for spinal cord monitoring, turning the patient into the prone position and other tasks typically performed by people other than the attending surgeon. Then there is the actual surgical procedure, which lasts from the time the skin incision is made until the incision is completely closed.

Defining overlapping, staggered OR

It is important to understand two key concepts. Overlapping surgery implies any portion of an operation occurs simultaneously in two ORs. One example is a long deformity case that is expected to last 6 hours. It may get underway in one OR with its extensive presurgical preparations, while a short case, such as a discectomy that is expected to last 60 minutes, is begun in a second room. In this case, the surgeon can easily complete the discectomy procedure before the deformity case incision is made, and certainly well before the critical portion of the deformity case begins.

Staggered surgery implies the surgeon alternates between two rooms to eliminate the room clean-up and set-up time, but is present for the majority of the operative procedure that takes place in each OR. This pattern, in which the surgeon alternates between two ORs to eliminate the clean-up and set-up and reduces the empty room time that inevitably occurs between cases, is typically used when there are multiple cases to complete that are expected to take a similar short amount of time.

Another important factor to consider is the motivation that leads surgeons to perform overlapping or staggered surgeries. This practice requires considerable planning, organization and technical excellence, and usually is attempted only by surgeons who have demonstrated the ability to do this safely at their institutions. Moreover, surgeons who adopt these practices are often those who are most in-demand by patients. When the resources an OR requires are used more efficiently, there is better access to these surgeons and improved value and lower overall cost of health care may result.

Address complications

However, noble motivations do not justify safety risks. In fact, complications can occur in the presence or absence of the attending surgeon and they may not be related to the technical performance of surgical tasks. Sometimes things do just happen. Even in the Boston example, the hospital and surgeons deny the complication was in any way related to the fact the surgery was done as part of an overlapping surgery situation. Moreover, there is good evidence that patients treated by higher volume surgeons have fewer complications and higher success rates. This is fostered by the practice of overlapping and staggered surgeries. Ultimately, examination of actual data can help determine if surgeons with overlapping and staggered surgical schedules have more, less or the same rate of complications as surgeons who operate in a single room. But data, not speculation by the media about a single spine surgery case, should drive that conclusion.

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In the meantime, I have the following recommendations for spine surgeons. Make sure the hospital has a policy in place about overlapping and staggered surgeries. In addition, make sure to provide adequate transparency to patients about the reality that, even in single-room surgeries, not every task is performed by the attending surgeon, even though the surgeon accepts full responsibility for the surgery as “captain of the ship.”

Levels of transparency

The challenge is some patients want complete transparency with detail and other patients would rather not know those details. For example, as passengers on commercial airliners, everyone knows the less experienced co-pilot is going to perform some landings. Do we want to know prior to a landing whether it is the pilot or co-pilot who will perform the landing? I would think many people do not want to know that at the time they are flying.

I think the same is true for some patients when it comes to who is doing what during their surgical procedure. For some, too much information will create undue stress. I think we should consider an addition to the surgical informed consent form that clearly states various trained personnel will help the attending surgeon perform many non-critical aspects of the procedure. Patients can then be invited to discuss this in further detail with their surgeon, if they wish.

This issue is important and requires a balance of quality and safety issues, and access to resources in health care. At present, we should focus on appropriate transparency with patients and their families, which are customized to the level they desire. Running overlapping or staggered ORs safely is only a problem if patients are not made aware of this practice as a possibility or if they do not understand its rationale. They need to be informed of the careful thought and organization behind the use of overlapping and staggered ORs.

Disclosure: Boden reports no relevant financial disclosures.