“Concurrent” Surgeries – Is it OK for a surgeon to operate in different ORs at the same time?

Over fifteen years ago a general surgeon at one of our community hospitals left the OR to operate at a competing hospital, and told a nurse to close the incision. He claimed OR nurses could train and be certified as “closers”. Problem was the nurse hadn’t been certified and did not have hospital privileges for this competency. The nurse was fired and the surgeon fought disciplinary action although up to the Board of Trustees. Recollection is that he had been suspended from the medical staff, by me for over six months and that became his penalty as well as a long period of probation.

“Dr. Kirkham Wood arrived in the operating room at Massachusetts General Hospital before 7 one August morning with a schedule for the day that would give many surgeons pause.
Wood, chief of MGH’s orthopedic spine service at the time and a nationally renowned practitioner in his specialty, is a confident, veteran surgeon. He would need all of his talent and confidence this day, and then some, as he planned to tackle two complicated spinal surgeries over the next many hours — two patients, two operating rooms, moving back and forth from one to the other, focusing on the challenging tasks that demanded his special skills, leaving the other work to a general surgeon, who assisted briefly, and two surgeons in training.
In medicine it is called concurrent surgery, and the practice is hardly unique to Wood or MGH. It is allowed in some form at many prestigious hospitals, limited or banned at many others. Hospitals that permit double-booking consider it an efficient way to deploy the talents of their most in-demand specialists while reducing wasted operating room time.” (A)

‘Known as “running two rooms” – or double-booked, simultaneous or concurrent surgery – the practice occurs in teaching hospitals where senior attending surgeons delegate trainees – usually residents or fellows – to perform parts of one surgery while the attending surgeon works on a second patient in another operating room. Sometimes senior surgeons aren’t even in the OR, but are seeing patients elsewhere.
The decision about whether to allow the practice is left to hospitals, which are primarily responsible for policing it. Medicare billing rules permit it as long as the attending surgeon is present during the critical portion of each operation – and that portion is defined by the surgeon. And while it occurs in many specialties, double-booking is believed to be most common in orthopedics, cardiac surgery and neurosurgery.” (B)

American College of Surgeons – Overlapping Operations- Statements on Principles (C)
“Overlap of two distinct operations by the primary attending surgeon occurs in two general circumstances.
The first and most common scenario is when the key or critical elements of the first operation have been completed, and there is no reasonable expectation that the primary attending surgeon will need to return to that operation. In this circumstance, a second operation is started in another operating room while a qualified practitioner performs noncritical components of the first operation—for example, wound closure—allowing the primary surgeon to initiate the second operation. In this situation, a qualified practitioner must be physically present in the operating room of the first operation.
The second and less common scenario is when the key or critical elements of the first operation have been completed and the primary attending surgeon is performing key or critical portions of a second operation in another room. In this scenario, the primary attending surgeon must assign immediate availability in the first operating room to another attending surgeon.
The patient needs to be informed in either of these circumstances. The performance of overlapping procedures should not negatively affect the seamless and timely flow of either procedure.””

“The Centers for Medicare and Medicaid Services does allow surgeons to bill for concurrent surgeries under certain circumstances but requires that the attending physician is “present during all critical and key portions of both operations.”
Surgeon Matthew Indeck, president of the American College of Surgeons’ central Pennsylvania chapter, said he “certainly would not support [concurrent] cases being done in distant hospitals” or keeping a patient under anesthesia longer than necessary.
But he acknowledged that a line delineating what’s appropriate and what isn’t “is very fuzzy.”” (D)

“……transparency and patient consent. Wrong is the only way to describe the fact that secretaries, nurses, anesthesiologists, residents, and fellows knew but the patient did not. If you defend double-booking, tell the patient. Sometimes I wonder why doctors don’t see themselves as patients. To us, the experienced professional, medical, and surgical practice is rote. It’s hardly so to the person being wheeled onto a narrow table on which they will be cut open. Would any surgeon-patient consent to this practice?” (E)

“Swedish Health has decided to largely prohibit its doctors from conducting overlapping surgeries, responding to the concerns of patients who were troubled by the practice…
Under the new policy, implemented Monday, surgeons must be present for the “substantial majority” of each surgical procedure. They are not required to be present for the very end of the case — closing the surgical incision once the planned procedure is completed — as that can be delegated to a qualified fellow assisting on the case.
Some smaller aspects at the beginning of a surgery, such as the harvesting of healthy blood vessels that would later be used in a coronary-artery bypass surgery, can also be delegated while the attending surgeon is out of the room, according to the policy. There is also flexibility for unexpected emergencies.
Staff will document the times surgeons enter and exit the operating room — something that didn’t previously appear in the records of many surgical patients.” (F)

“Patients whose hip surgeries were performed by surgeons overseeing two operations at once were nearly twice as likely to suffer serious complications as those whose doctors focused on one patient at a time, according to a large Canadian study, the first research to show that overlapping surgery can pose health risks.
The study of more than 90,000 hip operations at some 75 hospitals in Ontario also found that the longer the duration of overlap between surgeries, the more likely patients were to suffer a serious complication within a year, including infections and a need for follow-up surgery.
“If your surgeon is in multiple places, there’s an increased risk of having a complication,” Dr. Bheeshma Ravi, a hip surgeon at Sunnybrook Health Sciences Centre in Toronto and lead author of the study to be published Monday in JAMA Internal Medicine, told the Globe. “I think that just makes sense.”” (G)

Note: This blog shares general information about understanding and navigating the health care system. For specific medical advice about your own problems, issues and options talk to your personal physician.

(A) Clash in the name of Care, by Jenn Abelson, Jonathan Saltzman, Liz Kowalczyk and editor Scott Allen, https://apps.bostonglobe.com/spotlight/clash-in-the-name-of-care/story/
(B) (B) Is your surgeon double-booked?, by Sandra G. Boodman, http://www.philly.com/philly/health/is-your-surgeon-double-booked-20170712.html
(C) https://www.facs.org/about-acs/statements/stonprin
(D) Senate committee looks at policies on surgeons performing more than one surgery at once, by Steve Twedt, http://www.post-gazette.com/business/healthcare-business/2016/03/28/Senate-committtee-looks-at-hospital-policies-regarding-concurrent-surgeries/stories/201603270074
(E) The Wrongness of a Doctor Being in Two Places at Once, by John Mandrola, http://www.medscape.com/viewarticle/853447
(F) Swedish Health largely bans overlapping surgeries, by Mike Baker, http://www.seattletimes.com/seattle-news/health/swedish-health-largely-bans-overlapping-surgeries/
(G) For the first time, a study finds double-booked surgeries put patients at risk, by PAT GREENHOUSE, https://www.bostonglobe.com/metro/2017/12/04/for-first-time-study-finds-double-booked-surgeries-put-patients-risk/faccZlQYS4bsvz5CDlrwNM/story.html

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