Concurrent (overlapping) surgery: addressing the risks

Hospitals are re-examining their surgical and risk management policies in relation to overlapping surgery, as Kathleen Shostek, vice president of healthcare risk management at Sedgwick, describes.

Concurrent or overlapping surgery has been described as when a surgeon begins a second operation, leaving the rest of the first procedure to another surgeon or practitioner to complete.1 Concurrent surgery has long been a common practice in teaching hospitals, and is thought of as an acceptable way to optimize surgeons’ skills, reduce delays, and allow surgeons in training or assistants to complete routine procedures.

However, the practice came under scrutiny recently when Boston Globe reporters published an investigative report on the topic, spurring state and federal investigations. The report detailed patient-related events and subsequent complaints and lawsuits, and described concerns raised by surgeons about the practice to hospital administration.2

Professional and public outcries prompted the American College of Surgeons (ACS) to address the practice by revising its Statements on Principles to speak to concurrent surgery. With patient safety as a primary consideration, and the desire to avoid claims and lawsuits possibly related to concurrent surgery, hospitals are re-examining their surgical policies and practices.

"A clear means of communication and a chain of command for OR nurses and surgical support staff to ask questions and voice concerns should be established."

There are a number of ethical, risk management and patient safety issues surrounding concurrent surgery. Sedgwick risk management consultants have encountered many of these issues and concerns related to the practice while performing surgical risk assessments and making observations in the operating room. We have also received calls from our customers asking for information, resources and advice on the topic.

Common issues and concerns include the following:

• Longer anesthesia time for patients waiting for the attending surgeon who was delayed in the first procedure;
• Lack of patient awareness (consent) regarding what portions of the surgery are performed by which surgeons or practitioners involved in the procedure;
• Inadequate supervision of surgical residents and scope of practice creep with surgical assistants when the primary surgeon leaves for a second procedure;
• Operating Room (OR) nurses reporting fears of “patient abandonment” to administration; and
• Inadequate pre-procedure briefings and the absence of surgical debriefs.

Read on for an overview of the risk management implications including regulatory compliance, professional practice guidance and surgical department policy considerations.

Regulations and compliance

The Centers for Medicare and Medicaid Services (CMS) permits providers to bill the Medicare program for up to two simultaneous or overlapping surgeries, but the regulations note that the surgeon must be available for “critical” portions of both operations. CMS does not define what is meant by “critical”.3

The Medicare rules do, however, include requirements for another surgeon to be immediately available when the attending surgeon leaves to begin a second procedure and the attending surgeon must document his or her presence for the surgery.

According to a December 2015 Boston Globe report, a Wisconsin medical school paid $840,000 to settle a lawsuit alleging that neurosurgeons illegally billed Medicare for simultaneous spine surgeries that were largely done by unsupervised medical residents. Similar settlements have been made by other teaching facilities and providers.4

At the state level, the Massachusetts Board of Registration in Medicine recently approved a rule to regulate the practice of concurrent surgery that mirrors CMS’ rules, requiring documentation of the attending surgeon’s presence in the operating room and designation of a backup surgeon to cover when the attending surgeon leaves.

Professional guidelines

The ACS addresses concurrent surgery in its revised Statement on Principles, a guiding document for surgical practice.5 Article II of the ACS Principles includes statements about informed consent and notes that this consent should include a “discussion [with the patient] of the different types of qualified medical providers who will participate in their operation and their respective roles.” This suggests that the patient be informed about which parts of the operation will be performed by whom.

Examples of statements in surgical policies that address this disclosure include: “if the surgeon will not be present for any portion of the surgical procedure, the patient must be informed,” and “overlapping surgery should be disclosed to the patient during the informed consent process.”

The ACS Principles note that when the primary attending surgeon is not present nor immediately available, another attending surgeon should be assigned as being immediately available. Further, the Principles define concurrent or simultaneous operations as when “the critical or key components of the procedure occur all or in part at the same time,” and note that a “primary attending surgeon’s involvement in concurrent or simultaneous surgeries on two different patients in two different rooms is not appropriate.” This is in keeping with the Medicare requirements that the surgeon be available for “critical” portions of both operations, which cannot occur simultaneously.

Overlapping operations, according to ACS Principles, occur when the critical or key components of the first surgery have been completed, and the primary attending surgeon moves to a second operation, leaving the non-critical components of the first procedure to another surgeon or qualified practitioner. In the event the primary attending surgeon is performing critical components in the second operation, another attending surgeon must be assigned in the first operation.

In the case of multidisciplinary operations where several surgical specialists may only be present for that component of the operation for which he or she is responsible, ACS Principles state that in these operations, an attending surgeon must still be immediately available for the entire operation.

Other important definitions in the ACS Principles include “critical or key” portions of an operation (segments when essential technical expertise and surgical judgment are required, as determined by the attending surgeon), “physically present” (in the same room as the patient), and “immediately available” (reachable and able to return to the OR immediately).

Surgical department policy considerations

One study involving 3,000 overlapping cardiothoracic surgeries at the University of Virginia found no negative impact on surgical complications, length of hospital stay, or operative mortality.6 But because there is a general dearth in the literature on concurrent surgery and its effect on patients and outcomes, surgical departments must identify and define their own practices and policies with patient care and safety at the forefront.

Once developed, policies must be communicated to the surgical, teaching, scheduling and nursing staff. A process to review surgeon compliance and provide feedback to physicians and department chairpersons should be implemented. In addition, a clear means of communication and a chain of command for OR nurses and surgical support staff to ask questions and voice concerns should be established.

Recommendations for addressing the risks of concurrent surgery include:

• Having the surgical executive committee define concurrent or overlapping surgery, identify what surgeries are acceptable for concurrent or overlapping performance, and what the “critical parts” of the operation are;
• Implementing a comprehensive informed consent process, including a discussion about which surgeons and other surgical practitioners will perform what parts of the operation;
• Establishing a process to ensure that a surgeon is immediately available to return to the OR as necessary;
• Ensuring that the surgeon’s entry and exit times from the OR are documented, noting the portions of the procedure when the surgeon was present;
• Addressing the application of standard safety procedures such as the universal protocol for the prevention of wrong patient, procedure or site surgeries; and the responsibility for conducting pre-procedure briefs and post-procedure debriefs; and
• Reviewing any unexpected outcomes in cases involving concurrent performance or overlaps, as well as any extended anesthesia times while awaiting a surgeon’s arrival.

Healthcare risk managers can work with surgeons and clinical staff, legal counsel and administrators to proactively address patient safety, as well as the ethical and regulatory issues that currently surround the practice of concurrent or overlapping surgery. Bringing the topic to an appropriate decision-making body or committee with related guidelines and regulations for review, along with recommendations for action, can be the first step in developing policies that aim to protect patient safety, set guidance for providers and mitigate risks for the organization.

Kathleen Shostek, RN, ARM, FASHRM, CPHRM, CPPS, is vice president, healthcare risk management, Sedgwick. She can be contacted at: kathleen.shostek@sedgwick.com

References

1 Mello M. and Livingston E. Managing the Risks of Concurrent Surgeries. JAMA 2016;315(15):1563-1564.
2 Abelson J., et. al. Clash in the Name of Care. Boston Globe Spotlight Team Report. https://apps.bostonglobe.com/spotlight/clash-in-the-name-of-care/story/.
3 CMS Manual System. Teaching Physician Services. Sept. 14, 2011. https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/downloads/R2303CP.pdf.
4 Abelson J. et. al. Concurrent Surgeries Come Under Scrutiny. Boston Globe. Dec. 20, 2015. https://www.bostonglobe.com/metro/2015/12/19/concern-over-double-booked-surgeries-emerges-national-issue-for- hospitals/6IjRw2WkDYdt5oZljpajcO/story.html.
5 ACS. Statements on Principles. April 12, 2016. https://www.facs.org/about-acs/statements/stonprin.
6 Yount KW, Gillen JR, Kron IL, et al. American Association for Thoracic Surgery. 2014 Annual Meeting. Toronto, ON. http://aats.org/annualmeeting/Program-Books/2014/2.cgi