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Advances in Surgery 51 (2017) 113–124

ADVANCES IN SURGERY

Concurrent Surgery
What is Appropriate?

David B. Hoyt, MDa,b,*, Peter Angelos, MD, PhDc


a
University of California, Irvine, Irvine, CA, USA; bAmerican College of Surgeons, 633 North
Saint Clair Street, Chicago, IL 60611-3211, USA; cEndocrine Surgery, Department of Surgery,
MacLean Center for Clinical Medical Ethics, The University of Chicago Medicine, MC 4052, 5841
South Maryland Avenue, Chicago, IL 60637, USA

Keywords
 Concurrent surgery  Overlapping surgery  Backup surgeon
 Immediately available  Statements on principles  Informed consent
Key points
 The American College of Surgeons (ACS) and other stakeholder organizations
throughout the United States are responding to public concerns about patient
safety when an operating surgeon is involved in more than one surgical pro-
cedure at a time.
 These procedures are known as overlapping or concurrent operations; some-
times the terms are used interchangeably, although the terms refer to distinct
practices, and the differences need to be clarified.
 The ACS has updated its ‘‘Statements on Principles’’ to add clarity to the orga-
nization’s position on this issue, to more clearly identify acceptable procedures,
and to identify best practices moving forward.
 The ACS maintains that patients should be fully informed before consenting to
surgery of the possibility that some portions of their operation may be performed
by someone other than the primary surgeon.
 The ACS is consulting with congressional committees and regulatory bodies on
how best to regulate overlapping and concurrent operations and address re-
maining concerns.

Disclosure Statement: The authors have nothing to disclose.

*Corresponding author. American College of Surgeons, 633 North Saint Clair Street, Chicago,
IL 60611-3211. E-mail address: dhoyt@facs.org

http://dx.doi.org/10.1016/j.yasu.2017.03.009
0065-3411/17/ª 2017 Elsevier Inc. All rights reserved.
114 HOYT & ANGELOS

INTRODUCTION
Surgeons commonly perform procedures in which the beginning of one
operation overlaps with the conclusion of another. Such procedures are
defined as concurrent operations when the critical portions of both
procedures occur at the same time and as overlapping when they do not.
Advocates of overlapping operations say that they improve efficiency,
access to surgical care, and surgical training by exposing students and
trainees to opportunities to develop their skills and knowledge in the clinical
setting [1].
An October 2015 article in the Boston Globe, however, called these practices
into question [2]. The reporters described a case in which a patient experi-
enced an adverse outcome after undergoing an operation that was performed
by a surgeon who was involved in another procedure at the same time.
The Boston Globe article further suggested that patients often are not informed
that their operation may occur at the same time as another procedure and
questioned hospital consent processes in general. Some patient advocates
also raised concerns that the primary motivation for a surgeon to conduct
concurrent surgery was financial at the expense of highest-quality patient
care.
The Senate Finance Committee, which has jurisdiction over the Centers for
Medicare and Medicaid Services (CMS) and has worked on many projects
over the years to improve patient safety and transparency, sought the advice
of the American College of Surgeons (ACS) and other members of the surgical
community on the possible ethical issues associated with this practice and its
effects on patient care.
In response to these concerns and questions, the ACS reviewed its policies
and procedures and decided to revisit its guidelines on perioperative patient
care in an effort to create greater clarity around this issue [3].
Of particular concern to the ACS and the surgical community as a whole
was the need to educate the public about why overlapping operations occur,
the precautions that hospitals and clinicians take to ensure their safety, and
possible effects of this common practice on their care. Providing this
information, the ACS determined, was integral to maintaining the integrity
of the process of obtaining informed consent and the physician-patient
relationship.

AN ORGANIZED SURGERY RESPONSE


Advocates of overlapping surgery argue that this long-standing practice in-
creases access to highly skilled, in-demand surgeons by freeing up their
time to perform more operations, advances surgical education and training
by pairing senior physicians with residents and fellows, and improves the ef-
ficiency of surgical facilities. The use of a team to perform staggered proced-
ures has been a common and accepted practice in high-complexity surgery for
many years. Internal analysis at hospitals has demonstrated no increased rate
of complications. This practice has, in fact, been studied for cardiothoracic
CONCURRENT SURGERY 115

surgery with no increase in operative duration or negative effect on patient


outcomes [4].
In an attempt to provide guidance, clarity, and assurance to the public that
some overlap in procedures is, indeed, safe, the ACS examined its guidelines
on surgery to consider where there was opportunity for improvement of this
practice and clarify the safety of this practice to the public. Leading this effort
was an ad hoc committee of the ACS Board of Regents that was appointed in
November 2015. The ACS also reached out to The Joint Commission, the
American Hospital Association, the Senate Oversight Committee, and the me-
dia to assure them that the college was responding to these concerns and that
they would examine this issue carefully.
The committee’s specific charge was to review the issues of concern and
revise the ACS’ ‘‘Statements on Principles’’ as needed.
The ACS’ statements regarding surgical procedures and practice are devel-
oped through an evidence-based and consensus-driven process. These state-
ments are published in the college’s publication of record, the Bulletin, and
available to the public through the college’s Web site. To address this issue spe-
cifically, the college revised sections II.D and II.A of their ‘‘Statements on Prin-
ciples.’’ [5]
The committee sought to clarify the distinctions between concurrent surgery
and overlapping surgery. These terms are often used interchangeably but
refer to very different practices. The committee sought to explain when these
practices are appropriate and unlikely to have a negative effect on patient
safety and when these practices are inappropriate and may have harmful
consequences.
By defining the circumstances and contingencies involved in overlapping
and concurrent operations, the committee was able to elucidate the scenarios
in which these procedures occur and reach agreement about appropriate and
inappropriate behavior. The committee submitted its recommendations to
members of the ACS Board of Governors who represent multiple hospital or-
ganizations and specialty societies as well as to the full ACS Board of Regents.
This process led to some revisions and ultimately allowed the House of Sur-
gery to achieve consensus on the issue.
From the beginning, the intent was not to create new content but to add
clarity to the existing surgical guidelines. The revised language was released
on April 12, 2016. The Joint Commission and the American Hospital Associ-
ation now use these principles to determine the appropriate use of overlapping
operations. Furthermore, the revisions to the ‘‘Statements on Principles’’ has
been shared with the Senate Finance Committee for use in shaping the policies
and procedures that US hospitals will be expected to follow in order to receive
Medicare reimbursement for surgical care.

THE AMERICAN COLLEGE OF SURGEONS’ STATEMENT


The revised language in section II.D and II.A of the ACS’ ‘‘Statements on Prin-
ciples’’ is as follows [5].
116 HOYT & ANGELOS

II. D. The operation: intraoperative responsibility of the primary surgeon


General statement
The primary attending surgeon is personally responsible for patients’ welfare
throughout the operation. In general, patients’ primary attending surgeon
should be in the operating suite or should be immediately available for the
entire surgical procedure. There are instances consistent with good patient
care that are valid exceptions. However, when the primary attending surgeon
is not present or immediately available, another attending surgeon should be
assigned to be ‘‘immediately available.’’
The definitions at the end of this statement provide essential clarification for
terms used herein.
Concurrent or simultaneous operations
Concurrent or simultaneous operations occur when the critical or key com-
ponents of the procedures for which the primary attending surgeon is
responsible are occurring all or in part at the same time. The critical or
key components of an operation are determined by the primary attending
surgeon. A primary attending surgeon’s involvement in concurrent or
simultaneous surgeries on 2 different patients in 2 different rooms is
inappropriate.
Overlapping operations
Overlap of 2 distinct operations by the primary attending surgeon occurs in 2
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 compo-
nents of the first operation, for example, wound closure, allowing the pri-
mary 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.
Patients need to be informed in either of these circumstances. The perfor-
mance of overlapping procedures should not negatively affect the seamless
and timely flow of either procedure.
Multidisciplinary operations
Contemporary surgical care often involves a multidisciplinary team of sur-
geons. During such operations, it is appropriate for surgeons to be present
only during the part of the operation that requires their surgical expertise.
CONCURRENT SURGERY 117

However, an attending surgeon must be immediately available for the entire


operation.
Delegation to qualified practitioners
The surgeon may delegate part of the operation to qualified practitioners,
including but not limited to residents, fellows, anesthesiologists, nurses,
physician assistants, nurse practitioners, surgical assistants, or another
attending under his or her personal direction. However, the primary
attending surgeon’s personal responsibility cannot be delegated. The
surgeon must be an active participant throughout the key or critical
components of the operation. The overriding goal is the assurance of patient
safety.
Procedure-related tasks
A primary attending surgeon may have to leave the operating room for a
procedure-related task, such as review of pertinent pathology (frozen section)
and diagnostic imaging, discussion with patients’ families, and breaks during
long procedures. The surgeon must be immediately available for recall during
such absences.
Unanticipated circumstances
Unanticipated circumstances may arise during procedures that require the sur-
geon to leave the operating room before completion of the critical portion of
the operation. In this situation, a backup attending surgeon must be identified
and available to come to the operating room promptly.
Circumstances in this category might include sudden illness or injury
to the surgeon, a life-threatening emergency elsewhere in the operating
suite or contiguous hospital building, or an emergency in the surgeon’s
family.
If more than one emergency occurs simultaneously, the attending surgeon
may oversee more than one operation until additional attending surgeons
are available.
II. A. Surgeon-patient communication
The surgical team involved in an operation depends on the type of facility
where the operation is performed and on the complexity of the surgical proced-
ure. At a freestanding outpatient surgery center, many procedures are
performed solely by the primary attending surgeon with no assistant. In
contrast, a complex procedure at an academic medical center may involve mul-
tiple qualified medical providers in addition to the primary attending surgeon.
As part of the preoperative discussion, patients should be informed of the
different types of qualified health care professionals who will participate in their
operation (assistant attending surgeon, fellows, residents and interns, physician
assistants, nurse practitioners, and so forth) and their respective role should be
explained. If an urgent or emergent situation arises that requires the surgeon to
leave the operating room unexpectedly, patients should be informed
subsequently.
118 HOYT & ANGELOS

Definitions
In an effort to provide some standardization of nomenclature, the following
definitions are provided:

Backup surgeon/surgical attending


This person is the qualified surgical attending who has been designated to pro-
vide immediately available coverage for an operation, during a period when
the primary surgeon might be unable to fill this role.

Concurrent or simultaneous operations


These operations are surgical procedures whereby the critical or key components
of the procedures for which the primary attending surgeon is responsible are
occurring all or in part at the same time.

Critical or key portions of an operation


The critical or key portions of an operation are those stages whereby essential
technical expertise and surgical judgment are necessary to achieve an optimal
patient outcome. The critical or key portions of an operation are determined by
the primary attending surgeon.

Immediately available
Immediately available means reachable through a paging system or other elec-
tronic means and able to return immediately to the operating room. This term
should be defined more completely by the local institution.

Informed consent
This term is described in the ACS’ ‘‘Statements on Principles’’ II.A.

Multidisciplinary operations
An example of a multidisciplinary operation is a procedure in which a surgeon of
one specialty provides the exposure required by a second surgeon who performs
the main surgical intervention (such as a general or thoracic surgeon providing
exposure for a neurosurgeon or orthopedist to operate on the spine). Another
example would be an operation that requires the involvement of 22 or more sur-
geons of different specialties (such as chest wall or head and neck resection fol-
lowed by plastic surgical reconstruction, face or hand transplantation, and repair
of complex craniofacial defects).

Overlapping or sequenced operations for surgeons


These terms refer to the practice of the primary surgeon initiating and partici-
pating in another operation when he or she has completed the critical portions
of the first procedure and is no longer an essential participant in the final phase
of the first operation. These procedures are by definition surgical procedures
whereby key or critical portions of the procedure are occurring at different times.

Physically present
Physically present means located in the same room as the patients.
CONCURRENT SURGERY 119

Primary attending surgeon


This surgeon is considered the surgical attending of record or the principal sur-
geon involved in a specific operation. In addition to his or her technical and clin-
ical responsibilities, the primary surgeon is responsible for the orchestration and
progress of a procedure.

Qualified practitioner
A qualified practitioner is any licensed practitioner with sufficient training to
conduct a delegated portion of a procedure without the need for more experi-
enced supervision and who is approved by the hospital for these operative or pa-
tient care responsibilities.

CRITICAL QUESTIONS REMAIN


In early 2016, the Senate Finance Committee asked 20 hospitals to respond to
questions regarding these issues. After reviewing hospitals’ policies and proced-
ures, they found some variability in several areas where hospitals need to
improve their policies and procedures. More specifically, the Senate Finance
Committee has determined that institutions need to more clearly and consis-
tently define concurrent and overlapping surgery as well as the critical portions
of overlapping procedures. The congressional committee further maintains that
hospitals need to institute more consistent policies on disclosing information to
patients, ensuring the immediate availability of the primary surgeon or a suit-
ably trained replacement, arranging for a backup surgeon, and ensuring
compliance with the new policies [6].

Defining concurrent and overlapping surgery


Most hospitals use a definition of concurrent and overlapping surgery that is
similar to the college’s. Some hospitals, however, define overlapping surgery
more loosely, allowing operations to occur in 2 rooms at the same time. Other
hospitals only allow surgeons to perform overlapping operations if their out-
comes and quality data show that they are able to perform these procedures
safely. Still other hospitals specify the end point of the first procedure when
a second operation may begin.

Defining the critical portion of an overlapping surgery


The ACS and the CMS have policies that allow the surgeon to determine the
critical portions of an operation [7]. It is important that surgeons be allowed to
make this determination, as they are in the best position to determine for each
specific patient what the critical portions of each specific operation are and
whether the assisting surgeon is capable of performing the remaining steps of
an operation. That is to say, if the assistant is a first-year resident, he or she
might only be skilled in wound closure, whereas if the assistant is completing
a fellowship, he or she can perform more complex tasks. It is part of the
attending surgeon’s responsibility to ensure that all portions of an operation
120 HOYT & ANGELOS

are performed safely for each patient regardless of which member of the oper-
ating room team is actually performing that step.
Some policymakers suggest that each hospital should develop its own defini-
tion of the critical portion of each procedure and its own policies on when
direct surgeon supervision is necessary. The ACS maintains that in these in-
stances, the department chair bears responsibility for ensuring direct supervi-
sion of the critical portions of the operation. Chairs can fulfill this obligation
by issuing written guidelines for various types of procedures.
Patient advocates would argue that any work beneath subcutaneous tissue
should be designated as a critical portion of an operation. Although the college
maintains that rigid definitions such as this one are unlikely to achieve the
desired balance between safety and efficiency, the ACS recognizes that this is
an area that requires further study and discussion.

Disclosing information to patients


The ACS maintains that patients should be given an explanation of the roles
and responsibilities of all the health care professionals who will be involved
in their operation. This information should be shared during the process of ob-
taining informed consent and should include a discussion regarding if and
when overlapping surgery may occur.
Informed consent is central to ensuring patient autonomy in medical decision-
making. If a patient knows that the primary surgeon will be absent for a portion of
the operation, he or she may decide to seek care from another surgeon. In light of
concerns about patient consent to being involved in overlapping procedures, most
hospitals are reviewing their consent process and making changes accordingly.
One recent opinion piece suggests that American physicians inadequately
educate patients about overlapping surgery, providing incomplete information
or using euphemisms that may be unfamiliar to patients [8]. The authors sug-
gest that in order for disclosure to be meaningful to patients, it must be pre-
sented in a straightforward fashion that is understandable to patients.
One example of best practice that has emerged from the Senate Finance
Committee’s evaluation calls for patients to sign an attestation that they have
been informed that their surgeon is scheduled to perform an operation that
may overlap in part with their procedure but that their surgeon will be present
for the critical portion of the operation and that their surgeon will supervise a
team of professionals who may perform parts of their operation. Finally, this
statement should indicate that another qualified surgeon will be immediately
available, should the need arise.
In addition to concerns about what should be discussed during the process of
obtaining informed consent for overlapping surgery, the timing of these conversa-
tions has been the subject of debate. A patient needs adequate time to consider what
is going to occur and to deliberate how best to proceed. Consequently, the timing
and structure of the preoperative consent process are under broad discussion [9].
Based on a review of present practices, the Senate Finance Committee has
recommended that hospitals and departments of surgery develop policies
CONCURRENT SURGERY 121

that require surgeons to inform patients that an operation will overlap with
another procedure that the surgeon is scheduled to perform, create consent
forms that inform patients what overlapping procedures entail, require patients
to explicitly consent to overlapping surgery, and provide educational materials
to patients and their family members that they can use to guide them in
providing consent to undergo overlapping surgery [6].
Clearly informed consent for overlapping surgery is an area that will be
subject to regulatory oversight and scrutiny going forward. The professional
community and the hospitals where operations are performed must be for-
ward thinking and find ways to address these important issues so that pa-
tients are informed in an environment that places patient safety at the
forefront.

Determining immediate availability


The definition of immediate availability varies from institution to institution. In
general, surgeons should be able to return to an operating room for any change
that requires their attention. The ACS defines immediately available as reach-
able through a paging system or another communications device and able to
immediately return to the operating room.
Some hospitals define immediately available as being on campus. At large in-
stitutions in particular, the hospital campus may cover a significant expanse of
terrain, which could result in a substantial delay in the surgeon’s ability to re-
turn to the operating room. Some hospitals have sought to resolve this problem
by defining the physical area of the hospital that the surgeon must stay within
and by designating the amount of time the surgeon has to return to the oper-
ating room (for example, 5 to 15 minutes).

Arranging for backup


CMS’ billing requirements mandate that if a primary surgeon is not going to be
immediately available, he or she must designate a backup surgeon [7]. Like-
wise, many hospitals require a backup surgeon to be identified when overlap-
ping operations are scheduled. Other institutions only require that a backup
surgeon be designated when the need arises.
Many hospitals require that a specific backup surgeon be identified on the
morning of an operation and communicated to the operating room staff, so
if he or she is needed, this surgeon can be easily reached. Some hospitals
further mandate that the backup surgeon be credentialed in and have privileges
to perform the procedure.
Clearly, we need to develop more consistent guidelines on arranging for
backup that ensure patient safety is maintained. Hospitals should use their
quality-improvement process to more closely scrutinize deviations from their
policies.

Ensuring compliance with policies


Given the CMS9 conditions of participation, hospitals will need to develop pol-
icies and compliance procedures to demonstrate that overlapping operations
122 HOYT & ANGELOS

are performed safely within their confines. At present, the patient chart must
include documentation that the surgeon was available for and was physically
present during the critical portion of the surgery, but a more consistent system
will be required in the future.
The authors maintain that the medical record and progress notes should
document the following: whether the surgeon was immediately available
throughout the operation, whether a portion of the procedure was performed
by a backup surgeon, and the names of all staff who participated in the proced-
ure. The timeout should be used to document and communicate to the oper-
ating room team a surgeon’s availability. In Massachusetts, hospitals are
considering adding documentation of the times that the surgeon is in and
out of the operating room during surgical procedures.
To ensure compliance with these policies, hospitals should conduct random
audits of adherence to the CMS’ billing requirements for teaching physicians
and encourage staff to report violations of their guidelines on overlapping sur-
gery policy. Violations of these policies should result in the loss of a surgeon’s
privileges to perform overlapping operations. Some hospitals have tried to
achieve compliance by allowing anesthesiologists to reschedule cases when
the proper precautions are not taken or by prohibiting fellows, residents, or
qualified assistants from initiating a procedure if the surgeon is not immediately
available. Such policies should be carefully considered as they may lead to chal-
lenging stresses on the collaborative nature of intraoperative care provided by
surgeons and anesthesiologists for the patients’ benefit.

Frequency of occurrence
Little information is available to suggest how commonly overlapping and con-
current operations are performed. The Senate Finance Committee’s assessment
indicates that overlap occurs in anywhere from 1% to 33% with variation from
hospital to hospital. It is the responsibility of the hospital to identify when over-
lapping or concurrent surgery occurs through use of schedules or audits of sur-
geons’ practices.
A recent study conducted by researchers at the Mayo Clinic Rochester, Min-
nesota evaluated outcomes for overlapping operations using mortality and
length-of-stay data from the University Hospital Consortium and the ACS Na-
tional Surgical Quality Improvement Program [10].
Based on the evaluation of more than 10,000 overlapping cases, the study
found that overlapping and nonoverlapping operations had comparable mor-
tality rates and lengths of stay due to complications. These results are reassur-
ing in that they suggest that overlapping surgery does not seem to have
negative consequences for patients. The findings are, in fact, consistent with
the general feeling of many surgeons who have been performing these opera-
tions for a long time.
Although this study involves one institution and only one comparative
study, the Mayo Clinic’s experience with complex procedures and overlapping
procedures, as well as its commitment to high quality, add some credence to
CONCURRENT SURGERY 123

the evidence. The Mayo Clinic is known for its advanced electronic record-
keeping system, which allows it to monitor for and identify patient safety
issues.

SUMMARY
The purpose of overlapping surgery is to increase efficiency and maximize sur-
gical expertise by involving trainees and teams in the noncritical portions of an
operation and increase the numbers of patients that can be efficiently cared for
on a hospital surgical service. Overlapping surgery is not inherently unethical.
However, it is essential that patients be informed of this practice and given
enough notice so they may decide whether to seek care from another surgeon
or at another institution.
In light of recent revelations and debate about the practice of overlapping
surgery, the ACS and hospitals throughout the United States have examined
the issue carefully and have revised some of their guidelines to add precision
to how the practice is defined and to the requirements for the operating sur-
geon or similarly credentialed backup surgeon to be immediately available
when problems arise.
The net result of these efforts has included a careful evaluation of a legiti-
mate patient safety issue. The authors have reinforced their commitment to
developing and enforcing the principles that should be applied in the conduct
of overlapping procedures. Ongoing dedication to monitoring overlapping sur-
gery and improving the quality and safety of these operations must be
encouraged.
The most recent data available show that this practice is safe and well toler-
ated. Furthermore, this practice does increase patient access to timely surgical
care. Nonetheless, the surgical community and profession must be ever mind-
ful of the need to adequately inform patients about what this practice involves
and how it may affect their care.

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