Patient Safety Tip of the Week

December 13, 2016

More on Double-Booked Surgery



It’s only been two weeks since our last column on double-booked surgery (see our November 29, 2016 Patient Safety Tip of the Week Doubling Down on Double-Booked Surgery”) but already there have been two significant publications regarding the practice.


We previously noted the paucity of evidence in the literature for or against the practice of double-booked surgery. In our November 10, 2015 Patient Safety Tip of the Week “Weighing in on Double-Booked Surgery” we noted Massachusetts General Hospital’s review of its own cases. And in our November 29, 2016 Patient Safety Tip of the Week Doubling Down on Double-Booked Surgery” we highlighted the study done by Zhang and colleagues at UCSF comparing overlapping cases with non-overlapping cases for a variety of orthopedic surgical procedures performed in an academic ambulatory surgery setting (Zhang 2016). The latter found no difference in patient operating room time, procedure time, and 30-day complication rates between overlapping and non-overlapping surgery.


Now a new retrospective review has compared overlapping surgery with nonoverlapping surgery at the Mayo Clinic (Hyder 2016). Over 10,000 cases of overlapping surgery were matched to a similar number of nonoverlapping surgeries. Adjusted odds ratio for inpatient mortality was greater for nonoverlapping procedures (adjusted odds ratio, OR = 2.14 vs overlapping procedures) and length of stay and morbidity were no different.


That’s reassuring in that it likely means that the overall occurrence of adverse events related to double-booked or overlapping cases is small. The frequency of retained surgical items or wrong-site surgery is also small but that doesn’t mean we don’t need to take steps to prevent such adverse events. The same applies to double-booked or overlapping surgery. The Hyder review also cannot conclude that there were no adverse events related to overalapping surgery since they did not do full case reviews on all cases. And, while they did the best they could in matching overlapping cases to nonoverlapping cases, we don’t know why the latter were done without overlapping. There may well have been a selection bias in which some factor not accounted for in the risk adjustment led the surgeons to schedule these cases as nonoverlapping. And you’ll recall in our November 29, 2016 Patient Safety Tip of the Week Doubling Down on Double-Booked Surgery” we also described a scenario where as complication that could have been prevented had a post-op debriefing been done for one case of an overlapping surgery actually gets attributed instead to a nonoverlapping case. And, lastly, the results from a single academic center may not be generalizable to other academic centers or to non-teaching venues.


In addition, the Boston Globe (Saltzman 2016) recently noted an unpublished study by an assistant professor of surgery at the University of Toronto found an increased risk for postoperative complications in concurrent surgery for hip fractures. The study, which used data from about 100 hospitals, compared about 1,000 concurrent hip surgeries with 1,000 that were not performed simultaneously from 2009 to 2014. They noted that the longer the overlap, the greater the rate of complications. From the Globe article, however, it is not clear whether these surgeries were concurrent or overlapping, an important distinction as we’ll note below under definitions.


The second, and perhaps more significant, publication comes not from traditional medical literature but rather from the Senate Finance Committee! You may recall that, after the 2015 Boston Globe investigative report (Abelson 2015) on the practice of double-booked surgery, the Senate Finance Committee, which oversees CMS (Centers for Medicare & Medicaid Services), launched an investigation into double-booked surgery. It has just released a report on the findings of that investigation (Senate Finance Committee 2016). That committee solicited responses from 20 academic medical centers regarding a variety of issues surrounding double-booked surgery plus received testimony from CMS, The Joint Commission, the American College of Surgeons (ACS), AHRQ, the HHS OIG, and multiple other stakeholders.


After the American College of Surgeons issued its position/guidance on concurrent and overlapping surgery (ACS 2016) all of the 20 medical centers responding to the Senate committee had either modified their existing policies, adopted new policies, or were in the process of adopting new policies on double-booked surgery. The Senate committee reviewed those policies and other key issues and, while generally comfortable with the progress made to date, had some additional recommendations.


Hereafter, we’ll refer to “overlapping” surgery. The definition of “concurrent” surgery is a practice in which a surgeon is participating in the “critical portion(s)” of 2 cases simultaneously. The ACS and the Senate committee and pretty much all parties agree that “concurrent” surgery should never be performed.


The Senate committee specifically looked to see if the hospital policies conformed to the ACS guidance on the following:


Under the definitions of concurrent and overlapping surgeries, they wanted to see that “concurrent” surgery was defined and specifically prohibited. They also looked to see that hospitals used the ACS definitions for the 2 types of “overlapping” surgeries (see our November 29, 2016 Patient Safety Tip of the Week Doubling Down on Double-Booked Surgery” for those definitions from the ACS). Half the respondent hospitals used the ACS definitions but several had used definitions that were more vague.


They drew special attention to one hospital policy that required department chairs allow surgeons to conduct overlapping surgery only after reviewing the surgeons’ outcome and quality data. In our November 29, 2016 Patient Safety Tip of the Week Doubling Down on Double-Booked Surgery” we recommended that such review be conducted as part of both the credentialing and privileging process for new surgeons and for continuation of privileges for “overlapping” surgeries for current surgeons, keeping in mind that some older surgeons may maintain their surgical skills even as their ability to multitask deteriorates.


As you might expect, there was more variability when it came to defining “critical portions” of overlapping surgeries. Basically, both CMS and the ACS guidance leave that definition up to the individual surgeon. Most of the hospital policies reviewed by the Senate committee either did not define the critical portions or left it up to the attending physician. A few hospitals, however, did develop lists of procedures (usually by department) and their critical components. The report also notes that discussion of the “critical portions” could be part of the pre-op “huddle” or surgical “time out” and could also be written on the OR white board.


The Senate report notes that both CMS and the ACS generally consider opening and closing of the surgical site as not critical. But in our November 29, 2016 Patient Safety Tip of the Week Doubling Down on Double-Booked Surgery” we gave real-life examples of some instances where circumstances identified after wound closure would likely merit return of the attending surgeon, with resultant increases in patient time under anesthesia.


The Senate report recognizes that the optimal manner of defining “critical portion” is wanting. But it does find merit in the approach where “surgical departments within a hospital’s medical staff develop guidelines that identify critical components of particular procedures while accounting for the individualized clinical judgment of the surgeon”. We feel strongly that there must be definitions that are uniform for each of the surgical procedures done within a department and across departments when the same procedure is done by multiple departments. (Definitions set by the “hospital” would really have to rely upon the expertise of department chairs, anyway.) Likewise, we would hope that each specialty society will help develop such definitions so that regulatory bodies don’t have to step in and develop such for them.


When overlapping surgery is performed, there should be designation of a backup surgeon who will be “immediately available” to intervene if the original attending surgeon is doing other surgery. Defining “immediately available”, as anticipated, was controversial. There was wide variation in the timeframes and locations in the policies of respondent hospitals. A third simply stated the surgeon must be “on campus”, which does not specify how readily he/she could respond. Some did not define immediately available at all. Others noted specific timeframes, such as 5 minutes or 15 minutes. The Senate report notes that neither CMS nor the ACS defined the term adequately. The ACS guidance does state the surgeon should be “reachable through a paging system or other electronic means, and able to return immediately to the operating room.”


The Hyder study (Hyder 2016), in describing overlapping surgery as performed at the Mayo Clinic, noted that “Each surgical specialty operates in dedicated operating room cores with multiple surgeons of the same specialty present throughout the business day; therefore, second surgeons are available to assist when needed.” That’s simply not good enough. A specific surgeon needs to be designated for each such overlapping case and that surgeon must not be doing activities that would preclude him/her from immediately going to the OR case in need of help (nor jeopardizing any other patient he/she may have been involved with prior to the call for help).


The Senate report notes that some hospitals set additional expectations for the backup surgeon. For example, he/she should be credentialed/privileged to perform the procedure being done, be willing to serve as backup, and be fully aware of the responsibility. The ACS apparently testified that some surgical fellows, with appropriate training, could be qualified to serve as the backup surgeon. We especially like what some policies require regarding communication about the backup surgeon:


The section of the Senate committee report dealing with informed consent is quite useful. It makes it clear that patients must be informed that their surgeon will not be in the operating room for parts of their surgery. But their review of informed consent documents found only 3 in which the consent forms explicitly stated the patient was scheduled to have overlapping surgery and that their surgeon would not be present for portions of their surgery. Many hospitals used wording too vague, such as their surgeon “may” be involved in other surgeries. In addition, 6 hospitals had wording that other providers may perform portions of their surgery without mentioning that their attending surgeon might not be present for those portions.


Moreover, it emphasizes that patients must be made aware of this in a manner in which they fully comprehend the implications and have both the ability to ask questions and refuse to have overlapping surgery. They cite an informative Health Affairs Blog by Dr. James Rickert dealing with informed consent in such cases (Rickert 2016). Rickert discusses the problems of ensuring patients truly understand what is told to them during informed consent and suspects that in discussing overlapping surgery “Euphemisms, incomplete information, and oblique discussions will be the norm.” It is clear that this discussion must take place at a time when the patient would have adequate time to digest the information, ask questions, and be able to cancel the surgery if desired. So having the discussion on the day of surgery is a no-go. Some of the hospitals included a specific time period, such as “at least 24 hours prior to the surgery”, but many left the wording vague such as “sufficiently prior to” surgery.


Some hospitals included in their general surgery consent a place for a patient to initial or sign that he/she understands their surgeon may be absent for a portion of their surgery. The report provides an excellent example the specific text of a paragraph one hospital uses on its form that must be signed by patients only in cases where overlapping surgery applies. Rickert notes that when surgery is first discussed, surgeons should tell patients if they practice simultaneous surgery, and explain what this will mean for them in the operating room. Because surgery schedules for elective procedures are usually done weeks or even months ahead of time, patients would then have sufficient time to find another surgeon if they are uncomfortable with the practice of simultaneous surgery. You’ll also recall from our November 29, 2016 Patient Safety Tip of the Week Doubling Down on Double-Booked Surgery” the practice at UCSF in the Zhang study (Zhang 2016) typically involved such discussion during a clinic visit, typically a week prior to surgery and in the editorial accompanying the Zhang study, Healy (Healy 2016) recommended obtaining specific informed consent at least 2 weeks prior to the operation.


Our November 29, 2016 Patient Safety Tip of the Week Doubling Down on Double-Booked Surgery” also cited a viewpoint on informed consent in concurrent surgery (Langerman 2016) which pointed out the “information asymmetry” involved, where “surgeons know much and our patients know little about what will happen during their operation.” Patients may not understand the implications of potentially spending extra time under anesthesia in the event their surgeon is delayed in responding to something in their case because he/she is doing surgery on another patient. Most patients in academic centers understand that physicians in training will actively participate in the surgery and likely improve the quality of their overall care. But they also likely expect that their primary surgeon will be present to oversee all aspects of their surgery.


We would also like to point out a surgeon should never refuse to perform surgery on a patient who refuses to consent to overlapping surgery. It may be appropriate to let a patient know his/her surgery may not be able to be scheduled as soon if it is not overlapping. But to refuse to do the surgery as a nonoverlapping case would be unethical. We feel that including specific wording to that effect in the informed consent document or the educational materials provided to the patient should be part of every hospital’s policy on overlapping surgery. And hospitals obviously need to make it clear to their staff that such refusal would not be tolerated.


Perhaps the strongest recommendations in the Senate committee report deal with ensuring compliance with policies. The report stresses that developing policies on overlapping surgery are an important first step but that training all staff to ensure they understand the policies and then overseeing that the policies are adhered to are critical steps. They liked language similar to that used by some hospitals:


They also liked language used by some hospitals to describe roles played by others staff in ensuring compliance with the policies:


Monitoring surgeon location and tracking the critical portions of the surgical procedures is also considered important in the Senate committee report. Many hospital policies simply used the CMS billing requirement that the surgeon document in the medical record that he/she was present for the critical portion(s) of the surgery. We previously noted the Massachusetts Board of Registration in Medicine proposal requiring that surgeon presence or absence in the room at various times be documented. We like the latter idea. We actually have proposed hospitals record entry and exit of all OR personnel in attempt to reduce opening and closing of OR doors (which  may predispose to infections) as described in our July 26, 2016 Patient Safety Tip of the Week “Confirmed: Keep Your OR Doors Closed”.


In our November 29, 2016 Patient Safety Tip of the Week Doubling Down on Double-Booked Surgerywe also suggested that you might as part of your quality management program occasionally try to get hold of that “backup” physician and see how long it actually takes for him/her to get to the OR.


The Senate committee was also concerned that hospitals need to specify how complaints about surgeries from patients or staff would be addressed.


Missing from the Senate committee report, from our perspective, is discussion about pre-op huddles/briefings and post-op debriefings. We’ve discussed these important issues in our Patient Safety Tips of the Week for November 10, 2015 “Weighing in on Double-Booked Surgery” and November 29, 2016 Doubling Down on Double-Booked Surgery”.


The Senate committee report does make mention of the surgical time out only in that the “time out” should include identification of the backup surgeon. It also notes that discussion of the “critical portions” could be part of the pre-op “huddle” or surgical “time out” and could also be written on the OR white board. We also think that the surgeon should announce during both the pre-op “huddle” and surgical “time out” that he/she will be doing an overlapping case and when staff can expect him/her to leave the current case. For the second case, the surgeon obviously needs to be present for the surgical “time out”. But what about the pre-op “huddle” for that second case? Is it skipped? Is it done prior to the first case? And, remember, if you do two pre-op huddles back-to-back you may be vulnerable to transposing information or intents between cases, particularly when the cases are similar procedures.


The Senate committee report tried to get an estimate of the scope of overlapping surgery across the US. But they found such statistics are difficult to come by. At respondent hospitals the percentages of overlapping cases ranged from less than 1% to 33% of all surgeries. The percentage of overlapping cases was even higher for some specific surgeons.


The Senate report also notes that neither CMS nor The Joint Commission has specifically investigated overlapping surgery in their surveys. The HHS OIG has audited billing practices at teaching hospitals and has found several violations over the years, resulting in fines for those hospitals. So the Senate Finance Committee has also recommended that CMS and the HHS OIG review compliance with billing practices related to overlapping surgery. They also note that the CMS billing guidelines only apply to teaching hospitals. The Senate committee recommends that CMS also review whether those billing requirements should also be applied to non-teaching venues where overlapping surgery may be done (private hospitals, ambulatory surgery centers, etc.).


The recent Boston Globe article (Saltzman 2016) also included a comment from the chairman of surgery at the University of Michigan, stating that “the practice benefits only the surgeons who get to do it by increasing their productivity. It is inefficient for all other medical staff, he said, including other surgeons who lose operating room time.” We hadn’t quite thought about it in that way but it is really in keeping with our conviction that the fundamental driving force for double-booked surgery is the financial incentive.


As before, we personally would not consent to any form of double-booked surgery and expect our attending surgeon to be present at our procedure even when portions of the surgery are being performed by residents, fellows, or other personnel. While we would hope most hospitals eliminate or minimize any form of double-booked surgery, we would expect those hospitals allowing overlapping surgery meet the positive elements noted in this column.


For those of you who plan to allow overlapping surgery at your institution, we offer the the “Overlapping Surgery Checklist” to help you plan for safe implementation.




See all our columns on double-booked, concurrent, or overlapping surgery:







Zhang AL, Sing DC, Dang DY, et al. Overlapping Surgery in the Ambulatory Orthopaedic Setting. J Bone Joint Surg Am, 2016; 98 (22): 1859-1867



Hyder JA, Hanson KT, Storlie CB, et al. Safety of Overlapping Surgery at a High-volume Referral Center. Annals of Surgery 2016; Published ahead of print (Post Author Corrections): December 5, 2016



Saltzman J, Abelson J. Senate committee calls for ban on surgeons conducting simultaneous operations. The Boston Globe 2016; December 6, 2016



Abelson J, Saltzman J, Kowalcyzk L, Allen S. Clash in the Name of Care. Boston Globe October 26, 2015



Senate Finance Committee. Concurrent and Overlapping Surgeries: Additional Measures Warranted. A Senate Finance Committee Staff Report 2016; December 6, 2016



ACS (American College of Surgeons). Statements on Principles. Revised April 12, 2016



Rickert J. A Patient-Centered Solution To Simultaneous Surgery. Health Affairs Blog 2016; June 14, 2016



Healy WL. Overlapping Surgery: Do the Right Thing. Commentary on an article by Alan L. Zhang, MD, et al.: “Overlapping Surgery in the Ambulatory Orthopaedic Setting”. J Bone Joint Surg Am, 2016; 98 (22): e101



Langerman A. Concurrent Surgery and Informed Consent. JAMA Surg 2016; 151(7): 601-602



Our own “Overlapping Surgery Checklist”.







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