What’s New in the Patient Safety World

May 2017

The Concurrent Surgery Debate Continues



The Boston Globe’s Spotlight Team, which thrust double-booked or concurrent/ overlapping surgery into the headlines back in 2015 (see our November 10, 2015 Patient Safety Tip of the Week “Weighing in on Double-Booked Surgery”), has again focused attention on this practice. In the new investigation, the Spotlight Team (Saltzman 2017) noted that a urologist routinely performed overlapping surgery in up to 70% of his cases. The Spotlight investigation notes that state regulatory agencies and the ACGME (Accreditation Council for Graduate Medical Education) are reviewing this as well.


The Globe report, of course, again raises the issue of informed consent and whether patients understand that their surgeon may not be physically present for portions of their surgery. A recent survey (Kent 2017) looked at knowledge of overlapping surgery, expectations on disclosure during the informed consent process, and their willingness to participate in such a procedure. That survey found that only 3.9% of respondents had any knowledge of the practice of overlapping surgery. Interestingly, though the majority of respondents were not supportive of the practice, 31% supported or strongly supported this practice. But 94.7% believed that the attending surgeon should inform them in advance of overlapping surgery and 95.6% would want definition of the critical components of the operation. And 91.5% felt that the surgeon should document what portion of the operation he or she was present for.


We’ve previously noted the paucity of evidence in the literature for or against the practice of double-booked surgery. In our December 13, 2016 Patient Safety Tip of the Week “More on Double-Booked Surgery” we alluded to an unpublished Canadian study that showed increased frequency of complications with overlapping surgery. That study has now been presented in abstract form (Ravi 2017). The researchers defined concurrent hip fracture cases as those that overlapped in time with any other orthopedic case performed by the same attending surgeon. These were matched to hip fractures that were managed non-concurrently on the age and sex of the patient, the type of procedure, the primary surgeon and the hospital. Comparing almost 1000 patients each in concurrent vs. non-concurrent surgery, they found that concurrent patients were at increased risk for surgical complications at 90 days (7% vs. 4.7%) and at one year (8.6% vs. 6%) and that increasing duration of overlap was associated with an increased risk for complication (adjusted OR 1.08 per 10 minutes of overlap).


This contrasts with three previous reviews that concluded there was no increase in complications with overlapping 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. And our December 13, 2016 Patient Safety Tip of the Week “More on Double-Booked Surgerynoted the retrospective review comparing overlapping surgery with non-overlapping surgery at the Mayo Clinic (Hyder 2016). Over 10,000 cases of overlapping surgery were matched to a similar number of non-overlapping surgeries. Adjusted odds ratio for inpatient mortality was greater for non-overlapping procedures (adjusted odds ratio, OR = 2.14 vs overlapping procedures) and length of stay and morbidity were no different.


Also, a just released abstract presented at the 2017 American Association of Neurological Surgeons (AANS) Annual Meeting (Bohl 2017, Melville 2017) found better, not worse, outcomes with overlapping surgery. The better outcome measures included hospital length of stay, return to the operating room, and disposition status.


Though the Ravi study has only been presented in abstract form and not yet subject to peer review, the findings do raise further concern about overlapping surgery. In our previous columns we noted that the absolute frequency of adverse events related to concurrent surgery is likely relatively small and, hence, such adverse events are likely to be “buried” in large series.


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. We hope that you’ll see our prior columns (listed below) to see our arguments against overlapping surgery and our recommendations for those of you who do allow it. For those of you who plan to allow overlapping surgery at your institution, we refer you to our “Overlapping Surgery Checklist” to help you plan for safe implementation.




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







Saltzman J, Abelson J. Star surgeon is scrutinized on concurrent procedures. Boston Globe 2017; March 12, 2017




Kent M, Whyte R, Fleishman A, et al. Public Perceptions of Overlapping Surgery. Journal of the American College of Surgeons 2017; Published online: February 11, 2017




Ravi B, Pincus D, Wasserstein D, et al. Concurrent Surgery for Hip Fractures is Associated with an Increased Risk for Postoperative Complications. AAOS (American Academy of Orthopaedic Surgeons) Annual Meeting 2017




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




Bohl M. Overlapping Surgeries are not Associated with Worse Patient Outcomes: Retrospective Multivariate Analysis of 14,872 Neurosurgical Cases Performed at a Single Institutiion. American Association of Neurological Surgeons (AANS) 2017 Annual Meeting. Abstract 917. Presented April 26, 2017


and summarized in:

Melville NA. Outcomes Better, Not Worse, in Overlapping Neurosurgeries. Medscape Medical News 2017; April 28, 2017




Our own “Overlapping Surgery Checklist”.







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