Committee seeks to ban concurrent surgeries

Bob GattyThe practice of performing concurrent and overlapping surgeries in hospitals and ambulatory surgery centers (ASCs) across the nation has come under scrutiny by the Senate Finance Committee, and hospitals and surgeons are on notice that some practices that may have been commonplace in the past need to change. 

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On Dec. 8, 2016, the committee issued a report warning that concurrent surgeries-two surgeries led by the same surgeon in which critical procedures occur at the same time-should be prohibited. The report, which followed a year-long inquiry by the panel’s staff, said that overlapping surgeries-those in which critical elements of the first operation have been completed and the surgeon initiates a second operation in another operating room-should be carefully controlled.

Furthermore, the staff said hospitals should make certain that patients are clearly informed during consent discussions that their surgery will overlap with another patient’s, and that the Centers for Medicare & Medicaid Services (CMS) should evaluate billing policies for overlapping procedures.

Report: Concurrent surgery may cause harm

The committee staff’s examination of the issue was prompted by an October 2015 Boston Globe report that provided an in-depth review of concurrent surgeries being practiced at hospitals in the Boston area, alleging that the practice may have resulted in several instances of measurable patient harm, including deaths.

In its report, the committee noted that, “Specifically, the article described operations in which surgeons divided their attentions between two operating rooms over several hours, failed to return to the operation when residents or fellows needed assistance, or failed to arrive on-time for surgeries, leaving residents or fellows to perform surgeries unsupervised or resulting in patients under anesthesia for prolonged periods.” The article noted that patients were not informed their surgeries would run concurrently with another.

The committee’s staff said hospitals and surgeons should carefully adhere to the recently updated American College of Surgeons (ACS) Statements of Principles regarding such procedures. The AUA provided input to the ACS as it developed its revised statements, which include the following regarding “concurrent or simultaneous operations”: “A primary attending surgeon’s involvement in concurrent or simultaneous surgeries on two different patients in two different rooms is inappropriate.”

The statements also discuss overlapping operations: “The performance of overlapping procedures should not negatively affect the seamless and timely flow of either procedure.” (For the full statements, please see: bit.ly/ACSstatements.)

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“We commend the work of the AUA, Dr. David Penson and all of those specialists involved with the ACS in diligently working to better define concurrent surgeries and establish guidelines for such cases,” said AUA President-elect J. Brantley Thrasher, MD. “We all recognize such clarification was necessary for the safety of our patients.”

Next: Recommendations for health care institutions

Recommendations for health care institutions

The report made these recommendations for hospitals and other health care institutions that perform surgeries and accept Medicare and Medicaid payments:

• develop a concurrent and overlapping surgical policy that clearly prohibits concurrent surgeries and regulates overlapping surgeries consistent with the ACS guidance

• identify the critical portions of particular procedures, to the extent practicable, as well as those portions unsuitable for overlap

• develop processes to ensure patient consent discussions result in a complete understanding by the patient that his/her surgery will overlap with another patient’s; develop materials such as Frequently Asked Questions; and educate patients prior to their surgeries, providing sufficient time for them to review materials and fully consider their options

• identify the backup surgeon in advance when scheduling overlapping surgeries

• develop mechanisms to enforce the established concurrent and overlapping surgical policies and monitor and enforce their outcomes.

The report also recommended that CMS modify its regulations or survey processes and direct accrediting organizations to modify their hospital standards or survey processes to ensure that hospitals eligible for payment from Medicare and Medicaid have policies consistent with the ACS’s revised guidance.

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The committee staff pointed out that CMS’s billing requirements apply only to teaching physicians operating in hospitals and should be extended to non-teaching scenarios, such as when a physician is assisted by a technician or in a setting such as an ASC.

Following the publication of the Boston Globe article, the committee staff contacted 20 teaching hospitals querying them about the practice of concurrent or overlapping surgeries at their institutions. Initially, the staff report said, officials and staff at those hospitals “were largely skeptical of concerns regarding the safety of the practice of concurrent surgeries.”

Since then, however, the staff said the committee recognizes that many of the hospitals and medical professionals have taken steps in a short period of time to address many of the concerns.

But the staff pointed out that it has no way of knowing what the larger population of 4,900 hospitals and other facilities nationwide that receive Medicare payments are doing to address the issue, noting that in 2014, hospitals performed over 26 million surgeries, including 9 million inpatient and 17 million outpatient procedures.

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