Multiple-room surgery scrutinized by policymakers, institutions

Based on a partnership with Urology Times, articles from the American Association of Clinical Urologists (AACU) provide updates on legislative processes and issues affecting urologists. We welcome your comments and suggestions. Contact the AACU government affairs office at 847-517-1050 or info@aacuweb.org for more information.

Overlapping scheduling is considered an important means of giving surgical trainees hands-on experience. What's more, the practice is known to enhance access to surgical specialists, lower costs, and improve efficiency. Scientific literature supports overlapping surgery as a safe practice, but public opinion, informed by sensational reports in the press, is driving changes in policy within institutions, professional organizations and state statutes.

The American College of Surgeons (ACS) defines "'overlapping or sequenced' operations" as:

The practice of the primary surgeon initiating and participating 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 are by definition surgical procedures where key or critical portions of the procedure are occurring at different times.

Unfortunately, personal injury lawyers and the lay press frequently misrepresent this practice as being the same as "concurrent or simultaneous operations," which are defined as "surgical procedures when 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."

The ACS directs the primary surgeon to determine critical portions of an operation within the following parameters: "The ‘critical’ or ‘key’ portions of an operation are those stages when essential technical expertise and surgical judgment are necessary to achieve an optimal patient outcome."

The frequency of the practice of concurrent or overlapping surgeries remains unknown. Among a group of teaching hospitals surveyed by a congressional committee, administrators estimated the percentage of overlapping surgeries performed from January 2015 through March 2016 to range from less than 1% to 33% of all surgeries.

Multiple-room surgery has figured prominently in cases in Boston, South Florida, Nashville, and Seattle. A Boston Globe investigation drew attention to the lack of a consistent policy regarding overlapping surgery from state to state and from hospital to hospital. The decision about whether to allow the practice is left to hospitals, which are also primarily responsible for policing it. Medicare billing rules permit it as long as the attending surgeon is present during the critical portion of each operation, but that applies only to teaching hospitals and the government does not routinely monitor compliance.

In response to the public controversy, the ACS updated its Statement of Principles in April 2016 to address the practice of concurrent and overlapping surgeries (as described above). The U.S. Senate Finance Committee, which oversees Medicare and Medicaid, published a Staff Report in December of that year. According to the Boston Globe, the committee asked "hospitals, not surgeons, to clarify the circumstances under which it is safe for surgeons to schedule [overlapping] operations."

Furthermore, the influential panel "suggests authorizing anesthesiologists to cancel operations if surgeons violate policies; and urges hospitals to explicitly tell patients about any overlapping surgeries far enough in advance that they can decide whether to cancel the procedure."

Next:"At the state level, Massachusetts has led the way in issuing new regulations for multiple-room surgery."At the state level, Massachusetts has led the way in issuing new regulations for multiple-room surgery. The Board of Registration in Medicine approved a new rule in January 2016 requiring that surgeons document each time they enter and leave an operating room, as well as officially designate a secondary surgeon. State legislators, meanwhile, are currently considering a new law establishing certain patient rights (2018 H.3514), including a right to:

• refuse to undergo a concurrent surgical procedure

• a standardized consent form for obtaining consent

• a medical record that includes whether or not the attending physician was present or absent during the procedure

• public notification from health facilities regarding their multiple-room surgery policy.

The topic of overlapping surgery remains a misunderstood and controversial issue. An abundance of evidence suggests there is no increased incidence of poor outcomes. Top-down regulation by governments and payers will likely contribute to inefficiency and increased costs. According to the Congress of Neurological Surgeons, significant steps have been made in defining the terms utilized by practitioners and lawmakers when discussing the topic and its impact on access to care and provider training. The AACU will continue to play a role in those discussions in an effort to represent practicing urologists' perspectives.