ACS Updates Guidelines Regarding Overlapping Surgeries

Marcia Frellick

April 18, 2016

In light of news reports questioning the practice of one surgeon performing in two surgeries scheduled at the same time, the American College of Surgeons (ACS) has updated its guidelines to clarify when this may be appropriate and what patients should know before consent.

The guidelines are part of a larger document called Statements on Principles, revised by ACS April 12.

In it, ACS advises against concurrent or simultaneous surgeries and defines them as those in which "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 guidelines state: "A primary attending surgeon's involvement in concurrent or simultaneous surgeries on two different patients in two different rooms is not appropriate."

But "overlapping" surgeries are different, they say, and may be appropriate; for instance, if "key or critical elements" of the first operation are finished, freeing up the primary attending to start an operation in another room while others finish the first operation.

Patient Consent

David Hoyt, MD, executive director of ACS, told Medscape Medical News the paper also aims to clarify guidance around patient consent so that patients know who will be performing their care before the operation.

Language in the guidelines reads, "As part of the preoperative discussion, patients should be informed of the different types of qualified medical providers that will participate in their surgery (assistant attending surgeon, fellows, resident and interns, physician assistants, nurse practitioners, etc.) and their respective role explained. If an urgent or emergent situation arises that require the surgeon to leave the operating room unexpectedly, the patient should be subsequently informed."

But that is where James Rickert, MD, an orthopedist in Bedford, Indiana, and president of the Society for Patient Centered Orthopedics, says he finds a loophole, one of three main problems he has with the guidelines.

First, he says, the language says the patient should be told that another surgeon may assist in his or her surgery, but not necessarily that the original surgeon may leave to assist in a surgery in another room, and patients might have a problem with that.

"If you don't have to explain that, I just don't think you will because you're afraid of upsetting the patient," he said.

He told Medscape Medical News the guidelines do not go far enough.

"I think they merely change the name from concurrent surgery to overlapping surgery in an attempt to legitimize the practice without making any real reform," he said.

In addition, Dr Rickert said, patients are often asked to consent the day of the surgery, and they are likely to feel compelled to sign when so much has been put in motion — the patient has taken time off work and the family has flown in, for instance.

"I don't think it's fair. At that point, what are they to do?" he said. He said patients should be informed that the physician may be out of the room "as soon as discussion of possible surgery begins" to give patients a chance to select another physician if they wish.

Dr Rickert's third criticism surrounds the fact that primary surgeons decide what parts of the surgery are considered "critical components" of a surgery, therefore essentially deciding themselves when being between operating rooms is appropriate.

"ACS needs to put out a much more definitive statement of 'critical components' for these guidelines to mean anything," he said.

Efficient Practice or Trust Violation?

Although some say double-booked or overlapping surgeries are an efficient way to complete more surgeries and that primary surgeons do not necessarily have to be in the room for every facet of the surgery, others say the practice can violate patient trust.

Questions in a Boston Globe series about the practice led the Massachusetts Board of Registration in Medicine in January of this year to require surgeons to document each time they enter or leave an operating room, as previously reported by Medscape Medical News. According to the report, it is apparently the first such move by a medical board nationally.

Although such actions and media reports put the practice in the spotlight recently, the guidelines do not introduce new ideas, Dr Hoyt said. "These changes were really to clarify what has been the practice all along."

Steven Steinberg, MD, chief of trauma and critical care at The Ohio State University Wexner Medical Center in Columbus, says the guidelines are important in clarifying the differences between concurrent, overlapping, multidisciplinary, and sequential operations.

"I believe that patients have a right to know these details," he told Medscape Medical News. "It is also my opinion that most patients will have few, if any, concerns with overlapping surgeries as long as their surgeon is present for the critical portion of the operation and they are informed, and agree to, the surgeon who will be performing the noncritical portions of their operation."

However, he said, the guidelines will likely have little effect on the large majority of surgeons, most of whom do not "flip back and forth between rooms to save the room turnover time."

Dr Steinberg said one of the positive aspects of the guidelines will be that "surgeons will need to have discussions about what 'critical portion of the operation' means and who might be performing some of the noncritical portions of the operation."

Dr Rickert, Dr Hoyt, and Dr Steinberg have disclosed no relevant financial relationships.

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