COMMENTARY

Should Overlapping and Multiple-Room Surgeries Be Allowed?

Alex Macario, MD, MBA

Disclosures

August 30, 2017

The American Academy of Otolaryngology-Head and Neck Surgery (AAO-HSNF) sent out an online survey (22 questions) to its members to ask about practices and attitudes toward multiple-room surgery.[1] The authors used the term ''multiple-room surgery'' to cast a broad net regarding the range of situations where there is some overlap in cases by one attending surgeon. This could include such scenarios as incision on a patient in an operating room during closure of the patient in another room.

Study Summary

Of the 9520 AAO-HSNF members, 907 (9.5%) completed the survey, and 40% perform some form of multiple-room surgery. Of those, 22% indicated "Yes, I participate in multiservice surgeries and run a second room when my key portion of the multiservice surgery is not occurring"; 20% indicated "Yes, I start a second room when my first room is closing"; and 17% indicated, "Yes, I coordinate simultaneous procedures to be present during key portions of both." Because respondents had the option to click more than one of those response items, the percentages don't add up to the 40% of those who engage in multiple-room surgery.

When asked, "What is/are the reason(s) you do not perform multiple-room surgery?" the responses were as follows:

  • Facilities/institution does not allow it: 13%;

  • Do not work with residents, fellows, or physician extenders: 33%;

  • Case volume and practice do not warrant multiple rooms: 38%;

  • Insufficient operating rooms or nursing are available: 25%; and

  • Do not feel comfortable performing multiple-room surgery: 43%.

Most believed that regulations disallowing multiple-room surgery would result in an increase in late starts (74%), an increase in the time to schedule surgery (85%), a detriment to residency training (63%), and no improvement in patient safety (60%).

Specialists, such as pediatric otolaryngologists or head and neck surgeons, were more likely than generalists to perform multiple-room surgery.

Viewpoint

Having the same attending surgeon scheduled in two different operating rooms to perform elective procedures concurrently is not unusual in academic medical centers. However, this practice has been increasingly scrutinized. In 2015, for example, the Boston Globe published an investigative article profiling multiple-room surgery and raising safety and ethical questions.

It is important to keep in mind key definitions, so dialogue on running two parallel rooms involves terms whose definitions are agreed on. According to the American College of Surgeons, the definitions are as follows:

  • Concurrent or simultaneous operations: 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.

  • "Critical" or "key" portions of an operation: Stages of an operation when essential technical expertise and surgical judgment are necessary to achieve an optimal patient outcome. The critical or key portions are determined by the primary attending surgeon.

  • "Overlapping or sequenced" operations for surgeons: 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.

Late in 2016, the US Senate Finance Committee issued a report urging hospitals to prohibit "concurrent surgery." Many hospitals are reviewing their internal policies on multiple-room surgery, including whether and how to establish definitions of the critical portions of each case and need for patient consent when overlapping surgery is going to occur.

One of several challenges in discussing the complex topic of multiple-room surgery is the large variety of situations that it entails, some more black-and-white than others. And the range of potential unintended consequences related to access, efficiency, and training should be evaluated if interventions are put in place to limit multiple-room surgery. As such, when a surgeon requests to run two rooms, hospitals need to assess each resulting scenario and monitor safety and compliance.

Although the response rate to the survey was low (9.5%), potentially leading to several biases, this article from the AAO-HSNF community is helpful because it provides some data about the extent of multiple-room surgery in that surgical specialty. Multiple-room surgery was common, with 58% of respondents reporting that it occurs at the centers in which they operate and 40% reporting that they personally perform it.

Approximately one half of these surgeons broach the multiple-room subject with their patients, with a breakdown of sometimes (21%), usually (13%), or always (14%).

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