NEW ORLEANS — The policy of overlapping surgeries is not only safe but may be beneficial to neurosurgery patients, a new analysis of a vulnerable patient population suggests.
“Allowing overlapping surgeries reduces length of stay and complications while improving discharges to home for urgent neurological patients,” said Anthony DiGiorgio, DO, MHA, a sixth-year neurosurgery resident at Louisiana State University (LSU) Health, New Orleans. “It also improves resource utilization and reduces costs.”
DiGiorgio reported the findings, from a study of neurosurgery patients treated before and after overlapping was allowed, here at the American Association of Neurological Surgeons (AANS) 2018 Annual Meeting.
Overlapping surgery is defined as the practice of one surgeon running more than one operating room simultaneously, when the critical portions of the surgery do not overlap. It has become a common practice in academic medical centers, largely to enhance access to care, training of residents, and the efficient use of the operating rooms, the paper’s formal discussant, William T. Couldwell, MD, professor and chair of neurosurgery at the University of Utah, Salt Lake City, explained.
He said the findings not only add to growing reports — including those from his own center — that support the safety of overlapping procedures, but “represent the first data that actually demonstrate a positive effect on the outcome for patient care.”
Bad Publicity for Overlapping
The practice of overlapping surgeries became controversial after a 2015 article in the Boston Globe, called “Clash in the Name of Care.”
The report detailed a case involving overlapping rooms and the simultaneous occurrence of several “high-profile” complications from spinal surgery. This led to the eventual dismissal of the surgeon, along with the uncovering of embarrassing emails and quotes from administrative staff. “This article painted surgeons in a bad light,” DiGiorgio commented.
After more “inflammatory” coverage, the issue was brought to the attention of the US Senate, he said. The Senate initially considered banning the practice but settled for some safeguards, starting with disclosure to patients. A survey of 1454 patients from the American College of Surgeons did, in fact, find that most patients are unaware of the practice: Only 4% knew that overlapping occurs, only 31% would support it, and 95% wanted to be informed about it.
“If this is something that we think as a profession is beneficial, maybe we need to wage a little public relations campaign,” DiGiorgio commented.
Several large studies across surgical subspecialties have since shown that overlapping of surgery is a safe practice in terms of adverse events and complication rates.
Because overlapping surgeries were only recently allowed at their hospital, the investigators felt they had a good opportunity to compare outcomes in patients treated while overlapping was and was not practiced. “Individual cases have been shown to be safe. I wanted to look at the effect of overlapping on the patient population as a whole,” DiGiorgio said.
The study was conducted across a 7-month period at the LSU interim safety net hospital that replaced Charity Hospital after Hurricane Katrina. Of note, despite being a Level 1 trauma center, the hospital was somewhat understaffed, with the operating room schedule covered by one neurosurgeon, one chief resident, and one lower-level resident, with no midlevel providers. “We were not just able to add more staff to cover the second operating room,” he said.
Patient demographic characteristics before and after the policy shift, referred to as “One Room” and “Two Rooms,” were fairly well matched in terms of sex, age, and insurance coverage. The groups were also well matched in terms of indications and case types; approximately three quarters of cases were spinal surgery and one quarter were cranial. This included many spinal cord injury stabilizations, advanced degenerative spine cervical myelopathies, and resections of advanced tumors.
The population exemplified the hospital’s safety net status, with 84% of patients uninsured or covered by Medicare or Medicaid. “We accept all comers, regardless of their ability to pay.…They are vulnerable, needy patients that have to have their surgical needs met one way or another,” he commented.
More Surgeries and More Urgent Cases
During the period in which overlapping was allowed, the elective neurosurgery case volume increased as expected, from 98 cases to 141. Most important, urgent cases increased from 59 to 63 and emergent cases from 44 to 47. “These [latter cases] present through the emergency department and have to be fit into an already busy schedule and handled immediately,” he emphasized.
“We all know that once you pass that witching hour, there’s no telling if you’re even going to get OR [operating room] time,” he said. “These patients are often pushed up to late at night or the next day.”
Typically, when overlapping is not allowed, urgent and emergent add-ons are postponed, but when overlapping is allowed, they can be squeezed in rather easily. Even short elective cases can be added, to optimize the use of the operative resources, he continued.
The comparison over a 7-month period also showed that the average patient went to surgery about 2 days faster vs single-room use. While this trend did not reach statistical significance, what was significant was that the 2-day reduction in wait time for surgery “ballooned” into a 6-day reduction in length of stay, he reported.
DiGiorgio speculated that patients who undergo surgery sooner are less at risk for hospital-acquired infections, thromboses, delirium, and other complications. This may also explain the lower rate of medical complications and the more frequent discharge to home, rather than a costly nursing facility, he added.
Table 1. Outcomes of One Room vs Two Rooms
| Variable | One Room | Two Rooms | P Value |
|---|---|---|---|
| Wait time (d) | 7.00 | 5.12 | .133 |
| Length of stay (d) | 19.5 | 13.1 | .043 |
| Surgical complications (%) | 16.9 | 14.3 | .685 |
| Medical complications (%) | 30.5 | 14.3 | .031 |
| Discharge to home (%) | 42.4 | 69.8 | .003 |
| 30-d readmission (%) | 10.2 | 11.1 | 1.000 |
| Total charges ($) | 200,076 | 150,942 | .052 |
The surgical complications and 30-day readmission rates were equivalent, suggesting that surgical quality was not compromised by overlapping rooms. The practice also trended toward a $50,000 savings in hospital charges, he reported.
Limitations to the study are that the population was relatively small and heterogeneous and that data were obtained retrospectively by chart review, he acknowledged. “But I do think it shows that allowing the policy of operating in overlapping rooms is not only safe but is actually beneficial for patients,” DiGiorgio concluded. “This is a very vulnerable patient population who come to us in need. We think that if administrators were to step in and ban this, it would severely harm our patients.”
Where to From Here?
In commenting on the paper, Couldwell reiterated that overlapping surgery “has obviously become a very controversial issue,” largely because of public perception.
But a growing body of evidence suggests overlapping neurosurgical operations may be undertaken safely if the operating framework is controlled, he emphasized. “As shown by DiGiorgio and colleagues, this allows for a more expeditious management of urgent cases, improving on-calls,” he pointed out.
“What hasn’t been emphasized in reading these papers is that this experience provides an enhanced number of cases for the operating surgeon — increasing the surgeon’s competency and therefore optimizing outcomes, ie, [demonstrating] the well-established volume-outcome relationship,” he added.
“The pushback is public perception, so where do we go from here?” he asked. “Here’s a suggestion: We should reframe the discussion into one of ‘team neurosurgery with lifelong learning.'”
“This can be implemented using the established programs we have in our residencies already,” he suggested. “We have milestones in our training programs, and we could credential each of our residents to be able to open and close independently at the appropriate level — much as we do with the placement of external ventricular drains. We have a mechanism to do this now.”
DiGiorgio and Couldwell have disclosed no relevant financial relationships.
American Association of Neurological Surgeons (AANS) 2018 Annual Meeting. Abstract 614. Presented May 1, 2018.
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