Massachusetts General Hospital in Boston has been the focus of controversy over the safety of concurrent surgeries and whether patients have a right to know when surgeons are dividing their attention. One patient safety leader says that the practice is not necessarily improper but should be monitored by management.
The controversy arose with a lengthy story in The Boston Globe about a malpractice suit filed by a plaintiff who was paralyzed during spinal surgery. He contends that his injury was due, in part, to the fact that his surgeon was splitting his time between that operating room and another where he was operating on a second patient at the same time (concurrent surgeries). Massachusetts General has since limited surgeons from double-booking some complex surgeries.
A hospital spokesman also told the newspaper that while surgeons are “encouraged and expected” to tell patients when they’ll be absent for part of the surgery, they are not explicitly required to do so. (The Boston Globe story is available online at http://tinyurl.com/zowtss6.)
The hospital went to extraordinary lengths to respond to the story. It issued a statement saying, “We are confident that our surgical practices are very safe and among the strongest in the nation. The American College of Surgeons, in fact, called our overlapping surgery policy a best practice and said it exceeds national standards. We have reviewed the complication rates in overlapping and non-overlapping surgeries and found the rates to be the same. We also have reviewed overlapping cases with complications from 2013 and 2014 and found no association between the complications and overlapping. Several studies from other hospitals around the country have shown similar results.”
However, Massachusetts General went far beyond the standard statement by creating several pages on its web site devoted to explaining concurrent surgery, the hospital’s policies and experience, and medical literature regarding its safety. A link to the material is placed prominently on the hospital’s home page. (The link is http://tinyurl.com/jrn9kob.)
NO TIE TO MALPRACTICE
AHC Media, publisher of Same-Day Surgery, contacted The Doctors Company, a malpractice insurer in Napa, CA, to determine how often concurrent surgeries are cited in malpractice cases. Robin Diamond, MSN, JD, RN, senior vice president of patient safety and risk management, says the data show no correlation. A review of 7,330 surgery malpractice cases in the company’s database from the past eight years found no mention of concurrent surgery as a factor, she says.
Diamond also says the medical literature is scant on any connection between concurrent surgery and malpractice or patient safety. However, she says the lack of data doesn’t necessarily mean there is no reason to worry. “Sometimes, until there is a big case or a focus on an issue by regulators, the medical community doesn’t shine a light on an issue, and the data is not collected,” Diamond says. “I think some of this recent publicity will raise public awareness, and risk managers are going to need to look at the issue more closely.”
The issue might become problematic for healthcare facilities as members of the general public become more aware of a practice that is common but largely unknown to them, she says. Patients will not react favorably when they learn that their surgeons leave the operating room during their procedures and divide their attention, she says.
“You leave me anesthetized and go down the hall to work on somebody else? And I’m just lying there waiting for you to come back?” Diamond says. “That’s not going to go over well with most people. And, at that point, the question of how it actually affects patient safety can become secondary to the fact that people don’t like it and feel threatened by it.”
ASSESS YOUR FACILITY'S USE
Diamond advises managers to determine how much overlapping surgery occurs in their facilities. The practice is common and has been accepted for so long that it might be happening in a facility without anyone other than the surgical team taking note.
Diamond suggests conducting a failure mode effects analysis (FMEA) to assess the risk. This FMEA will help the manager determine how many surgeons perform concurrent procedures and whether there are any restrictions in place.
There should be policies that limit who can do concurrent surgeries and how much procedures can overlap, Diamond says. Even if concurrent surgery is an accepted practice at your facility, it should not be done by just anyone. Only experienced surgeons should have this option, she says.
“There should be a competency and privileging process for this,” Diamond says. “If you are allowing any surgeon to overlap, you are going to get into trouble eventually. The leading hospitals have policies that make sure this is an option only for the surgeons who have proven they can do this without endangering patients.”
Surgeons also should be required to justify why concurrent surgeries are necessary. Busy OR schedules can be justification enough, Diamond says, but there should be some reason beyond the surgeon simply wanting to double up and get out of the facility sooner.
Managers should urge full disclosure of concurrent surgery to patients, Diamond says. The policy should be part of the informed consent process, she says.
Documentation also is an issue. Diamond suspects that concurrent surgery often is not documented in the surgery record, possibly only in the OR administrative record. Facility policy should require that concurrent surgeries are documented fully in the OR record, including the surgeon’s exit and return times for each procedure.
Managers also should look at the times of the overlap, Diamond says. “How long are patients waiting, and are they left waiting under anesthesia longer than is reasonable?”
Facility policies on concurrent surgeries often require that a supervising or attending surgeon be immediately available to respond if a patient needs help while his or her surgeon is in a second operating room, but Diamond says those policies often are vague. “Immediately available” can be interpreted as in the next room, down the hall in the doctors’ lounge, or even 10 minutes away conducting rounds, Diamond says. Such policies should be included in the risk assessment.
Concurrent surgeries require good patient handoff procedures, Diamond notes. The surgeon’s exit and return should be accompanied by a standardized script that notes information such as the patient’s vital signs, status of the procedure, when to call the surgeon on standby, and changes since the surgeon’s departure.
Diamond also expresses concern that concurrent surgeries might interfere with some safety processes, such as the preop checklist and timeout.
“Is the surgeon doing the preop checklist and timeout on both patients? Or did the rest of the team in the second OR do it without him, and then he shows up later?” she says. “That’s a major concern for me, because it is such an important part of the safety process.”
