Barriers to overlapping complex and general spine surgery at a tertiary academic hospital

OBJECTIVE

Policy concern and debate surround the concept of overlapping spine surgery. Overlapping surgery specifically refers to nonessential portions of the case or noncutting time overlap. This differs from concurrent surgery, in which critical portions of the procedure overlap. Here the authors explore the barriers for safe and efficient overlapping surgery in academic spinal deformity practice.

METHODS

Over a 24-month period, cases of spinal deformity, degenerative cases, anterior cervical discectomy and fusions (ACDFs), and laminectomy were reviewed for duration in operating room (OR) prior to surgery, duration of cutting time, duration in OR after surgery, turnover duration, and time delay from initial start time. Standard degenerative cases were referenced as 1-2 ACDFs as well as 1- to 2-level laminectomy surgery. The blocks of time between two consecutive cutting periods were investigated to determine the feasibility of overlapping an additional surgery. Specifically, the authors compared the blocks of time that include the postsurgery period, the turnover period, and the presurgery period to cutting periods.

RESULTS

One hundred twenty-six complex spinal deformity procedures and 85 degenerative cases (including 49 ACDFs and 36 laminectomies) from one center and one neurosurgeon were reviewed. These procedures were performed between September 2019 and December 2021 with a 3-month gap in military deployment. On average, the procedure's duration for cases of deformity was 236.5 minutes, for cases of ACDFs it was 84 minutes, and for cases of laminectomies it was 105.5 minutes. The block of noncutting time while the patient was in the OR showed no difference from the surgical cut time. The turnover time between cases was 52.35 minutes. Of 100 cases scheduled as the first case of the day, 94 had a delay to the OR averaging 18.2 minutes.

CONCLUSIONS

The data in this study indicate that estimates for pre- and postsurgical times alone are not sufficient to allow for overlapping surgery. The average cut-time duration of ACDF was 84 minutes; the average presurgical time for deformity was 68 minutes. This highlights the critical analysis for further examination of optimal scheduling, on-time first start, turnover periods, and the orchestration of all members of the providing team to optimize the cutting time for safe and consistent implementation of overlapping spine surgery.

Complication rate of overlapping versus nonoverlapping functional and stereotactic surgery: a retrospective cohort study

OBJECTIVE

Overlapping surgery, in which one attending surgeon manages two overlapping operating rooms (ORs) and is present for all the critical portions of each procedure, is an important policy that improves healthcare access for patients and case volumes for surgeons and surgical trainees. Despite several studies demonstrating the safety and efficacy of overlapping neurosurgical operations, the practice of overlapping surgery remains controversial. To date, there are no studies that have investigated long-term complication rates of overlapping functional and stereotactic neurosurgical procedures. The primary objective of this study was to investigate the 1-year complication rates and OR times for nonoverlapping versus overlapping functional procedures. The secondary objective was to gain insight into what types of complications are the most prevalent and test for differences between groups.

METHODS

Seven hundred eighty-three functional neurosurgical cases were divided into two cohorts, nonoverlapping (n = 342) and overlapping (n = 441). The American Society of Anesthesiologists (ASA) scale score was used to compare the preoperative risk for both cohorts. A complication was defined as any surgically related reason that required readmission, reoperation, or an unplanned emergency department or clinic visit that required intervention. Complications were subdivided into infectious and noninfectious. Chi-square tests, independent-samples t-tests, and uni- and multivariable logistic regressions were used to determine significance.

RESULTS

There were no significant differences in mean ASA scale score (2.7 ± 0.6 for both groups, p = 0.997) or overall complication rates (8.8% nonoverlapping vs 9.8% overlapping, p = 0.641) between the two cohorts. Infections accounted for the highest percentage of complications in both cohorts (46.6% vs 41.8%, p = 0.686). There were no statistically significant differences between mean in-room OR time (187.5 ± 141.7 minutes vs 197.1 ± 153.0 minutes, p = 0.373) or mean open-to-close time (112.2 ± 107.9 minutes vs 121.0 ± 123.1 minutes, p = 0.300) between nonoverlapping and overlapping cases.

CONCLUSIONS

There was no increased risk of 1-year complications or increased OR time for overlapping functional and stereotactic neurosurgical procedures compared with nonoverlapping procedures.

Increasing Nonconcurrent Overlapping Surgery Is Not Associated With Outcome Changes in Lumbar Fusion

BACKGROUND

There remains a paucity of literature on the impact of overlap on neurosurgical patient outcomes. The purpose of the present study was to correlate increasing duration of surgical overlap with short-term patient outcomes following lumbar fusion.

METHODS

The present study retrospectively analyzed 1302 adult patients undergoing overlapping, single-level, posterior-only lumbar fusion within a single, multicenter, academic health system. Recorded outcomes included 30-day emergency department visits, readmission, reoperation, mortality, overall morbidity, and overall morbidity/surgical complications. The amount of overlap was calculated as a percentage of total overlap time. Comparison was made between patients with the most (top 10%) and least (bottom 40%) amount of overlap. Patients were then exact matched on key demographic factors but not by the attending surgeons. Subsequently, patients were exact matched by both demographic data and the attending surgeons. Univariate analysis was first carried out prior to matching and then on both the demographic-matched and surgeon-matched cohorts. Significance for all analyses was set at a P value of <0.05.

RESULTS

Within the whole population, increasing duration of overlap was not correlated with any short-term outcome (P = 0.41-0.91). After exact matching, patients with the most and least durations of overlap did not have significant differences with respect to any short-term outcomes (P = 0.34-1.00).

CONCLUSION

Increased amount of overlap is not associated with adverse short-term outcomes for single-level, posterior-only lumbar fusions.

CLINICAL RELEVANCE

The present results suggest that increasing the duration of overlap during lumbar fusion surgery does not lead to inferior outcomes.

LEVEL OF EVIDENCE: 3

Postoperative outcomes and the association with overlap before or after the critical step of lumbar fusion

OBJECTIVE

This study assesses how degree of overlap, either before or after the critical operative portion, affects lumbar fusion outcomes.

METHODS

The authors retrospectively studied 3799 consecutive patients undergoing single-level, posterior-only lumbar fusion over 6 years (2013-2019) at a university health system. Outcomes recorded within 30-90 and 0-90 postoperative days included emergency department (ED) visit, readmission, reoperation, overall morbidity, and mortality. Furthermore, morbidity and mortality were recorded for the duration of follow-up. The amount of overlap that occurred before or after the critical portion of surgery was calculated as a percentage of total beginning or end operative time. Subsequent to initial whole-population analysis, coarsened exact-matched cohorts of patients were created with the least and most amounts of either beginning or end overlap. Univariate analysis was performed on both beginning and end overlap exact-matched cohorts, with significance set at p < 0.05.

RESULTS

Equivalent outcomes were observed when comparing exact-matched patients. Among the whole population, the degree of beginning overlap was correlated with reduced ED visits within 30-90 and 0-90 days (p = 0.007, p = 0.009; respectively), and less 0-90 day morbidity (p = 0.037). Degree of end overlap was correlated with fewer 30-90 day ED visits (p = 0.015). When comparing only patients with overlap, degree of beginning overlap was correlated with fewer 0-90 day reoperations (p = 0.022), and no outcomes were correlated with degree of end overlap.

CONCLUSIONS

The degree of overlap before or after the critical step of surgery does not lead to worse outcomes after lumbar fusion.

Overlapping single-level lumbar fusion and adverse short-term outcomes

OBJECTIVE

There is a paucity of research on the safety of overlapping surgery. The purpose of this study was to evaluate the impact of overlapping surgery on a homogenous population of exactly matched patients undergoing single-level, posterior-only lumbar fusion.

METHODS

The authors retrospectively analyzed case data of 3799 consecutive adult patients who underwent single-level, posterior-only lumbar fusion during a 6-year period (June 7, 2013, to April 29, 2019) at a multihospital university health system. Outcomes included 30-day emergency department (ED) visit, readmission, reoperation, and morbidity and mortality following surgery. Thereafter, coarsened exact matching was used to match patients with and without overlap on key demographic factors, including American Society of Anesthesiologists (ASA) class, Charlson Comorbidity Index (CCI) score, sex, and body mass index (BMI), among others. Patients were subsequently matched by both demographic data and by the specific surgeon performing the operation. Univariate analysis was carried out on the whole population, the demographically matched cohort, and the surgeon-matched cohort, with significance set at a p value < 0.05.

RESULTS

There was no significant difference in morbidity or any short-term outcome, including readmission, reoperation, ED evaluation, and mortality. Among the demographically matched cohort and surgeon-matched cohort, there was no significant difference in age, sex, history of prior surgery, ASA class, or CCI score. Overlapping surgery patients in both the demographically matched cohort and the matched cohort limited by surgeon had longer durations of surgery (p < 0.01), but no increased morbidity or mortality was noted. Patients selected for overlap had fewer prior surgeries and lower ASA class and CCI score (p < 0.01). Patients with overlap also had a longer duration of surgery (p < 0.01) but not duration of closure.

CONCLUSIONS

Exactly matched patients undergoing overlapping single-level lumbar fusion procedures had no increased short-term morbidity or mortality; however, duration of surgery was 20 minutes longer on average for overlapping operations. Further studies should assess long-term patient outcomes and the impact of overlap in this and other surgical procedures.

Not without my attending: a survey of patient and family member attitudes and perceptions about concurrent and overlapping surgery

BACKGROUND CONTEXT

Recent media coverage of overlapping surgery has led to several studies investigating public perception of concurrent and overlapping surgery, both of which involve a single attending surgeon working on two separate cases in two separate operating rooms. In concurrent surgery, the critical periods of the surgeries overlap, while in overlapping surgery they do not. The literature revealed a general lack of knowledge about these practices and strong disapproval of their use by the public.

PURPOSE

To determine the comfort level of spine surgery patients and their family members toward concurrent and overlapping surgery.

STUDY DESIGN/SETTING

This cross-sectional survey study was performed at an urban, adult academic spine surgery clinic.

PATIENT SAMPLE

Patients and their companions who were waiting to be seen at their initial clinic visit or follow-up visit were approached to participate in the study.

OUTCOME MEASURES

The survey queried respondents' baseline knowledge of and comfort level with concurrent and overlapping surgery, in addition to comfort level with different levels of surgical trainees on a 5-point Likert scale.

METHODS

A five-section, 36-item questionnaire was administered by a research assistant to respondents over a 3-month period spanning June 2019 - August 2019. A research assistant described the terms overlapping surgery and concurrent surgery to participants of the survey using diagrams and a preformulated script after self-reported knowledge questions. Statistical analysis was performed using the chi-square test for categorical variables, and Kendall's tau-c rank correlation coefficient with ordinal independent variables for correlations.

RESULTS

Knowledge about concurrent and overlapping surgery was low in our study population (8.22% and 6.16%, respectively). Over half of respondents reported that they felt comfortable with overlapping surgery (58.22%). Most respondents reported that they would like their surgeon to disclose the participation of surgical trainees (residents and fellows) in their surgery (98%). In addition, the 4th and 5th years of surgical training were associated with a significant increase in patient comfort with surgical trainee participation. There was no difference in response distribution between patients versus nonpatients.

CONCLUSIONS

Knowledge about concurrent and overlapping surgery remains poor in our study population. Lack of general knowledge about overlapping surgery can be a serious impediment to obtaining informed consent, and further study is required to determine the best methods to raising patient awareness.

Comparison of Patient Outcomes and Safety between Overlapping and Nonoverlapping Surgeries in Patients Undergoing Laparoscopic Common Bile Duct Exploration

PURPOSE

Overlapping surgery or double-booking is a vital yet disputed issue in healthcare field. However, safety of the overlapping surgery during laparoscopic common bile duct exploration (LCBDE) remains unclear. This study aimed to assess the clinical outcomes and safety of overlapping surgery during laparoscopic cholecystectomy and LCBDE for gallbladder and common bile duct stones (CBDS).

MATERIAL AND METHODS

This study retrospectively reviewed 2736 laparoscopic cholecystectomy and LCBDE surgeries during 2013-2020. One thousand, two hundred eighty patients underwent LCBDE through cystic duct, including 867 receiving overlapping procedures, while 1456 underwent LCBDE through laparoscopic choledochotomy (LC), including 981 who underwent overlapping procedures. Data regarding patient sex, age, body mass index, the American Society of Anesthesiology grade, comorbidities, preoperative liver function test, previous upper abdominal surgery, presence of acute cholecystitis, cholangitis, pancreatitis, or jaundice, common bile duct (CBD) or CBDS diameter, CBDS number, LCBDE operation time, procedure duration, length of stay, stone clearance, CBD closure methods, conversion to open surgery, and complications were collected.

RESULTS

Differences in demographics and clinical variables between both groups were not significant, and the unadjusted outcomes were comparable, except for the total procedure duration (transcystic: p < .001; LC: p < .001). After adjusting for demographics and clinical variables, overlapping surgery showed an extended total surgical procedure duration (transcystic: standardized coefficient = 0.084, p = .004; LC: standardized coefficient = 0.072, p = .015). Other effects of overlapping surgery were also comparable.

CONCLUSIONS

Overlapping surgery in laparoscopic cholecystectomy and LCBDE was safe at our institution. However, the association of patient outcomes with overlapping laparoscopic cholecystectomy and LCBDE should be further investigated.

Comparison of single-stage and two-stage bilateral video-assisted thoracic surgery

OBJECTIVE

Single-stage sequential bilateral video-assisted thoracoscopic surgery (VATS) is a controversial procedure. In the present study, we retrospectively compared the outcomes of single-stage and two-stage VATS.

METHODS

This study involved patients who underwent single-stage sequential bilateral VATS (SS-VATS group) or two-stage VATS at a 3-month interval (TS-VATS group) for treatment of non-small cell lung cancer from 2010 to 2018. The major outcome was the comparison of intraoperative changes.

RESULTS

The inspiratory peak pressure was higher, the incidences of intraoperative hypoxia and unstable hemodynamics were higher, the surgical time was longer, and the durations of the intensive care unit stay and postoperative hospitalization were longer in the SS-VATS group than in the TS-VATS group. However, the chest tube duration, incidence of postoperative mechanical ventilation, and clinical complications were not different between the two groups.

CONCLUSIONS

Compared with two-stage VATS, single-stage sequential bilateral VATS can be performed for successful treatment of bilateral pulmonary lesions with a shorter total time and higher cost-effectiveness in terms of anesthesia and hospitalization but with a higher incidence of intraoperative adverse effects and a longer hospital stay.

Overlapping Surgery Increases Operating Room Efficiency Without Adversely Affecting Outcomes in Total Hip and Knee Arthroplasty

BACKGROUND

Several recent studies have demonstrated that overlapping surgeries in total hip (THA) and knee (TKA) arthroplasty do not increase the rates of complications, but whether this practice is cost-effective has yet to be addressed in the literature. The purpose of this study is to determine the effect of overlapping surgery on procedural costs and surgical productivity during THA and TKA.

METHODS

We identified all patients undergoing primary THA or TKA from 2015 to 2018 by 18 surgeons at a single orthopedic specialty hospital. Procedural and personnel costs were calculated for each case using a time-driven activity-based costing algorithm. Overlap of surgical time by at least 30 minutes was used to define an overlapping procedure. We compared costs and outcomes between overlapping and nonoverlapping procedures, standardizing all costs to 8-hour time blocks. A multivariate regression analysis was performed to determine independent effect of overlapping procedures on costs and outcomes.

RESULTS

Of the 4786 consecutive procedures, 968 (20.2%) overlapped by at least 30 minutes. Although overlapping rooms increased mean operative time by 8.3 minutes (P < .0001) and operating room personnel costs by $80 per case (<.0001), overlapping surgeons could perform significantly more procedures per 8 hours (7.6 vs 6.4; P < .0001), increasing total 8-hour profit margin by $1215 per procedure. There was no difference in 90-day readmission rate, length of stay, or rates of discharge home between the groups.

CONCLUSION

Overlapping noncritical portions of procedures in primary THA and TKA appear to be both a safe practice and an effective strategy.

Association of overlapping cardiac surgery with short-term patient outcomes

OBJECTIVE

This study seeks to assess the safety of overlap in cardiac surgery.

METHODS

Coarsened exact matching was used to assess the impact of overlap on outcomes among cardiac surgical interventions (n = 4463) over 2 years (2014-2016). Overlap was categorized as any, beginning, or end overlap. Study subjects were matched 1:1 on 11 variables, including Charlson comorbidity score, surgical costs, body mass index, length of postoperative hospitalization, and race, among others. Serious unanticipated events were studied, including readmission, unplanned return to the operating room, and mortality.

RESULTS

A total of 984 patients had any overlap and were matched to similar patients without overlap (n = 1501). For beginning/end overlap, separate matched groups were created (n = 462, n = 329 patients, respectively). Among matched patients, any overlap did not predict unanticipated return to surgery at 30 or 90 days. Any overlap did not predict increased readmission, reoperation, or emergency department visits at 30 or 90 days. Overlap did not predict higher rates of death over follow-up. Beginning/end overlap had results similar to any overlap.

CONCLUSIONS

Nonconcurrent, overlapping surgery is not associated with an increase in adverse outcomes in a large, matched cardiac surgery population.

Overlapping Surgery in Primary Total Knee Arthroplasty: Are 6-Week Complications Worse than Single Operating Room Scheduling?

BACKGROUND

Overlapping surgery is common in high-volume total knee arthroplasty (TKA) practices and has come under recent scrutiny in the press. The aim of this study was to evaluate differences in 6-week clinical and radiographic outcomes for primary TKA patients between single and overlapping operating room (OR) days.

METHODS

We retrospectively reviewed individual patient records of a consecutive series of primary TKAs with complete 6-week follow-up performed by a single academic surgeon between 2008-2016 (N= 452). Patients were stratified by single vs. overlapping OR days. 177 patients (39%) had an overlapping surgery. Age, body mass index (BMI), Charlson Comorbidity Index (CCI) and American Society of Anesthesiologists (ASA) class were recorded to assess for confounding variables. Outcomes included anesthesia time, 6-week readmission, unplanned return to OR, medical and surgical complication, and 6-week radiographic alignment.

RESULTS

There were no significant differences in anesthesiology time (165.5 vs 164.5 min, p=0.85), medical or surgical complication rates (10.5% vs 6.2%, p=0.11), 6-week readmissions (4.4% vs 1.7%, p=0.12), or return to OR (1.8% vs 1.7%, p=1.00) before or after adjusting for age, BMI, gender, ASA and CCI. There was no difference between overlapping and single OR cohorts in rate of neutral coronal alignment (2°-8° valgus) (98.3% vs 98.9%, respectively, p=0.68) or presence of periprosthetic lucency (p=0.43).

CONCLUSIONS

This study demonstrates no differences in 6-week clinical or radiographic outcomes between patients undergoing primary TKA on single versus overlapping OR days. These results support the safe practice of overlapping surgical scheduling in high-volume primary TKA centers.Level of Evidence: III.

Dorr Surgical Techniques & Technologies Award: "Running Two Rooms" Does Not Compromise Outcomes or Patient Safety in Joint Arthroplasty

BACKGROUND

Scrutiny from the federal government and the media regarding the safety of 1 surgeon doing cases in 2 operating rooms (ORs) on the same day, prompted us to examine our own institutional data. Over the past 11 years, surgeons at our facility have operated consecutively in 1 OR on a given day or used 2 alternating ORs. This study compares these cases with a focus on revisions and complications in both groups.

METHODS

Six surgeons performed a total of 16,916 primary hip and knee arthroplasties from 2006-2016. 7002 cases (41%) were consecutive cases (CCs) and 9914 cases (59%) were overlapping cases (OCs). Intraoperative complications, component revisions, and postoperative complications within 90 days of surgery were compared between the CC and OC groups.

RESULTS

There was no difference in intraoperative complication rates between the two groups (CC 1.6% vs. OC 1.7%, relative risk 1.082, 95% confidence interval 0.852 to 1.375, P = .52). There was no difference in 90-day component revision rates among the CC and OC groups (0.66% vs. 0.85% respectively, relative risk = 1.290, 95% confidence interval 0.901 to 1.845, P = .19). There was also no difference in 90-day complication rates among the CC and OC groups (1.33% vs. 1.45% respectively, relative risk = 1.094, 95% confidence interval 0.844 to 1.417, P = .54).

CONCLUSION

This large study of a single institution with multiple surgeons over an 11-year period shows no compromise in patient safety or outcomes when comparing cases done in either consecutive or overlapping rooms.

Analysis of overlapping surgery in patients undergoing microsurgical aneurysm clipping: acute and long-term outcomes from the Barrow Ruptured Aneurysm Trial

OBJECTIVE Overlapping surgery is a controversial subject in medicine today; however, few studies have examined the outcomes of this practice. The authors analyzed outcomes of patients with acutely ruptured saccular aneurysms who were treated with microsurgical clipping in a prospectively collected database from the Barrow Ruptured Aneurysm Trial. Acute and long-term outcomes for overlapping versus nonoverlapping cases were compared. METHODS During the study period, 241 patients with ruptured saccular aneurysms underwent microsurgical clipping. Patients were separated into overlapping (n = 123) and nonoverlapping (n = 118) groups based on surgical start/stop times. Outcomes at discharge and at 6 months, 1 year, 3 years, and 6 years after surgery were analyzed. RESULTS Patient variables (e.g., age, smoking status, cardiovascular history, Hunt and Hess grade, Fisher grade, and aneurysm size) were similar between the 2 groups. Aneurysm locations were similar, with the exception of the overlapping group having more posterior circulation aneurysms (18/123 [15%]) than the nonoverlapping group (8/118 [7%]) (p = 0.0495). Confirmed aneurysm obliteration at discharge was significantly higher for the overlapping group (109/119 [91.6%]) than for the nonoverlapping group (95/116 [81.9%]) (p = 0.03). Hospital length of stay, discharge location, and proportions of patients with a modified Rankin Scale (mRS) score > 2 at discharge and up to 6 years postoperatively were similar. The mean and median mRS, Glasgow Outcome Scale, Mini-Mental State Examination, National Institutes of Health Stroke Scale, and Barthel Index scores at all time points were not statistically different between the groups. CONCLUSIONS Compared with nonoverlapping surgery, overlapping surgery was not associated with worse outcomes for any variable at any time point, despite the complexity of the surgical management in this patient population. These findings should be considered during the discussion of future guidelines on the practice of overlapping surgery.

An analysis of surgical and nonsurgical operating room times in high-volume shoulder arthroplasty

BACKGROUND

A significant portion of operating room time in shoulder arthroplasty is devoted to nonsurgical tasks. To maximize efficiency and to increase access to care, it is important to accurately quantify surgical and nonsurgical time for shoulder arthroplasty. This study aimed to evaluate surgical vs. nonsurgical time and to assess the viability of using a 1-surgeon, 2-operating room model.

METHODS

An institutional database was used to identify all primary and revision shoulder arthroplasty cases from February 2011 through December 2013. Time intervals were analyzed, including anesthesia and positioning time, surgical time, conclusion time, and turnover time.

RESULTS

We identified 1062 shoulder arthroplasties. The average anesthesia and positioning time was 48.2 ± 11.7 minutes, surgical time was 122.7 ± 36.4  minutes, and conclusion time was 10.5 ± 7.0  minutes. Average turnover time at our institution was 40 minutes. An average of 58.8 ± 13.8 minutes (33.2%) of the patient's time in the operating room was not surgical. A 1-room surgical model, with each case following the next, would allow 3 arthroplasties to be performed in a 10-hour surgical day. A 2-room model would allow 4 cases to be performed in a 9-hour surgical day or 5 in an 11-hour day. In this 2-room model, there would be no time in which the surgeon is absent for any surgical portion of the case.

CONCLUSION

For a high-volume shoulder arthroplasty practice, a 2-room model leads to greater efficiency and patient access to care without sacrificing the surgeon's presence during surgical portions of the case.

Performing concurrent operations in academic vascular neurosurgery does not affect patient outcomes

OBJECTIVE Concurrent surgeries, also known as "running two rooms" or simultaneous/overlapping operations, have recently come under intense scrutiny. The goal of this study was to evaluate the operative time and outcomes of concurrent versus nonconcurrent vascular neurosurgical procedures. METHODS The authors retrospectively reviewed 1219 procedures performed by 1 vascular neurosurgeon from 2012 to 2015 at the University of California, San Francisco. Data were collected on patient age, sex, severity of illness, risk of mortality, American Society of Anesthesiologists (ASA) status, procedure type, admission type, insurance, transfer source, procedure time, presence of resident or fellow in operating room (OR), number of co-surgeons, estimated blood loss (EBL), concurrent vs nonconcurrent case, severe sepsis, acute respiratory failure, postoperative stroke causing neurological deficit, unplanned return to OR, 30-day mortality, and 30-day unplanned readmission. For aneurysm clipping cases, data were also obtained on intraoperative aneurysm rupture and postoperative residual aneurysm. Chi-square and t-tests were performed to compare concurrent versus nonconcurrent cases, and then mixed-effects models were created to adjust for different procedure types, patient demographics, and clinical indicators between the 2 groups. RESULTS There was a significant difference in procedure type for concurrent (n = 828) versus nonconcurrent (n = 391) cases. Concurrent cases were more likely to be routine/elective admissions (53% vs 35%, p < 0.001) and physician referrals (59% vs 38%, p < 0.001). This difference in patient/case type was also reflected in the lower severity of illness, risk of death, and ASA class in the concurrent versus nonconcurrent cases (p < 0.01). Concurrent cases had significantly longer procedural times (243 vs 213 minutes) and more unplanned 30-day readmissions (5.7% vs 3.1%), but shorter mean length of hospital stay (11.2 vs 13.7 days), higher rates of discharge to home (66% vs 51%), lower 30-day mortality rates (3.1% vs 6.1%), lower rates of acute respiratory failure (4.3% vs 8.2%), and decreased 30-day unplanned returns to the OR (3.3% vs 6.9%; all p < 0.05). Rates of severe sepsis, postoperative stroke, intraoperative aneurysm rupture, and postoperative aneurysm residual were equivalent between the concurrent and nonconcurrent groups (all p values nonsignificant). Mixed-effects models showed that after controlling for procedure type, patient demographics, and clinical indicators, there was no significant difference in acute respiratory failure, severe sepsis, 30-day readmission, postoperative stroke, EBL, length of stay, discharge status, or intraoperative aneurysm rupture between concurrent and nonconcurrent cases. Unplanned return to the OR and 30-day mortality were significantly lower in concurrent cases (odds ratio 0.55, 95% confidence interval 0.31-0.98, p = 0.0431, and odds ratio 0.81, p < 0.001, respectively), but concurrent cases had significantly longer procedure durations (odds ratio 21.73; p < 0.001). CONCLUSIONS Overall, there was a significant difference in the types of concurrent versus nonconcurrent cases, with more routine/elective cases for less sick patients scheduled in an overlapping fashion. After adjusting for patient demographics, procedure type, and clinical indicators, concurrent cases had longer procedure times, but equivalent patient outcomes, as compared with nonconcurrent vascular neurosurgical procedures.

Managing overlapping surgery: an analysis of 1018 neurosurgical and spine cases

OBJECTIVE Overlapping surgery-the performance of parts of 2 or more surgical procedures at the same time by a single lead surgeon-has recently come under intense scrutiny, although data on the effects of overlapping procedures on patient outcomes are lacking. The authors examined the impact of overlapping surgery on complication rates in neurosurgical patients. METHODS The authors conducted a retrospective review of consecutive nonemergent neurosurgical procedures performed during the period from May 12, 2014, to May 12, 2015, by any of 5 senior neurosurgeons at a single institution who were authorized to schedule overlapping cases. Overlapping surgery was defined as any case in which 2 patients under the care of a single lead surgeon were under anesthesia at the same time for any duration. Information on patient demographics, premorbid conditions, surgical variables, and postoperative course were collected and analyzed. Primary outcome was the occurrence of any complication from the beginning of surgery to 30 days after discharge. A secondary outcome was the occurrence of a serious complication-defined as a life-threatening or life-ending event-during this same period. RESULTS One thousand eighteen patients met the inclusion criteria for the study. Of these patients, 475 (46.7%) underwent overlapping surgery. Two hundred seventy-one patients (26.6%) experienced 1 or more complications, with 134 (13.2%) suffering a serious complication. Fourteen patients in the cohort died, a rate of 1.4%. The overall complication rate was not significantly higher for overlapping cases than for nonoverlapping cases (26.3% vs 26.9%, p = 0.837), nor was the rate of serious complications (14.7% vs 11.8%, p = 0.168). After adjustments for surgery type, surgery duration, body mass index, American Society of Anesthesiologists (ASA) physical classification grade, and intraoperative blood loss, overlapping surgery remained unassociated with overall complications (OR 0.810, 95% CI 0.592-1.109, p = 0.189). Similarly, after adjustments for surgery type, surgery duration, body mass index, ASA grade, and neurological comorbidity, there was no association between overlapping surgery and serious complications (OR 0.979, 95% CI 0.661-1.449, p = 0.915). CONCLUSIONS In this cohort, patients undergoing overlapping surgery did not have an increased risk for overall complications or serious complications. Although this finding suggests that overlapping surgery can be performed safely within the appropriate framework, further investigation is needed in other specialties and at other institutions.