Is Overlapping Surgery the Answer to the Pandemic Backlog?

Ute Eppinger

November 07, 2022

With use of so-called high-intensity theater (HIT) lists, two surgical teams, working simultaneously, are able to perform a month's worth of procedures in just 1 day. This is the outcome of an experiment at a London teaching hospital that is assessing ways to tackle the National Health Service (NHS) backlog of 6.6 million patients.

The HIT lists were developed by Imran Ahmad, MD, anesthesiologist at Guy's and St. Thomas's NHS Foundation Trust in London. The aim is to reach maximum efficiency and safety by increasing surgeons' operating times (the most expensive and scarce resource) from 40% per session (according to conventional procedure) to 90%. "We are motivated by the attempt to tackle the backlog of patients and thereby be able to treat more patients. The HIT lists relieve pressure from the whole system," Ahmad told Medscape UK.

Three Guy's and St. Thomas's Trust sites use the lists to schedule surgeries on specific Saturdays. The success has far exceeded expectations, said Ahmad. Quadruple the number of procedures is consistently performed on these surgical Saturdays, and no short- or long-term complications have been observed. On the first day of the experiment, in February 2021, 20 hip operations were performed (instead of five), and 17 patients were treated for inguinal hernias (instead of five) said Ahmad.

Ahmad's lists are based on the concept of overlapping surgery. Some of the prerequisites for HIT lists include having two operating rooms with one surgeon and three surgical teams, 50% more surgical staff than for two conventional surgery lists, and specially selected, low-risk patients.

Critical Perspectives

Jaideep Pandit, MD, PhD, anesthesiologist at Oxford University Hospitals, NHS Foundation Trust, wrote an article that was recently published in Anaesthesia in which he outlined the catastrophic experiences with overlapping operations in hospitals in Canada and the United States. In Canada, the number of complications from hip fractures and hip replacements doubled as a result of overlapping operations. In the US, Massachusetts General Hospital had to pay more than £26 million due to a lack of consent and problems with insurance companies.

Pandit and his colleagues were motivated to undertake this investigation because the waiting lists for surgical procedures in the United Kingdom continue to grow and because the Getting It Right First Time initiative sets explicit, targeted numbers of procedures for certain fields to reach. "The NHS tends to clutch at straws, the effect of which is not proven," Pandit told Medscape UK. "Our aim is to urge a certain amount of caution in this regard."

Overlapping operations are also performed in German clinics, but not all overlapping surgeries are the same, said Thomas Schmitz-Rixen, MD, PhD, general secretary of the German Society of Surgery and former director of the Department of Vascular and Endovascular Surgery and of the University Wound Center of the University Hospital Frankfurt, during a conversation with Medscape.

He referred to the renowned surgeon Michael DeBakey, MD, who, at the Texas Heart Institute, went from operating room to operating room, "scrubbing up" and operating on each patient for 10 to 15 minutes. "Afterwards, they could then say they had been operated on by the famous DeBakey. This has fallen out of fashion somewhat," said Schmitz-Rixen.

Senior Surgeon's Tasks

Schmitz-Rixen has performed overlapping operations, but not in the same way as DeBakey. His team opened access to the exact operation site in the patient; Schmitz-Rixen then performed the procedure; and the team then closed up the wound after the procedure had been completed. "This actually provided me with a degree of freedom to also attend to my other tasks. A senior surgeon does more than just operate. Briefing discussions with the patients, visits, establishing indications, and then there are the administrative tasks," said Schmitz-Rixen.

In contrast, a switching model, in which the surgeon switches from operation to operation, was investigated in the review by Pandit and his colleagues. In this model, the senior surgeon spends his or her entire day exclusively performing operations. "I am curious," said Schmitz-Rixen. "How and when should a senior surgeon then perform their other tasks?"

Emergencies sometimes occur in other operating rooms while the surgeon is in the middle of surgery. "If I know it is critical, then I do it myself. It is always possible somehow," said Schmitz-Rixen. But to perform overlapping operations systematically, such as in the London model, correspondingly high prerequisites are necessary. One prerequisite is that none of the cases be critical. "A critical case means at least 1 additional hour in the operating room should the unexpected occur." From time to time, a case becomes critical and requires the use of a senior surgeon.

"If this happens while such a model is being practiced, the whole system goes to pot, since everything grinds to a halt in the other operating room in which an operation should be taking place at this time," said Schmitz-Rixen. "This cannot be justified ethically. Why should the patient under general anesthesia have to wait?"

It also has no economic benefit. In the article by Pandit and his colleagues, operating room 1 is occupied from 9:00 AM onward, and room 2 is occupied from 11:30 AM onward. Therefore, the second room is empty from 9:00 to 11:30 AM. That is not beneficial in terms of productivity. Also, no additional procedures can be carried out. Instead, the maximum number of procedures is the same as before. This system achieves only one thing: "It puts the surgeon under stress, since he or she must operate for 9 hours of the day," said Schmitz-Rixen.

Higher Complication Rates?

Pandit and his colleagues also pointed out that, not surprisingly, higher complication rates should be expected. "Perhaps due to the time pressure, you are not so careful ― perhaps insufficient hemostasis is induced. This then increases the risk of secondary bleeding," said Schmitz-Rixen. He noted that physicians in training would be in the operating room without supervision, which reduces the quality of training.

"Imagine the following situation: The abdomen has to be opened, and the senior surgeon is operating in another room," said Schmitz-Rixen. "However, the patient has already been prepared for surgery. This can be difficult, because the surgical area is misshapen. Now, the physician in further training could muddle through without specialist supervision. This would not be great and would increase the complication rate further. Or else the operating room comes to a standstill because the physician says that he or she cannot proceed alone."

Pandit's review revealed that there is no evidence that the use of overlapping operations is any more productive than having two surgeons work in parallel. Overlapping operations could have a positive effect in situations in which the changeover times between patients are long and the operations short (<2 hours) and the "critical parts" of the operation take up about half of the entire operation time. However, the potential benefits must still be considered against aspects of safety, ethics, and training.

Lack of Staff

"The productivity benefit calculated in this model is theoretical. I personally dismiss such an increase in productivity. It has nothing to do with economization; it is a commodification of surgery, and it does not result in any significant advantage to productivity," said Schmitz-Rixen.

The problem in German hospitals is wholly different: a lack of staff at all levels. Much more sensible would be "overlapping anesthesia," he added. Because of the lack of staff, a procedure is first carried out in full, then the next anesthetic induction follows, with the same staff. "If there were enough staff available and it were possible to induce anesthetic in a second patient while the first patient was emerging from anesthesia, a lot of gains would be made," said Schmitz-Rixen.

"Only when that is achieved can we consider whether a switching model for operations with a high level of routine, such as orthopedic procedures, is possible. The likelihood of something happening in between such procedures is minimal. If such prerequisites are in place and there is only one surgeon operating, then working with an overlapping, second operating room can be considered."

This article was translated from the Medscape German edition.

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