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

View More View Less
  • 1 Department of Neurological Surgery,
  • | 2 Center for Healthcare Value,
  • | 3 Department of Quality, UCSF Health, and
  • | 4 Department of Anesthesiology, University of California, San Francisco, California
Restricted access

Purchase Now

USD  $45.00

JNS + Pediatrics - 1 year subscription bundle (Individuals Only)

USD  $515.00

JNS + Pediatrics + Spine - 1 year subscription bundle (Individuals Only)

USD  $612.00
Print or Print + Online

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.

ABBREVIATIONS

AVM = arteriovenous malformation; ASA = American Society of Anesthesiologists; CM = cavernous malformation; EBL = estimated blood loss; ED = emergency department; LOS = length of stay; MGH = Massachusetts General Hospital; OR = operating room; UCSF = University of California, San Francisco.

JNS + Pediatrics - 1 year subscription bundle (Individuals Only)

USD  $515.00

JNS + Pediatrics + Spine - 1 year subscription bundle (Individuals Only)

USD  $612.00
  • 1

    Abelson J, Saltzman J, Kowalczyk L, Allen S: Clash in the name of care. Boston Globe Oct 25 2015. (https://apps.bostonglobe.com/spotlight/clash-in-the-name-of-care/story/) [Accessed November 15, 2016]

    • Search Google Scholar
    • Export Citation
  • 2

    Beasley GM, Pappas TN, Kirk AD: Procedure delegation by attending surgeons performing concurrent operations in academic medical centers: balancing safety and efficiency. Ann Surg 261:10441045, 2015

    • Search Google Scholar
    • Export Citation
  • 3

    Birgand G, Saliou P, Lucet JC: Influence of staff behavior on infectious risk in operating rooms: what is the evidence?. Infect Control Hosp Epidemiol 36:93106, 2015

    • Search Google Scholar
    • Export Citation
  • 4

    Bohl M, Clark JC, Oppenlander ME, Meeusen AJ, Budde A, Porter RW, et al.: The Barrow Randomized OR Traffic (BRITE) Trial: The effect of OR traffic on infection rates. Neurosurgery 62:Suppl 1 196197, 2015. (Abstract)

    • Search Google Scholar
    • Export Citation
  • 5

    Langerman A: Concurrent surgery and informed consent. JAMA Surg 151:601602, 2016

  • 6

    Massachusetts General Hospital: About Concurrent/Overlapping Surgery Fact Sheet. (http://www.massgeneral.org/overlapping-surgery/about.aspx) [Accessed November 15, 2016]

    • Search Google Scholar
    • Export Citation
  • 7

    Massachusetts General Hospital: Monitoring Outcomes for Procedural Overlap Surgeries at MGH. (http://www.massgeneral.org/news/assets/pdf/MonitoringOutcomes.pdf) [Accessed November 15, 2016]

    • Search Google Scholar
    • Export Citation
  • 8

    Massachusetts General Hospital: Perioperative Policy for Concurrent Surgical Staffing of Two Rooms. (http://www.massgeneral.org/news/assets/pdf/MGHConcurrentSurgeryPolicy.pdf) [Accessed November 15, 2016]

    • Search Google Scholar
    • Export Citation
  • 9

    Yount KW, Gillen JR, Kron IL, Kern JA, Kozower BD, Ailawadi G, et al.: Attendings' performing simultaneous operations in academic cardiothoracic surgery does not increase operative duration or negatively affect patient outcomes. 94th AATS Annual Meeting Toronto April 26–30, 2014 (Abstract) (http://aats.org/annualmeeting/Program-Books/2014/2.cgi) [Accessed November 15, 2016]

    • Search Google Scholar
    • Export Citation

Metrics

All Time Past Year Past 30 Days
Abstract Views 421 123 31
Full Text Views 736 138 2
PDF Downloads 377 105 2
EPUB Downloads 0 0 0