Across different parts of the country at different times, non-urgent surgery was canceled or delayed due to COVID-19. As we anticipated in an earlier article in the American Spectator, this policy has created a bottleneck of surgical cases ranging from the routine to significant. Some estimates suggest that operating room productivity must increase by 20 percent just to clear the surgical backlog within a year. The safe and proper practice of overlapping surgery must be a subtle but prominent part of the solution.
In 2016, the Boston Globe shined its spotlight on the practice of overlapping surgery with an emotional cry to ban the practice of senior surgeons managing more than one operating room at a given time. This led to significant pushback and a pivot from most major health institutions to limit the practice.
In 2020, COVID-19 shined its spotlight on the scarcity of medical resources. There were simply not enough human and material assets in a time of need.
Downward pressure against overlapping surgery has exacerbated this resource rationing, and it has had the greatest impact on our most vulnerable patients.
Overlapping surgery refers to the practice of a surgeon being responsible for more than one operating room at a time with non-critical portions of the procedure overlapping. Neurosurgery, for example, is not just incision time for a surgeon; it’s team-based care delivery with multiple health-care professionals. There can be a significant amount of time spent in the room prior to “surgery” for anesthesia induction, neuro-navigation (intraoperative GPS system) setup, or integrating professionals who perform sophisticated neuromonitoring. Simply opening all the instrument sets in a complex spine deformity surgery can take over an hour. Allowing trained professionals to do their specific job task while the surgeon focuses his or her skills on another sick patient allows for a better use of resources and faster delivery of care.
The concept is similar to the episodic-series-based delivery of dental care in the United States. Patients see a trained dental hygienist, that hygienist performs his or her specific professional task, and then the dentist will see the patient with assistance from the hygienist. Both are professionals performing their roles, and this approach allows more patients to receive high-quality, safe dental care in a prudent time frame. If you have ever needed a root canal, you can appreciate the need for this immediate availability.
Brain surgery may not be like cleaning teeth, but the necessary safety mechanisms are dramatically heightened to match the vulnerability of the neurosurgery patient. Critical portions should never overlap. Components of the overlapping case need to be discussed with all members of the team, patients have a right to know about planned overlapping surgery, and it is important to note that in almost all circumstances the overlap occurs before or after the other surgery is completed, during the room cleaning or set up. Also, there are clearly certain complex cases where this does not apply and surgeons must be present during the entire set-up, closure, and wake-up test at the end of the case.
The unintended consequence of a blanket prohibition on all forms of overlapping surgery is reduced access to care for our most vulnerable populations.
This has been clearly documented by Dr. Anthony DiGiorgio in a peer-reviewed scientific publication that evaluated overlapping surgery at a Level 1 trauma center and safety-net hospital. Allowing overlapping surgery was not only safe but also reduced length of stay in the hospital. Patients who came in through the Emergency Room needing neurosurgical care were able to get surgery sooner and be discharged sooner. Of those treated, 26.2 percent had no insurance, and 39.3 percent had Medicaid or safety net insurance. This includes the patients who, if overlapping surgery were not allowed, would have their elective surgery canceled when a patient with a more urgent need came in. Allowing overlapping surgery prevented having to delay their care for weeks or even months.
For those who rely on a safety-net hospital for health care, it might mean more time off work that they can’t afford, more time in the hospital while they wait for care, or even a worse outcome if they have complications while waiting for that care.
The banning of overlapping surgery is not a safety issue.
Multiple separate academic studies released through the University of California at San Francisco, the Mayo Clinic, and the University of Utah have proven that concurrent surgery during non-essential overlap poses no additional complication risk for neurosurgery.
The banning of overlapping surgery is indirectly an actual health-care equity issue.
And COVID-19 has made all of this substantially worse.
As communities respond to the pandemic, inter-hospital transfers have become challenging at times due to bed availability infrastructure. Leadership at our specific academic Level 1 trauma safety-net hospitals have led the way in regional COVID-19 response and have been fantastic in serving their communities in new and robust ways.
But the national momentum needs to shift. To fight the pandemic, hospitals, and especially safety-net hospitals must be allowed to expand capacity when the needs arise. This doesn’t just mean more beds, but the ability to treat more patients when they need surgical intervention. At its core, when properly and ethically integrated, overlapping surgery is just one method to better use health-care resources and improve access to care.
Dr. Richard Menger is an assistant professor of neurosurgery and an assistant professor of political science at the University of South Alabama.
Dr. Anthony DiGiorgio is an assistant professor of neurosurgery at the University of California San Francisco.
