Looking forward – June 2016

David B. Hoyt

David B. Hoyt, MD, FACS

Over the last several months, the issue of concurrent and overlapping operations has received considerable attention in the lay and professional press. The American College of Surgeons (ACS) Statements on Principles have long included a section on the surgeon’s responsibility to be present for key parts of the preoperative, intraoperative, and postoperative phases of care. In light of the media play that this topic is now receiving, however, the ACS leadership recently determined that the time was ripe to clarify the College’s position on this matter.

Overlapping and concurrent operations: The controversy

The issue of concurrent and overlapping surgery came to the public’s attention last fall, when the Boston Globe’s Spotlight team reported on alleged double-bookings of surgical procedures at a nationally recognized area hospital.*

As most surgeons know, overlapping operations are performed routinely and safely at many health care centers, particularly teaching hospitals and trauma centers. Overlapping operations occur in two general circumstances. The most common scenario is when the key or critical elements of the first operation have been completed, and it is unlikely that the primary attending surgeon will need to return to that procedure. In this circumstance, the surgeon may supervise the start of another operation while a qualified health care professional, such as a resident or a surgical assistant, performs the final, rudimentary components of the first operation, such as closing the incision. Less commonly, the primary surgeon will have completed the critical elements of the first operation and begun performing key portions of a second procedure in another room.

Concurrent operations, on the other hand, are procedures in which a surgeon is involved in two operations—both of which are in the critical stages simultaneously.

Proponents of overlapping and concurrent operations maintain that the practice allows hospitals to reduce wait times and frees up their most in-demand surgeons to do more procedures. Furthermore, teaching hospitals often condone the practice as a means of allowing trainees to develop graduated autonomy in the completion of common procedures, and trauma centers sometimes rely on overlapping operations when faced with clusters of emergency and urgent cases.

Opponents have two primary concerns: that sometimes the attending surgeon may be away from a case for an extended period of time, during which complications may arise; and that some surgeons may provide their patients with insufficient information about the practice before receiving consent.

The College’s stance

As an organization dedicated to surgical education and training, the College recognizes the benefits of allowing interns, residents, and fellows to participate in certain aspects of operations with varying levels of autonomy based on experience, technical skill, and cognitive ability. To ensure patient safety, though, the College also maintains that the attending surgeon should remain in the operating room or immediate vicinity for the entire procedure, ready to intervene should a complication arise. Furthermore, the ACS has advocated that patients be fully informed of their primary surgeon’s direct and indirect involvement in their care before they consent to an operation.

The College’s Statements on Principles have long reflected these positions. However, the ACS has avoided being overly prescriptive and has viewed surgical scheduling as a responsibility best handled at the institution’s discretion.

The revelations in the Boston Globe’s exposé and subsequent articles brought to light the considerable variations in standards from institution to institution. As a result, the federal government—specifically the Senate Finance Committee, chaired by Sen. Orrin Hatch (R-UT)—and various groups have sought clarity.

Achieving consensus, setting standards

As the standard-bearer for surgical patient safety and surgical education, the College’s leadership took responsibility for gathering the collective intelligence of ACS leaders, representatives from stakeholder groups, the ACS legal counsel, and advisors to the Senate Finance Committee. We used their insights to develop more definitive yet unobtrusive guidelines for overlapping and concurrent operations.

What emerged from these discussions is the updated version of the section on “The Operation—Intraoperative responsibility of the primary surgeon,” in the ACS Statements on Principles, which is reprinted here and posted on the ACS website. The new language sets forth details about when overlapping operations are appropriate and how they should be handled. The revised document also more clearly delineates what information the surgeon should provide to the patient in order to receive truly informed consent and when this information should be communicated to the patient, and defines key terms.

Ultimately, the issue of overlapping and concurrent surgery revolves around three key concerns: ensuring patient safety, training the next generation of surgeons, and empowering patients with the information they need to make informed decisions. The College believes that the updated language in the Statements on Principles will serve as a useful guide for institutions to use in balancing these demands.

*Abelson J, Saltzman J, Kowalczyk L, Allen S. Clash in the name of care. Boston Globe. October 25, 2015. Available at: https://apps.bostonglobe.com/spotlight/clash-in-the-name-of-care/story/. Accessed March 28, 2016.

Mello MM, Livingston EH. Managing the risks of concurrent surgeries. JAMA. 2016;315(15):1563-1564. Available at: http://jama.jamanetwork.com/article.aspx?articleid=2505160&resultClick=3. Accessed April 25, 2016.

Abelson J, Saltzman J, Kowalczyk L. Concurrent surgeries come under new scrutiny. Boston Globe. December 20, 2015. Available at: www.bostonglobe.com/metro/2016/01/07/massachusetts-require-surgeons-document-operating-room-comings-and-goings/2uIu1IDhmz4K8CRaJtL1vL/story.html. Accessed April 25, 2016

ACS Statements on Principles

D. The Operation—Intraoperative responsibility of the primary surgeon

General Statement

The primary attending surgeon is personally responsible for the patient’s welfare throughout the operation. In general, the patient’s primary attending surgeon should be in the operating suite or be immediately available for the entire surgical procedure. There are instances consistent with good patient care that are valid exceptions. However, when the primary attending surgeon is not present or immediately available, another attending surgeon should be assigned as being immediately available.

The definitions at the end of this Statement provide essential clarification for terms used herein.

Concurrent or Simultaneous Operations

Concurrent or simultaneous operations occur when the critical or key components of the procedures for which the primary attending surgeon is responsible are occurring all or in part at the same time. The critical or key components of an operation are determined by the primary attending surgeon. A primary attending surgeon’s involvement in concurrent or simultaneous surgeries on two different patients in two different rooms is not appropriate.

Overlapping Operations

Overlapping of two distinct operations by the primary attending surgeon occur in two general circumstances.

The first and most common scenario is when the key or critical elements of the first operation have been completed and there is no reasonable expectation that there will be a need for the primary attending surgeon to return to that operation. In this circumstance a second operation is started in another operating room while a qualified practitioner performs non-critical components of the first operation allowing the primary surgeon to initiate the second operation, for example, during wound closure of the first operation. This requires that a qualified practitioner is physically present in the operating room of the first operation.

The second and less common scenario is when the key or critical elements of the first operation have been completed and the primary attending surgeon is performing key or critical portions of a second operation in another room. In this scenario, the primary attending surgeon must assign immediate availability in the first operating room to another attending surgeon.

The patient needs to be informed in either of these circumstances. The performance of overlapping procedures should not negatively impact the seamless and timely flow of either procedure.

Multidisciplinary Operations

Contemporary surgical care may require multidisciplinary operations. During such operations, it is appropriate for surgeons to be present only during the part of the operation that requires their surgical expertise. However, an attending surgeon must be immediately available for the entire operation.

Delegation to Qualified Practitioners

The surgeon may delegate part of the operation to qualified practitioners including, but not limited to residents, fellows, anesthesiologists, nurses, physician’s assistants, nurse practitioners, surgical assistants or another attending under his or her personal direction. However, the primary attending surgeon’s personal responsibility cannot be delegated. The surgeon must be an active participant throughout the key or critical components of the operation. The overriding goal is the assurance of patient safety.

Procedure-Related Tasks

A primary attending surgeon may have to leave the operating room for a procedure-related task. Such procedure-related tasks could include review of pertinent pathology (“frozen section”) and diagnostic imaging; a discussion with the patient’s family; and breaks during long procedures. The surgeon must be immediately available for recall during such absences.

Unanticipated Circumstances

Unanticipated circumstances may occur during procedures that require the surgeon to leave the operating room prior to completion of the critical portion of the operation. In this situation, a backup surgical attending must be identified and available to come to the operating room promptly.

Circumstances in this category might include sudden illness or injury to the surgeon, a life-threatening emergency elsewhere in the operating suite or contiguous hospital building, or an emergency in the surgeon’s family.

If more than one emergency occurs at the same time, the attending surgeon may oversee more than one operation until additional attending surgeons are available.

Surgeon-Patient Communication (Section II.A.)

The surgical team involved in an operation is dependent on the type of facility at which the operation is performed and the complexity of the surgery. At a free standing outpatient surgical center, many procedures are performed solely by the primary attending surgeon with no assistant. In contrast, a complex procedure at an academic medical center may involve multiple qualified medical providers in addition to the primary attending surgeon. As part of the pre-operative discussion, patients should be informed of the different types of qualified medical providers that will participate in their surgery (assistant attending surgeon, fellows, resident and interns, physician assistants, nurse practitioners, etc.) and their respective role explained. If an urgent or emergent situation arises that require the surgeon to leave the operating room unexpectedly, the patient should be subsequently informed.


In an effort to provide some standardization of nomenclature and terminology, the following definitions are provided:

  • Back-up surgeon/surgical attending
    The qualified surgical attending who has been designated to provide immediately available coverage for an operation, during a period when the primary surgeon might be unable to fill this role.
  • “Concurrent or simultaneous operations” (or surgeries)
    Surgical procedures when the critical or key components of the procedures for which the primary attending surgeon is responsible are occurring all or in part at the same time.
  • “Critical” or “key” portions of an operation
    The “critical” or “key” portions of an operation are those segments of the operation when essential technical expertise and surgical judgment are required in order to achieve an optimal patient outcome. The critical or key portions of an operation are determined by the primary attending surgeon.
  • Immediately Available
    Reachable through a paging system or other electronic means, and able to return immediately to the operating room. This should be defined more completely by the local institution.
  • Informed consent
    Described in ACS Statements on Principles II.A.
  • Multidisciplinary Operations
    One example of this would be a procedure where a surgeon of one specialty provides the exposure required by a second surgeon who performs the main surgical intervention (e.g.; a general or thoracic surgeon providing exposure for a neurosurgeon or orthopaedist to operate on the spine). Another example would be an operation that requires the involvement of two or more surgeons with different specialty expertise (e.g.; chest wall or head and neck resection followed by plastic surgical reconstruction; face or hand transplantation; repair of complex craniofacial defects).
  • “Overlapping or sequenced” operations for surgeons
    The practice of the primary surgeon initiating and participating in another operation when he/she has completed the critical portions of the first procedure and is not essential for the final phase of the first operation. These are by definition surgical procedures where key or critical portions of the procedure are not occurring simultaneously.
  • Physically Present
    Located in the same room as the patient.
  • Primary Attending Surgeon
    Considered the surgical attending of record or the principal surgeon involved in a specific operation. In addition to his/her technical and clinical responsibilities, the primary surgeon is responsible for the orchestration and progress of a procedure.
  • Qualified Practitioner
    Any licensed practitioner with sufficient training to conduct a delegated portion of a procedure without the need for more experienced supervision and who is approved by the hospital for these operative or patient care responsibilities.

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