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Double-Booked Surgeries: Policy and Practice for Anesthesiologists

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Operations Management for hospitals, healthcare providers, and outpatient units that provide surgical services encounter several challenges with respect to managing census and providing services in a timely, cost-effective operation. One central challenge that has gained traction in the press is that on the instances of double-booked surgeries. As the name suggests, double-booked surgeries refers to the practice in which a lead surgeon, and potentially a lead anesthesiologist, is assigned to more than one surgery scheduled in the same time-slot. In this manner, the lead physician will typically execute the major or most complex parts of the surgery, leaving the simpler elements to physicians-in-training, e.g. residents and/or fellows. In many ways, the process of double-booking surgeries is treated as an educational training tool. Junior physicians are able to observe experts in the field, while also taking on significant surgical tasks that will mirror their clinical responsibilities as full-time, attending physicians. However, there are also potential downsides to the practice as detailed in the literature, namely that double-booked surgeries may pose a risk to the patient, and can be logistically difficult to execute from the management perspective. This article will detail the challenges associated with double-booking surgeries for anesthesiologists and practice managers, while also considering the impact to patient population.

The practice of double-booking surgeries, while mainstream at many healthcare institutions, can pose a serious administrative challenge to practice managers. Double-booking surgeries requires a level of coordination at the individual level. Surgeons must identify which segments of the surgery are most difficult to perform, and effectively communicate these recommendations to operating room (OR) managers, who then schedule surgeries in specific OR rooms and with associated staff, including anesthesiologists. For lead anesthesiologists and other anesthesia staff, the process of a surgeon moving from room to room can be a distraction. Specifically, one viable side effect of double-booking surgeries is the potential for tardiness. Tardiness can contribute to OR delays, result in anesthesiologists and anesthesia staff working over-time, and cause an unnecessary cost burden to the institution. Allen et al measured the impact of tardiness on surgical healthcare institutions in the Journal of Healthcare Management1. The research team concluded that each lost minute in the OR was valued at approximately $9.56 in associated costs. In an intervention that targeted delayed surgical start times, part of which were attributed to the presence of double-booked surgeries, cost savings resulted in over $700,000 to the facility. Therefore, if not executed smoothly, double-booked surgeries may represent a significant economic impact to the hospital.

In addition to the economic impact of double-booked surgeries, patient safety represents a viable cause for concern. Given that double booking surgeries requires multiple transitions during the operation, combined with junior surgeons performing a majority of the surgery, several thought leadership pieces have questioned whether there is a significant patient safety issue associated with double-booked surgeries. The literature in fact, suggests the opposite. In a recent publication in JAMA, Sun et al conducted a large-scale retrospective study to determine post-operative outcomes of patients who underwent surgery under double-booked conditions2. The cohort included over 60,000 adult patients, and data points were analyzed for in-hospital mortality, post-operative complications, and surgical characteristics. It was found that patients who were in the
double-booked situation did not experience any increase in mortality or complication rates.

However, the mean length of time in surgery was increased for double-booked surgeries, which aligns with previously stated concerns. This research was impactful for providing data to counter any patient safety concerns around double-booked surgeries, while acknowledging that the surgery itself may be impacted in ways including time.

surgical characteristics. It was found that patients who were in the double-booked situation did not experience any increase in mortality or complication rates.

However, the mean length of time in surgery was increased for double-booked surgeries, which aligns with previously stated concerns. This research was impactful for providing data to counter any patient safety concerns around double-booked surgeries, while acknowledging that the surgery itself may be impacted in ways including time.

To sum, the process of double-booking surgeries provides benefits, as well as costs, for individual physicians as well as healthcare institutions at-large. Anesthesiologists and anesthesia staff, who are deeply involved in surgical coordination initiatives, will find value in understanding the policies, research, and practice connected with this initiative.

1. Allen, Robert W., et al. “First Case On-Time Starts Measured by Incision On-Time and No Grace Period.” Journal of Healthcare Management, vol. 64, no. 2, 2019, pp. 111–121., doi: 10.1097/jhm-d-17-00203.

2. Sun, Eric, et al. “Association of Overlapping Surgery with Perioperative Outcomes.” Jama, vol. 321, no. 8, 2019, p. 762. doi:10.1001/jama.2019.0711.

The Debate on Pediatric Anesthesia and Child Development

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In February 2019, the New York Times published an article entitled, “Having Anesthesia Once as a Baby Does Not Cause Learning Disabilities, New Research Shows”1. The article unveiled the results of a randomly controlled trial that compared neural development between infants that were exposed to anesthesia, and the control cohort of infants who had no such exposure. This study conclusively found that there were no significant neurodevelopment differences among the cohort. In producing such results, the New York Times contributed to a larger debate in the surgical and anesthesia services community on the use of pediatric anesthesia. Over the past decade, multiple conflicting reports have emerged regarding the effects of administering anesthesia to pediatric patients on neurological development. The topic is oft-debated in the academic literature. A brief summary of important research to-date is useful for evaluating this question and deciding treatment plans for the pediatric population.

The theory suggesting that pediatric anesthesia administration could potentially impart negative effects on patients was early introduced on by results from animal studies. In 2003, Dr. Jevtovic-Todorovic and her research team discovered that exposure to nitrous oxide, isoflurane, and midazolam led to significant neurodevelopmental effects in neonatal rats2. In this study, the exposure to anesthesia agents was designed to mimic that of percentages utilized in surgery. Furthermore, the length of exposure similarly matched an average surgery, approximately 6 hours, in order to include time as a relevant factor. The results revealed that the neonatal rats exposed to anesthesia suffered apoptotic neurodegeneration, impaired memory and learning, and a decrease in hippocampal function. These specific and impactful results served as a cause for concern, as animal models often preempt human subjects’ trials. The result of this animal study therefore spurred debate among the anesthesiology and surgical academic fields as to the relevance of the results, as well as the possible mechanisms by which these effects occur.

Of note, Block et al revealed in a 2012 study that early exposure to anesthesia, defined in this study as before one year of age, results in a significant decrease of white matter in the brain3. The longitudinal study followed two cohorts, the anesthesia exposure cohort and the control, recording intellectual capability as measured by academic achievement over a decade. The study subjects also underwent significant neuro-imaging, including MRI. In this study, subjects who had anesthesia as infants reported a 4% decrease in white matter content compared to the control. For reference, white matter is linked with neural communications, as well as learning and neuronal function4.

In the same wave that academic research commenced a focus on these topics, national healthcare policy similarly followed suit. The U.S. Food and Drug Administration (FDA) has released multiple bulletins detailing that the agency warned against administering anesthesia to patients less than three years of age5. If anesthesia is necessary, the FDA recommended that the procedure be less than three hours in totality. These guidelines were readily adopted in multiple healthcare institutions across the States, according to FDA data.

However, in recent years, human subject studies have provided results in contrast with earlier research on this topic, thus suggesting that previous results may have been based on confounding factors. The Mayo Anesthesia Safety in Kids study, results published in 2018, compared three cohorts of pediatric patients and followed the subjects for up to 20 years post-exposure6. The cohorts included control of unexposed patients, patients who were exposed to anesthesia once, and patients who were exposed to anesthesia multiple times. The results showed that exposure of anesthesia before 3 years of age was not associated with negative impacts with regards to IQ and neuropsychological assessment. These results were supported by a recent large-scale study, which examined the effect of anesthesia exposure for more than 10,000 study subjects over time and found that exposure to anesthesia was not associated with any neurocognitive deficits7. Therefore, current studies clearly suggest that the previous links to neurological defects are not indicative of causality and are likely due to confounding or external biological and environmental factors.

Researchers in the anesthesia and surgical space will continue to study pediatric anesthesia and its specific effects until the advent of a clinically accepted definition. However, the recent press attributed to this topic underscores the importance of focusing clinical care on pediatric and other vulnerable populations, for anesthesia providers, researchers, and policy-makers alike.

1 Klass, Perri. “Having Anesthesia Once as a Baby Does Not Cause Learning Disabilities, New Research Shows.” The New York Times, The New York Times, 18 Feb. 2019, www.nytimes.com/2019/02/18/well/family/one-exposure-to-anesthesia-in-children-does-not-cause-learning-disabilities-new-research-shows.html.

2 Jevtovic-Todorovic, V, et al. “Early Exposure to Common Anesthetic Agents Causes Widespread Neurodegeneration in the Developing Rat Brain and Persistent Learning Deficits.” Journal of Neurosurgical Anesthesiology, vol. 15, no. 3, 1 Feb. 2003, pp. 295–296., doi:10.1097/00008506-200307000-00029.

3 Block, Robert I., et al. “Are Anesthesia and Surgery During Infancy Associated With Altered Academic Performance During Childhood?” Survey of Anesthesiology, vol. 57, no. 2, 2013, p. 80., doi:10.1097/sa.0b013e318287d938.

4 U.S. National Library of Medicine. “White Matter of the Brain: MedlinePlus Medical Encyclopedia.” MedlinePlus, U.S. National Library of Medicine, medlineplus.gov/ency/article/002344.htm.

5 Center for Drug Evaluation and Research. “Drug Safety and Availability – FDA Drug Safety Communication: FDA Review Results in New Warnings about Using General Anesthetics and Sedation Drugs in Young Children and Pregnant Women.” U S Food and Drug Administration Home Page, Center for Drug Evaluation and Research, www.fda.gov/drugs/drugsafety/ucm532356.htm.

6 Warner, David O, et al. “Neuropsychological and Behavioral Outcomes after Exposure of Young Children to Procedures Requiring General Anesthesia: The Mayo Anesthesia Safety in Kids (MASK) Study.” Anesthesiology, U.S. National Library of Medicine, July 2018, www.ncbi.nlm.nih.gov/pubmed/29672337.

7 O’Leary, James D., et al. “Influence of Surgical Procedures and General Anesthesia on Child Development Before Primary School Entry Among Matched Sibling Pairs.” JAMA Pediatrics, vol. 173, no. 1, 2019, p. 29., doi:10.1001/jamapediatrics.2018.3662.