Can you run dual ortho rooms without running into trouble? The surgeons we spoke with say overlapping surgeries, in which surgeons delegate another doctor or a physician assistant to close one surgery while he works on a second patient in another OR, are safe if you establish a precise protocol — and never deviate from it.

“It’s easy to do it poorly and it’s hard to do it well,” says Daniel Branham, MD, of Tennessee Orthopaedic Clinics in Knoxville, Tenn.

Running dual ortho ORs is known by many names — double-booked, simultaneous, overlapping or concurrent surgery — but the practice got a bad rap a few years ago. In October 2015, the Boston Globe investigated concurrent surgery at Harvard’s Massachusetts General Hospital. Reports described patients waiting under anesthesia for prolonged periods and absentee surgeons who forced residents or fellows to operate on their own.

“I never want to be the one who gets told, ‘I had my patient under anesthesia for 10 minutes before you even got here,’” says Mark Topolski, MD, of Gundersen Health System in La Crosse, Wis.

It starts with scheduling

One scheduling snafu caused by one patient not showing up can upset a day of dual ortho ORs.

At Tennessee Orthopaedic Clinics, safety begins at the first point of contact when the patient is booked, says Dr. Branham. He tries to put as much information on the booking slip as he can, including vendor, length of case, X-ray or fluoroscopic imaging, graft and implants. The surgeon’s office sends that information to the surgery center or hospital so it can formulate its schedule in conjunction with the surgeon’s schedule.

Two days before surgery, the center calls all patients — 12 to 14 in 2 rooms — to confirm their arrival time. On the day before surgery, the center calls patients again to confirm them.

“I don’t want to schedule a flip situation where that patient doesn’t show and then my rooms are messed up in terms of the rotation,” says Dr. Branham. “It makes the whole day go out of sequence.”

Dr. Branham numbers the patients — the evens go in one room and the odds in another — and then schedules the procedures based on what the most efficient flip is going to be. He schedules the shorter cases with local anesthesia for earlier in the day, the longer, more difficult ones with spinal blocks and implants for later in the day.

Dr. Branham doesn’t want to keep the anesthesia team tied up either, so he does locals on the second, fourth and sixth cases in OR 1. OR 2 hosts the first, third and fifth cases that require an anesthesia provider. That usually works best in the mornings because the quick local anesthesia cases flip better, says Dr. Branham, adding that he can cut the anesthesia team loose a bit sooner.

“You have to have people who are willing to coordinate, communicate and be on the front end of it to get that full, smooth-running day,” says Dr. Branham. “There are several hours spent in the planning stages to make sure it all goes down the right way.”

Precision planning

A big part of operating 2 rooms smoothly, though, is knowing when to call for the next patient, says Dr. Topolski.

“Once we get to a certain point of the surgery, then I’ll say, ‘Send in the other room.’ At that point, I know my implants are in or are going to be in safely and that my PAs can handle the rest of the case,” he says.

When he makes that call, he knows he has enough time to scrub out, complete the op note, talk to the patient’s family and go to the pre-op area and sign the next patient. He never wants to make the call early for the next case, but he wants it timed so that he can get into the next room in time to help position the patient.

“If I send for the patient earlier, then I may find myself rushing to make sure I get there on time,” says Dr. Topolski. “I really try to not put myself in a position where I feel like I’m rushing.”

Dr. Topolski prefers to make his incisions on the half hour. He’ll make his first one in OR 1 at 7:30 a.m., his second one in OR 2 at 8:30 a.m. and so on. He typically makes his last incision of the day around 12:30 p.m. Of course, there can be delays.

“Let’s say there was a couple of tough spinals and it took them an extra 10 minutes to get it, I just kind of twiddle my thumbs in the corner,” says Dr. Topolski. “I know that it’s better for the patient to end up getting a spinal than to just randomly put them to sleep. I’d rather everybody spend that extra time to do what’s going to turn out to be better for the patient.”

Several years ago, OrthoCarolina in Charlotte, N.C. — which has been running dual ortho rooms for 20 years — looked at ways to best maximize the surgeon’s time. What they didn’t want was the surgeon sitting around in the doctor’s lounge waiting for the room to be cleaned or for the next patient to be prepped.

“If I have the ideal length surgery — which for me is just under an hour — and if I have the proper staff with me, whether it’s a physician assistant, resident or fellow who can put in the final stitches, then I can be doing another surgery in another room and all that down time gets washed away,” says W. Hodges Davis, MD, of OrthoCarolina.

Dr. Davis sees every patient personally in the recovery room. Before he walks into the next room, though, he goes to the pre-op area and talks to the on-deck patients. He reminds them of the procedure that is to be done and goes over the consent and marks the site. And he goes through the same procedure with each patient every time.

In addition, once in the OR, with the patient asleep and before he makes the incision, he stops again to take a time out to go over the consent with the team and confirm the procedure.

“That’s where there can be problems, if you don’t pause and go over the consent again,” says Dr. Davis.

He then confirms the correct side and pauses again and either he or the circulating nurse will repeat the consent once more. At that point, the anesthesiologist confirms that it is the right patient, that it is the correct limb and the type of anesthetic.

Dr. Davis admits there are times when he goes to talk with a patient’s family and then heads for the next case without having had the pre-op conversation with the next patient or signed the site. That’s when the staff becomes the next safeguard. They stop the process until he goes back and completes all the steps. It takes buy-in from the staff to know that the doctor is not going to get angry at them for delaying him and it takes buy-in from the surgeon to know that if he misses a step and if he doesn’t participate in those key times, then patients could get hurt.

To run dual rooms safely and efficiently, you have to be absolutely rigid in your approach, and the surgeons and staff have to actively participate in the process.

“You can’t be passive,” says Dr. Davis. “As the so-called captain of the legal ship, you have to be actively involved.”

And you have to have a feel for what you and your staff can reasonably do in one day.

“What you have to have is no compromise. What you’re really concerned about is wrong-site surgery and you just can’t compromise on that,” says Dr. Branham. “There is no secret recipe to this other than going through your center and finding out what steps are specific to your center, your surgeon and your day. And then you work the schedule like a jigsaw puzzle or a Jenga game.” OSM