Overlapping surgery, where “critical” portions of surgery are performed sequentially in separate operating rooms, is used to increase efficiency and number of procedures performed each day. This systematic review and meta-analysis was performed to determine differences in risk of complications between overlapping surgery (OS) and non-overlapping surgery (NOS) in total hip and total knee arthroplasty. Consistent with prior studies and reviews, there were no significant differences in adverse events or complications between OS and NOS. The authors stress that informed consent and patient education prior to OS is critically important.

Fatigue and sleep deprivation among healthcare workers can increase the risk of errors. This prospective study including 60 attending surgeons from departments of surgery or obstetrics and gynecology at eight hospitals found that sleep deficiency was not associated with greater numbers of errors during procedures performed the next day. However, non-technical skill performance, situational awareness, and decision making were adversely associated with sleep deficiency.  

Reports of poor care in the media or public reporting systems can serve as an impetus to overhauling hospitals or hospital units. After several unexpected deaths and a drop in several rating systems, this cardiac surgery department launched a comprehensive quality improvement review. This paper describes the major changes made in the department, including role clarity and minimizing variation in 24/7 staffing.

Anesthesiologists often must oversee multiple surgeries. This study evaluated adult patients from 23 US academic and private hospitals who underwent major surgery between 2010, and 2017, to examine anesthesiologist staffing ratios against patient morbidity and mortality. The authors categorized the staffing into four groups based on the number of operations the anesthesiologist was covering. The study found that increased anesthesiologist coverage was associated with greater risk-adjusted morbidity and mortality of surgical patients. Hospitals should consider evaluating anesthesiology staffing to determine potential increased risks.

Clinician workload has been linked with poor patient outcomes. This retrospective cohort study assessed the outcomes for patients undergoing coronary artery bypass graft (CABG) performed as a surgeons’ first versus non-first procedure of the day. Findings suggest that prior workload adversely affected outcomes for patients undergoing CABG surgery, with increases in adverse events, myocardial infarction, and stroke compared to first procedures.

In 2011, the Accreditation Council for Graduate Medical Education (ACGME) updated the duty hour restrictions (DHR) for medical residents to increase resident well-being. This review focused on surgical patient outcomes, resident case volume, and resident quality of life following the implementation of the 2011 update. Results showed DHR did not improve patient safety or surgical resident quality of life. The authors suggest future revisions meant to improve resident well-being not focus solely on hours worked in a single shift or week.

Prior research suggests that patients undergoing surgery at night are at greater risk for intraoperative adverse events. This retrospective cohort study including over 350,000 adult patients undergoing non-cardiac surgery found that night surgery was associated with an increased risk of postoperative mortality and morbidity. The effect was mediated by potentially preventable factors, including higher blood transfusion rates and more frequent provider handovers.

This direct observation study found that minor disruptions in usual workflow can combine to lead to an adverse event. More than half of the observed disruptions were related to the physical layout of the operating room, suggesting that physical design of operating rooms may affect surgical safety.

Scheduling overlapping surgeries has raised substantial patient safety concerns. However, research regarding the impact of concurrent surgery on patient outcomes has produced conflicting results. In this multicenter retrospective cohort study, researchers examined the relationship between overlapping surgery and mortality, postoperative complications, and surgery duration for 66,430 surgeries between January 2010 and May 2018. Although overlapping surgery was not significantly associated with an increase in mortality or complications overall, researchers did find a significant association between overlapping surgery and increased length of surgery. An accompanying editorial discusses the role of overlapping surgery in promoting the autonomy of those in surgical training and suggests that further research is needed to settle the debate regarding the impact of overlapping surgery on patient safety.

This systematic review of the safety of overlapping surgery included 14 studies and did not find differences in 30-day mortality or overall morbidity in overlapping versus nonoverlapping surgery across a range of procedures. Researchers noted a small increase in length of procedure for overlapping surgeries. They conclude that overlapping surgery does not lead to higher risk for morbidity and mortality, despite the controversy associated with this practice.

Overlapping surgery is a controversial practice in which an attending surgeon performs more than one procedure concurrently. This retrospective cohort of overlapping orthopedic surgeries across five academic institutions found no differences between complication rates for overlapping versus nonoverlapping procedures. The authors recommend individualizing decisions regarding overlapping surgeries.

This prospective cohort study examined the association between self-rated daytime sleepiness among trainee surgeons and attending surgeon–rated intraoperative technical skill. Higher ratings of sleepiness were associated with worse technical skills, echoing concerns about procedures performed by sleep-deprived surgeons.

Missed nursing care may result from inadequate nurse staffing and explain the relationship between nurse-to-patient ratios and patient outcomes. Research has shown that higher nurse staffing levels are associated with lower inpatient mortality and that reduced staffing increases the risk for postoperative complications. In this study, investigators examined data from more than 400,000 surgical patients from 300 hospitals in 9 countries as well as survey responses from 26,516 nurses. They found a significant association between nurse staffing and missed nursing care with 30-day risk-adjusted postoperative mortality. The authors conclude that measuring missed nursing care may help identify patients at greater risk for adverse outcomes earlier in their course. A past WebM&M commentary highlighted important issues associated with nurse staffing ratios.

Duty hour limitations have been controversial due to inconclusive evidence regarding their impact on care outcomes. This review examined the effect of work hour restrictions on surgical residents. The authors found that duty hour restrictions have fallen short of their goals, discuss unintended consequences of the strategy that diminish safety, and call for amended policy solutions to address concerns.

The 2011 ACGME resident physician duty hour changes shortened the number of consecutive hours interns could work and mandated more time off between shifts. The FIRST trial randomly assigned general surgery residency programs to the standard duty hour policy or to a more flexible duty hour policy. After one year, the trial demonstrated no difference in patient outcomes, but did show that residents assigned to the more flexible schedule were more likely to perceive a negative impact of duty hours on wellbeing. In this follow-up survey study of surgery residents after year 2 of the trial, researchers found that negative perceptions of wellbeing remained higher among those exposed to the flexible duty hour policy, but concerns about wellbeing had decreased.

Resident physician duty hour policies have generated rigorous debate, particularly following the most recent ACGME changes implemented in 2011, which shortened maximum shift lengths for interns and increased time off between shifts. This national study cluster-randomized 118 general surgery residency programs to adhere to current ACGME duty hour policies or to abide by more flexible rules that essentially followed the prior standard of a maximum 80-hour work week. Between these two groups, there were no significant differences in patient outcomes, including death and serious complications. Residents reported similar levels of satisfaction with their overall education quality and their well-being. An accompanying editorial notes that the study authors interpret these results as supporting flexible work-hour rules. Alternatively, the editorial author suggests that this study refutes concerns that the new policy compromises patient safety, and as such there is no compelling reason to backtrack on its implementation.

Resident duty hours have resulted in the need for medical specialties to design and implement strategies to fulfill service demands while meeting educational goals. Examining the impact of duty hour restrictions for training neurosurgical residents, this review suggests that work hour limits be applied with unique consideration for the needs of distinct specialties.

The weekend effect is a well-documented phenomenon where patients admitted over the weekend have inferior outcomes compared to those admitted on a weekday. This retrospective study utilized the AHRQ Healthcare Cost and Utilization Project database and found that specific factors, such as full adoption of electronic health records, home health programs, and increased nurse-to-bed ratios, were associated with overcoming the weekend effect in hospitals.